Influence of parental healthy-eating attitudes and nutritional knowledge on nutritional adequacy and diet quality among preschoolers: the SENDO project

Parental nutrition knowledge and attitudes play a fundamental role in their children's food knowledge. However, little is known about their influence on their children's diet quality and micronutrient intake. Thus, we aimed to assess the association of parental nutrition knowledge and healthy-eating attitudes with their children's adherence to the Mediterranean dietary pattern and micronutrient adequacy. Parental healthy-eating attitudes and knowledge of the quality of their child's diet as well as anthropometric, lifestyle, and nutrient intake characteristics were recorded with a basal questionnaire that included a 140-item-food frequency-questionnaire. A total of 287 pre-school children were included in the analyses. Intake adequacy was defined using the Estimated Average Requirements (EAR) cut-off point method. We developed a parental nutrition knowledge and healthy-eating attitudes scores and evaluated whether they were independently associated with 1) children's inadequate intake (probability of failing to meet 3 EAR) of micronutrients, using logistic regression analyses, and 2) children's diet quality (adherence to the Mediterranean Diet according to a Mediterranean Diet Quality Index for children and adolescents, the KIDMED index), using multiple linear regression models. A higher score in the parental healthy-eating attitudes score was associated with lower risk of failing to meet 3 EAR compared with the reference category (odds ratio (OR): 0.3; 95% confidence interval (CI) 0.12-0.95; p for trend: 0.037) and a higher adherence to the Mediterranean diet in the most adjusted model ( coefficient: 0.34; 95% CI 0.01-0.67; p for trend: 0.045). Our results suggest a positive association of parental healthy-eating attitudes with nutritional adequacy and diet quality in a sample of Spanish preschoolers. Public health strategies should focus on encouraging parental healthy-eating attitudes rather than simply educating parents on what to feed their children, recognizing the important influence of parental behavior on children's practices

Associations between overall, healthful, and unhealthful low-fat dietary patterns and breast cancer risk in a Mediterranean cohort: The SUN project

Objectives: Dietary patterns may have a greater influence on human health than individual foods or nutrients, and they are also of substantial interest in the field of breast cancer prevention. Beyond the adequate balance of macronutrients, evidence indicates that the quality of macronutrient sources may play an important role in health outcomes. We sought to examine the relationship between healthful and unhealthful low-fat dietary patterns in relation to breast cancer. Methods: We used observational data from a Mediterranean cohort study (the Seguimiento Universidad de Navarra project). We prospectively followed 10 930 middle-aged women initially free of breast cancer during a median follow-up of 12.1 y. We calculated an overall, an unhealthful, and a healthful low-fat diet score, based on a previously validated 136-item food frequency questionnaire and grouped participants into ter- tiles. Incident breast cancer—overall and stratified by menopausal status—was the primary outcome. It was self-reported by participants and confirmed based on medical reports or consultation of the National Death Index. We used multivariable Cox regression models adjusted for potential confounders. Results: During 123 297 person-years of follow-up, 150 cases of incident breast cancer were confirmed. No signifi- cant associations were observed for overall or premenopausal breast cancer. For postmenopausal women, we observed a significant association for moderate adherence to the unhealthful low-fat dietary score and postmeno- pausal breast cancer (comparing tertile 2 to tertile 1; hazard ratio = 2.18; 95% confidence interval, 1.15 4.13). Conclusions: In conclusion, no clear associations were observed, although more research is needed to address the association between an unhealthful dietary pattern and postmenopausal breast cancer risk

Validity and reproducibility of a semi-quantitative food frequency questionnaire in Spanish preschoolers - The SENDO project

