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Background: The present study aimed to examine how different meal and snack patterns are associated with micronutrient intakes and diet quality among a nationally representative sample of Greek children and adolescents aged 1–19 years from the cross‐sectional Hellenic National Nutrition and Health Survey (n = 598). Methods: Meal and snack patterns were derived using 24‐h dietary recalls. Mean adequacy ratio (MAR) was used as an overall measure of diet quality. Multiple linear regression adjusted for covariates was conducted to examine associations between eating patterns, nutrient intakes and MAR. Results: Four most frequently reported eating schemes were identified including breakfast (B), lunch (L), dinner (D) and two snacks (S) (20.9%); B, L, D and 1S (16.2%); B, L, D and 3S (10.8%); and B, L and D (7.9%). Based on these schemes, the daily consumption of all main meals from the majority of the sample was highlighted. In children and adolescents aged 4–19 years, increasing snack frequency was positively associated with intakes of vitamin D, vitamin K, riboflavin, niacin, pantothenic acid, folate, magnesium, copper and selenium. An inverse association was recorded for vitamin E, vitamin B6, calcium and iron. Among children aged 1–3 years, only niacin and copper were significantly associated with number of snacks, with the group of 'B‐L‐D‐2S' presenting the highest intake. As for the overall diet quality, among all participants, there was no significant association of MAR with the type of meal and snack pattern, and thus the snack frequency. Conclusions: Snacking behaviour is a common practice among children and adolescents. Modifying current snack foods with nutrient‐rich choices could lead to an improvement of their diet's nutritional quality. [ABSTRACT FROM AUTHOR]

Background: The present study aimed to assess micronutrient intake among Greek adults and to identify the main food sources that contribute to it., Methods: Food consumption data from 2389 participants in the Hellenic National Nutrition and Health Survey (HNNHS), collected with 24-h recalls, was used to calculate micronutrient intakes. Usual nutrient intake was estimated according to the National Cancer Institute method. Nutrient adequacy was estimated using the estimated average requirement (EAR) cut-point method, when available, or adequate intake otherwise. The probability approach was used to determine iron intake adequacy in females of reproductive age. Food group contribution for each nutrient assessed was derived to identify their main food sources., Results: Almost all individuals had vitamin D intake below EAR, whereas vitamins A, E, K and C, as well as potassium intake, were also insufficient in a considerable percentage of the population (>70% in most age groups). Calcium intake was substantially below the EAR for females aged >50 years and males >70 years; the same for magnesium in males >70 years. Furthermore, 50% of females, including those of reproductive age, had intake of folate below EAR. More than 50% of the population (to 79%) exceeded the upper tolerable limit for sodium (2300 mg day -1 ). Food contribution analysis revealed that most vitamins were derived from low-quality foods (i.e. fast-food)., Conclusions: A significant proportion of adults residing in Greece have low nutrient intake and poor food selections. These results provide guidance to public health policy makers for developing strategies to improve the dietary quality in Greece., (© 2021 The British Dietetic Association Ltd.)

Objective: To assess the usual dietary intake of twenty micronutrients and to identify their food sources in a representative sample of Greek children and adolescents., Design: Cross-sectional data from the Hellenic National Nutrition and Health Survey (HNNHS). Vitamin and mineral intakes were estimated from two 24 h dietary recalls by sex and age groups. Estimates were calculated using the National Research Council method and the statistical software package Stata13 to account for within- and between-person variations. The prevalence of nutrients' inadequacy among sample was estimated using the estimated average requirement (EAR) cut-point method. The contribution of food groups to nutrient intake was estimated to identify micronutrients food sources., Setting: Greece., Participants: Children and adolescents aged 1-19 years (n 577) who provided sufficient and plausible 24-h recalls., Results: A substantial percentage of children and adolescents had insufficient intakes of numerous micronutrients. Usual intake of vitamins D, K and potassium was inadequate in practically all individuals. Vitamin A, folate, Ca and Mg were also insufficient to a considerable percentage, especially in girls aged 14-18 years. Pantothenic acid was highlighted as nutrient of interest since only one out of ten boys 9-13 years and girls 14-19 years had intake above the EAR. Data demonstrated that food groups highly ranked in energy contribution were not necessarily important sources of micronutrients., Conclusions: Results suggest that micronutrient density of Greek children and adolescents' diet should be improved. These findings might be used by public health policy-makers to help young people optimise their food choices in Greece.

