Determinants of Adherence to the Mediterranean Diet in Spanish Children and Adolescents: The PASOS Study

Eating distractions as predictors of ultra-processed food consumption and Mediterranean diet adherence in adolescents

Previous studies have examined the relationships between some eating distractions and diet quality in the young population. However, to our knowledge, no study has analyzed the associations between multiple eating distractions (e.g., using a mobile phone, watching television [TV], eating while standing) and diet quality, particularly in terms of ultra-processed food (UPF) consumption and adherence to the Mediterranean diet (MedDiet) among adolescents. The objective of the current study was to analyze the relationships of eating distractions with UPF consumption and adherence to the MedDiet in a sample of Spanish adolescents. This cross-sectional study used data from 826 adolescents aged 12-17 years from the Eating Healthy and Daily Life Activities study in Spain. The following eating distractions were assessed via a self-report questionnaire: "(1) eating while talking on the phone/sending short message service [SMS]/emails or using social networks", (2) watching TV while dinner, and (3) eating while standing". The Mediterranean Diet Quality Index for children and adolescents (KIDMED) was utilized to evaluate adherence to the MedDiet. A self-administered food frequency questionnaire, previously validated for the Spanish population, was used to assess UPF consumption. The associations of eating distractions with UPF consumption and MedDiet adherence were analyzed via generalized linear models. The models were adjusted for sex, age, socioeconomic status, body mass index, physical activity, sedentary behavior, and sleep duration. A significant association was found, with a higher eating distraction score corresponding to greater UPF consumption (unstandardized beta coefficient [B] = 71.25; 95% confidence interval [CI] 34.69-107.82; p < 0.001). Furthermore, a higher eating distraction score was associated with a lower KIDMED score (B - 0.29; 95% CI - 0.39 to - 0.18; p < 0.001). Individually, for grams of UPFs consumed, a significant association was observed for eating while using a phone or social network, which was linked to higher UPF consumption (B = 120.70; 95% CI 57.83-183.57; p < 0.001). However, the associations for eating while watching TV (B = 49.60; 95% CI - 9.01 to 108.21; p = 0.098) and eating while standing (B = 63.66; 95% CI - 37.92 to 165.25; p = 0.220) did not reach statistical significance. For KIDMED score, all the eating distractions were associated with a significant decrease, with the largest effect observed for phone or social network use (B = - 0.44; 95% CI - 0.62 to - 0.26). Watching TV (B = - 0.18; 95% CI - 0.35 to - 0.01; p = 0.037) and eating while standing (B = - 0.42; 95% CI - 0.71 to - 0.13; p = 0.004) also showed significant negative associations. Although diet quality is influenced by multiple factors, eating distractions may negatively impact adolescents by increasing UPF consumption and reducing adherence to the MedDiet. These findings underscore the importance of understanding the role of the eating environment in shaping healthy dietary habits.

Healthier Diet and Diet-Related Behaviors Are Associated with Increased Physical Activity and Reduced Sedentary Behavior Among Adolescents in Greece

BACKGROUND/OBJECTIVES

Healthy diet, regular physical activity (PA), and minimizing sedentary behavior (SB) are crucial in promoting adolescents' health and well-being. We assessed adherence to PA and SB recommendations among a representative sample of adolescents and explored their relationship with diet and diet-related behaviors.

METHODS

Data from the Greek arm of the 2017/2018 international Health Behavior in School-Aged Children (HBSC) cross-sectional study were used, including a probability sample of 3357 students (47.6% boys) who were 11, 13, and 15 years old. PA, SB, consumption of food groups/beverages, and diet-related behaviors were self-reported. Multiple logistic regression was used to identify potential associations.

