Scholarly article on topic 'Energy Intake, Profile, and Dietary Sources in the Spanish Population: Findings of the ANIBES Study'

Energy Intake, Profile, and Dietary Sources in the Spanish Population: Findings of the ANIBES Study Academic research paper on "Health sciences"

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Academic research paper on topic "Energy Intake, Profile, and Dietary Sources in the Spanish Population: Findings of the ANIBES Study"

Nutrients 2015, 7, 4739-4762; doi:10.3390/nu7064739

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nutrients

ISSN 2072-6643

www.mdpi.com/j ournal/nutrients

Article

Energy Intake, Profile, and Dietary Sources in the Spanish Population: Findings of the ANIBES Study

Emma Ruiz 1, José Manuel Ávila 1, Teresa Valero 1, Susana del Pozo 1, Paula Rodriguez 1,

Javier Aranceta-Bartrina 2, Ángel Gil 3, Marcela González-Gross 4, Rosa M. Ortega 5,

Lluis Serra-Majem 6 and Gregorio Varela-Moreiras 1'7'*

1 Spanish Nutrition Foundation (FEN), C/General Alvarez de Castro 20, 1apta, 28010 Madrid, Spain; E-Mails: eruiz@fen.org.es (E.R.); jmavila@fen.org.es (J.M.A.); tvalero@fen.org.es (T.V.); susanadelpozo@fen.org.es (S.P.); prodriguez@fen.org.es (P.R.)

2 Department of Preventive Medicine and Public Health, University of Navarra, C/Irunlarrea 1, 31008 Pamplona, Spain; E-Mail: jaranceta@unav.es

3 Department of Biochemistry and Molecular Biology II and Institute of Nutrition and Food Sciences, University of Granada, Campus de la Salud, Avda. del Conocimiento, 18100 Armilla, Granada, Spain; E-Mail: agil@ugr.es

4 ImFINE Research Group, Department of Health and Human Performance, Technical University of Madrid, C/Martín Fierro 7, 28040 Madrid, Spain; E-Mail: marcela.gonzalez.gross@upm.es

5 Department of Nutrition, Faculty of Pharmacy, Complutense University of Madrid, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; E-Mail: rortega@ucm.es

6 Research Institute of Biomedical and Health Sciences, Universidad de Las Palmas de Gran Canaria, Facultad de Ciencias de la Salud, C/Doctor Pasteur s/n Trasera del Hospital, 35016 Las Palmas de Gran Canaria, Spain; E-Mail: lluis.serra@ulpgc.es

7 Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, Urb. Montepríncipe, Crta. Boadilla Km. 5.3, 28668 Boadilla del Monte, Madrid, Spain

* Author to whom correspondence should be addressed; E-Mail: gvarela@ceu.es or gvarela@fen.org.es; Tel.: +34-913724726; Fax: +34-913510496.

Received: 29 April 2015 /Accepted: 28 May 2015 /Published: 12 June 2015

Abstract: Energy intake, and the foods and beverages contributing to that, are considered key to understanding the high obesity prevalence worldwide. The relative contributions of energy intake and expenditure to the obesity epidemic, however, remain poorly defined in Spain. The purpose of this study was to contribute to updating data of dietary energy intake and its main sources from food and beverages, according to gender and age. These data were derived from the ANIBES ("Anthropometry, Intake, and Energy Balance in Spain") study,

a cross-sectional study of a nationally representative sample of the Spanish population (from 9-75 years old). A three-day dietary record, collected by means of a tablet device, was used to obtain information about food and beverage consumption and leftovers. The final sample comprised 2009 individuals (1,013 men, 996 women). The observed mean dietary energy intake was 7.6 ±2.11 MJ/day (8.2 ± 2.22 MJ/day for men and 6.9 ±1.79 MJ/day for women). The highest intakes were observed among adolescents aged 13-17 years (8.4 MJ/day), followed by children 9-12 years (8.2 ±1.80 MJ/day), adults aged 18-64 (7.6 ±2.14 MJ/day) and older adults aged 65-75 years (6.8 ± 1.88 MJ/day). Cereals or grains (27.4%), meats and derivatives (15.2%), oils and fats (12.3%), and milk and dairy products (11.8%) contributed most to daily energy intake. Energy contributions from non-alcoholic beverages (3.9%), fish and shellfish (3.6%), sugars and sweets (3.3%) and alcoholic beverages (2.6%) were moderate to minor. Contributions to caloric profile were 16.8%E from proteins; 41.1%E from carbohydrates, including 1.4%E from fiber; 38.5%E from fats; and 1.9%E from alcohol intake. We can conclude that energy intake is decreasing in the Spanish population. A variety of food and beverage groups contribute to energy intake; however, it is necessary to reinforce efforts for better adherence to the traditional Mediterranean diet.

Keywords: energy intake; dietary energy sources; dietary surveys; food intake; ANIBES study

1. Introduction

In Europe, national and regional lifestyle practices, including dietary habits, have been changing over the past 50 years, becoming less distinct and moving towards a more homogeneous "Western diet" [1-3]. Spain has undergone dramatic social and socioeconomic change since the 1960s, including massive rural-urban migration, rapid urbanization processes during the 1980s, and generalized incorporation of females into the active workforce [4]. As a result of these transitions, the Spanish population has partially turned away from its traditional Mediterranean diet. The changes in diet, physical activity, and lifestyle seem to have had potentially negative consequences for both present and future populations. Overweight and/or obesity affect more than 50% of the adult population and nearly 30% of the population of infants and children [5]. It has been suggested that excessive energy intake is the primary cause of overweight and obesity. However, a sedentary lifestyle and lack of physical activity are thought to have at least as important a role as diet in the etiology of obesity [4,6].

The methodologies and procedures used in dietary surveys have been widely developed with the aim of evaluating the nutritional status of a population [7,8]. Problems associated with such studies are difficulties in terms of methodology, relative participation (high level of respondent commitment, biased sampling, and others), collecting intake data (truthfulness, forgetfulness, and others) and quantifying amounts consumed (portion size, ingredients in recipes, and others) [9]. Therefore, using new available methodologies (e.g., "real-time" recording of eating/drinking events) to avoid the usual bias is challenging, but urgently needed [10-12]. Moreover, there is consensus that determinants of diet, food composition, and consumption remain largely unknown, a fact that has become more true as related factors have become more complex, such as origin, production, availability, gastronomic trends, and

others [7,12]. In this regard, there is a need to improve tools such as food composition tables and databases that include detailed information on composition of the different food and beverage groups and subgroups representative of the current Spanish food basket, as well as to update energy requirements and serving sizes. We first stated this need in 2013, in the consensus document and conclusions on "Obesity and Sedentarism in the 21st Century: what can be done and what must be done?" [4] and, more recently, in the "Consensus Meeting on the Methodology of Dietary Surveys, Classification of Physical Activity and Healthy Lifestyles" [13].

