Walkability and socio-economic status in relation to walking, playing and sports practice in a representative Spanish sample of youth: The PASOS study.

PURPOSE: Physical activity (PA) provides multiple health-related benefits in children and adolescents, however, at present, the majority of young people are insufficiently physically active. The aim of this study was to evaluate if neighborhood walkability and/or socio-economic status (SES) could affect the practice of walking, play outdoors and sports practice in a representative sample of Spanish children and adolescents. METHODS: A sample of 4092 youth (aged 8-16 years old) from 245 primary and secondary schools in 121 localities from each of the 17 Spanish autonomous communities participated in the study. Walk Score was used to evaluate walkability of the neighborhood and household income was used as an indicator of SES. A 7-item self-reported validated questionnaire, was used to assess PA levels, and in a subsample of 10% of the participants, randomly selected from the entire sample, PA was objectively measured by accelerometers. RESULTS: Youth from more walkable areas reported more minutes walking per day compared with those from less walkable neighborhoods (51.4 vs 48.8 minutes, respectively). The lowest average minutes spent in playing outdoors was found among participants from low-SES and low-walkable neighborhoods. Neighborhood SES influenced on the participation in team sports during the weekend, being this participation higher in high SES neighborhoods. CONCLUSION: Providing high walkable environments seems a good strategy to promote PA regardless SES levels. It seems that improving the walkability is a key component to partially overcome the SES inequalities, especially in urban areas with low SES. High-SES environments can offer better sports facilities and more organized physical activities than low-SES ones.

Lifestyle behaviors clusters in a nationwide sample of Spanish children and adolescents: PASOS study.

BACKGROUND: Youth is a vulnerable period. To classify lifestyle behaviors and its relationship with health-related outcomes of Spanish children and adolescents. METHODS: Cross-sectional study including 3261 children aged 7.5-17.5 y (52.8% females). Physical activity (PA), screen-time, sleep time, adherence to Mediterranean diet (MD), weight status (WS) by validated methods. Cluster analysis was run considering chronological age. RESULTS: Six clusters were identified: C1: high screen time, low adherence to MD and sleep time (n = 431,13.20%); C2: high WS, medium adherence to MD,high sleep time, and low screen time (n = 466,14.30%); C3: young group with low screen time and high PA, adherence to MD and sleep (n = 537,16.40%); C4: worst profile regarding adherence to MD, PA, WS and sleep time (n = 609,18.70%); C5: low screen time and PA, high sleep time (n = 804,24.70%); C6: high PA and screen time, low WS (n = 414,12.70%). Mean absolute values were statistically different among PA levels, screen and sleep time, adherence to MD, age, and WS (all p < 0.001). CONCLUSIONS: The most prevalent pattern was low levels of PA, MD, and screen time, and high sleep time. The second most prevalent was characterized by very low levels of PA, sleep time, and adherence to MD, and high screen time, and WS in adolescents. IMPACT STATEMENT: The main identified lifestyle behavior was poor physical activity, low adherence to Mediterranean Diet and high screen and sleep time. Children should increase physical activity levels, adherence to Mediterranean diet, decrease screen and sleep the appropriate hours per day. Families, schools, and medical communities must work together to gloss over present and future diseases. Sleep time had not been previously included in cluster analysis with physical activity, sedentary behaviors, obesity, and nutritional status, thus the present data open a new perspective in Spanish population. Health policies should focus on promoting physical activity, Mediterranean diet, adequate sleep and reducing screen time.

Trends in Adherence to the Mediterranean Diet in Spanish Children and Adolescents across Two Decades.

