Food consumption and adherence to dietary guidelines among Jordanian children and adolescents

Ethical statement

Institutional Research Ethics Board approval was obtained from the Hashemite University (No.7/13/2020/2021). Following the head of the household’s oral permission, one of the participant’s parents signed an informed consent form for children and adolescents under 16. A written consent form was signed by adolescents over 16 years, and data collection began during the first visit in the presence of one of the parents.

Design and sample selection

The current study is based on Jordan’s Population-based Food Consumption Survey (JPFCS), conducted between October 2021 and March 2022. The JPFCS was created to collect dietary habits, eating patterns, and nutritional status among children, adolescents, adults, and the elderly, as well as Jordanian individuals aged eight years and older. A representative sample of 701 households was invited to participate. The number of agreed-upon households to participate was 632, with a 90.2% response rate drawn from simple random sampling from Jordan’s three major regions (Central, Northern, and Southern). Two thousand seven hundred twenty-one household members were approached, and 2,145 participants agreed to participate. The total number of children and adolescents who took part was 617 (28.8%). Children and adolescents with chronic diseases, physical disabilities, food allergies and intolerance, or cognitive impairment were excluded from the study to neutralize the effect of the disease on food intake and to reduce the impact of the medications taken on the dietary pattern and food consumption. A study protocol has been described in detail by Al-Shami et al. (2023).³⁴

The current study included JPFCS children and adolescents divided into two age groups: children (8-12 years) and adolescents (13-19 years). Obtaining food intake for children under eight during the past 24 hours is challenging, especially while they are away from home (food eaten in kindergarten or daycare centers).³⁴ As a result, data reliability is higher for children aged eight and above. As a result, from 617 JPFCS participants, the final net sample size for the current analysis was 561 eligible participants (the calculated minimum sample size was 425).

Survey tool

The Hashemite University’s website stated that nutritionists were required to assist with data collection. Based on their experience, they were chosen through in-person interviews and then trained. The above-mentioned trained nutritionists conducted a face-to-face interview with the head of the household to obtain dietary and anthropometric measurements, particularly for children (see extended data³⁵). Dietary data were collected from the children (<12 years) with parents’ help, while older participants were those who answered their dietary questions. The data above was gathered via a structured questionnaire completed during the interview.

Anthropometric measurements

An experienced nutritionist used established methods to measure anthropometric measurements of children and adolescents, including height (cm) using Seca portable stadiometer), without shoes, weight (kg) (using Tanita digital weighing scale), and waist circumference (WC) (cm) (using Seca measuring tape). Participants’ body weight and height were recorded to the nearest 0.1kg and 0.1cm. A flexible anthropometric tape measured the participant’s WC while standing. Body mass index (BMI) was calculated ’as weight (kg) divided by the square of the height (m²).³⁶ Moreover, the BMI-for-Age Z-Score (BAZ) was calculated. For the association of BMI-for-age with overweight and obesity, values > +1 SD represent overweight, and values > +2 SD represent obesity according to WHO reference curves. Values between +1 SD and -2 SD were considered ‘normal’. In comparison, values > -2 SD were considered ‘thin’.³⁶ The waist-to-height ratio (WHtR) was calculated by dividing the participant’s waist circumference by height. A WHtR cutoff of ≥ 0.5 is generally accepted as a universal cutoff for obesity in children.³⁷

Dietary assessment

Two non-consecutive 24-hour dietary recalls (24-h DR) were obtained to assess food intake on one weekday and one weekend. Furthermore, the child’s parents were asked to be present during the collection of the 24-hour DR. The first 24-hour DR was collected during the interview, while the second recall was obtained via phone. Participants were asked to recall and list all foods and beverages they consumed from midnight to midnight the previous day, along with their quantity, preparation method, and most popular food brand names. A photographic food atlas was also created to simplify the estimation of consumed food portion size; this tool contains over 150 foods and composite recipes consisting of high-definition-colored photos of various foods and meals commonly consumed in Jordanian diets. The survey was introduced in Arabic and translated into English before the analysis.³⁵

Three food composition databases were used to estimate nutrient intake in children and adolescents. The consumed foods collected by 24-DR were entered into a Computerized Nutrient Analysis Program: ESHA’s Food Processor^®, Nutrition Analysis Software (version 11:0; ESHA Research), Composition of Local Jordanian Food Dishes,³⁸ and Lebanon Food Composition Data: Traditional Dishes, Arabic Sweets, and Market Foods.³⁹ Furthermore, based on MyPlate dietary guidelines, consumed foods were classified into five food groups (grains, vegetables, fruits, protein, and dairy), with a specified number of consumed servings of each food group. The Essential Guide to Nutrient Requirements, published by the Institute of Medicine in 2019, was approved and recommended by the USDA as part of the Dietary Guidelines for Americans, 2020-2025. This guide reflects the Acceptable Macronutrient Distribution Ranges (AMDR).⁴⁰ The mean recommended energy intake for children and adolescents based on the MyPlate Dietary Guidelines, and AMDR were 1800 and 2200 ( Table 1), regardless of sex.⁵ The recommended daily intake of fruits and vegetables based on the Joint FAO/WHO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases is a minimum of 400 g of fruits and vegetables/day, an equivalent of ≥5 servings/d.⁴¹

