Food sources of free sugars in children's diet and identification of lifestyle patterns associated with free sugars intake: the GRECO (Greek Childhood Obesity) study.

OBJECTIVE: Excessive free sugars consumption has a possible role in health issues, diet quality and obesity development. The present cross-sectional study aimed to identify the major food sources of free sugars in Greek children's diet and investigate possible associations of dietary patterns with free sugars intake. DESIGN: Anthropometric measurements and information on dietary and physical activity habits were obtained. Energy and free sugars intake coming from foods were estimated and principal components analysis was applied to identify dietary patterns. SETTING: The GRECO (Greek Childhood Obesity) study. SUBJECTS: Nationwide sample of 3089 children (aged 10-12 years). RESULTS: Adopting WHO criteria, 44·2 % of participants were categorized as having free sugars intake above 10 % of total energy intake. Mean contribution of free sugars to energy intake was 11·2 %, and the major food sources of free sugars differed from those of other childhood populations. Free sugars intake was not associated with overweight/obesity. Multiple linear regression analysis revealed that two lifestyle and dietary patterns, characterized by higher consumption of sweets, fast foods, fries, sugared drinks, frequently ordering/eating outside home and having meals in front of a screen (pattern 1) and higher consumption of whole fruits, 100 % fruit juices, vegetables, legumes and honey/jam (pattern 2), were positively associated with free sugars intake. CONCLUSIONS: A large proportion of children exceeded the recommended cut-off and free sugars intake was associated with lifestyle patterns rather than single foods. Public health programmes aiming to reduce free sugars consumption should be tailored on promoting the correct dietary habits of specific childhood populations.

Anthropometric, lifestyle and parental characteristics associated with the prevalence of energy intake misreporting in children: the GRECO (Greek Childhood Obesity) study.

The objectives of the present study were to identify childhood energy misreporting, and evaluate characteristics that are associated with its prevalence in a nationwide cross-sectional sample of Greek schoolchildren. Under the context of the GRECO (Greek Childhood Obesity) study, data from a total of 4547 children aged 10-12 years and 2318 parents were included in the analysis. Anthropometric, lifestyle and parental characteristics plus psychological concerns were investigated in relation to the prevalence of energy misreporting. Of the included children, 36 % were classified as energy under-reporters and 16 % as over-reporters. Multinomial logistic regression analysis revealed that the most important predictors of energy under-reporting (URP) were children's BMI (OR 1·11, 95 % CI 1·09, 1·14) and weight satisfaction (OR 0·87, 95 % CI 0·78, 0·97). In the case of energy over-reporting (ORP), children's BMI (OR 0·87, 95 % CI 0·84, 0·90), meal and snack consumption frequency (OR 1·52, 95 % CI 1·32, 1·75), female sex (OR 0·65, 95 % CI 0·45, 0·90), and maternal education (OR 0·95, 95 % CI 0·91, 0·99) remained as significant predictors. Additionally, parental perception that the body weight of their children was normal reduced the odds of URP (OR 0·69, 95 % CI 0·48, 0·99) and ORP (OR 0·53, 95 % CI 0·31, 0·93). In conclusion, the present study confirms that the issue of URP and ORP in childhood populations is evident and quite serious. Although there are no definite guidelines on how to use data obtained from misreporters in an epidemiological dataset, validity of reported energy intake seems to be influenced by children's BMI and weight satisfaction, as well as by parental perceptions regarding their children's weight.

Socio-economic and demographic determinants of childhood obesity prevalence in Greece: the GRECO (Greek Childhood Obesity) study.

