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This study aimed to assess the impact of the introduction of pneumococcal conjugate vaccine 13 (PCV13) on the molecular epidemiology of invasive pneumococcal disease (IPD) in children from Andalusia. A population-based prospective surveillance study was conducted on IPD in children aged <14 years from Andalusia (2018–2020). Pneumococcal invasive isolates collected between 2006 and 2009 in the two largest tertiary hospitals in Andalusia were used as pre-PCV13 controls for comparison of serotype/genotype distribution. Overall IPD incidence rate was 3.55 cases per 100 000 in 2018; increased non-significantly to 4.20 cases per 100 000 in 2019 and declined in 2020 to 1.69 cases per 100 000 (incidence rate ratio 2020 vs. 2019: 0.40, 95% confidence interval (CI) 0.20–0.89, P = 0.01). Proportion of IPD cases due to PCV13 serotypes in 2018–2020 was 28% (P = 0.0001 for comparison with 2006–2009). Serotypes 24F (15%) and 11A (8.3%) were the most frequently identified non-PCV13 serotypes (NVT) in 2018–2020. Penicillin- and/or ampicillin-resistant clones mostly belonged to clonal complex 156 (serotype 14-ST156 and ST2944 and serotype 11A-ST6521). The proportion of IPD cases caused by PCV13 serotypes declined significantly after the initiation of the PCV13 vaccination programme in 2016. Certain NVT, such as serotypes 24F and 11A, warrant future monitoring in IPD owing to invasive potential and/or antibiotic resistance rates.
The term Postlaunch Evidence Generation (PLEG) refers to evidence generated after the launch or licensing of a health technology. The aim of this paper is to provide an overview of the implementation of these practices in the European Union in order to explore cross-border cooperation opportunities.
In December 2019, a survey composed of nine closed-ended questions with multiple choice answers about the PLEG practices in each country was sent to all twenty-five dedicated work package (WP5B) partners of the European Network of Health Technology Assessment (EUnetHTA) Joint Action 3. In addition to the survey, the national practices were discussed during a face-to-face meeting with WP5B partners.
Twelve Health TechnologyAssessment (HTA) bodies completed the survey. Of these, eleven reported procedures in place for official requests for PLEGs in their remit. In the large majority of cases, the requests are made at the time of the assessment/appraisal. Several agencies participate in the definition of the scope of the PLEG or review of its protocol. Data collection and analysis mainly lie with companies for pharmaceuticals, whereas it is more the responsibility of the HTA bodies for medical devices. Only one agency owns the data and is able to exchange them without asking permission.
Most agencies recommend European collaboration on PLEG commence once the evidence gaps have been defined or during the production of the HTA report in the case of European joint assessment.
The European Health Technology Assessment Network (EUnetHTA) Work Package 5B1, is focused on testing the levels of cross-border collaboration on real world data for supporting reimbursement/pricing decision-making. Within this Work Package, we are conducting a pilot on Left Ventricular Assist Device on destination therapy in collaboration with the National Institute for Health and Care Excellence (NICE, UK), the Belgian Health Care Knowledge Centre (KCE, Belgium) and the Italian National Agency for Regional Health Services (AGENAS, Italy). This pilot aims to define the minimum data set for gathering and sharing high quality registry data on key uncertainties found at the time of the health technology assessment (HTA). Furthermore, the pilot will assess the feasibility of carrying out a common analysis or reusing this data for National or Joint Reassessments.
Evidence gaps were based on the four national assessments. Collaborating partners were responsible for agreeing on the key outcomes and proposing the minimum dataset to be registered. European clinical experts and patients rated and prioritized the dataset using a two round Delphi technique (not relevant, important but not critical; critical). The dataset will confirm the basis for the Spanish LVAD registry, implemented at the national health service level to inform inclusion into the healthcare portfolio.
