Search Results (715)

Bamboo fibers are increasingly incorporated into food products as sustainable dietary fiber ingredients, yet their gastrointestinal digestion resistance and fermentative behavior by human gut microbiota remain insufficiently characterized. This study combined an INFOGEST-based in vitro digestion protocol with colonic fermentation using fecal microbiota from three healthy donors as an exploratory donor panel. Bamboo fibers were resistant to salivary, gastric, and intestinal enzymatic hydrolysis, as demonstrated by the absence of structural modifications in FTIR spectra, preserved morphology observed by scanning electron microscopy, and negligible release of reducing sugars (<0.1 g/L across all digestive phases), in contrast to extensively hydrolyzed wheat starch used as a positive control. During in vitro colonic fermentation, microbial responses were strongly dependent on substrate availability. In nutrient-limited minimal medium, bamboo fiber supplementation increased gas production, acidification, and SCFA formation compared with control conditions. Concomitantly, SCFA concentrations increased under minimal-medium conditions, although the magnitude of the response varied among donors, with the strongest changes observed for donor 1 (acetate reaching 5.4 vs. 3.3 g/L and propionate 1.48 vs. 0.76 g/L). These effects were markedly attenuated in nutrient-rich medium, indicating competition with readily fermentable substrates. Beta-diversity analyses and metagenomic profiling revealed that microbial community composition clustered primarily according to donor identity rather than experimental conditions. SEM further showed surface erosion and microbial attachment on fermented fibers, supporting partial structural alteration. Overall, bamboo fibers are resistant to upper gastrointestinal digestion but display context-dependent fermentative activity by human gut microbiota under carbohydrate-limited conditions, highlighting the importance of inter-individual variability, dietary context and substrate availability in determining their fermentative potential. Full article

Background: This study aimed to examine trends in physical fitness among 10–12-year-old children in Ningxia, China, from 2019 to 2024 and to investigate associations between dietary behaviors and physical fitness outcomes using repeated cross-sectional data from the National Student Physical Fitness and Health Survey. Methods: This repeated cross-sectional study included 3970 children aged 10–12 years from Ningxia, China (1960 boys and 2010 girls), based on data from the National Student Physical Fitness and Health Survey conducted in 2019 and 2024. Physical fitness indicators and dietary behaviors (breakfast consumption, egg intake, milk intake, and sugar-sweetened beverage consumption) were assessed using standardized assessments and questionnaires. Sex-stratified t-tests and multivariable linear regression models were performed to examine temporal changes and associations between dietary behaviors and physical fitness outcomes, adjusting for age, BMI, survey year, physical activity, and sleep duration. Results: From 2019 to 2024, both boys and girls showed improvements in multiple physical fitness indicators, including lung capacity, muscular endurance, and speed–agility performance, accompanied by increases in BMI. Adjusted analyses showed modest associations between dietary behaviors and specific fitness outcomes. Egg and breakfast consumption were associated with some measures of muscular endurance, whereas sugary beverage consumption showed associations with several fitness indicators, particularly among girls. Conclusion: Children in Ningxia experienced improvements in physical fitness from 2019 to 2024, alongside changes in body mass status. The observed associations between dietary behaviors and fitness outcomes highlight the potential relevance of modifiable lifestyle factors during late childhood. Integrated school-based strategies combining physical activity promotion, healthy dietary behaviors, and weight monitoring may support healthy development in this population. Full article

Sleep characteristics have been associated with body mass index (BMI) among adolescents, but population-representative evidence on sleep timing and variation across demographic subgroups remains limited. We conducted a cross-sectional analysis of 2017–2018 California Health Interview Survey data from 880 adolescents aged 12–17 years. Weeknight sleep duration was obtained from the CHIS-derived sleep-duration variable, based on reported school-night bedtimes and school-day wake times. Sleep-timing measures included bedtime, wake time, and the derived sleep midpoint. Pooled survey-weighted linear and logistic regression models used 160 jackknife replicate weights and adjusted for age, sex, race/ethnicity, household poverty category, and survey year; sensitivity models additionally adjusted for dietary and behavioral factors. Sleep duration was not associated with BMI overall (p = 0.161) or with the odds of having overweight or obesity (p = 0.36). The association between sleep duration and BMI varied by age group (p for interaction = 0.042). Each additional hour of sleep was associated with a lower BMI among adolescents aged 14–17 years (β = −0.895 kg/m²; 95% CI: −1.464 to −0.326; p = 0.002), but not among those aged 12–13 years. However, there was no evidence of an interaction when age was modeled continuously (p for interaction = 0.36). Bedtime, wake time, and sleep midpoint were not independently associated with BMI. Exploratory evidence that the association between sleep duration and overweight or obesity varied by race/ethnicity was attenuated after adjustment for dietary and behavioral factors (p for interaction changed from 0.04 to 0.05). In this cross-sectional study, neither sleep duration nor sleep timing was associated with BMI in the overall sample, and sleep duration was not associated with BMI-defined weight status. Subgroup findings were not consistent across model specifications and should be examined in longitudinal studies using objective and repeated measures of sleep. Full article

