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.

Dietary assessment training: The Italian IV SCAI study on 10-74 year-old individuals' food consumption.

Dietary surveys are conducted to examine the population's dietary patterns that require a complex system of databases, and rules for constructing the data matrix (precision, coding, deriving new variables, e.g., body mass index from individual's height and weight, classes, e.g., age-class, socio-economic status, physical activity, etc.). Management of the data collection requires specialized fieldworkers to allow for the collection of harmonized and standardized data. In this way, only statistical variability is envisaged and any eventual biases are due to probabilistic distribution but data are not affected by inaccuracy. Training the fieldworkers is a crucial part of each dietary survey. The idea to provide constant training throughout the whole survey period, from the preparatory phase to the data collection phase, relies on the necessity to train fieldworkers and monitor the skills acquired during the study, in addition to helping fieldworkers to gain the necessary experience. This study aims to relate the experience in conducting the course path to high specialized interviewers who carried out the cycle devoted to the 10-74 age class of the fourth nationwide food consumption study in Italy (IV SCAI ADULT) according to the European Food Safety Authority (EFSA) guide. A course path was structured in three steps corresponding to the preparation, pilot, and collection phases. The whole path achieved the goal of collecting data related to 12 individuals by each participant, with an overall success rate (successful trainees/total participants) of 16.8% (84 out of an initial 500). The study aimed to provide good quality data in the short term and a highly specialized community in the long term. Surveillance nutritional systems can count on a highly skilled community, so decision-making in public health nutrition and a sustainable and healthy food system can rely on this infrastructure.

Corrigendum: A Dietary Assessment Training Course Path: The Italian IV SCAI Study on Children Food Consumption.

[This corrects the article DOI: 10.3389/fpubh.2021.590315.].

The Association between Portion Sizes from High-Energy-Dense Foods and Body Composition in European Adolescents: The HELENA Study.

Obesity prevalence has been simultaneously increasing with high consumption of large food portion sizes (PS). However, there is scarce information on PS of energy-dense (ED) foods as a potential risk factor of obesity in adolescents. In the present study, we investigate the association between the PS of the most ED foods and body composition. A sample of 1889 adolescents (54.4% females) from the Healthy Lifestyle in Europe by Nutrition in Adolescence cross-sectional multicenter study (HELENA-CSS) study were included. Most ED foods (e.g., cheese) were selected according to higher fat and/or sugar content and low fiber and water. Linear and ordinal logistic regression models were adjusted for age, physical activity, total energy intake (TEI), and socioeconomic status (SES). Analysis was performed both in those adolescents reporting plausible energy intake according to the approach of Goldberg et al. and in the whole sample. In male plausible reporters, PS from "breakfast cereals" showed a significant and positive association with BMI (ß = 0.012; 0.048). PS from "carbonated soft drinks" in males (OR = 1.001; 95% CI 1.000; 1.002) and "bread and rolls" in females (OR = 1.002; 95% CI 1.000; 1.004) were associated with higher probability of having obesity, while "sweet bakery products" were associated with lower probability of having obesity (OR = 0.996; 95% CI 0.991; 0.999) in females. The present study suggests association between PS of ED foods and obesity in European adolescents. Prospective studies are needed to examine the effect of prolonged exposure to large PS and obesity development.

A Dietary Assessment Training Course Path: The Italian IV SCAI Study on Children Food Consumption.

The eating patterns in a population can be estimated through dietary surveys in which open-ended assessment methods, such as diaries and interviews, or semi-quantitative food frequency questionnaires are administered. A harmonized dietary survey methodology, together with a standardized operational procedure, in conducting the study is crucial to ensure the comparability of the results and the accuracy of information, thus reducing uncertainty and increasing the reliability of the results. Dietary patterns (i) include several target variables (foods, energy and nutrients, other food components), (ii) require several explanatory variables (age, gender, anthropometric measurements, socio-cultural and economic characteristics, lifestyle, preferences, attitudes, beliefs, organization of food-related activities, etc.), and (iii) have impacts in several domains: imbalance diets; acute and chronic exposures affect health, specifically non-communicable diseases; and then sanitary expenditure. On the other hand, food demand has impacts on the food system: production, distribution, and food services system; food wastes and other wastes generated by food-related activities of the households (e.g., packaging disposal) have consequences on the "health of the planet" which in turn can have effects on human health. Harmonization and standardization of measurement methods and procedures in such a complex context require an ad hoc structured information system made by databases (food nomenclatures, portion sizes, food atlas, recipes) and methodological tools (quantification methods, food coding systems, assessment of nutritional status, data processing to extrapolate what we consider validated dietary data). Establishing a community of professionals specialized in dietary data management could lead to build a surveillance system for monitoring eating habits in the short term, thus reducing costs, and to arrange a training re-training system. Creating and maintaining the dietary data managers community is challenging but possible. In this context, the cooperation between the CREA Research Centre for Food and Nutrition and the Italian National Health Institute (ISS) promoted and supported by the Italian Ministry of Health may represent a model of best practice that can ensure a continuous training for the professional community carrying out a nutritional study.

