Dietary and Lifestyle Patterns in the Spanish Pediatric Population (One to <10 Years Old): Design, Protocol, and Methodology of the EsNuPI Study

nutrients Article Dietary and Lifestyle Patterns in the Spanish Pediatric Population (One to <10 Years Old): Design, Protocol, and Methodology of the EsNuPI Study † Casandra Madrigal 1,2, María JoséSoto-Méndez 2,Ángela Hernández-Ruiz 2, Emma Ruiz 3,4,5 , Teresa Valero 5, JoséManuel Ávila 5, Federico Lara-Villoslada 6, Rosaura Leis 7,8 , Emilio Martínez de Victoria 9,10, Jose Manuel Moreno 11 , Rosa M Ortega 12 , María Dolores Ruiz-López 1,2,10,* , Gregorio Varela-Moreiras 5,13 and Ángel Gil 2,8,10,14 1Department of Nutrition and Food Sciences, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain; [email protected].es 2 Iberoamerican Nutrition Foundation (FINUT), Armilla, 18016 Granada, Spain; [email protected]g (M.J.S.-M.); [email protected] (Á.H.-R.); [email protected] (Á.G.) 3CIBERESP, Consortium for Biomedical Research in Epidemiology and Public Health, Carlos III Health Institute, 28029 Madrid, Spain; [email protected] 4National Center for Epidemiology, Carlos III Health Institute, 28029 Madrid, Spain 5Spanish Nutrition Foundation (FEN), 28010 Madrid, Spain; [email protected]g.es (T.V.); [email protected] (J.M.Á.); gvar[email protected] (G.V.-M.) 6Instituto de Nutrición Puleva, 18004 Granada, Spain; [email protected] 7 Department of Pediatrics, Unit of Pediatric Gastroenterology, Hepatology and Nutrition, University Clinical Hospital of Santiago, 15705 Santiago de Compostela, Spain; [email protected] 8 CIBEROBN (Physiopathology of Obesity and Nutrition CB12/03/30038), Instituto de Salud Carlos III (ISCIII), 28029 Madrid, Spain 9Department of Physiology, University of Granada, 18071 Granada, Spain; [email protected] 10 Institute of Nutrition and Food Technology ”JoséMataix”, Biomedical Research Center, University of Granada, 18100 Granada, Spain 11 Department of Pediatrics, University of Navarra Clinic, 28027 Madrid, Spain; [email protected] 12 Department of Nutrition and Food Sciences, Faculty of Pharmacy, Complutense University, 28040 Madrid, Spain; [email protected] 13 Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, 28668 Madrid, Spain 14 Department of Biochemistry and Molecular Biology II University of Granada, University of Granada, 18071 Granada, Spain *Correspondence: [email protected]; Tel.: +34-630-327-291 †Nutritional Study in Spanish Pediatric Population (EsNuPI). Received: 6 November 2019; Accepted: 10 December 2019; Published: 13 December 2019   Abstract: The interest in a healthy diet and lifestyle during the early stages of life increased, pointing out its role in the development of noncommunicable chronic diseases throughout adult life. Dietary habits and dietary patterns begin to be established in early childhood and persist during adulthood. Therefore, the EsNuPI (“Nutritional Study in Spanish Pediatric Population”) study aims to depict the dietary patterns, physical activity, and sedentary behaviors in Spanish children aged from one to <10 years old. This prospective, cross-sectional, observational study recruited a total of 1514 children from Spanish cities with >50,000 inhabitants, stratified by Nielsen areas. Participants were involved in one face-to-face survey, followed by a telephone survey after at least one week. Information about dietary intake and habits was obtained using a quantitative food frequency questionnaire and two 24-h dietary recalls. Physical activity and sedentary behaviors were registered using a specific questionnaire based on a seven-day record. Data were processed and stratified by categorical variables to be statistically analyzed in order to meet the study objectives. This study is the first Nutrients 2019,11, 3050; doi:10.3390/nu11123050 www.mdpi.com/journal/nutrients Nutrients 2019,11, 3050 2 of 21 of its kind in a Spanish reference population of this age range and the first to evaluate whether the consumption of adapted milk formulas and dairy products is associated with healthier dietary patterns and better diet quality and lifestyles in this group. Keywords: dietary habits; feeding behaviors; food intake; physical activity; sedentary behaviors; pediatrics; Spanish children; dairy products; infant formula; EsNuPI study 1. Introduction The interest in a healthy diet and lifestyle during the early stages of a child’s life increased, pointing out its role in the development of noncommunicable chronic diseases (NCCDs) throughout life [ 1 ]. At later ages, in addition to favoring optimal growth and development, feeding constitutes a means for the acquisition of healthy eating habits, which have an impact on nutritional behavior in the short, medium, and long term. Dietary habits and dietary patterns begin to be established in early childhood, are consolidated before the end of the first decade of life and persist during adulthood [ 2 ]. Technological advances and environmental and social changes that took place in recent years also changed lifestyles and dietary patterns, conditioning the prevalence of overweight, obesity, and NCCDs such as hypertension, type 2 diabetes, and cardiovascular disease. Currently, there are only a few grouped data on the dietary habits of the European pediatric population [ 3 , 4 ]. The World Health Organization (WHO) publishes data in relation to healthy habits in children aged 11–15 years, but not in younger children [5]. A systematic analysis for the Global Burden of Disease found that, in 2017, 11 million deaths and 255 million disability-adjusted life-years were attributable to dietary risk factors. High intake of sodium, low intake of whole grains, and low intake of fruits were the leading dietary risk factors for death and disability-adjusted life-years globally and in many individual countries [6]. In Spain, very few studies were conducted on dietary habits and lifestyle behavior in the pediatric population. The two most important were the ALSALMA (from the Spanish “Alimentando la salud del mañana”) [ 7 ] and the ENALIA (“National Dietary Survey on the Child and Adolescent Population in Spain”) studies [ 8 ], both of them cross-sectional studies, carried out in 2013 and 2013–2014, respectively. The ALSALMA study was conducted in a representative sample of Spanish children 0–36 months (n=1559, 54% boys), and the ENALIA study was carried out on a national sample of children and adolescents aged from six months to 17 years (n=1862, 50% girls) [7,8]. Finally, in 2015, the ANIBES (“Anthropometry, Intake and Energy Balance”) study was published; ANIBES was a cross-sectional study performed in the Spanish population, including children and adolescents between nine and 17 years old (n=2009, 50.4% males) [9]. Also, European studies that involve