Pedro Graça

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.

Dietary guidelines and food nutrient intakes in Portugal

The average intakes of nutrients by a group of 489 adult Portuguese (> or = 40 years) living in a metropolitan area of Northern Portugal were studied using a food frequency questionnaire, and used to compare with the most recent recommendations for the same population by the National Council of Food and Nutrition. The data suggested a relative concordance between consumption levels and nutritional goals, however we found differences between subgroups of the population. Higher intakes of total fat and saturated fat, and lower intakes of fibre/energy and carbohydrates were shared by younger people (40-55 years), and higher intakes of total fat, saturated fat, fibre/energy, protein and carbohydrates and lower intakes of alcohol by women. Nutrients have been analysed in terms of the percentage contribution to total energy intake, but as alcohol is energy dense, its consumption can decrease the proportion of the energy intake from nutrients other than alcohol, and some caution must be taken in interpreting these results.

Promoting health equity in European children: Design and methodology of the prospective EPHE (Epode for the Promotion of Health Equity) evaluation study

BackgroundReducing health inequalities is a top priority of the public health agendas in Europe. The EPHE project aims to analyse the added value of a community-based interventional programme based on EPODE methodology, adapted for the reduction of socio-economic inequalities in childhood obesity. The interventions that will be implemented by this project focus on four energy balance-related behaviours (fruit and vegetable consumption, tap water intake, physical inactivity, sleep duration) and their determinants. This article presents the design of the effect evaluation of the EPHE project.Methods/DesignThis is a prospective two-year follow-up evaluation study, which will collect data on the energy balance-related behaviours and potential environmental determinants of 6–8 year olds, depending on the socio-economic status of the parents. For this purpose a parental self-reported questionnaire is constructed. This assesses the socio-economic status of the parents (5 items) and the dietary (12 items), sedentary (2 items) and sleeping (4 items) behaviour of the child. Alongside potential family-environmental determinants are assessed. The EPHE parental questionnaire will be disseminated in schools of a selected medium-sized city in seven European countries (Belgium, Bulgaria, France, Greece, Portugal, Romania, The Netherlands).DiscussionThis study will evaluate the effects of the EPHE community-based interventional programmes. Furthermore, it will provide evidence for children’s specific energy balance-related behaviours and family environmental determinants related to socio-economic inequalities, in seven European countries.

Food Insecurity Is Associated with Low Adherence to the Mediterranean Diet and Adverse Health Conditions in Portuguese Adults

Background Food insecurity is a limited or uncertain access to the adequate food and is a significant public health problem. We aimed to assess determinants of food insecurity and the corresponding health impact in Portugal, a southern European country that faced a severe economic crisis. Methods Data were derived from the Epidemiology of Chronic Diseases Cohort Study (EpiDoC), a population-based cohort of 10,661 individuals that were representative of the Portuguese adult population and followed since 2011. A cross-sectional analysis of the third wave of evaluation (EpiDoC 3) was performed between 2015 and 2016. Food insecurity was assessed with the household food insecurity psychometric scale. Socioeconomic, demographic, lifestyle, adherence to Mediterranean diet (MD), self-reported non-communicable disease, health-related quality of life (HRQoL) (EQ-5D-3L), physical function (HAQ score), and health resource consumption information was also collected. Results The estimated proportion of food insecurity was 19.3% among a total of 5,653 participants. Food insecure households had low adherence to the MD (OR = 0.44; 95% IC 0.31–0.62). In addition, diabetes (OR = 1.69; 95% IC 1.20–2.40), rheumatic disease (OR = 1.67; 95% IC 1.07–2.60), and depression symptoms (OR = 1.50; 95% IC 1.09–2.06) were independently associated with food insecurity. On average, food insecure households had a lower HRQoL (OR = 0.18; 95% IC 0.11–0.31) and a higher disability (OR = 2.59; 95% IC 2.04–3.29). A significantly higher proportion of food insecure households reported being hospitalized (OR = 1.57; 95% IC 1.18–2.07) and had more public hospital medical appointments (OR = 1.48; 95% IC 1.12–1.94) in the previous 12 months. Conclusion We found that food insecurity is highly prevalent in Portugal. Food insecurity was associated with low adherence to the MD, non-communicable chronic diseases, lower quality of life, and higher health resource consumption. Therefore, this study provides valuable insight into the relationship between food security and the diet and health of the population during an economic crisis.

