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Objective: To systematically review and meta-analyze randomized controlled trials on the effects of technology-based interventions for maintenance of lost weight., Methods: A systematic literature search was performed to identify randomized controlled trials with at least one intervention arm delivered through the internet or mobile application, published in English until September 2021. Weight change at the end of the weight loss maintenance phase was considered the primary outcome., Results: Twelve manuscripts with 2941 adults were included in the review; 10 studies were meta-analyzed. Included interventions had a duration of 3-30 months and were tested compared with minimum interventions (no contact with the study staff or intervention with only a limited number of features) or in-person groups. Technology-based interventions resulted in similar weight regain when compared with minimum interventions (ES = -0.07 kg; 95% CI = [-0.57, 0.42]; p = 0.770). However, when compared with in-person interventions, technology-based interventions were found to lead in significantly higher weight regain (ES = 1.36 kg; 95% CI = [0.29, 2.43]; p = 0.010)., Conclusion: Web- and app-based interventions for weight loss maintenance produced similar results with minimum interventions and resulted in greater weight regain compared with in-person interventions. Appropriate interventions for weight loss maintenance provide benefits against weight regain, only when provided in-person., (© 2022 World Obesity Federation.)

Background/objectives: We evaluated the role of the presence of non-alcoholic fatty liver disease (NAFLD) at baseline in the transition from metabolically healthy to metabolically unhealthy obesity (MHO to MUO) ten years later., Methods: A prospective cohort study (ATTICA study, Greece) was performed between 2002 and 2012 studying a sample from the greater metropolitan Athens area. In total, 1514 (49·8%) men and 1528 (50.2%) women (aged >18 years old) free-of-CVD were included. Healthy metabolic status was defined as absence of all NCEP ATP III (2005) metabolic syndrome components. NAFLD was defined according to validated liver steatosis indices. Follow-up CVD assessment (2011-2012) was achieved in n = 2020 participants (n = 317 cases)., Results: NAFLD prevalence among MHO participants ranged from 29% to 39% according to the specific NAFLD score used. MHO participants who developed metabolically unhealthy status had about two times higher odds to have NAFLD at baseline compared with their metabolically healthy normal weight counterparts whereas stable MHO was not associated significantly with NAFLD. Moreover, MHO status accompanied by NAFLD was associated with increased CVD risk (Hazard Ratio = 2.90 95% Confidence Interval (1.35, 5.40)) in comparison to their non-NAFLD MHO counterparts. Further analysis revealed that in the obese, NAFLD indices and not simply visceral adiposity increased significantly the ability of metabolic status (using standard definition) to predict long-term CVD incidence., Conclusions: Considering NAFLD, even when assessed using validated indices only, in the clinical assessment of apparently healthy obese individuals predicts who is to develop MUO and contributes independently and more accurately to defining future cardiometabolic risk., Competing Interests: Declaration of competing interest CSM has been a shareholder of and reports grants through his institution and personal consulting fees from Coherus Inc. and AltrixBio, he reports grants through his institution and personal consulting fees from Novo Nordisk, reports personal consulting fees and support with research reagents from Ansh Inc., reports personal consulting fees from Genfit, Lumos, Corcept, Intercept, Astra Zeneca, Aegerion and Regeneron, reports support (educational activity meals at and through his institution) from Amarin, Jansen, Boehringer Ingelheim and travel support and fees from TMIOA, Elsevier, the California Walnut Commission, College Internationale Researche Servier and the Cardio Metabolic Health Conference. None ir related to the work presented herein., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To assess whether Health Literacy (HL) acts as a determinant of obesity in adults and children by synthesizing the results of recent scientific evidence., Content: This is a systematic qualitative review following the MOOSE guidelines. A systematic, computer-assisted literature search via PubMed scientific database, between January 1st, 2000, and September 30th 2020, was conducted. Only cross-sectional epidemiologic research studies that were published in the English language, investigating HL's possible role as a determinant of childhood and adult obesity, were included., Summary: After screening 725 citations from the PubMed database, 39 (n=39) studies in total were included in this literature review; Four (n=4) studies were conducted in the children population, seven (n=7) studies were performed in children-parent/caregiver dyads, and 28 studies (n=28) enrolled adults. There is significant evidence that HL knowledge and skills determine the consequent management of obesity and BMI rates in children and adult populations., Outlook: Despite policies and action plans put in place by countries globally, overweight and obesity continue to be a pressing public health issue and one of the critical drivers of non-communicable diseases, constituting a health, social and economic burden worldwide. Health Literacy as an essential health policy and promotion agenda item and a critical empowerment strategy could increase children's and adults' control over their overall health and awareness to overcome obesity issues. Initiatives to improve HL levels could be useful tools in managing the obesity epidemic, starting from integrating HL in the school curriculum and further in family and community action plans., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Weight loss maintenance is crucial for obesity management, yet optimal dietary patterns for this period are not established. We aimed to explore the relationship between adherence to the Mediterranean diet and weight loss maintenance. Sample includes 565 adults (62 % women) of the MedWeight study. Eligible volunteers were those reporting intentional weight loss of ≥10 %, starting from a BMI ≥ 25 kg/m2, over 12 months prior to enrolment. Based on current weight, participants were characterised as maintainers (≤90 % maximum weight) or regainers (>95 % maximum weight). Socio-demographics and weight history were recorded. Dietary intake was assessed by two non-consecutive 24-h recalls within 10 d and analysed in energy, macronutrient and food group intakes. Adherence to the Mediterranean diet was assessed with the Mediterranean Diet Score (MedDietScore) (range 0-55, greater scores showing higher adherence). Protein intake was higher in maintainers than in regainers (P < 0·001). When MedDietScore quartiles were considered, a linear trend for weight loss maintenance was revealed (P < 0·05). After adjustment for basic demographic characteristics, being in the third or fourth quartile of the MedDietScore (v. first) was associated with 2·30 (95 % CI 1·29, 4·09) and 1·88 (95 % CI 1·10, 3·22) increased odds of maintenance. Regarding individual MedDietScore components, only fruit intake is associated with increased odds for maintenance (1·03 (95 % CI 1·01, 1·06)). The leave-one-out approach revealed that at least six MedDietScore components were essential for the observed relationship. Higher adherence to the Mediterranean diet was associated with 2-fold increased likelihood of weight loss maintenance. Future studies should replicate these findings in non-Mediterranean populations as well.

Background and Aims: Predictive and prognostic ability of muscle mass in CVD settings is increasingly discussed. The gender-specific effect of skeletal muscle mass index (SMI) on 10-year recurrent fatal/non fatal cardiovascular disease (CVD) event of acute coronary syndrome (ACS) patients was evaluated., Methods and Results: In 2006-2009, n = 1000 consecutive patients (n = 222 women), hospitalized at the First Cardiology Clinic of Athens with ACS diagnosis and with symptoms and left ventricular function indicative of heart failure were selected. SMI was created to reflect skeletal muscle mass through appendicular skeletal muscle mass (indirectly calculated through population formulas) divided by body mass index (BMI). In the 10-year follow-up (2016), 55% of ACS patients experienced recurrent fatal/non fatal CVD events (53% in women vs.62% in men, p = 0.04). Patients in the 2nd SMI tertile (mostly overweight) had 10% lower risk for CVD recurrence (women:men rate ratio = 0.87) over their counterparts in the 1st (mostly normalweight) and 3rd tertile (mostly obese). Multivariate analysis revealed that ACS patients in the 2nd SMI tertile presented 46% and 85% lower CVD event risk over their counterparts in the 1st tertile (Hazard Ratio (HR) = 0.54, 95% Confidence Interval (95% CI) 0.30, 0.96, p = 0.002) and 3rd tertile (HR = 1.85, 95%CI 1.05, 2.94, p = 0.03). Gender-based analysis revealed that this trend remained significant only in women. Inflammatory markers had strong confounding effect., Conclusion: A U-shape association between SMI and 10-year CVD event especially in women was highlighted. This work reveals gender-specific remarks for "obesity-lean paradox" in secondary prevention, implying that high muscle mass accompanied by obesity and excess adiposity may not guarantee better prognosis., (Copyright © 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Individual socioeconomic status is linked to obesity risk, though, less is known about the influence of an area's socio-environmental conditions on obesity/overweight prevalence. This association was investigated using obesity/overweight data collected from 2445 individuals in Athens greater area, who were randomly enrolled in ATTICA study, during 2001 to 2002, and factors related to educational and economic level, population density, immigrants and green urban areas. Thematic mapping illustrated the socio-environmental status and highlighted the obesity/overweight prevalence across the municipalities of Athens. Global statistical models revealed that high socio-environmental status, educational and economic level were inversely associated with obesity/overweight (p < 0.001). Furthermore, local Geographically Weighted Regression revealed spatial non-stationarity in the relationship between green urban areas and obesity/overweight. The findings of the study lead to the better understanding of the factors affecting obesity/overweight and may support the development of policies that target to well-being, decrease of obesity/overweight prevalence and improvement of public health., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: To examine the concomitant associations between physical activities (PA) and lifestyle factors in a representative sample of children and adolescents., Study Design: Cross-sectional, observational study., Methods: Population data were derived from a school-based health survey carried out in 2015 on 177,091 (51% boys) Greek children aged 8 to 17 yr old. PA, sedentary activities and sleeping habits were assessed through self-completed questionnaires. Dietary habits were evaluated using the Mediterranean Diet Quality Index for children and adolescents. Anthropometric and physical fitness measurements were obtained by trained investigators. Logistic regression models were estimated and adjusted for relevant covariates., Results: More boys as compared to girls (65.1% vs. 50.7%, P<0.001) and children than adolescents (59.8% vs. 52.8%, P<0.001) met the recommendations for PA. Frequent fast food consumption and skipping breakfast were associated with inadequate PA levels. In the whole population, sufficient dietary habits, sufficient (&gt;8-9 h/d) sleeping and accepted screen time increased the participant's odds of adequate PA levels by 38% (95% CI: 1.32, 1.44), 5% (95% CI: 1.01, 1.09) and 21% (95% CI: 1.16, 1.26), respectively, while, overweight/obese and central obesity decreased the odds of adequate PA levels by 7% and 5%, respectively, after adjusting for several covariates. Participants with combination of healthy aerobic fitness/dietary habits/screen time had 60% increased odds for adequate PA levels than those with unhealthy choices., Conclusion: Healthy aerobic fitness, dietary habits and screen time were strongly associated with PA status among children. The results support the development of interventions to help children adopt a healthy lifestyle.

