Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ
NESA Publicação oficial
ISSN: 2177-5281 (Online)
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Páginas 15 a 24
Autores: Priscilla Rayanne e Silva Noll1; Matias Noll2; João Luiz Ribeiro Neto3; Pammela Munique Vilela4
1. Master's Degree student in Collective Health, Goiás Federal University (UFG). Nutritionist, Student Aid Office, Instituto Federal Goiano (IF GOIANO-CERES). Ceres, Goiás State, Brazil
Priscilla Rayanne e Silva Noll
How to cite this article
Keywords: Feeding behavior, food habits, adolescent health.
It is generally agreed that the early appearance of overweight has been rising at an alarming rate among adolescents all over the world, often associated with malnutrition resulting from micronutrient shortages. This global pandemic affects around a fifth of Brazilian adolescents,1 at 22.1% and 2.3% for boys and girls respectively2.
The explanations for this upsurge in overweight focus on an assortment of possible reasons that are being explored through vigorous discussions, including higher calorie intakes, changing diets, lower physical activity levels and alterations to intestinal microbiota2. Being overweight is assessed through anthropometrics, measuring weight and height and then calculating the Body Mass Index (BMI) which is the main parameter used to assess obesity during adolescence in population studies.
The current eating habits profile is shaped by ample consumption of high-fat items, particularly those that are high in saturated in trans fats, simple sugars, sodium and preservatives, with little fiber and micronutrients, particularly ready-to-eat or processed foods, compared to fresh produce3.
In this context, it is vital to encourage healthy eating habits in this age bracket, in order to enhance the health of these youngsters and prevent diseases among them, as habits formed during childhood and adolescence are likely to extend through into adult life, with overweight being a risk factor for other diseases such as cardiovascular problems, metabolic syndrome, diabetes and some types of cancer. Moreover, overweight affects the quality and length of life, in parallel to direct effects on social acceptance among adolescents failing to meet the appearance standards rated as acceptable by modern society3.
As education has been indicated as an important factor for establishing appropriate behaviors, there is a clear need to extend and improve eating and nutrition education programs, with the classroom being the best place to do so4. In order to provide scientific evidence for eating and nutrition education programs, it is vital to be familiar with the anthropometric profiles and eating habits of the target public, as these aspects vary in different contexts, influenced by social and cultural, environmental and genetic aspects.
To analyze the anthropometric profiles and eating habits of schoolchildren in different education networks through an epidemiological study.
As shown in Table 1, this population-based study encompasses 827 adolescent boys and girls between 14 and 19 years old in a hub municipality in Goiás State, enrolled in in secondary schools in the Federal, State and private school networks.
Anthropometric profile assessment
The anthropometric profile was assessed on the basis of the BMI by age, as recommended for the age bracket addressed by this research project. Height was measured on a Sanny® stadiometer, after asking pupils to remove their shoes and stand up straight, with their heels, calves, shoulder-blades and shoulders touching a wall with no kickboard, with their knees locked, feet together and arms alongside their bodies, with their heads erect at a 90° angle to their bodies, measured three times and noting the mean figures. Their weight was obtained through a calibrated Tanita® BC585F scale, on which they were asked to stand upright, wearing light clothes and without shoes, in its center, with their arms alongside their bodies, remaining motionless in this position until the scale displayed their weight.
Assessment of eating habits
The tool used to assess their eating habits was the questionnaire developed and used in the National Schoolchildren´s Health Survey (PENSE)5, which was also validated6. The questions explored their food intake for the week prior to the study, divided into two groups: healthy food markers (beans; vegetables and / or greens excluding potatoes and cassava; raw salads; fresh fruit or juice; milk) and unhealthy food markers (sweets; processed meats; fried snacks, pizza, sandwiches and French fries; savory biscuits and crackers; sweet biscuits and cookies; soda pop and industrialized juice). This division was based on evidence showing an association between these variables and risk factors for the development of Non-Communicable Chronic Diseases (NCCD) 7.
Data collection and analysis procedures
This research project was approved by the Ethics Committee at the Instituto Federal Goiano, through Protocol Nº 046/2014. Schools were invited to join this study at meetings with their administration, with 80% agreeing to participate. The assessments were conducted in their classrooms by trained researchers at pre-scheduled times, after receipt of Deeds of Informed Assent or Deeds of Informed Consent signed by the adolescents themselves and / or their parents / guardians, depending on their age, compliant with Resolution N° 466/2012 issued by the National Health Council (CNS). A questionnaire was handed out to each pupil for self-completion. While they were being completed, height and weight were measured individually elsewhere. The researcher remained in the room while the questionnaires were being completed, which took around forty minutes on average, collecting them up once all the respondents had finished.
