Nu ien s 2021, 13, 474. h ps://doi.o g/10.3390/nu13020474 www.mdpi.com/jou nal/nu ien s
A icle
Medi e anean Die , Sc een-Time-Based Seden a y Beha io
and Thei In e ac ion E ec on Adiposi y in Eu opean
Adolescen s: The HELENA S udy
Miguel Se al-Co es 1,*, Se gio Sab oso-Lasa 2, Alexand o Bailo-Aysa 3, Ma cela Gonzalez-G oss 4,5,6,
Dénes Molná 7, Lau a Censi 8, C is ina Molina-Hidalgo 9, F ede ic Go and 10, S e aan De Henauw 11,
Yannis Manios 12, Ch is ina Ma ogianni 12, Ku Widhalm 13, An hony Ka a os 14, Jean Dallonge ille 15,
Luis A. Mo eno 1,4, Luis Ma iano Es eban 16, Idoia Labayen 17, Pila De Miguel-E ayo 1,4 and
on behal o he HELENA S udy G oup †
1 G ow h, Exe cise, NU i ion and De elopmen (GENUD) Resea ch G oup, Facul y o Heal h Sciences,
Ins i u o Ag oalimen a io de A agón (IA2), Ins i u o de In es igación Sani a ia A agón (IIS A agón),
Uni e sidad de Za agoza, 50009 Za agoza, Spain; lmo [email p o ec ed] (L.A.M.),
[email p o ec ed] (P.D.M.-E.)
2 Gene ic and Molecula Epidemiology G oup (GMEG), Spanish Na ional Cance Resea ch Cen e (CNIO),
28029 Mad id, Spain; ssab[email p o ec ed]
3 Depa men o Physia y and Nu sing, Facul y o Heal h Sciences, Uni e sidad de Za agoza,
50009 Za agoza, Spain; abailo[email p o ec ed]
4 CIBER Fisiopa ología de la Obesidad y Nu ición (CIBERobn), Ins i u o de Salud Ca los III,
28029 Mad id, Spain; ma cela.gonzalez[email p o ec ed]
5 ImFine Resea ch G oup, Depa men o Heal h and Human Pe o mance,
Facul ad de Ciencias de la Ac i idad Física y del Depo e-INEF, Uni e sidad Poli écnica de Mad id,
28040 Mad id, Spain
6 Ins i u e o Nu i ional and Food Sciences, Nu i ional Physiology, Uni e si y o Bonn,
53113 Bonn, Ge many
7 Depa men o Pedia ics, Medical School, Uni e si y o Pécs, 7623 Pécs, Hunga y; molna .dene[email p o ec ed]
8 Depa men o Applied Science o Nu i ion, Council o Ag icul u al Resea ch and Economics, Resea ch
Cen e o Food and Nu i ion, 00198 Rome, I aly; l[email p o ec ed]
9 EFFECTS 262 Depa men o Medical Physiology, School o Medicine, Uni e si y o G anada,
18071 G anada, Spain; c iismh@co eo.ug .es
10 CHU Lille, Inse m U1286 INFINITE, Uni e si y o Lille, F-59000 Lille, F ance;
F ede [email protected]
11 Depa men o Public Heal h and P ima y Ca e, Facul y o Medicine and Heal h Sciences, Ghen Uni e si y,
9000 Ghen , Belgium; S e aan.DeHenauw@UGen .be
12 Depa men o Nu i ion and Die e ics, School o Heal h Science & Educa ion, Ha okopio Uni e si y,
176 71 A hens, G eece; [email p o ec ed] (Y.M.); [email p o ec ed] (C.M.)
13 Di ision o Clinical Nu i ion and P e en ion, Depa men o Paedia ics, Medical Uni e si y o Vienna,
Aus ia and Aus ian Academic Ins i u e o Clinical Nu i ion, 1090 Vienna, Aus ia; ku .widhalm@me-
duniwien.ac.a
14 Facul y o Medicine, Uni e si y o C e e, 715 00 C e e, G eece; ka[email p o ec ed]
15 Depa men o Epidemiology Public Heal h, Ins i u Pas eu de Lille, 59800 Lille, F ance; jean.dallonge-
[email p o ec ed]
16 Escuela Poli écnica de La Almunia, Uni e sidad de Za agoza, 50100 Za agoza, Spain; [email p o ec ed]
17 Depa men o Heal h Sciences, Public Uni e si y o Na a a, 31006 Pamplona, Spain;
idoia.labayen@una a a.es
† Membe ship o HELENA s udy g oup is p o ided in Appendix A.
