Marcela González-Gross’s research while affiliated with Instituto de Salud Carlos III and other places

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Publications (508)


Flow chart of the study sample selection. SES, socioeconomic status; BMI, body mass index; FMI, fat mass index; WC, waist circumference.
Interaction model between breastfeeding duration and obesity GRS for z‐BMI (2A), z‐FMI (2B) and z‐WC (2C). Model adjusted by FAS, DQI and MVPA. X axis: beta coefficients of obesity GRS; Y axis: unstandardized predicted values of adiposity indices in z‐scores. Coloured lines represent different breastfeeding duration categories: Never Breastfed (blue), 1–3 months (green), ≥4 months (fuchsia). Crossed lines suggest breastfeeding x GRS effect. Z‐BMI, body mass index z‐score; z‐FMI, fat mass index z‐score; z‐WC, waist circumference z‐score; GRS, genetic risk score; FAS, family affluence scale; DQI, Diet Quality Index; MVPA, Moderate to Vigorous Physical Activity.
Mean z‐BMI (3A), z‐FMI (3B) and z‐WC (3C) across breastfeeding categories according to genetic risk, adjusted by FAS, DQI and MVPA. Significant mean differences are presented as p < 0.05* and p < 0.001**. X axis: Mean low and high genetic risk; Y axis: mean adiposity indices in z‐scores. Colour intensity of bars represents different breastfeeding duration categories: Never Breastfed (light grey), 1–3 months (grey) and ≥4 months (black). Z‐BMI, body mass index z‐score; z‐FMI, fat mass index z‐score; z‐WC, waist circumference z‐score; GRS, genetic risk score; FAS, family affluence scale; DQI, Diet Quality Index; MVPA, Moderate to Vigorous Physical Activity.
Interaction between breastfeeding duration and an obesity genetic risk score to predict body fat composition in European adolescents: The HELENA study
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January 2025

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Background Although the genetic interplay with the environment has a major impact on obesity development, little is known on whether breastfeeding could modulate the genetic predisposition to obesity. Objectives To investigate whether breastfeeding attenuates the effect of an obesity genetic risk score (GRS) on adiposity in European adolescents. Methods Totally 751 adolescents from the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) cross‐sectional study were included, divided according to breastfeeding status into never breastfed, 1–3 months and ≥4 months. Adjusting by socioeconomic status and lifestyle factors multiple linear regression models were used to assess (1) the main effect of breastfeeding duration and (2) its interaction effect with an obesity GRS, to predict different adiposity measures. Results A significant negative association between ≥4 months of breastfeeding and waist circumference (WC) z‐score was observed [β (95% confidence interval), p‐value] = [β = −0.189 (−0.37, −0.00), p = 0.044]. Also, significant interaction effects were observed for 1–3 and ≥4 months of breastfeeding and obesity GRS regarding body mass index (BMI) z‐score [β = 0.155 (0.06, 0.24), p = 0.001] and [β = 0.108 (0.01, 0.18), p = 0.020, respectively] and fat mass index (FMI) z‐score [β = 0.134 (0.04, 0.22), p = 0.003] and [β = 0.100 (0.01, 0.18), p = 0.026, respectively]. Conclusions Breastfeeding modulates the association between the obesity GRS and body composition in adolescents.

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Is There a Relationship Between Physical Performance Factors and Adverse Reactions to Foodstuffs? The ALASKA Study