The key outcomes agreed upon by agencies relate to safety, effectiveness, satisfaction and acceptability of the patient and cost-effectiveness, budget impact and organizational impact. Expert cardiologists and cardiac surgeons representing the European and Spanish Society, among others, participated in the prioritization of basic data. The final dataset is expected by December 2020.
The variation in the quality and definition of outcome measures for measuring key evidence gaps reduces the utility of registries for HTA, making it difficult to compare, link, and aggregate data across countries. The EUnetHTA pilot is intended to offer a model for cross-border collaboration on real world data for supporting the decision-making process for pricing and reimbursement.
Extensive and semi-extensive production based on local swine breeds such as Majorcan Black Pig, Cinta Senese, Gascon, Krškopolje and Turopolje is becoming extremely rare and on the verge of disappearing in Europe. In this context, the main aim of this study was to assess the potential feasibility of marketing strategies to act as guidelines for stakeholders along the supply chain to create and improve added value and match market demands. The sustainability of five production systems was evaluated together with 60 stakeholders representing five local swine breeds, using a World Café (WC) method combined with an Analytical Hierarchical Process (AHP). The results showed that the proposed strategies could differ slightly depending on each system, while the product strategy was a common marketing priority for most of the stakeholders and represented all the systems evaluated. Diversifying production toward quality, innovative products, enhanced standardization, and quality labeling or seals of guarantee, such as the protected geographical indication or the protected designation of origin, would contribute to the sustainability of these chains. Advertising the storytelling of the meat products and emphasizing their healthier properties were also considered as positive strategies. To this effect, promotion should involve improving knowledge of the local systems and raising the profile of the meat products via public relations (networks, web pages, food and gastronomic events, workshops and so on) in the Hotels, Restaurants and Catering (HORECA) sector, stores selling top-quality products and local food shops. Better showcasing of these products and keeping the price in the premium segment would indirectly help the primary sector. By way of conclusion, other more developed local swine systems could be strong competitors, hence it is extremely important to effectively identify and trace all autochthonous swine breed products throughout the production chain. Furthermore, the entire chain must place greater emphasis on grazing (extensive or semi-extensive), the origin of the swine and their meat products. However, of utmost importance is cooperation between farms, firms and institutions.
Fluorescence techniques have been widely used by scientists to reveal valuable information from biological samples, but in food science, small progress is known due to the complexity of the samples. In this study, two different biological samples, garlic skin (GS) and agave fibers (AF), were used to evaluate the techniques of confocal laser scanning microscopy (CLSM) and total internal reflection fluorescence (TIRF) microscopy, to obtain valuable information on the fiber size of the samples. A compositional characterization with calcofluor white in CLSM was achieved, but a superficial characterization of the samples with TIRF was made, evidencing fiber sizes of 398.67 ± 48.47 nm and 677.38 ± 76.88 nm for GS and AF, respectively. This work reveals that only an untreated sample can be used with the two techniques in the same microscope. In addition, it is possible to characterize the sample only using a spatial field of research and which valuable information about the structure of the material is found. This work provides the opportunity to use advanced fluorescence techniques for elucidation of structures shortly before studied with these techniques.
In recent years, the GRADE system has been adopted internationally to make judgments about evidence and/or recommendations. Recently, the Spanish Network of HTA (RedETS) has promoted among its members the use of the GRADE system, especially the “Evidence to Decision” tool (EtD) where a multidisciplinary panel is involved. The objective is to describe the methodological approach with the first AQuAS experience using this methodology in HTA, focused on inclusion/exclusion of these technologies in the Spanish National Health Service (NHS) portfolio.
The standard EtD tool was used for clinical and financial decisions. Four multidisciplinary panels were constituted by relevant professionals in clinical practice and, where possible, patients. The four panels discussed on the following four interventions: in two cases, AQuAS prepared preliminary recommendations and participants provided feedback, while in the other two cases, experts received the evidence review and were asked to formulate recommendations. These recommendations were voted on and, in the case of disagreement, adapted and then voted on for a second time. Finally, any discrepancies were noted in the report. Evaluated interventions were: maxillofacial 3D-reconstruction, cataract surgery equipment, non-invasive surgery in obesity and pharmacological treatment in secondary fracture prevention.
