Adherence to the Mediterranean dietary pattern and BMI change among US adolescents

Development and Validation of a Questionnaire to Measure Adherence to a Mediterranean-Type Diet in Youth

Proper nutrition during childhood is crucial for preventing chronic diseases and ensuring optimal growth. This study aimed to develop and validate the Korean version of the KIDMED (K-KIDMED) questionnaire to accurately measure Mediterranean diet (MD) adherence among Korean children and adolescents. A total of 226 parents, representing their children and adolescents, completed the K-KIDMED, a 112-item food frequency questionnaire (FFQ), and a 24-h dietary recall method through an anonymous online survey. The K-KIDMED comprised 11 questions, with five excluded from the original scoring as they did not apply to the FFQ. Scores were categorized into three levels of adherence to the MD: low (1 or less), average (2-4), and good (5 or more). The agreement between total MD scores from the Korean version of the Mediterranean diet adherence screener and the FFQ was moderate (intraclass correlation coefficient = 0.455, 95% confidence interval: 0.346, 0.553). Among the 226 children and adolescents, 36.7% had low adherence to the KIDMED, 43.3% had intermediate adherence, and 19.9% had good adherence. Higher K-KIDMED scores were correlated with greater intakes of fiber, vitamin K, vitamin B6, and potassium (all p < 0.05). We developed the K-KIDMED as a valid tool to assess MD adherence in Korean children and adolescents.

Diet Quality at 3 Years of Age Relates to Lower Body Mass Index but Not Lower Blood Pressure at 10 Years of Age

A healthy diet prevents overweight problems and hypertension. We investigated the associations of a healthy diet with the body mass index (BMI) and blood pressure (BP) in early childhood. In the GECKO birth cohort, height, weight, and BP were measured at 5 and 10 years of age. Diet was evaluated at 3 years using three diet scores: the Dietary Approaches to Stop Hypertension (DASH), the Mediterranean Diet Score (MDS), and the Lifelines Diet Score (LLDS). Linear and logistic regression models assessed the associations of diet scores with the BMI and BP. Of the 1077 children included, 10.8% were overweight or obese at 5 years. That number was 16.5% at 10 years. In addition, 34.5% had elevated BP at 5 years. That number was 23.9% at 10 years. Higher DASH, MDS, and LLDS, which indicate healthier diets, were all associated with lower BMI z-scores at 10 years of age. Higher DASH is related to lower overweight risk at 10 years. None of the diet scores were associated with BP or elevated BP at either 5 or 10 years. Also, in an overweight subset, diet was not related to BP. A healthy diet in early childhood is related to children being less overweight but not having lower BP at 10 years of age.

Change analysis for intermediate disease markers in nutritional epidemiology: a causal inference perspective

BACKGROUND

Several approaches are commonly used to estimate the effect of diet on changes of various intermediate disease markers in prospective studies, including "change-score analysis", "concurrent change-change analysis" and "lagged change-change analysis". Although empirical evidence suggests that concurrent change-change analysis is most robust, consistent, and biologically plausible, in-depth dissection and comparison of these approaches from a causal inference perspective is lacking. We intend to explicitly elucidate and compare the underlying causal model, causal estimand and interpretation of these approaches, intuitively illustrate it with directed acyclic graph (DAG), and further clarify strengths and limitations of the recommended concurrent change-change analysis through simulations.

METHODS

Causal model and DAG are deployed to clarify the causal estimand and interpretation of each approach theoretically. Monte Carlo simulation is used to explore the performance of distinct approaches under different extents of time-invariant heterogeneity and the performance of concurrent change-change analysis when its causal identification assumptions are violated.

RESULTS

Concurrent change-change analysis targets the contemporaneous effect of exposure on outcome (measured at the same survey wave), which is more relevant and plausible in studying the associations of diet and intermediate biomarkers in prospective studies, while change-score analysis and lagged change-change analysis target the effect of exposure on outcome after one-period timespan (typically several years). Concurrent change-change analysis always yields unbiased estimates even with severe unobserved time-invariant confounding, while the other two approaches are always biased even without time-invariant heterogeneity. However, concurrent change-change analysis produces almost linearly increasing estimation bias with violation of its causal identification assumptions becoming more serious.

CONCLUSIONS

Concurrent change-change analysis might be the most superior method in studying the diet and intermediate biomarkers in prospective studies, which targets the most plausible estimand and circumvents the bias from unobserved individual heterogeneity. Importantly, careful examination of the vital identification assumptions behind it should be underscored before applying this promising method.

Position statement on nutrition therapy for overweight and obesity: nutrition department of the Brazilian association for the study of obesity and metabolic syndrome (ABESO-2022)

Obesity is a chronic disease resulting from multifactorial causes mainly related to lifestyle (sedentary lifestyle, inadequate eating habits) and to other conditions such as genetic, hereditary, psychological, cultural, and ethnic factors. The weight loss process is slow and complex, and involves lifestyle changes with an emphasis on nutritional therapy, physical activity practice, psychological interventions, and pharmacological or surgical treatment. Because the management of obesity is a long-term process, it is essential that the nutritional treatment contributes to the maintenance of the individual's global health. The main diet-related causes associated with excess weight are the high consumption of ultraprocessed foods, which are high in fats, sugars, and have high energy density; increased portion sizes; and low intake of fruits, vegetables, and grains. In addition, some situations negatively interfere with the weight loss process, such as fad diets that involve the belief in superfoods, the use of teas and phytotherapics, or even the avoidance of certain food groups, as has currently been the case for foods that are sources of carbohydrates. Individuals with obesity are often exposed to fad diets and, on a recurring basis, adhere to proposals with promises of quick solutions, which are not supported by the scientific literature. The adoption of a dietary pattern combining foods such as grains, lean meats, low-fat dairy, fruits, and vegetables, associated with an energy deficit, is the nutritional treatment recommended by the main international guidelines. Moreover, an emphasis on behavioral aspects including motivational interviewing and the encouragement for the individual to develop skills will contribute to achieve and maintain a healthy weight. Therefore, this Position Statement was prepared based on the analysis of the main randomized controlled studies and meta-analyses that tested different nutrition interventions for weight loss. Topics in the frontier of knowledge such as gut microbiota, inflammation, and nutritional genomics, as well as the processes involved in weight regain, were included in this document. This Position Statement was prepared by the Nutrition Department of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO), with the collaboration of dietitians from research and clinical fields with an emphasis on strategies for weight loss.

