Developing rights-based standards for children having tests, treatments, examinations and interventions: using a collaborative, multi-phased, multi-method and multi-stakeholder approach to build consensus.

Children continue to experience harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. The international ISupport collaboration aimed to develop standards to outline and explain good procedural practice and the rights of children within the context of a clinical procedure. The rights-based standards for children undergoing tests, treatments, investigations, examinations and interventions were developed using an iterative, multi-phased, multi-method and multi-stakeholder consensus building approach. This consensus approach used a range of online and face to face methods across three phases to ensure ongoing engagement with multiple stakeholders. The views and perspectives of 203 children and young people, 78 parents and 418 multi-disciplinary professionals gathered over a two year period (2020-2022) informed the development of international rights-based standards for the care of children having tests, treatments, examinations and interventions. The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.    Conclusion: This is the first study of its kind which outlines international rights-based procedural care standards from multi-stakeholder perspectives. The standards offer health professionals and educators clear evidence-based tools to support discussions and practice changes to challenge prevailing assumptions about holding or restraining children and instead encourage a focus on the interests and rights of the child. What is Known: • Children continue to experience short and long-term harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. • Professionals report uncertainty and tensions in applying evidence-based practice to children's procedural care. What is New: • This is the first study of its kind which has developed international rights-based procedural care standards from multi-stakeholder perspectives. • The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.

Compassion fatigue and compassion satisfaction in pediatric and neonatal care nurses during the COVID-19 pandemic in Sweden.

PURPOSE: Quality of care and the mental and physical health of nurses are interlinked. The COVID-19 pandemic has imposed an extremely high burden on health care. This study aimed to: 1) describe professional quality of life of registered nurses (RN) working in the pediatric and neonatal care units during the COVID-19 pandemic in Sweden, 2) compare professional quality of life between RNs with and without a Master's degree in specialist nursing pediatric care (MSc), and 3) compare differences in professional quality of life associated with the nursing experience (years). DESIGN AND METHODS: This study adopted a cross-sectional survey design. The PROQoL®-5-questionnaire was administered as a web survey to 160 RNs at four pediatric wards and two neonatal units of two hospitals in Sweden. RESULTS: Seventy-one RNs responded to the survey. Overall, they reported a sufficient professional quality of life. RNs with an MSc suffered significantly lower secondary traumatic stress levels. Experienced RNs reported significantly higher compassion satisfaction and lower occupational burnout. CONCLUSION: Higher education and longer experience are beneficial for nurses' professional quality of life when working in pediatric care units. PRACTICAL IMPLICATIONS: Results from this study highlights the importance of offering RN education in pediatric care at master level and supporting novice nurses, to prevent negative professional well-being outcomes in pediatric care, because the health of nurses is of utterly importance when crisis such as a pandemic hits the world. The findings also suggest that the conditions for professional quality of life could improve through activities such as self-care, time for reflection, better working hours, competence-adjusted salary, and educational opportunities.

How children in Sweden accessed and perceived information during the first phase of the Covid-19 pandemic.

AIM: To describe how children in Sweden accessed and perceived information about SARS-CoV2 and Covid-19 during the first phase of the outbreak. METHODS: This study is a substudy of an international cross-sectional online mixed methods survey examining elements of children's health literacy in relation to Covid-19. The survey included multiple-choice questions, open-ended questions and drawings and collected information from 50 Swedish children (7-12 years). Data were analysed concurrently on a descriptive level using statistics and content analysis. Quantitative and qualitative data, including the drawings, were considered equally important and resulted in six categories, illuminating how children accessed and perceived information about the pandemic. RESULTS: The survey showed that children accessed information mainly from school but also from TV. They preferred information from reliable sources. Children reported the information they accessed as easy to understand and it prompted them to ask new questions. They reported they knew a lot about the pandemic, for example, the potential danger to themselves and others and how to act to protect themselves and others. They perceived the pandemic as an intrusion on their lives. CONCLUSIONS: This study indicates that Swedish children between 7 and 12 years old were well informed about SARS-CoV2 and Covid-19 during the first phase of the pandemic. School was shown to be an important source of information. The children could explain how to act to protect themselves and others from becoming infected by the virus.

