Factors Associated With Unhealthy Snacks Consumption Among Adolescents in Iran’s Schools

Document Type : Original Article

Authors

1 Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

2 School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Department of Community Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran

4 Social Determinants of Health Research Center and Department of Public Health, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran

5 Epidemiology and Biostatistics Department, School of Public Health, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background
Well-informed interventions are needed if school-based health promotion is to be effective. Amongother aims, the Iranian Health Promoting School (IHPS) program that was launched in 2011, has an important aimof promoting dietary behaviors of adolescents. The present study, therefore, aimed to investigate the factors affectingunhealthy snacking of adolescents and provide evidence for a more effective IHPS program.
 
Methods
In a cross-sectional study design, 1320 students from 40 schools in Kerman city were selected using aproportional stratified random sampling method. A modified qualitative Food Frequency Questionnaire (FFQ) wasused to gather data about unhealthy snacking behavior. Data about intrapersonal and environmental factors wereobtained using a validated and reliable questionnaire. A mixed-effects negative-binomial regression model was usedto analyze the data.
 
Results
Taste and sensory perception (prevalence rate ratio [PRR] = 1.18; 95% CI: 1.09-1.27), being a male (PRR = 1.20;95% CI: 1.05-1.38) and lower nutritional knowledge (PRR = 0.96; 95% CI: 0.91-0.99) were associated with higher weeklyunhealthy snaking. Perceived self-efficacy (PRR = 0.95; 95% CI: 0.91-1.00) negatively influenced the frequency ofunhealthy snaking, with this approaching significance (P< .06). In case of environmental factors, high socio-economicstatus (SES) level (PRR = 1.45; 95% CI: 1.26-1.67), single-parent family (PRR = 1.14; 95% CI: 1.01-1.30), more socialnorms pressure (PRR = 1.08; 95% CI: 1.01-1.17), pocket money allowance (PRR = 1.21; 95% CI: 1.09-1.34), easyaccessibility (PRR = 1.06; 95% CI:1.01-1.11), and less perceived parental control (PRR= 0.96; 95% CI: 0.92-0.99) all hada role in higher consumption of unhealthy snacks. Interestingly, larger school size was associated with less unhealthysnacking (PRR = 0.79; 95% CI: 0.68-0.92).
 
Conclusion
Unhealthy snacking behavior is influenced by individual, socio-cultural and physical-environmentalinfluences, namely by factors relating to poor parenting practices, high SES level, family characteristics, improper socialnorms pressure, and less knowledge and self-efficacy of students. This evidence can be used to inform a more evidencebased IHPS program through focusing on supportive strategies at the home, school, and local community levels.

