A Kafatos

Design and implementation of the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study.

Objective:To provide an overview of the Healthy Lifestyle in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) design, with particular attention to its quality control procedures. Other important methodological aspects are described in detail throughout this supplement.Design:Description of the HELENA-CSS sampling and recruitment approaches, standardization and harmonization processes, data collection and analysis strategies and quality control activities.Results:The HELENA-CSS is a multi-centre collaborative study conducted in European adolescents located in urban settings. The data management systems, quality assurance monitoring activities, standardized manuals of operating procedures and training and study management are addressed in this paper. Various quality controls to ensure collection of valid and reliable data will be discussed in this supplement, as well as quantitative estimates of measurement error.Conclusion:The great advantage of the HELENA-CSS is the strict standardization of the fieldwork and the blood analyses, which precludes to a great extent the kind of immeasurable confounding bias that often interferes when comparing results from isolated studies.

Short sleep duration is associated with increased obesity markers in European adolescents: effect of physical activity and dietary habits. The HELENA study

Background:Adequate sleep is a critical factor for adolescents health and health-related behaviors.Objective:(a) to describe sleep duration in European adolescents from nine countries, (b) to assess the association of short sleep duration with excess adiposity and (c) to elucidate if physical activity (PA), sedentary behaviors and/or inadequate food habits underlie this association.Design:A sample of 3311 adolescents (1748 girls) aged 12.5–17.49 years from 10 European cities in Austria, Belgium, France, Germany, Greece, Hungary, Italy, Spain and Sweden was assessed in the Healthy Lifestyle in Europe by Nutrition in Adolescence Study between 2006 and 2008. We measured anthropometric data, sleep duration, PA (accelerometers and questionnaire), television watching and food habits (Food Frequency Questionnaire).Results:Average duration of daily sleep was 8 h. Shorter sleepers showed higher values of BMI, body fat, waist and hip circumferences and fat mass index (P<0.05), particularly in females. Adolescents who slept <8 h per day were more sedentary, as assessed by accelerometry, and spent more time watching TV (P<0.05). The proportion of adolescents who eat adequate amounts of fruits, vegetables and fish was lower in shorter sleepers than in adolescents who slept ⩾8 h per day, and so was the probability of having adequate food habits (P<0.05). Correlation analysis indicated that short sleep is associated with higher obesity parameters.Conclusions:In European adolescents, short sleep duration is associated with higher adiposity markers, particularly in female adolescents. This association seems to be related to both sides of the energy balance equation due to a combination of increased food intake and more sedentary habits.

Quality assurance of ethical issues and regulatory aspects relating to good clinical practices in the HELENA Cross-Sectional Study

Rationale:Research involving humans is regulated by regulatory authorities through their specific requirements and controls. The Healthy Life Style in Europe by Nutrition in Adolescence Cross-Sectional Study (HELENA-CSS) is a multicenter biomedical research study of adolescents in several representative European cities, which requires satisfying medico-regulatory requirements including Independent Ethics Committee (IEC) approval and agreement by the national or local regulatory authorities. To achieve a high level of quality assurance relating to ethical issues, we followed the good clinical practices (GCP) described at the International Conference on Harmonisation (ICH), which we adapted to the national and local situations of each of the 11 participating cities in 10 European countries.Objective:The main objective of the HELENA-CSS is to evaluate reliable and comparable data of nutritional habits and lifestyle in a representative sample of European adolescents. The aim of this paper is to present the methods relating to the ethical and regulatory issues of this study and to describe the current state of the medico-regulatory requirements involved in conducting this kind of study in each country.Materials and Methods:Following the GCP–ICH guidelines, a protocol describing the HELENA-CSS was written and approved by all partners. In the pilot study, a case report form adapted to the study objectives and its manual of operation was constructed and used by all partners. All information letters to adolescents and their parents and consent forms were first written in English, then translated into the local language, and adapted to each local situation. All documents were then checked centrally for any deviation and corrected if required. An operation manual relating to ethical issues and other medico-regulatory requirements was also developed. This paper presents the current status of the medico-regulatory requirements from each HELENA-CSS participant country.Results:Before the beginning of the study, most centers had satisfied the medico-regulatory requirements of IEC approval and agreement with other national or local regulatory authorities/organizations. For a few centers, some problems were detected and corrective actions were taken to improve missing information to reach a high level of quality assurance of ethical issues.Conclusion:The GCP–ICH guidelines about nontherapeutic biomedical research are interpreted and applied differently across Europe. This study shows that high-quality nontherapeutic biomedical research can address the ethical issues included in the GCP–ICH regulations and can be harmonized among the HELENA European partners.