Many valuable dietary surveys have been previously conducted in Spain [14-20], although to the best of our knowledge, no one has approached energy intake and its determinants using new, more accurate technologies. To fill this gap, the ANIBES ("Anthropometry, Intake, and Energy Balance in Spain") study was specifically designed to focus on energy balance and its determinants in Spain. The main objective of the present study was to analyze energy intake in a nationally representative sample of the Spanish population, its distribution by sex and age groups, and to identify those food and beverages sources that contribute to energy intake.

2. Materials and Methods

The design, protocol, and methodology of the ANIBES study have been already described in detail elsewhere [21,22].

2.1. Sample

The ANIBES study was conducted using stratified multistage sampling. To guarantee better coverage and representativeness, the fieldwork was performed at 128 sampling points all across Spain. No pre-recruitment was considered so as to minimize the risk of bias in responses. The design of the ANIBES study aimed to define a sample size that is representative of all individuals living in Spain, aged 9 to 75 years, and living in municipalities of at least 2000 inhabitants. The initial potential sample consisted of 2634 individuals, and the final sample comprised 2009 individuals (1013 men, 50.4%; 996 women, 49.6%). In addition, for the youngest age groups (9-12, 13-17, and 18-24 years), a boost sample was included to have at least n = 200 per age group (error +/-6.9%). Therefore, the random sample plus booster comprised 2285 participants.

The sample quotas according to the following variables were: age groups (9-12, 13-17, 18-64, and 65-75 years); sex (men/women); geographical distribution (Northeast, Levant, Southwest, North-Central, Barcelona, Madrid, Balearic and Canary Islands); and locality size: 2000 to 30,000 inhabitants (rural population); 30,000 to 200,000 inhabitants (semi-urban population) and over 200,000 inhabitants (urban population). Additionally, other factors for sample adjustment were considered: unemployment rate, percentage of foreigners (immigrant population), physical activity level, and education or economic level.

The fieldwork for the ANIBES study was conducted from mid-September 2013 to mid-November 2013, and two previous pilot studies were also performed. To equally represent all days of the week, subjects participated during two weekdays and one weekend day. The final protocol was approved by the Ethical Committee for Clinical Research of the Region of Madrid (Spain).

2.2. Food and Beverage Record

Study participants were provided with a tablet device (Samsung Galaxy Tab 2 7.0) and trained in how to record information by taking photos of all food and drinks consumed during the three days of the study, both at home and outside the home. Photos had to be taken before beginning to eat and drink, and again after finishing, so as to record the actual intake. Additionally, a brief description of meals, recipes, brands, and other data was recorded using the device. Participants who declared or demonstrated that they were unable to use the tablet device were offered other options, such as using a digital camera and paper record and/or conducting telephone interviews. A total 79% of the sample used a tablet, 12% a digital camera, and 9% opted for a telephone interview. In addition to details of what and how much was eaten, for each eating/drinking event participants recorded where they were, who they were eating with, and whether they were watching television and/or sitting at a table. After each survey day, participants recorded if their intake was representative for that day (or the reason why if it was not), and details of any dietary supplements taken. The survey also contained a series of questions about participants' customary eating habits (e.g., the type of milk or fat spread usually consumed) to facilitate further coding. Food records were returned from the field in real time, to be coded by trained coders who were supervised by dieticians. An ad hoc central server software/database was developed for this purpose, to be able to work in parallel with the codification and verification processes. The software was developed to receive information from the field tablets every 2s, and the database was updated every 30 min. Food, beverages, energy and nutrient intakes were calculated from food consumption records using this software (VD-FEN 2.1), which was newly developed for the ANIBES study by the Spanish Nutrition Foundation and is based mainly on Spanish food composition tables [23], with several expansions and updates. Data obtained from food manufacturers and nutritional information provided on food labels were also included. A food photographic atlas was used to assist in assigning gram weights to portion sizes. Energy distribution objectives for the Spanish population were used to analyze the overall quality of the diet [24].

2.3. Statistical Analysis

Once all dietary intake information was transformed into energy and nutrient data, these data were processed using different statistical analysis tools and packages. The following statistics were calculated to qualify each variable in the analysis: average, standard deviation, and variance to measure dispersion in the values; minimum and maximum values, median, quartiles (as well as interquartile range), and deciles to describe the shape of the distribution. The Kolmogorov-Smirnoff test was used to test normality of the distribution. In addition, the intake data were grouped into 14 food groups, 45 subgroups and 754 ingredients for in-depth analysis.

Table 1. Total daily energy intake, by sex and age group, in the ANIBES survey of the Spanish population aged 9-75 years, expressed as kilocalories and megajoules.

ENERGY Total a Children 9-12 Years * Adolescents 13 -17 Years * Adults 18-64 Years Ä Elderly 65-75 Years *

(kcal/day) n Mean SD SEM n Mean SD SEM n Mean SD SEM n Mean SD SEM n Mean SD SEM

Total Men Women 2009 1013 996 1810 504.4 1957 531.0 1660 426.7 11.25 16.68 13.52 213 126 87 1960 431.3 2006 456.1 1893 385.5 29.6 40.6 41.3 211 137 74 2018 2124 1823 508.1 514.6 435.7 35.0 44.0 50.6 1655 1816 798 1966 857 1675 512.0 543.2 436.9 12.6 206 1618 19.2 99 1771 14.9 107 1476 448.4 31.2 484.7 48.7 359.9 34.8

ENERGY Tota l Ä Children 9-12 Years * Adolescents 13 -17 Years * Adults 18-64 Years Ä Elderly 65-75 Years *

(MJ/day) n Mean SD SEM n Mean SD SEM n Mean SD SEM n Mean SD SEM n Mean SD SEM

Total Men Women 2009 1013 996 7.6 8.2 6.9 2.11 2.22 1.79 0.05 0.07 0.06 213 126 87 8.2 8.4 7.9 1.80 1.91 1.61 0.12 0.17 0.17 211 137 74 8.4 8.9 7.6 2.13 2.15 1.82 0.15 0.18 0.21 1655 7.6 798 8.2 857 7.0 2.14 2.27 1.83 0.05 206 6.8 0.08 99 7.4 0.06 107 6.2 1.88 0.13 2.03 0.20 1.51 0.15

* Denotes statistical difference (p < 0.05) by ' sex; SD: mean standard deviation; SEM: mean standard error.

Table 2. Energy distribution (kcal/day; MJ/day), by age group and sex, in the ANIBES survey of the Spanish population aged 9-75 years.

