Country-level sociocultural context and socioeconomic inequalities in adolescent dietary behaviours: A multilevel analysis in 21 European countries.

Studies to date have predominantly focused on countries' socioeconomic conditions (e.g., income inequality) to explain cross-national differences in socioeconomic inequalities in adolescent health (behaviours). However, the potential explanatory role of sociocultural contexts at country-level remains underexamined. This study examined whether the country-level sociocultural context and changes thereof were associated with adolescent socioeconomic inequalities in dietary behaviours. International comparative data of 344,352 adolescents living in 21 countries participating in 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey were combined with aggregated levels of openness-to-change from the European Social Survey (ESS). Four dietary behaviours (i.e., fruit, vegetable, sweets and soft drink consumption) and two measures of socioeconomic status (SES) on the individual level (i.e., family affluence scale [FAS] and occupational social class [OSC]) were studied. Multilevel logistic regression analyses returned contrasting results for the two SES measures used. In countries with higher levels of openness-to-change, smaller FAS inequalities in daily fruit, sweets and soft drink consumption were observed, but no such inequalities were found for vegetable consumption. Conversely, in these countries, larger OSC inequalities in soft drink consumption were found. Country-specific changes in openness-to-change over time were not associated with the magnitude of adolescent dietary inequalities. Findings underscore the importance of including country-level sociocultural contexts to improve the understanding of cross-national differences in socioeconomic inequalities in adolescents' diets. Future studies, spanning a longer timeframe, are required to examine whether such associations exist within countries over time since our timeframe might have been too small to capture these long-term trends.

Sixteen-year trends in fruit consumption and related socioeconomic inequalities among adolescents in Western European countries.

PURPOSE: To investigate time trends in daily fruit consumption among Western European adolescents and in related socioeconomic inequalities. METHODS: We used nationally representative data from 18 countries participating in five rounds (2002 to 2018) of the cross-sectional "Health Behaviour in School-aged Children" (HBSC) survey (n = 458,973). The questionnaire, standardised across countries and rounds, was self-administered at school by 11-, 13- and 15-year-old adolescents. Daily fruit consumption was assessed using a short food frequency questionnaire (sFFQ). Socioeconomic inequalities were measured using the Family Affluence Scale (FAS). Multilevel logistic regressions were applied to study linear time trends in daily fruit consumption, overall, by country and by FAS. RESULTS: Between 2002 and 2018, daily fruit consumption increased in 10 countries (OR range, 1.04 to 1.13, p < 0.05) and decreased in 3 (OR range 0.96 to 0.98, p < 0.05). In all survey years combined, prevalence of daily fruit consumption was significantly higher among high FAS groups (42.6%) compared to medium (36.1%) and low FAS groups (31.7%; all countries: p < 0.001). Between 2002 and 2018, socioeconomic inequalities in fruit consumption increased in Austria, Germany, Italy, Netherlands, Scotland, Sweden, and Switzerland. Only in Norway FAS inequalities decreased while the prevalence increased. CONCLUSION: The prevalence of daily fruit consumption generally increased among adolescents between 2002 and 2018 in Western European countries, yet socioeconomic inequalities increased in some countries. Public health interventions should continue to promote fruit consumption with special attention to lower socioeconomic groups.

The Correlation between Adolescent Daily Breakfast Consumption and Socio-Demographic: Trends in 23 European Countries Participating in the Health Behaviour in School-Aged Children Study (2002-2018).