* Co espondence: m[email p o ec ed]
Abs ac : Childhood obesi y is a wo ldwide epidemic. Medi e anean die (MD) is in e sely asso-
cia ed wi h childhood obesi y, bu he in e ac ion wi h o he en i onmen al ac o s, such sc een
ime, migh in luence he heal h bene i s o a high MD adhe ence in adolescen s. The aim o he
p esen s udy was o assess whe he an associa ion be ween MD and sc een ime exis s in Eu opean
adolescen s. Mo eo e , we also explo ed whe he seden a y ime has a modula o y e ec on he
Ci a ion: Se al-Co es, M.;
Sab oso-Lasa, S.; Bailo-Aysa, A.;
Gonzalez-G oss, M.; Molná , D.;
Censi, L.; Molina-Hidalgo, C.;
Go and, F.; De Henauw, S.;
Manios, Y.; e al. Medi e anean
Die , Sc een- ime-Based Seden a y
Beha io and Thei In e ac ion E ec
on Adiposi y in Eu opean
Adolescen s: The HELENA S udy.
Nu ien s 2021, 13, 474.
h ps://doi.o g/10.3390/nu13020474
Academic Edi o : Ma ia Annunzia a
Ca luccio
Recei ed: 31 Decembe 2020
Accep ed: 27 Janua y 2021
Published: 30 Janua y 2021
Publishe ’s No e: MDPI s ays neu-
al wi h ega d o ju isdic ional
claims in published maps and ins i-
u ional a ilia ions.
Copy igh : © 2021 by he au ho s. Li-
censee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and con-
di ions o he C ea i e Commons A -
ibu ion (CC BY) license (h p://c ea-
i ecommons.o g/licenses/by/4.0/).
Nu ien s 2021, 13, 474 2 o 16
associa ion be ween MD and adiposi y. Adhe ence o he MD (24 h ecalls), sc een ime (ques ion-
nai e), pube al de elopmen , body mass index (BMI), a mass index (FMI) and wais ci cum e ence
(WC) we e e alua ed in 2053 adolescen s (54.7% emales), aged 12.5–17.5 yea s. In emales, MD ad-
he ence was associa ed wi h lowe BMI and FMI only when hey we e exposed o less han 338
min/day o sc een ime (81.8% o emales); MD adhe ence was also associa ed wi h lowe WC only
when emales we e exposed o less han 143 min/day o sc een ime (31.5% o emales). No signi i-
can MD-sc een ime in e ac ion was obse ed in males. In conclusion, sc een- ime-based seden a y
beha iou s had a modula o y e ec in he associa ion be ween MD adhe ence and adiposi y in Eu-
opean emale adolescen s.
Keywo ds: Medi e anean die ; seden a y ime; adiposi y; adolescen s; gende and HELENA
1. In oduc ion
Childhood o e weigh and obesi y’s p e alence has been ising wo ldwide in ecen
yea s [1]. Recen s udies showed ha o e all, Eu opean child en con inue o s uggle wi h
high p e alence o obesi y despi e he e o in e ms o p e en ion p og ams in p e ious
yea s [2]. Me abolic synd ome and ype 2 Diabe es a e mo e likely o occu in adul hood
in hose child en and adolescen s whe e obesi y is g adually es ablishing [3]. The Medi-
e anean die a y pa e n is in e sely associa ed wi h childhood obesi y [4]. In ac , a high
Medi e anean die (MD) adhe ence om an ea ly age is ela ed o a lowe isk o o e -
weigh and obesi y de elopmen in childhood [5]. Howe e , he in e ac ion wi h o he
en i onmen al ac o s, such as sc een ime, migh in luence he heal h bene i s o a high
MD adhe ence in adolescen s. Seden a y beha iou s, such sc een ime and physical inac-
i i y we e ound o inc ease he isk o o e weigh and obesi y in Eu opean adolescen s
[6,7]. Cu en ecommenda ions sugges limi ing ec ea ional sc een ime o less han 2 h
pe day [8]. Howe e , p e ious s udies ha e shown ha mo e han hal o all child en
exceed sc een ime ecommenda ions [9–11]. Addi ionally, inc easing seden a y ime is
associa ed wi h unheal hy die a y pa e ns in Eu opean adolescen s [12]. Fu he mo e,
he e is a g owing e idence o ansi ion om he adi ional MD pa e n in o consump-
ion o ene gy-dense oods, such as in he Wes e n die s, especially in Medi e anean
coun ies [13–16].
