Quantitative analysis of nutrient intake in children under 3 years old. ALSALMA study 夽,夽夽

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www.analesdepediatria.org

ORIGINAL ARTICLE

Quantitative analysis of nutrient intake in children under 3 years old. ALSALMA study ^夽,夽夽

J. Dalmau

^a

, L. Pe˜ na-Quintana

^b

, A. Moráis

^c

, V. Martínez

^d

, V. Varea

^e

, M.J. Martínez

^f

, B. Soler

^g,^∗

aUnidaddeNutriciónyMetabolopatías,HospitalInfantilLaFe,Valencia,Spain

bUnidaddeGastroenterologíayNutriciónPediátrica,HospitalUniversitarioMaternoInfantil,UniversidaddeLasPalmasdeGran Canaria,LasPalmasdeGranCanaria,Spain

cUnidaddeNutriciónInfantilyEnfermedadesMetabólicas,HospitalUniversitarioLaPaz,Madrid,Spain

dCentrodeSaludElLlano,Gijón,Asturias,Spain

eSeccióndeGastroenterología,HepatologíayNutrición,HospitalSantJoandeDéu,UnidaddeGastroenterologíaPediátrica, DepartamentdePediatría,InstitutDexeus,Barcelona,Spain

fSeccióndeGastroenterología,HepatologíayNutrición,HospitalInfantilNi˜noJesús,Madrid,Spain

gDepartamentomédico,E-C-BIOS.L.,Madrid,Spain

Received11September2014;accepted22September2014 Availableonline15April2015

KEYWORDS Nutrition;

Survey;

Nutrients;

Protein;

Spain

Abstract

Objective: Theobjectiveofthestudywastoanalysethenutritionalpatternsofchildrenunder threeyearsofageandtocomparetheresultsagainsttherecommendations forenergy and nutrientintake.

Patientsandmethods: In this cross-sectional epidemiological study, parents completed a dietarydiaryontheirfood intakeoftheir childrenon4non-consecutive days.The percent- ageofchildrenwithmeanintakesbelowtherecommendationsforeachageandnutrientwas analysedusingthe‘‘EstimatedAverageRequirement(EAR)cut-pointmethod.’’

Results:A total of186 paediatriciansincluded 1701children inthestudy.A total of95.9%

(n=1320)ofthechildrenbetween7and36monthshadaproteinconsumptionmorethantwice thatofthe RecommendedDaily Allowances.The deficienciesobserved (% <EAR)intheage groups 13---24months and25---36months, respectively,were:vitaminDin81.7% and92.1%;

vitaminEin39.3%and53.4%;folicacidin12.5%and14.8%;calciumin10.1%and5.5%;iodine in27.1% and31%.Itwas observed thatahigherpercentage inthedaily intakeofproteins (P=.013)andofcarbohydrates(P<.0001),andalowerpercentageoftotallipids(P<.0001), wererelatedtoagreaterbodymassindex,regardlessofenergyintake.

夽 Pleasecitethisarticleas:DalmauJ,Peña-QuintanaL,MoráisA,MartínezV,VareaV,MartínezM,etal.Análisiscuantitativodelaingesta denutrientesenniñosmenoresde3años.EstudioALSALMA.AnPediatr(Barc).2015;82:255---266.

夽夽PreviousPresentations:NationalCongressofPediatrics,2014:CommunicationtoCongress.

∗Correspondingauthor.

E-mailaddress:[email protected](B.Soler).

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Conclusions:ThestudypresentsaverydetailedviewoftheeatingpatternsofSpanishchildren lessthanthreeyearsofage.Theencouragementofhealthyfeedingshouldbedirectedtowards thecorrectionofthedietaryimbalancesdetected,inordertopromotethefuturehealthof children.

PALABRASCLAVE Nutrición;

Encuesta;

Nutrientes;

Proteínas;

Espa˜na

Análisiscuantitativodelaingestadenutrientesenni˜nosmenoresde3a˜nos.Estudio ALSALMA

Resumen

Objetivo:Elobjetivodelestudiofueanalizarelpatróndealimentacióndeni˜nosmenoresde3 a˜nosycompararlosresultadosconlasrecomendacionesdeconsumoenergéticoydenutrientes.

Pacientesymétodos: Enesteestudioepidemiológicotransversal,lospadrescompletaronun diariodietético sobreelconsumodealimentos desushijos,durante4díasnoconsecutivos.

Seanalizólaproporcióndeni˜nosconingestasmediasinferioresalasrecomendacionespara cadaedadynutriente,medianteelmétodo«EstimatedAverageRequirement(EAR)cut-point method».

Resultados: Participaron186pediatras,queincluyeron a1.701 ni˜nos.El95,9%(n=1320)de losni˜nosde7a36mesesconsumieronproteínasporencimadeldobledelasRecommended DietaryAllowances.Lasdeficienciasobservadas(%<EAR)enlosgruposdeedadde13-24meses y25-36meses,respectivamente,fueron:vitaminaDenel81,7yel92,1%;vitaminaEenel39,3 yel53,4%;ácidofólicoenelel12,5yel14,8%;calcioenel10,1yel5,5%;yodoenel27,1 yel31%.Seobservóqueunamayorproporciónenelconsumodiariodeproteínas(p=0,013) ydehidratosdecarbono(p<0,0001),yunamenorproporcióndelípidostotales(p<0,0001), estabanrelacionadasconunmayoríndicedemasacorporal,independientementedelconsumo energético.

Conclusiones:Elestudiomostróunavisiónmuydetalladadelospatronesdealimentaciónde losniñosespañolesmenoresde3años.Lapromocióndeunaalimentaciónsaludabledebería irdirigidaalacorreccióndelosdesequilibriosdietéticosdetectados,parafavorecerlasalud futuradelosniños.

Introduction

Nutrition is one of the main determinants of health in humans.Anadequate nutritionisessentialacrossthelife- span, but it is of particular importanceduring childhood, as nutritional deficiencies and imbalances in this period maynotonlyhavedeleteriouseffectsonchildren’shealth, butalsoimpactontheirfuturehealthasadults.Aninade- quatenutritionmayincreasetheriskofdevelopingseveral chronic disorders (cancer, high blood pressure, coronary artery disease and other cardiovascular diseases, cere- brovascular diseases, type 2 diabetes mellitus, obesity, osteoporosis) that are the main causes of morbidity and mortality.^1,2

If we take action during childhood, we can influence the learning and development of future dietary habits and lifestyle. But the first step is to observe the base- line, to recognise the deviation from the recommended dietarypatternsandassessthemagnitudeofthisproblem.