Mediterranean Diet, Screen-Time-Based Sedentary Behavior and Their Interaction Effect on Adiposity in European Adolescents: The HELENA Study.

Childhood obesity is a worldwide epidemic. Mediterranean diet (MD) is inversely associated with childhood obesity, but the interaction with other environmental factors, such screen time, might influence the health benefits of a high MD adherence in adolescents. The aim of the present study was to assess whether an association between MD and screen time exists in European adolescents. Moreover, we also explored whether sedentary time has a modulatory effect on the association between MD and adiposity. Adherence to the MD (24 h recalls), screen time (questionnaire), pubertal development, body mass index (BMI), fat mass index (FMI) and waist circumference (WC) were evaluated in 2053 adolescents (54.7% females), aged 12.5-17.5 years. In females, MD adherence was associated with lower BMI and FMI only when they were exposed to less than 338 min/day of screen time (81.8% of females); MD adherence was also associated with lower WC only when females were exposed to less than 143 min/day of screen time (31.5% of females). No significant MD-screen time interaction was observed in males. In conclusion, screen-time-based sedentary behaviours had a modulatory effect in the association between MD adherence and adiposity in European female adolescents.

Clustering of multiple energy balance related behaviors is associated with body fat composition indicators in adolescents: Results from the HELENA and ELANA studies.

The objective of this study was to identify clustering patterns of four energy balance-related behaviors (EBRB): television (TV) watching, moderate and vigorous physical activity (MVPA), consumption of fruits and vegetables (F&V), and consumption of sugar-sweetened beverages (SSB), among European and Brazilian adolescents. EBRB associations with different body fat composition indicators were then evaluated. Participants included adolescents from eight European countries in the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescents) study (n = 2,057, 53.8% female; age: 12.5-17.5 years) and from the metropolitan region of Rio de Janeiro/Brazil in the ELANA study (the Adolescent Nutritional Assessment Longitudinal Study) (n = 968, 53.2% female; age: 13.5-19 years). EBRB data allowed for sex- and study-specific clusters. Associations were estimated by ANOVA and odds ratios. Five clustering patterns were identified. Four similar clusters were identified for each sex and study. Among boys, different cluster identified was characterized by high F&V consumption in the HELENA study and high TV watching and high MVPA time in the ELANA study. Among girls, the different clusters identified was characterized by high F&V consumption in both studies and, additionally, high SSB consumption in the ELANA study. Regression analysis showed that clusters characterized by high SSB consumption in European boys; high TV watching, and high TV watching plus high MVPA in Brazilian boys; and high MVPA, and high SSB and F&V consumption in Brazilian girls, were positively associated with different body fat composition indicators. Common clusters were observed in adolescents from Europe and Brazil, however, no cluster was identified as being completely healthy or unhealthy. Each cluster seems to impact on body composition indicators, depending on the group. Public health actions should aim to promote adequate practices of EBRB.

Comparative validity of the ASSO-Food Frequency Questionnaire for the web-based assessment of food and nutrients intake in adolescents.

BACKGROUND: A new web-based food frequency questionnaire (the ASSO-FFQ) was developed within the ASSO Project funded by the Italian Ministry of Health. OBJECTIVE: The aim of the present study is to assess the validity of the ASSO-FFQ at food groups, energy, and nutrients level. DESIGN AND SUBJECTS: The validation study compared the ASSO-FFQ against a weighted food record (WFR) measuring foods, beverages and supplements intake, compiled during the week following the ASSO-FFQ administration. Ninety-two subjects aged 14-17, recruited from secondary schools in Palermo (Italy), completed the ASSO-FFQ and WFR. The intake of 24 food groups, energy, and 52 nutrients were taken as main outcomes. Tests for paired observations, Spearman and Pearson's correlation coefficients (cc), kappa statistics and classification in quintiles, Bland-Altman plots and multiple regressions, on untransformed and transformed data were used for the statistical analysis. RESULTS: High cc (≥0.40) were found for soft drinks, milk, tea/coffee, vegetables, and lactose; fair energy-adjusted cc (0.25-0.40) for water, alcoholic drinks, breakfast cereals, fishery products, savory food, fruit juice, eggs, and 19 nutrients. The subjects classified in the same or adjacent quintile for food groups ranged from 40% (alcoholic drinks) to 100% (dried fruit); for energy and nutrients from 43% (phosphorus, thiamin, niacin) to 77% (lactose). Mean differences were not significant for water, soft drinks, meat, sweets, animal fats, milk and white bread, and vitamin B12 and folate. Limits of Agreement were broad for all food groups and nutrients. School, gender, alcohol consumption and between meals mainly affected most food groups' intake differences. Gender stratification showed females had increased Pearson's cc for energy and 28 nutrients, such as almost all fats, carbohydrates, vitamins and minerals. CONCLUSIONS: The ASSO-FFQ could be applied in epidemiological studies for the assessment of dietary consumption in adolescents to adequately rank food, energy and nutrient intakes at a group level.

European adolescent ready-to-eat-cereal (RTEC) consumers have a healthier dietary intake and body composition compared with non-RTEC consumers.

