[Development of a conceptual model for interpretation of monitoring indicators of childhood obesity prevention from the Italian National Prevention Plan]. / Sviluppo di un modello concettuale di riferimento per l'interpretazione degli indicatori di prevenzione dell'obesità infantile e nell'adolescenza nel Piano nazionale della prevenzione.

BACKGROUND: the Italian National Prevention Plan (PNP) posed the standard to be achieved by Regions for the prevention of obesity in childhood and adolescence. The PNP also set up a monitoring system to assess the impact of implemented policies. OBJECTIVES: to develop a conceptual model to facilitate interpretation of variation in outcome indicators. METHODS: after a systematic review, the DPSEEA («Driving forces¼, «Pressures¼, «State¼, «Exposure¼, «Effect¼, «Actions¼) was identified as the more appropriate framework to assess the results of preventive policies. Factors for each component of the framework were identified and indicators that allow measuring the changing of each of these factors were defined. RESULTS: the included «driving forces¼ were related to the profit-led food industry, to the nutrition environment at school, and to household-level factors. Among the «pressures¼, parenting behaviours, food provided by school canteens, sociocultural factors, social context, physical activity (PA), opportunities at school or after-school were included. In the State, the high consumption of processed food, the large quantities of high-calorie food easy available, the consumption of carbonated and sugar-sweetened beverages, the reduced social function of mealtimes in families, the early cessation of breastfeeding, the reduction of outdoors activity, active transportation, and PA at school for children were identified. The «exposure¼ factors were the reduced opportunities of doing PA and the over-consumption of calories that influence the «effect¼, described as the prevalence of children and adolescents affected by obesity. CONCLUSIONS: through the DPSEEA, a conceptual model was set up; it allows to place in the causal chain the «actions¼ and the mechanisms through which these actions should impact on the «exposure¼ (PA and over-consumption of calories), making the rationale of process and impact indicators explicit.

Decline of childhood overweight and obesity in Italy from 2008 to 2016: results from 5 rounds of the population-based surveillance system.

BACKGROUND: Given the effects of childhood obesity on future health, and the lack of information of its prevalence in Italy, a national surveillance system was implemented in 2007. It is OKkio alla SALUTE, part of the WHO/Europe Childhood Obesity Surveillance Initiative (COSI). This study reports the 2008-2016 trends by sex, area of residence and socio-demographic characteristics in the prevalence of overweight and obesity in primary school children (8-9 years). METHODS: In each round of the surveillance held in 2008, 2010, 2012, 2014 and 2016, a nationally representative sample of about 45,000 children, was weighed and measured with standard equipment and methods by trained personnel. Children were classified as normal weight, overweight or obese using World Obesity Federation (WOF) (formerly the International Obesity Task Force (IOTF)) and WHO cut-offs. Children's sex, area of residence and mothers' education and citizenship, were obtained using self-reported questionnaires and were assessed using multivariate logistic regression models. RESULTS: Between 2008 and 2016, the overall prevalence of obesity dropped from 12.0 to 9.3% (WOF-IOTF) and from 21.2 to 17.0% (WHO), while the overall prevalence of overweight (including obesity) from 35.2 to 30.6% (WOF-IOTF) and from 44.4 to 39.4% (WHO). Reduction in the prevalence of overweight and obesity was greater in boys (- 14.5%, p for trend< 0.001; and - 24.7%, p = 0.001) compared to girls (- 11.1%, p < 0.001; and - 19.2%, p = 0.034). Decreasing trends were observed in overweight prevalences within children resident in the center and in the south. Decreasing trends in obesity prevalences were observed among boys resident in the north and in the south, and among girls resident in the center. Decreasing trends were observed in overweight prevalences within socio-demographic characteristics, except among children with low educated and foreign mothers; and in obesity prevalences for children with medium educated mothers, and girls with Italian mothers. CONCLUSIONS: From 2008 to 2016 a decrease of childhood overweight and obesity was observed in Italy. However, as these prevalences are still among the highest in Europe, there is need to continue their monitoring and implement more interventions to promote healthy lifestyles. More effort should be focused on children belonging to low social classes.