The ALINFA Intervention Improves Diet Quality and Nutritional Status in Children 6 to 12 Years Old

The study aimed to evaluate the efficacy of a new nutritional intervention, focused on improving the quality of the diet in children aged 6 to 12 years. A 2-month parallel, controlled randomized trial was conducted in the Spanish child population. The children were randomized to ALINFA nutritional intervention, which consisted of a normocaloric diet that incorporates products, ready-to-eat meals and healthy recipes specifically designed for the study, or a control group, which received the usual advice on healthy eating. The change in diet quality was assessed through the Kidmed index. The secondary outcomes were anthropometry, glucose and lipid profiles, inflammation markers, dietary intake and lifestyle. The participants in the intervention group showed an increase in the mean score of the Kidmed index (p < 0.001). Alongside that, these children decreased their intake of calories (p = 0.046), and total and saturated fat (p = 0.016//p = 0.011), and increased fiber intake (p < 0.001). Likewise, the children in the ALINFA group increased the intake of white fish (p = 0.001), pulses (p = 0.004), whole grains (p < 0.001) and nuts (p < 0.001), and decreased fatty meat (p = 0.014), refined grain (p = 0.008), pastry (p < 0.001), fast food (p < 0.001) and sugar (p = 0.001) intake. Moreover, these children had a significantly decreased BMI (p < 0.001), BMI z-score (p < 0.001), waist circumference (p = 0.016) and fat mass (p = 0.011), as well as leptin (p = 0.004). Participants in the control group did not report significant changes in diet quality. In conclusion, ALINFA nutritional intervention is possibly a useful strategy to increase the diet quality in children, which is associated to improvements in the nutritional status. These results highlight the importance of developing well-designed nutritional interventions.

KIDMED 2.0, An update of the KIDMED questionnaire: Evaluation of the psychometric properties in youth

BACKGROUND AND AIMS

As children and adolescents' eating patterns have changed over the last few years, researchers have found inconsistencies in the current questionnaires. Therefore, this research aims to (i) update the 2019 KIDMED questionnaire; and (ii) test the psychometric properties of this new questionnaire.

METHOD

A study with 419 children and adolescents in southwestern Spain was conducted in 2021. The new version of the KIDMED 2.0 was tested, which measures adherence to the Mediterranean diet through 16 items, of which 12 are positive, and 4 are negative. Content validation involved consultation with nutritionists, experts, and adolescents to assess whether the questionnaire was reliable and valid regarding dietary patterns associated with the Mediterranean diet. The expert assessment provided content validity indices for the clarity and representativeness of the questionnaire. Construct validity and test-retest reliability involved 419 students (M age = 14.40 ± 2.00) from southwestern Spain. Students responded twice (one week apart) to the KIDMED developed in the previous stage and completed a 7-day dietary record.

RESULTS

Regarding validity, results show a moderate agreement for 10 items (ranging between 0.21 and 0.47) of the KIDMED and the 7-day dietary record. Concerning Items 3, 4, 5, and 6, the agreement was slight (ranging between 0.08 and 0.17), whereas the agreement for Item 8 was low. Cohen's kappa showed that most items had moderate to substantial test-retest reliability. Also, kappa showed significant test-retest values for all items (p < 0.001).

CONCLUSION

The new version of the KIDMED 2.0 was shown to be a reliable and valid instrument to measure adherence to the Mediterranean diet in children and adolescents.

Global dietary quality in 185 countries from 1990 to 2018 show wide differences by nation, age, education, and urbanicity

Evidence on what people eat globally is limited in scope and rigour, especially as it relates to children and adolescents. This impairs target setting and investment in evidence-based actions to support healthy sustainable diets. Here we quantified global, regional and national dietary patterns among children and adults, by age group, sex, education and urbanicity, across 185 countries between 1990 and 2018, on the basis of data from the Global Dietary Database project. Our primary measure was the Alternative Healthy Eating Index, a validated score of diet quality; Dietary Approaches to Stop Hypertension and Mediterranean Diet Score patterns were secondarily assessed. Dietary quality is generally modest worldwide. In 2018, the mean global Alternative Healthy Eating Index score was 40.3, ranging from 0 (least healthy) to 100 (most healthy), with regional means ranging from 30.3 in Latin America and the Caribbean to 45.7 in South Asia. Scores among children versus adults were generally similar across regions, except in Central/Eastern Europe and Central Asia, high-income countries, and the Middle East and Northern Africa, where children had lower diet quality. Globally, diet quality scores were higher among women versus men, and more versus less educated individuals. Diet quality increased modestly between 1990 and 2018 globally and in all world regions except in South Asia and Sub-Saharan Africa, where it did not improve.

A Qualitative Analysis of the Remote Food Photography Method and the Automated Self-Administered 24-hour Dietary Assessment Tool for Assessing Children's Food Intake Reported by Parent Proxy

BACKGROUND

Accuracy and participant burden are two key considerations in the selection of a dietary assessment tool for assessing children's full-day dietary intake.

OBJECTIVE

The aim of this study was to identify barriers experienced by parents and burden when using two technology-based measures of dietary intake to report their child's intake: the Remote Food Photography Method (RFPM) and the Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24).

DESIGN

Qualitative, semistructured, focus groups were conducted with parents who served as proxy reporters of their child's dietary intake using the two different dietary assessment methods (ie, RFPM and ASA24) 1 week apart.

PARTICIPANTS/SETTING

This study was conducted in 2019 and included 32 parents of children aged 7 to 8 years in Colorado and Louisiana.

MAIN OUTCOME MEASURES

Barriers adhering to the protocol and burden with the RFPM and ASA24.

QUALITATIVE ANALYSES

Qualitative content analysis and Atlas.ti software were used to analyze and interpret focus group data.

RESULTS

For the RFPM, parents described missing photos due to unobserved intake, forgetting to capture images, disruption of mealtimes, and child embarrassment when meals were photographed at school. For the ASA24, parents described the time commitment as the main source of burden and the need to expand the food database to include additional ethnic foods and restaurant items. The main strengths were ease of use for the RFPM and the consolidated workload for the ASA24.

