Nutrition, Physical Activity and Smoking Habit in the Italian General Adult Population: CUORE Project Health Examination Survey 2018–2019

Background: Tobacco consumption, incorrect nutrition and insufficient physical activity/sedentariness represent modifiable NCDs risk factors in Western countries. To evaluate recent lifestyle indicators in Italy, data from the national Health Examination Survey (HES), implemented in 2018–2019 within the CUORE Project, were assessed. Methods: Age–sex standardized results from random samples of Italian general population (35–74 years) were reported by sex, age-class, educational level and geographical area. From 2106 participants, 2090 were considered for smoking habit, 2016 for physical activity and 1578 for nutrition. Standardized questionnaires were used for smoking habit and physical activity, and the EPIC questionnaire for nutrition. Results: Total cigarette current smokers were 23% in men and 19% in women; sedentariness during leisure time was 34% in men and 45% in women and at work 45% and 47% in men and women, respectively. Prevalence of balanced eating behaviours for vegetables was 28% in men and 39% in women; and for fruits 50% and 52%, respectively; prevalence of correct lifestyle (not smoker, regular physical activity and following at least five correct eating behaviours) was 7% and 12% for men and women, respectively. Conclusions: In 2018–2019, levels of unhealthy lifestyles were found to be still epidemic and basically stable compared to 10 years earlier (slight smoking habit decrease, slight sedentariness increase and slight nutrition improvements); intersectoral strategies and monitoring need to be continued.


Introduction
Non-communicable diseases (NCDs), such as cardiovascular diseases, cancers, chronic respiratory diseases, diabetes and musculoskeletal disorders, remain the leading causes of death worldwide [1].Tobacco consumption, incorrect eating habits, insufficient physical activity/sedentariness and risky and harmful alcohol consumption, together with the characteristics of the environment and the social, economic and cultural context represent the main modifiable risk factors in Western countries [1].
These main behavioural risk factors act directly and indirectly to increase the risk of NCDs since they can lead to intermediate risk factors such as arterial hypertension, overweight/obesity, dyslipidaemia, hyperglycaemia and precancerous and early cancerous precancerous lesions.To combat global mortality from NCDs, at the Sixty-sixth World Health Assembly in 2013, Member States developed a Global Plan of Action for 2013-2020, extended to 2030, setting global targets; they included the achievement of nine global targets regarding overall mortality from NCDs, harmful use of alcohol, insufficient physical activity/sedentariness, intake of salt/sodium, current tobacco use, raised blood pressure, diabetes and obesity, heart attacks and strokes drug therapy and counselling for prevention and basic technologies and essential medicines to treat major NCDs [1][2][3].
To intervene on the four main modifiable risk factors of NCDs (tobacco consumption, sedentary lifestyle/low physical activity, risky alcohol consumption and poor diet), in Italy, the program "Gaining Health: making healthy choices easy" was implemented together with the National Preventive Plans (NPPs) through actions and policies adopting an intersectoral vision.The WHO recommended improving country-level surveillance and monitoring as a priority in the fight against NCDs, and also providing data disaggregated by age, gender and socioeconomic groups [1,2].Monitoring should provide internationally comparable assessments of the trends in NCDs and related risk factors over time, help to benchmark the situation in individual countries versus others in the same region or development category and provide a support for advocacy, policy development and coordinated action [1,2].
In Italy, national Health Examination Surveys (HESs) have been conducted since 1998.The assessment of tobacco use, physical inactivity and dietary habits was carried out in 1998-2002 and 2008-2012 in the Italian adult general population through national HESs implemented within the CUORE Project [5].
In order to provide more recent lifestyles indicators, data collected in 2018-2019 in random samples of Italian adult general population, through the national HES implemented within the CUORE Project, were analysed and reported by sex, age-classes, educational level and geographical area.

Sampling
From April 2018 to December 2019, the Italian National Institute of Health (Istituto Superiore di Sanità-ISS), within the CUORE Project, conducted a HES in 10 Regions (out of 20) chosen in the North, Centre and South of Italy, enrolling a sample of 100 men and 100 women aged 35-74 years in each examined region (participation rate 40%) randomly selected from the resident registries and stratified by sex and age-group (35)(36)(37)(38)(39)(40)(41)(42)(43)(44)45-54, 55-64 and 65-74 years) [6][7][8][9].The HES was approved by the Ethical Committee of the ISS; all participants received an invitation letter and an informative note by ordinary postal service and signed an informed consent at the time of the visit.The HES is recognized within the Italian National Statistical Program and within the European HES collaboration [10,11].The HES 2018-2019-CUORE Project used international standardized procedures and methods for measurements and data collection [6][7][8][9].

Smoking Habit Data Collection
The smoking questionnaire assessed current and former smokers.Current smoker was defined as a person who smokes one or more cigarettes per day.A former smoker is defined as a person who has quit smoking for at least 12 months.Number of cigarettes consumption was recorded for current smokers, as well as type of cigarettes (packaged, handmade or electronic).

