Maria Daniel Vaz de Almeida

Promoting Fruit and Vegetable Consumption among European Schoolchildren: Rationale, Conceptualization and Design of the Pro Children Project

Background/Aims: The Pro Children Project was designed to assess fruit and vegetable consumption in European schoolchildren and their parents, as well as determinants of the children’s consumption patterns. A second objective was to develop and test strategies, applicable across Europe, for promoting consumption of fruits and vegetables among schoolchildren and their parents. In this paper, the rationale, theoretical background, overall design and implementation of the project is presented. Methods: Surveys of national, representative samples of 11-year-old schoolchildren and their parents were conducted in 9 countries, i.e. in Austria, Belgium, Denmark, Iceland, the Netherlands, Norway, Portugal, Spain and Sweden. Comprehensive school-based educational programmes have been developed and tested in three settings, i.e. in Spain, the Netherlands and in Norway. A precoded 24-hour recall form combined with a set of food frequency questions assessing regular intake were used to assess fruit and vegetable consumption. Determinants were assessed employing a comprehensive theoretical framework including personal, social and environmental factors related to fruit and vegetable consumption. The intervention programmes have been tested employing a group-randomized trial design where schools have been randomly allocated to an intervention arm and a delayed intervention arm. Surveys among all participating children and their parents were conducted prior to the initiation of the intervention, immediately after the end of the intervention and at the end of the subsequent school year. Conclusion: The project is expected to provide new information of great importance for improving our understanding of consumption patterns of fruits and vegetables and for guiding future efforts to promote increased consumption patterns across Europe.

Physical activity levels and body weight in a nationally representative sample in the European Union

OBJECTIVES The main objectives of this pan-European study were: (1) to identify different types of physical activity and the time devoted to them, (2) to assess physical activity/inactivity at work and in leisure time, and (3) to determine self-reported body weight and height. DESIGN AND SUBJECTS In each member state of the EU, approximately 1000 adults, aged 15 years or more, were selected to participate in an interview-assisted face-to-face questionnaire on physical activity and body weight. In each country, sample selection was quota-controlled to ensure national representativeness. Overall, 15,239 subjects in the EU completed the study. RESULTS On average in the EU, nearly three-quarters of the population participate in some kind of activity. In general, the highest proportions of participants were found in the Nordic countries and the lowest in the southern ones. At the European level, the five most common activities include walking, gardening, cycling, keep fit and swimming. Higher participation rates were found among men, younger subjects and those with a higher level of education. The majority of Europeans fall within the normal body mass index (BMI) range but more than one-third are overweight (31%) or obese (10%) and 11% have a BMI below 20. CONCLUSIONS Several risk groups related to physical activity emerge from this survey: women, those with a lower level of education, older subjects, the overweight/obese and the underweight. Programmes to promote physical activity need to be tailored to the different groups identified in each country/region in order to increase adherence of non-participants and for the maintenance of those already engaged in activities.

Worldwide variation of adherence to the Mediterranean diet, in 1961–1965 and 2000–2003

OBJECTIVE The present study aimed to analyse the worldwide trends of adherence to the Mediterranean diet (MD), in 1961-1965 and 2000-2003. DESIGN Data were obtained from the FAO food balance sheets in two periods: 1961-1965 and 2000-2003. In order to have a sample from across the world, forty-one countries were selected. The average of available energy for different food groups was calculated for all selected countries. These values were used to evaluate the adherence to the MD through a variation of Mediterranean Adequacy Index (MAI). RESULTS The majority of the forty-one countries in this study have tended to drift away from a Mediterranean-like dietary pattern. Mediterranean Europe and the Other Mediterranean country groups suffered a significant decrease in their MAI values. The Mediterranean European group, especially Greece, experienced the greatest decrease in MAI value. In both periods, the Other Mediterranean countries showed the highest MAI values. In an analysis by countries, Iran had the highest increase in MAI across the time periods, and Egypt occupied the first place in the ranking in 2000-2003. The Northern European group was the only one that registered an increase in MAI, although this was not statistically significant. CONCLUSIONS Many countries in the Mediterranean basin are drifting away from the Mediterranean dietary pattern (MDP). However, countries in Northern Europe and some other countries around the world are taking on a Mediterranean-like dietary pattern. The Other Mediterranean countries have the closest adherence to the MDP, currently and in the 1960s. Nutrition policy actions to tackle dietary westernisation and preserve the healthy prudent MDP are required.