P e ious da a showed an in e se associa ion be ween MD adhe ence and seden a y
ime, including sc een ime [17,18]. Howe e , o ou knowledge, a po en ial in e ac ion
e ec be ween MD and sc een ime on adiposi y emains unknown. The e o e, he aim o
he p esen s udy is o assess whe he an associa ion be ween MD and seden a y ime
exis s in Eu opean adolescen s in he Heal hy Li es yle in Eu ope by Nu i ion in Adoles-
cence (HELENA) s udy. Mo eo e , we in end o explo e whe he seden a y ime has a
modula o y e ec on he associa ion be ween MD and adiposi y ma ke s. We hypo hesize
ha high le els o sc een ime may a enua e he p o ec i e e ec o MD adhe ence on
adiposi y pa ame e s.
2. Ma e ials and Me hods
2.1. S udy Design and Popula ion
HELENA is a mul icen ic and c oss-sec ional s udy. Desc ip ion o he s udy sam-
pling and ec ui men , s anda diza ion and ha moniza ion me hodology, da a collec ion,
analysis s a egies and quali y con ol p ocedu es was published elsewhe e [19,20]. The
HELENA s udy was designed o ob ain eliable and compa able in o ma ion on adoles-
cen s’ nu i ional, en i onmen al and heal h- ela ed in luences o p e en isk ac o s o
p esen and u u e nu i ion- ela ed ch onic diseases [21]. Each one o he pa icipa ing
coun ies in ol ed in he HELENA s udy app o ed he p o ocol by he local Resea ch
E hics Commi ees and ollowed he e hical guidelines o he Decla a ion o Helsinki 1961
Nu ien s 2021, 13, 474 3 o 16
( e ision o 2000), he Good Clinical P ac ice and he legisla ion abou clinical esea ch in
humans [22]. A w i en consen was p o ided o he pa en s o all indi iduals pa icipa -
ing in he s udy, which was ead and signed. The p esen s udy comp ises 2047 adoles-
cen s (54.7% emales), aged 12.5–17.5 yea s, wi h alid and speci ic da a on adhe ence o
MD, sc een ime and adiposi y. Desc ip ion o he selec ion p ocess is shown in a low
cha (Figu e 1).
Figu e 1. Flow cha o he sample selec ion p ocess. Abb e ia ions: FAS, amily a luence scale;
BMI, body mass index; FMI, a mass index and WC, wais ci cum e ence.
2.2. Physical Examina ion and Adiposi y Measu emen s
An h opome ic measu emen s we e s ic ly con olled and pe o med ollowing
s anda d p o ocols [23]. Body heigh was measu ed ba e oo wi h a elescopic s adiome e
(SECA 225) o he nea es 0.1 cm. Body weigh was measu ed in unde wea and wi h no
oo wea o he nea es 0.1 kg wi h an elec onic scale (SECA 861, Hambu g, Ge many).
Heigh and weigh we e measu ed in iplica e. Body mass index (BMI) was calcula ed by
di iding weigh (kg) by he squa e o heigh (m) [24]. Wais ci cum e ence (WC) measu e-
men s we e pe o med wi h a non-elas ic ape (SECA 200) o he nea es 0.1 cm a he mid-
poin be ween he lowes ib and he iliac c es . Subscapula and icipi al skin old hick-
nesses we e measu ed in iplica e. In o de o assess he con ibu ion o a mass ela i e
o body size, he body a pe cen age was calcula ed using he Slaugh e ’s equa ion [25],
Nu ien s 2021, 13, 474 4 o 16
and hen, FMI was calcula ed as body a in ela ion o heigh squa ed [FM (kg)/heigh
(m2)] [26]. Pube al s a us was e alua ed du ing a medical examina ion by a physi-
cian/paedia ician ollowing he me hodology desc ibed by Tanne and Whi ehouse [27].
Pube al s a us was ca ego ized as Tanne s ages om no sexual ma u a ion (s age I) o
comple e sexual ma u a ion (s age V).
2.3. Die a y In ake and Medi e anean Die Sco e (MDS) Assessmen
The HELENA Die a y Assessmen Tool (HELENA-DIAT) is a sel -adminis e ed com-
pu e ized 24 h die a y ecall used o collec all he adolescen s’ die a y in ake [28,29]. This
ool was i s alida ed in Flemish adolescen s [29] and hen adap ed o be implemen ed
in he pa icipa ing cen es o each coun y [30]. Pa icipan s p o ided wice die a y in-
o ma ion h ough he HELENA-DIAT on 2 non-consecu i e days wi hin a space o 2
weeks. P e ious au ho s conside ed his me hod as an use ul p ocedu e o e alua e he
die a y in ake in Eu opean child en and adolescen s [31]. The mul iple sou ce me hod
(MSM) allowed us o calcula e usual die a y in ake o each indi idual, which enables he
possibili y o co ec he die a y in o ma ion o be ween and wi hin indi iduals´ a ia-
bili y [32].