The ALSALMA study was created to this end, a three- phaseprojectdesignedtoexploretheclinicalperceptionof

paediatriciansandtheopinionofparentsregardingthemain nutritional problems in children.³ The third phase of the projectconsistedofanepidemiologicalstudy,precededby apilotstudy,⁴thepurposeofwhichwastoassesstheactual nutrientintakeofarepresentativesampleofSpanishchil- dren lessthan 3yearsofage. Thisstudy isthe firstofits kindinthisagegroupinSpain,andthisarticlepresentsthe resultsofthequantitativeanalysisofnutrientintakes.

Methods

Studydesignandethicalprinciples

We designed an observational cross-sectional epidemiological study adhering to the principles applicable to observational studies in Spain and to the Declaration of Helsinki.ThestudywasapprovedbytheEthicsBoardofthe HospitalClíniciProvincialdeBarcelona (2.013/8.152).All parents signed an informed consent to participatein the study.

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Selectioncriteria

Thesample sizewascalculatedonthebasisoftheenergy intakedataobtainedintheALSALMA-pilot study,⁴ andthe minimumsizewasestimatedtobe200children0---6months of age (precision, 24.08; power [ˇ], 81.3%); 200 children 7---12monthsofage(precision, 32.57;ˇ,85.3%);800chil- dren13---24monthsofage(precision,22.41;ˇ86.5%),and 800 children 25---36 months of age (precision, 25.32; ˇ, 87.2%).Thesamplewasstratifiedbyprovince.⁵

The parentsincluded inthestudyhadtohavechildren thatmetthefollowingcriteria:(a)ofanyethnicityorsex;

(b)0---36monthsofage;(c)meetingthecriteriaforahealthy child, with no chronic condition that might affect their dietaryintake,and(d)notfollowingaspecificdiet.

Datacollection

We designed a 24-h dietdiary for theparents, who were instructed by the paediatricians on how to complete it, writingdownthetypeoffood,timeofday,andquantities consumed.Thediaryincludedtheweightofthefoods,mea- sureduncookedandunpeeled.Thefullnameofproductand brandwasrecordedforprocessedchildnutritionproducts.

Whenthevolumeofbreastmilkcouldnotbemeasured,it wasestimatedaccordingtothechild’sage:700---900mL/day inchildrenyoungerthan6monthsand600mL/dayinchil- drenolderthan6months.^6,7

Thediarieswerecompletedover4non-consecutivedays during the week and at the weekend. The paediatricians recorded the child’sdate of birth, sex, birth and current weightandheight,weeksofgestation,physicalactivitylevel (light,moderate,vigorous),whetherthechildateattheday care centre, and intake of vitamin supplements(descrip- tionanddosage).Theanthropometricdataoftheparents, whetherthemothersmokedduringthepregnancy,andthe parents’educationallevelwerealsorecorded.

Qualitycontrol

Theinformationcollectedinthediarieswasreviewedbythe paediatricians,whoenteredthedatainthestudy’swebsite (www.estudioalsalma.es). A centralised quality control of thedatawasperformedbyaspeciallytrainedcoordinating medicalteam.

Statisticalanalysis

We analysedthe frequencies andpercentages for qualita- tivevariables,andthemean±standarddeviation,median, minimum,maximum,and95%confidenceintervalforquan- titativevariables.

Weconvertedeachconsumedfoodtoitsmacronutrient andenergycontentsusingtheDIALfoodsdatabaseandother Spanish and international databases, analysing the edible portion.^8---11 We createda newdatabaseof morethan460 nutritiondatasheetswiththecompositionofchildformulas andnutritionproducts.

We calculated the mean daily intakeof energy andof eachnutrientbasedonthedatacollectedinthediariesusing

repeated-measuresplit---plotanalysisofvariance(ANOVA).

Westudiedtheenergyintakeprofileorenergydistribution bymacronutrientforevery100kcal.

Wecomparedthe resultsof ourstudywiththe Dietary Reference Intake (DRI) recommendations of the National AcademyofSciences(2002/2005)andtherecommendations oftheComitédeNutricióndelaAsociaciónEspa˜noladePedi- atría(CommitteeonNutritionoftheSpanishAssociationof Paediatrics).^12---14Thecalculationsfortheestimatedaverage requirement(EAR)ofenergyweremadebasedonweightand sexforchildren7---11monthsofage,andbasedonthechild’s sexforchildrenolderthan12months.Wedidnotcalculate theenergyEAR for infants youngerthan 6 months,which canonlybeevaluatedinexclusivelybreastfedinfants.¹⁵We usedtheEstimatedAverageRequirementcut-pointmethod, whichisrecommendedbytheInstituteofMedicine¹⁶andwas adoptedbytheEFSAin2010,¹⁷todeterminethepopulation prevalenceofintakesbelowthoserecommended.

We used one-factor ANOVA to analyse differences in weight, height and body mass index (BMI) between age groups,usingaBonferroniorGamesHowelladjustmentto correct for multiple comparisons. Proportions were com- pared by means of Fisher’s exact test or the chi square test.

Weconductedtheexploratoryassessmentsoftheasso- ciation between nutrient intake and BMI by means of a multiple linear regression analysis that included all the variables recorded for children and their parents.

Macronutrients wereassessed by the mean intakeand by contributiontothetotalenergyintakeusingdifferentequa- tions. We adjusted the significance levels based on the numberofvariablesincludedintheequation.

Wesetthelevelofsignificanceat.05.Thesoftwareused inthestatisticalanalysiswasSPSS14.0,C-SIDE(IowaState University)fortheEARassessment,andWHOAnthroforthe anthropometricassessment.¹⁸

Results

Sampledata

Therewere 186 participatingpaediatricians that included 1701childreninthestudybetweenApril4andOctober14, 2013. The sample reached 85% of the initial sample size estimation(2000children;power>80%). Thedata of1559 children,whoamounted to91.7% ofthepatientsselected forthestudy,wasvalidandcouldbeusedinthenutritional analysis.

Demographicandanthropometricdataofthe children

The sample, which included children from 51 provinces, matched thenational distribution and wasrepresentative oftheSpanishpopulation.¹⁹ Outofall children,54%were male(n=919) and 46% female(n=782), withamean age of20 months(95%CI,19.5---20.5) andamedian age of20 months;99.9%wereCaucasian(n=1699).Theagedistribu- tionwas:10.8% (n=183)0---6months;10.9%(n=186)7---12 months;40.6%(n=690)13---24 months;and37.7%(n=642) 25---36months.

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Table1 Meannutrientintakesandproportionofchildrenyoungerthan6monthswithinadequateintakesbelowtheEARsor abovetheULs.