Physical Activity Data Collection
Data on physical activity were collected through a questionnaire including four levels of exercise (sedentariness, mild, moderate and heavy), separately for work and leisure time.During the leisure time, the four levels of physical activity correspond to the answer to the question "What is your physical activity during your leisure time?":

•
Usually reading, watching television, getting to the movies or spend leisure time in other sedentary activities (defined as sedentariness); • Walking, riding a bicycle or to carry out some kind of physical activity for at least 4 h a week, anything more tiring than going to work on foot or by bicycle, gardening, hunting or fishing or playing ping-pong (defined as mild physical activity intensity); • Doing sports as a hobby, such as running, swimming, tennis, gymnastics, or to do hard work in the garden or at home or other similar efforts (this is valid if this activity is carried out at least 3 times a week) (defined as moderate physical activity intensity); • Training regularly or playing sport professionally such as athletics, skiing, swimming, football, basketball or tennis, several times a week (defined as heavy physical activity intensity).
Physical activity during leisure time was also assessed considering only participants who no longer carried out a working activity (retired).At work, the four levels of physical activity correspond to the answer to the question "What is (was) the physical activity deriving from your job?": • Work performed mainly sitting at a desk and generally without the need to walk; (defined as sedentariness); • Work that implies standing and walking for a long time, but does not oblige to carry or move heavy weights (this category also includes normal housework, except hard work) (defined as mild physical activity intensity); • Work that implies a lot of walking and handling heavy weights (this category also includes the cases of normal hard housework, such as doing the laundry, scrubbing the floors manually) (defined as moderate physical activity intensity);

•
Hard manual work, with great efforts and lifting and handling heavy weights (defined as heavy physical activity intensity).Sedentariness was also investigated among retired participants, who no longer carries out a work activity.The questionnaire was previously used in an Italian research project sponsored by the National Research Council and in the previous Italian HESs within the CUORE Project [5,12].

Nutrition and Alcohol Consumption Data Collection
Dietary information was collected by the self-administered Italian version of the European Prospective Investigation into Cancer (EPIC) food frequency questionnaire (FFQ), which focused on diet as a major determinant of health.Accuracy and validation of the dietary questionnaire were of paramount importance since it had to be applied in several countries and to thousands of study participants [13].The FFQ was designed to capture eating behaviours in the Italian population [14].The questionnaire included images that defined food portions; it investigated general dietary habits (preferred food items, type of dressing, cooking modalities), frequency of meals consumed away from home and how frequently (weekly, monthly, yearly) each specific food was generally consumed.
For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad and mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese: cheeses (including fresh cheeses).For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For cereals intake, the following foods were considered: pasta, rice, white and wholemeal bread, other grains, crispbread, rusks and breakfast cereals.For potatoes intake, the following foods were considered: french fries, boiled potatoes, roasted potatoes, pure potatoes and croquette potatoes.For meats intake, the following foods were considered: beef, veal, pork, horse, chicken, turkey and rabbit (domestic).
A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than once per week (330 mL); and consumption of alcoholic beverages limited to ≤24 g/day in men 35-64 years, ≤12 g/day in women 35-64 years and ≤12 g/day in men and women 65-74 years old [15][16][17][18][19].These eight eating habits were also grouped together, and the population was divided into those who had no balanced eating behaviour or only one, and those who had 2, 3, 4, 5 or more balanced eating behaviours, respectively.Food items were linked using specifically designed software [20] to Italian Food Tables [21] to obtain estimates of daily intake of 37 macro-and micronutrients plus energy (not all nutrients are shown in the tables).

Statistical Analysis
The prevalence of people who followed a healthy lifestyle was evaluated, including them in the group of people who reported being non-smokers, non-sedentariness during leisure time and to have a food consumption comparable to at least five balanced eating behaviours.Educational level was used as a proxy for socioeconomic position; social class was characterized as those with primary/middle school degree (≤8 years)-lower education and those with high school/university degree (>8 years)-higher education.Data are presented separately for men and women, age classes, geographical areas and educational levels as mean, standard deviation and prevalence, with 95% confidence intervals (CI).Following the suggestion reported in the WHO Global NCDs Action Plan 2013-2020 extended to 2030 [1,2], indicators, where appropriate, were age standardized using the direct method, referring to the age-and sex-specific distributions of the Italian adult population in 2019 (Italian National Institute of Statistics-ISTAT) (Tables and figures, and Supplemental Materials Tables S1-S13) [22].Data were also age-standardized using the European Standard Population (EuStPop) 2013 for international comparisons (Supplemental Materials Tables S14-S25) [23].ANOVA was used to compare means and chi-square test to compare prevalence among classes.Two-sided p-values < 0.05 were considered statistically significant.Statistical analyses were performed using R software, release 4.2.3.

