Abstract

The aim of the present study was to analyze the relationship between time spent engaged in sedentary behaviors, type of diet, and overweight in adolescents. A cross-sectional study using data from the Longitudinal Study on Sedentary Behavior, Physical Activity, Eating Habits, and Health of Adolescents - LONCAAFS Study. A total of 1,438 adolescents (10 to 14 years old) from public schools in the city of João Pessoa, Brazil, participated in the study. To evaluate the combined effects of excessive time in sedentary behavior and consumption from two food groups: Convenience and Prudent on overweight, we performed multiple logistic regression analyses, adjusted for energy, level of physical activity, sex, and age. Excessive time in sedentary behavior increased the chance of adolescents being overweight by 37% (OR = 1.37; 95%CI: 1.04-1.80). This chance increased to 43% when the adolescents were simultaneously engaged in excessive sedentary behavior and had high consumption of the Convenience food group (OR = 1.43; 95%CI: 1.05-1.94) and increased to 39% on those who engaged in excessive sedentary behavior and had low consumption of foods from the Prudent (OR = 1.39; 95%CI: 1.04-1.84). Excessive sedentary behavior is associated with being overweight and the chance increases with the consumption of convenient foods.

Key words:
Overweight; Sedentary lifestyle; Diet; Adolescents

Resumo

O objetivo do estudo foi analisar a relação entre tempo gasto em comportamentos sedentários, dieta e excesso de peso em adolescentes. Estudo transversal com dados do Estudo Longitudinal sobre Comportamento Sedentário, Atividade Física, Hábitos Alimentares e Saúde do Adolescente - Estudo LONCAAFS. Participaram 1.438 adolescentes (10 a 14 anos) de escolas públicas de João Pessoa, Brasil. Para avaliar os efeitos combinados do tempo excessivo no comportamento sedentário e no consumo de dois grupos de alimentos: Conveniência e Prudente sobre o excesso de peso, foram realizadas análises de regressão logística múltipla, ajustadas para energia, nível de atividade física, sexo e idade. O tempo excessivo em comportamento sedentário aumentou em 37% a chance de os adolescentes apresentarem excesso de peso (OR = 1,37; IC95%: 1,04-1,80). Essa chance aumentou para 43% quando os adolescentes apresentaram, simultaneamente, comportamento sedentário excessivo e alto consumo do grupo de alimentos de conveniência (OR = 1,43; IC95%: 1,05-1,94), e aumentou para 39% naqueles com excesso de comportamento sedentário e baixo consumo de alimentos do Prudente (OR = 1,39; IC95%: 1,04-1,84). O comportamento sedentário excessivo está associado ao excesso de peso e a chance aumenta com o consumo de alimentos convenientes.

Palavras-chave:
Excesso de peso; Comportamento sedentário; Dieta; Adolescentes

Introduction

The increase in the prevalence of overweight in children and adolescents is a global concern due to the associated health problems that manifest at this stage of life and into adulthood¹1 Daw J, Margolis R, Wright L. Emerging adulthood, emergent health lifestyles: sociodemographic determinants of trajectories of smoking, binge drinking, obesity, and sedentary behavior. J Health Soc Behav 2017; 58(2):181-197.. It is one of the main risk factors for chronic non-communicable diseases (NCDs)²2 World Health Organization (WHO). Obesity and overweight [Internet]. [cited 2023 ago 3]. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/
http://www.who.int/mediacentre/factsheet... and is very costly with respect to health spending³3 Canella DS, Novaes HMD, Levy RB. The influence of excess weight and obesity on health spending in Brazilian households. Cad Saude Publica 2015; 31(11):2331-2341..

Overweight has multiple causes, and it is known that that they are closely correlated to increased consumption of high-energy foods rich in sugars and fats⁴4 Askari M, Heshmati J, Shahinfar H, Tripathi N, Daneshzad E. Ultra-processed food and the risk of overweight and obesity: a systematic review and meta-analysis of observational studies. Int J Obes 2020; 44(10):2080-2091., low rates of physical activity⁵5 Silveira EA, Mendonça CR, Delpino FM, Souza GVE, Rosa LPS, Oliveira C, Noll M. Sedentary behavior, physical inactivity, abdominal obesity and obesity in adults and older adults: a systematic review and meta-analysis. Clin Nutr ESPEN 2022; 50:63-73., and excessive engagement in sedentary behaviors⁵5 Silveira EA, Mendonça CR, Delpino FM, Souza GVE, Rosa LPS, Oliveira C, Noll M. Sedentary behavior, physical inactivity, abdominal obesity and obesity in adults and older adults: a systematic review and meta-analysis. Clin Nutr ESPEN 2022; 50:63-73.

6 Barbosa Filho VC, Campos W, Lopes AS. Epidemiology of physical inactivity, sedentary behaviors, and unhealthy eating habits among Brazilian adolescents: a systematic review. Cien Saude Colet 2014; 19(1):173-193.^-77 World Health Organization (WHO). Health Behaviour in School-Aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen: WHO; 2012.. Sedentary behaviors are activities with low energy expenditure (< 1.5 metabolic equivalents [METs]), performed while awake in a sitting or reclining position⁸8 Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE, Chastin SFM, Altenburg TM, Chinapaw MJM; SBRN Terminology Consensus Project Participants. Sedentary Behavior Research Network (SBRN) - Terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act 2017; 14(1):75.. These include watching television, using a computer, sitting during a transit commute, playing video games, using mobile devices and tablets, and others⁹9 Santos CC, Ressel LB, Alves CN, Wilhelm LA, Stumm KE, Silva SC. The influence of culture on eating behavior of adolescents: an integrative review of the productions in healthcare. Adolesc Saude 2012; 9:37-43.^,1010 Tremblay MS, LeBlanc AG, Kho ME, Saunders TJ, Larouche R, Colley RC, Goldfield G, Connor Gorber S. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act 2011; 8: 98..