Nutrientsperday DRI Age0---6months,N=172

EAR RDA AI UL Meanintake(95%CI) Medianintake %<EAR %>UL

Energy(kcal) --- --- --- --- 611.6(568.6---654.6) 580.8 --- ---

Proteins(g) --- --- 9.1^a --- 12.3(10.3---14.3) 10.9 --- ---

Carbohydrates(g) --- --- 60 --- 71.3(65.5---77.2) 63.7 --- ---

Lipids(g) --- --- 31 --- 30.6(28.3---33) 29.6 --- ---

Saturatedfats(g) --- NS --- --- 25.6(23.5---27.6) 14.7 --- ---

Monounsaturatedfats(g) --- NS --- --- 7.7(6.4---9) 10.1 --- ---

Polyunsaturatedfats(g) --- NS --- --- 3.9(3.6---4.2) 3.9 --- ---

Cholesterol(mg) --- NS --- --- 121.5(108.9---134) 160.9 --- ---

Fibre(g) --- NS --- --- 9.6(8.5---10.7) 0.6 --- ---

Water(mL)^b --- --- 700 --- 745.7(698---793.5) 727.1 --- ---

VitaminA(␮g) --- --- 400 600 620.7(566.2---675.3) 568.2 --- 41.9

VitaminC(mg) --- --- 40 --- 72.8(66.6---79.1) 64.4 --- ---

VitaminD(␮g) --- 10 --- 25 6.1(5.2---6.9) 1.6 --- 2.3

VitaminE(mg) --- --- 4 --- 5.8(5.3---6.3) 3.3 --- ---

VitaminK(␮g) --- --- 2 --- 25.7(19.4---32) 9.5 --- ---

VitaminB1(mg) --- --- 0.2 --- 0.4(0.3---0.5) 0.2 --- ---

VitaminB2(mg) --- --- 0.3 --- 0.6(0.5---0.7) 0.4 --- ---

Niacin(mg) --- --- 2 --- 5.4(4.4---6.3) 4.3 --- ---

VitaminB6(mg) --- --- 0.1 --- 0.4(0.3---0.4) 0.2 --- ---

Folicacid(␮g) --- --- 65 --- 89.1(78---100.2) 76.6 --- ---

VitaminB12(␮g) --- --- 0.4 --- 0.9(0.6---1.1) 0.6 --- ---

Pantothenicacid(mg) --- --- 1.7 --- 1.1(1---1.3) 1.4 --- ---

Biotin(␮g) --- --- 5 --- 3.6(2.3---4.8) 3.9 --- ---

Copper(mg) --- --- 0.2 --- 0.3(0.3---0.4) 0.3 --- ---

Iodine(␮g) --- --- 110 --- 61.9(57.6---66.2) 51.3 --- ---

Iron(mg) --- --- 0.27 40 3.5(2.8---4.1) 1.1 --- 0

Magnesium(mg) --- --- 30 --- 41.4(34.7---48.2) 32.7 --- ---

Calcium(mg) --- --- 200 1000 350.2(315.6---384.7) 297.3 --- 0.6

Phosphorus(mg) --- --- 100 --- 201.5(163.6---239.3) 157.9 --- ---

Sodium(mg) --- --- 120 --- 170.7(99.1---242.2) 130.8 --- ---

Potassium(mg) --- --- 400 --- 556.6(483.8---629.3) 461.7 --- ---

Selenium(␮g) --- --- 15 45 36.9(27.4---46.5) 22.4 --- 0

Zinc(mg) --- --- 2 4 7.2(6.6---7.9) 1.7 --- 39.5

DRImetthroughdiet;^11---13EARrepresentstheaveragedailynutrientintakelevelestimatedtomeettherequirementofhalfthehealthy individualsinaparticularlifestageandsexgroup;NS,therearenocurrentrecommendationsforthisnutrientinthisagegroup;RDAis thereferencevalueforeachnutrientsufficienttomeettherequirementsof97---98%ofhealthyindividualsinaparticularlifestageor sexgroup;AIisthevalueestimatedtomeettherequirementsofallhealthyindividualsineachagegroupbasedonobservationsmadein apparentlyhealthyindividualsforwhichitisassumedtobeadequate.Thisvalueisusedasareferenceintheabsenceofanestablished EARforagivennutrientandagegroup;ULrepresentsthehighestaveragedailynutrientintakelevelthatislikelytoposenoriskof adversehealtheffectstoalmostallindividualsinthegeneralpopulation.AsintakeincreasesabovetheUL,thepotentialriskofadverse effectsmayincrease.

AI:AdequateIntake;DRI:DietaryReferenceIntakes;EAR:Estimated AverageRequirement;95%CI:95%confidenceinterval forthe mean;NS:notspecified;RDA:RecommendedDietaryAllowances;UL:TolerableUpperIntakeLevel;%<EAR:prevalenceorproportionof individualswithmeanintakesbelowtheEARsintheanalysisofinadequatedietaryintakes;%>UL:prevalenceorproportionofindividuals withmeandailyintakesofthenutrientabovetheULintheanalysisofthepopulationatpotentialriskofsufferingadverseeffectsdue toexcessiveintakeofthenutrient.

aThecalculationofAIinthisagegroupisbasedon1.5g/kg/day.

b Drinkingwaterandwatercontainedinfoodsandbeverages.

The mean gestational age was 39 weeks (95% CI, 38.9---39.1;median39),withnodifferencesbetweensexes oragegroups.

Wedidnotobserveanydifferencesinthebirthweight, heightor BMI between children in the 4 age groups. The

currentBMIofchildrenwas16.5kg/m²(95%CI,16.4---16.6).

UsingthestandardsoftheWorldHealthOrganization(WHO Anthro)asareference,wedeterminedthat6.1%ofthechil- drenwere2standarddeviations(SDs)abovethemeanBMI (95%CI,4.2---8.7%)and1.5%ofthechildrenwere3SDsabove

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ZINC

Selenium

Phosphorus

Calcium

Magnesium

Iron

Iodine

Copper

VITB12

Folate

VITB6

Niacin

VITB2

VITB1

VITE

VITD

VITC

VITA

Carbohydrates

Proteins ZINC

Selenium

Phosphorus

Calcium

Magnesium

Iron

Iodine

Copper

VITB12

Folate

VITB6

Niacin

VITB2

VITB1

VITE

VITD

VITC

VITA

Carbohydrates

Proteins

900 800 700 600 500 400 300 200 100 0

Mean percentage of adherence to DRI (RDA) and 95% CI Mean percentage of adherence to DRI (RDA) and 95% CI

227 205 196 114 192 152 91 184 322

132 279 324 292 199 107 41 702

288

114 370

Age group: 13–24 months

222 290 233 122 225 136 87 212 435

118 282 367 314 194 91 25 555

230 117 441

Age group: 25–36 months 900

800 700 600 500 400 300 200 100 0

Figure1 MeanpercentageofadherencetoDRIs(RDAs)inthedailynutrientintake.Anadequate adherencetoDRIs(RDA/AI) correspondsto a100%adherence(horizontal line at100%).Valuesbelow100%representenergy ornutrient intakesbelowthe recommendedvalues.Valuesabove100%representenergyornutrientintakesabovetherecommendedvalues.