Introduction: nowadays, it is important to determine whether food frequency questionnaires (FFQ) are valid tools to collect information on usual diet in children. Objective: we evaluated the reproducibility and validity of the semi-quantitative FFQ used in a Spanish cohort of children aged 4-7 years. Methods: to explore its reproducibility, parents filled a 138-item FFQ at baseline (FFQ-0) and then one year later (FFQ-1). To explore its validity, the FFQ-1 was compared with four weighed 3-day dietary records (DRs) that were used as standard of reference. To estimate associations we calculated deattenuated Pearson’s correlation coefficients to correct for season-to-season variability, and the Bland-Altman index. We also calculated the weighted kappa index and assessed participant’s gross misclassification across quintiles. We analyzed data from 67 (for reproducibility) and 37 (for validity) children aged 4-7 years old, recruited by the pilot study of the SENDO project. Results: regarding reproducibility, we found mean Bland-Altman indexes of 0-10.45 % for nutrients and 1.49 %-10.45 % for foods. The adjusted r ranged between 0.29 and 0.71, and between 0.27 and 0.74 for nutrients and foods, respectively. Regarding validity, we found mean Bland-Altman indexes of 0 %-16.22 % and 0 %-10.81 % for nutrients and for food groups, respectively. The deattenuated r ranged between 0.38 and 0.81 for nutrients, and between 0.53 and 0.68 for foods. The weighted kappa index for agreement across quintiles ranged from 54.1 to 85.1 for nutrients, and from 55.4 to 78.4 for food groups. Conclusions: our results showed acceptable levels of both reproducibility and validity, and that the ad-hoc developed FFQ is a valid tool for assessing usual diet in Spanish preschoolers.Introducción: es importante determinar si los cuestionarios de frecuencia de consumo de alimentos (CFCA) son herramientas válidas para recopilar información sobre la dieta habitual en los niños. Objetivo: evaluar la reproducibilidad y validez del CFCA semi-cuantitativo de una cohorte española de niños de 4 a 7 años. Métodos: en total se estudiaron 67 (para reproducibilidad) y 37 (para validez) niños de 4 a 7 años de edad del estudio piloto del proyecto SENDO. Para explorar la reproducibilidad, los padres cumplimentaron el CFCA basalmente (CFCA-0) y al año (CFCA-1). Para explorar la validez, el CFCA-1 se comparó con cuatro registros dietéticos (DR) pesados de 3 días. Calculamos coeficientes de correlación de Pearson desatenuados para corregir la variabilidad inter-estacional, y el índice de Bland-Altman. El índice kappa ponderado permitió evaluar la clasificación errónea de los participantes entre quintiles. Resultados: respecto a la reproducibilidad, encontramos índices promedio de Bland-Altman de 0-10,45 % para los nutrientes y de 1,49-10,45 % para los alimentos. La r ajustada varió entre 0,29 y 0,71, y entre 0,27 y 0,74 para nutrientes y alimentos, respectivamente. En cuanto a la validez, encontramos índices promedio de Bland-Altman de 0-16,22 % y 0-10,81 % para nutrientes y alimentos, respectivamente. La r desatenuada osciló entre 0,38 y 0,81 para los nutrientes y entre 0,53 y 0,68 para los alimentos. El índice kappa ponderado para el acuerdo entre quintiles varió entre 54,1 y 85,1 para los nutrientes y entre 55,4 y 78,4 para los grupos de alimentos. Conclusiones: nuestros resultados mostraron niveles aceptables tanto de reproducibilidad como de validez. El FFQ desarrollado ad hoc es una herramienta válida para evaluar nutrientes y alimentos en preescolares españoles

Leisure-time physical activity, sedentary behavior, and risk of breast cancer: Results from the SUN (‘Seguimiento Universidad De Navarra’) project

Evidence is still limited on the influence of sedentary lifestyles on breast cancer (BC) risk. Also, prospective information on the combined effects of both sedentariness and leisure-time physical activity (LTPA) is scarce. We aimed to assess the association of higher sedentary behavior and LTPA (separately and in combination) with the risk of BC in a middle-aged cohort of university graduates. The SUN Project is a follow-up study initiated in 1999 with recruitment permanently open. Baseline assessments included a validated questionnaire on LTPA and sedentary habits. Subsequently, participants completed biennial follow-up questionnaires. Multivariable adjusted Cox models were used to estimate the hazard ratios (HR) for incident BC according to LTPA, TV-watching, the joint classification of both, and a combined 8-item multidimensional active lifestyle score. We included 10,812 women, with 11.8 years of median follow-up of. Among 115,802 women-years of follow-up, we confirmed 101 incident cases of BC. Women in the highest category of LTPA (>16.5 MET-h/week) showed a significantly lower risk of BC (HR = 0.55; 95% CI: 0.34–0.90) compared to women in the lowest category (≤6 MET/h-week). Women watching >2 h/d of TV sh owed a higher risk (HR = 1.67; 95% CI:1.03–2.72) than those who watched TV 2 h/d may substantially increase BC risk, independently of each other