December 2024

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8 Reads

Background/Objectives: An optimal physical condition has beneficial effects in adults at risk of chronic diseases. However, research data on how adverse reactions to food (ARFSs) are linked to physical performance are lacking. The aims of this study were (a) to investigate the prevalence of ARFS according to age; (b) to analyze physical performance level according to the type of ARFS; and (c) to determine the probability of having a positive ARFS according to physical performance levels. Methods: A cross-sectional study with 254 Spanish adults (61% women; mean age 43.7 ± 13 y) scoring ≥ 6 in PSIMP-ARFSQ-10 (pathologies and symptomatology questionnaire associated with adverse reactions to foodstuffs) was conducted in the region of Madrid, Spain, following the ALASKA study protocol. Immune-mediated variables used to measure ARFS were sIgE and sIgG4 antibody reactions (AbR) (type 1 and type 2 food hypersensitivities, respectively); non-immune-mediated variables used to measure ARFS were lactose intolerance and fructose malabsorption. Physical performance variables were body balance, leg power, sit-to-stand speed, resting heart rate, handgrip strength, and cardiorespiratory fitness. Statistical significance was set at 0.05. Results: The most prevalent sIgE- and sIgG4-mediated ARFSs were against legumes (53% and 46%; 60% and 68% in subjects with ≤45 y and >45 y, respectively). Handgrip strength was significantly lower in subjects positive for lactose intolerance compared to subjects negative for lactose intolerance (p < 0.05). Both the positive mean sIgE and sIgG4 AbR were significantly associated with high physical performance (p < 0.05). Subjects with high physical performance showed a 1.5-fold increase in the odds of the positive mean total sIgE and positive sIgG4 AbR against legumes. Conclusions: In conclusion, subjects aged 45 or younger had a higher prevalence of total type 1 and type 2 food hypersensitivities than subjects older than 45 y. Positive lactose intolerance was linked to lower values of handgrip strength. Subjects with high physical performance, whether male or female, aged ≤45 years, or with a BMI of ≥25, showed significant odds of experiencing type 1 food hypersensitivity to nuts.



Physical activity reference curves based on accelerometer outputs. A girls, counts per minute (CPM). B Boys, counts per minute (CPM). C Girls, sedentary time (SED). D Boys, sedentary time (SED). E Girls, light physical activity (LPA). F Boys, light physical activity (LPA). G Girls, moderate-to-vigorous physical activity (MVPA). H Boys, moderate-to-vigorous physical activity (MVPA). CPM, counts per minute. SED, sedentary time. LPA, light physical activity. MVPA, moderate to vigorous physical activity. Min/day, minutes per day. Yr, year
Age- and sex-specific reference percentile curves for accelerometry-measured physical activity in healthy European children and adolescents

December 2024

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158 Reads

European Journal of Pediatrics

Physical activity measured by accelerometry (PA-accelerometry) is used as an indicator of physical capacity in chronic diseases. Currently, only fragmented age ranges of reference percentile curves are available for European children and adolescents. This study aimed to provide age- and sex-specific percentiles for physical activity measured by hip-worn accelerometry derived throughout the full age range of European children and adolescents. Individual-level population-based PA data measured by accelerometry from HELENA and IDEFICS/I.Family studies were pooled and harmonized. Together these studies involved children and adolescents aged 2–18 years from 12 European countries. Primary outcomes included averaged counts per minute (CPM), sedentary time (SED), light PA (LPA) and moderate-to-vigorous PA (MVPA). Generalized Additive Models for Location, Scale and Shape were used to derive age- and sex-specific reference percentile curves for these outcomes. The combined cohort consisted of 11,645 children and adolescents aged 2 to 18 years who contributed 14,610 valid accelerometry recordings, with a median accelerometer wear time of 6 days. This dataset allowed for the construction of age- and sex-specific reference percentile curves for CPM, SED, LPA, and MVPA. The curves demonstrated varying trends and variability across age groups. Conclusions: This study provides age- and sex-specific percentile curves for PA-accelerometry in European children and adolescents, addressing a current gap in the availability of full-age range reference data. These curves based on healthy children and adolescents can be used by clinicians, researchers, and policymakers to interpret PA-accelerometry measurements, track physical activity trends, and evaluate treatment responses and health interventions. What is Known: • Daily physical activity (PA) is considered an important measure in various paediatric conditions. Existing reference data for PA in European children based on hip-worn accelerometers are limited to specific age ranges, and comprehensive data covering the full age range are lacking. What is New: • The study provides age- and sex-specific reference curves for PA derived by hip-worn accelerometers in European children and adolescents. These curves aid clinicians, researchers, and policymakers in interpreting PA measurements and tracking trends over time in European children.