Background: Preventive oral-health behaviors are crucial for reducing the incidence of dental caries, but there is still little data on whether Chinese dental patients continue to practice these behaviors. This study investigated self-reported changes in oral-health practices after treatment and explored factors associated with the adoption of preventive behaviors. Methods: A cross-sectional questionnaire-based survey was carried out in a hospital in Guangzhou with 246 dental patients. The frequency of brushing both before and after treatment, interdental cleaning, dietary modifications, attendance at follow-up, receiving and understanding preventive advice, and following recommendations were reported. Changes in brushing behavior were analyzed, and logistic regression models were used to evaluate factors associated with preventive behaviors. Results: The proportion of participants brushing ≥2/day increased after treatment (7.7%, p < 0.05). Daily interdental cleaning remained low (23.2%), while 61.0% reported dietary modification and 53.3% attended follow-up. In multivariable models adjusting for all covariates, most sociodemographic factors were not significantly associated with preventive behaviors. Male participants had lower odds of brushing ≥2/day. Understanding of preventive recommendations was the most consistent predictor, with lower understanding associated with reduced flossing, follow-up, and adherence. Receipt and format of advice were not independently associated with outcomes after adjustment. Periodontal treatment was associated with lower follow-up compared with restorative care. Conclusions: Preventive oral-health behaviors improved modestly after treatment, but overall adherence remained limited. Clear understanding of preventive advice was the strongest determinant of behavior, while sociodemographic factors and advice format showed no independent effects. Lower follow-up attendance among periodontal patients highlights the need for improved patient communication and recall strategies. Full article

Anemia among adolescent girls remains a persistent public health challenge in Indonesia, driven by limited nutritional knowledge, poor dietary practices, and suboptimal adherence to iron supplementation programs. This study is grounded in the Social–Ecological Model (SEM), which frames health behaviors as shaped by individual, interpersonal, institutional, and community-level factors. This study aimed to explore students’ knowledge and dietary behaviors related to anemia, assess perceptions of existing supplementation programs, and examine teachers’ and students’ perspectives on school-based digital education for anemia prevention in Denpasar, Bali. A qualitative descriptive design was employed across eight public junior high schools. Participants included eight teachers and 40 female students (aged 13–15 years) selected via purposive sampling. Data were collected through semi-structured in-depth interviews, non-participant observations, and document analysis. Thematic analysis was conducted using Atlas.ti version 23, with trustworthiness ensured through triangulation, member checking, peer debriefing, and iterative saturation assessment. Four inter-related themes emerged: (1) students held superficial, menstruation-centric conceptualizations of anemia with limited understanding of iron deficiency as an underlying cause; (2) dietary patterns were dominated by low-iron foods with poor vegetable consumption; (3) adherence to the Weekly Iron and Folic Acid Supplementation (WIFAS) program was inconsistent, hindered by side effects, forgetfulness, and low perceived benefit; and (4) both teachers and students expressed strong interest in digital education tools while identifying infrastructure and training gaps as barriers. Anemia prevention in school settings requires a multi-level approach integrating knowledge improvement, dietary behavior support, and institutional reinforcement. School-based digital education represents a contextually appropriate, youth-aligned innovation with strong potential to bridge the gap between health information and sustained behavioral change. Full article