Energy (kcal/day) n Mean Median SD SEM P5 P10 P25 P50 P75 P90 P95 Minimum Maximum

Total * 2009 1810 1756 504.4 11.3 1092 1217 1440 1756 2109 2487 2717 799 4819

Men Women 1013 996 1957 1660 1907 1620 531.0 426.7 16.7 13.5 1190 1030 1320 1146 1558 1337 1907 1620 2296 1930 2641 2214 2926 2415 799 801 4819 3340

Children 9- 12 years * 213 1960 1954 431.3 29.6 1301 1428 1651 1954 2189 2565 2712 538 3519

Men Women 126 87 2006 1893 1987 1937 456.1 385.5 40.6 41.3 1232 1338 1481 1404 1759 1608 1987 1937 2307 2117 2625 2349 2733 2526 538 1021 3519 3048

Adolescents 13-17

211 2018 1972 508.1 35.0 1266 1412 1624 1972 2334 2683 2909 799 3572

years *

Men Women 137 74 2124 1823 2140 1819 514.6 435.7 44.0 50.6 1410 1176 1480 1299 1752 1525 2140 1819 2459 2057 2759 2253 2952 2633 799 1049 3572 3127

Adults 18-64 years * 1655 1816 1758 512.0 12.6 1091 1214 1435 1758 2118 2501 2742 801 4819

Men Women 798 857 1966 1675 1919 1648 543.2 436.9 19.2 14.9 1184 1030 1309 1141 1557 1340 1919 1648 2326 1936 2649 2259 2954 2454 801 801 4819 3340

Elderly 65-75 years * 206 1618 1531 448.4 31.2 1016 1122 1308 1531 1882 2147 2278 874 3899

Men Women 99 107 1771 1476 1711 1426 484.7 359.9 48.7 34.8 1101 965 1256 1065 1481 1247 1711 1426 2003 1627 2253 1996 2697 2133 874 886 3899 2800

* Denotes statistical difference (p < 0.05) by sex; SD: mean standard deviation; SEM: mean standard error.

Table 3. Energy and lipid profile (%) in the ANIBES survey of the Spanish population aged 9-75 years, by sex and age group.

Total Children Adolescents Adults Elderly

9-75 Years 9-12 Years 13-17 Years 18-64 Years 65-75 Years

Total Men Women Total Men Women Total Men Women Total Men Women Total Men Women

n 2009 1013 996 213 126 87 211 137 74 1655 798 857 206 99 107

Mean energy intake

1810 1957 1660 1960 2006 1893 2018 2124 1823 1816 1966 1675 1618 1771 1476

(kcal/day)

(%) Proteins 16.8 * 16.7 17.0 16.0 16.3 15.6 16.2 16.4 15.9 16.9 16.8 17.0 17.1 16.9 17.3

(%) Carbohydrates 41.1 41.0 41.2 43.8 43.4 44.4 44.4 43.9 45.2 40.7 40.6 40.9 40.7 * 39.6 41.7

(%) Sugars 17.0 * 16.3 17.8 18.8 18.8 18.8 17.7 * 16.9 19.2 16.7 * 16.0 17.3 18.3 * 16.7 19.8

(%) Lipids 38.5 38.2 38.7 38.9 39.0 38.6 38.1 38.4 37.5 38.6 * 38.2 39.0 37.2 37.0 37.4

(%) SFA 11.7 11.6 11.7 13.1 13.2 12.9 12.5 12.6 12.2 11.7 11.5 11.8 10.6 10.5 10.7

(%) MUFA 16.8 16.6 16.9 16.0 16.1 15.8 15.7 15.9 15.4 16.8 * 16.6 17.0 17.1 17.0 17.2

(%) PUFA 6.63 6.6 6.6 6.4 6.3 6.5 6.4 6.4 6.5 6.7 6.6 6.7 6.2 6.2 6.1

(%) n-6 5.40 5.43 5.37 5.44 5.36 5.55 5.53 5.53 5.54 5.45 5.48 5.43 4.90 4.87 4.92

(%) n-3 0.63 0.72 0.55 0.44 0.43 0.45 0.45 0.45 0.46 0.66 0.77 0.55 0.62 0.66 0.57

(%) Alcohol 1.9 * 2.5 1.4 0.0 0.0 0.0 0.0 0.0 0.1 2.1 * 2.8 1.5 2.7 * 4.1 1.4

(%) Fiber 1.4 * 1.4 1.5 1.2 * 1.2 1.3 1.2 1.2 1.2 1.4 * 1.4 1.5 1.8 1.8 1.9

* Denotes statistical difference (P < 0.05) by sex; SD: mean standard deviation; SEM: mean standard error.

3. Results

3.1. Total Energy Intake, Profile, and Distribution

Mean daily energy intakes for total energy for the entire Spanish population aged 9-75 years are shown in Table 1. Males had statistically higher intakes than females (p < 0.05) for the whole sample. By age group, adolescents and elderly males had higher intakes than females (p < 0.05).

Table 2 shows the energy intake distribution (median, percentiles, and maximum/minimum) according to age group and sex. In terms of the contribution of macronutrients to dietary energy (Table 3), carbohydrates contributed the highest proportion (41.1%), followed by fats (38.5%) and proteins (16.8%); other minor energy sources were alcohol (1.9%) and fiber (1.4%). Women had higher sugar and fat intakes (p < 0.05) and men higher alcohol intakes (p < 0.05). Concerning the energy provided by fatty acids, monounsaturated fatty acids (MUFA) contributed 16.8%, saturated fatty acids (SFA) 11.7%, and polyunsaturated fatty acids (PUFA) 6.6% (5.40% n-6 class; 0.63% n-3). No gender differences were observed for the lipid profile. However, there were differences according to age group: SFA contribution to energy intake was highest for children (13.1%) and lowest for the oldest age group (10.6%). The opposite was seen for MUFA, with the highest contribution for elderly adults. There were no differences for PUFA between age groups (Table 3).

3.2. Contribution of Food and Beverage Groups to Total Intake

The contribution (%) of food and beverage categories to the daily energy intake is shown in Table 4, ranked from high to low, and categorized by age group.

Table 4. Dietary sources of energy (%) from food groups/subgroups in the ANIBES survey of the Spanish population aged 9-75 years.

_% Energy_Total 9-75 Children 9-12 Adolescents 13-17 Adults 18-64 Elderly 65-75

n 2009 213 211 1655 206

Energy (kcal/day) 1810 1960 2018 1816 1618

Cereals/Grains 27.4 30.4 31.1 27.9 26.2

Bread 11.6 11.3 11.5 11.8 12.5

Bakery and pastry 6.8 9.4 8.4 6.8 6.4

Grains and flours 4.5 4.0 4.7 4.6 4.1

Pasta 3.6 4.1 4.5 3.7 2.5

Breakfast cereals and cereal bars 1.0 1.6 2.0 1.0 0.8

Meat and meat products 15.2 15.3 16.2 15.7 13.1

Meat 9.2 8.2 9.2 9.6 8.5

Sausages and other meat products 5.8 7.1 7.0 5.9 4.5

Viscera and offal 0.1 0.0 0.0 0.1 0.2

Oils and fats 12.3 10.4 9.8 12.2 14.9

Olive oil 9.2 7.1 6.6 9.1 12.2

Other oils 1.7 2.0 1.9 1.8 0.8

Butter, margarine and shortening 1.4 1.3 1.2 1.3 1.8

Table 4. Cont.