Results
From 2106 participants examined within the HES-CUORE Project 2018-2019, after excluding those with missing data for relevant variables, 2090 participants were considered in the statistical analyses for smoking habit and 2016 for physical activity; 1578 participants were considered in the statistical analyses for nutrition, after excluding those with missing data for relevant variables, those outside the range of the first and last percentile for the total energy consumption and the basal metabolic rate ratio (34 persons), and the participants residing in Abruzzo region with no nutritional data (211 persons).

Smoking Habit
Prevalence of current smokers of cigarettes was 23% in men and 19% in women, with a mean number of daily smoked cigarettes of 13 and 11, respectively, with significantly lower prevalence in older men (17%) in comparison to the first age-class, with no significant association by educational level and geographical area.In men, the mean number of cigarettes was higher in the older adults and in the Southern regions (Tables 1, S1 and S14).
Packaged cigarettes were consumed by 70% of smoking men and 84% of smoking women, handmade cigarettes by 19% and 7%, respectively, and electronic ones by 6%, both in smoking men and women.Prevalence of handmade and electronic cigarettes consumption decreased by age-class and among persons with a lower educational level (Figures 1, S1 and S2).

Physical Activity
During leisure time, the most prevalent activities were walking, cycling or engaging in physical activity of some kind for at least 4 h a week (43% of men and 40% of women), closely followed by sedentariness activities (34% and 45%), physical activity as a pastime for at least 3 h a week (20% and 14%) and systematic workout (4% and 2%) (Tables 2, S2 and S15, Figures 2 and S3-S6).Prevalence of former smokers of cigarettes was 43% in men and 28% in women, showing a significant increasing trend with age in both genders (from 24% of youngers to 47% of older men; from 19% to 30% in corresponding aged women); a decreasing trend with the educational level in men (54% in low educational level to 39% in high educational level), the opposite in women (24% and 30%, respectively).Prevalence of former-smoker men had a significant geographical gradient from Northern/Central Regions (40/41%) to Southern ones (47%); the opposite in women, from Northern/Central Regions (30/34%) to Southern ones (23%) (Tables 1, S1 and S14).
Cigar-smoker prevalence was 13% in men and 1% in women; 4% in men and 0.2% in women if in combination with cigarette smoking.Pipe-smoker prevalence was 7% in men and 1% in women; 2% in men and 0.3% in women in combination with cigarette smoking (Tables 1 and S14).

Physical Activity
During leisure time, the most prevalent activities were walking, cycling or engaging in physical activity of some kind for at least 4 h a week (43% of men and 40% of women), closely followed by sedentariness activities (34% and 45%), physical activity as a pastime for at least 3 h a week (20% and 14%) and systematic workout (4% and 2%) (Tables 2, S2 and S15, Figures 2 and S3-S6).
A significantly lower prevalence of sedentariness during leisure time was found in older men (22%) in comparison to the overall prevalence and first two age classes; it rises among retired older adults (37% in men and 56% in women) (Table S3).
A significantly lower prevalence of sedentariness at work was found in persons with lower educational level in comparison to those with higher educational level (19% vs. 53% in men, 21% vs. 53% in women) (Tables 2, S5, S6 and S15).
Combining physical activity during leisure time and at work in working people, 16% of men and 18% of women were classed as sedentary, with a significantly higher proportion in men and women with a higher educational level in comparison to those with a low educational level (18% vs. 8% in men, 21% vs. 9% in women) (Tables 2, S2 and S15).

