Dietary and other lifestyle characteristics of Cypriot school children: results from the nationwide CYKIDS study.

Abstract

Dietary and lifestyle behaviors at young ages have been associated with the development of various chronic diseases. Schools are regarded as an excellent setting for lifestyle modification; there is a lack, however, of published dietary data in Cypriot school children. Thus, the objective of this work was to describe lifestyle characteristics of a representative segment of Cypriot school children and provide implications for school health education.
The CYKIDS (Cyprus Kids Study) is a national, cross-sectional study conducted among 1140 school children (10.7 +/- 0.98 years). Sampling was stratified and multistage in 24 primary schools of Cyprus. Dietary assessment was based on a 154-item semi-quantitative food-frequency questionnaire and three supplementary questionnaires, assessing dietary patterns and behaviors. Adherence to the Mediterranean diet was evaluated by the KIDMED index (Mediterranean Diet Quality Index for children and adolescents). Physical activity was assessed by a 32-item, semi-quantitative questionnaire.
Analysis revealed that 6.7% of the children were classified as high adherers, whereas 37% as low adherers to the Mediterranean diet. About 20% of boys and 25% of girls reported "not having breakfast on most days of the week", while more than 80% of the children reported having meals with the family at least 5 times/week. Some food-related behaviors, such as intake of breakfast, were associated with socio-demographic factors, mostly with gender and the geomorphological characteristics of the living milieu. With respect to physical activity, boys reported higher levels compared to girls, however, one fourth of children did not report any kind of physical activity.
A large percentage of Cypriot school children have a diet of low quality and inadequate physical activity. Public health policy makers should urgently focus their attention to primary school children and design school health education programs that target the areas that need attention in order to reduce the future burden of metabolic disorders and chronic diseases.

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BioMed Central
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BMC Public Health
Open Access
Research article
Dietary and other lifestyle characteristics of Cypriot school
children: results from the nationwide CYKIDS study
Chrystalleni Lazarou*1, Demosthenes B Panagiotakos1, Christiana Kouta2
and Antonia-Leda Matalas1
Address: 1Harokopio University, Department of Nutrition and Dietetics, Athens, Greece and 2Cyprus University of Technology, School of Health
Sciences, Nicosia, Cyprus
Email: Chrystalleni Lazarou* - stalolaz@logosnet.cy.net; Demosthenes B Panagiotakos - d.b.panagiotakos@usa.net;
Christiana Kouta - christiana.kouta@cut.ac.cy; Antonia-Leda Matalas - amatala@hua.gr
* Corresponding author
Abstract
Background: Dietary and lifestyle behaviors at young ages have been associated with the
development of various chronic diseases. Schools are regarded as an excellent setting for lifestyle
modification; there is a lack, however, of published dietary data in Cypriot school children. Thus,
the objective of this work was to describe lifestyle characteristics of a representative segment of
Cypriot school children and provide implications for school health education.
Methods: The CYKIDS (Cyprus Kids Study) is a national, cross-sectional study conducted among
1140 school children (10.7 ± 0.98 years). Sampling was stratified and multistage in 24 primary
schools of Cyprus. Dietary assessment was based on a 154-item semi-quantitative food-frequency
questionnaire and three supplementary questionnaires, assessing dietary patterns and behaviors.
Adherence to the Mediterranean diet was evaluated by the KIDMED index (Mediterranean Diet
Quality Index for children and adolescents). Physical activity was assessed by a 32-item, semi-
quantitative questionnaire.
Results: Analysis revealed that 6.7% of the children were classified as high adherers, whereas 37%
as low adherers to the Mediterranean diet. About 20% of boys and 25% of girls reported "not
having breakfast on most days of the week", while more than 80% of the children reported having
meals with the family at least 5 times/week. Some food-related behaviors, such as intake of
breakfast, were associated with socio-demographic factors, mostly with gender and the
geomorphological characteristics of the living milieu. With respect to physical activity, boys
reported higher levels compared to girls, however, one fourth of children did not report any kind
of physical activity.
Conclusion: A large percentage of Cypriot school children have a diet of low quality and
inadequate physical activity. Public health policy makers should urgently focus their attention to
primary school children and design school health education programs that target the areas that
need attention in order to reduce the future burden of metabolic disorders and chronic diseases.