Overweight Prevalence Changes Before and After COVID-19 in Spain: The PESCA Program Longitudinal Outcomes 2018–2021

November 2024

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9 Reads

Background: Overweight prevalence in Spain reached critical levels before the COVID-19 pandemic, which likely exacerbated this issue. The PESCA (Programa Escolar de Salud Cardio-vascular) program is a multicomponent school-based intervention, launched in 2018 with the aim of tackling this health problem and reducing overweight rates in youth. Objectives: (1) To analyze the efficacy of the PESCA program intervention on body composition, overweight prevalence, physical activity (PA)/sport practice, resting time, and screentime before COVID-19 and (2) to evaluate the impact of COVID-19 and the associated lockdown measures on these parameters in the studied sample. Methods: This longitudinal study included 207 children and adolescents from schools in Madrid (aged 2.82 to 15.84 years; 44.4% girls), with measurements taken at three time points: two before COVID-19 and one after its onset. Overweight prevalence, body fat percentage diagnosis, physical activity, resting time, and screentime were assessed. Cochran’s Q test and repeated-measures ANOVA were used to compare outcomes across the three assessment time points. Results: Overweight prevalence remained stable among children in the PESCA program before COVID-19 (17.87% to 19.81%). However, a significant increase was observed from point 2 to point 3, post-COVID-19 onset (19.81% to 26.57%). Similarly, healthy body composition significantly deteriorated from 63.16% at point 2 to 52.48% at point 3. PA/sport practice prevalence significantly increased until COVID-19 onset (80.19% to 91.22%) but declined thereafter (91.22% to 79.10% from point 2 to point 3). Although the differences were small, resting time significantly decreased post-COVID-19 onset (from 10.18 h at point 2 to 9.96 h at point 3), with no changes in the first period. Non-academic screentime showed a similar pattern: stable before COVID-19 and significantly increased after its onset (1.61 h at point 1; 1.70 h at point 2; 2.29 h at point 3). Conclusions: The PESCA program positively impacted PA/sport practice prevalence and may have provided some protection against overweight and related variables during the pre-COVID period. However, health authorities’ restrictions and lockdown policies during COVID-19 negatively affected the health and lifestyle variables studied, offsetting previous improvements.



Twenty-year trend in the prevalence of increased cardiometabolic risk, measured by abdominal obesity, among Spanish children and adolescents across body mass index categories

November 2024

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62 Reads

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1 Citation

BMC Medicine

Background Identifying children and adolescents with cardiometabolic risk at an early stage is crucial for effective treatment and prevention. From a practical perspective, this could be accomplished by assessing the presence of abdominal obesity, which serves as a surrogate indicator of increased cardiometabolic risk and is easy to measure. However, the assessment of abdominal obesity via waist circumference has not yet become a standard procedure in pediatric healthcare. The present study aimed to analyze the secular trends in increased cardiometabolic risk, as indicated by waist circumference among Spanish children and adolescents. Methods This study included 4861 children and adolescents aged 8 to 16 years from two nationwide representative cross-sectional surveys, the EnKid study and the PASOS study, conducted in 1998–2000 and 2019–2020, respectively. Anthropometric variables were measured in both surveys by trained personnel. Three different waist-to-height (WHtR) cutoffs were used to define abdominal obesity as criteria for cardiometabolic risk. BMI categories were defined according to the IOTF and WHO growth charts. Results Abdominal obesity [waist to height ratio (cm/cm) > 0.49] significantly increased from 40.7 to 56.1% and 93.8 to 97.2% in participants with overweight and obesity, respectively, between 1998–2000 and 2019–2020 (p < 0.05). Logistic regression analysis, adjusted for sex and age, revealed that the odds of being at increased cardiometabolic risk in 2019–2020 was 1.99 (95% CI 1.48–2.67) in participants with overweight in comparison with 1998–2000. The effect size was comparable among the three WHtR criteria for abdominal obesity or the BMI categories according to IOTF and WHO boundaries. Conclusions The prevalence of Spanish children with increased cardiometabolic risk, identified by abdominal obesity, significantly increased among those with overweight during the last two decades. This finding underlines the need of including the measurement of waist circumference as a standard procedure in pediatric practice.


Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants

November 2024

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795 Reads

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25 Citations

The Lancet

Background Diabetes can be detected at the primary health-care level, and effective treatments lower the risk of complications. There are insufficient data on the coverage of treatment for diabetes and how it has changed. We estimated trends from 1990 to 2022 in diabetes prevalence and treatment for 200 countries and territories. Methods We used data from 1108 population-representative studies with 141 million participants aged 18 years and older with measurements of fasting glucose and glycated haemoglobin (HbA1c), and information on diabetes treatment. We defined diabetes as having a fasting plasma glucose (FPG) of 7·0 mmol/L or higher, having an HbA1c of 6·5% or higher, or taking medication for diabetes. We defined diabetes treatment as the proportion of people with diabetes who were taking medication for diabetes. We analysed the data in a Bayesian hierarchical meta-regression model to estimate diabetes prevalence and treatment. Findings In 2022, an estimated 828 million (95% credible interval [CrI] 757–908) adults (those aged 18 years and older) had diabetes, an increase of 630 million (554–713) from 1990. From 1990 to 2022, the age-standardised prevalence of diabetes increased in 131 countries for women and in 155 countries for men with a posterior probability of more than 0·80. The largest increases were in low-income and middle-income countries in southeast Asia (eg, Malaysia), south Asia (eg, Pakistan), the Middle East and north Africa (eg, Egypt), and Latin America and the Caribbean (eg, Jamaica, Trinidad and Tobago, and Costa Rica). Age-standardised prevalence neither increased nor decreased with a posterior probability of more than 0·80 in some countries in western and central Europe, sub-Saharan Africa, east Asia and the Pacific, Canada, and some Pacific island nations where prevalence was already high in 1990; it decreased with a posterior probability of more than 0·80 in women in Japan, Spain, and France, and in men in Nauru. The lowest prevalence in the world in 2022 was in western Europe and east Africa for both sexes, and in Japan and Canada for women, and the highest prevalence in the world in 2022 was in countries in Polynesia and Micronesia, some countries in the Caribbean and the Middle East and north Africa, as well as Pakistan and Malaysia. In 2022, 445 million (95% CrI 401–496) adults aged 30 years or older with diabetes did not receive treatment (59% of adults aged 30 years or older with diabetes), 3·5 times the number in 1990. From 1990 to 2022, diabetes treatment coverage increased in 118 countries for women and 98 countries for men with a posterior probability of more than 0·80. The largest improvement in treatment coverage was in some countries from central and western Europe and Latin America (Mexico, Colombia, Chile, and Costa Rica), Canada, South Korea, Russia, Seychelles, and Jordan. There was no increase in treatment coverage in most countries in sub-Saharan Africa; the Caribbean; Pacific island nations; and south, southeast, and central Asia. In 2022, age-standardised treatment coverage was lowest in countries in sub-Saharan Africa and south Asia, and treatment coverage was less than 10% in some African countries. Treatment coverage was 55% or higher in South Korea, many high-income western countries, and some countries in central and eastern Europe (eg, Poland, Czechia, and Russia), Latin America (eg, Costa Rica, Chile, and Mexico), and the Middle East and north Africa (eg, Jordan, Qatar, and Kuwait). Interpretation In most countries, especially in low-income and middle-income countries, diabetes treatment has not increased at all or has not increased sufficiently in comparison with the rise in prevalence. The burden of diabetes and untreated diabetes is increasingly borne by low-income and middle-income countries. The expansion of health insurance and primary health care should be accompanied with diabetes programmes that realign and resource health services to enhance the early detection and effective treatment of diabetes.


Age- and Sex-Specific Reference Percentile Curves for Accelerometry-Measured Physical Activity in Healthy European Children

July 2024

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117 Reads

PURPOSE Physical activity measured by accelerometry (PA-accelerometry) is used as an indicator of disease severity in chronic diseases. Currently, only fragmented age ranges of reference percentile curves are available for European children. This study aimed to provide age- and sex-specific percentiles for physical activity measured by hip-worn accelerometry derived throughout the full age range of European children. METHODS Individual-level population-based PA data from HELENA and IDEFICS/I.Family studies were pooled and harmonized. Together these studies involved children aged 2–18 years from 12 European countries. PA was measured using uni-axial or tri-axial Actigraph accelerometers. Accelerometry recording was defined as valid if lasted at least 6 hours on at least 2 weekdays and 1 weekend day. Primary outcomes included averaged counts per minute (CPM), sedentary time (SED), light PA (LPA) and moderate-to-vigorous PA (MVPA). Generalized Additive Models for Location, Scale and Shape were used to derive age- and sex-specific reference percentile curves for these outcomes. RESULTS The combined cohort consisted of 11,645 children aged 2 to 18 years who contributed 14,610 valid accelerometry recordings, with a median accelerometer wear time of 6 days and a median wear time of 745 minutes per day. This dataset allowed for the construction of age- and sex-specific reference percentile curves for CPM, SED, LPA, and MVPA. The curves demonstrated varying trends and variability across age groups. CONCLUSIONS This study provides age- and sex-specific percentile curves for PA-accelerometry in European children, addressing a current gap in the availability of full-age range reference data. These curves based on healthy children can be used by clinicians, researchers, and policymakers to interpret PA-accelerometry measurements, assess severity of disease in paediatric chronic illness, track physical activity trends, and evaluate treatment responses and health interventions.


