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Introduction Physical activity (PA) is essential to healthy mental and physical development in early life. However, the prevalence of physical inactivity, which is considered a key modifiable driver of childhood obesity, has reached alarming levels among European youth. There is a need to update the data for Spain, in order to establish if current measures are effective or new approaches are needed. Methods and analysis We present the protocol for Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS). This observational, nationally representative, multicentre study aims to determine the PA levels, sedentary behaviours and prevalence of physical inactivity (defined as <60 min of moderate to vigorous PA per day) in a representative sample of Spanish children and adolescents. The PASOS study has recruited a representative random sample of children and adolescents aged 8-16 years from 242 educational centres in the 17 'autonomous regions' into which Spain is divided. The aim is to include a total of 4508 youth participants and their families. Weight, height and waist circumference will be measured by standardised procedures. Adherence to the Mediterranean diet, quality of life, sleep duration, PA and sedentary behaviour are being measured by validated questionnaires. PA is measured by the Physical Activity Unit 7-item Screener. A representative subsample (10% of participants) was randomly selected to wear accelerometers for 9 days to obtain objective data on PA. Parents are asked about their educational level, time spent doing PA, diet quality, self-perceived stress, smoking habit, weight, height, their child's birth weight and if the child was breast fed. ; PASOS study has been funded mainly by Fundación PROBITAS and Gasol Foundation. Additional funds were received from the Barça Foundation, Banco Santander, IFA, Viena and Fundación Deporte Jóven. MMB is funded by the official funding agency for biomedical research of the Spanish government, Institute of Health Carlos III (ISCIII), which is cofunded by the European Regional Development Fund (CIBEROBN CB12/03/30038), grant of support to research groups number 35/2011 (Balearic Islands Gov) and EU COST Action CA16112. PASOS has the institutional support of Spain's Ministry of Education and Vocational Training, the Ministry of Health, Consumption and Social Welfare through the Spanish Agency for Food Safety and Nutrition (ASEAN), the High Commission against Child Poverty, the High Sports Council, the General College of Professional Associations of Physical Education and Sports, and the Departments of Education and/or Health and/or Sports of Spain's 17 autonomous regions. The CIBERESP and the CIBEROBN are initiatives of the Institute of Health Carlos III, Madrid, Spain.

Lin, Y. et al. ; [Background] Previous studies suggest that dietary protein might play a beneficial role in combating obesity and its related chronic diseases. Total, animal and plant protein intakes and their associations with anthropometry and serum biomarkers in European adolescents using one standardised methodology across European countries are not well documented. ; [Objectives] To evaluate total, animal and plant protein intakes in European adolescents stratified by gender and age, and to investigate their associations with cardio-metabolic indicators (anthropometry and biomarkers). ; [Methods] The current analysis included 1804 randomly selected adolescents participating in the HELENA study (conducted in 2006–2007) aged 12.5-17.5 y (47% males) who completed two non-consecutive computerised 24-h dietary recalls. Associations between animal and plant protein intakes, and anthropometry and serum biomarkers were examined with General linear Model multivariate analysis. ; [Results] Average total protein intake exceeded the recommendations of World Health Organization and European Food Safety Authority. Mean total protein intake was 96 g/d (59% derived from animal protein). Total, animal and plant protein intakes (g/d) were significantly lower in females than in males and total and plant protein intakes were lower in younger participants (12.5-14.9 y). Protein intake was significantly lower in underweight subjects and higher in obese ones; the direction of the relationship was reversed after adjustments for body weight (g/(kg.d)). The inverse association of plant protein intakes was stronger with BMI z-score and body fat percentage (BF%) compared to animal protein intakes. Additionally, BMI and BF% were positively associated with energy percentage of animal protein. ; [Conclusions] This sample of European adolescents appeared to have adequate total protein intake. Our findings suggest that plant protein intakes may play a role in preventing obesity among European adolescents. Further longitudinal studies are needed to investigate the potential beneficial effects observed in this study in the prevention of obesity and related chronic diseases. ; The HELENA-study took place with the financial support of the European Community Sixth RTD Framework Programme. This work was also partially supported by the European Union in the framework of the Public Health Programme, the Swedish Council for Working Life and Social Research (FAS), the Spanish Ministry of Education, and the Spanish Ministry of Health, Maternal, Child Health and Development Network and the Spanish Ministry of Science and Innovation AGL2007-29784-E. The content of this paper reflect only the authors' views and the rest of HELENA-study members and the European Community is not liable for any use that may be made of the information contained therein. Augusto César F. de Moraes is in receipt of a PhD scholarship from the São Paulo State Research Foundation (FAPESP: proc. 2011/11137-1 and 2011/20662-2) and Postdoctoral Research Fellow scholarship from National Counsel of Technological and Scientific Development (CNPq: proc. 313772/2014-2); Luis A. Moreno was given scholarship of Visiting Professor from Brazilian government by Science without Borders Program by CNPq and CAPES (Coordination of Improvement of Higher Education Personnel) (proc. 007/2012). The GENUD Research Group co-financed by the European Regional Development Fund (MICINN-FEDER). Many thanks to Petra Pickert, Anke Carstensen and Rosa Maria Torres for their contribution to laboratory work.

