Lifestyle Behaviours in Pre-Schoolers from Southern Spain—A Structural Equation Model According to Sex and Body Mass Index

Ci a ion: Villod es, G.C.; Padial-Ruz, R.; Salas-Mon o o, J.-A.; Mu os, J.J. Li es yle Beha iou s in P e-Schoole s om Sou he n Spain—A S uc u al Equa ion Model Acco ding o Sex and Body Mass Index. Nu ien s 2024,16, 3582. h ps://doi.o g/10.3390/ nu16213582 Academic Edi o s: Ja ie Gómez- Amb osi and Ahmad Alkha ib Recei ed: 11 Sep embe 2024 Re ised: 14 Oc obe 2024 Accep ed: 21 Oc obe 2024 Published: 22 Oc obe 2024 Copy igh : © 2024 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). nu ien s A icle Li es yle Beha iou s in P e-Schoole s om Sou he n Spain—A S uc u al Equa ion Model Acco ding o Sex and Body Mass Index G acia C is ina Villod es 1, Rosa io Padial-Ruz 1, José-An onio Salas-Mon o o 2and JoséJoaquín Mu os 1,* 1Depa men o Didac ics o Co po al Exp ession, Facul y o Educa ion, Uni e si y o G anada, 18071 G anada, Spain; gc illod es@ug .es (G.C.V.); padial@ug .es (R.P.-R.) 2Depa men o Physical Educa ion and Spo s, Facul y o Spo s Sciences, Uni e si y o G anada, 18071 G anada, Spain; salasmon o o@ug .es *Co espondence: jjmu os@ug .es; Tel.: +34-958246350 Abs ac : Objec i es: The p esen s udy aimed o examine he ela ionship be ween sc een ime (ST), sleep ime (SLT), physical i ness (PF), Medi e anean die (MD) adhe ence, ea ing beha iou s, and body mass index (BMI) in a sample o p e-schoole s om G anada (Spain). In o de o add ess his aim, an explana o y model was de eloped o examine exis ing ela ionships be ween ST, SLT, PF, MD, p o-in ake (PRO-I) and an i-in ake (ANT-I) beha iou s, and BMI. Fu he , he p oposed s uc u al model was examined ia mul i-g oup analysis as a unc ion o sex and BMI. Me hods: A c oss- sec ional s udy was conduc ed wi h 653 h ee- o six-yea -old p e-schoole s a ending 18 di e en schools in i ed o ake pa in he p esen s udy. S uc u al equa ion modelling (SEM) was employed o analyse ela ionships be ween s udy a iables as a unc ion o sex and BMI. Resul s: SEM analysis e ealed nega i e associa ions be ween ST and PF (p< 0.005), ST and MD adhe ence ( p< 0.0 05), ST and SLT (p< 0.005), MD adhe ence and ANT-I beha iou s (p< 0.005), and MD adhe ence and BMI (p= 0.033). In con as , posi i e associa ions eme ged be ween SLT and MD adhe ence (p< 0.005), and PRO-I beha iou s and BMI (p< 0.005). SEM e ealed di e ences acco ding o sex and BMI. Conclusions: The s udy highligh s signi ican ela ionships be ween li es yle beha iou s and physical and die a y ou comes in p e-schoole s om sou he n Spain, wi h a ia ions based on sex and BMI. These indings sugges he need o in e en ions aimed a educing ST and p omo ing be e sleep, PF, and die a y habi s in o de o limi weigh - ela ed and gene al heal h isks in p e-schoole s om sou he n Spain. Keywo ds: sc een ime; sleep ime; physical i ness; Medi e anean die ; ea ing beha iou s; body mass index; childhood 1. In oduc ion Obesi y is a ch onic and complex condi ion cha ac e ised by excessi e a accumula- ion ha can nega i ely impac heal h. I can in luence quali y o li e, including aspec s such as sleep and mobili y. Likewise, obesi y is associa ed wi h inc eased isk o ype 2 diabe es, hea disease, and ce ain cance s, and may a ec bone heal h and ep oduc ion. Addi ionally, childhood obesi y con e s majo isks o excess and p ema u e mo bidi y and mo ali y in bo h sexes [ 1 ]. This is suppo ed by he Wo ld Heal h O ganiza ion (WHO) [ 2 ], which also epo ed in 2022 ha 37 million child en unde he age o i e we e o e weigh . In Spain, in 2020, one in h ee child en be ween wo and 17 yea s old was o e weigh , whils one in en was obese [ 3 ]. Mo eo e , he mos ecen da a ga he ed by he ALADINO s udy in 2019 [ 4 , 5 ] e eal ha 23.3% o Spanish schoolchild en a e conside ed o e weigh , whils 17.3% a e conside ed obese. This means ha a o al o 40.6% o he child popula ion is a ec ed by excess bodyweigh . Gi ls a e mo e likely o be o e weigh (24.7%) han boys (21.9%), whils he p e alence o obesi y is no ably highe in boys (19.4%) han in gi ls Nu ien s 2024,16, 3582. h ps://doi.o g/10.3390/nu16213582 h ps://www.mdpi.com/jou nal/nu ien s Nu ien s 2024,16, 3582 2 o 20 (15.0%). When compa ed wi h o he na ions co e ed by he COSI s a egy, Spain anks second wi h ega ds o p e alence o excess weigh and six h wi h ega ds o obesi y p e a- lence [ 6 ]. Fu he , acco ding o he PASOS s udy [ 7 ], 33.4% o he adolescen popula ion is o e weigh o obese. These s a is ics unde line he u gency o add essing his issue in Spain, making i necessa y o in e ene om an ea ly age, including wi h he p e-school popula ion, and cu bing he ise in o e weigh and obesi y du ing he school yea s and h oughou adolescence. Excess weigh , along wi h he ch onic non-communicable diseases associa ed wi h i , is la gely p e en able. I is c ucial o unde s and he scale o his issue and he ac o s ha con ibu e o i . This knowledge is essen ial o he design, implemen a ion, and e alua ion o s a egies and in e en ions aimed a mi iga ing his p oblem [ 5 ]. The main cause o childhood obesi y is ene gy imbalance in which ene gy in ake su passes ene gy expendi u e, wi h gene ics also playing a signi ican ole ega ding p edisposi ion owa ds weigh gain [ 8 ]. Ne e heless, o mos obese child en, weigh gain canno be a ibu ed o a single gene ic o endoc ine ac o [ 9 ]. This sugges s ha li es yle ac o s a e he dominan con ibu o s o he ea ly de elopmen