Published: 20 May 2009
BMC Public Health 2009, 9:147 doi:10.1186/1471-2458-9-147
Received: 29 October 2008
Accepted: 20 May 2009
This article is available from: http://www.biomedcentral.com/1471-2458/9/147
© 2009 Lazarou et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Background
During the past decades Cyprus has experienced marked
socio-demographic changes [1] which have been followed
by an accelerating pace of epidemiological transition and
the emergence of risk factors for chronic diseases, such as
obesity, in both children and adults [2,3], as well as
deaths due to chronic diseases, such as cardiovascular dis-
ease (CVD) and cancer [4-6]. Epidemiological transition
is generally attributed to major lifestyle changes, espe-
cially in dietary choices and physical activity, which lead
to increased morbidity and mortality at population level,
both in developed and less developed societies [7,8]. Well
designed, effective health planning and interventions
should be based on sound knowledge of the health status
of a population through the evaluation of lifestyle behav-
iors (i.e. dietary choices, physical activity habits, smoking
habits, etc), prevalence of major risk factors (i.e. obesity,
hypertension, diabetes, dyslipidemias), and incidence
rates of common chronic diseases. In Cyprus however,
despite the improvements in health care services during
the past years, published data on lifestyle characteristics
for any group of the population, including children, are
segmentary. Provided that, as it is widely acknowledged,
the effectiveness of chronic diseases prevention might be
maximized when it starts from early childhood [9,10],
there is an emerging need for obtaining data on children's
lifestyle habits. The CYprus KIDS (CYKIDS) study is a pri-
mary school population-based survey that aimed to assess
lifestyle characteristics, i.e. dietary and physical activity
patterns, in a representative sample of Cypriot children
and provide needed information for public health preven-
tive programs aimed at primary school children. The aim
of the present work is to report results of the CYKIDS
study on basic dietary and physical activity patterns in
relation to selected sociodemographic factors and exam-
ine implications for public health programs.
Methods
Study population
The CYKIDS (CYprus KIDS) study is a nation-wide, cross-
sectional survey that was conducted during the school
year 2004–2005 and covered all the freely accessed dis-
tricts of the Republic of Cyprus. Sampling was multistage
and stratified by the number of students in each of the five
provinces, as provided by the Ministry of Education (data
available on request from the Department of Primary
Education) and by place of residence (place of school was
used as a proxy), urban or rural, as provided by the Cyprus
Statistical Service [11].
A total of 1589 children of 4th, 5th and 6th grade (9–13
years, x = 11 ± 0.98) in 24 primary schools were identified
for potential inclusion; 1140 agreed to participate (72%
participation rate), representing 3.7% of the total popula-
tion. All classes were of mixed ability. Diet quality was
assessed in all children and the participating parents. We
received 1068 responses from parents; only 72 less com-
pared to children's responses.
A detailed description of the study design and dietary
assessment methodology has been published elsewhere
[12].
The research protocol and all means used were approved
by the Ministry of Education and Culture (Department of
Primary Education) as the law provides in Cyprus for the
studies carried out in the school environment and during
formal school hours. Informed consent was signed by the
parent or the guardian of each participant.
Dietary assessment
Dietary assessment was based on a semi-quantitative
food-frequency questionnaire (FFQ), consisting of 154
food items (including all of the commonly used foods of
the local Greek-Cypriot cuisine) and three supplementary
questionnaires that evaluated other aspects of dietary hab-
its. Specifically, a Food Groups Frequency Questionnaire
(FGFQ), which evaluated on a four point scale the fre-
quency of consumption of 15 food groups, a Short Eating
Habits Behaviors & Beliefs Questionnaire (SEBBQ), which
evaluated 8 psychological aspects of eating, using a four
point Likert-type of scale, and a short Dietary Habits
Questionnaire (SDHQ) that evaluated 19 core eating hab-
its on a two-point of yes/no scale. Detailed description of
these tools is provided elsewhere [12,13]. The question-
naires are available online at http://195.251.30.202:
8080/dspace/handle/123456789/305 or can be requested
by the corresponding author.