Especially when more than one evaluative question was addressed in the HTA report the EtD and the consensus results required discussion. Consensus was fast but not immediate. Meeting length depended on the number of HTA questions and the amount of original disagreement in the recommendations. The nuances on how to write recommendations also affected the panel duration. All panels were successful in formulating the final recommendations.
Standardizing methodologies increased the homogeneity across HTA reports. The GRADE system is a feasible and useful tool because it favors transparency and rigor in drawing up recommendations on the inclusion/exclusion of technologies in the NHS portfolio. The EtD framework complements GRADE tables, which display the relevant evidence in a way that can be used by multidisciplinary groups to reach a consensual recommendation.
Although all participants received a short training video, more experience in the use of these methodologies might shorten the duration of the process and facilitate reaching consensus. Some considerations on how to overcome the difficulties and complexity of this methodological approach are discussed.
Pulses such as peas, beans or lentils are one of the most complete foods at the nutritional level; however, they are one of the most often neglected foods in the diets of university students. Entrance to university translates into a major lifestyle change for many young people, and the habits acquired or cemented at this time will remain into adulthood. The objective of this study is to analyse the association between personal/sociodemographic factors, dietary intake of other food groups and the consumption of pulses in first-year university students. This cross-sectional study is part of the UniHcos project, a multicentre study of multipurpose prospective cohorts in eleven Spanish universities. Data from 9862 university students were collected through an online self-questionnaire completed by all students who met the selection criteria and agreed to participate in the project during the 2011–2018 academic years. Of students, 75·8 % presented an inadequate (≤2 times/week) consumption of pulses. Living outside the family home in either a student residence (OR 0·76; 95 % CI 0·69, 0·84) or rental (OR 0·81; 95 % CI 0·70, 0·95) decreased the compliance with recommendations on the consumption of pulses. Low consumption of pulses is seemingly not restricted to a specific profile or dietary pattern among university students, and no specific focus group for intervention can be identified. Policies promoting the consumption of pulses among the university population as a whole are necessary to increase compliance rates with the dietary recommendations.
The objective was to evaluate maternal Mediterranean diet (MD) pattern adherence during pregnancy and its association with small for gestational age (SGA) and preterm birth. A secondary objective of the current study was to describe the sociodemographic, lifestyle and obstetric profile of the mothers studied as well as the most relevant paternal and newborn characteristics.
The current study is a two-phase retrospective population-based study of maternal dietary habits during pregnancy and their effect on newborn size and prematurity. The descriptive first phase examined maternal dietary habits during pregnancy along with the maternal sociodemographic, lifestyle and obstetric profile in a cross-sectional period study. In the second phase, newborn outcomes were evaluated in a nested case–control study. Adherence to MD during pregnancy was measured with the Spanish version of Kidmed index.
Obstetrics ward of the La Fe Hospital in Valencia.
All mother–child pairs admitted after delivery during a 12-month period starting from January 2018 were assessed for eligibility. A total of 1118 provided complete outcome data after signing informed consent.
14·5 % met the criteria of poor adherence (PA); 34·8 %, medium adherence (MA); and 50·7 %, optimal adherence (OA). Medium adherence to MD was associated in the adjusted scenarios with a higher risk of giving birth to a preterm newborn. No association was found between MD adherence and SGA.
Early intervention programmes geared towards pregnant women, where women were aided in reaching OA to MD, might reduce the risk of preterm newborn.
The increasing prevalence of overweight and obesity has developed into an epidemic public health problem worldwide. In this regard, in the last years several investigations have suggested that water intake and water balance could have important implications for both weight management and body composition. The aim of this study was to analyse the association between fluid intake, water balance and body composition in a sample of healthy young adults from Spain.
