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To analyze the association between modifiable behavioral risk factors for non-communicable diseases and sleep parameters in Brazilian adolescents. The exposures of interest were the behavioral risk factors for non-communicable diseases NCDs : screen time, physical inactivity, alcohol, smoking, illicit drugs, caffeine intake, and consumption of sugar-sweetened beverages. Excess weight was considered a possible mediator of this association between the exposures of interest and the outcomes. The models were analyzed by modeling with structural equations. Overweight was neither a mediator nor associated with sleep quality or excessive daytime sleepiness. The main modifiable behavioral risk factors for NCDs are associated with worse sleep parameters already in adolescence, which serves as a warning toward the accumulation of risks for sleep disorders in the future. Sleep is an essential biological process for survival and is important for the physical, mental, and social well-being of individuals 1 1. Past, present, and future: trends in sleep duration and implications for public health. Sleep Health. Since it is essential for healthy development, the American Academy of Sleep Medicine recommends that adolescents should regularly sleep 8 to 10 hours a day, an amount associated with better health outcomes and quality of life 2 2. Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep Med. Adolescence is a period marked by changes in sleep patterns due to biological, environmental, and psychosocial factors, such as pubertal maturation, circadian rhythm regulation, and less regular schedules 3 3. Functional consequences of inadequate sleep in adolescents: a systematic review. Sleep Med Rev. These changes are characterized by diurnal sleep dysfunctions, which, in turn, are risk factors for excessive daytime sleepiness in this age group 4 4. Rev Bras Epidemiol. Adolescents are not getting enough sleep, and this is a chronic problem worldwide. Insufficient sleep in adolescents and young adults: an update on causes and consequences. Sleep duration and consumption of sugar-sweetened beverages and energy drinks among adolescents. Factors associated with sleep duration across life stages: results from the Canadian Health Measures Survey. Less screen time and more physical activity is associated with more stable sleep patterns among Icelandic adolescents. Rev Paul Pediatr. Loss of sleep and its disorders can have their effects accumulated over time, being associated with several harmful health consequences, such as non-communicable diseases NCDs 10 Prevalence of poor sleep quality and its associated factors among hypertensive patients on follow up at Jimma University Medical Center. J Hum Hypertens. Some of the factors that lead to changes in sleep are considered as risks for major NCDs. World Health Organization. Noncommunicable diseases country profiles Geneva: World Health Organization; The obesity epidemic is a reality in all age groups and has been considered one of the main causes of the NCDs numbers in the world 12 Poor quality sleep has been linked to higher rates of being overweight, just as obesity can trigger comorbidities that affect sleep quality. In this bidirectional relationship 13 The epidemiology of sleep and obesity. The most frequent behavioral health risks in adolescence act together as part of an unhealthy style and increase the risk of obesity. Therefore, better understanding the complex association between these risk factors and sleep in an adolescent population becomes necessary, since this combination can impact health throughout life. In addition, no study to our knowledge of has used overweight as a mediator of these associations. This study, therefore, aims to estimate, by structural equation modeling, the association between modifiable behavioral risk factors for NCDs and sleep quality and excessive daytime sleepiness in adolescents, considering overweight as a mediator of these pathways. Cad Saude Publica. In this study, we used data collected in the second follow-up of the cohort, obtained in Those identified were invited to attend the follow-up, totaling participants. To increase the power of the sample and to prevent future losses, the cohort was opened to include other individuals born in In a second stage, volunteers identified in schools and universities were included, totaling 1, participants. The final sample consisted of 2, adolescents. Data were collected by health students and professionals duly trained, on the premises of UFMA, who conducted interviews to apply structured questionnaires answered by the participants themselves. The following information was used: schooling of the head of the family and the adolescent, monthly family income, economic class, alcohol consumption, smoking, use of illicit drugs, time of exposure to screens, food consumption, level of physical activity, quality of sleep, and daytime sleepiness. The frequency of daily consumption of sugar-sweetened beverages and caffeine were obtained with a food frequency questionnaire validated for adolescents 17 The questionnaire contained food items, which assess the frequency and portion of consumption of these foods in the last 12 months. The consumption of sugar-sweetened beverages was estimated by the intake of soft drinks, industrialized juices, chocolates, and energy drinks. The percentage of energy from these beverages in relation to the daily energy intake of the adolescent was calculated by the sum of energy from all sugar-sweetened beverages, multiplied by and