# Do Single Food Habits Matter? Fish and Vegetables Intake and Risk of Low HRQoL in Schoolchildren (ASOMAD Study)

## TL;DR

Eating vegetables and fish regularly is linked to better quality of life in Madrid schoolchildren, but the combined effect is less than expected.

## Contribution

Identifies specific dietary targets (≥2 vegetables/day and ≥2–3 fish/week) that may improve children's health-related quality of life.

## Key findings

- Vegetable and fish intake were inversely associated with low HRQoL, with adjusted probabilities of 25.8% and 29.7% respectively.
- Combined vegetable and fish intake had a smaller protective effect than the sum of individual effects.
- MVPA reduced risk while recreational screen time increased it.

## Abstract

What are the main findings?
•In Madrid children aged 8–12, eating vegetables ≥2/day and fish ≥2–3/week was associated with a lower risk of KIDSCREEN <40; adjusted probabilities: 40.1% (neither), 25.8% (vegetables only), 29.7% (fish only), 34.0% (both). The combined effect was smaller than the sum of the separate effects.•Moderate-to-vigorous physical activity was protective; recreational screen time was detrimental.

In Madrid children aged 8–12, eating vegetables ≥2/day and fish ≥2–3/week was associated with a lower risk of KIDSCREEN <40; adjusted probabilities: 40.1% (neither), 25.8% (vegetables only), 29.7% (fish only), 34.0% (both). The combined effect was smaller than the sum of the separate effects.

Moderate-to-vigorous physical activity was protective; recreational screen time was detrimental.

What are the implications of the main findings?
•Two concrete, feasible targets for school canteens and households, alongside more physical activity and less screen time.•Causal validation is needed, with an equity focus by SES and by school.

Two concrete, feasible targets for school canteens and households, alongside more physical activity and less screen time.

Causal validation is needed, with an equity focus by SES and by school.

Background/Objectives: Evidence links children’s health-related quality of life (HRQoL) to overall diet, but data on specific, actionable habits are limited. We tested whether vegetable intake ≥2 portions/day and fish intake ≥2–3 times/week were associated with risk of low HRQoL (KIDSCREEN-10 Index score <40) and assessed their joint effect and robustness to overall diet quality. Methods: In three waves (2020–2023) in Madrid (Spain), 1127 observations from 771 children (8–12 years) were analysed. Logistic Generalised Estimating Equations (GEE) adjusted for age, sex, socioeconomic status (four levels), moderate-to-vigorous physical activity (MVPA), screen time, body mass index (BMI) z-score, wave and school ownership. Marginal predicted probabilities were computed for four exposure combinations (neither, vegetables only, fish only, both). Sensitivity models added school area and the Mediterranean Diet Quality Index (KIDMED; KIDMED_wo_FV and total); hybrid within–between GEE and a linear mixed model for continuous KIDSCREEN-10 were also fitted. Results: Vegetables ≥2/day and fish ≥2–3/week were inversely associated with low HRQoL (odds ratio (OR) 0.49 (95% confidence interval (CI) 0.30–0.82) and 0.61 (0.43–0.87)). The interaction was positive (OR 2.50 (1.39–4.53)). Adjusted probabilities were 40.1% (neither), 25.8% (vegetables only; −14.3 percentage points (p.p.)), 29.7% (fish only; −10.5 p.p.), and 34.0% (both; −6.1 p.p.). Findings persisted with KIDMED_wo_FV and attenuated with total KIDMED. MVPA related inversely and screen time directly to risk. Conclusions: Vegetables ≥2/day and fish ≥2–3/week were associated with lower odds of low HRQoL, with non-additive combined effects. These simple targets may complement physical-activity promotion and reduced screen time; longitudinal/experimental studies should test causality and dose–response.