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Conteúdo (article):

Brazilian school-based survey of adolescent health: food intake markers, by geographical region, in the 2019 PeNSE.

Juliane Macedo dos Santos, Universidade Federal do Piauí-UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil. ID ORCID: 0000-0002-2895-6106, giulianemacedo@gmail.com.

Bruna Grazielle Mendes Rodrigues, Universidade Federal do Piauí-UFPI, Programa de Pós-graduação em Alimentos e Nutrição, Teresina, Piauí, Brasil. ID ORCID: 0000-0002-0190-4138, bgrazielle67@gmail.com.

Vanessa Silva do Nascimento, Universidade Federal do Piauí-UFPI, Programa de Pós-graduação em Alimentos e Nutrição, Teresina, Piauí, Brasil. ID ORCID: 0000-0002-5404-0134, vanessanascimento@ufpi.edu.br.

Layanne Cristina de Carvalho Lavor, Universidade Federal do Piauí-UFPI, Programa de Pós-graduação em Alimentos e Nutrição, Teresina, Piauí, Brasil. ID ORCID: 0000-0003-3954-2870, layannecristina94@gmail.com.

Márcio Dênis Medeiros Mascarenhas, Universidade Federal do Piauí-UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID: 0000-0001-5064-2763, mdm.mascarenhas@gmail.com.

Malvina Thaís Pacheco Rodrigues, Universidade Federal do Piauí-UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID: 0000-0001-5501-0669, malvina@ufpi.edu.br.

Fernando Ferraz do Nascimento, Universidade Federal do Piauí-UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID: 0000-0003-0625-0097, fernandofn@ufpi.edu.br

Karoline de Macêdo Gonçalves Frota, Universidade Federal do Piauí-UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID: 0000-0002-9202-5672, karolfrota@ufpi.edu.br

ABSTRACT
A cross-sectional study was conducted with data from the 2019 National School Health Survey (n = 129,922) to examine the prevalence of intake of healthy and unhealthy marker foods in adolescents, by school administration type (public or private) and geographic region. Using Poisson regression, prevalence and crude-to-adjusted prevalence ratios were estimated, by sociodemographic variables, school administration type and geographic region. Adolescents at private schools returned lower prevalences of intake of beans (PRadj = 0.88; 95%CI = 0.86-0.90) and soft drinks (PRadj = 0.93; 95%CI = 090-0.97) and higher intake of fruit (PRadj = 1.06; 95%CI = 1.04-1.09) and vegetables (PRadj = 1.09; 95%CI = 1.07-1.12) than those at public schools. Fruit and vegetable intake was significantly higher in the South (PRadj = 1.28; 95%CI = 1.24-1.32) and Midwest (PRadj = 1.17; 95%CI = 1.13-1.20) regions. The Midwest region returned the highest prevalences of intake of soft drinks (PRadj = 1.40; 95%CI = 1.33-1.46) and sweet treats (PRadj = 1.24; 95%CI = 1.20-1.28). Adolescents at private schools were better protected by healthy consumption, while, by region, those in the Midwest, South and Southeast were more exposed to less healthy consumption.
Keywords: diet; adolescent; ultraprocessed foods; cross-sectional studies.

