Adherence to the Mediterranean diet in Italian school children (The ZOOM8 Study)

Improvement of Adherence to the Mediterranean Diet through a Nutrition Education Teaching Pack for Teachers within the "School Fruit Scheme" Program: An Italian Long-Term Trial in School Children

A previous short time span study related to the effectiveness of a teaching pack (TP) in improving the adherence to the Mediterranean Diet (MD) showed positive results. The present study was aimed at investigating and confirming those results, with a follow up data collection, in the same sample, a year after the baseline intervention. Pre- and post-intervention assessments were conducted. Weight and height were measured. Eating patterns/lifestyle were assessed by the KIDMED test and questionnaires. Thirteen schools in three areas with low, medium and high prevalence of overweight/obesity (North, Center and South respectively) were involved, with a representative baseline cluster sample of 494 fourth class children (8-10 years old) in 2015. An intervention group and a control group were recruited in each school; the intervention group (n = 395) got the intervention, the control group (n = 99) did not. The children's KIDMED score changes were the main outcome measures. Differences in percentages of adherence and in yes/no answers on the KIDMED test, at baseline and after one year, for both the intervention and the control groups, were assessed through contingency tables and statistical tests. Improvements in the high and low adherence rates to MD were observed (high adherence: 24.4% to 43.3%; low adherence: 15.0% to 3.9%, p < 0.0001). The percentages of subjects with optimal adherence improved in both sexes (females: 25.5% to 49.5%, p < 0.0001; males: 23.1% to 36.6%, p < 0.0001) in all the geographical areas and ponderal status classes. Accompanying free distribution of fruit and vegetables with a nutritional intervention led by trained teachers with a cross-curricular approach can be successful in promoting healthy eating in children.

Adherence to Mediterranean Diet and its main determinants in a sample of Italian adults: results from the ARIANNA cross-sectional survey

Introduction

Over the last years, many Mediterranean countries, including Italy, have witnessed a shift away from the Mediterranean Diet, thus contributing to the high rates of overweight and obesity. The survey "Adherence to Mediterranean Diet in Italy (ARIANNA)" aimed to evaluate the Adherence to Mediterranean Diet (AMD) and its main determinants in the Italian population.

Materials and methods

This study started on March 2023 and was addressed to adults aged ≥17 years, born and resident in Italy, proficient in Italian. Data are collected electronically through a voluntary, anonymous and self-administered questionnaire on the project website. Univariate and then multivariate logistic regressions were performed to evaluate associations between AMD and demographic characteristics, socio-economic status, health status, and lifestyle.

Results

On a total of 3,732 completed questionnaires, the 87.70% of the respondents was female and the 71.28% was 17-40 years old. The 83.82% of the respondents had medium AMD, 11.33% low and only 4.85% high. The multivariate analysis revealed that being male (p < 0.001), aged >40 years (p < 0.05), workers (p ≤ 0.001), and unemployed (p < 0.05), determined the probability of having a lower AMD. Vegans and vegetarian's diets positively contributed to a higher AMD (p < 0.001).

Discussion

These results highlighted a medium AMD in the Italian adult participants and suggested the necessity to implement tailored public health intervention strategies to improve food habits.

Adherence to Mediterranean Diet and Food Neophobia Occurrence in Children: A Study Carried out in Italy

Food Neophobia (FN), defined as the reluctance to eat new or unfamiliar foods, mainly concerns fruit, vegetables, and legumes, typical of the Mediterranean Diet (MD). Considering these premises, this study aimed to clarify the relationship between FN and AMD in a sample of Italian children and their association with some socio-demographic factors and children's nutritional status. A sample of 288 children aged 3-11 years participated in an assessment carried out with a questionnaire evaluating FN and AMD, respectively, with the Child Food Neophobia Scale (CFNS) and the KIDMED test. Most of the sample showed an intermediate (67.3%) or high level of FN (18.1%), with high rates among 6-11-year-old children (63.9%) and especially in those who were the only child (50%). The AMD was mostly low (29.5%) or medium (54.8%) and reached lower levels among higher neophobic children (51.9%; p value < 0.05). The present results confirm the study hypothesis that FN is a driver of MD abandonment and shows the positive effects on children's eating habits and siblings. Finally, this study proves the relevance of adopting effective feeding strategies against FN to avoid its maintenance in adulthood and the detrimental effects on future overall health and well-being.

Inequalities in Childhood Nutrition, Physical Activity, Sedentary Behaviour and Obesity in Italy

Unhealthy diets, physical inactivity and high body mass index (BMI) are preventable risk factors for non-communicable diseases throughout a person's lifespan. The higher prevalence of these risk factors in children from lower socio-economic groups has been generally observed. The aim of this study is to explore the effect of parents' socio-economic conditions on children's consumption of fruit, vegetables and sugar-sweetened drinks, and inactivity, sedentary behaviour, overweight and obesity. This study used data from the sixth cross-sectional survey of the surveillance "OKkio alla Salute" (Italian COSI), involving 2467 schools and 53,275 children in 2019. All the information was collected through four questionnaires addressed to parents, children, teachers and head teachers. The weights and heights of the children were measured with standard techniques and equipment to classify overweight/obesity according to the WOF-IOTF cut-offs. The results showed a high percentage of children who do not adhere to health recommendations and a high prevalence of overweight and obesity. In particular, "less healthy" behaviours and higher BMI were more frequent in children from families with a lower socio-economic status and those residing in Southern Italy. These findings highlight the need for effective interventions that address the differences in these health-related behaviours.

Cross-Sectional Analysis of Family Factors Associated with Lifestyle Habits in a Sample of Italian Primary School Children: The I-MOVE Project

The acquisition of healthy dietary and exercise habits during childhood is essential for maintaining these behaviors during adulthood. In early childhood, parents have a profound influence on a child's lifestyle pursuits, serving as both role models and decision-makers. The present study examines family factors as potential contributors to healthy lifestyle habits and their child's overall diet quality among a sample of primary school children. A secondary aim is to evaluate several aspects of diet quality using the Mediterranean adaptation of the Diet Quality Index-International (DQI-I). This cross-sectional study involved 106 children enrolled in a primary school located in Imola, Italy. Data were collected from October to December 2019 using an interactive tool used to assess parent characteristics, children's lifestyle, food frequency (ZOOM-8 questionnaire), and actigraph accelerometers to capture children's physical activity and sedentary behavior. Adherence to the Mediterranean Diet (expressed by KIDMED Index) was positively associated with fathers' educational level, parental sport participation, and the parent's overall nutritional knowledge. Higher mothers' educational level was inversely associated with children's leisure screen time. Parents' nutritional knowledge was positively related to children's average daily minutes of organized sport activities. The better score for DQI-I was for consumption adequacy, followed by variety and moderation. The lowest score was for overall balance. The present study reinforces the importance of family factors in young children's lifestyle choices, particularly their dietary, leisure time, and exercise habits.

