Nivel socioeconómico y obesidad infantil: hábitos dietéticos en niños europeos

La alarmante prevalencia de obesidad infantil a nivel global presenta una distribución desigual en los distintos niveles socioeconómicos de la sociedad. En los países industrializados, los grupos socioeconómicamente más desfavorecidos suelen presentar mayor prevalencia de sobrepeso y obesidad infantil. La evidencia acumulada demuestra que los determinantes de este problema de salud, son complejos e incluyen diversos mecanismos, tales como las condiciones materiales, ocupacionales, psicosociales, conductuales, etc. Dentro de los estilos de vida, la calidad de la dieta también se asocia con el estatus socioeconómico, encontrando habitualmente patrones menos saludables en los grupos más desfavorecidos, predisponiendo a su vez al desarrollo de sobrepeso y obesidad durante el ciclo vital. A nivel general, los objetivos de la presente Tesis Doctoral son: 1) evaluar la asociación entre distintos indicadores socioeconómicos y la prevalencia de sobrepeso y obesidad infantil en niños europeos, 2) analizar la calidad global de la dieta de los niños según el nivel socioeconómico de las familias y 3) evaluar la asociación entre los patrones dietéticos y los cambios en composición corporal, de manera prospectiva. Para la consecución de los objetivos, se evaluaron los resultados obtenidos en los participantes en el estudio IDEFICS (Identification and prevention of Dietary- and lyfestyle induced health EFfects In Children and infantS), provenientes de ocho países (Alemania, Bélgica, Chipre, España, Estonia, Hungría, Italia y Suecia). El tamaño de la muestra, en los distintos trabajos presentados, varió entre 8341 y 14426 sujetos, en base al total de participantes con información completa en cada caso. Los resultados del presente trabajo muestran la existencia de un gradiente socioeconómico inverso en la prevalencia de sobrepeso, en cinco de las ocho regiones investigadas (Alemania, Bélgica, España, Estonia y Chipre), mientras que no se encontró gradiente alguno en las otras tres (Chipre, Hungría e Italia). Las variables que mostraron una mayor fortaleza en la asociación entre el nivel socioeconómico y el sobrepeso, fueron el nivel de desarrollo humano de cada región y el nivel de ingresos medio. En segundo lugar, los participantes de familias de menor nivel socioeconómico mostraron hábitos alimentarios menos saludables que sus compañeros de mayor nivel socioeconómico. Esta asociación fue descrita analizando grupos de alimentos de manera individua,l así como patrones dietéticos globales, tanto para el total de la muestra como de manera específica para cada centro de estudio. Los participantes de menor nivel socioeconómico presentaron más frecuentemente perfiles caracterizados por un consumo frecuente de alimentos procesados, ricos en azúcares y grasas, snacks dulces y salados, y refrescos azucarados. Además, dichos perfiles también se caracterizaron por un consumo menos frecuente de frutas, verduras y productos integrales. Por el contrario, los sujetos de mayor nivel socioeconómico mostraron una mayor tendencia a presentar patrones más saludables, con menor frecuencia de consumo de productos de alta densidad energética y mayor frecuencia de consumo de frutas, verduras y productos integrales. Por último, se pudo constatar que los participantes que mostraron patrones dietéticos caracterizados por un consumo frecuente de alimentos procesados, a lo largo del estudio, fueron los que mostraron a su vez cambios antropométricos más desfavorables, con mayor incremento en la masa grasa total y abdominal. Entre las principales limitaciones de la presente Tesis Doctoral, se encuentran las propias del cuestionario de frecuencia de consumo de alimentos utilizado en el estudio IDEFICS. Dicho cuestionario no fue diseñado para valorar la ingesta energética total, sino los grupos de alimentos asociados positiva o negativamente con el sobrepeso y obesidad infantil, de manera que no se pudo obtener información precisa acerca del consumo de energía total. Además, el tamaño de las porciones no fue estimado y la información fue aportada por los padres, disminuyendo la precisión, ya que no se consideró la ingesta de alimentos que no tuvo lugar bajo la supervisión de los padres. Por ello, la información obtenida tiene en cuenta solo aquellas comidas realizadas a lo largo del día bajo supervisión de los padres, variando de un país a otro. La deseabilidad social a la hora de facilitar información sobre los estilos de vida, también puede suponer un sesgo, ya que puede afectar de manera diferencial a los sujetos de distinto estatus socioeconómico o perfil antropométrico. Adicionalmente, el análisis transversal realizado en cuatro de los cinco artículos, supone otra de las limitaciones a tener en cuenta, puesto que no permite determinar relaciones causales. En resumen, los datos obtenidos ponen de manifiesto la mayor vulnerabilidad a la que se encuentran expuestos los niños europeos de bajo