Material and methods
A total of 358 healthy subjects (121 males; 237 females) aged 18–39 years participated in the current study. The validated questionnaire entitled “The hydration status questionnaire” was used to assess fluid intake, elimination, and water balance. Anthropometric measurements (height, weight and waist circumference) were performed according to the recommendations of the International Standards for Anthropometric Assessment (ISAK). The estimates of total body water (TBW), fat mass (FM) and fat free mass (FFM) were acquired by bioelectrical bioimpedance analysis. Physical activity was estimated through the Short form of the International Physical Activity Questionnaire (IPAQ-SF). Differences in anthropometric and body composition variables were assessed through the ANOVA test and considered significant at p < 0.05.
Fluid intake was correlated with body water content in females (r = 0.180, p = 0.006) and males (r = 0.266, p = 0.003). An inverse association between water consumption per weight (ml/kg) with body weight (females (f): r = -0.318, p = 0.000; males (m): r = -0.220, p = 0.015), body fat mass (f: r = -0.320, p = 0.000; m: r = -0.200, p = 0.028), and waist circumference (f: r = -0.237, p = 0.000; m: r = -0.215, p = 0.018) was found. Finally, significant differences in body water content in females according to water balance were observed (p = 0.04).
Higher fluid intake seems to be related with a better body composition, therefore the improvement of water intake and water balance could be useful in weight management and in the prevention of overweight and obesity in healthy young adults.
Age-related hearing loss (ARHL) is a sensory impairment, with a dramatic increase in its incidence, which is caused by genetic and environmental factors such as noise and ototoxic drugs. Recent studies correlated ARHL to elevated plasma homocysteine (Hcy) by folate deficiency, suggesting that reduction of Hcy levels by folate supplementation could potentially ameliorate ARHL.
Hyperhomocysteinemia (HHcy), a status that contributes to ARHL, may also arise from malfunction of Hcy remethylation by betaine homocysteine S-methyltransferases (BHMTs) and methionine synthase in the methionine cycle. The expression and/or activity of these enzymes may be altered by ototoxic drugs, including paracetamol (APAP).
To determine the effect of APAP in cochlear morphology and function of control and Bhmt-/- mice, and to analyze putative preventive effects of folic acid (FA) supplementation.
Materials and Methods
Two-month-old Bhmt-/- mice (n = 47), with greater dependence on folate metabolism for Hcy remethylation, and Bhmt + / + mice (n = 42) were fed control or FA supplemented diets for 30 days. The last day APAP (250 mg/kg) or placebo were injected intraperitoneally.
Hearing was evaluated by recording auditory brainstem responses (ABR) at the beginning of the experiment and after treatments. Picrosirius red staining was used for evaluation of the cochlear lateral wall cytoarchitecture. Plasma and hepatic metabolite levels were determined by HPLC or on Spinlab 100® autoanalyzer.
Loss of Bhmt expression induced HHcy, but an impact on hearing acuity was not observed. Acute APAP administration did not induce ABR threshold shifts. However, following ototoxic treatment, changes of 5–17% in the areas of the stria vascularis and spiral ligament were detected between Bhmt-/- mice under different dietary treatments; cochlear structures of Bhmt-/- mice receiving APAP plus FA supplementation resemble those of the control group. APAP increases susceptibility to ototoxic damage in the presence of HHcy.
BHMT plays a central role in cochlear methionine metabolism. FA supplementation modulates Hcy levels, contributing to a proper remethylation status that prevents ARHL.
To assess weight status and eating habits of undergraduate university students in relation to gender and examine the relationships between weight status, physical activity and eating habits.
Cross-sectional study conducted between October 2016 and May 2017.
Young adults in Midwest Brazil.
Undergraduate university students (n 2163) majoring in health care.