Background and Aims: The lipid accumulation product (LAP) is an index describing lipid over-accumulation based on waist circumference (WC) and fasting triglycerides, and can outperform the body mass index (BMI) in recognizing cardiovascular disease (CVD) risk. We aimed to explore the association of LAP with long-term CVD risk and compare its CVD-predictive value against common anthropometric indices/ratios of obesity., Methods: ATTICA is a prospective, population-based cohort that recruited 3042 adults without pre-existing CVD from the Greek general population (age 18-89 years; 1514 men). The 10-year study follow-up (2011-2012) captured the fatal/non-fatal CVD incidence in 2020 participants (50% men). Baseline LAP (cm·mmol/L) was calculated and analyzed in relation to the 10-year CVD incidence., Results: In total, 317 CVD cases (15.7%) were documented during the follow-up. Baseline LAP showed a significant positive association with the 10-year CVD incidence, even after adjusting for hypertension, diabetes, hypercholesterolemia, smoking, physical activity, Mediterranean diet adherence, and key pro-inflammatory biomarkers (Hazard Ratios per 10 cm·mmol/L of LAP ranging from 1.1 to 1.21, p = 0.04). Moreover, LAP predicted the 10-year CVD study incidence better than common obesity indices (BMI, WC, waist-to-hip, waist-to-height ratio)., Conclusions: These findings support a positive association between LAP and long-term CVD incidence in CVD-free Caucasian adults from the general population., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: There is recent evidence that poor health literacy (HL) could be implicated in the aetiology of obesity and could be an important reason behind obese people's inability to encounter difficulties in overcoming obesity issues. The current study reviews the recent scientific evidence investigating the possible link between poor HL levels and excess body weight in adults and children., Methods: The authors performed a thorough systematic computer-assisted literature search from 1 January 2005 up to 31 May 2017. Only English original studies in healthy people, investigating the relationship between HL and excess body weight, were included., Results: Twenty-two studies in total were included in this literature review, 17 studies were conducted in adults and 5 in children. In 17 out of 22 studies reviewed, low HL was significantly associated with increased body mass index, overweight and obesity. In case of children and adolescents, the above association seems to be more consistent compared to adults., Conclusion: There is good evidence that low levels of HL are associated with excess body weight, particularly in children. Initiatives to improve health literacy levels could be a useful tool in the management of the obesity epidemic.

Aim: To describe the study protocol of the MEDiterranean ISlands-Australia (MEDIS-Australia) Study modelled on the MEDIS Study conducted in Greece. The present study aims to explore adherence to the traditional Mediterranean diet pattern, determine enablers and barriers to adherence, explore the definition of Greek cuisine, and associations between adherence to the diet pattern and risk factors for cardiovascular disease (CVD) and metabolic syndrome in older Greek Australians originally from Greek islands and Cyprus. Now long-term immigrants, with at least 50 years in Australia, characteristics and risk factor profiles of older Greek islander-born Australians will be compared and contrasted to their counterparts living on Greek islands to evaluate the influence of migration on adherence., Methods: The present study is an observational study of cross-sectional design using a modified lifestyle and semi-quantitative food frequency questionnaire to capture sociodemographic, health, psychosocial and dietary characteristics, including cuisine, of 150 older Greek islander-born Australians. Anthropometric measures and medical history will be collected. Participants will be aged over 65 years, live independently, are originally from a Greek island and are free from CVD., Results: Data collection is underway., Conclusions: Characteristics and behaviours associated with adherence, if identified, could be evaluated in future studies. For example, exploration of enablers or barriers to adherence to a Mediterranean dietary pattern in an Australian population., (© 2017 Dietitians Association of Australia.)

Background: The role of inflammation in diabetes development is not fully elucidated. The aim of this work was to investigate the independent effect of individual inflammatory markers and combinations of them on diabetes incidence and the potential mediating role of obesity., Methods: In 2001 to 2002, a random sample of 1514 men (18-87 years old) and 1528 women (18-89 years old) was selected to participate in the ATTICA study, where Athens is a major metropolis. Interleukin-6 (IL-6), C-reactive protein (CRP), tumour necrosis factor-alpha, serum amyloid alpha, fibrinogen, and homocysteine were measured. Covariates included various clinical, demographic, and lifestyle characteristics, assessed with standard procedures. In 2012, the 10 year follow-up was performed. Diabetes diagnosis was defined according to American Diabetes Association criteria among n = 1485 participants., Results: One hundred ninety-one incident cases of diabetes were documented, yielding an incidence of 12.9% (13.4% in men and 12.4% in women). After adjustments, only elevated IL-6 increased by 2.2 times the 10 year diabetes risk (third vs first tertile, 95% CI: 1.13, 4.28). After investigating combinations of inflammatory markers, combined elevated levels of CRP and IL-6 or CRP and fibrinogen (both markers ≥75th percentile vs <75th percentile) increased the risk by 1.93 times (95% CI: 1.20, 3.08) and 2.37 times (95% CI: 1.37, 4.16), respectively. Body mass index was found to significantly mediate the aggravating effect of inflammation., Conclusions: The reported results underline the significant role of individual IL-6 or combinations of CRP-IL-6 and CRP-fibrinogen in diabetes prediction. Adiposity seems to be primarily responsible for an increase in inflammatory markers, leading through this mechanism to insulin resistance and increasing diabetes risk., (Copyright © 2017 John Wiley & Sons, Ltd.)

Background: The present study aimed to investigate the association between gestational weight gain (GWG) and birth weight, as well as the body mass index (BMI) status, of children at the ages of 2 and 8 years., Methods: Population-based data were obtained from a database of all 7-9-year-old Greek children who attended primary school during 1997-2007. The study sample consisted of 5125 children matched with their mothers, randomly selected according to region and place of residence, and equally distributed (approximately 500 per year) throughout the study period (1997-2007). A standardised questionnaire was applied; telephone interviews were carried out to collect maternal age, BMI status at the beginning and the end of pregnancy and GWG, birth weight of offspring and BMI status at the ages of 2 and 8 years, as well as several other pregnancy characteristics (e.g. pregnancy duration, gestational medical problems, maternal smoking and alcohol consumption habits, and lactation of offspring after pregnancy)., Results: Gestational weight gain was positively associated with the weight status of offspring at all three life stages studied: newborn (birth weight), infant (BMI) and child (BMI) [b = 0.008 (0.001), b = 0.053 (0.009) and b = 0.034 (0.007), respectively, all P < 0.001], after adjusting for maternal age at pregnancy (significant inverse predictor only at age 2 years). The same applied to excessive GWG, as defined by the Institute of Medicine guidelines., Conclusions: Excessive GWG was associated with a higher risk of greater infant size at birth and a higher BMI status at the ages of 2 and 8 years. Healthcare providers should encourage women to limit their GWG to the range indicated by the current guidelines., Competing Interests: The authors report no conflict of interest in the reporting of the data., (© 2016 The British Dietetic Association Ltd.)