OBJECTIVE: Given the rapid increase in the prevalence of childhood obesity, identifying the sociodemographic influences on obesity status is important for planning and implementing effective prevention initiatives. However, this type of data is limited for Greek children. Therefore the aim of the present study was to identify possible sociodemographic factors associated with childhood obesity at the national level. DESIGN: Cross-sectional, population-based survey, carried out from October to May 2009. Setting Under the context of the GRECO (Greek Childhood Obesity) study, a nationwide sample of 2315 primary-school children. SUBJECTS: Children aged 10-12 years and their parents were voluntarily enrolled. Direct anthropometric measurements of the children were obtained and information on sociodemographic characteristics of the parents, as well as their self-reported values of body weight and height, were collected. RESULTS: Overweight and obesity prevalence was 29·5 % and 13·1 %, respectively, among boys; 29·5 % and 9·0 %, respectively, among girls. Multiple logistic regression analysis revealed that the most important sociodemographic predictors of childhood obesity were mother's age, parental BMI classification and father's type of occupation. More specifically, increased mother's age and normal BMI status of the parents seemed to have a protective effect on the likelihood of having an overweight/obese child. Additionally, the odds of a female child of being overweight/obese were reduced when the father's type of occupation tended to be less manual. CONCLUSIONS: Anti-obesity health policy interventions have to address to the parents and promote their active involvement, to effectively confront the alarming magnitude of the paediatric obesity problem in Greece.

Nutritional management of individuals with SARS-CoV-2 infection during rehabilitation.

The combination of poor dietary intake and increased healthcare needs predisposes COVID-19 patients to malnutrition and sarcopenia. The scope of this narrative review is tο present epidemiology and etiology of malnutrition and sarcopenia in COVID-19 patients, their consequences as well as the content and delivery mode of optimum nutritional services for malnourished/sarcopenic COVID-19 patients in the rehabilitation setting. This narrative review also summarizes nutritional recommendations, consensus statements and treatment pathways developed by scientific societies for COVID-19 patients. COVID-19 patients are prone to malnutrition and sarcopenia due to inactivity, comorbidities, cytokine response, nutritional deficiencies, anosmia, loss of taste, anorexia and treatment with dexamethasone. Thus, all COVID-19 patients, including those who are overweight or obese, should be regularly screened for malnutrition and sarcopenia at admission to the rehabilitation setting, using a validated tool to identify those with (or at risk of) malnutrition. As a consequence of malnutrition and sarcopenia, COVID-19 patients demonstrate diminished immune potential, lower respiratory function, swallowing dysfunction, and low resilience to metabolic stress. COVID-19 patients have increased energy (27-30 kcal/day) and protein needs (1-1.5 g/kg body weight/day). Personalized nutritional education and counseling, food fortification with energy dense and/or protein rich whole foods or with powdered supplements and use of high protein, energy dense oral nutritional supplements are recommended.

Effects of Three Different Family-Based Interventions in Overweight and Obese Children: The "4 Your Family" Randomized Controlled Trial.

Childhood overweight and obesity prevalence has risen dramatically in the past decades, and family-based interventions may be an effective method to improve children's eating behaviors. This study aimed to evaluate the effectiveness of three different family-based interventions: group-based, individual-based, or by website approach. Parents and school aged overweight or obese children, 8-12 years of age, were eligible for the study. A total of 115 children were randomly allocated in one of the three interventions, and 91 completed the study (79% compliance); Group 1 (n = 36) received group-based interventions by various experts; Group 2 (n = 30) had interpersonal family meetings with a dietitian; and Group 3 (n = 25) received training through a specifically developed website. Anthropometric, dietary, physical activity, and screen time outcomes were measured at baseline and at the end of the study. Within-group comparisons indicated significant improvement in body weight, body mass index (BMI)-z-score, physical activity, and screen time from baseline in all three study groups (p < 0.05). Furthermore, total body fat percentage (%TBF) was also decreased in Groups 2 and 3. Between-group differences varied with body weight and %TBF change, being larger in Group 3 compared to Groups 1 and 2, in contrast to BMI-z-score, screen time, and health behaviors, which were significantly larger in Group 2 than the other two groups. In conclusion, personalized family-based interventions are recommended to successfully improve children's lifestyle and body weight status.