Unhealthy dietary habits determined during childhood may represent a risk factor to many of the chronic non-communicable diseases (NCDs) in adulthood. Mediterranean Diet (MD) adherence in children and adolescents (8-16 years) living in Spain was investigated using the KIDMED questionnaire in a comparative analysis of two cross-sectional nationwide representative studies: enKid (1998-2000, n = 1001) and PASOS (2019-2020, n = 3540). Taking into account the educational level of pupils, as well as the characteristics of the place of living, a significant association was found between a KIDMED score ≥ 8 (optimal MD adherence) and primary education as well as residency in an area of <50,000 inhabitants, while living in the southern regions was associated with non-optimal MD adherence (p < 0.001). Participants of the 2019-2020 study showed an increase in the consumption of dairy products (31.1% increase), pasta/rice (15.4% increase), olive oil (16.9% increase), and nuts (9.7% increase), as well as a decreased sweets and candies intake (12.6% reduction). In contrast, a significantly lower MD adherence was found when comparing the 2019-2020 (mean ± SE: 6.9 ± 0.04) and the 1998-2000 study (7.37 ± 0.08); p < 0.001), due to less consumption of fish (20.3% reduction), pulse (19.4% reduction), and fruits (14.9% reduction), and an increased intake of commercial goods/pastries or fast-food intake (both 19.4% increase). The lowest adherence was recorded for adolescents also in the most recent study, where 10.9% of them presented a KIDMED score ≤ 3. This study shows that eating habits are deteriorating among Spanish children and adolescents. Such findings point out the urgency of undertaking strong measures to promote the consumption of healthy, sustainable, and non-ultra-processed food, such as those available in an MD, not only at a scientific and academic level, but also at a governmental one.

Independent and Joined Association between Socioeconomic Indicators and Pediatric Obesity in Spain: The PASOS Study.

Childhood obesity is a public health problem worldwide. An important determinant of child and adolescent obesity is socioeconomic status (SES). However, the magnitude of the impact of different SES indicators on pediatric obesity on the Spanish population scale is unclear. The aim of this study was to assess the association between three SES indicators and obesity in a nationwide, representative sample of Spanish children and adolescents. A total of 2791 boys and girls aged 8 to 16 years old were included. Their weight, height, and waist circumference were measured. SES was assessed using two parent/legal guardian self-reported indicators (educational level -University/non-University- and labor market status -Employed/Unemployed-). As a third SES indicator, the annual mean income per person was obtained from the census section where the participating schools were located (≥12.731€/<12.731€). The prevalence of obesity, severe obesity, and abdominal obesity was 11.5%, 1.4%, and 22.3%, respectively. Logistic regression models showed an inverse association of both education and labor market status with obesity, severe obesity, and abdominal obesity (all p < 0.001). Income was also inversely associated with obesity (p < 0.01) and abdominal obesity (p < 0.001). Finally, the highest composite SES category (University/Employed/≥12.731€ n = 517) showed a robust and inverse association with obesity (OR = 0.28; 95% CI: 0.16-0.48), severe obesity (OR = 0.20; 95% CI: 0.05-0.81), and abdominal obesity (OR = 0.36; 95% CI: 0.23-0.54) in comparison with the lowest composite SES category (Less than University/Unemployed/<12.731€; n = 164). No significant interaction between composite SES categories and age and gender was found. SES is strongly associated with pediatric obesity in Spain.

Association between Meal Frequency and Weight Status in Spanish Children: A Prospective Cohort Study.

Childhood obesity is a major international problem, and unhealthy eating habits remain widespread. Increasing the frequency of meals of nutritious food can help children to regulate their appetite and maintain a healthy weight. However, there is scarce prospective evidence on the relationship between the meal frequency and weight outcomes. Therefore, the objective of the present study was to determine the prospective association between the meal frequency, body mass index, and waist circumference in Spanish children. Additionally, we analyzed the impact of the meal frequency on the incidence of excessive weight and abdominal obesity. The study included 1400 children with a mean (SD) age of 10.1 (0.6) and an average follow-up of 15 months. Anthropometric measurements, including the body weight, height, and waist circumference, were measured by trained personnel, and children were asked about whether they usually had the following meals: breakfast, a mid-morning snack, lunch, an afternoon snack, and dinner. Multiple linear regression models revealed a significant (p < 0.05) inverse association between the meal frequency with a standardized BMI (zBMI) and the waist-to-height ratio (WHtR) after adjusting for sex, age, allocation to an intervention group, school, maternal education, physical activity, diet quality, and for the corresponding outcome variable at the baseline. Furthermore, the odds of developing abdominal obesity or excessive weight during the follow-up significantly decreased with an increase in the meal frequency after controlling for the same confounders. In conclusion, a higher meal frequency at the baseline was predictive for a lower zBMI, WHtR, and odds of the incidence of excessive weight and abdominal obesity.