Objectives: Globally, vitamin D intake from food and supplements is low, consistent with the high prevalence of low serum 25-hydroxyvitamin D concentration. The aims of this study were to assess vitamin D intake and major relevant food contributors among Greek adults and to propose subsequent policies for intervention., Methods: Vitamin D from diet and supplements was estimated in adults (≥19 y of age) from two 24-h recalls using the Automated Multiple-Pass Method (vitamin D from food intake) and a drug and supplement questionnaire (vitamin D supplements). Over- and underreporters were identified using the Goldberg cutoff. The final analysis included 2218 individuals. The National Research Council method was used to account for within- and between-person variation. Vitamin D food intake adequacy was estimated based on the estimated average requirement (EAR) of 10 mcg/d, set by the Institute of Medicine. Major foods contributing to intake were identified and the effect on meeting EAR, of a potential food fortification example was examined., Results: Median vitamin D intake from food ranged from 1.16 to 1.72 and 1.01 to 1.26mcg/d in different age groups in men and women, respectively. Major food sources of vitamin D were fish (46%), meat (15%), and cereals (12%); however, >90% of the population in all age groups failed to meet the EAR, even when supplemental use was accounted for (~5% of the population consumed supplements)., Conclusion: Overall vitamin D intake is below the average requirements. Public health policies to increase the consumption of foods high in vitamin D or food fortification may significantly reduce the percentage of individuals who do not meet the recommendations., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Hypertension is a major risk of cardiovascular diseases. This study's aim was to examine associations between hypertension and a priori known lifestyle risk factors, including weight status and Mediterranean diet adherence. The study included a representative sample of the adult population (N = 3775 (40.8% males)), from the Hellenic National Nutrition and Health Survey (HNNHS), which took place from September 2013 to May 2015. Demographic and anthropometric data were collected using validated questionnaires, and blood pressure (BP) measurements were performed for the two main metropolitan areas (N = 1040; 41.1%). Hypertension diagnosis was according to the International Classification of Diseases (ICD-10) guidelines. Weighted proportions, extended Mantel-Haenszel (M-H) analyses, and multiple logistic regressions (for the survey data) were performed. Mean systolic BP (SBP) and diastolic BP (DBP) were 118.6 mmHg and 72.2 mmHg respectively, with both values being higher in males compared to females in all age groups ( p < 0.001). Study participants with hyperlipidemia or diabetes, and those overweight, were almost twice as likely to be hypertensives, with the odds increasing to 4 for those obese ( p for all, < 0.05). Stricter Mediterranean diet adherence significantly decreased the likelihood of hypertension by 36% (OR: 0.64; 95% CI: 0.439, 0.943), and a significant interaction was found between Mediterranean diet adherence and weight status on hypertension. The presence of hypertension is clustered with comorbidities, but is significantly associated with modifiable risk factors, including Mediterranean diet and weight status, underlining the need for personalized medical nutritional treatment.

Background and Aims: Empirically-derived dietary patterns have been shown to have both positive and adverse associations with cardiovascular disease (CVD). Yet, such associations remain unclear in the Greek population. The aim of this study was to investigate the association between empirically-derived dietary patterns and the presence of CVD and CVD-related medical conditions in a nationally representative sample of Greek adults., Methods and Results: Adult participants (≥20 years old) of the Hellenic National Nutrition and Health Survey (HNNHS) were included (N = 3552; 41.2% men; 43.7 years, SD: 18.1). Dietary patterns were derived by principal component analysis using 24-h recall data. The presence of dyslipidemia (elevated cholesterol and/or triglycerides), hypertension, coronary heart disease, and total CVD, was defined according to the International Clinical Diagnosis (ICD)-10 codes. Odds ratios of CVD outcomes were estimated across dietary patterns using multivariable logistic regression analysis. Three dietary patterns -Traditional (proxy Mediterranean), Western, and Prudent-were identified explaining 16.5% of the total variance in consumption. Logistic regression analysis, adjusted for age, sex, total caloric intake, sociodemographic characteristics, and other CVD risk factors, showed an inverse association between the Traditional dietary pattern and CVD presence (OR: 0.53; 95% CI: 0.30-0.95), and a positive association between the Western pattern and dyslipidemia (1.52; 1.02-2.26). No association was found between the Prudent pattern and CVD outcomes., Conclusion: The variability of food intake combinations in the Greek population seem to be associated with the presence of CVD and CVD related conditions. Such findings are imperative for national monitoring and informed priority setting., Competing Interests: Declaration of Competing Interest RM reports grants from NIH/NHLBI, grants from Unilever R&D, grants from Bill and Melinda Gates Foundation, personal fees from World Bank and personal fees from Bunge., (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. All rights reserved.)