INTRODUCTION
Adolescence is a period of biological, emotional and social changes that associate with modifications in eating habits, which can result in the adoption of unhealthy diets involving low intake of fresh foods and higher intake of ultraprocessed foods (UPFs) 1.2. Higher intake of UPFs is associated with diets that are hyper-calorific, of poor nutritional quality and delivering lower intake of the food fibres and micronutrients present in fresh foods 3.4.
Populations’ changing dietary patterns have brought about a nutritional transition characterised by increasing prevalence of overweight and obesity. In 2020, 31.9% of Brazilian adolescents treated in primary health care facilities were classified as overweight and 12%, as obese; an estimated 11 million adolescents were overweight and 4.1 million, obese 5. Overweight is the main nutritional condition connected with inappropriate diet in all age groups, including adolescence. In this latter population, body weight has been found to be the main reason for accessing health services, as shown by data from Brazil’s 2015 national schoolchildren’s health survey (Pesquisa Nacional de Saúde do Escolar, PeNSE) 6.7.
Inappropriate diet, physical inactivity, worsening sleep quality and increasing screen time have favoured rising prevalence of ever earlier overweight and obesity, as well as the development of related comorbidities, all increasing the risk of developing chronic non-communicable diseases, such as diabetes, cardiovascular diseases, cancer and higher odds of mortality 1.8-10.
In that context, food intake needs to be examined in the light of better knowledge of the realities of the adolescent population, as well as the deficiency and overweight conditions that originate in childhood and adolescence and can persist through to other stages of life. Knowledge of diet at this early stage can inform interventions to reduce obesogenic behaviour while taking account of regional differences in eating habits in a country of continental dimensions, such as Brazil.
Given that diet and nutrition are determinant and conditioning health factors, knowledge of a population’s diet is essential in order to encounter a scenario more favourable to promoting healthy dietary profiles ¹¹. Dietary markers are being used to determine food intake, because of the importance of monitoring certain markers of healthy diet, comprising fresh foods such as fruit, vegetables and beans, and unhealthy diet based on ultraprocessed foods, so as to guide health policies and measures ¹²,¹³. In order to monitor health among schoolchildren, a health survey, the PeNSE, has been applied regularly in all regions of Brazil 14.
Studies based on the PeNSE – since the first edition in 2009, as well as in the 2012 and 2015 editions – have shown high intake of unhealthy diet markers, demonstrating the need to monitor and intervene in adolescent diets 15.16. Accordingly, this study drew on the 2019 PeNSE to examine the prevalence of healthy and unhealthy diet markers in Brazilian adolescents’ diets, by school administration type (public or private) and geographical region.

METHODS

Study design

This analytical cross-sectional study considered Brazilian adolescents enrolled in the sixth to ninth years of lower secondary school and the first to third years of upper secondary school. It used secondary data originating from the 2019 edition of the PeNSE survey of Brazilian schoolchildren, conducted since 2009 in partnership between Brazil’s official bureau of statistics, the Instituto Brasileiro de Geografia e Estatística (IBGE), and the Ministries of Health and Education.
The study participants were approximately 188,000 schoolchildren, as the intention was to provide information to inform monitoring of risk behaviour in the school population. All questionnaires with complete answers on the set of study variables were considered eligible for inclusion in the study.

Inclusion and exclusion criteria

The study participants were adolescents of both sexes attending public and private schools in urban and rural areas of all Brazil’s state capitals and the Federal District. All students who did not provide complete responses on the set of study variables were excluded from the study.

Data collection

Study data were collected between April and September 2019 by applying a student questionnaire addressing topics of food intake, oral health, physical activity, body image, security, home and school situation, health service access, sexual and reproductive health, smoking, alcohol and drug use. This study considered only the data on the adolescents’ eating habits and sociodemographic characteristics.