Statistical analysis

Analysis was conducted using SPSS software (IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp) (https://www.ibm.com/products/spss-statistics ). PSPP (https://www.gnu.org/software/pspp/), a freely accessible software, can run the same analysis used in this study. All analyses were stratified based on sex and age group. Anthropometric characteristics were described using frequencies and percentages for categorical variables. Dietary intakes were normally distributed, also outlier values for participants’ energy intake were calculated by excluding any value that increased or decreased by 2.5 standard deviations of the group mean, as outliers can significantly impact statistical analyses and skew the results of any hypothesis test if they are inaccurate. The energy and macronutrient intake distribution were reported as means and standard deviation (Mean ± SD). An independent sample t-test was used to compare differences between boys and girls within each age group. The normality of the distributions was assessed through the Kolmogorov-Smirnov test and Kurtosis and Skewness values. Differences were considered significant at p < 0.05.

Baseline characteristics of the participants

A total of 561 Jordanian children and adolescents participated in this study: 217 (38.7%) children and 344 (61.3%) adolescents.⁷⁰ The general characteristics of the study population are presented in Table 1. Based on the household analysis, there were 4.5 people per family on average. Additionally, nearly 50% of the sample under study (JPFCS original sample) stated that their household’s overall income is less than 500 JD.

Although boys and girls accounted for almost equal proportions within the children group, adolescent girls accounted for the disproportionation compared to boys within the same age group (57% vs. 43%, respectively). For the overall children group, participants who consumed dietary supplementations accounted for only 6%, with no significant difference between boys and girls. A higher proportion of adolescents were using dietary supplements (any vitamins or minerals or herbs consumed as capsules, tablets, or drinks instead of the diet) (12.5%), with a significant difference between sexes. Adolescent girls were found to be the most frequent group to use nutritional supplements (16.3%) when compared to boys (7.4%) from the same group (p = 0.014). When compared to other regions in Jordan that were distributed according to their geographic distribution, the central areas had higher proportions of either children or adolescents of both sexes (children: 61.8% of boys and 53.3% of girls; adolescents: 56.1% of boys and 62.2% of girls).

Findings related to the participant’s anthropometric characteristics stratified by age and sex are presented in Table 2. About two-thirds of adolescents were classified as normal weight (64.5%), and about half of the children were also within the normal weight category (52.3%). Without significant differences between both sexes in each age group, children’s boys had the highest overweight and obesity prevalence (46.3%), followed by girls in the same age group (41.5%), adolescent boys (33.8%), and the lowest prevalence was for adolescent girls (30.6%). About a quarter of the children’s boys had abnormal WHtR (≥0.5) (25.5%), and 23.8% of the same group of girls too; however, 30.4% and 21.4% of adolescent boys and girls, respectively, were also classified as having abnormal WHtR (≥0.5), with no significant differences.

Graphic representation of adherence to MyPlate dietary guidelines

Table 1 categorizes the most common food items consumed by Jordanian children and adolescents into five food groups and the recommended number of servings for each food group for both age groups, based on 1800 kcal/day for children and 2200 kcal/day needs for adolescents. The reference MyPlate dietary guidelines image was presented for children in Figure 1 and adolescents in Figure 2.

Figure 1. Compliance of the mean habitual food consumption with the MyPlate dietary guidelines in children.

Figure 2. Compliance of the mean habitual food consumption with the MyPlate dietary guidelines in adolescents.

In children, the entire group consumes less than the recommended number of servings from all food groups. On the other hand, boys came close to meeting the recommended servings for grains, achieving 30.6% of the standard plate recommendation of 30%, while all other food groups were lower than the recommended number of servings, as shown in Figure 1. Mismatching between real and recommended intake based on the standard plate has been indicated. As shown in Figure 1, a higher gap has been found among children girls’ intake of dairy, protein, and fruits (11%, 9.6%, and 6.8%, respectively) when compared to boys from the same age group (13%, 12.4%, and 8.7%; respectively) ( Figure 1). Furthermore, Jordanian adolescents, overall or according to sex differences, consumed less than the recommended serving number of each food group ( Figure 2), based on 2200 kcal/day as the average total energy requirement ( Table 1). In girls, the actual intake of grains, fruits, vegetables, and proteins was 22%, 7.3%, 7.8%, and 11%, respectively, which did not meet the recommended reference plate. This discrepancy was also observed in boys’ consumption of fruit and vegetables (6.1% and 9.1%, respectively). However, there appears to be less mismatch in grain and protein intake (28.8% and 15.1%, respectively) ( Figure 2). Interestingly, both age groups showed the same outcome regarding sex differences because there was a significant difference in their intake of grains and proteins (p-value < 0.05) among all the food groups.