Inequities in energy-balance related behaviours and family environmental determinants in European children: baseline results of the prospective EPHE evaluation study

BackgroundTackling inequalities in overweight, obesity and related determinants has become a top priority for the European research and policy agendas. Although it has been established that such inequalities accumulate from early childhood onward, they have not been studied extensively in children. The current article discusses the results of an explorative analysis for the identification of inequalities in behaviours and their determinants between groups with high and low socio-economic status.MethodsThis study is part of the Epode for the Promotion of Health Equity (EPHE) evaluation study, the overall aim of which is to assess the impact and sustainability of EPODE methodology to diminish inequalities in childhood obesity and overweight. Seven community-based programmes from different European countries (Belgium, Bulgaria, France, Greece, Portugal, Romania, The Netherlands) participate in the EPHE study. In each of the communities, children aged 6–8 years participated, resulting in a total sample of 1266 children and their families. A parental self-administrated questionnaire was disseminated in order to assess the socio-economic status of the household, selected energy balance-related behaviours (1. fruit and vegetable consumption; 2. soft drink/ fruit juices and water consumption; 3. screen time and 4. sleep duration) of the children and associated family environmental determinants. The Mann–Whitney U test and Pearson’s chi-square test were used to test differences between the low and high education groups. The country-specific median was chosen as the cut-off point to determine the educational level, given the different average educational level in every country.ResultsChildren with mothers of relatively high educational level consumed fruits and vegetables more frequently than their peers of low socio-economic status. The latter group of children had a higher intake of fruit juices and/or soft drinks and had higher screen time. Parental rules and home availability were consistently different between the two socio-economic groups in our study in all countries. However we did not find a common pattern for all behaviours and the variability across the countries was large.ConclusionsOur findings are indicative of socio-economic inequalities in our samples, although the variability across the countries was large. The effectiveness of interventions aimed at chancing parental rules and behaviour on health inequalities should be studied.

Sodium and potassium urinary excretion and dietary intake: a cross-sectional analysis in adolescents

Background Hypertension is the leading cause for heart disease and stroke, for mortality and morbidity worldwide, and a high sodium-to-potassium intake ratio is considered a stronger risk factor for hypertension than sodium alone. Objective This study aims to evaluate sodium and potassium urinary excretion, and assess the food sources of these nutrients in a sample of Portuguese adolescents. Design A cross-sectional study with a sample of 250 Portuguese adolescents. Sodium and potassium excretion were measured by one 24-h urinary collection, and the coefficient of creatinine was used to validate completeness of urine collections. Dietary sources of sodium and potassium were assessed using a 24-h dietary recall. Results Valid urine collections were provided by 200 adolescents (118 girls) with a median age of 14.0 in both sexes (p=0.295). Regarding sodium, the mean urinary excretion was 3,725 mg/day in boys and 3,062 mg/day in girls (p<0.01), and 9.8% of boys and 22% of girls met the World Health Organization (WHO) recommendations for sodium intake. Concerning potassium, the mean urinary excretion was 2,237 mg/day in boys and 1,904 mg/day in girls (p<0.01), and 6.1% of boys and 1.7% of girls met the WHO recommendations for potassium intake. Major dietary sources for sodium intake were cereal and cereal products (41%), meat products (16%), and milk and milk products (11%); and for potassium intake, main sources were milk and milk products (21%), meat products (17%), and vegetables (15%). Conclusions Adolescents had a high-sodium and low-potassium diet, well above the WHO recommendations. Health promotion interventions are needed in order to decrease sodium and increase potassium intake.

Time and regional perspectives of food insecurity during the economic crisis in Portugal, 2011-2013

Food insecurity (FI) has received much attention in recent years, even in high-income countries, due to the increasing trend of poverty and social inequalities indicators, as a result of the global financial crisis. The establishment of a monitoring system of FI becomes a priority for food and nutrition policies. Our study aims to evaluate FI trends during the economic crisis in Portugal and to identify regional disparities throughout the country. Data derived from three surveys conducted by the Portuguese Directorate-General of Health, concerning FI of the Portuguese population, during the period that Portugal was under the International Monetary Fund financial assistance program (2011‐2013). Data were collected by face-to-face interviews and FI was evaluated using a psychometric scale. Logistic regression models were used to identify regional disparities in FI. The prevalence of FI was relatively unchanged at national and regional levels, during the analysis period. Data from 2013 indicates a high prevalence of FI (50.7%), including 33.4% for low FI, 10.1% for moderate FI and 7.2% for severe FI. Disparities according health region were also found for household FI. Algarve, Lisboa and Vale do Tejo were the two regions with the highest levels of FI, even after controlling for other socioeconomic variables. High levels of FI found in Portugal and the different regional profiles suggest the need for regional strategies, in particu

Dietary Patterns Characterized by High Meat Consumption Are Associated with Other Unhealthy Life Styles and Depression Symptoms