For the statistical analysis, the Statistical Package for the Social Sciences (version 20.0) was used. Anthropometric profiles and eating habits were analyzed by school network, through descriptive statistics. The chi-squared test was used to explore the existence of an association between anthropometric profiles, eating habits and school networks (α = 0.05).
The results demonstrated high levels of overweight and obesity in all school networks, as shown in Table 2. With regard to eating habits, a broad range of unsuitable options was noted in the weekly consumption of breakfast and dinner, as well as snacks between main meals (Table 3). The findings were positive in terms of eating lunch throughout the week, with Tables 4 and 5 showing the weekly food intake frequency for healthy and non-healthy diet markers. Low consumption of fish, vegetables and greens was noted, in addition to salads, fruits, juices and yogurts in all school networks. On the other hand, consumption was higher than recommended for fried snacks, pizzas, sandwiches, cookies, sweets, carbonated soft drinks and processed juices, alcoholic beverages and / or energy drinks.
The assessed schoolchildren showed high levels of overweight, varying among the three networks: Federal (24.2%), State (20%) and Private (21.3%). The prevalence of overweight in this population has been rising substantially 2, 8 over the past three decades, which is a brief period of time, with overweight trends varying in different countries, reaching between 20% and 25% of children and adolescents in Latin America, according to Rivera et al. (2014)8, based on the BMI/Age classification, and 23.8% and 22.6% of boys and girls respectively worldwide, up 47.1%, between 1980 and 2013, according to the International Obesity Task Force2. A longitudinal study of 37,801 children and youngsters living in different parts of Brazil conducted between 2005 and 2011 showed that around 20% were overweight and 5.5 to 12.2% were obese during the last assessment period (2009 - 2011), indicating that 27.6% were overweight9, corroborating other studies. 2,8
Moreover, different regional standards are noted in Brazil9, as shown by the 2008-2009 Family Budget Survey (POF)1, with a nationwide mean of 20.5% of schoolchildren overweight and 4.9% obese. However, at the regional level, overweight was more frequent in the South, Southeast and Center-West, compared to the North and Northeast, varying from 16.5 to 24.4%; it was also more prevalent in urban areas than in rural zones, indicating the need for region-specific surveys10. Among the three school networks, there was no difference in nutritional status, although overweight was associated with higher incomes in the 2008-2009 Family Budget Survey 1. Meal frequency explored in this study indicated differences among the school networks for all meals, with more severely fragmented meals in the Federal school network, where meals were less prevalent, except for bedtime snacks. Barufaldi et al.11 found an association between eating breakfast regularly and other dietary profiles, which might reflect healthier individual dietary patterns11.
There was a difference in the consumption of some of the healthy diet markers in the school networks. Most schoolchildren ate beans five days a week or more, with a higher percentage in the State school network. This characteristic is probably related to the fact that beans are a staple in the Brazilian diet, with percentages similar to those of other Brazilian studies 5,12. International research projects did not indicate significant bean consumption, as they are not a substantial element in the diets of other cultures. However, an analysis of adult Brazilian diets showed that consuming beans, associated specifically with rice, offers greater protection against overweight13. The 2008-2009 Family Budget Survey (POF) 1 showed higher consumption of beans and rice among the lower-income classes, although this research project was unable to discover whether pupils in the Federal and State school networks belonged to lower income classes than youngsters enrolled in private schools. However, according to the National Schoolchildren´s Health Survey (PENSE), the parents of children enrolled in government schools tend to be less educated than their counterparts whose offspring attend private schools, in addition to owning fewer assets, indicating lower economic status5.
Cooked vegetables were consumed by 47.5% of schoolchildren on five days a week or more and raw vegetables by 56.7%, which are figures higher than usually indicated by the literature. According to another study conducted with 6871 adolescent schoolchildren in Fiji, 73.6% of them did not eat five portions (400g) of fruit and vegetables a day 14, which is the recommended amount7. In the private school network, vegetable consumption was more prevalent which is associated with higher income levels, according to Borges et al.15, due to the high costs of a healthy diet, in terms of family budgets. Moreover, parental schooling levels influence food consumption, with better education associated with the social and economic status of families and adequate nutrient intakes16.
