Open Access
Mediterranean diet and cardiometabolic biomarkers in children and adolescents: a systematic review and meta-analysis
(American Medical Association, 2024-07-12) López Gil, José Francisco; García Hermoso, Antonio; Martínez González, Miguel Ángel; Rodríguez Artalejo, Fernando; Ciencias de la Salud; Osasun Zientziak
Importance: no prior systematic review and meta-analysis has specifically verified the association of Mediterranean diet (MedDiet)-based interventions with biomarkers of cardiometabolic health in children and adolescents. Objective: to review and analyze the randomized clinical trials (RCTs) that assessed the effects of MedDiet-based interventions on biomarkers of cardiometabolic health among children and adolescents. Data Sources: four electronic databases were searched (PubMed, Cochrane Library, Web of Science, and Scopus) from database inception to April 25, 2024. Study Selection: only RCTs investigating the effect of interventions promoting the MedDiet on cardiometabolic biomarkers (ie, systolic blood pressure [SBP], diastolic blood pressure [DBP], triglycerides [TGs], total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], glucose, insulin, and homeostatic model assessment for insulin resistance [HOMA-IR]) among children and adolescents (aged ≤18 years) were included. Data Extraction and Synthesis: a systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data were extracted from the studies by 2 independent reviewers. Results across studies were summarized using random-effects meta-analysis. Main Outcome and Measures: the effect size of each trial was computed by unstandardized mean differences (MDs) of changes in biomarker levels (ie, SBP, DBP, TGs, TC, HDL-C, LDL-C, glucose, insulin, HOMA-IR) between the intervention and the control groups. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Results: nine RCTs were included (mean study duration, 17 weeks; range, 8-40 weeks). These studies involved 577 participants (mean age, 11 years [range, 3-18 years]; 344 girls [59.6%]). Compared with the control group, the MedDiet-based interventions showed a significant association with reductions in SBP (mean difference, -4.75 mm Hg; 95% CI, -8.97 to -0.52 mm Hg), TGs (mean difference, -16.42 mg/dL; 95% CI, -27.57 to -5.27 mg/dL), TC (mean difference, -9.06 mg/dL; 95% CI, -15.65 to -2.48 mg/dL), and LDL-C (mean difference, -10.48 mg/dL; 95% CI, -17.77 to -3.19 mg/dL) and increases in HDL-C (mean difference, 2.24 mg/dL; 95% CI, 0.34-4.14 mg/dL). No significant associations were observed with the other biomarkers studied (ie, DBP, glucose, insulin, and HOMA-IR). Conclusions and Relevance: these findings suggest that MedDiet-based interventions may be useful tools to optimize cardiometabolic health among children and adolescents.
Open Access
Electronic device and social network use and sleep outcomes among adolescents: the EHDLA study
(BMC, 2023) Gaya, Anelise; Brum, Rodolfo; Brites, Keith; Gaya, Adroaldo; Borba Schneiders, Letícia de; Duarte Junior, Miguel Angelo; López Gil, José Francisco; Ciencias de la Salud; Osasun Zientziak; Universidad Pública de Navarra / Nafarroako Unibertsitate Publikoa
Background: Considering the evident risk in the literature between the use of screen devices and sleep, there are still few studies on the relationship between each electronic screen device, media programs and sleep duration and sleep-related problems among adolescents and which variables interfere in these relationships. Therefore, this study has the following objectives: (1) to determine which are the most common electronic display devices related to sleep time and outcomes and (2) to determine which are the most common social network applications, such as Instagram and WhatsApp, associated with sleep outcomes. Methods: This was a cross-sectional study with 1101 Spanish adolescents between 12 and 17 years old. Age, sex, sleep, psychosocial health, adherence to the Mediterranean diet (MD), sport practice, and time spent on screen devices were assessed by an ad hoc questionnaire. Linear regression analyses were applied, adjusting for several covariables. Poisson regression was applied between the sexes. A p value < 0.05 was considered statistically significant. Results: Cell phone use was more associated with sleep time (13%). In boys, time spent on cell phones (prevalence ratio [PR] = 1.09; p < 0.001) and videogames (PR = 1.08; p = 0.005) had a higher prevalence ratio. When psychosocial health was included in the models, we found the greatest association (Model 2: PR = 1.15; p = 0.007). For girls, time spent on the cell phone was significantly associated with sleep-related problems (PR = 1.12; p < 0.001), and adherence to the MD became the second most important in the model (PR = 1.35; p < 0.001), followed by psychosocial health and cell phone use (PR = 1.24; p = 0.007). Time spent on WhatsApp was associated with sleep-related problems only among girls (PR = 1.31; p = 0.001) and was the most important variable in the model along with MD (PR = 1.26; p = 0.005) and psychosocial health (PR = 1.41; p < 0.001). Conclusions: Our results suggest a relationship between cell phones, video games, and social networks with sleep-related problems and time.
