Vegetarianism and meat consumption: A comparison of attitudes and beliefs between vegetarian, semi-vegetarian, and omnivorous subjects in Belgium.

High levels of meat consumption in Belgium may be contributing to increased risk of non-communicable diseases in this population. The objective of this study is to investigate the attitudes and beliefs about vegetarianism and meat consumption among the Belgian population, ultimately to better understand the motivations underlying these dietary behaviours. This cross-sectional study was initiated in March 2011. A total of 2436 individuals from a representative consumer panel from the Flemish and Brussels communities participated. The study sample was evenly distributed by education level and sex (1238 men and 1198 women). An online questionnaire with multiple-choice questions about vegetarianism and meat consumption was completed by all participants. Although representative of the prevalence of vegetarians in the population, the number of vegetarians in the study was low (n = 38); the number of semi-vegetarians (n = 288) and omnivores was high (n = 2031). Vegetarians were more likely than semi-vegetarians to agree that meat production is bad for the environment and that meat consumption is unhealthy. Important reasons for not being vegetarian included lack of interest and awareness, taste, and limited cooking skills. Encouragingly, health and discovering new tastes were seen as the most important motives for considering eating a more vegetarian-based diet. The results of this study highlight the motivations that can be used for encouraging the general public to reduce their meat consumption in favour of a plant-rich diet, and will help to inform more targeted health campaigns for reducing meat consumption in Belgium.

Cross-lagged associations between children's stress and adiposity: the Children's Body Composition and Stress study.

OBJECTIVE: The public health threats stress and adiposity have previously been associated with each other. Longitudinal studies are needed to reveal whether this association is bidirectional and the moderating factors. METHODS: In the longitudinal Children's Body Composition and Stress study, 316 children (aged 5-12 years) had measures of stress (questionnaires concerning negative life events, problem behavior, and emotions) and adiposity (body mass index, waist-to-height ratio, and fat percentage) in three waves at 1-year intervals. The bidirectionality of the association between stress and adiposity was examined using cross-lagged analyses. We tested moderation by cortisol and life-style (physical activity, screen time, food consumption, eating behavior and sleep duration). RESULTS: Adiposity (body mass index: ß = 0.48 and fat percentage: ß = 0.18; p < .001) were associated with subsequent increased stress levels, but stress was not directly related to subsequent increases in adiposity indices. Cortisol and life-style factors displayed a moderating effect on the association between stress and adiposity. Stress was positively associated with adiposity in children with high cortisol awakening patterns (ß = 0.204; p = .020) and high sweet food consumption (ß = 0.190; p = .031), whereas stress was associated with lower adiposity in the most active children (ß = -0.163; p = .022). CONCLUSIONS: Stress is associated with the development of children's adiposity, but the effects depend on cortisol levels and life-style factors. This creates new perspectives for multifactorial obesity prevention programs. Our results also highlight the adverse effect of an unhealthy body composition on children's psychological well-being.

Family structure and childhood obesity: results of the IDEFICS Project.

OBJECTIVE: To analyse the association between family structure and adiposity in children. DESIGN: Cross-sectional and longitudinal analysis of the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study cohort. SETTING: Primary schools and kindergartens. SUBJECTS: Children (n 12 350; aged 7·9 (SD 1·8) years) for the cross-sectional analysis and children (n 5236; at baseline: normal weight, aged 5·9 (SD 1·8) years) for the longitudinal study underwent anthropometry. Family structure was analysed as (i) number and type of cohabiting adults and (ii) number of siblings. RESULTS: In the cross-sectional analysis, after controlling for covariates, children living with grandparents had significantly higher BMI Z-score than those living with both parents (0·63; 95% CI 0·33, 0·92 v. 0·19; 95% CI 0·17, 0·22; P < 0·01); in addition, the higher the number of siblings, the lower the BMI Z-score (only child = 0·31; 95% CI 0·24, 0·38; 1 sibling = 0·19; 95% CI 0·16, 0·23; 2 siblings = 0·15; 95% CI 0·09, 0·20; >2 siblings = 0·07, 95% CI 0·04, 0·19; P < 0·001). Over the 2-year follow-up, differences in weight gain were observed across family-structure categories. Further, the risk of incidence of overweight/obesity was significantly lower the higher the number of siblings living in the household (v. only child: 1 sibling = 0·74, 95% CI 0·57, 0·96; 2 siblings = 0·63, 95% CI 0·45, 0·88; >2 siblings = 0·40, 95% CI 0·21, 0·77), independently of confounders. CONCLUSIONS: The study suggests that an independent association between family structure and childhood obesity exists.