Background/Objectives: Pakistan has one of the highest burdens of adolescent anaemia in South Asia. A Weekly Iron-Folic Acid Supplementation (WIFAS) program for school-going adolescent girls aged 10–19 years was piloted in the Lodhran District, Punjab, Pakistan. Methods: A quantitative cross-sectional study was conducted among 750 girls, selected by multi-stage random cluster sampling from 50 public schools across Lodhran; qualitative data were generated through in-depth interviews and focus group discussions with 327 stakeholders. Quantitative data were analyzed using a chi-square test in SPSS. Qualitative data were analyzed in NVIVO using thematic analysis based on the Socio-Ecological Model, enabling environment and institutional systems, community engagement, behavior change and adolescent empowerment and agency. Coding was guided by overarching research questions of acceptability, feasibility and impact. Cases of anaemia averted were estimated using program data and outcome modeling. Qualitative findings were triangulated with quantitative results. Results: The program reached 30,506 girls and was estimated to have averted 5659 cases of anaemia. WIFAS coverage increased from 0% to 100%, with a high level of adherence (80%). Knowledge about anaemia, its signs/symptoms and preventative measures increased significantly at endline. Dietary practices showed positive changes, with significant increase in girls never skipping a meal. Stakeholders attributed success to the creation of an enabling environment through institutional alignment and multisectoral collaboration, culturally adapted, adolescent-friendly materials, and robust community mobilization that proactively addressed socio-cultural barriers. Conclusions: The school-based WIFAS program for reducing anaemia among adolescent girls was feasible and acceptable in a context where few nutrition services are available to girls. Full article

While standard dietary frameworks and public health guidelines predominantly evaluate honey based on its high free-sugar content to regulate caloric intake, its comprehensive role as a complex and dense biological signaling matrix is often less characterized. This review integrates raw chemical profiling with physiological bioaccessibility to evaluate the effect of the floral source on the functional quality of monofloral honeys. Through a structured literature-based comparative synthesis, the specific enzymatic behaviors, gastrointestinal metabolic fates, and chemical biomarkers of four representative monofloral honeys—Manuka, Chestnut, Acacia, and Argan—were systematically mapped and contrasted. Honey bioactives undergo extensive metabolic transformation during gastrointestinal transit, actively communicating with the mucosal environment rather than acting as a static nutrient solution The synthesized literature highlights distinct botanical-specific mechanisms: Manuka honey matrices exhibit well-characterized topical antimicrobial kinetics, while data on Chestnut honey suggest a potential role in cellular redox homeostasis via the Nrf2 pathway and a highly specific, though preclinical, signaling axis through kynurenic acid–GPR35 interactions. Furthermore, in vitro profiles of Acacia honey support its potential to modulate digestive carbohydrate enzymes, providing a plausible framework for its lower postprandial glycemic responses. Conversely, Argan honey bioactivity remains restricted to preliminary baseline antioxidant screenings. We also note that sophisticated sugar adulteration and climate change create critical “phytochemical drift,” endangering the therapeutic consistency of honey. In summary, the identification of honey as a “functional interactome” offers a strong scientific foundation for evidence-based dietetics. The targeted use of verified medical-grade monofloral honeys must be supported by advanced authenticity testing, metabolomics, and in vivo pharmacokinetics in future clinical dietetic interventions. Full article

With changes in lifestyle and dietary patterns, the incidence of prostate cancer in China has been increasing steadily, and it has become one of the most common malignancies in men. Chemotherapy remains a primary treatment for prostate cancer, but the subsequent development of drug resistance by tumor cells markedly compromises its therapeutic efficacy. Growth differentiation factor 15 (GDF15) has been shown to be closely associated with tumor cell proliferation and metastasis; however, its contribution to the drug resistance of prostate cancer cells within the tumor microenvironment has not been systematically investigated. In this study, we treated drug-resistant prostate cancer cells (PC3-TXR and DU145-TXR) with conditioned medium (CM) and examined GDF15 expression by Western blotting, real-time PCR, and ELISA. We then exposed drug-resistant cells to various concentrations of recombinant GDF15 (rGDF15) and CM, and assessed invasive and metastatic abilities as well as sensitivity to paclitaxel using Transwell and CCK-8 assays. We generated GDF15-knockout osteocytes using CRISPR-Cas9 technology and detected the expression of resistance-related signaling pathway components and epithelial–mesenchymal transition (EMT) markers. These findings were further validated through subcutaneous tumor formation assays in mice combined with immunohistochemistry to explore the mechanism by which GDF15 regulates drug resistance and metastasis in the crosstalk between drug-resistant prostate cancer cells and bone cells. Our results revealed that GDF15 expression was significantly upregulated in both drug-resistant prostate cancer cells and their surrounding microenvironment. rGDF15 enhanced the invasion and drug resistance of resistant cells, whereas knockout of GDF15 effectively inhibited these effects. Furthermore, we demonstrated that GDF15 regulates the biological behavior of drug-resistant cells by targeting and modulating the AKT signaling pathway and by promoting EMT initiation and progression. These findings clarify the molecular pathway through which GDF15 governs drug resistance in prostate cancer cells, offering a new direction for the treatment of tumor metastasis and biologically targeted therapy. Full article