o obesi y. A sys ema ic e iew and me a-analysis by Poo olajal e al. [ 10 ] indica ed ha ac o s associa ed wi h highe childhood body mass index (BMI) we e insu icien physical ac i i y, poo die , inadequa e sleep, and engaging in mo e han wo hou s o sc een ime pe day. Limi ing sc een ime (ST) (<1 h), adequa e sleep du a ion (SLT) (10–13 h), good physical i ness (PF) (adequa e ca dio espi a o y capaci y, s eng h, speed/agili y and balance, and adequa e Medi e anean die (MD) adhe ence ( ui s, ege ables, whole g ains, legumes, nu s, oli e oil and lean p o eins, pa icula ly ish, and limi ed p ocessed oods) play a c ucial ole in o e all quali y o li e in child en [ 11 – 13 ]. Fu he , highe MD adhe ence, physical ac i i y engagemen , and good PF a e associa ed wi h a hea hy weigh s a us in child en [14]. In con as , dec eased physical ac i i y and inc eased seden a y beha iou a e wo o he main ac o s ha ha e con ibu ed o he ise in obesi y [ 15 ]. Speci ically in Spain, i has been obse ed ha 26.3% o schoolchild en spend wo hou s o mo e wa ching TV o using elec onic de ices du ing he week, wi h his being ue o 75.4% o schoolchild en on weekends [ 4 ]. This inc ease in ST may be associa ed wi h g ea e educ ions in SLT, wi h one in h ee child en unde i e yea s o age epo ed o ha e poo sleep quali y a nigh [ 16 ]. A he same ime, only 37.1% o Spanish schoolchild en consume esh ui daily, and jus 13.4% ea ege ables e e y day. Mo eo e , 53.9% consume pas ies, comme cial juices, o milkshakes as pa o hei b eak as s. Also o conce n is he equen consump ion o ce ain oods ha should only be pa o a schoolchild’s die occasionally, such as biscui s, cakes, o pas ies, wi h 25.3% o schoolchild en epo ing ea ing such oods mo e han ou imes a week [4]. In ligh o he ac o s discussed abo e, p e-schoole ’s ST is nega i ely associa ed wi h hei consump ion o ege ables and ui s, and posi i ely associa ed wi h hei consump- ion o snacks and suga y d inks [ 17 ]. In his sense, insu icien physical ac i i y and excessi e ST in his popula ion ha e been ound o be linked wi h less heal hy pa e ns o ood and be e age consump ion [ 18 ]. Fu he , Spanish child en aged h ee o we l e yea s wi h mo e seden a y li es yle ha e also been epo ed o exhibi sho e du a ion and poo e quali y sleep, lowe MD adhe ence, and poo e PF, wi h such child en also ha ing a less heal hy weigh [ 19 , 20 ]. In his ega d, due o he ise in new echnologies, child en can easily be a ac ed o echnological de ices, leading hem o engage in mo e seden a y beha iou and less physical ac i i y, which in u n causes hem o miss oppo uni ies o de eloping PF. Socially, his beha iou is o en accompanied by he consump ion o unheal hy snacks [ 17 ], which can ha e a nega i e in luence on child en’s BMI and isk o being o e weigh o obese. Wi h ega ds o ea ing habi s, no only is i necessa y o ollow a heal hy die bu , also, ood p e e ences play a signi ican ole a his s age. Ea ing beha iou s a e o med in he ea ly yea s o childhood; howe e , such beha iou s can e ol e o e ime based on Nu ien s 2024,16, 3582 3 o 20 indi idual expe iences [ 21 ]. Jimeno-Ma ínez e al. [ 22 ] epo ed ha Spanish p e-schoole s wi h a highe BMI epo ed highe p o-in ake (PRO-I) sco es, speci ically wi h ega ds o he “ ood esponsi eness”, “emo ional o e ea ing”, and “enjoymen o ood” subscales. Fu he , highe ST and sho e SLT a e associa ed wi h poo e ea ing beha iou s such as “mindless ea ing” o he inclina ion owa ds “ ewa d oods” [ 23 , 24 ]. Along he same lines, p e- schoole s wi h highe an i-in ake (ANT-I) beha iou s epo ed lowe ish consump ion and mo e equen ly consumed as ood [ 25 ], hus mo ing away om adequa e MD adhe ence. Mo eo e , exis ing s udies highligh he impo ance o di e en ia ing in e en ion ac o s as a unc ion o sex and BMI and o conside ing he sociocul u al di e ences a play [ 26 ]. In his sense, wi h ega ds o sex di e ences in child en, boys gene ally spend mo e ime playing ideo games, whils gi ls engage mo e wi h social media and passi e en e ainmen [ 27 ]. Gi ls also end o ha e s ic e sleep ou ines, leading o be e sleep quali y, whe eas boys o en use sc eens la e a nigh , esul ing in sho e and poo e sleep [ 28 ]. In he case o physical i ness, boys a e mo e in ol ed in compe i i e spo s, whils gi ls lean owa ds non-compe i i e ac i i ies such as dance, wi h his end being la gely in luenced by social ba ie s [ 29 ]. Wi h ega ds o die a y habi s, gi ls ypically choose heal hie oods and exhibi be e emo ional con ol, whe eas boys a e mo e likely o consume unheal hy snacks [30]. Simila ly, ega ding BMI di e ences in child en, compa ed o hose wi h a heal hy BMI, child en wi h a highe BMI end o ha e mo e ST, cha ac e ised by high ideo games and passi e en e ainmen use [ 31 ]. An unheal hy BMI is also linked o sho e and poo e quali y sleep due o inc eased ST be o e bed, whe eas child en wi h a heal hy BMI engage in mo e egula and be e sleep [ 32 ]. Wi h ega ds o PF, child en wi h a heal hy BMI a e mo e likely o engage in igo ous ac i i ies and belong o spo s clubs, whils hose wi h an unheal hy BMI end o be mo e seden a y [ 33 ]. In e ms o die , child en wi h a heal hy BMI consume mo e ui s, ege ables, and MD s aples, whils hose wi h an unheal hy BMI a ou p ocessed oods and suga y d inks, and exhibi mo e emo ional ea ing beha iou s [34]. In physiological e ms, posi i e co ela ions ha e been demons a ed be ween BMI and iglyce ides (TG) and low-densi