The association between childhood stress and body composition, and the role of stress-related lifestyle factors--cross-sectional findings from the baseline ChiBSD survey.

BACKGROUND: Stress has been hypothesised to be involved in obesity development, also in children. More research is needed into the role of lifestyle factors in this association. PURPOSE: This study investigates the cross-sectional relationship between stress and body composition and, more importantly, the possible moderating or mediating role of lifestyle factors. METHODS: A total of 355 Belgian children (5-10 years old) participating in the baseline 'Children's Body composition and Stress' survey were included in this study. The following variables were studied: psychosocial stress (i.e. stressful events, emotions and behavioural/emotional problems, salivary cortisol), stress-related lifestyle factors (high-caloric snack consumption frequency, screen exposure time and sleep duration) and body composition parameters [BMI z-score, waist to height ratio (WHtR)]. Using linear regression analyses (adjusted for sex, age and socio-economic status), the relation between stress and body composition and, more importantly, the possible moderating or mediating role of lifestyle factors was tested. RESULTS: No association was observed between body composition and negative emotions, conduct and emotional problems and salivary cortisol. However, negative life events were positively and happiness was negatively associated with BMI z-score and WHtR. Peer problems and WHtR were positively associated in girls only. These associations were not significantly reduced after correction for lifestyle factors. Nevertheless, all lifestyle parameters moderated one or more stress-body composition associations, resulting in even more significant relations after subgroup analysis. CONCLUSION: Childhood stress was positively related to both overall and central adiposity measures with lifestyle factors acting as moderators but not as mediators. Thus, lifestyle could be a vulnerability factor in stress-induced adiposity, creating a perspective for multi-factorial obesity prevention, targeting stress and lifestyle factors in parallel.

Caucasian children's fat mass: routine anthropometry v. air-displacement plethysmography.

The present paper will use fat mass percentage (FM%) obtained via BOD POD® air-displacement plethysmography (FMADP%) to examine the relative validity of (1) anthropometric measurements/indices and (2) of FM% assessed with equations (FMeq%) based on skinfold thickness and bioelectrical impedance (BIA). In 480 Belgian children (aged 5-11 years) weight, height, skinfold thickness (triceps and subscapular), body circumferences (mid-upper arm, waist and hip), foot-to-foot BIA (Tanita®) and FMADP% were measured. Anthropometric measurements and calculated indices were compared with FMADP%. Next, published equations were used to calculate FMeq% using impedance (equations of Tanita®, Tyrrell, Shaefer and Deurenberg) or skinfold thickness (equations of Slaughter, Goran, Dezenberg and Deurenberg). Both indices and equations performed better in girls than in boys. For both sexes, the sum of skinfold thicknesses resulted in the highest correlation with FMADP%, followed by triceps skinfold, arm fat area and subscapular skinfold. In general, comparing FMeq% with FMADP% indicated mostly an age and sex effect, and an increasing underestimation but less dispersion with increasing FM%. The Tanita® impedance equation and the Deurenberg skinfold equation performed the best, although none of the used equations were interchangeable with FMADP%. In conclusion, the sum of triceps and subscapular skinfold thickness is recommended as marker of FM% in the absence of specialised technologies. Nevertheless, the higher workload, cost and survey management of an immobile device like the BOD POD® remains justified.

Cortisone in hair of elementary school girls and its relationship with childhood stress.