divided by the sum of total daily energy intake. Guideline: sugars intake for adults and children. To estimate caffeine intake in milligrams per day, we calculated the daily consumption of foods coffee and energy drinks , in grams or milliliters, from multiplying the daily frequency and the size of the portion recorded for each food. The calculation of caffeine intake was obtained from the knowledge of caffeine values in grams or milliliters of each food from the USDA Nutrient Database for Standard Reference 19 US Department of Agriculture. Nutrient database for standard reference - SR Validation of interviewer- and self-administered physical activity checklists for fifth grade students. Med Sci Sports Exerc. For participants aged 19 years, the WHO classification 22 Physical status: the use of and interpretation of anthropometry. WHO technical report series; The adolescents were categorized as overweight overweight and obese or not. To assess sleep, two self-administered instruments were used separately, which use subjective measures in scales validated in Brazil: Pittsburgh Sleep Quality Index PSQI 23 Reliability and validity of the Brazilian version of the Pittsburgh Sleep Quality Index in adolescents. J Pediatr Rio J. Portuguese-language version of the Epworth sleepiness scale: validation for use in Brazil. J Bras Pneumol. The PSQI is a questionnaire with 19 questions regarding sleep quality and disorders in the last month, and evaluates seven sleep components subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disorders, use of sleeping medications, and daytime dysfunction with scores ranging from 0 to 3, totaling a maximum of 21 points. Scores greater than 5 indicate poor sleep quality. Other scores were categorized as good sleep quality 23 The ESS 24 Two theoretical models were constructed to estimate the association between the main modifiable risk factors for NCDs and sleep in adolescents, differing only in the variable used to assess the outcome: sleep quality Model 1 or excessive daytime sleepiness Model 2. The SES latent variable was the most distal determinant exogenous variable associated with all variables of the model. The variables considered behavioral risk factors were the exposures of interest: substance use tobacco, alcohol, and illicit drugs , unhealthy food consumption intake of beverages sweetened with sugar and caffeine , screen time, and physical inactivity. Overweight was considered a mediator in the analysis Figure. To investigate the effect of behavioral and metabolic risk factors for NCDs on adolescent sleep, structural equation modeling SEM was used. The advantage of this technique is that it allows analyzing the dependency relationships between multiple exposure variables and outcomes, estimating direct and indirect effects, in addition to being able to represent unobserved concepts latent variables in these relationships, modeling the measurement error in the estimation process 25 Porto Alegre: Bookman; Statistical analysis was performed using Mplus software version 7. When the proposed modification suggestions were considered plausible from the theoretical point of view, a new model was elaborated and analyzed, if the modification index value was higher than Direct and indirect effects of the observed and latent variables on sleep quality and excessive daytime sleepiness were estimated with standardized coefficients SC. In the sample of 2, adolescents, Regarding economic class, Among the adolescents, The percentage of According to the PSQI, In this study, risk factors for NCDs, such as physical inactivity, increased consumption of alcohol and sugar-sweetened beverages were associated with excessive daytime sleepiness in adolescents. More distally, higher socioeconomic status was also associated with excessive daytime sleepiness in adolescents. Physical inactivity and higher consumption of sugar-sweetened beverages were also associated with poor sleep quality. Overweight was neither a mediator nor associated with sleep quality or excessive daytime sleepiness in our sample. Physical inactivity was associated with worse sleep parameters analyzed in our study: poor sleep quality and excessive daytime sleepiness. A study with a representative sample of the population of Canada showed that sedentary young men were more likely to have short-term sleep 7 7. Physical exercise has been pointed out as an important behavioral treatment to improve sleep quality, in addition to preventing sleep disorders 26 Sleep and exercise: a reciprocal issue? The beneficial effects of physical activity on sleep can be explained by multiple pathways, for example by the interaction of circadian rhythm and metabolic, vascular, thermoregulatory, immunological, endocrine, and mood effects 26 Higher consumption of sugar-sweetened beverages was also associated with worse sleep parameters: poor sleep quality and excessive daytime sleepiness. The consumption of sugar-sweetened beverages has been associated with poor sleep quality 27 Association between the degree of processing of consumed foods and sleep quality in adolescents. The consumption of sugar-sweetened beverages can lead to a short duration of sleep, especially when consumed close to bedtime 6 6. The results of this study add knowledge by showing that caffeine consumption was not associated with poor sleep quality or excessive daytime sleepiness in adolescents, which suggests that the association may stem from the effect of sugar. A higher consumption of sugar-sweetened beverages was also associated with excessive daytime sleepiness, which may be