Healthcare | Free Full-Text | Adherence to the Mediterranean Diet in Children and Adolescents and Association with Multiple Outcomes: An Umbrella Review

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Healthcare | Free Full-Text | Adherence to the Mediterranean Diet in Children and Adolescents and Association with Multiple Outcomes: An Umbrella Review


Bujtor et al. [26]
2021
Australia, Spain, UK Type of review: systematic review
10/53 included studies:
10 observational studies Sample size = 5661/51,556
Age = 6.5–18 y
Countries = Colombia, Portugal, Austria, Belgium, France, Gerseveral, Greece, Hungary, Italy, Spain, Sweden, USA, Turkey Inflammation markers:
CRP, TNF-alpha, IL-1, IL-2, IL-6, TGF-Beta1, sVCAM1, IL-4, IL-17, IL-33 KIDMED;
m-KIDMED;
MDS;
m-MDS;
ad hoc score MD and CRP
Inverse significant association: 2 studies (only 1 in females)
Direct significant association: 1 study (only in males)
Non-significant association: 6 studies (1 in DMT1 patients and 3 in obese/overweight patients)
MD and IL-1
Inverse significant association: 1 study
Non-significant association: 1 study
MD and IL-2
Inverse significant association: 1 study
Non-significant association: 1 study
MD and IL-6
Inverse significant association: 1 study
Non-significant association: 3 studies (1 in DMT1 patients)
MD and TNF-alpha
Inverse significant association: 1 study
Non-significant association: 3 studies
MD and TGF-Beta1
Direct significant association: 1 study (only in males)
MD and sVCAM1
Inverse significant association: 1 study
MD and IL-4
Inverse significant association: 1 study
Non-significant association: 2 studies
MD and IL-17
Inverse significant association: 1 study
MD and IL-33
Direct significant association: 1 study (only in asthmatics) Adequate adherence to MD in healthy populations
results in decreased levels of pro-inflammatory biomarkers Heterogeneity of studies in terms of
sample size,
age of participants, biological markers considered,
index for assessing MD adherence,
health status of the populations
Studies do not consider the biological effect of food (intake versus absorption)
Currently no consensus regarding the inflammatory biomarkers best used to represent chronic low-grade inflammation in children and adolescents
Biomarker measurement errors, such as sampling, storage, and laboratory errors, cannot be excluded Eslami et al. [31]
2020
Iran Type of study:
systematic review
5/11 included studies:
5 cross-sectional Sample size = 180,898/198,271
Age = 8–18 y
Countries = Spain, Iceland, Chile, Greece PF
(20 m—SRT (stages); 20 m—SRT (VO2 max)) KIDMED MD and PF
Direct significant association: 5 studies Eligible studies showed that MD adherence was directly associated with CRF improvement Study designs
(all cross-sectional)
Did not control for major potential confounding factors (PA and total energy intake)
Most studies were conducted with populations living in developed or high-income countries García-Hermoso et al. [27]
2022
Spain, Chile Type of review: systematic review with meta-analysis
39/39 included studies:
37 cross-sectional
2, longitudinal (only data from baseline) Sample size = 565,421/565,421
Age = 6–19 y
Countries = Chile, Colombia, Israel, Portugal, Spain, Greece, Iceland, Estonia, Italy, Lithuania, Croatia, Serbia PA (instrument, i.e., actigraph,
questionnaire)
SB (screen media time or frequency; sitting time):
PF: CRF, muscular fitness, speed—agility
(Eurofit Battery,
Alpha-Fitness Battery) KIDMED MD and PA
(r = 0.14; 95% CI 0,11, 0,17; I2 88.6)
MD and CRF
(r = 0.22; 95% CI 0.13, 0.31; I2 95.7)
MD and muscular fitness
(r = 0.11; 95% CI 0.03, 0.18; I2 95.4)
MD and speed—agility
(r = –0.06; 95% CI –0.12, –0.01; I2 84.2)
MD and SB
(r = –0.15; 95% CI –0.20, –0.10; I2 97.3)
MD and SB in children