Objectives: A long-term abnormal blood lipid profile increases the risk of cardiovascular disease (CVD). A probable protective role may be played by the Mediterranean diet. The aim of this study was to assess prevalence of dyslipidaemia, assess blood lipid status and treatment and examine the association between blood lipids, dyslipidaemia and Mediterranean diet., Methods: Data were from the Hellenic National Nutrition and Health Survey (HNNHS). Data from 3775 adults (40.8% males) were obtained by trained personnel and disease status was categorized according to the International Classification of Diseases codes (10th version). Blood lipid measurements were obtained from a subsample ( N  = 1080, mean age 40.1 years; 37.8% male). The Mediterranean diet score (MedDiet score) was calculated from 24-h recalls. The relationships between higher MedDiet score (>23), lipid levels and status were examined using linearized multiple linear and logistic regressions, respectively., Results: In total, 20.7% of the population was dyslipidaemic, with 59.0% (no sex differences) receiving treatment, and 46.6% of the treated having a normal lipid profile. Lipid status awareness was 35.5% (64.5% unaware). Males aged 19-39 had higher total cholesterol, low-density lipoprotein cholesterol and triglycerides, and lower high-density lipoprotein cholesterol levels than females (in mg/dl; p for all <0.05); these were significantly higher in overweight and obese individuals in all age groups, except high-density lipoprotein cholesterol ( p for all <0.001). Higher MedDiet score was associated with significantly lower low-density lipoprotein cholesterol in the pooled sample (-6.39 mg/dl; 95% confidence interval (CI): -12.60, 0.17), in all males (-10.61 mg/dl; 95% CI: -19.89, -1.34) and in overweight and obese males (-15.6 mg/dl; 95% CI: -29.25, -1.94)., Conclusion: This study underlines the abnormal lipid profile in the young, mostly male, population who are highly unaware and under-treated.

Background & Aims: Serum 25(OH)D deficiency is becoming an epidemic. The aim was to assess vitamin D status of the adult Greek population in relation to intake, sun exposure and other factors, using data from the Hellenic National Nutrition and Health Survey (HNNHS)., Methods: Data from 1084 adult participants (37.8% males) were analyzed. Vitamin D intake was assessed using 24-h recalls. Serum 25(OH)D concentration was evaluated and related to anthropometric measurements and other covariates including supplements used, by sex. Variables significantly associated with 25(OH)D < 20 ng/ml were assessed using simple and multiple logistic regression., Results: Median vitamin D intake from food was 1.23 mcg/day (0.60, 2.44), with 9.1% consuming supplements. Median serum 25(OH)D was 16.72 ng/ml, with no sex differences (P = 0.923). The odds of having 25(OH)D < 20 ng/ml significantly decreased with being very active (OR 0.55, 95% CI 0.35, 0.98), increasing length of sun exposure [1-3 h/day (OR 0.59, 95% CI 0.44, 0.80), >3 h/day (OR 0.36, 95% CI 0.24, 0.55)], and skin colour [light to medium skin (OR 0.47, 95% CI 0.24, 0.91), fairly dark skin colour (OR 0.34, 95% CI 0.17, 0.67) and dark or very dark skin colour (OR 0.34, 95% CI 0.15, 0.75)], compared to respective baseline levels. The odds significantly increased with obesity (OR 1.95, 95% CI 1.24, 3.08), and spring season of blood sample collection (OR 1.75, 95% CI 1.22, 2.50)., Conclusions: Vitamin D deficiency is highly prevalent in Greek adults. Relevant public health policies are highly recommended, which could include vitamin D fortification. and suggestion for increased but safe sun exposure., (Copyright © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Background: Gaps remain on the safety of egg intake on cardiovascular health, setting the study's aim to investigate the association between quantity and frequency of egg consumption, with established dyslipidemia., Methods: Study participants ( N = 3558, 40.3% males) included individuals from the Hellenic National and Nutrition Health Survey (HNNHS), of national representation. Quantity and frequency of egg consumption was determined. Minimally adjusted, multivariable logistic and linear analysis were used to assess egg consumption and dyslipidemia., Results: The more frequent egg consumption compared to no or rare egg consumption significantly decreased the odds of dyslipidemia in the minimally adjusted (Odds Ratio (OR) for frequency: 0.83; 95% Confidence Interval (CI): 0.752, 0.904; OR for quantified frequency: 0.87; 95% CI: 0.796, 0.963) and the fully adjusted models (OR for frequency: 0.80; 95% CI: 0.718, 0.887; OR for quantified frequency: 0.85; 95%CI: 0.759, 0.945). Level of serum cholesterol and LDL-c were significantly lower with higher frequency and quantified frequency of egg consumption in all models., Conclusion: Eggs do not increase the risk of dyslipidemia and can be consumed as part of a healthy diet that is high in fiber and low in saturated fat, without excessive energy intake, by all individuals.