The dietary questionnaires were administered to all stu-
dents of each class during school hours, from February to
June of 2005, by the same person- a qualified nutritionist,
according to a written protocol describing a standardized
methodology for dietary data collection.[12] Standard
portion sizes that could be easily understood by children,
such as the size of a fruit, were included in the questions,
whereas for other foods, food models of the USA Dairy
Council [14] and NASCO[15] were used as aids to visual-
ize the regular portion. Food models were also used to
help children recognize unfamiliar food terms.
Test-retest repeatability of the FFQ was tested by giving the
same questionnaire in 100 children of the sample, within
one month apart and was found to be good (Spearman
rho correlation coefficient ranged from 0.180 to 0.670,
with 95% items above 0.400 (indicating good reliability)
and only 7 out of 154 items, i.e., 5%, were less than
0.200). Internal reliability was tested by Cronbach's alpha

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and found to be equal to 0.908, which indicates very good
consistency of the FFQ. Validation against the short food
groups' frequency questionnaire showed a mean coeffi-
cient of the association (Spearman's rho) between the two
dietary tools of 0.237. Validation against a 24 hr recall is
in future plans. The above figures indicate an adequate
reliability and validation coefficients of the FFQ used.
Food consumption frequencies among boys and girls are
presented in the Results section.
Assessment of Mediterranean diet patterns
The KIDMED index (Mediterranean Diet Quality Index
for children and adolescents) was used to evaluate the
overall quality of diet. This index has been developed by
Serra – Majem et al [16] and includes 16 components that
summarize the principles of the Mediterranean diet by an
arithmetic score, which ranges from 0–12. According to
authors, a score of 0–3 reflects a poor diet in relation to
the Mediterranean diet principles, whereas values of 4–7
and values of 8–12, average and good adherence to the
principles of the Mediterranean diet, respectively [16]. A
more detailed description of the KIDMED index is pro-
vided elsewhere [12,16]
Physical activity assessment
Children responded to a 32-item, semi-quantitative ques-
tionnaire, and assessed organized and free-time physical
activity [17,18]; i.e. frequency and duration of everyday
physical and sedentary activities on the weekdays, the
weekend and on the previous day, using an 8-level answer
scale ranging from "0" to "more than 8 hours" per day or
week. Furthermore, for assessing the time spent to indi-
vidual physical activities, such as bicycling, basketball,
racket sports, volleyball, running, soccer, swimming e.t.c.,
a four-level answer scale ranging from "0 times per week"
to "more than 6 times per week", was used. Questions
about physical activity lifestyle and behaviors (e.g., com-
muting to school) were also included, having four quali-
tative frequencies as possible answers ranging from
"rarely/never", to "always".
Anthropometry and obesity definition
Children's height and weight were reported by parents via
a short socio-demographic questionnaire sent out from
the schools. Obesity and overweight among children were
calculated using the International Obesity Task Force
(IOTF) age and sex -specific Body Mass Index (BMI) cut –
off criteria [19]. Parents' obesity and overweight percent-
ages were also estimated from self reported values of body
weight and height. BMI measures were used to define
adult (parents) obesity (BMI ≥ 30 kg/m2) and adult over-
weight (BMI 25–29.9 kg/m2), according to the World
Health Organization classification for adults. Further
information is provided elsewhere [3].
Socio-demographic variables
Socio-demographic characteristics such as age, gender,
size of the family, (children)living in a refugee camp (yes/
no), and parental relationship, were provided by the chil-
dren who filled a respective questionnaire. Place of living
was defined by using as a proxy the location of the school,
as in Cyprus, is mandatory for children to attend the
school of their area. Information regarding other demo-
graphic characteristics, that could not be answered with
sufficient reliability by children, such as parents' age, edu-
cational level, whether parents ever living in a refugee
camp, yearly income, and profession, were collected via a
short questionnaire – attached to the consent form – that
was completed by the parents. Family SES was defined by
the InterCollege Research Center of Cyprus, based on par-
ents' profession and educational level; the highest level of
profession, reported by either parent, was used as a proxy
of the family's SES level, along with family income. A sim-
ilar procedure for defining parental educational level has
been used by Velde et al. [20].
Statistical analysis
Continuous variables are presented as mean ± SD,
whereas qualitative variables are presented as absolute
and relative frequencies. Normality of variables' distribu-
tion was tested by Kolmogorov- Smirnov test. Associa-
tions between gender and normally distributed variables
were tested by Student's independent t- test, or by the
Mann-Whitney U test for the non-normally distributed
variables. Associations between categorical variables were
tested using contingency tables and the calculation of the
chi-square test without Yate's correction.