Objective We aimed to identify dietary patterns (DPs) of Portuguese adults, to assess their socioeconomic, demographic, lifestyle determinants, and to identify their impact on health. Design EpiDoC 2 study included 10,153 Portuguese adults from the EpiDoC Cohort, a population-based study. In this study, trained research assistants using computer-assisted telephone interview collected socioeconomic, demographic, dietary, lifestyles, and health information from March 2013 to July 2015. Cluster analysis was performed, based on questions regarding the number of meals, weekly frequency of soup consumption, vegetables, fruit, meat, fish, dairy products, and daily water intake. Factors associated with DP were identified through logistic regression models. Results Two DPs were identified: the “meat dietary pattern” and the “fruit & vegetables dietary pattern.” After multivariable adjustment, women (OR = 0.52; p < 0.001), older adults (OR = 0.97; p < 0.001), and individuals with more years of education (OR = 0.96; p = 0.025) were less likely to adopt the “meat dietary pattern,” while individuals in a situation of job insecurity/unemployment (OR = 1.49; p = 0.013), Azores island residents (OR = 1.40; p = 0.026), current smoking (OR = 1.58; p = 0.001), daily alcohol intake (OR = 1.46; p = 0.023), and physically inactive (OR = 1.86; p < 0.001) were positively and significantly associated with “meat dietary pattern.” Moreover, individuals with depression symptoms (OR = 1.50; p = 0.018) and the ones who did lower number of medical appointments in the previous year (OR = 0.98; p = 0.025) were less likely to report this DP. Conclusion Our results suggest that unhealthy DPs (meat DP) are part of a lifestyle behavior that includes physical inactivity, smoking habits, and alcohol consumption. Moreover, depression symptoms are also associated with unhealthy DPs.

Behavioural Interventions for Childhood Obesity Prevention: State of the Art in Portugal

Objetivo: A prevencao do excesso de peso e obesidade infantis em Portugal e prioritaria e tem sido alvo de varios programas de intervencao. Este estudo teve como objetivo principal desenvolver um registo nacional, caracterizando as intervencoes implementadas. Metodo: Incluiram-se programas de promocao de estilos de vida saudaveis implementados em Portugal, identificados atraves do “Google” e de websites Institucionais, que visavam contribuir direta ou indiretamente para a prevencao e controlo da obesidade infantil. A selecao foi realizada pela leitura dos titulos e informacao disponibilizada nos websites, e foram depois extraidas informacoes sobre cada projeto. Resultados: Foram incluidos na analise 29 programas de promocao de alimentacao saudavel (n = 19), atividade fisica (n = 2) ou ambos (n = 8), realizados entre 2001 e 2015. A excecao de um programa, as atividades realizadas sao descritas, mas o racional teorico e as tecnicas de mudanca comportamental utilizadas nao sao explicitadas. Apenas 16 programas foram avaliados, disponibilizando online os resultados obtidos. Conclusao: A maioria dos programas nao fornece dados relativamente a sua fundamentacao teorica e empirica, nem informacao detalhada sobre as atividades realizadas e avaliacao. Futuros programas devem fornecer maior detalhe sobre o racional teorico e as tecnicas de modificacao comportamental utilizadas, e a avaliacao da eficacia na mudanca do comportamento-alvo.

Inequalities in energy-balance related behaviours and family environmental determinants in European children: changes and sustainability within the EPHE evaluation study

BackgroundIncreasing social inequalities in health across Europe are widening the gap between low and high socio-economic groups, notably in the prevalence of obesity. Public health interventions may result in differential effects across population groups. Therefore, the EPHE (EPODE for the Promotion of Health Equity) project analysed the added value of community-based programmes, based on the EPODE (Ensemble Prévenons l’Obésité Des Enfants-Together Let’s Prevent Obesity) model, to reduce socio-economic inequalities in energy balance-related behaviours of children and their family-environmental related determinants in seven European communities. This study presents the changes between baseline and follow-up after the one-year interventions and their sustainability one year after.MethodsThis is a prospective study with a one school-year intervention, followed by one year of follow-up. In all, 1266 children (age 6-8 years) and their families from different socio-economic backgrounds were recruited at baseline. For 1062 children, information was available after one year (T1) and for 921 children after two years (T2). A self-reported questionnaire was completed by the parents to examine the children’s energy balance-related behaviours and family- environmental determinants. Socio-economic status was defined by the educational level of the mother. The Wilcoxon signed-rank test for paired data was used to test the differences between baseline and intermediate, and between intermediate and final, measurements for each of the socio-economic status groups.ResultsPost-intervention effects in energy-balance related behaviours showed the following improvements among the low socio-economic status groups: increased fruit consumption (Netherlands), decreased fruit juices amount consumed (Romania) and decreased TV time on weekdays (Belgium). Whereas in only the latter case the behavioural change was accompanied with an improvement in a family-environmental determinant (monitoring the time the child watches TV), other improvements in parental rules and practices related to soft drinks/fruit juices and TV exposure were observed. A few of those effects were sustainable, notably in the case of Belgium.ConclusionsInequalities in obesity-related behaviours could be potentially reduced when implementing community-based interventions, tailored to inequality gaps and using the EPODE methodology. Within-group changes varied widely, whereas monitoring of interventions and process evaluation are crucial to understand the observed results.