CONCLUSIONS

The barriers experienced by parents and burden differed by method, highlighting the importance of considering the unique characteristics of each assessment tool when designing a pediatric dietary assessment study and interpreting findings.

Mediterranean diet and adiposity in children and adolescents: A systematic review

Our aim was to summarize, through a systematic review, the current evidence from dietary intervention and observational studies on the impact of adherence to the Mediterranean diet on adiposity markers and obesity in children and adolescents. We searched Medline up to June 1, 2021 for the identification of intervention and observational studies meeting the inclusion criteria, following the PRISMA statement. We included 55 articles: 8 intervention studies and 47 observational studies. Three trials report a beneficial effect of the dietary intervention, whereas two did not, and three did not compare with a control. All observational studies were cross-sectional, and only five studies also included a longitudinal analysis. More than half of the cross-sectional studies found no significant association between adherence to Mediterranean diet and adiposity. Three out of the five longitudinal studies found a negative association. The majority of both observational and intervention studies was of low quality. Despite a large number of published studies, overall, there is only limited evidence of a beneficial effect of following a traditional Mediterranean diet to maintain a healthy body weight in childhood. More high-quality intervention and longitudinal data are needed to form the base of large-scale health programs to prevent childhood obesity.

Diet quality of Norwegian children at 3 and 7 years: changes, predictors and longitudinal association with weight

BACKGROUND/OBJECTIVES

Poor diet quality in early life can have long-term health effects, but the evidence is largely from cross-sectional studies. Our objective was to examine diet quality of Norwegian children by applying a-priori diet quality indices, identify early life determinants and examine prospective associations with overweight.

SUBJECTS/METHODS

We included 34,074 preschoolers (3-year-olds) and 18,350 school-aged children (7-years-olds) from the prospective, population-based Norwegian Mother, Father and Child Cohort Study. Diet quality was assessed as (i) adherence to a Mediterranean diet, estimated by the food frequency-based Mediterranean Diet Score (fMDS, score range: 0-6) and (ii) by the diet quality index (DQI, score range: -33% to 100%), reflecting compliance to food-based dietary guidelines. In multivariate analyses we explored perinatal and childhood characteristics as potential determinants of diet quality. We used logistic regression to examine the associations between diet quality at 3 years and BMI status at 8 years, adjusting for relevant confounders and diet quality at 7 years.

RESULTS

One in three children had high MD adherence at 3 and 8 years, and DQI (mean 60%) at 3 and 7 years was strongly correlated (r = 0.48, p < 0.001). Short breastfeeding duration, physical activity and sleep duration and long screentime at 18 months were associated with 2-3% lower DQI at 3 years. At both ages, maternal diet quality was the strongest prospective predictor of DQI (beta = 5%, 95% CI = 4.7, 5.2 and beta = 3.1%, 95% CI = 2.8, 3.4), and screentime was the strongest cross-sectional predictor (beta = -5.2%, 95% CI = -5.9, -4.5 and beta = -4.1%, 95% CI = -5.0, -3.2). High DQI score at 3 years, but not MD adherence, was associated with a lower risk for overweight (including obesity) at 8 years, compared to low DQI (lower tertile) (adjusted OR = 0.77, 95% CI = 0.62, 0.96).

CONCLUSIONS

Our study provides evidences that high diet quality in early childhood may reduce the risk for overweight in later childhood, independent of the current dietary behaviors.

Healthy and Sustainable Dietary Patterns in Children and Adolescents: A Systematic Review

The need for adherence to a healthy and sustainable dietary pattern in the pediatric stage is discussed worldwide, being linked to a progressive incidence of noncommunicable diseases in adulthood. The aims of this systematic review were to summarize the healthy and/or sustainable dietary patterns, defined a priori, described in the literature for use during the pediatric stage; to evaluate the adherence to these dietary patterns; and identify the health-related benefits associated with adherence to these patterns. A literature search was carried out on Medline, Scopus, and Web of Science from 2010 up to 2021, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 128 articles were included according to the following criteria: participants 2-17 y old, healthy and/or sustainable dietary patterns defined by an a priori methodology; articles written in English or Portuguese; and published since 2010. Fifty instruments with 14 adaptations that measure adherence to healthy and/or sustainable dietary patterns in children and adolescents were found. The Mediterranean Diet was the most studied dietary pattern. Adherence to healthy and/or sustainable dietary patterns has wide variations worldwide. Most of the instruments described have been little studied at pediatric ages, reducing the ability to extrapolate results. Higher adherence to these dietary patterns was associated with lower body fat, waist circumference, blood pressure, and metabolic risk. There is no consensus regarding the association with BMI. No studies have proofs of the sustainability characteristics of these instruments, it being necessary to produce a new sustainable instrument or test the association of the previous ones with, for example, the ecological footprint. Further validations of these instruments in each country and more prospective studies are needed to establish temporal relations with health-related outcomes. This systematic review was registered at www.crd.york.ac.uk/prospero/ as CRD42020221788.

Adherence to index-based dietary patterns in childhood and BMI trajectory during the transition to adolescence: the EPOCH study

BACKGROUND

In the United States, one in five adolescents are obese. Index-based dietary patterns are measures of the overall diet that have the potential to serve as valuable obesity risk stratification tools. However, little is known about the association between adherence to index-based dietary patterns in childhood and BMI during the transition from childhood to adolescence.

OBJECTIVE

To prospectively examine the relationship between adherence to three index-based dietary patterns in childhood and BMI trajectory during the transition to adolescence.

METHODS

The study included 581 children enrolled in a Colorado prospective cohort study conducted between 2006 and 2015. Dietary intake was assessed with the Block Kids Food Frequency Questionnaire at age 10 years. Scores were calculated for the Healthy Eating Index-2010 (HEI-2010), the alternate Mediterranean (aMED) diet, and the Dietary Approaches to Stop Hypertension (DASH) diet. Weight and height were assessed via anthropometry at two research visits (ages 10 and 16 years), with interim clinical measurements extracted from Kaiser Permanente medical records. Separate mixed models were used to assess the association between each diet index score and BMI over a 6-year period. Models were stratified by sex and adjusted for age, race/ethnicity, income, and exposure to gestational diabetes.

