Sleep duration and consumption of ultra-processed foods among Brazilian adolescents

doi:10.21203/rs.3.rs-2248512/v1

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Sleep duration and consumption of ultra-processed foods among Brazilian adolescents

https://doi.org/10.21203/rs.3.rs-2248512/v1

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Background: Sleep duration influences adolescents eating patterns and quality of life. Thus, the study objective was to verify the association between sleep duration and ultra-processed food (UPF) intake among Brazilian adolescents participating in the Study of Cardiovascular Risks in Adolescents (ERICA).

Methods: Cross-sectional study using ERICA data, conducted between March 2013 and December 2014 with adolescents aged 12 to 17 years from public and private schools. UPF intake was obtained by recording a 24-hour food diary, and sleep duration through a questionnaire, stratified into: recommended sleep duration (from 8 to 10 hours) and inadequate sleep duration (less than 8 hours and more than 10 hours). Linear regression was performed to verify the association between sleep duration and UPF consumption.

Results: 66,791 adolescents were evaluated. Adolescents with inadequate sleep duration showed an increase in UPF consumption.

Conclusion: This result can contribute to the development of multifactorial interventions to improve adolescents’ quality of life, emphasizing the importance of adopting healthy lifestyle habits.

Sleep

Ultra-processed foods

Food Intake

Adolescent

Brazil

The sleep time recommended by the American Academy of Sleep Medicine for adolescents is 8 to 10 hours a day [1-4]. Maintaining this habit is essential for promoting good cardiometabolic functioning, good school performance, and quality of life for this age group [5,6]. In situations where sleep duration is inadequate, increased adiposity, insulin resistance, and elevated blood pressure may occur [7-11].

Dietary components can influence adolescent sleep behavior [9,12-14], but sleep duration also influences dietary behavior. For instance, the association between the tendency to consume more foods with low nutritional value, such as ultra-processed foods (UPF), by adolescents who have insufficient sleep duration [12,15] could be related to the increased prevalence of obesity in this age group [16-20].

Evidence points to the association between insufficient sleep duration and unhealthy food consumption in both international [12-14,21,22] and Brazilian [23] contexts. However, studies with representative samples of adolescents have not been carried out yet in Brazil. Given the need for multifactorial actions to reduce overweight and obesity rates, the present study aims to verify the association between sleep duration and the intake of ultra-processed foods among Brazilian adolescents participating in the Study of Cardiovascular Risks in Adolescents (ERICA).

Experimental design

The Study of Cardiovascular Risks in Adolescents (ERICA) is a multicenter, cross-sectional, nationwide, school-based study conducted between March 2013 and December 2014 with adolescents aged between 12 and 17 years of all genders, enrolled in public and private schools located in cities with more than one hundred thousand inhabitants [24]. ERICA aimed to estimate the prevalence of cardiovascular risk factors and metabolic syndrome in Brazilian adolescents.

The ERICA sample included thirty-two strata composed of twenty-seven capitals and five sets of municipalities with more than 100,000 inhabitants in each of the five geographic macro-regions of the country. For each geographic stratum, schools were selected with probability proportional to the size and inversely proportional to the distance from the capital. In the sample, three classes from each school were selected. Using the grade year as an age proxy, 7th, 8th, and 9th grades of elementary school and 1st, 2nd, and 3rd grades of high school were eligible for selection. All students from the selected classes were invited to participate. The sample is representative of medium and large municipalities (> 100,000 inhabitants) at the national and regional levels and Brazilian capitals [24].

Participants

ERICA had 102,327 eligible adolescents. Adolescents with some degree of disability, temporary or permanent, that would make it impossible to participate in the study and pregnant adolescents were considered ineligible. Excluding adolescents absent on the collection day and those who refused to participate, 74,589 adolescents from 1,247 schools in 124 Brazilian municipalities were evaluated [25]. Three questionnaires were applied: one for teenagers, one for parents/educators, and one about the school. In addition, anthropometric assessment, blood pressure measurement, and blood sample collection were performed. In the present study, we only used the form for adolescents, including a 24-hour diary (24hR) and information on weight and height, to calculate the adolescents' Body Mass Index.

