European Journal of Clinical Nutrition (1997) 51, 273±285
ß 1997 Stockton Press. All rights reserved 0954±3007/97 $12.00
Nutritional survey in Greek children: nutrient intake
E Roma-Giannikou, D Adamidis, M Gianniou, R Nikolara and N Matsaniotis
1st Department of Paediatrics of Athens University, Athens, Greece
The aim of the survey was to record the food habits and nutrient intake of Greek children. Data was obtained by a
3 d household measured diet record from a random strati®ed sample (1936 children aged 2±14 y). Mean daily
protein intake was much higher than PRI and none of the children had lower intake than AR. Mean energy intake
from protein was 15%, carbohydrate 44% and fat 41%. Eighty-four percent of children had energy intake from
fat higher than the AR. Saturated fatty acids (SFA) provided approximately 15%, monounsaturated (MUFA)
17% and polyunsaturated (PUFA) 6% of energy. Eighty-seven percent of children had higher intake of SFA than
the AR. Six percent of children had SFA intake lower than the AR and 50% higher than the AR. None of the
children had PUFA intake lower than PRI and 0.3% higher than the maximum limit. 4.2% of children had
calcium intake lower than LTI and 88% higher or equal to PRI. All children had phosphorus intake higher than
PRI and less than the lower safe ratio of Ca/P; 50% of them had P intake higher than 1.5 g/d. The majority of
children had suf®cient iron intake with the exception of menstruated girls. Mean vitamin A intake was higher
than PRI and lower than the toxic levels. All children had vitamin C intake higher than LTI. Median vitamin D
intake varied from 1.7±2.1 mgr. Median energy intake was higher than the AR in preschool children, but lower in
the older children. We conclude that Greek children do not underintake energy and protein, overintake SFA, have
safe intake of PUFA, vitamin A and C and high intake of MUFA, underintake carbohydrates, have adequate Ca,
but a considerably high P intake. Vitamin D is low in small children, but the biological available vitamin D is
obviously higher due to sunlight.
Descriptors: nutrient intake; nutritional survey; children
Introduction
It is well recognized that nutrition is very important for the
normal physical, mental and psychological development of
children and that it is fundamental for their future health.
Recently investigators have been interested in the correlation between various risk factors established during childhood and subsequent adult diseases, especially in the
correlation between nutrition and cardiovascular diseases.
Many of them believe that eating habits begin in childhood
and remain almost unchanged for the rest of a person's life
(Oliveira, 1992; Sub-Committee on Nutritional Surveillance, Committee on Reports on Health and Social Subjects, 1989; Pranzetti, 1989; Arbeit, 1988; Gittelsohn, 1991;
Nicklas, 1987; Boulton, 1985). For these reasons the
investigation of the role of children's nutrition in their
future health must be a serious concern of every country. In
order to change and improve Greek children's nutrition we
must ®rst study their eating habits and estimate their
nutrient intake. There are few studies about the food
habits and nutrient intake of Greek children in the literature, limited to small selective samples and especially for
population at high risk (Kafatos, 1979, 1982a, 1982b,
Aravanis, 1988). The aim of this ®rst national Greek
nutritional survey was to record the food habits and nutrient
intake of Greek children, to compare this to the Dietary
Reference Values, and to correlate the results with body
development and socio-economic factors, in order to orgaCorrespondence: Dr E Roma-Giannikou.
Received 8 December 1995; revised 20 November 1996; accepted
22 November 1996
nise a nation-wide dietary intervention. This paperÐpart of
the above larger studyÐpresents only descriptive data
about the main nutrient intake.
Methodology
Subjects
A random strati®ed sample (Trichopoulos, 1982) was taken
from three (over 52) counties of Greece (illustrated in
Figure 1) and comprized 1936 children aged 2±14 y. A
strati®cation was made according to urban, rural and
semiurban areas of the three counties, and at second step
according to the socioeconomic distribution of the population of each area. Villages and blocks of the selected towns
were randomly selected and all children aged 2±14 y living
in them were included in the study, obtaining a multiform
sample (Trichopoulos, 1982). Material was collected in
cooperation with the local authorities. One of the researchers accompanied with a member of the municipality or
district council visited all houses twice in their block or
selected village. They visited 2966 children, 356 (12%)
were not found and 674 did not respond, so 1936 children
®nally participated in this study (65.3% of the selected
sample or 74.1% of the children that were found). Four
children were excluded because they suffered from chronic
disease related to digestion, absorption or metabolism or
they were on a special diet.
Methods
A pilot study was preceded with the participation of 40
children in order to estimate the response of dietary record
methods in Greek children: 1 d record was successfully
Nutritional survey in Greek children
E Roma-Giannikou et al
274
Figure 1 Map of Greece. Prefectures selected are represented in dark
colour.
completed by 90% of the sample; 2 and 3 d records by
80%; 4 d by 50%; 5, 6 and 7 d by 10% and second and
third 3 d record by 10% and 7% respectively. Therefore the
3 d record method was selected.
Each parent was given a 3 d diet diary (Morgan, 1978;
Neisheim, 1982; Young, 1960; Block, 1982; McGee, 1982;
Schwerin, 1981; Hackett, 1983; Gersovitz, 1978; Knuiman,
1987; Emmons, 1973) and a standard volumetric measure
for food quantities. In order to avoid bias due to the days of
the week, the season and the year, the sample was equally
divided into days, seasons and years. Food quantities were
expressed in units of the standard volumetric measure.
Parents were instructed to measure each component of
the meal separately before it was served, any remains
should be measured again after the meal. Small quantities
were expressed in tea or table spoons and ready made
industrial food was taken down by the weight indicated on
the labels. Parents were instructed to take down a detailed
description of the food (for example fruits peeled or not,
speci®c kind of breads, speci®c portion of meats etc.). On
the second visit all researchers, child and parents checked
out the 3 d diary for anything left out or ambiguities. Three
day records were completed from 1804 children from 1932
(93%). Ten of them were not properly completed and were
excluded from the analysis. In order to calculate the daily
nutrient intake of each subject we used the food tables of
the Federal Republic of Germany (B.L.S.) (Polensky, 1986)
in combination with the recipes of Greek food (Trichopoulou, 1982). The composition of ready made industrial food
was of®cially obtained by the manufacturers. As for food
items not included in the above sources we studied the way
Greek mothers cook them. So from 10 mothers we recorded
the exact proportions of ingredients they use to prepare
100 g of a Greek composite dish and then we calculated the
average composition using the B.L.S. food tables. All
nutrient losses during cooking were taken into account
(Paul, 1978; Paul, 1986). Finally with the combination of
the four sources we made a data base of 503 food items,
usually consumed by Greek children. The 3 d records were
processed by a special PC software in order to calculate the
nutrient intake of each child by meal and day of the week.
Individual mean nutrient intake were compared to Dietary
Reference Values (DRV): Population Reference Intake
(PRI), Average Requirement (AR), Lowest Treshold
Intake (LTI), and maximum safe intake (Scienti®c Committee for Food of the Commission of the European
Communities, 1993; Panel on Dietary Reference Values
of the Committee on Medical Aspects of Food Policy of the
Department of Health, 1991). Intra- and inter-individual
variance was computed for all nutrients as well as their
ratio (variance ratio) (Trichopoulos, 1982; Young, 1960;
Hackett, 1983; Rush, 1982; Todd, 1983; Liu, 1978; Pao,
1985).
