Top Clin Nutr Vol. 31, No. 2, pp. 168–177 c 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright
PRACTICE PROJECTS
Sandwich A Healthy Choice in the Mediterranean Diet Ismael San Mauro Mart´ın, PhD; Jose Ignacio Gil de Sola D´ıaz, BSc; Elena Garicano Vilar, BSc Children, adolescents, and adults have dropped foods from the Mediterranean diet in favor of less healthy products. Seventeen nutritional features of sandwiches were calculated for a 2500 kcal diet (5%-10% for midday and afternoon breaks). Ideal reference values of macronutrients were obtained using the Mediterranean diet energy distribution. Sandwiches covering 5% of the total energy were composed of 17.2-g carbohydrates, 4.7-g protein, and 4-g fat; total fat was divided into 1.4-g saturated fatty acids, 1.4-g monounsaturated fatty acids, and 1.8-2.5 g polyunsaturated fatty acids. The composition of the sandwiches covering 10% of the total energy composition was 34-g carbohydrates, 9-g protein, 8-g fat, 2.8-g saturated fatty acids, 2.78-g polyunsaturated fatty acids, and monounsaturated fatty acids. Both types of sandwiches covered 100% of the ideal nutritional recommendations. Sandwiches that conform to the Mediterranean diet pattern are considered healthy options for a balanced diet. Key words: calorie distribution, diet, Mediterranean diet, sandwich
I
N EUROPE, schoolchildren and adults are abandoning the Mediterranean diet (MD) in favor of industrial products with a relatively high content of calories, saturated fatty acids (SFA), salt, sugars, and poor nutrient composition.1,2 These changes have resulted from various sociocultural and lifestyle factors that negatively influence health.3,4 Schoolchildren in Spain between 6 and 16 years of age regularly consume sweets and bakery products. This consumption normally occurs as midmorning snack (42% con-
Author Affiliation: Research Centers of Nutrition and Health (CINUSA Group), Artistas, Madrid, Spain. The authors are grateful to Jes´ us Ortiz for his collaboration on this project and Victor Paredes for camera equipment and photo treatment. The authors have disclosed that they have no close relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Ismael San Mauro Mart´ın, PhD, Grupo CINUSA. Artistas 39, 2-5, 28020, Madrid, Spain (
[email protected]). DOI: 10.1097/TIN.0000000000000066
sume bakery or cookies) and for tea time (65% consume pastries and bakery).5 In contrast, 29% of school-aged children consume sandwiches.5 There is also evidence of high intakes of sweets, bakery, cakes, and pastries for breakfast (57.9%) and at noon (19.9%) among Spanish university students (aged 1825 years).6 These habits were observed not only in Spain but also in other parts of the world. A survey of elementary school students in the United Kingdom about “what they took in their lunch boxes” concluded that besides the lack of fresh fruit and vegetables, a high percentage (69%) of lunches included chocolate bars and chips. More than half of the respondents (58%) took a chocolate bar or biscuits, and only a small proportion of them (26%) included starchy foods, proteinrich items, fruits or vegetables, and/or dairy products.7 In the United States, there has been a change in habits as well with an increase of products with a high content of total fat and saturated fat and low in dietary fiber.8 Approximately 50% of adults and more than 20% of children of school age in the European Union are overweight or obese, and
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Sandwich Spain is not an exception in the European context.9,10 Lessons about nutrition and healthy habits, both at school and at home, are very important to prevent obesity in children and in adulthood.11 Educational workshops aimed at school children are becoming more and more frequent. The enKid study12 showed that children who received nutrition education improved their diet, reaching an MD pattern. In the study, “Changes on dietary habits of the late-breakfast in a school population,” the prevalence of children overweight and obesity was 10.6% and 2.6%, respectively. After an intervention, there was an increase of 9.2% individuals (of those who had lunch) who modified the type of food that they consumed.13 There is increasing evidence that family and environmental factors are associated with obesity.2,14 In fact, only 12% of Spanish adults strictly conform to the MD, while the rest of the adult population adheres to a dietary pattern rich in red and processed meat, French fries, refined cereals, sweetened beverages, and few fresh fruit.15 The MD is increasingly associated with a lower incidence of mortality16 along with a lower incidence of cardiovascular disease, type II diabetes, certain cancers, and neurodegenerative diseases.17 In addition, diverse, seasonal, and local food products are important elements in health, as are certain aspects of culture and lifestyle, such as cohabitation, culinary activities, physical activity, and adequate rest.17 As a result, the MD has an optimal nutrient intake with a beneficial fatty acids profile: high in monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs) and a greater ratio MUFAs/PUFAs than other (non-MD) dietary patterns. It also represents a low glycemic index and glycemic load, a high intake of dietary fiber, and ingestion of antiinflammatory and antioxidant compounds with positive effects on health status.17 Bach-Faig et al18 observed that there was a significant decrease in the Adaptation to the MD Index in Spain during the last 2 decades. From 1987 to 1997, adherence to the MD decreased significantly, slightly recov-
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ering after 1998 and more notably during the last decade. Another factor affecting health status is a sedentary lifestyle. About a third of children spend more than 2 hours a day watching television (TV) on weekdays and even more on weekends, which increases when children have a TV in their own rooms.19 Undoubtedly, these changes affecting health are associated with additional socioeconomic and cultural factors, consumer preferences, food prices, and the emergence of new processed products such as snacks, bakery, bars, ready meals, substitute products, and so forth, whose availability was much lower 2 decades ago.20 The appearance of new products has triggered studies on their use with a healthy orientation in different situations. Examples include flours with a better nutrient profile and improved taste for healthy sandwiches or snacks21 ; relocation of food in counters and displays so that consumers choose healthy snacks before unhealthy ones22 ; and controlling unhealthy foods advertisements during children’s TV programming.23 In Spain, the sandwich has traditionally been the snack of choice, largely due to the use of bread with a protein supplement (ham, turkey, other meats), sweet (chocolate, quince), or dairy products (cheese) in the culinary culture.24 Besides tradition, nutritional consensus recommends a proper, balanced distribution of sandwiches throughout the day, as well as eating 5 meals a day: breakfast, midmorning, lunch, afternoon snack, and dinner.20 However, not only is tasty eating important but also optimal and healthy dietary recommendations need to be respected. The main objective of this study is to demonstrate that sandwiches can be a healthy choice for a midmorning snack. The specific objectives are to create sandwiches with suitable amounts of ingredients that are nutritionally balanced and adjusted to caloric recommendations and macronutrient distributions for a young adult and to compare 2 sandwiches that meet either 5% or 10% of
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daily caloric intake for a young adult (hereafter “5% sandwich” and “10% sandwich”).