Open Access
Factors associated with meeting the WHO physical activity recommendations in pregnant colombian women
(Springer Nature, 2022) López Gil, José Francisco; Izquierdo Redín, Mikel; García Hermoso, Antonio; Alonso Martínez, Alicia; Rincón Pabón, David; Morales Osorio, Marco Antonio; Ramírez Vélez, Robinson; Ciencias de la Salud; Osasun Zientziak
In the absence of medical contraindications, physical activity (PA) can offer health maternal and fetal health outcomes during pregnancy. However, most pregnant women may not consider PA to be feasible, suitable and safe. Hence, it is essential to determine the prevalence of pregnant women who meet the PA recommendations and the possible factors associated with that meeting, since it might be important from the perspective of pregnant women's health. The aim of the present study was to establish the prevalence of meeting the World Health Organization PA recommendations for Colombian pregnant women, as well as possible factors that may be associated with meeting that recommendations. A cross-sectional study including representative data from the National Nutritional Situation Survey (2015) in Colombia was performed. Data were collected in 2015–2016. From an initial sample of 1140 Colombian pregnant women, 702 participants with complete data were included in the final analysis. PA was assessed by self-reported information through the long version of the International Physical Activity Questionnaire. Several potential factors were analysed according to four levels of the socioecological model: the individual, interpersonal, organizational and community levels. The prevalence of Colombian pregnant women who met with the PA recommendations was 7.5%. Indigenous and Mestizo pregnant women showed lower probabilities of meeting the PA recommendations [Indigenous: OR 0.05, 95% CI (0.01–0.18); Mestizo: OR 0.12, 95% CI (0.06–0.22)] than Afro-Colombian participants. Additionally, participants who lived near green and safe spaces for PA were more likely to meet the PA recommendations [OR 2.30, 95% CI (1.06–4.79)] than those who did not live near green areas. In conclusion, a low percentage of Colombian pregnant women met the new PA recommendations. The associations found according to race/ethnicity and living near green and safe areas underline the presence of fundamental disparities associated with meeting PA recommendations.
Open Access
Healthy lifestyle behaviors and their association with self-regulation in Chilean children
(MDPI, 2020) López Gil, José Francisco; Oriol Granado, Xabier; Izquierdo Redín, Mikel; Ramírez Vélez, Robinson; Fernández Vergara, Omar; Ciencias de la Salud; Osasun Zientziak
Background: Self-regulation comprises a series of important competencies, such as the ability to control inner states or responses toward thoughts, attention, emotions, or even performance. The relationship between self-regulation and different healthy lifestyle behaviors among children has not been examined in depth to date. The aim of this study was to explore the association between physical activity, screen time levels, and/or Mediterranean Diet adherence and self-regulation in Chilean children. Methods: A total of 1561 children aged 8–12 years from eight public schools with low socioeconomic status were included. Physical activity, screen time, Mediterranean Diet, and self-regulation were assessed with validated questionnaires. Results: Children who were classified as active or those who reported less than 2 h per day of screen time had higher self-regulation than those who were classified as inactive or counterparts with 2 h per day or more of screen time, respectively. Using joint categories, active children both with low and high screen time showed higher self-regulation compared to inactive/high screen time peers. Additionally, active groups with adherence or non-adherence to the Mediterranean Diet had higher self-regulation compared to inactive and non-adherence peers. Conclusion: Having a greater number of healthy habits, mainly regular physical activity, was associated with higher self-regulation, which might be one potential strategy to promote child social-emotional development.