RESULTS

Most students failed to meet PA (83.9%) (i.e., ≥1 h of moderate-to-vigorous physical activity/day) and SB (90.2%) (i.e., ≤2 h of screen time/day) recommendations. Daily consumption of fruit and vegetables compared to consumption at ≤1 day/week was associated with increased adherence to PA recommendations (adjusted Odds Ratio (aOR) = 2.26, 95% Confidence Intervals (CI): 1.62-3.17 for fruit; aOR = 1.35, 95%CI: 1.00-1.82 for vegetables). Eating sweets ≤1 day/week vs. every day was associated with higher adherence to SB recommendations (aOR = 2.41, 95%CI: 1.43-4.04). Poor diet quality was related to lower adherence to PA and SB recommendations. Daily breakfast consumption vs. never and abstaining from eating at fast-food restaurants were associated with better adherence to PA and SB recommendations. Rarely eating in front of screens was associated with substantially higher odds of adhering to SB recommendations (aOR = 5.79, 95%CI: 3.67-9.14).

CONCLUSIONS

Healthier diet/diet-related behaviors were associated with increased PA and reduced SB in this sample of adolescents.

Lifestyle Factors Associated with Children's and Adolescents' Adherence to the Mediterranean Diet Living in Mediterranean Countries: The DELICIOUS Project

Background/Objectives. Traditional dietary patterns are being abandoned in Mediterranean countries, especially among younger generations. This study aimed to investigate the potential lifestyle determinants that can increase adherence to the Mediterranean diet in children and adolescents. Methods. This study is a cross-sectional analysis of data from five Mediterranean countries (Italy, Spain, Portugal, Egypt, and Lebanon) within the context of the EU-funded project DELICIOUS (UnDErstanding consumer food choices & promotion of healthy and sustainable Mediterranean Diet and LIfestyle in Children and adolescents through behavIOUral change actionS). This study comprised information on 2011 children and adolescents aged 6-17 years old collected during 2023. The main background characteristics of both children and parents, including age, sex, education, and family situation, were collected. Children's eating (i.e., breakfast, place of eating, etc.) and lifestyle habits (i.e., physical activity level, sleep, and screen time) were also investigated. The level of adherence to the Mediterranean diet was assessed using the KIDMED index. Logistic regression analyses were performed to test for likelihood of higher adherence to the Mediterranean diet. Results. Major determinants of higher adherence to the Mediterranean diet were younger age, higher physical activity level, adequate sleep duration, and, among dietary habits, having breakfast and eating with family members and at school. Parents' younger age and higher education were also determinants of higher adherence. Multivariate adjusted analyses showed that an overall healthier lifestyle and parents' education were the factors independently associated with higher adherence to the Mediterranean diet. Conclusions. Higher adherence to the Mediterranean diet in children and adolescents living in the Mediterranean area is part of an overall healthy lifestyle possibly depending on parents' cultural background.

Switching Mediterranean Consumers to Mediterranean Sustainable Healthy Dietary Patterns (SWITCHtoHEALTHY): Study Protocol of a Multicentric and Multi-Cultural Family-Based Nutritional Intervention Study

BACKGROUND/OBJECTIVES

Populations in Mediterranean countries are abandoning the traditional Mediterranean diet (MD) and lifestyle, shifting towards unhealthier habits due to profound cultural and socioeconomic changes. The SWITCHtoHEALTHY project aims to demonstrate the effectiveness of a multi-component nutritional intervention to improve the adherence of families to the MD in three Mediterranean countries, thus prompting a dietary behavior change.

METHODS

A parallel, randomized, single-blinded, and controlled multicentric nutritional intervention study will be conducted over 3 months in 480 families with children and adolescents aged 3-17 years from Spain, Morocco, and Turkey. The multi-component intervention will combine digital interactive tools, hands-on educational materials, and easy-to-eat healthy snacks developed for this study. Through the developed SWITCHtoHEALTHY app, families will receive personalized weekly meal plans, which also consider what children eat at school. The engagement of all family members will be prompted by using a life simulation game. In addition, a set of activities and educational materials for adolescents based on a learning-through-playing approach will be codesigned. Innovative and sustainable plant-based snacks will be developed and introduced into the children's dietary plan as healthy alternatives for between meals. By using a full-factorial design, families will be randomized into eight groups (one control and seven interventions) to test the independent and combined effects of each component (application and/or educational materials and/or snacks). The impact of the intervention on diet quality, economy, and the environment, as well as on classical anthropometric parameters and vital signs, will be assessed in three different visits. The COM-B behavioral model will be used to assess essential factors driving the behavior change. The main outcome will be adherence to the MD assessed through MEDAS in adults and KIDMED in children and adolescents.