Energy and macronutrient intakes among the study population

The mean daily energy and macronutrient intake of the study population, stratified by age and sex, is shown in Table 3. In the children’s group, the mean total energy intake was 1796.4 ± 557.1 kcal/day, with a significant difference between boys and girls; the mean total energy intake for boys was 1950 kcal/day compared to 1638 kcal/day for girls (p < 0.001). Similar results were shown in the adolescent group, with a significantly higher mean energy intake in boys compared to girls (2116.3 kcal/day vs. 1688.5 kcal/day) (p < 0.001), while the average total intake of the group was 1872. 6 ± 579.1 kcal/day.

Table 3 further examines the various types of fat consumed; the mean saturated fat (SFA) intake was nearly equal for both age groups and rounded to 16 g/day ( Table 3), which was within an acceptable amount when compared to the MyPlate dietary guidelines allowed amounts of 20 g/day and 22 g/day for children and adolescents, respectively ( Table 2, Figure 1, and Figure 2). Boys of both ages consumed significantly more saturated fats than girls of the same age (children: 18.3 g/day vs. 14.3 g/day, and adolescents: 18.7 g/day vs. 14.5 g/day, for boys and girls, respectively) (p < 0.001) ( Table 4).

Moving in sequence, the mean intake of polyunsaturated (PUFA) and monounsaturated fats (MUFA) was nearly equal in both age groups; however, boys in both age groups consumed significantly more than girls (p < 0.05) ( Table 3). Trans fat (TFA) intake was considerably higher in adolescent boys than in girls (0.81 g/day vs. 0.45 g/day) (p = 0.006). Irrespective of sex-specific differences, the mean cholesterol intake of the adolescents was higher than that of the children’s group (168.1 ± 150.1 mg/day vs. 133.2 ± 93.7 mg/day, respectively). Also, mean cholesterol intake was significantly higher in boys than in girls in the child group (148 mg/day vs. 118 mg/day (p = 0.02) and in adolescents (219 mg/day for boys vs. 130 mg/day for girls) (p < 0.001). In addition, omega-3 and omega-6 fatty acid intake was significantly higher in boys than in girls in both age groups ( Table 3).

Consumption of discretionary calories

According to the MyPlate dietary guidelines, which aim to make every bite count and choose options full of nutrients, some foods and beverages were recommended to be explicitly limited: added sugars and saturated fats. Foods that were analyzed as added sugars and saturated fats were listed in Table 2, as well as their typical serving sizes. The maximum allowed amount to consume for each age group was presented in the same table.

Age differences in mean intake from added sugar were almost equal to 57 g/day, and this means higher than MyPlate dietary guidelines allowed amounts, which were <45 g/day and <50 g/day for children and adolescents, respectively ( Table 4, Figure 1, and Figure 2). Although no significant difference between boys and girls was found within the children group, adolescent boys significantly consumed higher amounts of added sugars when compared to girls from the same group (60.87 g/day vs. 53.28 g/day, respectively) (p = 0.015). Moreover, children and adolescent boys consumed significantly higher amounts of total added fats than girls (39.33 g/day, 38.92 g/day vs. 32.7 g/day, and 31.42 g/day (p = 0.007; 0.001; respectively) ( Table 4). For children and adolescents, total discretionary calorie intake (added sugar and fat) accounted for approximately 30.7% and 28.6% of total energy intake, respectively, which is considered higher than the recommendations (<10% of total energy intake).

Strengths and limitations

The large representative sample from a population-based study, the careful data quality control methods by reducing dietary intake misreporting, evaluating overweight and obesity by using WHtR (indicating central obesity) rather than BMI (indicating overall obesity), and the repaint of the specific MyPlate dietary guidelines for all age groups were significant strengths of our study. One of the current study’s limitations was that it was cross-sectional, which hindered the observation of causal effects. Furthermore, there is a lack of evaluation of physical activity, nutrition-related blood tests, and blood pressure. Moreover, potential biases include recall bias from 24-hour dietary recalls or potential underrepresentation of dietary intakes.

Implications for research and practice

It appears that fat and added sugar consumption must be controlled, while the amount of grains that should be consumed by “boys,” youngsters, children, and adolescents did not follow all of the MyPlate dietary recommendations. Children and adolescents consumed a slightly larger proportion of fat than the AMDRs, even though the mean energy intake was within the calculated requirements; policymakers and health professionals must take appropriate steps to address this issue. It is recommended that families, children, and adolescents receive nutrition education about the components of MyPlate dietary guidelines and the adverse health effects of obesogenic diets. Implementing community education programs about healthy eating habits requires cooperation between governmental and non-governmental organizations.