Statistical
analysis
was
operated
by
the
SPSSPC ‡ software using the multivariate analysis of variance (Norusis, 1986; Timm, 1975; Olsen, 1976). Age and
sex were entered as independent variables, day of the week,
season and year of observation as covariates. Canonical
distribution of each variable was examined using the
criterion goodness of ®t. Variables that had not a canonical
distribution were mathematically transformed using where
necessary the square root, the logarithm or the square root
of the logarithm. The homogeneity of variability was
examined using the criteria Box-F, Cochran-C, Box-M
(Olsen, 1976; Timm, 1975; Hand, 1981).
Results
Nutrient variance
The total variance of vitamins A, C and D is higher than
100% while it is lower in all other nutrients estimated.
(Table 1). The variance ratio of all nutrients except vitamins and fatty acids is less than one.
Protein
There is a progressive increase, related to age in the daily
amount of protein intake and a corresponding decrease in
the daily amount per body weight (P < 0.0001) (Table 2).
Boys have higher intake than girls (P < 0.0001). The mean
intake in all age groups is much higher than PRI (Scienti®c
Committee for Food of the Commission of the European
Communities, 1993). Only 0.2% of children have protein
intake 50±75% of PRI and 0.8% 75±90% of PRI (expressed
either as g/d or g/Kg/d) and all of them were older than 8 y.
On the opposite 59% of children (from 86% aged 2±3 y
with progressive decrease to 35% of those aged 12±14 y)
have protein intake higher than twice the PRI, which is
considered to be the maximum protein intake for adults
(Panel on Dietary Reference Values of the Committee on
Medical Aspects of Food Policy of the Department of
Health, 1991). None of the children have protein intake
lower than the AR (Panel on Dietary Reference Values of
the Committee on Medical Aspects of Food Policy of the
Department of Health, 1991). Mean energy intake derived
from protein (Table 4) remains unchanged (P ˆ ns) in
relation to age and sex (approximately 15%).
Carbohydrates
There is a progressive increase, related to age in the daily
amounts of carbohydrate and boys have higher intake than
girls (P < 0.0001) (Table 3). Mean percentage of energy
intake derived from carbohydrates (Table 4) remains
unchanged (about 44%) in different age groups and both
sexes (P ˆ ns) and it is lower than the AR (Panel on Dietary
Reference Values of the Committee on Medical Aspects of
Food Policy of the Department of Health, 1991). Mean
percentage of energy intake derived from carbohydrates is
b
a
30
38
36
35
53
42
90
67
57
41
33
51
156
111
265
79
50
49
Total
variance, %
24
28
27
28
39
31
60
45
39
33
26
35
99
75
175
64
40
39
Inter-individual
variance, %
18
26
24
20
35
28
68
49
42
24
20
37
121
82
200
47
30
29
Intra-individual
variance, %
Beaton HG, 1979; Pao ME, 1985.
The variance ratio of this study is lower than in the referred methodological studies of nutrition.
Energy
Protein
Fat
Carbohydrate
Fibre
Saturated fatty acids
Monounsaturated fatty acids
Polyunsaturated fatty acids
Dietary cholesterol
Calcium
Phosphorus
Iron
Vitamin A
Vitamin C
Vitamin D
Monosaccharides
Disaccharides
Polysaccharides
Nutrients
Greek nutritional survey
Total variance, %
36
46
42
38
Ð
45
46
58
59
56
42
43
109
70
Ð
Ð
Ð
Ð
Variance ratio
0.74b
0.93b
0.91b
0.69b
0.90
1.14b
1.14b
1.09b
1.10b
0.72b
0.77
1.05
1.23
1.08
1.14
0.73
0.75
0.73
Table 1 Total, intra-individual, inter-individual variance and variance ratio of nutrients studied in the Greek nutritional survey compared with other studies
25
29
28
23
Ð
31
29
30
28
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Inter-individual
variance, %
25
32
31
29
Ð
32
35
50
52
Ð
Ð
±
Ð
Ð
Ð
Ð
Ð
Ð
Intra-individual
variance, %
Other studiesa
1.00
1.20
1.10
1.30
Ð
1.00
1.20
1.70
1.90
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Ð
Variance ratio
Nutritional survey in Greek children
E Roma-Giannikou et al
275
Nutritional survey in Greek children
E Roma-Giannikou et al
276
Table 2 Daily protein intake
Age (y)
Boys
2±3
4±5
6±7
8±9
10±11
12±14
Girls
2±3
4±5
6±7
8±9
10±11
12±14
g/24 h
g/Kg body weight
PRI
Median
Mean s.d.
Median
Mean s.d.
g/24 h
g/Kg
50
54
62
64
70
72
53 20
57 20
65 22
68 22
73 25
76 27
3.3
2.8
2.6
2.1
2.0
1.7
3.5 1.4
3.0 1.6
2.7 1.0
2.3 0.9
2.1 0.8
2.0 3.0
15.5
18.5
22.0
27.5
34.5
45.5
1.13
1.06
1.01
1.01
0.99
0.97
47
52
57
59
62
59
53 22
55 19
59 21
61 22
66 24
63 27
3.1
2.8
2.4
2.0
1.6
1.3
3.5 1.6
3.2 2.4
2.5 1.0
2.1 0.8
1.8 0.7
1.4 0.6
15.5
18.5
22.0
27.5
35.5
45.0
1.13
1.06
1.01
1.01
1.00
0.94
s.d. ˆ standard deviation.
PRI ˆ Population Reference intake
less than 40% in 25% of children, between 41±49% in 56%
of children and only 19% of them have an equal or higher
intake to the AR (50% of daily energy). The above ®ndings
are independent from age and sex (P ˆ ns).
Fat
Boys have higher fat intake than girls, mainly in pre and
pubertal age groups (P < 0.0001) (Table 3). The mean
energy intake derived from fat is approximately 40% for
boys and 41% for girls, being higher in children 2±3 y old
(P < 0.001) (Table 4). Fat provides less than 30% of energy
in 2% of children, 31±35% of energy in 14% of children,
36±40% of energy in 35% of children, 41±45% of energy in
30% of children and more than 45% in 19% of them. The
above means that 84% of children have energy intake from
fat higher than the AR (35%) (Panel on Dietary Reference
Values of the Committee on Medical Aspects of Food
Policy of the Department of Health, 1991).
The percentage of children having energy intake from
fat less than 30% is higher in the older age groups (8±14 y
old), and the percentage of children with energy intake
from fat more than 40% decreases considerably with age.
Fiber
There is a progressive increase in dietary ®ber intake
related to age (P < 0.0001) (Table 5), but the ®ber density
of the food remains stable (median values from 7.0±7.7 g/
1000 Kcal). The ratio of ®ber intake/fat intake shows a
slight increase in relation to age from 18±21 g of ®ber/
100 g of fat (P < 0.0001) (Table 13).