nivel socioeconómico, que los lleva a presentar con mayor frecuencia patrones de alimentación desfavorables, que a su vez facilitan el desarrollo de sobrepeso y obesidad. Por tanto, es necesario el desarrollo de estrategias de prevención y promoción de la salud que sean efectivas en dichos subgrupos poblacionales, facilitando el consumo de alimentos saludables, para intentar reducir las desigualdades socioeconómicas en el sobrepeso y obesidad infantil. The alarming global childhood obesity prevalence presents an uneven distribution across socioeconomic segments of the population. In industrialized countries, the most disadvantaged socioeconomic groups present higher rates of obesity. The up-to-date evidence shows a complex interaction between several determinants, such as material and occupational conditions, psychosocial and behavioural factors, etc. Among lifestyle variables, diet quality has been associated with socioeconomic status, with poorer dietary habits in lower socioeconomic groups. This in turn, predispose to overweight development throughout life course. The general aims of the present Doctoral Thesis are: 1) to evaluate the association between several socioeconomic indicators and overweight prevalence in European children, 2) to analyse the children’s diet quality by socioeconomic status and 3) to evaluate the association between dietary patterns and children’s body composition changes prospectively. To full fill these aims, the available data from the IDEFICS (Identification and prevention of Dietary- and lyfestyle induced health EFfects In Children and infantS) study from eight countries (Belgium, Cyprus, Estonia, Italy, Germany, Hungary, Sweden and Spain) were taken into account. The sample size varied throughout the different articles from 8341 to 14426 participants, based on the number of participants with complete information available in each case. The results of the present work show the existence of an inverse socioeconomic gradient on overweight prevalence in five of the eight investigated regions (in Belgium, Estonia, Germany, Spain and Sweden), while in the other three regions (in Cyprus, Hungary and Italy) no association was found. The socioeconomic status-overweight association was best explained by the country-specific human development index and the centre-specific mean income. Second, the participants from families with lower socioeconomic status did show unhealthier dietary habits compared to their better-off counterparts. This association was described for single food groups and for global dietary patterns as well, both in country-specific and global analyses. Lower socioeconomic status was associated with dietary profiles characterized by a more frequent consumption of high-fat high-sugar processed foods, sweet and savoury snacks and soft drinks. In addition, these profiles were also characterized by a less frequent consumption of fruits and vegetables and wholemeal products. On the contrary, higher socioeconomic status was associated with healthier profiles, with less frequent consumption of highenergy density products and with more frequent consumption of fruits, vegetables and wholemeal products. Finally, the results showed that participants characterized by persistently showing dietary patterns with frequent consumption of processed foods presented the most unfavourable changes in fat mass and abdominal fat. The main limitations of the present Doctoral Thesis are the ones related to the food frequency questionnaire applied in the IDEFICS study. This questionnaire was not designed to capture total energy intake or total food intake, but rather to investigate the consumption frequency of food groups positively or negatively associated with obesity. Therefore, no information about total energy intake was obtained. Moreover, portion sizes were not estimated. The information about children’s food intake was provided by the parents, and thus limiting the accuracy of the information about the total amount of foods consumed. The presented information takes into account the meal occasions under parental control, which varies from country to country. Social desirability bias cannot be ruled-out, and can affect the data obtained to a different extent depending on the socioeconomic or anthropometric status of participants. In addition, the cross-sectional design of the first four articles has to be taken into account, as it does not allow drawing causal associations. In conclusion, the obtained results highlight the vulnerability of European children from families with lower socioeconomic status, presenting more frequently unhealthier dietary patterns, which in turn facilitates the overweight and obesity development. Therefore, prevention and health promotion strategies shown to be effective in low socioeconomic groups need to be developed, in order to facilitate the consumption of healthier foods, and subsequently reducing socioeconomic inequalities in children’s overweight and obesity.<br /