Adolescents' dietary polyphenol intake in relation to serum total antioxidant capacity: the HELENA study.

We evaluated the association between intake of total polyphenols, polyphenol classes and the 10 most consumed individual polyphenols with serum total antioxidant capacity (TAC) in 749 European adolescents (53% girls; 15% overweight; 12.5-17.5 years-old) from the cross-sectional HELENA study of 2006-2007. Dietary polyphenol intake was calculated from two non-consecutive 24-h recalls matched with the Phenol-Explorer database. Multilevel linear models examined the associations between dietary polyphenols and TAC. Polyphenol intake was rather low (median = 321mg/day; p25 = 158; p75 = 536) and TAC was comparable to other literature findings (median = 1.57 mmol/L; p25 = 1.45; p75 = 1.74). Total polyphenol intake, polyphenol classes and the top 10 compounds were not associated with TAC in a linear, quadratic or cubic way in partially or fully confounder-adjusted models. A direct anti-oxidative effect of dietary polyphenol intake was not observed in European adolescents. Polyphenol biomarkers and additional antioxidant measures are needed in future prospective studies to confirm these results.

Needle-Related Pain, Affective Reactions, Fear, and Emotional Coping in Children and Adolescents With Type 1 Diabetes: A Cross-Sectional Study.

BACKGROUND: The self-care of type 1 diabetes (T1D) includes undergoing procedures with needles several times daily, which may cause pain and fear. AIMS: The aim was to identify the degree of perceived pain, affective reactions, fear, and emotional coping among children and adolescents with T1D. DESIGN: A cross-sectional survey was performed. METHODS: Children and adolescents 7-18 years of age (n = 197) and their parents (n = 123) completed the Coloured Analogue Scale (CAS), the Facial Affective Scale (FAS), the Diabetes Fear of Injection Questionnaire (D-FISQ), and the Faces Emotional Coping Scale (FECS) in relation to needle procedures. RESULTS: The higher the values of the CAS, FAS and D-FISQ scores, the lower values for coping were reported by children and adolescents regarding treatment with insulin pen or pump, blood glucose test, and venipuncture (p < .001). Patients reported strong negative affect regarding insulin injections (35%) and blood glucose tests (32%), as well as negative affect (48%, 69%) and substantial pain (27%, 50%) for inserting a pump needle and venipuncture, respectively. Parents reported significantly higher values than children on all scales and procedures except D-FISQ (blood glucose tests) and FECS (venipuncture). CONCLUSIONS: Children and adolescents who perceive greater pain during needle-related procedures have poorer coping ability. Pediatric diabetes teams need to identify those in need of extra support to develop pain coping strategies.

Total Polyphenol Intake Is Inversely Associated with a Pro/Anti-Inflammatory Biomarker Ratio in European Adolescents of the HELENA Study.

BACKGROUND: Although high dietary polyphenol intake is negatively associated with risk of certain inflammation-associated chronic diseases, the underlying mechanisms are not fully understood and few studies have explored this in adolescents. OBJECTIVE: This study aimed to evaluate the association between intakes of total polyphenols, polyphenol classes, and the 10 most commonly consumed individual polyphenols with inflammatory biomarkers in the blood of European adolescents. METHODS: In the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Study, 526 adolescents (54% girls; 12.5-17.5 y) had data on inflammatory biomarkers and polyphenol intake from 2 nonconsecutive 24-h recalls via matching with the Phenol-Explorer database. Inflammatory biomarkers in serum were IL-1, IL-2, IL-4, IL-5, IL-6, IL-10, transforming growth factor ß1 (TGF-ß1), TNF-α, IFN-γ, soluble vascular adhesion molecule 1 (sVCAM-1), soluble intercellular adhesion molecule 1 (sICAM-1), soluble E-selectin (sE-selectin), white blood cells, lymphocytes, T cells, and C-reactive protein. Multilevel linear models were used to test associations of polyphenol intake with a pro/anti-inflammatory biomarker ratio [(zTNF-α + zIL-6 + zIL-1)/3/zIL-10] as well as with separate inflammatory biomarkers, adjusted for sociodemographic variables, diet inflammation index, BMI z score, and serum triglycerides. RESULTS: The pro/anti-inflammatory biomarker ratio was linearly inversely associated with the intake of total polyphenols (ß = -0.11, P = 0.040). When other inflammation biomarkers were considered, the serum IL-10 concentration was inversely associated with total polyphenol (ß = -0.12, P = 0.017) and flavonoid (ß = -0.12, P = 0.013) intakes, findings that were inconsistent with the biomarker ratio results. However, the anti-inflammatory capacity of polyphenols was confirmed by positive associations of IL-4 with phenolic acid (ß = 0.09 P = 0.049) and stilbene (ß = 0.13, P = 0.019) intakes and the negative association of IL-1, IL-2, and IFN-γ with lignan intake (ß = -0.10, P = 0.034; ß = -0.09, P = 0.049; ß = -0.11, P = 0.023). CONCLUSIONS: The negative relation with the overall pro/anti-inflammatory biomarker ratio suggests a potential anti-inflammatory role of high polyphenol intakes among European adolescents. Nevertheless, associations are dependent on polyphenol type and the inflammatory biomarker measured.