the Spanish population were carried out, e.g., the IDEFICS (“Identification and prevention of dietary- and lifestyle-induced health effects in children and infants”) study that included a cohort study (I.Family) which is a population-based multi-center study of children aged 2–9 years recruited in selected and specific regions of eight European countries (including only the cities of Zaragoza and Huesca in Spain). These two studies published several reports describing dietary intake, dietary patterns, and the changes in children’s diet over time [10–12]. In addition, a review of the evidence was conducted to evaluate associations between milk or dairy product intake and health outcomes in children and adolescents (2–19 years). Available data indicated that childhood dairy product consumption may affect various facets of growth and development, and evidence suggests that dairy products are important for linear growth and bone health [13,14]. Moreover, Santaliestra-Pas í as et al. studied the relationship between specific lifestyle behaviors and dairy consumption in a sample of European children and adolescents from the IDEFICS study. The study found that European children with a healthy lifestyle, specifically regarding physical activity and sedentary behaviors over time, consumed more milk and yogurt. This study suggests that the Nutrients 2019,11, 3050 3 of 21 protective effect of dairy products on cardiovascular diseases (CVD) could be related to the association between their consumption and specific lifestyle behaviors [15]. In Spain, Ortega et al. studied the association between dairy consumption and dietary patterns and intake of selected nutrients in 7–11-year-old children and concluded that children who drank more milk also had better dietary patterns [16]. Unfortunately, no precise data for adapted and fortified milk formulas (those whose composition is adapted to the nutritional needs of the child population) are available in Spain. However, they are consumed at around 9225 tons per year and are gaining importance and increased sales [ 17 ]. According to the Food Consumption Report in Spain 2018, sales of fortified milk increased by 26.3% compared to 2017 [18]. As already stated, there is a paucity of information about dietary patterns, dietary habits, and physical activity and sedentary behaviors in Spanish children in the one- to <10-year-old age group, and there is also no information about any possible association between these patterns, habits, and behaviors and the consumption of adapted and fortified milk formulas and dairy products. Therefore, the EsNuPI (“Nutritional Study in Spanish Pediatric Population”) study is aimed at depicting the food consumption, nutrient intake, and dietary patterns, as well as physical activity and sedentary behaviors of Spanish children from one to <10 years old in urban areas with >500,000 inhabitants, distributed across nine geographical areas (according to the Nielsen Spanish criteria), and it is aimed at evaluating whether or not the regular consumption of dairy products and adapted and fortified milk formulas is associated with the quality of the diet. To that end, the specific objectives of the EsNuPI study were (1) to characterize the dietary energy, food consumption, and nutrient intake, as well as the dietary patterns and habits of the study population, (2) to evaluate the dietary quality through the determination of dietary diversity and variety, as well as through the use of diverse dietary quality indexes, (3) to describe the physical activity and sedentary behaviors and to evaluate them according to the existing activity and resting recommendations for this age group, and according to the World Health Organization’s growth standards, (4) to combine data on diet and physical activity in order to determine the over- and under-reporters of energy consumption, (5) to stratify the population according to different categorical variables (e.g., sex, age, socioeconomic status, household habits, etc.), and test for any possible differences or interactions in dietary patterns and diet quality, and (6) to compare all different variables of the study among the urban Spanish reference population and the booster sample of adapted and fortified milk formula consumers. 2. Experimental Section 2.1. Pilot Study Even though the final fieldwork was carried out from October 2018 to January 2019, a pilot study was previously carried out in September 2018 by MADISON MK, the company in charge of data collection and processing for the EsNuPI study. For this purpose, 25 interviews were conducted in several geographical locations across Spain. Once the results from the pilot study were completed, the limitations were detected and corrected. Then, the questionnaires were approved for the final protocol. 2.2. Study Design The EsNuPI study is a prospective, cross-sectional, observational study. The EsNuPI study aimed to have a sample size representative of children living in Spain (excluding the autonomous cities of Melilla and Ceuta) aged one to <10 years and living in urban areas with >50,000 inhabitants. These urban areas represent 1.8% of the total number of municipalities of Spain and 52.6% of the total Spanish children population of one to <10 years old [19]. Nutrients 2019,11, 3050 4 of 21 The sample of the EsNuPI study was calculated based on the 2018 census data published by the Spanish Bureau of Statistics (“Instituto Nacional de Estadistica” (INE)) [ 19 ] and stratified appropriately by age, sex, Nielsen geographical area, population size, and type of milk consumed. 2.3. Inclusion and Exclusion Criteria Inclusion and exclusion criteria involved the ability to eat a diversity and variety of food items; Table 1details all these criteria. Table 1. Inclusion and exclusion criteria for the EsNuPI study. Inclusion Criteria Exclusion Criteria Healthy participants between 1 and <10 years old without diseases entailing changes in their dietary patterns. Children with any disease that causes changes in their dietary patterns or any dietary restriction, or children following a therapeutic diet due to recent surgery or any other medical prescription and pathology. Children whose parents/caregivers report that they are following their habitual diet. Children whose parents reported that they were not following a normal diet for any reason, including a transitory pathology (cold, flu, gastroenteritis, chickenpox, etc.) at the time of the fieldwork. Children whose parents or caregivers can read and understand the questionnaires properly. Children following a vegan diet. Children who live in an institution (boarding schools, nursing homes, hospitals, host institutions, etc.). Children related to Madison MK or Lactalis employees *. Children whose parents or caregivers did not provide a signed consent form for their participation or did not complete any study phase. * Children related to employees of Madison MK, company in charge of the interviews, and Lactalis, the flagship company of “Instituto Puleva de Nutrici ó n”, the financing collaborator of this project are excluded in order to avoid bias because the parents could be aware of the study and their answers could be conditioned, and bias due to the consumption of Lactalis-branded product within these families. 