% Energy Total 9-75 Children 9-12 Adolescents 13-17 Adults 18-64 Elderly 65-75

Milk and dairy products 11.8 15.9 12.8 11.8 12.2

Milk 5.0 6.9 5.9 4.9 5.9

Cheese 3.0 2.6 2.9 3.2 2.3

Yogurt and fermented milk 2.4 3.1 2.0 2.3 3.1

Other dairy products 1.5 3.2 2.0 1.5 0.8

Fruits 4.7 3.0 2.4 4.7 8.7

Ready-to-eat-meals 4.2 5.7 6.6 4.3 1.8

Vegetables 4.0 3.0 3.0 4.2 5.0

Non-alcoholic beverages 3.9 4.9 6.1 3.9 2.2

Sugared soft drinks 2.0 1.9 3.4 2.1 0.7

Juices and nectars 1.3 2.9 2.5 1.3 0.9

Other drinks 0.3 0.0 0.1 0.3 0.3

Coffee and herbal teas 0.2 0.0 0.0 0.2 0.3

Sports drinks 0.1 0.2 0.0 0.1 0.0

Energy drinks 0.0 0.0 0.1 0.0 0.0

Unsweetened soft drinks 0.0 0.0 0.0 0.0 0.0

Fish and shellfish 3.6 2.2 2.1 3.7 4.7

Sugars and sweets 3.3 5.1 4.4 3.3 2.6

Chocolate 1.5 4.2 3.3 1.4 0.5

Sugar 1.4 0.5 0.7 1.5 1.4

Jams and other 0.3 0.2 0.1 0.3 0.8

Other sweets 0.1 0.2 0.2 0.1 0.0

Alcoholic beverages 2.6 0.0 0.0 2.9 3.5

Low alcohol content beverages 2.4 0.0 0.0 2.6 3.3

High alcohol content beverages 0.2 0.0 0.0 0.3 0.3

Pulses 2.2 2.0 2.0 2.3 2.9

Eggs 2.2 2.0 2.1 2.2 2.8

Sauces and condiments 1.6 1.4 1.7 1.7 0.9

Appetizers 0.8 1.1 1.0 0.8 0.3

Supplements and meal replacements 0.1 0.0 0.0 0.1 0.1

A detailed analysis of the food and beverage groups and subgroups, by sex, is shown in Tables 5-9.

Table 5. Dietary sources of energy (%) from food subgroups in the ANIBES survey of the Spanish population aged 9-75 years, by sex.

Total 9-75 Years

Total Men Women

n 2009 1013 996

Energy (kcal/day) 1810 1957 1660

Bread 11.6 12.2 11.0

Meat 9.2 9.7 8.8

Olive oil 9.2 8.7 9.8

Bakery and pastry 6.8 6.5 7.1

Sausages and other meat products 5.8 6.3 5.2

Table 5. Cont.

Total 9-75 Years

Total Men Women

n 2009 1013 996

Energy (kcal/day) 1810 1957 1660

Milk 5.0 4.6 5.3

Fruits 4.7 4.2 5.3

Grains and flours 4.5 4.4 4.5

Ready-to-eat-meals 4.2 4.6 3.8

Vegetables 4.0 3.8 4.3

Pasta 3.6 3.7 3.4

Fish and shellfish 3.6 3.2 3.9

Cheese 3.0 2.9 3.1

Low alcohol content beverages 2.4 3.1 1.7

Yogurt and fermented milk 2.4 2.2 2.6

Pulses 2.2 2.2 2.3

Eggs 2.2 2.3 2.1

Sugared soft drinks 2.0 2.2 1.8

Other oils 1.7 1.7 1.7

Sauces and condiments 1.6 1.6 1.5

Chocolate 1.5 1.6 1.4

Other dairy products 1.5 1.5 1.6

Sugar 1.4 1.2 1.5

Butter, margarine and shortening 1.4 1.1 1.6

Juices and nectars 1.3 1.4 1.3

Breakfast cereals and cereal bars 1.0 1.0 1.1

Appetizers 0.8 0.8 0.8

Jams and other 0.3 0.2 0.4

Other drinks (non-alcoholic) 0.3 0.2 0.3

High alcohol content beverages 0.2 0.3 0.2

Coffee and herbal teas 0.2 0.2 0.2

Viscera and offal 0.1 0.1 0.1

Other sweets 0.1 0.1 0.1

Supplements and meal replacements 0.1 0.1 0.1

Sports drinks 0.1 0.1 0.0

Energy drinks 0.0 0.1 0.0

Unsweetened soft drinks 0.0 0.0 0.0

Table 6. Dietary sources of energy (%) from food subgroups in children from the ANIBES survey of the Spanish population.

Children 9-12 Years

Total Men Women

n 213 126 87

Energy (kcal/day) 1960 2006 1893

Bread 11.3 11.2 11.4

Bakery and pastry 9.4 9.1 10.0

Meat 8.2 8.9 7.2

Sausages and other meat products 7.1 7.1 7.1

Olive oil 7.1 7.0 7.2

Milk 6.9 7.3 6.3

Ready-to-eat-meals 5.7 6.0 5.2

Chocolate 4.2 4.1 4.3

Pasta 4.1 3.9 4.3

Grains and flours 4.0 3.7 4.4

Other dairy products 3.2 3.4 2.9

Yogurt and fermented milk 3.1 3.1 3.2

Vegetables 3.0 2.9 3.2

Fruits 3.0 2.7 3.4

Juices and nectars 2.9 2.8 3.1

Cheese 2.6 2.6 2.6

Fish and shellfish 2.2 2.0 2.5

Pulses 2.0 1.7 2.5

Other oils 2.0 1.9 2.1

Eggs 2.0 2.0 1.9

Sugared soft drinks 1.9 2.2 1.5

Breakfast cereals and cereal bars 1.6 1.6 1.7

Sauces and condiments 1.4 1.3 1.5

Butter, margarine and shortening 1.3 1.3 1.3

Appetizers 1.1 1.1 1.1

Sugar 0.5 0.5 0.6

Other sweets 0.2 0.2 0.3

Jams and other 0.2 0.1 0.2

Sports drinks 0.2 0.2 0.1

Viscera and offal 0.0 0.0 0.0

Other drinks (non-alcoholic) 0.0 0.0 0.0

Unsweetened soft drinks 0.0 0.0 0.0

Coffee and herbal teas 0.0 0.0 0.0

High alcohol content beverages 0.0 0.0 0.0

Energy drinks 0.0 0.0 0.0

Low alcohol content beverages 0.0 0.0 0.0

Supplements and meal replacements 0.0 0.0 0.0

Water 0.0 0.0 0.0

Table 7. Dietary sources of energy (%) from food subgroups in adolescents from the ANIBES survey of the Spanish population.

