Accepted Manuscript “Evaluating Greek Adolescents’ Mediterranean Diet Quality and the Factors Influencing it” Stamatina Papadaki, Med, Msc Evangelia Mavrikaki, Phd PII:
S0899-9007(14)00424-9
DOI:
10.1016/j.nut.2014.09.003
Reference:
NUT 9368
To appear in:
Nutrition
Received Date: 29 October 2013 Revised Date:
21 June 2014
Accepted Date: 3 September 2014
Please cite this article as: Papadaki S, Mavrikaki E, “Evaluating Greek Adolescents’ Mediterranean Diet Quality and the Factors Influencing it”, Nutrition (2014), doi: 10.1016/j.nut.2014.09.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE PAGE
“Evaluating Greek Adolescents’ Mediterranean Diet Quality and the Factors
Corresponding Author’s details: Stamatina Papadaki, Med, Msc National & Kapodistrian University of Athens Faculty of Primary Education Department of Science, Technology & Environment
10680, Athens, Greece Email:
[email protected] Tel: 00306948270521
Author’s details:
Assistant Professor
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Dr. Evangelia Mavrikaki, Phd
National & Kapodistrian University of Athens Faculty of Primary Education
Department of Science, Technology & Environment
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Navarinou 13A,
10680, Athens, Greece
Email:
[email protected] AC C
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Navarinou 13A,
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Influencing it”
Tel./ fax: 0030 2103688033
Word count: 5.000
Number of tables: 4
ACKNOWLEDGEMENTS
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We express our appreciation to everyone that took part in our research: the head teachers for their kind permission to use a sample from their schools, the teachers for their time and
was no funding or any outside support for this study.
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ABSTRACT
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patience and the adolescents for their willingness, their trust and their collaboration. There
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Objective: To evaluate adolescents’ Adherence to the Mediterranean Diet (AMD) and its connection to anthropometric, demographic, socio- economic and lifestyle characteristics.
Research Methods & Procedures: A total of 525 adolescents aged 12- 18 years, from Athens and Heraklion, Greece participated in this cross- sectional, school- based study which took place during March- April 2012. The dependent variable was scored on the KIDMED
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test, with score> 8 indicating an optimal Mediterranean Diet (MD). Analysis included Chisquare test and Student t test for the association between variables. Linear regression analysis was used to identify the determinants of AMD. A 2- sided P- value of less than .05 was
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considered statistically significant.
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Results: Twenty- one percent of participants had very good AMD. Positive predictors were mother’s educational level (P< .01), living with both parents (P< .05) and in a smaller city (P< .01). Negative predictors were age (P< .05), > 4 hours computer use/ day (P< .01) and lack of exercise (P< .01). No correlation was found between AMD and Body Mass Index (BMI) (P> .05).
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Conclusions:
Several
anthropometric,
demographic,
socioeconomic
and
lifestyle
characteristics were significantly associated with AMD. It is highly important that children and adolescents adhere at a very young age to the MD as the healthier dietary choice. Further
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research might explore whether the economic recession in Greece has any effects on adolescents’ dietary habits.
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Keywords: Mediterranean diet; Greece; BMI; Adolescents; Dietary habits.
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INTRODUCTION
Numerous epidemiological and experimental studies in nutrition have focused on the MD as it is well known for its health benefits [1- 6]. However, lately there has been great concern as
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to whether Mediterranean countries are still devoted to this dietary model [7].
Yannakoulia et al., (2004) [8] found that Greek adolescents have high adherence to some characteristics of the MD, such as the daily consumption of fruits and vegetables, but they
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also have high consumption of saturated fats and simple sugars due to increased consumption of industrialized/ fast foods. Also, Schröder et al., (2013) showed that high energy density
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diets are associated with less healthy food patterns and low AMD in young Spaniards [9].
A cross-sectional study in Tunisia found that dietary habits are closely correlated with modernization, urbanization and regional socio-economical changes [10]. Economic transitions were also found to be closely correlated with dietary changes by Moreno et al., (2002) [11] along with the reduction of free time and the reduction of physical activities. Other researchers correlated improved living conditions, new technologies for food 3
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preservation and the development of new methods of production in the agricultural and livestock sectors with dietary changes [12] and also, food availability and accessibility, TV commercials along with peer and parental attitude [13], [14] and [15]. Furthermore, Xie et al.,
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(2003) [16] found that gender, ethnicity and family income influence long- term adherence to healthy behavior among children and adolescents and Serra-Majem et al., (2004) [17] found that age, gender and geographical and socio- economic differences were correlated with
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AMD.
