Clustering of energy balance-related behaviors and parental education in European children : the ENERGY-project

Background:Recent research and literature reviews show that, among schoolchildren, some specific energy balance-related behaviors (EBRBs) are relevant for overweight and obesity prevention. It is also well known that the prevalence of overweight and obesity is considerably higher among schoolchildren from lower socio-economic backgrounds. This study examines whether sugared drinks intake, physical activity, screen time and usual sleep duration cluster in reliable and meaningful ways among European children, and whether the identified clusters could be characterized by parental education. Methods: The cross-sectional study comprised a total of 5284 children (46% male), from seven European countries participating in the ENERGY-project ("EuropeaN Energy balance Research to prevent excessive weight Gain among Youth"). Information on sugared drinks intake, physical activity, screen time and usual sleep duration was obtained using validated self-report questionnaires. Based on these behaviors, gender-specific cluster analysis was performed. Associations with parental education were identified using chi-square tests and odds ratios. Results: Five meaningful and stable clusters were found for both genders. The cluster with high physical activity level showed the highest proportion of participants with highly educated parents, while clusters with high sugared drinks consumption, high screen time and low sleep duration were more prevalent in the group with lower educated parents. Odds ratio showed that children with lower educated parents were less likely to be allocated in the active cluster and more likely to be allocated in the low activity/sedentary pattern cluster. Conclusions: Children with lower educated parents seemed to be more likely to present unhealthier EBRBs clustering, mainly characterized by their self-reported time spent on physical activity and screen viewing. Therefore, special focus should be given to lower educated parents and their children in order to develop effective primary prevention strategies

Parental education associations with children's body composition: Mediation effects of energy balance-related behaviors within the ENERGY-project

Background: It is well known that the prevalence of overweight and obesity is considerably higher among youth from lower socio-economic families, but there is little information about the role of some energy balance-related behaviors in the association between socio-economic status and childhood overweight and obesity. The objective of this paper was to assess the possible mediation role of energy balance-related behaviors in the association between parental education and children's body composition. Methods: Data were obtained from the cross sectional study of the ``EuropeaN Energy balance Research to prevent excessive weight Gain among Youth'' (ENERGY) project. 2121 boys and 2516 girls aged 10 to 12 from Belgium, Greece, Hungary, the Netherlands, Norway, Slovenia and Spain were included in the analyses. Data were obtained via questionnaires assessing obesity related dietary, physical activity and sedentary behaviors and basic anthropometric objectively measured indicators (weight, height, waist circumference). The possible mediating effect of sugared drinks intake, breakfast consumption, active transportation to school, sports participation, TV viewing, computer use and sleep duration in the association between parental education and children's body composition was explored via MacKinnon's product-of-coefficients test in single and multiple mediation models. Two different body composition indicators were included in the models, namely Body Mass Index and waist circumference. Results: The association between parental education and children's body composition was partially mediated by breakfast consumption, sports participation, TV viewing and computer use. Additionally, a suppression effect was found for sugared drinks intake. No mediation effect was found for active transportation and sleep duration. The significant mediators explained a higher proportion of the association between parental education and waist circumference compared to the association between parental education and BMI. Conclusions: Tailored overweight and obesity prevention strategies in low SES preadolescent populations should incorporate specific messages focusing on the importance of encouraging daily breakfast consumption, increasing sports participation and decreasing TV viewing and computer use. However, longitudinal research to support these findings is needed

Test-retest reliability and construct validity of the ENERGY-child questionnaire on energy balance-related behaviours and their potential determinants: the ENERGY-project

<p>Abstract</p> <p>Background</p> <p>Insight in children's energy balance-related behaviours (EBRBs) and their determinants is important to inform obesity prevention research. Therefore, reliable and valid tools to measure these variables in large-scale population research are needed.</p> <p>Objective</p> <p>To examine the test-retest reliability and construct validity of the child questionnaire used in the ENERGY-project, measuring EBRBs and their potential determinants among 10-12 year old children.</p> <p>Methods</p> <p>We collected data among 10-12 year old children (n = 730 in the test-retest reliability study; n = 96 in the construct validity study) in six European countries, i.e. Belgium, Greece, Hungary, the Netherlands, Norway, and Spain. Test-retest reliability was assessed using the intra-class correlation coefficient (ICC) and percentage agreement comparing scores from two measurements, administered one week apart. To assess construct validity, the agreement between questionnaire responses and a subsequent face-to-face interview was assessed using ICC and percentage agreement.</p> <p>Results</p> <p>Of the 150 questionnaire items, 115 (77%) showed good to excellent test-retest reliability as indicated by ICCs > .60 or percentage agreement ≥ 75%. Test-retest reliability was moderate for 34 items (23%) and poor for one item. Construct validity appeared to be good to excellent for 70 (47%) of the 150 items, as indicated by ICCs > .60 or percentage agreement ≥ 75%. From the other 80 items, construct validity was moderate for 39 (26%) and poor for 41 items (27%).</p> <p>Conclusions</p> <p>Our results demonstrate that the ENERGY-child questionnaire, assessing EBRBs of the child as well as personal, family, and school-environmental determinants related to these EBRBs, has good test-retest reliability and moderate to good construct validity for the large majority of items.</p