Polyphenol intake and metabolic syndrome risk in European adolescents: the HELENA study.

PURPOSE: The role of polyphenol intake during adolescence to prevent metabolic syndrome (MetS) is little explored. This study aimed to evaluate the association between intake of total polyphenols, polyphenol classes and the 10 most consumed individual polyphenols with MetS risk in European adolescents. METHODS: Of the cross-sectional HELENA study, 657 adolescents (54% girls; 14.8% overweight; 12.5-17.5 year) had a fasting blood sample and polyphenol intake data from two non-consecutive 24-h recalls matched with the Phenol-Explorer database. MetS was defined via the pediatric American Heart Association definition. Multilevel linear regressions examined the associations of polyphenol quartiles with MetS components, while logistic regression examined the associations with MetS risk. RESULTS: After adjusting for all potential confounders (socio-demographics and nine nutrients), total polyphenol intake, polyphenol classes and individual polyphenols were not associated with MetS risk. From all MetS components, only BMI z-score was modestly inversely associated with total polyphenol intake. Further sub analyses on polyphenol classes revealed that flavonoid intake was significantly associated with higher diastolic blood pressure and lower BMI, and phenolic acid intake was associated with higher low-density cholesterol. For individual polyphenols, the above BMI findings were often confirmed (not independent from dietary intake) and a few associations were found with insulin resistance. CONCLUSION: Higher intakes of total polyphenols and flavonoids were inversely associated with BMI. No consistent associations were found for other MetS components.

A new measure of health motivation influencing food choices and its association with food intakes and nutritional biomarkers in European adolescents.

OBJECTIVE: To develop a scale to assess health motivation influencing food choices and to explore its performance in the associations with food intakes and nutritional biomarkers. DESIGN: Psychometric study using cross-sectional self-report questionnaires and nutritional biomarkers. SETTING: Multi-centre investigation conducted in ten European cities. PARTICIPANTS: 2954 adolescents who were included in the HELENA study and completed the Food Choices and Preferences (FCP) questionnaire. RESULTS: Nineteen out of 124 items of the FCP questionnaire were in the same dimension. Sixteen presented adequate parameters for the Scale of evaluatiOn of Food choIcEs (SOFIE). The scores were positively associated with the intakes of cereals, dairy products, meats and eggs, and fish, as well as with blood concentrations of vitamin C, ß-carotene, n-3 fatty acids, cobalamin, holo-transcobalamin and folate; scores were negatively associated with the intake of alcohol. CONCLUSIONS: SOFIE can improve the assessment of motivation influencing food choices based on items with the best performance and is proposed as a new measure to health-related studies.

Diet as a moderator in the association of sedentary behaviors with inflammatory biomarkers among adolescents in the HELENA study.