Among 2163 students, 69·3 % were female, 65·4 % were aged 20–29 years, 66·8% consumed alcohol and 44·2% did not achieve more than 150 min of physical activity per week. We found significant differences in the consumption of beans (P < 0·04) and full-fat milk (P < 0·01) between women and men. Women also had more sedentary lifestyles (P < 0·01) and showed higher prevalence of overweight (33·8 %) and obesity (5·0 %) than men. Students who did not engage in physical activity were more overweight (P = 0·03), consumed more soft drinks (P < 0·01) and meat with excess fat (P = 0·01). There was a positive association between weight status and fruit (P = 0·02), salad (P < 0·01), greens/vegetables (P < 0·01) and beans (P < 0·01) intake.
The low level of physical activity and unhealthy eating patterns reported by the study participants were inconsistent with the national recommendations for a healthy active lifestyle for adults and may contribute to the increasing rate of overweight and obesity in this population. A joint effort between universities and all relevant government agencies is needed to develop and promote school- and community-based interventions.
In the past decades the community-based participatory research method known as PhotoVoice has gained relevance, but there are few published studies on its application in the field of health technology assessment (HTA) and clinical practice guidelines (CPGs). The aim of this presentation was to describe a PhotoVoice project linked to a CPG on major depression in children and adolescents.
The design of the study was adapted to the main objective, which was to enhance the understanding of major depression and improve clinical practice with the contributions of clinicians, methodologists, and patients. Seven adolescents and ten of their family members participated in the study through PhotoVoice sessions and focus groups. The audio recordings of all sessions were transcribed verbatim and coded, and a thematic analysis was undertaken.
Six themes emerged: (i) a lack of understanding and information about depression in childhood and adolescence; (ii) the importance of support groups; (iii) the need to favor early care and access to services; (iv) the adaptation of therapeutic strategies tailored to individual needs; (v) the sensitivity of professionals; and (vi) fostering interaction between the health and education systems. Photographic exhibitions were planned to share the main results. These exhibitions were promoted to increase public awareness and reduce stigmatization, and to reach clinicians and policy makers. From a methodological point of view, the use of PhotoVoice in this study helped to effectively incorporate the lived experiences, concerns, and preferences of patients and their relatives into the CPG. The study also confirmed the value of photographs and participatory methods. The main limitations and strengths of the study, as well as suggestions for future research, are also outlined.
PhotoVoice is a flexible, effective, and innovative method of obtaining information about patients’ perspectives and experiences, and it offers the added value of being able to reach the main stakeholders, including policymakers and the public.
The specificities of non-pharmaceuticals can require adapting classical health technology assessment (HTA) methodologies and developing additional regional approaches to support decision-making processes. However, little information exists regarding the explicit approaches used in different countries. The aim of this work is to provide an overview of the role and activities of the Galician HTA agency (avalia-t, Spain) regarding assessment, appraisal and continued evaluation across the whole life cycle of non-pharmaceutical technologies.
In depth review and analysis of the activities undertaken by avalia-t during the past five years to support the introduction and appropriate use of non-pharmaceutical health care technologies at the regional level.
A multidisciplinary Commission judges the added value of new non-pharmaceuticals and establishes the indications and conditions for use. HTAs, which are mandatory for all relevant technologies, rely on the best available evidence on safety and effectiveness but also provide fit for purpose contextualized information based on organizational data and administrative registers. Interaction with multidisciplinary stakeholders is commonly needed to complement the evidence base (ad hoc working groups, face to face discussions), and post-launch studies can be implemented to analyze the utilization and results in real world practice. Performance indicators and other HTA based products can also be required to ensure the quality of health care (e.g., appropriate use indications, quality indicators, evidence based patient information). In addition, technical and scientific advice/support can be provided at different decision levels of the health organization to promote the quality of care and appropriate use of technologies (e.g., regional mental health program, suicide management strategy, bariatric surgery surveillance registry).