Keywords

Main Subjects


  1. Ezzati  M, Riboli  E. Behavioral and dietary risk factors for noncommunicable diseases. N Engl J Med. 2013;369(10):954-964. doi:10.1056/NEJMra1203528
  2. Malik VS, Willett WC, Hu FB. Global obesity: trends, risk factors and policy implications. Nat Rev Endocrinol. 2013;9(1):13-27. doi: 10.1038/nrendo.2012.199
  3. Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011;377(9775):1438-1447. doi:10.1016/S0140-6736(11)60393-0
  4. Resnick MD, Catalano RF, Sawyer SM, Viner R, Patton GC. Seizing the opportunities of adolescent health. Lancet. 2012;379(9826):1564-1567. doi:10.1016/S0140-6736(12)60472-3
  5. Sawyer SM, Afifi RA, Bearinger LH, et al. Adolescence: a foundation for future health. Lancet. 379(9826):1630-1640. doi: 10.1016/S0140-6736(12)60072-5
  6. West P. School effects research provide new and stronger evidence in support of the health‐promoting school idea. Health Educ. 2006;106(6):421-424. doi:10.1108/09654280610711370
  7. Lee A. Health-promoting schools. Appl Health Econ Health Policy. 2009;7(1):11-17. doi:10.1007/BF03256138
  8. Motlagh ME, Chinian M, Dashti M, et al. A national guideline for implementation health promoting schools in Islamic Republic of Iran. Iran, Qom: Khadem Al-Reza; 2011.
  9. Langford R, Bonell C, Jones H, et al. The World Health Organization’s Health Promoting Schools framework: a Cochrane systematic review and meta-analysis. BMC Public Health. 2015;15:130. doi:10.1186/s12889-015-1360-y
  10. Wang D, Stewart D. The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review. Public Health Nutr. 2013;16(6):1082-1100. doi: 10.1017/S1368980012003497
  11. Fung C, Kuhle S, Lu C, et al. From "best practice" to "next practice": the effectiveness of school-based health promotion in improving healthy eating and physical activity and preventing childhood obesity. Int J Behav Nutr Phys Act. 2012;9(1):1-9. doi:10.1186/1479-5868-9-27
  12. Langford R, Bonell C, Jones H, Campbell R. Obesity prevention and the Health promoting Schools framework: essential components and barriers to success. Int J Behav Nutr Phys Act. 2015;12(1):1-17. doi:10.1186/s12966-015-0167-7
  13. Lynagh M, Perkins J, Schofield M. An evidence-based approach to health promoting schools. J Sch Health. 2002;72(7):300-302. doi:10.1111/j.1746-1561.2002.tb01337.x
  14. Brug J, te Velde SJ, Chinapaw MJ, et al. Evidence-based development of school-based and family-involved prevention of overweight across Europe: The ENERGY-project's design and conceptual framework. BMC Public Health. 2010;10:276. doi:10.1186/1471-2458-10-276
  15. Lien N, Haerens L, te Velde SJ, et al. Exploring subgroup effects by socioeconomic position of three effective school-based dietary interventions: the European TEENAGE project. Int J Public Health. 2014;59(3):493-502. doi:10.1007/s00038-013-0524-8
  16. Popkin BM, Gordon-Larsen P. The nutrition transition: worldwide obesity dynamics and their determinants. Int J Obes Relat Metab Disord. 2004;28 Suppl 3:S2-9. doi:10.1038/sj.ijo.0802804
  17. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. John Wiley & Sons; 2008.
  18. Dunn KI, Mohr P, Wilson CJ, Wittert GA. Determinants of fast-food consumption. An application of the Theory of Planned Behaviour. Appetite. 2011;57(2):349-357. doi: 10.1016/j.appet.2011.06.004
  19. van Ansem WJ, Schrijvers CTM, Rodenburg G, van de Mheen D. Children’s snack consumption: role of parents, peers and child snack-purchasing behaviour. Results from the INPACT study. Eur J Public Health. 2015;25(6):1006-1011. doi: 10.1093/eurpub/ckv098
  20. Story M, Neumark-Sztainer D, French S. Individual and Environmental Influences on Adolescent Eating Behaviors. J Am Diet Assoc. 2002;102(3 Suppl):S40-S51. doi: 10.1016/S0002-8223(02)90421-9
  21. de Bruijn G-J, Kremers SPJ, de Vries H, van Mechelen W, Brug J. Associations of social–environmental and individual-level factors with adolescent soft drink consumption: results from the SMILE study. Health Educ Res. 2007;22(2):227-237. doi:10.1093/her/cyl066
  22. Galobardes B, Shaw M, Lawlor DA, Lynch JW, Davey Smith G. Indicators of socioeconomic position (part 1). J Epidemiol Community Health. 2006;60(1):7-12. doi:10.1136/jech.2004.023531
  23. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan. 2006;21(6):459-468. doi:10.1093/heapol/czl029
  24. Beydoun MA, Wang Y. How do socio-economic status, perceived economic barriers and nutritional benefits affect quality of dietary intake among US adults? Eur J Clin Nutr. 2007;62(3):303-313. doi:10.1038/sj.ejcn.1602700
  25. Vengiau G, Umezaki M, Phuanukoonnon S, Siba P, Watanabe C. Associations of Socioeconomic Status with Diet and Physical Activity in Migrant Bougainvilleans in Port Moresby, Papua New Guinea. Ecol Food Nutr. 2014;53(5):471-483. doi:10.1080/03670244.2013.855206
  26. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007;30(4):459-467. doi:10.1002/nur.20199
  27. Wilson FR, Pan W, Schumsky DA. Recalculation of the Critical Values for Lawshe’s Content Validity Ratio. Meas Eval Couns Dev. 2012;45(3):197-210. doi:10.1177/0748175612440286
  28. Loewenthal KM. An Introduction to Psychological Tests and Scales. 2nd ed. UK: Psychology Press; 2004.
  29. Karimi-Shahanjarini A, Rashidian A, Majdzadeh R, Omidvar N, Tabatabai MG, Shojaeezadeh D. Parental Control and Junk-Food Consumption: A Mediating and Moderating Effect Analysis1. J Appl Soc Psychol. 2012;42(5):1241-1265. doi:10.1111/j.1559-1816.2011.00885.x
  30. Community Nutrition Improvement Office and Health Affairs Office. National guideline for healthy food canteen in schools: Food section Health Affairs Office affiliated with Ministry of Education; 2013.