Mediterranean diet, physical activity, and family characteristics associated with cognitive performance in Italian primary school children: analysis of the I-MOVE project

Working memory (WM) is a multicomponent system that supports cognitive functioning. It has been linked to a wide variety of outcomes including academic success and general well-being. The present study examined the relations between adherence to the Mediterranean diet (MD) and WM among Italian children, adjusting for important parent characteristics and children's lifestyle habits. Data for this study was obtained from 106 children attending primary school in Imola (Italy) who were part of the I-MOVE study emphasizing school-based physical activity. Children's adherence to the MD was calculated using the KIDMED index (KI) based on the ZOOM-8 questionnaire. Physical activity (PA) levels were assessed using an actigraph accelerometer and WM using the backward digit span test. Univariate regression was used to select significant child-level and family measures associated with WM, which were then tested in a single multivariate regression model. Older age is positively associated with higher WM (β = 0.36; 95% CI 0.25, 0.47). Dietary adherence (KI) (β = 0.07; 95% CI 0.01, 0.14) and engagement in organized PA outside school hours (β = 0.58; 95% CI 0.09, 1.10) are positively related to WM. Among the family measures, father's education was positively associated with WM for high school education and for university vs. middle school or lower, respectively.

CONCLUSION

Adherence to the MD was associated with better WM capacity in primary school children. These findings can be used to guide policymakers in designing health promotion programs and instituting policies emphasizing healthy nutrition to improve physical health and boost cognitive functioning.

WHAT IS KNOWN

• The development of working memory involves the entire childhood with a rapid spurt between 2 and 8 years of age. • Working memory plays a critical role in children's learning and academic performance and underlies higher-order cognitive abilities.

WHAT IS NEW

• Adherence to the Mediterranean Diet was associated with higher working memory capacity in primary school children. • Health promotion interventions based on PA and sound nutrition involving children benefit not only physical and mental health, but also cognitive health.

Parent, child, and environmental predictors of vegetable consumption in Italian, Polish, and British preschoolers

This study compared the vegetable intake of preschool children from three European countries [Italy, Poland, and the United Kingdom (UK)] and explored the parent, child, and environmental factors that predicted intake in each country. A total of 408 parents of preschoolers (Italy: N = 61, Poland: N = 124, and UK: N = 225; child mean age = 32.2 months, SD = 9.47) completed an online survey comprising a set of standardised questionnaires. For all three countries, the questionnaires included measures of children's vegetable intake (VegFFQ), child eating behaviour (CEBQ-FF), parents' mealtime goals (FMGs), and sociodemographic questions about family background and environment. In the UK and Italy, additional questionnaires were used to assess child temperament (EAS-T) and parents' feeding practices (CFPQ). The results showed that the number of child-sized portions of vegetables consumed per day varied significantly across countries; Polish children consumed the most (∼3 portions) and Italian children the least (∼1.5 portions). Between-country differences were seen in parents' goals for family mealtimes; compared to Italian parents, Polish and UK parents were more motivated to minimise mealtime stress, increase family involvement in meal preparation, and share the same foods with family members. British and Italian parents also adopted different feeding practices; parents in the UK reported more use of healthy modelling behaviours and more use of foods to support their child's emotion regulation. In terms of child factors, Italian children were reported to be more emotional and more sociable than British children. Analyses of the relationships between the parent, child, and environmental factors and children's vegetable intake revealed both similarities and differences between countries. Negative predictors of vegetable intake included child food fussiness in the UK and Poland, child temperament (especially, shyness) in Italy, and the use of food as a reward and child emotionality in the UK. Positive predictors included the parental mealtime goal of 'family involvement' in the UK. These results highlight differences in the extent to which European preschoolers achieve recommended levels of vegetable intake, and in the factors that influence whether they do. The results suggest a need to develop healthy eating interventions that are adopted to meet the specific needs of the countries in which they are implemented.

Parental Traits Associated with Adherence to the Mediterranean Diet in Children and Adolescents in Croatia: A Cross-Sectional Study

The Mediterranean diet (MD) is known to be one of the healthiest dietary patterns. Despite the significance of a healthful diet during the early stage of life, data for young individuals indicate that nutrition problems are common. This cross-sectional study aimed to determine parental factors associated with MD adherence in children and adolescents living in the Mediterranean region in Croatia. In total, 2623 children aged 2 to 18 years and their parents participated in this study. Data were collected during the period from September 2021 to February 2022 by using an anonymous questionnaire. We used KIDMED and MEDAS questionnaires for assessing MD adherence in young individuals and their parents, respectively. To assess the association of children’s MD adherence categories with the parental predictors, we performed multivariate multinomial logistic regression. Results showed that the children of parents with a low MD adherence are much more likely to have poor MD adherence than good (OR = 47.54 (95% C.I 18.24, 123.87), p < 0.001) or average (OR = 5.64 (95% C.I 3.70, 8.6), p < 0.001) MD adherence. Further, children of fathers with higher BMI (OR = 1.035 (95% C.I 1.0, 1.071)) and those who do not live with both parents (OR = 1.703 (95% C.I 0.994, 2.916), p = 0.053) are more likely to have poor MD adherence than good MD adherence. These results indicate that interventions focusing on enhancing the quality of both parents’ diets could effectively improve their children’s eating habits.

Mediterranean Diet in Developmental Age: A Narrative Review of Current Evidences and Research Gaps

Numerous studies in recent decades have shown that Mediterranean diet (MD) can reduce the risk of developing obesity in pediatric patients. The current narrative review summarizes recent evidence regarding the impact of MD across the different stages of child development, starting from fetal development, analyzing breastfeeding and weaning, through childhood up to adolescence, highlighting the gaps in knowledge for each age group. A literature search covering evidence published between 1 January 2000 and 1 March 2022 and concerning children only was conducted using multiple keywords and standardized terminology in PubMed database. A lack of scientific evidence about MD adherence concerns the age group undergoing weaning, thus between 6 months and one year of life. In the other age groups, adherence to MD and its beneficial effects in terms of obesity prevention has been extensively investigated, however, there are still few studies that correlate this dietary style with the incidence of non-communicable diseases. Furthermore, research on multi-intervention strategy should be implemented, especially regarding the role of education of children and families in taking up this healthy dietary style.

Weekday and Weekend Differences in Eating Habits, Physical Activity and Screen Time Behavior among a Sample of Primary School Children: The "Seven Days for My Health" Project

BACKGROUND

Healthy eating and active lifestyle habits are essential for a child's development, wellbeing, and health. School setting and family environment play a crucial role in shaping these habits and this could be reflected in different behavior patterns during weekdays and weekends.

METHODS

We investigated primary school children's lifestyle habits through a cross-sectional analysis of 428 Italian primary school children, with a mean age of 8.99 years (±1.43). Data were collected from May to June 2017 using a weekly diary to assess children's lifestyles.

RESULTS

Children who eat their morning snack and lunch at school three or more times during the weekdays were 5.47 times more likely (95% CI 3.02, 10.2) to consume adequate snacks and 7.79 times more likely (95% CI 4.43, 14.5) to have adequate meals than those who did not.

CONCLUSION

Consumption of vegetables, lunch, and snacks are significantly more adequate during the weekdays as compared to the weekends. Physical activity levels did not differ between weekdays and weekends. Moreover, children spent more time engaged in physical activities than in front of a screen during both the weekdays and the weekends. The present results are good indicators of the importance of the school canteen in defining correct eating habits. Family-based and school-based interventions could represent valuable integrative strategies for promoting a healthy lifestyle in children.