[The health determinants in young children: testing a new surveillance system in Italy]. / I determinanti di salute nella prima infanzia: la sperimentazione di un nuovo sistema di sorveglianza in Italia.

In recent years, the scientific community has stressed the need to invest in the first 1,000 days of life - the time spanning between conception and the 2nd birthday - because it is during this period that the foundations of health are laid and whose effects will be present throughout the life and may influence the next generation. Taking this into account, in 2013 the National Centre for Disease Prevention and Control (CCM) of the Italian Ministry of Health promoted and financed a project to test a surveillance system of the main determinants of health concerning the child between the conception period and the 2nd years of life which are included in the National Programme "GenitoriPiù": folic acid before and during pregnancy, abstention from tobacco and alcohol during pregnancy and lactation, breastfeeding, infant sleep position, vaccination attitude, and early reading. The Project, started in January 2014 and ended in August 2016, has piloted the design, testing, and evaluation of the surveillance system with the view to national extension and the repeatability over time. The surveillance system has been designed to collect data through a questionnaire compiled by mothers in vaccination centres, in order to produce indicators which will enable territorial and intertemporal comparisons to be made. The project has shown the feasibility of this system, identifying favourable conditions and possible difficulties, and its ability to collect important information on children's health.

Good practice criteria for childhood obesity prevention in kindergartens and schools-elaboration, content and use.

Background: In accordance with the policy actions that address childhood overweight and obesity at European level and as a contribution to the EU Action Plan on Childhood Obesity 2014-20, a Joint Action on Nutrition and Physical Activity (JANPA) was established. As part of JANPA work package 6, an evaluation framework to identify good practices, targeting childhood obesity prevention in kindergartens and schools, was developed. This article describes the WP 6 JANPA framework of good practice criteria and its development, compares it to other frameworks and discusses its potential for future use. Methods: Based on the analysis of scientific literature, a set of 47 potential good practice criteria was drafted, that was then revised and complemented through a series of online Delphi consultations. Results: A final list of 48 good practice criteria (9 of which were rated as core criteria) was developed and grouped into three categories: intervention characteristics (n = 17), implementation (n = 17) and monitoring and evaluation (n = 14). Conclusion: The identified JANPA framework of good practice criteria complements the existing frameworks by focussing on kindergarten- and school-based initiatives and provides guidance for evaluators, programme planners and decision makers bearing in mind that a one-size-fits-all approach is inadequate. To ensure the effectiveness of future practices, programme planners should endeavour to meet at least the nine JANPA core criteria.

[Dietary behaviour of children attending primary school in Italy found by the surveillance system "OKkio alla salute"]. / I comportamenti alimentari dei bambini della scuola primaria in Italia fotografati dal sistema di sorveglianza nazionale OKkio alla salute.

OBJECTIVES: to describe the dietary behaviour of children attending primary school and the school activities which promote healthy dietary habits. DESIGN OF THE STUDY: surveillance system with biannual prevalence studies. SETTING AND PARTICIPANTS: the fourth round of data collection of the surveillance system OKkio alla SALUTE took place in 2014, promoted and financed by the Ministry of Health and coordinated by the National Institute of Health in collaborations with all regions. 2,408 schools, 48,426 children and 50,638 parents participated. Stratified cluster sampling (with third grade classes as units) was used; information was collected using questionnaires completed by children, parents, teachers and head-teachers. OUTCOME MEASURES: consumption of breakfast, mid-morning snack, fruit and vegetables, sweetened and gassy drinks; school initiatives to promote healthy dietary habits. RESULTS: 31% of children have an adequate breakfast and 8% skip this meal; 52% consume an energy-dense mid-morning snack; 25% do not eat fruit and vegetables daily; 41% drink sweetened/gassy beverages daily. The unhealthy dietary habits are more common among children who have less educated parents or live in the South (more deprived area of the Country). Data show an improvement in the period 2008-2014, except in the consumption of fruit and vegetables. 74% of the schools include nutritional education in the curriculum, 66% have started initiatives of healthy dietary habits and 55% distribute healthy food; 35% involve parents in their initiatives. In the schools of the South nutritional education and involvement of parents are more frequent, while the distribution of healthy food and refectories are less common. CONCLUSIONS: the high frequency of unhealthy dietary behaviour and their geographic and social inequalities show that there is a great potential for improvement. Schools are very involved in initiatives of promotion, but they need more support from the institutions and involvement of the families.

