Energy and macronutrient intake and dietary pattern among school children in Bahrain: a cross-sectional study

Increasing evidence suggests that diet and lifestyle in childhood and adolescence have a potential lifelong effect for risks of many chronic diseases such as obesity, coronary heart disease, hypertension, diabetes and certain types of cancer [1–6]. The types of diet linked with chronic diseases are found to prevail before pubertal maturation, and children's dietary patterns change only marginally during pubertal development [7]. Childhood and adolescence are also considered two critical periods in the development of obesity, and hence, the prevention of obesity during this phase of life has been suggested as a public health priority [8, 9].

With the progress of socio-economic status in Bahrain in recent years, there has been a substantial shift from traditional healthy foods, to diets consisting of high intake of fat, sugar and red meat [10, 11] including western fast food. Research has shown that such diets have contributed to increased energy intake and consequently to increasing obesity in children and adults in this region [12–14]. The dietary habits of school children and adolescents are characterized by low intake of fresh fruits, vegetables and milk and a high intake of carbonated beverages and empty calorie foods [15]. Musaiger and Gregory reported that Bahraini teenagers are a group most susceptible to unsound food habits which places them at risk of an adverse nutritional status [16].

While studies have been conducted on the nutritional status and dietary habits of Bahraini children [12, 15–20], there is lack of information on energy and macro- nutrient intake. Such information could guide us to suggest need based changes in the eating habits of children for delaying or preventing the development of chronic diseases. The current study addresses the intake of energy and macronutrients as well as food frequency in Bahraini school children; a subsequent publication will focus on intake of micronutrients.

The age of the students ranged from 6 to 18 years. Mean ages of the girls and boys were 12.63 (SD 3.27) and 12.45 (SD 3.39) respectively.

3. Food Frequency

Table 3 shows that bread and cereal, meat group and sweets and snacks were the most commonly consumed daily food items among students. Only half of the children were consuming milk and its products and one-fourth of them were taking vegetables and fruits on a daily basis. However, regular soda drinks were consumed daily by approx. 50% of the children. Daily consumption of sweets and snacks was significantly more common in girls (64.2%) than in boys (47.5%) (p < 0.01). On the other hand, meat, milk and its products and tea/coffee were more popular with boys than girls (p < 0.01; p < 0.05; p < 0.01). Figure 1 shows that daily consumption of most food items in girls and milk and its products in boys decreased with age but intake of sweets and snacks increased with age in both genders.

Food	Almost daily 5-7 times/w		3-4 times/w		1-2 times/w		Never
	No.	%	No.	%	No.	%	No.	%
GIRLS
Milk & Milk Products	635	51.2	366	29.5	231	18.6	9	0.7
Bread, Rice & Cereal	870	70.1	256	20.6	114	9.2	1	0.1
Fruits	443	35.7	464	37.4	308	24.8	26	2.1
Fruit Juices	328	26.4	371	29.9	455	36.7	87	7
Vegetables Leafy	404	32.6	370	29.8	366	29.5	101	8.1
Vegetables Others	146	11.8	432	34.8	543	43.8	120	9.7
Meat (Fish, Poultry, Meat)	822	66.2	303	24.4	110	8.9	6	0.5
Eggs	111	8.9	396	31.9	627	50.5	107	8.6
Legumes: lentils, beans...	35	2.8 c	115	9.3	733	59.1	358	28.8
Sweets & Snacks: cakes, chips, candies,...	797	64.2 d	300	24.2	134	10.8	10	0.8
Miscellaneous: tea & coffee	289	23.3	318	25.6	411	33.1	223	18
Miscellaneous: sauce & spreads	214	17.2	356	28.7	497	40	174	14
Soda Drinks: regular	600	48.3	322	25.9	254	20.5	65	5.2
Soda Drinks: diet	19	1.5 d	29	2.3	116	9.3	1077	86.8
BOYS
Milk & Milk Products	659	55.4 a	356	29.9	170	14.3	5	0.4
Bread, Rice & Cereal	904	76 b	227	19.1	56	4.7	3	0.3
Fruits	492	41.3 a	425	35.7	258	21.7	15	1.3
Fruit Juices	359	30.2	358	30.1	399	33.5	74	6.2
Vegetables Leafy	400	33.6	340	28.6	340	28.6	110	9.2
Vegetables Others	176	14.8	397	33.4	520	43.7	97	8.2
Meat (Fish, Poultry, Meat)	889	74.7 b	234	19.7	65	5.5	2	0.2
Eggs	107	9 a	396	33.3	621	52.2	66	5.5
Legumes: lentils, beans,...	30	2.5	139	11.7	730	61.3	291	24.5
Sweets & Snacks: cakes, chips, candies,...	565	47.5	353	29.7	262	22	10	0.8
Miscellaneous: tea & coffee	412	34.6 b	267	22.4	331	27.8	180	15.1
Miscellaneous: sauce & spreads	178	15	396	33.3	443	37.2	173	14.5
Soda Drinks: regular	629	52.9 b	322	27.1	197	16.6	42	3.5
Soda Drinks: diet	17	1.4	25	2.1	67	5.6	1081	90.8

Difference between genders: a p < 0.05; b: p < 0.01 (within gender); c p < 0.05, d p < 0.01 (between genders)

* Non responders: 72 for girls and 59 for boys

The current research is the first study to evaluate the energy and macronutrient intake in Bahraini school children. It was part of a larger study on nutritional status of children and hence it was possible to validate some of the findings. Though there is a possibility of under or over-reporting of food consumption in a 24-hour recall study for various reasons related to knowledge, memory and interview situation [35], reported data on energy intake when compared to Body Mass Index of the students showed a significant trend in the expected direction. This finding allowed us to make some assumption on the validity of the responses.

