The EsNuPI study is the most recent survey in Spain that provides data about energy and food consumption in one general population-representative sample of milk consumers and in one sample of adapted milk consumers aged one to <10 years.
Understanding usual food consumption, energy and nutrient intake and nutrient adequacy to European and International standards in this specific population sample will provide useful data for identifying possible gaps and to conduct public intervention programs.
4.2. Nutrient Profile and Distribution
In our study, the mean percentage of protein contribution to the EI was 16.5% for the SRS and 15.6% for the AMS (
p < 0.001), hence, both samples were above the upper tolerable limit of protein derived energy intake recommended by EFSA, 2015 [
44] and Who, 2007 [
45]; nevertheless, the AMS had adequacy closer to the recommendations and a lower percentage of protein contribution to the EI than the SRS.
Regarding to the ESPGHAN, the amount of protein in YCF available on the European market varies significantly (median 2.6 g/100 kcal); hence, the majority of the YCF has a lower protein content than the regular cow´s milk (4.8 g/100 kcal). Consequently, children who consume YCF, that is, SMA have a lower intake of protein when compared to the children that majorly consume cow´s milk, that is, SRS [
11].
In accordance with the EFSA, the dietary reference intake for total protein is about 0.90 to 1.14 g/kg body weight for children. As we have data on self-reported weight for our study population, we were able to analyze the adequacy of protein intake that was 3.5 times higher than the EFSA and 3.4 times than the IOM recommendations [
38,
39].
Increasing research suggests that high protein intake may be detrimental to metabolic risk factors such as for overweight in infants and toddlers [
46,
47,
48] by increasing body weight in the absence of improvements in fat-free mass [
49]. It is believed that protein consumption stimulates the secretion of insulin-like growth factor I, which leads to cellular proliferation, accelerated growth and increased body fat [
50,
51].
The latest Spanish data on infants and young children are described in the ENALIA, ALSALMA and ANIBES studies. In all cases, the reported protein intake was also higher than the available recommendations [
24,
52,
53].
The ENALIA study concluded that protein contribution to energy was 16.7% for children aged 1–3 years old and 17.1% for children 4–8 years old, when using the Acceptable Macronutrient Distribution Range (AMDR) [
22]. Besides, in the ALSALMA study, 95.9% of the children between 7 and 36 months had a protein consumption more than twice the Recommended Daily Allowances (RDA) [
24]. Finally, when comparing our data with the ANIBES study, the results are similar, overall energy intake derived from protein was 16.8%. Only 10% of the ANIBES population was within the recommended range for protein intake (<15%) [
23].
Similar results have been found in other European countries for this age group. Huysentruyt et al. found that all the Belgium children between 6 to 36 months (
n = 500) had a protein intake above the recommended dietary intakes and for 156 children (33.5%), were above the UL of 15% of total energy intake that was proposed by ESPGHAN [
54,
55]
The NUTRINTAKE cross-sectional study (
n = 390) in Italian children aged 6 months to 3 years found a high intake of proteins, simple carbohydrates, saturated fats and sodium compared with the Italian recommended dietary allowances [
56].
In 2012, the Estudo do Padrão Alimentar e de Crescimento Infantil (EPACI) a cross-sectional study (
n = 2232) in Portuguese children aged 12–36 months, found that the mean daily protein intake was four times more than the RDA [
57].
Moreover, Brunner et al. found that in Swiss toddlers between one to 3 years (
n = 188) the protein intake was three to fourfold higher than the recommended daily intake (RDI) and reached the upper limit of 15% of total energy intake [
27].
Regarding carbohydrates, the EFSA recommendations (38) for children, specify that this macronutrient should provide 45%–60% of the energy intake; and the IOM recommends an intake of 45%–65% of the total energy. In the present study, the percentage of carbohydrates contribution to the energy intake was 45.4% for the SRS and 46.7% for the AMS; hence, both samples mean values were in accordance with the recommendations and were in line with the findings of other studies [
22,
58,
59]. Nevertheless, the percentage of children that were below the EFSA and the IOM recommendations was 47.8% in the SRS and 39.3% in the AMS (
p < 0.001) [
38,
39].