UNLABELLED: Children may be exposed to stressful situations with adverse effects on their physiological and psychological health. As cortisone may be a useful additional biomarker for stress research and as it has been shown to be detectable in human hair, this study measured physiological concentrations of hair cortisone in 223 elementary school girls and explored its relationship with child-reported estimates of stress, more specifically questionnaires on major life events (i.e., Coddington Life Events Scale for Children), emotions (i.e., anger, anxiety, sadness, and happiness), and coping strategies (i.e., emotion- versus problem-focused coping). Cortisone concentrations were positively correlated with the overall life event score for the past 6 months (rho = 0.223, p = 0.004), as well as with the negative event score for this period (rho = 0.227, p = 0.003; N = 165). Cortisone did not correlate with emotions or coping styles reported by the children. CONCLUSION: Despite its exploratory nature, this study may suggest elevated hair cortisone concentrations under psychosocial stress in young children. Although the observed findings should be interpreted with prudence, this study may encourage further research elucidating the potential importance and relevance of hair cortisone analysis as an additional or substituting stress biomarker for hair cortisol.

Validity of self-reported lunch recalls in Swedish school children aged 6-8 years.

BACKGROUND: Previous studies have suggested that young children are inaccurate reporters of dietary intake. The purpose of this study was to validate a single recall of the previous day's school lunch reported by 6-8 year old Swedish children and to assess teacher-recorded intake of the same meal in a standardized food journal. An additional research question was whether parents could report their child's intake of the previous day's lunch. Subjects constituted a convenience sample from the large, multi-country study Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS (IDEFICS). Validations of both children's recalls and teachers' records were made by comparing results with the duplicate plate reference method. FINDINGS: Twenty-five children (12 boys/13 girls) aged 6-8 years participated in the validation study at one school in western Sweden. Children were accurate self-reporters of their dietary intake at lunch, with no significant difference between reported and weighed intake (Mean difference (SD): 7(50) kcals, p=0.49). Teachers significantly over-reported intake (Mean difference (SD): 65(79) kcals, p=0.01). For both methods, child-reported and teacher-recorded, correlations with weighed intake were strong (Pearson's correlations r=0.92, p<0.001 and r=0.83, p<0.001 respectively). Bland-Altman plots showed strong agreement between child-reported and weighed intakes but confirmed systematic differences between teacher-records and weighed intakes. Foods were recalled by children with a food-match rate of 90%. In all cases parents themselves were unable to report on quantities consumed and only four of 25 children had parents with knowledge regarding food items consumed. CONCLUSIONS: Children 6-8 years of age accurately recalled their school lunch intake for one occasion while teachers recorded with less accuracy. Our findings suggest that children as young as six years of age may be better able to report on their dietary intake than previously suggested, at least for one main meal at school. Teacher-recorded intake provides a satisfactory estimate but with greater systematic deviation from the weighed intake. Parents were not able to report on their children's school lunches consumed on the previous day.

Diet-obesity associations in children: approaches to counteract attenuation caused by misreporting.

OBJECTIVE: Measurement errors in dietary data lead to attenuated estimates of associations between dietary exposures and health outcomes. The present study aimed to compare and evaluate different approaches of handling implausible reports by exemplary analysis of the association between dietary intakes (total energy, soft drinks, fruits/vegetables) and overweight/obesity in children. DESIGN: Cross-sectional multicentre study. SETTING: Kindergartens/schools from eight European countries participating in the IDEFICS Study. SUBJECTS: Children (n 5357) aged 2-9 years who provided one 24 h dietary recall and complete covariate information. RESULTS: The 24 h recalls were classified into three reporting groups according to adapted Goldberg cut-offs: under-report, plausible report or over-report. In the basic logistic multilevel model (adjusted for age and sex, including study centre as random effect), the dietary exposures showed no significant association with overweight/obesity (energy intake: OR=0·996 (95 % CI 0·983, 1·010); soft drinks: OR = 0·999 (95 % CI 0·986, 1·013)) and revealed even a positive association for fruits/vegetables (OR = 1·009 (95 % CI 1·001, 1·018)). When adding the reporting group (dummy variables) and a propensity score for misreporting as adjustment terms, associations became significant for energy intake as well as soft drinks (energy: OR = 1·074 (95 % CI 1·053, 1·096); soft drinks: OR = 1·015 (95 % CI 1·000, 1·031)) and the association between fruits/vegetables and overweight/obesity pointed to the reverse direction compared with the basic model (OR = 0·993 (95 % CI 0·984, 1·002)). CONCLUSIONS: Associations between dietary exposures and health outcomes are strongly affected or even masked by measurement errors. In the present analysis consideration of the reporting group and inclusion of a propensity score for misreporting turned out to be useful tools to counteract attenuation of effect estimates.