2.4. Sample The sample was randomized in multiple stages and stratified according to sex, age, population size, and Spanish Nielsen areas. Two subsamples were selected for the EsNuPI Study; one subsample is representative of the urban, non-vegan Spanish population from one to <10 years old, and the other subsample is a booster of non-vegan one to <10-year-old Spanish children who lived in urban areas and regularly consumed adapted and fortified milk formulas. The initially estimated sample was 1500 individuals, and the sample errors were ± 2.52% and ± 2.59%, respectively, for a 95.5% confidence level and estimation of equally probable categories (p=q=50%), considering a universe of 2,205,646 children. For the final sample, 1514 parents or caregivers signed consent forms and completed the first interview (face-to-face) providing sociodemographic information, answering a quantitative food frequency questionnaire (FFQ), a physical activity and sedentary behaviors questionnaire (PABQ), and the first 24-h dietary recall (24-h DR). Later, only 1448 subjects completed the study by answering the telephone survey that collected the second 24-h DR. Details of the use of these questionnaires are described below. The final sample consisted of two subsamples, children representative of the urban Spanish population (vegans excluded), hereinafter called the “reference population”, and a “booster” sample that consumed adapted and fortified milk formulas. For this study, the following were considered as milk formulas: infant formula, follow-on milk formula, toddler’s milk formula (also termed in Spain “growing up” milk formula), and fortified milk formula (e.g., docosahexaenoic acid (DHA), calcium, vitamin D, iron). Nutrients 2019,11, 3050 5 of 21 In addition, considering the need for all age and sex groups to be represented, the sample was stratified (50% boys, 50% girls, one to <3 years old, three to <6 years old, and six to <10 years old). Table 2shows the distribution of the targeted and final samples, and Figure 1shows the distribution of the sample by Nielsen areas. Table 2. Distribution of the sample for the EsNuPI study. Sample (n) Targeted Sample (n=1500) Final Sample (n=1514) Reference * Booster ** Reference * Booster ** Total n=750 n=750 n=742 n=772 n=1514 Sex Boys 375 375 374 385 759 Girls 375 375 368 387 755 Age (years) 1 to <3 250 250 171 303 474 3 to <6 250 250 257 276 533 6 to <10 250 250 314 193 507 * Sample of non-vegan one- to <10-year-old children representative of the Spanish population living in urban areas. ** Booster sample of non-vegan one- to <10-year-old children who consumed adapted and fortified milk formulas and lived in urban areas. Figure 1. Nielsen geographical distribution of the sample for the EsNuPI study: Area 1 (9.8%), northeast; Area 2 (12.6%), Levant (east); Area 3 (15.1%), south; Area 4 (7.6%), central; Area 5 (11.9%), northwest; Area 6 (8.6%), north central; Area 7 (9.4%), metropolitan area of Barcelona; Area 8 (19.0%), metropolitan area of Madrid; Area 9 (6.0%), Canary Islands. Individual quotas were defined for all the variables, which allowed the identification of the total number of interviews required to properly represent the sociodemographic distribution under study. The sample design and the high number of sampling points determined the number of required interviewers and their interviewing area. Nutrients 2019,11, 3050 6 of 21 2.5. Ethical Aspects The final protocol followed the ethical standards recognized by the Declaration of Helsinki of 1964 and was approved by the Research Ethics Committee of the University of Granada (Spain), coded as “659/CEIH/2018” in September 2018. Thereafter, the study was registered at ClinicalTrials.gov (Protocol Registration and Results System—PRS—Receipt Release Date: 22 April 2019; Unique Protocol ID: FF01/2019). Before any information request, during the interview, the study was explained to the parents or legal guardians. Children whose parents or caregivers did not provide a signed consent form or who did not complete any study phase were excluded from the study. Participants of the study could stop the interviews at any moment, and their collected partial information was excluded from any analysis. Participant Confidentiality MADISON MK (TELECYL. S.A.) was responsible for collecting all personal data of respondents in order to manage and carry out the survey. MADISON MK is knowledgeable and adapted to the new General Data Protection Regulation of the European Union (EU) 2016/679. Each participant gave their express consent to participate in the survey. Once the data collection and the survey verification work were finished, the files obtained were anonymized for their processing. 2.6. Survey Instruments All the survey instruments were adapted for the study and were designed, verified, and modified previously in the pilot study. Below, a brief description of the survey instruments that were used for this study is given. 2.6.1. Sociodemographic and Personal Questionnaire This questionnaire allowed the researcher to know the characteristics of the study population. The questionnaire included date and place of birth, nationality, gender, educational level of the parent or caregiver (elementary or less/secondary/university/higher education), place of residence (Nielsen area), employment situation (unemployed/employed), household information (household members/family feeding/lifestyle factors), professional occupation (administrative/farmers/professionals), working times (working days/working hours), and household income. Moreover, the questionnaire was used to determine if participants met the inclusion criteria. 