Consistently with our results, in the ENALIA study, the median values from carbohydrates were 46.8% of total energy and the proportion of participants below the lower limit of the AMDR was between 35.7–28.7% for boys and 42.9–29.7% for girls [
22]. In the ALSALMA study, a low energy intake of 41.1% from carbohydrates was observed according to the RDA [
24]. In the ANIBES study, a low contribution from carbohydrates to energy intake was found (41.4%) according to the EFSA recommendations [
23].
In European countries, data from dietary surveys show that average carbohydrates intakes for children and adolescents ranged between 43% and 58% of the total energy intake [
59,
60]. The GENESIS cross-sectional study (
n = 2374) in Greek children aged one to 5 years concluded that 21.0% of the children had lower intakes for carbohydrates, according to the AMDR [
61]. On the contrary, in the IDEFICS study, the mean percentage of usual energy intake from carbohydrates was 52.1%; thus, according to this study, the majority of European children were complying with common macronutrient intake recommendations [
18].
The EFSA suggests consuming 35–40% energy intake from fat for children one – <3 years old and 20–35% for children 4–17 years old and according to the IOM recommendations range 30% to 40% for toddlers between one to 3 years and 25–35% for children between 4 to <10 years of energy from total fat [
38].
The percentage of fat contribution to the energy intake was 36.5% for the SRS and 35.9% for the AMS; consequently, the percentage of fat was higher than the EFSA and IOM recommendations. Additionally, in both samples of our study, there was a high percentage of children above the EFSA and the IOM recommendations for fat; being SRS the sample with the higher percentage of children above both recommendations (47.2% for EFSA and 38.5% for IOM, p < 0.001)
Similarly, in the ANIBES study, the total fat intake was higher (37.9%) than the EFSA recommendations [
53]. Moreover, a systematic review conducted by Wanden-Berghe et al., in 2015 in Spanish population 5 to 81 years old, found that the mean energy contribution from macronutrients was 18% protein, 44% carbohydrates and 38% fat. Therefore, the Spanish population of this review does not meet the macronutrient intake recommendations [
62].
Manios et al., in the GENESIS study, concluded that the “at risk of being overweight” and the “overweight” children consumed more total energy, protein and fat compared with their normal-weight counterparts [
61]. However, the IDEFICS study found that only 25% of the European children consume more fat than the recommended in the D-A-C-H references values (nutritional guidelines for Germany, Switzerland and Austria) [
18].
In general, in our study, we can observe that both samples do not meet the EFSA and the IOM recommendations for the protein and fat distribution range (high consumption of protein and fat) and adequate consumption of carbohydrates as a whole; nevertheless, a high percentage of children do not meet the recommendations. Likewise, according to the EFSA, intervention studies concluded that high fat (>35% E) and low carbohydrates (<50% E) diets are associated with adverse short- and long-term effects on body weight [
52]. Similar results were found in two groups of Irish children (
n = 85) ages 12-24 months that consumed growing up milks (GUM) together with cow’s milk (
n = 29) or cow’s milk only (
n = 56). While average total daily energy intakes were similar in both consumers and non-consumers of GUM (1050 kcal vs 1027 kcal), intakes of protein (14.3% vs. 17%) and fat (33.2% vs. 35.1%) were lower and intakes of carbohydrate were higher in consumers of GUM (48.4% vs. 44.6%) [
63].
The high protein and fat intakes in Spanish children represent a major concern. In Spain, 40% of children have overweight or obesity and there is an association between high protein intakes, adiposity and a higher body mass index (BMI) in infancy and early childhood [
22,
25]. Moreover, the high percentage of subjects that were above the fat recommendations is worrying and should be modified. High-fat diets may decrease insulin-sensitivity and are positively associated with changes in fasting and postprandial factor VII, which may increase cardiovascular risk and other chronic diseases [
39]. Nevertheless, it is crucial to maintain an adequate intake of carbohydrates, because they are essential to the contribution of energy and glucose to the brain, which is the only carbohydrates-dependent organ in the body [
40]. Likewise, high carbohydrates diets tend to induce adverse effects on the blood lipid profile [
58].
4.3. Contribution of Food Groups to Energy Intake
In this study, the contribution of food groups to energy in Spanish children one to <10 years old is reported. To our knowledge, this is the first study that provides this information of Spanish children in this range of age.