(r = –0.21; 95% CI –0.29, –0.12; I2 96.5)
MD and CRF in adolescents
(r = 0.30; 95% CI 0.12, 0.47; I2 96.5) Weak-to-moderate direct relationships between MD adherence and PA, CRF, and muscular fitness
Weak-to-moderate inverse relationship between MD adherence and SB and speed—agility
Youths with higher adherence to the MD were more likely to be physically active and fit and have a less sedentary lifestyle Heterogeneity between studies in the associations, exposure, outcomes assessment, and publication bias
Study designs (cross-sectional)
Most of the studies did not consider potential confounding factors, such as socio-economic status and/or parental education Garcia-Marcos et al. 2013 [24]
Spain, Chile, Gerseveral, Greece Type of study: systematic review with meta-analysis
7/8 included studies:
7 cross-sectional Sample size = 38,047/39,804
Age = 6–18 y
Countries = Spain, Mexico, Albania, China, Ecuador, Estonia, France, Georgia, Gerseveral, Ghana, Greece, India, Italy, Latvia, The Netherlands, New Zealand, Norway, Sweden, Turkey, UK, West Bank Asthma:
current wheeze (CW), current severe wheeze (CSW),
asthma ever (AE)
(wheeze episodes survey) KIDMED;
MDS;
m-MDS MD and CW
OR: 0.85; 95% CI 0.75–0.98; p = 0.02
Mediterranean centers: OR: 0.79; 95% CI 0.66–0.94; p = 0.009
Non-Mediterranean centers: OR: 0.91; 95% CI 0.78–1.05; p = NS
MD vs. non-MD centers: Q = 1.38; p = NS
MD and CSW
OR: 0.82; 95% CI 0.55–1.22; p = NS
Mediterranean centers: OR: 0.66; 95% CI 0.48–0.90; p = 0.008
Non-Mediterranean centers: OR: 0.99; 95% CI 0.79–1.25; p = NS
MD vs. non-MD centers: Q: 4.33; p = 0.037
MD and AE
OR: 0.86; 95% CI 0.78–0.95; p = 0.004
Non-Mediterranean centers: OR: 0.86; 95% CI 0.75–0.98; p = 0.027
Mediterranean centers: OR: 0.86; 95% CI 0.74–1.01; p = NS
MD vs. non-MD regions: Q = 0.001; p = NS Adherence to the MD is a protective factor for CW, SCW, and AE
specifically for Mediterranean centers Heterogeneity in adherence to the MD assessment
Study designs (all studies were cross-sectional)
The use of the highest vs. the lowest tertile instead of a
different approach, such as using the median as a cut-off point,
probably minimized the effect of the different scoring systems
across studies Iaccarino et al. [33]
2017
Italy Type of study: systematic review
25/58 included studies:
23 cross-sectional,
2 longitudinal Sample size = 51,781/137,846
Age = 6–19 y
Countries = Spain, Italy, Greece, UK, Cyprus, Portugal, Ireland Anthropometric variables/body composition:
BMI, WC, BF
PA (questionnaires, accelerometers)
SB (media screen time)
PF (20 m Shuttle Run test) KIDMED;
m-KIDMED;
MDS;
m-MDS MD and BMI
Inverse significant association: 8 studies
Direct significant association: 1 study
Non-significant association: 12 studies
2 prospective studies found no longitudinal relationship
MD and WC
Inverse significant association: 2 studies
Direct significant association: 1 study
Non-significant association: 4 studies
MD and BF
Non-significant association: 5 studies
MD and PA
Direct significant association: 14 studies
Non-significant association: 3 studies
MD and PF
Direct significant association: 1 study
MD and SB
Inverse significant association: 9 studies
Non-significant association: 1 study Most of the eligible studies showed that MD adherence was directly associated with physical activity and inversely associated with sedentary behavior, while the results for weight status were not consistent Study designs (most of the studies were cross-sectional)
Methodological differences and limitations in the studies included
Use of self-reported anthropometric data can have biased the association between MD adherence and weight status Koumpagioti et al. [28]
2022
Greece Type of study:
systematic Review
7/12 included studies:
5 cross-sectional,
1 case-control,