Dietary factors and breast cancer risk in two cohort studies

Globalmente, el cáncer de mama es el tumor más diagnosticado en la mujer, la primera causa de mortalidad por cáncer en ésta y un problema de salud pública preponderante a nivel mundial. La evidencia epidemiológica muestra resultados heterogéneos en la relación entre la dieta y el cáncer de mama, aunque se cree que podría desempeñar un papel protector, tanto en la etiología como incluso a la hora de modular el desarrollo del tumor. En este contexto, el objetivo global de la presente tesis doctoral fue valorar prospectivamente la asociación de algunos factores modificables relacionados con la dieta sobre la incidencia de cáncer de mama en el estudio de cohortes español Proyecto SUN (Seguimiento Universidad de Navarra) y en las cohortes americanas Nurses Health Studies (NHS) o Estudios de las Enfermeras. El proyecto SUN es una cohorte prospectiva, dinámica y multipropósito iniciada en 1999, en la que se han incluido y seguido más de 22,500 graduados universitarios durante una media de 10,3 años, de las cuales aproximadamente 10,000 son mujeres. La relación entre las distintas variables de exposición y la incidencia de cáncer de mama se estudió con modelos de regresión de Cox ajustados por múltiples factores de confusión. Además, en la presente tesis, hemos utilizado datos del NHSI que incluye 121,700 enfermeras (de 30 a 55 años) que comenzaron a formar parte del estudio en 1976, y del NHSII que ha seguido a 116,429 enfermeras (de 25 a 42 años) desde 1989. Se ajustaron modelos de regresión de Cox con medidas repetidas para estudiar la asociación entre la dieta y la incidencia de cáncer de mama. En el Proyecto SUN, una adhesión moderada a un patrón provegetariano, donde se promueve el consumo de alimentos de origen vegetal junto con reducciones compensatorias en el consumo de alimentos de origen animal, se asoció a una menor incidencia de cáncer de mama. Por otro lado, en los NHS, una versión saludable de un patrón dietético basado en alimentos de origen vegetal se asoció con una menor incidencia de cáncer de mama, sobre todo, con receptores de estrógenos negativos. Existen alimentos que son ampliamente consumidos dentro de patrones dietéticos que merecen ser evaluados de forma individual, como las bebidas azucaradas, fuente de carbohidratos simples (principalmente sacarosa). En el Proyecto SUN, el consumo frecuente de bebidas azucaradas entre mujeres postmenopáusicas se asoció a una mayor incidencia de cáncer de mama en comparación con las que no consumían estas bebidas o lo hacían con una frecuencia inferior a una vez al mes. En línea con lo anterior, se debería de poner más énfasis en la calidad de los carbohidratos que se ingieren más que en la cantidad. En el Proyecto SUN, una mayor calidad de los carbohidratos ingeridos, es decir, aquellos con mayor contenido en fibra dietética, con menor índice glucémico, que dan preferencia a carbohidratos sólidos frente a los líquidos y de grano entero o integral, se asoció a un menor riesgo de padecer cáncer de mama, sobre todo, en mujeres premenopáusicas. En el Proyecto SUN observamos una asociación inversa entre la ingesta de ácidos hidroxicinámicos y clorogénicos con el riesgo de cáncer de mama postmenopáusico. Por último, numerosos estudios experimentales y epidemiológicos han puesto de manifiesto la relación existente entre las grasas o lípidos de la dieta y el cáncer de mama, sin embargo, esta posible asociación sigue siendo controvertida y sujeta a cuestiones metodológicas. En el Proyecto SUN no encontramos evidencia de una asociación entre el total de grasa dietética o sus subtipos con la incidencia de cáncer de mama. En general, los resultados de esta tesis aportan nueva evidencia del papel de la dieta sobre la incidencia de cáncer de mama en dos estudios de cohortes. Finalmente, cabe insistir en la necesidad de llevar a cabo más estudios en grandes cohortes que avalen los resultados de nuestro trabajo para la prevención primaria del cáncer de mama