Determinants and reference values of short-term heart rate variability in children.

This paper provides age- and sex-specific reference values for short-term heart rate variability (HRV) data in children by time domain and frequency domain methods. Furthermore, HRV determinants will be determined. In 460 children (5-10 years), 5-minute HRV measurements in supine position were undertaken with Polar chest belts. The data were manually edited and processed with time and frequency domain methods. Age, time point, physical activity (accelerometry), physical fitness (cardiopulmonary fitness, upper and lower limb muscular fitness) and body composition (body mass index, fat%, fat and fat-free mass) were analysed as determinants using multiple regression analysis stratified by sex. Sex- and age-specific reference values were produced. Overall, girls had lower HRV. Age-related parasympathetic increases and sympathetic decreases were seen with sometimes age-related year-to-year wave-like changes in boys. The time point of recording had limited influence on HRV. Of the lifestyle related factors, fatness (only 7 % overweight) was not associated with HRV but fat-free mass, physical activity and in particular physical fitness (over and above activity) had a favourable association by increased parasympathetic activity. Future HRV studies in children should consider age, sex and physical fitness.

Parental and children's report of emotional problems: agreement, explanatory factors and event-emotion correlation.

BACKGROUND: As often only parents are addressed, studying parent-child agreement and its explanatory factors is crucial in gaining accurate information on young children's emotional problems. METHOD: Parental and children's reports of children's emotional problems (anger, anxiety, sadness) and children's reports of life events were gathered between February and June, 2010 from 464 Belgian nonclinical children 5-10 years old. RESULTS: Children reported more emotional problems than their parents. Parental underestimation was higher in the case of girls, older children, nontraditional family structures and authoritative parenting style. Furthermore, life events and emotional problems were significantly correlated only when using children's reported emotions. CONCLUSIONS: In our nonclinical children, interviewing both parents and children on children's emotional problems is necessary and parent-child disagreement can partially be explained by child or family characteristics.

Dietary fatty acid intake, its food sources and determinants in European adolescents: the HELENA (Healthy Lifestyle in Europe by Nutrition in Adolescence) Study.

Dietary fatty acids (FA) play a role in several (patho)physiological processes at any age, and different FA have different effects on lipid status and health outcome. The present study aims to describe the FA intake and its main food sources in a population of healthy European adolescents and to assess the variation in intake as a function of non-dietary factors. FA intake was assessed with 24 h recall interviews in 1804 adolescents aged 12·5-17·5 years. Usual intakes were calculated using the multiple source method. Multilevel analyses, adjusting for study centre, were used to investigate the influence of non-dietary factors. The mean total fat intake was 33·3 (sd 1·2) % of total energy intake (%E). The mean SFA intake was 13·8 (sd 1·2) %E, with 99·8 % of the population exceeding the recommendations. SFA was mainly delivered by meat and cake, pies and biscuits. In most adolescents, the PUFA intake was too low, and 35·5 % of the population did not achieve the minimum recommended intake for α-linolenic acid (ALA). The main determinants of FA intake in the present study population were age and sex, as well as physical activity in the male subgroup. No contributions of body composition, socio-economic status or sexual maturation to the variance in FA intake were observed. In conclusion, the most important public health concerns regarding FA intake in this adolescent population were the low intake of ALA and the high intake of SFA, mainly seen in the younger-aged boys. In this group the major contributor to SFA was meat.

Epidemiological approaches to measure childhood stress.

The prevalence of childhood stress has repeatedly been shown to be high, with 'parental separation' and 'being bullied at school' as the most frequently reported stressors in the child's everyday life. This is quite alarming as children are most vulnerable to the adverse psychological and physiological health consequences of chronic stress exposure. Despite growing research interest in this field over the last years, literature falls short in providing an overview of methods to adequately assess stress in elementary school children (6-12 years old). This review describes questionnaires and interviews, as well as laboratory measurements of cortisol in biological samples (serum, urine, saliva and hair) as stress assessment methods in children, with the emphasis on epidemiological research settings. Major characteristics, strengths and limitations of these methods are established, examples of child-specific stressor questionnaires and interviews are provided and specific recommendations with respect to epidemiological research are formulated. In addition, hair cortisol as a potential biomarker for chronic stress (in children) is discussed more thoroughly. This review is meant to serve as a preliminary guide for health researchers new to this research area by reflecting on theoretical and methodological aspects in childhood stress assessment.