Saccharides
The daily energy intake deriving from monosaccharides
(Table 6) remains unchanged in relation to age (median
value approximately 4.5%), with the exception children 2±
3 y old (P < 0.01). On the contrary there is a continuous
decrease related to age in energy intake from disaccharides
(P < 0.0001) (17% in the ®rst age group to 13% in the last
one) and a parallel increase in energy intake from polysaccharides (P < 0.0001). The mean ratio of monosaccharides to total carbohydrates remains stable in all age groups
(11±12%), while the ratio of disaccharides to total carbohydrates decreases in relation to age from 40±29%
(P < 0.0001) and the ratio of polysaccharides to total
carbohydrates increases from 47±59% (P < 0.0001)
(Table 13).
Table 3
Daily nutrient intake
Carbohydrate
Boys
Girls
Age (y)
g/24 h
Median
g/24 h
Mean s.d.
g/24 h
Median
g/24 h
Mean s.d.
2±3
4±5
6±7
8±9
10±11
12±14
143
162
179
192
200
215
130
152
169
169
177
175
136 45
154 48
174 56
174 55
183 61
187 66
2±3
4±5
6±7
8±9
10±11
12±14
60
64
71
76
81
82
146 49
165 52
183 55
199 64
205 61
220 77
Fat
63 22
68 23
75 24
80 27
84 28
86 28
59
63
68
69
73
73
62 24
65 21
71 25
72 25
77 28
78 31
s.d. ˆ standard deviation.
Fatty acids
Saturated fatty acids provide approximately 15% of energy
intake, monounsaturated fatty acids 17% and polyunsaturated fatty acids 6%. Mean values for polyunsaturated fatty
acids have a slight increase related to age (P < 0.0001),
while saturated have a slight decrease (P < 0.0001) (Table
7); monounsaturated have no statistical difference in the
various age and sex groups. Mean saturated fatty acid
intake is considerably higher than the average requirement
(10%) proposed by the Panel on Dietary Reference Values
of the United Kingdom and 87% of Greek children have
higher intake. Monounsaturated fatty acids intake provide
12±14% of the energy in 44% of children, close to the AR
(13% proposed by the Panel on Dietary Reference Values
of the United Kingdom); 1% of children have monounsaturated fatty acids intake 9%, 5% of them from 10±11%,
22% have an intake from 15±16%, 15% from 17±23% and
18% of children have monounsaturated fatty acids intake
higher than 23% of the daily energy intake, without any
differences in the various age groups. Polyunsaturated fatty
acids intake exceeds the maximum (15% of daily energy
intake) proposed by the Scienti®c Committee for Food of
the Commission of the European Communities 1993 in
0.3% of children, while 3% of them have higher intake than
the maximum limit (10%) proposed by the Panel on Dietary
Nutritional survey in Greek children
E Roma-Giannikou et al
Table 4
277
Daily nutrient intake (% of energy intake)
Age (y)
Protein
Boys
Carbohydrate
Fat
Median
Mean s.d.
Median
Mean s.d.
Median
Mean s.d.
15.1
14.9
15.1
14.8
15.3
15.3
15.5 3.5
15.3 3.6
15.6 3.4
15.2 3.5
15.7 3.8
15.6 3.8
43
44
44
45
44
45
43 8
44 8
44 8
45 8
44 9
45 9
41
40
40
40
40
39
41 7
41 7
40 7
40 7
40 7
40 7
15.4
15.3
14.9
15.0
15.3
14.5
16.0 3.9
15.5 3.6
15.1 3.4
15.3 3.7
15.6 3.9
14.7 3.4
42
43
44
44
44
44
42 8
43 9
44 8
44 9
44 9
45 9
42
41
41
41
41
41
42 7
41 7
40 6
40 7
41 7
41 8
2±3
4±5
6±7
8±9
10±11
12±14
Girls
2±3
4±5
6±7
8±9
10±11
12±14
Average requirement for carbohydrate ˆ 50%.
Average requirement for fat ˆ 35%.
s.d. ˆ standard deviation.
Table 5 Daily dietary ®ber intake
Boys
Girls
g/24 h
g/1000 Kcal
g/24 h
g/1000 Kcal
Age (y)
Median
Mean s.d.
Median
Mean s.d.
Median
Mean s.d.
Median
Mean s.d.
2±3
4±5
6±7
8±9
10±11
12±14
9.3
10.7
13.0
13.4
14.0
15.3
10.6 6.1
11.9 6.2
13.9 6.5
14.7 6.9
15.6 7.9
16.7 8.2
7.1
7.0
7.5
7.2
7.2
7.7
7.4 3.5
7.5 3.5
8.0 3.8
7.8 3.3
8.8 3.6
8.1 3.5
8.7
10.3
11.8
12.2
13.2
13.7
9.8 5.2
11.6 6.8
12.8 6.6
13.1 6.0
14.1 6.9
15.4 8.2
6.7
7.0
7.1
7.4
7.4
8.0
7.1 3.1
7.8 3.9
7.7 3.4
8.0 3.3
8.0 3.6
8.8 4.2
s.d. ˆ standard deviation.
Table 6
Age (y)
Boys
2±3
4±5
6±7
8±9
10±11
12±14
Girls
2±3
4±5
6±7
8±9
10±11
12±14
Daily saccharides intake (% of energy intake)
Monosaccharides
Disaccharides
Polysaccharides
Median
Mean s.d.
Median
Mean s.d.
Median
Mean s.d.
5.00
4.00
4.30
4.10
4.00
4.10
5.45 3.90
4.92 3.91
4.92 3.53
5.12 4.08
4.85 3.63
4.83 3.65
15.6
15.2
14.2
13.7
12.9
11.6
17.4 7.6
16.1 7.2
15.0 6.1
14.5 6.4
13.7 6.3
13.0 6.4
20
23
24
25
25
27
20 8
23 8
24 8
25 8
26 8
27 9
3.70
4.40
4.40
4.40
4.40
4.30
5.04 4.33
5.48 4.21
5.10 3.63
5.08 3.74
5.02 3.38
5.45 4.45
16.3
14.9
14.8
12.8
13.1
12.5
17.2 7.2
16.1 7.1
15.8 7.3
14.0 6.4
13.9 6.3
13.6 7.0
19
21
23
25
24
25
19 8
22 8
23 8
25 9
25 8
25 9
s.d. ˆ standard deviation.
Reference Values of the United Kingdom). There is a
progressive increase related to age in the percentage of
children who exceed the limit of 10% (from 2% in the age
2±3 y up to 5% in the age 12±14 y old). The average
requirement of polyunsaturated fatty acids is 6.5% (Panel
on Dietary Reference Values of the Committee on Medical
Aspects of Food Policy of the Department of Health, 1991)
of the daily energy intake; 42% of children have higher
intake and 12% lower intake. None of the children have
lower intake than the PRI (Scienti®c Committee for Food
of the Commission of the European Communities, 1993).
The ratios of saturated, mono- and poly-saturated fatty
acids to total fat (Table 13) showed that with increasing
age mono- and poly-unsaturated fatty acids increased
(P < 0.0001), while saturated decreased (P < 0.0001). The
ratio of poly- to saturated fatty acids has a progressive
increase related to age (P < 0.0001).