2.6.2. Food Frequency Questionnaire Dietary diversity and variety, as well as an estimation of food consumption, were measured using a quantitative FFQ. For our study, an FFQ was used that was previously modified, adapted and validated with the portion sizes and food groups that the Spanish child population usually consumes [ 20 , 21 ]. This FFQ was a quantitative one, including 10 food groups and 160 items, and with foods and beverages most commonly consumed by the Spanish population, with standard portion sizes for each item using the common units of weight (g) and of volume (mL) [ 22 ]. These groups were divided into subgroups due to the great diversity of food products that currently exists. The main food groups and subgroups, and the specific portion sizes that were considered in this study are shown in Table 3. Participants were asked to answer questions regarding their child’s usual food consumption over the last 12 months and indicate how frequently they consumed these foods from the options of never, rarely, monthly, weekly, and daily. Nutrients 2019,11, 3050 7 of 21 Table 3. Main food groups and subgroups and reference portion sizes used in the EsNuPI study quantitative food frequency questionnaire. Food Groups Dairy products Breast milk (150 mL), infant formula, toddler’s milk formula, cow’s milk, enriched milk, and specially formulated milk, 200 mL Vegetable drinks (200 mL) Yogurt (125 g) Fresh cheese (15–30 g) and cured cheese (15 g) Sugared dairy dessert (125 g) and ice cream (120 g) Other dairy products (condensed milk, 10 g; cream, 20 g; and flavored milk, 200 mL) Oils and fats Olive oil (10 g) Other vegetable oils and lard (10 g) Margarine and butter (12 g) Eggs, meat, and fish Eggs (64 g) Chicken and turkey with or without skin, medium-fat meat, fatty pork, lamb meat, rabbit meat, or liver and other viscera (55 g) “Serrano” ham, cooked ham, sausages, other processed meats (15 g) Fish: white fish (55 g), bluefish (small and large, 55 g), fresh seafood (90–100 g), and canned fish (25 g) Bakery products Cookies and cakes (25–50 g) Homemade bakery products (50 g) Sugary cocoa (5 g), nougat (20 g), and shortbread cookies (45 g) Vegetables and potatoes All kind of vegetables (55 g) Potatoes (55–80 g) Miscellaneous Industrial pre-cooked products (25–50 g) Homemade pre-cooked products (25–50 g) Sauces (8 g) Condiments (0.25 g) Sugar, honey, and marmalade (10 g) Low- or no-calorie sweetener (0.05 g) Snacks (fried snacks, 50 g) Fruits and nuts All kinds of fresh fruits (100–200 g) Olives (20 g) Fruits with juice and fruits with syrup (50 g) Dried fruits (20 g)Nuts (17.5 g) Beverages Sugar-sweetened carbonated beverages or low-calorie carbonated beverages (200 mL) Natural juices and commercial juices (200 mL) Mixtures of fruit juice and milk, sugar-sweetened or low-calorie sweetened (200 mL) Legumes, cereals, and pasta Legumes (40 g) Bread (20–25 g) Breakfast cereals (30 g) Rice and pasta (40 g) Homemade and commercial baby food, homemade and commercial baby porridge Homemade baby food (200 mL) Fruit commercial baby food (200 mL) Vegetable baby food (200 mL) Vegetable commercial baby food (200 mL) Vegetables with meat and/or fish homemade baby food (200 mL) Cereals with milk homemade baby porridge (200 mL) Cereals with milk commercial baby porridge (200 mL) Gil-Campos, M. Personal communication from Mercedes Gil-Campos, as coordinator of the Meli-Pop Project (Reference PI18/0093 del Fondo de Investigaciones Sanitarias, Instituto Carlos III), 2018, modified. 2.6.3. Twenty-Four-Hour Dietary Recall Food consumption can be estimated using different methods, and the most common for quantitative assessment of the intake of energy and nutrients from the data obtained is the 24-h DR [ 23 , 24 ]. For this study, an ad hoc questionnaire was designed and previously verified and modified during the already explained pilot study. For the 24-h DR, the participants or their caregivers recalled all food and beverage intake at home and away from home in the last 24 h (one day’s intake). For this study, two non-consecutive recalls, including weekdays and weekend days, were developed; the first one was performed through a face-to-face interview, and the second one was performed through a telephone call. For the 24-h DR, we followed the guidance on the EU menu methodology of the European Food Safety Authority [ 25 ]. Nutrients 2019,11, 3050 8 of 21 The information obtained was structured as mealtimes (breakfast, mid-morning, lunch, mid-afternoon, dinner, and other moments). Subjects were also asked about the place (home, school, in another house, outside in a restaurant) and time of meal consumption. The participant made a detailed description of the food consumption (ingredients, method of preparation, and brands), and this information allowed the correct coding and weight assignment for each food item. To facilitate the process, the interviewers used the “tables of common home measures and habitual portion sizes for Spain population” [ 26 ] and the “photo guide of common portions sizes of Spanish foods” [ 27 ]. The latter photo guide includes 12 food groups, 204 foods commonly consumed in the Spanish population, and 944 photographs. 2.6.4. Physical Activity and Sedentary Behavior Questionnaire Questionnaires for the assessment of physical activity were indicated as useful instruments because they are easy to manage, with a low cost, and they can extract information from numerous samples in a short interval of time [28]. The PABQ used for this study was a modification of a questionnaire previously validated in children <10 years from Colombia based on a seven-day record [ 29 ]. Small modifications, mostly in commonly used language terms, were made to this questionnaire to adapt it to the needs of the present study. Physical activity was reported indicating all the activities performed by the child in one day (24 h) during the last week (a seven-day record), including hours of sleep and screen time, and was reported separately for weekdays and weekends. This questionnaire included activities that require more effort (cycling, walking, dancing, jumping, etc.) and activities that require little or no effort (reading time/homework, hours spent watching television, time spent using the computer and game consoles or screens, foreign language classes, music or drawing courses). Also, participants could fill in other activities that were not included in the other sections. Finally, sleeping and eating habits included the number of hours each child slept per night and duration of naps, as well as the number of hours eating, on average, and they were reported separately for weekdays and weekends. 2.7. Stages of the Fieldwork For the fieldwork process, the following two stages were achieved: 1. Personal survey: the initial contact with the interviewer and the face-to-face interview. 2. Telephone survey: contact with the interviewer through a telephone call. Both surveys were carried out with the children’s parents or caregivers, and, when it was possible, in the presence of the child to try to complete the information. 