Nutritional quality and acceptability of a weekly vegetarian lunch in primary-school canteens in Ghent, Belgium: 'Thursday Veggie Day'.

OBJECTIVES: To determine the nutritional adequacy and acceptability to children of vegetarian lunches served on 'Thursday Veggie Day' - a public health initiative in Ghent (Belgium) primary schools. DESIGN: A comparison of food leftovers from main courses on regular days and Thursdays was made using a visual plate waste method. The nutritional value of the vegetarian meat analogue and meat components of main courses served on five 'Thursday Veggie Days' and five comparable conventional main courses was evaluated using three criteria (maximum 30 % of energy from fat, maximum of one-third of fat as saturated fat and minimum 1.5 g of dietary fibre per 420 kJ). SETTING: Two canteens from primary schools in Ghent, Belgium, participating in the 'Thursday Veggie Day' campaign. SUBJECTS: Primary-school children aged between 6 and 12 years. RESULTS: In total, 1242 and 472 main course plate waste observations of conventional and vegetarian menus, respectively, were evaluated. There was no significant difference in plate waste between vegetarian (16.7 %) and conventional (17.3 %) main courses. Overall, the five vegetarian components were found to be nutritionally adequate with a mean score of 2.2 out of 3, compared with 0.4 for the meat component. However, three of the vegetarian components provided >30 % of energy from fat and, in one, the amount of saturated fat exceeded one-third of total fat. CONCLUSIONS: Vegetarian canteen meals offered as part of 'Thursday Veggie Day' appear to be nutritionally appropriate and as acceptable as conventional main courses to children in primary schools in Ghent.

Determinants of vitamin D status in young children: results from the Belgian arm of the IDEFICS (Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants) Study.

OBJECTIVE: To describe the vitamin D status of Belgian children and examine the influence of non-nutritional determinants, in particular of anthropometric variables. DESIGN: Cross-sectional data of Belgian participants of the EU 6th Framework Programme IDEFICS (Identification and Prevention of Dietary- and Lifestyle-Induced Health Effects in Children and Infants) Study. SETTING: 25-Hydroxyvitamin D (25(OH)D) was measured using RIA. Vitamin D status was categorized as deficient (<25 nmol/l), insufficient (25-50 nmol/l), sufficient (50-75 nmol/l) and optimal (≥75 nmol/l). Anthropometric measurements included height, weight, waist and hip circumferences and triceps and subscapular skinfold thicknesses. SUBJECTS: Children (n 357) aged 4-11 years. RESULTS: Serum 25(OH)D ranged from 13·6 to 123·5 nmol/l (mean 47·2 (sd 14·6) nmol/l); with 5 % deficient, 53 % insufficient, 40 % sufficient and 2 % optimal. No significant differences were found by age and gender. Significant differences in 25(OH)D were observed for month of sampling (P < 0·001), number of hours playing outside per week (r = 0·140), weight (r = -0·121), triceps (r = -0·112) and subscapular (r = -0·119) skinfold thickness, sum of two skinfold thicknesses (r = -0·125) and waist circumference (r = -0·108). Linear regression analysis of 25(OH)D adjusted for age, month of sampling and hours playing outside per week suggested that (i) weight, (ii) BMI Z-score, (iii) waist circumference and (iv) triceps and subscapular skinfold thickness (as well as the sum of both) independently influenced 25(OH)D. CONCLUSIONS: The majority of Belgian children had a suboptimal vitamin D status, with more than half having an insufficient status in winter and spring. Month of the year, weekly number of hours playing outside and body composition - both central and abdominal obesity - were identified as important determinants of vitamin D status in Belgian children.

Stress, emotional eating behaviour and dietary patterns in children.