Dietary factors and breast cancer risk in two cohort studies

Globalmente, el cáncer de mama es el tumor más diagnosticado en la mujer, la primera causa de mortalidad por cáncer en ésta y un problema de salud pública preponderante a nivel mundial. La evidencia epidemiológica muestra resultados heterogéneos en la relación entre la dieta y el cáncer de mama, aunque se cree que podría desempeñar un papel protector, tanto en la etiología como incluso a la hora de modular el desarrollo del tumor. En este contexto, el objetivo global de la presente tesis doctoral fue valorar prospectivamente la asociación de algunos factores modificables relacionados con la dieta sobre la incidencia de cáncer de mama en el estudio de cohortes español Proyecto SUN (Seguimiento Universidad de Navarra) y en las cohortes americanas Nurses Health Studies (NHS) o Estudios de las Enfermeras. El proyecto SUN es una cohorte prospectiva, dinámica y multipropósito iniciada en 1999, en la que se han incluido y seguido más de 22,500 graduados universitarios durante una media de 10,3 años, de las cuales aproximadamente 10,000 son mujeres. La relación entre las distintas variables de exposición y la incidencia de cáncer de mama se estudió con modelos de regresión de Cox ajustados por múltiples factores de confusión. Además, en la presente tesis, hemos utilizado datos del NHSI que incluye 121,700 enfermeras (de 30 a 55 años) que comenzaron a formar parte del estudio en 1976, y del NHSII que ha seguido a 116,429 enfermeras (de 25 a 42 años) desde 1989. Se ajustaron modelos de regresión de Cox con medidas repetidas para estudiar la asociación entre la dieta y la incidencia de cáncer de mama. En el Proyecto SUN, una adhesión moderada a un patrón provegetariano, donde se promueve el consumo de alimentos de origen vegetal junto con reducciones compensatorias en el consumo de alimentos de origen animal, se asoció a una menor incidencia de cáncer de mama. Por otro lado, en los NHS, una versión saludable de un patrón dietético basado en alimentos de origen vegetal se asoció con una menor incidencia de cáncer de mama, sobre todo, con receptores de estrógenos negativos. Existen alimentos que son ampliamente consumidos dentro de patrones dietéticos que merecen ser evaluados de forma individual, como las bebidas azucaradas, fuente de carbohidratos simples (principalmente sacarosa). En el Proyecto SUN, el consumo frecuente de bebidas azucaradas entre mujeres postmenopáusicas se asoció a una mayor incidencia de cáncer de mama en comparación con las que no consumían estas bebidas o lo hacían con una frecuencia inferior a una vez al mes. En línea con lo anterior, se debería de poner más énfasis en la calidad de los carbohidratos que se ingieren más que en la cantidad. En el Proyecto SUN, una mayor calidad de los carbohidratos ingeridos, es decir, aquellos con mayor contenido en fibra dietética, con menor índice glucémico, que dan preferencia a carbohidratos sólidos frente a los líquidos y de grano entero o integral, se asoció a un menor riesgo de padecer cáncer de mama, sobre todo, en mujeres premenopáusicas. En el Proyecto SUN observamos una asociación inversa entre la ingesta de ácidos hidroxicinámicos y clorogénicos con el riesgo de cáncer de mama postmenopáusico. Por último, numerosos estudios experimentales y epidemiológicos han puesto de manifiesto la relación existente entre las grasas o lípidos de la dieta y el cáncer de mama, sin embargo, esta posible asociación sigue siendo controvertida y sujeta a cuestiones metodológicas. En el Proyecto SUN no encontramos evidencia de una asociación entre el total de grasa dietética o sus subtipos con la incidencia de cáncer de mama. En general, los resultados de esta tesis aportan nueva evidencia del papel de la dieta sobre la incidencia de cáncer de mama en dos estudios de cohortes. Finalmente, cabe insistir en la necesidad de llevar a cabo más estudios en grandes cohortes que avalen los resultados de nuestro trabajo para la prevención primaria del cáncer de mama