CONCLUSIONS

SWITCHtoHEALTHY will provide new insights into the use of sustained models for inducing dietary and lifestyle behavior changes in the family setting. It will facilitate generating, boosting, and maintaining the switch to a healthier MD dietary pattern across the Mediterranean area. Registered Trial, National Institutes of Health, ClinicalTrials.gov (NCT06057324).

Cross-Sectional Assessment of Nutritional Status, Dietary Intake, and Physical Activity Levels in Children (6-9 Years) in Valencia (Spain) Using Nutrimetry

The aims of this research were to evaluate the current nutritional status, dietary intake, and level of physical activity and assess the need for intervention. This was a cross-sectional study with 2724 participating children aged 6-9 years old. Nutritional status was assessed using nutrimetry, dietary intake with a 3-day food-recall questionnaire and physical activity with an ad hoc questionnaire. The nutricode with the highest prevalence was healthy weight/normal stature, with 51.3% of the sample. For the BMI for age Z-score, those in the overweight/obesity category represented 37.5% of the sample, while the thinness category included 7.6%. Intake of calories, proteins, sugar, lipids, SFA, MUFA, and cholesterol were significantly higher than recommended. The thinness groups consumed a significantly higher amount of excess calories while the overweight/obesity groups had the lowest mean excess calorie intake. Children in the thinness category presented the highest rates at both ends of the spectrum for sedentary activities. This study showed the high prevalence of malnutrition in schoolchildren. The results for the risk of thinness and overweight/obesity according to individual nutrient intake should be carefully interpreted. Lifestyle is a fundamental aspect to consider when combating malnutrition, especially at the level of dietary and physical activity habits, to combine various methods of intervention to improve nutritional status.

[Adherence to the Mediterranean diet and eating behaviour in Spanish schoolchildren]

Introduction

Introduction: eating behaviors may modulate or influence diet quality and the degree of adherence to the Mediterranean diet in children and adolescents. Aims: to investigate the association between diet quality and eating behavior in a group of Spanish schoolchildren. Methods: descriptive cross-sectional study of 283 Spain schoolchildren aged six to 16. Each subject was assessed using the KIDMED questionnaire for adherence to the Mediterranean diet and the Children's Eating Behaviour Questionnaire (CEBQ) questionnaire to assess eating behavior. Results: of the sample, 12.80 % had low adherence to the Mediterranean diet, 59.80 % had poor adherence, 59.80 % could be improved, and 27.40 % had high adherence. When relating eating behavior to dietary quality, it was found that, generally, schoolchildren with greater enjoyment of food and less demand for food have double the adherence to the Mediterranean diet due to almost twice the consumption of vegetables, nuts, and fish, and a lower intake of low-quality processed foods (sweets). The response to satiety and the speed of ingestion also played an important role in food choices. Conclusions: eating behaviors may play an essential role in the quality of school children's diets highlighting the enjoyment and acceptance or rejection of food. Given the bidirectional nature of the effects between eating behaviors and diet quality, the joint analysis may be the basis for future research with the aim of a better nutritional approach from the earliest ages.

Determinants of Diet Quality in Adolescents: Results from the Prospective Population-Based EVA-Tyrol and EVA4YOU Cohorts

(1) Background: Unhealthy dietary behaviors are estimated to be one of the leading causes of death globally and are often shaped at a young age. Here, we investigated adolescent diet quality and its predictors, including nutrition knowledge, in two large Central European cohorts. (2) Methods: In 3056 participants of the EVA-Tyrol and EVA4YOU prospective population-based cohort studies aged 14 to 19 years, diet quality was assessed using the AHEI-2010 and DASH scores, and nutrition knowledge was assessed using the questionnaire from Turconi et al. Associations were examined utilizing multivariable linear regression. (3) Results: The mean overall AHEI-2010 score was 42%, and the DASH score was 45%. Female participants (60.6%) had a significantly higher diet quality according to the AHEI-2010 and DASH score. AHEI-2010 and DASH scores were significantly associated (p < 0.001) with sex, school type, smoking, and total daily energy intake. The DASH score was additionally significantly associated (p < 0.001) with age, socioeconomic status, and physical activity. Participants with better nutrition knowledge were more likely to be older, to attend a general high school, to live in a high-income household, to be non-smokers, and to have a higher diet quality according to the AHEI-2010 and DASH score. (4) Conclusions: Predictors of better diet quality included female sex, physical activity, educational level, and nutrition knowledge. These results may aid focused interventions to improve diet quality in adolescents.