Validity and Reproducibility of a Precoded Questionnaire to Assess Fruit and Vegetable Intake in European 11- to 12-Year-Old Schoolchildren

Background/Aims: Validity and reproducibility were evaluated of a new questionnaire to assess fruit and vegetable intakes in 11- to 12-year-old children. Methods: The precoded teacher-assisted self-administered questionnaire included two sections: a 24-hour recall part and a food frequency part. Validity was tested in 4 countries (Denmark, Iceland, Norway, Portugal; n = 43–60 per country) using a 1-day weighed food record and 7-day food records as reference methods. Test-retest (7–12 days apart) reproducibility was assessed in 6 countries (Belgium, Denmark, Iceland, Norway, Portugal, Spain; n = 60–74 per country). Results: Spearman rank correlations for fruit and vegetable intake according to the frequency part and the 7-day food record ranged between r = 0.40–0.53. Between 25–50% were classified into the same quartile and 70–88% into the same or adjacent quartile. Test-retest Spearman rank correlations for the food frequency part were r = 0.47–0.84. Three countries showed no significant difference between fruit intake as assessed with the 24-hour recall part and the 1-day weighed food record, and 2 countries showed no significant difference for vegetables. In the other countries, the 24-hour recall part resulted in substantially higher mean intake levels. Conclusion: Validity and reproducibility as to ranking of subjects were regarded to be satisfactory in all countries. Group mean intake, based on the original 24-hour part, was valid for fruit in 3 countries and for vegetables in 2 countries, and this part was subsequently adjusted to avoid overestimation, before the questionnaire was used in the Pro Children study.

Attitudes toward genetic testing and personalised nutrition in a representative sample of European consumers

Negative consumer opinion poses a potential barrier to the application of nutrigenomic intervention. The present study has aimed to determine attitudes toward genetic testing and personalised nutrition among the European public. An omnibus opinion survey of a representative sample aged 14-55+ years (n 5967) took place in France, Italy, Great Britain, Portugal, Poland and Germany during June 2005 as part of the Lipgene project. A majority of respondents (66 %) reported that they would be willing to undergo genetic testing and 27 % to follow a personalised diet. Individuals who indicated a willingness to have a genetic test for the personalising of their diets were more likely to report a history of high blood cholesterol levels, central obesity and/or high levels of stress than those who would have a test only for general interest. Those who indicated that they would not have a genetic test were more likely to be male and less likely to report having central obesity. Individuals with a history of high blood cholesterol were less likely than those who did not to worry if intervention foods contained GM ingredients. Individuals who were aware that they had health problems associated with the metabolic syndrome appeared particularly favourable toward nutrigenomic intervention. These findings are encouraging for the future application of personalised nutrition provided that policies are put in place to address public concern about how genetic information is used and held.

Personal, social and environmental factors regarding fruit and vegetable intake among schoolchildren in nine European countries.

Background/Aims: Children in Europe are consuming less fruit and vegetables than recommended. Knowledge about the potential determinants of fruit and vegetable intake is vital to understand discrepancies in intake and to guide interventions. The aim of the present study was to assess personal, social and environmental factors regarding fruit and vegetable intake among 11- to 12-year-old children in Europe. Methods: A cross-sectional survey was undertaken, with nationally or regionally representative samples of in total 13,305 children (mean age 11.4 years) from nine European countries. Pupils in the classroom completed a self-administered questionnaire measuring fruit and vegetable intake and personal, social and environmental factors during one school lesson. Age-adjusted covariance analyses were carried out by gender, for the full sample and for each country separately. Proportions responding positively to the constructs are presented. Results: Overall, European children held a positive attitude towards fruit and vegetable intake. For some constructs, large between-country differences were found. Children had a more positive attitude towards fruit than towards vegetables, and girls were on average more positive than boys. The children perceived their social environment as supportive towards fruit and vegetable intake. They reported good to very good availability of fruit and vegetables at home. However, availability at school and during leisure time activities seemed to be low, both for fruit and for vegetables. Conclusion: A large majority of the children reported positively to the personal and social factors regarding fruit and vegetable intake. As regards availability of fruit and vegetables at school and leisure time, and accessibility of fruit and vegetables at home, there is room for improvement.

Regional, demographic and national influences on attitudes and beliefs with regard to physical activity, body weight and health in a nationally representative sample in the European Union

INTRODUCTION Although the benefits of physical activity regarding body-weight gain and health in general are now widely accepted, physical activity levels remain low among citizens in the western world. This could be attributed to certain attitudes and beliefs about physical activity. Identifying and understanding these parameters would be the first step in an attempt to increase the levels of physical activity in populations generally characterized as having a sedentary lifestyle. OBJECTIVE The aim of the present study was to identify the attitudes and beliefs regarding physical activity, body weight and health in a nationally representative sample in the EU and in particular to explore the demographic and national (cultural) influences on attitudes towards physical activity. DESIGN In each member state of the EU, approximately 1000 adults aged 15 years and over, were selected to complete an interviewer-assisted face-to-face questionnaire. Overall, a sample of 15,239 individuals in the EU participated in the study. Subject selection was quota-controlled to ensure samples in each country were nationally representative. RESULTS On a European level wide variations were observed regarding the levels, beliefs and attitudes towards physical activity. More positive beliefs were observed among Finns, while less positive beliefs were observed among southern Europeans. A similar pattern was observed for attitudes, with the Portuguese having the highest percentage feeling that they do not need to be more physically active than they already are. However, most southern Europeans felt that a campaign would encourage them to become more active than they already are. On a demographic level, the youngest, more educated and most physically active subjects had more positive attitudes and beliefs towards physical activity and the health benefits derived from it; while for the overweight, beliefs and attitudes toward physical activity were related primarily to the benefits related to weight control. CONCLUSIONS Lower levels of physical activity, an unwillingness to become active among non-participants and confusion regarding the weight gain benefits and general health benefits of exercise were reported more frequently among southern Europeans and older and less educated subjects. The Finns scored highest in all these parameters, possibly due to the programmes implemented and the beliefs and behaviour changes observed in this country during the last few years. The actions taken in Finland and their benefits could be employed appropriately in the other European states.