Psychological stress has been suggested to change dietary pattern towards more unhealthy choices and as such to contribute to overweight. Emotional eating behaviour could be an underlying mediating mechanism. The interrelationship between stress, emotional eating behaviour and dietary patterns has only rarely been examined in young children. Nevertheless, research in children is pivotal as the foundations of dietary habits are established starting from childhood and may track into adulthood. In 437 children (5-12years) of the ChiBS study, stress was measured by questionnaires on stressful events, emotions (happy, angry, sad, anxious) and problems (emotional, peer, conduct and hyperactivity). Data were collected on children's emotional eating behaviour and also on dietary patterns: frequency of fatty foods, sweet foods, snacks (fat and sweet), fruit and vegetables. Stressful events, negative emotions and problems were positively associated with emotional eating. Positive associations were observed between problems and both sweet and fatty foods consumption. Negative associations were observed between events and fruit and vegetables consumption. Overall, stress was associated with emotional eating and a more unhealthy dietary pattern and could thus contribute to the development of overweight, also in children. Nevertheless, emotional eating behaviour was not observed to mediate the stress-diet relation.

Prevalence of psychosomatic and emotional symptoms in European school-aged children and its relationship with childhood adversities: results from the IDEFICS study.

The prevalence of childhood stress and psychosomatic and emotional symptoms (PES) has increased in parallel, indicating that adverse, stressful circumstances and PES in children might be associated. This study describes the prevalence of PES in European children, aged 4-11 years old, and examines the relationship among PES, negative life events (NLE) and familial or social adversities in the child's life. Parent-reported data on childhood adversities and PES was collected for 4,066 children from 8 European countries, who participated in the follow-up survey of IDEFICS (2009-2010), by means of the 'IDEFICS parental questionnaire'. A modified version of the 'Social Readjustment Rating Scale', the 'KINDL Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents' and the 'Strengths and Difficulties Questionnaire' were incorporated in this questionnaire, as well as questions on socio-demographics, family lifestyle and health of the child. Chi-square analyses were performed to investigate the prevalence of PES among survey centres, age groups and sex of the child. Odds ratios were calculated to examine the childhood adversity exposure between PES groups and logistic regression analyses were conducted to investigate: (a) the contribution of the number and (b) the specific types of experienced adversities on the occurrence of PES. 45.7% of the children experienced at least one PES, with low emotional well-being during the last week being most frequently reported (38.2%). No sex differences were shown for the prevalence of PES (P = 0.282), but prevalence proportions rose with increasing age (P < 0.001). Children with PES were more frequently exposed to childhood adversities compared to children without PES (e.g. 13.3 and 3.9% of peer problems and 25.4 and 17.4% of non-traditional family structure in the PES vs. no PES group, respectively, P < 0.001). An increasing number of adversities (regardless of their nature) was found to gradually amplify the risk for PES (OR = 2.85, 95% CI = 1.98-4.12 for a number of ≥3 NLE), indicating the effect of cumulative stress. Finally, a number of specified adversities were identified as apparent risk factors for the occurrence of PES, such as living in a non-traditional family structure (OR = 1.52, 95% CI = 1.30-1.79) or experiencing peer problems (OR = 3.55, 95% CI = 2.73-4.61). Childhood adversities were significantly related to PES prevalence, both quantitatively (i.e. the number of adversities) and qualitatively (i.e. the type of adversity). This study demonstrates the importance and the impact of the child's family and social context on the occurrence of PES in children younger than 12 years old.

Success rates in restoring hearing loss in patients with chronic otitis media: A systematic review.

OBJECTIVE: To assess the effectiveness of tympanoplasty in treating chronic otitis media-related hearing loss, published literature was systematically reviewed to determine the clinical success rate of tympanoplasty at restoring hearing in chronic otitis media patients at a minimum follow-up period of 12-months. DATA SOURCES: PubMed, Embase and the Cochrane Library. METHODS: Two independent reviewers performed literature searches. Publications reporting long-term (≥12-month) hearing outcomes and complications data on adult and pediatric patients with chronic otitis media were included and assessed for risk of bias and strength of evidence. To assess how tympanoplasty influences long-term hearing outcomes, data on pure tone audiometry (air-bone gap) and complications were extracted and synthesized. RESULTS: Thirty-nine studies met the inclusion criteria. Data from 3162 patients indicated that 14.0% of patients encountered postoperative complications. In adult patients, mean weighted air-bone gap data show closure from 26.5 dB hearing level (HL) (preoperatively) to 16.1 dB HL (postoperatively). In studies that presented combined adult and pediatric data, the mean preoperative air-bone gap of 26.7 dB HL was closed to 15.4 dB HL. In 1370 patients with synthesizable data, 70.7% of patients had a postoperative air-bone gap ˂ 20 dB HL at long-term follow-up. Finally, subgroup analysis identified that mean improvement in ABG closure for patients with and without cholesteatoma was 10.0 dB HL and 12.4 dB HL, respectively. CONCLUSION: In patients with chronic otitis media, tympanoplasty successfully closed the air-bone gap to within 20 dB HL in 7/10 cases and had an overall complication rate of 14.0%. LEVEL OF EVIDENCE: 2a.