RESULTS

Median (IQR) number of BMI assessments was 14 (10-18). Among girls, for every ten-unit increase in HEI-2010 score, there was an average 0.64 kg/m² decrease (p = 0.007) in BMI over time, after adjustment for covariates. Among girls, there was no association between BMI and aMED (β = -0.19, p = 0.24) or DASH (β = 0.28, p = 0.38). Among boys, there was no statistically significant association between BMI and HEI-2010 (0.06, p = 0.83), aMED (0.07, p = 0.70), or DASH (0.42, p = 0.06).

CONCLUSIONS

Efforts to prevent adolescent obesity could benefit from considering the degree of adherence to federal dietary guidance, as assessed by the HEI, in the period preceding adolescence, especially among girls.

Searching for the Antioxidant, Anti-Inflammatory, and Neuroprotective Potential of Natural Food and Nutritional Supplements for Ocular Health in the Mediterranean Population

Adherence to a healthy diet offers a valuable intervention to compete against the increasing cases of ocular diseases worldwide, such as dry eye disorders, myopia progression, cataracts, glaucoma, diabetic retinopathy, or age macular degeneration. Certain amounts of micronutrients must be daily provided for proper functioning of the visual system, such as vitamins, carotenoids, trace metals and omega-3 fatty acids. Among natural foods, the following have to be considered for boosting eye/vision health: fish, meat, eggs, nuts, legumes, citrus fruits, nuts, leafy green vegetables, orange-colored fruits/vegetables, olives-olive oil, and dairy products. Nutritional supplements have received much attention as potential tools for managing chronic-degenerative ocular diseases. A systematic search of PubMed, Web of Science, hand-searched publications and historical archives were performed by the professionals involved in this study, to include peer-reviewed articles in which natural food, nutrient content, and its potential relationship with ocular health. Five ophthalmologists and two researchers collected the characteristics, quality and suitability of the above studies. Finally, 177 publications from 1983 to 2021 were enclosed, mainly related to natural food, Mediterranean diet (MedDiet) and nutraceutic supplementation. For the first time, original studies with broccoli and tigernut (chufa de Valencia) regarding the ocular surface dysfunction, macular degeneration, diabetic retinopathy and glaucoma were enclosed. These can add value to the diet, counteract nutritional defects, and help in the early stages, as well as in the course of ophthalmic pathologies. The main purpose of this review, enclosed in the Special Issue "Health Benefits and Nutritional Quality of Fruits, Nuts and Vegetables," is to identify directions for further research on the role of diet and nutrition in the eyes and vision, and the potential antioxidant, anti-inflammatory and neuroprotective effects of natural food (broccoli, saffron, tigernuts and walnuts), the Mediterranean Diet, and nutraceutic supplements that may supply a promising and highly affordable scenario for patients at risk of vision loss. This review work was designed and carried out by a multidisciplinary group involved in ophthalmology and ophthalmic research and especially in nutritional ophthalmology.

Trends in the adherence to the Mediterranean diet in Israeli adolescents: results from two national health and nutrition surveys, 2003 and 2016

PURPOSE

To compare the adherence to the Mediterranean diet (MD) in Israeli adolescents in 2003-4 and in 2015-6, and associated factors.

METHODS

Adolescents (aged 11-19 years) from two cross-sectional, school-based, nationally representative surveys, Mabat Youth I (2003-4, n 5005) and II (2015-6, n 3906), completed self-administered questionnaires on food frequency, eating behaviors and lifestyle. The Mediterranean Diet Quality Index for Children and Adolescents (KIDMED index), derived from these questionnaires, was used; higher scores indicate better diet quality. The samples comprised eight subgroups, according to population group (Jews/Arabs), school level (middle/high) and sex.

RESULTS

The percentages with poor, average and good KIDMED scores were 11.6, 45.3 and 43.1% in 2015-6, compared to 25.5, 55.2 and 19.3%, respectively, in 2003-4. Significant improvement was seen in all subgroups (all p < 0.001), and was attributed to increased consumption of fruits, vegetables, cereals, dairy products, and decreased negative eating behaviors. In Mabat Youth II, physical activity at least 1 h/day was positively associated with good KIDMED scores among Jewish adolescents; dieting and sleeping at least 7 h/day were associated with good MD adherence in Jewish boys; always/often reading food labels predicted good MD adherence among Jewish boys and Arab girls. Overweight and obesity were negatively associated with better KIDMED scores in Jewish boys.

CONCLUSION

MD adherence in Israeli adolescents has improved overall. The changes in MD components and the associated behavioral factors indicate the initiatives, relevant to the different subgroups, that are necessary to promote healthier nutrition and lifestyles.

The Role of Snack Choices, Body Weight Stereotypes and Smoking Behavior in Assessing Risk Factors for Adolescent Overweight and Obesity

This study investigated the relationship of behavioral factors, such as snack choices, obesity stereotypes and smoking with adolescents’ body weight. Individual-level data for 1254 Greek youths were selected via a formal questionnaire. Snack choices seem to be gender specific with girls showing a stronger preference for healthier snacks. Frequent consumption of high-calorie and more filling snacks was found to increase Body Mass Index (BMI) in both genders. Fruit/vegetable snacks were associated with lower body weight in females, whereas cereal/nut snacks had a negative influence in males’ BMI. The majority of participants expressed anti-fat attitudes and more boys than girls assigned positive attributes to lean peers. The endorsement of the thin-ideal was positively associated with the BMI of both adolescent boys and girls. This study also revealed that neglecting potential endogeneity issues can lead to biased estimates of smoking. Gender may be a crucial moderator of smoking–BMI relationships. Male smokers presented a higher obesity risk, whereas female smokers were more likely to be underweight. Nutrition professionals should pay attention to increase the acceptance of healthy snack options. Gender differences in the influence of weight stereotypes and smoking on BMI should be considered in order to enhance the efficacy of obesity prevention interventions.

