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Cadernos de Saúde Pública

Print version ISSN 0102-311XOn-line version ISSN 1678-4464

Cad. Saúde Pública vol.35 no.7 Rio de Janeiro  2019  Epub July 22, 2019

https://doi.org/10.1590/0102-311x00153918 

ARTICLE

Eating meals with parents is associated with better quality of diet for Brazilian adolescents

Bianca Garcia Martins1  2 
http://orcid.org/0000-0002-2199-9111

Camila Zancheta Ricardo2 
http://orcid.org/0000-0003-3643-302X

Priscila Pereira Machado1 
http://orcid.org/0000-0003-4607-5094

Fernanda Rauber1 
http://orcid.org/0000-0001-9693-7954

Catarina Machado Azeredo2  3 
http://orcid.org/0000-0002-6189-4429

Renata Bertazzi Levy2 
http://orcid.org/0000-0001-5388-7002

1 Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo Brasil.

2 Faculdade de Medicina, Universidade de São Paulo, São Paulo Brasil.

3 Universidade Federal de Uberlândia, Uberlândia, Brasil.


Abstract:

The objective was to investigate how often Brazilian adolescents eat meals with their parents and verify the association between this habit and quality of the diet. Data were from the Brazilian National Survey of School Health (PeNSE-2015). The sample consisted of adolescents enrolled in the ninth grade in public and private schools, ranging in age from 11 to 19 years. The target exposure was eating meals with parents (0-4 and ≥ 5 days/week) and the outcomes were frequent consumption (≥ 5 days/week) of healthy and unhealthy dietary markers. Healthy diet scores (range 0-21) and unhealthy diet scores (range 0-35) were based on total days that the adolescent reported consuming each of the dietary markers. Poisson and linear regression models were used, adjusted by sociodemographic variables. Frequent sharing of meals with parents (≥ 5 days/week) was seen in 74% (95%CI: 73.4-74.7) of the adolescents. Those reporting this habit showed higher likelihood of frequent consumption of beans (PR = 1.22; 95%CI: 1.19-1.26), fruits (PR = 1.34; 95%CI: 1.28-1.39), and vegetables (PR = 1.39; 95%CI: 1.34-1.44), and lower likelihood of frequent consumption of sweets (PR = 0.91; 95%CI: 0.88-0.94), ultra-processed salty foods (PR = 0.91; 95%CI: 0.87-0.94), and fried salty snacks (PR = 0.85; 95%CI: 0.80-0.90). Eating meals with parents was positively associated with healthy diet scores and inversely associated with unhealthy diet scores . Eating meals with parents is a common habit in Brazilian adolescents and is associated with better quality of diet.

Keywords: Meals; Family; Food Consumption; Adolescent

Resumo:

O objetivo foi investigar a frequência com que os adolescentes brasileiros realizam as refeições com os pais e verificar a associação deste hábito com a qualidade da dieta. Foram utilizados dados da Pesquisa Nacional de Saúde do Escolar - 2015 (PeNSE). A amostra foi composta por adolescentes matriculados no nono ano do ensino fundamental de escolas públicas e privadas, com idades entre 11 e 19 anos. A exposição de interesse foi realizar refeições com os pais (0-4 e ≥ 5 dias/semana) e os desfechos estudados foram consumo frequente (≥ 5 dias/semana) de alimentos marcadores de alimentação saudável e não saudável. Escores de alimentação saudável (variação 0-21) e não saudável (variação 0-35) foram elaborados com base no somatório dos dias que o adolescente relatou consumir cada um dos marcadores de alimentação. Foram usados modelos de regressão de Poisson e linear, ajustados por variáveis sociodemográficas. A realização frequente de refeições com os pais (≥ 5 dias/semana) foi observada em 74% (IC95%: 73,4-74,7) dos adolescentes. Aqueles que afirmaram ter esse hábito apresentaram maior probabilidade do consumo frequente de feijão (RP = 1,22; IC95%: 1,19-1,26), frutas (RP = 1,34; IC95%: 1,28-1,39) e hortaliças (RP = 1,39; IC95%: 1,34-1,44); e menor probabilidade de consumo frequente de guloseimas (RP = 0,91; IC95%: 0,88-0,94), ultraprocessados salgados (RP = 0,91; IC95%: 0,87-0,94) e salgados fritos (RP = 0,85; IC95%: 0,80-0,90). Realizar as refeições com os pais foi positivamente associado ao escores de alimentação saudável e inversamente associado ao escores de alimentação não saudável. O hábito de realizar refeições com os pais é frequente entre adolescentes brasileiros e está associado à melhor qualidade da alimentação.