Background: Children with Autism Spectrum Disorder (ASD) frequently exhibit severe food selectivity and micronutrient deficiencies, impacting growth and nutritional status. Evidence on integrated nutritional interventions in resource-constrained settings remains limited. Objective: To assess the feasibility and preliminary pre–post changes associated with a 12-week multicomponent nutritional intervention among Vietnamese children with ASD. Methods: In this exploratory single-arm pilot study, 56 children with ASD (mean age 59.0 ± 22.3 months; 80.4% male) were recruited from five community centers in Nghe An Province, Vietnam. The intervention comprised caregiver nutrition education, individualized dietary counseling, and daily multi-micronutrient supplementation. Anthropometric indicators, biochemical markers, feeding behaviors, and dietary intake were assessed at baseline and after 12 weeks. Pre–post changes were evaluated using paired statistical tests, and multivariable linear regression examined factors associated with growth response. Results: The study achieved a 100% completion rate, with all 56 recruited participants finishing the 12-week intervention and all scheduled follow-up assessments. Among children < 60 months, mean Weight-for-Age Z-score (WAZ) increased from −0.66 to −0.28 and mean Height-for-Age Z-score (HAZ) from −1.18 to −0.97 (p < 0.001). For children older than 60 months, mean HAZ increased from −0.87 to −0.58 (p < 0.001) and Body Mass Index-for-Age Z-score (BAZ) from −0.20 to 0.06 (p = 0.006). Significant increases occurred in serum zinc (10.29 to 11.72 µmol/L; p = 0.001), ferritin (31.74 to 34.79 ng/mL; p = 0.001), and hemoglobin (122.73 to 124.77 g/L; p = 0.002), while albumin remained unchanged. Concurrent improvements were observed in feeding behaviors and nutrient-dense food intake. Regression analysis indicated that lower baseline anthropometric status was significantly associated with greater gains in WAZ and HAZ. Conclusions: This community-based multicomponent intervention was feasible and associated with short-term improvements in feeding behaviors, dietary intake, selected biomarkers, and growth measures in children with ASD, supporting further evaluation in randomized controlled trials. Full article

The accelerating urgency of global public health challenges, biodiversity loss, and climate change has driven rapid innovation in novel foods and alternative proteins, including cultured cells, fermentation-derived components, plant-based meats, insects, and algae, which promise nutritious, sustainable, and ethical dietary choices with lower environmental footprints. Although technologies have advanced, consumer perception and preferences remain key hindrances due to perceptual, cultural, and sensory challenges. This semi-systematic narrative literature review aims to incorporate interdisciplinary studies (2020–2025) that span sensory science, AI-driven marketing, behavioral economics, and policy analysis to explore consumer incentives, barriers, and intervention approaches associated with novel food categories. Of 1260 initial records, 310 duplicates were removed, 530 were excluded at title/abstract screening, 233 were excluded at full-text review, leaving 197 studies for the final synthesis. The focus is on understanding cultural contexts, cognitive biases, digital and social influences, and the global framing impacts that shape consumer adoption. Consumer perceptions and preferences are primarily influenced by health benefits, ethical concerns, and environmental sustainability; however, neophobia, sensory unfamiliarity, trust deficits, and price temper these factors. Preliminary evidence suggests that AI-generated personalization, transparent labeling, behavioral nudges, and social norms may be useful tools for overcoming resistance to change, though the effectiveness of AI-driven personalization in actual purchasing behavior is not yet firmly established. Cultural diversity affects acceptance routes, with culturally established insect consumption differing from Western neophobia. Future studies should integrate interdisciplinary methodologies, longitudinal cross-cultural analyses, and innovative technologies to enhance communication and product design. Full article

