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Conteúdo (article):

STAGES OF CHANGE IN THE FEEDING BEHAVIOR ARE ASSOCIATED WITH THE CONSUMPTION OF FRUITS, VEGETABLES, SWEETS AND FATS BY ADOLESCENTS

Hérica Thaís Vieira Aguiar1 (ORCID: 0000-0001-6268-5680, hericaaguiar28@gmail.com) Lucinéia de Pinho2 (ORCID: 0000-0002-2947-5806, lucineiapinho@gmail.com),
Antônio Prates Caldeira2 (ORCID: 0000-0002-9990-9083, antonio.caldeira@unimontes.br), Luciana Neri Nobre1 (ORCID: 0000-0001-5709-7729, luciana.nobre@ufvjm.edu.br),
Cíntia Ramos Lacerda1*(ORCID: 0000-0002-8096-2300, cintia.ramos@ufvjm.edu.br)

1Federal University of Jequitinhonha and Mucuri Valleys, Diamantina, Brazil
2State University of Montes Claros, Montes Claros, Brazil

* Corresponding author: Cíntia Lacerda Ramos - cintia.ramos@ufvjm.edu.br

Abstract
This study verified the stages of change in adolescents\' eating behavior regarding the regular consumption of fruits, vegetables, sweets, and fatty foods. This was a cross-sectional study with adolescents from public schools in Montes Claros, MG/Brazil, who were identified through a sample selected by probabilistic cluster sampling. The adolescents completed a questionnaire that covered food consumption, stage of change in eating behavior, and sociodemographic characteristics. Their weight and height were assessed. Food consumption was evaluated according to Vigitel, which considers regular consumption when the food group is consumed ≥5 times per week. The factors influencing the probability of the stage of change in eating behavior, specifically the consumption of fruits, vegetables, sweets, and fats, were analyzed using Poisson regression. A total of 880 adolescents participated in the study; the majority reported being in the “maintenance” (25.6%) and “action” (13.6%) stages for all markers of food consumption. Compared with those in the “maintenance” phase, adolescents in the “precontemplation” stage were less likely to consume fruits (RP = 2.21; p value < 0.001) and vegetables (RP = 2.54; p value < 0.001) daily. The less advanced they were in the change stage, the lower the frequency of vegetable consumption.
Keywords: Feeding Behavior; Transtheoretical Model; Adolescent Nutrition; Diet, Healthy; Fats.

