Yannis Manios

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.

Television Food Advertising to Children: A Global Perspective

OBJECTIVESnWe compared television food advertising to children in several countries.nnnMETHODSnWe undertook a collaboration among 13 research groups in Australia, Asia, Western Europe, and North and South America. Each group recorded programming for 2 weekdays and 2 weekend days between 6:00 and 22:00, for the 3 channels most watched by children, between October 2007 and March 2008. We classified food advertisements as core (nutrient dense, low in energy), noncore (high in undesirable nutrients or energy, as defined by dietary standards), or miscellaneous. We also categorized thematic content (promotional characters and premiums).nnnRESULTSnFood advertisements composed 11% to 29% of advertisements. Noncore foods were featured in 53% to 87% of food advertisements, and the rate of noncore food advertising was higher during childrens peak viewing times. Most food advertisements containing persuasive marketing were for noncore products.nnnCONCLUSIONSnAcross all sampled countries, children were exposed to high volumes of television advertising for unhealthy foods, featuring child-oriented persuasive techniques. Because of the proven connections between food advertising, preferences, and consumption, our findings lend support to calls for regulation of food advertising during childrens peak viewing times.

Critical review of health effects of soyabean phyto-oestrogens in post-menopausal women

A consensus view of soyabean phyto-oestrogens in clinical interventions in post-menopausal women is presented that is based on data from the EU-funded project Phytohealth. The phyto-oestrogens, primarily genistein and daidzein, were given as soyabean-protein isolates, whole-soyabean foods or extracts, supplements or pure compounds. A comprehensive literature search was conducted with well-defined inclusion or exclusion criteria. For areas for which substantial research exists only placebo-controlled double-blind randomised controlled trials (RCT) conducted on healthy post-menopausal women were included. For emerging areas all available human studies in post-menopausal women were reviewed. In order to make cross comparisons between studies the doses of isoflavones were calculated as aglycone equivalents. There is a suggestion, but no conclusive evidence, that isoflavones from the sources studied so far have a beneficial effect on bone health. The consumption of whole-soyabean foods and soyabean-protein isolates has some beneficial effects on lipid markers of cardiovascular risk. The consumption of isolated isoflavones does not affect blood lipid levels or blood pressure, although it may improve endothelial function. For menopausal symptoms there is currently limited evidence that soyabean-protein isolates, soyabean foods or red-clover (Trifolium pratense L.) extract are effective but soyabean isoflavone extracts may be effective in reducing hot flushes. There are too few RCT studies to reach conclusions on the effects of isoflavones on breast cancer, colon cancer, diabetes or cognitive function. The health benefits of soyabean phyto-oestrogens in healthy post-menopausal women are subtle and even some well-designed studies do not show protective effects. Future studies should focus on high-risk post-menopausal women, especially in the areas of diabetes, CVD, breast cancer and bone health.

Overweight and obesity in infants and pre-school children in the European Union: a review of existing data

The objective of this study was to synthesize available information on prevalence and time trends of overweight and obesity in pre‐school children in the European Union. Retrieval and analysis or re‐analysis of existing data were carried out. Data sources include WHO databases, Medline and Google, contact with authors of published and unpublished documents. Data were analysed using the International Obesity Task Force reference and cut‐offs, and the WHO standard. Data were available from 18/27 countries. Comparisons were problematic because of different definitions and methods of data collection and analysis. The reported prevalence of overweight plus obesity at 4 years ranges from 11.8% in Romania (2004) to 32.3% in Spain (1998–2000). Countries in the Mediterranean region and the British islands report higher rates than those in middle, northern and eastern Europe. Rates are generally higher in girls than in boys. With the possible exception of England, there was no obvious trend towards increasing prevalence in the past 20–30 years in the five countries with data. The use of the WHO standard with cut‐offs at 1, 2 and 3 standard deviations yields lower rates and removes gender differences. Data on overweight and obesity in pre‐school children are scarce; their interpretation is difficult. Standard methods of surveillance, and research and policies on prevention and treatment, are urgently needed.