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As far as Greek children’s and adolescents’ dietary habits are concerned, Yannakoulia et al., (2004) [8] suggested that Greek school-aged adolescents’ unhealthy dietary habits were correlated with going out and lots of television watching, whereas Kontogianni et al., (2008) [18] showed that age, parental educational status, time spent on sedentary activities and eating frequency were correlated with AMD. Greek children and adolescents tend to abandon
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‘traditional’ and follow a more ‘Westernized’ way of living and so do their eating habits, increasing the danger of adverse health conditions due to the high consumption of unhealthy foods [19] and [8]. As a result, child obesity rates in Greece are increasing [20- 23].
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Since 2009 Greek people have become increasingly impoverished and are reporting
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difficulties in facing unexpected expenses as the unemployment rates have gone up, the direct and indirect taxes are higher and the salaries decrease. Due to the austerity measures Greek households are suffering from severe material deprivation, very low work intensity and are at risk of poverty [24]. This trend is occurring all over Greece but with different magnitude with households at sparsely populated areas being at more risk from poverty than those living in densely populated areas [25]. It would be important to see if this situation has altered Greek
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adolescents’ dietary habits. We don’t expect it to become evident in just three years but we could provide data for further research.
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Furthermore, as Cretans’ traditional dietary habits were considered among those that formed what today is called the MD [26] and [27], we chose adolescents from the city of Heraklion to study if they still have good AMD and to seek the differences between their AMD and
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AMD of the adolescents from the capital of Greece, Athens.
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Are Greek adolescents’ anthropometric, demographic, socio-economic and lifestyle characteristics related to AMD?
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Our research questions were:
Are there differences between adolescents living in the greater urban area of Athens and in Heraklion- a much smaller city than Athens, in Crete- regarding their dietary
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habits?
MATERIALS AND METHODS
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Study Design
We carried out an extensive survey of 525 adolescents, 275 residents of Athens and 250 residents of Heraklion, Crete. The study was conducted during the months of March and April of 2012. Using a random stratified sampling method, we distributed 525 questionnaires in 8 public high schools and lyceums from all over Athens and Heraklion. Classes were selected based on availability and cooperation. In terms of socio- economic status, according to the authors’ estimates and the teachers’ personal views, pupils were from all types of 5
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families with parents having different educational levels, employment and economic status. The adolescents took part in the study voluntarily during formal school hours, after informed consent forms were signed by the corresponding parent or guardian. The sample was
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informed about the objectives and methods of the study, about the confidentiality of their answers and their right to refuse to take part in the survey and was given instructions on how to fill in the questionnaire. The researcher was present at the classroom in order to provide
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guidance. Completion of the questionnaires lasted approximately 30 minutes. The survey was approved by the Department of Research, Documentation and Educational Technology of the
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Pedagogical Institute of Greece with Protocol Number: 24404/ Γ2. Instruments
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Independent variable measures were developed for the research. The specifically designed self administrated questionnaire included questions about adolescents’ anthropometric, demographic, socio- economic and lifestyle characteristics such as sedentary and physical
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activities, dietary habits and the KIDMED test, which evaluates the degree of AMD [17].
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The anthropometric questions involved self- reported data about gender, age, height and weight. The demographic questions intended to provide information about the place of residence. Parental educational status, parental employment status and family income were used as indicators of socioeconomic status. Nonetheless, only half of the pupils (56.4%) gave us information about their family’s income, therefore we excluded this variable from further analysis.
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As far as lifestyle characteristics are concerned, adolescents were asked about their family structure (living with parents, living with mother, living with father), the frequency of going out per week, the frequency of getting involved in hobbies per week, the average hours they
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sleep during a day. In order to find out about sedentary activities we asked the adolescents about the number of hours they spent on homework per day, the hours spent on TV/DVD watching during weekdays and weekends and the hours spent on PC games or surfing the
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web per day. In order to find out about physical activities we asked the adolescents about the frequency of exercise they get per week and for dietary habits, we asked questions about the
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meals they choose to eat every day and the meals they eat with their parents.