All adolescents studied answered the questionnaire using the Personal Digital Assistant (PDA), 73,160 adolescents answered a 24-hour food reminder (24hR), and 73,787 participated in the anthropometric assessment. The questionnaire consisted of approximately 100 questions divided into 11 blocks covering: socioeconomic status, work, smoking, alcohol use consumption, physical activity, medical and health history, sleep scheduled hours, eating behaviors, oral health, mental disorders, and both general and reproductive health. Adolescents with complete data from the R24h, anthropometric assessment, and questionnaire were eligible for the present study, totaling 71,553 participants [25]. Students with total energy consumption of fewer than 500 kilocalories (kcal) and more than 6,000 kcal (n = 1,443) [26] and with sleep duration of fewer than 4 hours and more than 14 hours (n = 4,949) [27] were excluded from the sample to eliminate outliers that might have resulted from measurement errors.

Outcome variable

UPF consumption, in grams, was used as the outcome variable. The R24h was used and applied through interviews by trained researchers to assess food consumption. The interview technique used was that of multiple passages, which consists of an interview conducted in five stages to reduce underreporting of food consumption [28].

The data collected were recorded on netbooks using Brasil Nutri software. It included a list of 1,626 food items from the Food and Beverage Purchase Database from the 2002–2003 Family Budget Survey, conducted by the Brazilian Institute of Geography and Statistics [29]. Foods not included in the database were added by the interviewers.

After converting the food items into grams, the dataset was linked to the Table of Nutritional Composition of Foods Consumed in Brazil [30] and the Table of Referred Measures for Foods Consumed in Brazil [31] to obtain the caloric intake of each adolescent by calculating the conversion of grams of macronutrients to kcal.

Food items were classified according to the degree of processing in agreement with NOVA classification [32]. This classification divides foods into groups according to the type, extent, and purpose of the industrial processes to which they are submitted. These are natural and minimally processed foods, culinary ingredients, processed foods, and ultra-processed foods [32]. Two independent researchers did the categorization of these foods in the NOVA classification. In case of discrepancies, a specialized researcher was contacted to determine the final result.

Explanatory variable

Sleep duration was used as an explanatory variable. Sleep-related data were obtained from the information in the tenth block of the adolescent questionnaire, which consists of questions about sleeping and waking time on weekdays and weekends. To measure sleep duration, the time the adolescents woke up was subtracted from the time they fell asleep. In cases where negative values were found, 24 hours were added to the final subtraction result.

In the present study, the 8 to 10 recommended hours of sleep per night were adopted for Brazilian adolescents [1–4]. The sleep duration variable was divided into recommended sleep duration (8 to 10 hours) and insufficient sleep duration (less than 8 hours and more than 10 hours).

Adjustment variables

The adjustment variables considered were: sex, self-reported skin color (white, black, brown, yellow, and indigenous), age (12–13, 14–15, and 16–17), socioeconomic score (high, medium, and low), consumption of fresh and minimally processed foods (in grams) obtained through R24h and successive classification by NOVA, consumption of processed foods (in grams) obtained through R24h and subsequent classification by NOVA, total energy value consumed (in kcal) obtained through of the R24h, physical activity, body mass index z-score, smoking and alcohol consumption.

The socioeconomic classification was defined by ERICA using the Brazilian Economic Classification Criteria (CCEB) of the Brazilian Association of Research Enterprises (ABEP) in its 2013 version [33], in which ownership of goods (color television, radio, bathroom, car, refrigerator, freezer, washing machine, and DVD player), presence of a domestic worker, and education of the head of the family were considered [33]. However, information on the mother's education was not obtained for 30.8% of the questionnaires. Excluding these adolescents would represent a significant sample loss. Therefore, we decided to use the "wealth proxy" adopted by Moura [34], renamed "socioeconomic score" in the present study, which consists of the CCEB but only considers the possession of goods and the presence of a labor force. Therefore, instead of analyzing the socioeconomic classification, the socioeconomic score was used and divided into three equal intervals (low socioeconomic score: 0 to 12; medium socioeconomic score: 13 to 25; high socioeconomic score: 26 to 38).

Physical activity practice was assessed using the Physical Activity Questionnaire for Adolescents (FAQ), validated by Farias Junior et al. [35]. The physical activity practice variable considered the minutes of physical activity performed by adolescents per week, based on the World Health Organization (WHO) recommendation of 300 minutes per week [36]. The physical activity variable was specified according to the categories used in the National School Health Survey (PeNSE) [37]. Adolescents, who did not engage in any type of activity (0 minutes), were categorized as inactive; those, who exercised between 1 and 149 minutes per week, were categorized as insufficiently active 1; those, who exercised between 150 and 299 minutes per week, were categorized as insufficiently active 2, and those, who exercised at least 300 minutes per week, were categorized as active. The body mass index z-score was determined from the adolescents' weight and height measurements.