Breakfast is often considered the most important meal of the day and can benefit adolescent health in several ways. The aims of the present study were (1) to identify adolescents' socio-demographic (sex, family affluence and family structure) determinants of daily breakfast consumption (DBC) and (2) to describe trends in DBC among adolescents across 23 countries. Cross-sectional surveys of nationally representative samples of adolescents (aged 11, 13, and 15 years) (n = 589,737) participating in the Health Behaviour in School-aged Children (HBSC) survey from 2002 to 2018 were used. Multilevel logistic regression analyses modeled DBC over time, adjusted for family affluence, family structure and year of survey. Four countries showed an increased trend in DBC (the Netherlands, Macedonia, Slovenia, and England). A significant decrease in DBC was observed in 15 countries (Belgium-Fr, France, Germany, Croatia, Portugal, Spain, Hungary, Poland, Russian Federation, Ukraine, Denmark, Finland, Latvia, Lithuania and Sweden). In 4 countries no significant change was observed (Czech Republic, Scotland, Ireland and Norway). In most of the countries (n = 19), DBC was higher among the adolescents from high-affluence homes. In all the countries analysed, the adolescents living in two-parent households report higher DBC use than those in single-parent households. More than half of the countries showed a decrease in DBC. There is a need to implement key interventions by developing different strategies (education, incorporating educational curriculum and counselling programmes) to increase DBC. Comparing DBC patterns across HBSC countries is important for understanding regional and global trends, monitoring strategies, and developing health promotion programmes.

Tax on sugary drinks and trends in daily soda consumption by family affluence: an international repeated cross-sectional survey among European adolescents.

BACKGROUND: The WHO recommends soda taxes to reduce sugar consumption, but the effect across socioeconomic groups is unclear. OBJECTIVES: We assessed 16-y trends in daily soda consumption among adolescents in 4 European countries with a soda tax and 5 comparison countries, by family affluence. METHODS: Five rounds of the international "Health Behaviour in School-Aged Children" school-based survey were used (school years 2001/2002 to 2017/2018, repeated cross-sectional design). Finland, France, Belgium, and Portugal introduced or updated a soda tax during this period. For comparison, we selected 5 neighboring countries without such a tax. Nationally representative samples of adolescents aged 13 and 15 y (n = 165,521; 51.2% girls) completed a standardized questionnaire, including a question on soda consumption frequency. Using the family affluence scale (FAS), we categorized adolescents into lower-, middle- or higher-affluent groups. Changes in daily soda consumption were assessed in each country independently. RESULTS: Before taxation, daily soda consumption was more likely among lower-affluent adolescents in France and Belgium (P < 0.001, socioeconomic inequalities) and was similar across FAS groups in Finland and Portugal (no inequalities). After the tax, daily soda consumption was reduced across all FAS groups in Finland, Belgium, and Portugal (Pinteractions ≥ 0.33). In France, a posttax decrease was observed only among lower-affluent adolescents (ORlower, 0.76; 95% CI: 0.60, 0.96; reduced inequalities). During the same periods, socioeconomic patterns remained stable in 3 comparison countries (Pinteractions ≥ 0.38), and larger reductions in daily soda consumption were observed among middle- or higher-affluent adolescents compared with lower-affluent adolescents in the remaining 2 comparison countries (Pinteractions ≤ 0.08, increased inequalities). CONCLUSIONS: Socioeconomic patterns did not change after the tax implementation in 3 out of 4 countries, and socioeconomic inequalities were reduced in France. Taxing sodas might be an effective measure to attenuate, or at least not exacerbate, socioeconomic inequalities in adolescent daily soda consumption. Am J Clin Nutr 20XX;xx:xx-xx.

Sixteen-year trends in adolescent consumption of sugar-sweetened soda in six European countries with a soda tax and comparison countries: a repeated cross-sectional survey analysis.