The Paradox of Ingestion of Dietary Cholesterol in "Vegans"-Reply.

In a comment on several articles on the vegan dietary pattern, Antoniazzi & Acosta-Navarro (2017) mentioned the paradox of the presence of dietary cholesterol as a nutritional component in the analysis of the vegan dietary pattern [1]. [...].

Longitudinal association between child stress and lifestyle.

OBJECTIVE: Psychosocial stress has been linked with an unhealthy lifestyle but the relation's direction remains unclear. Does stress induce sleeping problems, comfort food consumption, and lower physical activity, or do these unhealthy lifestyle factors enhance stress? This study examined the bidirectional stress-lifestyle relation in children. METHOD: The relation between stress and lifestyle was examined over 2 years in 312 Belgian children 5-12 years old as part of the Children's Body Composition and Stress study. Stress-related aspects were measured by questionnaires concerning negative events, negative emotions, and behavioral problems. The following lifestyle factors were assessed: physical activity (by accelerometers), sleep duration, food consumption (sweet food, fatty food, snacks, fruits and vegetables), and eating behavior (emotional, external, restrained). Bidirectional relations were examined with cross-lagged analyses. RESULTS: Certain stress aspects increased physical activity, sweet food consumption, emotional eating, restrained eating, and external eating (ßs = .140-.319). All relations were moderated by sex and age: Dietary effects were mainly in the oldest children and girls; stress increased physical activity in the youngest, whereas it tended to decrease physical activity in the oldest. One reversed direction effect was found: Maladaptive eating behaviors increased anxiety feelings. CONCLUSIONS: Relations were mainly unidirectional: Stress influenced children's lifestyle. Stress stimulated eating in the absence of hunger, which could facilitate overweight. Consequently, families should realize that stress may influence children's diet, and problem-solving coping skills should be acquired. In contrast to recent findings, stress might also stimulate physical activity in the youngest as positive stress coping style.

Comparison of nutritional quality of the vegan, vegetarian, semi-vegetarian, pesco-vegetarian and omnivorous diet.

The number of studies comparing nutritional quality of restrictive diets is limited. Data on vegan subjects are especially lacking. It was the aim of the present study to compare the quality and the contributing components of vegan, vegetarian, semi-vegetarian, pesco-vegetarian and omnivorous diets. Dietary intake was estimated using a cross-sectional online survey with a 52-items food frequency questionnaire (FFQ). Healthy Eating Index 2010 (HEI-2010) and the Mediterranean Diet Score (MDS) were calculated as indicators for diet quality. After analysis of the diet questionnaire and the FFQ, 1475 participants were classified as vegans (n = 104), vegetarians (n = 573), semi-vegetarians (n = 498), pesco-vegetarians (n = 145), and omnivores (n = 155). The most restricted diet, i.e., the vegan diet, had the lowest total energy intake, better fat intake profile, lowest protein and highest dietary fiber intake in contrast to the omnivorous diet. Calcium intake was lowest for the vegans and below national dietary recommendations. The vegan diet received the highest index values and the omnivorous the lowest for HEI-2010 and MDS. Typical aspects of a vegan diet (high fruit and vegetable intake, low sodium intake, and low intake of saturated fat) contributed substantially to the total score, independent of the indexing system used. The score for the more prudent diets (vegetarians, semi-vegetarians and pesco-vegetarians) differed as a function of the used indexing system but they were mostly better in terms of nutrient quality than the omnivores.