Fruit was consumed even less than vegetables, with a mean of 30.1% consumption on five days a week or more among the assessed schoolchildren. Other references indicate inadequate fruit consumption among adolescents, reaching 65.7% of `youngsters who do not eat fruit frequently, falling below the recommended level for this age bracket1. It is widely agreed that fruit and vegetable consumption is a protective factor7 as, in addition to lowering the risks of several NCCDs, their consumption is crucial during adolescence due to growth spurts that require ample supplies of nutrients, in addition to the formation of eating habits in this age bracket7. Fruit was less consumed in the Federal school network, compared to the others. Nutritious fresh foods such as fruit require special care and preparation skills, in addition to being more expensive and fairly perishable15. As pupils spend all day at these schools, where no morning or afternoon snacks are offered, which could well include fruit, it may be assumed that this is due to difficulties in transportation and storage for this school network. Similar to fruit, only 38.1% of the pupils reported consumption of milk and / or dairy products ≥5 times a week, which is inadequate, falling below the lowest figures for the latest National Schoolchildren´s Health Survey (PENSE) (51.5%)5.
Unhealthy diet markers were also inadequate, with higher consumption than recommended. Processed meats were mentioned by 11.1% of the schoolchildren on five days or more a week, which is lower than the figures found in the literature, where consumption was noted for up to 78.3% of the respondents17. Processed meats are not healthy due to their high salt and fat content, acceptable only for sporadic consumption3. It is important to underscore the fragility of the questionnaire used in terms of processed meats, with only six examples (hamburger, hot dogs, mortadella, salami, ham and nuggets) listed in the self-completed questionnaire, with possibilities of underestimating consumption due to difficulties in understanding the question6.
Fried snacks, pizzas and sandwiches are eaten on a weekly basis by almost all the respondents, with 14.9% of them eating these foods on five days or more. The 2008-2009 Family Budget Survey indicated more than 30% consumption of these foods by adolescents, with the mean per capita consumption reaching 35.3%1, due largely to modern lifestyles where fast, practical and tasty meals are sought that are affordable and easy to access, with proper meals often replaced by snacks18. A study of some 20,000 adolescents in Finland showed an association between the presence of a supermarket or snack bar near to the school and the number of meals such as breakfast and lunch replaced by snacks among schoolchildren 19.
Over-consumption of ultra-processed foods has negative impacts on food intake quality, due to massive amounts of trans and saturated fats and sugars, with high calorie counts, in addition to poor fiber and potassium contents18. Cookies and sweets are also rated as ultra-processed products due to high levels of additives such as sodium and saturated and trans fats, also with extremely high calorie counts. Moreover, they contain large amounts of sugar, particularly sandwich cookies3, constituting a risk factor for several NCCDs7. High consumption of ≥5 times a week was also found in the National Schoolchildren´s Health Survey (PENSE), reaching 32.5% for cookies and 41.3% for sweets5. The prevalence of cookies and sweets consumption was higher in the State school network. Carbonated soft drinks and processed juices are also favorites among adolescents, at mean levels twice as high as adults1, being closely linked to rising weight and body fat, in addition to other medical problems 12,20. State schools - which is the only network where classes do not extend throughout the day - also posted high consumption levels, as the fact that snacks and drinks are easily available at home is closely related to higher consumption of these items, suggesting a link to social levels and availability. The consumption of sweets, soda pops, pizzas, sandwiches and fried snacks drops for lower income categories, according to the 2008-2009 Family Budget Survey 1, although it was not possible to examine this link in this study.
Despite some differences, the reality of these youngsters must be reshaped through effective and well-articulated actions steered by public health policies and education, in order to enhance their health through curtailing risk factors, while also preventing obesity and treating overweight youngsters. As limitations, it is stressed that this type of study - including this paper - offers the possibility of causal bias for the association between diet and nutritional status, as dietary under-notification is common among adolescents, frequently not reporting what they have actually consumed.
These schoolchildren presented a high prevalence of ultra-processed unhealthy food consumption, in parallel to inadequate consumption of foods that are healthy diet markers. Differences between school networks should be studied in greater depth, particularly in terms of family incomes, in order to steer effective interventions leading to better diet and nutrition education.
NOTE OF THANKS
The authors appreciate the support received from the Instituto Federal Goiano through the Teacher Training Institutional Grants Program (PIBID) and extension grants, as well as for the technical support provided.
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