Open Access
Overall proportion of orthorexia nervosa symptoms: a systematic review and meta-analysis including 30 476 individuals from 18 countries
(International Society of Global Health, 2023) López Gil, José Francisco; Tárraga López, Pedro J.; Hershey, María Soledad; López-Bueno, Rubén; Gutiérrez Espinoza, Héctor; Soler-Marín, Antonio; Fernández-Montero, Alejandro; Victoria-Montesinos, Desirée; Ciencias de la Salud; Osasun Zientziak
Background. To date, no previous meta-analysis has determined the overall proportion of orthorexia nervosa symptoms on a global scale. The aim of the present study was 2-fold: first, to establish the overall proportion of orthorexia nervosa symptoms on a global scale, assessed with the ORTO-15 questionnaire; and second, to determine the role of sex, type of population, mean age, body mass index, and the temporal trend in relation to orthorexia nervosa symptoms. Methods. Four databases were searched (PubMed, Scopus, Web of Science, and Cochrane Database of Systematic Reviews) with date limits from January 2005 to June 2023. Studies assessing the proportion of orthorexia nervosa assessed using the ORTO-15 questionnaire with a cutoff of <35 or <40 points were included in this review. Results. The overall proportion of orthorexia nervosa symptoms (using the cutoff <35 points) was 27.5% (95% confidence interval (CI) = 23.5-31.6, I2 = 97.0%). In addition, no significant differences were observed between females (34.6%, 95% CI = 29.5-39.8, I2 = 96.1%) and males (32.1%, 95% CI = 26.5-38.1, I2 = 93.1%). According to the type of population, the highest overall proportion was found in people focused on sports performance or body composition (34.5%, 95% CI = 23.1-47.0, I2 = 98.0%). Notwithstanding, caution should be exercised in interpreting this result, as reverse causality could be a potential pitfall in this relationship. Conclusions. We found that approximately three out of 10 study participants showed orthorexia nervosa symptoms according to the ORTO-15 tool. This overall proportion was higher in those participants who were athletes or fitness practitioners. Over the years, the proportion of orthorexia nervosa symptoms seems to be increasing. These high percentages and their increase are worrisome from a public health perspective and highlight the need to develop psychometric instruments to aid in clinical diagnosis and treatment efficacy.
Open Access
Twenty-four-hour movement guidelines during middle adolescence and their association with glucose outcomes and type 2 diabetes mellitus in adulthood
(Elsevier, 2022) García Hermoso, Antonio; López Gil, José Francisco; Ezzatvar, Yasmin; Ramírez Vélez, Robinson; Izquierdo Redín, Mikel; Ciencias de la Salud; Osasun Zientziak
Background: The aim of the present study was to determine the association between adherence to the 24-h movement guidelines during middle adolescence and glucose outcomes (glycated hemoglobin and fasting glucose) and type 2 diabetes mellitus (T2DM) in adulthood, 14 and 22 years later. Methods: We analyzed data from apparently healthy adolescents aged 12-18 years who participated in Waves I and II (1994-1996, n = 14,738), Wave IV (2008-2009, n = 8913), and Wave V (2016-2018, n = 3457) of the National Longitudinal Study of Adolescent to Adult Health (Add Health) in the United States. Physical activity, screen time, and sleep duration were measured using questionnaires, and the 24-h guidelines were defined as: 5 or more times moderate-to-vigorous physical activity per week, ≤2 h per day of screen time, and sleeping 8-10 h per day and or night. Capillary and venous whole blood was collected and analyzed to determine glycated hemoglobin and fasting glucose for Waves IV and V, respectively. Results: Only 2.1% of the adolescents met all the 3 guidelines, and 37.8% met none of them. In both waves IV and V, adolescents who met physical activity and screen time guidelines had lower odds of T2DM in adulthood than those who did not meet any of these guidelines (Wave IV; prevalence ratio (PR) = 0.57, 95%CI: 0.21-0.89; Wave V: PR = 0.43, 95%CI: 0.32-0.74). Only for Wave V did adolescents who met all three guidelines have lower odds of T2DM at follow-up compared with those who did not meet any of these guidelines (PR = 0.47, 95%CI: 0.24-0.91). Also, for each increase in meeting one of the 24-h recommendations, the odds of T2DM decreased by 18% (PR = 0.82, 95%CI: 0.61-0.99) and 15% (PR = 0.85, 95%CI: 0.65-0.98) in adulthood for Waves IV and V, respectively. Conclusion: Promoting all 24-h movement guidelines in adolescence, especially physical activity and screen time, is important for lowering the potential risk of T2DM in adulthood.