AMD was assessed using the KIDMED test [17] which was created to estimate AMD in children and young adults based on the principles that support the Mediterranean style dietary patterns and those that undermine it. KIDMED test classifies individuals into three categories
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(KIDMED index) according to their answers to 16 yes or no questions: 12 of them denote a positive connotation with respect to the MD (and they are assigned a value of+ 1) and 4 of them denote a negative connotation with respect to the MD (and they are assigned a value of
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- 1). If the score is> 8 the responder has an optimal MD. If the score is between 4- 7 improvements need to be made to reach the MD patterns and if the score is ≤ 3 the diet’s
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quality is very low.
The BMI (kg/ m2) of each participant was calculated according to the weight and height he/ she reported. Greek adolescents were categorized accordingly as underweight, normal weight, overweight or obese following the International Obesity Task Force sex- and agespecific BMI cut- off points [28].
Data Analysis 7
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All data analyses were performed by the use of IBM SPSS 19.0, (SPSS version 19.0, IBM
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Corp. Armonk, NY, 2010) and the level of statistical significance was set at alpha < 0.05. Continuous variables were presented as means± SD and Students’ t test was applied for the evaluation of differences between means of normally distributed variables for the two
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genders or between adolescents from Athens and Heraklion. Categorical variables were presented as relative frequencies (%).The chi-square test was used for evaluating differences
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between demographic and lifestyle characteristics of adolescents from Athens and Heraklion and between KIDMED test, gender and place of residence. In order to explore our research questions we used Ordinary Least Squares (OLS). This regression analysis is used to predict the value of one variable on the basis of other variables with the development of a mathematical equation that describes the relationship between the variable to be forecast-
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AMD- and the variables which are believed to be related to the depended variableanthropometric, demographic, socio-economic and lifestyle characteristics. OLS was estimated for total KIDMED score on independent variables as these are presented below-
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statistically non-significant variables were omitted from the model:
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KIDMEDi = a0 + a1age + a2 residence + a3educmother + a4livewith + a5computer + a6 noexercise + ει
where KIDMEDi is a quantitative variable indicating the AMD, αο is the constant term, age is the responder’s age, residence is a dummy variable (1= Heraklion and 0= Athens), educmother is a dummy variable (1= mother has higher educational status (university degree) and 0= otherwise), livewith is a dummy variable (1= lives with both parents and 0= otherwise), computer is a dummy variable (1= daily use of computer> 4 hours and 0=
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otherwise), noexercise is a dummy variable (1= no physical activities and 0= otherwise) and finally, ει is the error term of the regression.
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RESULTS
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From the sample in Athens, 58.2% were girls and 41.8% boys, while from the sample in Heraklion, 62.4% were girls and 37.6% boys. The age of the participants was between 12 and
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18 years with mean age 14.7 (±1.7) years. Greek adolescents in our sample were 1.67m (±0.09) in height and weighed 58.5kg (±12.3).
Most of our sample (76.1%) was considered of normal weight, 7.4% underweight, 14.6% overweight and 1.9% obese. No statistically significant correlation (P> .05) was found
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between BMI and AMD.
The anthropometric characteristics, BMI and KIDMED scores of adolescents in Athens and Heraklion are presented in Table 1 and their demographic and lifestyle characteristics are
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(Table 1)
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presented in Table 2.
(Table 2)
Data presented in Table 2 reveal that adolescents living in Athens study more than those living in Heraklion and adolescents in Heraklion more often have breakfast and lunch (65.2% and 100.0% in Heraklion in contrast to 48.4% and 94.5% in Athens respectively).
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Table 3 summarizes the empirical results of the OLS equation’s estimated coefficients with respect to the total score of KIDMED. All the estimated coefficients of the independent
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variables have the expected sign and are statistically significant.
(Table 3)
Higher AMD is found in younger more than older adolescents and those living in Heraklion
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more than in Athens. More specifically, it was estimated that holding all other variables fixed, as the age of the adolescents increases by one year, the KIDMED score decreases.
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Furthermore, we estimated that the KIDMED score of adolescents living in Heraklion is higher than those living in Athens. Results also show that adolescents whose mother has a high educational level have a higher KIDMED score than those in other categories and this difference is statistically significant with P< .01. The mother’s educational level is the factor
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that most affects the KIDMED score.