Screen time, defined as the sum of the time spent watching television, using the computer, or playing video games, is the most frequently used method to determine a measure of sedentary behavior in studies with children and adolescents. Results fromThe Health Behaviour in School-aged Children(HBSC)¹¹11 World Health Organization (WHO). Health Behaviour in School-Aged Children (HBSC) study: international report from the 2013/2014 survey. Health policy for children and adolescents. Copenhagen: WHO; 2015., a research collaboration with the World Health Organization (WHO) Regional Office in Europe performed in 48 countries and regions in Europe and North America, in 2013/2014, reported that about 60% of adolescents, between 11 and 15 years old, spent two hours or more per day watching television¹¹11 World Health Organization (WHO). Health Behaviour in School-Aged Children (HBSC) study: international report from the 2013/2014 survey. Health policy for children and adolescents. Copenhagen: WHO; 2015.. In Brazil, according to the National Survey of Health in Schools (PeNSE) performed in 2019, approximately 40% of adolescents spend more than 2 hours a day watching television¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar (PeNSE). Rio de Janeiro: IBGE; 2019.. The Study of Cardiovascular Risks in Adolescents (ERICA) also showed that 70% of adolescents spend two or more hours per day in front of a television, computer, or video games¹³13 Oliveira JS, Barufaldi LA, Abreu GA, Leal VS, Brunken GS, Vasconcelos SML, Santos MM, Bloch KV. ERICA: use of screens and consumption of meals and snacks by Brazilian adolescents. Rev Saude Publica 2016; 50(Suppl. 1):7s..

Studies of adolescents have identified a direct association between screen time or its components (e.g, television and computer time) and an increase in the consumption of unhealthy foods¹⁴14 World Health Organization (WHO). Inequalites in young people´s health: Health Behavior in School-Aged Children (HBSC) international report from 2005-2006. Copenhagen: WHO; 2008.^,1515 Tambalis KD, Panagiotakos DB, Psarra G, Sidossis LS. Screen time and its effect on dietary habits and lifestyle among schoolchildren. Cent Eur J Public Health 2020; 28(4):260-266.. An inverse association has similarly been identified with the consumption of healthy foods such as fruit and vegetables¹⁵15 Tambalis KD, Panagiotakos DB, Psarra G, Sidossis LS. Screen time and its effect on dietary habits and lifestyle among schoolchildren. Cent Eur J Public Health 2020; 28(4):260-266.^,1616 Barr-Anderson DJ, Larson NI, Nelson MC, Neumark-Sztainer D, Story M. Does television viewing predict dietary intake five years later in high school students and young adults? Int J Behav Nutr Phys Act 2009; 6:7.. In Brazil, the ERICA study showed that 40% of adolescents reported consuming snacks in front of screens¹⁷17 Hobbs M, Pearson N, Foster PJ, Biddle SJ. Sedentary behaviour and diet across the lifespan: an updated systematic review. Br J Sports Med 2015; 49:1179-1188.. However, these results are still controversial; to specific questions about having meals and snacks in front of the television, which is a method that and uses time spent watching television as the only factor to estimate time in sedentary behaviors, when in actuality time spent in front of other types of screens is particularly relevant¹⁷17 Hobbs M, Pearson N, Foster PJ, Biddle SJ. Sedentary behaviour and diet across the lifespan: an updated systematic review. Br J Sports Med 2015; 49:1179-1188.. In addition, these studies were conducted primarily with adolescents from developed countries¹⁷17 Hobbs M, Pearson N, Foster PJ, Biddle SJ. Sedentary behaviour and diet across the lifespan: an updated systematic review. Br J Sports Med 2015; 49:1179-1188..

It is assumed that adolescents who spend more time on screen activities have a poorer quality diet, with higher consumption of snacks with high energy density and low nutritional value, and that the consumption of these foods and screen time act synergistically and are directly associated with overweight. Thus, this study analyzed the relationship between time spent engaging in sedentary behaviors, type of diet, and overweight in adolescents.

Materials and methods

This study uses data collected in the base year (2014) of the Longitudinal Study on Sedentary Behavior, Physical Activity, Diet and Health of Adolescents (LONCAAFS Study). LONCAAFS is a longitudinal study (2014-2017), carried out with a representative sample of 6th grade adolescents, in the base year (2014), from public schools (municipal and state) of elementary education II in the city of João Pessoa, Paraíba, with the aim of analyzing the interrelationships between sedentary behavior, physical activity, nutrition and health in adolescents.

For the calculation of sample size, the following parameters were considered: a reference population size of 9,520 schoolchildren in their sixth year of primary school II in 2013, an outcome rate of 50%, a degree of error of four percentage points, a confidence interval of 95%, and a design effect (deff) equal to 2. Based on these parameters, the minimum sample size established was 1,130 adolescents. This was, however, increased by 40% to compensate for losses and refusals, resulting in a sample of 1,582 adolescents. Subsequently, the sample power was calculated for the present study, which was 99%.