When promoting physical activity (PA) participation, it is important to consider the plausible environmental determinants that may affect this practice. The impact of objectively-measured public open spaces (POS) and walk-friendly routes on objectively-measured and self-reported PA was explored alongside the influence of rainy conditions on this association, in a Mediterranean sample of overweight or obese senior adults with metabolic syndrome. Cross-sectional analyses were undertaken on 218 PREDIMED-Plus trial participants aged 55⁻75 years, from the city of Palma, in Mallorca (Spain). Indicators of access to POS and walk-friendly routes were assessed in a 1.0 and 0.5 km sausage network walkable buffers around each participant's residence using geographic information systems. Mean daily minutes of self-reported leisure-time brisk walking, and accelerometer objectively-measured moderate-to-vigorous PA in bouts of at least 10 min (OM-MVPA) were measured. To investigate the association between access to POS and walk-friendly routes with PA, generalized additive models with a Gaussian link function were used. Interaction of rainy conditions with the association between access to POS and walk-friendly routes with OM-MVPA was also examined. Better access to POS was not statistically significantly associated with self-reported leisure-time brisk walking or OM-MVPA. A positive significant association was observed only between distance of walk-friendly routes contained or intersected by buffer and OM-MVPA, and was solely evident on non-rainy days. In this elderly Mediterranean population, only access to walk-friendly routes had an influence on accelerometer-measured PA. Rainy conditions during the accelerometer wear period did appear to modify this association. ; Funding: Instituto de Investigación en Salud Carlos III (PI14/00853, PI16/00662 and PI17/00525), and Consejería de Salud de la Junta de Andalucía (PS0358-2016). Co-funded by FEDER. AstraZeneca Foundation (Young Investigator Award on obesity and type 2 diabetes to D.R. 2017). The authors wish to thank the participants in the city of Palma de Mallorca, Spain who took part in the PREDIMED-Plus study for their collaboration, and the PREDIMED-Plus personnel and investigators who collected, catalogued, and provided the data that made this study possible, as well as all affiliated primary care centers, for their excellent work. Thanks to the CIBEROBN, CIBERESP, CIBERDEM initiatives of Instituto de Salud Carlos III, Spain. Thanks also to the European Research Council (grant 340918). We are grateful to the Municipal Sports Institute of the City of Palma, the Department of Infrastructure and Accessibility of Palma City Council, and Agencia Estatal de Meteorología for the transparency of the data necessary for this study; and to. Gonzalo Serrano for his expert assessment in open access database management from public services. M.C. is the recipient of a pre-doctoral FPI Fellowship from the Conselleria d'Innovació, Recerca i Turisme of the regional Government of the Balearic Islands co-financed by the European Social Fund as part of the FSE 2014–2020 operational program. We appreciate the English revision by Meryl Jones and the service of linguistic support of the Research Committee of the University Hospital Son Espases (HUSE). Finally, we thank three anonymous reviewers for comments on an earlier draft.