As for lifestyle characteristics, higher AMD is found in adolescents living with both parents. On the other hand, lower AMD is found when adolescents spend more than 4 hours a day in
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front of their computer and when they do not do physical activity. It is very important to say that both of these coefficients were estimated as having high negative values and a high level
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of significance.
The percentages of adolescents’ positive answers to the KIDMED test and the distribution (%) of KIDMED index by gender and place of residence are presented in Table 4.
(Table 4)
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Data presented in Table 4 reveals that boys have a better adherence to healthier dietary habits than girls, although the KIDMED index reveals no differences between the two genders. In particular, more boys than girls are found to consume a second fruit every day, more boys
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than girls consume cereals or grains for breakfast, more boys than girls consume nuts regularly (at least 2- 3times/ week), boys skip breakfast less often than girls and boys consume dairy products for breakfast more often than girls. On the other hand, more girls
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girls than boys eat fast food more than once a week.
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than boys are found to consume fresh or cooked vegetables regularly once a day and fewer
Adolescents living in Heraklion, compared to those living in Athens, consume more fruits and fresh or cooked vegetables daily, consume pulses more often, consume cereals or grains for breakfast in a greater percentage and consume less yoghurt and/ or cheese.
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DISCUSSION
Greek adolescents’ AMD was found to be low- just 21% of the total sample had very good
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AMD- but better than relevant findings five years ago [18] when only 8% of Greek
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adolescents reported an optimal KIDMED score.
In Greece, socioeconomic factors having impact on adolescents’ AMD have not been thoroughly investigated. Although many studies suggest that children in lower-income families are more vulnerable to becoming obese due to poor dietary habits, in our study the findings revealed a very low percentage (1.9%) of obese adolescents and no statistical significant correlation (P> .05) was found between BMI and AMD.
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We assume that adolescents’ higher AMD during the period of the economic recession in Greece is due to the fact that the MD is based on cereals, fresh fruits and vegetables, pulses and olive oil, products that are sold at relative low prices in Greece. Maybe the economic
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recession has helped the Greek people adhere to a better quality diet that does not cost much, in contrast with a diet based on increased consumption of meat and other processed products.
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Also, Heraklion is an area in Crete with a major amount of agricultural and livestock selfproduction and self- sufficiency. Many families could possibly consume more of their crops/
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products during the period of economic recession.
Furthermore, our findings about the determinants of adolescent’s AMD also agree with previous literature. These determinants are anthropometric characteristics such as age, demographic and socioeconomic characteristics such as place of residence and maternal educational status, lifestyle characteristics such as the time spent on physical and sedentary
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activities and family structure. Specifically, we estimated higher AMD in younger adolescents [8] and [18]. It is of major concern to realize that as Greek children become older
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they tend to abandon traditional diet models.
Our study indicates higher AMD among adolescents whose mother has a higher educational
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level, a finding in line with many other studies [16], [18], [29] and [30]. In particular, results show that mother’s educational level is the factor that most influences adolescents’ AMD.
Lower AMD is found among adolescents that spend many hours using their computer and adolescents that do not engage in physical activity. Previous literature also correlates children’s poor dietary habits with screen watching [18], [31] and [32] and reduced physical activity [18] and [32]. 12
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Furthermore, adolescents who live with both parents have a higher AMD. Previous literature suggests that adolescents’ families’ structure influences some of their dietary habits [33].
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Finally, adolescents from Heraklion still have a higher AMD than the residents of a big urban capital such as Athens [19] and [34].
The results of this study support the idea that Greece has to take initiatives to promote
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healthier dietary models, healthier life style and better AMD among adolescents. It is highly recommended that the state organize school-based programs and interventions promoting the
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MD. Also, a curriculum with more emphasis on physical activities is recommended, especially among older adolescents, as they tend to have lower AMD. Finally, communitybased educational programs among mothers with lower educational levels could help them adapt and change their families' diet to the healthier choice of the MD.
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Limitations
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One study limitation is the lack of data about the family’s economic status, as it is considered an important factor affecting adolescents’ dietary habits. Another limitation is the use of self
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reported data as they could not be independently verified. Lack of data from adolescents living in other parts of Greece does not permit us to make generalizations for the whole Greek adolescent population.
CONCLUSION
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In this study conducted during an economic recession, adolescents' AMD is associated with age, maternal educational status, family structure, time spent on the computer, frequency of
AMD after the economic recession would be very interesting.