2.7.1. Stage 1, Personal Survey: Initial Contact with the Interviewer and Face-To-Face Interview The initial contact with the possible participants was made by different approaches, e.g., outside schools, daycare centers, playgrounds, and recreational parks. The interviewer verified through a filter questionnaire that the participant was eligible for the EsNuPI study according to the abovementioned inclusion and exclusion criteria; if criteria were met, the interviewer set an appointment with the parent or caregiver. The face-to-face interviews were always conducted at home, and there was only one interview per subject of each house. The computer application CAPI (Computer-Assisted Personal Interviewing) was used for the collection of the data according to the guidance of the EU menu methodology [ 25 ] in order to make this process easier and more efficient. The first interview (face-to-face) with an approximate duration of 120 min comprised the following items: Nutrients 2019,11, 3050 9 of 21 1. Classification and sociodemographic questionnaire (18 min). 2. Anthropometric data (2 min): weight and size data declared by parents or caregivers based on the child’s health card. 3. FFQ (60–90 min). 4. 24-h DR (20 min). 5. PABQ (15 min). No prior notification was given to the subjects about whether or when they would be interviewed about their food consumption. 2.7.2. Stage 2, Telephone Survey: Contact with the Interviewee through a Telephone Call The data collection was done by telephone using the CATI (Computer-Assisted Telephone Interviewing) computer application by the same previously trained interviewers [25]. The second interview (“telephone survey”) with an approximate duration of 20 min comprised the following item: • Second 24-h DR, ≥ 7 days after the first survey, considering that one should collect information about weekdays and the other about weekends. Once stages 1 and 2 were completed and the quality of the information was assured, the verification of all data provided by the interviewers was carried out. This verification was done by MADISON MK at the end of each working day. In those cases where it was necessary to complete information by the participants, MADISON MK proceeded to contact them and verify the missing data. Subsequently, the information submitted was verified and the suitable corrections were applied and approved by the dieticians/nutritionists from the FEN (“Spanish Nutrition Foundation”) and FINUT (“Iberoamerican Nutrition Foundation”). Finally, the information was sent back to MADISON MK, who considered all the changes proposed to create the final EsNuPI database. Figure 2shows the scheme for the methodological process of the EsNuPI study. 2.8. Quality Control The quality control of the collected information was supervised by trained personnel, according to the following protocol: •Necessity to answer all the questionnaires’ items. • The initial quality control was based on the descriptions sent by the participants and combined with the photo guide information. Special attention was given to validate some variables such as ingredients, brands of processed and fast food, portion size, or culinary technique in order to obtain adequate information for future codification. •FEN and FINUT were responsible for checking the food consumption records during the study. • From the beginning of the coding process, FEN and FINUT worked together with MADISON MK to check the information and give them individual feedback on their work. • The surveys received throughout the fieldwork were coded and depurated, transferring continuous feedback to the interviewers about possible errors or inconsistencies in their completion. • Verification calls were performed by each interviewer to verify the incomplete answers and correct possible inconsistencies. •The questionnaires that did not pass the stipulated quality controls were removed. •The final approval of the received information was given by FEN and FINUT. 2.9. Statistical Analysis A database was created with the information that was obtained from the two fieldwork stages. All data were coded, depurated, and processed to generate a database with all the variables for their Nutrients 2019,11, 3050 16 of 21 countries of the world. In each FITS and KNHS participant country, dietary intake was assessed using 24-h DR on one, two, or more days. The age groups and food grouping systems were not consistent, the level of detail varied between countries, and not all country surveys recorded details about the meals or times when foods were consumed [64]. Finally, the IDEFICS and I.Family studies shared objectives and outcomes with our study, and they will be helpful to discuss our future publications. Even though this was a project designed at an international level, it did not include a representative sample of the Spanish population. Hence, it will be interesting to compare outcomes of both studies [10–12]. We consider that the EsNuPI study will provide valuable and new information about dietary habits, sociodemographic data, and physical activity and sedentary behaviors for a wider age range of the Spanish pediatric population (one to <10 years) in the current economic situation, using different tools and methods of collection. Additionally, and as already mentioned, different valuable dietary surveys were conducted in Spain, although, to the best of our knowledge, none attempted to determine the role of adapted and fortified milk formula consumption in this population. This food group has special relevance in children’s diets (especially in early childhood); thus, the consumption of dairy products and the specific role of adapted and fortified milk formulas will be analyzed in this study. The methods we followed to complete this study show a series of strengths that allowed a good quality of the information obtained. In this study, the data collection method was not invasive; consequently, the interviews were carried out with the children’s parents or caregivers. This fact is also an advantage due to the ease for parents to remember established routines and mealtimes. For this reason, we expected less bias in their answers [ 66 ]. Another strength would be the quality of the survey tools that were specifically adapted to this population and that were verified and modified during the pilot study. We used the computer application CAPI for the collection of all the data to make this process easier and more efficient, and the VD-FEN 2.1 software [ 38 ] allowed the conversion of all the information into a database that can be used in different statistical programs. Finally, the use of supporting material such as the “tables of common home measures and habitual portion sizes for Spain” [ 26 ] and the “photo guide of common portions sizes of Spanish foods” [ 27 ], built using the “pilot study for the assessment of nutrient intake and food consumption among kids in Europe” (PANCAKE) standards [ 67 ] to improve the quality of the answers obtained during the interviews, is another recognized