Association of Sleep Duration and Quality With Subclinical Atherosclerosis.

BACKGROUND Sleep duration and quality have been associated with increased cardiovascular risk. However, large studies linking objectively measured sleep and subclinical atherosclerosis assessed in multiple vascular sites are lacking. OBJECTIVES The purpose of this study was to evaluate the association of actigraphy-measured sleep parameters with subclinical atherosclerosis in an asymptomatic middle-aged population, and investigate interactions among sleep, conventional risk factors, psychosocial factors, dietary habits, and inflammation. METHODS Seven-day actigraphic recording was performed in 3,974 participants (age 45.8 4.3 years; 62.6% men) from the PESA (Progression of Early Subclinical Atherosclerosis) study. Four groups were defined: very short sleep duration 8 h. Sleep fragmentation index was defined as the sum of the movement index and fragmentation index. Carotid and femoral 3-dimensional vascular ultrasound and cardiac computed tomography were performed to quantify noncoronary atherosclerosis and coronary calcification. RESULTS When adjusted for conventional risk factors, very short sleep duration was independently associated with a higher atherosclerotic burden with 3-dimensional vascular ultrasound compared to the reference group (odds ratio: 1.27; 95% confidence interval: 1.06 to 1.52; p ¼ 0.008). Participants within the highest quintile of sleep fragmentation presented a higher prevalence of multiple affected noncoronary territories (odds ratio: 1.34; 95% confidence interval: 1.09 to 1.64; p ¼ 0.006). No differences were observed regarding coronary artery calcification score in the different sleep groups. CONCLUSIONS Lower sleeping times and fragmented sleep are independently associated with an increased risk of subclinical multiterritory atherosclerosis. These results highlight the importance of healthy sleep habits for the prevention of cardiovascular disease. (J Am Coll Cardiol 2019;73:134–44) © 2019 Published by Elsevier on behalf of the American College of Cardiology Foundation.post-print454 K

Association Between a Social-Business Eating Pattern and Early Asymptomatic Atherosclerosis.

BACKGROUND: The importance of a healthy diet in relation to cardiovascular health promotion is widely recognized. Identifying specific dietary patterns related to early atherosclerosis would contribute greatly to inform effective primary prevention strategies. OBJECTIVES: This study sought to quantify the association between specific dietary patterns and presence and extent of subclinical atherosclerosis in a population of asymptomatic middle-aged adults. METHODS: The PESA (Progression of Early Subclinical Atherosclerosis) study enrolled 4,082 asymptomatic participants 40 to 54 years of age (mean age 45.8 years; 63% male) to evaluate the presence of subclinical atherosclerosis in multiple vascular territories. A fundamental objective of this cohort study was to evaluate the life-style-related determinants, including diet, on atherosclerosis onset and development. We conducted a cross-sectional analysis of baseline data, including detailed information on dietary habits obtained as part of the overall life-style and risk factor assessment, as well as a complete vascular imaging study that was performed blinded to the clinical information. RESULTS: Most PESA participants follow a Mediterranean (40% of participants) or a Western (41%) dietary pattern. A new pattern, identified among 19% of participants, was labeled as a social-business eating pattern, characterized by a high consumption of red meat, pre-made foods, snacks, alcohol, and sugar-sweetened beverages and frequent eating-out behavior. Participants following this pattern presented a significantly worse cardiovascular risk profile and, after adjustment for risk factors, increased odds of presenting subclinical atherosclerosis (odds ratio: 1.31; 95% confidence interval: 1.06 to 1.63) compared with participants following a Mediterranean diet. CONCLUSIONS: A new social-business eating pattern, characterized by high consumption of red and processed meat, alcohol, and sugar-sweetened beverages, and by frequent snacking and eating out as part of an overall unhealthy life-style, is associated with an increased prevalence, burden, and multisite presence of subclinical atherosclerosis. (Progression of Early Subclinical Atherosclerosis [PESA]; NCT01410318)

Flavonoid Intake From Cocoa-Based Products and Adiposity Parameters in Adolescents in Spain.