explained by the high-sugar intake resulting in less restorative sleep and more nocturnal awakenings 28 Fiber and saturated fat are associated with sleep arousals and slow wave sleep. The best socioeconomic status was directly associated with excessive daytime sleepiness. These findings are contrary to those of a systematic review, which included 12 articles, showing that lower socioeconomic status was associated with shorter sleep duration, worse subjective perception of sleep quality assessed with questionnaires , and greater daytime sleepiness in adolescents 9 9. J Bras Psiquiatr. Prevalence and correlates of screen time among Brazilian adolescents: findings from a country-wide survey. Appl Physiol Nutr Metab. Screen time showed no association with sleep among adolescents in this study. Screen time did not even mediate associations in the analysis, even with most adolescents A systematic review, conducted with 42 articles, aiming to analyze the evidence on the sleep of adolescents, concluded that screen time is an increasingly frequent factor and that it has affected the onset and duration of sleep, with consequent daytime sleepiness, tiredness, and decreased academic performance of adolescents 31 Association between screen viewing duration and sleep duration, sleep quality, and excessive daytime sleepiness among adolescents in Hong Kong. In our study, the variable screen time included joint exposure to television, video games, cell phones, tablets, and computers, which may possibly explain the different findings. Alcohol consumption presented the highest standardized coefficient associated with excessive daytime sleepiness. This effect happens as the body adjusts to the presence of alcohol during the first half of sleep in an effort to maintain the normal sleep pattern 33 Roehrs T, Roth T. Sleep, sleepiness, and alcohol use. Alcohol Res Health. The authors highlight that both the pattern and duration of sleep and substance use among young people are interconnected by bidirectional associations 34 Longitudinal bi-directional relationships between sleep and youth substance use. J Youth Adolesc. Despite the known effect of being overweight on increased sleep problems 35 Sleep in overweight adolescents: shorter sleep, poorer sleep quality, sleepiness, and sleep-disordered breathing. J Pediatr Psychol. In addition, excess weight did not act as a mediator of associations in the studied models. Prevalence of overweight and obesity among Brazilian adolescents over time: a systematic review and meta-analysis. Public Health Nutr. This study has some limitations. The use of different scales in the literature, for assessing both sleep and other variables used, such as socioeconomic status, hinders the comparison of results. The study has a cross-sectional design, thus establishing a causal relationship between the risk factors for NCDs and sleep is impossible due to the possibility of reverse causality and the bidirectional relationship between exposures and outcome. However, this is one of the few studies that evaluated the effect of multiple risk factors for NCDs in association with sleep quality and excessive daytime sleepiness in adolescents. Strengths include the sample size and the method of analysis used to evaluate the effect of the associations. The modeling with structural equations allowed to observe the paths of the effects from mediating variables in sleep, estimating several separate and interdependent multiple regression equations. The main modifiable behavioral risk factors for NCDs are associated with worse sleep indicators in adolescents, such as poor sleep quality and excessive daytime sleepiness, and are independent of overweight. These findings contribute to emphasize the importance of coordinated surveillance and prevention actions against NCDs and altered sleep, focusing on behavioral risk factors, which begin in adolescence and can trigger health problems throughout life. Open menu Brazil. Open menu. Abstract Resumo English Resumo Portuguese. Caffeine consumption To estimate caffeine intake in milligrams per day, we calculated the daily consumption of foods coffee and energy drinks , in grams or milliliters, from multiplying the daily frequency and the size of the portion recorded for each food. Proposed Theoretical Models Two theoretical models were constructed to estimate the association between the main modifiable risk factors for NCDs and sleep in adolescents, differing only in the variable used to assess the outcome: sleep quality Model 1 or excessive daytime sleepiness Model 2. Publication Dates Publication in this collection 20 Oct Date of issue History Received 14 July Accepted 9 Nov This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Departamento de Ensino. Departamento de Odontologia II. Pedro Martins Lima Neto Data collection, analysis, and interpretation. Imperatriz, MA, Brasil. Conflict of Interest: The authors declare no conflict of interest. Figures 1 Tables 4. Notes: SCHAD: level of education of the adolescent; SCHE: level of education of the head of the family; income: monthly family income; CCEB: Brazilian Economic Classification Criterion; SES: socioeconomic status; alco: alcohol consumption; toba: smoking; drug: use of illicit drugs; SSBEV: consumption of sugar-sweetened beverages; coffee: caffeine consumption; screen: screen time; innat: physical inactivity; weight: overweight; sleep: sleep. Latent variable Model 1 Model 2 Socioeconomic status Factor loading Standard error p-value Factor loading Standard error p-value Education level of the head of the family 0. Stay informed of issues for this journal through your RSS reader. PDF English Portuguese. Google Google Scholar. Modifiable behavioral risk factors for NCDs and sleep in Brazilian adolescents.