Palavras-chave: Refeições; Família; Consumo de Alimentos; Adolescente

Resumen:

El objetivo fue investigar la frecuencia con la que los adolescentes brasileños comen con los padres y verificar la asociación de este hábito con la calidad de la dieta. Se utilizaron datos de la Encuesta Nacional de Salud del Escolar - 2015 (PeNSE). La muestra estaba compuesta por adolescentes matriculados en el noveno año de enseñanza fundamental de escuelas públicas y privadas, con edades entre 11 y 19 años. La exposición de interés fue realizar comidas con los padres (0-4 y ≥ 5 días/semana) y los resultados estudiados fueron consumo frecuente (≥ 5 días/semana) de alimentos marcadores de alimentación saludable y no saludable. Los marcadores de alimentación saludable (variación 0-21) y no saludable (variación 0-35) se elaboraron basándose en el sumatorio de los días en los que el adolescente informó consumir cada uno de los marcadores de alimentación. Se usaron modelos de regresión de Poisson y lineales, ajustados por variables sociodemográficas. La realización frecuente de comidas con los padres (≥ 5 días/semana) se observó en un 74% (IC95%: 73,4-74,7) de los adolescentes. Aquellos que afirmaron tener ese hábito presentaron una mayor probabilidad de consumo frecuente de frijoles (RP = 1,22; IC95%: 1,19-1,26), frutas (RP = 1,34; IC95%: 1,28-1,39) y hortalizas (RP = 1,39; IC95%: 1,34-1,44); y menor probabilidad de consumo frecuente de golosinas (RP = 0,91; IC95%: 0,88-0,94), aperitivos ultraprocesados (RP = 0,91; IC95%: 0,87-0,94) y aperitivos fritos (RP = 0,85; IC95%: 0,80-0,90). Realizar las comidas con los padres estuvo positivamente asociado al marcadores de alimentación saludable e inversamente asociado al marcadores de alimentación no saludable. El hábito de realizar comidas con los padres es frecuente entre adolescentes brasileños y está asociado a una mejor calidad de la alimentación.

Palabras-clave: Comidas; Familia; Consumo de Alimentos; Adolescente

Introduction

Obesity is a public health problem that affects children and adolescents at high rates worldwide 1,2. In Brazil, prevalence of obesity in this age group is 14% 3. Data from a national survey in 2014 showed that one out of four Brazilian adolescents had excess weight and 8.4% were already obese 4. Meanwhile, adolescents’ dietary habits have been characterized by high consumption of ultra-processed foods, high in fats, sugars, and sodium, and low consumption of fruits and vegetables 5,6,7. Factors contributing to this scenario include the familiar environment, which plays an important role in the development of eating habits in children and adolescents 8,9,10.

Studies have suggested that sharing meals with the family may serve as a protective factor against problems related to health conditions in childhood and adolescence 11,12. Sharing meals also has great potential as a learning environment, where parents can demonstrate healthy eating habits and children can learn about foods and their preparation and eating behaviors and attitudes 13.

A meta-analysis published in 2018 including 57 studies showed that family meals were associated with healthy diet and low body mass index in children and adolescents 14. Still, these studies were conducted in high-income countries, the vast majority in the USA, followed by European countries. Studies assessing the family environment and its association with dietary patterns are still rare in Brazil. The existing scientific studies address anthropological aspects of sharing meals and the impacts of globalization on changes in eating practices 15,16, or only report the prevalence of this practice and its association with some of the population’s sociodemographic characteristics 17. The current study thus aimed to investigate how often Brazilian adolescents eat meals with their parents and verify the association between this habit and quality of diet.

Methods

Study population, sampling, and data collection

We analyzed data from the third edition of the Brazilian National Survey of School Health (PeNSE), conducted in 2015 by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Brazilian Ministries of Health and Education. PeNSE is a cross-sectional survey with a representative sample of Brazilian ninth-grade students (n = 102,072) 11 to 19 years of age and enrolled in public and private schools (n = 3,040 schools).

Schools were selected according to the number of classes and type of administration (public versus private). In each school in the sample, ninth-grade classes were selected randomly and with equal probabilities between classes existing in 2015, as follows: one class in each school that reported having up to two ninth-grade classes, and two classes in each school with three or more ninth-grade classes. All the students in the selected classes were invited to participate in the study.

Students answered a self-applied smartphone questionnaire with questions of sociodemographic characteristics, family and school context, and dietary practices. Further details on the sampling process can be assessed by the PeNSE publication 18.