Physical fitness levels among European adolescents: The HELENA study

Objective To report sex- and age-specific physical fitness levels in European adolescents. Methods A sample of 3428 adolescents (1845 girls) aged 12.5–17.49 years from 10 European cities in Austria, Belgium, France, Germany, Greece (an inland city and an island city), Hungary, Italy, Spain and Sweden was assessed in the Healthy Lifestyle in Europe by Nutrition in Adolescence study between 2006 and 2008. The authors assessed muscular fitness, speed/agility, flexibility and cardiorespiratory fitness using nine different fitness tests: handgrip, bent arm hang, standing long jump, Bosco jumps (squat jump, counter movement jump and Abalakov jump), 4×10-m shuttle run, back-saver sit and reach and 20-m shuttle run tests. Results The authors derived sex- and age-specific normative values for physical fitness in the European adolescents using the LMS statistical method and expressed as tabulated percentiles from 10 to 100 and as smoothed centile curves (P5, P25, P50, P75 and P95). The figures showed greater physical fitness in the boys, except for the flexibility test, and a trend towards increased physical fitness in the boys as their age increased, whereas the fitness levels in the girls were more stable across ages. Conclusions The normative values hereby provided will enable evaluation and correct interpretation of European adolescents fitness status.

Harmonization process and reliability assessment of anthropometric measurements in a multicenter study in adolescents

Objective:To describe the standardization process and reliability of anthropometric and bioelectrical impedance analysis (BIA) measurements. We examined both intra- and interobserver errors for skinfolds, circumferences and BIA.Methods:For the intraobserver error assessment, first of all, 202 adolescents in the pilot study (110 boys, 92 girls, aged 13.64±0.78 years) were assessed. For the second intraobserver and interobserver assessments, 10 adolescents were studied (5 boys and 5 girls).Results:The pilot studys intraobserver technical errors of measurement (TEMs) were between 0.12 and 2.9u2009mm for skinfold thicknesses, and between 0.13 and 1.75u2009cm for circumferences. Intraobserver reliability for skinfold thicknesses was greater than 69.44% and beyond 78.43% for circumferences. The final workshops intraobserver TEMs for skinfold thicknesses and circumferences were smaller than 1; for BIA resistance TEMs were smaller than 0.1u2009Ω and for reactance they were smaller than 0.2u2009Ω. Intraobserver reliability values were greater than 95, 97, 99 and 97% for skinfold thicknesses, circumferences, BIA resistance and reactance, respectively. Interobserver TEMs for skinfold thicknesses and circumferences ranged from 1 to 2u2009mm; for BIA they were 1.16 and 1.26u2009Ω for resistance and reactance, respectively. Interobserver reliability for skinfold thicknesses and circumferences were greater than 90%, and for BIA resistance and reactance they were greater than 90%.Conclusions:After the results of the pilot study, it was necessary to optimize the quality of the anthropometric measurements before the final survey. Significant improvements were observed in the intraobserver reliabilities for all measurements, with interobserver reliabilities being higher than 90% for most of the measurements.The Healthy Lifestyle in Europe by Nutrition in Adolescence Study aims to describe total body fat percentage and anthropometric indices of body fat distribution in European adolescents.

Development and evaluation of a self-administered computerized 24-h dietary recall method for adolescents in Europe