The Influence of Adherence to the Mediterranean Diet among Children and Their Parents in Relation to Childhood Overweight/Obesity: A Cross-Sectional Study in Greece

Background: Childhood overweight/obesity constitutes a serious issue, as may cause several health problems. The main characteristics of the Mediterranean Diet have been acknowledged as the most appropriate shield mainly for obesity. Methods: The study was performed on 1728 primary students, during school years 2014-2016, in Greece. Children and their parents completed questionnaires which included dietary and lifestyle habits. The KIDMED score (range -4 to 12) was used to assess the level of childhood adherence to the Mediterranean diet and the MedDietScore (range 0 to 55) was used to assess parental adherence. For the purposes of this analysis, the examined sample was n = 875 of students (522 girls)-parents pairs whose level of adherence to the Mediterranean diet was able to be evaluated. Results: The prevalence of overweight and obesity in the Greek sample was 26.0%, according to International Obesity Task Force (IOTF) cutoff criteria for children. KIDMED Score was significantly lower in children with overweight/obesity compared with children with normal weight (4.65 ± 2.14 vs. 5.16 ± 2.05, p = 0.002). The multiadjusted analysis revealed that children close to the Mediterranean diet were less likely to be overweight/obese (p < 0.001), either parents are away from or close to the Mediterranean diet. Conclusions: This study revealed that children's adherence to the Mediterranean diet was inversely associated with weight status either parents are away from or close to this dietary pattern. Future interventions against childhood obesity have to take into consideration the crucial importance of familial aggregation of healthy food choices and interfamily influences in the home environment on children's weight status.

Diet quality indices and their associations with health-related outcomes in children and adolescents: an updated systematic review

BACKGROUND

To describe a-priori diet quality indices used in children and adolescents, appraise the validity and reliability of these indices, and synthesise evidence on the relationship between diet quality and physical and mental health, and growth-related outcomes.

METHODS

Five electronic databases were searched until January 2019. An a-priori diet quality index was included if it applied a scoring structure to rate child or adolescent (aged 0-18-years) dietary intakes relative to dietary or nutrient guidelines. Diagnostic accuracy studies and prospective cohort studies reporting health outcomes were appraised using the Academy of Nutrition and Dietetics Quality Criteria Checklist.

RESULTS

From 15,577 records screened, 128 unique paediatric diet quality indices were identified from 33 countries. Half of the indices' scores rated both food and nutrient intakes (n = 65 indices). Some indices were age specific: infant (< 24-months; n = 8 indices), child (2-12-years; n = 16), adolescent (13-18 years; n = 8), and child/adolescent (n = 14). Thirty-seven indices evaluated for validity and/or reliability. Eleven of the 15 indices which investigated associations with prospective health outcomes reported significant results, such as improved IQ, quality of life, blood pressure, body composition, and prevalence of metabolic syndrome.

CONCLUSIONS

Research utilising diet quality indices in paediatric populations is rapidly expanding internationally. However, few indices have been evaluated for validity, reliability, or association with health outcomes. Further research is needed to determine the validity, reliability, and association with health of frequently utilised diet quality indices to ensure data generated by an index is useful, applicable, and relevant.

REGISTRATION

PROSPERO number: CRD42018107630 .

Grand-maternal lifestyle during pregnancy and body mass index in adolescence and young adulthood: an intergenerational cohort study

To examine associations of healthy lifestyle during pregnancy with body mass index (BMI) and risk of overweight or obesity of grandchildren during adolescence and young adulthood. Our study population included 14,001 grandmother–mother–child triads comprised of participants of two ongoing prospective cohort studies of related individuals. We used self-reported grand-maternal gestational weight gain, diet, physical activity, and smoking during pregnancy to create a lifestyle score ranged from 0 to 12, with a higher score indicating healthier lifestyle. Grandchild BMI was self-assessed in follow-up questionnaires. Compared with individuals whose grandmothers had the least healthy lifestyle during pregnancy, individuals whose grandmothers had the most healthy lifestyle had 0.17 (95% CI 0.01, 0.33; P for trend = 0.05) kg/m² lower BMI and 7% (95% CI 2%, 12%; P for trend = 0.001) lower risk of overweight or obesity during adolescence and young adulthood. The inverse associations between grand-maternal lifestyle and BMI in grandchildren were mainly mediated by maternal pre-pregnancy BMI (mediation effect: 64%; P value = 0.001). Overall, maternal BMI, along with maternal socioeconomic status and lifestyle factors in the second and third generations accounted for all of the inter-generational association (mediation effect: 99%; P value < 0.001). The inverse associations of grand-maternal lifestyle with BMI of offspring were not modified by grand-maternal pre-pregnancy BMI, grandchild age, or grandchild gender. Grandchildren of women who had the healthiest lifestyles during pregnancy defined by no excess gestational weight gain, no smoking, a healthy diet and being physically active, were less likely to be overweight or obese in adolescence and early adulthood.

Defining diet quality: a synthesis of dietary quality metrics and their validity for the double burden of malnutrition

Achieving most of the UN Sustainable Development Goals requires a strong focus on addressing the double burden of malnutrition, which includes both diet-related maternal and child health (MCH) and non-communicable diseases (NCDs). Although, the most optimal dietary metric for assessing malnutrition remains unclear. Our aim was to review available global dietary quality metrics (hereafter referred to as dietary metrics) and evidence for their validity to assess MCH and NCD outcomes, both separately and together. A systematic search of PubMed was done to identify meta-analyses or narrative reviews evaluating validity of diet metrics in relation to nutrient adequacy or health outcomes. We identified seven dietary metrics aiming to address MCH and 12 for NCDs, no dietary metrics addressed both together. Four NCD dietary metrics (Mediterranean Diet Score, Alternative Healthy Eating Index, Healthy Eating Index, and Dietary Approaches to Stop Hypertension) had convincing evidence of protective associations with specific NCD outcomes, mainly mortality, cardiovascular disease, type 2 diabetes, and total cancer. The remaining NCD dietary metrics and all MCH dietary metrics were not convincingly validated against MCH or NCD health outcomes. None of the dietary metrics had been validated against both MCH and NCD outcomes. These findings highlight major gaps in assessing and addressing diet to achieve global targets and effective policy action.