Erythrocyte damage and leukocyte activation in ischemic stroke

BACKGROUND The traditional lipid risk factors can only predict some of the cardiovascular events. Our work has focused on new potential biological markers of risk, namely leukocyte activation and erythrocyte membrane damage, in ischemic stroke cases. METHODS Besides the traditional lipid profile, we evaluated the plasma levels of elastase and lactoferrin as markers of leukocyte activation, and membrane band 3 protein profile and membrane bound hemoglobin as markers of erythrocyte damage. Total and differential leukocyte counts and erythrocyte counts, hematocrit and hemoglobin concentrations were also evaluated. The lipid study included the evaluation of triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDLc), low-density lipoprotein cholesterol (LDLc), apolipoprotein AI (Apo AI) and B (Apo B), and lipoprotein (a) (Lp(a)). The work was performed in a control group (n=29) with no history of cardiovascular events, presenting normal hematological and lipid values, and in a pathologic group (n=21) of ischemic stroke cases diagnosed by computed tomographic imaging. RESULTS We found that ischemic stroke was associated with significantly higher values of leukocytes, which seem to be activated, as shown by significant higher levels of elastase and lactoferrin. This activation seems to impose erythrocyte damage, as suggested by a significant increase in membrane bound hemoglobin and by a different band 3 profile. CONCLUSIONS Our data suggest that plasma levels of elastase and lactoferrin, together with levels of erythrocyte membrane bound hemoglobin and band 3 profile, could be used as powerful new markers of risk for cardiovascular events.

Fruit and Vegetable Intake of Mothers of 11-Year-Old Children in Nine European Countries: The Pro Children Cross-Sectional Survey

Objective: To describe and compare fruit and vegetable intakes of mothers of 11-year-old children across Europe. Methods: Cross-sectional surveys were carried out in 9 European countries in October/November 2003. Self-administered questionnaires assessing fruit and vegetable consumption were used for data collection. The current paper presents dietary intake data obtained by a precoded 24-hour recall and a food frequency questionnaire. Results: The consumption levels of fruit and vegetables (without fruit juice) were in line with World Health Organization recommendations of ≧400 g/day for only 27% of all participating mothers. Based on both instruments, the Pro Children results showed comparatively high average fruit intake levels in Portugal, Denmark and Sweden (211, 203 and 194 g/day) and the lowest intake in Iceland (97 g/day). High vegetable intake levels were found in Portugal and Belgium (169 and 150 g/day), the lowest in Spain (88 g/day). A south-north gradient could not be observed in the Pro Children study. Conclusion: Fruit and vegetable intakes are low in mothers of 11-year-olds across Europe. Especially vegetable consumption can be regarded as marginal in most of the studied European countries. A high percentage of mothers indicated to eat fruit and vegetables less than once a day. The results have shown that national and international interventions are necessary to promote fruit and especially vegetable consumption in the European population of mothers.

Fruit and vegetable consumption in a sample of 11-year-old children in ten European countries : the PRO GREENS cross-sectional survey

OBJECTIVE To describe fruit and vegetable intake of 11-year-old children in ten European countries and compare it with current dietary guidelines. DESIGN Cross-sectional survey. Intake was assessed using a previously validated questionnaire containing a pre-coded 24 h recall and an FFQ which were completed in the classroom. Portion sizes were calculated using a standardized protocol. SETTING Surveys were performed in schools regionally selected in eight countries and nationally representative in two countries. SUBJECTS A total of 8158 children from 236 schools across Europe participating in the PRO GREENS project. RESULTS The total mean consumption of fruit and vegetables was between 220 and 345 g/d in the ten participating countries. Mean intakes did not reach the WHO population goal of ≥400 g/d in any of the participating countries. Girls had a significantly higher intake of total fruit and vegetables than boys in five of the countries (Sweden, Finland, Iceland, Bulgaria and Slovenia). Mean total fruit intake ranged between 114 and 240 g/d and vegetable intake between 73 and 141 g/d. When using the level ≥400 g/d as a cut-off, only 23·5 % (13·8-37·0 %) of the studied children, depending on country and gender, met the WHO recommendation (fruit juice excluded). CONCLUSIONS Fruit and vegetable consumption was below recommended levels among the schoolchildren in all countries and vegetable intake was lower than fruit intake. The survey shows that there is a need for promotional activities to improve fruit and vegetable consumption in this age group.