strength of the present study. We recognize a series of limitations in this study; for example, even though the interviewers were previously trained by experienced dieticians/nutritionists, they were professionals of different areas and degrees (e.g., law, history, nursing, and designer degrees, administrative work, etc.). Moreover, the anthropometric data declared by parents based on the child ´ s health card may introduce somewhat misreporting responses. Also, potential biases may occur when self-reported data are analyzed, as is the case for dietary recall questionnaires. In epidemiologic studies of dietary factors as determinants of diseases, FFQs are commonly used to assess long-term or usual food consumption [ 68 ]. FFQs are based on an individual’s recall of usual intake over a specified time and, thus, are subject to measurement error, which leads to an under- or over-estimation of food consumption. However, two 24-h DRs were performed to control and reduce the measurement error and to evaluate the validity of the food frequency questionnaire. Furthermore, the instruments that evaluated the dietary quality were previously validated and adapted to our studied population in order to reflect the reality of their diet [ 69 ]. Additionally, misreporting was determined in our study, and secondary analyses will be run with plausible data [70]. Another limitation was the use of a subjective method for measuring physical activity. The use of accelerometers combined with self-reported data could probably provide more accurate information; in our case, the use of accelerometers was not possible due to the ages of the youngest group in our study population. Furthermore, another limitation was the use of the Youth Compendium of Physical Activities for children under six years old, due to the lack of information for activities under this age Nutrients 2019,11, 3050 17 of 21 and the lack of MET values for this age range. Finally, although the sample is representative of Spain, we would have liked to be able to enroll more participants, which would enlarge our sample size and, consequently, would reduce the sampling error. 5. Conclusions The EsNuPI study is the first study targeted at the one- to <10-year-old age group to collect data about dietary habits, dietary patterns, physical activity, and sedentary behaviors in the Spanish population. Considering that the protocol was designed based on the best available evidence and previous experience, the EsNuPI study will contribute to provide valuable information for the development of dietary guidelines, and nutritional and health policies focused on improving the health of the child population. Author Contributions: Methodology, C.M., M.J.S.-M., Á .H.-R., E.R., J.M. Á ., G.V-M. and Á .G.; Investigation, M.J.S -M., Á .H.-R., E.R., G.V.-M and Á .G.; Writing-Original Draft Preparation, C.M., M.J.S.-M. and Á .H.-R.; Writing-Review & Editing, C.M., M.J.S.-M., Á .H.-R., E.R., T.V., J.M. Á ., F.L.-V., R.L., J.M.M., E.M.d.V., R.M.O., M.D.R-L., G.V.-M. and Á .G.; Supervision, F.L.-V., R.L., J.M.M., E.M.d.V., R.M.O., M.D.R.-L., G.V.-M. and Á .G.; Project Administration, G.V.-M. and Á .G.; Funding Acquisition, G.V.-M. and Á .G. All authors approved the final version of the manuscript. Funding: This research was funded by Instituto Puleva de Nutrición (IPN). Acknowledgments: The authors would like to thank IPN for its support and technical advice. The results presented in this article constitute part of Casandra Madrigal Arellano’s doctoral thesis, performed in the Nutrition and Food Sciences Doctorate Program of the University of Granada and financed by Consejo Nacional de Ciencia y Tecnología (CONACYT). Conflicts of Interest: The funding sponsor had no role in the design of the study; in the collection, analyses, or interpretation of the data; in the writing of the manuscript, and in the decision to publish the results. The authors declare no conflicts of interest, with the exception of Federico Lara who is a member of the IPN. References 1. Martorell, R. Importancia de la nutrici ó n en los primeros 1.000 d í as de vida. In Tratado de Nutrici ó n, 3rd ed.; Angel Gil: Madrid, Spain, 2019; Volume 4, pp. 237–267. 2. Gil, Á .; Ortega, R.M. Introduction and executive summary of the supplement, role of milk and dairy products in health and prevention of noncommunicable chronic diseases: A series of systematic reviews. Adv. Nutr. 2019,10, 67–73. [CrossRef] [PubMed] 3. European Food Safety Authority (EFSA). Use of the EFSA Comprehensive European Food Consumption Database in Exposure Assessment. EFSA J. 2011,9, 2097. [CrossRef] 4. Gonz á lez-Gil, E.M.; Santab á rbara, J.; Russo, P.; Ahrens, W.; Claessens, M.; Lissner, L.; Börnhorst, C.; Krogh, V.; Lacoviello, L.; Molnar, D.; et al. Food intake and inflammation in European children: The IDEFICS study. Eur. J. Nutr. 2016,55, 2459–2468. [CrossRef] [PubMed] 5. Kelly, C.; Whitehead, R.; Maes, L.; Focus, G.H. An overview of adolescent dietary behaviours. In Dietary Habits; HBSC’s International Coodinating Centre: Glasgow, Scotland, 2017; 4p. Available online: http: //www.hbsc.org/publications/factsheets/Dietary-Habits-english.pdf. 6. GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2019,393, 1958–1972. [CrossRef] 7. Dalmau, J.; Peña Quintana, L.; Morais, A.; Mart í nez, V.; Varea, V.; Mart í nez, M.; Soler, B. An á lisis cuantitativo de la ingesta de nutrientes en niños menores de 3 años. An. Pediatr. (Barc) 2015 ,82, 255–266. [CrossRef] [PubMed] 8. Ministerio de Sanidad, Servicios Sociales e Igualdad Agencia Española de Consumo. Encuesta Nacional de consumo de Alimentos en poblaci ó n Infantil y Adolescentes (ENALIA) (2012–2014); Ministerio de Sanidad, Consumo, Igualdad y Servicios Sociales: Madrid, Spain, 2013. 9. P é rez, C.; Gil, Á .; Gonz á lez-Gross, M.; Ortega, R.; Serra-Majem, L.; Varela-Moreiras, G. Clustering of dietary patterns, lifestyles, and overweight among Spanish children and adolescents in the ANIBES study. Nutrients 2015,8, 11. [CrossRef] Nutrients 2019,11, 3050 18 of 21 10. Fern á ndez-Alvira, J.M.; Bammann, K.; Pala, V.; Krogh, V.; Barba, G.; Eiben, G.; Hebestreit, A.; Veidebaum, T.; Reisch, L.; Tornaritis, M.; et al. Country-specific dietary patterns and associations with socioeconomic status in European children: The IDEFICS study. Eur. J. Clin. Nutr. 2014,68, 811–821. [CrossRef] 11. Hebestreit, A.; Intemann, T.; Siani, A.; De Henauw, S.; Eiben, G.; Kourides, Y.A.; Kovacs, E.; Moreno, L.A.; Veidebaum, T.; Krogh, V.; et al. Dietary patterns of European children and their parents in association with family food environment: Results from the I. family study. Nutrients 2017,9, 126. [CrossRef] 12. Hebestreit, A.; Börnhorst, C.; Barba, G.; Siani, A.; Huybrechts, I.; Tognon, G.; Eiben, G.; Moreno, L.A.; Fern á ndez Alvira, J.M.; Loit, H.M.; et al. Associations between energy intake, daily food intake and energy density of foods and BMI z-score in 2–9-year-old European children. Eur. J. Nutr. 2014 ,53, 673–681. [CrossRef] 13. Dror, D.K.; Allen, L.H. Dairy product intake in children and adolescents in developed countries: Trends, nutritional contribution, and a review of association with health outcomes. Nutr. Rev. 2014 ,72, 68–81. [CrossRef] 14. Lamas, C.; Castro, M.J.; Gil-Campos, M.; Gil, A.; Couce, M.L.; Leis, R. Effects of dairy product consumption on height and bone mineral content in children: A systematic review of controlled trials. Adv. Nutr. 2019 ,10, 88–96. 