Variables independently associated with self-reported obesity in the European Union

OBJECTIVE The rapid increase in obesity rates over recent years suggest that cultural and societal influences are affecting the adjustment in the energy balance equation in addition to other physiopathological or genetic determinants. Therefore, a pan-EU study was carried out to explore the influence of sociodemographic factors as well as some attitudes (smoking and exercise) on the prevalence of obesity in the adult population of all 15 member states of the EU. DESIGN Overall, a sample of 15,239 individuals aged 15 years and upwards in the EU completed the questionnaire. Subject selection was quota-controlled to make the sample nationally representative following a multistage stratified cluster sampling. Self-reported height and weight were used to calculate body mass index (BMI). RESULTS From the EU average results, it can be seen that only about half of the EU population (48%) is within the normal weight range, while the obesity (BMI > or = 30 kg m(-2)) prevalence was about 10% in the EU and the overweight prevalence was 36.6% and 25.6% among men and women, respectively. UK subjects had the highest prevalence of obesity (12%), while Italians, French and Swedes had the lowest levels of obesity (about 7%). Concerning age and social class interactions, logistic regression analysis showed that high social class and younger individuals in all groups had a lower odds ratio for obesity prevalence. People with a higher level of education are less likely to be obese, while the interaction between educational levels and obesity was different for men and women. A low participation in various leisure-time physical activities, the lack of interest (precontemplation) in being involved in exercise/physical activity and the increasing number of hours sitting down at work appear to be predictors of obesity. Single individuals were less prone to become obese than couples or widowed/divorced people. Finally, smoking status was statistically linked to the prevalence of obesity, since non-smokers or ex-smokers for more than 1 year presented a higher tendency for a BMI > 30. CONCLUSIONS This survey confirms that a priority area for health intervention aimed at preventing the development of obesity should be to increase levels of physical activity, although the approach will depend on the population, especially with respect to educational and socioeconomic aspects.

The high-fat Greek diet: a recipe for all?

Objective: To examine critically the published results of dietary surveys on the fat content of the Greek diet, and to assess its evolution and its relationship to the health of the Greeks. To consider the implications of these findings for current views on the nature and health implications of the traditional Mediterranean diet and how best to define it for use in modern policy making.Design: A systematic review of the literature on food consumption in Greece.Setting: Greece.Results: The first fully published data on the fat content of the Greek diet—the Seven Countries Survey—relates only to a small number of adult males in Crete and Corfu; the legitimacy of extrapolating these results to the rest of Greece is questioned. Earlier studies and chemical validation of intakes point to a lower fat content of the traditional diet than that inferred for Crete. Nearly all later surveys relate only to urban groups in Athens (mostly case–control hospital-based samples) and a variety of non-representative Cretan groups. Only two studies are larger and more representative, but one uses FAO food balance-sheets to reflect the national diet, and the other surveyed school-age children in three out of the 52 Greek counties. Unfortunately recent dietary studies have proved unreliable, given the continuing lack of national food composition tables with survey methods which proved inaccurate for dietary fat content. A progressive upward trend in total and saturated fat intake appears to have occurred with all health indicators in relation to fat indicating remarkable increases in adult and childhood obesity with attendant progressive deterioration in cardiovascular mortality and its risk factors, ie hypertension and diabetes. These data emphasise the need to alter current nutritional advice in Greece, particularly when it focuses on the promotion of olive oil and a high-fat diet.Conclusions: The findings reaffirm low–moderate fat policies for optimum health, within which olive oil can be an important component of the diet.

Obesity indices in a cohort of primary school children in Crete: a six year prospective study.