Objective:To describe the development of a European computerized 24-h dietary recall method for adolescents, and to investigate the feasibility of self-administration (self report) by comparison with administration by a dietician (interview).Methods:Two hundred and thirty-six adolescents (mean age 14.6 years (s.d.=1.7)) of eight European cities completed the 24-h recall (Young Adolescents Nutrition Assessment on Computer (YANA-C)) twice (once by self-report and once by interview).Results:A small but significant underestimate in energy (61 (s.e.=31)u2009kcal) and fat (4.2 (s.e.=1.7)u2009g) intake was found in the self-reports in comparison with the interviews; no significant differences were found for the intake of carbohydrates, proteins, fibre, calcium, iron and ascorbic acid. Spearmans correlations were highly significant for all nutrients and energy ranging between 0.86 and 0.91. Agreement in categorizing the respondents as consumers and non-consumers for the 29 food groups was high (kappa statistics ⩾0.73). Percentage omissions were on average 3.7%; percentage intrusions: 2.0%. Spearmans correlations between both modes were high for all food groups, for the total sample (⩾0.76) as well as for the consumers only (⩾0.72). Analysing the consumer only, on an average 54% of the consumed amounts were exactly the same; nevertheless, only for one group ‘rice and pasta’ a significant difference in consumption was found.Conclusion:Adaptation, translation and standardization of YANA-C make it possible to assess the dietary intake of adolescents in a broad international context. In general, good agreement between the administration modes was found, the latter offering significant potential for large-scale surveys where the amount of resources to gather data is limited.

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.

Health and nutrition education in primary schools of Crete: changes in chronic disease risk factors following a 6-year intervention programme.

The effectiveness of a health and nutrition education programme, in changing certain chronic disease risk factors, was assessed after the 6 years intervention period was completed. The school-based intervention programme was applied to all children registered in the first grade (age 5.5-6.5 years) in 1992 in two counties of Crete, while the children from a third county served as a control group. In order to assess the effectiveness of the intervention, a variety of biological and behavioural parameters were measured before and following completion of the intervention in a randomly selected school-based sample of 602 intervention group (IG) and 444 control group (CG) pupils. At the end of the 6-year period, it was found that biochemical indices generally improved significantly more in the IG compared with the CG (mean change for IG v. CG was -0.27 v. -0.12 mmol/l for total cholesterol (TC); -0.07 v. +0.24 for TC:HDL and -0.13 v. +0.14 for LDL:HDL). Similarly, the changes observed in the anthropometric variables in the two groups were in favour of the IG (+3.68 v. +4.28 kg/m2 for BMI; +2.97 v. +4.47 mm for biceps skinfold). Total energy intake and consumption of total fat and saturated fat increased significantly less in the IG compared with the CG (+747.7 v. 1534.7 kJ (+178.7 v. +366.8 kcal); +5.9 v. +18.8 g and +0.8 v. +5.1 g respectively), while time devoted to leisure time physical activity and cardiovascular run test performance increased significantly more in the IG (+281 v. +174 min/week and +2.5 v. +1.2 stages respectively). The findings of the present study underline the importance of such programmes in health promotion and disease prevention. Although the long-term effects of these programmes can only be assessed by tracking this population through to adolescence and adulthood, these programmes seem to have the potential to lead to a healthier lifestyle and thus a reduction in risk factor levels.

Sedentary patterns and media availability in European adolescents: The HELENA study

OBJECTIVEnTo describe sedentary behaviors in adolescents and to examine the influence of media availability on TV viewing.nnnMETHODnThe study assessed 3278 adolescents (1537 males and 1741 females, 12.5-17.5 years) involved in the HELENA study (2007). Adolescents reported hours of TV viewing, computer games, console, internet for study and non-study reasons, and study, as well as availability of TVs, computers and consoles.nnnRESULTSnTime spent in sedentary behaviors was higher during weekends (all p<0.001). Males spent more hours on TV viewing (for > or = 15 years at weekends), playing computer games and console games while females spent more time studying and surfing for non-study reasons. During weekdays, one third of adolescents exceeded the screen time guidelines (>2h/day) based solely on TV viewing, whereas around 60% exceeded it at weekends. Having a TV or a console in the bedroom was associated with higher TV viewing (OR=2.66; 95% CI 2.23-3.18; and OR=1.92; 95% CI 1.61-2.28, respectively) whereas the presence of computer reduced it (OR=0.57; 95% CI 0.48-0.68).nnnCONCLUSIONnAdolescents living in Europe are not meeting media recommendations, especially during weekend. The absence of a TV in the adolescents bedroom might reduce TV viewing. Further studies are needed to confirm or contrast our findings.