Instrument and variables

The dependent variables examined in order to ascertain the adolescents’ eating habits were those relating to intake of fruit, vegetables, beans, sweet treats, soft drinks, fast food snacks and skipping breakfast, as given in responses to the PeNSE questionnaire. The independent variables considered were the sociodemographic characteristics sex, age, school administration type, adolescent’s level of schooling, mother’s level of schooling and geographical region.
The adolescents’ sociodemographic characteristics were ascertained by way of data on sex (male or female), age (< 13 years; 13-15 years; 16-17 years; ≥ 18 years), school administration type (public or private), level of schooling: lower secondary school (6th year; 7th year; 8th year; or 9th year); and upper secondary school (1st year; 2nd year; or 3rd year), mother’s level of schooling (no schooling; lower secondary school, incomplete/complete; upper secondary school, incomplete/complete; higher education, incomplete/complete) and geographical region of residence (North; Northeast; South; Southeast; and Midwest).
In order to determine markers of healthy or unhealthy diet, foods were categorised, by degree of processing. Fresh or minimally processed (fresh fruit or fruit salad, legumes and/or vegetables and beans), were considered to be markers of healthy diet. Ultraprocessed foods (soft drinks, sweet treats and fast food) were considered to be markers of unhealthy diet. Regularly skipping breakfast was considered to be a marker of unhealthy behaviour.
Food intake was ascertained from the responses to the food frequency questionnaire, which inquired whether or not, in the seven days prior to the survey, the respondent had consumed the healthy diet markers, soft drinks, sweet treats and fast food (In the last 7 days, I consumed on 1 day; 2 days; 3 days; 4 days; 5 days; 6 days; Every day), where intake on five or more days per week was considered to be regular. Regularly skipping breakfast was ascertained by the variable for eating this meal (Yes, every day; Yes, 5 to 6 days a week; Yes, 3 to 4 days a week; Yes, 1 to 2 days a week; Rarely; No) and defined as eating breakfast on fewer than five days a week. The questions on food intake in the questionnaire were:
- In the past 7 days, on how many days did you eat beans?
- In the past 7 days, on how many days did you eat at least one type of legume or vegetable, except potato or cassava (manioc/yucca)?
- In the past 7 days, on how many days did you eat fresh fruit or fruit salad?
- In the past 7 days, on how many days did you eat sweet treats, such as sweets, confectionery, chocolates, chewing gum, individual chocolates with filling, lollipops or others?
- In the past 7 days, on how many days did you drink soft drinks?
The study also examined whether or not the adolescents skipped breakfast, which was included as a marker of unhealthy eating behaviour:
- Do you usually have breakfast?
The study population was described by relative frequency distribution, by sex, age group, mother’s level of schooling, school administration type and geographical region. Percentage intakes were then estimated, so as to ascertain regular intake of healthy and unhealthy diet markers in the overall school sample, as well as by school administration type and geographical region of residence.

Statistical analysis

The data were presented in the form of relative prevalences and their respective confidence intervals (95%CI). The association of prevalence of intake of food markers for healthy and unhealthy eating habits/regularly skipping breakfast with type of school, as well as with geographical region, were examined by Poisson regression with robust variance, and expressed as crude prevalence ratios (PRs) and PRs adjusted for potential confounders. Potential confounders contemplated were age, sex, adolescent’s level of schooling and mother’s level of schooling, which were used to adjust the prevalence ratios.
The analyses were performed using the survey mode of Stata (Statistical software for data science), version 13.0 (https://www.stata.com), with post-stratification weighting. The level of significance was set at 5%.

Ethical considerations

The four editions of Brazil’s PeNSE school health survey (2009, 2012, 2015 and 2019) were approved by the national human subject research ethics committee, attached to the Ministry of Health, under Opinion No. 11.537, the information of which is available for public access and use. The information on the adolescents and schools participating in this study are confidential and unidentifiable. As the study was conducted with secondary data, it did not need to be submitted to a research ethics committee.