Prevención del sobrepeso y obesidad infantil : actividades sedentarias

Comportamiento sedentario en los niños en edad preescolar y su prevención desde la escuela

Dietary energy density in young children across Europe

OBJECTIVES: To describe energy density (ED; kcal g(-1)) of dietary intake of European children. METHODS: From 16 228 children who participated in the IDEFICS (Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS) baseline examination, 8551 children with 24-h dietary recalls (24-HDR), with plausible reported energy intakes and complete covariate information were included in the present analysis. ED was calculated using two methods: (1) ED including solid foods (EDF) and (2) ED including solid foods and energy-containing beverages (EDF&B). Beverage energy was calculated in kcal per day. Dietary characteristics and body mass index (BMI) z-score of children aged 2 to 75th percentile. Standardised regression coefficients were estimated to assess the association between dietary characteristics, BMI z-score and ED of the diet. RESULTS: Children with low EDF and EDF&B diets consumed less energy but higher quantity of food and beverages than children with high EDF and EDF&B diets. Consumption of caloric beverages decreased with increasing EDF&B of the diet owing to the relatively low ED of the beverages, in relation to solid foods. Generally, children with low EDF and EDF&B diets showed healthier food choices than peers with higher EDF and EDF&B diets. In this sample, EDF and EDF&B were not associated with BMI z-score. CONCLUSION: Health promotion strategies should proclaim lower ED diets by means of foods with high water and low fat content and mainly fruit and vegetable components. Excluding caloric beverages from EDF calculation is a useful method to avoid misinterpretation of true exposure to a high energy dense diet. We recommend excluding caloric beverages from EDF calculation when investigating the effect of ED on a certain (health) outcome

Rationale and design of the SI! Program for health promotion in elementary students aged 6 to 11 years: A cluster randomized trial

Unhealthy habits in children are increasing at an alarming rate. The school provides a promising setting for effective preventive strategies to improve children's lifestyle behaviors. The SI! Program is a multilevel multicomponent school-based educational intervention aimed at all stages of compulsory education in Spain. Here, we present the design of the SI! Program for Elementary School cluster-randomized controlled trial, targeting children aged 6 to 11 years. This trial aims to study the impact of different timings and intensities of exposure to SI! Program activities on elementary school children and their immediate environment (parents/caregivers, teachers, and school). The trial includes 1770 children from 48 public elementary schools in Madrid (Spain), together with their parents and teachers. Schools and their children were randomly assigned to the intervention group (the SI! curriculum-based educational program over 3 or 6 academic years) or to the control group (standard curriculum). The primary outcomes are the change from baseline at 3-year and 6-year follow-up in children's scores for knowledge, attitudes, and habits (KAH) and health factors (blood pressure, height, weight, waist circumference, and skinfold thickness). Secondary outcomes include 3-year and 6-year changes from baseline in lifestyle questionnaire scores for parents/caregivers and teachers, and in the school environment questionnaire. The overarching goal of the SI! Program is to provide an effective and sustainable health promotion program for the adoption of healthy behaviors in children. The present trial will address the impact and the optimal timing and duration of this educational intervention in the elementary school setting. (Am Heart J 2019;210:9-17.)This study is partly funded by the Daniel & Nina Carasso Foundation and the la Caixa Foundation (LCF/PR/CE16/ 10700001). This study forms part of a project that has received funding from the European Union Horizon 2020 research and innovation programme under Marie Skłodowska- Curie grant agreement No. 707642 and from the American Heart Association under grant No. 14SFRN2049031

Metabolic syndrome, adiposity, diet, and emotional eating are associated with oxidative stress in adolescents

Background: Metabolic syndrome (MS), a condition related to adiposity and oxidative stress, can develop in adolescence, a critical stage in life that impacts health in adulthood. However, there is scarce scientific research about the relationship between lifestyle factors, emotion management, and oxidative stress in this phase of life.Aim: To analyze whether nutritional parameters, lifestyle factors, emotion management, and MS in adolescents are associated with oxidative stress measured by the biomarker 8-isoprostane.Methods: A cross-sectional study was carried out in 132 adolescents (48.5% girls, aged 12 ± 0.48 years) and data were collected on nutritional parameters (anthropometric measurements, biochemical analyzes, and blood pressure), lifestyle factors (physical activity, sleep, and diet), and emotion management (self-esteem, emotional eating, and mood). 8-isoprostane was analyzed in spot urine samples. The study population was categorized in three groups (healthy, at-risk, and with MS) using the International Diabetes Federation definition of MS in adolescents. To capture more complex interactions, a multiple linear regression was used to analyze the association between 8-isoprostane and the aforementioned variables.Results: Urinary 8-isoprostane levels were significantly higher in the MS group compared to the healthy group (1,280 ± 543 pg./mg vs. 950 ± 416 pg./mg respectively). In addition, univariable analysis revealed positive significant associations between 8-isoprostane and body mass index, waist circumference, waist-to-height ratio, body fat percentage, blood lipid profile and glucose, emotional eating, and refined cereal intake. Conversely, a negative significant association was found between 8-isoprostane and sleep duration and fish intake. The multiple linear regression analysis revealed associations between 8-isoprostane and LDL-c (β = 0.173 value of p = 0.049), emotional eating (low β = 0.443, value of p = 0.036; high β = 0.152, value of p = 0.470), refined cereal intake (β =0.191, value of p = 0.024), and fish intake (β = -0.187, value of p = 0.050).Conclusion: The MS group, LDL-c, emotional eating, and high refined cereals and low fish intakes were associated with higher levels of oxidative stress in an adolescent population.</p