Twenty-eight schools (15 municipal and 13 state schools) were systematically selected to constitute the sample. They were distributed proportionally to the geographical region (North, South, East, and West) and to number of students enrolled in their sixth year. In the selected schools, all students in their sixth year of primary school II education were invited to participate in the study.

Adolescents who were part of the 1st moment of LONCAAFS and who had performed analysis of food consumption, anthropometry and answered a questionnaire on sedentary behavior were included for analysis. The exclusion criteria adopted were: adolescents outside the age range of interest in the study (under 10 and over 14 years old in 2014); having a disability that prevented or limited the practice of physical activity or answering the questionnaire; be pregnant; not having performed anthropometric measurements (height, body mass); not having performed the 24-hour recall.

Data collection

The LONCAAFS Study began in February 2014, with three more consecutive years (2015 to 2017) with collections carried out annually, in the same schools and in the same evaluation periods of the initial year. The present study used data collected in 2014. Data collection was conducted in the school during regular classes’ hours, between February and December 2014 by a trained team consisting of undergraduate and graduate students and professionals in the areas of nutrition and physical education. For data collection of demographic variables, sedentary behavior, and physical activity, a questionnaire was administered in a face-to-face interview that lasted, on average, for 50 minutes. The questionnaire was previously tested, in a pilot study¹⁸18 Barbosa Filho VC, Rech CR, Mota J, Farias Júnior JC, Lopes AS. Validity and reliability of scales on intrapersonal, interpersonal and environmental factors associated with physical activity in Brazilian secondary students. Rev Bras Cineantropom Desempenho Hum 2016; 18(2):207-221.

19 Farias Júnior JC, Loch MR, Lima Neto AJ, Sales JM, Ferreira FELL. Reproducibility, internal consistency, and construct validity of KIDSCREEN-27 in Brazilian adolescents. Cad Saude Publica 2017; 33(9):e00131116.^-2020 Prazeres A, Barbosa AO, Mendonça G, Farias JC de. Reproducibility and concurrent validity of the Physical Activity Questionnaire for Adolescents (QAFA) aged 10-14 years. Rev Bras Cineantropom Desempenho Hum 2017; 19(3):270-282., with students in the same school grade, from schools that were not selected for the study.

The data were tabulated with EpiData 3.1 (Epidata Assoc., Odense, Denmark), following a double data entry process with automatic checks of the consistency and amplitude of the responses for the variables. The “validate double data entry” tool was used to identify typographical errors, which were subsequently corrected.

Dietary assessment

Information on adolescents’ dietary intake was collected based on their memory of the preceding 24 hours. Adolescents reported the food and beverages they consumed during the last 24 hours, the way it was prepared, the commercial brand of any processed foods, and the weight and size of portions. A second R24h was applied to 30% of the total sample to decrease the intrapersonal variability of the diet and increase the accuracy of the estimated dietary intake. The collected data were converted in to energy and nutrients using a Brazilian software, Virtual Nutri Plus version 2015 (January 2015). Usual energy, macro and micronutrient consumption was estimated using Multiple Source Method (MSM)²¹21 Harttig U, Haubrock J, Knüppel S, Boeing H. The MSM program: web-based statistics package for estimating usual dietary intake using the Multiple Source Method. Eur J Clin Nutr 2011; 65(Suppl. 1):S87-S91.. This method is suitable to estimate individual usual intake in the case of repeated measurements and a defined time period. The Multiple Source Method (MSM) is characterized by a two-part shrinkage technique applied to residuals of two regression models, one for the positive daily intake data and one for the event of consumption²¹21 Harttig U, Haubrock J, Knüppel S, Boeing H. The MSM program: web-based statistics package for estimating usual dietary intake using the Multiple Source Method. Eur J Clin Nutr 2011; 65(Suppl. 1):S87-S91..

Two food groups were formed, which were not inclusive of all foods: Group 1 - Prudent foods, were characterized by foods low in sugars, fats, and sodium and with high nutritional value, such as fruits and natural juices, beans and vegetables, dairy products, root vegetables, and tubers; Group 2 - Convenience foods, were characterized by high-energy foods rich in sugars, fats, and sodium, and with low nutritional value. Examples are sweets, desserts, ice cream, cookies, cakes, pies, biscuits, sugary drinks, snacks in general, sausages, pastries, and instant noodles. Based on reported consumption of foods from these groups, an individual’s energy consumption with respect to each group was considered. In order to identify adolescents with higher or lower consumption of foods from the two groups, the median value of energy from each food group (Prudent and Convenience) was used.

Sedentary behavior

Sedentary behavior (“screen time”) was determined through measuring the average time spent in activities such as watching television, using the computer/tablet, and playing video games. Separate measures were considered for weekdays and weekends. For analytical purposes, the arithmetic mean was calculated by multiplying the mean time for weekdays by five and by multiplying the mean for weekends by two, and then dividing by seven to obtain the mean time per day (hours/day) of sedentary behavior. The cutoff time of more than two hours per day was used to define “excessive time in sedentary behavior”, based on screen time²²22 American Academy of Pediatrics. Children, adolescents, and television. Pediatrics 2001; 107(2):423-426.^,2323 Silva KS, Minatto G, Bandeira AS, Santos PC, Sousa ACFC, Barbosa Filho VC. Sedentary behavior in children and adolescents: an update of the systematic review of the Brazil's Report Card. Rev Bras Cineantropom Desempenho Hum 2021; 23:e82645..