Objective: The objective of the present study was to investigate possible associations of dietary patterns with high blood pressure (BP) in a nationwide cross-sectional sample of 10-12 years old Greek schoolchildren., Methods: Anthropometric measurements and information on dietary (by a semi-quantitative food frequency questionnaire) and physical activity habits were obtained from the children. BPs was measured in a single occasion using a standard protocol. Data from 2024 normal energy reporting children were included in the analysis. Principal component analysis was applied to identify dietary patterns., Results: Seven dietary components (patterns) were extracted explaining 55% of the total variation in intake. Multiple logistic regression analysis revealed that predictors of high BP (75th percentile of SBP and/or DBP) were a pattern mainly characterized by the high consumption of cheese and red processed meat [odds ratio (OR) 1.15; 95% confidence intervals (CI) 1.03-1.30], being overweight (OR 2.10; 95% CI 1.61-2.73) or obese (OR 3.84; 95% CI 2.44-6.06) and breakfast frequency (OR 0.95; 95% CI 0.90-0.99). After controlling for sodium intake levels, the dietary pattern did not remain a significant predictor of high BP, indicating the potential mediating effect of sodium in the association., Conclusion: A dietary pattern that is characterized by high cheese and red processed meat consumption increases the likelihood of having high BP in children, probably through increasing dietary sodium intake. These findings could guide future interventions or public health initiatives to prevent the increasing rates of childhood elevated BP levels.

Background: To investigate the association between gestational weight gain, maternal age and lifestyle habits (e.g., physical activity, smoking, and alcohol consumption) during pregnancy, with Body Mass Index of the offspring at the age of 8., Methods: Α random sample of 5,125 children was extracted from a national database and matched with their mothers. With the use of a standardised questionnaire, telephone interviews were carried out for the collection of information like: maternal age at pregnancy, gestational weight gain (GWG), exercise levels, smoking and alcohol consumption. The Body Mass Index (BMI) status of the offspring at the age of 8 was calculated from data retrieved from the national database (e.g., height and weight)., Results: The odds for being overweight/obese at the age of 8 for 1 kg GWG, for smoking, and for mild exercise during pregnancy compared to sedentary was 1.01 (95%CI: 1.00, 1.02), 1.23 (95%CI: 1.03, 1.47) and 0.77 (95%CI: 0.65, 0.91), respectively. Further analysis revealed that offspring of women who exceeded the Institute of Medicine (IOM) maternal weight gain recommendations were at an increased risk of obesity (OR: 1.45; 95%CI, 1.26, 1.67) compared with offspring of women with GWG within the recommended range. Maternal age and alcohol consumption were not associated with the outcome (p > 0.05)., Conclusion: GWG, physical activity and smoking status during pregnancy were significantly associated with obesity for the offspring at the age of 8. Health care professionals should strongly advise women to not smoke and to perform moderate exercise during pregnancy to prevent obesity in the offspring in later life.

Objectives: To determine the effect of eating frequency on body weight status in children and adolescents., Methods: In this meta-analysis, original observational studies published to October 2011 were selected through a literature search in the PubMed database. The reference list of the retrieved articles was also used to identify relevant articles; researchers were contacted when needed. Selected studies were published in English, and they reported on the effect of eating frequency on overweight/obesity in children and adolescents. Pooled effect sizes were calculated using a random effects model., Results: Ten cross-sectional studies and 1 case-control study (21 substudies in total), comprising 18 849 participants (aged 2-19 years), were included in the analysis. Their combined effect revealed that the highest category of eating frequency, as compared with the lowest, was associated with a beneficial effect regarding body weight status in children and adolescents (odds ratio [OR] = 0.78, log OR = -0.24, 95% confidence interval [CI] -0.41 to -0.06). The observed beneficial effect remained significant in boys (OR = 0.76, log OR = -0.27, 95% CI -0.47 to -0.06), but not in girls (OR = 0.96, log OR = -0.04, 95% CI -0.40 to 0.32) (P for sex differences = 0.14)., Conclusions: Higher eating frequency was associated with lower body weight status in children and adolescents, mainly in boys. Clinical trials are warranted to confirm this inverse association, evaluate its clinical applicability, and support a public health recommendation; more studies are also needed to further investigate any sex-related differences, and most importantly, the biological mechanisms.

Objective: Given the rapid increase in the prevalence of childhood obesity, identifying the sociodemographic influences on obesity status is important for planning and implementing effective prevention initiatives. However, this type of data is limited for Greek children. Therefore the aim of the present study was to identify possible sociodemographic factors associated with childhood obesity at the national level., Design: Cross-sectional, population-based survey, carried out from October to May 2009. Setting Under the context of the GRECO (Greek Childhood Obesity) study, a nationwide sample of 2315 primary-school children., Subjects: Children aged 10-12 years and their parents were voluntarily enrolled. Direct anthropometric measurements of the children were obtained and information on sociodemographic characteristics of the parents, as well as their self-reported values of body weight and height, were collected., Results: Overweight and obesity prevalence was 29·5 % and 13·1 %, respectively, among boys; 29·5 % and 9·0 %, respectively, among girls. Multiple logistic regression analysis revealed that the most important sociodemographic predictors of childhood obesity were mother's age, parental BMI classification and father's type of occupation. More specifically, increased mother's age and normal BMI status of the parents seemed to have a protective effect on the likelihood of having an overweight/obese child. Additionally, the odds of a female child of being overweight/obese were reduced when the father's type of occupation tended to be less manual., Conclusions: Anti-obesity health policy interventions have to address to the parents and promote their active involvement, to effectively confront the alarming magnitude of the paediatric obesity problem in Greece.

Objective: To explore associations of perinatal and family factors with preadolescence overweight and obesity in a sample of Greek schoolchildren., Methods: A nationwide cross-sectional study among 2093 students (10.9 ± 0.72 years, 44.9% boys) and their parents were conducted. Anthropometric (e.g., height, weight, mother's body mass index (BMI) at the time of the study and at conception), socio-demographic (e.g., age, education, socio-economic status), diet and other major lifestyle characteristics (e.g., smoking, alcohol intake, physical activity and inactivity) and perinatal factors (e.g., breast- and formula-feeding) were collected with validated questionnaires. Height and weight of students were measured. Overweight/obesity was classified using IOTF cut-offs. Multivariable logistic and linear regression analyses were used to identify major independent factors of overweight/obesity among preadolescents and factors related with the percentage change of mother's BMI, respectively., Results: Increased age at pregnancy [odds ratios (OR)=0.95, 95% Confidence Interval (CI): 0.93-0.97], higher BMI at conception (OR=1.17, 95% CI: 1.12-1.22) and heavy smoking (OR = 2.02, 95% CI: 1.23-3.33) were positively associated with child's overweight/obesity status. Moreover, mother's age and TV viewing, indicating inactivity, were the strongest factors of the percentage increase in mother's BMI (b ± se = 0.23 ± 0.07, p = 0.002; b ± se=0.32 ± 0.10, p = 0.002, respectively)., Conclusions: Preadolescent obesity is associated with mother's pre-pregnancy weight, age and heavy smoking at conception and mother's BMI change after gestation., (Copyright © 2012 Ministry of Health, Saudi Arabia. Published by Elsevier Ltd. All rights reserved.)

Despite the well-known association of obesity with increased mortality and the development of chronic diseases, an "obesity paradox" has been reported in several patient categories; i.e., overweight and obese patients have a better prognosis than normal or low-weight individuals. The present review aims to identify potential factors lying beneath the beneficial effect of overweight and obesity. In particular, the role of nutritional status, malnutrition and catabolic state, as well as intentional vs. unintentional weight loss and the possibility of a U-shape relationship between body mass index and survival will be examined. Furthermore, methodological considerations framing the obesity paradox will be presented and discussed., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Increased meal frequency and daily breakfast consumption have been inversely associated with childhood obesity. The purpose of the study was to examine the possible interaction effect between meal frequency and breakfast consumption on childhood obesity., Methods: Seven hundred children (323 boys) aged 10-12 years were enrolled in this cross-sectional study. Several lifestyle, dietary and physical activity characteristics were recorded with food frequency and physical activity questionnaires. Body height and weight were measured and body mass index was calculated in order to classify children as overweight or obese (International Obesity Task Force classification). Multiple logistic regression analysis was used in order to evaluate the interaction between daily breakfast intake and more than three meals per day consumption with overweight or obesity., Results: Of the children, 27.6% and 9.0% were overweight and obese, respectively. Moreover, 60.2% consumed three or more meals per day and 62.7% consumed breakfast in a regular daily basis. Children who consumed more than three meals per day and also consumed breakfast daily, were two times less likely to be overweight or obese (adjusted odds ratio: 0.49, 95% confidence interval: 0.27-0.88)., Conclusion: A combined higher meal frequency and daily breakfast consumption dietary pattern may prevent overweight and obesity in children., (© 2011 The Authors Pediatric Obesity © 2011 International Association for the Study of Obesity.)