Prospective Association between Adherence to the Mediterranean Diet and Health-Related Quality of Life in Spanish Children.

Health-Related Quality of Life (HRQoL) is gaining attention in children and adolescents because it is an important outcome of their health status and well-being. Therefore, it is important to identify determinants for HRQoL. Currently, there is scarce and mainly cross-sectional evidence on the relationship between adherence to the Mediterranean diet and HRQoL in children and adolescents. Therefore, the objective of the present study was to assess the prospective association between adherence to the Mediterranean diet and HRQoL in Spanish children. The study was carried out in 1371 children aged 8 to 10 from different Catalan elementary schools with a medium follow-up of 15 months. The KidMed and KIDSCREEN-10 questionnaires were used to assess the relationship between diet and HRQoL, respectively. The KidMed score at baseline was positively associated with HRQoL (ß = 0.320; 95% CI 0.101−0.540) after adjusting for confounders. Additionally, the logistic regression analysis showed positive associations between baseline consumption of fruit, vegetables, pulses, and high adherence to the Mediterranean diet and HRQoL at follow-up (p < 0.05 for all) while the consumption of fast-food, pasta or rice, baked good or pastries, and sweets were negatively correlated (p < 0.05 for all) with HRQoL at follow-up. In conclusion, adherence of the Mediterranean diet was predictive for HRQoL in Spanish children, but further prospective studies are needed to confirm this result.

Determinants of Adherence to the Mediterranean Diet in Spanish Children and Adolescents: The PASOS Study.

A progressive shift away from traditional healthy dietary patterns, such as the Mediterranean diet (MedDiet), has been observed in recent decades. The aim of this study was to assess determinants of optimal adherence to the MedDiet in Spanish children and adolescents. A cross-sectional analysis was included in the PASOS nationwide representative study in Spain. Participants were 3607 children and adolescents; 8-16 years old. Primary and secondary outcome measures of weight and height were measured. Adherence to the MedDiet, physical activity, and sedentary behavior in children and adolescents, as well as parental physical activity and dietary habits, were assessed. Optimal adherence to the MedDiet was observed in 45.5% of primary school students and 34.8% of secondary school students (OR: 0.65; 95%CI: 0.56-0.75). Optimal adherence to the MedDiet was higher in children/adolescents meeting daily recommended moderate and vigorous physical activity (OR: 2.39, 95%CI: 1.97-2.89) and in those meeting daily recommended screen time on weekdays (OR: 2.05, 95%CI: 1.77-2.38) and weekends (OR: 1.76, 95%CI: 1.48-2.10). Participants with optimal adherence to the MedDiet were more likely to have mothers with a high-level education and high-tercile of SDQS, mothers who never smoked or were former smokers, and mothers who met the recommended physical activity and screen time. It can be concluded that a low prevalence of optimal adherence to the MedDiet was found among current Spanish children and adolescents. Optimal adherence to the MedDiet was associated with reaching the recommendations on physical activity and screen time, with the highest maternal educational level, and healthier maternal lifestyles.

Combined Body Mass Index and Waist-to-Height Ratio and Its Association with Lifestyle and Health Factors among Spanish Children: The PASOS Study.