Overweight among students aged 11-15 years and its relationship with breakfast, area of residence and parents' education: results from the Italian HBSC 2010 cross-sectional study.

BACKGROUND: The international increase in overweight and obesity among children and adolescents over the past three decades confirms that childhood obesity is a global 'epidemic'. The World Health Organization considers childhood obesity to be a major public health concern. Childhood obesity is associated with cardiovascular, endocrine, musculoskeletal and gastrointestinal complications, and may have psycho-social consequences. The aim of this paper is to examine overweight (including obesity) prevalence and its association with geographic area of residence, parental education and daily breakfast consumption in Italian students aged 11-15 yrs. METHODS: A nationally representative sample of 11-15 year old students from 20 Italian Regions (Italian Health Behaviour in School-aged Children 2010-HBSC) was randomly selected (2,504 schools and 77,113 students). Self-reported anonymous questionnaires, prepared by the international HBSC network, were used to collect the data. BMI was calculated using self-reported weight and height and the International Obesity Task Force cut-offs. Multiple logistic regressions were performed to assess the relationship between the risk of overweight and parental education, area of residence and breakfast consumption in each age group and gender. RESULTS: Boys were more likely to be overweight or obese than girls (28.1% vs. 18.9% at 11 yrs-old, 24.8% vs. 16.5% at 13 yrs and 25.4 vs. 11.8% at 15 yrs). The prevalence of overweight and obesity was lower among the older girls. Overweight and obesity rates increased from the North of Italy to the South in both boys and girls and in all age groups. Boys 11-15 yrs living in southern Italy had an OR=2.05 (1.77-2.38) and girls 2.04 (95% CI 1.70-2.44) for overweight (including obesity) compared with those living in the North. Parent's low educational level and no daily breakfast consumption were also associated with overweight including obesity (p<0.05). CONCLUSION: The prevalence of obesity and overweight in Italian school-children 11-15 yrs old are high, in particular in the South and in boys. These findings suggest appropriate interventions are needed, at the community as well as the individual level, in particular in the southern regions. However, more research is warranted on intermediary factors to determine which interventions are likely to be most effective.

Dressed or undressed? How to measure children's body weight in overweight surveillance?

OBJECTIVE: To simplify body weight measurement and, particularly, to encourage children and their parents to participate in the Italian nutritional surveillance system OKkio alla SALUTE, children were measured with clothes and then the weight was corrected for the estimated weight of the clothes. In the present study we compared the children's weight measured in underwear, as recommended by the WHO (WWHO), with that obtained using the OKkio alla SALUTE protocol (WOK) and investigated how the latter affects the calculation of BMI and the assessment of overweight and obesity prevalence. DESIGN: Weight (twice in close sequence, with and without clothing) and height were measured. A checklist was used to describe the type of clothing worn. The estimated weight of clothing was subtracted from the WOK. BMI was calculated considering both values of weight and height; ponderal status was defined using both the International Obesity Task Force and WHO BMI cut-offs. SETTING: Thirty-seven third grade classes of thirteen primary schools in Rome and in two towns in the Lazio Region were recruited. SUBJECTS: The anthropometric measurements were taken on 524 children aged 8-9 years. RESULTS: The error in the calculation of BMI from WOK was very low, 0·005 kg/m2 (95 % CI -0·185, 0·195 kg/m2); the agreement between the percentages of overweight (not including obesity) and obese children calculated with the two methods was very close to 1 (κ = 0·98). CONCLUSIONS: The error in BMI and in nutritional classification can be considered minor in a surveillance system for monitoring overweight/obesity, but eases the procedure for measuring children.

WHO European Childhood Obesity Surveillance Initiative: body mass index and level of overweight among 6-9-year-old children from school year 2007/2008 to school year 2009/2010.