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Introduction Growing evidence suggesting that dietary intakes of adolescents are generally of poor quality but not adequately assessed in relation to the early manifestation of non-communicable diseases. This study aimed; 1 to examine tracking of an empirical dietary pattern DP linked to cardiometabolic risk factors and, 2 to assess prospective relationships between a DP characterised by high intakes of dietary energy density DED and added sugar, and cardiometabolic risk factors, non-alcoholic fatty liver disease NAFLD , carotid intima-medial thickness CIMT and mental well-being during adolescence. Methods and analysis The PUTRA-Adol is a prospective follow-up study that builds up from Malaysian adolescents who were initially recruited from three southern states in Peninsular Malaysia in aged 13 years then. Two sessions are planned; the first session will involve the collection of socio-economy, physical activity, dietary intakes, mental well-being, body image, risk taking behaviour, sun exposure, family functioning and menstrual in women information. The second session of data collection will be focused on direct assessments such as venesection for blood biochemistry, anthropometry and ultrasonography imaging of liver and bilateral carotid arteries. Z-scores for an empirical DP will be identified at 16 years using reduced rank regression. The findings from this study will be disseminated in conferences and peer-reviewed journals. Discussion The findings gathered from this study will provide evidence on prospective relationships between DPs, cardiometabolic risk factors, NAFLD, early atherosclerosis and mental well-being and that it may be mediated particularly DED and added sugar during adolescence. You will be able to get a quick price and instant permission to reuse the content in many different ways. Understanding the tracking or maintenance of dietary patterns may be useful in identifying subgroups of population and timing for effective interventions to improve diet quality during adolescence. One of the first studies in Malaysia to prospectively assess associations between an empirically identified dietary pattern and various cardiometabolic risk factors, non-alcoholic fatty liver disease NAFLD , risk of atherogenesis and mental well-being during adolescence. Collects various prospective data on predictors of cardiometabolic risk factors, NAFLD, risk of atherogenesis and mental well-being during adolescence. The generalisation of the study findings may be limited due to the location of the study samples. The concept of tracking in epidemiological studies refers to the stability of measurements on an individual over time. This is of much importance considering that growing evidence suggests a link between diet and lifestyle factors in childhood and adolescence and the risk of developing diet-related diseases in adulthood. Several observational studies conducted in Western countries have evaluated the tracking of nutrient or single food group intakes as well as dietary patterns DP between childhood and adulthood. To help identify targets for interventions to improve DP in adolescents, information on DP tracking is needed. Furthermore, the understanding of the food groups within the pattern that shows stronger or weaker tracking, can help identify dietary targets that may be more or less acquiescent to change. The formation of lifelong dietary habits may be evident in adolescents due to the rapid physiological and psychological development as well as the increasing autonomy and independence during this stage of life. In addition, adolescents who often consumed dietary intakes of poor quality were found to maintain these dietary habits into adulthood where the manifestation of various comorbidities took place. In children and adolescents, only a few studies have reported prospective associations between DP and cardiometabolic risk factors. For instance, the intake of unhealthy DP, characterised by high intake of takeaways, confectionary and red meat, was prospectively associated with poor mental health status among adolescents aged 14 years in Western Australia. The aims of this study are; 1 to examine the tracking of a DP characterised by high intakes of dietary energy density DED and added sugar that was previously linked to cardiometabolic risk factors and, 2 to assess prospective relationships between the DP characterised by high intakes of DED and added sugar and cardiometabolic risk factors, NAFLD, risk of atherogenesis using carotid intima-medial thickness CIMT information and mental well-being during adolescence. A dietary pattern characterised by high intake in percentage of energy from sugar, fibre density, dietary energy density and low percentage of energy from total fat will feature at age 16 years. The PUTRA-Adol is a prospective follow-up study that builds up on a total of Malaysian school-going adolescents women and men who were initially recruited from 21 public secondary schools in three southern states of Peninsular Malaysia namely Negeri Sembilan, Melaka and Johor in The details of the study adolescents whose age was 13 years at their recruitment in were previously described. Prior to the study conduct, written approvals from the Ministry of Education MOE , Malaysia, and each state education department will be obtained. Following these approvals, 21 schools