  31. Bonate PL. The Effect of Collinearity on Parameter Estimates in Nonlinear Mixed Effect Models. Pharmaceut Res. 1999;16(5):709-717. doi:10.1023/a:1018828709196
  32. Gugglberger L, Dür W. Capacity building in and for health promoting schools: Results from a qualitative study. Health Policy. 2011;101(1):37-43. doi: 10.1016/j.healthpol.2010.08.019
  33. West P, Sweeting H, Leyland A. School effects on pupils' health behaviours: evidence in support of the health promoting school. Research Papers in Education. 2004;19(3):261-291. doi:10.1080/02671522.2004.10058645
  34. Brown T, Summerbell C. Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: an update to the obesity guidance produced by the National Institute for Health and Clinical Excellence. Obes Rev. 2009;10(1):110-141. doi:10.1111/j.1467-789X.2008.00515.x
  35. Van Cauwenberghe E, Maes L, Spittaels H, et al. Effectiveness of school-based interventions in Europe to promote healthy nutrition in children and adolescents: systematic review of published and ‘grey’ literature. Br J Nutr. 2010;103(06):781-797. doi: 10.1017/S0007114509993370
  36. Bonell C, Wells H, Harden A, et al. The effects on student health of interventions modifying the school environment: systematic review. J Epidemio Community Health. 2013. doi:10.1136/jech-2012-202247
  37. Evans CE, Christian MS, Cleghorn CL, Greenwood DC, Cade JE. Systematic review and meta-analysis of school-based interventions to improve daily fruit and vegetable intake in children aged 5 to 12 y. Am J Clin Nutr. 2012;96(4):889-901. doi:10.3945/ajcn.111.030270
  38. Karimi-Shahanjarini A, Omidvar N, Bazargan M, Rashidian A, Majdzadeh R, Shojaeizadeh D. Iranian female adolescent's views on unhealthy snacks consumption: a qualitative study. Iran J public health. 2010;39(3):92-101.
  39. Wright K, Norris K, Newman Giger J, Suro Z. Improving healthy dietary behaviors, nutrition knowledge, and self-efficacy among underserved school children with parent and community involvement. Child Obes. 2012;8(4):347-356. doi:10.1089/chi.2012.0045
  40. Shi Z, Lien N, Kumar BN, Holmboe-Ottesen G. Socio-demographic differences in food habits and preferences of school adolescents in Jiangsu Province, China. Eur J Clin Nutr. 2005;59(12):1439-1448. doi:10.1038/sj.ejcn.1602259
  41. Park S, Blanck HM, Sherry B, Brener N, O’Toole T. Factors Associated with Sugar-Sweetened Beverage Intake among United States High School Students. J Nutr. 2012;142(2):306-312. doi:10.3945/jn.111.148536
  42. Wouters EJ, Larsen JK, Kremers SP, Dagnelie PC, Geenen R. Peer influence on snacking behavior in adolescence. Appetite. 2010;55(1):11-17. doi: 10.1016/j.appet.2010.03.002
  43. Fletcher A, Bonell C, Sorhaindo A. You are what your friends eat: systematic review of social network analyses of young people's eating behaviours and bodyweight. J Epidemiol Community Health. 2011. doi:10.1136/jech.2010.113936
  44. Fitzgerald A, Heary C, Kelly C, Nixon E, Shevlin M. Self-efficacy for healthy eating and peer support for unhealthy eating are associated with adolescents’ food intake patterns. Appetite. 2013;63:48-58. doi: 10.1016/j.appet.2012.12.011
  45. Grosso G, Mistretta A, Turconi G, Cena H, Roggi C, Galvano F. Nutrition knowledge and other determinants of food intake and lifestyle habits in children and young adolescents living in a rural area of Sicily, South Italy. Public Health Nutr. 2013;16(10):1827-1836. doi:10.1017/S1368980012003965
  46. Salvy S-J, de la Haye K, Bowker JC, Hermans RCJ. Influence of peers and friends on children's and adolescents' eating and activity behaviors. Physiol Behav. 2012;106(3):369-378. doi: 10.1016/j.physbeh.2012.03.022
  47. Yip C, Gates M, Gates A, Hanning RM. Peer-led nutrition education programs for school-aged youth: a systematic review of the literature. Health Educ Res. 2015. doi:10.1093/her/cyv063
  48. Wang D, Stewart D, Chang C, Shi Y. Effect of a school-based nutrition education program on adolescents’ nutrition-related knowledge, attitudes and behaviour in rural areas of China. Environ Health Prev Med.2015;20(4):271-278. doi:10.1007/s12199-015-0456-4
  49. Scully M, Wakefield M, Niven P, et al. Association between food marketing exposure and adolescents’ food choices and eating behaviors. Appetite. 2012;58(1):1-5. doi: 10.1016/j.appet.2011.09.020
  50. Soyer MT, Ergin I, Gursoy ST. Effects of social determinants on food choice and skipping meals among Turkish adolescents. Asia Pac J Clin Nutr. 2008;17(2):208-215. doi: 10.6133/apjcn.2008.17.2.04
  51. Campbell KJ, Crawford DA, Salmon J, Carver A, Garnett SP, Baur LA. Associations Between the Home Food Environment and Obesity-promoting Eating Behaviors in Adolescence. Obesity. 2007;15(3):719-730. doi:10.1038/oby.2007.553
  52. Katz DL, O'Connell M, Njike VY, Yeh MC, Nawaz H. Strategies for the prevention and control of obesity in the school setting: systematic review and meta-analysis. Int J Obesity. 2008;32(12):1780-1789. doi:10.1038/ijo.2008.158
  53. Kehm R, Davey CS, Nanney MS. The Role of Family and Community Involvement in the Development and Implementation of School Nutrition and Physical Activity Policy. J Sch Health. 2015;85(2):90-99. doi:10.1111/josh.12231
  54. Maas CJM, Hox JJ. Sufficient Sample Sizes for Multilevel Modeling. Methodology. 2005;1(3):86-92. doi:10.1027/1614-2241.1.3.86

 

  • Receive Date: 03 July 2016
  • Revise Date: 29 December 2016
  • Accept Date: 18 January 2017
  • First Publish Date: 01 September 2017