AIM: To assess if a healthy diet might attenuate the positive sedentary-inflammation relation, whereas an unhealthy diet may increase the effect of sedentary behaviors on inflammatory biomarkers. METHODS: In 618 adolescents (13-17 years) of the European HELENA study, data were available on body composition, a set of inflammation markers, and food intake assessed by a self-administered computerized 24 h dietary recall for 2 days. A 9-point Mediterranean diet score and an antioxidant-rich diet z-score were used as dietary indices and tested as moderators. A set of low-grade inflammatory characteristics was used as outcome: several cytokines in an inflammatory ratio (IL-6, IL-10, TNF-α, TGFß-1), C-reactive protein, three cell-adhesion molecules (sVCAM-1, sICAM-1, sE-selectin), three cardiovascular risk markers (GGT, ALT, homocysteine) and three immune cell types (white blood cells, lymphocytes, CD3). Sedentary behaviors were self-reported and analyzed as total screen time. Multiple linear regression analyses tested moderation by diet in the sedentary behaviors-inflammation association adjusted for age, sex, country, adiposity (sum of six skinfolds), parental education, and socio-economic status. RESULTS: Both diet scores, Mediterranean and antioxidant-rich diet, were significant protective moderators in the effect of sedentary behaviors on alanine-transaminase enzyme (P = 0.014; P = 0.027), and on the pro/anti-inflammatory cytokine ratio (P = 0.001; P = 0.004), but not on other inflammatory parameters. CONCLUSION: A higher adherence to the Mediterranean diet or an antioxidant-rich diet may attenuate the onset of oxidative stress signs associated by sedentary behaviors, whereas a poor diet seems to increase inflammation.

Estimated dietary intake of polyphenols in European adolescents: the HELENA study.

PURPOSE: Knowledge about polyphenols intakes and their determinants among adolescents might be helpful for planning targeted prevention strategies at an early age. METHODS: In the European multicenter cross-sectional HELENA study of 2006-2007, 2428 subjects (47% boys) had data on dietary intake of polyphenols from 2 non-consecutive 24 h recalls via linking with the Phenol-Explorer database. Differences by sex, age, country, BMI, maternal education, paternal education, family affluence, smoking status, alcohol use, and physical activity were explored by linear regression. RESULTS: Median, lower and upper quartiles of polyphenol intakes were 326, 167 and 564 mg/day, respectively. Polyphenol intake was significantly higher in the oldest (16-17.49 years), girls, non-Mediterranean countries, lowest BMI, highest paternal education, and alcohol consumers. Main food contributors were fruit (23%, mainly apple and pear, i.e., 16.3%); chocolate products (19.2%); and fruit and vegetable juices (15.6%). Main polyphenol classes were flavonoids (75-76% of total) and phenolic acids (17-19% of total). The three most consumed polyphenols were proanthocyanidin polymers (> 10 mers), hesperidin, and proanthocyanidin 4-6 oligomers. CONCLUSION: The current study provided for the first time numbers on the total polyphenol intake and their main food sources in a heterogeneous group of European adolescents. Major differences with adult populations are the lower polyphenol consumption and the major food sources, such as chocolate and biscuits. The discussed determinants and polyphenol types already point to some important population groups that need to be targeted in future public health initiatives.

Mediation of psychosocial determinants in the relation between socio-economic status and adolescents' diet quality.

PURPOSE: To examine the underlying reasons for the positive relation between socio-economic status (SES) and the diet quality of adolescents. METHODS: In 2081 adolescents (12.5-17.5 years) of the European HELENA study, a continuous variable on diet quality via 2-day 24-h recalls was available. SES was reflected by parental education, parental occupation and family affluence. Mediation by several psychosocial determinants was tested: self-efficacy, availability at school and home, social support, barriers, benefits, awareness and some self-reported influencers (parents, school, taste, health, friends, food readily available, easy preparation, hunger, price and habits). Multiple mediation analyses were adjusted for age, sex and country. RESULTS: The availability of soft drinks and fruit at home, social support, parental influence, barriers, price influence, taste influence, health influence and food being readily available were significant mediators. The multiple mediation indirect effect accounted for 23-64% of the total effect. Both occupation and education and both maternal and paternal factors could be explained by the mediation. The unavailability of soft drinks was the strongest mediator (17-44% of the total effect). CONCLUSION: Up to 64% of the positive relation between SES and the diet quality in adolescence could be explained by several healthy eating determinants. Focusing on these factors in low-SES populations can minimize social inequalities in diet and health by improving the diet of these specific adolescents.