Objective: In order to provide estimates of overweight and obesity among Greek schoolchildren, and the adherence rates to the Mediterranean diet (MD), a nationwide survey was performed among fifth and sixth grade students aged 10-12 years old., Methods: A stratified sampling in 10 regions of the country was applied to voluntarily enroll a representative sample of 4786 children. Children were weighed and measured and completed a semi-quantitative food frequency questionnaire with a supplementary section for the assessment of dietary aspects and physical activity levels. Additionally, the KIDMED index was used to evaluate the degree of adherence to the MD., Results: According to the IOTF cut-offs, overweight (OW) and obesity (OB) prevalence among boys was 29.9% and 12.9%, while in girls 29.2% and 10.6%, respectively. Only 4.3% of the children had an optimal KIDMED score. KIDMED score did not differ between boys and girls and no differences were detected between normal weight and OW and OB children. However, children from semi-urban or rural regions had higher score. Furthermore, children with higher KIDMED score reported following a healthier diet and having higher physical activity levels., Conclusion: The prevalence of childhood obesity in Greece is the highest ever reported together with low adherence rates to the dietary patterns of the MD. Current findings suggest an increased risk for even higher rates of obesity in adolescence and adulthood in the near future. Taking into account that children are also abandoning the traditional cardio-protective MD, the increased risk for future adverse health consequences seems evident., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To compare 12-year (1997-2008) trends in the distribution of Body Mass Index (BMI) status and physical fitness test performances among 8- to 9-year-old Greek children living in rural and urban areas., Methods: Population data derived from 11 national school-based health surveys conducted from 1997 to 2008. Anthropometric measurements and physical fitness test performances (ie, multistage shuttle run, vertical jump, small ball throw, and 30-meter sprint) from 725,163 children were analyzed. Distribution between rural and urban areas was based on the Hellenic National Statistics Service (HNSS) criteria., Findings: Trend analysis showed an increase in the prevalence of obesity in children living in urban areas from 7.2% in 1997 to 11.3% in 2008 for girls (P < .001) and from 8.1% to 12.4% (P < .001) for boys. In rural areas, obesity increased from 7% in 1997 to 13% in 2008 for girls (P < .001), and from 8.2% to 14.1% (P < .001) for boys. The annual rate of obesity increase was 40%-50% higher in children from rural areas. Nevertheless, rural children presented better performances in all of the physical fitness tests examined. Specifically, mean values of aerobic performance decreased from 3.58 ± 1.9 stages in 1997 to 3.02 ± 2.1 stages in 2007 for boys (P < .001), and from 2.97 ± 1.5 stages to 2.53 ± 1.7 stages (P < .001) for girls in urban areas, whereas in rural areas, the correspondent values were not significantly different between 1997 and 2007., Conclusions: Childhood obesity rates are higher in rural compared with urban areas in Greece, despite an apparent higher fitness level of children living in rural areas., (© 2010 National Rural Health Association.)

Background and Aim: The aim of the present work was to evaluate the relationship between energy-generating nutrients and the presence of central and overall obesity after correcting for socio-demographic, lifestyle and clinical characteristics, among healthy elders., Methods and Results: During 2005-2007, 553 elderly men and 637 elderly women (mean age 74±7years) from eight Mediterranean islands in Greece and Cyprus, were enrolled. The retrieved information included demographic, bio-clinical and dietary characteristics. MedDietScore assessed adherence to the Mediterranean dietary pattern. The prevalence of obesity was 27% in males and 39% in females (p<0.001), while 73% of males and 87% of females had central obesity. The prevalence of diabetes, hypercholesterolemia and hypertension was higher in the obese than in the non-obese participants (p<0.01). After adjusting for various confounders, a 1% increase in carbohydrate consumption was associated with a 12% (95% CI 0.78-0.99) lower likelihood of having central obesity, while a 1% increase in carbohydrate and protein consumption was associated with a 14% (95% CI 0.78-0.95) and 16% (95% CI 0.72-0.97) lower likelihood of being obese, respectively. Vegetable protein was found to be associated with a 15% (95% CI 0.77-0.93) lower likelihood of being obese while, only low glycemic index carbohydrates seem to be associated with a 6% (95% CI 0.90-0.98) lower likelihood of having central obesity., Conclusions: The presented findings suggest that a diet high in carbohydrates and vegetable protein is associated with a lower likelihood of being obese and may help elderly people to preserve normal weight., (Copyright © 2009 Elsevier B.V. All rights reserved.)

Obesity is associated with impaired postprandial triacylglycerolemia, an independent risk factor for cardiovascular disease. Given that obesity is hard to treat, efforts should focus on treating its comorbidities. We aimed to investigate whether moderate weight loss normalizes postprandial triacylglycerol (TAG) concentrations, in the absence of the acute effects of negative energy balance. For this purpose, postprandial lipemia was investigated in eight obese but otherwise healthy, sedentary men (age: 41.3 ± 4.1 years, BMI: 36.5 ± 1.6 kg·m(-2)), once before and again after a 10% weight loss followed by ≥4 weeks of weight maintenance, and was compared with that of eight age-matched healthy lean men (BMI: 24.7 ± 0.6 kg·m(-2)). Dietary intervention consisted of reduced carbohydrate and saturated fat intake and increased monounsaturated fat intake. Obese volunteers were advised to increase physical activity using pedometers to record daily activity. Postprandial triacylglycerolemia after weight loss was reduced by 27-46% (P < 0.05), and became similar to that of lean men despite persisting obesity (BMI after weight loss: 32.9 ± 1.5 kg·m(-2)). Reduction in postprandial TAG responses was inversely correlated with the decrease in postprandial insulin sensitivity index (ISI) after weight loss (r = -0.714, P = 0.047). We conclude that moderate weight loss induced by a low-carbohydrate and saturated fat diet and a slight increase in daily physical activity normalizes postprandial triacylglycerolemia in obese men, independently of acute diet-induced negative energy balance, and possibly through enhancement of insulin action.

Background: To date, no published dietary indices have evaluated the overall effects of various dietary components, beliefs, and practices on the development of obesity in children., Objective: To develop a dietary index that contains dietary characteristics and practices implicated in the development of obesity., Methods: The proposed index (i.e., the E-KINDEX [Electronic Kids Dietary Index]) incorporates 3 subindices: (1) a food groups intake index (13 items), (2) an index related to eating beliefs and behaviors (8 items), and (3) an index that evaluates dietary practices (9 items). The theoretical overall score ranges from 1 (worst) to 87 (best). For validation of the E-KINDEX, multiple linear and logistic regression analyses were applied that had as dependent outcomes various body composition indices of 622 children (9-13 years) from the CYKIDS (Cyprus Kids) study. In all models, adjustments were made for age, gender, physical activity level, TV viewing time, socioeconomic status, breastfeeding, and parental obesity status., Results: The highest E-KINDEX category (>60 points) was associated with 85% less likelihood of a child being obese or overweight (odds ratio [OR], 0.15; 95% confidence interval [CI], 0.05-0.41) and 86% less likelihood of having a waist circumference ≥75th percentile (OR, 0.14; 95% CI, 0.05-0.43). The correct classification rate of E-KINDEX (C-statistic) against excess body fat percentage was 84% (CI, 0.74-0.94). Moreover, for a single SD increase in the index score (i.e., 7.81 units), a decrease of 2.31 ± 0.23 kg/m(2) in body mass index (BMI), of 2.23 ± 0.35 in percent of body fat (BF%), and of 2.16 ± 0.61 cm in waist circumference was observed. Similar results were found during 1-year follow-up of study participants. In particular, baseline E-KINDEX levels were inversely associated with children's BMI at 1-year follow-up (p = 0.024). Latent class analysis showed that the index has good discriminative value for only 68% of the total sample., Conclusion: The proposed E-KINDEX could be helpful in dietary assessment and in further research in the field of childhood obesity.