BACKGROUND AND AIMS: The World Health Organization recommended simultaneous measurement of body mass index (BMI) and waist circumference (WC) and suggested joint use to predict disease risks. The aim of this study was to assess the prevalence of BMI and waist-to-height ratio (WHtR) categories among Spanish children and adolescents, as well as their associations with several lifestyle factors. METHODS: Cross-sectional analysis of 8-16-year-old children and adolescents (n = 3772) were included in the PASOS nationwide representative study. Children/adolescents and their mothers/female caregivers answered a questionnaire on lifestyle and health factors. Child/adolescent anthropometrics were measured. Four combined BMI-WHtR disease risk categories were built. RESULTS: A third of participants showed combined BMI-WHtR categories with high disease risk (12.3% 'increased risk', 9.7% 'high risk', 14.3% 'very high risk'). Participants in the 'very high risk' group were less likely to be females (odds ratio 0.63; 95% CI: 0.52-0.76) and adolescents (0.60; 95% CI: 0.49-0.72), to practice ≥60 min/day of moderate-vigorous physical activity (MVPA) (0.73; 95% CI: 0.57-0.93), and to watch <120 min/day of total screen time on weekdays (0.61; 95% CI: 0.49-0.76). Mothers of participants in the 'very high risk' group were less likely to have a high educational level, be in the overweight or normal range, have never smoked or were former smokers, and watch <120 min/day of total screen time on weekends. Participants in the 'increased' and 'high risk' categories had mothers with normal weight and ≥60 min/day of MVPA. Participants in the 'high risk' group did not achieve ≥60 min/day of MVPA and showed lower adherence to the Mediterranean diet. CONCLUSIONS: Adherence to a healthy lifestyle in children and adolescents, but also in their mothers/female caregivers during offspring's childhood and adolescence, is associated with low BMI-WHtR disease risk.

Validity, reliability, and calibration of the physical activity unit 7 item screener (PAU-7S) at population scale.

BACKGROUND: Validation of self-reported tools, such as physical activity (PA) questionnaires, is crucial. The aim of this study was to determine test-retest reliability, internal consistency, and the concurrent, construct, and predictive validity of the short semi-quantitative Physical Activity Unit 7 item Screener (PAU-7S), using accelerometry as the reference measurement. The effect of linear calibration on PAU-7S validity was tested. METHODS: A randomized sample of 321 healthy children aged 8-16 years (149 boys, 172 girls) from the nationwide representative PASOS study completed the PAU-7S before and after wearing an accelerometer for at least 7 consecutive days. Weight, height, and waist circumference were measured. Cronbach alpha was calculated for internal consistency. Test-retest reliability was determined by intra-class correlation (ICC). Concurrent validity was assessed by ICC and Spearman correlation coefficient between moderate to vigorous PA (MVPA) derived by the PAU-7S and by accelerometer. Concordance between both methods was analyzed by absolute agreement, weighted kappa, and Bland-Altman statistics. Multiple linear regression models were fitted for construct validity and predictive validity was determined by leave-one-out cross-validation. RESULTS: The PAU-7S overestimated MVPA by 18%, compared to accelerometers (106.5 ± 77.0 vs 95.2 ± 33.2 min/day, respectively). A Cronbach alpha of 0.76 showed an acceptable internal consistency of the PAU-7S. Test-retest reliability was good (ICC 0.71 p < 0.001). Spearman correlation and ICC coefficients of MVPA derived by the PAU-7S and accelerometers increased from 0.31 to 0.62 and 0.20 to 0.62, respectively, after calibration of the PAU-7S. Between-methods concordance improved from a weighted kappa of 0.24 to 0.50 after calibration. A slight reduction in ICC, from 0.62 to 0.60, yielded good predictive validity. Multiple linear regression models showed an inverse association of MVPA with standardized body mass index (ß - 0.162; p < 0.077) and waist to height ratio (ß - 0.010; p < 0.014). All validity dimensions were somewhat stronger in boys compared to girls. CONCLUSION: The PAU-7S shows a good test-retest reliability and acceptable internal consistency. All dimensions of validity increased from poor/fair to moderate/good after calibration. The PAU-7S is a valid instrument for measuring MVPA in children and adolescents. TRIAL REGISTRATION: Trial registration number ISRCTN34251612 .

Prospective Associations between Maternal and Child Diet Quality and Sedentary Behaviors.