RESULTS
After exclusion of any questionnaires lacking complete responses on the set of study variables, the sample comprised 129.922 adolescents. Most were female (51.9%; 95%CI = 51.6-52.2), in the 13 to 15 year age group (51.4%; 95%CI = 50.4-52.5), enrolled at private schools (51.88%; 95%CI = 50.4-53.3) and the mother’s level of schooling was reported as higher education (47.5%; 95%CI = 46.5-48.5) (Table 1).
Of the markers of healthy diet (regular intake ≥ 5 days a week), intake was poor in fruit (29.3%; 95%CI = 29.0-29.6) and vegetables (33.0%; 95%CI = 32.7-33.4) and regular in beans (51.9%; 95%CI = 51.4-52.4). Of the markers of regular intake of unhealthy diet (≥ 5 days a week), characterised by intake of UPFs, the variable that returned highest prevalence was sweet treats, reported by 32.5% of the adolescents (95%CI = 32.3-32.9), followed by soft drinks (15.8%; 95%CI = 15.5-16.0). Only 9.3% (95%CI = 9.2-9.6) of interviewees reported regularly skipping breakfast (Table 2).
On examining for an association between food intake and school administration type, in crude analysis (PR), regular intake of beans was found to be lower among students in private schools (PR = 0.85; 95%CI = 0.83-0.87). Regular intake of soft drinks (PR = 0.93; 95%CI = 0.90-0.96) was less frequent among private school students than among those at public schools. Private schools were also associated with higher prevalence of intake of sweet treats (PR = 1.06; 95%CI = 1.04-1.08), fruit (PR = 1.23; 95%CI = 1.20-1.25) and vegetables (PR = 1.25; 95%CI = 1.23-1.28), as well as with lower prevalence of regularly skipping breakfast (PR = 0.87; 95%CI = 0.83-0.90) (Table 3).
The associations persisted after adjustment, with adolescents at private schools showing lower regular intake of beans (PRadj = 0.88; 95%CI = 0.86-0.90) and soft drinks (PRadj = 0.93; 95%CI = 0.90-0.97) and higher intake of fruit (PRadj = 1.06; 95%CI = 1.04-1.09) and vegetables (PRadj = 1.09; 95%CI = 1.07-1.12. Adolescents at private schools were found to consume more fruit (32.2%; 95%CI = 31.7-32.7) and vegetables (36.6%; 95%CI = 36.1-37.1) than public school students, who returned regular intake values of 26.2% for fruit (95%CI = 25.8-26.6) and 29.2% for vegetables (95%CI = 28.7-29.6) (Table 3).
Markers of healthy eating showed regular intake of beans to be least prevalent in the South region (38.8%; 95%CI = 37.5-40.3), while regular intake of fruit was least prevalent in the North (26.2%; 95%CI = 25.5-26.9) and Northeast (26.8%; 95%CI = 26.3-27.3). The Northeast region also returned lowest prevalence of regular intake of vegetables (27.1%; 95%CI = 26.7-27.5). Prevalence ratios for intake of beans among adolescents were lowest in the South region (PRadj = 0.92; 95%CI = 0.88-0.96) and highest in the Southeast (PRadj = 1.47; 95%CI = 1.42-1.51), Midwest (PRadj = 1.44; 95%CI = 1.40-1.48) and Northeast (PRadj = 1.23; 95%CI = 1.19-1.27). Fruit and vegetable intake was less prevalent among adolescents in the Northeast region (fruit: PRadj = 1.04; 95%CI = 1.01-1.07; vegetables: PRadj = 0.83; 95%CI = 0.81-0.86) than in the South (fruit: PRadj = 1.28; 95%CI = 1.24-1.32; vegetables: PRadj = 1.16; 95%CI = 1.12-1.19), Southeast (fruit: PRadj = 1.22; 95%CI = 1.18-1.26; vegetables: PRadj = 1.09; 95%CI = 1.06-1.13) and Midwest (fruit: PRadj = 1.23; 95%CI = 1.19-1.28; vegetables: PRadj = 1.17; 95%CI 1.13-1.20) (Table 4).
The highest prevalence of sweet treat intake was found in the Midwest region (36.7%; PRadj = 1.24; 95%CI = 1.20-1.28), while the lowest occurred in the North, where 29.4% consumed this marker. Highest prevalence of regular soft drink intake was found in the Midwest region (20.9%; PRadj = 1.40; 95%CI = 1.33-1.46). The Northeast and North regions returned lowest prevalences of skipping breakfast, at values of 7.6% (PRadj = 0.93; 95%CI = 0.88-0.99) and 8.2%, respectively (Table 4).