BACKGROUND: The World Health Organization (WHO) Regional Office for Europe has established the Childhood Obesity Surveillance Initiative (COSI) to monitor changes in overweight in primary-school children. The aims of this paper are to present the anthropometric results of COSI Round 2 (2009/2010) and to explore changes in body mass index (BMI) and overweight among children within and across nine countries from school years 2007/2008 to 2009/2010. METHODS: Using cross-sectional nationally representative samples of 6-9-year-olds, BMI, anthropometric Z-scores and overweight prevalence were derived from measured weight and height. Significant changes between rounds were assessed using variance and t-tests analyses. RESULTS: At Round 2, the prevalence of overweight (including obesity; WHO definitions) ranged from 18% to 57% among boys and from 18% to 50% among girls; 6 - 31% of boys and 5 - 21% of girls were obese. Southern European countries had the highest overweight prevalence. Between rounds, the absolute change in mean BMI (range: from -0.4 to +0.3) and BMI-for-age Z-scores (range: from -0.21 to +0.14) varied statistically significantly across countries. The highest significant decrease in BMI-for-age Z-scores was found in countries with higher absolute BMI values and the highest significant increase in countries with lower BMI values. The highest significant decrease in overweight prevalence was observed in Italy, Portugal and Slovenia and the highest significant increase in Latvia and Norway. CONCLUSIONS: Changes in BMI and prevalence of overweight over a two-year period varied significantly among European countries. It may be that countries with higher prevalence of overweight in COSI Round 1 have implemented interventions to try to remedy this situation.

BACE2 expression increases in human neurodegenerative disease.

ß-Secretase, the rate-limiting enzymatic activity in the production of the amyloid-ß (Aß) peptide, is a major target of Alzheimer's disease (AD) therapeutics. There are two forms of the enzyme: ß-site Aß precursor protein cleaving enzyme (BACE) 1 and BACE2. Although BACE1 increases in late-stage AD, little is known about BACE2. We conducted a detailed examination of BACE2 in patients with preclinical to late-stage AD, including amnestic mild cognitive impairment, and age-matched controls, cases of frontotemporal dementia, and Down's syndrome. BACE2 protein and enzymatic activity increased as early as preclinical AD and were found in neurons and astrocytes. Although the levels of total BACE2 mRNA were unchanged, the mRNA for BACE2 splice form C (missing exon 7) increased in parallel with BACE2 protein and activity. BACE1 and BACE2 were strongly correlated with each other at all levels, suggesting that their regulatory mechanisms may be largely shared. BACE2 was also elevated in frontotemporal dementia but not in Down's syndrome, even in patients with substantial Aß deposition. Thus, expression of both forms of ß-secretase are linked and may play a combined role in human neurologic disease. A better understanding of the normal functions of BACE1 and BACE2, and how these change in different disease states, is essential for the future development of AD therapeutics.

Changes in Food Consumption and Eating Behaviours of Children and Their Families Living in Italy during the COVID-19 Pandemic: The EPaS-ISS Study.

The aim of the EPaS-ISS study was to describe the changes in food consumption and eating behaviours of children (mainly aged 8-9 years) and their families between the pre-COVID-19 period (before February/March 2020) and the COVID-19 period (from February/March 2020 to April 2022). A web questionnaire completed by parents was used to collect data. The sociodemographic characteristics of the children and their parents were also explored through the web questionnaire. Seventeen regions out of nineteen and the two autonomous provinces (PA) of Italy participated in the study. The survey was completed for 4863 children (47.9% females). The study showed that only small changes in children's food consumption happened between the pre-COVID-19 period and the COVID-19 period; in particular, about 25% of parents reported an increase in savoury snacks and sweet food. A decrease in fruit and vegetable (about 8%) and fish (14%) consumption was also found. However, the changes seem to have mainly affected children from most disadvantaged families. The results also indicate positive changes during the COVID-19 pandemic in some families' eating behaviours, such as eating more home-cooked meals (42%) and family meals (39%), as well as cooking more with children (42%).

Exploring changes in children's well-being due to COVID-19 restrictions: the Italian EpaS-ISS study.