(1.1---2.1%). The physical activity level was light in 15.2%

of the children (n=259), moderate in 53.9% (n=916) and vigorousin30.9%(n=526).

Ofallchildren,32.9%(n=559)ateatthedaycarecentre.

Thisproportionincreasedsignificantlywiththechild’sage (P<.0001).

Also, 14.6% of the children (n=248) tookvitamin supplements, in greater proportionthe younger the children (P<.01).ThesupplementwasvitaminD3in74.5%ofthem (n=173children).

Parentdata

Themeanagewas34.7yearsinmothers(95%CI,34.5---34.9;

median 35) and 36.8 years in fathers (95% CI, 36.5---37;

median36).Ofallmothers,7.2%smokedduringpregnancy (n=123). The educational level of mothers and fathers, respectively,was:nostudies0.1%,0.2%;elementaryschool 6.8%, 9.2%; secondary education 14.5%, 16.2%; middle vocationaleducation14.3%,16.2%;superiorvocationaledu- cation 12.8%,15.3%,and post-secondaryeducation51.4%, 42.9%.

Mean daily energyand nutrient intakeand comparison withDietaryReferenceIntakes(EstimatedAverageRequire- mentandUpperlimits)

We analysed 76,472 intakes of 1265 different foods.

Tables1---4summarisetheresultsofthemeandailyintake foreachmacronutrientbyagegroupandtheproportionof childrenwithintakesbelowtheEARorabovetheupperlimit (UL).^11---13

PercentageofadherencetoRecommendedDietary Allowances

Fig.1showstheresultsoftheanalysisofthemeanpercent- ageandthe95%CIfortheadherencetoRDAsfrom13months ofage.At7---12months,themeanpercentageofadherence

toRDAs was267%(95% CI,254---279) forprotein,91%(95%

CI,84---98)foriron,and157%(95%CI,149---166)forzinc.

Theproportionofadherenceforenergyintakewas135%

(95%CI,130---140)inthe7---12month group,123%(95%CI, 121---125) in the 13---24 month group, and 124% (95% CI, 122---126)in the25---36 monthgroup. Adherencewas125%

(95%CI,123---127)inchildren7---36monthsofage.

Proportionofchildrenwithenergyandprotein intakesabovetheRecommendedDietary Allowances

Table5showstheproportionofchildrenwithenergy(EAR) andprotein(RDA)intakes1/3(133---166%),2/3(166---200%) andtwice(>200%)abovetheDRI.

Analysisoftheenergydistribution

Fig.2showstheproportionofenergycontributedbyeach macronutrient per 100kcal consumedby age andtime of day.Weobservedasignificantincreaseintheproportionof energycontributedbyproteinsasageincreased(P<.05),as wellasasignificantreductioninthelipidcontributiontothe energyintake(P<.05).Wedidnotobserveanydifferences inthecarbohydratecontributiontothetotalenergyintake betweentheagegroups.

Relationshipbetweenbodymassindexand nutrientintake

Weperformedamultiplelinearregressionanalysistostudy thevariables with a potentialassociation tocurrent BMI.

Thedataof1495childrenwerevalidandcouldbeusedin the analysis (r²=0.069). We found that BMI decreased as the child’s age increased, an association that was statis- tically significant (0.024kg/m² per month of age;95% CI, 0.011---0.037; P<.0001). The BMI was lower in girls than in boys (0.293kg/m²; 95% CI,0.112---0.475; P=.002). The

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Table2 Meannutrientintakesandproportionofchildren7---12monthsofagewithinadequateintakesbelowtheEARsorabove theULs.