Cocoa-based products are a good source of flavonoids, which may have beneficial effects on metabolic health. The aim of this study is to assess the relationship between flavonoids from cocoa-based products and adiposity parameters in adolescents. A cross-sectional study was conducted involving 944 adolescents aged 11-14 years enrolled in the SI! Program for Secondary Schools trial in Spain with available baseline data from food frequency questionnaires and anthropometric measurements [weight, height, waist circumference (WC), and fat mass percentage (% FM) by bioimpedance analysis]. Fat mass index (FMI) and waist-to-height ratio (WHtR) were obtained by dividing fat mass by height and WC by height, respectively. Body mass index (BMI), WC, and FMI for age and gender z-score were calculated. Overweight/obesity was defined as BMI ≥ 85th percentile and excess adiposity as %FM or FMI ≥ 75th percentile. WC ≥ 90th percentile and WHtR with a 0.5 threshold were considered as criteria of abdominal obesity. Multilevel mixed-effect regressions were used to evaluate the association between flavonoids from cocoa-based products and adiposity parameters. Municipalities and schools were considered random effects. Participants with a higher flavonoid intake from cocoa-based products had lower WC z-score [B = -0.04, 95% CI (-0.07; -0.01), P-for trend = 0.045] and WHtR [B = -0.01, 95% CI (-0.02; -0.01), P- for trend < 0.001]. They also had lower probability of having abdominal obesity [OR 0.66, 95% CI (0.52; 0.85), P- for trend = 0.001]. Inverse associations were observed between flavonoids from cocoa powder and BMI z-score [B = -0.08, 95% CI (-0.12; -0.05), P < 0.001], WC z-score [B = -0.06, 95% CI (-0.11; -0.02), P = 0.003], WHtR [B = -0.01, 95% CI (-0.01; -0.00), P < 0.001], %FM [B = -1.11, 95% CI (-1.48; -0.75), P < 0.001], and FMI z-score [B = -0.18, 95% CI (-0.20; -0.17), P < 0.001]. Regarding dark chocolate, an inverse association only with WC z-score [B = -0.06, 95% CI (-0.08; -0.05), P < 0.001] was found. However, no association was observed between flavonoids from milk chocolate intake and anthropometric parameters. A higher intake of flavonoids from cocoa-based products was associated with lower adiposity parameters and a lower probability of presenting abdominal obesity.The SI! Program for Secondary Schools trial was supported by the SHE Foundation, the la Caixa Foundation (LCF/PR/CE16/10700001), the Fundació la Marató de TV3 (grant number 369/C/2016), and by the funding from Idilia Foods (FBG 311240). Support was also provided by the Ministerio de Ciencia, Innovación y Universidades (PID2020- 114022RB-I00), CIBEROBN from the Instituto de Salud Carlos III, ISCIII from the Ministerio de Ciencia, Innovación y Universidades (AEI/FEDER, UE), and Generalitat de Catalunya. JM-G was a postgraduate fellow of the Ministerio de Ciencia e Innovación of Spain at the Residencia de Estudiantes (2020– ongoing). RF-J was a recipient of grant PI19/01704 funded by the Fondo de Investigación Sanitaria- Instituto de Salud Carlos III (ISCIII) and co-funded by the European Regional Development Fund/European Social Fund a way to make Europe/Investing in your future. The CNIC was supported by the ISCIII, the Ministerio de Ciencia e Innovación (MCIN), the Pro CNIC Foundation, and was a Severo Ochoa Center of Excellence (CEX2020-001041-S). GS-B was the recipient of grant LCF/PR/MS19/12220001 funded by la Caixa Foundation (ID 100010434). AT-R is a Serra Húnter fellow. EL-S was a FI-SDUR (EMC/3345/2020) fellowship from the Generalitat de Catalunya.S

Total urinary polyphenols and ideal cardiovascular health metrics in Spanish adolescents enrolled in the SI Program: a cross-sectional study.