BACKGROUND: While existing research has explored changes in health behaviours among adults and adolescents due to the COVID-19 outbreak, the impact of quarantine on young children's well-being is still less clear. Moreover, most of the published studies were carried out on small and non-representative samples. The aim of the EpaS-ISS study was to describe the impact of the COVID-19 pandemic on the habits and behaviours of a representative sample of school children aged mainly 8-9 years and their families living in Italy, exploring the changes in children's well-being during the COVID-19 pandemic compared to the immediately preceding time period. METHODS: Data were collected using a web questionnaire. The target population was parents of children attending third-grade primary schools and living in Italy. A cluster sample design was adopted. A Well-Being Score (WBS) was calculated by summing the scores from 10 items concerning the children's well-being. Associations between WBS and socio-demographic variables and other variables were analysed. RESULTS: A total of 4863 families participated. The children's WBS decreased during COVID-19 (median value from 31 to 25; p = 0.000). The most statistically significant variables related to a worsening children's WBS were: time of school closure, female gender, living in a house with only a small and unliveable outdoor area, high parents' educational level and worsening financial situation. CONCLUSIONS: According to parents ' perception, changes in daily routine during COVID-19 negatively affected children's well-being. This study has identified some personal and contextual variables associated with the worsening of children's WBS, which should be considered in case of similar events.

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

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

Trend in Breakfast Consumption among Primary School Children in Italy.

Eating breakfast daily improves cognitive function, may contribute to learning and academic performance in children and can decrease the risk of childhood obesity. The aim of this study was to analyse how breakfast consumption changed in the period from 2008/9 to 2019 in Italy among children aged 8-9 years old participating in the OKkio alla SALUTE surveys and to explore the associations with some socio-demographic and lifestyle factors. Information about children's daily breakfast consumption (adequate, inadequate, and no breakfast) and the socio-demographic characteristics of the children and their mothers was collected through four questionnaires addressed to parents, children, teachers and head teachers. Data were analysed for the 272,781 children from 21 Italian regions from 2008/9 to 2019. The prevalence of adequate breakfast decreased from 60.7% in 2008/9 to 55.7% in 2019 and no breakfast from 10.9 to 8.7%; conversely, inadequate breakfast increased from 28.4 to 35.6%. Logistic regression models showed that the occurrence of inadequate or no breakfast consumption was significantly higher among girls, children living in the southern regions and children with less educated mothers. These findings highlight the need for effective interventions to increase daily breakfast consumption and its adequacy among children.

The Correlation between Adolescent Daily Breakfast Consumption and Socio-Demographic: Trends in 23 European Countries Participating in the Health Behaviour in School-Aged Children Study (2002-2018).

Breakfast is often considered the most important meal of the day and can benefit adolescent health in several ways. The aims of the present study were (1) to identify adolescents' socio-demographic (sex, family affluence and family structure) determinants of daily breakfast consumption (DBC) and (2) to describe trends in DBC among adolescents across 23 countries. Cross-sectional surveys of nationally representative samples of adolescents (aged 11, 13, and 15 years) (n = 589,737) participating in the Health Behaviour in School-aged Children (HBSC) survey from 2002 to 2018 were used. Multilevel logistic regression analyses modeled DBC over time, adjusted for family affluence, family structure and year of survey. Four countries showed an increased trend in DBC (the Netherlands, Macedonia, Slovenia, and England). A significant decrease in DBC was observed in 15 countries (Belgium-Fr, France, Germany, Croatia, Portugal, Spain, Hungary, Poland, Russian Federation, Ukraine, Denmark, Finland, Latvia, Lithuania and Sweden). In 4 countries no significant change was observed (Czech Republic, Scotland, Ireland and Norway). In most of the countries (n = 19), DBC was higher among the adolescents from high-affluence homes. In all the countries analysed, the adolescents living in two-parent households report higher DBC use than those in single-parent households. More than half of the countries showed a decrease in DBC. There is a need to implement key interventions by developing different strategies (education, incorporating educational curriculum and counselling programmes) to increase DBC. Comparing DBC patterns across HBSC countries is important for understanding regional and global trends, monitoring strategies, and developing health promotion programmes.