Heat stress is a growing concern in cattle production systems due to the increasing frequency and intensity of extreme weather events driven by climate change. This review synthesizes current knowledge on the multifaceted impacts of heat stress and focuses on nutritional strategies to mitigate its effects on ruminating cattle. A comprehensive literature search was conducted using PubMed, Scopus, Web of Science, and Google Scholar. Heat stress adversely affects cattle physiology, behavior, rumen function, and overall productivity, particularly in dairy animals with high metabolic activity. During heat stress episodes, changes in the microbial population have been reported; however, there is no clear consensus, as findings vary widely among studies depending on diet, feed intake, animal type and experimental design. This variability limits the ability to draw general conclusions regarding changes in the rumen microbiome driven by heat stress. In this context, dietary nutritional intervention strategies offer a practical and scalable approach to enhance thermotolerance and maintain performance under heat stress conditions. Key nutritional strategies include modifications in diet composition to reduce metabolic heat production, with some approaches carrying potential risks to animal health, e.g., increasing dietary energy density through concentrates while minimizing forage content. Supplementation with rumen-protected nutrients like amino acids, vitamins, and minerals can be used to support immune function, antioxidant capacity, and metabolic stability. Polyphenols and betaine contribute to oxidative stress reduction and gut integrity, while probiotics may be used to improve rumen fermentation and nutrient utilization. Sensor technologies, including rumen boluses and wearable devices, offer the potential to monitor physiological responses to heat stress in real time and offer opportunities for precision feeding and early intervention. Most published studies only cover short periods of heat stress, and there is a lack of in vitro models simulating rumen hyperthermia. In parallel, future research should therefore prioritize longitudinal, in vivo trials that integrate physiological, metabolic, and microbial responses to understand the long term and systemic effect of heat stress. In addition, controlled trials in commercial settings are necessary to prove the transferability of results to commercial herds. A multidisciplinary approach combining nutritional, environmental, and technological strategies is likely to play an important role in safeguarding cattle welfare and productivity in a warming climate. Full article

Background/Objectives: Early childhood is a critical period for establishing lifelong dietary patterns, and early learning environments play a central role in shaping children’s eating behaviors. However, many childhood educators receive limited training in evidence-based nutrition practices. This study evaluated the impact of the Feeding Brighter Futures workshop, an experiential, case-based training intervention, on participants’ nutrition-related knowledge, perceptions, and attitudes. Methods: Using a pre–post survey design, undergraduate and graduate students, faculty, and staff (n = 33 pre; n = 19 post) from universities in Mississippi and southeastern Arkansas completed electronic surveys before and after the workshop. Survey questions aimed to assess participants’ knowledge of nutrition-focused regulations pertaining to early learning centers and comprehension of USDA MyPlate recommendations. Results: Results showed a statistically significant increase in agreement that teachers should only consume snacks available to children and further strengthening of already positive attitudes toward involving children in snack preparation. Attitudes toward using food as a reward did not significantly change. Conclusions: These findings suggest that brief experiential training may improve alignment with evidence-based nutrition practices, though further research with larger samples is warranted. Full article

Background: The Nutrition Improvement Program has been implemented in China for over a decade; however, its assessment in Hubei Province has not yet been systematically reported. This study evaluated the implementation outcomes of the Rural Compulsory Education Students’ Nutrition Improvement Program in Hubei Province. Methods: A multi-stage cluster sampling design with stratification by school type was used. Standardized questionnaires were administered to schools, districts, and students to assess the food environment, nutrition policies, and dietary behaviors. Anthropometric and biochemical measurements were collected from all participants in 2014 and 2023. Results: A total of 24 schools across six counties in Hubei Province were surveyed at two time points, comprising 8619 students (4388 in 2014 and 4231 in 2023). Between 2014 and 2023, the proportion of students in the Nutrition Improvement Program reporting satisfaction with school meals increased significantly, and average nutritional knowledge scores improved. Nevertheless, several deficiencies persisted: menus remained poorly aligned with dietary guidelines, food variety was limited, full-time nutrition or health teachers were scarce, and absolute levels of nutritional knowledge remained low. In 2023, the prevalence of undernutrition, overweight/obesity, and anemia among program participants was 9.5%, 15.9%, and 12.2%, respectively. Compared with girls, boys had higher rates of undernutrition and overweight/obesity and a lower anemia rate; the same pattern was observed in primary school students relative to junior high school students. Compared with 2014, the nutritional profile shifted markedly (p < 0.001). Undernutrition and anemia declined by 7.4 and 4.9 percentage points, respectively, whereas overweight/obesity increased by 6.9 percentage points. Conclusions: From 2014 to 2023, students in the Nutrition Improvement Program of Hubei Province experienced observable changes in nutritional status: the primary nutritional concern had shifted from undernutrition to overnutrition, and the prevalence of anemia has generally decreased, while it has increased in some areas. However, given the observational nature of the repeated cross-sectional design, causal inference regarding the program’s impact was not supported. Full article