Background: The aim of the Hellenic National Nutrition and Health Survey was to assess nutritional intake, health status and various behaviors in a representative sample of the Greek population., Methods: Data collection took place from 01.09.2013 to 31.05.2015. Random stratified sampling was performed by (a) geographical density criteria of Greece (7 regions), (b) age group of the reference population (< 19, 20-64 and > 65 years) and (c) gender distribution. The final population enrolled included (throughout Greece), 4574 individuals (42.5% men; 57.5% women of who 47.2% were from Athens metropolitan area, 18.5% from Central Macedonia, and the remaining 34% almost equally scattered throughout the country (p for the comparisons with official statistics by region, age group and sex > 0.7). Questionnaires developed were based on extensive review of the literature, following a validation procedure when necessary., Results: Preliminary analyses revealed that 32% of the adult population were overweight and 15.5% were obese, with significant gender differences in total and per age group (p < 0.001, for all). The majority of the adult population reported being active smokers (50.4%) or regular alcohol consumers (72.4%); with significant gender differences (p < 0.001, for all). Prevalence of hyperlipidemia was 16.7%, cardiovascular disease 13.9%, hypertension 13.3%, thyroid disease 13.8%, and Diabetes Mellitus 3.6%. Significant gender and age group differences were found in various diseases., Conclusions: Study's preliminary results provide valuable information about the Hellenic population's health. Findings from this survey could be used to detect disease risk factors for public health prevention policies and programs.

Background: School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear., Objective: To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children., Methods: We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children's dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg's and Egger's test evaluated potential publication bias., Results: From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified., Conclusions: Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.

Background: Eating frequency (EF) has been associated with generalized obesity., Aim: We aimed to prospectively investigate potential associations of frequency of eating episodes with regional fat layers., Design: EF was evaluated at baseline in 115 subjects free of clinically overt cardiovascular disease (54 ± 9.1 years, 70 women) in a prospective, observational study., Methods: Metabolic parameters known to be associated with dietary factors and anthropometric markers including ultrasound assessment of subcutaneous (Smin) and pre-peritoneal (Pmax) fat and their ratio Smin/Pmax (AFI) were evaluated at baseline and at follow-up, 5 years later., Results: EF at baseline positively correlated with Pmax, even after adjustment for potential confounders. EF above median was also an independent predictor for Pmax (beta coefficient = -0.192, P = 0.037) and AFI (beta coefficient = 0.199, P = 0.049) at follow up. Multivariable linear mixed models analysis demonstrated that subjects with increased EF presented a lower progression rate of Pmax (beta = -0.452, P = 0.006) and a higher progression rate of AFI (beta = 0.563, P = 0.003) over time, independently of age, sex, progression of BMI, energy intake, smoking and changes in parameters of glucose metabolism., Conclusions: High EF is associated with lower progression rate of pre-peritoneal fat accumulation. Future interventional studies should further investigate the clinical utility of these findings., (© The Author 2017. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com)