Adverse reactions to foodstuffs classification updated and adapted from a selected literature (described below). Adapted from: Immune-mediated reactions: [6–9]; Non-immune-mediated reactions: [7, 10, 11]
Flow diagram of the ALASKA study. ARFS: adverse reactions to foodstuffs; FASSD: food allergen-specific substitutive diet; M1: physical and clinical assessments at month 1; M5/6: physical and clinical assessments at month 5 or 6; PSIMP-RAA-10: Pathologies and Symptomatology Questionnaire associated with Adverse Reactions to Foodstuffs; y: years of age
ALASKA study main variables organized as 10 main assessments for the adverse reaction to foodstuffs management
Checklist example of a participant’s timeline with assessments and instruments during the ALASKA study
The multifactorial approach and the food allergen-specific substitutive diet as a tool to manage and ameliorate adverse reactions to foodstuffs in adulthood: study protocol for a randomized controlled trial—the ALASKA study

July 2024

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50 Reads

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1 Citation

Trials

Background Adverse reactions to foodstuffs (ARFS), specifically food allergy (FA) and food intolerance (FI), are increasing worldwide and represent a major public health concern. Thus, ARFS management, its identification, evaluation, and intervention, must provide a comprehensive solution. Objectives (a) To develop a multifactorial strategy for ARFS management in adults with FA and/or FI; (b) to describe the multiple influential variables in ARFS within the realm of ARFS management; and (c) to design a personalized food allergen-specific substitutive diet (FASSD), as a 6-month dietary treatment option for adults with ARFS and as a component of ARFS management. Methods The ALASKA study will consider the following main variables as part of the ARFS management: (1) demographics and clinical information; (2) symptomatology, food and beverages intake and physical activity; (3) hematobiochemical study; (4) immunology; (5) enzymatic activity; (6) anthropometry, body composition, and physical fitness; (7) QoL; (8) 6-month intervention; (9) end of the study; and (10) other assessments. The FASSD will be designed with special emphasis on the commonly lacking micronutrients in the ARFS population: niacin, Mg, K, P, Ca, Zn, B12, folate, Fe, and fiber. Discussion The ALASKA study protocol has been developed as a global strategy to manage and evaluate ARFS in Spanish adults older than 18 years of age. Approaching ARFS with multiple assessments, as influencing factors, will lead to a novel strategy for ARFS management. The FASSD has been designed as a personalized tool to avoid crucial micronutrient deficiencies that a current strict food allergen avoidance or elimination diet may provoke. Trial registration The protocol has been approved by the Ethics Committee of the UPM (REF.20200602) and registered on ClinicalTrials.gov (NCT05802017).


Citations (71)


... However, these hospitalizations frequently lead to readmissions, underscoring the chronic and progressive nature of the disease [17,18]. In Chile, hypertension and obesity significantly contribute to the exacerbation of T2D complications, increasing the likelihood of hospitalizations and poor outcomes [19]. These conditions often coexist with T2D, compounding the challenges of managing this chronic disease. ...

Reference:

Trends and determinants of hospitalizations among diabetic patients in Chile: A 4-year analysis (2019–2022)
Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants

The Lancet

... Abdominal obesity has been consistently linked to cardiometabolic risk factors including insulin resistance, type 2 diabetes, hypertension, and dyslipidemia, among other early markers of cardiovascular disease. Thus, it is necessary to include the measurement of abdominal obesity in the determination of nutritional status and to identify children and adolescents with cardiometabolic risk [33]. Other biases arise from the fact that the information collected in the ENSANUT is based on self-reporting by participants or their parents/guardians and may exclude certain groups of children and adolescents from rural areas that are very difficult to access or that are in situations of extreme vulnerability. ...

Twenty-year trend in the prevalence of increased cardiometabolic risk, measured by abdominal obesity, among Spanish children and adolescents across body mass index categories

BMC Medicine

... ARFSs encompass a range of related aspects that can be affected by intrinsic and extrinsic factors [3]. Optimal cardiorespiratory fitness and other physical performance variables have been shown to have a positive apparent impact on the health of adults with chronic diseases in developed countries. ...