Outcome assessment

For weight measurement, a digital Techline brand scale, with an accuracy of 100 g, was used. To measure height, a portable Sanny brand stadiometer was used. Measures of each adolescent’s weight and height were taken in triplicate, always by the same evaluator, and the average was used for posterior calculations. Body Mass Index (BMI) was calculated in accordance with the recommendations of the WHO, with sex and age taken into account²⁴24 World Health Organization (WHO). Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1995; 854:1-452.^,2525 World Health Organization (WHO). Growth reference data for 5-19 years [Internet]. [cited 2023 ago 3]. Available from: http://www.who.int/growthref/en/
http://www.who.int/growthref/en... . The adolescents were then categorized as either overweight or not overweight.

Covariate assessment

The sociodemographic variables were: sex (male or female), age in complete years (the difference between the date of data collection and date of birth), skin color (brown, black, white, Asian, or indigenous - according to the Brazilian Institute of Geography and Statistics - IBGE)²⁶26 Instituto Brasileiro de Geografia e Estatística (IBGE). Cidades [Internet]. [acessado 2023 ago 3]. Disponível em: https://cidades.ibge.gov.br/pesquisas
https://cidades.ibge.gov.br/pesquisas... , the mother’s level of education (illiterate or studied up to the 3rd grade, up to the 4th grade, incomplete primary education, completed primary education, incomplete secondary education, completed secondary education, incomplete higher education, or completed higher education) and economic class (using the methodology of the Brazilian Association of Research Companies - ABEP²⁷27 Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de Classificação Econômica [Internet]. [acessado 2023 ago 3]. Disponível em: Brasil. http://www.abep.org/criterio-brasil
http://www.abep.org/criterio-brasil... , which considers the presence of material goods and the presence of a salaried domestic employee in the residence, as well as the level of education of the parents, and groups people in the following classes: “A/B”, “C/D/E”). The groups “A/B” represent people higher economic status, and “C/D/E” correspond to lower economic status.

Level of physical activity was measured using a previously validated questionnaire, the Physical Activity Questionnaire for Adolescents²⁸28 Farias Júnior JC, Lopes AS, Mota J, Santos MP, Ribeiro JC, Hallal PC. Validity and reproducibility of a physical activity questionnaire for adolescents: adapting the Self-Administered Physical Activity Checklist. Rev Bras Epidemiol 2012; 15(1):198-210.. From a list of 19 physical activities ranging from moderate to vigorous, plus active commuting, the adolescents reported if they had performed or not such activities, for at least ten minutes each in the week prior to data collection. Those adolescents who did perform the activities then also reported the frequency and duration of performance of each activity. For purposes of analysis, a physical activity score, in minutes per week, was created from the sum of the performance time of all activities during the week. Adolescents were classified as physically active when they performed 420 minutes of physical activity or more per week²⁹29 World Health Organization (WHO). Guidelines on Physical Activity and Sedentary Behaviour. Geneva: WHO; 2020..

Statistical analysis

Descriptive analysis, tests were performed to ascertain mean, median, and frequency measurements. The Chi-square test was used to compare the proportion of adolescents with excessive time in sedentary behavior and the median consumption of food from the Prudent and Convenience food group, with sex, age, skin color, economic class, parental education, overweight and level of physical activity.

The association between intake from the Prudent and Convenience food groups, excessive time in sedentary behavior, and overweight was evaluated using logistic regression. Overweight was considered the outcome, and the combined effect of excessive time in sedentary behavior and food consumed was considered to be the independent variable. Thus, to obtain the combined effect, two variables were created. The variable that expressed the interplay of engagement in excessive time in sedentary behavior and prudent food consumption pattern had three categories. The first category (for reference) was defined as without engagement in sedentary behavior based on screen time (≤ 2 hours/day). The second category was defined as engagement in excessive time in sedentary behavior (> 2 hours/day) along with below the median consumption of foods from the Prudent group (lower consumption of foods considered to be indicators of a healthy diet). The third category was defined engaged in excessive time in sedentary behavior (> 2 hours/day) as well as above the median consumption of foods from the Prudent group (higher consumption of prudent foods considered to be indicators of a healthy diet). The second variable, that expressed the interplay of engagement in excessive time in sedentary behavior and Convenience food consumption pattern, was created in the same way, using the medians of the Convenience group (being above the median consumption of foods considered an indicator of unhealthy diet).

Variables that are well-established as associated with the outcome in the literature were considered as potential confounding factors: sex, age, economic class, skin color, level of physical activity, and total energy consumed. In the adjusted model, the variables were selected using the stepwise method. The final model was adjusted for total energy, level of physical activity, sex, and age. The goodness of fit of the model was assessed using the Hosmer-Lemeshow test (p = 0.48). A significance level of 5% was used for all tests. All analyses were performed using Stata 14.0 (StataCorp LP, College Station, USA) through the survey module, which considers the effects of complex sampling.