(1) Background: Vaccination is the most effective intervention to control seasonal influenza morbidity and mortality. The present study aimed to determine the influenza vaccination coverage in the Military Health Corps personnel in the 2020–2021 season, as well as the time trend and the possible influence of the pandemic on coverage, in order to study the reasons that led to the non-vaccination of health professionals and to analyze adverse drug reactions (ADRs). (2) Methods: A descriptive, cross-sectional study was conducted from February to May 2021. All FAS CMS personnel were included. A self-administered questionnaire was sent by e-mail to the selected personnel. (3) Results: Vaccination coverage in the 2016–2017 season was 15.8% (n = 276), in the 2019–2020 season it was 17.41% (n = 424), and in the 2020–2021 season it was 24.22% (n = 590). The percentage of vaccinated men was higher than the percentage of women. In 2019 and 2020 the most vaccinated group was 31–40 years old. Lieutenants had the highest vaccination uptake in 2019 and 2020. The personnel with the highest uptake of vaccines were those in the specialty of nursing in each of 2016, 2019 and 2020, with >30 years of time worked in 2016. In terms of factors leading to refusal of vaccination, the most reported was "not considered a risk group" (23.0%), and the least reported was "avoidance of vaccine administration" (2.2%). Eighty individuals presented adverse reactions after vaccine administration (9.6%). (4) Conclusions: The rate of influenza vaccination among healthcare professionals was lower during the 2020 season compared to the previous season, but was expected to increase in the upcoming 2021 season.

Objective Independently of total caloric intake, a better quality of the diet (for example, conformity to the Mediterranean diet) is associated with lower obesity risk. It is unclear whether a brief dietary assessment tool, instead of full-length comprehensive methods, can also capture this association. In addition to reduced costs, a brief tool has the interesting advantage of allowing immediate feedback to participants in interventional studies. Another relevant question is which individual items of such a brief tool are responsible for this association. We examined these associations using a 14-item tool of adherence to the Mediterranean diet as exposure and body mass index, waist circumference and waist-to-height ratio (WHtR) as outcomes. Design Cross-sectional assessment of all participants in the "PREvención con DIeta MEDiterránea" (PREDIMED) trial. Subjects 7,447 participants (55–80 years, 57% women) free of cardiovascular disease, but with either type 2 diabetes or ≥3 cardiovascular risk factors. Trained dietitians used both a validated 14-item questionnaire and a full-length validated 137-item food frequency questionnaire to assess dietary habits. Trained nurses measured weight, height and waist circumference. Results Strong inverse linear associations between the 14-item tool and all adiposity indexes were found. For a two-point increment in the 14-item score, the multivariable-adjusted differences in WHtR were −0.0066 (95% confidence interval, –0.0088 to −0.0049) for women and –0.0059 (–0.0079 to –0.0038) for men. The multivariable-adjusted odds ratio for a WHtR>0.6 in participants scoring ≥10 points versus ≤7 points was 0.68 (0.57 to 0.80) for women and 0.66 (0.54 to 0.80) for men. High consumption of nuts and low consumption of sweetened/carbonated beverages presented the strongest inverse associations with abdominal obesity. Conclusions A brief 14-item tool was able to capture a strong monotonic inverse association between adherence to a good quality dietary pattern (Mediterranean diet) and obesity indexes in a population of adults at high cardiovascular risk. ; The Official funding agency for Biomedical Research of the Spanish Government, Instituto de Salud Carlos III (ISCIII), provided the grants for his study: RTIC G03/140, CIBERobn, RD 06/0045, PI04-2239, PI 05/2584, CP06/00100, PI07/0240, PI07/1138, PI07/0954, PI 07/0473, PI10/01407 and PI11/01647. CIBERobn and RTIC RD 06/0045 are initiatives of ISCIII, Spain. RT is supported by a Rio-Hortega post-residency fellowship of the Instituto de Salud Carlos III, Spanish Government. ; Peer reviewed