A Medi e anean die sco e (MDS) was compu ed om he sum o 9 single subcom-
ponen s ha we e desc ibed elsewhe e [33]. In sho , ege ables, ui s and nu s, ce eals,
legumes, ish, dai y p oduc s ( ecommended du ing g ow h and de elopmen pe iods
[34]) and unsa u a ed o sa u a ed a a io we e conside ed heal hy ood subg oups o
MD, whe eas mea p oduc s (including p ocessed mea ) and alcohol consump ion we e
classi ied as unheal hy ac o s. The e o e, a pa icipan consuming a heal hy MD-associ-
a ed ood g oup was designa ed wi h 1 poin , whe eas he unheal hy ood subg oups con-
ibu ed wi h −1 poin s. A Medi e anean die sco e (MDS), showing he deg ee o adhe-
sion o he MD o each indi idual, was de eloped using a 0–9 poin scale, wi h low alues
(0–4) indica ing poo adhe ence and high alues (5–9) g ea e adhe ence, espec i ely
[35,36]. Supplemen a y Table S1 shows he median in ake in g/day by sex o each sub-
g oup om he MDS and he adhe ence le els o he MD.
2.4. Sc een-Time-Based Seden a y Beha io Assessmen
In o de o epo he habi ual ime de o ed o sc een ime among adolescen s, a al-
ida ed sel - epo ed sc een- ime-based seden a y beha iou s ques ionnai e was used [37].
The ime spen in TV iewing, compu e games, ideo games and in e ne o non-s udy
easons du ing bo h week and weekend days was collec ed in ca ego ies in a scale anging
om 0–240 min pe day. The daily mean ime o each ca ego y was ob ained and he inal
ime was calcula ed summing weekdays and weekend days, ob aining he o al sc een
ime in minu es pe day (min/day). Las ly, a o al seden a y ime alue was ob ained by
summing up he ime epo ed in each ca ego y. The weigh ed Cohen’s κ-coe icien s
we e used o assess he es – e es eliabili y o he sc een- ime-based ques ionnai e used
in he HELENA s udy. The mos common alues obse ed we e mode a e, subs an ial o
almos pe ec ag eemen (>0.7). Excep ionally, in e ne o s udy easons showed 0.46 in
weekdays and 0.33 in weekends, espec i ely [38]. Fu he mo e, a sensi i i y analysis was
ca ied ou in o de o disca d po en ial dispa i ies in he in e ac ion models due o hose
ou lie indi iduals conside ed (o no ) in he sc een ime a iable.
2.5. Socioeconomic S a us
The amily a luence scale (FAS) is an indica o o ma e ial a luence, which anges
om 0 (lowes ) o 8 (highes ) and u he eca ego ized in low (0–2), medium (3–5) and
high (6–8) le els [39]. The scale conside s pa ame e s such as ca owne ship, ha ing an
own bed oom, in e ne a ailabili y and compu e owne ship. This in o ma ion was as-
sessed h ough a ques ionnai e, and i was used as a p edic o o he adolescen s’ heal h
ou comes [40].
Nu ien s 2021, 13, 474 5 o 16
2.6. S a is ical Analysis
The no mali y o he a iables was assessed wi h he Shapi o–Wilk non-pa ame ic
es . No all a iables ollowed a no mal dis ibu ion, so he desc ip i e sex-speci ic cha -
ac e is ics a e shown as median and in e qua ile ange (IQR) o con inuous a iables,
while ca ego ical a iables a e shown as absolu e and ela i e equencies. Mo eo e ,
Pea son’s chi-squa e s a is ical es was used o ob ain compa a i e sex- ela ed di e ences
o ca ego ical a iables; he Mann–Whi ney–Wilcoxon es was pe o med o con inuous
a iables. In o de o obse e he associa ion be ween MD and sc een ime, sex-speci ic
mul iple linea eg ession models we e pe o med. Fi s , a aw simple linea eg ession
model was cons uc ed o obse e associa ions be ween MD and sc een ime. Then, an
ini ial mul iple linea eg ession model was pe o med conside ing ene gy in ake, socio-
economic s a us and Tanne s age as con ounde s. A s ep-by-s ep algo i hm was applied
o selec he signi ican a iables in a mul i a ia e model o sho lis he independen a -
iables signi ican ly associa ed wi h he adiposi y pa ame e s in he inal model. Fu he -
mo e, a new mul iple eg ession analysis was c ea ed o assess he associa ion be ween
adiposi y pa ame e s and MD, adding he sc een ime in e ac ion e ec , he MD e ec
alone and he abo emen ioned con ounde s. Finally, as we obse ed ex eme alues o
sc een ime in he highes end o he dis ibu ion, we pe o med a sensi i i y analysis,
excluding he ou lie s in he op end o he dis ibu ion. Le el o signi icance was se a p
< 0.05. RS udio Ve sion 1.2.5001 (RS udio Team (2015). RS udio: In eg a ed De elopmen
o R. RS udio, Inc., Bos on, MA, USA, URL h p://www. s udio.com/) was used o pe -
o m all s a is ical analyses.