As the most likely primary caregivers, mothers are an integral part of children's social influence and are therefore greatly involved in shaping their children's behaviors. The objectives were to determine the prospective associations between maternal and child diet quality and sedentary behaviors. This study, within the framework of a community-based intervention study, included 1130 children aged 8-10 years and their mothers. The study was carried out during two academic years (2012/2014) with a mean follow-up of 15 months. Exposure and outcome variables were measured at baseline and follow-up, respectively. Diet quality was assessed by the KIDMED questionnaire and the short Diet Quality Screener, respectively. Sedentary behaviors were determined by standardized questions of sedentary behaviors. Maternal consumption of fruits, vegetables, fish, legumes, pasta/rice, dairy products, nuts and baked goods were positively associated (p < 0.05) with the corresponding child behavior. Multiple linear regression models adjusted for sex, age, maternal education and intervention group revealed significant cross-sectional (p < 0.005) and prospective (p < 0.01) associations between maternal and child overall diet quality and sedentary behaviors. Maternal diet quality and sedentary behaviors were predictive for these lifestyle behaviors in children.

Screen Time and Parents' Education Level Are Associated with Poor Adherence to the Mediterranean Diet in Spanish Children and Adolescents: The PASOS Study.

The aim of this study is to evaluate if screen time and parents' education levels are associated with adherence to a Mediterranean dietary pattern. This cross-sectional study analyzed a representative sample of 3333 children and adolescents (8 to 16 years) included in the Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS) study in Spain (which ran from March 2019 to February 2020). Data on screen time (television, computer, video games, and mobile phone) per day, Mediterranean diet adherence, daily moderate or vigorous physical activity, and parents' education levels were gathered using questionnaires. A descriptive study of the variables according to sex and parents' education level was performed. Logistic regression models (adjusted by sex and weight status) were fitted to evaluate the independent association between screen time and Kids' level of adherence to the Mediterranean diet (KIDMED) index, as well as some of its items. A greater amount of screen time was associated with worse adherence to the Mediterranean diet; a lower consumption of fruit, vegetables, fish, legumes, and nuts; and a greater consumption of fast food, sweets, and candies. A lower parents' education level was associated with worse adherence to the Mediterranean diet. It is necessary to promote the responsible, limited use of screen time, especially in children with parents with a lower education level.

Prospective Association of Maternal Educational Level with Child's Physical Activity, Screen Time, and Diet Quality.

Evidence has identified unhealthy lifestyle behaviors as the main contributors to obesity in children, so it is essential to identify factors that could influence children's lifestyles. The objective of the present study was to analyze the association of baseline maternal educational level with child's physical activity, screen time, and dietary habits at follow-up. This community-based cohort study was carried out between 2012 and 2014 and included 1405 children aged 8 to 10 years old. Maternal educational level was used as an indicator of child's socioeconomic status. Physical activity, screen time, and dietary habits were assessed by validated questionnaires. The odds of having commercially baked goods for breakfast [OR 1.47 (95% CI 1.03 to 2.10)], going more than once a week to a fast-food restaurant [OR 1.64 (95% CI 1.20 to 2.26)], and taking sweets and candys several times a day [OR 3.23 (95% CI 2.14 to 4.87) were significantly higher among children whose mothers had a lower educational level compared to their peers whose mothers had a higher level. These associations held for taking sweets and candy several times a day after additional adjustment for the corresponding dietary behavior at baseline. Maternal educational level was inversely associated (p < 0.001) with child's screen time at follow up and being in the lowest maternal educational category was associated with an increased odds of surpassing the maximum recommended time of screen time of 120 min per day (OR (95% CI) 1.43 (1.07 to 1.90), p = 0.016). Maternal education is a predictor for unhealthy dietary habits and high screen time in children.

Study protocol of a population-based cohort investigating Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth: the PASOS study.