OBJECTIVE: To report on the body mass index (BMI), waist-to-hip ratio (WHR) and sum of skinfolds in a cohort of Cretan children and identify the factors associated with these indices.DESIGN: The present study was a follow-up study. Children were measured prospectively at ages 6, 9 and 12.SUBJECTS: Pupils came from 40 schools randomly selected from the 541 primary schools in three different provinces of Crete. 1046 pupils were examined at age 6. At age 9, a representative sample from the original cohort (n=579) was randomly selected for re-evaluation. At the age of 12, a sample of 831 pupils was re-examined, following similar procedures.MEASUREMENTS: Both during baseline and each subsequent follow-up, data were obtained on pupils’ anthropometry, serum lipids, dietary intake, physical fitness and physical activity as well as their dietary and their health knowledge. Data on parents’ anthropometry, age, occupation, educational level, and issues relating to health habits, attitudes and knowledge were also collected.RESULTS: Half of the obese children at age 6 were also obese at age 12. Cretan children had higher mean BMI than similar American cohorts. Compared to their American counterparts, Cretans had higher proportions of overweight in both genders across all ages tested. The endurance run test (ERT), an index of physical fitness, was positively associated with obesity indices. Sum of skinfolds related positively to serum LDL-C. Children from urban areas had higher skinfold sums than children from rural areas. Parental health-related hedonism related positively to childrens BMI.CONCLUSION: It appears that these findings offer some support to the reported increasing prevalence of obesity among Greek children. Higher ERT, presumably reflecting higher physical activity, is associated with lower obesity. The relationship between degree of fatness and LDL-C appears to be evidenced at an early age in life. This relationship may relate to the reported VLDL and cholesteryl ester transfer protein elevations in obesity. The parental attitude of health-related hedonism appears to be linked with childrens adiposity.

Socioeconomic questionnaire and clinical assessment in the HELENA Cross-Sectional Study: methodology

Rationale:Environmental factors such as dietary habits, breastfeeding, socioeconomic conditions and educational factors are strong influences on nutritional and puberty status, physical activity, food choices and their interactions. Several diseases of adulthood seem to be linked to, or to originate from, lifestyle in childhood and adolescence.Objective:The aims of this study are to describe birth parameters and socioeconomic factors and to assess clinical status in adolescents aged 13–16 years from 10 European countries participating in the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Cross-Sectional Study (CSS).Methodology:A self-report questionnaire on the socioeconomic status, a parental questionnaire concerning neonatal period and also a case report form (CRF), in which clinical items during clinical examination (such as medical history, treatments, anthropometry, Tanner staging, blood pressure, heart rate) were assessed. To develop these documents, first a list of items was established, a search of existing documents was performed and the advice of local and international experts was taken. All documents (questionnaires and an operations manual) were discussed in plenary HELENA meetings; a final version of these documents was fixed, and the process of translation and back translation was performed.Results:The questionnaires and CRF were tested for validation in all 10 participant cities; 208 adolescents were enrolled during the pilot study. All items that caused problems or questions in one or more participating centers or were completed by < 85% of the adolescents were reviewed before the beginning of the HELENA-CSS.Conclusion:These final questionnaires and CRF will contribute to better understanding of the inequalities in nutrition, behavior and health in the European adolescent population. The experience and process should be useful for other multicenter studies.

Secular trends in cardiovascular risk factors among school-aged boys from Crete, Greece, 1982-2002

Objective: The aim of the present study was to examine secular trends in major cardiovascular disease (CVD) risk factors, that is, obesity and dyslipidaemia, among Cretan children during 1982–2002.Design: Epidemiological survey.Setting and subjects: A total of 528 boys in 1982 and 620 boys in 2002, aged 12.1±0.1 y, were randomly selected from urban and rural regions throughout the county of Iraklio, Crete, Greece. Care was taken so that all procedures in 2002 closely matched those in 1982.Results: Mean height, weight, and body mass index (BMI) were 1.1, 9.6, and 8.4% higher, respectively, in 2002 vs 1982 (P<0.001). The prevalence of overweight and obesity has risen by 63 and 202%, respectively (P<0.001). Contemporary children were found to have 3.6% higher total cholesterol (TC), 24.9% lower high-density lipoprotein-cholesterol (HDL-C), 25.3% higher low-density lipoprotein-cholesterol (LDL-C), 19.4% higher triacylglycerol, 36.6% higher TC/HDL-C ratio, and 60.3% higher LDL-C/HDL-C ratio compared with their peers in 1982 (P<0.003). These differences persisted even when adjusting for BMI (P<0.02). The proportion of children having abnormal lipid values was much greater nowadays than in the 1980s, yielding odds ratios of 1.4–8.8 (P<0.005).Conclusions: Results are indicative of a largely deteriorated CVD risk profile in Cretan children since 1982, and predict an unfavourable CVD morbidity and mortality for this population in the foreseeable future.Sponsorship: Greek Ministry of Sports and Kellogg Europe.