y lipop o ein choles e ol (LDL-C) om as ea ly as h ee yea s old [35] . Consequen ly, BMI co ela es wi h u u e obesi y isk and me abolic issues such as insulin esis ance and dyslipidaemia [ 36 ]. Fu he , p e ious s udies ha e shown ha a BMI classi ied as o e weigh (abo e he 85 h pe cen ile) o obese (95 h pe cen ile) in ea ly childhood is linked wi h a accumula ion, wais ci cum e ence, and adiposi y [ 37 ], making i a use ul p edic o e en when body composi ion canno be di ec ly measu ed. Addi ionally, BMI is easily measu ed, making i a use ul a iable o la ge-scale s udies. I is also especially impo an du ing he p e-school yea s, as i can p edic u u e weigh ajec o ies [ 38 ] and highligh he need o ea ly in e en ion. A mo e ac i e li es yle adop ed in he i s yea s o li e o en pe sis s in o la e li e, making he pe iod be ween h ee o six yea s o age c i ical o beginning o es ablish a heal hy li es yle [ 38 ]. Despi e his, p e-schoole s ha e been less ex ensi ely s udied han olde age g oups when i comes o he heal h impac o ce ain li es yle habi s [ 39 ]. This is p ima ily due o challenges associa ed wi h assessing his popula ion and es ic ed access o po en ial pa icipan s, pa icula ly in heal h- ela ed a eas, such as pa en al con- ce ns a ound educa ion, pa icipa ion bu den, lack o us , gene al esea ch conce ns, in o ma ional- and consen - ela ed challenges, and ela ional issues [ 40 ]. These challenges mus , he e o e, be o e come in o de o be e examine his popula ion. The opic add essed by he manusc ip has been widely s udied, howe e , no p e ious s udies ha e examined he wide se o po en ial li es yle de e minan s oge he . This includes ea ing beha iou s, wi h a ele an ques ionnai e being ecen ly adap ed o use wi h Spanish samples [ 22 ], al hough i s applica ion o p e-schoole s is highly inno a i e. Ano he ques ion o add ess is whe he ela ionships exis be ween heal hy li es yle habi s and BMI a such ea ly ages and whe he sex plays a ole. Based on he exis ing li e a u e, an al e na i e hypo hesis o he p esen s udy is ha , om e y ea ly ages, ela ionships Nu ien s 2024,16, 3582 4 o 20 eme ge be ween heal hy li es yle habi s and BMI and, consequen ly, heal h. Likewise, i is expec ed ha sex will impac his ela ionship. Thus, he p esen s udy aimed o examine he ela ionship be ween ST, SLT, PF, and MD adhe ence, ea ing beha iou s, and BMI in a sample o p e-schoole s om G anada, Spain. In o de o add ess his aim, an explana o y model was de eloped o examine exis ing ela ionships be ween ST, SLT, PF, MD, ANT-I and PRO-I, and BMI. Fu he , he p oposed s uc u al model was examined ia mul i-g oup analysis as a unc ion o sex and BMI. 2. Ma e ials and Me hods 2.1. Pa icipan s A c oss-sec ional s udy was designed. A sample o 653 p e-schoole s aged h ee o six yea s was ec ui ed o he s udy. A o al o 2250 child en om 18 schools (G anada, Spain) we e in i ed o ake pa in he p esen s udy be ween Ap il 2023 and Ap il 2024. Pa icipa ing schools we e selec ed h ough con enience due o hem being easy o access. In o al, 336 gi ls (51.5%) and 317 boys (48.5%) wi h an a e age age o 4.78 yea s ± 0.93 yea s pa icipa ed in he s udy. The main inclusion c i e ion e e ed o p e-school child en who do no su e om ood alle gies o physical o psychia ic condi ions. In o de o add ess his, he s a emen “obse a ions” was included a he end o he ques ionnai e, in i ing open esponses and enabling pa en s o disclose in o ma ion ega ding any physical, psychia ic, o die a y condi ions ha could a ec ou comes. No pa en s esponded o his ques ion, sugges ing ha no pa icipan s ell in o his ca ego y. 2.2. P ocedu e The ec ui men s a egy is p esen ed in Figu e 1. In o de o access he s udy a ge popula ion o p e-school child en, 30 schools we e selec ed which had a p e-exis ing ela ionship wi h esea che s. O hese 30 schools, di ec o s a 12 schools declined o pa icipa e. A e ecei ing pe mission om 18 schools (n= 2250), in o med consen was eques ed om he pa en s o legal gua dians o he child en belonging o each o he schools. In his way, pa en s we e in o med abou he s udy aims, design, and p ocedu e. Following he eceip o w i en in o med consen (n= 653), a ques ionnai e was sen ou o olun a y comple ion by pa en s o legal gua dians on behal o hei child en. The Google D i e ® applica ion (Alphabe , Moun ain View, CA, USA) was used. E hical p inciples o he Decla a ion o Helsinki o Medical Resea ch we e ollowed, and e hical app o al was g an ed by he E hics Commi ee o he Uni e si y o G anada 2794/CEIH/2022. 2.3. Ins umen s The la es e sion o he Medi e anean Die Quali y Index (KIDMED) was used o e alua e child en’s MD adhe ence [ 41 ]. This comp ises a o al o 16 i ems which can ass bina y esponses (“yes” o “no”). Fou i ems a e nega i ely amed, and so posi i e esponses a e sco ed as − 1. Con e sely, he emaining i ems a e posi i ely amed, wi h a i ma i e esponses being sco ed as +1 and nega i e esponses ecei ing a sco e o 0. As a esul , po en ial o e all inal sco es ange om −4 o 12. PF was e alua ed using he la es Spanish edi ion o he In e na ional Fi ness Scale (IFIS) [ 42 ]. This ques ionnai e comp ises i e i ems, wi h each being measu ed on a i e-poi n scale anging om 1 ( e y poo ) o 5 ( e y good). I ems assess essen ial aspec s o sel -pe cei ed i ness (1: ca dio espi a o y i ness; 2: muscula i ness; 3: speed-agili y; 4: balance; and 5: o e all PF). Indi idual sco es o each i em a e summed o p