3. Resul s
3.1. Desc ip i e Cha ac e is ics o he S udy Sample
Table 1 shows he main cha ac e is ics o he HELENA pa icipan s included in he
p esen s udy. Summa izing, males had highe weigh , heigh and WC (p ≤ 0.001), and
lowe FMI han emales (all p < 0.001). Mo eo e , males we e mo e exposed o sc een ime
(p ≤ 0.001) and had highe ene gy in ake (p ≤ 0.001) han emales, al hough emales we e
in mo e ad anced pube al s ages han males (p ≤ 0.001). Finally, he e we e no signi ican
di e ences ega ding FAS and MDS.
Table 1. Demog aphics and beha iou al cha ac e is ics o he Heal hy Li es yle in Eu ope by Nu i ion in Adolescence
(HELENA) pa icipan s displayed by sex.
To al
Male
Female
p
n = 2047
n = 925
n = 1122
Age (yea s)
14.7
(13.7–15.7)
14.8
(13.7–15.7)
14.7
(13.7–15.7)
0.590
Heigh (cm)
165.9
(159.3–172.0)
170.1
(163.9–177.1)
162.4
(157.7–167.0)
<0.001
Weigh (kg)
58.4
(50.3–64.3)
61.5
(52.3–68.9)
55.8
(49.0–61.2)
<0.001
BMI (kg/m2)
21.1
(18.7–22.8)
21.1
(18.6–22.8)
21.1
(18.8–22.8)
0.282
WC (cm)
71.8
(66.2–75.8)
73.8
(67.8–78.3)
70.2
(65.0–74.4)
<0.001
FMI (kg/m2)
5.15
(3.1–6.3)
4.5
(2.4–5.3)
5.7
(4.0–6.8)
<0.001
Pube al s age [n (%)]
<0.001
I
7 (0.3%)
7 (0.8%)
0 (0%)
II
134 (6.5%)
84 (9.1%)
50 (4.5%)

Nu ien s 2021, 13, 474 6 o 16
III
502 (24.5%)
226 (24.4%)
276 (24.6%)
IV
881 (43.0%)
381 (41.2%)
500 (44.6%)
V
523 (25.5%)
227 (24.5%)
296 (26.4%)
FAS [n (%)]
0.112
Low
199 (9.7%)
76 (8.2%)
123 (11.0%)
Medium
1133 (55.3%)
519 (56.1%)
614 (54.7%)
High
715 (35.0%)
330 (35.7%)
385 (34.3%)
MDS * (poin s)
4
(3–5)
4
(3–5)
4
(3–5)
0.071
Ene gy in ake (kcal/day)
2180.1
(1634.9–2569.7)
2517.9
(1921.0–2984.3)
1901.6
(1492.4–2244.9)
<0.001
Sc een ime (min/day)
256.2
(139.3–330.0)
288.1
(171.4–367.4)
229.9
(126.4–300.0)
<0.001
Median alues (p25–p75) exp essed. Abb e ia ions: BMI, body mass index; WC, wais ci cum e ence; FMI, a mass index;
FAS, amily a luence scale; MDS, Medi e anean die sco e. * Medi e anean die sco e esul ing om he sum o 9 ood
subg oups compliance. Sco e anging om 0–9 poin s. Signi ican alues (p
< 0.05) exp essed in bold on .
The sc een ime dis ibu ion (min/day) be ween HELENA pa icipan s is shown in
Figu e 2.
Figu e 2. Dis ibu ion o sc een ime (% displayed) among HELENA pa icipan s by sex.