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

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

Lessons Learned From 10 Years of Preschool Intervention for Health Promotion: JACC State-of-the-Art Review.

Implementing a health promotion program for children is a complex endeavor. In this review, we outline the key lessons learned over 10 years of experience in implementing the SI! Program (Salud Integral-Comprehensive Health) for cardiovascular health promotion in preschool settings in 3 countries: Colombia (Bogotá), Spain (Madrid), and the United States (Harlem, New York). By matching rigorous efficacy studies with implementation science, we can help bridge the divide between science and educational practice. Achieving sustained lifestyle changes in preschool children through health promotion programs is likely to require the integration of several factors: 1) multidisciplinary teams; 2) multidimensional educational programs; 3) multilevel interventions; 4) local program coordination and community engagement; and 5) scientific evaluation through randomized controlled trials. Implementation of effective health promotion interventions early in life may induce long-lasting healthy behaviors that could help to curb the cardiovascular disease epidemic.This work is supported by the SHE Foundation and “la Caixa” Foundation (LCF/CE16/10700001). The project in Colombia was funded by Santo Domingo Foundation; the study in the United States (FAMILIA) was funded by the American Heart Association (grant no. 14SFRN20490315); and the study in Spain (SI! Program) was funded by the SHE Foundation, the research grant FIS-PI11/ 01885 (Fondo de Investigación Sanitaria del Instituto de Salud Carlos III), and Fundació la Marató de TV3 (369/C/2016). Dr SantosBeneit is the recipient of grant LCF/PR/MS19/12220001 funded by “la Caixa” Foundation (ID 100010434). Dr Fernández-Jiménez is the recipient of grant PI19/01704 funded by the Fondo de Investigación Sanitaria–Instituto de Salud Carlos III and co-funded by the European Regional Development Fund/European Social Fund “A way to make Europe”/“Investing in your future.” The Centro Nacional de Investigaciones Cardiovasculares is supported by the Instituto de Salud Carlos III, the Ministerio de Ciencia e Innovación, and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (CEX2020-001041-S). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.S

Polyphenols in Urine and Cardiovascular Risk Factors: A Cross-Sectional Analysis Reveals Gender Differences in Spanish Adolescents from the SI! Program

Abstract: (1) Background: Epidemiological studies have shown an inverse association between polyphenol intake and cardiovascular risk factors (CVRFs) in adults, but few have provided information about adolescents. The aim of this study was to evaluate the relationship between urinary total polyphenol excretion (TPE) and CVRFs in adolescents. (2) Methods: A cross-sectional study was performed in 1194 Spanish adolescents from the SI! (Salud Integral) program. TPE in urine samples was determined by the Folin-Ciocalteu method, after solid-phase extraction, and categorized into quartiles. The association between TPE and CVRFs was estimated using mixed-effect linear regression and a structural equation model (SEM). (3) Results: Linear regression showed negative associations among the highest quartile of TPE and body fat percentage (B = −1.75, p-value = <0.001), triglycerides (TG) (B = −17.68, p-value = <0.001), total cholesterol (TC) (B = −8.66, p-value = 0.002), and low-density lipoprotein (LDL)-cholesterol (LDL-C) (B = −4.09, p-value = 0.008) in boys, after adjusting for all confounder variables. Negative associations between TPE quartiles and systolic blood pressure (SBP), diastolic blood pressure (DBP), and TC were also found in girls. Moreover, a structural equation model revealed that TPE was directly associated with body composition and blood glucose and indirectly associated with blood pressure, TG, LDL-C, and high-density lipoprotein-cholesterol (HDL-C) in boys. Conclusions: Higher concentrations of TPE were associated with a better profile of cardiovascular health, especially in boys, while in girls, the association was not as strong. Keywords: antioxidants; pediatric; body composition; cardiovascular; lipid profile; Folin-Ciocalte