Erosion of the Mediterranean diet among adolescents: evidence from an Eastern Mediterranean Country

At a time when the health benefits of the Mediterranean diet (MD) are pervasively recognised, a paradoxical observation is the decreasing adherence to this dietary pattern in its native countries. This study aims to investigate temporal trends in adherence to the MD among adolescents (10–19 years old) in Lebanon. Data were drawn from three national cross-sectional surveys conducted at three points in time: 1997 (n2004), 2009 (n3656) and 2015 (n1204). Dietary intake was assessed using 24-h dietary recalls, and adherence to the MD was assessed using two country-specific indexes: the composite Mediterranean diet (c-MED) index and Lebanese Mediterranean diet (LMD) index. Significant decreases in c-MED and LMD scores and in the proportion of adolescents adhering to the MD were observed between 1997 and 2015, with more consistent results among females (P< 0·05). Projections for the year 2030 showed further decreases, with less than a quarter of adolescents remaining adherent to the MD. Based on linear regression analyses, belonging to the year 2009 was associated with significantly lower MD scores compared with 1997, even after adjustment for potential covariates (c-MEDβ= –0·16, 95 % CI –0·30, –0·01; LMDβ= –0·42, 95 % CI –0·67, –0·17). Similar results were obtained when comparing survey year 2015 with 1997 (c-MED scoreβ= –0·20, 95 % CI –0·33, –0·06; LMD scoreβ= –0·60, 95 % CI –0·82, –0·37). Findings highlight the erosion of the MD among Lebanese adolescents and underline the need for a comprehensive food system approach that fosters the promotion of the MD as a nutritionally balanced and sustainable dietary pattern.

Prevention of Childhood Obesity: A Position Paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN)

Global childhood obesity increased more than 8-fold over 40 years, inducing a very large personal, societal, and economic burden. Effects of available treatments are less than satisfactory; therefore, effective prevention is of high priority. In this narrative review, we explore preventive opportunities. The available evidence indicates large benefits of improving nutrition and lifestyle during early life, such as promoting breast-feeding and improving the quality of infant and early childhood feeding. Promoting healthy eating patterns and limiting sugar-containing beverage consumption from early childhood onwards are of great benefit. Regular physical activity and limited sedentary lifestyle and screen time alone have limited effects but are valuable elements in effective multicomponent strategies. The home environment is important, particularly for young children, and can be improved by educating and empowering families. School- and community-based interventions can be effective, such as installing water fountains, improving cafeteria menus, and facilitating regular physical activity. Reducing obesogenic risk factors through societal standards is essential for effective prevention and limiting socioeconomic disparity; these may comprise food, drink, and physical activity standards for day cares and schools, general food quality standards, front-of-pack food labeling, taxation of unhealthy foods, restriction of food advertisements to children, and others. Effective prevention of childhood obesity is not achieved by single interventions but by integrated multicomponent approaches involving multiple stakeholders that address children, families, and societal standards. Pediatricians and their organizations should be proactive in supporting and empowering families to support their children's health, and in promoting societal measures that protect children.

Adherence to Medication, Diet and Physical Activity and the Associated Factors Amongst Patients with Type 2 Diabetes

INTRODUCTION

The prevalence of type 2 diabetes mellitus (T2D) has increased considerably while the outcome of diabetic management is suboptimal. In order to promote diabetic management, associated factors for adherence to medications, diet, and physical activity (PA) need to be more clearly identified amongst patients with T2D.

METHODS

This cross-sectional study was conducted on 206 men and 294 women amongst patients with diabetes who were registered in ten special diabetic clinics in Shiraz, Iran from November 2018 to April 2019. Levels of adherence to medication, Mediterranean diet (MD), and physical activity were measured with validated and appropriate questionnaires.

RESULTS

Mean age (± SD) was 56.92 ± 0.52 years and 294 (58.8%) were female. Data showed that reduced adherence to medication, MD, and PA increased glycated hemoblobin (HbA1c). Adherence to medication among low, moderate, and high levels was 27.2%, 59.2%, and 13.6%, respectively. Associated factors such as 50-64 years of age, at least 65 years of age, overweight, obese, divorced widow, smoker, and ex-smoker had a significant influence on adherence to medication, P = 0.017, P = 0.018, P = 0.008. P = 0.045, P = 0.026, P < 0.004, and P = 0.001, respectively. In addition, adherence to MD among low, moderate, and high levels was 5.4%, 77.2%, and 17.4%, respectively. Associated factors such as 50-64 years of age, at least 65 years of age, overweight, obese, and smoker had a significant influence on adherence to MD, P = 0.011, P = 0.046, P = 0.002, P < 0.001, and P = 0.032, respectively. Furthermore, adherence to PA among low, moderate, and high levels was 21%, 68.6%, and 10.4%, respectively. Only the non-smoker factor played a significant role in PA adherence, P = 0.010.

CONCLUSION

Levels of adherence to medications, diet, and PA amongst patients with T2D are not within the acceptable range. Recognized associated factors that contribute to adherence might improve diabetes management and allow one to tailor the appropriate message to improve glycemic indices.

Evaluation of Mediterranean diet adherence in children diagnosed with pancreatitis: a case-control study

Introduction

Background: the incidence of childhood acute pancreatitis has been increasing in the last two decades. The number of studies on the effects of diet on the pathogenesis of pancreatitis is very small. The aim of this study was to evaluate adherence to the Mediterranean diet among children with acute pancreatitis. Material and method: this study was conducted by administering the Mediterranean Diet Quality Index (KIDMED) to 100 children -children diagnosed with acute pancreatitis (n = 50) and a control group (n = 50). Results: there was a statistically significant difference between groups in terms of body mass index Z-score (p = 0.017). When the KIDMED scores of the children diagnosed with pancreatitis (4.48 ± 2.45) and the control group (6.62 ± 2.18) were compared, the KIDMED scores of the children diagnosed with pancreatitis group were significantly lower (u = 638.5; p < 0.001). Those with a moderate KIDMED index (score: 4-7) (OR: 3.734, 95 % CI, 1.068-13.058, p = 0.039) and those with a poor KIDMED index (score ≤ 3) (OR: 6.444, 95 % CI, 1.595 -26.075, p = 0.009) were found to have an increased risk of developing pancreatitis. It was found that the risk of pancreatitis increased with age (OR: 1.136, 95 % CI, 1.020-1.266, p = 0.021). Conclusion: according to the data obtained from our study, it was found that the pancreatitis group had poorer dietary habits than the control group. Larger and multicenter studies are needed to evaluate the role of diet in pancreatitis development.

The association of dietary patterns and adherence to WHO healthy diet with metabolic syndrome in children and adolescents: Tehran lipid and glucose study

BACKGROUND

The optimal dietary pattern for reducing the extent of metabolic syndrome (MetS) has not been well established yet. The aim of this study was to evaluate dietary patterns and adherence to WHO healthy diet in children and adolescents and their associations with MetS.