1 cohort Sample size = 33,340/34,972
Age = 6–19 y
Countries = Turkey, Greece, Peru, Lebanon, France Asthma (spirometry):
physician-diagnosed asthma,
ever asthma symptoms,
current asthma, asthma control, FEV1, FVC, Fractional Exhaled Nitric Oxide (FeNO)
Allergies:
physician-diagnosed allergic rhinitis, lifetime rhinitis, current rhinoconjunctivitis, atopic status,
current eczema KIDMED;
MDS;
m-MDS MD and asthma
Inverse significant association: 4 studies
Non-significant association: 1 study
MD and allergies
Non-significant association: 4 studies Adherence to the MD seemed to have a protective role against childhood asthma, but no effect was found on allergic rhinitis, eczema, or atopy Heterogeneity among the included studies in the designs, sample sizes, tools assessing MD adherence, participants’ ages, variable outcomes, and adjusted confounders
Study designs (most of the studies were cross-sectional) Lassale et al. [29]
2021
Spain Type of study:
systematic review
45/55 included studies:
6 RCTs,
36 cross-sectional,
3 longitudinal Sample size = 234,236/601,740
Age: = 6–19 y
Countries = Spain, Italy, Greece, Mexico, Israel, Chile, Colombia, Croatia, Lebanon, Estonia, Iceland, Iran, Lithuania, Serbia, USA, Finland, Turkey, UK Anthropometric variables: BMI, WHtR, WC, general and abdominal obesity, BF KIDMED;
m-KIDMED;
m-MDS;
MediLIFE Index;
Krece plus test MD and obesity
Intervention studies:
Before/after comparisons: significant reduction: 4 studies
With control group comparisons:
Significant differences: 2 studies
Non-significant differences: 2 studies
Observational studies:
General adiposity:
Non-significant association: 25 studies
Inverse association: 14 studies
Abdominal adiposity:
Non-significant association: 7 studies
Inverse association: 2 studies Most of the eligible studies showed limited evidence for the MD and obesity Only one of these studies was of high quality and included paternal educational level as a potential confounder in the analysis
Low quality of the included studies
Heterogeneity in the adherence to the MD assessment
Study design (most of the studies were cross-sectional) Lv et al. [30]
2014
USA Type of study:
systematic review
10/31 included studies:
9 cross-sectional,
1 cohort Sample size = 90,102/518,782
Age = 6–18 y
Countries = Greece, Spain, Mexico, Ecuador, Estonia, France, Georgia, Gerseveral, Ghana, Iceland, India, Italy, Latvia, New Zealand, Norway, Sweden, Turkey, UK Asthma:
asthma symptoms,
current
severe asthma,
ever asthma, prevalence and
severity of ever asthma,
current occasional asthma,
clinically significant asthma,
ever wheeze,
current
wheeze,
atopic wheeze,
persistent wheeze,
exercise wheeze,
wheezing ever with atopy,
lung function (FEV1, FVC),
inflammatory response
(IL-8) KIDMED:
m-KIDMED;
MDS;
m-MDS;
ad hoc score MD and asthma
Inverse significant association: 7 studies
Non-significant association: 3 studies Higher adherence to the Mediterranean Diet may be associated with reduced asthma risk in children Study designs
(most of the studies were cross-sectional)
Heterogeneity in MD adherence assessment and in asthma outcomes Papamichael et al. [32]
2017
Australia Type of study: systematic review
12/15 included studies:
9 cross-sectional,
1 case-control,
2 longitudinal (only baseline) Sample size = 100,968/103,248
Age = 6–19 y
Countries = Spain, Greece, Mexico, Turkey, Peru, Brazil, Albania, China, Ecuador, Estonia, France, Georgia, Gerseveral, Ghana, India, Italy, Latvia, The Netherlands, New Zealand, Norway, Spain, Sweden, UK, West Bank Asthma:
(ISAAC respiratory questionnaire; spirometry):
current asthma,
ever asthma,
overall lifetime
prevalence of asthma,
any asthma symptoms,
current severe asthma
(CSA),
current occasional
asthma (COA), doctor-diagnosed
asthma,
severe asthma,