Aim: Childhood obesity has become a modern epidemic with escalating rates. The aim of our study was the assessment of the association between extracurricular sports participation with the obesity status among Greek schoolchildren aged 10-12 years., Methods: Seven-hundred children (323 boys) aged 10-12 years were evaluated through a standardized questionnaire. Several lifestyle, dietary and physical activity attributes were recorded. Children according to the median hours of participation in after-school structured physical activity were classified as participating for more or less than 3 hours per week. Body height and mass were measured and body mass index was calculated in order to classify children as overweight or obese according to IOTF classification. Multiple logistic regression analysis was used in order to evaluate the association between the participation of more than 3 hours per week in structured physical activity after school with overweight or obesity., Results: A total of 48.9% of the boys and 31.8% of the girls were participating for more than 3 hours per week (P<0.001) in extracurricular sport activities. Moreover, 33.9 % of the boys and 22.1 % of the girls were classified as overweight and 9.4% of the boys and 8.6% of the girls as obese (P=0.006). Girls who participated in excess of 3 hours in extracurricular sport activities were 59% less likely to be overweight or obese than their non participating counterparts, adjusted for several confounders (adjusted OR: 0.41, 95% CI: 0.20-0.83)., Conclusion: Participation in extracurricular sports activity is inversely related to overweight or obesity in 10-12 years old Greek girls.

Background: The epidemiological evidence supporting a causal link between Mediterranean diets and body weight is contrasting. We evaluated the effect of Mediterranean diets on body weight in randomized controlled trials (RCTs) using a meta-analysis., Methods: We searched English and non-English publications in PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from inception to January, 2010. Two evaluators independently selected and reviewed eligible studies. Sixteen randomized controlled trials, with 19 arms and 3,436 participants (1,848 assigned to a Mediterranean diet and 1,588 assigned to a control diet) were included., Results: In a random-effects meta-analysis of all 19 arms, the Mediterranean diet group had a significant effect on weight [mean difference between Mediterranean diet and control diet, -1.75 kg; 95% confidence interval (CI), -2.86 to -0.64 kg] and body mass index (mean difference, -0.57 kg/m², -0.93 to -0.21 kg/m²). The effect of Mediterranean diet on body weight was greater in association with energy restriction (mean difference, -3.88 kg, -6.54 to -1.21 kg), increased physical activity (-4.01 kg, -5.79 to -2.23 kg), and follow up longer than 6 months (-2.69 kg, -3.99 to -1.38 kg). No study reported significant weight gain with a Mediterranean diet., Conclusions: Mediterranean diet may be a useful tool to reduce body weight, especially when the Mediterranean diet is energy-restricted, associated with physical activity, and more than 6 months in length. Mediterranean diet does not cause weight gain, which removes the objection to its relatively high fat content. These results may be useful for helping people to lose weight.

Introduction: The world's population is ageing and it has been suggested that improvements to health, wellbeing and lifespan can be attributed to improved standards of living, especially regarding diet and nutritional status. The impact of nutritional services provided by a dietician on an older population's health status has not been well evaluated or documented. This study sought to determine whether an association exists between available nutritional services and older people's health status in selected Greek islands and the Cyprus Republic., Methods: During 2010, information on nutritional services provided in 9 Greek Islands and the Cyprus Republic was retrieved through interviews of almost all dieticians (n=88) working on these islands. The health status (ie prevalence of hypertension, diabetes, hypercholesterolemia, obesity) of the older population studied (aged >65 years) was retrieved from the Mediterranean Islands Study (MEDIS)., Results: The main reasons for an older person's visit to a dietician was for the treatment of diabetes (79%), hypercholesterolemia (75%) and obesity (70%); 90% of older individuals visited the dietician on a physician's recommendation and 45% of them completed their consultations. The longer the presence of a dietician on an island, the lower the likelihood of observing the prevalence of hypertension (OR=0.59, 95% CI=0.36-0.94), hypercholesterolemia (OR=0.66, 95%CI=0.46-0.95), diabetes (OR=0.77, 95%CI=0.61-0.96) and obesity (OR=0.66, 95%CI=0.45-0.95) above the median rate of the population studied. Financial concerns and a long distance from home to the dieticians' office were the major reasons for ceasing visits to the dietician., Conclusions: Enhancing nutritional services within the healthcare system may contribute to reducing the burden of disease among older adults and, consequently, improve their quality of life.

Objective: We examined secular trends in physical fitness and BMI status in 8- to 9-year-old Greek children during an 11-year period (1997-2007)., Methods: Population data derived from a yearly health survey performed in over 85% of Greek schools. Anthropometric measurements and physical fitness tests from 651,582 children were analyzed. The gender- and age-specific BMI cut-off points by the International Obesity Task Force were used to define overweight/obesity., Results: Aerobic performance decreased by 4.9% (p < 0.001) for boys and 4.4% (p < 0.001) for girls between 1997 and 2007 while obesity increased by approximately 50% in both genders (p < 0.001). Time-series analyses revealed that the increasing trends in obesity were independent of the reduction in fitness levels. An increase from 21% in 1997 to 48.2% in 2007 was observed in the prevalence of the low quartile of aerobic performance for girls (p < 0.001) and from 25.7% in 1997 to 38.7% in 2007 (p < 0.001) for boys. Approximately 80% and 85% of obese boys and girls, respectively, failed to pass the low quartile of all aerobic tests in 2007., Conclusions: Inverse but independent trends in obesity and fitness levels were observed among Greek children during an 11-year period (1997-2007), a fact that predisposes our children to serious health risks as they grow older., (Copyright © 2011 S. Karger AG, Basel.)

A significant increase in the prevalence of obesity has occurred worldwide and the importance of considering the role of diet in the prevention and treatment of obesity is widely acknowledged. A growing body of evidence encourages the consumption of ready-to-eat cereals (RTEC) as part of a healthful diet. Research has shown an inverse association between the consumption of RTEC and the rate of obesity. However, other findings claim that this association was only attributed to the consumption of whole-grain cereals and not the refined-grain ones. Although meta-analyses of clinical trials support the use of a low-glycaemic index diet on weight loss, findings from other studies on the effect of the dietary glycaemic index on body weight have not been consistent. Thus, further research into the role of glycaemic index in the prevention and management of obesity and chronic disease is needed. Moreover, significant differences have been observed in composition among the marketed RTEC. In light of the revealing protective role of whole-grain, fibre-rich, low-energy-dense and low-glycaemic index/glycaemic load foods against obesity, public health professionals could drive their efforts towards the promotion of even more healthier RTEC when issuing advice on weight management. It seems, however, that despite any differences in their composition, the frequent consumption of RTEC due to their nutritional contribution is recommended in moderation and under the current recommendations in the context of a healthy balanced diet.

Aims: Adherence to a healthy dietary pattern, such as the Mediterranean diet, exerts a beneficial role regarding the development of coronary heart disease. In addition, several studies support the protective role of the Mediterranean diet as far as obesity is concerned. This review, examining results from prospective cohort and cross-sectional studies, as well as clinical trials, aims to clarify whether the beneficial effect of the Mediterranean dietary pattern on coronary heart disease is due to the impact of this diet on weight loss and obesity status or an independent effect., Data Synthesis: 35 original-research studies that were published in English until 2009, selected through a computer-assisted literature search are discussed, from which 3 were prospective, 11 were cross-sectional studies, and 21 were clinical trials., Conclusion: Although not all studies show a protective effect of the Mediterranean diet on body weight and obesity, the evidence suggests a possible beneficial role of this dietary pattern. Thus the Mediterranean diet protects against the development of coronary heart disease not only because of its beneficial role regarding cardiovascular risk factors, but also due to a possible effect on body weight and obesity., (Copyright 2010 Elsevier B.V. All rights reserved.)

Background: Childhood obesity has become a modern epidemic with escalating rates. The aim of our study was to identify physical activity patterns among Greek schoolchildren and to examine their relationship with obesity., Methods: 700 adolescents age 10 to 12 years were evaluated through a standardized questionnaire. Several demographic, socioeconomic, and physical activity characteristics were recorded. Physical activity was assessed and adolescents were characterized as active and nonactive. Body height and weight were measured and body mass index was calculated in order to classify subjects as overweight or obese (IOTF classification). Multiple logistic regression and multivariate techniques (principal components analysis) were performed., Results: Eight physical activity patterns were identified, including increased physical activity in weekdays and weekends, sports physical activity, vigorous, moderate, and low physical activity. Increased physical activity on weekends and vigorous physical activity in boys were negatively associated with being overweight or obese (OR: 0.65; 95% CI: 0.48-0.90 and OR: 0.66; 95% CI: 0.49-0.88, correspondingly) and moderate physical activity was marginally positively associated in girls (OR: 1.28; 95% CI: 0.97-1.69), after adjusting for several confounders., Conclusions: Our findings demonstrate the important role of vigorous physical activity in the maintenance of normal weight of adolescents.