METHODS

Subjects of this cohort study were selected from among children and adolescents of the Tehran Lipid and Glucose Study participants, aged 6-18 years (n = 424). Dietary measurements were collected using a valid and reliable food frequency questionnaire. MetS was defined as the existence of at least 3 risk factors according to the Cook criteria. Diet was assessed based on dietary components of the WHO healthy diet. Dietary patterns were defined by principal component analysis.

RESULTS

The mean ± SD age of participants (42% boys and 57% girls) was 13.5 ± 3.7 years. The most consistency with the WHO healthy diet was observed for cholesterol, free sugar and protein consumption in both genders, and the least was for n-3 poly-unsaturated fatty acid, trans-fatty acid and salt. Intake of SFA up to 12% of energy intake (third quartile) reduced the risk of MetS, compared to the first quartile. Subjects in the third quartile of n-6 poly-unsaturated fatty acid intake (6.2% of energy) showed the lowest odds ratio of MetS compared to the first quartile (OR: 0.18, CI: 0.04-0.66). In the adjusted model, the risk of MetS reduced across quartiles of MUFA intake by 60% (OR: 1, 0.40, 0.40, 0.42; P trend = 0.05). No significant trends were observed in the risk of MetS components across quartiles of the WHO healthy diet components. Three major dietary patterns were identified, the healthy, unhealthy and cereal/meat. An increased risk of MetS was observed in the highest quartile of unhealthy dietary pattern score compared to the lowest quartile (OR: 1, 0.81, 0.93, 2.49; P trend = 0.03).

CONCLUSIONS

Our results demonstrated that the majority of our population did not meet some components of WHO healthy diet recommendations. The quality and quantity of fatty acid intakes were associated with risk of MetS. Adherence to unhealthy dietary pattern was associated with two-fold increase in MetS risk.

Inverse association of long-term nut consumption with weight gain and risk of overweight/obesity: a systematic review

Nuts contain a variety of nutrients and bioactive compounds that are capable of promoting metabolic health. However, due to their high energy density, concerns have been raised that nut consumption in the long term may contribute to weight gain. This systematic review summarizes the findings of prospective studies regarding the relationship between long-term nut consumption and obesity. Searches were conducted up through February 2018, using the PUBMED, EMBASE, and SCOPUS databases with the relevant MeSH terms and phrases. This systematic review included prospective cohort studies investigating the relationship between consumption of total nut and/or nut subtypes with changes in weight, body mass index (BMI), and waist circumference (WC), as well as the risk of overweight/obesity, with follow-up duration ≥1-year. Out of a total of 1580 papers that were initially examined, 6 met the inclusion criteria. Four out of the 6 studies showed an inverse association between nut consumption (typically at the dosages of ≥1 to 2 servings per week) and weight gain and risk of overweight/obesity. The remaining 2 studies evaluated the association between nut intake and changes in WC. From these 2 studies, only one study reported a significant inverse association. Overall, evidence from limited cohort studies demonstrated that long-term nut intake was associated with less weight gain and reduced risk of overweight/obesity. Whether such findings are generalizable to racially diverse ethnic groups, individuals of low socioeconomic status, and populations in developing countries should be addressed in future studies.

Healthy Lifestyle: Relationship between Mediterranean Diet, Body Composition and Physical Fitness in 13 to 16-Years Old Icelandic Students

Childhood and adolescent obesity are currently among the greatest challenges for public health. Physical activity, physical fitness, and adherence to the Mediterranean diet (MD), representing powerful indicators of healthy lifestyles, are shown as determinant factors in the prevention and treatment of obesity. The aim of the present study has been to analyse the relationship between health-related physical fitness components, body composition, and adherence to MD in 387 Icelandic adolescents of 13⁻16-years old (54% boys). The ALPHA Fitness Test was used to measure physical fitness and body composition. The KIDMED questionnaire was used to assess the adherence to MD among participants. Associations between variables were tested according to gender and age using linear regression models and analysis of variance. Participants with high/medium adherence to MD showed significantly higher endurance scores in both the boys and the girls. Gender differences were found. The boys in high/medium MD categories had significantly lower fat percentages and ran a 4 × 10 m sprint faster than the girls. The girls scored higher than the boys in endurance and speed-agility tests. It can be concluded that a high and medium adherence to MD is associated with high and very high endurance in both the girls and the boys.

Dietary Patterns in Primary School are of Prospective Relevance for the Development of Body Composition in Two German Pediatric Populations

This study performed comparative analyses in two pediatric cohorts to identify dietary patterns during primary school years and examined their relevance to body composition development. Nutritional and anthropometric data at the beginning of primary school and two or four years later were available from 298 and 372 participants of IDEFICS-Germany (Identification and prevention of Dietary-induced and lifestyle-induced health Effects In Children and infants Study) and the KOPS (Kiel Obesity Prevention Study) cohort, respectively. Principal component analyses (PCA) and reduced rank regression (RRR) were used to identify dietary patterns at baseline and patterns of change in food group intake during primary school years. RRR extracted patterns explaining variations in changes in body mass index (BMI), fat mass index (FMI), and waist-to-height-ratio (WtHR). Associations between pattern adherence and excess gain in BMI, FMI, or WtHR (>75th percentile) during primary school years were examined using logistic regression. Among PCA patterns, only a change towards a more Mediterranean food choice during primary school years were associated with a favorable body composition development in IDEFICS-Germany (p < 0.05). In KOPS, RRR patterns characterized by a frequent consumption of fast foods or starchy carbohydrate foods were consistently associated with an excess gain in BMI and WtHR (all p < 0.005). In IDEFICS-Germany, excess gain in BMI, FMI, and WtHR were predicted by a frequent consumption of nuts, meat, and pizza at baseline and a decrease in the consumption frequency of protein sources and snack carbohydrates during primary school years (all p < 0.01). The study confirms an adverse impact of fast food consumption on body composition during primary school years. Combinations of protein and carbohydrate sources deserve further investigation.

Association of eating behaviors, lifestyle, and maternal education with adherence to the Mediterranean diet in Spanish children

BACKGROUND

The Mediterranean diet serves as a proxy of a high-quality diet. Although several factors are known to affect a child's ability to follow a high-quality diet, no prospective data are available on factors that influence adherence to a Mediterranean diet among children. Our objective was to investigate the association of Mediterranean diet adherence with eating behaviors, lifestyle habits, and maternal education in a prospective cohort of children.