Study variables

The habit of sharing meals (lunch or dinner) with the family was assessed with the following question: “Do you usually eat lunch or dinner with your mother, father, or guardian?”, with the following answers: “Yes, every day”; “Yes, 5-6 days a week”; “Yes, 3-4 days a week”; “Yes, 1-2 days a week”; “Rarely”; or “No”. The study adopted the term “parents” for “mother, father, or guardian”, and eating meals with parents was categorized as 0-4 and ≥ 5 days per week, with the latter defined as frequent consumption.

Diet quality was assessed with the following question: “In the last 7 days, on how many days did you eat ...?”, for each of the markers of healthy diet (beans, fruits, vegetables) and unhealthy diet (candy, hamburger, ham, baloney, salami, sausage, hotdog, instant noodles, packaged salty foods, crackers, fried salty snacks, sodas, and fast food). The term “ultra-processed salty foods” was used for the group that included processed meats (hamburger, ham, baloney, salami, sausage, hotdog), packaged snacks, instant noodles, and crackers. Consumption of markers of healthy and unhealthy diet was categorized as frequent (≥ 5 days a week) and not frequent (0-4 days a week). Next, two scores were created for the continuous analysis. Healthy diet score was based on the sum of days of the week that the adolescent reported consuming each of the three healthy markers, and could vary from zero (did not consume any of these foods on any day) to 21 (consumed all of the foods on all 7 days). The unhealthy diet score was created in the same way, but adding the frequency of consumption of the five unhealthy markers, ranging from zero to 35. The higher the score, the higher the consumption of these dietary markers. The scores were created to allow consolidating healthy and unhealthy indicators, and not only each single variable.

The sociodemographic variables were: sex; age bracket (≤ 13 years, 14, 15, ≥ 16 years); maternal schooling (incomplete elementary, complete elementary, complete secondary; complete university); school administration (public versus private); race/color (white, black, brown, Asian-descendent, indigenous); geographic region of school and student’s residence (North, Northeast, Southeast, South, Central); municipality of residence (state capital and non-capital); family arrangement (lives with mother and father, only with mother, only with father, or with neither); and household assets and services score. The assets and services score was based on the following reported items: landline, mobile phone, computer, internet access, car, and housemaid services three or more days a week. Each item was assigned a weight, the equivalent to the inverse frequency of possession of assets or presence of services in the total sample. The sum of the weights produced the score for each individual, later divided into tertiles 19.

Ethical aspects

The PeNSE 2015 survey was approved by the National Committee for Research Ethics of the National Health Council (CNS), under case review n. 1.006.467 of March 30, 2015. Students and schools were advised as to guaranteed data confidentiality and anonymity.

Data analysis

We calculated the prevalence rates and confidence intervals for frequent consumption of the dietary markers, as well as frequent consumption of meals with parents, according to the socioeconomic variables.

Multiple imputation by chained equations was performed for the variable maternal schooling, which showed 26.9% of losses. Sociodemographic and dietary variables were used as predictive variables in the imputation because they were part of subsequent analytical models 20. The other variables showed losses less than 0.3%.

The association between eating meals with parents and frequent consumption of each healthy and unhealthy dietary marker was assessed as prevalence ratio (PR), obtained by Poisson regression models. The association between eating meals with parents and healthy and unhealthy diet scores was assessed with linear regression models. Covariables with p < 0.20 in the univariate models with the outcome were used for adjustment in the multiple models.

All the analyses used Stata 14.1 (https://www.stata.com), considering the sample’s complexity and setting statistical significance at p < 0.05.

Results

Tables 1 and 2 show frequent consumption of markers of healthy and unhealthy diet according to the sociodemographic characteristics of Brazilian adolescents. More than half (52.8%; 95%CI: 51.8-53.8) showed frequent consumption of beans, and about one-third ate fruits (32.7%; 95%CI: 32.1-33.4) and vegetables (37.7%; 95%CI: 37.0-38.4) at least 5 days a week. As for unhealthy dietary markers, 41.6% (95%CI: 41.0-42.3) of the adolescents reported frequent consumption of sweets, 31.3% (95%CI: 30.7-32.0) of ultra-processed salty foods, 13.7% (95%CI: 13.2-14.2) of fried salty snacks, 26.7% (95%CI: 26.0-27.3) of sodas, and 5.2% (95%CI: 4.9-5.4) of fast food. Frequent consumption of beans was higher in public school students, in black, brown, or indigenous students compared to whites, and in those not living in state capitals, and was inversely associated with the household assets/services score and maternal schooling. Consumption of fruits and vegetables showed a direct association with the assets/services score and maternal schooling. Frequent consumption of vegetables was higher in private school students and white students compared to black, brown, and indigenous (Table 1). Frequent consumption of all unhealthy dietary markers was higher in students reporting higher maternal schooling and in the higher tertiles of household assets/services. Frequent consumption of ultra-processed salty foods, which included processed meats, packaged salty snacks, and crackers was also higher in private school students (Table 2).