Early life programming of attention capacity in adolescents: The HELENA study.

The study aims to examine the individual and combined association of early life factors (birth weight, birth length, and any and exclusive breastfeeding) with attention capacity in adolescents. The study included 421 European adolescents (243 girls), aged 12.5-17.5 years, who participated in the Healthy Lifestyle in Europe by Nutrition in Adolescence Study. Body weight and length at birth of adolescents were collected from parental records. The duration of any and exclusive breastfeeding were self-reported. The d2 Test of Attention was administered to assess attention capacity. The main results showed that birth weight, birth length, breastfeeding, and exclusive breastfeeding were related to attention capacity in boys (ß ranging from 0.144 to 0.196; all p < .05) after adjustment for age, centre, gestational age, maternal education, family affluence scale, and body mass index. Among boys, differences in attention capacity were found according to tertiles of birth weight and birth length (p < .05), as well as borderline significant differences across groups of any and exclusive breastfeeding (p = 0.055 and p = 0.108, respectively) after adjusting for potential confounders. In addition, boys with 3 early life risk factors (low birth weight, low birth length, and <3 months of breastfeeding) had significantly lower scores in attention capacity compared with boys with 0 risk factors (percentile score - 15.88; p = 0.009). In conclusion, early life factors, both separately and combined, may influence attention capacity in male European adolescents. Importantly, the combination of the 3 early life risk factors, low birth weight, low birth length, and <3 months of breastfeeding, even in normal ranges, may provide the highest reduction in attention capacity.

Relaxation and guided imagery do not reduce stress, pain and unpleasantness for 11- to 12-year-old girls during vaccinations.

AIM: Relaxation and guided imagery is a distraction technique known to reduce discomfort during paediatric medical procedures. We examined whether its use decreased the stress experienced by 11- to 12-year-old girls receiving the human papilloma virus vaccination, as well as the intensity and unpleasantness of any pain. METHODS: A randomised crossover trial was conducted with 37 girls. During the first vaccination, each girl was randomised to receive either relaxation and guided imagery or standard care. They then received the other form of care during the second vaccination. Salivary cortisol was measured before each vaccination, and 30 minutes after it was administered. The girls reported pain intensity and pain unpleasantness before and directly after each vaccination and stress after each vaccination. RESULTS: On a group level, relaxation and guided imagery did not decrease cortisol levels, self-reported stress, pain intensity and pain unpleasantness. Salivary cortisol levels decreased significantly in both groups during the second vaccination. CONCLUSION: Relaxation and guided imagery did not prove beneficial during the vaccination of 11- to 12-year-old girls and is not recommended as a regular nursing intervention. However, further research is needed into effective techniques to help children who experience pain unpleasantness in connection with needle procedures.

Ethical challenges when caring for dying children.

BACKGROUND: Caring for dying children presents special challenges, according to the children themselves, their relatives and healthcare professionals. OBJECTIVE: The aim of this study was to describe caring as represented in healthcare workers' experiences of caring for dying children. METHOD: A phenomenological approach was chosen, in-depth interviews were carried out and data were analysed in four steps focusing on (a) open reading, (b) meaning units, (c) constituents and (d) essence. ETHICAL CONSIDERATIONS: Four nurses in a general acute paediatric care setting in Sweden participated after providing written informed consent. Voluntary participation and confidentiality were ensured, and the study was ethically approved. FINDINGS: The essence of caring for dying children was likened to a musically attuned composition, comprising five constituents: presence, self-knowledge, injustice in dying, own suffering and in need of others. Presence was found to be a prerequisite for caring when a child is dying. Self-knowledge and support from others can be of help when struggling with emotional pain and injustice. DISCUSSION: Caring for dying children has been found to be a delicate task for healthcare workers all over the world, and the ethical dimension is emphasized in international research. In this study, emotional pain and suffering accompanied caring, but an atmosphere in which it is possible to give and get support from colleagues and to have time to grieve and time to focus on the patient's needs may ease the burden, as can having time to process thoughts about life and death, and a possibility to grow in self-knowledge. CONCLUSION: Caring in ethically demanding situations may be facilitated through presence, atmosphere, self-knowledge and time. The challenge does not demand highly technological solutions; these assets are readily available, no matter where on earth. However, there is a need to further investigate these prerequisites for caring, particularly when a child is dying.