METHODS

The present prospective cohort analysis included 1639 children aged 8-10 years. The study was carried out during two academic years, 2012/2014, with an average follow-up of 15 months. Eating behaviors, physical activity, and adherence to Mediterranean diet were estimated by the Dutch Eating Behavior Questionnaire for Children, the Physical Activity Questionnaire for Children, and the KIDMED index, respectively.

RESULTS

Multivariate linear regression analysis adjusted for sex, age, maternal education, baseline adherence to the Mediterranean diet, and intervention group revealed a significant (p < 0.01) inverse association of external eating and screen time with adherence to the Mediterranean diet at follow-up (mean of 15 months). The opposite association was found for meal frequency and physical activity (p < 0.02). A high level of maternal education increased the odds of a child's high adherence to the Mediterranean diet (OR = 1.56 CI 1.13; 2.14) compared to peers whose mothers had only a primary education.

CONCLUSIONS

Screen time, physical activity, meal frequency, and external eating predict adherence to the Mediterranean diet independently of baseline diet quality. Maternal education level is an important prospective determinant for the adherence to the Mediterranean diet.

TRIAL REGISTRATION NUMBER

ISRCTN68403446.

The health-nutrition dimension: a methodological approach to assess the nutritional sustainability of typical agro-food products and the Mediterranean diet

BACKGROUND

The aim of this paper is to provide a methodological approach to evaluate the nutritional sustainability of typical agro-food products, representing Mediterranean eating habits and included in the Mediterranean food pyramid.

RESULTS

For each group of foods, suitable and easily measurable indicators were identified. Two macro-indicators were used to assess the nutritional sustainability of each product. The first macro-indicator, called 'business distinctiveness', takes into account the application of different regulations and standards regarding quality, safety and traceability as well as the origin of raw materials. The second macro-indicator, called 'nutritional quality', assesses product nutritional quality taking into account the contents of key compounds including micronutrients and bioactive phytochemicals. For each indicator a 0-10 scoring system was set up, with scores from 0 (unsustainable) to 10 (very sustainable), with 5 as a sustainability benchmark value. The benchmark value is the value from which a product can be considered sustainable. A simple formula was developed to produce a sustainability index.

CONCLUSION

The proposed sustainability index could be considered a useful tool to describe both the qualitative and quantitative value of micronutrients and bioactive phytochemical present in foodstuffs. This methodological approach can also be applied beyond the Mediterranean, to food products in other world regions. © 2018 Society of Chemical Industry.

Effects of an Intensive Lifestyle Intervention to Treat Overweight/Obese Children and Adolescents

Objective

The purpose of the present study is to examine the effects of a multidisciplinary lifestyle intervention to treat overweight/obese children and adolescents. The main outcome was cardiometabolic risk based on the waist-to-height ratio (WHTR) measurement. Secondary outcomes were (1) changes in body composition; (2) adherence to a Mediterranean diet; and (3) physical performance.

Method

The study involved 74 overweight/obese children or adolescents. The intervention was multidisciplinary including nutrition, exercise, and psychological aspects based on a family-based approach; it was delivered for six months for children and three months for adolescents. Before and after the intervention, several anthropometric measures (height, body weight, body mass index or BMI, waist circumference, and body composition), cardiometabolic risk index (waist-to-height ratio or WHTR), and nutrition habits of the participants and their families were evaluated. In addition, a set of functional motor fitness tests was performed to evaluate physical performance measures.

Results

After the intervention both children and adolescents showed a significant reduction in body weight, BMI, waist circumference, fat mass, and WHTR index and an improvement of fat-free mass, adherence to the Mediterranean diet, and physical fitness performance.

Conclusion

A family-based multidisciplinary approach is effective in the short term in ameliorating the health status, the nutrition habits, and physical performance in children and adolescents.

The Reliability of the Mediterranean Diet Quality Index (KIDMED) Questionnaire

The purpose of the present study was to determine the test–retest reliability of the Mediterranean Diet Quality Index (KIDMED) questionnaire in college students. Two hundred and seventy-six college students (127 men, 46%; 149 women, 54%; mean age 19.70 ± 1.32 years; mean height 1.75 ± 0.09 m; mean weight 69.28 ± 13.84 kg; mean body-mas index 22.41 ± 3.19 kg/m²) participated in the study. To investigate the reliability of the KIDMED questionnaire, the participants were asked to complete the questionnaire on two occasions two weeks apart, stratified by gender. Kappa statistics showed moderate to excellent agreement (ranging from 0.504 to 0.849) in the total sample and moderate to excellent agreement in both men (ranging from 0.467 to 0.803) and women (ranging from 0.435 to 0.927). Results in the total KIDMED score showed a moderate correlation between two occasions inthe total sample (κ = 0.597, p < 0.001) and in women (κ = 0.586, p < 0.001) and a good correlation in men (κ = 0.611, p < 0.001). Our study shows that the KIDMED questionnaire is a reliable instrument for assessing adherence to the Mediterranean diet in college students. Future studies should focus on investigating the reliability of the questionnaire in other countries and in different age groups for generating comparable data.

Mediterranean Diet and Its Correlates among Adolescents in Non-Mediterranean European Countries: A Population-Based Study

Little is known about the factors which might influence the adherence to a Mediterranean diet in non-Mediterranean European countries. Thus, the main purpose of this study was to determine the associations between socioeconomic, psychological, and physical factors on a Mediterranean diet. In this cross-sectional study, participants were 14–18-year-old adolescents (N = 3071) from two non-Mediterranean countries: Lithuania (N = 1863) and Serbia (N = 1208). The dependent variable was Mediterranean diet, and was assessed with the Mediterranean Diet Quality Index for children and adolescents questionnaire. Independent variables were gender, body-mass index, self-rated health, socioeconomic status, psychological distress, physical activity, and sedentary behavior. The associations between dependent and independent variables were analyzed by using logistic regression. Results showed that higher adherence to a Mediterranean diet was associated with higher self-rated health, socioeconomic status, and physical activity, yet low adherence to a Mediterranean diet was associated with being female, having higher body-mass index, psychological distress, and sedentary behavior. Our findings suggest that future studies need to explore associations between lifestyle habits—especially in target populations, such as primary and secondary school students.