Osteosarcopenic obesity, the coexistence of osteoporosis, sarcopenia and obesity and consequences in the quality of life in older adults ≥65 years-old in Greece.

OBJECTIVE: We investigated the coexistence of sarcopenia and obesity in older adults≥65 years diagnosed with osteoporosis and the association with Quality of Life (QoL). METHODS: A Cross-sectional survey has been performed on a randomized sample of 50 diagnosed osteoporotic elderly people from both sexes (Men=16; Women=34). MEASUREMENTS: Quantitative ultrasound was conducted to identify osteoporosis and defined with a T score ≤2.5. Validated anthropometric equations were used in order to estimate body fat percentage and skeletal muscle mass so as to detect the reallocation of body fat and lean muscle. 10m gait speed and hand grip strength was measured in order to diagnose sarcopenia according to European Society for Clinical Nutrition and Metabolism (ESPEN) algorithm. The evaluation of QoL was conducted using a QoL questionnaire specific to osteoporosis. The data were analyzed with descriptive statistics and a chi-square test was performed to examine if Osteosarcopenic Obesity (OSO) is sex related and the correlation between OSO and QoL. RESULTS: From the 50 participants, 40%(n=19) were classified as people with OSO and 60%(n=31) without OSO. From n=19 people that experienced OSO women represent 20% (n=9) and men 18% (n=9); with the latter had a greater decline in muscle mass than women, while women had lower BMD than men according to the z score. OSO is not related with sex (p>.05) and there is no significant association between OSO and QoL (p> .05 for all the domains of QoL questionnaire). CONCLUSION: Osteoporosis in the elderly often coexists with reduced muscle mass and muscle strength as well as an increase in adiposity and was independently associated with QoL. People that experience OSO presenting lower functionality that increases the risk for falls and bone fractures originated from the decline in bone and muscle mass, and increased adiposity. Increased awareness of OSO may help develop efficient interventions and public health policies for healthier and more active elderly people.

The relationship between behavioral factors, weight status and a dietary pattern in primary school aged children: The GRECO study.

BACKGROUND & AIMS: Numerous factors have been associated with the increase in childhood overweight and obesity, including environmental, dietary and behavioral. The latter have been associated with unhealthy eating behaviors but studies of their relation to dietary patterns are limited. Dietary patterns serve as a better means to evaluate children's diet and risk of obesity and therefore the aim of the study was to examine the relationship of behavioral factors with a specific dietary pattern developed for children (child derived Food Index (cdFI)), and to assess how behavioral and diet are related to children's weight status when addressed together in a model. METHODS: Study included school-aged children (n = 4434) from the Greek Childhood Obesity study (GRECO), a cross-sectional survey. Participants self-reported behavioral habits and dietary intake, using a semi-quantitative food-frequency questionnaire (FFQ). A high dietary pattern-cdFI is related to a healthier dietary pattern. Anthropometric data were measured. Multiple linear and logistic regressions were performed, adjusting for age and gender. RESULTS: The dietary pattern was positively associated with sleep, family meals and study hours, and was inversely associated with total screen time, frequency of eating out and eating while on some screen. Overweight and obese children were more likely to have a lower cdFI score (2%), sleep less (8%) and report more study hours (6%). CONCLUSION: In order to reduce and prevent child overweight and obesity, interventions probably need to address specific behavioral and dietary patterns together.

Factors associated with food choices among Greek primary school students: a cluster analysis in the ELPYDES study.