15. Santaliestra-Pas í as, A.M.; Gonz á lez-Gil, E.; Pala, V.; Intemann, T.; Hebestreit, A.; Russo, P.; Van Aart, C.; Rise, P.; Veidebaum, T.; Molnar, D.; et al. Predictive associations between lifestyle behaviours and dairy consumption: The IDEFICS study. Nutr. Metab. Cardiovasc. Dis. 2019,19, 1–24. 16. Ortega, R.O.; Gonz á lez-Rodr í guez, L.; Jim é nez Ortega, A.; Perea S á nchez, J.; Bermejo L ó pez, L. N ◦ 920030, G. de investigaci ó n. Implicaci ó n del consumo de l á cteos en la adecuaci ó n de la dieta y de la ingesta de calcio y nutrientes en niños españoles. Nut. Clin. Diet Hosp. 2012,32, 28–36. 17. MERCASA. Alimentaci ó n en España 2018, 21st ed.; Ministerio de Agricultura, Pesca y Alimentaci ó n: Madrid, Spain, 2018; pp. 333–344. 18. Informe del Consumo Alimentario en España. 2018. Available online: https://www.mapa.gob.es/ es/alimentacion/temas/consumo-y-comercializacion-y-distribucion-alimentaria/panel-de-consumo- alimentario/ultimos-datos/(accessed on 1 August 2019). 19. Instituto Nacional de Estad í stica. Available online: https://www.ine.es/dyngs/INEbase/es/categoria.htm?c= Estadistica_P&cid=1254734710990 (accessed on 1 January 2018). 20. Gil-Campos, M.; Personal Comunication of Mercedes Gil-Campos, as cordinator of the Meli-Pop Proyect (Expediente PI18/0093 del Fondo de Investigaciones Sanitarias, Instituto Carlos III). Personal Comunication, 2018. 21. Fernandez-Ballart, J.D.; Pinol, J.L.; Zazpe, I.; Corella, D.; Carrasco, P.; Toledo, E.; Perez-Bauer, M.; Martinez-Gonzalez, M.A.; Salas-Salvado, J.; Martin-Moreno, J.M. Relative validity of a semi-quantitative food-frequency questionnaire in an elderly mediterranean population of spain. Br. J. Nutr. 2010 ,103, 1808–1816. [CrossRef] 22. P é rez, C.; Aranceta, J.; Salvador, G.; Varela-Moreiras, G. M é todos de Frecuencia de consumo alimentario. Rev. Esp. Nutr. Com. 2015,21, 45–52. 23. Castell, G.; Serra, L.; Ribas, L. ¿Qu é y cu á nto comemos? El m é todo Recuerdo de 24 horas. Rev. Esp. Nutr. Comunitaria 2015,2, 42–44. 24. Ortega, R.; Perez-Rodrigo, C.; Lopez-Sobaler, A.M. M é todos de evaluaci ó n de la ingesta actual: Registro o diario dietético. Nutr. Hosp. 2015,21, 34–41. 25. European Food Safety Authority (EFSA). Guidance of the EU Menu methodology. EFSA J. 2014,12, 3944. 26. Fundaci ó n Española de la Nutrici ó n (FEN). Tablas de Medidas Caseras y Raciones Habituales de Consumo; Fundación Española de la Nutrición (FEN): Madrid, Spain, 2013. 27. L ó pez, R.; Mart í nez de Victoria, E.; Gil, A.M. Gu í a Fotogr á fica de Porciones de Alimentos Consumidos en España, Universidad de Granada; Fundación Iberoamericana de Nutrición: Granada, Spain, 2019. 28. Mart í nez-Lemos, R.I.; Ay á n P é rez, C.; S á nchez Lastra, A.; Cancela Carral, J.M.; Valcarce S á nchez, R. Cuestionarios de actividad f í sica para niños y adolescentes españoles: Una revisi ó n sistem á tica. An. Sist. Sanit. Navar. 2016,39, 1137–6627. 29. Camargo, D.M.; Santisteban, S.; Paredes, E.; Fl ó rez, M.; Bueno, D.A. Confiabilidad de un cuestionario para medir actividad f í sica y comportamientos sedentarios en niños desde preescolar a cuarto grado de primaria. Biomedica 2015,35, 347–356. [CrossRef] Nutrients 2019,11, 3050 19 of 21 30. Zhao, W.; Yu, K.; Tan, S.; Zheng, Y.; Zhao, A.; Wang, P.; Zhang, Y. Dietary diversity scores: An indicator of micronutrient inadequacy instead of obesity for Chinese children. BMC Public Health 2017 ,17, 440. [CrossRef] 31. Royo-Bordonada, M.A.; Gorgojo, L.; Oyab, M.; Garc é s, C.; Rodr í guez-Artalejo, F.; Rubio, R.; Barrio, J.L. Variedad y diversidad de la dieta de los niños españoles: Estudio Cuatro Provincias. Med. Clin. 2003 ,120, 167–171. [CrossRef] 32. Vadiveloo, M.; Dixon, L.B.; Mijanovich, T.; Elbel, B.; Parekh, N. Development and evaluation of the US Healthy Food Diversity index. Br. J. Nutr. 2014,112, 1562–1574. [CrossRef] [PubMed] 33. Newby, P.K.; Tucker, K.L. Empirically derived eating patterns using factor or cluster analysis: A review. Nutr. Rev. 2004,62, 177–203. [CrossRef] [PubMed] 34. Hu, F.B. Dietary patterns an á lisis: A new direction in nutritional epidemiology. Curr. Opin. Lipidol. 2002 ,13, 3–9. [CrossRef] [PubMed] 35. Sociedad Española de la Nutrici ó n Comunitaria. Gu í a de la Alimentaci ó n Saludable, Recomendaciones para una Alimentaci ó n Individual, Familiar o Colectiva Saludable, Responsable y Sostenible, 1st ed.; Sociedad Española de la Nutrición Comunitaria: Madrid, Spain, 2018; pp. 1–32. 36. Sociedad Española de la Nutrici ó n Comunitaria, Pir á mide de la Alimentaci ó n Saludable. Available online: http://www.nutricioncomunitaria.org/es/noticia/piramide-de-la-alimentacion-saludable- senc-2015 (accessed on 5 June 2019). 37. Serra-Majem, L.; Aranceta Bartrina, J. Objetivos nutricionales para la poblaci ó n española: Consenso de la Sociedad Española de Nutrición Comunitaria 2011. Rev. Esp. Nutr. Comu. 2011,17, 178–199. 38. Fundaci ó n Española de la Nutrici ó n (FEN). Software VD-FEN 2.1 Programa de Valoraci ó n Diet é tica de la FEN; Fundación Española de la Nutrición (FEN): Madrid, Spain, 2013. 39. Moreiras, O.; Carbajal, A.; Cabrera, L. Ingestas Diarias Recomendadas de Energ í a y Nutrientes para la Poblaci ó n Española. Tablas de Composici ó n de Alimentos, 19th ed.; Ediciones Pir á mide (Grupo Anaya, SA): Madrid, Spain, 2018. 40. European Food Safety Authority. Available online: https://efsa.onlinelibrary.wiley.com/doi/epdf/10.2903/j. efsa.2013.3408 (accessed on 22 April 2018). 