INTRODUCTION
Adolescence is a transitional phase between childhood and adulthood. In Brazil, according to the Statute of the Child and Adolescent, adolescence is defined as the phase between 12 and 18 years of age1. During this phase, significant physiological changes occur in the adolescent\'s body, including hormonal regulation, redistribution of body fat, changes in appetite, development of sexual organs, weight gain, alterations in eating patterns2, and the establishment of eating habits3.
A significant concern during adolescence can be weight gain, as it can persist into adulthood. This increases the risk of developing chronic conditions. This scenario highlights the importance of preventing obesity at an early age to avoid long-term health complications4. The eating habits established at this stage can influence the proper development of adolescents, as well as the appearance of health problems, including excess weight5, the risk of developing metabolic syndrome (MS) and dyslipidemia, hypertension6, abnormal bone development, and anemia7.
Notably, people\'s eating patterns are influenced by a variety of factors, including urbanization, which has favored changes in people\'s lifestyles and food preferences8,9. With urbanization, the availability of processed foods and fast food chains has increased. This increase has altered people\'s food consumption around the world, including in Brazil. In general, Brazilians have adopted a Westernized diet10.
In addition to urbanization, economic factors are also significant, as low-income individuals often have limited access to healthy foods, such as fruits and vegetables, and greater access to unhealthy foods, including certain ultra-processed foods. According to Maia et al.11, in Brazil, the price of ultraprocessed foods has been decreasing since the beginning of the 2000s, making it cheaper than both processed and unprocessed foods. This context may favor an increase in the consumption of ultra-processed foods by the Brazilian population.
Studies have shown that food consumption among adolescents presents a worrying pattern5,7-8. The regular consumption of whole foods such as fruits, vegetables, and legumes is still insufficient in this age group7-8. On the other hand, foods rich in fats, sugars, and ultraprocessed foods, such as fast food and sweets, have been widely consumed, contributing to the increase in cases of obesity, diabetes, and other health problems5-8.
Considering that adolescence is a phase in which there may be lifestyle changes, i.e., increased consumption of ultraprocessed foods and physical inactivity7, the transtheoretical model of behavior change (TTM) has been widely used to assess behavior changes and health education interventions, such as physical activity12, the consumption of fruits and vegetables13-15, unhealthy and sugary foods13, and weight control12. The TTM describes behavior change not as an individual event, but as a series of steps that occur according to a person\'s degree of motivation15,16.
The TTM is composed of four constructs: change stages, processes of change, self-efficacy, and balance in decision-making16. The most explored construct is the five stages of change, namely, "precontemplation", "contemplation", "decision", "action", and "maintenance", which are determined based on the level of motivation for change. Individuals in the “precontemplation” phase are unaware that their behavior is harmful and lack knowledge on how to change, resulting in low or nonexistent motivation16. Individuals in the “contemplation” stage are less reluctant to change, and they may be aware that there is something wrong with their behavior but are not yet willing to act. Individuals in the “decision” stage feel more prepared to act and plan changes in accordance with their short-term goals. In the “action” stage, significant behavioral changes occur. In the final stage, the “maintenance” stage, the individual has already adopted a new behavior, which persists for at least six months16.
Assessing the stages of behavioral change in adolescents regarding the consumption of healthy and unhealthy foods is crucial so that educational and health measures can be implemented. Although some studies3,7 have been conducted to understand food consumption in adolescents, the use of the MTT to assess changes in food consumption of food groups is still scarce12-13, especially studies with Brazilian adolescents and in regions outside large urban centers. Furthermore, identifying the stages of change in eating behavior among adolescents, particularly in the adoption of healthy eating practices, is highly important for providing support for the design of more effective food and nutrition education strategies aimed at preventing obesity and noncommunicable chronic diseases early in life.
Considering these aspects, the present study aims to identify the stages of change in the eating behavior of adolescents in relation to the consumption of fruits, vegetables, sweets, and fats in municipal public schools in Montes Claros, Minas Gerais, Brazil, and to verify whether there is an association between the frequency of consumption of healthy food groups and the stages of change in behavior.

METHODS
Study design and participants
This is a cross-sectional study, which is part of the research entitled "School health: nutritional assessment and cardiovascular risk among adolescents from public schools". The study was developed in municipal public schools in Montes Claros, Minas Gerais, Brazil. The study population consisted of students enrolled in sixth to ninth grades in elementary schools within the municipal public network in 2017. According to information provided by the Municipal Department of Education of Montes Claros, in 2017, a total of 9,162 students were enrolled in 51 municipal schools. For this research, schools in rural areas and those in which not all grades/years of interest to the research were completed (n = 36 schools), resulting in a total of 6,743 students eligible to participate, distributed across 15 schools, were excluded.
The sample size was defined considering the finite population of adolescents and the prevalence of 50% for precontemplation17, taking into account that, as adolescents, many might not recognize the need for adjustments in their food consumption. A confidence level of 95% and a standard error of 5.0% were used. A correction for the design effect was adopted, using deff = 2. A 10% increase was established to compensate for possible non-responses and losses. The participation of at least 844 adolescents was estimated. The sample was selected by probabilistic cluster sampling. Both schools and classes were drawn by simple random sampling. All the students from the selected classes were invited to participate in the research.
The inclusion criteria were being a student regularly enrolled in the educational institution and in the selected class, and being in the age range of 11-14 years (students in elementary school 2). Those who presented physical limitations and/or pain that prevented them from performing the physical assessment tests, as reported by the school, parents, or the adolescents themselves, were excluded. Students who did not attend school on the days of the anthropometric measurements and physical assessment tests were considered lost.

Data collection
Recruitment and data collection were conducted during the second half of 2017 by previously trained researchers. During the recruitment phase, all schools were visited, and the school principals were contacted to explain the research and obtain their authorization for participation. In the second phase, the study was presented to the students, and consent and assent forms were delivered for them to sign within 7 days. Data collection took place inside the classrooms during school hours on a single day.
The study complies with Resolution 466/12 and was approved by the Research Ethics Committee of the State University of Montes Claros under number 1,908,982. The students who participated in the study were those who signed an informed form and whose parents or guardians also signed an informed consent form (ICF). The reporting of this study follows the STROBE-nut Framework (Strengthening the Reporting of Observational Studies in Epidemiology), which guides observational studies in nutrition18.