[Abstract] Introduction: Physical activity (PA) is essential to healthy mental and physical development in early life. However, the prevalence of physical inactivity, which is considered a key modifiable driver of childhood obesity, has reached alarming levels among European youth. There is a need to update the data for Spain, in order to establish if current measures are effective or new approaches are needed. Methods and analysis: We present the protocol for Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS). This observational, nationally representative, multicentre study aims to determine the PA levels, sedentary behaviours and prevalence of physical inactivity (defined as <60 min of moderate to vigorous PA per day) in a representative sample of Spanish children and adolescents. The PASOS study has recruited a representative random sample of children and adolescents aged 8–16 years from 242 educational centres in the 17 'autonomous regions' into which Spain is divided. The aim is to include a total of 4508 youth participants and their families. Weight, height and waist circumference will be measured by standardised procedures. Adherence to the Mediterranean diet, quality of life, sleep duration, PA and sedentary behaviour are being measured by validated questionnaires. PA is measured by the Physical Activity Unit 7-item Screener. A representative subsample (10% of participants) was randomly selected to wear accelerometers for 9 days to obtain objective data on PA. Parents are asked about their educational level, time spent doing PA, diet quality, self-perceived stress, smoking habit, weight, height, their child's birth weight and if the child was breast fed. ; PASOS study has been funded mainly by Fundación PROBITAS and Gasol Foundation. Additional funds were received from the Barça Foundation, Banco Santander, IFA, Viena and Fundación Deporte Jóven. MMB is funded by the official funding agency for biomedical research of the Spanish government, Institute of Health Carlos III (ISCIII), which is cofunded by the European Regional Development Fund (CIBEROBN CB12/03/30038), grant of support to research groups number 35/2011 (Balearic Islands Gov) and EU COST Action CA16112. PASOS has the institutional support of Spain's Ministry of Education and Vocational Training, the Ministry of Health, Consumption and Social Welfare through the Spanish Agency for Food Safety and Nutrition (ASEAN), the High Commission against Child Poverty, the High Sports Council, the General College of Professional Associations of Physical Education and Sports, and the Departments of Education and/or Health and/or Sports of Spain's 17 autonomous regions. The CIBERESP and the CIBEROBN are initiatives of the Institute of Health Carlos III, Madrid, Spain. ; Gobierno de las Islas Baleares; 35/2011 ; European Cooperation in Science and Technology; CA16112

[Abstract] The aim of this study is to evaluate if screen time and parents' education levels are associated with adherence to a Mediterranean dietary pattern. This cross-sectional study analyzed a representative sample of 3333 children and adolescents (8 to 16 years) included in the Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS) study in Spain (which ran from March 2019 to February 2020). Data on screen time (television, computer, video games, and mobile phone) per day, Mediterranean diet adherence, daily moderate or vigorous physical activity, and parents' education levels were gathered using questionnaires. A descriptive study of the variables according to sex and parents' education level was performed. Logistic regression models (adjusted by sex and weight status) were fitted to evaluate the independent association between screen time and Kids' level of adherence to the Mediterranean diet (KIDMED) index, as well as some of its items. A greater amount of screen time was associated with worse adherence to the Mediterranean diet; a lower consumption of fruit, vegetables, fish, legumes, and nuts; and a greater consumption of fast food, sweets, and candies. A lower parents' education level was associated with worse adherence to the Mediterranean diet. It is necessary to promote the responsible, limited use of screen time, especially in children with parents with a lower education level. ; The PASOS study was funded by Fundación PROBITAS and the Gasol Foundation. Additional funds were received from the Barça Foundation, Banco Santander, IFA, Vienna and the Fundación Deporte Jóven. J.A.T. and M.M.B. are funded by the official funding agency for biomedical research of the Spanish government, the Institute of Health Carlos III (ISCIII), which is co-funded by the European Regional Development Fund (CIBEROBN CB12/03/30038).

The online version contains supplementary material available at https://doi.org/10.1186/s12966-021-01169-w Additional file 1 Supplementary Table 1.Characteristics of the validation study participants and the remaining participants of the population-based PASOS cohort. Additional file 2 Supplementary Table 2.Correlation coefficients and between-method agreement of moderate to vigorous physical activity measurements derived by the Physical Activity Unit 7-item screener, non-calibrated and calibrated, and the reference method (accelerometer),stratified by age ; [Abstract] Background Validation of self-reported tools, such as physical activity (PA) questionnaires, is crucial. The aim of this study was to determine test-retest reliability, internal consistency, and the concurrent, construct, and predictive validity of the short semi-quantitative Physical Activity Unit 7 item Screener (PAU-7S), using accelerometry as the reference measurement. The effect of linear calibration on PAU-7S validity was tested. Methods A