Influence of parental healthy-eating attitudes and nutritional knowledge on nutritional adequacy and diet quality among preschoolers: the SENDO project

Parental nutrition knowledge and attitudes play a fundamental role in their children's food knowledge. However, little is known about their influence on their children's diet quality and micronutrient intake. Thus, we aimed to assess the association of parental nutrition knowledge and healthy-eating attitudes with their children's adherence to the Mediterranean dietary pattern and micronutrient adequacy. Parental healthy-eating attitudes and knowledge of the quality of their child's diet as well as anthropometric, lifestyle, and nutrient intake characteristics were recorded with a basal questionnaire that included a 140-item-food frequency-questionnaire. A total of 287 pre-school children were included in the analyses. Intake adequacy was defined using the Estimated Average Requirements (EAR) cut-off point method. We developed a parental nutrition knowledge and healthy-eating attitudes scores and evaluated whether they were independently associated with 1) children's inadequate intake (probability of failing to meet 3 EAR) of micronutrients, using logistic regression analyses, and 2) children's diet quality (adherence to the Mediterranean Diet according to a Mediterranean Diet Quality Index for children and adolescents, the KIDMED index), using multiple linear regression models. A higher score in the parental healthy-eating attitudes score was associated with lower risk of failing to meet 3 EAR compared with the reference category (odds ratio (OR): 0.3; 95% confidence interval (CI) 0.12-0.95; p for trend: 0.037) and a higher adherence to the Mediterranean diet in the most adjusted model ( coefficient: 0.34; 95% CI 0.01-0.67; p for trend: 0.045). Our results suggest a positive association of parental healthy-eating attitudes with nutritional adequacy and diet quality in a sample of Spanish preschoolers. Public health strategies should focus on encouraging parental healthy-eating attitudes rather than simply educating parents on what to feed their children, recognizing the important influence of parental behavior on children's practices

Mediterranean dietary pattern is associated with lower incidence of premenopausal breast cancer in the Seguimiento Universidad de Navarra (SUN) Project

OBJECTIVE: Due to the growing interest in the role of dietary patterns (DPs) on chronic diseases, we assessed the association between a posteriori identified DPs in the Seguimiento Universidad de Navarra (SUN) Project - a prospective cohort study in a Mediterranean country - and breast cancer (BC) risk. DESIGN: DPs were ascertained through a principal component analysis based on 31 predefined food groups. BC cases were initially identified through self-report or, if deceased, from death certificates or by notification by the next kin. Women reporting BC were asked to provide a copy of their medical report and diagnoses for confirmation purposes. We fitted Cox regression models to assess the association between adherence to the identified DPs and BC risk. SETTING: Spanish university graduates. PARTICIPANTS: We included 10 713 young and middle-aged - mainly premenopausal - women. RESULTS: After a median follow-up of 10·3 years, we identified 100 confirmed and 168 probable incident BC cases. We described two major DPs: 'Western dietary pattern' (WDP) and 'Mediterranean dietary pattern' (MDP). A higher adherence to a WDP was associated with an increased risk of overall BC (multivariable-adjusted HR for confirmed BC Q4 v. Q1 1·70; 95 % CI 0·93, 3·12; P for trend = 0·045). Contrarily, adherence to a MDP was inversely associated with premenopausal BC (multivariable-adjusted HR Q4 v. Q1 0·33; 95 % CI 0·12, 0·91). No significant associations were observed for postmenopausal BC. CONCLUSIONS: Whereas a higher adherence to the WDP may increase the risk of BC, a higher adherence to the MDP may decrease the risk of premenopausal BC.The study was supported by the “Acción Transversal del Cáncer", approved on the Spanish Ministry Council on the 11th October 2007, by the Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), by the Instituto de Salud Carlos III grants, cofunded by FEDER funds -a way to build Europe- PI08/1770 (to M. Kogevinas), PI09/0773 and FIS 12/00715 (to J. Llorca), PI09/1903 (to R. Peiró), PI09/2078 (to F.J. Caballero), PI09/1662 (to J.J. Jiménez- Moleón), PI11/01403 (to N. Aragonés), PI12/00150 (to B.Pérez- Gómez), PI12/00488 (to M.Pollán), by the Fundación Marqués de Valdecilla grant API 10/09 (to J. Llorca), by the Consejería de Salud of the Junta de Andalucía grant 2009-S0143 (to J. Alguacil), by the Conselleria de Sanitat of the Generalitat Valenciana grant AP061/10 (to R. Peiró), by the Regional Government of the Basque Country, by the Fundación Caja de Ahorros de Asturias, by the University of Oviedo and by the Spanish Ministry of Economyand Competitiveness Juan de la Cierva de Incorporación grant IJCI-2014-20900 (to A. Castelló). None of the funding institutions played any role in the present work. The content and views of this publication are those of the authors and do not necessarily reflect the official position of the Instituto de Salud Carlos III.S