Missing cases were within the accepted limits of 10–15%.
No significant patterns with regards to any socio-demo-
graphic factors were evident in missing cases.
All reported p-values are based on two-sided tests and
compared to a significance level of 5%. SPSS 13.0 software
(Statistical Package for Social Sciences, Chicago, IL, USA)
was used for all statistical calculations.
Results
Demographic characteristics of the participants
Mean age was 10.7 years for both boys and girls (p =
0.827) (Table 1). Distribution of socio-demographic char-
acteristics including school grade, place of residence, geo-
graphic characteristics of place of residence, SES, ethnicity,
refugee status, type of house, and number of household
inhabitants was similar in boys and girls.
Lifestyle characteristics of the participants
Table 2 presents results from analyses carried out to exam-
ine differences between boys and girls with regards to the

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frequency of consumption of several food groups and
individual food items. Significant differences were
observed for 14 food groups or individual items; boys
reported more frequent consumption of eggs, meat, poul-
try, delicatessen, fish, legumes, nuts, puff pastry, fresh leg-
umes, potatoes, olives, candy and soda, whereas 'low
glycemic foods' were consumed more frequently by girls.
Evaluation of the overall quality of diet (using the
KIDMED index) showed no difference between genders
(P = 0.097) (Table 2). Further details are provided else-
where [12].
Data on basic food-related behaviors, such as types and
location of meals, having meals with family company and
methods of cooking are presented in Table 3. About 20%
of boys and 25% of girls reported "not having breakfast
on most days of the week", while more than 80% of the
children reported having at least 5 times/week meals with
the family.
The relationship of socio-demographic chracteristics to
these food-related behaviors was also examined. Besides
gender (Table 3), significant relations were found for the
geomorphological traits of the living milieu (plain, sub-
mountainous, mountainous): compared to children liv-
ing in plains, children in mountainous and sub -moun-
tainous regions ate less frequently outside home (i.e. in
fast food outlets or restaurants (p < 0.001) and with fam-
Table 1: Descriptive characteristics of the sample
BoysGirlsP
Age
Grade
10.68 (0.96)10.67 (0.99)0.827
0.705
4th
5th
6th
183 (34.5)
174 (32.8)
174 (32.8)
195 (32.1)
206 (33.9)
206 (33.9)
Place of living
0.602
Urban
Rural
291 (54.8)
240 (45.2)
342 (56.3)
265 (43.7)
Geomorphologic characteristics of residence
0.590
Plain
415 (78.2)
36 (6.8)
80 (15.1)
466 (76.8)
51 (8.4)
90 (14.8)
Sub-mountainous
Mountainous
Socioeconomic level
0.772
High
87 (21.2)
171 (41.7)
152 (37.1)
111 (21.9)
219 (43.3)
34.8 (176)
Average
Low
Ethnicity
0.667
Greek
377 (88.7)
14 (3.3)
34 (8.0)
461 (88.5)
13 (2.5)
47 (9.0)
Foreigners
Mixed
Type of residence
0.263
Apartment
65(12.9)
403(80.3)
34(6.8)
31(6.4)
84(14.3)
476(81.1)
27(4.6)
43(7.6)
House with a yard
House without a yard
Residence in a refugee camp
Number of inhabitants in home
0.472
0.518
≤ 3–4
5–6
≥ 7
191(42.2)
218 (48.1)
44(9.7)
227(41.1)
281(50.9)
44(4.4)
Body Mass Index Classification- Children
0.081
Normal weight
Overweight
277 (75.1)
70 (19.0)
22 (6.0)
358 (78.9)
83 (18.3)
13 (2.9)
Obese
Parental obesity status
0.085
Both lean
Both obese
131 (33.3)
90 (22.9)
146(37.2)
26(6.6)
137 (29.2)
87 (18.6)
203(43.3)
42(9.0)
Father obese/mother lean
Father lean/mother obese
Data are presented as mean (SD) and categorical variables as frequencies and percentages in parentheses.

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ily (p = 0.001), but ate fried food at least 3 times a week
(p = 0.002). Additionally, children from mountainous
areas ate breakfast over 5 times/week (p = 0.005) and ate
more frequently during the course of the day (≥ 4 times/
day).