OBJECTIVE: To examine changes in the proportions of daily, weekly and occasional consumers of sugar-sweetened soda in six European countries that introduced/updated a tax between 2001-2002 and 2017-2018 and in neighbouring comparison countries (without a tax). DESIGN: Repeated cross-sectional surveys. SETTING: Health Behaviour in School-aged Children study, spanning five survey years (school years 2001-2002 to 2017-2018). PARTICIPANTS: Nationally representative samples of 13-year- and 15-year-old adolescents (n 236 623, 51·0 % girls). RESULTS: Tax sizes (€0·02/l to €0·22/l) and pre-tax soda consumption were heterogeneous across countries. Prevalence of daily soda consumption reduced in the survey year following tax implementation in Latvia (from 17·9 to 11·9 %, P = 0·01), Finland (4·2 to 2·5 %, P = 0·001), Belgium (35·1 to 27·8 %, P < 0·001) and Portugal (17·4 to 14·9 %, P = 0·02), but not in Hungary (29·8 to 31·3 %, P = 0·47) or France (29·4 to 28·2 %, P = 0·27). However, reductions were similar (Finland) or smaller (Belgium, Portugal) than those in the comparison countries, except in Latvia where the reduction was larger (Pinteraction < 0·001). Prevalence of weekly soda consumption remained stable (Finland, Hungary and France) or increased (Latvia, Belgium); only Portugal experienced a decline (P < 0·001), which was larger than in the comparison country (Pinteraction < 0·001). Prevalence of occasional soda consumption (<1x/week) did not rise after implementation of the tax in Latvia, Finland, Hungary, France or Belgium, or the rise was similar to the comparison country in Portugal (Pinteraction = 0·15). CONCLUSIONS: Countries with a soda tax did not experience larger beneficial changes in post-tax adolescent consumption frequency of soda than comparison countries. Further studies, with different taxation types, are needed in the adolescent population.

Long-term trends in the consumption of sugary and diet soft drinks among adolescents: a cross-national survey in 21 European countries.

PURPOSE: To assess country-level trends in the prevalence of daily consumption of sugary (2002-2018) and diet (2006-2018) soft drinks among European adolescents, overall and by family material affluence. METHODS: We used 2002, 2006, 2010, 2014 and 2018 data from the 'Health Behaviour in School-aged Children' survey. Nationally representative samples of adolescents completed a standardised questionnaire at school, including a short food frequency questionnaire (n = 530,976 and 21 countries for sugary soft drinks; n = 61,487 and 4 countries for diet soft drinks). We classified adolescents into three socioeconomic categories for each country and survey year, using the Family Affluence Scale. Multilevel logistic models estimated time trends, by country. RESULTS: Sugary soft drinks: the prevalence of daily consumption (≥ 1×/day) declined in 21/21 countries (Plinear trends ≤ 0.002). Absolute [range - 31.7 to - 3.4% points] and relative [range - 84.8 to - 22.3%] reductions varied considerably across countries, with the largest declines in Ireland, England and Norway. In 3/21 countries, the prevalence of daily consumption decreased more strongly in the most affluent adolescents than in the least affluent ones (P ≤ 0.002). Daily consumption was more prevalent among the least affluent adolescents in 11/21 countries in 2018 (P ≤ 0.002). Diet soft drinks: overall, daily consumption decreased over time in 4/4 countries (Plinear trends ≤ 0.002), more largely among the most affluent adolescents in 1/4 country (P ≤ 0.002). CONCLUSIONS: Daily consumption of sugary and diet soft drinks in European adolescents decreased between 2002 (2006 for diet drinks) and 2018. Public health interventions should continue discouraging daily soft drink consumption, particularly among adolescents from lower socioeconomic groups.

Dietary disparities among adolescents according to individual and school socioeconomic status: a multilevel analysis.

This study aimed to estimate disparities in dietary habits according to the individual and contextual socioeconomic status (SES), while taking into account school nutrition-related characteristics. Data came from the 2018 cross-sectional "Health Behaviour in School-aged Children" (HBSC) survey. Multilevel multiple logistic regressions were performed. Over two-thirds of the observed variance was explained by individual and school characteristics, with SES being the main contributors. For example, 76.9% of the variance in daily sugar-sweetened beverage (SSB) intake was explained by individual and school characteristics. Adolescents of a secondary or lower parental education level were more likely to consume SSB daily than those of a post-secondary level (aOR = 1.46 (1.29-1.66)). Compared to those in a high SES school, the odds to consume SSB daily was higher for adolescents in low SES schools (aOR = 2.37(1.90-2.96)). These findings support the need for schools to pursue a consistent nutrition policy, with an increased support in low socioeconomic populations.

The cost of diets according to diet quality and sociodemographic characteristics in children and adolescents in Belgium.