that participated in will be contacted for the current follow-up study arrangement, that is, a suitable date and time for the study to take place. They will be screened once again for the presence of physical limitations and asked to self-report any chronic diseases such as diabetes mellitus, heart disease, asthma, renal dysfunction and other metabolic disorders. Adolescents who either reported any of the above-mentioned diseases or were found to have physical limitations will be excluded from this follow-up. In addition, adolescents for whom the follow-up is impractical, for example, moved to another school or state or absent on the day of data collection, will be excluded. Eligible adolescents who agree to participate in this study will be given an information sheet on the study and asked to sign an assent form afterwards. In addition to that, an invitation letter and an informed consent form will be sent to the eligible parents illustrating the study details and recruitment process. Adolescents whose parents have agreed to participate will be enrolled in this study a week after disseminating the information sheet and consent form to the parents. Parents who do not wish their children to participate in this study will be respected. A graphical summary of the study flow is shown in figure 1. Data collection is planned from August to April with a total of two sessions for each participating school figure 2. During the first session at school, study enumerators will describe the nature of the study, including venesection for biochemical assessments and ultrasonography procedures as well as some details pertaining to the adolescent questionnaires. Adolescents will be also informed that any unforeseen outcomes from the study procedures will be made available to their parents, subsequently. Soon after the thorough description on the study, the enrolled study adolescents will be asked to self-administer a set of questionnaires on socio-economy, physical activity, dietary intakes food frequency questionnaire FFQ , mental well-being, body image, risk taking behaviour, sun exposure, family functioning and menstrual information in women at school as well as at home 3-day food diary. Since the second session comprised of direct assessments, that is, anthropometric measurements, venesection for biochemical assessments and ultrasonography imaging, this visit will be attended by a group of healthcare professionals including a family medicine physician or paediatrician, radiologist and research enumerators. The research enumerators will coordinate the study arrangement, collect and check parental questionnaires and 3-day food diaries for their completeness and conduct anthropometric measurements. Blood pressure and venesection will be performed by family medicine physician or paediatricians and phlebotomists, respectively. An emergency standard measure will be employed by the assigned family medicine physician or paediatrician if there are any complications during the venesection procedure, that is, fainting, nausea or convulsion. Adolescents who experience any complications after the venesection procedure such as infection, prolonged bleeding, excessive bruising and pain, will be asked to immediately contact the nearest health care clinic for further medical care. Ultrasonography imaging will be performed by an experienced radiologist in a closed room. Any incidental findings from the ultrasonography imaging assessment such as pregnancy or tumour will be immediately referred to the nearest hospital for further diagnosis confirmation. In addition to that, verified study findings including biochemical, imaging and other screening assessments for mental health depression , body image disorder and high risk behaviour smoking and drug intake measured in this study will be made available to the study adolescents and their parents soon after the data collection. Along with the study findings, a referral letter for further expert management will be sent to the parents if the test results are found to be unfavourable. These results will not be revealed to the school authorities to protect data confidentiality of the study adolescents. Several outcome measures, namely, cardiometabolic risk factors, NAFLD, CIMT, life satisfaction and subjective mental well-being, will be investigated in this follow-up study. Findings from both the anthropometric and biochemical assessments will be used to determine cardiometabolic risk factors in this study. Anthropometric assessments including body weight kg , height m and waist circumference cm measurements will be conducted. Body weight will be measured to the nearest 0. Participants will be measured in light clothing and no shoes. Height will be measured in cm, to the nearest 0. Waist circumference will be measured to the nearest 0. All measurements will be measured twice, and each mean value of the measurements will be computed and used in the analysis. Z-scores for waist circumference will be computed and abdominal obesity will be defined according to the Malaysian waist circumference centile curves of equal or more than the 90th centiles. The average of the two systolic and diastolic blood pressure measurements will be computed. Apart from estimating dyslipidaemia, lipid parameters will be individually defined using the abovementioned cut-offs. Ultrasonography of the liver and bilateral carotid arteries will be conducted by an experienced radiologist using the modified scan protocol by Kim et al in The imaging of the liver will include both long-axis and transverse views. Liver span measurement