Rigorous, comprehensive and systematic processes for supporting non-pharmaceutical technology adoption and implementation are required. Although it is acknowledged that core information does not differ substantially within countries, contextualized information is recognized as essential for establishing the conditions for use at the regional level.
Decision making regarding national population-based prenatal and newborn screening policies is recognized to be highly challenging. This paper aims to describe the formalized collaboration that has been established between the Spanish National Public Health Screening Advisory Committee (PHSAC) and the Spanish Network of Health Technology Assessment (HTA) agencies to support the development of evidence- and consensus-based recommendations to support this process.
In-depth description and analysis of the strategic and methodological processes that have been implemented within the Spanish National Health System prenatal and newborn screening frameworks, with special emphasis on the role, actions, and responsibilities of HTA agencies.
The role of HTA agencies is threefold: (i) support the PHSAC by providing evidence on safety, effectiveness and cost/effectiveness of the screening tests/strategies, as well as contextualized information regarding costs, organizational, social, legal and ethical issues; (ii) collaborate with the PHSAC in the development of formal evidence- and consensus-based recommendations for defining population screening programs, when required; (iii) analyze real-world data that is generated by piloted programs. This paper will provide real-life examples of how these processes were implemented in practice, with a special focus on the development of the non-invasive prenatal testing (NIPT) policy. Recommendations for NIPT were developed by a multidisciplinary group based on the European network for Health Technology Assessment (EUnetHTA) rapid assessment report and the predictive models that were built using national statistics and other contextualized data.
The current work represents an innovative approach for prenatal and newborn screening policymaking, which are commonly difficult to evaluate due to the low quality of evidence and the confounding public health issues. The paper raises awareness regarding the importance of joint collaborations in areas where evidence is commonly insufficient for decision making.
To assess the daily intake of polychlorinated biphenyls not similar to dioxins (NDL-PCB) derived from fish consumption in Spain and compare it with tolerance limits in order to establish a safe threshold so that the nutritional benefits derived from fish consumption may be optimized.
Analysis of NDL-PCB in fish samples and ecological study of the estimated intake of NDL-PCB from fish consumption in different Spanish population groups.
National representative sample of the Spanish population.
The intake of NDL-PCB was estimated in two different scenarios: upper bound (UB) and lower bound (LB). Estimating intake using the average concentration of NDL-PCB found in the fish samples, the intake for ‘other children’ is estimated as: 1·80 (UB) and 5·33 (LB) ng/kg per d at the 50th percentile (P50); 7·39 (UB) and 21·94 (LB) ng/kg per d at the 95th percentile (P95) of fish consumption. Estimated NDL-PCB intake shoots up in the toddler group, reaching values of 30·43 (UB) and 90·37 (LB) ng/kg per d at P95. Estimated intake values are lower than those previously estimated in Europe, something expected since in previous studies intake was estimated through total diet. In adults, our estimated values are 1·59 (UB) and 4·72 (LB) ng/kg per d at P50; 4·95 (UB) and 14·72 (LB) ng/kg per d at P95.
NDL-PCB concentration in fish is under the tolerance limits in most samples. However, daily intake in consumers of large quantities of fish should be monitored and special attention should be given to the youngest age groups due to their special vulnerability and higher exposure.