Open Access
Long-term impact of adherence to muscle-strengthening guidelines on inflammation markers: a 17-year follow-up study with obesity parameters as mediators
(BMJ Publishing, 2024-12-07) García Hermoso, Antonio; Ezzatvar, Yasmin; Yáñez-Sepúlveda, Rodrigo; Olivares-Arancibia, Jorge; Páez-Herrera, Jacqueline; López Gil, José Francisco; Ciencias de la Salud; Osasun Zientziak
Objective: To evaluate the relationship between adherence to muscle-strengthening guidelines in young adulthood and inflammation markers over a 17-year follow-up period. Additionally, it aims to examine whether body mass index (BMI) and waist circumference (WC) act as mediators in this relationship. Methods: The study analysed data from young adults aged 18–26 years who participated in waves III (2001–2002), IV (2008–2009) and V (2016–2018) of the Add Health Study. Adherence to muscle-strengthening guidelines was self-reported, and participants were classified as adherent if they engaged in strength training ≥2 days per week across all waves. Venous blood samples were collected at participants’ homes to measure highsensitivity C reactive protein (hs-CRP) levels and various cytokine concentrations, including interleukin (IL)−6, IL1beta, IL-8, IL-10 and tumour necrosis factor-alpha (TNFα). A global inflammation score was also calculated using z-scores of these markers. Results: A total of 2320 individuals participated (60.8% females). Participants adhering to muscle-strengthening guidelines exhibited significant reductions in hs-CRP, IL-6 and the inflammation z-score, with mean difference (MD) of −1.556mg/L (95% CI BCa −2.312 to −0.799), −0.324 pg/mL (95% BCa CI −0.586 to −0.062), and −0.400 (95% BCa CI −0.785 to −0.035), respectively. Mediation analysis revealed that BMI and WC levels at wave V significantly mediated the relationship between strength training and inflammation z-score, with significant indirect effects of −0.142 (95% CI −0.231 to −0.055) for BMI and −0.210 (95% CI −0.308 to −0.124) for WC. Conclusion: Adherence to muscle-strengthening guidelines alone may not be sufficient to achieve a notable decrease in inflammation without concurrent reductions in these obesity parameters.
Open Access
Environmental tobacco smoke exposure and 24-h movement guidelines in Spanish young people
(AME Publishing, 2023) López Gil, José Francisco; Pozo Cruz, Jesús del; Pozo Cruz, Borja del; Tárraga López, Pedro J.; García Hermoso, Antonio; Ciencias de la Salud; Osasun Zientziak
Background: No prior research has investigated how exposure to environmental tobacco smoke is related to the combination of 24-h movement behaviors among young populations thus far. The aim of this study was to examine the associations between exposure to secondhand smoke and the 24-h movement guidelines. Methods: This is a cross-sectional study using data from the last available wave of the Spanish National Health Survey [2017], a nationally representative survey of the Spanish children and adult population. The final sample included 4,378 (49.0% girls) Spanish young people aged 2-14 years. Results: A lower likelikood of meeting screen time (ST) and all three 24-h movement guidelines were found in those exposed to environmental tobacco smoke in unadjusted models. After adjusting for several covariates, meeting screen time [odds ratio (OR) =0.76; 95% confidence interval (CI), 0.59-0.97], sleep duration (OR =0.75; 95% CI, 0.58-0.96), and all three 24-h movement guidelines (OR =0.63; 95% CI, 0.44- 0.91) reached significance after adjusting for potential confounders. Conclusions: Given the inverse associations found, environmental tobacco smoke exposure should be a relevant factor to consider when promoting 24-h behaviors in the young population. Avoiding exposure to tobacco smoke in the environment is essential, as it can potentially influence the 24-h movement behaviors of young people, and consequently, the health benefits associated with such behaviors.