Nutrition and Alcohol Consumption
Prevalence of balanced eating behaviours in men and women was, respectively: 28% and 39% for vegetables (a mean of 168 g per day in men and 184 g/day in women), 50% and 52% for fruits (a mean of 268 g/day in men and 276 g/day in women), cheese 45% and 54% (a mean of 43 g/day and 37 g/day, respectively), 11% and 21% for processed meats (36.4 g/day and 24.4 g/day), 44% and 40% for fish (46 g/day and 43 g/day), 9% and 11% for sweets/cakes (84 g/day and 78 g/day), 54% and 60%, for sweet drinks (100 mL/day and 73 mL/day) and 74% and 84% for alcohol consumption (15 mL/day and 6 mL/day) (Tables 3-8 and S4-S9, Figure 3).N: number of participants denominator.n: number of participants related to the prevalence numerator.For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For vegetables intake, the following foods were considered: leafy vegetable-cooked, leafy vegetable-raw, other vegetables, tomatoes-raw, tomatoescooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.
For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).Dietary information was collected by the selfadministered Italian version of the food frequency questionnaire (FFQ) of the European Prospective Investigation into Cancer (EPIC).A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than one per week (330 mL); and consumption of alcoholic beverages limited to two glasses per day for men (24 g of ethanol), one glass per day for women (12 g of ethanol) and one glass per day for men and women aged 65-74 (12 g of ethanol).SD: standard deviation; CI: confidence interval.N: number of participants denominator.n: number of participants related to the prevalence numerator.For processed meat intake, the following foods were considered: sausages, salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, nonchocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.Dietary information was collected by the self-administered Italian version of the food frequency questionnaire (FFQ) of the European Prospective Investigation into Cancer (EPIC).A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than one per week (330 mL); and consumption of alcoholic beverages limited to two glasses per day for men (24 g of ethanol), one glass per day for women (12 g of ethanol) and one glass per day for men and women aged 65-74 (12 g of ethanol  For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For vegetables intake, the following foods were considered: leafy vegetable-cooked, leafy vegetable-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses  For processed meat intake, the following foods were considered: sausages, salami and other preserved meat. For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.Persons with healthy consumption of vegetables resulted tendentially lower among older adults (25% in men, 32% in women), in Southern regions (26% in men, 34% in women) and among persons with lower educational level (25% in men, 32% in women) (Tables 3, 4, S4 and S16, Figures 4 and 5).
No associations were found between healthy consumption of fruit and class of age, geographical area and educational level (Tables 3, S4 and S16, Figures 4 and 5).Prevalence of healthy consumption of cheese was tendentially higher in Southern regions (Tables 3, S4 and S16).Healthy consumption of processed meat was significantly lower among younger men and women (6% and 15%, respectively) and in lower educated men (7%) and higher educated women (20%) (Tables 4 and S17, Figures 4 and 5).Healthy consumption of sweet drinks prevalence was significantly lower among younger men and women (41% and 46%, respectively) (Tables 4, S5 and S17, Figure 3).Prevalence of healthy consumption of alcohol significantly decreased by age-class, especially in men, and tendentially increased from Northern to Southern regions, but did not significantly differ by educational level (Tables 4, S5 and S17, Figures 3-5).The most frequent number of balanced eating behaviours, out of the considered eight, was three both in men and women (about 30%); 12% of men and 23% of women presented with five or more.Prevalence of those with five or more balanced eating behaviours was lower in less-educated men, while similar prevalence was found in both high and low educational level for women (Figures 3-5).

Balanced eating behaviours
Number of balanced eating behaviours.
Healthy lifestyles.For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoescooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages, salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.These eight eating habits were also grouped together, and the population was divided into those who had no healthy eating behaviour or only one, and those who had, respectively, 2, 3, 4, 5 or more healthy eating behaviours.A balanced nutrition was defined based on the following intake: vegetables ≥ For vegetables intake, the following foods were considered: leafy vegetablescooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages, salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.These eight eating habits were also grouped together, and the population was divided into those who had no healthy eating behaviour or only one, and those who had, respectively, 2, 3, 4, 5 or more healthy eating behaviours.A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than one per week (330 mL); and consumption of alcoholic beverages limited to two glasses per day for men (24 g of ethanol), one glass per day for women (12 g of ethanol) and one glass per day for men and women aged 65-74 (12 g of ethanol).Healthy lifestyle: people who reported being non-smokers, not sedentary during leisure time and to have a food consumption comparable to at least five balanced eating behaviours.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).
Healthcare 2024, 12, 475 22 of 36 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than one per week (330 mL); and consumption of alcoholic beverages limited to two glasses per day for men (24 g of ethanol), one glass per day for women (12 g of ethanol) and one glass per day for men and women aged 65-74 (12 g of ethanol).Healthy lifestyle: people who reported being non-smokers, not sedentary during leisure time and to have a food consumption comparable to at least five balanced eating behaviours.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).