Table 1 Frequent consumption of healthy dietary markers according to sociodemographic characteristics of Brazilian adolescents. Brazilian National Survey of School Health (PeNSE), 2015. 

Variables Beans Fruits Vegetables
% 95%CI % 95%CI % 95%CI
Total 52.8 51.8-53.8 32.7 32.1-33.4 37.7 37.0-38.4
Sex
Male 57.3 56.1-58.5 33.3 32.5-34.0 37.1 36.3-38.0
Female 48.5 47.3-49.7 32.2 31.3-33.1 38.2 37.4-39.1
Race/color
White 50.2 48.8-51.6 32.9 31.8-34.0 40.1 39.0-41.3
Black 58.8 57.0-60.6 33.1 31.6-34.7 34.9 33.3-36.6
Asian-descendent 50.2 47.4-52.9 32.6 30.2-35.2 40.5 37.8-43.3
Brown 53.2 52.1-54.4 32.4 31.6-33.2 36.5 35.7-37.3
Indigenous 54.0 51.0-57.1 33.0 30.4-35.8 34.0 31.3-36.8
Age (years)
≤ 13 53.6 51.5-55.7 33.4 31.7-35.1 39.8 38.3-41.4
14 52.7 51.5-53.9 33.5 32.6-34.4 39.3 38.3-40.2
15 52.5 51.0-53.9 31.2 30.2-32.3 35.0 33.9-36.1
≥ 16 52.4 50.7-54.1 30.6 29.2-32.0 31.7 30.3-33.2
p-value 0.328 < 0.001 < 0.001
Maternal schooling
Incomplete Elementary School 55.8 54.6-57.0 29.3 28.3-30.3 32.2 31.2-33.2
Complete Elementary School 54.2 52.5-56.0 32.3 30.9-33.8 37.0 35.4-38.5
Complete Secondary School 52.4 50.9-53.9 34.2 33.0-35.4 40.4 39.2-41.7
Complete University 45.6 43.7-47.4 37.7 36.3-39.2 45.4 43.7-47.1
p-value < 0.001 < 0.001 < 0.001
Type of school
Public 54.9 53.9-55.9 32.6 31.9-33.3 36.8 36.1-37.5
Private 40.6 38.1-43.1 33.3 31.5-35.2 42.8 40.8-44.9
Assets and services score
1st tertile 52.7 51.5-53.9 29.4 28.6-30.3 32.2 31.3-33.1
2nd tertile 55.4 54.2-56.5 32.8 31.7-33.8 38.0 37.0-39.0
3rd tertile 50.4 48.8-52.0 35.7 34.6-36.9 42.5 41.3-43.7
p-value 0.009 < 0.001 < 0.001
Geographic Region
North 32.7 30.9-34.5 29.8 28.6-31.0 36.4 35.2-37.7
Northeast 49.7 48.4-51.0 31.3 30.5-32.2 31.0 30.2-31.9
Southeast 61.7 59.9-63.5 34.2 32.9-35.5 40.9 39.6-42.3
South 39.3 37.0-41.6 31.9 30.6-33.2 38.9 37.5-40.4
Central 59.6 58.2-61.1 34.7 33.6-35.8 43.6 42.3-44.8
Municipality of residence
State capital 47.3 45.7-48.9 32.8 32.0-33.7 38.3 37.3-39.2
Non-state capital 54.4 53.2-55.6 32.7 31.9-33.5 37.5 36.7-38.4
Family arrangement
Mother and father 54.0 52.8-55.2 33.3 32.5-34.2 38.8 38.0-39.6
Mother only 50.9 49.5-52.2 31.9 30.9-32.9 36.3 35.2-37.3
Father only 54.2 51.6-56.8 32.3 29.9-34.8 37.3 34.8-39.9
Neither 50.0 47.8-52.1 31.1 29.2-33.1 34.4 32.3-36.4

95%CI: 95% confidence interval.

Table 2 Frequent consumption of unhealthy dietary markers according to sociodemographic characteristics of Brazilian adolescents. Brazilian National Survey of School Health (PeNSE), 2015. 