Tsangpoite, ideally Ca5(PO4)2(SiO4), the hexagonal polymorph of silicocarnotite, and matyhite, ideally Ca9(Ca0.5□0.5)Fe(PO4)7, the Fe-analogue of Ca-merrillite, were identified from the D'Orbigny angrite meteorite by electron probe microanalysis, electron microscopy and micro-Raman spectroscopy. On the basis of electron diffraction, the symmetry of tsangpoite was shown to be hexagonal, P63/m or P63, with a = 9.489(4) Å, c = 6.991(6) Å, V = 545.1(6) Å3 and Z = 2 for 12 oxygen atoms per formula unit, and that of matyhite was shown to be trigonal, R3c, with a = 10.456 (7) Å, c = 37.408(34) Å, V = 3541.6 (4.8) Å3 and Z = 6 for 28 oxygen atoms per formula unit. On the basis of their constant association with the grain-boundary assemblage: Fe sulfide + ulvöspinel + Al–Ti-bearing hedenbergite + fayalite–kirschsteinite intergrowth, the formation of tsangpoite and matyhite, along with kuratite (the Fe-analogue of rhönite), can be readily rationalised as crystallisation from residue magmas at the final stage of the D'Orbigny meteorite formation. Alternatively, the close petrographic relations between tsangpoite/matyhite and the resorbed Fe sulfide rimmed by fayalite + kirschsteinite symplectite, such as the nucleation of tsangpoite in association with magnetite ± other phases within Fe sulfide and the common outward growth of needle-like tsangpoite or plate-like matyhite from the fayalite–kirschsteinite symplectic rim of Fe sulfide into hedenbergite, infer that these new minerals and the grain-boundary assemblage might represent metasomatic products resulting from reactions between an intruding metasomatic agent and the porous olivine–plagioclase plate + fayalite-kirschsteinite overgrowth + augite + Fe sulfide aggregates. Still further thermochemical and kinetics evidence is required to clarify the exact formation mechanisms/conditions of the euhedral tsangpoite, matyhite and kuratite at the grain boundary of the D'Orbigny angrite.
To study the association of meal patterns and timing with central obesity to identify the best dietary strategies to deal with the increasing obesity prevalence.
A cross-sectional study performed on data from a representative sample of the Spanish population. Height and waist circumference were measured using standardized procedures and waist-to-height ratio (WHtR) was calculated. The sample was divided into those without central obesity (WHtR<0·5) and those with central obesity (WHtR≥0·5).
ANIBES (‘Anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles in Spain’) Study.
Adults aged 18–64 years (n 1655; 798 men and 857 women).
A higher percentage of people ate more than four meals daily in the group without central obesity and those with central obesity more frequently skipped the mid-afternoon snack than those without. Breakfasts containing >25 % of total energy intake and lunches containing >35 % of total energy intake were associated with increased likelihood of central obesity (OR=1·874, 95 % CI 1·019, 3·448; P<0·05 and OR=1·693, 95 % CI 1·264, 2·268; P<0·001, respectively). On the contrary, mid-morning snacks and mid-afternoon snacks containing >15 % of total energy were associated with decreased likelihood of central obesity (OR=0·477, 95 % CI 0·313, 0·727; P<0·001 and OR=0·650, 95 % CI 0·453, 0·932; P<0·05, respectively). The variety of cereals, wholegrain cereals and dairy was higher in the population without central obesity.
Our results suggest that ‘what and when we eat’ should be considered dietary strategies to reduce central obesity.
The worldwide cultivation of fig (Ficus carica L.) has achieved great economic importance, mainly, due to its important role as a food supplement. This situation has generated great interest in researching its methods of production, processing and conservation. The objective of this research was to evaluate six intensive production systems of fig in hydroponic and greenhouse conditions. The experimental phase started on November 15, 2010 and was completed in September 2011. Production systems were established by varying the number of productive stems between three and eight in each plant, with densities of 1.25 plants m−2. A completely experimental – randomized design was used with five replications, with a pot and a plant as an experimental unit. The results indicate that the highest yielding of fresh fruit was presented by eight productive stems (109.5 t ha−1), this one outperformed the seven productive stems (94.8 t ha−1) in 13.3% and six productive stems (78.6 t ha−1), at 26.8%. The handling of productive stems allowed an increase in the leaf area index, harvest index and fruit yielding. These results suggest that intensive production in hydroponic and greenhouse conditions of fig is an excellent alternative production, allowing to collect up to 20 times of fresh fruit yielding in relation to the plantations in the open field.