BACKGROUND: Food choice in Greece follows a westernized model. We tried to identify the characteristics of clusters regarding food choice and behaviour in a large sample of Greek primary school students, in order to acknowledge some mediating parameters that need to be addressed when planning interventions to promote healthy nutrition. METHODS: Cross-sectional study in 2439 fifth and sixth grade students from the Attica and Thessaloniki regions. Three self-administered questionnaires were distributed assessing food consumption, nutrition knowledge and factors associated with dietary change. Data were analysed using principal components analysis (PCA) and K-means cluster analysis. RESULTS: A total of 28.4% (n = 592) of the students were identified as demonstrating 'unbalanced nutrition' whereas 44.8% (n = 1018) and 22.8% (n = 319) demonstrated 'balanced' and 'low food intake', respectively. With regards to nutrition knowledge, the clusters were as follows: medium (n = 319, 14.5%), good (n = 1788, 80.9%) and bad knowledge (n = 101, 4.57%) cluster. After analysing the results of PCA, three clusters were formed: A 'negative effect' (n = 561, 28.8%), a 'health oriented' (n = 777, 39.9%) and a 'reinforced' to eat fruits and vegetables (n = 506, 31.3%) group. CONCLUSIONS: The present study managed to identify clusters that correspond to food intake, nutrition knowledge and other factors associated with dietary behaviour and to describe their characteristics.

Maternal smoking and risk of obesity in school children: Investigating early life theory from the GRECO study.

Based on the Early Life Theory, maternal smoking may be a factor affecting child weight status, adiposity level and blood pressure later in life. The purpose of this study was primarily to examine the risk of maternal smoking during pregnancy with overweight and obesity, central and total adiposity in school children. Secondarily, to assess the effect of maternal smoking, with children's blood pressure (BP). Data from the Greek Childhood Obesity cross sectional study (GRECO), conducted from October 2008 to May 2009, were used. A total of 2400 questionnaires gathered from children and their parents were analysed. Maternal and gestational data were gathered by a self-administered questionnaire. Women were categorized as non-smokers or smokers if they smoked ≥ 1 cigarettes/day during pregnancy. Children's body weight, height, waist circumference and BP were measured. Multiple logistic and linear regression analysis was conducted, adjusting for covariates. Four models were used in the process. The study found that children of maternal-smokers were more likely to be overweight or obese (OR: 1.6 to 1.82) and to have a larger waist circumference (OR: 1.73 to 1.85), compared to children of non-smokers in all models used. Total fat percentage was not significantly associated with maternal smoking when adjusted. Systolic and diastolic BP was not associated with maternal smoking. Results of this study strengthen the need for smoking cessation during pregnancy in order to possibly reduce the childhood obesity epidemic. Creating public health awareness of the potential risk of maternal-smoking on children's weight status later in life is warranted.

Dietary and lifestyle patterns in relation to high blood pressure in children: the GRECO study.

OBJECTIVE: The objective of the present study was to investigate possible associations of dietary patterns with high blood pressure (BP) in a nationwide cross-sectional sample of 10-12 years old Greek schoolchildren. METHODS: Anthropometric measurements and information on dietary (by a semi-quantitative food frequency questionnaire) and physical activity habits were obtained from the children. BPs was measured in a single occasion using a standard protocol. Data from 2024 normal energy reporting children were included in the analysis. Principal component analysis was applied to identify dietary patterns. RESULTS: Seven dietary components (patterns) were extracted explaining 55% of the total variation in intake. Multiple logistic regression analysis revealed that predictors of high BP (75th percentile of SBP and/or DBP) were a pattern mainly characterized by the high consumption of cheese and red processed meat [odds ratio (OR) 1.15; 95% confidence intervals (CI) 1.03-1.30], being overweight (OR 2.10; 95% CI 1.61-2.73) or obese (OR 3.84; 95% CI 2.44-6.06) and breakfast frequency (OR 0.95; 95% CI 0.90-0.99). After controlling for sodium intake levels, the dietary pattern did not remain a significant predictor of high BP, indicating the potential mediating effect of sodium in the association. CONCLUSION: A dietary pattern that is characterized by high cheese and red processed meat consumption increases the likelihood of having high BP in children, probably through increasing dietary sodium intake. These findings could guide future interventions or public health initiatives to prevent the increasing rates of childhood elevated BP levels.