INTRODUCTION: Physical activity (PA) is essential to healthy mental and physical development in early life. However, the prevalence of physical inactivity, which is considered a key modifiable driver of childhood obesity, has reached alarming levels among European youth. There is a need to update the data for Spain, in order to establish if current measures are effective or new approaches are needed. METHODS AND ANALYSIS: We present the protocol for Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS). This observational, nationally representative, multicentre study aims to determine the PA levels, sedentary behaviours and prevalence of physical inactivity (defined as <60 min of moderate to vigorous PA per day) in a representative sample of Spanish children and adolescents. The PASOS study has recruited a representative random sample of children and adolescents aged 8-16 years from 242 educational centres in the 17 'autonomous regions' into which Spain is divided. The aim is to include a total of 4508 youth participants and their families. Weight, height and waist circumference will be measured by standardised procedures. Adherence to the Mediterranean diet, quality of life, sleep duration, PA and sedentary behaviour are being measured by validated questionnaires. PA is measured by the Physical Activity Unit 7-item Screener. A representative subsample (10% of participants) was randomly selected to wear accelerometers for 9 days to obtain objective data on PA. Parents are asked about their educational level, time spent doing PA, diet quality, self-perceived stress, smoking habit, weight, height, their child's birth weight and if the child was breast fed. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of the Fundació Sant Joan de Déu, Barcelona, Spain. Main findings of the study will be disseminated to the scientific community and to general public by media conferences, social media and a website. TRIAL REGISTRATION NUMBER: ISRCTN34251612.

Association of eating behaviors, lifestyle, and maternal education with adherence to the Mediterranean diet in Spanish children.

BACKGROUND: The Mediterranean diet serves as a proxy of a high-quality diet. Although several factors are known to affect a child's ability to follow a high-quality diet, no prospective data are available on factors that influence adherence to a Mediterranean diet among children. Our objective was to investigate the association of Mediterranean diet adherence with eating behaviors, lifestyle habits, and maternal education in a prospective cohort of children. METHODS: The present prospective cohort analysis included 1639 children aged 8-10 years. The study was carried out during two academic years, 2012/2014, with an average follow-up of 15 months. Eating behaviors, physical activity, and adherence to Mediterranean diet were estimated by the Dutch Eating Behavior Questionnaire for Children, the Physical Activity Questionnaire for Children, and the KIDMED index, respectively. RESULTS: Multivariate linear regression analysis adjusted for sex, age, maternal education, baseline adherence to the Mediterranean diet, and intervention group revealed a significant (p < 0.01) inverse association of external eating and screen time with adherence to the Mediterranean diet at follow-up (mean of 15 months). The opposite association was found for meal frequency and physical activity (p < 0.02). A high level of maternal education increased the odds of a child's high adherence to the Mediterranean diet (OR = 1.56 CI 1.13; 2.14) compared to peers whose mothers had only a primary education. CONCLUSIONS: Screen time, physical activity, meal frequency, and external eating predict adherence to the Mediterranean diet independently of baseline diet quality. Maternal education level is an important prospective determinant for the adherence to the Mediterranean diet. TRIAL REGISTRATION NUMBER: ISRCTN68403446.

Effect of a community-based childhood obesity intervention program on changes in anthropometric variables, incidence of obesity, and lifestyle choices in Spanish children aged 8 to 10 years.

Results of community-based childhood obesity intervention programs do not provide strong evidence for their effectiveness. In this study, we evaluated the effect of the Thao-Child Health Program (TCHP), a community-based, multisetting, multistrategy intervention program for healthy weight development and lifestyle choices. In four Catalan cities, a total of 2250 children aged 8 to 10 years were recruited. Two cities were randomly selected for the TCHP intervention, and two cities followed usual health care policy. Children were selected from 41 elementary schools. Weight, height, and waist circumference were measured at baseline and after a mean follow-up of 15 months. Physical activity and adherence to the Mediterranean diet were measured with validated questionnaires. Generalized estimating equations (GEE) models were fitted to determine the intervention's effect on body mass index (BMI) z-score, waist-to-height ratio, Mediterranean diet adherence, and physical activity. Fully adjusted models revealed that the intervention had no significant effect on the BMI z-score, incidence of general and abdominal obesity, Mediterranean diet adherence, and physical activity. Waist-to-height ratio was significantly lower in controls than in the intervention group at follow-up (p < 0.004). CONCLUSIONS: The TCHP did not improve weight development, diet quality, and physical activity in the short term. What is Known: • There is inconsistent evidence for the efficacy of school-based childhood obesity prevention programs. • There is little evidence on the efficacy of childhood obesity intervention programs in other settings. What is New: • This paper contributes information about the efficacy of a multisetting and multistrategy Community Based Intervention (CBI) program that uses the municipality as its unit of randomization. • This CBI had no effect on the prevention and treatment of childhood obesity in the short term.