In both samples, the milk and dairy products were the major contributors to the total energy among all 18 food groups, providing a series of critical nutrients but the contribution was significantly higher in the AMS (24.3%) than in the SRS (20.4%) (
p < 0.001). Overall, in infancy, the adapted and fortified milk formulas are important contributors to the total energy and nutrient intakes beyond calcium, such as potassium and vitamin D [
11,
64].
Furthermore, it is important to emphasize that the consumption of milk and dairy products promote adherence to the nutrient recommendations and may protect against the most prevalent non-communicable chronic diseases [
8,
9]. Similarly, in the NHANES study, found that milk was the top food source of energy in all ages [
32].
In both study samples, the cereals food group followed the milk and dairy products as the second contributor to energy intake. Cereals are the main staple food in many diets, providing a large percentage of daily energy intake. In a balanced diet, cereals represent a healthy source of multiple nutrients, dietary fibers and bioactive peptides with anticancer, antioxidant and antithrombotic effects [
65]. This food group represents the first contributor to energy intake in the ANIBES study population aged 9 to 17 years [
23].
Additionally, our results show that meat and meat products are the third contributor to energy intake in both samples; this increased in accordance with the age. However, the percentage of contribution to energy from meat and meat products was significantly higher in the SRS than in the AMS (11% vs. 7.8%) (
p < 0.001). As informed by EFSA in 2012 [
58], in most European countries, the main contributors to the dietary protein intake are meat and meat products. In the Helena study, conducted in 2006–2007 with children aged 12.5–17.5 years, the average total protein intake exceeded the recommendations of the WHO and EFSA and 59% of total protein intake was derived from animal protein [
66].
Meat contributes to important nutrients such as protein, saturated fatty acids, vitamins B, vitamin D and essential minerals, for example, iron (Fe) and zinc (Zn); however, processed meat is the principal food that contributes to SFA and sodium intakes across all ages and stages of life [
39,
58,
67]. Additionally, a high SFA intake has been identified as a risk factor for weight gain or higher weight; this has been associated with an increased cardiovascular risk [
68,
69].
Similarly, with our results, in the Melbourne Infant Feeding Activity and Nutrition Trial (InFANT) (
n = 542) developed in Australian children aged 9 months to 5 years, the principal sources of energy intake were milk and dairy products, cereals and bread and meat-meat products [
70].
The fourth group contributing to energy intake was oils and fats but there were no differences by groups between the two samples. Similar to our results, in the ANIBES study, the food group of oils and fats represents the third contributor to energy intake and the group of children and adolescents had a lower percentage of contribution of oils and fats than the adults (10% EI and 15% EI, respectively) [
23].
Furthermore, in our study population, there is a consistent trend toward a decrease in the consumption of fruit and vegetables as age increases, indicating that they were not sufficiently consumed. Several studies have shown that the consumption of these foods groups protects against chronic diseases and obesity because their high level of water and fiber, so incorporating them into the diet can reduce energy density, promote satiety and decrease energy intake [
71,
72]. Similarly, a cross-sectional study on a sample of GENESIS cohort of 2287 children (aged one to 5 years) concluded that about 80% of the children had a poor diet associated with low fruit, vegetable and grains intake and high saturated fat intake [
61]. Moreover, in the NHANES study, for children 2–5 and 6–11 years old, the fruit and vegetables were the 7º and 16º ranked food sources of energy, respectively [
32].
Finally, the contribution of bakery, sugar and sweets and ready to cook/eat products to total energy intake augmented with increasing age in SRS and AMS. The consumption of sugar and sweets and bakery is of concern because they are rich in free sugars and according to the World Health Organization their intake should be limited to no more than 10% of the total energy and preferably to no more than 5% in children [
73]. Additionally, high sugar consumption increases the risk for overweight, obesity and dental caries, which can result in poor nutrient supply and reduced dietary diversity and may be associated with increased risk of type 2 diabetes mellitus, cardiovascular risk and other health effects [
74].
In general, it can be observed that the SRS consumed significantly more cereals, meat and meat products, oils and fats, beverages, legumes and nuts than the AMS. Meanwhile, the AMS has a significantly higher consumption of milk and dairy products, fruits, eggs and cereal-based baby foods and supplements. Likewise, 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 [
9]. Santaliestra-Pasías et al. concluded that the consumption of dairy products could be part of a healthy lifestyle, including physical activity and low time of sedentary behavior activities [
8].