There may have been some misreporting of data for boys ≤10 years old whose mothers did not participate in the study. The study data has its drawbacks of a one-time 24-hour dietary recall that may not be representative of the usual diet for an individual child. However, it does represent estimations of the average dietary intake of a group because the means of data collection are robust and unaffected by within-person variation [35].

The mean energy intakes of Bahraini children and adolescents were higher than the EAR standards as well as values reported from the US, some European countries such as, Switzerland, Spain, Germany and the UK [36–40] and some Asian countries such as China, Greece and Bangladesh [37, 41, 42]. Mean energy intake of Bahraini children is comparable to data of adolescents from France [36]. High intake of energy by the Bahraini students is a cause of serious concern. Could excessive calorie consumption have contributed to the high prevalence of overweight status found in Bahraini children of this study [43]?

The average protein intake was well in excess of the RNI at all ages. Although there are methodological differences between the present study and dietary studies from the UK [39], Sweden [44] and the USA (Bogalusa Heart Study) [45], Bahraini children were observed to consume more protein than children from these western countries.

Protein is required for growth of children. However, if it is consumed in excess of needs, it is diverted to the energy pathway, or if it is above caloric needs it is metabolized into fat [46]. In fact, a high protein intake early in life could increase the risk of adiposity later in life [47].

The mean daily intake of sugars (intrinsic and extrinsic) was high as per DRV recommendations [22] suggesting an increased risk of dental caries, obesity and its related health problems in Bahraini children. While sugar consumption increased with age due to increasing intake of chocolates, candies and sugared soft drinks, the intake of lactose which helps in calcium absorption, decreased with age due to reduced intake of milk (Table 2). It is a cause of concern that around 50% of the study population consumed at least 1 regular soda drink per day. Research has shown that daily consumption of a 12-oz sugared soda drink has been associated with a 0.18-point increase in a child's BMI and a 60% increased risk of obesity. Over-consumption is a problem when energy is ingested in liquid form; moreover, these drinks represent energy added to, without displacing other dietary intake [48].

Besides weight gain, increased sugar consumption in Bahraini children is likely to decrease their HDL cholesterol, increase LDL cholesterol, triglycerides, blood glucose and insulin concentrations, factors which are related to Coronary Heart Disease mortality [49]. Further, research suggests that high sugar intake may lead to nutritional inadequacy of micronutrients especially those of Vitamin A, C, B12, Folate, Calcium, Phosphorus, Magnesium and Iron [50].

Dietary fiber is a part of carbohydrate and is necessary for normal laxation; it may also help prevent future risk of cardiovascular disease, some cancers, and adult-onset diabetes [31, 32]. A reasonable goal for dietary fiber intake during childhood and adolescence may be approximately equivalent to the age of the child +5 grams per day and a safe range is age +5 to +10 g/day [30–32].

Fiber intake by the Bahraini adolescents apparently fell short of the current recommendations and may be considered inadequate for optimal health promotion and chronic disease prevention [31]. This is apparently due to low consumption of fresh fruits and vegetables as observed in the food frequency data of the children and possibly due to insufficient quantities of other sources of fiber such as whole grains, legumes, and high fiber cereals. Indeed, findings of this survey were consistent with those of a recent national nutrition survey conducted on Bahraini adults, 50% of whom were not consuming fruits and vegetables on a daily basis [9].

Regional studies have also shown that daily consumption of fruits and vegetables were uncommon among Omani adolescent girls and young females from the United Arab Emirates [15, 51].

Nutrition messages in Bahraini school children should emphasize that foods high in starches (polysaccharides; e.g., bread, pasta, cereal, potatoes) are recommended over sugar (monosaccharide's and disaccharides) as per dietary guidelines of the American Heart Association [49]. Moreover, foods that are sources of complex carbohydrates (whole grains) as well as nutrient-fortified and enriched starches, such as cereals should be the major sources of calories in the diet.

A higher mean total fat intake by boys than girls might be explained by their more frequent consumption of fat-rich foods such as meats, eggs, and whole milk and dairy products. The mean total fat intake was lower among Bahraini adolescent girls compared to their younger counterparts. Two possible reasons could explain these finding. Older girls are more likely to be preoccupied with body image [52], and hence are less keen to accurately report foods higher in fat and sugar, which they perceive to be "unhealthy"; alternatively some of them were under a controlled diet at the time of the survey to reduce their body weight and hence were cautious in fat consumption. These possibilities need further exploration since they were not investigated in the present study.