Ethical aspects

The project was approved by the Human Research Ethics Committee of the Health Sciences Center of the Federal University of Paraíba (Protocol No. 0240/13). Each interview was conducted only after clarification of the research objectives and consent of the participant as well as signing of the Informed Consent Form by parents or guardians.

Results

A total of 2,767 adolescents were invited, of whom 372 (13%) refused to participate and 830 (30%) did not return the Informed Consent Form. A total of 1,565 adolescents consented to participate in the study; however, 127 (8%) were excluded according to previously set criteria. The final sample size was 1,438 adolescents, 53% female and 56% were between the ages of 10 and 11 years. The majority was non-white (81.1%), almost two-thirds (63.0%) belonged to economic classes C/D/E and 53.4% were physically active. Approximately, 76.4% of adolescents was excessive time in sedentary behavior and 52.2% was consumption above the median Convenience group, being that 34.0% and 28.8% of these adolescents were overweight, respectively (Table 1).

The characteristics of the sample with regard to excessive time in sedentary behavior and consumption of foods belonging to the Prudent and Convenience groups are presented in Table 2. Higher mean values for time involved in s excessive time in sedentary behavior were observed in male adolescents (p < 0.01), belonging to economic classes A/B (p < 0.05) and with excess body weight (p < 0.05). There was also a statistically significant difference between having an above the median level of consumption of foods from the Prudent group and being male (p < 0.01) and being physically inactive (p < 0.01). There was also a statistically significant difference between having an above-the-median consumption of Convenience foods and being in the 12/14 year-old age group (p < 0.05), being of white ethnicity (p < 0.05), and not having an excess body weight (p < 0.01).

It was found that engagement in excessive time in sedentary behavior increased the chance that adolescents being overweight by 37% (Table 3). The results of this analysis of the association between excessive time in sedentary behavior, consumption the Convenience or Prudent groups, and overweight among adolescents are shown in Table 4. It was observed that the chance of adolescents being overweight increased by 39% among those who were simultaneously engaged excessive time in sedentary behavior and who also had low consumption of foods from the Prudent group (OR = 1.39; 95%CI: 1.04-1.84).

It was also observed that there was a 43% increase in the chance of being overweight in adolescents who were simultaneously engaged in excessive time in sedentary behavior and who had higher consumption of foods from the Convenience group, (OR = 1.43; 95%CI: 1.05-1.94).

Discussion

This study, by analyzing two determinants of nutritional status (time engaged in sedentary behavior and patterns of food consumption) found an increased probability that an adolescent be overweight if the adolescent engaged in sedentary behavior for excessive amounts of time while also having increased consumption of food from the Convenience group. The Convenience group consisted of food that is generally associated with an unhealthy diet. Also, adolescents with excessive time in sedentary behavior and food consumption belonging to the Prudent group, which are low in sugars, fats and sodium and high in nutritional value, below the median had a higher chance (39%) of being overweight when compared to those with consumption above the median (35%).

Recently, a new proposal of food classification was developed, named NOVA ³⁰30 Monteiro CA, Cannon G, Levy RB, Moubarac JC, Jaime P, Martins AP, Canella D, Louzada M, Parra D, Ricardo C, Calixto G, Machado P, Martins C, Martinez E, Baraldi L, Garzillo J, Sattamini I. NOVA. The star shines bright. World Nutrition 2016; 7:28-40. categorizing food into four groups, according to the extent and purpose of its processing: (1) fresh or minimally processed foods; (2) processed culinary ingredients; (3) processed foods; and (4) ultra-processed foods³⁰30 Monteiro CA, Cannon G, Levy RB, Moubarac JC, Jaime P, Martins AP, Canella D, Louzada M, Parra D, Ricardo C, Calixto G, Machado P, Martins C, Martinez E, Baraldi L, Garzillo J, Sattamini I. NOVA. The star shines bright. World Nutrition 2016; 7:28-40.. Although the ultra-processed foods group includes some foods that compose the Convenience group of this study, we built a group based on the concept of easy and ready to eat food, which minimizes the time and physical effort required for preparation, consumption and cleaning³¹31 Brunner TA, Van Der Horst K, Siegrist M. Convenience food products. Drivers for consumption. Appetite 2010; 55:498-506..