Association between parental attitudes towards their offspring's diet and children's actual dietary habits - The SENDO project

Introduction: the preschool stage is a critical period for teaching and modeling healthy habits to positively influence children's health and wellbeing throughout their lifetime. Objectives: to evaluate the association between parental attitudes towards their offspring's dietary habits in Spanish children aged 4 to 7 years participating in the Follow-up of Children for Optimal Development (SENDO) project. Methods: we defined an index to measure information on parental attitudes towards their offspring's diet (0 to 8 points), and another one to measure children's actual dietary habits (0 to 19 points). A higher score meant healthier attitudes and healthier habits, respectively. Information was collected through an online questionnaire completed by parents. We calculated crude and multivariable-adjusted odds ratios (OR) and 95 % confidence intervals (CI) for children's healthy dietary habits associated with parental scores in the parental attitudes index. Generalized estimation equations (GEE) were used to account for intra-cluster correlation between siblings. Results: a total of 423 preschoolers (52.3 % boys, mean age 5.3 years) were included in the analyses. Half of the children (51 %) reported unhealthy dietary habits, whereas 56 % of parents reported high adherence to the healthy eating index. Compared to those in the lowest category, the children whose parents were in the highest category in the parental attitudes index showed significantly higher odds of having healthy dietary habits (OR: 2.91; 95 % CI: 1.30-6.53, p for trend = 0.004). Conclusions: our results support a direct association between parental attitudes and their offspring's dietary habits, suggesting that public health interventions aimed at improving children's dietary habits should shift from the individual- to a family-based approach

Parental perception of child's weight, their attitudes towards child's dietary habits and the risk of obesity

Background: The association between parental perception of child's weight and their attitudes towards his/her dietary habits has not been reported yet. This study aimed to assess the association between parental underestimation of child's weight and parental attitudes towards child's dietary habits. Methods: We conducted a cross-sectional analysis of SENDO cohort participants recruited between January 2015 and June 2020. All information was collected through online questionnaires completed by parents. We calculated crude and multivariable-adjusted odds ratio (OR) and 95% confidence intervals (CI) for unhealthy attitudes towards child's dietary habits associated with parental underestimation of child's weight. Results: Sixteen percent of children in the SENDO project had parents who underestimated their weight. Parents who underestimated their child's weight status were more likely to have unhealthy attitudes toward his/her dietary habits [OR 3.35; 95% CI (1.71-6.53)]. Conclusions: Parental underestimation of child's weight was associated with unhealthy attitudes towards child's dietary habits. Pediatricians and public health practitioners should pay attention to the parental perception of child's weight to identify parents who underestimate it as an at-risk group in which to inquire about lifestyle and dietary habits