Variables evaluated
The variables investigated were food consumption (weekly consumption of beans, fruits, milk, vegetables, plain biscuits, fried snacks, hamburgers, biscuits with filling, packaged snacks, soft drinks and sweets), sociodemographic (age and gender), anthropometric (weight and height) and behavioral (time spent per day watching television, whether they are concerned about their physique, which makes them think about dieting, how many days a week they exercise, and whether they participate in any nutritional activity at school, which takes place at school through the school health program (SHP). The variables were collected through a specific questionnaire, which was completed by the participants, and through anthropometric assessments (weight and height).
To assess the frequency of consumption of food markers, the questionnaire was based on a questionnaire from an annual national survey developed by the Ministry of Health entitled Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey (VIGITEL19), which includes markers of healthy and unhealthy eating. The participants indicated which of these food groups they had consumed or not, as well as the frequency of consumption of each food in the last seven days.
In this study, dietary variables are considered outcome variables. The consumption of fruits, beans, vegetables, plain biscuits, milk, fried snacks, hamburgers, packaged snacks, filled biscuits, soft drinks, and sweet treats in the last seven days was evaluated. Did not eat received code 1, ate 1x/week received code 2, and so on; code 8 occurred if the adolescent reported eating the foods every day of the week.
Initially, the average frequency of consumption of healthy markers (fruits, beans, vegetables, plain biscuits, milk) and unhealthy markers (fried snacks, hamburgers, packaged snacks, filled biscuits, soft drinks, and sweet or savory treats)18 was calculated. For this calculation, the sum of the frequency of consumption of each food in the group was divided by the number of foods in the group. These foods were subsequently divided into four groups (fruits, vegetables, sweets, and fatty foods), which were coded as consumed regularly or not.
With respect to the coding of the healthy eating marker, fruit and vegetable consumption was assigned a code of 0 for consumption 5 times per week or more and a code of 1 for consumption less than 5 times per week. For the group of sweet and fatty foods, the coding was reversed. For this group, regular consumption was adopted as the consumption of 5 or more days a week. These cutoff points have been used by the VIGITEL study19 for monitoring the health of the Brazilian population.
A validated algorithm previously used in studies in Brazil20,21 was employed (Appendix 1) to identify the stages of change in adolescents\' eating behaviors. This algorithm was used to determine the stages of change, which were based on the dietary perceptions of adolescents for the consumption of fruits, vegetables, sweets, and fatty foods. The questionnaire consists of four questions related to each of these food groups, which allows adolescents to be classified into five stages of change: precontemplation, contemplation, decision, action, and maintenance16. Each stage represents the temporal dimension of behavior change. It shows when the change occurs and the degree of motivation to carry it out22.
Sociodemographic, anthropometric, and behavioral variables were used as adjustment variables in the regression model. These variables were categorized according to the following description: sex (female; male), age (<13 years; ≥13 years), BMI (overweight; not overweight), screen time (≤2 hours; >2 hours), how many days a week they practice physical activity (≤3 times; >3 times), whether they are concerned about their physique that makes them think about dieting (rarely/never, sometimes/frequently, very frequently/always) and whether they participate in any nutritional action (yes; no). For this last variable, "yes" was considered if there was at least one positive response from the following questions: (i) Have you ever participated in nutrition workshops at your school? (ii) Do you participate in individual nutrition care at your school? (iii) Do you participate in individual nutrition care at any health service? (iv) Do you participate in any other nutritional activity elsewhere? When all the answers were negative, they were classified as “no”; if any were positive, they were classified as “yes”. Studies have shown that sociodemographic, anthropometric, and behavioral variables can influence food consumption by adolescents23,24; therefore, these adjustment variables were chosen.
Weight and height data were collected by previously trained evaluators. For weight measurement, a Welmy® portable electronic scale with a capacity of 200 kg and a 50 g division was used. In this assessment, the students wore light clothing and no shoes and were positioned centrally on the scale platform. The students\' heights were measured using an Avanutri® portable stadiometer, which has a range of 20 cm to 210 cm and a precision of 0.1 cm. The measurements were taken with the student standing, arms along the body, feet together, and barefoot. The measurement procedures followed the protocols recommended by Lohman25.
With weight, height, date of birth, and sex data, z scores for body mass index for age (BMI/A) were calculated using the Anthro Plus® programs (WHO Anthro-2007, Geneva, Switzerland)26. Those with a z score greater than +1 were classified as overweight, and those with a z score less than or equal to 1 were classified as not overweight. The classification of this index was based on the cutoff points established by the Sisvan/WHO27.
Thus, in the present study, the stages of change in eating behavior were initially analyzed as response variables and subsequently as explanatory variables.