oduce an o e all i ness sco e. An a e age sco e is calcula ed om he i e i ems o ob ain an o e all es sco e. The la es Spanish edi ion o he Child Ea ing Beha iou Ques ionnai e (CEBQ) was employed o e alua e child en’s ea ing beha iou s [ 22 , 43 ]. This comp ises a o al o 36 i ems ha a e a ed along a i e-poin Like scale. I ems can be g ouped in o wo dimensions, namely, p o-in ake (PRO-I) and an i-in ake (ANT-I). PRO-I e e s o ood esponsi eness, Nu ien s 2024,16, 3582 5 o 20 emo ional o e ea ing, enjoymen o ood, and desi e o d ink, whils ANT-I e e s o sa ie y esponsi eness, slowness in ea ing, emo ional unde ea ing, and ood ussiness. Nu ien s 2024, 16, x FOR PEER REVIEW 5 o 22 Figu e 1. Rec ui men s a egy. 2.3. Ins umen s The la es e sion o he Medi e anean Die Quali y Index (KIDMED) was used o e alua e child en’s MD adhe ence [41]. This comp ises a o al o 16 i ems which can ass bina y esponses (“yes” o “no”). Fou i ems a e nega i ely amed, and so posi i e e- sponses a e sco ed as −1. Con e sely, he emaining i ems a e posi i ely amed, wi h affi ma i e esponses being sco ed as +1 and nega i e esponses ecei ing a sco e o 0. As a esul , po en ial o e all inal sco es ange om −4 o 12. PF was e alua ed using he la es Spanish edi ion o he In e na ional Fi ness Scale (IFIS) [42]. This ques ionnai e comp ises i e i ems, wi h each being measu ed on a i e-poin scale anging om 1 ( e y poo ) o 5 ( e y good). I ems assess essen ial aspec s o sel -pe cei ed i ness (1: ca dio espi a o y i ness; 2: muscula i ness; 3: speed-agili y; 4: balance; and 5: o e all PF). Indi idual sco es o each i em a e summed o p oduce an o e all i ness sco e. An a e age sco e is calcula ed om he i e i ems o ob ain an o e - all es sco e. The la es Spanish edi ion o he Child Ea ing Beha iou Ques ionnai e (CEBQ) was employed o e alua e child en’s ea ing beha iou s [22,43]. This comp ises a o al o 36 i ems ha a e a ed along a i e-poin Like scale. I ems can be g ouped in o wo di- mensions, namely, p o-in ake (PRO-I) and an i-in ake (ANT-I). PRO-I e e s o ood e- sponsi eness, emo ional o e ea ing, enjoymen o ood, and desi e o d ink, whils ANT-I e e s o sa ie y esponsi eness, slowness in ea ing, emo ional unde ea ing, and ood ussiness. Sociodemog aphic da a we e collec ed h ough an ad hoc ques ionnai e. Pa en s epo ed hei child en’s sex, da e o bi h, heigh , and weigh . BMI was hen calcula ed Figu e 1. Rec ui men s a egy. Sociodemog aphic da a we e collec ed h ough an ad hoc ques ionnai e. Pa en s epo ed hei child en’s sex, da e o bi h, heigh , and weigh . BMI was hen calcula ed om heigh and weigh (BMI = weigh [kg]/(heigh [m]) 2 ). Age and sex s anda dized clas- si ica ions o heal hy weigh , o e weigh , and obese we e calcula ed in line wi h anking pe cen iles ou lined by Sob adillo e al. [ 44 ]. O e weigh and obese g oups we e combined due o he low pe cen age o child en epo ing being o e weigh (4.9%) and obese (6.3%). Child en’s pa en s epo ed he numbe o hou s o nigh ly sleep on weekdays and week- ends. Simila ly, wo i ems we e added o examine he numbe o hou s spen daily solely engaged in sc een-based leisu e ac i i ies (wa ching ele ision, playing ideo games, using a mobile phone, using a compu e , e c.) on weekdays and weekends. Hou s spen in on o he sc een in in-pe son o online classes we e no conside ed. O e all summa y sco es we e calcula ed om he mean numbe o hou s epo ed o e he se en days examined. 2.4. S a is ical Analysis Ca ego ical da a such as sex and BMI a e ep esen ed as pe cen ages. Mean and s an- da d de ia ions a e epo ed o all quan i a i e a iables. No mali y o he da a was es ed using he Kolmo o –Smi no es . A e e i ying ha da a we e no no mally dis ibu ed, he da a we e analysed using he Mann–Whi ney U es o compa e w o inde penden g oups. Associa ions be ween quan i a i e a iables we e examined acco ding o Spea - Nu ien s 2024,16, 3582 6 o 20 man co ela ions (p< 0.05). All s a is ical analyses we e pe o med using e sion 25 o IBM-SPSS ® o Windows. Then, s uc u al equa ion modelling (SEM) was pe o med using IBM AMOS ® 24.0 so wa e. SEM acili a es he es ablishmen o connec ions be ween a i- ables speci ied in a heo e ical model (Figu e 2). The model cons uc ed in he p esen s udy comp ised se en obse ed a iables. O hese, i e we e endogenous (PF, MD, ANT-I and PRO-I and IMC) and wo we e exogenous a iables (ST and SLT). Endogenous a iables a e ep esen ed wi hin he de eloped model alongside hei associa ed e o e ms, which a e illus a ed wi h a ci cle, whils exogenous a iables do no ha e associa ed e o e ms and a e depic ed ia wo-way a ows. SEM was employed o de e mine exis ing ela ionships be ween he a iables included in he heo e ical model as a unc ion o sex (boy/gi l) and BMI (heal hy weigh /o e weigh /obese). Nu ien s 2024, 16, x FOR PEER REVIEW 6 o 22 om heigh and weigh (BMI = weigh [kg]/(heigh [m]) 2 ). Age and sex s anda dized classi ica ions o heal hy weigh , o e weigh , and obese we e calcula ed in line wi h anking pe cen iles ou lined by Sob adillo e al. [44]. O e weigh and obese g oups we e combined due o he low pe cen age o child en epo ing being o e weigh (4.9%) and obese (6.3%). Child en’s pa en s epo ed he numbe o hou s o nigh ly sleep on weekdays and weekends. Simila ly, wo i ems we e added o examine he numbe o hou s spen daily solely engaged in sc een-based leisu e ac i i ies (wa ching ele ision, playing ideo games, using a mobile phone, using a compu e , e c.) on weekdays and weekends. Hou s spen in on o he sc een in in-pe son o online classes we e no con- side ed. O e all summa y sco es we e calcula ed om he mean numbe o hou s e- po ed o e he se en days examined. 