This study aims to estimate cost variations according to diet quality and sociodemographic characteristics in children. Data (n = 1,596; 5-17 y) from the Belgian National Food Consumption Survey were used. The "Kidmed index" and dietary patterns (DP) identified through principal component analysis were used to assess diet quality. Daily diet cost was estimated after linking the consumed foods with the GfK ConsumerScan panel food prices. The mean diet cost was 4.68€/day (SEM: 0.05). Adjusted for covariates and energy intake, the mean diet cost was 9.1% higher in the highest Kidmed adherence (vs. the lowest) and 6.2% higher in the tercile T3 (vs. T1) of the "Healthy" DP score. It was 4.8% lower in the T3 (vs. T1) for the "Junk food" DP score. Diet cost was higher in 12-17 year-olds (vs. 5-11 years) and in medium and high educated household (vs. the lowest). These findings support policies to make healthy diets more affordable.

Time trends in consumption of sugar-sweetened beverages and related socioeconomic differences among adolescents in Eastern Europe: signs of a nutrition transition?

BACKGROUND: High intake of sugar-sweetened beverages (SSBs) contributes to detrimental cardio-metabolic indicators in youth. Monitoring of SSB consumption is lacking in Eastern Europe. OBJECTIVES: We assessed trends in the prevalence of adolescent daily consumption of SSBs in 14 Eastern European countries between 2002 and 2018, both overall and according to family material affluence. METHODS: We used 2002, 2006, 2010, 2014, and 2018 data of the Health Behaviour in School-Aged Children school-based study (repeated cross-sectional). Nationally representative samples of adolescents aged 11, 13, and 15 years were included (n = 325,184; 51.2% girls). Adolescents completed a standardized questionnaire, including a question on SSB consumption frequency. We categorized adolescents into 3 socioeconomic groups based on the relative Family Affluence Scale (FAS). Adjusted prevalences of daily SSB consumption by survey year, as well as country-level time trends between 2002 and 2018, were computed using multilevel logistic models (overall and by FAS groups). RESULTS: In 2018, the prevalence of adolescents consuming SSBs every day varied considerably between countries (range, 5.1%-28.1%). Between 2002 and 2018, the prevalence of daily SSB consumption declined in 10/14 countries (P for linear trends ≤ 0.004). The largest reductions were observed in Slovenia (OR, 0.48; 95% CI: 0.45-0.50) and the Russian Federation (OR, 0.67; 95% CI: 0.64-0.70). Daily SSB consumption was reduced at faster rates among the most affluent adolescents (who were larger consumers in 2002) than in the least affluent adolescents in 11/14 countries (P for linear trends ≤ 0.004). Thus, differences between FAS groups narrowed over time or even reversed, leading to larger proportions of daily consumers in the least affluent adolescents in 2018 in 5/14 countries (P ≤ 0.05). CONCLUSIONS: Adolescent daily consumption of SSBs decreased between 2002 and 2018 in most Eastern European countries. Declines were larger among higher-affluence adolescents. These results are useful to evaluate and plan interventions promoting healthy childhood diets.

The Cost of Diets According to Nutritional Quality and Sociodemographic Characteristics: A Population-Based Assessment in Belgium.

BACKGROUND: Prices of foods can influence purchase and, therefore, overall quality of diet. However, a limited number of studies have analyzed the cost of diets according to the overall quality of diets taking into account sociodemographic characteristics. OBJECTIVE: Our aim was to estimate cost variations according to diet quality and to identify sociodemographic characteristics associated with such cost differences in adults' diets in Belgium. DESIGN: This cross-sectional study used nationally representative data from Belgium. PARTICIPANTS/SETTINGS: Participants were adults (aged 18 to 64 years; n = 1,158) included in the 2014-2015 Belgian National Food Consumption Survey. MAIN OUTCOME MEASURES: Dietary assessment was based on two 24-hour dietary recalls and a food frequency questionnaire. The Mediterranean Diet Score and the Healthy Diet Indicator were used to assess diet quality. Daily diet cost was estimated after linking the consumed foods with the 2014 GfK ConsumerScan Panel food price data. STATISTICAL ANALYSES PERFORMED: Associations were estimated using linear regressions. RESULTS: The mean daily diet cost was US$6.51 (standard error of mean [SEM] US$0.08; €5.79 [€0.07]). Adjusted for covariates and energy intake, mean (SEM) daily diet cost was significantly higher in the highest tercile (T3) of both diet quality scores than in the T1 (Mediterranean Diet Score: T1 = US$6.29 [US$0.10]; €5.60 [€0.09] vs T3 = US$6.78 [US$0.11]; €6.03 [€0.10]; Healthy Diet Indicator: T1 = US$6.09 [US$0.10]; €5.42 [€0.09] vs T3 = US$7.13 [US$0.11]; €6.34 [€0.10]). Both diet quality and cost were higher in 35- to 64-year-old respondents (vs 18- to 34-year-olds), workers (vs students), and those with higher education levels (vs the lowest). The association between quality and cost of diets was weaker in men and among individuals with higher education levels. CONCLUSIONS: In Belgium, a high-quality diet was more expensive than a low-quality diet. These findings can be used to inform public health policies.