DISCUSSION
During adolescence, there is an increase in behaviour and attitudes that can incur health risks, including inappropriate diet, in which UPFs, due to ease of access and palatability, contribute significantly to daily calorie consumption 16-18. Intake of fresh and minimally processed foods, such as beans, fruit and vegetables, has been found to decrease among youth, while UPF intake increases 19.20.
More than half the adolescents were found to eat beans regularly, making them the most prevalent marker of healthy diet. Prevalence of regular intake of beans was higher among adolescents at public schools than at private schools, corroborating studies conducted with data from earlier editions of the PeNSE. In 2009, 2012 and 2015, prevalences of this intake marker were 62.5%, 60.0% and 56.3%, respectively, demonstrating considerable decline in intake of beans over time. Changing eating habits, adolescents’ social contexts and media impacts on diet have been identified as possible factors influencing this scenario 21-24. Also, although trend analyses based on the PeNSE have found steadily decreasing intake of beans, higher regular intake among adolescents at public schools may result from the introduction of Brazil’s national school meals programme (Programa Nacional de Alimentação Escolar, PNAE), which is designed to offer students at public schools meals based on intake of fresh and minimally processed foods, which is considered essential as a strategy for improving school children’s eating habits 25.26.
A study of the prevalence of sweet treat and soft drink intake, based on comparable data from the 2009, 2012 and 2015 editions of the PeNSE, also found intake of these unhealthy foods to be decreasing steadily over the editions of the survey. In 2009 and 2015, prevalences soft drink intake were 37.2% and 28.8%, respectively, while sweet treat intake was 50.9% and 40.9% prevalent 21. The study showed that, despite these reductions, both markers of unhealthy diet still form a regular part of adolescents’ diet, in that they are consumed on 5 or more days a week 17.27. A population-based study of adolescents and young adults in the municipality of São Paulo found that the main foods contributing to adolescents’ total calorie intake were, in order of frequency, cakes, sweets and sweet treats, sugary drinks and salty snacks, which contributed 30.5% of this age group’s energy intake 28, demonstrating the impact that these high energy, low nutritional quality foods have on this population’s dietary routines.
That study also found low prevalence of skipping breakfast, which is an important factor in that lesser adherence to regular intake of this meal has been associated with higher intake of UPFs, lower intakes of fruit and vegetables, the development of overweight conditions and increased cardiovascular risk in adolescent populations 18.29-31. In 2012 and 2015, prevalence of skipping breakfast was 38.1% and 35.4%, respectively, indicating that the number of adolescents who do not breakfast regularly has been decreasing over editions of the PeNSE 26.
It is in this population that health-risk behaviour builds up and, at this stage of life, inappropriate eating habits have conspicuous impact as a determinant and conditioning factor in health and disease. Intake of markers of unhealthy diet, characteristically UPFs, has been associated with other factors such as sedentarity, mother’s level of schooling and school administration type 16.21.32.33. Studies conducted with data from the 2015 PeNSE have demonstrated associations between length of time in sedentary activity, mother’s level of schooling and higher prevalence of unhealthy food intake 20.32.
By public or private school administration type, prevalence of UPF intake was greater among adolescents at private schools 16.21.32. That study, however, found that sweet treats was the only unhealthy diet marker more prevalent among adolescents at private schools than among public school students.
In that context, school environment showed significant impact on adolescents’ eating habits. The kiosks and snack bars present in these environments, where food is sold inside and around schools, influence adolescents’ food choices. Their presence is one of the major factors in lesser adherence to school meals; they are often found in private schools and, for lack of sufficient regulation of this commerce, are still present in public schools. These stalls and snack bars foster continuous contact with UFPs 34, and heighten the risk of forming and establishing inappropriate eating habits which, when associated with the other inappropriate behaviour, increase the risk of developing obesity, diabetes, arterial hypertension, dyslipidemia and cardiovascular diseases 1.35-37.