With respect to the other socio-economic factors, differ-
ences were found by refugee status, socio-economic sta-
tus, ethnicity, and family size. Specifically, children living
in refugee camps, ate with their family less frequently (p <
0.001) while they also ate fried food less frequently (p =
Table 2: Food consumption and diet quality by frequency category among boys and girls
Food groupsFrequency categories BoysGirls p*
N
DAIRY
533607
Milk
≥ 7 times/week
≥ 7 times/week
≥ 7 times/week
88.0
66.0
45.1
89.1
69.5
42.2
0.602
0.217
0.346
Semi Skimmed milk
Yogurt
MEAT & ALTERNATIVES
Eggs
≥ 2 times/week
≥ 2 times/week
≥ 2 times/week
≥ 5 times/week
2–4 times/week
≤ 4 times/month
≥ 2 times/week
≥ 5 times/week
2–4 times/week
≤ 4 times/month
≥ 2 times/week
52.8
29.0
25.3
28.2
18.6
53.2
30.0
18.1
12.7
69.2
29.3
44.8
18.6
15.1
16.2
15.1
68.7
20.6
11.1
14.1
74.8
18.2
0.010
<0.001
<0.001
<0.001
Meat (excluding poultry, mixed dishes)
Poultry & rabbit meat
Delicatessen
Fish & seafood
Legumes
<0.001
0.005
Nuts
<0.001
CEREALS, GRAINS &PRODUCTS
White bread
Whole grain bread
Breakfast cereals
Puff pastry
≥ 7 times/week
≥ 7 times/week
≥ 5 times/week
≥ 5 times/week
2–4 times/week
≤ 4 times/month
≥ 5 times/week
≥ 5 times/week
≥ 5 times/week
70.0
21.2
51.2
21.3
12.7
66.0
14.0
35.1
32.6
69.9
19.5
48.2
13.4
9.4
77.3
10.6
31.8
31.5
0.960
0.502
0.324
<0.001
Pasta
Bulgur
0.100
0.260
0.695
Rice dishes
FRUITS
Fresh fruit juices
≥ 7 times/week
≥ 2/day
35.8
73.8
36.3
74.2
0.867
0.860
Fruits
VEGETABLES
Vegetables
≥ 2/day
≥ 5 times/week
≥ 2 times/week
≥ 5 times/week
46.1
12.1
41.7
31.1
41.8
7.4
35.0
22.4
0.159
0.010
0.028
0.001
Fresh legumes, other seasonal consumed vegetables
Potatoes & potatoes dishes
Olives
OTHER GROUPINGS
Potato chips
Biscuits
Candy
≥ 7 times/week
≥ 7 times/week
≥ 7 times/week
≥ 7 times/week
≥ 7 times/week
≥ 5 times/week
≥ 2 times/week
≥ 3 times/week
≥ 3 times/week
≥ 3 times/week
25.1
48.6
21.8
31.3
25.1
45.6
45.7
59.2
66.1
60.9
22.0
51.4
15.1
21.9
21.1
43.3
41.1
67.4
65.3
58.4
0.222
0.521
0.005
<0.001
0.121
0.442
0.123
0.031
0.854
0.472
0.097
Soda
Chocolates
Pizza
Low glycemic index foods**
Medium glycemic index foods
High glycemic index foods
Quality of diet (as assessed by KIDMED score)
Poor quality diet: score 0–3
Average quality diet: score 4–7
Good quality diet: score 8–12
44.8
40.9
55.4
55.2
59.1
44.6
Data are presented as percentages.
* From chi-square.

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0.012); children belonging to low SES had lunch at school
more frequently (p = 0.004), and ate fried food more fre-
quently (p = 0.035); children belonging to minorities
were more likely to eat alone (p = 0.007), while those of
families with four or less members,, ate more frequently
outside home (p = 0.054).
With respect to dietary quality, no significant relation-
ships were found for any of the above socio-economic fac-
tors.