PURPOSE: This study aims to analyse the association of European adolescents' ready-to-eat-cereal (RTEC) consumption frequency with their dietary intake by applying the concept of diet quality index and nutritional status. METHODS: From the multi-centre European HELENA study, relevant data were available in 1,215 adolescents (12.5-17.5 years). RTEC consumption was identified from a food frequency questionnaire. A diet quality index, daily nutrient intakes and daily milk/yoghurt and fruit intake were calculated from two 24-h dietary recalls. BMI, waist and hip circumference and body fat were measured for body composition. Cross-sectional regression analyses were adjusted for sex, age, socio-economic status, city and breakfast skipping. Differences in sub-regions within Europe were explored. RESULTS: RTEC consumers showed a more favourable daily micronutrient intake (vitamin B2, B5, B7, D, calcium, phosphorus and potassium), a better diet quality index, more frequent fruit (57 vs. 51%) and milk/yoghurt consumption (81.2 vs. 56%) and less breakfast skipping (25.1 vs. 36.7%). No differences in energy and macronutrient intake were observed. Daily RTEC consumers were 57% less likely to be overweight than RTEC non-consumers but did not differ in glucose and lipid status (N = 387). CONCLUSION: This is the first comprehensive pan-European survey elucidating socio-demographic determinants of European adolescents' RTEC consumption and indicating better dietary habits in RTEC consumers. The improved dietary profile was reflected in a more beneficial body composition. Our results have also shown the advantage of using an all-integrating diet quality index by capturing the diet complexity.

Dietary habits among children aged 8-9 years in Italy.

OBJECTIVE: To describe dietary habits and related geographic and socio-demographic characteristics among children aged 8-9 years in Italy. MATERIALS AND METHODS: Data from the 2012 national nutritional surveillance system collected from children, parents and teachers, have been linked to determine the children's eating habits. Logistic regression analyses were used to investigate the association between incorrect dietary habits and their potential predictors. RESULTS: Of the 46 307 children, 8.6% skipped breakfast, 48.8% did not eat vegetables and 28.7% did not eat fruit daily, 64.8% ate an abundant mid-morning snack, 41.4% drank sugary beverages and 12.5% drank carbonated beverages at least once a day. Three or more incorrect habits were found in 43.9% of the children. Incorrect dietary habits were more common among children with lower socio-economic conditions, who were resident in the South of the country and who spent more time watching TV. CONCLUSION: In Italy, unhealthy dietary habits are common among children. The deficiencies identified may well be a harbinger of future public health problems.

The web-based ASSO-food frequency questionnaire for adolescents: relative and absolute reproducibility assessment.

BACKGROUND: A new food frequency questionnaire (FFQ) has been recently developed within the Italian Adolescents and Surveillance System for the Obesity prevention (ASSO) Project; it was found to be appropriate for ranking adolescents in food and nutrient levels of intake. The aim of this study was to assess the relative and absolute reproducibility of the ASSO-FFQ for 24 food groups, energy and 52 nutrients. METHODS: A test-retest study was performed on two ASSO-FFQs administered one month apart of each other to 185 adolescents, aged 14-17 and attending secondary schools in Palermo (Italy). Wilcoxon test assessed differences in median daily intakes between the two FFQs. Agreement was evaluated by quintiles comparison and weighted kappa. Intraclass Correlation Coefficients (ICC) and Bland-Altman method assessed the relative and absolute reliability respectively. RESULTS: Significant difference (p < 0.05) in median intakes was found only for bread substitutes, savoury food, water, soft drinks, carbohydrates and sugar. The subjects classified into the same or adjacent quintiles for food groups ranged from 62% (white bread) to 91% (soft drinks); for energy and nutrients from 64% (polyunsaturated fatty acids) to 90% (ethanol). Mean values of weighted kappa were 0.47 and 0.48, respectively for food groups and nutrients. Fair to good ICC values (>0.40) were assessed for thirteen food groups, energy and forty-three nutrients. Limits of Agreement were narrow for almost all food groups and all nutrients. CONCLUSIONS: The ASSO-FFQ is a reliable instrument for estimating food groups, energy and nutrients intake in adolescents.

Adherence to the Mediterranean diet in Italian school children (The ZOOM8 Study).

The adherence to the Mediterranean diet (MD) of 1740 Italian 8-9-year-olds was evaluated using the KIDMED index and a descriptive analysis of it by socio-demographic and lifestyle factors was performed. Only 5.0% of the children resulted "high" adherers of MD (62.2% "average" and 32.8% "poor"). This scarce adherence was due to a low consumption of fruit, vegetables, legumes, dairy products and a high intake of commercially baked goods for breakfast and sweets. Hindrances to fruit, vegetables and pulses consumption were reported for one-third of the sample. The adherence rates did not differ significantly with BMI and gender. Adherence improved with: having lunch at school; liking lunch at school; breakfast with family; no free access to food; availability of fruit and pulses; liking vegetables; higher maternal education; lower child screen time; population size of place of residence. The results show it is important to improve family food habits and dietary knowledge.