Balanced eating behaviours
Number of balanced eating behaviours.
Healthy lifestyles.For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoescooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad and mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages, For vegetables intake, the following foods were considered: leafy vegetablescooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad and mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages, salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milkbased), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.These eight eating habits were also grouped together and the population was divided into those who had no healthy eating behaviour or only one, and those who had, respectively, 2, 3, 4, 5 or more healthy eating behaviours.A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than one per week (330 mL); and consumption of alcoholic beverages limited to two glasses per day for men (24 g of ethanol), one glass per day for women (12 g of ethanol) and one glass per day for men and women aged 65-74 (12 g of ethanol).Healthy lifestyle: people who reported not being smoker, not sedentariness during leisure time, and to have a food consumption comparable to at least five balanced eating behaviours.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).
Healthcare 2024, 12, 475 23 of 36 salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.These eight eating habits were also grouped together and the population was divided into those who had no healthy eating behaviour or only one, and those who had, respectively, 2, 3, 4, 5 or more healthy eating behaviours.A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than one per week (330 mL); and consumption of alcoholic beverages limited to two glasses per day for men (24 g of ethanol), one glass per day for women (12 g of ethanol) and one glass per day for men and women aged 65-74 (12 g of ethanol).Healthy lifestyle: people who reported not being smoker, not sedentariness during leisure time, and to have a food consumption comparable to at least five balanced eating behaviours.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages, salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.These eight eating habits were also grouped together, and the population was divided into those who had no healthy eating behaviour or only one, and those who had, respectively, 2, 3, 4, 5 or more healthy eating behaviours.A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least twice per week (150 g per serving); cheese no more than three times per week (50-100 g per serving); sausages, salami and other preserved meat no more than once per week (50 g per serving); cake and desserts no more than once per week (100 g per serving); sugar beverages less than one per week (330 mL); and consumption of alcoholic beverages limited to two glasses per day for men (24 g of ethanol), one glass per day for women (12 g of ethanol) and one glass per day for men and women aged 65-74 (12 g of ethanol Regarding nutrients, significantly lower levels were found in men than in women for total protein (15% of total kcal in men and 16% of total kcal in women), total lipids (35% and 38% of total kcal, respectively), vegetable lipids (17% and 20% of total kcal, respectively), monounsaturated lipids (16% and 18% of total kcal, respectively), simple carbohydrates (19% and 20% of total kcal, respectively), cholesterol (154 and 162 mg/day, respectively); and fibre (10 and 11 g/day).Similar values were found in men and women for saturated fats (11% of total kcal for both sexes), carbohydrate (48% and 47% of total kcal, respectively), vegetables proteins (5% of total kcal for both sexes), animal protein (10% and 11% of total kcal, respectively), animal lipids (18%of total kcal for both sexes), polyunsaturated fat (5% of total kcal for both sexes) and potassium (3 g/day for both sexes).Statistically significant higher levels of sodium were found in men than in women (3 and 2 g/day, respectively) (Tables 9-12, S10-S13 and S18-S25).Associations between nutrients and subgroups of population are worth mentioning: significantly lower levels were found in older men and women for total lipid, animal lipids, saturated fats, polyunsaturated fats and sodium; significant higher levels were found in older men and women for fibre and vegetables proteins; significant higher levels were found in men and women from Southern Regions for cholesterol, animal lipids and carbohydrate, lower levels for vegetables lipid; significant lower level were found in men and women from Northern Regions for fibre and vegetables proteins; significant higher levels were found in men and women with low educational level for cholesterol, vegetables proteins, vegetables lipids, lower levels for fibre (Tables 9-12, S10-S13 and S18-S25).

Healthy Lifestyles
Prevalence of people who followed a correct lifestyle (non-smoker, non-sedentary during leisure time and reporting at least five healthy eating behaviours) was 10% in men and 14% in women, with a higher prevalence in those with high educational level, especially in men (4% vs. 11% in men, 13% vs. 14% in women) (Figures 3-5).