Variables Sweet Ultra-processed salty foods Fried snacks Sodas Fast food
% 95%CI % 95%CI % 95%CI % 95%CI % 95%CI
Total 41.6 41.0-42.3 31.3 30.7-32.0 13.7 13.2-14.2 26.7 26.0-27.3 5.2 4.9-5.4
Sex
Male 35.5 34.7-36.3 29.1 28.3-29.9 12.9 12.4-13.5 28.7 27.8-29.5 5.5 5.2-5.9
Female 47.4 46.5-48.4 33.4 32.5-34.3 14.4 13.8-15.1 24.7 23.9-25.6 4.8 4.4-5.2
Race/color
White 41.0 40.0-42.1 33.4 32.5-34.3 12.5 11.8-13.3 27.3 26.2-28.4 5.2 4.7-5.7
Black 42.3 40.7-44.0 29.8 28.4-31.2 15.1 13.9-16.4 29.2 27.7-30.8 5.9 5.2-6.7
Asian-descendent 40.6 37.8-43.5 33.6 31.2-36.0 16.0 14.0-18.3 26.9 24.7-29.2 6.6 5.4-8.0
Brown 42.1 41.2-43.1 29.9 28.9-30.8 14.0 13.4-14.7 25.2 24.4-26.1 4.7 4.3-5.0
Indigenous 39.8 37.1-42.5 30.6 28.0-33.3 13.7 11.7-15.9 27.7 24.9-30.7 6.2 4.9-7.8
Age (years)
≤ 13 44.7 43.0-46.4 33.8 32.5-35.1 13.4 12.3-14.5 25.0 23.6-26.4 3.9 3.4-4.6
14 42.2 41.2-43.1 31.7 30.9-32.6 12.9 12.3-13.5 25.6 24.8-26.5 4.5 4.2-4.9
15 39.9 38.7-41.1 29.7 28.6-30.9 14.8 13.9-15.7 30.0 28.9-31.1 6.6 6.0-7.3
≥ 16 36.9 35.4-38.4 28.2 26.8-29.7 16.1 15.1-17.2 28.2 26.9-29.5 7.6 6.8-8.4
p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Maternal schooling
Incomplete Elementary School 39.6 38.6-40.6 27.3 26.3-28.4 12.4 11.7-13.1 23.9 22.9-24.8 4.0 3.6-4.5
Complete Elementary School 42.4 40.9-43.8 32.3 30.9-33.6 13.8 12.7-14.8 27.8 26.3-29.3 5.4 4.7-6.0
Complete Secondary School 43.1 42.0-44.2 33.4 32.4-34.4 14.5 13.7-15.4 28.7 27.6-29.8 5.6 5.1-6.1
Complete University 42.8 41.2-44.5 35.1 33.8-36.5 14.9 13.7-16.1 27.6 26.0-29.1 6.4 5.8-7.1
p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Type of school
Public 41.6 40.9-42.3 29.9 29.2-30.5 13.7 13.2-14.2 26.5 25.8-27.2 5.1 4.8-5.4
Private 41.7 39.9-43.4 39.9 38.3-41.6 13.8 12.7-15.1 27.5 25.7-29.5 5.5 4.9-6.2
Assets and services score
1st tertile 38.7 37.8-39.7 26.8 25.9-27.6 12.5 11.8-13.2 21.1 20.3-22.0 3.9 3.6-4.3
2nd tertile 42.3 41.3-43.3 31.3 30.4-32.4 13.8 13.1-14.5 27.1 26.2-28.0 4.7 4.3-5.1
3rd tertile 43.6 42.5-44.8 35.6 34.6-36.6 14.7 13.9-15.6 31.3 30.0-32.5 6.8 6.3-7.4
p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Geographic region
North 36.1 34.8-37.4 24.0 22.9-25.1 13.7 12.8-14.6 23.8 22.7-24.9 5.3 4.9-5.8
Northeast 37.8 36.9-38.8 30.6 29.7-31.5 14.7 14.0-15.4 21.7 20.9-22.6 5.1 4.7-5.4
Southeast 45.1 43.9-46.4 32.9 31.6-34.1 13.8 12.9-14.7 30.0 28.7-31.3 5.2 4.7-5.8
South 39.6 38.2-41.1 33.6 32.3-34.9 11.7 10.8-12.6 25.0 23.7-26.3 4.3 3.8-4.9
Central 45.6 44.4-46.8 30.9 29.8-31.9 12.8 12.1-13.5 32.0 30.8-33.2 6.1 5.7-6.5
Municipality of residence
State capital 41.8 40.9-42.6 34.0 33.2-34.9 14.5 13.7-15.2 28.8 27.9-29.8 6.0 5.7-6.4
Non-state capital 41.6 40.7-42.4 30.5 29.7-31.3 13.5 12.9-14.1 26.0 25.2-26.8 4.9 4.6-5.2
Family arrangement
Mother and father 40.7 39.8-41.6 31.1 30.3-31.9 12.8 12.3-13.4 25.5 24.6-26.3 4.8 4.5-5.1
Mother only 43.7 42.6-44.7 32.2 31.2-33.1 14.7 14.0-15.5 28.0 27.0-29.0 5.6 5.1-6.1
Father only 41.1 38.6-43.6 30.4 28.0-32.9 15.7 13.9-17.8 31.5 29.2-33.9 5.7 4.6-7.0
Neither 41.1 38.9-43.3 30.2 28.5-32.1 15.7 14.2-17.4 28.0 26.0-30.0 6.2 5.3-7.3

95%CI: 95% confidence interval.