Physical activity levels and sedentary patterns levels
Associations between physical activity habits and the
socio-demographic factors listed in Table 1 revealed that
Table 3: Meal patterns among boys and girls
BoysGirlsP*
N
Intake of breakfast ≥ 5 times/week vs. ≤ 4 times/week(%)
533
81.3
18.7
39.1
60.9
26.5
73.5
54.2
45.8
84.6
15.4
41.8
58.2
14.9
85.1
49.4
50.6
41.4
58.6
607
75.3
24.7
35.9
64.1
22.3
77.7
60.8
39.2
82.1
17.9
33.0
67.0
10.5
89.5
44.8
55.2
36.7
63.3
0.019
Number of main meals & snacks daily ≤ 3/day vs. ≥ 4/day(%)0.301
Number of snacks per day ≤ 1 per day vs. ≥ 2 per day(%)0.116
Eating outside home or order fast food in past 2 days 0 times vs. ≥ 1 times(%)0.033
Have meals with family ≥ 5 times/week vs. ≤ 4 times/week(%) 0.261
Have meals alone ≥ 5 times/week vs. ≤ 4 times/week(%) 0.030
Have lunch at school 4 times/week vs. ≤ 3 times/week(%)0.032
Eat fried food ≥ 3 times/week vs. ≤ 2 times/week(%)0.112
Eat grilled food ≥ 3 times/week vs. ≤ 2 times/week(%)0.116
From chi-square, df = 1
Table 4: Comparison of physical activity pursuits by gender
PercentageBoysGirlsp
Have private lessons > 2 hours/day
Do homework ≥ 2 hours/day
Watch TV- DVD ≥ 2 hours/day
Watch TV- DVD ≥ 2 hours in weekend days
Play electronic games or use computers ≥ 1 hours/day
Play electronic games or use computers ≥ 1 hours in weekend days
Did not participate at all in sports the previous day
Did not participate at all in any kind of physical activity the previous day
Do any kind of home chores at least 1/2 hour/day
Do in any kind of out of home chores at least 1 hour/week
Mean (SD) Hours
Have private lessons at weekdays
Do homework at weekdays
Watched TV-video the day before
Watched TV-video at weekends
Played with electronic games, computer the day before
Played with electronic games, computer at weekends
Engaged in sports after school the day before
Engaged in physical activity after school the day before
Engaged in home chores/week
Engaged in outside home chores/week
51.8
28.6
65.8
77.1
69.8
74.2
34.6
22.6
73.3
37.3
55.1
38.5
61.4
79.2
41.5
50.3
65.4
24.8
93.2
32.3
0.280
<0.001
0.280
0.700
<0.001
<0.001
<0.001
0.385
<0.001
0.086
2.56 (1.93)
1.70 (1.19)
2.42 (2.06)
4.25 (2.63)
1.15 (1.73)
2.79 (2.68)
1.32 (1.58)
1.50 (1.74)
2.79 (6.52)
2.31 (6.05)
2.62 (1.83)
1.95 (1.32)
2.32 (1.96)
4.18 (2.64)
0.64 (1.16)
1.59 (2.05)
0.66 (1.06)
1.17 (1.35)
5.69 (8.37)
1.90 (4.31)
0.151
0.079
0.317
0.806
<0.0001
<0.001
<0.0001
0.001
<0.0001
0.219
Data are expressed as mean (SD) or percentages.

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the most important and consistent differences were those
observed between the two genders. Physical activity and
sedentary behaviour are therefore presented by gender, as
well (Table 4).
In specific, Table 4 shows the percentage of children who
were engaged in certain physical or sedentary activities, as
well as the mean duration of the corresponding behav-
iours. Boys generally seem to have higher level of physical
activities and spend more time in electronic games, while
girls spend more time in homework and do more home
chores. However, about one fourth of the children
reported that they did not have any kind of physical activ-
ity and one third of boys and two thirds of girls that do
not participate in any kind of sports in a typical day. More-
over, there are no gender differences regarding the time
spent in TV viewing in week days (p = 0.317) or weekends
(p = 0.806), as well as the percentage of children who
spent more than 2 hours per day in weekdays (p = 0.280)
or in weekend days (p = 0.700) watching TV (Table 4).
Discussion
In this paper we present the aims, methodology and basic
findings of the CYKIDS study, a nationwide, epidemiolog-
ical study that examines the dietary habits and physical
activity patterns of school-aged children in Cyprus. Our
aim was to evaluate school children's dietary habits and
physical activity patterns in relation to selected socio-
demographic factors and examine implications for public
health programs.