Background/objectives: There is controversy over dietary protein's effects on cardiovascular disease risk factors in diabetic subjects. It is unclear whether observed effects are due to increased protein or reduced carbohydrate content of the consumed diets. The aim of this study was to compare the effects of two diets differing in protein to fat ratios on cardiovascular disease risk factors., Subjects/methods: A total of 17 obese (body mass index (BMI) ranging from 31 to 45 kg/m(2)) volunteers with type 2 diabetes (DM2), aged 46+/-3 years, consumed two diets, each for 4 weeks, with 3 weeks of washout period in a random, blind, crossover design. The diets were: (1) a high-protein low-fat diet (HP-LF, with 30% protein, 50% carbohydrates and 20% fat) and (2) a low-protein high-fat diet (LP-HF, with 15% protein, 50% carbohydrates and 35% fat). Their effects on fasting glycemic control, lipid levels and blood pressure, and on postprandial glucose and insulin responses after a standard test meal at the beginning and end of each dietary intervention were analyzed., Results: Both diets were equally effective in promoting weight loss and fat loss and in improving fasting glycemic control, total cholesterol and low-density lipoprotein (LDL) cholesterol, but the HP-LF diet decreased to a greater extent triglyceride (TG) levels (P=0.04) when compared with the LP-HF diet. HP-LF diet improved significantly both systolic and diastolic blood pressure when compared with the LP-HF diet (P<0.001 and P<0.001, respectively). No differences were observed in postprandial glucose and insulin responses., Conclusions: A protein to fat ratio of 1.5 in diets significantly improves blood pressure and TG concentrations in obese individuals with DM2.

Background: When substituted for carbohydrate in a meal, dietary protein enhances glycaemic control in subjects with type 2 diabetes (DM2). It is unknown whether the effect is a result of increased protein or reduced carbohydrate. The present study aimed to compare the effects of two meals differing in protein to fat ratios on post-prandial glucose and insulin responses., Methods: This was a crossover, blind study in which obese subjects with (n = 23) and without (n = 26) DM2 consumed two meals in random order with equal amounts of energy (3.1 MJ, 741 kcal), fibre and carbohydrates and a 1-week washout period. Meals were a high protein, low fat (30% protein, 51% carbohydrates, 19% fat) meal and a low protein, high fat (15% protein, 51% carbohydrates, 34% fat) meal. Subjects were matched for age and body mass index. Plasma glucose and insulin were measured at fasting, 30, 60, 90, 120 min post-prandially. Insulin resistance and insulin sensitivity were assessed., Results: There was no significant meal effect on glucose and insulin responses within groups. Glucose response was higher in diabetic (120 min 11 +/- 0.7 mmol L(-1)) compared to nondiabetic (120 min 5 +/- 0.2; P < 0.001) subjects. Diabetic subjects had significantly higher insulin resistance (P < 0.001) and lower insulin sensitivity (P < 0.001) than nondiabetics. Although peak insulin levels, 60 min post-prandially, did not differ between groups (81 +/- 9 pmol L(-1) for diabetic versus 79 +/- 7 pmol L(-1) for nondiabetic subjects), they were achieved much later, 90 min post-prandially, in diabetic, (99 +/- 8 pmol L(-1)) compared to nondiabetic (63 +/- 7 pmol L(-1), P = 0.002) subjects., Conclusions: Manipulating protein to fat ratio in meals does not affect post-prandial plasma blood glucose or insulin responses in obese people with and without DM2.

Background: Metabolic syndrome, i.e. the clustering of visceral obesity, dyslipidemia, hyperglycemia, and hypertension, has become a major public-health challenge worldwide. An acute-phase reactant is one whose level increases by 25% of the standard value during inflammation. Associations of acute-phase reactants with the components of metabolic syndrome among overweight or obese patients has rarely been examined., Material/methods: The CRP, ferritin, fibrinogen, haptoglobin, and ESR levels of 117 consecutive overweight or obese patients were measured. Metabolic syndrome was defined if central obesity was combined with at least two of the following factors: triglyceride level > or = 150 mg/dl or specific treatment for this abnormality, HDL cholesterol < 40 mg/dl in males and < 50 mg/dl in females or specific treatment for this abnormality, systolic/diastolic blood pressures > or = 130/85 mmHg or treatment of previously diagnosed hypertension, and fasting plasma glucose > or = 100 mg/dl or previously diagnosed type 2 diabetes., Results: Eighty-two patients were characterized as having metabolic syndrome and 35 as healthy controls. CRP, haptoglobin, and ESR levels increased with increasing number of components of metabolic syndrome. Ferritin and fibrinogen, in contrast, were increased in patients with metabolic syndrome but did not correlate with the number of components., Conclusions: CRP, haptoglobin, and ESR may add significant information regarding the severity of metabolic syndrome among overweight and obese patients.

We examined 11-year (1997-2007) trends in underweight, overweight, and obesity in Greek children. Population data derived from a yearly, school-based health survey carried out between 1997 and 2007 in >80% of all Greek schools. Height and weight measurements from 651,582 children, aged 8-9 years (boys: 51.2%) were analyzed. The gender- and age-specific BMI cutoff points by the International Obesity Task Force (IOTF) were used in order to define underweight, normal weight, overweight, and obesity. Trend analysis showed an increase in the prevalence of obesity from 7.2 +/- 0.2% in 1997 to 11.3 +/- 0.2% in 2004 for girls (P < 0.001) and from 8.1 +/- 0.2% in 1997 to 12.3 +/- 0.2% in 2004 for boys (P < 0.001). An apparent leveling off in obesity rates was observed during 2004-2007 for both boys and girls. The prevalence of overweight rose between 1997 and 2007 from 20.2 +/- 0.2% to 26.7 +/- 0.2% for girls (P < 0.001) and from 19.6 +/- 0.2% to 26.5 +/- 0.2% for boys (P < 0.001). The overall prevalence of thinness in the same period remained constant in both sexes. The presented population-based data revealed that the prevalence of overweight and obesity among 8- to 9-year-old Greek children is alarmingly elevated, with the overweight rates rising continuously. However, an apparent leveling off in obesity rates for the past 4 consecutive years was documented for the first time in both genders.

Objective: There is some evidence regarding the association between adherence to the Mediterranean diet (MD) and obesity among adults; to our knowledge, however, no relevant data exist for children. We investigated the association between adherence to the MD and obesity status in children., Methods: A national cross-sectional study among 1140 children (mean age 10.7+/-0.98 y) was carried out in Cyprus using stratified multistage sampling design. Body mass index was calculated according to International Obesity Task Force criteria, from parental reference. Adherence to the MD was assessed by the Mediterranean Diet Quality Index for children and adolescents (KIDMED diet score). To test the research hypothesis, a logistic regression analysis was applied with two dependent variable categories of obesity status, normal weight (NW) versus overweight/obese (OW/OB), and the three categories of the KIDMED score independently, after controlling for several potential confounders., Results: Compared with low MD adherers, children with a high KIDMED score were 80% less likely to be OW/OB (95% confidence interval 0.041-0.976), adjusted for age, gender, parental obesity status, parental educational level, and dietary beliefs and behaviors (model 2). When physical activity was taken into account, however, the aforementioned relation was not significant (model 3; odds ratio 0.20, 95% confidence interval 0.021-1.86). Furthermore, male gender, maternal obesity, and dietary beliefs and behaviors emerged as more significant in predicting obesity in children compared with their KIDMED score., Conclusion: Adherence to the MD is inversely associated with obesity in this sample of 9- to 13-y-old children; however, other behaviors, and in particular physical activity, maternal obesity, dietary beliefs and behaviors, seem to be more significant.

We sought to develop an index that incorporated various dietary and lifestyle behaviours that are associated with overweight/obesity status in adolescents. We assigned discrete scores into each component of the proposed index. The Diet-Lifestyle Index ranged from 11 to 57. We examined the accuracy of the index in relation to adolescents' body mass status using a sample of 2,008 students. The mean score of the index was 30.9+/-5.2 for boys and 31.4+/-4.7 for girls. The index was inversely associated with the odds of being obese/overweight (odds ratio = 0.93, 95% confidence interval=0.90-0.96), after adjusting for age and gender. Particularly, an 11/57-unit increase of the index was associated with a 6% and 9% decrease in the odds of being overweight/obesity in boys and girls, respectively (P<0.001). Thus, the proposed Diet-Lifestyle Index could be a useful tool in a primary healthcare setting for preventing obesity in adolescence.