The multifactorial approach and the food allergen-specific substitutive diet as a tool to manage and ameliorate adverse reactions to foodstuffs in adulthood: study protocol for a randomized controlled trial—the ALASKA study

Trials

... Although the association between Profile 3 and PLE was mainly driven by other factors rather than team sports, it is possible that involvement in team sports (e.g. pick-up basketball) and perhaps other informal social interactions may be less likely to occur in more rural and less walkable places (Aznar et al., 2024). This lack of social engagement with peers may play a role in the future risk of psychotic experiences (Glover, Todd, & Moyer, 2022). ...

Walkability and socio-economic status in relation to walking, playing and sports practice in a representative Spanish sample of youth: The PASOS study

... In 2022, approximately 2.5 billion adults aged 18 years and older were classified as overweight, with over 890 million individuals living with obesity, accounting for 43% of adults globally, a significant rise from 25% in 1990 [1]. Regional disparities are striking, with prevalence ranging from 31% in the WHO South-East Asia and African Regions to 67% in the Region of the Americas [28]. ...

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

The Lancet

... Kidney damage is also a common complication of hypertension [26]. In recent years, an increasing number of studies indicate a rising trend in the prevalence of hypertension among children and adolescents, posing significant threats to their health by causing organ damage [27,28]. Due to the incomplete development of children and adolescents, the diagnostic criteria for hypertension in this population differ significantly from those used for adults [29]. ...

Interplay of the Mediterranean diet and genetic hypertension risk on blood pressure in European adolescents: Findings from the HELENA study

European Journal of Pediatrics

... However, while the positive effects of physical activity on body composition are well-documented, further research is essential to determine the most effective types, intensities, and durations of exercise interventions. Additionally, understanding how to tailor these interventions to different populations, taking into account factors such as age, gender, and baseline fitness levels, is crucial for maximizing their impact [15,16]. ...

Longitudinal Changes in the Body Composition of Non-Institutionalized Spanish Older Adults after 8 Years of Follow-Up: The Effects of Sex, Age, and Organized Physical Activity

... According to the recently published ARFS classification by Pantoja-Arévalo et al. (2024), ARFS refers to any immune-mediated and non-immune-mediated food reaction, such as food allergy or type 1 food hypersensitivity (mostly sIgE-mediated ARFS), and type 2 food hypersensitivity (mostly sIgG 4 -mediated ARFS) refers to immune-mediated reactions, while food malabsorption (e.g., fructose malabsorption) and food intolerance (e.g., lactose intolerance) are referred to as non-immune-mediated food reactions, among other ARFSs [3]. Type 1 and type 2 food hypersensitivities have been linked to the food allergy pathogenesis identification and to self-reported symptoms related to ARFS, respectively [4,5]. Additionally, individuals with lactose intolerance and fructose malabsorption presenting symptoms related to the digestive system have been observed to have higher physical commotions than those without lactose intolerance [6]. ...

Association between Food-Specific Immunoglobulin G4 Antibodies in Adults with Self-Reported Signs and Symptoms Attributed to Adverse Reactions to Foodstuffs

... Feranti R. et al. also found that adolescents who have parents with higher education or a specialized occupation are more likely to be underweight or have normal weight [15]. The existing data relate an adequate body composition with good physical fitness and/or a high rate of adherence to the Mediterranean diet (MD) [3,[19][20][21]. The results of last research showed low opportunities to imitate MD among adolescents, who belong to the group of Mediterranean or non-Mediterranean countries [6,[22][23][24]. ...

Perceived Quality of Life Is Related to a Healthy Lifestyle and Related Outcomes in Spanish Children and Adolescents: The Physical Activity, Sedentarism, and Obesity in Spanish Study

... Currently, research indicates that the PHD is associated with numerous health benefits. For example, many studies have found that adhering to the PHD can reduce the risk of diabetes [10] improve cardiovascular health [11]and reduce the risk of mortality [12]. However, the impact of PHD on mortality is not well established. ...

Association between adherence to the EAT-Lancet sustainable reference diet and cardiovascular health among European adolescents: the HELENA study

European Journal of Clinical Nutrition