Caring for children in pediatric intensive care units: an observation study focusing on nurses' concerns.

Children in the pediatric intensive care unit are indisputably in a vulnerable position, dependent on nurses to acknowledge their needs. It is assumed that children should be approached from a holistic perspective in the caring situation to meet their caring needs. The aim of the study was to unfold the meaning of nursing care through nurses' concerns when caring for children in the pediatric intensive care unit. To investigate the qualitative aspects of practice embedded in the caring situation, the interpretive phenomenological approach was adopted for the study. The findings revealed three patterns: medically oriented nursing--here, the nurses attend to just the medical needs, and nursing care is at its minimum, leaving the children's needs unmet; parent-oriented nursing care--here, the nursing care emphasizes the parents' needs in the situation, and the children are viewed as a part of the parent and not as an individual child with specific caring needs; and smooth operating nursing care orientation--here, the nursing care is focused on the child as a whole human being, adding value to the nursing care. The conclusion drawn suggests that nursing care does not always respond to the needs of the child, jeopardizing the well-being of the child and leaving them at risk for experiencing pain and suffering. The concerns present in nursing care has been shown to be the divider of the meaning of nursing care and need to become elucidated in order to improve the cultural influence of what can be seen as good nursing care within the pediatric intensive care unit.

It hurts to get forced: Children's narratives about restraint during medical procedures.

According to the UN Convention on the Rights of the Child (UNCRC), children have the right to be involved in decisions about medical procedures affecting them. However, research has shown that healthcare professionals sometimes find this difficult to achieve and those procedures then are performed against the will of the child. The aim was to illuminate restraint from the perspective of children's and young people's experiences of feeling forced during medical procedures. Following the phenomenological hermeneutic method, a secondary qualitative analysis of narrative data from four datasets collected between 2001 and 2020 was performed. Twelve children and young people aged 6-19 years (three male, nine female) from central and northern Sweden narrated their experiences of restraint related to medical procedures in nine narrative interviews and three short written narratives. The analysis revealed that it hurts to get forced, this being illustrated in six themes: bodily misery, emotional rebellion, feeling disregarded, physically limited, desiring escape, and leaving deep traces. From the perspective of children and young people, restraint was interpreted with inspiration from the philosopher Michel Foucault, as being overpowered - not voluntary submission but offering resistance - and according to the theory of caring and uncaring, a relationship in which the healthcare professional is perceived as indifferent to the patient as a person. In conclusion restraint hurts and means powerlessness to the child, leaving deep traces that remain for a long time. The findings call the healthcare profession to take action to support children's self-determination, participation, and integrity in healthcare. How children experience restraint in healthcare merits further investigation from the children's own perspective.

Children's and adolescent's narratives about pain and negative experiences in diabetes treatment.

Pain and fear associated with needle procedures have been found to be more common among children and adolescents treated for type 1 diabetes (T1D) than among others in their age group. Furthermore, high glycated haemoglobin (HbA1c) values are associated with needle-related fear. AIM: To describe negative experiences of needle procedures in childhood diabetes treatment from children's and adolescents' own perspectives. METHODS: Short written narratives (n = 83) and drawings (n = 2) from children and adolescents treated for T1D, aged 7-18 years, were subjected to inductive qualitative content analysis. RESULTS: Negative experiences with needle procedures had many facets, such as pain and fear, changing over time and affecting everyday life. All kinds of needle procedures caused difficulties, but venipunctures were described as the worst. CONCLUSION: All needle procedures involved in diabetes treatment are potentially experienced as creating pain and fear, but the negative experiences are multifaceted and vary between individuals. These experiences create suffering for children and adolescents, and influence their daily lives. Besides finding techniques to decrease the number of needle procedures in the treatment, research should focus on implementing methods to decrease pain, fear, and other negative experiences as well as to promote self-coping. This is urgent, since needle-related fear has an impact on glycaemic control and therefore increases the risk of long-term complications. CLINICAL IMPLICATIONS: When caring for children and adolescents with diabetes, their previous experiences with needle procedures need to be considered.

