Introduction

An unbalanced diet, that is, rich in processed foods and/ or with low consumption of fruit and vegetables, is a key risk factor in the etiology of many chronic diseases, such as cardiovascular diseases, certain types of cancer, diabetes, and obesity¹. In Portugal, more than half of the adult population (57.1%) was overweight for their height: 22.3% of the population was classified as obese and 34.8% as pre-obese². In childhood, the most recent study by Childhood Obesity Surveillance Initiative (COSI Portugal) 2019³ reports that 11.9% of children were obese and 29.7% were overweight (including obesity). The Autonomous Region of the Azores had the highest prevalence of childhood overweight in the country (35.9%)³. Portugal presents a decrease in the prevalence of childhood obesity, following the trend of some countries^4,5, even so, in 31 European countries, Portugal is the 14^th with the highest prevalence of childhood obesity³.

The Portuguese dietary guidelines (Roda dos Alimentos) consist of 7 food groups of different sizes, the recommended number of servings depends on individual energy needs (Cereals and derivatives, tubers - 4 to 11; Vegetables - 3 to 5; Fruit - 3 to 5; Dairy products - 2 to 3; Meat, fish, and eggs - 1.5 to 4.5; Pulses - 1 to 2; Fats and oils - 1 to 3). It is recommended that children aged 1 to 3 years should be guided by the lower limits and active men and adolescent boys by the upper limits; the rest of the population should be guided by the intermediate values⁶. However, studies have shown that these recommendations have not been followed^2,3.

The Portuguese population has a consumption of “Fruit” and “Vegetables” below the recommended values (13% vs. 20% and 14% vs. 23%, respectively) and a consumption of “Meat, fish and eggs” above the recommended values (17% vs. 5%)². In the case of children, in the 5^th COSI Portugal round, it was observed that the daily consumption of meat, between 2016 and 2019, decreased from 17.3% to 9.2%, maintaining, in 2019, this consumption was higher than that of fish (3.8%)³. About 80.0% of the child population consumed cookies/sweet cookies, cakes, and donuts up to 3 times a week and 71.3% consumed sugary soft drinks³.

Deviation from healthy eating guidelines is also found in other countries that report poor eating habits, characterized by a low intake of fruits, vegetables, and dairy products, along with a high intake of sugary drinks and frequent consumption of sweets and snacks^7,8.

Eating habits from a very early age tend to be maintained throughout the life cycle, with implications such as being very selective and having little food variety, or high responsiveness to food stimuli and an increased risk of overweight⁹. It is known that children's eating behaviors and weight are difficult to directly modify, however parents' eating practices are a potential target for interventions to promote healthy eating habits and prevent overweight in children⁹. It is important to study food consumption among children and parents for the development of more effective community or clinical interventions to promote healthy eating habits and health-promoting foods. This study aims to evaluate and relate the food consumption of certain foods and the weight status of students in the third cycle of basic education and their parents.

Methodology

Results

The sociodemographic characterization of the participants (students and parents) is presented in Table 1. Most students were female (56.8%), were 14 (SD=1.2) years old, lived in Angra do Heroísmo (73.9%), were Portuguese (97.8%), had a household size of 4 members (43.4%). Regarding parents, most were female (92.5%), were 42 (SD=5.9) years old, married (83.9%), lived in Angra do Heroísmo (72.1%), were Portuguese (98.1%), had completed the second cycle of basic education (corresponding to six years of schooling - 30.3%), had a household composed of four elements (48.1%) and were employed (68.1%).

Regarding nutritional status, about 30% of students and 60% of parents were classified as being pre-obese/obese. A relationship between parents' BMI and students' BMI (r: 0.352; p<0.001) was found.

Regarding parents, most were female (92.5%), were 42 (SD=5.9) years old, married (83.9%), lived in Angra do Heroísmo (72.1%), were Portuguese (98.1%), had completed the second cycle of basic education (corresponding to six years of schooling - 30.3%), had a household composed of four elements (48.1%) and were employed (68.1%).

Regarding nutritional status, about 30% of students and 60% of parents were classified as being pre-obese/obese. A relationship between parents' BMI and students' BMI (r: 0.352; p<0.001) was found.