Energy(kcal) ^a --- --- --- 927.2(884.3---970.1) 912.4 14.2 ---

Proteins(g) 1g/kg 11 --- --- 29.4(27.4---31.4) 28.4 0.6 ---

Carbohydrates(g) --- --- 95 --- 129.3(123.4---135.1) 127.6 --- ---

Lipids(g) --- --- 30 --- 30.7(28.4---33) 29.7 --- ---

Monounsaturatedfats(g) --- NS --- --- 7.8(6.3---8.9) 6.8 --- ---

Polyunsaturatedfats(g) --- NS --- --- 4(3.7---4.3) 3.9 --- ---

Cholesterol(mg) --- NS --- --- 85.9(73.4---98.4) 62.4 --- ---

Fibre(g) --- NS --- --- 10.1(9---11.2) 10.2 --- ---

Water(mL)^b --- --- 800 --- 817.2(769.5---864.8) 817.2 --- ---

VitaminA(␮g) --- --- 500 600 1004.7(950.3---1059.1) 938.5 --- 89.6

VitaminC(mg) --- --- 50 --- 117.5(111.3---123.7) 113.7 --- ---

VitaminD(␮g) --- 10 --- 38 7.6(6.8---8.5) 7.4 --- 0

VitaminE(mg) --- --- 5 --- 7.4(6.9---7.9) 7.2 --- ---

VitaminK(␮g) --- --- 2.5 --- 92.7(86.4---99) 85.6 --- ---

VitaminB1(mg) --- --- 0.3 --- 1.1(1---1.2) 0.8 --- ---

VitaminB2(mg) --- --- 0.4 --- 1.1(1---1.2) 1 --- ---

Niacin(mg) --- --- 4 --- 13.5(12.5---14.5) 12 --- ---

VitaminB6(mg) --- --- 0.3 --- 1.2(1.1---1.2) 1 --- ---

Folicacid(␮g) --- --- 80 --- 182.6(171.5---193.8) 172.2 --- ---

VitaminB12(␮g) --- --- 0.5 --- 1.7(1.4---1.9) 1.5 --- ---

Pantothenicacid(mg) --- --- 1.8 --- 1.8(1.6---2) 1.6 --- ---

Biotin(␮g) --- --- 6 --- 7.6(6.3---8.9) 6.9 --- ---

Copper(mg) --- --- 0.22 --- 0.5(0.5---0.52) 0.5 --- ---

Iodine(␮g) --- --- 130 --- 77.8(73.5---82.1) 73.9 --- ---

Iron(mg) 6.9 11 --- 40 10.1(9.4---10.8) 9 27.7 0

Magnesium(mg) --- --- 75 --- 106.4(99.6---113.2) 101.6 --- ---

Calcium(mg) --- --- 260 1500 596.1(561.7---630.6) 577.8 --- 0.6

Phosphorus(mg) --- --- 275 --- 533(495.2---570.7) 500.7 --- ---

Sodium(mg) --- --- 370 --- 640.7(569.3---712.1) 617.1 --- ---

Potassium(mg) --- --- 700 --- 1390.7(1318.1---1463.3) 1354.4 --- ---

Selenium(␮g) --- --- 20 60 27(17.5---36.5) 24.8 --- 1.2

Zinc(mg) 2.5 3 --- 5 4.7(4.03---5.4) 4.6 9.2 41

DRImetthroughdiet;^11---13EARrepresentstheaveragedailynutrientintakelevelestimatedtomeettherequirementofhalfthehealthy individualsinaparticularlifestageandsexgroup;NS,therearenocurrentrecommendationsforthisnutrientinthisagegroup;RDAis thereferencevalueforeachnutrientsufficienttomeettherequirementsof97---98%ofhealthyindividualsinaparticularlifestageor sexgroup;AIisthevalueestimatedtomeettherequirementsofallhealthyindividualsineachagegroupbasedonobservationsmade inapparentlyhealthyindividualsandthatissupposedtobeadequate.Thisvalueisusedasareferenceintheabsenceofanestablished EARforagivennutrientandagegroup;ULrepresentsthehighestaveragedailynutrientintakelevelthatislikelytoposenoriskof adversehealtheffectstoalmostallindividualsinthegeneralpopulation.AsintakeincreasesabovetheUL,thepotentialriskofadverse effectsmayincrease.

aThecalculationoftheEARwasmadebasedontheage,sexandweightofthechild.

childrenthathadhigherBMIsat birthalsohadhighercur- rent BMIs (0.222kg/m²: 95% CI, 0.159---0.284; P<.0001).

Higherlevelsof physical activity correlatedtolowerBMIs (0.148kg/m²;95%CI,0.002---0.295;P=.048).Highercurrent energyintakes were associated with higher current BMIs, aseachadditional100kcalinenergyintakewasassociated

with a 0.5kg/m² increase in IMC (95% CI, 0---1; P=.032).

Higher dietary lipid intakes were significantly associated withlowerBMIs(0.054kg/m²;95%CI,0.012---0.97;P=.013).

We observed that higher contributions of protein to the total energy intake were associated to higher BMIs (0.029kg/m²; 95% CI, 0.006---0.051; P=.013). Higher

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Table3 Meannutrientintakesandproportionofchildren 13---24monthsofagewithinadequateintakesbelowtheEARsor abovetheULs.

Energy(kcal) ^a 1240.1(1217.3---1262.9) 1211 20.3 ---

Proteins(g) 0.87g/kg 13 --- --- 47.9(46.9---49) 46.3 0 ---

Carbohydrates(g) 100 130 --- --- 148.1(145---151.2) 143 9.5 ---

Lipids(g) --- NS --- --- 48.3(47.1---49.5) 46 --- ---

Monounsaturatedfats(g) --- NS --- --- 17.9(17.2---18.6) 16.8 --- ---

Cholesterol(mg) --- NS --- --- 177.4(170.8---184.1) 166.9 --- ---

Fibre(g) --- --- 19 --- 11.2(10.6---11.8) 10.9 --- ---

Water(mL)^b --- --- 1300 --- 936.7(911.3---962) 924.5 --- ---

VitaminA(␮g) 210 300 --- 600 856.8(827.9---885.7) 822.1 1.3 73.8

VitaminC(mg) 13 15 --- 400 105(101.7---108.3) 103.2 0.3 0

VitaminD(␮g) 10 15 --- 63 6.1(5.6---6.6) 5.2 81.7 0.2

VitaminE(mg) 5 6 --- 200 6.4(6.1---6.7) 5.9 39.3 0

VitaminK(␮g) --- --- 30 --- 88.4(85---91.7) 81.5 --- ---

VitaminB1(mg) 0.4 0.5 --- --- 0.99(0.95---1) 0.9 4.3 ---

VitaminB2(mg) 0.4 0.5 --- --- 1.5(1.4---1.5) 1.4 1.1 ---

Niacin(mg) 5 6 --- 10 19.4(18.8---19.9) 18.6 0.6 94.2

VitaminB6(mg) 0.4 0.5 --- 30 1.4(1.3---1.4) 1.3 0.6 0

Folicacid(␮g) 120 150 --- 300 197.3(191.3---203.2) 185.2 12.5 9.6

VitaminB12(␮g) 0.7 0.9 --- --- 2.9(2.8---3) 2.8 0.8 ---

Pantothenicacid(mg) --- --- 2 --- 3.04(3---3.1) 2.8 --- ---

Biotin(␮g) --- --- 8 --- 15.9(15.2---16.5) 13.5 --- ---

Copper(mg) 0.26 0.34 --- 1 0.6(0.6---0.64) 0.6 2.7 4.8

Iodine(␮g) 65 90 --- 200 81.9(79.6---84.1) 79.9 27.1 0.3

Iron(mg) 3 7 --- 40 10.6(10.3---11) 9.7 1.4 0.2

Magnesium(mg) 65 80 --- --- 152.9(149.3---156.5) 151.3 2.1 ---

Calcium(mg) 500 700 --- 2500 795.1(776.8---813.4) 784.6 10.1 0

Phosphorus(mg) 380 460 --- 3000 900.5(880.4---920.5) 883 1.8 0

Sodium(mg) --- --- 1000 1500 1148.3(1110.4---1186.3) 1092 --- 17.7

Potassium(mg) --- --- 3000 --- 1877.6(1839---1916.2) 1859 --- ---

Selenium(␮g) 17 20 --- 90 45.3(40.2---50.4) 42.9 3.2 2.4

Zinc(mg) 2.5 3 --- 7 6.1(5.8---6.5) 6 1.4 28.9

AI:AdequateIntake;DRI:DietaryReferenceIntakes;EAR:EstimatedAverageRequirement;95%CI:95%confidenceinterval forthe mean;NS:notspecified;RDA:RecommendedDietaryAllowances;UL:TolerableUpperIntakeLevel;%<EAR:prevalenceorproportionof individualswithmeanintakesbelowtheEARsintheanalysisofinadequatedietaryintakes;%>UL:prevalenceorproportionofindividuals withmeandailyintakesofthenutrientabovetheULintheanalysisofthepopulationatpotentialriskofsufferingadverseeffectsdue toexcessiveintakeofthenutrient.

a ThecalculationoftheEARwasmadebasedontheageandsexofthechild.

contributions of carbohydrates were associated with higherBMIs (0.021kg/m²; 95%CI,0.009---0.033; P<.0001).