will be performed on longitudinal images. Apart from that, the echogenicity of the liver will be compared with that of the right kidney and the spleen to diagnose the presence of NAFLD. If the echogenicity is increased compared with the spleen, the following classification will be used to grade the severity of NAFLD based on Di Martino et al 32 :. Moderate NAFLD: the echogenicity of the walls of the portal vein branches is lost or obscured by the increased liver echogenicity. CIMT will be measured by using a linear ultrasound probe with 7. Imaging will be performed on the right and left carotid arteries using two-dimensional grey scale imaging in axial and longitudinal views. If there was the presence of posterior wall plaque, this will be included in the measurements. This mean maximum CIMT has demonstrated good reproducibility intra-observer coefficient of variation of 2. This instrument was later shortened by Sawatzky et al in to items by removing all the negatively worded and some positively worded items. Adolescents in this study will be asked to respond to their thoughts on life experiences during the past several weeks. Total score will be computed with a high score that corresponds to a high level of overall satisfaction and specific domains of life satisfaction. A item self-reporting DASS scale, developed by Lovibond will be used to assess subjective depressive and anxiety symptoms. Each of the three DASS scales contains seven items, divided into subscales with similar content. DASS in Malay language has been validated and showed high internal consistency. A various number of predictor measures that may be associated with the outcome measures will be examined in this study. These predictor measures incorporate both parental and adolescent factors. Adolescents enrolled in this study will be asked to complete questions on socio-economic factors including gender, ethnicity, religion, date of birth and their school location. Parental questionnaires on socio-economic factors will be completed at home and this will be comprised of age, education attainment, household income RM , occupation and number of dependents. Self-reported weight and height, smoking status and the presence of chronic diseases such as diabetes, hypertension, hypercholesterolaemia, cancer, heart disease and osteoporosis in parents and their relatives will also be asked in the parental questionnaire. Self-reported physical activity level will be assessed using a validated physical activity questionnaire for adolescents. The second to eighth items will assess activities performed during physical education classes, recess, lunch, after school, evenings, weekends and leisure periods. Item eight will include the frequency for physical activity level from the previous week and item nine will assess any unusual activities from the previous week. This questionnaire was previously validated and showed good internal consistency and acceptable validity. Both male and female adolescents in the present study will be asked to draw a mark below the drawing that they think most closely approximates their current body size. The total score is the sum of the values of each item divided by the number of items on the subscale. The score below 2 indicates healthy family functioning, while a score of 2 and above indicates unhealthy family functioning. Three risk taking behaviours, that is, internet usage, smoking and drug use, will be particularly assessed in this study. The majority of these risk-taking behaviour questions will be adapted from the Adolescent Healthy Survey conducted in by the Institute for Public Health, Malaysia. There will be a total of eight questions on internet usage among adolescents. Questions 1—8 will be on the internet access using any internet connecting devices in the past 30 days as well as using the internet as a learning source. Additional questions on internet addiction will also be measured using a self-administered items Malay Version Internet Addiction Test questionnaire. Questions related to menstruation information will be asked to female adolescents and this will be done using a questionnaire by Parker et al. Adolescents in this study will be asked to provide information on dietary intake using a validated adolescent FFQ, which was used in the previous study 9 as well as a 3-day food diary two weekdays and one weekend day. The study adolescents will be asked to complete the 3-day food diary at home with parental assistance. Guidance for completing the 3-day food diary will be provided to each study adolescent during the first session of data collection in school. For instance, adolescents will be asked to provide detailed information on food and drinks consumed, including brand name where available and quantity consumed based on household measures or actual weights from labels or packets. Apart from this, adolescents will be asked to record any eating outs, fast food consumption and night eating in the food diary. Foods and beverages from the 3-day food diary will be coded using NutriPro software. The reported food items will be categorised into 14 predefined food groups based on their own nutrient profiles or culinary usage, and their hypothesised contribution to cardiometabolic diseases. Dietary misreporting is a very common issue among adolescents. Therefore, estimation of dietary misreporting using a standardised equation will be performed. The variable of dietary misreporting will be comprised of under-reporting, plausible and over-reporting and will be used as a potential covariate in the prospective modelling. The