3.2. Associa ion be ween MD Adhe ence and Sc een-Time-Based Seden a y Beha io s
The associa ions be ween MD and sc een ime a e shown in Table 2. The uni a ia e
model (Model I) showed ha MD and sc een ime we e in e sely associa ed in bo h males
and emales (p < 0.001). These ela ionships we e main ained in he ini ial mul i a ia e
model (p < 0.001) and a e adjus ing by con ounde s (Model II; p < 0.001).
Table 2. Mul iple linea eg ession models showing he associa ions o he Medi e anean die
sco e (MDS) wi h sc een ime.
Sc een Time (min/day)
Model I a
Model II b
β
p
β
p
R2
Male
0.029
Nu ien s 2021, 13, 474 7 o 16
MDS (poin )
−12.535
<0.001
−12.402
<0.001
Ene gy In ake
(kcal/day)
-
-
0.026
<0.001
Female
0.016
MDS (poin )
−12.402
<0.001
−12.402
<0.001
Ene gy In ake
(kcal/day)
-
-
-
-
a Model I, unadjus ed model, s udies he associa ion be ween sc een ime and MDS. b Model II
p esen s he a iables s a is ically signi ican in ela ion o seden a y ime as ollows: an ini ial
model was cons uc ed be ween sc een ime and MD conside ing Tanne s age, FAS ca ego ies
and ene gy in ake as co a ia es. Fu he mo e, a s ep-by-s ep algo i hm was applied o disca d
non-signi ican associa ions. Only s a is ically signi ican a iables a e shown in he p esen able.
Signi ican alues (p<0.05) exp essed in bold on .
3.3. In e ac ion be ween MD Adhe ence and Sc een-Time-Based Seden a y Beha io s on
Adiposi y
The in e ac ion e ec s be ween MD and sc een ime on adiposi y pa ame e s by sex
g oup a e displayed in Table 3. In males, he sc een- ime–MD in e ac ion was no signi i-
can ly associa ed o any adiposi y index. Howe e , in emales, he e we e signi ican in-
e ac ion e ec s be ween he sc een ime and MD on BMI (p < 0.05), WC (p < 0.01) and FMI
(p < 0.05) (Table 3).
Table 3. Mul iple linea eg ession models o sc een ime and Medi e anean die sco e (MDS) in e ac ion and co a ia es
o p edic body mass index, wais ci cum e ence and a mass index displayed by sex.
Males
(p-Values)
Females
(p-Values)
BMI (kg/m2)
WC (cm)
FMI (kg/m2)
BMI (kg/m2)
WC (cm)
FMI (kg/m2)
Co a ia es
Pube al S age
II *
0.502
0.139
0.048
-
-
-
III
0.547
0.209
0.010
0.026
0.012
0.126
IV
0.534
0.936
0.047
<0.001
<0.001
<0.001
V
0.638
0.866
0.008
<0.001
<0.001
<0.001
FAS
Medium
0.048
0.604
0.045
<0.001
0.138
<0.001
High
0.024
0.695
0.019
<0.001
0.058
<0.001
Ene gy In ake (kcal/day)
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
S udied Va iables
MDS (poin )
0.049
0.260
0.198
0.043
0.160
0.042
Sc een ime: MDS
0.062
0.617
0.122
0.025
0.002
0.022
Abb e ia ions: BMI, body mass index; WC, wais ci cum e ence; FMI, a mass index; FAS, amily a luence scale; MDS
Medi e anean die sco e. * Tanne II p- alues we e no conside ed o be es ima ed in he emale g oup, as a s a is ically
small numbe o emales we e p esen in his s age o he cu en analysis. Signi ican alues (p<0.05) exp essed in bold
on .
In o de o in e p e he modula ion e ec o sc een ime on he ela ionship be ween
MD and adiposi y indices in emales, a se o igu es is displayed in a ma ix panel ela ing
o each adiposi y index (Figu e 3). A numbe o lines we e d awn o ep esen he MD and
adiposi y a iables modula ed by he dis ibu ion o he sc een ime. Mos pa icipan s
we e loca ed in lowe and cen al pa s o he dis ibu ion, co esponding o 50–350
min/day (74.5% o he o al popula ion); conside ing his dis ibu ion, he impac o ou li-
e s was ca e ully conside ed. Despi e he obse ed sc een ime habi s, hose indi iduals
ep esen ed by a nega i e slope could bene i om he p o ec i e ole o MD in ela ion
o adiposi y indices when he MD adhe ence is high. The e o e, a high MD adhe ence was
Nu ien s 2021, 13, 474 8 o 16
associa ed wi h lowe BMI only in hose emales being exposed o sc een ime less han
338 min/day (81.8% o he o al emales). Mo eo e , high MD adhe ence was associa ed
wi h lowe WC only in hose emales being exposed o sc een ime less han 143 min/day
(31.5% o o al emales). Finally, a high MD adhe ence was associa ed wi h lowe FMI only
in hose emales being exposed o sc een ime less han 338 min/day (81.8% o o al e-
males).