Approximately 74% (95%CI: 73.4-74.7) of the adolescents reported eating meals with parents at least 5 days a week, a habit that was more frequent in boys, younger adolescents, children of mothers with less schooling, public school students, and those not living in state capitals (Table 3).

Table 3 Frequency of meals with parents according to sociodemographic characteristics of Brazilian adolescents. Brazilian National Survey of School Health (PeNSE), 2015. 

Variables Frequency of meals with parents (days/week)
0-4 days 5 or more days
% 95%CI % 95%CI
Total 26.0 25.3-26.6 74.0 73.4-74.7
Sex
Male 22.5 21.7-23.3 77.5 76.7-78.3
Female 29.2 28.4-30.0 70.8 70.0-71.6
Race/color
White 24.4 23.5-25.4 75.6 74.6-76.5
Black 27.5 26.1-28.8 72.5 71.2-73.9
Asian-descendent 30.2 27.7-32.7 69.8 67.3-72.3
Brown 26.2 25.4-27.0 73.8 73.0-74.6
Indigenous 29.1 26.6-31.8 70.9 68.2-73.4
Age (years)
≤ 13 23.7 22.4-25.1 76.3 74.9-77.6
14 25.1 24.4-25.9 74.9 74.1-75.6
15 28.2 27.1-29.3 71.8 70.7-72.9
≥ 16 29.6 28.2-31.1 70.4 68.9-71.8
p-value < 0.001
Maternal schooling
Incomplete Elementary School 25.2 24.3-26.2 74.8 73.8-75.7
Complete Elementary School 25.6 24.3-27.0 74.4 73.0-75.7
Complete Secondary School 26.1 25.0-27.3 73.9 72.7-75.0
Complete University 27.4 26.1-28.8 72.6 71.2-73.9
p-value 0.012
Type of school
Public 25.2 24.5-25.9 74.8 74.1-75.5
Private 30.4 28.8-32.1 69.6 67.9-71.2
Assets and services score
1st tertile 27.6 26.6-28.5 72.4 71.5-73.4
2nd tertile 24.8 24.0-25.7 75.2 74.3-76.0
3rd tertile 25.6 24.5-26.8 74.4 73.2-75.5
p-value 0.011
Geographic region
North 25.1 23.9-26.3 74.9 73.7-76.1
Northeast 28.0 27.0-28.9 72.0 71.1-73.0
Southeast 26.3 25.1-27.6 73.7 72.4-74.9
South 22.6 21.4-23.8 77.4 76.2-78.6
Central 22.9 21.9-23.9 77.1 76.1-78.1
Municipality of residence
State capital 30.8 30.0-31.7 69.2 68.3-70.0
Non-state capital 24.5 23.7-25.3 75.5 74.7-76.3
Family arrangement
Mother and father 20.7 20.0-21.4 79.3 78.6-80.0
Mother only 32.5 31.4-33.5 67.5 66.5-68.6
Father only 34.4 31.9-37.0 65.6 63.0-68.1
Neither 39.8 37.8-41.8 60.2 58.2-62.2

95%CI: 95% confidence interval.

Table 4 shows the association between frequency of eating meals with parents and frequent consumption of healthy and unhealthy dietary markers. Eating meals with parents at least 5 days a week was positively associated with frequent consumption of beans (PR = 1.22; 95%CI: 1.19-1.26), fruits (PR = 1.34; 95%CI: 1.28-1.39), and vegetables (PR = 1.34; 95%CI; 1.28-1.39) and negatively associated with frequent consumption of sweets (PR = 0.91; 95%CI: 0.88-0.94), ultra-processed salty foods (PR = 0.91; 95%CI: 0.87-0.94), and fried salty snacks (PR = 0.85; 95%CI: 0.80-0.90). There was no significant association for consumption of sodas and fast food (p > 0.05).

The analysis of consolidated indicators via dietary scores showed that eating meals with parents was positively associated with the healthy diet score (β = 1.86; p < 0.001) and inversely associated with the unhealthy diet score (β = -0.62; p < 0.001) (Figure 1).