RRR approach identifies a linear combinations of weighted food intake, that is, food groups by explaining the maximum variation in a set of response variables, that is, biomarkers or nutrients that are hypothesised to be linked to health outcomes. These response variables were linked to obesity and cardiometabolic risk factors in children and adolescents from birth cohorts such as the Avon Longitudinal Study of Parents and Children in the UK and the Western Australian Pregnancy Raine cohort study. The percentage of energy from total fat will be estimated by dividing the total energy intake from total fat in kJ by the total energy intake in kJ and subsequently multiplied by This will similarly be done for the percentage of energy from added sugar. Separate RRR analysis will be performed for male and female adolescents due to sexual dimorphisms and differences in dietary intake during adolescence. Normally distributed continuous variables will be described using means and SD and non-normally distributed continuous variables will be reported using medians and IQRs. In addition, means and SD or medians and IQRs for outcome variables, that is, anthropometric, biochemical, clinical measurements as well as life satisfaction and depressive and anxiety scores will be reported. This DP was previously identified in these adolescents in Tracking coefficients will be assessed using an approach recommended by Twisk in By doing so, the longitudinal association between the DP found at 13 and 16 years will be modelled. Characteristics of predictor variables including dietary intake and DP characterised by food high in sugar, DED, fibre and low in fat as previously identified and its key contributing food groups will be presented. Outcome variables will be tabulated across the quartiles of DP z-scores to understand the trend of any associated factors. One-way analysis of variance or non-parametric Kruskal-Wallis test will be conducted to analyse differences between predictor or outcome variables, and quartiles of DP z-scores. Subsequently, prospective multilevel modelling will be conducted to examine associations between the identified DP and various cardiometabolic risk factors, NAFLD, marker of atherogenesis and mental well-being. These prospective modelling will be adjusted for various potential covariates including age, maternal education, dietary misreporting, the location of school urban or rural , physical activity and BMI for biochemical parameters. Separate analysis will be run in male and female adolescents due to puberty-related differences and sex dimorphism. No patients and public were involved in the development of the research concept, outcome measures or design of the study. The findings gathered from this study will further enhance evidence on the prospective relationships between DP, cardiometabolic risk factors, NAFLD, markers of atherogenesis and mental well-being and that these relationships may be mediated in part by selected nutrients, particularly dietary energy density and percentage energy from added sugar during adolescence. However, due to the lack of cohort studies in children and adolescents in Malaysia, longitudinal analyses assessing the contribution of poor DP on cardiometabolic risk factors and the manifestation of NAFLD, atherogenesis markers and mental health issues were therefore limited. Furthermore, the assessment of DP tracking in this study will provide information on the most appropriate time point for effective interventions to take place during the adolescence stage. This follow-up study is particularly important as a national survey in Malaysia in has reported that a majority of adolescents were found to consume dietary intakes of poor quality, that is, higher consumption of SSBs and fast food, and low intakes of fruit and vegetables. Globally, this study is relevant with the third goal of Sustainable Development Goals, whereby the good health and well-being of children should be protected. Therefore, the present policies and strategies should be improved with sustainable, comprehensive and multifaceted preventive actions to promote healthy nutritional exposure early in life. The findings of this study are expected to corroborate to those reported in the Western world and subsequently highlight the importance of healthy dietary intake early in life. Proper nutrition in early life offers one of the most effective and least costly ways to decrease the burden of chronic and non-communicable diseases and their risk factors. By identifying the dietary risk factors for cardiometabolic and mental health, this research will have a major positive impact on the lives and prospects of adolescents in the later stages of life. Prior to the study conduct, written approvals from the MOE, Malaysia, and each state education department will be obtained. The study respondents and their parents will be asked to provide written consent before the commencement of the study. The funder did neither play any role in the preparation nor submission of this manuscript. All authors have read and approved the final manuscript. The authors declare that the funding body has no role in the design of the study and collection, analysis and interpretation of data and in writing the manuscript. Provenance and peer review Not commissioned; externally peer reviewed. Skip to main content. Log In More Log in via Institution. Log in via OpenAthens. Log in using your username and password For personal accounts OR managers of institutional accounts. Forgot your log in details? Register a new account? Forgot your user name