Open Access
Exploring the link between home garden use and severe obesity: insights from a nationwide survey in Tuvalu
(International Society of Global Health, 2023) Lin, PoJen; Lee, Irene (Tai-Lin); Hershey, María Soledad; Shih, Wei-Chih; Tausi, Selotia; Sosene, Vine; Maani, Pauke P.; Tupulaga, Malo; Wu, Stephanie M.; López Gil, José Francisco; Lo, Yuan-Hung; Shiau, Shi-Chian; Hsu, Yu-Tien; Chang, Chia-Rui; Wei, Chihfu; Ciencias de la Salud; Osasun Zientziak; Universidad Pública de Navarra / Nafarroako Unibertsitate Publikoa, 1225/2022
Background Obesity is prevalent and increasing but understudied across Pacific Islanders. Tuvalu is a South Pacific country with a high obesity rate and faces multiple threats of food insecurity. Home garden serves as a sustainable food source and can be a possible intervention for the obesity pandemic in Tuvalu. This study investigated Tuvaluans’ home garden use and obesity, and explored factors associated with increased use of home gardens. Methods We conducted a nationwide, cross-sectional study in Tuvalu during 2022. Structured questionnaires were administered during the in-person interviews, and trained interviewers measured the height and weight of each participant. The association between home garden use, obesity and severe obesity were tested with univariate and multivariable logistic regression. We also applied overlapping weights to balance the distribution of baseline demographic factors. Results The average body mass index was 34.87 kilogrammes (kg)/square metre (m2 ) among the study population of 1024 adults (630 from Funafuti and 394 from other islands in Tuvalu). Overall, people having home gardens was associated lower odds for severe obesity compared to those without a home garden in overlap weighting models (odds ratio (OR)=0.946, 95% CI=0.897-0.997, P=0.039) and the association was stronger in Funafuti (OR=0.927, 95% CI = 0.866-0.991, P= 0.027) than in the outlying islands (OR= 0.967, 95% CI = 0.889-1.052, P = 0.435). Furthermore, increased age was positively associated with having a home garden in Funafuti, and smoking showed an inverse association. Conclusions Having a home garden is associated with lower odds of severe obesity in Tuvalu, and the association is stronger in Funafuti. Smokers are less likely to have home gardens, and increased age is positively associated with having home gardens. These findings promote more home garden utilisation and provide evidence for targeted interventions in Tuvalu.
Open Access
A cluster randomized controlled trial of the Archena Infancia Saludable project on 24-h movement behaviors and adherence to the mediterranean diet among schoolchildren: a pilot study protocol
(MDPI, 2023) López Gil, José Francisco; García Hermoso, Antonio; Smith, Lee; Gallego, Alejandra; Victoria-Montesinos, Desirée; Ezzatvar, Yasmin; Hershey, María Soledad; Gutiérrez Espinoza, Héctor; Mesas, Arthur; Jiménez-López, Estela; Sánchez-Miguel, Pedro Antonio; López-Benavente, Alba; Moreno Galarraga, Laura; Chen, Sitong; Brazo-Sayavera, Javier; Fernández-Montero, Alejandro; Alcaraz, Pedro E.; Panisello Royo, Josefa María; Tárraga López, Pedro J.; Kales, Stefanos N.; Ciencias de la Salud; Osasun Zientziak
Objective: The aim of this paper is to describe the protocol of pilot cluster randomized controlled trial (RCT) that will evaluate the effects of a lifestyle-based intervention. The Archena Infancia Saludable project will have several objectives. The primary objective of this project is to determine the 6-month effects of a lifestyle-based intervention on adherence to 24-h movement behaviors and Mediterranean diet (MedDiet) in schoolchildren. The secondary objective of this project is to test the intervention effects of this lifestyle-based intervention on a relevant set of health-related outcomes (i.e., anthropometric measurements, blood pressure, perceived physical fitness, sleep habits, and academic performance). The tertiary objective is to investigate this intervention’s “halo” effect on parents’/guardians’ 24-h movement behaviors and adherence to the MedDiet. Methods: The Archena Infancia Saludable trial will be a cluster RCT submitted to the Clinical Trials Registry. The protocol will be developed according to SPIRIT guidelines for RCTs and CONSORT statement extension for cluster RCTs. A total of 153 eligible parents/guardians with schoolchildren aged 6–13 years will be randomized into an intervention group or a control group. This project focuses on two fundamental pillars: 24-h movement behaviors and MedDiet. It will mainly focus on the relationship between parents/guardians and their children. Behavior change strategies for dietary and 24-h movement behaviors in schoolchildren will be based on healthy lifestyle education for parents/guardians through infographics, video recipes, brief video clips, and videos. Conclusions: Most of the current knowledge on 24-h movement behaviors and adherence to the MedDiet is based on cross-sectional or longitudinal cohort studies, warranting a need to design and conduct RCTs to obtain more robust evidence on the effect of a healthy lifestyle program to increase 24-h movement behaviors and to improve adherence to the MedDiet in schoolchildren.