Cholesterol
Median dietary cholesterol intake (Table 8) is higher in the
ages of 2±3 y (360 mg/24 h) (P < 0.01) and then remains
stable (about 320 mg/24 h for boys and 300 mg/24 h for
Nutritional survey in Greek children
E Roma-Giannikou et al
278
Table 7 Daily fatty acid intake (% of energy intake)
Age (y)
Saturated
Boys
2±3
4±5
6±7
8±9
10±11
12±14
Girls
2±3
4±5
6±7
8±9
10±11
12±14
Monounsaturated
Polyunsaturated
Median
Mean s.d.
Median
Mean s.d.
Median
Mean s.d.
15.3
15.0
14.7
14.4
14.5
13.7
15.6 3.9
15.2 4.2
15.1 4.4
14.9 4.4
14.9 4.5
14.4 4.4
14.2
14.0
14.0
14.2
14.0
13.8
15.9 8.7
16.0 11.2
17.3 4.5
17.1 13.7
17.1 14.3
17.6 15.1
4.8
4.9
5.1
5.1
5.5
5.4
5.6 2.8
5.7 3.0
6.0 3.0
6.1 3.5
6.4 3.3
6.5 3.3
15.7
14.6
14.7
14.5
14.4
14.2
16.4 4.6
15.2 5.0
15.2 4.6
15.1 4.6
14.9 4.6
14.8 5.0
14.3
14.3
14.2
14.2
14.1
14.7
17.8 14.5
16.1 9.9
18.0 16.1
17.5 15.6
16.9 14.2
18.6 18.8
4.7
5.0
5.2
5.3
5.5
5.6
5.9 3.4
6.0 3.7
6.3 3.6
6.2 3.2
6.5 3.9
6.6 3.7
s.d. ˆ standard deviation.
Average maximum for monounsaturated fatty acids ˆ 13% of energy intake.
Average maximum for polyunsaturated fatty acids ˆ 6.5% of energy intake.
Average maximum for saturated fatty acids ˆ 10% of energy intake.
Population reference intake for polyunsaturated fatty acids ˆ 3.5% of energy intake (2±3 y old).
Population reference intake for polyunsaturated fatty acids ˆ 2.5% of energy intake ( > 3 y old).
Maximum intake for polyunsaturated fatty acids ˆ 10% of energy intake.
Table 8 Daily dietary cholesterol intake (mg/24 h)
Boys
Girls
Age (y)
Median
Mean s.d.
Median
Mean s.d.
2±3
4±5
6±7
8±9
10±11
12±14
359
315
328
312
316
325
352 169
335 194
350 194
337 178
353 207
358 229
362
318
299
296
287
298
354 203
329 174
318 167
323 194
329 196
349 248
s.d. ˆ standard deviation.
girls). 62.8% of Greek children have a higher intake than
300 mg/24 h which was proposed by the American Academy of Cardiology as the upper limit.
Calcium
The daily amount of calcium intake increases with age, but
the food density in calcium decreases (P < 0.0001) (Table
9). 1.3% of children have calcium intake lower than 50% of
PRI (Scienti®c Committee for Food of the Commission of
the European Communities, 1993), 5.3% between 50% and
75% of PRI, 5.1% between 75% and 90% of PRI and
88.3% of them have suf®cient calcium intake. There are
major differences in relation to age: suf®cient calcium
intake have 97% of the children aged 2±3 y, 96% of
those aged 4±5 y, 95% of those aged 6±7 y, 93% of
those aged 8±9 y, 79% of those aged 10±11 y and only
57% of the children aged 12±14 y old. Calcium intake is
lower than 50% of the AR (Panel on Dietary Reference
Values of the Committee on Medical Aspects of Food
Policy of the Department of Health, 1991) in 0.4% of the
population, from 50±75% in 2.1% and from 75±90% in
2.8% of the Greek children. When calcium intake is
compared to the LTI (Panel on Dietary Reference Values
of the Committee on Medical Aspects of Food Policy of the
Department of Health, 1991) it is found that 0.4% of
children have lower than 50% of LTI, 1.7% from 50±
75% of LTI and 2.1% from 75±90% of LTI. None of the
children aged 2±3 y have lower intake than LTI.
Phosphorus
In all age groups the mean daily phosphorus intake is two to
four times greater than PRI (Table 9). All children have
phosphorus intake higher than PRI (Scienti®c Committee
for Food of the Commission of the European Communities,
1993) and 89.7% of them have mean daily values higher
than double of PRI. The mean ratio of calcium to phosphorus shows a progressive decrease in relation to age from
0.71±0.63 (P < 0.0001) (Table 13). All children have less
than the lower safe ratio of 1.2/1 (Scienti®c Committee for
Food of the Commission of the European Communities,
1993) and 50% of them have phosphorus intake more than
1500 mg/24 h.
Iron
Iron intake increases with age (P < 0.0001), while the iron
density of food consumed decreases (P < 0.0001) (Table
10). Girls have lower iron intake than boys and lower iron
density of food in all age groups (P < 0.0001). Daily iron
intake less than 50% of PRI (Scienti®c Committee for Food
of the Commission of the European Communities, 1993)
have 5.8% of children, specially girls older than 12 y old
(34% of menstruated girls). Iron intake 50±75% of PRI
have 3.7% of Greek children and intake between 75±90%
of PRI have another 2.6% of them. The majority of children
have suf®cient iron intake compared to the AR (Panel on
Dietary Reference Values of the Committee on Medical
Aspects of Food Policy of the Department of Health, 1991):
only 0.6% of them have an intake lower than 50% of AR,
4% from 50±75% ad 5.2% from 75±90%.
Vitamin A
Mean values for vitamin A in all age groups are higher than
PRI (Scienti®c Committee for Food of the Commission of
the European Communities, 1993) but lower than the toxic
level (Scienti®c Committee for Food of the Commission of
the European Communities, 1993). Standard deviation is
greater than mean value (even twice) in all groups (Table
11), because of the large intra-individual variation of
vitamin A. Mean daily intake is lower than 50% of PRI
in 0.7% of children, from 50±75% in 3.9% and from 75±
90% in 5.7%. The number of children whose intake is
Nutritional survey in Greek children
E Roma-Giannikou et al
279
Table 9 Daily nutrient intake
Phosphorus
Boys
Age (y)
mg/24 h
Girls
mg/1000 Kcal
mg/24 h
mg/24 h
mg/1000 Kcal
mg/24 h
Median
Mean s.d.
Median
Mean s.d.
PRI
Median
Mean s.d.
Median
Mean s.d.