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Table 1. Age, Anthropometric Characteristics, BMI and KIDMED Score of Adolescents from Athens (n= 275) and Heraklion (n= 250).
Heraklion
Girls
Boys
Girls
Boys
Girls
n
115
160
94
156
209
316
(%)
(41.8)
(58.2)
(37.6)
(62.4)
(39.8)
(60.2)
Age
14.3
14.7
14.9
14.8
14.6
14.8
(±1.5)
(±1.7)
(±1.7)
(±1.8)
(±1.6)
(±1.7)
60.7
55.6
66
55.5
63.0
55.6
(±14.0)
(±9.4)
(±14.7)
(±9.7)
(±14.5)
(±9.5)
1.7
1.6
1.7
1.6
1.7
1.6
(±0.11)
(±0.07)
(±0.10)
(±0.07)
(±0.11)
(±0.07)
21
20.3
22
20.5
21.5
20.6
Height (m)
KIDMED score
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BMI
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Weight (kg)
(±3.4)
(±2.9)
(±3.5)
(±2.9)
(±3.5)
(±2.9)
5.4
5.4
6.3
5.6
5.8
5.5
(±2.4)
(±2.3)
(±2.0)
(±2.3)
(±2.3)
(±2.3)
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BMI indicates Body Mass Index
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Boys
Total Sample
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Athens
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Table 2. Demographic and Lifestyle Characteristics of Adolescents from Athens (n= 275) and Heraklion (n= 250).
Heraklion
Total
(%)
(%)
(%)
Lower education (≤ 12 years)
66.3
70.0
Higher education (> 12 years)
31.6
28.0
62.1
67.6
64.7
37.1
32.0
34.7
92.4
90.0
92.1
0.7
0.8
0.8
6.2
4.8
5.5
Employed
76.1
75.6
75.8
Householding
17.1
20.0
18.5
Unemployed
6.9
4.4
5.7
Both parents
86.5
88.8
87.8
Mother only
10.9
11.2
11.1
Father only
2.2
-
1.1
5.1
5.2
5.1
Lower education (≤ 12 years) Higher education (> 12 years) Father’s employment (%) * Employed
Householding
TE D
Unemployed
M AN U
Mother’s educational level (%)
68.3 29.9
SC
Father’s educational level (%)
RI PT
Athens
AC C
EP
Mother’s employment (%)
Living with (%)
Going out/ week (%) Not at all
ACCEPTED MANUSCRIPT
24.7
22.4
23.6
2- 3 times/ week
53.5
46.8
50.3
4- 5/ week
7.6
10.0
8.8
daily
8.7
15.6
12.0
Not at all
20.7
16.0
1/ week
20.7
20.4
2- 3 times/ week
31.6
41.6
36.4
4- 5/ week
8.7
8.4
8.6
TV/ DVD watching weekdays (%) Not at all About 1 hour
20.6
18.2
13.2
15.8
8.0
7.6
7.8
38.5
38.4
38.5
40.0
38.4
39.2
TE D
2- 3 hours
M AN U
daily
18.5
SC
Hobbies/ week (%)
RI PT
1/ week
About 4 hours
9.1
8.0
8.6
> 4 hours
4.4
7.6
5.9
Not at all
6.9
6.8
6.9
About 1 hour
18.9
22.8
20.8
2- 3 hours
42.9
45.6
44.2
About 4 hours
17.8
13.6
15.8
> 4 hours
13.5
11.2
12.4
Not at all
12.0
9.2
10.7
About 1 hour
44.4
40.4
42.5
AC C
EP
TV/ DVD watching weekends (%)
PC games or Internet/ day (%)
ACCEPTED MANUSCRIPT
2- 3 hours
31.6
38.4
34.9
About 4 hours
6.5
4.0
5.3
> 4 hours
5.5
8.0
6.7
9 hours
8.4
13.6
About 1 hour
3.6
8.0
M AN U
Not at all
38.1
50.9
10.9
SC
Studying hours/day (%) *
RI PT
Sleeping hours/ day (%)
5.7
22.9
30.4
26.5
43.3
43.6
43.4
19.3
9.6
14.7
10.9
8.4
9.7
64.7
63.2
64.0
48.4
65.2
56.4
94.5
100.0
97.1
47.6
53.2
50.3
Eat dinner (%)
78.5
78.4
87.5
Eat breakfast with parent/ s (%)
17.5
18.4
17.9
Eat brunch with parent/ s (%)
0.7
0.4
0.6
Eat lunch with parent/ s (%) **
64.7
85.6
74.7
Eat evening with parent/ s (%)
9.5
6.8
8.2
Eat dinner with parent/ s (%)
55.6
55.6
55.6
8.0
9.2
8.6
2- 3 hours About 4 hours > 4 hours
Eat brunch (%) **
Eat lunch (%) **
AC C
EP
Eat evening (%)
TE D
Eat breakfast (%)
Frequency of exercise/ week (%) Not at all
ACCEPTED MANUSCRIPT
10.9
11.6
11.2
2- 3 times/ week
43.3
39.2
41.3
4- 5/ week
19.6
21.6
20.6
daily
18.2
18.4
18.3
RI PT
1/ week
(*) and (**) signify statistically significant differences at P< 0.05 and P< 0.01 level respectively
AC C
EP
TE D
M AN U
SC
Chi-square test was used
ACCEPTED MANUSCRIPT
Table 3. Estimated Linear Regression of KIDMED Score (n= 520).