Data analysis
The variables were analyzed using descriptive statistics, and the results are presented as simple frequencies (n) and relative percentages (%). The chi-square test was used to verify differences in the frequency of food group consumption according to students\' gender and to examine the associations between the stage of change in eating behavior and the independent variables. Poisson regression analysis was performed to evaluate the factors influencing the probability of stages of change in the eating behavior and consumption of the different food groups. However, only the fruit and vegetable groups presented statistically significant results, and only their results are presented.
The results of the Poisson regression analyses are expressed as adjusted prevalence ratios (PRs), 95% confidence intervals (95% CIs), and p values. Variables that presented a p value ≤ 0.2 in the univariate analysis were tested in the multivariate analysis; those with a p value < 0.05 remained in the model. Thus, only the fruit and vegetable groups, which presented a p value less than 0.2 in the univariate analysis, were included in the analyses. To assess the quality of the model fit, the value of the Pearson chi-square test divided by its degrees of freedom was used28. The model is considered well fitted if there is no overdispersion, and for this purpose, this proportion will be close to 1. For all analyses, p < 0.05 was considered significant. The analyses were performed using the Statistical Package for the Social Sciences (SPSS) 18.0 software (IBM Corporation, NY, USA)28.

RESULTS
The study included 880 adolescent students from public schools in Montes Claros, MG, Brazil. The average age of the adolescents was 12.9 years, and the majority were female (52.2%). The percentage distribution of adolescents, categorized by stages of change in their eating behavior in relation to their regular consumption of fruits, vegetables, and sweet and fatty foods, is presented in Figure 1.
Figure 1

Figure 1 shows that most adolescents self-reported being in the more advanced stages of eating behavior on the MTT, namely, "action" and "maintenance", for all food groups assessed. However, this proportion varied for each food group studied: 45.5% reported being in the maintenance stage for regular fruit consumption, 42.3% for regular vegetable consumption, 34.7% for regular consumption of sweets, and 28.9% for fatty foods. The distribution of adolescents in the "action" stage indicates that the largest proportion reported being in this stage for regular fruit consumption (32.5%), followed by fatty foods (29.6%), vegetables (27.4%), and sweets (27.0%). When the four food groups were assessed together, 25.6% (n=228) self-reported being in the "maintenance" stage, and 13.6% (n=120) reported being in the "action" stage.
Table 1 presents the regular or irregular consumption of food groups that serve as markers of healthy and unhealthy eating habits, categorized by the gender of the adolescents. Among the markers of healthy eating, beans and plain biscuits were the foods with the highest frequency of regular consumption (five times or more per week). Among the markers of unhealthy eating, sweets and filled biscuits were those with the highest frequency of regular consumption.
Notably, girls reported a higher frequency of regular consumption of sweet foods, whereas boys reported a higher frequency of milk consumption. When it was verified that consumption varied according to sex, a statistically significant difference (p value < 0.050) was identified only for the weekly frequency of consumption of beans, milk, and sweets (Table 1).
Table 1

The results of the stages of change in eating behavior (SCEBs) for the regular consumption of fruits, vegetables, and sweet and fatty foods, according to sociodemographic, anthropometric, and behavioral variables, are presented in Tables 2 and 3. For the fruit group, only age was associated with SCEB, indicating that younger adolescents were more advanced in this change, especially those who reported having regular fruit consumption for more than six months (p value = 0.022).
Table 2