Table 2 reports the food consumption among students in the third cycle of basic education and their parents. In general, students and parents have a high frequency of dairy consumption (about 30% to 80%). Lean and red meat and eggs are consumed more frequently on a weekly basis (about 40% to 50% “two or more times a week”) than fish (about 20% to 30% “two or more times a week”). In relation to the group of bread, cereals and tubers, there is a daily consumption of bread, and a frequent weekly presence of rice, pasta, and potatoes. Whole grains and sweet potatoes have a low frequency of consumption, with about 70% of students and parents never consuming flaxseed or consuming less than once a month. Vegetables, fruits, and pulses have a considerable weekly consumption based on “two or more times a week”, but about 70% of the participants consume less than once a month or never consume soy. The same happens for fatty fruits and berries (50%). The consumption of oils and fats has a weekly basis with around 50% consumption two or more times a week. Of note is the low daily prevalence of olive oil consumption, which is consumed by less than 40% of the participants. Regarding beverages, there is a high daily consumption by about 80% of the participants, and weekly consumption of juices enriched with vitamin C (50%) and soft drinks (50%). About 40-50% of participants consume sweets and fast-food weekly and consume vegetable soup daily. About 40% of participants consume less than once a month or never drink green tea.

As for food consumption among students and parents it was found that students consume milk more often than parents and less often yogurt. Meat from the Azores (beef), rice, pasta, potato, and fennel are consumed more frequently by students. Vegetables, roots, bulbs, and pulses are consumed most often by parents. Regarding fruits, apples, bananas, citrus fruits, and berries, are consumed more frequently (two or more times per day) by students. As for fats, parents report consuming olive oil more often than students. Finally, in the drinks and miscellaneous group, green tea and soup are consumed more frequently by parents, while juices enriched with vitamin C, soft drinks, sweets, and fast food are consumed more frequently by students. Most parents never consume or consume less than once a month: yogurt with probiotics, fiber-rich yogurts, fermented beverages for cholesterol reduction, and margarine with phytosterols.

Table 3 shows the differences in the frequency of food consumption between normal weight and overweight students and parents (with statistical significance). Normal weight students reported a higher frequency of soy, olive oil, sunflower oil, and sweets compared to students classified as being overweight. Overweight parents reported a higher frequency of consumption of milk, pork, fatty fish, potatoes, vegetables, citrus fruits, and sunflower oil, compared to parents classified as normal weight.

Discussion

This cross-sectional study aimed to evaluate the food consumption of certain foods by students in the third cycle of basic education and their parents. It is also intended to report your food consumption with your weight status. A high prevalence of pre-obesity/obesity was found in both groups of your sample.

In fact, our results are consistent with recent studies² on the prevalence of overweight/obesity in Portugal, which point out the Autonomous Region of the Azores as having one of the highest prevalence of pre-obesity/obesity at the national level (adults: Portugal - 58,1%, Azores - 61.6%; children: Portugal [10-17 years old] - 32,3%², Azores [6-8 years old] - 35,9%³).

Like other studies^18-20, a relationship between parents' BMI and students' BMI was found. In fact, parents model children's eating behavior⁹ and lifestyle^21,22. However, this study does not establish a causal relationship between these variables, so the interpretation must be careful, parents are not necessarily “blamed” for children's overweight.

In general, our dietary results are in line with those reported for the Portuguese population², however, it appears that both children and parents do not comply with the recommendations of the Portuguese dietary guidelines⁶ (in terms of frequency of food consumption).

The high consumption of milk and dairy products in the Azores was corroborated by another study²³. It is also worth noting that the dairy sector in the Azores is of great importance since there is a large production of milk and dairy products there, having a relevant impact on the archipelago's economy²⁴. Besides that, it is now well established that the regular consumption of fermented foods could be beneficial to health²⁵.

In relation to the high frequency of consumption of meat and eggs (weekly basis), it refers to what is reported in the literature that the Portuguese consume “Meat, fish and eggs” above the recommended values². Although meat and meat products are a source of micronutrients, including iron, zinc, selenium, vitamin D, and vitamin B₁₂, their excessive consumption can lead to several health problems (overconsumption of energy, and fat, resulting in excess weight, obesity and an increased risk of chronic diseases, like cardiovascular disease and type 2 diabetes)²⁶. Therefore, the consumption of meat, and meat products, when integrated into a healthy diet, provides a rich source of high-quality dietary protein and essential nutrients²⁷.