In the present study, the prevalence of overweight among adolescents was 32.6%. This was higher than the rate of overweight in developed countries, which was 23.8% for boys and 22.6% for girls³²32 Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, Abraham JP, Abu-Rmeileh NM, Achoki T, AlBuhairan FS, Alemu ZA, Alfonso R, Ali MK, Ali R, Guzman NA, Ammar W, Anwari P, Banerjee A, Barquera S, Basu S, Bennett DA, Bhutta Z, Blore J, Cabral N, Nonato IC, Chang JC, Chowdhury R, Courville KJ, Criqui MH, Cundiff DK, Dabhadkar KC, Dandona L, Davis A, Dayama A, Dharmaratne SD, Ding EL, Durrani AM, Esteghamati A, Farzadfar F, Fay DF, Feigin VL, Flaxman A, Forouzanfar MH, Goto A, Green MA, Gupta R, Hafezi-Nejad N, Hankey GJ, Harewood HC, Havmoeller R, Hay S, Hernandez L, Husseini A, Idrisov BT, Ikeda N, Islami F, Jahangir E, Jassal SK, Jee SH, Jeffreys M, Jonas JB, Kabagambe EK, Khalifa SE, Kengne AP, Khader YS, Khang YH, Kim D, Kimokoti RW, Kinge JM, Kokubo Y, Kosen S, Kwan G, Lai T, Leinsalu M, Li Y, Liang X, Liu S, Logroscino G, Lotufo PA, Lu Y, Ma J, Mainoo NK, Mensah GA, Merriman TR, Mokdad AH, Moschandreas J, Naghavi M, Naheed A, Nand D, Narayan KM, Nelson EL, Neuhouser ML, Nisar MI, Ohkubo T, Oti SO, Pedroza A, Prabhakaran D, Roy N, Sampson U, Seo H, Sepanlou SG, Shibuya K, Shiri R, Shiue I, Singh GM, Singh JA, Skirbekk V, Stapelberg NJ, Sturua L, Sykes BL, Tobias M, Tran BX, Trasande L, Toyoshima H, van de Vijver S, Vasankari TJ, Veerman JL, Velasquez-Melendez G, Vlassov VV, Vollset SE, Vos T, Wang C, Wang X, Weiderpass E, Werdecker A, Wright JL, Yang YC, Yatsuya H, Yoon J, Yoon SJ, Zhao Y, Zhou M, Zhu S, Lopez AD, Murray CJ, Gakidou E. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384(9945):766-781.. In Brazil, data from the Household Budget Survey during 2008-2009 (the Pesquisa de Orçamentos Familiares)³³33 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2008-2009: despesas, rendimentos e condições de vida. Rio de Janeiro: IBGE; 2010., showed a high prevalence of overweight in adolescents, reaching 27.6% in male adolescents and 23.4% in female adolescents. More recently, the 2015 National School Health Survey (PeNSE)¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar (PeNSE). Rio de Janeiro: IBGE; 2019. also showed a high incidence (23.7%) of overweight in adolescent students. These rates are higher than the prevalence of overweight in children and adolescents in developing countries, which is 12.9% for boys and 13.4% for girls³²32 Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, Abraham JP, Abu-Rmeileh NM, Achoki T, AlBuhairan FS, Alemu ZA, Alfonso R, Ali MK, Ali R, Guzman NA, Ammar W, Anwari P, Banerjee A, Barquera S, Basu S, Bennett DA, Bhutta Z, Blore J, Cabral N, Nonato IC, Chang JC, Chowdhury R, Courville KJ, Criqui MH, Cundiff DK, Dabhadkar KC, Dandona L, Davis A, Dayama A, Dharmaratne SD, Ding EL, Durrani AM, Esteghamati A, Farzadfar F, Fay DF, Feigin VL, Flaxman A, Forouzanfar MH, Goto A, Green MA, Gupta R, Hafezi-Nejad N, Hankey GJ, Harewood HC, Havmoeller R, Hay S, Hernandez L, Husseini A, Idrisov BT, Ikeda N, Islami F, Jahangir E, Jassal SK, Jee SH, Jeffreys M, Jonas JB, Kabagambe EK, Khalifa SE, Kengne AP, Khader YS, Khang YH, Kim D, Kimokoti RW, Kinge JM, Kokubo Y, Kosen S, Kwan G, Lai T, Leinsalu M, Li Y, Liang X, Liu S, Logroscino G, Lotufo PA, Lu Y, Ma J, Mainoo NK, Mensah GA, Merriman TR, Mokdad AH, Moschandreas J, Naghavi M, Naheed A, Nand D, Narayan KM, Nelson EL, Neuhouser ML, Nisar MI, Ohkubo T, Oti SO, Pedroza A, Prabhakaran D, Roy N, Sampson U, Seo H, Sepanlou SG, Shibuya K, Shiri R, Shiue I, Singh GM, Singh JA, Skirbekk V, Stapelberg NJ, Sturua L, Sykes BL, Tobias M, Tran BX, Trasande L, Toyoshima H, van de Vijver S, Vasankari TJ, Veerman JL, Velasquez-Melendez G, Vlassov VV, Vollset SE, Vos T, Wang C, Wang X, Weiderpass E, Werdecker A, Wright JL, Yang YC, Yatsuya H, Yoon J, Yoon SJ, Zhao Y, Zhou M, Zhu S, Lopez AD, Murray CJ, Gakidou E. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384(9945):766-781..

This high rate of overweight among adolescents in Brazil may be attributed to the nutritional transition that Brazil has experienced, resulting in obesity and also nutritional deficiencies caused by poor diet³⁴34 Lima NMS, Leal VS, Oliveira JS, Andrade MIS, Tavares FCLP, Menezes RCE, Santos CS, Lira PIC. Overweight among adolescents and nutritional status of their parents: a systematic review. Cien Saude Colet 2017; 22(2):627-636.. These have been attributed to increased consumption of high-energy foods, rich in sugars, fats, and sodium, and with low nutritional value, which compose the Convenience group in this study, decreased levels of physical activity, and increased time engaged in sedentary behavior³⁵35 Popkin BM. Nutritional patterns and transitions. Pop Dev Rev 1993; 19(1):138-157.. The findings of the present study, show an association that are in line with this view.