Higher contributions of lipids corresponded to lowerBMIs (0.028kg/m²;95%CI,0.016---0.039;P<.0001).

Our analysis of the relationship between BMI and the mean daily micronutrient intake (r²=0.095) showed that higherintakesofvitaminDcorrelatedtolowerBMIs(4.4␮g, 95%CI,1.9---10.2,P=.001).

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Table4 Meannutrientintakesandproportionofchildren25---36months ofagewithinadequateintakesbelowtheEARsor abovetheULs.

Nutrients DRI Age25---36months,N=584

Energy(kcal) ^a 1413(1389.6---1436.4) 1407.8 19 ---

Proteins(g) 0.87g/kg 13 --- --- 57.6(56.5---58.6) 56.4 0 ---

Carbohydrates(g) 100 130 --- --- 152.1(148.9---155.3) 151 8.8 ---

Lipids(g) --- NS --- --- 61.5(60.3---62.8) 60.4 --- ---

Saturatedfats(g) --- NS --- --- 22.9(21.7---24) 22.5 --- ---

Monounsaturatedfats(g) --- NS --- --- 25.7(25---26.4) 24.4 --- ---

Cholesterol(mg) --- NS --- --- 230(223.2---236.9) 227.8 --- ---

Fibre(g) --- --- 19 --- 11(10.4---11.6) 10.7 --- ---

Water(mL)^b --- --- 1300 --- 1006.1(980.2---1032.1) 929.8 --- ---

VitaminA(␮g) 210 300 --- 600 692.5(662.8---722.1) 646.6 1.4 57.6

VitaminC(mg) 13 15 --- 400 83.7(80.3---87.1) 74.8 0.2 0

VitaminD(␮g) 10 15 --- 63 3.8(3.3---4.3) 2.3 92.1 0

VitaminE(mg) 5 6 --- 200 5.5(5.2---5.8) 4.8 53.4 0

VitaminK(␮g) --- --- 30 --- 72.4(69---75.8) 64.3 --- ---

VitaminB1(mg) 0.4 0.5 --- --- 0.99(0.91---1) 0.9 1.6 ---

VitaminB2(mg) 0.4 0.5 --- --- 1.6(1.5---1.6) 1.5 0.5 ---

Niacin(mg) 5 6 --- 10 22.1(21.6---22.7) 21.3 0 97.8

VitaminB6(mg) 0.4 0.5 --- 30 1.4(1.4---1.5) 1.3 0.2 0

Folicacid(␮g) 120 150 --- 300 177.4(171.3---183.4) 165.1 14.8 4.5

VitaminB12(␮g) 0.7 0.9 --- --- 3.9(3.8---4) 3.4 0 ---

Pantothenicacid(mg) --- --- 2 --- 3.8(3.7---3.9) 3.7 --- ---

Biotin(␮g) --- --- 8 --- 21.4(20.7---22.1) 21.3 --- ---

Copper(mg) 0.26 0.34 --- 1 0.7(0.7---0.74) 0.7 1.4 11

Iodine(␮g) 65 90 --- 200 78.3(76---80.7) 74.4 31 0.2

Iron(mg) 3 7 --- 40 9.6(9.2---9.9) 8.6 0.5 0

Magnesium(mg) 65 80 --- --- 180.4(176.7---184.1) 178.2 1.2 ---

Calcium(mg) 500 700 --- 2500 858.6(839.8---877.4) 836.6 5.5 0

Phosphorus(mg) 380 460 --- 3000 1073.3(1052.8---1093.9) 1062.6 0.9 0

Sodium(mg) --- --- 1000 1500 1452.4(1413.5---1491.3) 1353.4 --- 38.3

Potassium(mg) --- --- 3000 --- 2097.5(2058---2137.1) 2066.1 --- ---

Selenium(␮g) 17 20 --- 90 58.4(53.2---63.6) 56.4 0.7 7.1

Zinc(mg) 2.5 3 --- 7 6.7(6.3---7.1) 6.4 0.7 37.1

aThecalculationoftheEARwasmadebasedontheageandsexofthechild.

Discussion

The high protein intake in children’s diets was the most remarkablefindingof ourstudy.Similarresultshave been found in other European countries(Table 6)for thesame agegroups.²⁰DatafromtheUnitedStatesarealsosimilar.²¹

The percentage of children that consumed more than twicetherecommendeddailyamountofproteinwas95.9%

(Table5).Althoughcurrentevidenceisinsufficienttoestab- lishupperlimits(ULs)forproteinintake,theEFSAestimates thanintakesuptotwicetherecommendedvaluearesafe in adults.²⁰ Proteincontributionsabove20%of theenergy

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Table5 Energyandproteinintake:proportionofchildrenwithvaluesabove133%,166%and200%oftheEARsandRDAs.

Agegroup Energy(kcal)

ProportionabovetheEAR

Protein(g)

ProportionabovetheRDA

>133%<166%

N(%)

>166%<200 N(%)

>200%

N(%)

>133%<166%

N(%)

>166%<200 N(%)

>200%

N(%)

7---12months 63(35.8) 19(10.8) 8(4.5) 10(5.8) 19(11) 142(82)

13---24months 152(24) 39(6.2) 10(1.6) 3(0.5) 15(2.4) 605(97.1)

25---36months 166(28.4) 31(5.3) 9(1.5) 3(0.5) 5(0.9) 573(98.8)

7---36months 381(27.5) 89(6.4) 27(2) 16(1.2) 39(2.8) 1320(95.9)

EAR:minimumreferencevaluethatmeetstherequirementsof50%ofthepopulationforeachagegroup.

RDA:referencevaluethatmeetstherequirementsof97---98%ofhealthyindividualsforeachagegroup.