Coefficients
Constant
6.689 ** (7.66)
Age
-0.130 * (-2.24) 0.536 **
SC
Residence in Heraklion
RI PT
Independent variables
(2.78)
M AN U
Higher education of
0.677 **
mother
(3.38)
Living with both parents
0.601 *
TE D
(2.06)
Daily use of computers (>
-1.162 **
4h)
AC C
EP
No physical activities
(-3.01)
-1.199 **
(-3.55)
(**) and (*) represent levels of significance P< 0.01and P< 0.05 respectively
Ordinary least squares regression was used
t- statistics are presented in parentheses
ACCEPTED MANUSCRIPT
Table 4. KIDMED index and Percentages of Greek Adolescents’ Positive Answers to the KIDMED test by Gender and by Place of Residence (n= 525).
Girls
Athens
Heraklion
(%)
(%)
(%)
(%)
Fruit or fruit juice daily
86.5
81.6
81.4
86.0
Second serving of fruit daily
50.5*
41.1*
39.4**
50.8**
Fresh or cooked vegetables daily
48.1**
60.8**
50.0**
62.0**
14.1
13.3
16.0
34.6
33.2
34.7
32.8
34.1**
22.5**
28.1
26.0
74.5
74.4
68.2**
81.2**
Pasta or rice almost daily (≥ 5/ week)
35.6
37.0
36.9
36
Cereal or cereal product for breakfast
78.7**
67.4**
68.1*
76.0*
34.1**
20.6**
27.4
24.4
96.2
94.3
93.4
96.8
Skips breakfast
31.3*
40.6*
35.9
38.0
Dairy product for breakfast
79.3*
72.5*
77.7
72.4
5.8
8.2
7.0
7.6
Two yoghurts and/ or some cheese daily
45.6
42.7
48.5*
38.8*
Sweets and candy several times a day
21.6
19.3
23.0
17.2
Fresh or cooked vegetables> 1/ day
Regular fish consumption (at least 2- 3/ week)
> 1/ week fast food (hamburger) restaurant
TE D
Pulses> 1/ week
15.4
SC
Boys
M AN U
KIDMED test
Residence
RI PT
Gender
week)
EP
Regular nut consumption (at least 2- 3/
AC C
Use of olive oil at home
Commercially baked goods or pastries for breakfast
ACCEPTED MANUSCRIPT
KIDMED index 15.4
19.6
21.5
14.0
Medium (4- 7)
61.1
61.1
59.5
62.8
High (≥ 8)
23.6
19.3
RI PT
Poor (≤ 3)
19.0
(*) and (**) signify statistically significant differences at P< 0.05 and P< 0.01 level respectively
AC C
EP
TE D
M AN U
SC
Chi-square test was used
23.2
ACCEPTED MANUSCRIPT
Highlights
We evaluate Greek adolescents’ Adherence to the Mediterranean Diet (AMD)
•
We find Greek adolescents’ AMD to be low
•
We estimate higher AMD in younger adolescents, among adolescents whose
RI PT
•
•
We estimate lower AMD among adolescents that spend many hours using
M AN U
their computer and do not engage in physical activity
•
SC
mother has a higher educational level, who live with both parents, and in Heraklion
Greece has to take initiatives to promote healthier life style and better AMD
AC C
EP
TE D
among adolescents