The practice of physical activity, despite being associated with various health benefits for adolescents, has decreased among this age group, while there has been a simultaneous increase in the prevalence of sedentary behaviors¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar (PeNSE). Rio de Janeiro: IBGE; 2019.^,3636 Dias PJP, Domingos IP, Ferreira MG, Muraro AP, Sichieri R, Gonçalves-Silva RM. Prevalence and factors associated with sedentary behavior in adolescents. Rev Saude Publica 2014; 48(2):266-274.^,3737 Lucena JMS, Cheng LA, Cavalcante TLM, Silva VA, Farias Júnior JC. Prevalence of excessive screen time and associated factors in adolescents. Rev Paul Pediatr 2015; 33(4):407-414.. This change in behavior may be related to safety conditions, violence and social relations in the place of residence, since the perception of less security in the neighborhood, on the part of parents of children and adolescents, seems to be associated with more time in sedentary behavior when compared to parents who consider their neighborhood safe³⁸38 Timperio A, Salmon J, Ball K, te Velde SJ, Brug J, Crawford D. Neighborhood characteristics and TV viewing in youth: nothing to do but watch TV? J Sci Med Sport 2012; 15(2):122-128.^,3939 Datar A, Nicosia N, Shier V. Parent perceptions of neighborhood safety and children's physical activity, sedentary behavior, and obesity: evidence from a national longitudinal study. Am J Epidemiol 2013; 177(10):1065-1073..

The results of the present study corroborate the data from previous research, showing that 76% of adolescents spend more than two hours a day in sedentary activities, most of them classified as physically inactive. Besides that, in this study, approximately 80% of those classified as overweight was engaged excessive time in sedentary behavior. This result is on line with the reported findings of a systematic review of studies conducted in Brazil, where 55.5% (n = 27) of 49 studies identified reported a positive association between screen time and overweight in adolescents⁴⁰40 Guerra PH, Farias Júnior JC, Florindo AA. Sedentary behavior in Brazilian children and adolescents: a systematic review. Rev Saude Publica 2016; 50:9..

Our findings showed that sedentary behavior was associated with being overweight, independent of total energy consumed, level of physical activity, sex, and age. Moreover, by performing a joint analysis of sedentary behavior and diet, the results point to a greater probability of being overweight when there was a greater amount of consumption of foods from the Convenience group, and a decrease in the chance of being overweight when there was greater consumption of foods from the Prudent group. These findings confirm a study that showed a positive association between sedentary behavior, measured by screen time, and the choice of foods that are low in nutritional value and high in calories, fats, and sugars⁴4 Askari M, Heshmati J, Shahinfar H, Tripathi N, Daneshzad E. Ultra-processed food and the risk of overweight and obesity: a systematic review and meta-analysis of observational studies. Int J Obes 2020; 44(10):2080-2091.^,4040 Guerra PH, Farias Júnior JC, Florindo AA. Sedentary behavior in Brazilian children and adolescents: a systematic review. Rev Saude Publica 2016; 50:9.. The results of the present study are concerning, since adolescents are consuming greater amounts of foods belonging to the Convenience group and, consequently, reducing their consumption of foods from the Prudent group¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar (PeNSE). Rio de Janeiro: IBGE; 2019.. This behavior is related to the food culture of today’s society, which encourages people to opt for practical foods that are easy to access⁴¹41 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020..

Another plausible explanation for this result may be due to the high number of advertisements for convenience foods broadcast mainly on open television⁴²42 Leite FHM, Mais LA, Ricardo CZ, Andrade GC, Guimarães JS, Claro RM, Duran ACDFL, Martins APB. Nutritional quality of foods and non-alcoholic beverages advertised on Brazilian free-to-air television: a cross-sectional study. BMC Public Health 2020; 20(1):385., since these adolescents spend more time in front of the television than in other screen activities⁴³43 Souza Neto JM, Costa FFD, Barbosa AO, Prazeres Filho A, Santos EVOD, Farias Júnior JC. Physical activity, screen time, nutritional status and sleep in adolescents in northeast Brazil. Rev Paul Pediatr 2021; 39:e2019138.. A recent study showed that 18.1% of the advertisements aired on Brazilian open TV are for food and beverages, and more than 80.0% of these were outside the nutritional quality standards of the World Health Organization (WHO) or the Pan American Health Organization (PAHO), which makes them eligible for marketing restrictions⁴²42 Leite FHM, Mais LA, Ricardo CZ, Andrade GC, Guimarães JS, Claro RM, Duran ACDFL, Martins APB. Nutritional quality of foods and non-alcoholic beverages advertised on Brazilian free-to-air television: a cross-sectional study. BMC Public Health 2020; 20(1):385.. The most frequently advertised foods and beverages all belong to the convenience group of the present study, such as soft drinks, processed meats, convenience foods, sugary drinks, sweets and desserts⁴²42 Leite FHM, Mais LA, Ricardo CZ, Andrade GC, Guimarães JS, Claro RM, Duran ACDFL, Martins APB. Nutritional quality of foods and non-alcoholic beverages advertised on Brazilian free-to-air television: a cross-sectional study. BMC Public Health 2020; 20(1):385..