PRI
2±3
4±5
6±7
8±9
10±11
12±14
1126
1184
1301
1346
1392
1520
1165 362
1224 379
1340 390
1406 449
1450 445
1595 460
814
774
762
739
727
738
823 163
787 234
773 154
753 153
741 159
754 158
300
350
400
450
450
775
1091
1126
1185
1209
1230
1218
1134 379
1151 346
1222 370
1241 426
1294 427
1276 436
829
763
733
731
725
703
837 180
778 177
754 171
752 212
737 162
725 168
300
350
400
450
450
625
2±3
4±5
6±7
8±9
10±11
12±14
797
805
862
927
942
906
824 307
823 301
899 335
938 362
963 402
960 403
527
510
512
498
470
445
588 183
535 189
519 163
509 177
494 185
474 187
Calcium
400
450
500
550
550
1000
764
725
779
797
783
752
782 301
754 306
819 323
822 334
851 395
748 321
561
491
484
482
463
445
583 199
513 194
511 192
500 181
485 187
451 165
400
450
500
550
550
800
s.d. ˆ standard deviation.
Table 10 Daily iron intake
Boys
mg/24 h
Girls
mg/1000 Kcal
mg/24 h
mg/24 h
mg/1000 Kcal
mg/24 h
Age (y)
Median
Mean s.d.
Median
Mean s.d.
PRI
Median
Mean s.d.
Median
Mean s.d.
PRI
2±3
4±5
6±7
8±9
10±11
12±14
7.1
7.9
9.1
9.6
10.4
10.9
7.7 4.7
8.6 4.7
9.6 3.9
10.2 4.6
11.0 5.1
11.9 6.1
0.48
0.41
0.37
0.32
0.29
0.25
0.51 0.28
0.45 0.29
0.40 0.17
0.34 0.15
0.31 0.16
0.33 0.56
3.9
4.2
5.0
5.9
8.0
9.7
6.6
7.5
8.1
8.7
9.2
9.5
7.2 3.7
8.3 4.5
8.8 3.8
9.3 4.3
10.0 4.9
10.1 4.8
0.44
0.41
0.34
0.30
0.26
0.21
0.49 0.26
0.47 0.35
0.37 0.16
0.32 0.16
0.27 0.13
0.23 0.11
3.9
4.2
5.0
5.9
9.0
21.8
s.d. ˆ standard deviation.
Table 11 Daily vitamin A intake
Boys
Age (y)
2±3
4±5
6±7
8±9
10±11
12±14
mg/24 h
Girls
mg/24 h
mg/24 h
mg/24 h
mg/24 h
mg/24 h
Median
Mean s.d.
PRI
AR
LTI
Maximum
Median
Mean s.d.
PRI
AR
LTI
Maximum
683
660
692
724
719
739
978 1273
955 1572
981 1285
990 1022
1167 1844
1151 2764
400
400
450
500
550
600
300
300
325
350
450
500
200
200
225
250
250
250
1800
3000
3500
4500
4500
4500
632
641
610
658
688
670
990 1976
936 1185
862 1404
1035 1621
1049 1490
922 1062
400
400
450
500
550
600
300
300
325
350
450
500
200
200
225
250
250
250
1800
3000
3500
4500
4500
4500
s.d. ˆ standard deviation.
AR ˆ Average Requirement.
LTI ˆ Lowest Treshold Intake.
PRI ˆ Population Reference Intake.
lower than 90% of PRI increases in relation to age (4.5% in
the age groups 2±5 y old, 9% in children aged 6±7 y, 11%
in children aged 8±9 y, 16% in the group of 10±11 y and
19% in the group 12±14 y old). Individual intake compared
(a) to the AR (Panel on Dietary Reference Values of the
Committee on Medical Aspects of Food Policy of the
Department of Health, 1991) is lower than 90% in 1.8%
of children (b) to the LTI (Panel on Dietary Reference
Values of the Committee on Medical Aspects of Food
Policy of the Department of Health, 1991) is lower than
90% in 0.3% of children. A small number of children
appear to exceed the maximum intake of vitamin A
(Panel on Dietary Reference Values of the Committee on
Medical Aspects of Food Policy of the Department of
Health, 1991): 0.8% of the population has mean daily
intake between 110±125% of the maximum level and
1.5% has vitamin A intake more than 125% of the maximum level.
Vitamin C
All children have vitamin C intake (Table 12) higher than
LTI (Panel on Dietary Reference Values of the Committee
Nutritional survey in Greek children
E Roma-Giannikou et al
280
Table 12 Daily vitamin intake
Vitamin C (mg/24 h)
Age (y)
2±3
4±5
6±7
8±9
10±11
12±14
Boys
Girls
Boys and girls
Median
Mean s.d.
Median
Mean s.d.
PRI
AR
LTI
54
62
77
78
84
83
77 83
78 84
104 119
102 103
119 137
118 122
46
67
73
76
78
81
67 76
84 80
93 94
101 113
108 119
118 135
25
25
27
30
32
35
20
20
20
20
20
22
8
8
8
8
9
9
Vitamin D (mg/24 h)
Age (y)
2±3
4±5
6±7
8±9
10±11
12±14
Boys
Girls
Median
Mean s.d.
Median
Mean s.d.
PRI
2.1
1.9
1.7
1.9
1.8
1.8
4.1 7.0
4.7 19.0
4.6 9.0
5.2 9.0
5.3 10.0
4.8 8.0
2.0
2.0
1.8
1.8
1.7
2.0
3.6 6.0
4.4 7.0
3.8 6.0
5.9 23.0
4.3 8.0
6.2 11.0
10
0±10
0±10
0±10
0±10
0±15
s.d. ˆ standard deviation.
AR ˆ Average Requirement.
LTI ˆ Lowest Treshold Intake.
PRI ˆ Population Reference Intake.
on Medical Aspects of Food Policy of the Department of
Health, 1991) and only 2.1% less than 90% of AR (Panel
on Dietary Reference Values of the Committee on Medical
Aspects of Food Policy of the Department of Health, 1991).
Vitamin C intake is lower than 50% of PRI (Scienti®c
Committee for Food of the Commission of the European
Communities, 1993) in 1.3% of children, from 50±75% of
PRI in 2.4% of them and from 75±90% in 2.2% of Greek
children. The percentage of children who have Vitamin C
intake lower than 90% of PRI is higher in the age of 2±5 y.
Vitamin D
Median values for vitamin D in all age groups varies from
1.7±2.1 mgr/24 h. There was not found any statistical
difference among age and sex groups. Standard deviation
is greater than mean value (even twice) in all groups (Table
12), because of the large intra-individual variation of
vitamin D. Vitamin A, B, D supplements are taken only
by 4% of children. 98% of children aged 2±3 y have lower
intake than 50% of PRI and 2% between 50±75%.
Energy
Median energy intake (Table 14) both for boys and girls is
higher than the AR (Scienti®c Committee for Food of the
Commission of the European Communities, 1993) in preschool children, but it becomes lower for children aged 6±
14 y. Daily energy intake is close to the AR in 1/3 of all
children. Very few children older than 10 y have energy
intake lower than 50% of AR, and none in the younger. The
number of children who have energy intake higher than
125% is considerably higher in preschool children.
Discussion
Until now studies of eating habits and nutrient intake in
Greek children have been few and based on small and
selected samples, without estimating the daily nutrient
intake in all cases (Kafatos, 1979, 1982a, 1982b, 1982c;
Gargoulas, 1982; Adamopoulos, 1985; Aravanis, 1988).