To study the relationship between urinary total polyphenol excretion (TPE) in adolescents and ideal cardiovascular (CVH) metrics. 1151 adolescents aged 12.04 (0.46) years participating in the SI! Program for Secondary Schools were selected based on the availability of urine samples and information required to assess CVH metrics. Data on health behaviours (smoking status, body mass index, physical activity, and healthy diet) and health factors (blood pressure, total cholesterol, and blood glucose) were used to calculate the CVH metrics. TPE in urine was analysed by a Folin-Ciocalteu method after solid-phase extraction. Associations between TPE (categorized into tertiles) and CVH metrics (total and separate scores) were assessed using multilevel mixed-effect regression models. Higher TPE levels were associated with higher (healthier) CVH scores and ideal smoking status (OR 1.54, 95% CI 1.10; 1.87, p value = 0.007), physical activity (OR 1.12, 95% CI 1.02; 1.23, p value = 0.022) and total cholesterol (OR 1.78, 95% CI 1.16; 2.73, p value = 0.009) after multivariate adjustment. An association between TPE and total CVH scores was observed only in boys. Girls with higher TPE had higher rates of ideal total cholesterol and blood pressure. According to our findings, higher urinary TPE is related to better CVH scores, with relevant differences in this association by gender.The authors wish to thank all the volunteers and their families, teachers, and schools for their contribution to the SI! Program for Secondary Schools. The SI! Program for Secondary Schools trial was supported by the SHE Foundation, the “la Caixa” Foundation (grant numbers LCF/PR/CE16//10700001 and LCF/PR/MS19/12220001), and the Fundació la Marató de TV3 (grant number 369/C/2016). Support was also provided by the Ministerio de Ciencia, Innovación y Universidades (grant number AGL2016–75329-R), and Generalitat de Catalunya. Rodrigo Fernández-Jiménez is a recipient of grant PI19/01704 funded by the Fondo de Investigación Sanitaria- Instituto de Salud Carlos III (ISCIII) and co-funded by the European Regional Development Fund/European Social Fund "A way to make Europe"/"Investi ng in your future". The Centro Nacional de Investigaciones Cardiovasculares is supported by the ISCIII, the Ministerio de Ciencia e Innovación, and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (CEX2020-001041-S). Anna Tresserra-Rimbau was supported by a Serra Húnter Fellowship. Emily P. Laveriano-Santos is thankful for the FI-SDUR (EMC/3345/2020) fellowship from the Generalitat de Catalunya. Isabella Parilli-Moser thanks the FI-SDUR (EMC/2703/2019) fellowship.S

Urinary Nitric Oxide Levels Are Associated with Blood Pressure, Fruit and Vegetable Intake and Total Polyphenol Excretion in Adolescents from the SI! Program.

Nitric oxide (NO) is important to cardiovascular health (CVH), and its bioavailability could be regulated by the antioxidant effect of polyphenols, improving endothelial function and consequently blood pressure (BP). However, scant research has been carried out on NO and CVH correlates in adolescent populations. Therefore, our aim was to investigate the association between NO and the CVH status and other health factors in adolescents. NO, total polyphenol excretion (TPE), anthropometric measurements, BP, blood lipid profile, blood glucose, diet, physical activity, and smoking status were recorded, while CVH score was classified as ideal, intermediate, and poor. Negative associations were observed between NO and body mass index, body fat percentage, BP, and triglycerides; and positive associations between NO and skeletal muscle percentage, HDL-cholesterol, fruit and vegetable intake, and TPE was observed. To capture more complex interactions among different factors, multiple linear regression was performed, obtaining a significant association between NO and fruit and vegetable intake (β = 0.175), TPE (β = 0.225), and systolic BP (β = -0.235). We conclude that urinary NO levels are positively associated with the consumption of fruits and vegetables rich in antioxidants such as polyphenols and negatively associated with systolic BP.The SI! Program for Secondary Schools trial was supported by the SHE Foundation, the la Caixa Foundation (LCF/PR/CE16/10700001), the Fundació la Marató de TV3 (grant number 369/C/2016). Support was also provided by the Ministerio de Ciencia, Innovación y Universidades (PID2020-114022RB-I00), CIBEROBN from the Instituto de Salud Carlos III, ISCIII from the Ministerio de Ciencia, Innovación y Universidades (AEI/FEDER, UE), and Generalitat de Catalunya. RF-J is a recipient of grant PI19/01704 funded by the Fondo de Investigación Sanitaria- Instituto de Salud Carlos III (ISCIII) and co-funded by the European Regional Development Fund/European Social Fund a way to make Europe/Investing in your future. The CNIC is supported by the ISCIII, the Ministerio de Ciencia e Innovación (MCIN) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (grant CEX2020-001041-S funded by MICIN/AEI/10.13039/501100011033). GS-B was the recipient of grant LCF/PR/MS19/12220001 funded by la Caixa Foundation (ID 100010434). AT-R is a Serra Húnter fellow. EL-S was a FI-SDUR (EMC/3345/2020) fellowship from the Generalitat de Catalunya. JM-G was a postgraduate fellow of the Ministerio de Ciencia e Innovación of Spain at the Residencia de Estudiantes (2020–ongoing).S

School-Based Cardiovascular Health Promotion in Adolescents: A Cluster Randomized Clinical Trial.