41. Serra-Majem, L.; Ribas, L.; Ngo, J.; Ortega, R.M.; Garc í a, A.; P é rez-Rodrigo, C.; Aranceta, J. Food, youth and the Mediterranean diet in Spain. Development of KIDMED, Mediterranean Diet Quality Index in children and adolescents. Public Health Nutr. 2004,7, 931–935. [CrossRef] 42. Roset-Sall, A.M.; Ramon-Cabot, J.; Salabarnada-Torras, J.; Pera, G.; Dalmau, A. Educational intervention to improve adherence to the Mediterranean diet among parents and their children aged 1–2 years. Public Health Nutr. 2015,19, 1131–1144. [CrossRef] 43. Krebs-Smith, S.M.; Pannucci, T.; Subar, A.F.; Kirkpatrick, S.I.; Lerman, J.L.; Tooze, J.A.; Wilson, M.M.; Reedy, J. Update of the Healthy Eating Index: HEI-2015. J. Acad. Nutr. Diet 2018,118, 1591–1602. [CrossRef] 44. Tognon, G.; Moreno, L.A.; Mouratidou, T.; Veidebaum, T.; Moln á r, D.; Russo, P.; Siani, A.; Akhandaf, Y.; Krogh, V.; Tornaritis, M.; et al. Adherence to a Mediterranean-like dietary pattern in children from eight European countries. The IDEFICS study. Int. J. Obes. 2017,2, 108–114. [CrossRef] 45. Manios, Y.; Kourlaba, G.; Grammatikaki, E.; Androutsos, O.; Moschonis, G.; Roma-Giannikou, E. Development of a diet-lifestyle quality index for young children and its relation to obesity: The Preschoolers Diet-Lifestyle Index. Public Health Nutr. 2010,13, 2000–2009. [CrossRef] [PubMed] 46. Butte, N.F.; Watson, K.B.; Ridley, K.; Zakeri, I.F.; Mcmurray, R.G.; Pfeiffer, K.A.; Fulton, J.E. A youth compendium of physical activities: Activity codes and metabolic intensities. Med. Sci. Sports Exerc. 2017 ,50, 246–256. [CrossRef] [PubMed] 47. Schofield, W.N. Predicting basal metabolic rate, new standards and review of previous work. Hum. Nutr. Clin. Nutr. 1985,39, 5–41. [PubMed] 48. Koletzko, B.; Goulet, O.; Hunt, J.; Krohn, K.; Shamir, R.; ESPGHAN; ESPEN. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J. Pediatr. Gastroenterol. Nutr. 2005,2, 1–87. 49. World Health Organization. Guidelines on Physical Activity, Sedentary Behaviour and Sleep for Children under 5 Years of Age; World Health Organization: Geneva, Switzerland, 2019. Nutrients 2019,11, 3050 20 of 21 50. World Health Organization. Global Recommendations on Physical Activity for Health; World Health Organization: Geneva, Switzerland, 2010. 51. Ministry of Health, Social Services and Equality. Physical Activity for Health and sedentary behavior reduction. Recommendations for population. In Estrategy for Health Promotion and Prevention in the National Health System; Ministry of Health, Social Services and Equality: Madrid, Spain, 2015. 52. Hirshkowitz, M.; Whiton, K.; Albert, S.M.; Alessi, C.; Bruni, O.; Doncarlos, L.; Ware, J.C. National Sleep Foundations updated sleep duration recommendations: Final report. SLEH 2015,1, 233–243. 53. Paruthi, S.; Brooks, L.; Ambrosio, C.D.; Hall, W.A.; Kotagal, S.; Lloyd, R.M.; Troester, M.M. Recommended Amount of Sleep for Pediatric Populations: A consensus statement of the American academy of sleep medicine. J. Clin. Sleep Med. 2016,12, 785–786. [CrossRef] 54. Contardo Ayala, A.M.; Nijpels, G.; Lakerveld, J. Validity of self-measured waist circumference in adults at risk of type 2 diabetes and cardiovascular disease. BMC Med. 2014,12, 170. [CrossRef] 55. Patrones de Crecimiento Infantil de la OMS. Available online: https://www.who.int/childgrowth/es/ (accessed on 2 July 2019). 56. Goldberg, G.R.; Black, A.E.; Jebb, S.A.; Cole, T.J.; Murgatroyd, P.R.; Coward, W.A.; Prentice, A.M. Critical evaluation of energy intake data using fundamental principles of energy physiology: 1. Derivation of cut-off limits to identify under-recording. Eur. J. Clin. Nutr. 1991,45, 569–581. 57. Black, A.E.; Goldberg, G.R.; Jebb, S.A.; Livingstone, M.B.; Cole, T.J.; Prentice, A.M. Critical evaluation of energy intake data using fundamental principles of energy physiology 2 Evaluating the results of published surveys. Eur. J. Clin. Nutr. 1991,45, 583–599. 58. Nelson, M.; Black, A.E.; Morris, J.A.; Cole, T.J. Between- and within-subject variation in nutrient intake from infancy to old age: Estimating the number of days required to rank dietary intakes with desired precision. Am. J. Clin. Nutr. 1989,50, 155–167. [CrossRef] 59. Black, A.E. Critical evaluation of energy intake using the Goldberg cut-offfor energy intake: Basal metabolic rate. A practical guide to its calculation, use and limitations. Int. J. Obes. 2000,24, 1119–1130. [CrossRef] 60. McGowan, L.; Pot, G.K.; Stephen, A.M.; Lavelle, F.; Spence, M.; Raats, M.; Dean, M. The influence of socio-demographic, psychological and knowledge-related variables alongside perceived cooking and food skills abilities in the prediction of diet quality in adults: A nationally representative cross-sectional study. Int. J. Behav. Nutr. Phys. Act. 2016,13, 111. [CrossRef] 61. UOE Data Collection on Formal Education, Manual on Concepts, Definitions and Classifications. Available online: http://uis.unesco.org/sites/default/files/documents/uoe2016manual_11072016_0.pdf (accessed on 15 September 2019). 62. Instituto Nacional de Estad í stica. Available online: https://www.ine.es/dyngs/INEbase/es/operacion.htm?c= Estadistica_C&cid=1254736177033&menu=ultiDatos&idp=1254735976614 (accessed on 9 October 2019). 63. Ziauddeen, N.; Page, P.; Penney, T.L.; Nicholson, S.; Kirk, S.F.; Almiron-Roig, E. Eating at food outlets and leisure places and “on the go” is associated with less-healthy food choices than eating at home and in school in children: Cross-sectional data from the UK National Diet and Nutrition Survey Rolling Program (2008–2014). Am. J. Clin. Nutr. 2018,107, 992–1003. [CrossRef] [PubMed] 64. Eldridge, A.L. FITS and KNHS overview: Methodological challenges in dietary intake data collection among infants, toddlers, and children in selected countries. Nestle Nutr. Inst. Workshop Ser. 2019 ,91, 69–78. [PubMed] 65. Varela-Moreiras, G. Libro Blanco de la Nutrici ó n en España (White Book on Nutrition in Spain); Spanish Foundation on Nutrition/Spanish Agency on Food Safety and Nutrition (AESAN, MSSSI): Madrid, Spain, 2013. 66. Ferrari, P.; Friedenreich, C.; Matthews, C.E. The role of measurement error in estimating levels of physical activity. Am. J. Epidemiol. 2007,166, 832–840. [CrossRef] [PubMed] 67. Ock é , M.; De Boer, E.; Brants, H.; Van der Laan, J.; Niekerk, M.; Van Rossum, C.; Temme, L.; Freisling, H.; Nicolas, G.; Casagrande, C.; et al. Pancake—Pilot study for the Assessment of Nutrient intake and food Consumption Among Kids in Europe. EFSA J. 2012,9, 1–120. [CrossRef] 68. Petra, A.; Hardie, L.J.; Frost, G.; Alwan, N.; Carter, M.; Elliot, P.; Ford, E.; Hancock, N.; Morris, M.; Mulla, U.; et al. Validity of an online 24-h recall tool (myfood24) for dietary assessment in population studies: Comparison with biomarkers and standard interviews. BMC Med. 2018,16, 1–14. Nutrients 2019,11, 3050 21 of 21 69. Castro Morais, D.; Sousa Moraes, L.; Guimar ã es da Silva, D.C.; Aparecida Pinto, C.; Farias de Novaes, J. Methodological aspects of dietary quality assessment in Brazil: Systematic review. Cien Saude Colet 2017 ,22, 2671–2680. 70. Example of a Protocol for Identification of Misreporting (under- and Overreporting of Energy Intake) Based on the PILOT-PANEU Project. Available online: http://www.efsa.europa.eu/sites/default/files/efsa_rep/ blobserver_assets/3944A-8-2-1.pdf (accessed on 5 October 2019). © 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).