Lifestyle behaviors clusters in a nationwide sample of Spanish children and adolescents: PASOS study

BACKGROUND

Youth is a vulnerable period. To classify lifestyle behaviors and its relationship with health-related outcomes of Spanish children and adolescents.

METHODS

Cross-sectional study including 3261 children aged 7.5-17.5 y (52.8% females). Physical activity (PA), screen-time, sleep time, adherence to Mediterranean diet (MD), weight status (WS) by validated methods. Cluster analysis was run considering chronological age.

RESULTS

Six clusters were identified: C1: high screen time, low adherence to MD and sleep time (n = 431,13.20%); C2: high WS, medium adherence to MD,high sleep time, and low screen time (n = 466,14.30%); C3: young group with low screen time and high PA, adherence to MD and sleep (n = 537,16.40%); C4: worst profile regarding adherence to MD, PA, WS and sleep time (n = 609,18.70%); C5: low screen time and PA, high sleep time (n = 804,24.70%); C6: high PA and screen time, low WS (n = 414,12.70%). Mean absolute values were statistically different among PA levels, screen and sleep time, adherence to MD, age, and WS (all p < 0.001).

CONCLUSIONS

The most prevalent pattern was low levels of PA, MD, and screen time, and high sleep time. The second most prevalent was characterized by very low levels of PA, sleep time, and adherence to MD, and high screen time, and WS in adolescents.

IMPACT STATEMENT

The main identified lifestyle behavior was poor physical activity, low adherence to Mediterranean Diet and high screen and sleep time. Children should increase physical activity levels, adherence to Mediterranean diet, decrease screen and sleep the appropriate hours per day. Families, schools, and medical communities must work together to gloss over present and future diseases. Sleep time had not been previously included in cluster analysis with physical activity, sedentary behaviors, obesity, and nutritional status, thus the present data open a new perspective in Spanish population. Health policies should focus on promoting physical activity, Mediterranean diet, adequate sleep and reducing screen time.

Parents' Diet Quality and Physical Activity Are Associated with Lifestyle in Spanish Children and Adolescents: The PASOS Study

BACKGROUND

Non-communicable chronic diseases are associated with a low-quality diet, low physical activity, and sedentary behavior.

OBJECTIVE

To assess how parents' diet and physical activity habits were associated with their offsprings' lifestyles.

STUDY DESIGN

A cross-sectional analysis of 8-16-year-old children and adolescents (n = 2539; 51.9% girls) was carried out within the frame of the first edition of the Physical Activity, Sedentarism, Lifestyles, and Obesity in Spanish Youth study (PASOS-2019). Data on adherence to the Mediterranean Diet (MedDiet), daily moderate-vigorous physical activity (MVPA), and screen time per day (television, computer, video games, and mobile phone) were collected from children and adolescents, and data on parents' diet quality and physical activity were compiled. Logistic regression models were used to assess the association between parents' lifestyles and those of children and adolescents.

RESULTS

High diet quality of parents was associated with higher adherence to the MedDiet of children and adolescents, as well as high consumption of fruit, vegetables, fish, nuts, and legumes. The high physical activity level of parents was associated with the low consumption of fast foods, sweets, and candies in children and adolescents. Children with high levels of physical activity were those whose parents showed better diet quality and physical activity levels.

CONCLUSIONS

Parents' high diet quality and physical activity were associated with healthy lifestyles, higher adherence to the MedDiet, and physical activity of their offspring, mainly in adolescents.