Discussion
Data on smoking habit collected within the Italian HES-CUORE Project in random samples of the general Italian population aged 35-74 years during 2018-2019 showed about a fifth of the population as current smokers of cigarettes, with consistently higher levels for men than for women in all age-groups, geographical areas and educational levels; the same was found for the number of smoked cigarettes among smokers.Over 60% of men and about 50% of women are or have been habitual smokers.Regardless of gender, geographical area or level of education, the most consumed type of cigarette remains the packaged, followed by the handmade, with a prevalence of use of electronic cigarette not higher than 10%.
Data on physical activity collected within the Italian HES-CUORE Project during 2018-2019 showed about a third of men and almost half of women conducting no physical activity in their free time, with peaks of 66% in women living in a Southern region.Physical inactivity at work was around 46% in both men and women; it exceeds 50% in people with a higher educational level versus around 20% in people with a lower educational level.Just less than 2 in 10 people live in a sedentary condition both at work and during leisure time.Among retirees, more than a third of men and half of women follow a sedentary lifestyle.
Data on nutrition collected within the Italian HES 2018-2019-CUORE Project showed that women more frequently than men had a number of balanced eating behaviours equal to or greater than four (out of eight).More than two-thirds of men and women consumed alcohol within the limits of consumption in relation to the gender and age; around 4/5 in 10 men and women consume amounts of fruit, fish, cheese and sugary drinks as recommended by the Italian guidelines for an healthy nutrition [15]; less than 3 in 10 men and about 3 in 10 women consume the right amount of vegetables, while the correct consumption of processed meat does not exceed 1 in 10 people in men and 2 in women; 1 in 10 also met the recommended consumption of sweets/cakes both in men and women.There was a greater propensity in people with a higher educational level, especially men, to have healthy consumption of vegetables, processed meat and sweets/cakes, which represent, among the food groups considered (vegetables, fruits, fish, cheeses, processed meat, sweets/cakes, sweet drinks and alcohol), the food groups with the lowest prevalence of balanced eating behaviours.
Regarding the older adults, a better lifestyle profile was found compared to the general population, in fact the results showed tendentially lower prevalence of smoking habit and a higher prevalence of former smokers, significantly lower prevalence of sedentariness during leisure time, significantly higher prevalence of healthy consumption of processed meat, sweet drinks, alcohol, significantly lower levels of total lipid, animal lipids, saturated fats, polyunsaturated fats and sodium and significantly higher levels of for fibre and vegetables proteins.
In comparison to previous HES conducted at national level in Italy, prevalence of current smokers 2018-2019 decreased compared to 20 years before (1998)(1999)(2000)(2001)(2002) and very slightly declined compared to 10 years before (2008-2012), both in men and women, while former smokers increased [5,24].The trend of current-smoker prevalence is consistent with WHO data that showed the age-standardized tobacco use prevalence rates are declining, on average, in all WHO regions; in particular, in the European region, a relatively slow decline is being recorded [25]; prevalence and trends are also consistent with other Italian studies [26,27].A 30% relative reduction in prevalence of current tobacco use within 2025, extended to 40% within 2030 (WHO targets for the prevention of NCDs), in Italy means a reduction in absolute terms of 7% in men and 6% in women within 2025, considering the 2008-2012 smoking prevalence as the reference (24% and 20% of cigarettes smokers in men and in women); reductions very far from the approximately 1% and 1.5% decline resulted in 2019 in men and in women, respectively [1,2,5,24].
Compared to 10 years before (2008-2012), the 2018-2019 prevalence of a sedentariness lifestyle during leisure time increased, both in men and women, returning to around the values found 20 years before (1998)(1999)(2000)(2001)(2002) and showing an increase in the gap between levels of education in both sexes [5].Prevalence of sedentariness from the HES 2018-2019 was in line with the European results showing that more than one third of adults are insufficiently active [28], with an increasing trend in high-income Western countries [29] and with the propensity of women to be less active than men [28,29].A 10% relative reduction in prevalence of sedentariness lifestyle within 2025, extended to 15% within 2030 (WHO targets for the prevention of NCDs), in Italy means a reduction in absolute terms of 3% in men and 4% in women within 2025, considering the 2008-2012 prevalence of sedentariness during leisure time as the reference (32% and 42% of sedentariness in men and women).Taking into account the observed trend until 2019, a stable reversal trend will represent a first goal [1,2,5,24].
Compared to 10 years before (2008-2012), the prevalence of balanced eating behaviours in 2018-2019 in Italy improved for vegetables and sweets/cakes in women, and for fish, sweet drinks and alcohol in both sexes; but got worse for fruits and processed meat in both men and women, and sweets/cakes in men [5].Mean intake of food groups was less than desirable, particularly for vegetables and fibres [30].Mean intake of nutrients resulted in desirable intervals, except for an excessive consumption of total lipid, both saturated fat and polyunsaturated fat, simple carbohydrates and not enough intake of fibre and potassium; mean level of nutrients remains stable, except for a decreased cholesterol and fibre intake, both in men and women [31].Mean values of sodium intake were significantly lower than those assessed in the same samples through the 24 h collection through which excessive consumption was found [8]; this result was due to the fact that questionnaires are not able to register the discretionary salt added during the preparation of meals and at table, which is instead included in the measurement carried out by the urine collection method; a similar order of difference was found for potassium consumption between the two methods of collection [9].There was no homogeneity in fruit and vegetable consumption across European countries: fruit consumption increased from 1950 to 2019 in Northern and Western Europe, while the greatest increase in vegetable consumption occurred in the Middle East and Northern Europe, followed by Western Europe [32,33].
About the alcohol consumption, it is worth specifying that although protective associations have been reported in the literature between occasional consumption of alcohol and coronary heart disease, ischemic stroke and diabetes, according to WHO, net of all supposed benefits, the harmful effects of alcohol consumption on health are nonetheless preponderant [34,35].In Italy, the guidelines for low-risk consumption have been included in the Scientific Dossier of the Guidelines for balanced eating [36,37], edited by the Council for Research in Agriculture and Agricultural Economics (CREA), reiterating that there are no safe levels of alcohol consumption.The non-"excess habitual consumption" is considered here as "healthy" way of consuming alcoholic beverages considering the limits of alcoholic beverages consumption in relation to the gender and age of the person [16][17][18][19].
Overall, the prevalence of healthy lifestyles assessed in the HES 2018-2019 was higher than 10 years earlier (2008-2012) both in men and women; in men the prevalence increased for both educational level, in women in those with lower educational level.The prevalence of people with at least five correct eating habits was higher than 10 years earlier (2008-2012), especially among men with higher education and women with lower education; a slight decreasing trend of people with only one or less correct eating habits was found [5,25].
Major strengths of this study are the following: the use of standardized questionnaires to collect very detailed data on smoking habit, physical activity, and, in a particular way, on nutrition; a good national coverage with the enrolment of study participants from half of the Italian regions distributed in the northern, central and southern areas of the country; the use of randomly selected samples of the general population stratified by sex and agegroup.Conversely, we acknowledge some study limitations, which should be taken in consideration when interpreting results.First, because of the choice of urban districts for the random selection of the study participants, the results may not be representative of the population living in rural areas.The participation rates in the surveys were lower than desirable, yet consistent, taking into account the low contact rates occurring in more highly urbanized areas and the decreasing trend of participation observed in the HESs implemented in other European countries [38].