PROCEDURES To calculate the nutritional properties of the sandwiches, a basal diet of 2500 kcal for a young adult was considered (based on FAO25 recommendations of energy from children 6-18 years of age, range: 1574-3410, mean 2482 kcal/d for boys; range 1554-2503 kcal/d, mean 2169 kcal/d for girls; and the adult standard recommendations26 ). For the midmorning and the afternoon snack, recommended energy intake is between 5% and 10% of this total27 and yields energy values of 125 and 250 kcal, respectively. Once the caloric value was calculated, grams of macronutrients were obtained. The MD energy distribution was used: 55% carbohydrates of total kcal, 15% of protein of total kilocalories, and 30% of fat of total kcal, of which SFA are less than 10% of total kilocalories, PUFAs are less than 11% of total kilocalories, and the rest are MUFAs.3 To obtain the grams of each macronutrient of the 5% sandwiches, the following calculations were performed: 125 kcal × 0.55/4 kcal/g = 17.2-g CHO. Grams of the other macronutrients were calculated using the MD energy distribution mentioned previously, yielding 4.7-g protein, 4.2-g fat (1.4g SFA, 1.5-g MUFAs, and 1.3-g PUFAs). The same calculations were performed for 10% sandwiches. The values obtained for each macronutrient were used as “ideal reference values.” During the preparation of sandwiches, we aimed at the same “ideal reference values” for each nutrient expressed as a percentage (100% ± 10 standard deviation [SD]). Example: if the sandwich had 133 kcal, and the ideal energy value was 125 kcal, then the sandwich covered 106.62% of the ideal kcal (133 kcal × 100/125 = 106.62% of kcal). As for the ingredients, all sandwiches were made with natural and fresh ingredients (except for some processed foods, such as canned tuna, smoked salmon, or crab sticks). Wheat bread (whole and refined) or corn
bread (tortilla) was used as the base ingredient; tomatoes, lettuce, carrots, peppers, onion, and green beans as the vegetable source; cured meats (Serrano ham), cold meats (turkey breast, cooked ham), fresh cheese, or eggs as the protein source; and virgin olive oil or mayonnaise as fat source, among other ingredients (such as walnuts, honey, quince, lemon juice, or potato). The DIAL software for nutritional assessment28 and a laboratory precision weighing scale Ohaus Pioneer (with automatic calibration of 0.1 g) were used to design and weight the dishes.
FINDINGS A diet for a healthy young adult usually has about 2500 kcal of total energy expenditure. Given this fact, the energy distribution for the day is shown in Table 1. The reference weight values obtained in the 5% and 10% sandwiches were used to adjust their composition. Table 2 shows the different amounts of nutrients that constituted the sandwiches to cover the corresponding 5% and 10% of total calories of a standard diet, respectively. The amount of energy, carbohydrates (CHO), protein, fat, SFA, PUFAs, and MUFAs for each energy profile (5% or 10%) were calculated. These were compared with the ideal profile for a 5% sandwich (Table 3) and that for a 10% sandwich (Table 4). All 17 of the 5% sandwiches (Table 3), covered 100% (±10 SD) of the ideal kilocalorie recommendation with one exception (turkey sandwich). Similarly, the percentage of ideal protein recommendation was covered by most of the sandwiches, except the ham toast (above the recommendation: 118.19%) and the salad sandwich (below the recommendation: 89.23%). As for the carbohydrate, there were more defaults than excesses, always calculated over the 100% (± 10 SD) of the ideal expected. Cooked ham toast reached only an 85.53% of CHO, followed by the salmon with rocket integral toast (86.07% of CHO), and the turkey sandwich (89.98% of CHO).
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Table 1. Energy Distribution and Macronutrients in Grams (Carbohydrates, Fat, Protein, and Lipid Profile) of Ideal 5% and 10% of Total Daily Calories Sandwiches 5% Caloric
10% Caloric
Carbohydrates 55% Caloric value, 68.75 kcal Weight (4 kcal/g), 17.2 g Protein 15% Caloric value, 18.75 kcal Weight (4 kcal/g), 4.7 g Fat 30% Caloric value, 37.5 kcal Weight (9 kcal/g), 4.2 g Lipid profile SFA