For these reasons, these samples are not suf®ciently representative to allow valid and reliable conclusions to be
drawn regarding the population of children in Greece as a
whole. The present study aims to ful®ll this need and is the
®rst epidemiological nutritional survey in Greek children to
be based on a large, strati®ed multiform sample (1932
children). In other national studies the sample varies from
460±1401 children (Mcpherson, 1990; Nicklas, 1987; Salz,
1983; Leung, 1984; Hackett, 1985; Jenner, 1988; Arab,
1982; Hagman, 1986; Samuelson, 1971; Persson, 1989)
with the exception of the USA, where National Health and
Nutrition Examination Surveys I, II and III had a sample of
about 7000 children (Jones, 1985).
The selection of the suitable methods to collect dietary
information is of great importance for the validity (Young,
1960; Johansen, 1988) and the reliability of the results of
the nutritional survey. There is not, for the time being, a
method completely satisfying in order to estimate the
nutrient intake with both the maximum validity and reliability (Abramson, 1963; Wilett, 1990; Stallones, 1982;
Barret-Connor, 1991). Most researchers agree that diet
record household measures is a suitable method for large
®eld surveys (Willet, 1990; Barret-Connor, 1991) of a good
validity, especially if information is derived from both the
child and his parents (Block, 1982; Hackett, 1983;
Emmons, 1973; Kim, 1984; Hackett, 1985; Klesges,
1988). It is also a method suitable for quantitative estimation of daily nutrient intake (Bransby, 1948; Whiting, 1960;
Eagles, 1966) in order to compare it to the Dietary
Reference Values (Scienti®c Committee for Food of the
Commission of the European Communities, 1993; Panel on
Dietary Reference Values of the Committee on Medical
Aspects of Food Policy of the Department of Health, 1991).
When diet records are used for surveys on children, there is
no `Hawthorn effect' (Liu, 1978; Klesges, 1988) that means
there is not any change in individual's diet, as it happens in
nutrition surveys in adults. A 3 d period is the minimum
Nutritional survey in Greek children
E Roma-Giannikou et al
281
Table 13 Ratios of nutrient intake (Mean Standard Deviation)
Boys
Age (y) Calcium/ Polyunsaturated/ Fiber/ Saturated Monounsaturated Polyunsaturated Monosaccharides/ Disaccharides/ Polysaccharides/
phosphorus saturated fatty 100 g fat fat/total fat
fat/total fat
fat/total fat
total carbohydrate
total
total
acids
carbohydrate
carbohydrate
2±3
4±5
6±7
8±9
10±11
12±14
0.71 0.16
0.68 0.17
0.67 0.16
0.67 0.17
0.66 0.19
0.63 0.18
0.39 0.20
0.40 0.22
0.42 0.23
0.43 0.25
0.46 0.26
0.47 0.27
18 9
19 11
20 11
20 10
20 12
21 10
38 7
38 8
38 9
38 9
37 9
37 9
38 18
39 25
43 34
42 30
42 31
44 35
14 6
14 7
15 7
15 8
16 7
16 7
12 8
13 8
12 7
12 7
11 7
12 8
40 14
37 14
34 13
32 13
31 13
29 13
47 16
52 16
54 14
56 14
58 13
59 14
14 7
14 8
16 8
15 7
16 8
15 7
13 8
11 8
11 7
11 8
11 7
11 8
42 15
37 14
36 14
32 13
32 12
30 13
46 16
50 15
53 15
57 15
57 14
57 15
Girls
2±3
4±5
6±7
8±9
10±11
12±14
0.69 0.16
0.65 0.17
0.67 0.17
0.66 0.17
0.65 0.18
0.62 0.18
0.37 0.22
0.42 0.22
0.43 0.21
0.44 0.23
0.46 0.28
0.47 0.25
17 10
19 12
19 10
20 10
20 10
23 18
39 9
37 10
38 10
37 9
37 10
36 9
42 34
39 24
44 38
43 36
41 33
45 37
necessary duration in order to have a reliable estimation for
most nutrient intakes (Morgan, 1978; Young, 1960;
McGee, 1982; Hackett, 1983; Hackett, 1985; Marr, 1986;
St Jeor, 1983; Stuff, 1983) and at the same time the
maximum one that reassures a satisfying percentage of
response (Morgan, 1978), a fact also proved from our pilot
study. However 3 d are not enough for vitamins A, C and D
and some fatty acids because intra-individual variations are
large due to the fact that certain food items which are rich
in them are not eaten regularly.
As measure of reliability many nutritional investigators
use the variance ratio. The less the variance ratio of certain
nutrients the greater reliability of the results (Trichopoulos,
1982; Young, 1960; Hackett, 1983; Rush, 1982; Todd,
1983; Liu, 1978; Pao, 1985). With the exception of vitamins and some fatty acids the variance ratio is lower than
one, comparable to other studies (Beaton, 1979; Pao, 1985)
and this supports the reliability of the results.
Protein
Mean daily protein intake and mean percentage of energy
intake derived from protein is approximately the same as
that found in earlier Greek studies with small samples (up
to 170 children). The ®ndings of the present study are
comparable to studies in the USA (Leung, 1984; Pao, 1985;
Farris, 1986) while older USA studies showed a higher
protein intake than in Greece (Farris, 1986). In other
western countries such as France (Deheeger, 1990) and
Sweden (Hagman, 1986; Samuelson, 1971; Persson, 1989)
children have higher protein intake, while in Australia there
is lower intake (Hagman, 1986). There is not protein
underintake in Greek children since all have protein
Table 14 Daily energy intake compared to the average intake
Percentiles of energy intake
Boys
Girls
Age
10th ntile
50th ntile
90th ntile
AR
10th ntile
50th ntile
90th ntile
AR
2±3
4±5
6±7
8±9
10±11
12±14
1052
1155
1310
1389
1460
1604
1475
1607
1703
1889
1994
2126
1976
2056
2236
2459
2473
2850
1400
1550
1800
1950
2200
2350
1023
1105
1192
1253
1301
1403
1455
1545
1666
1692
1798
1910
1914
2009
2162
2170
2448
2559
1350
1500
1700
1750
1900
2000
Percentage of children with higher or lower energy intake
Age
< 50%
AR
50±75%
AR
75±90% AR
90±110% AR
110±125% AR
125±150% AR
> 150
AR
2±3
4±5
6±7
8±9
10±11
12±14
0.0%
0.0%
0.0%
0.0%
0.7%
1.6%
8.1%
14.2%
17.8%
16.5%
15.7%
31.2%
23.5%
24.9%
26.9%
28.9%
25.9%
34.4%
33.0%
38.2%
33.2%
32.4%
38.6%
22.6%
19.5%
15.2%
14.6%
16.2%
12.3%
8.6%
11.3%
7.0%
6.6%
5.9%
5.8%
1.1%
4.6%
0.4%
0.9%
0.0%
1.0%
0.5%
Nutritional survey in Greek children
E Roma-Giannikou et al
282
intake above the AR and very few under the PRI. On the
contrary the majority of children (especially the preschoolers) have twice than PRI protein intake which possibly
indicates protein overintake; this limit is proposed only for
adults because there is no evidence of certain health risks in
children (Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy of the Department of Health, 1991).