Conclusions
Data from some main lifestyle factors such as smoking habit, physical activity and nutrition collected within the Italian HES-CUORE Project in random samples of the general Italian population aged 35-74 years during 2018-2019 still showed epidemic levels of prevalence of current smokers, physical inactivity and incorrect eating behaviours, with an increasing prevalence of combined healthy lifestyles (not smoker, engaged in some regular physical activity and reporting at least five correct eating behaviours) which remains more prevalent in women.The prevalence of individual lifestyles is overall stable with small variations: slight decrease in smoking habit, slight increase in sedentariness during leisure time, slight increase in healthy consumption of vegetable and fish and slight decrease in healthy consumption of processed meat.The overall Italian picture of slight improvements in some healthy lifestyle factors and in the prevalence of combined correct lifestyles, together with the reduction in blood pressure and salt consumption, as well as the stop to the increasing obesity detected in the HES 2018-2019 as compared to the previous 10 years in the Italian general adult population, can be considered a partial success [6][7][8].National and local cross-sectoral strategies, based on actions that involve different sectors of society and institutions, and specific interventions to fight smoking and alcohol abuse and to promote physical activity and balanced eating should be continued, as well as the monitoring of lifestyles and related risk factors and conditions.

Figure 1 .
Figure 1.Age-standardized (Italian population) type of daily consumed cigarettes by sex.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Abruzzo, Basilicata, Calabria and Sicily.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by ageclasses).(a) Men; (b) Women.

Figure 1 .
Figure 1.Age-standardized (Italian population) type of daily consumed cigarettes by sex.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Abruzzo, Basilicata, Calabria and Sicily.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).(a) Men; (b) Women.

a
desk and generally without the need to walk.SD: standard deviation; CI: confidence interval.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).Chi-square test to compare prevalence among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Abruzzo, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Abruzzo, Basilicata, Calabria, Sicily).

Figure 2 .
Figure 2. Age-standardized (Italian population) physical activity during leisure time and at work by sex.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Abruzzo, Basilicata, Calabria and Sicily.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).(a) Men (b) Women (c) Men (d) Women.

Figure 3 .
Figure 3. Age-standardized (Italian population) nutrition and healthy lifestyles (EPIC questionnaire) by sex.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoescooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages, salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.These eight eating habits were also grouped together, and the population was divided into those who had no healthy eating behaviour or only one, and those who had, respectively, 2, 3, 4, 5 or more healthy eating behaviours.A balanced nutrition was defined based on the following intake: vegetables ≥

Figure 3 .
Figure 3. Age-standardized (Italian population) nutrition and healthy lifestyles (EPIC questionnaire) by sex.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.For vegetables intake, the following foods were considered: leafy vegetablescooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad, mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages, salami and other preserved meat.For sweets/cakes intake, the following foods were considered: sugar, honey, jam, chocolate, candy bars, paste, confetti/flakes, non-chocolate confectionery, ice cream, cakes, pies, pastries, puddings (not milk-based), dry cakes and biscuits.For sweet beverages intake, the following foods were considered: fruit and vegetable juices, carbonated/soft/isotonic drinks and diluted syrups.For alcohol intake, the following foods were considered: alcoholic beverages.These eight eating habits were also grouped together, and the population was divided into those who had no healthy eating behaviour or only one, and those who had, respectively, 2, 3, 4, 5 or more healthy eating behaviours.A balanced nutrition was defined based on the following intake: vegetables ≥ 200 g/day; fruit 150-375 g/day; fish at least

Figure 4 .
Figure 4. Age-standardized (Italian population) nutrition and healthy lifestyles (EPIC questionnaire) by education level.Men residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.For vegetables intake, the following foods were considered: leafy vegetables-cooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoescooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad and mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat intake, the following foods were considered: sausages,

Figure 4 .
Figure 4. Age-standardized (Italian population) nutrition and healthy lifestyles (EPIC questionnaire) by education level.Men residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.For vegetables intake, the following foods were considered: leafy vegetablescooked, leafy vegetables-raw, other vegetables, tomatoes-raw, tomatoes-cooked, root vegetables, cabbages, mushrooms, grain and pod vegetables, onion, garlic, stalk vegetables, mixed salad and mixed vegetables.For fruits intake, the following foods were considered: citrus fruits and other fruits.For fish intake, the following foods were considered: fish, crustaceans and molluscs.For cheese intake, the following foods were considered: cheeses (including fresh cheeses).For processed meat

Table 1 .
Age-standardized (Italian population) current smokers and former smokers prevalence, and mean number of cigarettes smoked per day, by sex, age classes, geographical area and educational level.Cigarette, cigar and pipe smokers prevalence.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.
N: number of participants denominator.n:number of participants related to the prevalence numerator.Current smoker is defined as a person who smokes one or more cigarettes per day.A former smoker is defined as a person who has quit smoking for at least 12 months.Number of cigarettes refers to packaged, handmade or electronic cigarettes.SD: standard deviation; CI: confidence interval.Means, standard deviations and prevalence were age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when they are reported by age-classes).ANOVA to compare mean values among classes; chi-square test to compare prevalence among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Abruzzo, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Abruzzo, Basilicata, Calabria, Sicily).cigarettesrefers to packaged, handmade or electronic cigarettes.SD: standard deviation; CI: confidence interval.Means, standard deviations and prevalence were age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when they are reported by age-classes).ANOVA to compare mean values among classes; chi-square test to compare prevalence among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Abruzzo, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Abruzzo, Basilicata, Calabria, Sicily).