Table 4 Associations between consumption of healthy and unhealthy dietary markers and habit of eating meals with parents. Brazilian National Survey of School Health (PeNSE), 2015. 

Markers Crude model Adjusted model *
PR 95%CI p-value PR 95%CI p-value
Healthy diet
Beans 1.26 1.22-1.29 < 0.001 1.22 1.19-1.26 < 0.001
Fruits 1.33 1.28-1.39 < 0.001 1.34 1.28-1.39 < 0.001
Vegetables 1.39 1.34-1.44 < 0.001 1.39 1.34-1.44 < 0.001
Unhealthy diet
Sweets 0.89 0.86-0.91 < 0.001 0.91 0.88-0.94 < 0.001
Ultra-processed salted foods 0.88 0.85-0.92 < 0.001 0.91 0.87-0.94 < 0.001
Fried salty snacks 0.81 0.76-0.85 < 0.001 0.85 0.80-0.90 < 0.001
Sodas 0.95 0.91-0.99 0.015 0.97 0.93-1.01 0.098
Fast food 0.85 0.77-0.94 0.001 0.91 0.82-1.00 0.051

95% CI: 95% confidence interval; PR: prevalence ratio.

* The covariables included in each model were: (a) beans: sex, color, type of school, maternal schooling, assets and services score, region, type of municipality, family arrangement; (b) fruits: sex, age, maternal schooling, assets and services score, region, family arrangement; (c) vegetables: sex, color, age, type of school, maternal schooling, assets and services score, region, family arrangement; (d) sweets: sex, color, age, maternal schooling, assets and services score, region, family arrangement; (e) ultra-processed salty foods: sex, color, age, type of school, maternal schooling, assets and services score, region, type of municipality, family arrangement; (f) fried salty snacks, sodas, and fast food: sex, color, age, maternal schooling, assets and services score, region, type of municipality, family arrangement.

Figure 1 Associations between healthy and unhealthy diet scores and habit of eating meals with parents. Brazilian National Survey of School Health (PeNSE), 2015. 

Discussion

This study aimed to assess the association between eating meals with parents as a family environment characteristic and quality of diet in Brazilian adolescents. The results showed that eating meals with parents was associated with better diet quality in adolescents, specifically more frequent consumption of beans, fruits, and vegetables, and less frequent consumption of sweets, ultra-processed salty foods, and fried salty snacks. Sharing meals frequently with parents was positively associated with healthy diet score and inversely with unhealthy diet score.

Eating meals with parents was a frequent habit in Brazilian adolescents, more than 70% of whom reported sharing meals with them at least 5 days of week. This was similar to another Brazilian study that found 68% of adolescents always or almost always eating meals with parents 17. In our study, this habit was more frequent in boys, younger adolescents, public school students, and those living with the mother and father.

More than half of the adolescents ate beans frequently, but fewer than one-third reported frequent consumption of other healthy dietary markers (fruits and vegetables). Meanwhile, unhealthy markers stood out, with more than 30% of adolescents reporting frequent consumption of sweets and ultra-processed salty foods. These results are consistent with previous studies showing that Brazilian adolescents’ diet is still marked by consumption of traditional foods like beans, but that these foods are being replaced by ultra-processed products like sweets, cookies, sodas, and fast food 6,7,19,21. A recent study also using data from the PeNSE 2015 survey showed that although the amounts consumed daily were not evaluated, it is worrisome that four out of ten Brazilian adolescents already reported consuming ultra-processed foods on a daily basis 22.

Socioeconomic differences in the consumption of healthy and unhealthy dietary markers in Brazilian adolescents were found in a previous study by Azeredo et al. using data from PeNSE 2012 21, in which the relations were similar to the more recent study. We found that older adolescents shared meals less frequently with their parents, corroborating a previous study by Barufaldi et al. 17, and consumed more fried snacks, fast food, and sodas. A possible explanation is that as they grow older, adolescents gain greater independence and autonomy to purchase and consume their own meals without their parents’ presence 23. The relationship between frequency of eating with parents and indicators of social vulnerability such as maternal schooling, household assets/services, and race/color is not clear. Although such characteristics favor consumption of meals with parents, they are also associated with less frequent consumption of fruits and vegetables, showing that other factors such as prices and availability of these foods in regions with lower socioeconomic status may influence the consumption of healthy foods in this population group 24,25.