Another interesting finding in this study was that there was greater consumption of food from the Convenience group among adolescents from lower economic classes. This result reinforces that one of the factors influencing diet is economic, since the foods from the Convenience group of this study often have a lower cost when compared to foods from the Prudent group, making them more accessible to those belonging to lower economic classes ⁴⁴44 Bigio RS, Júnior EV, Castro MA, César CLG, Fisberg RM, Marchioni DML. Determinants of fruit and vegetable intake in adolescents using quantile regression. Rev Saude Publica 2011; 45(3):448-456.. This is in agreement with data from the literature ⁴⁴44 Bigio RS, Júnior EV, Castro MA, César CLG, Fisberg RM, Marchioni DML. Determinants of fruit and vegetable intake in adolescents using quantile regression. Rev Saude Publica 2011; 45(3):448-456.. The increase in the consumption of this type of food has been reported in low-income countries and within the same country in poorer regions⁴⁵45 Muhammad A, D'Souza A, Meade B, Micha R, Mozaffarian D. How income and food prices influence global dietary intakes by age and sex: evidence from 164 countries. BMJ Glob Health 2017; 2(3):e000184..

Brazil has a long traditional of school lunch polices, the School Health Program (PNAE)⁴⁶46 Brasil. Ministério da Educação (MEC). Resolução nº 38 de 16 de julho de 2009. Dispõe sobre o atendimento da alimentação escolar aos alunos da educação básica no Programa Nacional de Alimentação Escolar - PNAE. Diário Oficial da União 2009; 17 jul., has and one of the goals is the development of healthy eating habits among students in the public-school system. This program encourages the consumption of foods from the Prudent group and increases access to these foods through school lunches and educational initiatives about diet and nutrition. In addition, some state laws are also being created to regulate food sold in schools⁴⁷47 Brasil. Ministério da Saúde (MS). Experiências estaduais e municipais de regulamentação da comercialização de alimentos em escolas no Brasil: identificação e sistematização do processo de construção e dispositivos legais adotados [Internet]. [acessado 2023 ago 3]. Disponível em: http://189.28.128.100/nutricao/docs/geral/regula_comerc_alim_escolas_exper_estaduais_municipais.pdf
http://189.28.128.100/nutricao/docs/gera... , which encourage reductions in the consumption of foods belonging to the Convenience group in order to promote more healthy eating habits and provide subsidies for healthy food policies at school⁴⁷47 Brasil. Ministério da Saúde (MS). Experiências estaduais e municipais de regulamentação da comercialização de alimentos em escolas no Brasil: identificação e sistematização do processo de construção e dispositivos legais adotados [Internet]. [acessado 2023 ago 3]. Disponível em: http://189.28.128.100/nutricao/docs/geral/regula_comerc_alim_escolas_exper_estaduais_municipais.pdf
http://189.28.128.100/nutricao/docs/gera... . However, according our results, it is clear that more efforts have to be put on these polices.

Diet deserves attention, because an excessive intake of foods with high energy density, when combined with sedentary behaviors, generates a positive energy balance, which in turn plays a fundamental role in the development of overweight ⁸8 Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE, Chastin SFM, Altenburg TM, Chinapaw MJM; SBRN Terminology Consensus Project Participants. Sedentary Behavior Research Network (SBRN) - Terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act 2017; 14(1):75.^,4848 De Craemer M, De Decker E, De Bourdeaudhuij I, Vereecken C, Deforche B, Manios Y, Cardon G; ToyBox-study group. Correlates of energy balance-related behaviours in preschool children: a systematic review. Obes Rev 2012; 13(Suppl. 1):13-28.. Although this study did not focus on the adequacy of adolescents’ energy intakes through food, the data point to an association between the type of food consumed and sedentary behaviors associated with nutritional status, suggesting that this assertion may be corroborated.

Faced with the impact of these behaviors on obesity, adolescents, parents and educators should be the focus of health education measures, promoting changes in eating habits and reducing sedentary behavior, in order to minimize the risks of obesity and associated pathologies in the future.

In this sense, the WHO recommends several strategies to reduce the consumption of foods belonging to the Convenience group and reduce sedentary behavior, such as the elaboration of nutritional information and guidelines for adults and adolescents with dissemination in a simple, understandable and accessible way to all groups in society; taxation of sugary drinks; reducing exposure of children and adolescents to foods belonging to the Convenience group; reduction of the marketing power of foods belonging to the Convenience group; implement interpretive front-of-pack labeling supported by public adult education and adolescents for nutritional literacy; creation of healthy eating environments; guide children and teenagers, their parents, caregivers, teachers and health professionals about healthy body size, physical activity and appropriate use of screen-based entertainment, i.e. time in sedentary behavior; availability of adequate facilities in schools and in public spaces for physical activities during recreational time for all teenagers (including people with disabilities), with the provision gender-friendly spaces where appropriate⁴⁹49 WHO Commission on Endling Childhood Obesity. Report of the WHO Commission on Ending Childhood Obesity. Geneva: WHO; 2016..

One of the limitations of this study is the cross-sectional design, which only allows exploring associations between variables, and it is not possible to ascertain causal relationships. However, our study describes the combined effect analysis of two risk factors for overweight, what is not usual in the literature of this field. In addition, the study has a representative sample of students from public schools in the sixth year of elementary school in the city of João Pessoa.

Conclusions

This analysis of adolescents show that a large proportion of adolescents are engaged in excessive time in sedentary behavior, but when adolescents favor diets high in ready-to-eat energy dense foods or diets low in nutritious and healthy foods, their chances of being overweight increase even more.

Therefore, it is suggested that measures and interventions should be undertaken to encourage healthy food choices, to create the conditions to make these choices possible, encourage physical activity, and reduce time in sedentary behavior during this stage of life.

References

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