Studies based on the 2015 PeNSE found that students at schools where meals were not offered in accordance with PNAE guidelines were more likely to consume UPFs than students enrolled at schools covered by the programme, underlining the fact that the presence of private stalls and snack bars at schools is associated with Brazilian adolescents’ consuming more inappropriate food 1.38.39. On the other hand, studies have highlighted challenges in putting the PNAE into practice, caused by low adhesion to school meals, which may be related to lower fruit and vegetable intake among adolescents enrolled in public schools. A study of 10,262 public school students found low prevalence of adherence to the meals offered by the programme, with 64.2% of students not eating school meals 40.41. Lower fruit and vegetable intake may also result from factors such as poor access to healthy foods on sale close to residences and schools, and to greater or lesser seasonal supply of fresh and minimally processed foods, which can favour economically less-favoured adolescents’ access to, and intake of, these foods 29.42-44.
A study of schoolchildren from 13 to 15 years old in the Greater Vitória region of Espírito Santo state, in Brazil’s Southeast region, found attending a private school to be a protective factor against intake of UPFs, as compared with adolescents at public schools 43. The findings of that study showed that prevalence of regular intake of fruit and vegetables was greater among adolescents at private schools than among those enrolled in public schools, and soft drink intake was lower.
It was found that adolescents’ diets may vary by geographical distribution, although this variable has been little explored. Nonetheless, it is important that it be studied in order to inform strategies at the national and regional levels to combat excessive intake of UPFs and to strengthen appropriate diets, while respecting the specific features and food cultures of different regions of Brazil, by continuing to expand the PNAE and strengthening food education in various different settings, including schools.
In the comparison made, by administrative regions of Brazil, to ascertain the prevalence of UPF intake among adolescents participating in the 2015 PeNSE, the Southeast region returned the highest prevalence of intake of these foods, while the North region returned the lowest 16. That situation persists, according to a study to examine food patterns among Brazilian adolescents by geographical region, which also found that it was in the North region that adolescents have maintained a diet closest to the typical regional diet 45. In the 2019 PeNSE, the North region continued to return the lowest prevalence of regular UPF intake among Brazilian regions, while the Midwest region returned the highest. That scenario is consistent with observations regarding adolescent diets, which found significantly higher prevalences in Brazil’s more developed regions. Skipping breakfast was another unhealthy habit with regional associations and was also more prevalent in the more developed regions (Southeast, Midwest and South) than in the North and Northeast 16.30.45.46. Nonetheless, the more developed regions returned the highest prevalences of fruit and vegetable intake by adolescents, a scenario which may result from higher purchasing power and residence in more urbanised areas.
In addition to regional food culture, less favoured socioeconomic position, less urbanised region of residence, residence in rural areas and in the North and Northeast regions have all been observed to associate with less access to purchase of UPFs and with more appropriate eating habits among adolescents, demonstrating that sociodemographic factors influence these individuals’ dietary profiles 2.
The PeNSE provides information that is essential to understanding aspects of school children’s health. The data its supplies make it possible to formulate and implement public policies directed to this population. There is a constant need for studies of risk behaviours in this age group, in various dimensions, including diet, which has substantial impact on quality of life and the development of health conditions originating in adolescents and extending into adult life.
The data examined in this study were both substantial and representative, given the methodological procedures employed and because they were population-based and nationally representative, which is important in identifying the behaviour of Brazilian adolescents. The study does, however, suffer from the limitation that the information was self-reported by the participants. Also, as the study design was cross-sectional, it is not possible to make causal inferences.
It is also suggested that the data by geographical region continue to be explored, so as to contribute to policy making directed to inequities among Brazilian regions, in that inappropriate diet has impact in the spread of conditions of obesity and chronic non-communicable diseases, increasing morbidity and mortality and incapacity, resulting in greater demand for, and spending on, health services.

CONCLUSION
Brazilian adolescents were found to display inappropriate dietary behaviour as regards regular intake of markers unhealthy diet, specifically sweet treats and soft drinks, and low intake of fruit and vegetables. These data demonstrate the need for attention to the impact of the school environment on this scenario and the need to regulate and oversee the sale of foods in these environments. Geographical region was also found to associate with intake of food markers, calling for differentiated care based on the specifics of each region.

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