EAR:EstimatedAverageRequirement;RDA:RecommendedDietaryAllowances.

intakecanseriously impairthewaterbalanceinchildren, sohighproteinintakes mustbeavoided,especiallyin the first year of life.²⁰ Our study showed that the mean pro- teinintakewas370%oftherecommendedintakeinchildren 13---24monthsofage,and441%oftherecommendedintake inchildren25---36monthsofage(Fig.1),thatis,intakesup to4timestherecommendedvalues.Thisincreasingtrendin proteinintakehasalsobeenobservedinchildrenbetween1 and3yearsofageinotherEuropeancountries,withenergy intakesof131%oftheRDA/adequateintake(AI)inItaly,²² 138%inFrance,²³and284%intheUnitedKingdom.²⁴Yetthe contribution ofproteindid notgoover 20% of theenergy

intakeinanyagegroup(Fig.2A),demonstratinganadequate energydistributionoverall,albeitwithatendency tocon- sumemoreproteinasageincreases,especiallyduringlunch andsupper(Fig.2B).Thehighabsolutevaluesoftheprotein intakecouldbeduetoanexcessiveenergyintake,asthey exceededrecommendedvaluesby135%at7---12months,by 123%at13---24monthsandby124%at 25---36months.Fur- thermore,27.5%ofchildrenhadenergyintakes1/3greater thantherecommendedvalues(Table5).Wemusttakeinto accountthattheintake recommendationsfor proteinand othernutrientsarebasedonthedeterminationofminimum valuesbelowwhichintakeswouldbeinsufficientandcould

0 10 20 30 40 50 60 70 80 90

A 100

B

0 10 20 30 40 50 60 70 80 90 100

0-6 months 7-12 months 13-24 months 25-36 months

Lipids proteins Carbohydrates Breakfast Mid-morning

snack

Lunch Afternoon snack

Dinner Evening snack

Between meals

Figure2 Energydistribution:energycontributionoflipids,proteins,andcarbohydratesbyagegroup(A)andtimeofday(B),per 100kcalofenergyintake.

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Table6 Proteinintakeinchildren1---3yearsofageinEuropeancountries.

Country Age N^a Meanprotein

intake(g/day)^a

SD^a

Belgium(HuybrechtsanddeHenauw,2007) 2.5---3years 102/95 62.5/57.7 11.3/11.3

Bulgaria(Abrashevaetal.,1998) 1---3years 154 39.4 14.8

Denmark(Andersenetal.,1996) 1---3years 129/149 52/54 NS

Finland(Kyttäläetal.,2010) 1year 257/198 35/34 11/8

2years 112/118 43/44 12/11

3years 236/235 49/46 12/44

Greece(Manios,2006) 12---24months 100/107 52.2/50.5 10.7/9.6

25---36 months 274/226 57.8/55.2 11.7/12.6

37---48 months 488/434 59.8/56.9 12.7/12.6

Netherlands(Ockeetal.,2008) 2---3years 327/313 44/43 NS

Netherlands(deBoeretal.,2006) 9months 333 28.8 6.2

12months 306 36.5 8.3

18months 302 43.1 6.5

UnitedKingdom(Batesetal.,2011) 1.5---3years 219 42.6 11.1

Italy(Setteetal.,2010) 0---3years 52 41.5 18

Norway(KristiansenandAndersen,2009) 2years 829/826 50.8/48.6 14.9/14.9

Poland(Szponaretal.,2003) 1---3years 70/48 46.4/41.2 21.3/13.4

SD:standarddeviation;NS:notspecified.

aDataforbothsexesorforboys/girls.

TakenfromtheEFSAPanelonDieteticProducts,NutritionandAllergies(NSA).²⁰

leadtonutritionaldeficiencies. More specifically,the cal- culation of the recommended protein intake is based on an adequate nitrogen balance.²⁰ An association between highproteinintakesandgreaterweightsinchildrenyounger than2yearshasbeenreported,²⁵ whichincreasestherisk offutureobesity.^26---30 It isbelievedthat proteinconsump- tionstimulates the secretionof insulin-like growth factor i,whichleadstocellularproliferation,acceleratedgrowth andincreasedbodyfat.^30,31Inthisregard,ourstudyshowed thathigher contributionsof protein andcarbohydrates to thetotalenergyintakewereassociatedwithasignificantly higherBMI.Weobservedarateof overweightandobesity (>2SD)of 6.1%.The most recent dataon8-year-old chil- dreninSpain(ALADINOstudy)showedan11.6%prevalence ofobesity.³²Thismeansthattheprevalenceofobesitydou- blesbetween3and8yearsofage.This isacrucialperiod forinterventionandtocounselchildrenandparentsonwhat constitutesabalanceddiet,asitisthetimewhenchildren developtheirdietaryhabits.

We observed the most important deficiencies in the vitamin D intake in 81.7% and 92.1% of the children (Tables3and4).Theuseofvitaminsupplementswaslower from12monthsofage,sothesewereactualdeficiencies.

Thisfindingmaybeimportantwhenitcomestofuturehealth inlightoftheassociationbetweenvitaminD andrisk fac- torsforcardiovascularandmetabolicdisease.^33,34Ourstudy alsoshowedaninversecorrelationbetweenvitaminDintake andBMI.Thisfindingisconsistentwiththeresultsofdiffer- entstudies onincreasedbodyfat anditsassociation with vitaminD.^35---38

We observed that 27.1% of children 13---24 months of age and 31% of children 25---36 months of age had iodine intakes belowthe EAR. Iodine deficiencyis considered to be the most frequent and preventable cause of intellec- tualdisability. AlthoughSpainisamongthecountrieswith

adequate iodine intakes, the percentage of children with aninsufficientintakefoundinourstudywassurprising.³⁹ It ispossiblethattheconsumptionofiodisedsaltwasunder- reportedinthedietdiaries,asconsideringthat17.7%and 38.3%ofchildrenhadasodiumintakeinexcessoftheULs (Tables3and4),itislikelythatsomeofthesaltconsumed wasiodised.

To conclude, similartowhat occursin other European countries and the United States, children younger than 3 yearsinSpainconsumeanimbalanceddietwithanexcessive protein intake,which indicates theneed for a nutritional interventioninthisagegroup.Thepaediatriciansordoctors that monitor children, scientific associations and govern- mentinstitutionsshouldmakedietaryrecommendationsto decreasetheproteinintakeandfacilitatethedevelopment ofhealthydietaryhabits, whichareofutmostimportance inthislifestage,whentheygetestablished.Theroleofthis imbalanceinoverweight,obesityandlowvitaminDlevels, which wasdemonstrated by ourstudy,are thesubject of extensivestudiesatpresent.

Funding

EveryphaseofthisstudyhasbeenfundedbyDanoneNutricia EarlyLifeNutrition,Spain.

Conflicts of interest

Bego˜naSolerwashiredbyDanoneNutriciaEarlyLifeNutri- tion,Spain,for thedesign,qualitycontrol,and statistical analysisofthestudy,andthewritingofthispaperforpub- lication.

Therest oftheauthorshave noconflictsofinterestto declare.