IMPORTANCE School-based interventions offer an opportunity for health promotion in adolescence. OBJECTIVE To assess the effect of 2 multicomponent educational health promotion strategies of differing duration and intensity on adolescents' cardiovascular health (CVH). DESIGN, SETTING, AND PARTICIPANTS The SI! Program for Secondary Schools is a 4-year cluster randomized clinical intervention trial conducted in 24 secondary schools from Barcelona and Madrid, Spain, from September 7, 2017, to July 31, 2021. Eligible participants were adolescents enrolled in the first grade of secondary school. INTERVENTIONS Schools and their participants were randomized to receive a health promotion intervention (SI! Program) over 4 school years (long-term intervention [LTI], 8 schools, 412 adolescents) or 2 school years (short-term intervention [STI], 8 schools, 504 adolescents) or to receive the standard curriculum (control, 8 schools, 441 adolescents). MAIN OUTCOME AND MEASURES The primary end point was the between-group difference at 2 and 4 years in the change from baseline of the overall CVH score, as defined by the American Heart Association (range, 0-14 points, with a higher score indicating a healthier CVH profile). Intervention effects were tested with multilevel mixed-effects models. A complete-case intention-to-treat analysis was performed as the primary analysis. RESULTS Of the randomized students, the study enrolled 1326 adolescents (684 [51.6%] boys, mean [SD] age, 12.5 [0.4] years at recruitment) with a study completion rate of 86.0%. Baseline overall CVH scores were 10.3 points in the LTI group, 10.6 points in the STI group, and 10.5 points in the control group. After 2 years, at halfway through the LTI and at the end of the STI, the difference in the CVH score change was 0.44 points (95% CI, 0.01-0.87; P = .04) between the LTI group and the control group and 0.18 points (95% CI, -0.25 to 0.61; P = .39) between the STI group and the control group. At 4 years, differences for the LTI and STI groups vs control were 0.12 points (LTI: 95% CI, -0.19 to 0.43; P = .42) and 0.13 points (STI: 95% CI, -0.17 to 0.44; P = .38). No adverse events were reported. CONCLUSIONS AND RELEVANCE Overall, the tested school-based health promotion strategies in this randomized clinical trial had a neutral effect on the CVH of the adolescents. Although there was evidence of a marginal beneficial effect at a point halfway through implementation in the LTI group, such a benefit was not noted at 4 years. Further research is warranted into the efficacy of school-based health promotion programs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03504059.This work was supported by the SHE Foundation-la Caixa Foundation (LCF/PR/CE16/ 10700001) and the Fundació la Marató de TV3 (369/C/2016). Dr Santos-Beneit is recipient of grant LCF/PR/MS19/12220001 funded by “la Caixa” Foundation (ID 100010434). Dr Tresserra-Rimbau is a Serra Húnter Fellow. Dr Laveriano-Santos is supported by the FI-SDUR (EMC/503/2021) grant from the Generalitat de Catalunya. Mr Martínez-Gómez was a postgraduate fellow of the Ministerio de Ciencia e Innovación at the Residencia de Estudiantes (2020-2022) and is a recipient of grant FPU21/04891 (Ayudas para la formación de profesorado universitario, FPU-2021) from the Ministerio de Educación, Cultura y Deporte. Dr Álvarez-Benavides is a María Zambrano fellow. Dr Fernández-Jiménez is recipient of grants PI19/01704 and PI22/01560 funded by the ISCIII and cofunded by the European Union. Support was also provided by the Ministerio de Ciencia, Innovación y Universidades (AEI/FEDER, UE, grant PID2020-114022RB-I00), and Generalitat de Catalunya. The Institute for Nutrition and Food Safety Research (INSA-UB) is a Unit of Excellence (María de Maeztu CEX2021-001234-M). The Centro Nacional de Investigaciones Cardiovasculares (CNIC) is supported by the ISCIII, the Ministerio de Ciencia e Innovación (MCIN) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (grant CEX2020-001041-S funded by MICIN/AEI/10.13039/501100011033).S