exercise-induced
asthma,
asthma control,
night cough,
BHR (hyper-responsiveness),
FEV1, IL-8, FVC,
exhaled nitric oxide level (eNO),
exhaled breath condensate (EBC),
ever wheeze,
ever diagnosed
wheeze,
exercise wheeze,
wheeze limiting speech,
wheeze disturbing sleep,
current wheeze,
wheezing ever with
atopy,
wheeze in
last 12 months,
severe attacks of
wheeze,
persistent wheeze,
atopic wheeze,
atopy KIDMED,
MDS,
m-MDS MD and asthma
Inverse significant association: 8 studies
Inverse non-significant association: 2 studies
Non-significant association: 1 study
Direct significant association: 1 study Adherence to the Mediterranean dietary pattern may reduce asthma symptoms in children (limited evidence) Heterogeneity in
study methodologies,
age of participants,
and sample size
The majority of studies
were cross-sectional Romero Robles et al. [24]
2022
Peru Type of study: systematic review
9/11 included studies:
9 cross-sectional Sample size = 4654/6796
Age = 8–18 y
Countries = Spain, Greece, Portugal,
Lebanon, Italy Health-related quality of life (KIDSCREEN-10, KIDSCREEN-27,
KIDSCREEN-52,
Peds-Ql) KIDMED MD and HRQoL general score
Direct significant association: 5 studies
Direct non-significant association: 2 studies
Inverse non-significant association: 1 study
MD and HRQoL subdomains
All dimensions
Direct significant association: 1 study Physical well-being and peers and school environment subdomain
Direct significant association: 1 study Positive correlation between adherence to the MD and HRQoL Study designs (all studies were cross-sectional)
Heterogeneity of the measurements used for HRQoL Teixeira et al. [25]
2022
Portugal Type of review: systematic review
23/128 included studies:
18 cross-sectional,
1 RCT,
1 case-control,
3 cohort longitudinal Sample size = 34,266/329,898
Age = 6–17 y
Countries = Italy, Spain, Portugal, Turkey, Chile, Greece, Colombia, Morocco, Gerseveral,
Austria, Belgium, France, Hungary, Sweden, UK, England Anthropometric variables/body composition:
BMI, WC, BF, skinfold thickness, neck circumference
Clinical markers:
albuminuria, blood pressure, C-RP,
bone mineral density
Asthma (symptoms)
ADHD
(diagnosis)
Depression,
night eating syndrome KIDMED;
m-KIDMED;
MDS;
m-MDS MD and BMI
Intervention studies:
Inverse significant association: 1 study
Observational studies:
Inverse significant association: 6 studies
Direct significant association: 1 study
Non-significant association: 8 studies
MD and WC
Inverse significant association: 4 studies
Direct significant association: 1 study
Non-significant association: 1 study
MD and BF
Inverse significant association: 2 studies
MD and subscapular skinfold thickness Inverse significant association: 1 study
MD and neck circumference
Inverse significant association: 1 study
MD and albuminuria
Inverse non-significant association: 1 study
MD and blood Pressure:
Inverse significant association: 1 study Direct significant association: 1 study
Non-significant association: 1 study
MD and C-RP
Inverse significant association: 1 study
MD and bone mineral density
Direct significant association: 1 study
MD and asthma
Inverse significant association: 1 study
MD and ADHD
Inverse significant association: 1 study
MD and depression
Non-significant association: 1 study
MD and night eating syndrome
Non-significant association: 1 study Inconsistent association between MD adherence and BMI
Potential significant association between MD adherence and anthropometric variables that needs to be further investigated; the evidence is still scarce Different characteristics of studies in terms of sample size, age of participants, outcomes assessment, method of food intake consumption
Study designs (most of the studies were cross-sectional)

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