Sedentariness during leisure time and at work
N: number of participants denominator.n: number of participants related to the prevalence numerator.Sedentariness during leisure time is defined as someone who usually carries out activities such as reading, watching television, getting to the movies or spend leisure time in other sedentary activities.Sedentariness at work is defined as one whose work mainly involves sitting at a desk and generally without the need to walk.SD: standard deviation; CI: confidence interval.Prevalence was age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).Chi-square test to compare prevalence among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Abruzzo, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Abruzzo, Basilicata, Calabria, Sicily).

Table 3 .
Age-standardized (Italian population) balanced nutrition food groups intake (EPIC questionnaire): vegetables, fruit, fish and cheese prevalence by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.
Prevalence was age-standardized by the Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).Chi-square test to compare prevalence among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Basilicata, Calabria, Sicily).

Table 4 .
Age-standardized (Italian population) balanced nutrition food groups intake (EPIC questionnaire): processed meat, sweets/cakes, sweet drinks and alcohol prevalence by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.

Table 5 .
Age -standardized (Italian population) food group intake (EPIC questionnaire): vegetables, fruit, fish and cheese mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.

Table 6 .
Age-standardized (Italian population) food group intake (EPIC questionnaire): processed meat, sweets/cakes, sweet drinks, and alcohol mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.

Table 7 .
Age-standardized (Italian population) food group intake (EPIC questionnaire): cereals, potatoes, legumes and oil mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.
For cereals intake, the following foods were considered: pasta, rice, white and whole meal bread, other grains, crispbread, rusks and breakfast cereals.For potatoes intake, the following foods were considered: French fries, boiled potatoes, roasted potatoes, pure potatoes, croquette potatoes.Dietary information was collected by the selfadministered Italian version of the food frequency questionnaire (FFQ) of the European Prospective Investigation into Cancer (EPIC).SD: standard deviation; CI: confidence interval.Means and standard deviations were age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when they are reported by age-classes).ANOVA to compare mean values among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Basilicata, Calabria, Sicily).

Table 8 .
Age -standardized (Italian population) food groups intake (EPIC questionnaire): meat, eggs, milk mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.
For meats intake, the following foods were considered: beef, veal, pork, horse, chicken, turkey, rabbit (domestic).Dietary information was collected by the self-administered Italian version of the food frequency questionnaire (FFQ) of the European Prospective Investigation into Cancer (EPIC).SD: standard deviation; CI: confidence interval.Means and standard deviations were age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when they are reported by age-classes).ANOVA to compare mean values among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Basilicata, Calabria, Sicily).
). Healthy lifestyle: people who reported not being smoker, not sedentariness during leisure time, and to have a food consumption comparable to at least five balanced eating behaviours.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Prevalence was age-standardized by the Italian National Institute of Statistics-ISTAT Italian population 2019 (except when it is reported by age-classes).

Table 9 .
Age-standardized (Italian population) nutrients intake (EPIC questionnaire): proteins (total, animal and vegetable) mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.

Table 9 .
Cont.Dietary information was collected by the self-administered Italian version of the food frequency questionnaire (FFQ) of the European Prospective Investigation into Cancer (EPIC).SD: standard deviation; CI: confidence interval.Means and standard deviations were age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when they are reported by age-classes).ANOVA to compare mean values among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Basilicata, Calabria, Sicily).

Table 10 .
Age-standardized (Italian population) nutrients intake (EPIC questionnaire): lipids (animal and vegetable) and cholesterol mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.

Table 11 .
Age-standardized (Italian population) nutrients intake (EPIC questionnaire): saturated, polyunsaturated and monounsaturated fat, lipids total mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.

Table 11 .
Cont.Dietary information was collected by the self-administered Italian version of the food frequency questionnaire (FFQ) of the European Prospective Investigation into Cancer (EPIC).SD: standard deviation; CI: confidence interval.Means and standard deviations were age standardized by Italian National Institute of Statistics-ISTAT Italian population 2019 (except when they are reported by age-classes).ANOVA to compare mean values among classes.The pool was made of the following Italian regions: Piedmont, Lombardy, Liguria, Emilia Romagna, Tuscany, Lazio, Basilicata, Calabria and Sicily.Italian Area: North (Piedmont, Lombardy, Liguria, Emilia Romagna); Centre (Tuscany, Lazio); South (Basilicata, Calabria, Sicily).

Table 12 .
Age-standardized nutrients intake (EPIC questionnaire) fibre, sodium, potassium, carbohydrates and simple carbohydrates mean by sex, age classes, geographical area and educational level.Men and women residing in Italy aged 35-74 years, Health Examination Survey 2018-2019-CUORE Project.