Perinatal and family factors associated with preadolescence overweight/obesity in Greece: the GRECO study.

OBJECTIVE: To explore associations of perinatal and family factors with preadolescence overweight and obesity in a sample of Greek schoolchildren. METHODS: A nationwide cross-sectional study among 2093 students (10.9 ± 0.72 years, 44.9% boys) and their parents were conducted. Anthropometric (e.g., height, weight, mother's body mass index (BMI) at the time of the study and at conception), socio-demographic (e.g., age, education, socio-economic status), diet and other major lifestyle characteristics (e.g., smoking, alcohol intake, physical activity and inactivity) and perinatal factors (e.g., breast- and formula-feeding) were collected with validated questionnaires. Height and weight of students were measured. Overweight/obesity was classified using IOTF cut-offs. Multivariable logistic and linear regression analyses were used to identify major independent factors of overweight/obesity among preadolescents and factors related with the percentage change of mother's BMI, respectively. RESULTS: Increased age at pregnancy [odds ratios (OR)=0.95, 95% Confidence Interval (CI): 0.93-0.97], higher BMI at conception (OR=1.17, 95% CI: 1.12-1.22) and heavy smoking (OR = 2.02, 95% CI: 1.23-3.33) were positively associated with child's overweight/obesity status. Moreover, mother's age and TV viewing, indicating inactivity, were the strongest factors of the percentage increase in mother's BMI (b ± se = 0.23 ± 0.07, p = 0.002; b ± se=0.32 ± 0.10, p = 0.002, respectively). CONCLUSIONS: Preadolescent obesity is associated with mother's pre-pregnancy weight, age and heavy smoking at conception and mother's BMI change after gestation.

Very high childhood obesity prevalence and low adherence rates to the Mediterranean diet in Greek children: the GRECO study.

OBJECTIVE: In order to provide estimates of overweight and obesity among Greek schoolchildren, and the adherence rates to the Mediterranean diet (MD), a nationwide survey was performed among fifth and sixth grade students aged 10-12 years old. METHODS: A stratified sampling in 10 regions of the country was applied to voluntarily enroll a representative sample of 4786 children. Children were weighed and measured and completed a semi-quantitative food frequency questionnaire with a supplementary section for the assessment of dietary aspects and physical activity levels. Additionally, the KIDMED index was used to evaluate the degree of adherence to the MD. RESULTS: According to the IOTF cut-offs, overweight (OW) and obesity (OB) prevalence among boys was 29.9% and 12.9%, while in girls 29.2% and 10.6%, respectively. Only 4.3% of the children had an optimal KIDMED score. KIDMED score did not differ between boys and girls and no differences were detected between normal weight and OW and OB children. However, children from semi-urban or rural regions had higher score. Furthermore, children with higher KIDMED score reported following a healthier diet and having higher physical activity levels. CONCLUSION: The prevalence of childhood obesity in Greece is the highest ever reported together with low adherence rates to the dietary patterns of the MD. Current findings suggest an increased risk for even higher rates of obesity in adolescence and adulthood in the near future. Taking into account that children are also abandoning the traditional cardio-protective MD, the increased risk for future adverse health consequences seems evident.

High sodium intake of children through 'hidden' food sources and its association with the Mediterranean diet: the GRECO study.