Whole blood fatty acid profile of young subjects and adherence to the Mediterranean diet: an observational cohort study

Background

Relatively little is known about the physiological whole blood fatty acid composition in young people. Likewise, few studies have addressed the question of correlations between Mediterranean diet (MedDiet) adherence and blood fatty acids in childhood.

Methods

The fatty acid profile in whole blood from subjects, 46 days-19 years old (n = 152), without acute, chronic, or inflammatory diseases was analysed by gas chromatography. Dietary data was extracted from a 24-h recall in a subgroup of subjects (n = 60) into a modified Diet Quality Index for Children (KIDMED) questionnaire to evaluate MedDiet adherence. The cohort was divided into three age groups: < 2, 2- < 10, and 10–19 years. Kruskal-Wallis test and Bonferroni post hoc test were used to check for age group fatty acid differences. For correlations, Spearman’s correlation coefficient and partial Spearman’s correlation coefficient were used.

Results

Linoleic acid, EPA, DHA, palmitic acid, and total saturated fatty acids were stable over age groups. Dihomo-gamma-linolenic acid (DGLA), arachidonic acid (AA), total polyunsaturated FAs (PUFA), and total omega-6 PUFA increased from age group < 2 years; alpha-linolenic acid, total omega-3 PUFA, oleic acid, and total monounsaturated FAs decreased. Adherence to the MedDiet was at low-medium level in 91.7% of the subjects. In the age group 2- < 10 yrs., the degree of adherence correlated positively with total MUFA and PUFA balance, negatively with total PUFA, total n6-PUFA, AA/DHA, AA/EPA, and n6/n3. Age did not influence the correlations as to PUFA balance and AA/EPA.

Conclusions

Increased FA proportions with age were seen in the n6-series of PUFA. The n3-FA species decreased or were stable. The vast majority of the subjects with dietary data, 92%, obtained a KIDMED score indicative of low-medium adherence to the MedDiet. The score correlated negatively with various n6-species, i.e. the MedDiet suppressed circulating n6-PUFA. Whole blood may be used to investigate FAs and MedDiet adherence correlations which may be applied in the study of health issues in childhood.

Adherence to the Mediterranean Diet among Children and Youth in the Mediterranean Region in Croatia: A Comparative Study

The Mediterranean diet (MD) is considered one of the healthiest dietary patterns. The aim of this study was to assess MD adherence in children and youth living in the Mediterranean region in Croatia and evaluate the differences in adherence to the MD among different educational stages. In total, 2722 individuals aged 2 to 24 years were enrolled in this study. Subjects were divided into different groups according to the Croatian educational system. Mediterranean Diet Quality Index (KIDMED) was used to assess adherence to the MD. In the total sample, the adherence to the MD was poor in 19.2%, average in 60.8%, and good in 20.1% of the study participants. The prevalence rate of poor adherence to the MD increased with higher educational stage, i.e., the highest prevalence rate of poor MD adherence was observed for college students (39.3%). Children having a higher number of snacks on days-off, those with lower physical activity, and not having breakfast together with a family are more likely to have poor MD adherence, while children having a higher number of snacks on working days are less likely to have a poor MD. The results of this study showed low adherence to the principles of the MD, confirming the need for improvement of adherence to the MD pattern in the studied population.

Buccal micronucleus cytome assay in children living in an area with low anthropogenic pressure: The EFFE.BI.P. study

The study aimed to evaluate the micronucleus (MN) frequency in exfoliated buccal cells (EBCs) of 256 6-8-years-old schoolchildren living in a rural area of Salento peninsula (Southern Italy) with low anthropogenic pressure and with a normal rate of chronic diseases in order to determine the basal level of MN and identify which factors are able to influence it. Information about the personal data, lifestyles and dietary habits of the children were obtained by the administration of a questionnaire to their parents. The buccal micronucleus cytome assay was performed to evaluate the presence of early genotoxic effects among the children. In addition, the level of environmental exposure was assessed by sampling atmospheric particulate fractions near the schools attended by participants. The association between MN frequency and individual or environmental factors was also assessed. The children had a mean MN frequency of 0.27 ± 0.43‰ (95%CI = 0.22-0.33). This frequency was positively associated with vehicular traffic (OR = 2.99; 95%CI = 1.15-7.74) and negatively associated with a high educational level of the mother (OR = 0.41; 95%CI = 0.18-0.95) and physical exercise (OR = 0.56; 95%CI = 0.32-0.57). Data on genotoxic effects in buccal cells found in this study could be considered as the MN level in a pediatric population not exposed to environmental pollution.

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.

Children's and Families' Determinants of Health-Related Behaviors in an Italian Primary School Sample: The "Seven Days for My Health" Project

Childhood obesity is an established health problem, and there is a growing need for health promotion interventions focused on healthy behaviors in collaboration with parents and schools. The Mediterranean diet (MD) could help to tackle obesity, but it is essential to maintain a good level of physical activity (PA) and limit time spent in sedentary activities (ST). To explore family determinants, adherence to the MD and PA levels as potential predictors of a child’s health-related behaviors, we performed a cross-sectional analysis of 368 Italian primary school children with a mean age of 8.95 years (SD = 1.43). Data were collected from May to June 2017 using a weekly diary, an interactive tool to assess the child’s and parents’ lifestyle. The child’s degree of adherence to the MD was calculated using the KIDMED index. Adherence to the MD was high, medium and poor in 5.2%, 62.5% and 32.3% of children, respectively. Higher maternal educational level was positively associated with children’s MD and PA (p < 0.05) and negatively correlated to ST. Maternal fruit and vegetable consumption was positively related to the MD and negatively related to ST (p < 0.05). Maternal PA was positively associated with the MD (p < 0.001). Paternal PA, and fruit and vegetable consumption, were positively associated with children’s PA (p < 0.05). Our results underline the need for future studies, mainly focused on school-based and family-based interventions, to promote healthy lifestyles and nutritional habits.

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.

Dietary Patterns and Weight Status in Italian Preschoolers with Autism Spectrum Disorder and Typically Developing Children

Atypical eating habits are more common in children with autism spectrum disorders (ASD) than typically developing (TD) peers. Feeding problems may lead to the double burden of specific nutrient deficiencies and excessive weight gain, with a consequent increase in obesity prevalence. The dietary intake of Italian preschoolers with ASD compared to their TD peers and the impact of their dietary choices on their weight status and relationship to food selectivity (FS) were investigated. Dietary patterns and their associations with body mass index (BMI) were evaluated in 65 children with ASD and 82 peers with TD aged 1.3-6.4 years. Eating habits were assessed with a modified version of a parent-rated semi-quantitative Food Frequency Questionnaire. Moreover, the prevalence of FS and possible links with dietary patterns and BMI were investigated in the ASD group. Children with ASD consumed significantly higher amounts of simple sugars, processed and ultra-processed carbohydrates, both low- and high-fat animal proteins, and lower amounts of vegetables and fruits compared to peers with TD. The obesity rate was 1.5% in children with TD and more than fourfold (6.2%) in children with ASD, although the difference between groups was not statistically significant. FS was significantly more frequent in children with ASD than in peers with TD. Children with ASD and FS showed significantly lower annual intakes of vegetable proteins and fiber (considered essential nutrients for a healthy diet) than children with ASD without FS. Our results showed that children with ASD showed different dietary habits than those with TD, with the higher consumption of energy-dense foods and lower amounts of food-sourced fibers, which could place them at increased risk to develop overweight, obesity, and micronutrient deficiencies later in life.