randomized sample of 321 healthy children aged 8–16 years (149 boys, 172 girls) from the nationwide representative PASOS study completed the PAU-7S before and after wearing an accelerometer for at least 7 consecutive days. Weight, height, and waist circumference were measured. Cronbach alpha was calculated for internal consistency. Test-retest reliability was determined by intra-class correlation (ICC). Concurrent validity was assessed by ICC and Spearman correlation coefficient between moderate to vigorous PA (MVPA) derived by the PAU-7S and by accelerometer. Concordance between both methods was analyzed by absolute agreement, weighted kappa, and Bland-Altman statistics. Multiple linear regression models were fitted for construct validity and predictive validity was determined by leave-one-out cross-validation. Results The PAU-7S overestimated MVPA by 18%, compared to accelerometers (106.5 ± 77.0 vs 95.2 ± 33.2 min/day, respectively). A Cronbach alpha of 0.76 showed an acceptable internal consistency of the PAU-7S. Test-retest reliability was good (ICC 0.71 p < 0.001). Spearman correlation and ICC coefficients of MVPA derived by the PAU-7S and accelerometers increased from 0.31 to 0.62 and 0.20 to 0.62, respectively, after calibration of the PAU-7S. Between-methods concordance improved from a weighted kappa of 0.24 to 0.50 after calibration. A slight reduction in ICC, from 0.62 to 0.60, yielded good predictive validity. Multiple linear regression models showed an inverse association of MVPA with standardized body mass index (β − 0.162; p < 0.077) and waist to height ratio (β − 0.010; p < 0.014). All validity dimensions were somewhat stronger in boys compared to girls. Conclusion The PAU-7S shows a good test-retest reliability and acceptable internal consistency. All dimensions of validity increased from poor/fair to moderate/good after calibration. The PAU-7S is a valid instrument for measuring MVPA in children and adolescents. ; PASOS study has been funded mainly by Fundación PROBITAS and Gasol Foundation. Additional funds were received from the Barça Foundation, Banco Santander, Grupo IFA, Viena and Fundación Deporte Jóven, grant of support to research groups number 35/2011 (Balearic Islands Gov) and EU COST Action CA16112. J.A.T. and M.M.B. are funded by the official funding agency for biomedical research of the Spanish government, Institute of Health Carlos III (ISCIII), which is cofunded by the 333 European Regional Development Fund (CIBEROBN CB12/03/30038). PASOS has the institutional support of Spain's Ministry of Education and Vocational Training, the Ministry of Health, Consumption and Social Welfare through the Spanish Agency for Food Safety and Nutrition (ASEAN), the High Commission against Child Poverty, the High Sports Council, the General College of Professional Associations of Physical Education and Sports, and the Departments of Education and/or Health and/or Sports of Spain's 17 autonomous regions. The CIBERESP and the CIBEROBN are initiatives of the Institute of Health Carlos III, Madrid, Spain. ; Gobierno de las Islas Baleares; 35/2011 ; European Cooperation in Science and Technology; CA16112

The aim of this study is to evaluate if screen time and parents' education levels are associated with adherence to a Mediterranean dietary pattern. This cross-sectional study analyzed a representative sample of 3333 children and adolescents (8 to 16 years) included in the Physical Activity, Sedentarism, lifestyles and Obesity in Spanish youth (PASOS) study in Spain (which ran from March 2019 to February 2020). Data on screen time (television, computer, video games, and mobile phone) per day, Mediterranean diet adherence, daily moderate or vigorous physical activity, and parents' education levels were gathered using questionnaires. A descriptive study of the variables according to sex and parents' education level was performed. Logistic regression models (adjusted by sex and weight status) were fitted to evaluate the independent association between screen time and Kids' level of adherence to the Mediterranean diet (KIDMED) index, as well as some of its items. A greater amount of screen time was associated with worse adherence to the Mediterranean diet; a lower consumption of fruit, vegetables, fish, legumes, and nuts; and a greater consumption of fast food, sweets, and candies. A lower parents' education level was associated with worse adherence to the Mediterranean diet. It is necessary to promote the responsible, limited use of screen time, especially in children with parents with a lower education level. ; The PASOS study was funded by Fundación PROBITAS and the Gasol Foundation. Additional funds were received from the Barça Foundation, Banco Santander, IFA, Vienna and the Fundación Deporte Jóven. J.A.T. and M.M.B. are funded by the official funding agency for biomedical research of the Spanish government, the Institute of Health Carlos III (ISCIII), which is co-funded by the European Regional Development Fund (CIBEROBN CB12/03/30038).