Twenty-Four-Year Trends in Family and Regional Disparities in Fruit, Vegetable and Sugar-Sweetened Beverage Consumption among Adolescents in Belgium.

Dietary habits are influenced by various determinants that may evolve over time. This study aimed to examine, among adolescents in Belgium, trends in the dietary habits between 1990 and 2014 and to determine changes in family and regional disparities related to diet during this time period. In the 1990, 2002 and 2014 cross-sectional "Health Behaviour in School-aged Children" (HBSC) surveys, food consumption was estimated using a short Food Frequency Questionnaire. The Relative Index of Inequality (RII) enabled quantification of the gradients of inequality related to the family structure and to the region for non-daily fruit and vegetable and daily sugar-sweetened beverage (SSB) consumption. Between 1990 and 2014, the prevalence of non-daily fruit consumption increased from 27.7% to 60.6%, whereas the daily SSB consumption decreased from 58.9% to 34.8%. Over time, a downward trend in family disparities (p = 0.007) was observed for daily fruit consumption (RII: 1.58 (1.33-1.88) to 1.18 (1.13-1.23)). An upward trend in region-related disparities (p < 0.001) for SSB was found (RII: 1.15 (1.07-1.23) to 1.37 (1.28-1.47)). The overall trend of increasing disparities when dietary habits improved and decreasing disparities when dietary habits worsened highlights the need to implement actions that improve overall dietary habits while ensuring that disparities do not increase.

Ten-year changes in diet quality among adolescents and young adults (Food Consumption Survey 2004 and 2014, Belgium).

PURPOSE: To estimate the 10-year change in the overall nutritional quality of adolescent and young adult's diet, as measured by the modified Nutrient Profiling System of the British Food Standards Agency individual Dietary Index (FSAm-NPS-DI) which funds the Nutri-Score development, and in different components of this score, overall and according to the individual characteristics. METHODS: Two 24-h dietary recalls were carried out in 15- to 39-year-old respondents included in the Belgian Food Consumption Surveys in 2004 (n = 1186) and 2014 (n = 952). The weighted mean individual FSAm-NPS-DI was computed from all foods and beverages consumed, converted into a scale from 0 to 100 (from the poorest to the most favorable diet), and compared between survey years. Subject characteristics associated with the score, along with the mean daily intake of food groups, energy, and nutrients were explored in multiple linear regressions stratified by survey year and age group. RESULTS: The weighted mean daily FSAm-NPS-DI significantly increased between 2004 and 2014 [2004: 55.3 (SEM: 0.2) vs. 2014: 57.4 (0.5), P < 0.001 in 15- to 18-year olds; 55.0 (0.6) vs. 58.1 (0.4), P < 0.001 in 19- to 25-year olds; 57.1 (0.4) vs. 58.5 (0.3), P < 0.01 in 26- to 39-year olds]. SFA intake decreased in all age groups, and sugar-sweetened beverage, sugar, sodium, and fiber intakes decreased among 15‒18-year olds. The nutritional quality changed unevenly according to sociocultural characteristics, levels of education and regions being the main sources of disparities. CONCLUSION: The quality of diet improved overall between 2004 and 2014 among young people in Belgium, an uneven change that need to be confirmed in future surveys, following the implementation of the Nutri-Score.