Childhood overweight and obesity in Europe: Changes from 2007 to 2017

The Childhood Obesity Surveillance Initiative (COSI) routinely measures height and weight of primary school children aged 6-9 years and calculates overweight and obesity prevalence within the World Health Organization (WHO) European Region using a standard methodology. This study examines the trends in the prevalence of overweight and obesity from the first round of COSI carried out in 2007/2008 to the latest of 2015/2017 in 11 European countries in which data were collected for at least three rounds. In total 303,155 children were measured. In general, the prevalence of overweight and obesity among boys and girls decreased in countries with high prevalence (Southern Europe) and remained stable or slightly increased in Northern European and Eastern European countries included in the analysis. Among boys, the highest decrease in overweight (including obesity) was observed in Portugal (from 40.5% in 2007/2008 to 28.4 in 2015/2017) and in Greece for obesity (from 30.5% in 2009/2010 to 21.7% in 2015/2017). Lithuania recorded the strongest increase in the proportion of boys with overweight (from 24.8% to 28.5%) and obesity (from 9.4% to 12.2%). The trends were similar for boys and girls in most countries. Several countries in Europe have successfully implemented policies and interventions to counteract the increase of overweight and obesity, but there is still much to be done.

Development of a stand-alone index for the assessment of diet quality in elementary school-aged children

OBJECTIVE

To develop and evaluate a stand-alone Elementary School-aged Children's Index of Diet Quality (ES-CIDQ).

DESIGN

In this cross-sectional study, children filled in a food frequency questionnaire (FFQ) with twenty-nine multiple-item questions on the consumption of foods, portion sizes and eating frequency and a 5-d food diary. Nutrient intakes were calculated with nutrient analysis software. FFQ questions best reflecting a health-promoting diet with reference to dietary recommendations were identified by correlations, logistic regression modelling and receiver-operating characteristics curve analysis.

SETTING

Southwest and Eastern Finland.

PARTICIPANTS

Healthy elementary school-aged volunteers [n 266, mean (sd) age 9·7 (1·7) years] were recruited between March 2017 and February 2018.

RESULTS

A set of questions was identified from the FFQ that best depicted the children's diet quality as defined in the dietary recommendations. These fifteen questions were scored and formulated into a stand-alone index as a continuous index score (range 0-16·5 points) and a two-category score: good and poor diet quality. The cut-off score of six points for a good diet quality had a sensitivity of 0·60 and a specificity of 0·78. Children with a good diet quality (49·8 % of the children) had higher intakes of protein, dietary fibre, and several vitamins and minerals, and lower intakes of sucrose, total fat, SFA and cholesterol compared to children with a poor diet quality.

CONCLUSIONS

The developed short stand-alone index depicted diet quality as defined in the dietary recommendations. Thus, ES-CIDQ may be used for assessing diet quality in Finnish elementary school-aged children in school health care and nutrition research.

Mediterranean diet adherence amongst adolescents in North Lebanon: the role of skipping meals, meals with the family, physical activity and physical well-being

The Mediterranean diet (MD) is a model of a healthy diet and healthy lifestyle. Adherence to the MD has been correlated with a reduction in many metabolic disorders including cancers. The factors associated with adolescents' adherence to the MD in North Lebanon using the KIDMED index have never been explored. Therefore, we thought to examine these factors amongst a sample of them. A cross-sectional survey was conducted in the city of Tripoli, North Lebanon. A total of 798 adolescents aged 11-18 years were randomly selected to participate in this study. All participants completed a questionnaire assessing adherence to the MD (KIDMED index), physical activity (physical activity questionnaires for older children and adolescents), health-related quality of life (KIDSCREEN-27 index) and sociodemographic characteristics (age, sex, grade level and parents' educational status). Anthropometric measurements, including weight, height and waist circumference, were also collected. Adherence to the MD was good amongst only 13·3 % of the adolescents. The prevalence rate of overweight and obesity was elevated, affecting 36·9 % of the students. Lower adherence to the MD was significantly correlated with skipping meals (P = 0·001). Meanwhile, adolescents who were engaged in a high level of physical activity, those who consumed more meals with their families and those who benefited from better physical well-being had a better diet quality (P < 0·001). Nutrition intervention programmes, as well as public health policies, would be of interest in order to improve diet quality amongst Lebanese adolescents.

Eating behaviour, physical activity and lifestyle of Italian children during lockdown for COVID-19

In March 2020 Italy went into lockdown due to COVID-19 pandemic and children changed rapidly their lifestyles with possible negative effects on their health status. An online survey collected data on eating habits, physical activity, perception/behaviour of 1027 Italian 2-11 years children during lockdown. The chi-square test was applied to test differences in proportions. Results showed a tendency of eating behaviour to worsen as children age and by areas. Only 32.3% of the children had high adherence to Mediterranean Diet, with better scores in 2-5 years children. 78.1% of the children stopped their habitual physical activity, with higher percentage among 6-11 and in Northern children; only 51.8% maintained some activities at home, playing mainly movement games/sports. Children spent more time on devices, missed school and friends, being more bored and less creative. This framework highlights the growing need for strategies to preserve children's health in this and future pandemics.

[Adherence to the Mediterranean diet in a sample of Colombian schoolchildren: an evaluation of the psychometric properties of the KIDMED questionnaire]

Introduction

Objective: since childhood and adolescence are critical periods for the acquisition of eating habits and lifestyles that will persist into adulthood, having a questionnaire that estimates adherence to the Mediterranean diet among the school-age population is necessary. The aim of this study was to assess the validity, reliability, and factor structure of the KIDMED questionnaire in a group of children and adolescents from Cali, Colombia. Methods: this was a cross-sectional study using a self-reported questionnaire in 167 schoolchildren (53.8% girls, mean age 13.3 ± 3.2 years). Cronbach's alpha and Cohen's kappa (κ) were calculated as reliability and reproducibility indicators. The extraction of main components by varimax rotation allowed to define the communalities of the proposed items as a measure of validity. Results: overall, one in every 3 schoolchildren showed an optimal Mediterranean diet pattern. The KIDMED questionnaire showed moderate reliability and reproducibility values (Cronbach's alpha = 0.79, 95% CI: 0.71-0.77, and κ = 0.66, 95% CI: 0.45-0.77). The factor structure showed six factors that accounted for 60.6% of the total variance with an adequate goodness-of-fit test (Kaiser-Meyer-Olkin = 0.730), and Bartlett's sphericity test (X2 = 414.8, p < 0.001, g/l = 120). Conclusions: the KIDMED questionnaire shown evidence adequate psychometric properties as an instrument for assessing adherence for assessing adherence to the Mediterranean diet in schoolchildren in Colombia. Future studies should focus on investigating the confirmatory structure and/or convergent validity of the questionnaire in different age groups for generating comparable data.