Carbohydrates
The majority of Greek children have energy intake derived
from carbohydrates lower than the AR and lower than in
other countries (McPherson, 1990; Nicklas, 1987; Leung,
1984; Jenner, 1988; Samuelson, 1971; Persson, 1989;
Jones, 1985; Deheeger, 1990; Farris, 1986). Carbohydrate
energy intake compared to a previous Greek study remains
unchanged for children aged 12±14 y, but is lower for
children 8±9 y old (Gargoulas, 1982). The previous study
had a different dietary survey method (12 h recall for the
®rst half of the day and 12 h record for the second half) and
a smaller sample (211 children) exclusively from Athens,
therefore the results of the two studies are not completely
comparable. Since the mean percentage of energy intake
from carbohydrates remains almost unchanged to different
age and sex groups we conclude that the contribution of
carbohydrates in the diet of Greek children remains stable.
The ratio of polysaccharides to total carbohydrates
increases in relation to age probably due to increased
vegetable and fruit consumption, while that of disaccharides to total carbohydrate decreases, possibly due to the
decreased consumption of milk in relation to age. Greek
preschoolers have higher intake of disaccharides than in
other countries (Salz, 1983; Deheeger, 1990).
Fat
The progressive increase in the daily intake of fat, as well
as protein and carbohydrates that was found, with the
corresponding decrease of the daily amount per body
weight according to age is in agreement with other studies
(Salz, 1983; Pao, 1985; Deheeger, 1990; McPherson, 1990;
Nicklas, 1987; Nicklas, 1991). The higher energy intake
derived from fat in children aged 2±3 y is possibly due to
the fact that they consume more milk, eggs, meat, biscuits
and confectionery than other food items. Boys have a
higher intake of fat (g/Kg of body weight/d) than girls,
mainly in pre and pubertal age groups, which agrees with
other studies (Nicklas, 1987; Hagman, 1986; Pao, 1985;
Neiderud, 1990). The percentage of energy intake derived
from fat is higher (41%) than in other countries: USA
(37%), Italy (28%), Finland (37%), Hungary (34%), Holland (38%), Portugal (29%), Australia (39%) and China
(31%) (West, 1990; McPherson, 1990; Nicklas, 1987;
Nicklas, 1991; Leung, 1984; Jenner, 1988; Pao, 1985;
Chen Chu-ming, 1986; Farris, 1984; Salz, 1983), but we
must take under consideration the different dietary investigation methods used in some of these studies. Fat intake is
much lower among children who live in undernourished
countries such as Kenya (12%), the Philippines (16%) and
Tanzania (12%). French and German children have the
same fat intake as Greek children (Boggio, 1981; West,
1990; Michaud, 1991). Countries such as the USA, Holland, Finland and Sweden have achieved a reduction in fat
intake after a successful campaign of intervention (West,
1990; Hagman, 1986; Farris, 1986). A reliable comparison
with previous studies in Greece is not possible, because
dietary investigation methods differ and the population
samples in former studies were small and selected only
from the island of Crete (Kafatos, 1982a; Kafatos, 1979;
Aravanis, 1988), where a decrease in fat was noticed (most
of the fat was mono-unsaturated), or from Athens where an
increase in fat intake was found (Gargoulas, 1982). The
majority of children, especially the younger, have more
energy intake from fat than the AR, which indicates fat
overintake. On the opposite, quite a few children, mainly
those aged 8±14 y, have energy intake from fat lower than
30%. The differences of saturated, mono- and poly-unsaturated fatty acid intake observed among the various age
groups are also reported in the Bogalusa study (Farris,
1984) and are explained by the fact that younger children
have a higher intake of saturated fat from meat, milk and
dairy products which are the main bulk consumed by them.
Most Greek children have saturated fatty acid intake higher
than AR and higher than USA children, who achieved a
considerable decrease (Oliveira, 1992; McPherson, 1990;
Farris, 1986). None of our children has lower intake of
polyunsaturated fatty acid than PRI. A few children (6%)
have monounsaturated fatty acid intake lower than the AR,
but one quarter of them have considerably higher intake.
The increased consumption of monounsaturated fatty acids
is due to the wide use of olive oil in most Greek recipes
(Trichopoulou, 1982; Trichopoulou, 1993; Trichopoulou,
1995). This ®nding is of great importance since it could
interfere to the reduction of serum cholesterol, low density
lipoprotein and apolipoproteins B with a parallel increase
of serum high density lipoprotein and apolipoproteins A1
(Parthasarathy, 1990; Katsouyanni, 1991). The above
effects are correlated to the prevention of ischemic heart
disease (Parthasarathy, 1990; Nikolaidou, 1993). There is
evidence that increased intake of polyunsaturated fatty acid
is related to the oxidosis of the serum low density lipoprotein which leads to atherogenesis (Parthasarathy, 1990;
Nikolaidou, 1993). The present study showed no evidence
of such overintake since almost all children do not exceed
the maximum intake proposed by the Scienti®c Committee
for Food of the Commission of the European Communities.
The present study shows that Greek children although they
overintake saturated fatty acids (a possible atherogenetic
factor), they are possibly protected against atherogenesis by
the fact that they do not overintake polyunsaturated and
have a considerably high intake of monounsaturated fatty
acids. Greek children have higher cholesterol intake than in
other countries (Salz, 1983; Farris, 1984; McPherson, 1990;
Quivers, 1992; Wilson, 1992; Oliveira, 1992). The higher
cholesterol intake in toddlers is probably due to the fact that
they proportionally consume more meat and eggs. Several
studies have proved that low dietary cholesterol intake did
not have a hypocholesterolemic effect (Salz, 1983; Lifshitz,
1989), therefore an intake higher than 300 mg/24 h (found
in more than half of the Greek children) seems to be
without any importance. Previous dietary suggestions of
the American Academy of Cardiology, American Heart
Association, European Atherosclerosis Society and the
National Education Program Expert Panel targeting reduction in the incidence of atherosclerosis encouraged an
energy intake from fat not exceeding 30% (Ciba Geigy
Limited, Geigy Scienti®c Tables, 1981; Study Group of the
European Atherosclerosis Society, 1987; Taitz, 1987;
Expert Panel: Report of the National Cholesterol Education
Program, 1988). In order to ful®ll his energy requirements a
person on a low fat diet must increase protein and carbohydrate intake. In a multicentre study of 12 countries
concerning children with high carbohydrate and low fat
Nutritional survey in Greek children
E Roma-Giannikou et al
intake it was found that they had lower levels of serum
cholesterol but also lower levels of high density lipoprotein
and higher levels of serum triglycerides compared to
children who have higher fat intake (West, 1990). Overzealous application of a low-fat, low-cholesterol diet may
lead to growth failure due to inadequate energy, vitamin
and mineral intake (Lifshitz, 1989).