The mean E% of macronutrients among Bahraini boys and girls were close to the current dietary recommendations set by COMA [22] and comparable with values of E% in the diet of French adolescents (48.1% carbohydrate, 36.9% fat, 15% protein) [36] and the UK children and adolescents (51.5% carbohydrate, 35.4% fat, 13.1% protein for boys; and 51% carbohydrate, 35.9% fat, 13.1% protein, for girls) [39]. However, a higher total fat E% was found in American children and adolescents (38%) [53] and Greek adolescents (40.25%) [37] compared to their Bahraini counterparts of this study.

The E% from fat and fatty acids for young people is generally compared with the DRVs for adults since the significance of any long-term effects are less well established for children than for adults and hence reference values have not been formulated separately for children. However it is suggested that the dietary patterns of fat intake recommended for adults should be appropriate for children from the age of five years [22].

It was encouraging to note that the average E% of total fat and saturated fat among Bahraini students were equal to or lower than the recommended Dietary Values [22]. Whether this suggests a lower risk of ischemic heart disease in the long term has yet to be established. Bahraini mean values of E% for saturated fat were also lower than the US mean values of 12% (NHANES III) for children aged 2 to 19 years [38] and UK mean values of 14% for children aged 7 to 18 years [39].

The mean E% of monounsaturated fat among Bahraini students was lower than the DRV value of 13% and that of the US children (12.5%) and UK children (11.8%) [22, 38, 39]. Bahraini E% values of polyunsaturated fat were close to the DRV of 6.5%, as well as to the mean values of boys and girls in the UK (6%) [22, 39]. However, the P:S ratio of 0.6 for both girls and boys, was lower than the usually recommended value of 1, suggesting higher consumption of saturated fat compared to polyunsaturated sources [23]. This situation is not encouraging considering saturated fatty acids in the diet raise plasma total and LDL cholesterol while polyunsaturated fatty acids (particularly linoleate in corn, safflower, sunflower, and soybean oils) and monounsaturated fatty acids (principally oleate in olive oils), lower these blood lipids [33].

The mean daily intake of dietary cholesterol among Bahraini boys was higher as per DRV standards of ≤ 300 mg/day [22] and is a cause of concern. A higher dietary cholesterol intake in boys than girls is possibly due to their higher consumption of cholesterol-rich foods such as meats, eggs, milk and other dairy products.

While the mean E% of total fat and saturated fat as well as mean cholesterol intake in the diet of Bahraini children was at an acceptable level as per DRV recommendations, a substantial proportion of the students exceeded prudent dietary recommendations. There are data to suggest, that children with high levels of serum cholesterol may have an increased risk of having high serum cholesterol as adults [54]. Dietary fat intake in children is of interest because of concerns about the atherosclerotic process which begins in childhood and increases cardiovascular disease risk factors including hypertension [53, 54]. Current dietary findings suggest that one-third to half of the Bahraini children may be at increased risk of cardiovascular disease and mortality in their adult life.

Though the mean E% of total and saturated fat in the study population was acceptable, increasing values of saturated fat and cholesterol and decreasing values of fiber intake in high fat dense diets

(> 30%) indicates the higher potential of an atherogenic effect and cardiovascular disease risk in those consuming such diets. P: S values of all 3 fat-dense diets were lower than the usually recommended value of 1 [23], suggesting that diets with apparently 'unfavorable' lipid profiles are not a phenomenon exclusive to the high fat group. These data suggest that, in addition to the quantitative aspects, the qualitative nature of dietary fat intake of school-aged children and adolescents deserves attention.

Sugar intake was significantly more in those on low than high fat dense diets. It is not unreasonable to speculate that students on low fat dense diets might compensate by increasing the use of sucrose to maintain energy requirements. In the Bogalusa Heart Study, children whose E% from total fat was less than 30% consumed more carbohydrates (mainly sucrose) than children who ate high-fat food [55]. To avoid increased calorie consumption and hence weight gain, high sugar and nutrient-poor foods should not be a substitution for reduced fat intake as per AHA guidelines [49].

The food frequency data showed that a small selection of foods made up the total diet for most children. While milk is a good source of protein and calcium necessary during the growth phase of children, there is concern about its infrequent consumption especially during adolescence. Infrequent intake of fruits and vegetables reflects lack of protective and healthy foods in the diet of Bahraini children. Moreover, high intake of regular soda drinks, sweets and snacks will contribute to surplus empty calories with an increased risk for obesity and its consequences.

Low intake of fruits and vegetables and dietary fiber, high sugar intake and high Energy % of saturated fat and dietary cholesterol by a substantial proportion of Bahraini children is likely to increase their risk of obesity and cardiovascular diseases in later life. Therefore, nutrition education programs in schools should emphasize the importance of healthy balanced diets and the risks of consuming empty calories. Parents too should be provided information on nutrients essential for the growth and health maintenance of children as well as dietary prevention of diseases. Moreover, food industries have a potential to change the eating habits of our children. They should provide healthier food choices and introduce attractive ways to market these new choices to appeal to the children. It is well known that the foundation for good health in adulthood is laid during childhood and adolescent years.