Is adherence to the Mediterranean diet associated with healthy habits and physical fitness? A systematic review and meta-analysis including 565 421 youths

The relationship between adherence to the Mediterranean diet (MD), physical activity (PA), sedentary behaviour and physical fitness levels has been analysed in several studies; however, there is mixed evidence among youth. Thus, this study aimed to meta-analyse the associations between adherence to the MD, PA, sedentary behaviour and physical fitness among children and adolescents. Three databases were systematically searched, including cross-sectional and prospective designs with a sample of healthy youth aged 3–18 years. Random effects inverse-variance model with the Hartung–Knapp–Sidik–Jonkman adjustment was used to estimate the pooled effect size (correlation coefficient (r)). Thirty-nine studies were included in the meta-analysis, yielding a total of 565 421 youth (mean age, 12·4 years). Overall, the MD had a weak-to-moderate positive relationship with PA (r 0·14; 95 % CI 0·11, 0·17), cardiorespiratory fitness (r 0·22; 95 % CI 0·13, 0·31) and muscular fitness (r 0·11; 95 % CI 0·03, 0·18), and a small-to-moderate negative relationship with sedentary behaviour (r –0·15; 95 % CI –0·20, –0·10) and speed–agility (r –0·06; 95 % CI –0·12, –0·01). There was a high level of heterogeneity in all of the models (I2 ≥ 75 %). Overall, results did not remain significant after controlling for sex and age (children or adolescents) except for PA. Improving dietary habits towards those of the MD could be associated with higher physical fitness and PA in youth, lower sedentary behaviours and better health in general.

A Multiple Targeted Research Protocol for a Quasi-Experimental Trial in Primary School Children Based on an Active Break Intervention: The Imola Active Breaks (I-MOVE) Study

BACKGROUND

Children and adolescents should perform, according to the World Health Organization guidelines, at least 60 min of moderate-to-vigorous physical activity per-day in order to avoid the risk of metabolic and cardiovascular diseases. The school represents a fundamental setting to conduct interventions to promote physical activity (PA) and contrast sedentary behaviors. Active breaks (ABs), bouts of 10 min of PA conducted inside the classroom, seem to be a good strategy to promote PA and improve classroom behavior. The aim of this study protocol is to describe the design and the assessment of the Imola Active Breaks I-MOVE study.

METHODS

The I-MOVE study is a school-based intervention trial, with a quasi-experimental design, performed in a primary school. It involves one experimental-group performing the intervention, focused on ABs, and one control-group. Nine main outcomes are evaluated: PA and sedentary behaviors; health related fitness; motor control development; dietary patterns; anthropometric evaluation; sociodemographic determinants; cognitive function; time-on-task behavior and quality of life.

CONCLUSIONS

Results from the I-MOVE study will help to clarify the effects of incorporating ABs in the Italian school curriculum as a new public health strategy and an innovative school model oriented to the well-being of children and teachers for the best quality of school life.

Mediterranean diet adherence and weight status among Sicilian Middle school adolescents

During the last decades, an important modification of dietary habits has been observed in the Mediterranean countries, especially among young people. The aim of this study was to evaluate adherence to the Mediterranean diet (MedDiet) and its relationship with weight status in a group of Italian middle school adolescents by using the KIDMED test. The evaluation of weight status revealed that 61.5, 26.8, and 11.7% were normal weight, overweight, and obese, respectively. MedDiet adherence was high in 13.3%, average in 27.1%, and low in 59.6% of the students with no differences by gender and age. MedDiet adherence was found significatively higher in normal weight and in played sport adolescents, in comparison to the overweight and obese ones (p < .001) who showed incorrect nutritional habits. This cross-sectional study shows a very low MedDiet adherence among adolescent living in the Mediterranean basin and highlights the role of Mediterranean dietary pattern in the fight against obesity.

Weight Status, Adherence to the Mediterranean Diet, Physical Activity Level, and Sleep Behavior of Italian Junior High School Adolescents

Inadequate diet, physical activity, and sleep-related behaviors are potential risk factors for overweight and obese, therefore we investigated the relations between body mass index (BMI) and behavioral factors in a sample of Italian adolescents. Four hundred nine Italian secondary school students (46% females, 12.5 ± 0.6 y.o.) were enrolled in this cross-sectional study. Anthropometric measures, adherence to the Mediterranean Diet (KIDMED), physical activity level (PAQ-C), sleep duration, daytime sleepiness (PDSS), sleep quality, and school achievement data were collected through an online questionnaire. The percentage of overweight adolescents was slightly lower (14%) compared to the regional and the national figures. Approximately 88% of the sample reported a medium/high adherence to the Mediterranean Diet and 77% a moderate/vigorous physical activity level. The average sleep duration was in line with the international sleep recommendation for adolescents and 82% had a medium/high sleep quality. No differences were found between genders except for BMI (lower in females). Unexpectedly, no differences were found among the BMI groups (normal weight vs. overweight vs. obese) for lifestyle variables; in contrast, Mediterranean Diet adherence was associated with sleep habits. Further investigation is required to better explore the associations among behavioral variables involved in adolescents' healthy development.

Micronucleus Frequency in Exfoliated Buccal Cells of Children Living in an Industrialized Area of Apulia (Italy)

Micronuclei (MN) are biomarkers of early biological effect often used for detecting DNA damage in human population exposed to genotoxic agents. The aim of this study was to evaluate the frequency of MN in exfoliated buccal cells of children living in an industrialized (impacted) area compared with that found in children living in a control area without significant anthropogenic impacts. A total of 462 6–8-year-old children (206 in the impacted area, 256 in the control area) attending primary school were enrolled. A questionnaire was administered to the parents of the recruited children to obtain information about personal data, lifestyles, and food habits of their children. Atmospheric particulate fractions were collected near the involved schools to assess the level of environmental exposure of the children. The presence of MN was highlighted in 68.4% of children living in the impacted area with a mean MN frequency of 0.66‰ ± 0.61‰. MN positivity and frequency were significantly lower in the control area (37.1% and 0.27‰ ± 0.43‰, respectively). The frequency of MN was positively associated with quasi-ultrafine particulate matter (PM_0.5), traffic near the home, and consuming barbecued food; while adherence to the Mediterranean diet and practicing sport were negatively associated.

Prevalence and Trends of Overweight and Obesity in European Children From 1999 to 2016: A Systematic Review and Meta-analysis

IMPORTANCE

Studies of trends in excess weight among European children throughout the last few decades have rendered mixed results. Additionally, some studies were outdated, were based on self-reported weight and height, or included only a few European countries.

OBJECTIVE

To assess prevalence trends in measured overweight and obesity among children across Europe from 1999 to 2016 using a systematic methodology.

DATA SOURCES

MEDLINE, Embase, CINAHL, and Web of Science were searched from their inception until May 2018. Moreover, searches were conducted on health institutions' websites to identify studies not published in scientific journals.

STUDY SELECTION

The inclusion criteria were: (1) studies reporting the population-based prevalence of excess weight (overweight plus obesity) or obesity according to body mass index cutoffs proposed by the International Obesity Task Force; (2) cross-sectional or follow-up studies; and (3) studies including populations aged 2 to 13 years.