Background: Validation of self-reported tools, such as physical activity (PA) questionnaires, is crucial. The aim of this study was to determine test-retest reliability, internal consistency, and the concurrent, construct, and predictive validity of the short semi-quantitative Physical Activity Unit 7 item Screener (PAU-7S), using accelerometry as the reference measurement. The effect of linear calibration on PAU-7S validity was tested. Methods: A randomized sample of 321 healthy children aged 8–16 years (149 boys, 172 girls) from the nationwide representative PASOS study completed the PAU-7S before and after wearing an accelerometer for at least 7 consecutive days. Weight, height, and waist circumference were measured. Cronbach alpha was calculated for internal consistency. Test-retest reliability was determined by intra-class correlation (ICC). Concurrent validity was assessed by ICC and Spearman correlation coefficient between moderate to vigorous PA (MVPA) derived by the PAU-7S and by accelerometer. Concordance between both methods was analyzed by absolute agreement, weighted kappa, and Bland-Altman statistics. Multiple linear regression models were fitted for construct validity and predictive validity was determined by leave-one-out cross-validation. ; PASOS study has been funded mainly by Fundación PROBITAS and Gasol Foundation. Additional funds were received from the Barça Foundation, Banco Santander, Grupo IFA, Viena and Fundación Deporte Jóven, grant of support to research groups number 35/2011 (Balearic Islands Gov) and EU COST Action CA16112. J.A.T. and M.M.B. are funded by the official funding agency for biomedical research of the Spanish government, Institute of Health Carlos III (ISCIII), which is cofunded by the 333 European Regional Development Fund (CIBEROBN CB12/03/30038). PASOS has the institutional support of Spain's Ministry of Education and Vocational Training, the Ministry of Health, Consumption and Social Welfare through the Spanish Agency for Food Safety and Nutrition (ASEAN), the High Commission against Child Poverty, the High Sports Council, the General College of Professional Associations of Physical Education and Sports, and the Departments of Education and/or Health and/or Sports of Spain's 17 autonomous regions. The CIBERESP and the CIBEROBN are initiatives of the Institute of Health Carlos III, Madrid, Spain.

This study cross-sectionally examines in the elderly population: (a) the association of type 2 diabetes with executive function (EF); (b) the effect of BMI on both type 2 diabetes and EF; (c) the association between glycaemia control and EF in type 2 diabetes. 6823 older individuals with overweight/obesity and metabolic syndrome participating in the PREDIMED-PLUS study, were assessed with a battery of cognitive tests and a medical interview. ANOVA showed a significantly worse performance on EF in type 2 diabetes vs. non-diabetic individuals. Two complementary models were displayed: (1) in the whole sample, the presence of type 2 diabetes, depressive symptoms and BMI had a direct negative effect on EF, while apnoea had an indirect negative effect; (2) in the diabetes subsample, higher illness duration was associated with worse performance in EF. Participants with type 2 diabetes and HbA1c<53 mmol/mol displayed better cognitive performance when compared to those with HbA1c≥53 mmol/mol. Our results provide a controlled comprehensive model that integrates relevant neuropsychological and physical variables in type 2 diabetes. The model suggests that, to improve treatment adherence and quality of life once diabetes has been diagnosed, cognitive decline prevention strategies need to be implemented while monitoring depressive symptoms, BMI and glycaemia control. ; This project is funded by Instituto de Salud Carlos III (ISCIII), the Spanish Government Official Agency for funding biomedical research - with competitive grants for the periods 2014–2016, 2015–2017, 2017–2019 and 2018–2020, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund [grants: PI13/00673, PI13/00492, PI13/00272, PI13/01123, PI13/00462, PI13/00233, PI13/02184, PI13/00728 PI13/01090 PI13/01056, PI14/01722, PI14/00636, PI14/00618, PI14/00696, PI14/01206, PI14/01919, PI14/00853, PI14/01374, PI16/00473, PI16/00662, PI16/01873, PI16/01094, PI16/00501, PI16/00533, PI16/00381, PI16/00366, PI16/01522, PI16/01120, PI17/00764, PI17/01183, PI17/00855, PI17/01347, PI17/00525, PI17/01827, PI17/00532, PI17/00215, PI17/01441, PI17/00508, PI17/01732, PI17/00926] and the European Research Council [Advanced Research Grant 2014–2019; agreement #340918]. Additional grants: Acciones Especiales from ISCIIII, Consejería-Salud, Junta -Andalucía [PI0458/2013, PS0358/2016], Recercaixa-grant 2013 [2013ACUP00194], a SEMERGEN grant, International Nut & Dried Fruit Council – FESNAD No. 201302. Fundación Patrimonio Comunal Olivarero is providing the necessary amounts of olive oil. Nuts were initially and only partially provided by Pistachios Growers and Almond Board of California, for the pilot study. This research was also partially funded by EU-H2020 Grant (Eat2beNICE/H2020-SFS-2016–2; Ref 728018), PI14/00290 y PI17/1167(Co-funded by European Regional Development Fund, ERDF, a way to build Europe), PERIS (Generalitat de Catalunya, SLT006/17/00077), Grant PROMETEO/2017/017 (Generalitat Valenciana) and Grant FEA/SEA 2017 for Primary Care Research. We thank CERCA Programme/Generalitat de Catalunya for institutional support. ML-M is supported by a predoctoral Grant of the Ministerio de Educación, Cultura y Deporte (FPU15/02911). None of these funding sources plays any role in the design, collection, analysis, or interpretation of the data or in the decision to submit manuscripts for publication

© 2020 by the authors. ; The main objective of this study was to examine the relationship between the level of physical activity (PA) and the degree of obesity with health-related quality of life (HRQoL) in individuals with metabolic syndrome (MetS) who participated in the Predimed-Plus study. A total of 6875 subjects between 55 and 75 years of age with MetS were selected and randomized in 23 Spanish centers. Subjects were classified according to categories of body mass index (BMI). PA was measured with the validated Registre Gironí del Cor (REGICOR) questionnaire and subjects were classified according to their PA level (light, moderate, vigorous) and the HRQoL was measured with the validated short-form 36 (SF-36) questionnaire. By using the ANOVA model, we found a positive and statistically significant association between the level of PA and the HRQoL (aggregated physical and mental dimensions p < 0.001), but a negative association with higher BMI in aggregated physical dimensions p < 0.001. Furthermore, women obtained lower scores compared with men, more five points in all fields of SF-36. Therefore, it is essential to promote PA and body weight control from primary care consultations to improve HRQoL, paying special attention to the differences that sex incurs ; The Predimed-Plus trial was supported by the Spanish government's official funding agency for biomedical research, ISCIII, through the Fondo de Investigación para la Salud (FIS), which is co-funded by the European Regional Development Fund (three coordinated FIS projects led by Jordi Salas-Salvadó and Josep Vidal, including the following projects: PI13/00673, PI13/00492, PI13/00272, PI13/01123, PI13/00462, PI13/00233, PI13/02184, PI13/00728, PI13/01090, PI13/01056, PI14/01722, PI14/0147, PI14/00636, PI14/00972, PI14/00618, PI14/00696, PI14/01206, PI14/01919, PI14/00853, PI14/01374, PI16/00473, PI16/00662, PI16/01873, PI16/01094, PI16/00501, PI16/00533, PI16/00381, PI16/00366, PI16/01522, PI16/01120, PI17/00764, PI17/01183, PI17/00855, PI17/01347, PI17/00525, PI17/01827, PI17/00532, PI17/00215, PI17/01441, PI17/00508, PI17/01732, PI17/00926, PI19/00957, PI19/00386, PI19/00309, PI19/01032, PI19/00576, PI19/00017, PI19/01226, PI19/00781, PI19/01560, PI19/01,332), the Special Action Project entitled: Implementación y evaluación de una intervención intensiva sobre la actividad física Cohorte PREDIMED-PLUS grant to Jordi Salas-Salvadó, the European Research Council (Advanced Research Grant 2013–2018; 340918) grant to Miguel Ángel Martínez-Gonzalez, the Recercaixa grant to Jordi Salas-Salvadó (2013ACUP00194), grants from the Consejería de Salud de la Junta de Andalucía (PI0458/2013; PS0358/2016; PI0137/2018), the PROMETEO/2017/017 grant from the Generalitat Valenciana, the SEMERGEN grant and FEDER funds (CB06/03 and CB12/03), Olga Castaner is funded by the JR17/00,022 grant, ISCIII. Christopher Papandreou is supported by a postdoctoral fellowship granted by the Autonomous Government of Catalonia (PERIS 2016–2020 Incorporació de Científics i Tecnòlegs, SLT002/0016/00,428). María Rosa Bernal-Lopez was supported by "Miguel Servet Type I" program (CP15/00028) from the ISCIII-Madrid (Spain), cofinanced by the Fondo Europeo de Desarrollo Regional-FEDER, Ignacio M.Giménez-Alba is supported by a FPU predoctoral contract (reference FPU18/01703) from the Ministerio de Ciencia, Innovación y Universidades, Spain. ; Peer reviewed