Background and Aim: Eating behaviours and obesity status among children have already been evaluated in several studies, with conflicting results. The aim of this study is to assess the correlation of breakfast cereal with childhood obesity., Methods and Results: A representative sample of 700 children (323 male) selected from 18 schools located in Athens greater area were enrolled. Children and their parents completed questionnaires that evaluated dietary habits and physical activity. We also retrieved information about the type of breakfast most frequently consumed. Height and weight of the children was measured and body mass index (BMI) was calculated. Simple and multiple logistic regression methods were used in order to determine the relationship between cereal intake for breakfast and obesity. Some boys (8.6%) and girls (9.0%) were obese, whereas 33.9% of boys and 22.1% of girls were overweight. For boys, the adjusted odds ratio for breakfast cereal intake for being overweight or obese was 0.54 (95% confidence interval (CI): 0.45-1.29), while for girls it was 0.41 (95% CI: 0.21-0.79). Moreover, the odds ratio of overweight/obesity for boys who ate daily breakfast was 0.51 (95% CI: 0.25-1.05), and for girls was 0.27 (95% CI: 0.12-0.64), adjusted for physical activity and other potential confounders., Conclusion: These data provide evidence that breakfast cereal as a most frequent choice, and daily consumption of breakfast, are inversely associated with the prevalence of overweight or obesity in 10-12-year-old children.

Objective: To evaluate whether consumption of breakfast cereals is associated with BMI in a sample of Greek adolescents., Design: A cross-sectional health and nutrition survey., Setting and Subjects: During 2004-5, 2008 schoolchildren aged 12-17 years were selected from twelve schools located in Vyronas region (Athens metropolitan area). Height and weight were measured and BMI was calculated. A semiquantitative FFQ was applied and multiple logistic regression analysis was used., Results: Overall, 4.7% of boys and 1.7% of girls were obese, whereas 19.4% of boys and 13.2% of girls were overweight. Only 20.7% of boys and 15.5% of girls reported that they consume cereals as a first choice for breakfast. Consumption of breakfast cereals was associated with lower BMI in boys (P=0.08) and girls(P=0.019), irrespective of age and physical activity status. More prominent results were observed for daily cereal consumption or for more than two daily servings of cereals consumed for breakfast. Consumption of pre-sweetened breakfast cereals was associated with lower BMI compared with non-pre-sweetened or no intake of cereals, in both genders (P<0.001). Consumption of breakfast cereals was associated with 33% (95% CI 14%, 48%) lower likelihood of overweight/obesity, irrespective of age, sex and physical activity status., Conclusions: Consumption of breakfast cereals was associated with lower BMI levels and a lower likelihood of overweight/obesity in both genders; thus a solid basis for public health professionals could be built when issuing advice on weight management.

Metabolic syndrome has been defined as the presence of abdominal obesity combined with 2 of the following factors: hypertension, dyslipidemia, and impaired glucose tolerance, or diabetes mellitus. Magnesium is an essential cofactor for more than 300 enzymes involved in carbohydrate and lipid metabolism. In this study, we enrolled 117 consecutive overweight and obese patients and we measured serum magnesium levels together with fasting serum glucose, high-density lipoprotein cholesterol, and triacylglycerols. A strong inverse relationship between magnesium levels in serum and the presence of metabolic syndrome was noticed. Moreover, magnesium levels decreased as the number of components of metabolic syndrome increased. Also, there is an inverse relationship between serum magnesium levels and high-sensitivity C-reactive protein. We concluded that decreased levels of serum magnesium are associated with increased risk for metabolic syndrome, perhaps by a low-grade inflammation process.

Background: The purpose of the present study was to determine the prevalence of overweight and obesity in a sample of Greek children aged 10-12 years, and to evaluate these rates in relation to parental weight and birthweight., Methods: During the 2005-2006 school period, 700 schoolchildren (323 boys, 377 girls) were randomly recruited from 18 schools, in Athens. Height and weight were measured and body mass index (BMI) was calculated. Cut-off points for BMI defining obesity and overweight for gender and age were calculated in accordance with international standards., Results: Overall, 8.6% of boys and 9.0% of girls were obese, and 33.9% of boys and 22.1% of girls were overweight. Having an obese parent increased the odds of having an overweight or obese child (P < 0.01). Compared to non-breast-fed, boys who were breast-fed for >3 months had 70% lower likelihood of being overweight or obese (P < 0.01) and breast-fed girls had 80% lower odds (P < 0.01). Excessive birthweight (>3500 g) increased by 2.5-fold the likelihood of being overweight or obese only in girls (P < 0.05)., Conclusions: Parental weight, lack of breast-feeding and excess birthweight (in girls) were significant predictors of overweight or obesity in Greek children aged 10-12 years.

The objective of this study was to evaluate whether Parental Body Mass Index is associated with overweight/obesity in a sample of Greek adolescents, taking into consideration dietary and lifestyle habits. The Vyronas study is a cross-sectional health and nutrition survey. During 2004/2005, 2008 schoolchildren were selected. BMI was calculated for both parents and adolescents. A semi-quantitative Food Frequency Questionnaire was applied. Results demonstrated that there is a strong positive association between the parental overweight/obesity status and their offspring's BMI. Some dietary and lifestyle habits seem to affect boys and girls BMI in relation to parental status differently.

Obesity status differs by socio-demographic factors, but data for Cyprus are scarce. An in-depth understanding of this relationship may be useful in designing public health programmes. The objective of the present study is to estimate overweight and obesity (OW/OB) prevalence among children and adults in Cyprus and identify related socio-demographic variables. National cross-sectional study of 1140 children (mean age 11 +/- 0.98 years) and their parents (mean age 42.5 +/- 5.8 years, total n = 1954). Obesity was defined according to the World Health Organization classification for adults and according to IOTF (International Obesity Task Force) criteria for children. Overweight and obesity prevalence among girls was 18.3% and 2.9%, respectively, while in boys, 19.0% and 6.0%. Among parents, OW/OB prevalence was, respectively, women, 22.6% and 5.8%; men, 47.1% and 14.1%. Logistic regression analysis in both children and adults revealed that the most important socio-demographic predictors of obesity status are factors of built environment. Higher prevalence of OW/OB was observed in adults living in a house as opposed to an apartment, in older adults, in younger children, and in men, irrespective of age. There is a severe obesity problem in the Cypriot population; almost one in two adults and at least one in four preadolescent children are overweight or obese. Prevalence of OW/OB was related to socio-demographic factors, especially among adults and women.

Objective: In this work we evaluated the 5-year incidence of hypercholesterolemia, in a sample of cardiovascular disease free adult men and women from Greece. We also evaluated the association of several socio-demographic, dietary and lifestyle habits on the incidence of this disorder., Methods: 1514 men and 1528 women (>18 y) without any clinical evidence of cardiovascular disease, living in Attica area, Greece, were enrolled in the ATTICA study from May 2001 to December 2002. The sampling was random, multi-stage, and included information about various socio-demographic, lifestyle (diet, exercise, smoking etc), biological (lipids, and inflammatory markers), and clinical characteristics of the participants. In 2006, a group of experts performed the 5-year follow-up through telephone calls or personal visits (941 of the 3042 (31%) participants were lost to follow-up). Hypercholesterolemia, among people who had normal blood lipids at initial examination, was defined as fasting total cholesterol levels > 200 mg/dl or use of lipids lowering agents (NCEP ATPIII)., Results: The 5-year incidence of hypercholesterolemia was 23.7% (n = 127) in men and 17.7% (n = 110) in women (p for gender differences < 0.001). Multi-adjusted logistic regression analysis which revealed that increased age (odds ratio = 1.05, p < 0.001), waist circumference (odds ratio = 1.02, p = 0.03), fasting blood glucose (odds ratio = 1.01, p = 0.08) and apolipoprotein B (odds ratio = 1.02, p = 0.001) levels, were the most significant baseline predictors of developing hypercholesterolemia within a 5-year period., Conclusion: Incidence of hypercholesterolemia was high in both genders, emphasizing the burden of this disorder at population level. Aging, increased waist circumference, fasting blood glucose and apolipoprotein B levels were the most significant baseline predictors of hypercholesterolemia.