OBJECTIVES: Sodium is the mineral that has been, mainly, linked to hypertension and cardiovascular disease. It is found naturally in many foods, but is also used in the food industry and manufacturing. Identification of total sodium intake, as well as 'hidden' sodium intake from food sources early in life is necessary. METHODS: Four thousand, five hundred and eighty children aged 10-12 years were enrolled, in a cross-sectional, population-based survey. Among other measurements, dietary data were obtained by a semi-quantitative food frequency questionnaire, and sodium intake was calculated. High sodium consumption was considered an intake over 2200 mg/day. Adherence to the Mediterranean dietary pattern was evaluated using the Mediterranean Diet Quality Index for children and adolescent score (KIDMED score). RESULTS: Twenty-three percent of Greek children had sodium intake which exceeded the 2200 mg/day recommendation, excluding salt added at table and during cooking. Sodium intake was found elevated in children with moderate and high adherence to the Mediterranean Diet. Additionally, 1 unit increase in KIDMED score (i.e. higher adherence) was associated with 10% [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.07-1.13] increased likelihood of consuming sodium above the median intake (i.e. >1500 mg/day). Thirty-four percent of sodium intake from 'hidden' sources came from bread, processed cereals and white cheese. CONCLUSIONS: Greek children have an elevated sodium intake from 'hidden' sources and main contributors are foods which are recommended to be consumed on a daily basis according to the Mediterranean Diet Pyramid. These findings should induce manufacturers to reduce the amount of sodium added during processing of 'healthy' foods, especially bread and cheese.

Factors affecting food choice in Greek primary-school students: ELPYDES study.

OBJECTIVE: To measure factors affecting food choice in a sample of Greek schoolchildren attending 5th and 6th grade. DESIGN: Three self-administered questionnaires were distributed to the participants - one on nutritional knowledge, one on self-efficacy and social support for dietary change and a food-frequency questionnaire. SETTING: One hundred Greek primary schools from Attica and Thessaloniki regions. SUBJECTS: In total, 2439 students in 5th and 6th grades. RESULTS: Principal components analysis was applied to extract the main factors affecting food choice of our subjects. Six components were derived explaining 66% of the total variation in factors affecting food choice. The first component was characterised by readiness to make the healthier choice when competitive foods are considered (explained variation 29%); the second was characterised by the impact of parents, friends and advertisements on students' choices and also the impact of taste, smell and cooking method on the consumption of vegetables (explained variation 11%); the third component was characterised by readiness to choose fresh foods instead of ready-to-eat, pre-packaged choices as a main meal and awareness of the health value of fruits and vegetables (explained variation 8%); the other components mainly expressed the interdependence of the main factors. CONCLUSIONS: Nutrition education and health promotion programs in Greece must include family members and activities regarding food preparation, as well as education and environmental changes in schools. Public health measures must include regulation of advertising. Moreover, the categorisation of foods as 'healthier but less tasty' and 'appealing but unhealthy' needs to be challenged in the future, since balanced nutrition is founded in variety and norm.

Epidemiology of overweight and obesity in a Greek adult population: the ATTICA Study.

OBJECTIVE: To evaluate the status of overweight and obesity in a Greek random sample. RESEARCH METHODS AND PROCEDURES: From 2001 to 2002, 1514 men (20 to 87 years old) and 1528 women (20 to 89 years old) were enrolled into the study. Among several sociodemographic, lifestyle, and bioclinical factors, anthropometric characteristics were also recorded. Overweight and obesity were defined according to the World Health Organization classification. RESULTS: The prevalences of overweight and obesity were 53% and 20% in men and 31% and 15% in women (p for gender differences < 0.05). The age-adjusted peak prevalence of obesity was observed in men older than 40 years old and women between 50 and 59 years old (Bonferonni alpha < 0.001). Central obesity prevailed in 36% of men and 43% of women (p for gender differences < 0.001). Obesity varied from 10% in rural to 25% in urban areas, but this difference was explained mainly by differences in occupational status (p = 0.9). Moreover, obese and overweight participants were older, less educated, more frequently sedentary, consumed higher quantities of alcoholic beverages, and were devoted to an unhealthier diet as compared with those of normal weight (all p < 0.05). A positive association was also observed between BMI and diastolic and systolic blood pressures, total cholesterol, triglycerides, and glucose levels (all p < 0.001). DISCUSSION: Overweight and obesity seem to be a great health problem in the Greek population, especially in middle-aged and older adults. Unfavorable lifestyle habits, low education, and the classical cardiovascular risk factors were associated with the prevalence of these health conditions.