2.4. S a is ical Analysis Ca ego ical da a such as sex and BMI a e ep esen ed as pe cen ages. Mean and s anda d de ia ions a e epo ed o all quan i a i e a iables. No mali y o he da a was es ed using he Kolmo o –Smi no es . A e e i ying ha da a we e no no mally dis ibu ed, he da a we e analysed using he Mann–Whi ney U es o compa e wo in- dependen g oups. Associa ions be ween quan i a i e a iables we e examined acco d- ing o Spea man co ela ions (p < 0.05). All s a is ical analyses we e pe o med using e sion 25 o IBM-SPSS ® o Windows. Then, s uc u al equa ion modelling (SEM) was pe o med using IBM AMOS ® 24.0 so wa e. SEM acili a es he es ablishmen o con- nec ions be ween a iables speci ied in a heo e ical model (Figu e 2). The model con- s uc ed in he p esen s udy comp ised se en obse ed a iables. O hese, i e we e endogenous (PF, MD, ANT-I and PRO-I and IMC) and wo we e exogenous a iables (ST and SLT). Endogenous a iables a e ep esen ed wi hin he de eloped model alongside hei associa ed e o e ms, which a e illus a ed wi h a ci cle, whils exogenous a ia- bles do no ha e associa ed e o e ms and a e depic ed ia wo-way a ows. SEM was employed o de e mine exis ing ela ionships be ween he a iables included in he he- o e ical model as a unc ion o sex (boy/gi l) and BMI (heal hy weigh /o e weigh /obese). Figu e 2. S uc u al equa ion model. No e: ST: sc een ime; SLT: sleep ime; PF: physical i ness; MD: Medi e anean die ; ANT-I: an i-in ake; PRO-I: p o-in ake; BMI: body mass index; E1–E5: e o e ms. In o de o de e mine he ex en o which he s uc u al equa ion model (SEM) aligns wi h he obse ed da a, se e al indices we e u ilized o assess model adequacy. Model i should p ima ily be e alua ed acco ding o chi-squa e, wi h a non-signi ican p- alue sugges ing good i . Howe e , By ne [ 45 ] a gues ha his s a is ic can be hea ily impac ed by sample size and so addi ional i indices should also be conside ed. To his end, compa - a i e i (CFI), inc emen al i (IFI), no malized i (NFI), and Tucke –Lewis (TLI) indices we e calcula ed. Fo model i o be deemed accep able, hese indices should e lec alues highe han 0.90, wi h alues abo e 0.95 indica ing excellen i . Fu he mo e, oo mean squa e e o o app oxima ion (RMSEA) was es ima ed, wi h alues below 0.08 e lec ing accep able i and alues below 0.05 sugges ing excellen i . Jus i ica ion o Model Speci ica ion and Goodness o Fi Indices The i s s uc u al equa ion model was buil based on esea ch p esen ed abo e. ST and SLT ha e been iden i ied as key ac o s in luencing physical heal h and ea ing beha iou s. Inc eased ST, along wi h inadequa e sleep, has been ound o be associa ed wi h g ea e physical inac i i y, lowe adhe ence o heal hy die s such as he MD, and less Nu ien s 2024,16, 3582 7 o 20 heal hy ea ing beha iou s [ 19 , 20 ]. Fo his eason, ST and SLT a e en e ed in he i s le el o he model. PF has been posi i ely linked o g ea e MD adhe ence, due o he ela ionship be ween egula physical ac i i y and inc eased awa eness o he impo ance o p ope nu i ion o physical pe o mance and o e all heal h. This aligns wi h s udies ha highligh ha physically ac i e indi iduals end o ollow heal hie die a y pa e ns [ 18 ]. Fo his eason, PF, MD adhe ence, and ea ing beha iou s a e included a he second le el o he model in o de o es ablish he in luence o PF on MD adhe ence and, in u n, ea ing beha iou s. Finally, e idence sugges s ha adequa e MD adhe ence, cha ac e ized by a balanced in ake o ui s, ege ables, legumes, and heal hy a s, has a posi i e impac on bo h ea ing beha iou s and he main enance o a heal hy BMI, wi h die being one o he main de e minan s o BMI [8]. Following speci ica ion o he model, di ec ions o associa ion be ween a iables we e de e mined in acco dance wi h he Spea man co ela ion analysis. Following his, ini ial model i was examined. Ul ima ely, model i was e ined un il accep able o excellen alues we e achie ed o CFI, IFI, NFI, and TLI. These indices we e selec ed due o hei abili y o p o ide comp ehensi e assessmen o model i . These indices a e widely ecognised in SEM li e a u e as obus me ics ha help o o e come he limi a ions o he chi-squa e s a is ic [45]. 3. Resul s Table 1p esen s he desc ip i e cha ac e is ics o he s udy sample. Wi h ega ds o sex, boys epo ed less SLT (10.29 ± 0.61 s. 10.41 ± 0.70; p= 0.011) and sco ed lowe o ANT-I (2.86 ± 0.56 s. 2.94 ± 0.53; p= 0.019) and sa ie y esponsi eness (2.75 ± 0.69 s. 2.8 8±0.6 4; p= 0.004) han gi ls. No u he sex di e ences we e obse ed o he emaining s udy pa ame e s. Wi h ega ds o BMI, ela i e o o e weigh o obese child en, child en wi h a heal hy body weigh epo ed highe sco es o o e all PF (4.30 ± 0.64 s. 4.14 ± 0.65; p= 0.045) and ca dio ascula i ness (4.08 ± 0.75 s. 3.82 ± 0.71; p= 0.003) and lowe sco es o PRO-I (2.48 ± 0.53 s. 2.74 ± 0.68; p= 0.003) and all o i s subdimensions excep desi e o d ink. Fu he , child en wi h a heal hy body weigh epo ed highe sco es o ANT-I (2.92 ± 0.56 s. 2.77 ± 0.53; p= 0.023) and sa ie y esponsi eness (2.84 ± 0.67 s. 2.66 ±0.67; p= 0.037) han o e weigh o obese child en. Table 2p esen s co ela ion coe icien s p oduced be ween s udy a iables. ST was posi i ely associa ed wi h ANT-I ( = 0.144; p< 0.01) and in e sely associa ed wi h SLT ( = −0.21 9; p< 0.01), o e all PF ( = − 0.152; p< 0.01), and MD adhe ence ( = − 0.262; p< 0.0 1). In con as , SLT was posi i ely associa ed wi h o e all PF ( = 0.093; p< 0.05) and MD adhe ence ( = 0.235; p< 0.01), and in e sely associa ed wi h ANT-I ( = − 0.106; p< 0.0 1). Fu he , highe o e all PF was posi i ely associa ed wi h MD adhe ence ( = 0.113 ; p<. 