The association in our study between eating meals with the family and better quality of diet in adolescents is corroborated by other studies, conducted in high-income countries 26,27,28,29,30,31. American adolescents that eat meals with parents tend to consume more fruits and vegetables 26,27,28. In New Zealand, adolescents that share meals with the family perceive more support from parents for a healthy diet, have limits on the time they spend watching television, and are more prone to having fruits and vegetables available at home every day 30. A systematic literature review identified household availability of fruits and vegetables, frequent family meals, and parental support for a healthy diet as potential determinants of consumption of fruits and vegetables by children and adolescents 31. These findings underline parents’ crucial role in children’s eating patterns through their eating behaviors, attitudes, and styles 10.

The experiences of shared meals can also have positive long-term effects. Data from a population-based cohort in Minnesota, USA, showed that regular meals with the family were associated with healthier eating patterns both in adolescence and later in adulthood 32,33. Recent analyses in this same cohort, followed for 15 years, showed that family eating practices were carried over to the next generation 34. The results evidenced that adolescents’ family environment can shape their eating practices in adulthood.

Meals with the family promote not only improved diet quality 26,27 and lower levels of excess weight in adolescents 29,30, but also provide an opportunity for dietary education (improvement of culinary skills and healthy habits, for example) 35 and social living, promoting commensality 36 and psychological well-being 28. Thus, sharing meals with family represents a key sociocultural element in health promotion for adolescents 23. Due to the potential short- and long-term impact of parents’ dietary practices on their children, it is important to invest in family interventions aimed at encouraging shared healthy meals, a practice recommended by the Food Guide for the Brazilian Population 36.

Some limitations and weaknesses in the study merit discussion. This was the first population-based study to analyze the relationship between eating meals with parents and diet quality in Brazilian adolescents. Another strength is the use of the database from PeNSE 2015, a nationwide school-based survey including data on students from rural towns and state capitals and the Federal District. The survey’s high response rate (82.2%) and high school coverage in this age bracket (97% from 6 to 14 years and 88% from 15 to 19 years) contributed to the study’s external validity 37. The study also assessed both regular consumption of single foods and healthy and unhealthy diet scores, and found consistency in the associations. The limitations feature the fact that the questionnaire used by PeNSE 2015 did not allow a more detailed quantitative analysis of the adolescents’ diet, since it included a limited number of foods and did not consider the size of portions or whether the food was consumed more than once a day, but rather the number of days the student ate a given food in the previous week. In addition, the absence of data on the parents’ diet prevented analyzing the association between quality of the adolescents’ and parents’ diet. Finally, residual unmeasured confounding or mediating factors may at least partially explain the associations. Nevertheless, the results were consistent for frequent consumption and for the diet scores. In addition, the cross-sectional design limits the capacity to acess causal associations between eating meals with parents and adolescents’ diet quality.

Conclusions

Our results showed that eating meals with parents is associated with more consumption of healthy foods and less consumption of unhealthy foods, thus suggesting that this habit reflects improved diet quality in Brazilian adolescents. Therefore, interventions focused on the promotion of healthy eating environments should address barriers to sharing meals in the family, besides acknowledging the role of this practice as an instrument for promoting healthy diet.

Acknowledgments

This study was financial supported by Brazilian National Research Council (CNPq, process #444794/2014-0), which is linked to process #426094/2018-2. B. G. Martins had an Undergraduate Research Mentorship scholarship from CNPq (grant #112083/2016-1). F. Rauber is beneficiary of a Post-Doctoral program scholarship from São Paulo State Research Foundation (FAPESP, grant # 2016/14302-7). C. Z. Ricardo is beneficiary of a Master’s program scholarship from FAPESP (grant #2014/26711-3). P. P. Machado is a beneficiary of a Doctoral scholarship (FAPESP, grant #2016/13168-5).

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Received: August 06, 2018; Revised: November 27, 2018; Accepted: December 10, 2018

Correspondence R. B. Levy Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455, 2º andar, São Paulo, SP 01246-903, Brasil. rlevy@usp.br

Contributors

B. G. Martins and C. Z. Ricardo participated in the study design, in the data analysis and interpretation and writing of the article. P. P. Machado participated in the data analysis and interpretation and writing of the article. F. Rauber and C. M. Azeredo and complemented the writing of the article and collaborated in the data analysis and final revision. R. B. Levy worked in the imputation of missing data and final revision of the article; participated in the study design, and the writing. All authors have approved the final version for publication.

Additional informations

ORCID: Bianca Garcia Martins (0000-0002-2199-9111); Camila Zancheta Ricardo (0000-0003-3643-302X); Priscila Pereira Machado (0000-0003-4607-5094); Fernanda Rauber (0000-0001-9693-7954); Catarina Machado Azeredo (0000-0002-6189-4429); Renata Bertazzi Levy (0000-0001-5388-7002).

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