Nu ien s 2021, 13, 474 9 o 16
Figu e 3. Ma ix panel o in e ac ion models on a BMI (body mass index), b WC (wais ci cum e -
ence), c FMI ( a mass index); and MD (Medi e anean die ) acco ding o sc een ime modula ion in
emales. In o de o design he ep esen a ion o he dis ibu ion in HELENA adolescen s, di e -
en lines we e aced as e e ence poin s o obse e he slope o he s udied popula ion acco ding
o he seden a y ime. A posi i e g adien ep esen s he MD ac ing as isk ac o , while a nega i e
g adien shows he MD ac ing as p o ec i e ac o .
3.4. Sensi i i y Analysis o Sc een-Time-Based Seden a y Beha io s Plausible Da a
Fo he signi ican in e ac ion models ( emales), sensi i i y analysis was pe o med
conside ing sc een ime ou lie s (highes alue: 856 min/day) s. in e ac ion models no
conside ing ou lie s (highes alue: 632 min/day) on adiposi y indices. Minimal di e -
ences we e obse ed in he wo in e ac ion models o each adiposi y pa ame e (β < 0.001
s. β < 0.001 in BMI, WC and FMI).
4. Discussion
The main indings o he p esen s udy a e he obse ed in e se associa ion be ween
MD adhe ence and sc een ime, and he join in e ac ion e ec be ween bo h ac o s on
adiposi y in Eu opean emale adolescen s. Thus, he bene i s associa ed wi h a high MD
adhe ence we e only obse ed in hose emales wi h lowe sc een ime. On he o he hand,
no MD–sc een- ime in e ac ion e ec was obse ed in males.
In line wi h ou indings, p e ious s udies epo ed an in e se associa ion be ween
MD adhe ence and seden a y ime among you h. In a popula ion o Medi e anean Eu o-
pean adolescen s, sel - epo ed inac i i y [41] was in e sely ela ed o MD adhe ence in
bo h sex g oups [42]. In non-Medi e anean Eu opean adolescen s, a low MD adhe ence
was associa ed wi h highe seden a y ime, al hough hei seden a y ime assessmen only
conside ed si ing ime du ing weekdays [43].
To ou knowledge, no o he s udies ha e examined sc een ime as modula o y ac o
in he MD e ec on adiposi y indices. Howe e , a combined e ec o di e en li es yle
pa e ns in clus e s udies assessing hei ela ionship o adiposi y has been epo ed in
simila age popula ions [44–47]. Rega ding he combined e ec o unheal hy habi s, in
Eu opean child en, a clus e including high seden a y ac i i ies (including sc een ime),
low PA, swee be e ages and low ui s and ege ables in ake was associa ed wi h high
BMI and WC [44]. Simila esul s we e ound in non-Eu opean child en, whe e an un-
heal hy clus e o TV iewing wi h ene gy dense oods was associa ed o high BMI [45].
Al hough we a e conside ing c oss-sec ional s udies, simila associa ions we e also ob-
ained in longi udinal s udies in Eu opean [46] and non-Eu opean child en [45]. In he
Nu ien s 2021, 13, 474 16 o 16
48. O e ae e, C.; Huyb ech s, I.; Bense , J.; De Bou deaudhuij, I.; Cuenca-Ga cia, M.; Dallonge ille, J.; Zacca ia, M.; Go and, F.;
Ke s ing, M.; Rey-López, J.; e al. Clus e ing pa e ns o physical ac i i y, seden a y and die a y beha io among Eu opean
adolescen s: The HELENA s udy. BMC Public Heal h 2011, 11, doi:10.1186/1471-2458-11-328.
49. Bel-Se a , S.; Ojeda-Rod íguez, A.; Heinen, M.; Buonc is iano, M.; Abd akhmano a, S.; Dule a, V.; San ’Angelo, V.;
Fijałkowska, A.; Hejgaa d, T.; Huidumac, C.; e al. Clus e ing o Mul iple Ene gy Balance-Rela ed Beha io s in School Child en
and i s Associa ion wi h O e weigh and Obesi y-WHO Eu opean Childhood Obesi y Su eillance Ini ia i e (COSI 2015–2017).