05) and nega i ely associa ed wi h ANT-I ( = − 0.160; p< 0.01). A he same ime, MD adhe ence was in e sely associa ed wi h ANT-I ( = − 0.287; p< 0.01), wi h he la e also being in e sely associa ed wi h PRO-I ( = −0.403; p< 0.01). Gi en ha a numbe o signi ican di e ences eme ged acco ding o sex and BMI, an- o he SEM was cons uc ed o be e unde s and he ela ionship be ween s udy a iables. This SEM showed good i indices o he mul i-g oup analysis. The chi-squa e ou come was signi ican ( χ2 = 16.9; d = 7; p= 0.018), meaning ha his index does no suppo he goodness o i o he model. None heless, acco ding o Ma sh [ 46 ], his index canno be in e p e ed in a s anda dised way due o i s sensi i i y o sample size. Thus, o he s anda dised i indices we e used ha a e less sensi i e o sample size [ 47 ]. In his way, NFI and TLI alues we e accep able, being 0.948 and 0.902, espec i ely. IFI and CFI alues we e excellen , being 0.969 and 0.967, espec i ely. A he same ime, he RMSEA alue was also excellen , being 0.047. Nu ien s 2024,16, 3582 8 o 20 Table 1. Desc ip i e cha ac e is ics o he s udy sample acco ding o sex and BMI. Sex BMI O e all (n= 653) Male (n= 317) Female (n= 336) p Heal hy Weigh (n= 580) O e weigh / Obese (n= 73) p Age (yea s) 4.78 ±0.93 4.78 ±0.97 4.78 ±0.90 0.892 4.76 ±0.93 4.92 ±0.92 0.210 BMI (kg/m2)15.53 ±2.09 15.52 ±1.92 15.53 ±2.23 0.691 ST (hou s) 1.78 ±1.07 1.81 ±1.11 1.75 ±1.02 0.604 1.76 ±1.06 1.94 ±1.12 0.271 SLT (hou s) 10.35 ±0.66 10.29 ±0.61 10.41 ±0.70 0.011 10.37 ±0.64 10.19 ±0.74 0.147 MD adhe ence 7.17 ±2.03 7.18 ±2.09 7.16 ±1.97 0.999 7.21 ±2.02 6.79 ±2.05 0.115 O e all PF 4.11 ±0.57 4.14 ±0.59 4.08 ±0.55 0.104 4.12 ±0.57 4.01 ±0.55 0.069 GPF 4.28 ±0.65 4.30 ±0.067 4.26 ±0.62 0.267 4.30 ±0.64 4.14 ±0.65 0.045 CF 4.05 ±0.75 4.09 ±0.76 4.02 ±0.74 0.203 4.08 ±0.75 3.82 ±0.71 0.003 MS 4.02 ±0.70 4.06 ±0.71 3.99 ±0.69 0.223 4.03 ±0.69 4.01 ±0.75 0.902 SA 4.12 ±0.72 4.17 ±0.72 4.07 ±0.73 0.074 4.13 ±0.74 4.05 ±0.62 0.237 B 4.07 ±0.71 4.08 ±0.74 4.07 ±0.69 0.765 4.08 ±0.72 4.05 ±0.62 0.495 PRO-I 2.51 ±0.56 2.50 ±0.56 2.51 ±0.56 0.998 2.48 ±0.53 2.74 ±0.68 0.003 FR 2.22 ±0.84 2.17 ±0.80 2.27 ±0.87 0.258 2.18 ±0.80 2.54 ±1.06 0.008 EO 1.76 ±0.64 1.74 ±0.65 1.78 ±0.64 0.442 1.73 ±0.62 1.97 ±0.77 0.015 EF 3.59 ±0.80 3.60 ±0.82 3.58 ±0.78 0.407 3.56 ±0.80 3.83 ±0.74 0.006 DD 2.46 ±0.87 2.48 ±0.91 2.43 ±0.84 0.560 2.44 ±0.86 2.61 ±0.96 0.223 ANT-I 2.90 ±0.55 2.86 ±0.56 2.94 ±0.53 0.019 2.92 ±0.56 2.77 ±0.53 0.023 SR 2.82 ±0.67 2.75 ±0.69 2.88 ±0.64 0.004 2.84 ±0.67 2.66 ±0.67 0.037 SE 3.08 ±0.79 3.02 ±0.81 3.13 ±0.77 0.050 3.10 ±0.79 2.92 ±0.71 0.093 EU 2.96 ±0.60 2.94 ±0.60 2.98 ±0.60 0.429 2.98 ±0.59 2.86 ±0.61 0.129 FF 2.76 ±0.84 2.73 ±0.86 2.80 ±0.81 0.193 2.78 ±0.84 2.65 ±0.81 0.211 No e: BMI: body mass index; ST: sc een ime; SLT: sleep ime; MD: Medi e anean die ; PF: physical i ness; GPF: gene al physical i ness; CF: ca dio espi a o y i ness; MS: muscula s eng h; SA: speed/agili y; B: balance; PRO-I: p o-in ake; FR: ood esponsi eness; EO: emo ional o e ea ing; EF: enjoymen o ood; DD: desi e o d ink; ANT-I: an i-in ake; SR: sa ie y esponsi eness; SE: slowness in ea ing; EU: emo ional unde ea ing; FF: ood ussiness. Table 2. Co ela ion coe icien s p oduced be ween s udy a iables adjus ed o sex. BMI ST SLT O e all PF MD ANT-I ST 0.074 SLT −0.053 −0.219 ** O e all PF −0.025 −0.152 ** 0.093 * MD −0.062 −0.262 ** 0.235 ** 0.113 * ANT-I −0.105 ** 0.144 ** −0.106 ** −0.160 ** −0.287 ** PRO-I 0.178 ** 0.002 0.015 0.067 0.039 −0.403 ** No e: * p < 0.05; ** p< 0.01. BMI: body mass index; ST: sc een ime; SLT: sleep ime du a ion; PF: physical i ness; MD: Medi e anean die ; ANT-I: an i-in ake; PRO-I: p o-in ake. Table 3and Figu e 3p esen eg ession weigh s and s anda dised eg ession weigh s pe aining o he SEM cons uc ed o he o e all sample. Ou comes demons a e ha associa ions exis be ween ST, SLT, PF, MD, ANT-I, and PRO-I and BMI. Nega i e ela ion- ships we e obse ed be ween ST and PF (b = − 0.137; p< 0.005), ST and MD adhe ence ( b = −0.21 2; p< 0.005), ST and SLT (b = − 0.221; p< 0.005), MD adhe ence and ANT-I ( b = −0.24 2; p< 0.005), ANT-I and PRO-I (b = − 0.407; p< 0.005), and MD adhe ence and BMI (b = − 0.085; p= 0.033). In con as , posi i e ela ionships we e ound be ween SLT and MD adhe ence (b = 0.181; p< 0.005), and PRO-I and BMI (b = 0.152; p< 0.005). Table 4and Figu e 4p esen eg ession weigh s and s anda dised eg ession weigh s pe aining o he SEM de eloped o gi ls. The chi-squa e s a is ic was non-signi ican ( χ2= 3.6 ;d = 7; p= 0.821), meaning ha , on his occasion, he model could be concluded o exhibi good i . The model could also be concluded o be homogeneous. Fu he mo e, NFI, IFI, TLI, and CFI alues we e excellen , being 0.980, 1.019, 1.063, and 1.000, espec i ely. A he same ime, he RMSEA alue was also excellen , being 0.000. This shows ha he SEM cons uc ed closely aligns wi h he empi ical da a collec ed, indica ing an excellen i . In Nu ien s 2024,16, 3582 9 o 20 his case, nega i e ela ionships we e obse ed be ween ST and PF (b = − 0.147; p= 