DATA EXTRACTION AND SYNTHESIS

Literature review and data extraction followed established guidelines. The Mantel-Haenszel method was used to compute the pooled prevalence estimates and their 95% CI whenever there was no evidence of heterogeneity (I2 < 50%); otherwise, the DerSimonian and Laird random-effects method was used. Subgroup analyses by study year, country, or European region (Atlantic, Iberian, Central, and Mediterranean) were conducted. Prevalence estimates were calculated as an aggregate mean, weighted by the sample size and the number of individuals in each study.

RESULTS

A total of 103 studies (477 620 children aged 2 to 13 years) with data from 28 countries were included. The combined prevalence of overweight and obesity in the Iberian region tended to decrease from 30.3% (95% CI, 28.3%-32.3%) to 25.6% (95% CI, 19.7%-31.4%) but tended to increase in the Mediterranean region from 22.9% (95% CI, 17.9%-27.9%) to 25.0% (95% CI, 14.5%-35.5%). No substantial changes were observed in Atlantic Europe or Central Europe, where the overweight and obesity prevalence changed from 18.3% (95% CI, 14.0%-23.9%) to 19.3% (95% CI, 17.7%-20.9%) and from 15.8% (95% CI, 13.4%-18.5%) to 15.3% (95% CI, 11.6%-20.3%), respectively.

CONCLUSIONS AND RELEVANCE

The prevalence of childhood overweight and obesity is very high, but trends have stabilized in most European countries. There are substantial between-country differences in the current levels and trends of overweight and obesity. The rising prevalence in some Mediterranean countries is worrisome.

TRIAL REGISTRATION

PROSPERO identifier: CRD42017056924.

Physical Activity, Body Mass, and Adherence to the Mediterranean Diet in Preschool Children: A Cross-Sectional Analysis in the Split-Dalmatia County (Croatia)

Physical activity, body mass, and dietary habits are known to be important determinants of overall health status, but there is an evident lack of studies that examine these issues specifically in preschool children. The aim of this study was to identify associations that may exist between adhering to the Mediterranean diet (MD), levels of physical activity (PA), and body composition indices in apparently healthy preschool children from southern Croatia. Participants were 5- to 6-year-old preschoolers from the Mediterranean part of the country (the Split-Dalmatia County; n = 260, 126 females). Adherence to the MD was observed by the Mediterranean Diet Quality Index (KIDMED), PA level was evaluated by the Preschool-age Children’s Physical Activity Questionnaire (Pre-PAQ), and responses were collected from the parents. The participants’ waist circumferences (in cm), waist-to-hip ratios, and body mass index (in kg/m², and in a z-score calculated relative to the normative value for age and sex) were used as indicators of body composition. All children were of the same age and tested over a one-month period of the same year as a part of the regular examination undertaken before attending elementary school. With only 6% of the children having a low KIDMED score, adherence to the MD was high. MD adherence was higher in girls (Chi-square = 15.31, p < 0.01) and children who live on the coast of the Adriatic Sea (Chi-square = 18.51, p < 0.01). A mixed effects logistic regression (with kindergarten as random factor) identified sedentary activity to be negatively associated with MD adherence (OR per point: 0.65, 95% CI: 0.44–0.91). High adherence to the MD in the studied sample may be attributed to regulated feeding in kindergarten. Considering that most Croatian elementary schools do not provide food to their students, MD adherence should be investigated later in life and also in other parts of the country where the MD is culturally less prevalent.

Access to health care, nutrition and dietary habits among school-age children living in socio-economic inequality contexts: results from the "ForGood: Sport is Well-Being" programme

Social frailty is a warring phenomenon in Europe, negatively impacting children's health and nutrition. We present the results of a social programme facilitating access to physical activities for vulnerable children in Italy. 311 school-age children enrolled in the programme between 2015 and 2017 were assessed for health and lifestyle, anthropometric and nutritional status. Data were compared by origin (Italians vs. immigrants) and then immigrants were split into sub-groups: first- and second-generation. Poor socio-economic status exposed children to a lack of access to health services, and drove imbalanced eating behaviour. 20.8% of children were not registered with the National Health Services (immigrants p < .0001); 22% were not fully vaccinated (no differences between groups). A double burden of malnutrition coexisted: overweight was higher for Italians, underweight and poor linear growth for immigrants. Nearly 40% of children had a poor Mediterranean Diet adequacy (KIDMED index). Our findings show that when social programmes, besides their main scope of inclusion and integration, holistically approach their beneficiaries, they can play an important role in monitoring lifestyle conditions and facilitating access to primary health care.

Breakfast Intake and Factors Associated with Adherence to the Mediterranean Diet among Lebanese High School Adolescents

The Mediterranean diet has shown to have positive health impacts on metabolic diseases and cognitive performance. However, Mediterranean countries have witnessed a decreased adherence during the past years and the adoption of a more westernized dietary pattern. The aim of this study was to evaluate the association of Mediterranean diet adherence with sociodemographic, lifestyle, and anthropometric factors among Lebanese high school adolescents. Specifically, we aimed to analyse in this group the association between low adherence and breakfast intake. A cross-sectional survey was carried out on randomly selected students (268 boys and 332 girls), aged between 15 and 18 years old, from private and public schools in Beirut and Mount Lebanon. Data were obtained from self-administered questionnaires and anthropometric measurements. The Mediterranean Diet Quality Index for children and adolescents was used to assess the adherence to the Mediterranean diet. The results showed a high percentage of adolescents having a low adherence (43%), with girls (64.2%) having a significant (p < 0.001) higher adherence than boys (35.8%). Furthermore, the study proved that a lower adherence to the Mediterranean diet was significantly associated with a higher risk of obesity (15.5%), breakfast skipping (69.4%), and an unhealthy breakfast options (17.4%). Younger adolescents (47.4%), students from public schools (92.6%), and students with the highest grades (25.3%) had a significantly higher adherence to the Mediterranean diet than those from private schools (7.4%) and older adolescents (18.9%). In conclusion, results should plead for an increased awareness in Lebanese schools, supporting students to be more adherent to the Mediterranean diet, in order to prevent a further increase in metabolic diseases later in adulthood.

The Relative Contribution of Food Groups to Macronutrient Intake in Children with Cystic Fibrosis: A European Multicenter Assessment

BACKGROUND

Optimal nutrition for children with cystic fibrosis (CF) improves prognosis and survival, but an increased caloric intake recommendation for this population raises concerns about the nutrient profile of their diets.

OBJECTIVE

Our aim was to assess the relative contribution of food groups to the total macronutrient intake of European pediatric patients with CF.

DESIGN

We conducted a cross-sectional study in which the participants recorded dietary intake from 2016 to 2017. Specifically developed nutritional composition databases were used to obtain nutritional data, including macronutrients and food groups, according to previously standardized criteria.

PARTICIPANTS/SETTING

Two hundred and seven pediatric patients with CF from six European centers were involved in the My App for Cystic Fibrosis self-management project.

MAIN OUTCOME MEASURES

Participants reported dietary intake with a detailed 4-day food record.