Food Consumption in Adolescents and Young Adults: Age-Specific Socio-Economic and Cultural Disparities (Belgian Food Consumption Survey 2014).

A key issue in nutritional public health policies is to take into account social disparities behind health inequalities. The transition from adolescence toward adulthood is a critical period regarding changes in health behaviors. This study aimed to determine how consumption of four emblematic food groups (two to favor and two to limit) differed according to socio-economic and cultural characteristics of adolescents and young adults living in Belgium. Two non-consecutive 24-h dietary recalls were carried out in a nationally representative sample of 10-39 year old subjects (n = 1505) included in the Belgian food consumption survey 2014. Weighted daily mean consumption of "fruits and vegetables", "whole grain bread and cereals", "refined starchy food", and "sugary sweetened beverages" (SSB) was calculated and explored in multivariable linear regressions stratified into four age groups. After adjustment, 10-13 year old adolescents living in less educated households daily consumed lower amounts of "fruits and vegetables" (adjusted mean: 165.6 g/day (95% CI: 125.3-206.0)) and "whole grain bread and cereals" (40.4 g/day (22.9-58.0)), and higher amounts of SSB (309.7 g/day (131.3-488.1) than adolescents of same ages living in more educated households (220.2 g/day (179.8-260.7); 59.0 g/day (40.3-77.8); and 157.8 g/day (1.7-314.0), respectively). The same trends were observed in older groups, along with strong consumption disparities according to region of residency, country of birth, and occupation, with specificities according to age. Our findings suggest the need to better explore such disparities by stage of transition to adulthood, and to adapt nutritional health programs.

Socioeconomic Disparities in Diet Vary According to Migration Status among Adolescents in Belgium.

Little information concerning social disparities in adolescent dietary habits is currently available, especially regarding migration status. The aim of the present study was to estimate socioeconomic disparities in dietary habits of school adolescents from different migration backgrounds. In the 2014 cross-sectional "Health Behavior in School-Aged Children" survey in Belgium, food consumption was estimated using a self-administrated short food frequency questionnaire. In total, 19,172 school adolescents aged 10-19 years were included in analyses. Multilevel multiple binary and multinomial logistic regressions were performed, stratified by migration status (natives, 2nd- and 1st-generation immigrants). Overall, immigrants more frequently consumed both healthy and unhealthy foods. Indeed, 32.4% of 1st-generation immigrants, 26.5% of 2nd-generation immigrants, and 16.7% of natives consumed fish ≥two days a week. Compared to those having a high family affluence scale (FAS), adolescents with a low FAS were more likely to consume chips and fries ≥once a day (vs.

Feelings about the timing of first sexual intercourse and health-related quality of life among adolescents.

BACKGROUND: Early sexual intercourse (SI) may have long-lasting negative impacts on health-related quality of life (HRQoL). So far, these impacts have been studied using age for defining early SI instead of feelings about its timing. The present study examined the association between feelings about the timing of first SI and current HRQoL. METHODS: Data came from the 2014 cross-sectional Health Behaviour in School-aged Children (HBSC) study in French-speaking Belgium. Among participants aged 16-20 years who already had SI, 1778 were included in analyses. Univariate and multivariate logistic regressions were performed, including potential confounders. RESULTS: One quarter of adolescents (26.4%) had poor HRQoL, 19.8% expressed a negative feeling about the timing of first SI and 19.6% did not think about it. Compared with adolescents who thought first SI happened at the right time or wished it had happened sooner, adolescents who had a negative feeling about the timing and those who did not think about it were more likely to have a poor HRQoL (cOR = 1.67 (1.28-2.17) and cOR = 1.37 (1.05-1.80), respectively). After adjustment, associations were no more significant (aOR = 1.22 (0.91-1.63) and aOR = 1.22 (0.91-1.64)). Sex disparity in expressing a negative feeling mostly explained the difference between crude and adjusted analyses. CONCLUSION: Further research is needed to better understand such a complex relationship. The high proportion of adolescents having poor HRQoL and negative feeling about the timing of first SI shows how important it is to find out effective prevention for both domains.