0.00 7), ST and MD adhe ence (b = − 0.259; p< 0.005), ST and SLT (b = − 0.210; p< 0.005), MD adhe ence and ANT-I (b = − 0.175; p= 0.002), ANT-I and PRO-I (b = − 0.424; p< 0.005) ), and MD adhe ence and BMI (b = − 0.114; p= 0.036). In con as , posi i e ela ionships we e ound be ween SLT and PF (b = 0.137; p= 0.012), SLT and MD adhe ence (b = 0.196; p< 0.005), and PRO-I and BMI (b = 0.174; p= 0.003). Table 3. Reg ession weigh s o he o e all sample. Associa ion Be ween Va iables RW SRW Es ima ion SE CR pEs ima ion PF ←ST −0.073 0.021 −3.466 *** −0.137 PF ←SLT 0.050 0.034 1.451 0.147 0.058 MD ←SLT 0.559 0.117 4.764 *** 0.181 MD ←PF 0.233 0.133 1.750 0.080 0.066 MD ←ST −0.403 0.073 −5.537 *** −0.212 ANT-I ←ST 0.032 0.020 1.554 0.120 0.062 ANT-I ←SLT −0.012 0.033 −0.379 0.705 −0.015 ANT-I ←MD −0.066 0.011 −6.088 *** −0.242 PRO-I ←ANT-I −0.415 0.038 −10.924 *** −0.407 PRO-I ←MD −0.020 0.010 −1.941 0.052 −0.072 BMI ←ANT-I −0.264 0.165 −1.606 0.108 −0.069 BMI ←PRO-I 0.566 0.156 3.632 *** 0.152 BMI ←MD −0.088 0.041 −2.130 0.033 −0.085 SLT ↔ST −0.155 0.028 −5.508 *** −0.221 No e: PF: physical i ness; ST: sc een ime; SLT: sleep ime; MD: Medi e anean die ; ANT-I: an i-in ake; PRO-I: p o-in ake; BMI: body mass index; RW: eg ession weigh ; SRW: s anda dised eg ession weigh ; ← : di ec ional ela ionships be ween a iables; ↔: co ela ion be ween wo a iables. *** p < 0.005. Nu ien s 2024, 16, x FOR PEER REVIEW 10 o 22 Figu e 3. S uc u al equa ion model o he o e all sample. No e: ST: sc een ime; SLT: sleep ime; PF: physical i ness; MD: Medi e anean die ; ANT-I: an i-in ake; PRO-I: p o-in ake; BMI: body mass index; E1–E5: e o e ms. Table 4 and Figu e 4 p esen eg ession weigh s and s anda dised eg ession weigh s pe aining o he SEM de eloped o gi ls. The chi-squa e s a is ic was non-signi ican (χ2 = 3.6; d = 7; p = 0.821), meaning ha , on his occasion, he model could be concluded o exhibi good i . The model could also be concluded o be homogeneous. Fu he mo e, NFI, IFI, TLI, and CFI alues we e excellen , being 0.980, 1.019, 1.063, and 1.000, espec i ely. A he same ime, he RMSEA alue was also excellen , being 0.000. This shows ha he SEM cons uc ed closely aligns wi h he empi ical da a collec ed, in- dica ing an excellen i . In his case, nega i e ela ionships we e obse ed be ween ST and PF (b = −0.147; p = 0.007), ST and MD adhe ence (b = −0.259; p < 0.005), ST and SLT (b = −0.210; p < 0.005), MD adhe ence and ANT-I (b = −0.175; p = 0.002), ANT-I and PRO-I (b = −0.424; p < 0.005) ), and MD adhe ence and BMI (b = −0.114; p = 0.036). In con as , posi i e ela ionships we e ound be ween SLT and PF (b = 0.137; p = 0.012), SLT and MD adhe - ence (b = 0.196; p < 0.005), and PRO-I and BMI (b = 0.174; p = 0.003). Table 4. Reg ession weigh s p oduced by he SEM de eloped o gi ls. Associa ion Be ween Va iables RW SRW Es ima ion SE CR p Es ima ion PF ← ST −0.079 0.029 −2.693 0.007 −0.147 PF ← SLT 0.109 0.043 2.523 0.012 0.137 MD ← SLT 0.553 0.149 3.716 *** 0.196 MD ← PF 0.034 0.186 0.185 0.853 0.010 MD ← ST −0.497 0.101 −4.908 *** −0.259 ANT-I ← ST 0.011 0.029 0.395 0.693 0.022 Figu e 3. S uc u al equa ion model o he o e all sample. No e: ST: sc een ime; SLT: sleep ime; PF: physical i ness; MD: Medi e anean die ; ANT-I: an i-in ake; PRO-I: p o-in ake; BMI: body mass index; E1–E5: e o e ms. Nu ien s 2024,16, 3582 16 o 20 in heal h-enhancing physical ac i i y (37.5% s. 18.2%, p< 0.001). In o de o ensu e ha p eschool gi ls engage in physical ac i i y a le els compa able o boys, i is i al o c ea e an inclusi e en i onmen ha coun e s cul u al p essu es [ 60 ]. This can be achie ed by p omo ing posi i e ole models, emphasising un o e compe i ion, and o e ing p og ams ailo ed o gi ls’ in e es s, such as dance o coope a i e games [ 65 ]. In ol ing pa en s can ein o ce posi i e a i udes owa ds physical ac i i y [ 66 ]. Mo eo e , a p omising app oach is o p omo e posi i e pee ela ionships and social suppo om iendship g oups in he PA se ing [ 67 ]. C ea ing sa e and suppo i e en i onmen s o gi ls o engage in play can enable hem o enjoy he heal h bene i s o physical ac i i y in he same way ha boys do. Finally, he use o mul i-g oup analysis based on sex and BMI adds nuance o he indings, whils he inno a i e me hodology in eg a es a ious li es yle de e minan s, con- ibu ing aluable insigh s o u u e esea ch and in e en ions ailo ed owa ds Spanish p e-schoole s. Addi ionally, he p ac ical implica ions o p esen indings a e a ied and ha e applica ions o heal h, educa ion, and li es yle in e en ions. Schools should be he p ima y enues o such in e en ions, as hey a e ideal en i onmen s o encou age s uden s and amilies o os e heal hy habi s. Indeed, heal hy habi s lea ned a school can la e be implemen ed a home and o en pe sis o e ime [68]. Limi a ions, S eng hs and Fu u e Pe spec i es P esen indings should be conside ed in ligh o a numbe o limi a ions. One such limi a ion pe ains o he c oss-sec ional s udy design employed, which limi s he abili y make conclusions ega ding causal ela ionships. In u u e esea ch, longi udinal s udies should be conside ed o analyse he e olu ion o ou comes. Mo eo e , he s udy’s eliance on sel - epo ed da a o a ious a iables inc eases he isk o measu emen e o . Howe e , since bo h he KIDMED o child en and he CEBQ ha e consis en ly demons a ed s ong alidi y and eliabili y in simila samples, his issue is unlikely o ha e subs an ially in luenced indings. Simila