STATISTICAL ANALYSIS PERFORMED

Descriptive analyses of nutrient intake, food group consumption, and dietary origin of macronutrients were conducted with R software.

RESULTS

Similar patterns were found in nutrient and food group intake; both sugar and saturated fatty acids contributed >10% each to the total daily energy intake in all the centers. Large mean and median percent differences were observed in the intake of other nutrient and food groups, because sweets and snacks were consumed once or twice a day, and fruit and vegetables were consumed two or three times a day. Milk, meat, sweets and snacks, and oils were the main sources of fat in all centers.

CONCLUSIONS

Study findings indicated less than optimal nutrient profiles, especially for sugars and saturated fatty acids, resulting from the high consumption of meat, dairy, and processed products and low consumption of fish, nuts, and legumes. These results can serve as a basis for future tailored interventions that target improved adherence to nutritional recommendations for patients with CF.

Mediterranean Diet and Motivation in Sport: A Comparative Study Between University Students from Spain and Romania

BACKGROUND

The Mediterranean Diet (MD) is one of the healthiest dietary models worldwide, being an essential mean of preventing pathologies along with the practice of physical activity. Through a comparative study carried out across different countries, it has been demonstrated how this type of habits vary depending on the geographical context. The aim of this research was to evaluate the adherence to MD and its relationships with motivational climate in sport on a sample of university students from Spain and Romania; Methods: A cross-sectional study was conducted on a sample of university students [specialization: Physical Education (n = 605; 20.71 ± 2.42 years old)], using as main instruments the Mediterranean Diet Quality Index (KIDMED) for students and adolescents and the Perceived Motivational Climate in Sport Questionnaire-2 (PMCSQ-2); Results: It was shown that students from Spain had a high adherence to the MD (6.65 ± 2.63 vs. 5.06 ± 1.31). Spanish university students got higher scores in task-oriented motivational climate (4.03 ± 0.62 vs. 3.11 ± 0.55) while ego-oriented climate was higher in university students from Romania (3.24 ± 0.54 vs. 2.07 ± 0.75). Finally, it was observed that the task-oriented motivational climate was related to a lower adherence to MD in Spanish students (4.49 ± 0.37 vs. 3.98 ± 0.62). In contrast, in Romanian youth, a medium adherence to the MD was associated with higher scores for the ego-oriented motivational climate (3.27 ± 0.53 vs. 3.00 ± 0.54); Conclusions: As main conclusions, it was shown that the students from Spain had a high adherence to the MD. In addition, it has been demonstrated that ego-oriented climates are linked to a better adherence to MD, especially due to the importance of following a proper diet in sport contexts, as demonstrated by young Romanians.

Adherence to the Mediterranean Diet among School Children and Adolescents Living in Northern Italy and Unhealthy Food Behaviors Associated to Overweight

The purposes of this study were to evaluate the differences in Mediterranean diet and its components among primary and secondary school children and adolescents living in northern Italy, and the associations with the weight status. Adherence was assessed by the KIDMED (Mediterranean Diet Quality Index) questionnaire on 669 subjects (6⁻16 years) attending five schools of Novara. The adherence was poor in 16.7%, average in 63.7%, and high in 19.6% of the students. Poor adherence was more frequent in primary than in secondary schools (20.7% vs. 13.7%, p < 0.04). Some unhealthy behaviors were more prevalent in younger children. Children of other ethnic origins had a mixed behavior, choosing both traditional healthy and unhealthy foods. Besides male gender and primary school, in Italian children, the risk of overweight was directly associated with eating at fast-food restaurants (OR: 1.890, CI 95% 1.002⁻3.563), and inversely with consumption of vegetables more than once a day (OR: 0.588, CI 95% 0.349⁻0.991), and olive oil at home (OR: 0.382, CI 95% 0.176⁻0.826). In children of other ethnic origins, this risk was associated with skipping breakfast (OR: 16.046, CI 95% 1.933⁻133.266), or consuming commercial baked good or pastries for breakfast (OR: 10.255, CI 95% 1.052⁻99.927). The overall KIDMED score correlated with height (β: 0.108; p < 0.005). Poor food quality is replacing the Mediterranean dietary pattern in children and adolescents, in particular among younger children. Because the risk of overweight was associated with different components of the Mediterranean diet depending on ethnic origins, tailored nutritional programs remain a need.

Adherence to the Mediterranean Diet Is Associated with Physical Activity, Self-Concept and Sociodemographic Factors in University Student

(1) Background: The aim of this study was to assess adherence to the Mediterranean diet (MD) and to examine the relationship between MD adherence, physical activity, self-concept, and other sociodemographic factors; (2) Methods: A cross-sectional study (N = 597; 18.99 ± 0.64 years) was conducted in a sample of university students from Ceuta, Melilla, and Granada (Spain). Religious beliefs and place of residence were directly reported, while physical activity and adherence to the MD were self-reported using the Physical Activity Questionnaire for Adolescents (PAQ-A) and the Mediterranean Diet Quality Index (KIDMED) respectively. Self-concept was evaluated using the Five-Factor Self-Concept Scale; (3) Results: Of those students reporting high levels of habitual physical activity, 82.3% also reported high adherence to the MD, with 17.7% reporting a medium adherence. Of students reporting no physical activity, 25.7% also reported medium adherence to the MD. No significant associations were found between the MD and religious beliefs. It was observed that the university campus was associated with the level of adherence to the MD (p = 0.030), with adherence being lowest in Ceuta and Melilla. Finally, the MD was associated with academic (p = 0.001) and physical self-concept (p = 0.005); 4) Conclusions: The MD should be promoted to university students, particularly those studying at Ceuta and Melilla, given the present findings of lower MD adherence. In addition, as higher MD adherence was also highlighted with more positive self-concept, its promotion would be beneficial in wider educational contexts.

Are school meals a viable and sustainable tool to improve the healthiness and sustainability of children´s diet and food consumption? A cross-national comparative perspective

There is little agreement among governments, institutions, scientists and food activists as to how to best tackle the challenging issues of health and sustainability in the food sector. This essay discusses the potential of school meals as a platform to promote healthy and sustainable food behavior. School meal programs are of particular interest for improving public diet because they reach children at a population scale across socio-economic classes and for over a decade of their lives, and because food habits of children are more malleable than those of adults. Current research on the history and health implications of school meal programs is reviewed in a cross-national comparative framework, and arguments explored that speak for the need of a new developmental phase of school meals as an integrative learning platform for healthy and sustainable food behavior. Nutritional, social, practical, educational, economical, political, and cultural perspectives and challenges linked to the implementation of healthy and sustainable school meals are discussed. Finally, the need for long-term interventions and evaluations is highlighted and new research directions are proposed.

Familia, escuela y adherencia a la dieta mediterránea en infancia y adolescencia

La infancia y la adolescencia representan dos etapas de vital importancia para el desarrollo de las personas, por lo que parece imprescindible consolidar una serie de patrones que reporten beneficios a corto y largo plazo. La obesidad y el sobrepeso infantil son factores de riesgo que aumentan la probabilidad de sufrir ciertas patologías, pudiendo evitarse, en gran medida, con unos adecuados hábitos alimenticios, como la adherencia a patrones alimentarios de estilo Mediterráneo. El análisis de contenido bibliográfico de algunas de las investigaciones más recientes permite confirmar el impacto que algunos factores como familia o escuela tienen sobre la misma. 