With respect to the regular consumption of sweet foods, girls (p value = 0.006) and those planning to diet (p value = 0.035) reported not having consumed this food group regularly for more than six months. With respect to the consumption of the fatty food group, adolescents without excess weight were those who reported not regularly consuming this food group for more than six months (p value = 0.009).
Notably, although a large proportion of the girls (47.0%) did not mention regular consumption of sweet foods for more than six months (maintenance stage) (Table 3), 53% reported regular consumption of this food group.
Table 3

The results of the Poisson regression analysis, adjusted for covariates with a p value < 0.2 in the univariate analysis, age (for fruits) and sex (for vegetables), are shown in Table 4. Notably, SCEB was associated with consumption frequency only for the food groups associated with healthy eating, such as fruits and vegetables. These results indicate that adolescents, in all stages of behavioral change, are more likely to have irregular fruit consumption. However, those in the "precontemplation" stage were more than twice as likely to have irregular consumption as those in the "maintenance" stage (PR = 2.21; 95% CI = 1.81-2.68, p value < 0.001). The further from the maintenance stage, the greater the chance of the adolescent not having regular fruit consumption, with a decreasing trend in PR as the stages progress (Table 4).
Table 4

With respect to vegetable consumption, adolescents in all SCEB stages, except for the "action" stage, were more likely (p < 0.001) to not have regular vegetable consumption. Those in the "precontemplation" (PR= 2.55; 95% CI= 2.08-3.10, p value < 0.001) and "contemplation" (PR= 2.07; 95% CI= 1.57-2.72, p value < 0.001) phases were twice as likely not to consume vegetables as were those in the maintenance phase (Table 4). These findings indicate that as adolescents progress through stages of change, approaching maintenance, there is a progressive improvement in their eating behavior, particularly in terms of increased fruit and vegetable consumption.