ly, BMI has known limi a ions as a s and-alone measu e, as i does no accoun o a pe cen age o bone densi y; howe e , i emains a p ac ical ool o assessing obesi y isk in young child en [ 37 ]. Speci ically, a ecen c oss-sec ional s udy conduc ed by Desca pen ie e al. [ 69 ] obse ed ha associa ions be ween unheal hy li es yle pa e ns and BMI may di e depending on he popula ion, wi h posi i e ela ionships only being obse ed in Spanish and I alian p e-school coho s. This sugges s ha BMI may be a good indica o in he con ex o he p esen s udy. The non- andom app oach o sample selec ion should also be conside ed. Despi e his limi a ion, a la ge numbe o pa icipan s we e ec ui ed om 18 public and p i a e schools in he p o ince o G anada. The la ge sample size o a di icul o ob ain popula ion ec ui ed by he p esen s udy p o ides es ima es ha be e app oxima e popula ion pa ame e s [ 70 ]. In o de o boos ec ui men , alongside p o ision o an in o ma ion le e p io o eques ing consen , pe sonal con ac de ails o he p incipal in es iga o we e p o ided o pa icipan s. This enabled pa en s o eques addi ional in o ma ion p io o s udy s a , helped o os e us in esea che s, and p omo ed pa en al mo i a ion o pa icipa e. In addi ion, pa icipan s we e in o med h oughou he s udy p ocess ha hey could wi hd aw om he s udy a any ime. These measu es we e es ablished ollowing sugges ions made by Sammons e al. [ 71 ] o mo i a ing pa en s o consen o pa icipa ion. Ano he limi a ion is ha he pa en s o pa icipa ing p e-schoole s wi hheld hei consen o socioeconomic s a us da a o be accessed. Fu u e esea ch can/should in es- iga e he in luence o pa en s’ heal hy habi s on hei child en, whils conside ing o he sociocul u al ac o s such as he amily’s educa ion o socioeconomic s a us, as hese appea o be key ac o s when i comes o p omo ing heal hy habi s in p e-school-aged child en. Al hough many po en ial co ounde s we e con olled o , some physiological and gene ic ac o s may ha e s ill con ounded es ima ions. In addi ion, i would be in e es ing o u u e esea ch o e alua e o he a iables ha may be ela ed o heal hy li es yles such as cogni i e pe o mance, men al heal h, and gene al well-being. Nu ien s 2024,16, 3582 17 o 20 Fu he mo e, i mus be acknowledged ha , o he bes o he au ho s’ knowledge, he p esen s udy ep esen s one o e y ew s udies a ailable ha conduc in eg a i e analysis o a ious heal hy li es yle de e minan s in child en unde six yea s o age. Thus, u he scien i ic esea ch is equi ed a his s age. 5. Conclusions P e-schoole s om sou he n Spain wi h lowe ST end o ha e highe PF, MD ad- he ence, and SLT. Likewise, p e-schoole s who epo adequa e MD adhe ence exhibi mo e SLT, ewe PRO-I and ANT-I beha iou s, and a lowe BMI. Wi h ega ds o he la e , child en wi h a highe BMI exhibi mo e PRO-I beha iou s. Rela ionships be ween hese ac o s a e clea e in gi ls and p e-schoole s who a e o e weigh o obese, indica ing ha bo h sex and weigh s a us play a ole in hese in e ac ions. In o de o imp o e PF in o e weigh o obese child en, in e en ions should ocus on educing ST. As indica ed by he co ela ions ound in he p esen s udy, such in e en ions a e c ucial gi en ha good PF is likely o lead o be e MD adhe ence in p e-schoole s. This, in u n, will b ing abou educ ions in BMI and educe he isk o being o e weigh o obese. Speci ically in he case o gi ls, i is sugges ed ha in e en ions ocus on educing ST and inc easing SLT as a means o imp o ing bo h PF and MD adhe ence. Whils his s a egy is also likely o be bene icial o boys, he p omo ion o MD adhe ence by a ge ing PF will likely p oduce be e ou comes. Au ho Con ibu ions: Concep ualiza ion, G.C.V. and J.J.M.; me hodology, G.C.V. and J.J.M.; so - wa e, G.C.V. and J.J.M.; alida ion, G.C.V., R.P.-R., J.-A.S.-M. and J.J.M.; o mal analysis, G.C.V. and J.J.M.; in es iga ion, G.C.V., R.P.-R., J.-A.S.-M. and J.J.M.; esou ces, J.J.M.; da a cu a ion, G.C.V. and J.J.M.; w i ing—o iginal d a p epa a ion, G.C.V.; w i ing— e iew and edi ing, G.C.V. and J.J.M.; isualiza ion, G.C.V., R.P.-R., J.-A.S.-M. and J.J.M.; supe ision, J.J.M.; p ojec adminis a ion, G.C.V. and J.J.M.; unding acquisi ion, G.C.V. and J.J.M. All au ho s ha e ead and ag eed o he published e sion o he manusc ip . Funding: This wo k was suppo ed by he Spanish “Minis e io de Uni e sidades” ia he p edoc o al g an “Fo mación de P o eso ado Uni e si a io” awa ded o G acia C is ina Villod es (FPU20/02739). Ins i u ional Re iew Boa d S a emen : This s udy was conduc ed acco ding o he guidelines laid ou in he Decla a ion o Helsinki and all p ocedu es in ol ing esea ch s udy pa icipan s we e app o ed by he E hics Commi ee o he Uni e si y o G anada, Spain (2794/CEIH/2022, da e o app o al: 28 Ap il 2022). In o med Consen S a emen : In o med consen was ob ained om all subjec s in ol ed in he s udy. Da a A ailabili y S a emen : Da a a e a ailable om he au ho s on eques . Da a a e no publicly a ailable due o p i acy easons. Acknowledgmen s: The au ho s would like o hank all s uden s and hei amilies o hei pa ici- pa ion in his s udy. The au ho s also wish o hank he s a a he schools o hei con ibu ions du ing da a collec ion. The au ho s would like o especially hank Emily Knox o he assis ance in e iewing he English e sion. Con lic s o In e es : The au ho s decla e no con lic s o in e es . Re e ences 1. Ho esh, A.; Tsu , A.M.; Ba dugo, A.; Twig, G. 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