Nu ien s 2019, 11, doi:10.3390/nu11030511.
50. Dumuid, D.; Olds, T.; Lewis, L.; Ma in-Fe nández, J.; Ba ei a, T.; B oyles, S.; Chapu , J.; Fogelholm, M.; Hu, G.; Ku iyan, R.; e
al. The adiposi y o child en is associa ed wi h hei li es yle beha iou s: A clus e analysis o school-aged child en om 12
na ions. Pedia . Obes. 2018, 13, doi:10.1111/ijpo.12196.
51. Leech, R.; McNaugh on, S.; Timpe io, A. The clus e ing o die , physical ac i i y and seden a y beha io in child en and
adolescen s: A e iew. In . J. Beha . Nu . Phys. Ac . 2014, 11, doi:10.1186/1479-5868-11-4.
52. Seghe s, J.; Ru en, C. Clus e ing o mul iple li es yle beha iou s and i s ela ionship wi h weigh s a us and ca dio espi a o y
i ness in a sample o Flemish 11- o 12-yea -olds. Public Heal h Nu . 2010, 13, doi:10.1017/S1368980010000418.
53. Myszkowska-Ryciak, J.; Ha on, A.; Lange, E.; Laskowski, W.; Waw zyniak, A.; Hamulka, J.; Gajewska, D. Reduced Sc een
Time is Associa ed wi h Heal hy Die a y Beha io s bu No Body Weigh S a us among Polish Adolescen s. Repo om he
Wise Nu i ion-Heal hy Gene a ion P ojec . Nu ien s 2020, 12, doi:10.3390/nu12051323.
54. Zhang, J.; Chan, N.; Lam, S.; Li, S.; Liu, Y.; Chan, J.; Kong, A.; Ma, R.; Chan, K.; Li, A.; e al. Eme gence o Sex Di e ences in
Insomnia Symp oms in Adolescen s: A La ge-Scale School-Based S udy. Sleep 2016, 39, doi:10.5665/sleep.6022.
55. Ga aule , M.; O ega, F.; Ruiz, J.; Rey-López, J.; Béghin, L.; Manios, Y.; Cuenca-Ga cía, M.; Plada, M.; Die helm, K.; Ka a os, A.;
e al. Sho sleep du a ion is associa ed wi h inc eased obesi y ma ke s in Eu opean adolescen s: E ec o physical ac i i y and
die a y habi s. The HELENA s udy. In . J. Obes. 2011, 35, doi:10.1038/ijo.2011.149.
56. Bel, S.; Michels, N.; De V iend , T.; Pa e son, E.; Cuenca-Ga cía, M.; Die helm, K.; Gu in, B.; G amma ikak, I.E.; Manios, Y.;
Lecle cq, C.; e al. Associa ion be ween sel - epo ed sleep du a ion and die a y quali y in Eu opean adolescen s. B . J. Nu .
2013, 110, doi:10.1017/S0007114512006046.
57. Agos inis-Sob inho, C.; Gómez-Ma ínez, S.; No a, E.; He nandez, A.; Labayen, I.; Ka a os, A.; Go and, F.; Molná , D.; Fe a i,
M.; Mo eno, L.; e al. Li es yle pa e ns and endoc ine, me abolic, and immunological bioma ke s in Eu opean adolescen s: The
HELENA s udy. Pedia . Diabe es 2019, 20, doi:10.1111/pedi.12802.
58. Ve eecken, C.; Dohogne, S.; Co en s, M.; Maes, L. How accu a e a e adolescen s in po ion-size es ima ion using he compu e
ool Young Adolescen s’ Nu i ion Assessmen on Compu e (YANA-C)? B . J. Nu . 2010, 103, doi:10.1017/S0007114510000127.
59. an G ieken, A.; Ezendam, N.; Paulis, W.; an de Wouden, J.; Raa , H. P ima y p e en ion o o e weigh in child en and
adolescen s: A me a-analysis o he e ec i eness o in e en ions aiming o dec ease seden a y beha iou . In . J. Beha . Nu .
Phys. Ac . 2012, 9, doi:10.1186/1479-5868-9-61.
60. B own, T.; Moo e, T.; Hoope , L.; Gao, Y.; Zayegh, A.; Ijaz, S.; Elwenspoek, M.; Foxen, S.; Magee, L.; O’Malley, C.; e al.
In e en ions o p e en ing obesi y in child en. Coch ane Da abase Sys . Re . 2019, 7, doi:10.1002/14651858.CD001871.pub4.