Are Physical Activity and Sedentary Screen Time Levels Associated With Food Consumption in European Adolescents? The HELENA Study.

One of the current main public health problems is the prevalence of obesity in children. Unhealthy lifestyle behaviors such as poor dietary habits, high sedentary screen time (SST), and low levels of physical activity (PA) have a strong tendency to track from childhood into adulthood. The aim of this manuscript is to assess the association between meeting or not meeting the PA and SST recommendations and the consumption of different food groups.Data were obtained from a sample of European adolescents from the multicenter cross-sectional HELENA study. In all, 1448 adolescents from 8 cities were included. PA was objectively measured by accelerometry and dietary intake by 24-hour dietary records. Adolescents were grouped according to PA and SST recommendations.In both sexes, intake of savory snacks was higher in those groups who did not meet any of the recommendations (p < 0.05). For males, those who met both recommendations were more likely to drink/eat milk, yogurt, and water (p < 0.05). Those not meeting recommendations were more likely to drink sugar-sweetened beverages (p < 0.05). For females, those not meeting recommendations were less likely to eat fruits and vegetables and more likely to have a higher intake of fats and oils (p < 0.05).Those adolescents meeting PA and SST recommendations had a higher intake of healthy foods, like fruit and vegetables and dairy products. However, the negative relationship unhealthier food and SST is stronger in males independently of PA. More studies assessing the combined effect of both PA and SST regarding dietary habits in children and adolescents are needed.

Shifting roles: physiotherapists' perception of person-centered care during a pre-implementation phase in the acute hospital setting - A phenomenographic study.

BACKGROUND: Person-centered care (PCC) is an acknowledged health care practice involving increased patient influence regarding decisions and deliberation. Research indicates that physiotherapists (PTs) embrace patient participation, but that PCC is difficult to grasp and fully implement. OBJECTIVE: To contribute to knowledge about how PCC influences physiotherapy by eliciting PTs' experiences from the acute care setting, this study aims to describe and illuminate variations in perceptions of PCC during a pre-implementation phase, among PTs in acute hospital care. METHODS: Phenomenological approach: individual interviews with PTs in acute care (n = 7) combined with focus group interviews (n = 3). FINDINGS: The analysis yielded two main categories: 1) Physiotherapists perceived a transformed patient role involved in the transition from patient to person; and 2) Physiotherapists perceived a challenged professional role when departing from the expert role, and entailed restrictions to prescribing the best treatment and, instead, meant aiming for a collaborative and equal relationship with the patient. CONCLUSION: Although the interviewed PTs embraced PCC in principle, PCC does seem to challenge the professional roles of patient and PT. The findings indicate that theories of power relations need to be considered, and further reflection may facilitate implementation. More research is needed to deepen the knowledge of how PTs perceive PCC during all implementation phases.

Breakfast consumption and its relationship with diet quality and adherence to Mediterranean diet in European adolescents: the HELENA study.

OBJECTIVE: The aim of the current study is to analyze the associations between breakfast consumption and adherence to diet quality index (DQI) and Mediterranean Diet Score (MDS) in European adolescents. METHODS: A multinational cross-sectional study was carried out in 1804 adolescents aged 12.5-17.5 years. The Food Choices and Preferences questionnaire was used to ascertain breakfast consumption (consumers, occasional consumers and skippers), and two non-consecutive 24 h dietary recalls were used to estimate the total daily intake and to calculate the subsequent DQI and MDS. Mixed linear regression models were used to examine the relationship between breakfast consumption and DQI-A and MDS. Age, maternal education, BMI, country and total energy intake were included as covariates. RESULTS: In both sexes, significant differences were observed among the breakfast consumption categories. In both boys and girls, breakfast consumers had significantly higher DQI indices than those adolescents who skipped breakfast regularly (p < 0.001). Regarding total MDS, in both boys and girls, breakfast consumers had a higher total MDS than breakfast skippers (p < 0.001), however, no associations were shown between occasional breakfast consumers and DQI indices and MDS. CONCLUSION: Breakfast consumption has been linked with better dietary quality scores compared with those children who usually skip breakfast. Promotion of regular breakfast consumption in adolescents could be an effective strategy to improve the overall diet quality.