Adherence to a Mediterranean dietary pattern and overweight and obesity among female adolescents in Iran

Background Given the high prevalence of overweight and obesity in Iran, identification of a healthy diet is essential. Objective This study aimed to assess the association between adherence to a Mediterranean diet and overweight and obesity in female adolescents. Methods Two hundred and eighty female adolescents from high schools in Tehran were recruited. General information, physical activity and food frequency questionnaires were completed. Adherence to the Mediterranean diet was evaluated using the Mediterranean Style Dietary Pattern Score (MSDPS). Results Under and over reporters of energy intake were excluded from the analysis (n = 37). Results indicated that prevalence of overweight and obesity was 13.3% and 12.5%, respectively. The mean of MSDPS was low in this population (15.99 ± 5.64). The MSDPS was positively associated with mother's education level and energy intake (p < 0.05). No significant relation was observed between MSDPS and overweight and obesity among adolescents. However, there was a negative significant association between MSDPS and WHR just among students who had educated mothers [high: second median v. low: first median, odds ratio (OR) = 0.36, 95% confidence interval (CI) = 0.12-1.03]. Conclusion Adherence to a Mediterranean dietary pattern is low among adolescent females in Tehran, with no association with overweight and obesity.

Associations between the adherence to the Mediterranean diet and cardiorespiratory fitness with total and central obesity in preschool children: the PREFIT project

PURPOSE

Early recognition of risk factors associated with overweight/obesity is an important step towards preventing long-term health consequences. The aim of the current study was to examine the associations of the adherence to the Mediterranean dietary pattern (MDP) and cardiorespiratory fitness (CRF) with adiposity in preschool children from the north of Spain.

METHODS

The adherence to the MDP (KIDMED), CRF (20-m shuttle run test), total (BMI) and central (waist circumference) adiposity and socio-demographic factors were assessed in 619 children (48.6% girls) who were on average 4.7 years old.

RESULTS

Higher MDP index (P < 0.05) and CRF levels (P < 0.01) were significantly related to lower waist circumference. CRF was inversely associated with BMI (P ≤ 0.001), yet no significant association was observed between MDP and BMI. Children not having high CRF levels and high MDP (i.e., non-upper sex-specific tertile of CRF or MDP, respectively) had the highest waist circumference.

CONCLUSIONS

Our findings support that higher adherence to the MDP and higher CRF are associated with lower waist circumference in preschool children, pointing them as relevant modifiable factors to be targeted by educational strategies aiming to prevent central obesity and later obesity-related comorbidities.

Weight Status Is Related with Gender and Sleep Duration but Not with Dietary Habits and Physical Activity in Primary School Italian Children

The prevalence of overweight and obesity in children has risen greatly worldwide. Diet and poor physical activity are the two risk factors usually examined, but epidemiological evidence exists suggesting a link between sleep duration and overweight/obesity in children. The aim of this study was to describe the relationship among body mass index (BMI), diet quality, physical activity level, and sleep duration in 690 children attending the 5th grade in primary schools (9-11 years old) in the city of Parma (Italy) involved in the Giocampus educational program. This was achieved through (i) measuring anthropometric data to compute body mass index; (ii) administering a food questionnaire to evaluate adherence to the Mediterranean Diet (KIDMED score); and (iii) administering a lifestyle questionnaire to classify children physical activity level (PAL), sleep duration, and school achievement. A highly significant negative association was found between BMI and sleep hours. Moreover, there was a significant positive association between PAL and KIDMED scores. No evidence was found of association between BMI and PAL, nor between BMI and KIDMED score. Data from this study established that BMI is correlated to gender and sleep duration, defining sleep habits as one of the factors linked to overweight and obesity.

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.

Adherence to the Mediterranean Diet in children and adolescents: A systematic review

BACKGROUND AND AIM

A decreased adherence to the Mediterranean Diet (MD) may be related to a rise in chronic non-communicable diseases from childhood onward. The aim of this systematic review was to summarize the available literature regarding MD adherence in children and adolescents, and focusing, more specifically, on the association of MD adherence with demographic and anthropometric variables, body composition, lifestyle, and diet adequacy.

METHODS AND RESULTS

A search of scientific literature was carried out on PUBMED, SCOPUS, Clinical Trials Results, Google Scholar, and British Library Inside for studies published in the last 20 years. Fifty-eight papers were finally included according to the following criteria: MD adherence evaluated through a quantifying score or index, age 2-20 years, sample size >200 participants, observational or intervention studies regarding the general population. The KIDMED index was the most widely used scoring system. MD adherence widely varied within the Mediterranean countries for both children and adolescents, with also large differences among various European countries, while few data are available for non-Mediterranean countries. Most of the eligible studies showed that MD adherence was directly associated with physical activity (and possibly with diet adequacy) and inversely with sedentary behavior, while the results for gender, age, socioeconomic status and weight status were not consistent.

CONCLUSIONS

Further validation of MD indexes in terms of reproducibility and consistency with the MD is needed. At the same time, more prospective cohort and intervention studies may better elucidate the relationships of MD adherence with behavioral and health outcomes.

A teachers' training program accompanying the "School Fruit Scheme" fruit distribution improves children's adherence to the Mediterranean diet: an Italian trial

The effects of a nutrition education program, led by trained teachers within the Italian School Fruit Scheme, were evaluated. Pre-post intervention children's adherence to the Mediterranean diet (MD) was assessed by the KIDMED test. A representative cluster sample of 494 fourth grade students from thirteen Italian schools in the three areas of low (North), medium (Centre) and high (South) prevalence of overweight and obesity was investigated. Within the same schools, the intervention group (n = 395) received the program, the control group (n = 99) did not. In the intervention group, the proportion of children with high adherence to the MD significantly increased in the total sample, females and South in the post-intervention; no significant changes in levels of adherence related to ponderal status were detected. A significant increase was found, particularly, in the proportion of children who improved their frequency of consumption of fruit and vegetables (FV) daily, especially in the South.

School and family-based interventions for promoting a healthy lifestyle among children and adolescents in Italy: a systematic review

AIMS

Cardiovascular diseases affect adult population but risk factors develop as a result of known or assumed behavior since childhood. In Italy, up to 22.2% of children are overweight, 10.6% are obese, and 2.5% have severe obesity.

METHODS

We performed a systematic review of the literature to identify studies and initiatives addressing health promotion among children in Italy. Given the high heterogeneity of interventions and outcomes assessed we opted to perform a qualitative synthesis of the results. We described also nonrandomized trial where the intervention of primary prevention was very innovative, explained in detail, and reached an improving outcome for participants.

RESULTS

We identified 11 projects since 1983, only five were randomized control trials. Three involved children and teachers of primary and secondary schools and were based on specific curricular lectures about health. One was based on a game developed for high schools with the purpose to promote healthy lifestyle and physical activity. The fifth project was based on an enhanced physical activity program.

CONCLUSION

Our results show that school and family should be considered as the privileged places for health promotion. In Italy, the development of scientific-validated lifestyle interventions for children is still an unmet need.