Adolescents 13- 17 Years

Total Men Women

n 211 137 74

Energy (kcal/day) 2018 2124 1823

Bread 11.5 11.7 11.1

Meat 9.2 9.9 7.9

Bakery and pastry 8.4 8.3 8.7

Sausages and other meat products 7.0 7.1 6.7

Olive oil 6.6 6.6 6.6

Ready-to-eat-meals 6.6 6.9 6.0

Milk 5.9 6.2 5.3

Grains and flours 4.7 4.6 4.9

Pasta 4.5 4.9 3.9

Sugared soft drinks 3.4 3.3 3.7

Chocolate 3.3 2.9 4.1

Vegetables 3.0 2.9 3.1

Cheese 2.9 2.7 3.3

Juices and nectars 2.5 2.3 2.9

Fruits 2.4 2.0 3.0

Fish and shellfish 2.1 2.0 2.4

Eggs 2.1 2.2 1.9

Yogurt and fermented milk 2.0 1.8 2.4

Pulses 2.0 1.9 2.1

Breakfast cereals and cereal bars 2.0 2.2 1.6

Other dairy products 2.0 2.1 1.8

Other oils 1.9 1.8 2.2

Sauces and condiments 1.7 1.6 1.7

Butter, margarine and shortening 1.2 1.2 1.3

Appetizers 1.0 0.9 1.2

Sugar 0.7 0.8 0.6

Other sweets 0.2 0.1 0.3

Jams and other 0.1 0.1 0.2

Other drinks (non-alcoholic) 0.1 0.0 0.2

Energy drinks 0.1 0.1 0.0

Low alcohol content beverages 0.0 0.0 0.1

Sports drinks 0.0 0.0 0.1

Coffee and herbal teas 0.0 0.0 0.0

Supplements and meal replacements 0.0 0.0 0.0

Viscera and offal 0.0 0.0 0.0

Unsweetened soft drinks 0.0 0.0 0.0

High alcohol content beverages 0.0 0.0 0.0

Water 0.0 0.0 0.0

Table 8. Dietary sources of energy (%) from food subgroups in adults from the ANIBES survey of the Spanish population.

Adults 18-64 Years

Total Men Women

n 1655 798 857

Energy (kcal/day) 1816 1966 1675

Bread 11.8 12.5 11.2

Meat 9.6 10.2 9.2

Olive oil 9.1 8.6 9.6

Bakery and pastry 6.8 6.3 7.2

Sausages and other meat products 5.9 6.5 5.4

Milk 4.9 4.4 5.3

Fruits 4.7 4.2 5.2

Grains and flours 4.6 4.6 4.7

Ready-to-eat-meals 4.3 4.6 4.1

Vegetables 4.2 4.0 4.4

Pasta 3.7 3.9 3.5

Fish and shellfish 3.7 3.4 3.9

Cheese 3.2 3.1 3.3

Low alcohol content beverages 2.6 3.5 1.8

Yogurt and fermented milk 2.3 2.1 2.5

Pulses 2.3 2.2 2.3

Eggs 2.2 2.4 2.1

Sugared soft drinks 2.1 2.3 1.9

Other oils 1.8 1.8 1.8

Sauces and condiments 1.7 1.7 1.7

Other dairy products 1.5 1.6 1.4

Sugar 1.5 1.3 1.6

Chocolate 1.4 1.3 1.5

Butter, margarine and shortening 1.3 1.1 1.6

Juices and nectars 1.3 1.3 1.2

Breakfast cereals and cereal bars 1.0 0.8 1.1

Appetizers 0.8 0.8 0.8

Jams and other 0.3 0.2 0.4

Other drinks (non-alcoholic) 0.3 0.2 0.4

High alcohol content beverages 0.3 0.3 0.2

Coffee and herbal teas 0.2 0.2 0.2

Viscera and offal 0.1 0.1 0.1

Supplements and meal replacements 0.1 0.1 0.1

Other sweets 0.1 0.1 0.1

Sports drinks 0.1 0.1 0.1

Energy drinks 0.0 0.0 0.0

Unsweetened soft drinks 0.0 0.0 0.0

Water 0.0 0.0 0.0

Table 9. Dietary sources of energy (%) from food subgroups in elderly adults from the ANIBES survey of the Spanish population.