Unlike other studies, a low frequency of fish consumption was found^2,28. In fact, it is known that the main motivating factors for the purchase of fish are the species, the price, and health, and that the importance of factors differs between social classes, with the price being more important for social classes with lower incomes²⁹. It should be noted that a news item from the time when the study was carried out already reported that the quantity of fish dropped by 18% between 2010 and 2015 and the price increased by 7.8% in Azores³⁰.

Higher consumption of olive oil would be expected since Portugal is considered a country where the Mediterranean food pattern prevails and where olive oil is the fat of choice and consumed daily. The low frequency of consumption of olive oil (daily based) reported by students may be because students who have their meals in the canteen do not identify olive oil as the fat used in the preparation of these meals. On the other hand, according to the National Food and Physical Activity Survey², 31% of the Portuguese have low adherence to the Mediterranean dietary pattern, with moderate adherence representing 50% of the population. It is recommended to promote the consumption of olive oil as a source of fat in the context of a healthy diet. The literature has demonstrated several health benefits of olive oil consumption, namely beneficial effects on the cardiovascular system and can help to prevent cancer and diabetes mellitus³¹. These properties have been associated with the content of nutrients and phytochemicals, especially polyphenols and fatty acids present in olive oil³².

Although water was identified in this study as the most consumed beverage, the high consumption of soft drinks and/or juices enriched with vitamin C is a reality, especially among students, which about 20% consume them daily. These data are supported by some studies^2,33,34. Consumption of soft drinks and sugary drinks only provide energy and have few nutritional benefits lacking micronutrients, vitamins, and minerals. It should also be noted that its consumption can contribute to the deterioration of health in general, with special emphasis on oral health³⁴. Therefore, its consumption should be avoided.

According to National Food and Physical Activity Survey², food products such as cakes, sweets, cookies, salty snacks, pizzas, soft drinks, nectars, and alcoholic beverages, which should not be part of our daily diet, represent around 21% of total consumption in the Portuguese population. These results agree with ours, especially among students.

The students in this study can be framed in an unhealthy diet pattern, like about half of Portuguese adolescents, since they have low consumption of fruits, vegetables, and pulses and higher consumption of sweets and fast food³⁵.

Thus the consumption of fruits and vegetables and fish should be promoted, and the consumption of fast food and sweets should be discouraged, in order to adopt a healthy diet¹. It cannot be stressed enough that a diet rich in processed foods and/or with low consumption of fruit and vegetables, is a key risk factor for the emergence of many chronic diseases like cardiovascular diseases, certain types of cancer, diabetes, and obesity¹

The results of the differences in the frequency of food consumption between normal weight and pre-obese/obese students and parents may suggest the existence of some myths related to food³⁶, namely that foods considered healthy or with health benefits can be consumed in large quantities such as milk, fruits, vegetables, and olive oil. In the case of the higher frequency of consumption of sweets by normal-weight students, a possible explanation is a compensation of the energy ingested with physical activity, however, this was not evaluated in this study.

According to a study³⁷ that aimed to determine strategies that could increase the consumption of fruits and vegetables in children, some that can be used in a school context were highlighted, namely: use relevant motivators for children to increase their preference for fruit and vegetables; increase food literacy education across a range of settings; and develop salient key messages and cooking tips that could be done with parents. In this way, food education sessions and cooking workshops could be developed for students and parents. Integrate health-promoting food-related content into the school curriculum to increase health/food literacy. Admitting the importance of consuming foods of local origin, not only at an economic level, but also at an environmental level, and having verified a low consumption of some of these foods, their consumption could be promoted in these community-based interventions.

Conclusions

A high prevalence of pre-obesity/obesity was found. Normal weight students reported a higher frequency of soy, olive oil, sunflower oil, and sweets, on the other hand, overweight parents reported a higher frequency of consumption of milk, pork, fatty fish, potatoes, vegetables, citrus fruits, and sunflower oil. Our results suggest that is necessary to adopt public policies, involving schools, parents, and government to implement healthy eating habits and demystify some beliefs, to promote the consumption of health-promoting foods, especially the ones produced locally, to make food sustainable and contribute to the local economy.