Physical Activity among Italian Adolescents: Association with Life Satisfaction, Self-Rated Health and Peer Relationships.

The aim of this study was to describe physical activity, both moderate-to-vigorous physical activity (MVPA) and vigorous physical activity (VPA), in a large nationally representative sample of Italian adolescents, aged 11, 13 and 15, and to evaluate if Italian adolescents were in line with the 2020 WHO recommendations. In order to assess the possible impact of physical activity on adolescent psychological and social wellbeing, the associations between MVPA and VPA with life satisfaction, self-rated health and peer relationships were also explored. Data from the 2018 Italian Health Behaviour in School-aged Children (HBSC) survey on 58,976 adolescents were analysed. Logistic regression analysis was used to investigate the association between physical activity and self-rated health, life satisfaction and peer relationships. The association of the Family Affluence Scale with self-rated health, life satisfaction and peer relationships was also studied. The results showed that the majority of Italian adolescents did not meet current physical activity WHO guidelines on MPVA. The prevalence of adolescents claiming to be involved "at least four or more times per week" in VPA was 29%. Overall, our findings highlighted a positive association between MVPA and VPA and life satisfaction, self-rated health and peer support. Data from this study underlined the need to encourage physical activity, especially among older adolescents and girls, who claimed lower levels of MPVA and VPA.

The methodology of the Italian Health Behaviour in School-aged Children (HBSC) 2018 study and its development for the next round.

Introduction: The Italian "Health Behaviour in School-aged Children" (HBSC) is a national surveillance system that collects data on health and well-being among adolescents aged 11, 13 and 15 years attending school. It is part of the HBSC Research Network, an international alliance of researchers from 45 European and North American countries and regions started in 1982. Methods: All countries and regions participating in HBSC must adhere to a common international standard protocol developed and systematically updated by the entire HBSC Network. Data collection occurs every four years. Italy joined the international Network in 2000 and, to date, five waves (in 2002, 2006, 2010, 2014 and 2018) have been carried out. From 2010 the Italian HBSC is representative at regional level and in 2017 the base of the "Surveillance system for risk behaviours in 11-17 year-olds" became part of the Prime Ministerial Decree "Identification of surveillance systems and registries of mortality, tumours and other diseases". Cluster sampling is used, with school class as primary sampling unit, and two validated questionnaires are used to collect the information. Results: In 2018, the Italian HBSC involved 3,608 classes and 58,976 students. The average response rates were 86% of sampled classes and 97% of students achieving a national and regional representative sample for youths of all age groups (19,504 eleven-year-old, 20,554 thirteen-year-old and 18,918 fifteen-year-old). The national coordination group prepared a standardized format for disseminating the results locally and indicating areas for intervention A national report and some articles have been published. The next round, which will take place in the 2021-2022 school year, will also involve a representative sample of students of grade four of secondary schools (adolescents aged 17 years) and use on line questionnaires. Conclusions: Over 3 decades at international and 2 decades at national level 35 years have demonstrated that HBSC methodology and its results are useful for monitoring and deepening the knowledge on the most critical issues of adolescents' well-being.

Mobilizing governments and society to combat obesity: Reflections on how data from the WHO European Childhood Obesity Surveillance Initiative are helping to drive policy progress.

To meet the need for regular and reliable data on the prevalence of overweight and obesity among children in Europe, the World Health Organization (WHO) European Childhood Obesity Surveillance Initiative (COSI) was established in 2007. The resulting robust surveillance system has improved understanding of the public health challenge of childhood overweight and obesity in the WHO European Region. For the past decade, data from COSI have helped to inform and drive policy action on nutrition and physical activity in the region. This paper describes illustrative examples of how COSI data have fed into national and international policy, but the real scope of COSI's impact is likely to be much broader. In some countries, there are signs that policy responses to COSI data have helped halt the rise in childhood obesity. As the countries of the WHO European Region commit to pursuing United Action for Better Health in Europe in WHO's new European Programme of Work, COSI provides an excellent example of such united action in practice. Further collaborative action will be key to tackling this major public health challenge which affects children throughout the region.