or password? Search for this keyword. Advanced search. Latest content Archive For authors About Browse by collection. Log in via Institution. You are here Home Archive Volume 11, Issue 5 PUTRA-Adol study: protocol for an observational follow-up study to assess the tracking of dietary patterns linked to cardiometabolic risk factors and its prospective relationship with non-alcoholic fatty liver disease, carotid intima-medial thickness and…. Email alerts. Article Text. Article menu. Nutrition and metabolism. PUTRA-Adol study: protocol for an observational follow-up study to assess the tracking of dietary patterns linked to cardiometabolic risk factors and its prospective relationship with non-alcoholic fatty liver disease, carotid intima-medial thickness and mental well-being during adolescence in Malaysia. Abstract Introduction Growing evidence suggesting that dietary intakes of adolescents are generally of poor quality but not adequately assessed in relation to the early manifestation of non-communicable diseases. Statistics from Altmetric. Self-report of various predictor variables may be associated with recall bias. Background The concept of tracking in epidemiological studies refers to the stability of measurements on an individual over time. Aims The aims of this study are; 1 to examine the tracking of a DP characterised by high intakes of dietary energy density DED and added sugar that was previously linked to cardiometabolic risk factors and, 2 to assess prospective relationships between the DP characterised by high intakes of DED and added sugar and cardiometabolic risk factors, NAFLD, risk of atherogenesis using carotid intima-medial thickness CIMT information and mental well-being during adolescence. Hypotheses The following hypotheses will be tested: A dietary pattern characterised by high intake in percentage of energy from sugar, fibre density, dietary energy density and low percentage of energy from total fat will feature at age 16 years. Methods and analysis Study settings The PUTRA-Adol is a prospective follow-up study that builds up on a total of Malaysian school-going adolescents women and men who were initially recruited from 21 public secondary schools in three southern states of Peninsular Malaysia namely Negeri Sembilan, Melaka and Johor in Recruitment and consent Prior to the study conduct, written approvals from the Ministry of Education MOE , Malaysia, and each state education department will be obtained. Data collection Data collection is planned from August to April with a total of two sessions for each participating school figure 2. Outcome measures Several outcome measures, namely, cardiometabolic risk factors, NAFLD, CIMT, life satisfaction and subjective mental well-being, will be investigated in this follow-up study. Cardiometabolic risk factors Findings from both the anthropometric and biochemical assessments will be used to determine cardiometabolic risk factors in this study. If the echogenicity is increased compared with the spleen, the following classification will be used to grade the severity of NAFLD based on Di Martino et al 32 : Mild NAFLD: echogenicity of the liver parenchyma is increased compared with the spleen. Predictor measures A various number of predictor measures that may be associated with the outcome measures will be examined in this study. Socio-economic factors Adolescents enrolled in this study will be asked to complete questions on socio-economic factors including gender, ethnicity, religion, date of birth and their school location. Physical activity Self-reported physical activity level will be assessed using a validated physical activity questionnaire for adolescents. Risk-taking behaviours Three risk taking behaviours, that is, internet usage, smoking and drug use, will be particularly assessed in this study. Menstruation information Questions related to menstruation information will be asked to female adolescents and this will be done using a questionnaire by Parker et al. Dietary assessment Adolescents in this study will be asked to provide information on dietary intake using a validated adolescent FFQ, which was used in the previous study 9 as well as a 3-day food diary two weekdays and one weekend day. Patient and public involvement No patients and public were involved in the development of the research concept, outcome measures or design of the study. Discussion The findings gathered from this study will further enhance evidence on the prospective relationships between DP, cardiometabolic risk factors, NAFLD, markers of atherogenesis and mental well-being and that these relationships may be mediated in part by selected nutrients, particularly dietary energy density and percentage energy from added sugar during adolescence. Tracking of body mass index in children in relation to overweight in adulthood. Am J Clin Nutr ; 70 : S — 8. Tracking of overweight status from childhood to young adulthood: the Bogalusa heart study. Eur J Clin Nutr ; 60 : 48 — Longitudinal changes in diet from childhood into adulthood with respect to risk of cardiovascular diseases: the cardiovascular risk in young finns study. Eur J Clin Nutr ; 58 : — Identification of a dietary pattern associated with greater cardiometabolic risk in adolescence. Nutr Metab Cardiovasc Dis ; 25 : — OpenUrl PubMed. 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J Clin Endocrinol Metab ; 97 : E — Institute for public health: Institute for public health , Competing interests None declared. Read the full text or download the PDF:. Log in.

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