Our survey revealed several negative trends with regards to
children's diet. A large percentage of participants reported
frequency of consumption of fruit, vegetables and whole
grain products that are well below recommended levels.
Adequate intake of these foods is important in achieving
optimal dietary quality as well as in preventing obesity
and other risk factors for chronic disease [21].
Certain dietary practices, such as eating breakfast and hav-
ing meals with family have been associated with sound
diet and prevention of childhood obesity [22,23]. It is
therefore of concern, that a fifth of boys and a quarter of
girls do not eat breakfast most days. Similar figures for
skipping breakfast (i.e. 10%–30%) have been reported by
previous studies conducted in the United States and
Europe [24]. It is encouraging however, that the vast
majority of children eat most of their meals with family
members. Several observational studies have shown that
parental presence at meal time is associated with better
dietary habits as well as, decreased frequency of skipping
breakfast [25-29]. Family-based interventions are there-
fore being regarded as effective means for the prevention
of childhood obesity and the promotion of healthy life-
styles [30,31]. Family cohesiveness is still very strong in
Cyprus [32] and it is still common that grandparents take
the care of children when they finish classes. Grandpar-
ents often prepare lunch and/or dinner on weekdays, and
even at weekends, for their children and grandchildren.
Thus, children eat home-made meals with their family. A
mountainous, rural environment was found to be a signif-
icant factor in determining children's eating behaviour. In
general terms, living in mountainous or sub-mountain-
ous regions was found to be associated with healthier
behaviours, such as having breakfast regularly, joining
family meals, and consuming fast food less often. Moun-
tains are generally acknowledged in Europe as a living
milieu where traditional ways of living have not been
abandoned and family cohesiveness has been preserved.
Family cohesion has been shown to be predictive of posi-
tive dietary behaviours [33]. Gender also appeared to
influence food-related behaviours, such as having break-
fast. Similarly to previous studies [34], we found that girls
are more likely to skip the first main meal of the day, in all
likelihood as a means to lose weight [35]
It is generally acknowledged that diet should be assessed
holistically taking into account foods and food groups
consumed as well as, dietary practices, such as meal pat-
terns[36]. We used the KIDMED index to assess the over-
all quality of children's diet in relation to the
Mediterranean diet model. Our findings point to no sig-
nificant differences between boys and girls. But noticea-
bly, only 6.7% of the children were classified as high
adherers to the Mediterranean diet, whereas 37% had a
poor KIDMED score. A previous study conducted in Crete
[37] that evaluated adherence to the Mediterranean diet
among 690 children and adolescents (7–18 years) by
using a modified KIDMED index, reported results similar
to ours for the lowest KIDMED category, i.e.27.9% of the
children had a poor Mediterranean diet score, but the per-
centage who scored highest was 4 times higher, i.e. 28.5%
as opposed to 6.5% in our study. A survey conducted by
Kontogianni et al [38] in a representative sample of 1305
Greek children and adolescents that assessed adherence to
Mediterranean diet by applying the same tool, the
KIDMED index also found, that only a small percentage of
children (11.3%) and adolescents (8.3%) obtained an
optimal KIDMED score (i.e. ≥ 8 points).
It seems that, there has been a shift from traditional
healthy diets towards unhealthy ones. This phenomenon
should be further explored by future studies to reveal the
underlying causes.
Regarding differences in levels of physical activity and sed-
entary patterns between boys and girls, the results of our
study were similar to those of other studies conducted in
Cyprus [39] and abroad [40], which show that boys have
higher levels of physical activity, compared to girls.
According to our study, a large percentage of both boys
and girls have less than the recommended levels of physi-

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cal activity (i.e. even though the average amount of phys-
ical activity is more than 60 minutes daily in both
genders, one fifth of boys and one quarter of girls are com-
pletely sedentary, after school. Even though factors associ-
ated with levels of physical activity in Cypriot children are
have been investigated [41,42], differences between gen-
ders however, have not been evaluated yet and this war-
rants further investigation.
Average TV viewing time was high compared to the Amer-
ican Academy of Pediatrics recommended daily time[43],
especially at weekends, and moreover, the vast majority of
children failed to meet these recommendations. Our data
are comparable with the findings of a previous study con-
ducted among 1337 Cypriot children (11–12 years) dur-
ing the period 1998–1999, which showed that 67.4% of
boys and 68.3% of girls spent more than 2 hours/day
watching TV [44]. These results call for specific measures
to target TV viewing and further investigations regarding
correlates and clustering of this particular behavior with
other lifestyle behaviors.