Elderly 65-75 Years

Total Men Women

n 206 99 107

Energy (kcal/day) 1618 1771 1476

Bread 12.5 12.6 12.3

Olive oil 12.2 12.0 12.5

Fruits 8.7 8.1 9.4

Meat 8.5 8.7 8.3

Bakery and pastry 6.4 6.1 6.8

Milk 5.9 5.3 6.4

Vegetables 5.0 4.7 5.2

Fish and shellfish 4.7 4.3 5.0

Sausages and other meat products 4.5 5.1 3.9

Grains and flours 4.1 4.3 3.9

Low alcohol content beverages 3.3 4.8 1.9

Yogurt and fermented milk 3.1 2.5 3.7

Pulses 2.9 3.2 2.5

Eggs 2.8 2.7 2.8

Pasta 2.5 2.1 2.8

Cheese 2.3 1.9 2.6

Butter, margarine and shortening 1.8 1.5 2.2

Ready-to-eat-meals 1.8 2.1 1.6

Sugar 1.4 1.3 1.4

Juices and nectars 0.9 0.9 0.9

Sauces and condiments 0.9 0.7 1.1

Other dairy products 0.8 0.7 1.0

Other oils 0.8 0.8 0.8

Breakfast cereals and cereal bars 0.8 0.7 0.9

Jams and other 0.8 0.6 0.9

Sugared soft drinks 0.7 0.6 0.7

Chocolate 0.5 0.6 0.4

Appetizers 0.3 0.3 0.3

Other drinks (non-alcoholic) 0.3 0.4 0.3

Coffee and herbal teas 0.3 0.2 0.4

High alcohol content beverages 0.3 0.5 0.0

Viscera and offal 0.2 0.2 0.1

Supplements and meal replacements 0.1 0.2 0.0

Sports drinks 0.0 0.0 0.0

Other sweets 0.0 0.0 0.0

Unsweetened soft drinks 0.0 0.0 0.0

Energy drinks 0.0 0.0 0.0

Water 0.0 0.0 0.0

Cereals and cereal products were the main source of energy for the entire sample and all age groups. Within this food group, bread was the major contributor in all age groups (11.6%); this was followed by baked goods and pastries (6.8%), which ranked highest for children and adolescents and much lower for elderly adults. Other minor contributors were grains and flours (4.5%), pasta (3.6%), and breakfast cereals and cereal bars (1.0%). Meat and meat products were the second largest contributor (15.2%), with the lowest ranking for the elderly population (13.1%) and the highest for adolescents (16.2%). Within this category, meat contributed 9.2% of total energy, whereas the sausage and meat derivative subgroup supplied 5.8%. Oils and fats (12.3%) were the third major contributor; these came mainly from olive oil (9.2%) with only 1.7% for other oils and 1.4% for butter, margarine and shortenings. Milk and dairy products contributed 11.8% of total energy intake, and this was higher in children (15.9%) than in adults (11.8%). The different types of milk represented about half the energy intake within this group, followed by cheeses (3.0%), and then closely by yogurt and fermented milk (2.4%). Interestingly, these four food and beverage groups contributed roughly two-thirds (66.7%) of the total energy intake. Much lower contributors included fruits (4.7%), except for in the elderly population (8.7%); ready-to eat meals (4.2%), ranking from 6.6% in adolescents to 1.8% in elderly adults; vegetables (4.0%: 5.0% in elderly adults and 3.0% in children); and non-alcoholic beverages (3.9%: 4.9% in children, 6.1% in adolescents, 3.9% in adults, and 2.2% in elderly adults). Within this category, sugared soft drinks contributed 2% of total daily energy intake (1.9% in children, 3.4% in adolescents, 2.1% in adults, and 0.7% in elderly adults), followed by juices and nectars (1.3%). Fish and shellfish contributed 3.6% of total daily energy intake (2.2%-4.7%, increasing with age group). Sugars and sweets contributed 3.3% for the entire population, and ranked from 4.2% in children to 2.6% in the elderly population. Alcoholic beverages contributed 2.6%, being highest in elderly adults (3.5%). Finally, pulses (2.2%) and eggs (2.2%) had minor contributions to energy intake.

4. Discussion

4.1. Energy Intake and Profile

There is consensus in the literature that society as a whole is currently in a nutritional transition and there is a need for accurate and updated dietary intake data. Total mean daily energy intake in the ANIBES study is lower than in other surveys like the ENIDE study ("Encuesta Nacional de Ingesta Dietética Española") [20], a nationwide survey carried out in 2011 with people aged 18-64 where leftovers were not considered as in the ANIBES study. The Food Consumption Survey (FCS), conducted in Spain since 1987, revealed that mean energy consumption for the Spanish adult population in 2010 was 2609 kcal/person/day, which was clearly lower than in 1964 (3008 kcal/person/day) [19,25,26]. However, it should be considered that overestimation may exist in this survey since discards were not recorded. Therefore, our present findings confirm a decreasing trend in energy intake, which has been observed in Spain from different surveys [19,26-28] and is consistent with a similar pattern that is occurring in most European countries [29-32]. When compared with EFSA (European Food Safety Authority 2013) dietary reference values for energy [33] and current (2013) Spanish dietary recommendations for energy [23], intake in the ANIBES study population was only adequate for boys and girls, whereas it was below the average requirement (AR) considering a physical activity level of 1.6 (moderate), for

adolescent males (80% of the AR), adult males (78.0% of the AR), and elderly males (77.9% of the AR). In adolescent men, P75 and higher was necessary to guarantee the established AR, and similar was observed for adolescent women. For females, these were 82.6% of the established AR for adolescent women, 82.0% in the case of adult women, and 80.5% for elderly women. It should be considered of special concern that P50 of elderly women in the ANIBES study consumed only 1,426 kcal/day, which may compromise an adequate nutrient-dense diet during the ageing process. In addition, the nutritional status of elderly men (65 to 75 years) may be compromised since only those above P75 reached the adequate AR for energy intake. When national current (2013) dietary recommendations for energy [23] were used for comparison, the results were even more marked in terms of potential insufficient energy intake, with boys only able to cover 81.9% of the recommended dietary intake (RDI); this was 82.3% in the case of girls. Of special note are adolescent men (75.9% of RDI) and women (76.0% of RDI), and particularly adults (69.0% of RDI for men; 79.5% for women) and the elderly population (73.8% of RDI for men; 78.7% for women). It should be considered, however, that these RDI may be insufficiently up to date with respect to stratification of current physical activity levels for the Spanish population.

One of the main dietary quality indices is the energy/caloric profile. In the ANIBES study, protein intake was 16.8%E, well above the upper recommended limit (<15%E). The ENIDE study showed a similar percentage of energy from protein, 18%E, and trends in the Spain FCS are similar [19,20]. Protein intake as a percent of total energy intake ranged from 11.1 %E to 17.6%E in the different European countries included in the European Nutrition Health Report (2009) [14]. Fat intake for the total ANIBES study population was 38.5%E, being significantly higher for women. However, there were no age differences in terms of fat contribution to energy, which ranged from 37.2%E in elderly adults to 38.9%E in children. Fat is an important dense source of energy and facilitates the absorption of fat-soluble dietary components, such as vitamins. Fats and oils are also important sources of essential fatty acids. However, high-fat diets may decrease insulin sensitivity and are positively associated with increased cardiovascular risk [34-36], although a precise dose-response relationship has not been defined. There is evidence that moderate fat intake (<35%E) is accompanied by reduced energy intake and therefore, moderate weight reduction and/or prevention of weight gain may be better achieved. However, EFSA has concluded that there are insufficient data to define a lower threshold intake (LTI) or tolerable upper intake level (UL) for total fat [37]. Presently, at a European level, a lower boundary for the reference intake range of 20%E and an upper boundary of 35%E have been proposed [37]. A similar range has been recently proposed by WHO and FAO [36].

The SFA intake in the ANIBES study was above the recommendations for all age groups and both genders. SFA are synthetized by the body and are not required in the diet; therefore, no dietary reference intakes have been set. However, there is a positive dose-dependent relationship between intake of a mixture of saturated fatty acids and blood low density lipoprotein (LDL) cholesterol concentrations, when compared with carbohydrates [36]. There is also evidence from dietary intervention studies that decreasing the intake of products rich in saturated fatty acids by replacing them with products rich in n-6 PUFA (without changing total fat intake) decreased the number of cardiovascular events [38-40]. Because the relationship between increased saturated fatty acid intake and increased LDL cholesterol concentrations is continuous, no threshold of saturated fatty acid intake can be defined below which there is no adverse effect; therefore, no UL can be set, as EFSA has recently established [37]. Even so, the WHO/FAO have recommended that a maximum intake of 10%E for saturated fatty acids should be

set [36]. This limit for SFA has also been proposed very recently in the FESNAD Consensus Document on Dietary Fats and Oils for the Adult Spanish Population [41]. Interestingly, the American Heart Association (AHA) has recommended a maximum intake of <7%E for SFA to reduce cardiovascular risk [42]. More recently (2013), the dietary guidelines launched jointly by the AHA and American College of Cardiology proposed a lower amount of energy from SFA (5%-6%E) [43], although there is insufficient scientific evidence proving an association between SFA and cardiovascular and/or diabetes risk.