Depression and long chain n-3 fatty acids in adipose tissue in adults from Crete

Background:Only one study has investigated the relationship of essential fatty acids in the adipose tissue with depression in adults and suggested an inverse relationship between docosahexaenoic acid (22:6 n-3) (DHA) and depression.Objective:To examine the relation between adipose tissue polyunsaturated fatty acids especially n-3 and n-6 fatty acids, an index of long-term or habitual fatty acid intake, and depression in adults.Design:Cross-sectional study of healthy adults from the island of Crete.Setting:The Preventive Medicine and Nutrition Clinic, University of Crete, Greece.Subjects:A total of 130 healthy adults (59 males, 71 females) aged 22—58 years. The sample was a sub-sample of the Greek ApoEurope study group.Methods:Fatty acids were determined by gas chromatography in adipose tissue. Information about depression was obtained through the Zung Self-rating Depression Scale.Results:Adipose tissue DHA was inversely related with depression. Multiple linear regression analysis taking into account the possible confounding effect of age, gender, body mass index, smoking and educational level confirmed this association.Conclusions:The inverse relationship between adipose DHA and depression in adults, replicates findings of a previous study. This relationship indicates that a low long-term dietary intake of DHA is associated with an increased risk for depression in adults.Funding:The International Olive Oil Council and the DG XII of the European Union.

The role of a baseline casual blood pressure measurement and of blood pressure changes in middle age in prediction of cardiovascular and all-cause mortality occurring late in life: a cross-cultural comparison among the European cohorts of the Seven Countries Study.

Objective The first objective was to study the long-term association of a casual measurement of systolic blood pressure (SBP) with cardiovascular deaths (CVD) and all causes of death (ALL) occurring during 35 years of follow-up in different population samples of men aged 40–59 years in five European countries. The second objective was to study the predictive power of early change in SBP levels (years 0–10) in relation to late fatal events (years 10–35). Design, setting and participants A single measurement of SBP was considered in cohorts in Finland, The Netherlands, Italy, Serbia and Greece for a total of 6507 men. Three partitioned proportional hazards models were solved, one for each independent and subsequent time block of 10 years, after excluding data from the first 5 years, to predict the risk of cardiovascular disease deaths of atherosclerotic origin (CVD) and all cause mortality (ALL). Independently, the predictive power of SBP changes (Δ-SBP) occurred during the first 10 years of follow-up was explored as a possible additional risk factor in relation to CVD and ALL deaths occurring between year 10 and year 35 of follow-up. Results Partitioned hazard scores derived from the three partitioned functions were cumulated. The resulting curves showed a continuous and significant association of baseline SBP with CVD and ALL deaths during three decades, although the strength of association declined significantly from the first to the third decade. The relative risk for 20 mmHg of SBP (and its 95% confidence intervals) in predicting CVD deaths was 1.65 (1.54–1.77) for the first 10-year block; 1.33 (1.24–1.42) for the second block; and 1.22 (1.13–1.31) for the last 10-year block. The corresponding levels of ALL deaths were 1.41 (1.34–1.49), 1.26 (1.19–1.32) and 1.11 (1.05–1.17). Changes in SBP during 10 years (Δ-SBP) added predictive power to baseline measurements in a direct and significant way, with a relative risk for a change of 10 mmHg of 1.14 (1.10–1.17) for CVD deaths and 1.11 (1.09–1.13) for ALL deaths. Conclusion A single measurement of systolic blood pressure in middle-aged men maintains a strong relationship with fatal CVD and ALL deaths during the next 35 years, although for late events the strength of the association definitely declines. Changes in systolic blood pressure levels during the first 10 years of follow-up add predictive power, while baseline measurements retain their predictive power.