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Acknowledgments

Wethankthefollowingpaediatriciansfortheirparticipation intheALSALMA2.0study:

Magdalena Aga Aguirre; Felix Aguado Galan; Ignacio Aguilar Rey; Aurora Alonso Alvarez; Maria Elena Alvarez Garnelo; IsabelAlvarezIba˜nez;Noelia AlvarezZallo;Jose Amoros Garau; M. Luisa Arroba Basanta; Carlos Arruga Fernandez; Maria Teresa Asensi Monzo; Uxue Astigarraga Irureta; Isabel Barón Ruiz; Maria Paz Barrio Alonso; Maria Lucia Bartolome Lalanza; Eduard Bastida Ratera; M. Car- menBezaresForner;JoseAngelBilbaoSustacha;LuisCarlos Blesa Baviera; Lorenzo Boira Sanz; Eva Cecilia Bono Bor- doy; Isabel Botana del Arco; Francisco Javier Bru Jaen;

AntonioCabreraMolina;JesusCalCal;FernandoCalatayud Sáez; Pilar Camacho Conde; Maria Concepcion Carballo Pazo; Lourdes Cardenal Ysegarra; Carol Castellares Gon- zalez; InmaculadaClara Vila; JorgeCocolina Andres;Jose MiguelColinaJimeno;GloriaColliLista;JeimyLidiceCorniel Pe˜na; Alba Costa Ramirez; Lourdes Cozar Navarro; Isabel Cubillo Serna; M. del Rocio Cuesta Lopez; Nieves Cuevas Ortiz; Ana Laura Chindemi; Maria Teresa Darder Alorda;

Montserrat de Alaiz Rojo; Carmen de la Torre Cecilia;

Cristina delas Heras Diaz-Varela;Antonio deMiguel Ruiz;

Carmen del Peral Aguilar; Carlos Diaz Gonzalez; Lourdes Diaz Martin; Antonia Diez Huerta; Maria Gabriela Dodino Furelos; Vasilica Doina Oniceag; Nieves Maria Dominguez Perez; EstherEliasVillanueva; NievesEscarti Molla;Maria IsabelEspinRios;MercedesEspinosaArevalo;JuanFrancisco ExpositoMontes; ElenaFabregatFerrer;José LuisFandi˜no Eguia;Jose ManuelFernandezBustillo;MariaAmparoFer- nandez Campos; Santiago Andres Fernandez Cebrian; M.

LuisaFernandezLlamasMorejon;SandraFernandezPlaza;

Francisco Jose Ferrandiz Pelegrin; Silvia Ferraz Sopena;

Montserrat Ferre Guri; BernardoFerriz Mas; Isabel Ferriz Vidal; Joaquin Figueroa Alchapar; José Galán Rico; Fran- cisca Galan Solano; Maria de la O Garcia Baeza; Olga Garcia Bodega; Maria Gloria Garcia Gomez; Eliecer Gar- ciaJimenez;FatimaGarciaMarin;EstrellaGarciaMartinez;

EloisaGarcia-CaroGarcia;FranciscoJavierGasconJimenez;

M. Luisa Gayan Guardiola; David Gil Ortega; M. Angeles GimenezAbian;PabloGimenezFernandez;MireiaGimenez SanAndres;CeciliaMatildeGomezMalaga;AliciaGonzález del Amo Lopez; Magdalena González Fernández; Maria IsabelGonzalezMarcos;JuanAntonioGonzálezMateos;Jose Antonio González Palacios; Juan Manuel Gonzalez Perez;

VictorMiguelHerrandoSanchis;AntonioHerreroHernandez;

JosuneHualdeOlascoaga;AdrianaJianuJianu;Inmaculada Jimenez del Barco Jaldo; Juan Manuel Jimenez Hereza;

TeodorikezJimenezRodriguez;JesúsJordanMartinez;Imad Kheiri Amin; Ana Lopez Aguileta deIbisate; Ferran Lopez Cacho;MariadelosReyesLopezdeMesa;DemetrioLópez Pacios; Maximiliano Lourenc¸o Diego; Manuel Luque Salas;

MariaCeledoniaLlorenteHernandez;CarmenMadrigalDiez;

Noemi Magro Benito; Jose Maldonado Lozano; Jorge Juan Manresa Martínez; Juan Ignacio Manrique Martinez; Joan MartiFernandez;JoseLuisMartínBlazquez;XiomaraMartin Guerrero;Beatriz MartinRedondo; MariaDolores Martinez Camara; Miguel Angel Martinez de los Rios; Marcelino Martínez Hornos; Eduardo Martinez-Bone Montero; Maria Reyes Mazas Raba; Aurora Mesas Arostegui; Maria de la

MercedMiguelezVara;SalvadorMilletFite;GiselaMimbrero Garcia;JoséLuisMolinaPagán;AgustinMondejarRodriguez;

AnaMaríaMonta˜nésSánchez;PilarMontesDeOcaRomero;

AnaIsabelMonzonBueno;CesarMoralesAlbert;JorgeMu˜noz Rueda;JoseMurciaGarcia;AliMusaMohamed-Ayesh;M.Car- menNavarro Zapata; Felix Notario Herrero; EstherNovoa Garcia; Cristina Ochoa; Carlos Maria Orbea Soroa; Victor Ormaechea Goiri; Rocio Ortega Guerra; Luis Ortigosa del Castillo;CarmenPadronAlvarez;JoseIgnacioParejaCerdo;

Montserrat Parrilla Roure; Francisco Pena Lamela; Gloria PerezCano;PatriciaPerezdelValle;JoseAngelPerezQuin- tero;NelsonEddyPinedo;M.ConcepciónPoloMellado;Juan Ramis Tarongi; Beatriz Real Rodriguez; Antonio Redondo Romero; Mercedes Reymundo Garcia; Ramiro Rial Gonza- lez; Gemma Rosa Ricos Furio; Maria Elena Riera Perez;

Matilde Riquelme Perez; Ana Isabel Rodriguez Cordobes;

JoseRamónRodríguezRuíz;BelenRomeroHidalgo;Esther RuizChercoles;BeatrizRuizDerlinchan; MiguelAngelRuiz Jimenez;ConcepciónSaleteAlhaja;MariaVictoriaSanchez Lopez;CarlosSánchezSalguero; JuanGonzaloSantosGar- cia;AniuskaSutilRosas;ElenaTaborgaDiaz;RafaelTalavera Rodriguez;M.delCarmenTorresHinojal;LuisMarianoVal- buenaBarrasa; Margarita Vazquez Olivares; Pilar Vazquez Tu˜nas; Antonio Verdu Mestre; Jordi Vila Cots; Elena Vil- lenaRodriguez;CristinaViqueGarcia;SusanaViverGomez;

Montserrat Vives Campos; Victor Zamora Gutierrez; Fer- nandoZarateOsuna.

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