Limitations and strengths
The present study has certain limitations which should be
taken into account before drawing generalisations from its
results. First, it was a cross-sectional study. Therefore, no
conclusions can be made about plausible causes, but
rather, indications can be extracted, valuable in future
investigations. Dietary and physical activity data were
based on self-reports. Although we made every effort to
get as accurate data as possible, there is a possibility that
misreporting has occurred, which might have influenced
our findings. Literature reports that food underreporting
is usually associated with gender and weight status
[45,46]. Girls and overweight children are more prone to
underreporting, underreporting high energy dense, and
low nutrient dense, foods, in particular[45,46]. Assess-
ment of obesity status was based on parental reported
heights and weights, but this practice has been previously
used with satisfactory results [47,48].
Some of the strengths of the present work deserve a com-
ment. First, its nation-wide character allows to draw gen-
eralizations from the findings for the Cypriot population.
It also evaluates a wide array of socio-demographic
parameters for their association to children's diet and
physical activity. Finally, it provides implications and sug-
gestions valuable in public health policies and remedial
actions.
Implications
The data presented here provide information which can
be useful in public health programs. Schools are regarded
as excellent settings for providing health education and
lifestyle intervention programs to children [49]. The Min-
istry of Education, educators, public health professionals
and parents should be aware of these findings and explore
new ways to encourage regular meal consumption and
urge more children to eat breakfast regularly, have meals
with their family and have fewer meals away from home.
In particular, health care professionals and dieticians have
an important role to play in encouraging the adoption of
regular family meals by highlighting the benefits of this
habit, suggesting strategies and helping families in setting
progressive and achievable goals. Furthermore, efforts
should be made to increase consumption of vegetables,
fruit, legumes, and whole grain products and limit con-
sumption of sodas and high glycemic foods.
The benefits of the Mediterranean Diet should be high-
lighted and concerted public health actions should be
undertaken in order to promote this traditional prototype
of healthy eating.
In the light of the above finding, that some important
food behaviours are related to certain socio-demographic
factors and especially to gender and the geomorphologi-
cal characteristics of living environment, public health
programs should be differentiated accordingly and pro-
vide for sustaining the positive dietary behaviours in the
groups that have preserved traditional foodways, while
giving special emphasis and planning targeted actions in
those populations, that are more susceptible in adopting
"unhealthy" dietary behaviours.
New research should be undertaken to reveal which are
the factors that influence the adoption of regular meal pat-
terns and optimal food consumption patterns. As for
physical activity, our results suggest that future interven-
tion programs should specifically target girls who were
found to be the less active.
Conclusion
This is the first study which reports on dietary habits of
Cypriot school children and showed that at least one third
of Cypriot children have adopted poor dietary habits,
whereas about one fourth, do not have any kind of phys-
ical activity on a typical day. It is noteworthy that more
than 60% of participants watch TV- DVD at least 2 hours/
day. Boys reported higher level of physical activities and
spend more time in electronic games, while girls spend
more time in homework and do more home chores. The
gender-specific differences in lifestyle factors that were
observed, point to the need for specific public health pro-
grams for this population group. Public health policy
makers and other health care professionals should
urgently focus their attention to school children in order
to reduce the burden of metabolic disorders and chronic
diseases in the future.

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Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CL designed the study, obtained the funding, performed
the data analysis, interpreted the results and wrote the
paper. DBP supervised the design of the study, the statisti-
cal analyses, contributed to the presentation and interpre-
tation of the results and critically reviewed the paper. CK
critically reviewed the paper and A-LM contributed to the
presentation and interpretation of the results and critically
reviewed the paper. All authors contributed to the final
version of the manuscript.
Acknowledgements
This work was supported by a Cyprus Research Promotion Foundation
research grant (AKGEN/0506/05). The study was partially supported by
'Charalambides' dairies and by Cyprus Dietetic Association. We thank the
Cyprus Ministry of Education & Culture (Primary Education Department)
and all the teachers who readily consented to carry out the study during
school hours. Warmth thanks to all the participated children and their par-
ents.
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