DISCUSSION
This study evaluated the stages of change in the eating behavior of 880 students from public schools in Montes Claros/MG, Brazil. It revealed that the majority self-reported being in the most advanced stages of the MTT for the different food groups evaluated. These results differ from those of other studies involving Brazilian schoolchildren13,17.
A study was conducted with adolescents and young adults (10-24 years old)13 from the Federal District/Brazil, to analyze the associations among SCEB, the consumption of healthy food markers (fruits and vegetables), and self-efficacy in adopting healthy eating practices. The results revealed that most students were in the least advanced stages (contemplation, 39.2%; precontemplation, 22.5%). Similarly, another study that aimed to verify the influence of the stage of readiness for behavioral change on the variation in food consumption (sweetened beverages, biscuits, fruits, and beans) of adolescents participating in a school-based community trial in Duque de Caxias17 reported that the majority were in the precontemplation stage (52%).
However, it is important to highlight that although in the present study, the students are in more advanced SCEB, we cannot say that it is free from an erroneous perception of adolescents about their food consumption, since in the assessment of the frequency of food consumption, the group of sweets showed regular consumption by a large number of the girls, despite them self-reporting that they were in the "maintenance" stage for this food group.
Notably, the students who attended the evaluated schools were those where the SHP was very active, and more than half of the students (n = 424) mentioned having already received some nutritional care. This justifies having information about foods that should be avoided or consumed to maintain a healthy diet and explains why many students reported being in "action" or "maintenance" of healthy eating practices, consuming unhealthy foods less regularly, and foods that are markers of a healthy diet (fruits and vegetables) more regularly.
A survey of Brazilian adolescents14 revealed a discrepancy between reported consumption and the dietary perceptions of the study participants, as 79.7% and 83.7% of adolescents mistakenly believed that their consumption of fruits and vegetables, respectively, was adequate when it was not.
The associations between sociodemographic, anthropometric, and behavioral variables and SCEB were evaluated for the different food groups. The age of the adolescents was associated only with fruit consumption, which was more prevalent among younger adolescents. Gender was associated with the consumption of vegetables and sweet foods. This result differs from that of Hintze et al.29, who reported that older adolescents presented more advanced SCEB in relation to the consumption of fruits, vegetables, and fatty foods but did not find an association with BMI or sex among adolescents.
In the present study, being eutrophic was associated with more advanced SCEB for the consumption of fatty foods. Bolognese et al.12, who evaluated the metabolic profile and its association with the stages of readiness for change in eating behavior and physical activity among overweight adolescents from Maringá, Paraná, Brazil, also reported similar results but were worse than those of this study. These authors12 reported that, in the domain of “amount of fat in the diet,” most participants were in the action stage (37.5%), followed by the preparation stage (33.8%). Notably, the participants in the study by Bolognese et al.12 were overweight or obese and were in a multidisciplinary obesity treatment program12.
No significant associations were observed between the variable “received nutritional care” and the food groups evaluated. However, it is worth noting that nutritional care was considered not only individual care within a health service or at school but also participation in nutrition workshops conducted by the SHP at school or in other nutrition activities at a different location. The latter, although important actions for raising awareness about healthy eating, do not provide individual follow-ups, which could be a crucial factor in changing eating behavior.
When we studied SCEB as an explanatory variable for the regular consumption of fruits, vegetables, and sweet and fatty foods, we found that the stages of change were not associated with the consumption of sweet or fatty foods but were associated with the consumption of fruits and vegetables. These results corroborate studies that indicate that being more advanced in the SCEB has a more positive effect on attitudes toward health13. This fact is a premise of the transtheoretical model30, which states that individuals in more advanced stages tend to have a greater number of positive attitudes related to nutrition13,15, adiposity12, and biochemical parameters12, allowing them to achieve better health status.
On the other hand, it is common to observe that being classified in the first stage of SCEB (“precontemplation” and “contemplation”) is associated with a higher consumption of unhealthy foods13,30,31. However, in the present study, no associations were found between unhealthy foods (sweet or fatty foods) and the stages of change, even after adjustments were made for the control variables. These findings suggest that adolescents in the final stages of MTT have increased their intake of healthy foods but have not necessarily reduced their consumption of unhealthy foods.
The habitual consumption of these foods, which can be classified as ultraprocessed foods32, likely occurs not solely because of the appreciation for this type of food but rather because of the search for identity and social approval, which is commonly found in adolescence33, as well as the low cost. Some studies have shown a connection between the price of unhealthy foods and their consumption, mainly by adolescents, which involves a complex interaction of factors34,35.
It is also possible that MTT is more effective in promoting gains (e.g., eating more fruit) than in reducing behaviors (e.g., eating fewer sweets), especially in adolescents, where there is strong social influence and easy access, as mentioned above. Furthermore, it is known that during adolescence, there is a greater demand for sweets, especially among girls36,37.
The limitations of this study stem from its cross-sectional nature, which does not allow for the identification of causal factors, including the influence of stages of behavioral change, particularly since it relies on a self-report questionnaire. Another limitation is puberty and its alterations, which are important factors to consider in the participants of this study. On the other hand, observational studies can generate hypotheses that improve the direction of future investigations. Furthermore, the consumption of food groups was reported by adolescents in the seven days preceding the survey, which may introduce a possible bias, as the instrument for assessing food group consumption, although validated and widely used in national research with adults25, was adapted for adolescents.

CONCLUSION
Most of the adolescents who participated in this study self-reported being in the final stages of “action” and “maintenance” of the MTT. The results showed that adolescents in the initial stages of behavioral change (“precontemplation” and “contemplation”) were less likely to have a regular consumption of healthy foods, as assessed in this study through the consumption of fruits and vegetables. However, this relationship was not observed for the consumption of unhealthy foods, assessed through foods high in sugars and fats. These data suggest that adolescents who are in the final stages of the MTT may have increased consumption of healthy foods, but do not necessarily reduce their consumption of unhealthy foods.
Furthermore, adolescents\' perceptions of the stages of behavioral change and the frequency of food consumption may be misleading. Sweets were frequently consumed by a large proportion of the girls; however, they self-reported being in the “maintenance” stage for this food group.
The results of this study provide a basis for healthcare professionals to guide nutritional interventions that better manage the consumption of unhealthy foods, thereby improving the eating habits of adolescents. Future studies should explore personal and environmental factors that contribute to unhealthy eating habits in adolescents at all stages of change. Furthermore, developing an algorithm to describe healthy eating is crucial for research aimed at evaluating these diverse food groups.

ACKNOWLEDGEMENTS
We thank all participants of this study, without whom this research would not have been possible.
FUNDING
Coordination for the Improvement of Higher Education Personnel - CAPES code 001.
CONFLICT OF INTEREST
The authors declare that there are no conflicts of interest.
DATA AVILABILITY
All data described in the study will be made available upon reasonable request and approval from the team.
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