Fiber
There are indications from many studies that dietary ®ber
intake is related to constipation (Burkitt, 1984; Graham,
1982; Meyer, 1981), appendicitis (Burkitt, 1984; Walker,
1973; Walker, 1974; Arnbjonsson, 1983), diverticular disease (Burkitt, 1984; Gear, 1979; Spiller, 1981; Leahy,
1985) and large bowel cancer (Burkitt, 1984; Dales,
1978; Modan, 1975). However there are not enough data
concerning ®ber reference values and some authors are
referred to non starch polysaccharides (NSP) instead of
dietary ®ber (Panel on Dietary Reference Values of the
Committee on Medical Aspects of Food Policy of the
Department of Health, 1991). Therefore we cannot estimate
if Greek children have enough ®ber intake, except to
compare it with other countries. Not enough data exist
concerning ®ber intake in children to allow a reliable
comparison between Greece and other countries (Nature,
1978; Jenner, 1988; Chen Chun-ming, 1986; Bright, 1984).
Calcium
Only a few children older than 3 y (mainly pubertal) have
calcium intake lower than LTI. The adequacy of calcium
intake in Greek children is obviously due to the considerable amount of milk that they consume and not to the
consumption of cheese, which our children do not seem to
particularly like. The percentage of children with calcium
intake lower than PRI increases along with age due to the
decreased milk consumption. Calcium intake is about the
same as in the USA (Leung, 1984; Pao, 1985; Lankarani,
1991), lower than in France and Sweden (Hagman, 1986;
Boggio, 1981) and higher than in Australia and China
(Jenner, 1988; Farris, 1984). In this study a higher calcium
intake was found compared to a previous Greek one in the
island of Crete and the region of Thrace using a 24 h recall,
where children were found to have an intake 50±75% of
PRI (Kafatos, 1982a).
Phosphorus
All Greek children have adequate phosphorus intake. In
Greece, as in other developed countries, the calcium to
phosphorus ratio is much lower than that proposed as safe
ratio, because meat and ®sh contain 10±15 times more
phosphorus than calcium and phosphorus chemical products are largely used as food additives (especially in
children's favorite foods such as refreshments, chocolates,
cocoa products, potato chips, doughnuts and croissants etc.)
(Ciba Geigy Limited, Geigy Scienti®c Tables, 1981). At
customary Ca/P has no signi®cance in¯uence on calcium
absorption or retention, but P intake higher than 1500 mg
with low Ca/P ratio (as it happens in half our children)
could alter Ca metabolism causing hypocalcaemia and
secondary hyperparathyroidism (Panel on Dietary Reference Values of the Committee on Medical Aspects of Food
Policy of the Department of Health, 1991).
Iron
The majority of children have adequate iron intake with the
exception of menstruated girls who have greater needs (1/3
of them have lower than 50% of PRI). Iron intake is now
higher than in a previous Greek study (Kafatos, 1982a),
higher than in France (Deheeger, 1990; Boggio, 1981) and
lower than in USA, Sweden and China (Leung, 1984;
Hagman, 1986; Pao, 1985; Chen Chun-ming, 1986).
Vitamin A
Almost all children have vitamin A intake higher than LTI,
and only 1/10 of them lower than PRI. The above ®ndings
must be interpreted with the limitation that 3 days are not
enough for an accurate estimation of vitamin intake
(Morgan, 1978; Young, 1960; McGee, 1982; Hackett,
1983; Hackett, 1985; Marr, 1986; St. Jeor, 1983; Stuff,
1983). Former Greek studies, using a 24 h recall which is
less reliable for estimating vitamin intake, showed that 50±
90% of children had lower intake than PRI (Kafatos, 1979,
1982a, 1982b; Olson, 1987a). Our results are comparable to
most USA studies (Pao, 1985),while in one USA study the
mean vitamin A intake was close to the maximum level,
due to the use vitamin A supplements (Leung, 1984). In
Greece only a few children use such supplements and fewer
have an intake higher than the maximum level. Swedish
and French children have a higher intake (Hagman, 1986;
Deheeger, 1990), while Chinese have considerably lower
(Chen Chun-ming, 1986).
Vitamin C
Greek children have adequate vitamin C intake probably
due to the citrus fruit and juice consumption, which are
abundant in Greece. Vitamin C intake is about the same in
the USA, Sweden and China (Leung, 1984; Hagman, 1986;
Samuelson, 1971; Pao, 1985; Chen Chun-ming, 1986) and
higher in France (Deheeger, 1990; Debry, 1980). In the
present study vitamin C intake is considerably higher than
in a previous 24 h-recall study (Kafatos, 1982b).
Vitamin D
All children 2±3 y old have lower vitamin D intake than
PRI (10 mgr/24 h). Greece has high solar UV radiation all
over the year and due to the warm weather even the
younger children are almost daily exposed to sunlight,
which increases the biologically available vitamin D.
Since older children are daily exposed to sunlight, their
dietary intake is assumed to be adequate. The low dietary
vitamin D intake in all age groups is due to the fact that
vitamin D has few sources, which, with exception of eggs
are not often eaten by children. As far as forti®ed food
items (cereals, margarine) are not widely consumed by
Greek children. Our ®ndings are in agreement with a
previous Greek study (Kafatos, 1982b). Swedish children
have higher vitamin D intake, but even lower than PRI
(Hagman, 1986).
Energy
The present study showed that there is no problem of low
calorie intake in Greek children under the age of 10 y. A
small percentage of pre- and pubertal children have energy
intake lower than 50% of AR and almost one third of
pubertal between 50±75% of AR. The last ®nding is
possibly due to the fact than pubertal boys and girls
voluntarily restrict their energy intake in order to achieve
an ideal body shape (Simou, 1996).
AcknowledgementsÐAuthors wish to acknowledge: The Ministry of
Health of the Federal Republic of Germany (F.R.G.) for the kind permission to use the B.L.S. food tables. The Institute of Social Medicine and
Epidemiology of the F.R.G. (Institut fur Sozialmedizin und Epidemiologie
283
Nutritional survey in Greek children
E Roma-Giannikou et al
284
des Bundesgesgesundheitsamtes) and especially Dr. Lenore Arab-Kohlmeier, director of the Department, and her colleagues for training one of
the authors in epidemiological food surveys and their valuable advice to
organize this survey. Prof. P. Bergman of Paediatrics of F.R.G. for his
valuable advice. World Health Organization and especially E. Helsing for
her help. The Greek Ministry of Health for funding part of the present
study. Prof. Trichopoulou A. and her colleagues for their valuable advice.
The local authorities of the survey regions for their help in collecting data.
Teachers of elementary and high schools and staff of Kindergartens for
their collaboration. The following contributors in speci®c parts of the
survey: Prof. Bakoula C., Kleitsa E., Karamolegou P., Legaki A., Koliopanou A., Drosou V., Manta C., Samartzi M., Michalaki M., Zerbou A.,
Antoniou P., Papavergis S., Fitsialos J., Tserkezou M., Kapolis J., Tsiava
M., Asvestopoulos D., Kokkinaki M., Sera®dou E., Moulatziko G., Rafail
S., Georganas G., Orfanou A., Bokis D., Da¯ou D., Kollia E., Kasimatis
A., Belou C., Katsikerou V., Koukosia V., Ampatzis D., Antonarou Z.,
Zois S., Sigalas G., Farmaki E., Giannakouli M., Fakriadou S., Mitsopoluos G., Konstantinidis Th. All children and their parents who participated
in this survey.
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