It is agreed that one positive aspect of the dietary patterns in Spain that should be maintained is the relatively high proportion of MUFA, mostly owing to the common use of olive oil in the Spanish diet [44,45]. In our ANIBES population, MUFA contributed 16.8%E; this was slightly higher in the elderly group and lower in children and adolescents. MUFA intake from energy across Europe ranged from 22% in Greece to 11% in non-olive-oil-consuming countries [37]. The 2011 goals of the Spanish Society of Community Nutrition (SENC) [24] recommended that MUFA should contribute >20%E of total energy. In 2010, an EFSA panel [37] proposed not setting any dietary reference value for MUFA based on the following: MUFA are synthesized by the body, have no known specific role in preventing or promoting diet-related diseases, and are therefore not indispensable constituents of the diet. This assumption by EFSA, however, is untenable as MUFA are among the most abundant fatty acids in most tissue cells and contribute to maintaining membrane fluidity and enzymatic activities. Additionally, there is convincing evidence that MUFA lower both total and LDL plasma cholesterol levels, and replacement of PUFA with MUFA decreases the risk of cardiovascular disease (CVD). Indeed, the FAO/WHO have recommended a MUFA intake of about 16%-19% (obtained by the difference in intake between SFA and PUFA) [36]. Moreover, in the PREDIMED intervention study [46], intake of virgin olive oil (high in MUFA content) was associated with a lower risk of CVD events and total mortality. Interestingly, participants who followed the olive oil-rich Mediterranean diet had a mean MUFA intake of 22%E. Therefore, from the PREDIMED study findings, a MUFA intake target of 20%E-25%E (with virgin olive oil as a main source) is desirable. As for PUFA, in view of the different metabolic effects of the various dietary PUFA [45,47], EFSA has proposed not to formulate a dietary reference value for the intake of total PUFA [37]. Other organizations, such as WHO/FAO in 2010 [36] and SENC (2011) [24], have suggested that PUFA should contribute 6%-10% and 5%, respectively, of total energy intake. In the present study, PUFA contributed roughly 6.6%E, with no gender or age differences. In addition, total n-3 PUFA intake expressed as the percentage of energy intake was 0.63%E for the ANIBES study population and increased with age. The WHO/FAO [36] have recommended a minimum intake for adults of 250 mg/day for n-3 long-chain PUFA and up to 2 g/day to help prevent CVD.

Intervention studies have provided evidence that high fat (>35%E), low carbohydrate (<50%E) diets are associated with adverse short- and long-term effects on body weight, although the data are insufficient to define an LTI for carbohydrates [47,48]. An EFSA panel [47] therefore reached the conclusion that only a reference intake range can be given, 45%E-60%E, where monosaccharides plus disaccharides should be below 10% of the total energy intake. Data from different dietary surveys have shown that average carbohydrate intakes for children and adolescents in European countries varied between 43%E and 58%E, and from 38%E to 56%E in adults, whereas average sugar intakes varied between 16%E and 36%E in children and adults [14,47]. In the present study, a low energy intake of 41.1% from carbohydrates was seen (17.0% from sugars); a trend was observed according to age, with

the lowest contribution in elderly males (39.6%E) and the highest in the youngest age groups (44.4%E). Similar results and trends were obtained for the ENIDE dietary survey in Spain [20]. It is known that frequent consumption of sugar-containing foods can increase the risk of dental caries [49]. However, the available data do not allow the setting of an upper limit for intake of (added) sugars on the basis of risk reduction for dental caries. Evidence relating a high intake of sugars (mainly as added sugars), compared with high starch intakes, to weight gain is also inconsistent [50]. In consequence, according to EFSA, the available data are insufficient to set an upper limit for added sugar intake [36]. Moreover, although there is some evidence that high sugar intakes (>20%E) may increase serum triglyceride and cholesterol concentrations and might adversely affect serum glucose and insulin levels, these data are also insufficient to set an upper limit for (added) sugar intake. The latter does not exclude, however, that food-based dietary guidelines and nutrition goals for the population should take into account the potential negative roles under certain conditions [24,51]. A new WHO guideline [52] recommends that adults and children reduce their daily intake of free sugars to less than 10% of their total energy intake. A further reduction to below 5% has been suggested to provide additional health benefits. The percentage of energy from sugars in our study was 17.0%E for the total population, and was significantly higher in females compared with males and more marked in the oldest participants.

Other minor sources of energy from diet were also estimated. Fiber intake contributed 1.4%E of the total energy, which was significantly higher in females than males. Alcohol intake contribution in the adult populations was considered moderate at 1.9%E. However, alcohol intake is one of the dietary components for which underreporting may occur, especially in women and participants with higher education levels and socioeconomic status [53,54]. In fact, energy contribution from alcohol in men was almost two-fold compared with women. On the other hand, the highest contribution from alcohol corresponded to elderly males (4.1%E), and it was much higher than for elderly women (1.4%E).

4.2. Food Sources of Energy

We were able to make the most detailed evaluation to date of how the different food groups and subgroups contribute to energy intake in the Spanish diet. The food group contributing the most to energy consumption was cereals and derivatives (27.4%), regardless of age group or gender. This pattern should be considered positive, but is insufficient for adequate nutrient density (i.e., carbohydrates and dietary fiber intake). Individually, bread was the main contributor, although more efforts are needed to return consumption to levels seen in previous generations of Spaniards, according to the traditional Mediterranean diet [55,56]. Moreover, the baked goods and pastry subgroup closely followed bread, with potentially higher contributions of sugar and unhealthy fats, which was the case for all age groups and especially the youngest (9.4%E). Interestingly, ready-to-eat breakfast cereals and cereal bars contributed most in adolescents, with much lower contribution in the elderly population. Our results also revealed that the contribution of meat and meat products seemed very high for all age groups, which made it difficult to reach the recommended energy and lipid profiles. For comparison, the meats and derivatives group accounted for a total 179 g/adult/day in the last FCS (2012), and has remained steadily high over the last 12 years. Moreover, it should be noted that this food group has increased by roughly 300% when compared with 1960s results in Spain. In addition, caution should be advised since the subgroup that includes sausages and other meat products represented approximately 7.0%E of the total

energy in children and adolescents from the ANIBES sample, which was quite different from the elderly group (4.5%E).