Assessment of the Health Status of Spanish Schoolchildren Based on Nutrimetry, Lifestyle and Intestinal Parasites

Malnutrition in Spanish schoolchildren, and its relationship with lifestyles, has been studied, but Nutrimetry (a nutritional status indicator), and data on intestinal parasitism and its risk factors, have never before been taken into account. A total of 206 children aged 3-11 years, from two schools in the Valencian Community, participated. Demographic characteristics, diet, lifestyles, behavioural habits and anthropometric (weight, height) and coproparasitological data were collected. Nutrimetry was used to analyse nutritional status. Statistical analyses were performed to ascertain associations between lifestyle, selected parasite species and nutritional status. Multivariate logistic regression analysis was used to assess the strength of the association of the suspected risk factors with the presence of intestinal parasitism. The prevalence of overweight was 32.6%. A total of 43.9% had a high adherence to the Mediterranean Diet, for which mean daily intake was 2428.7 kcal. Intestinal parasitism was identified in 49.5% of the children (Giardia duodenalis: 28.6%). The source of drinking water was found to be a risk factor for intestinal parasitism. No positive association between the variables analysed and nutritional status could be confirmed. Nutrimetry is a good indicator for a complete analysis of nutritional status. It highlights the prevalence of overweight. Intestinal parasitism was identified in almost half of the participants and is a variable that should not be underestimated.

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.

The Importance of Healthy Habits to Compensate for Differences between Adolescent Males and Females in Anthropometric, Psychological and Physical Fitness Variables

Adolescence is a crucial stage in human development, and differences in psychological, physical and body composition variables between males and females have been amply demonstrated. However, the role played by certain healthy habits, such as the practice of physical activity, adherence to the Mediterranean diet (AMD) or the maintenance of an adequate weight status, in compensating for the differences found between males and females in these variables, is not well known. For this reason, the study aimed to analyze whether the practice of physical activity, optimal AMD, and adequate weight status can compensate for the differences between adolescent males and females in anthropometric variables, psychological state, and physical fitness. The sample was composed of 791 adolescents (404 males and 387 females) aged twelve to sixteen years old, whose anthropometric, psychological (autonomy, competence, relatedness, and life satisfaction), and physical fitness variables (cardiorespiratory fitness, upper strength and explosive lower limb power, hamstring and lower back flexibility, and speed) were measured. All measurements were carried out in a single day using the sports pavilion of the four participating schools. The most novel results of this research show that the practice of physical activity was determinant mainly in females, as it reduced the differences found in comparison with males in psychological (p < 0.001−0.045) and anthropometric variables (p < 0.001). Regarding weight status and AMD, these were still relevant for the adolescent population, mainly the achievement of optimal AMD, but males continued to present higher values in physical fitness tests (p < 0.001) and lower values in fat accumulation (p < 0.001), regardless of weight status or AMD. Thus, physical activity seems to be the most determining factor that compensates for the differences between adolescent boys and girls.

Health Determinants Associated with the Mediterranean Diet: A Cross-Sectional Study

INTRODUCTION

The Mediterranean diet (MD) has been shown to be a good tool for the prevention of obesity and other chronic noncommunicable diseases (NCDs) and to have a low environmental impact. The aim of the present study was to evaluate the relationship between declared morbidity, lifestyles and other sociodemographic factors with high adherence to the MD (AMD) in an adult population in southeastern Spain.

MATERIAL AND METHODS

We conducted a cross-sectional study of a sample (n = 2728) representative of a non-institutionalized population ≥16 years. The data corresponded to the 2010-11 Nutrition Survey of the Valencian Community. The AMD was assessed using the Mediterranean Diet Adherence Screener questionnaire. The association of variables and high AMD was assessed by univariate and multivariate logistic regression determining crude and adjusted odds ratios.

RESULTS

Multivariate analysis showed that age 45 years or older, living with a partner, eating between meals, and not smoking were associated with high AMD. The age groups 45-64 years and 65 years or older showed the strongest association with high AMD in both sexes.

CONCLUSION

The investigation showed a generational loss of AMD. People older than 45 years and living in company are more likely to adhere to DM, the risk group being young people living alone and smokers.