The aim of this work was to assess the 5-year incidence of hypertension and its predictors among prehypertensive adults. Under the context of the ATTICA Study, data from 1188 individuals, free of cardiovascular disease, but with defined high blood pressure levels (prehypertension) at baseline examination (during 2001-2002) were retrieved. In 2006, the 5-year follow-up of the study was performed, and 798 of the prehypertensive participants were allocated. In this work, incidence and determinants of developing hypertension were evaluated. The 5-year ageadjusted incidence of hypertension was 18.7% in men and 24.6% in women (P = 0.05); while almost one half of prehypertensive individuals at the age of 55-65 years developed hypertension, and approximately 6 out of 10 people over 65 years of age developed the disease. Multiple logistic regression analysis revealed that increased age (odds ratio [OR] per 1 year = 1.09, 95% confidence interval [CI] 1.07-1.12), male sex (OR = 0.40, 95% CI 0.21-0.68), high education status (OR per 1 year of school = 0.94, 95% CI 0.88-0.98), waist circumference (OR per 1 cm = 1.04, 95% CI 1.02-1.06) and C-reactive protein (OR per 1 mg/l = 1.12, 95% CI 1.05-1.20), were positively associated with the development of hypertension. Moreover, greater adherence to Mediterranean diet seems to protect only prehypertensive, with abdominal obesity patients prone to develop hypertension (OR = 0.94, 95% CI 0.90-0.98). Annual incidence of hypertension was roughly 4% in men and women. Older people, with low education, abdominal obesity, lower adherence to the Mediterranean diet, and increased inflammation, constitute a model of prehypertensive individuals that are prone to develop hypertension.

Background and Aim: We evaluated the association of obesity with serum total antioxidant capacity (TAC), in a population-based sample of 3042 adults., Methods and Results: During 2001-2002 we randomly enrolled 1514 men (18-87 years old) and 1528 women (18-89 years old), from the Attica area in Greece into the study, and the sample was stratified by the age-sex distribution of the region (census 2001). Among several variables we also measured serum TAC and weight, height, waist and hip circumferences. Waist circumference greater than 102 cm for men and 88 cm for women was considered an indicator of central fat., Methods and Results: Mean waist circumference was 98+/-13 cm in men and 84+/-22 cm in women (P<0.001), while mean hip circumference was 106+/-28 cm in men and 103+/-13 cm in women (P<0.001). Central fat prevailed in 53% of men and 45% of women (P<0.001). Male participants with central fat exhibited 5% lower TAC concentrations compared to leaner individuals (214+/-35 vs. 226+/-33 micromol/L, P=0.04) and female participants with central fat exhibited 7% lower TAC concentrations (256+/-38 vs. 239+/-27 micromol/L, P=0.03). Similarly, obese or overweight male participants had 6% lower TAC concentrations compared to normal weight (217+/-33 vs. 234+/-39 micromol/L, P=0.03) and female obese or overweight participants had 10% lower TAC concentrations (226+/-32 vs. 250+/-30 micromol/L, P=0.02) compared to the others., Conclusions: Our results suggest an inverse relationship between body fat, central adiposity and antioxidant capacity, irrespective of age and various other potential confounders, namely smoking, physical activity, dietary habits, blood pressure, glucose levels, and lipid concentrations.

Background: The aim was to evaluate the dietary habits and some lifestyle characteristics of Greek adolescents 12-17 years of age in relation to the prevalence of overweight/obesity., Material/methods: During 2004-2005, 2008 school-aged adolescents (1021 male and 987 female) were selected from all public schools located in the Vyronas region of Athens. The participation rate was 95%. Height and weight were measured and the body mass index (BMI) was calculated. Cut-off points for BMI defining obesity and overweight for gender and age were calculated in accordance with international standards. A semi-quantitative Food Frequency Questionnaire was applied and multiple logistic regression was used to investigate the association between dietary habits/lifestyle characteristics and overweight/obesity in adolescents., Results: Eating cereals for breakfast and the number of meals per day (including snacks) were inversely associated with BMI in males. Furthermore, eating poultry as a meal and sedentary activities were positively associated with BMI in females, while eating breakfast more than five times per week and eating cereals for breakfast were inversely associated with BMI in females. Overall, 4.4% of males and 1.7% of females were obese and 19.2% of males and 13.2% of females were overweight., Conclusions: The consumption of cereals for breakfast and the daily frequency of meals consumed were associated with overweight/obesity in males, whereas the frequency of eating breakfast, the consumption of cereals for breakfast, the consumption of poultry, and the hours spent for activities excluding sports were associated with overweight/obesity in females.

Background: We aimed to investigate if overweight and obese adults "close" to Mediterranean diet present better insulin, lipids profile and better pressure levels, compared to individuals close to a more Westernized diet., Methods: The ATTICA study is a population-based cohort that has randomly enrolled 3042 adult men and women, stratified by age - gender, from the greater area of Athens, during 2001-2002. Of them, in this work were have studied 1762 participants with excess body weight, meaning overweight (BMI: 25-29.9 kg/m2) and obese (BMI>30 kg/m2). 1064 were men and 698 women (20-89 years old). Adherence to Mediterranean diet was assessed through a diet-score that was based on a validated food-frequency questionnaire. Blood pressure was measured and also fasting glucose, insulin and blood lipids. Insulin sensitivity was also assessed by the homeostasis model assessment (HOMA) approach (glucose x insulin/22.5)., Results: Individuals with excess bodyweight in the highest tertile of diet score, were more insulin sensitive than those in the lowest tertile (11.4% lower HOMA, p = 0.06), had 13% lower levels of total cholesterol (p = 0.001) and 3 mmHg decrease of systolic blood pressure levels (p < 0.001), when adjusted for age, sex and BMI. Multivariate analysis after taking into account several confounders demonstrated that insulin sensitivity, total cholesterol and systolic blood pressure were independently but only modestly correlated with Mediterranean diet in people with excess bodyweight., Conclusion: Adherence to Mediterranean diet is modestly associated with a better insulin sensitivity, lower levels of total cholesterol and lower levels of systolic blood pressure in overweight and obese subjects. This may suggest that compared to general population, the beneficial effect of this diet in cardiovascular system of excess body weight people is limited.

Background: Individuals with the metabolic syndrome (MS) are at high risk for coronary heart disease. In this study, we evaluated the levels of inflammatory, lipidaemic and glycaemic control markers in subjects with and without MS, as given by different definitions., Methods: During 2001-2002, we randomly enrolled 1,514 men (18-87 years old) and 1,528 women (18-89 years old), without any clinical evidence of cardiovascular disease, from the Attica area, Greece. Among several variables, we also measured inflammatory markers, total antioxidant capacity, glucose and insulin levels and various lipids. MS was defined according to either the National Cholesterol Education Program Adult Treatment Panel (NCEP ATP) III criteria or the International Diabetes Federation (IDF) Epidemiology Task Force group. In all the analyses, subjects with diabetes were excluded., Results: The prevalence of the MS was 17.9% according to the NCEP definition and 48.9% according to the IDF definition (p < 0.001). The prevalence of MS was higher in men compared with women according to both definitions (p for gender differences <0.001). Moreover, 3.9% of the total study sample fulfilled only the NCEP criteria, but not the IDF, while 38.6% fulfilled only the IDF criteria. Subjects who were defined as having MS using the IDF criteria were younger, had higher body mass index, C-reactive protein, fibrinogen, tumour necrosis factor-alpha levels, total antioxidant capacity and lower glucose and insulin levels., Conclusions: Prevalence of the MS is very high among Greek adults when the IDF definition is used, while it is still considerable when we adopt the NCEP criteria. It is evident that subjects who fulfilled the IDF criteria showed increased levels of inflammatory markers compared with those who fulfilled the NCEP ATP III criteria.

Purpose: We aimed to evaluate the relationship of physical activity and obesity with glycemic control and insulin resistance., Methods: A randomized, population-based, cross-sectional health and nutrition survey was conducted in the province of Athens, Greece. Subjects included 1514 men and 1528 women without evidence of cardiovascular or other chronic disease. Participants were classified as inactive, minimally active, or health-enhancing physical activity (HEPA) active based on the International Physical Activity Questionnaire. Insulin sensitivity was assessed by the homeostatic model (HOMA), and overweight or obesity was assessed according to BMI (BMI >or= 25). Related social, biological, and lifestyle factors were also recorded and used as potential confounders., Results: Five hundred sixty-five (37.3%) men and 493 (32.3%) women were classified as physically active. From the 1058 (34.8%) subjects who were classified as active, 306 (10.1%) met the criteria for HEPA active, and the rest were minimally active. HEPA active and minimally active subjects smoked less and had lower BMI, waist, and waist-to-hip ratio. Lean and overweight or obese subjects with sedentary lifestyle had greater levels of glucose, insulin, and insulin resistance [corrected] However, overweight or obese volunteers with physical activity levels classified as HEPA had similar levels of glucose and insulin sensitivity, with lower insulin than lean inactive individuals. Linear regression analysis between HOMA and physical activity, taking into consideration several social and biological factors, showed that physical activity (MET x min x wk(-1)), age, BMI, and total energy intake are important predictors of HOMA, whereas other factors such as waist circumference did not reach statistical significance., Conclusion: Our data show that physical activity is a significant factor on insulin sensitivity, whereas increased physical activity may ameliorate the well-known effects of obesity on insulin sensitivity.