The next main group contributing to energy intake was oils and fats (12.3%E), but age-marked differences were seen. The lowest contribution was in children and adolescents accounting for 10%E, but this was 15%E in elderly adults; this means that a "missing" percentage of the energy from oils and fats in the youngest age groups may be replaced by meat and meat products. Fortunately, olive oil represented the main contributor, with nearly 10%E of total intake. Milk and dairy products were next in energy contribution, showing a clear decreasing trend with advancing age. As expected, milk was the main subgroup, although a decreasing trend in milk consumption has been observed in Spain in recent years. In fact, a significant decrease in the amount of purchased dairy products has taken place from the years 2000 (416 g/person/day) to 2012 (359 g/person/day), according to the FCS [19,26]. One of the main concerns is the possibility that milk is being replaced by other less nutrient-dense foods and beverages, mainly in younger age groups. In the ENIDE dietary survey during 2011 in Spain [14], the main sources of energy were meat and meat products (18%), followed by cereals and derivatives (17%), oils and fats (12%), and milk and dairy products (11%). According to the Spain FCS, the food groups contributing most to energy consumption were cereals and derivatives (24.6%), meat and meat products (14.3%), oils and fats (13.6%) and milk and derivatives (12.5%). By contrast, fish and shellfish (3%), non-alcoholic beverages (2.9%), and alcoholic beverages (2.3%) showed a lower contribution to total energy intake. By comparison, data from other European countries (e.g., Nordic countries) showed that cereals and milk and dairy products are usually the main energy sources, ahead of the meat and derivatives group [57,58].

In the present ANIBES study, the following contributing groups showed a marked gap, since the sum of the remaining disaggregated 35 food and beverage groups and subgroups was only 33.2% (600 kcal/day) of the total energy intake. Interestingly, the contribution of fish to total energy intake was only 3.6% and increased markedly with advancing age. This may compensate for younger age groups, to achieve current dietary guidelines for fish consumption [24]. The FCS showed similar results for fish and shellfish as sources of energy (3.0%). However, the ENIDE results were much higher (9%) for fish, shellfish, and derivatives in the adult population [14].

The impact of sugared soft drink consumption on obesity and metabolic disorders has come under intense scrutiny and debate worldwide in recent years [59-62], and large differences between countries have been observed. The present study showed that sugared soft drinks contributed 2.0% (36 kcal/day out of 1810 kcal/day) to total energy intake. A lower consumption compared with mean contribution was seen in children (1.9%E, 34 kcal/day) whereas the lowest contribution was for the elderly population (0.7%E, 13 kcal/day). Higher consumptions were found, however, for adolescents (3.4%E, 61 kcal/day) and the contribution in adults was 2.1%E, 38 kcal/day. Using FCS data, we have previously shown [17] that all non-alcoholic drinks contributed 2.9% to total energy intake in Spain. For additional comparison, in the ENIDE dietary survey, non-dairy beverages (excluding alcoholic drinks) contributed 2%E (46 kcal/day) in the adult Spanish population [20]. By contrast, the United States has usually had the highest contribution to energy intake from sweetened beverages. However, a recent study using data from NHANES surveys showed that from 1988 to 1994 and 1999 to 2004, the consumption of these beverages increased [63], but consumption of beverages and foods with added sugars declined from 1999 to 2000 [64]. Another food group of concern, which is usually not well quantified, is that of

so-called sugars and sweets, mainly owing to its potential role in overweight, obesity, and several metabolic disorders [59-62]. We showed that this group currently represents 3.3% of total energy intake in Spain and decreases with age (5.1% in children and 2.6% in elderly adults). In the ENIDE survey, this food group contributed 5% to total energy intake [20].

Finally, we found lower contribution than initially expected from alcoholic drinks (2.6%E, 47 kcal/day), which was higher for elderly participants. Alcoholic beverages of lower alcohol content (beer, wine, cider) represented over 90% of energy contribution within this group. These results are similar to those obtained from the latest Spanish FCS (2.3%E) [19]. In general, alcoholic beverage consumption has undergone a slow decline during recent years (259 g/person/day in 2000 versus 208 g/person/day in 2012) [19]. Within this group, as a beverage traditionally included in the Mediterranean diet concept, wine only represented 23.5% of total alcoholic beverage consumption whereas it accounted for 62% of the total consumption in 1991. In the last few years, a gradual substitution of wine for beer has taken place, which represents almost 70% of the total alcoholic beverage consumption at present [19].

5. Conclusions

To summarize, the top 10 food groups and subgroups of energy sources in the Spanish diet were (in decreasing order): bread, olive oil, fresh meat, baked goods and pastry, sausages and other processed meats, milks, fruits, ready-to-eat meals, vegetables, and grains and flours. These accounted for about two-thirds of total energy intake, whereas the remaining 33% of the energy from foods and beverages was widely distributed among 35 different food and beverage subgroups. In conclusion, the strengths of the design, protocol and methodology used in the ANIBES study are the representative national sample targeted, the broad age range included (9-75 years), the geographical distribution (mainland and islands), successful logistics for the 128 sampling points, and innovative and novel use of tools to measure dietary intake and leftovers. However, the ANIBES study had some limitations, mainly difficulties for some participants (e.g., elderly adults) in using new technology to record intakes. There was also no accounting for seasonality in food consumption. Finally, although ANIBES data were representative of the Spanish population, caution should be used in inferring causal relationships between diet quality, body weight, and other health outcomes. Despite the limitations, these data are the best available to evaluate current dietary energy intake and its determinants for the Spanish population.

Acknowledgments

The authors would like to thank Coca-Cola Iberia for its support and technical advice, especially Rafael Urrialde, Isabel de Julián, and Estrella López Brea. The authors are also grateful to IPSOS Spain, in particular Jesus Caldeiro and José Díaz, for continuous support in the sampling procedure, fieldwork development, and statistical analysis.

Author Contributions

• ERM conceived of the protocol, methodology to be used, and designed the training procedures for interviewers and dietician-nutritionists. ERM also analyzed the data (collection, quality control) and contributed to the data interpretation and discussion.

• JMA conceived of the overall design, protocol, and methodology of the ANIBES study. JMA also contributed to the interpretation and discussion of the results.

• TV, SdP, and PR were responsible for the instruments to be used, training, and data cleaning. They also contributed to data analysis and interpretation.

• JA, AG, MGG, RMO, and LSM are members of the Scientific Advisory Board of the ANIBES study. They were responsible for careful review of the protocol, design and methodology and provided continuous scientific advice for the study and for the interpretation of results. These authors also critically reviewed the manuscript.

• GVM, Principal Investigator, was responsible for the design, protocol, methodology, and follow-up checks of the study. GVM drafted the manuscript.

• All authors approved the final version of the manuscript.

Conflicts of Interest

The study was financially supported by Coca-Cola Iberia. The funding sponsors had no role in the

design of the study, the collection, analysis, or interpretation of the data, writing of the manuscript, or in

the decision to publish the results. The authors declare no conflict of interest.

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