Background: Sedentary behavior is a major modifiable risk factor for chronic metabolic disorders, particularly type 2 diabetes mellitus (T2DM). Despite recommendations promoting regular physical activity (PA), adherence remains low. DIA/01 is a multidisciplinary study designed to promote healthy lifestyles for the prevention and management of T2DM, supporting healthcare systems. Methods: A total of 123 adults with T2DM diagnosed will be enrolled at the Diabetes Center of the University Hospital of Perugia throughout 2025. Inclusion criteria are age 25–80 years, ability to walk independently, being inactive, and BMI 18.5–40 kg/m². Exclusion criteria include severe cardiovascular, central nervous system, or musculoskeletal diseases contraindicating PA. Participants will be randomized into three groups: (1) standard care (SC); (2) SC plus theoretical PA counseling (TCPA); and (3) SC plus TCPA plus a 3-month supervised mixed exercise program. The assessment, conducted at baseline and at 6 and 12 months, includes total weekly PA (WPA) time, using IPAQ-SF and actigraphy. Moreover, glycated hemoglobin, sedentary time (ST), functional capacity, body composition, cardiometabolic risk factors, dietary adherence, perceived barriers and willingness to initiate PA, readiness to change, health-related quality of life, and sleep quality will be studied. This study is registered in the Clinical Trials Registry on 13 May 2026, with the identifier NCT07583355. Conclusions: Participants in groups (2) and (3) are expected to show greater improvements in WPA, reductions in ST, and favorable changes in metabolic and functional outcomes compared with SC. This approach may support long-term engagement in regular PA and contribute to improving the clinical management of T2DM. Full article

Background: This randomized controlled trial aimed to evaluate the effects of a school physician-led counseling intervention on total cholesterol (TC) levels, adherence to the Mediterranean diet, physical activity, and sedentary behavior in children aged 6–7 years with elevated cholesterol levels in a Mediterranean setting. Methods: A one-year randomized controlled study was conducted among children aged 6–7 years with elevated TC levels, excluding those with familial hypercholesterolemia (FH). Participants were randomly assigned to either a control group (n = 38) or an intervention group (n = 39). All participants received standard care consisting of educational materials and baseline counseling, while the intervention group additionally participated in three structured follow-up counseling sessions conducted by school physicians during the one-year study period. Counseling focused on Mediterranean dietary habits, implementation of basic dietary principles in cases of elevated TC levels, promotion of physical activity, and reduction in sedentary behavior. TC levels were measured at baseline and at the end of the study. Dietary habits, physical activity, and sedentary behavior were assessed using validated questionnaires. For the primary outcome, a descriptive change-from-baseline analysis, unadjusted mean difference, the approximate 95% confidence interval, and Cohen’s d effect size were calculated. Results: At baseline, no significant differences in TC levels were observed between groups (p = 0.852). After the intervention, mean TC levels were lower in the intervention group than in the control group (4.977 ± 0.414 mmol/L vs. 5.137 ± 0.410 mmol/L); however, the between-group difference did not reach statistical significance (p = 0.089). The unadjusted mean difference at follow-up was −0.160 mmol/L, with an approximate 95% confidence interval from −0.35 to 0.03 and a small-to-moderate effect size in favor of the intervention group (Cohen’s d = −0.39). Descriptive change-from-baseline analysis showed a greater mean reduction in TC in the intervention group than in the control group (−0.364 mmol/L vs. −0.195 mmol/L). A statistically significant improvement in adherence to the Mediterranean diet was observed in the intervention group compared with the control group (p < 0.001). Favorable changes were also observed in several physical activity and sedentary behavior variables, including participation in organized physical activity, walking and running activities, and reduced television viewing and video gaming time. Given the exploratory nature of behavioral analyses and the number of physical activity and sedentary behavior outcomes examined, these findings should be interpreted cautiously. Conclusions: The school physician-led counseling intervention did not result in a statistically significant between-group difference in TC levels after one year, although the direction and magnitude of change favored the intervention group. The intervention was associated with improved adherence to the Mediterranean diet and favorable exploratory lifestyle-related behavioral changes. Nevertheless, the findings should be interpreted cautiously in light of the relatively small sample size, non-significant primary outcome, and exploratory nature of behavioral analyses. Full article