Anthropometric measurements were taken from the entire sample by trained researchers. Weight was measured by a single evaluation on a Líder® electronic scale with a capacity of 200 kilograms and a variation of fifty grams, and height was obtained by the average of two measurements performed sequentially in a portable and detachable stadiometer of the Alturexata® brand, with millimeter and field resolution of use up to 213 centimeters.

The variable "smoking" was determined using the question: "Do you currently smoke?". The response options were "yes" and "no." Alcoholic beverage consumption was determined by the question: "How many days did you drink at least one glass or a dose of an alcoholic beverage in the past 30 days (one month)?". Responses were categorized as "do not consume" for those teenagers who had not consumed any type or quantity of alcoholic beverage on any day of the month before the survey and "consume" for those who had consumed at least one dose of any type of beverage.

Statistical analysis

The Shapiro-Wilk test was used to verify the hypothesis of normality of the quantitative variables of the study. To compare the average consumption of ultra-processed foods in grams between the variables stratified by sleep duration, the Student's T test was used for categorical variables with two categories and analysis of variance (ANOVA) and Bonferroni's test for categorical variables with more than two categories. Bivariate and multivariate analyses, in turn, were performed using linear regression models, with the dependent variable the consumption of UPF in grams and the independent variable the duration of sleep categorized according to the adopted recommendation. Beta with a 95% confidence interval (95%CI) was used as a measure of effect.

The final model relevance was evaluated by the F test of the variance analysis and the goodness-of-fit by the determination coefficient (R2). Residuals were evaluated according to normality, homoscedasticity, and linearity assumptions. In addition, multicollinearity was verified between the variables included in the model. The data obtained were analyzed using the Stata software version 14.0, adopting a significance value of 5%. All analyses used the survey module that considers the effects of the research's complex sampling plan.

Ethical aspects

The Research Ethics Committees of the Institute for Studies in Collective Health approved ERICA at the Federal University of Rio de Janeiro (Opinion 01/2009) and in each state and Federal District. All adolescents who agreed to participate signed the consent form. When local ethics committees required informed consent from parents, that was required for students to participate in the study.

A total of 66,791 adolescents were included, of which 55.94% were classified as having inadequate sleep duration, less than 8 hours or more than 10 hours. The average UPF consumption among adolescents with recommended sleep duration was 463.77 grams (95%CI: 458.79–468.74), and the average among adolescents with inadequate sleep duration was 504.86 grams (95%CI: 500.16–509.56), showing a statistically significant difference (p < 0.001) (results not shown). Male adolescents, regardless of sleep duration, had a higher average consumption of UPF, as well as adolescents aged between 14 and 15 years and who belong to a high socioeconomic score (Table 1). Adolescents who self-declare as white have a higher average consumption of UPF when they comply with the sleep recommendation compared to adolescents who self-declare as brown. Among those with inadequate sleep duration, adolescents who self-declare as black or white have an average consumption of UPF bigger than those who self-declare as brown and Indigenous (Table 1).

Table 1

Consumption of ultra-processed foods among adolescents participating in the ERICA stratified by sleep duration (Brazil, 2013–2014; n = 66,791).
Variables	Consumption of ultra-processed foods in grams
	Recommended: 8 to 10 hours	p-value	Inappropriate: < 8 and > 10 hours	p-value
	Average (CI95%)		Average (CI95%)
Gender¹
Female	447.65 (441.24–454.07)	< 0.001	482.16 (476.28–488.04)	< 0.001
Male	483.14 (475.37–490.90)	< 0.001	534.77 (527.15–542.40)	< 0.001
Self-reported skin color²
White	481.93 (473.62–490.25)^a	< 0.001	522.25 (514.45–530.05)^a,b	< 0.001
Black	475.81 (457.07–494.55)		528.66 (510.80–546.53)^c,d
Brown	450,06 (443.19–456.94)^a		490.93 (484.40–497.46)^a,c
East Asian descent	467.63 (432.54–502.72)		507.07 (476.63–537.51)
Indigenous	460.96 (405.99–515.93)		441.35 (389.44–493.26)^b,d
Age (years)²
12–13	461.46 (453.37–469.56)^a	< 0.001	492.18 (482.58–501.78)^a	< 0.001
14–15	478.45 (469.99–486.92)^a,b		515.86 (507.99–523.73)^a,b
16–17	447.93 (438.59–457.27)^b		501.85 (494.47–509.22)^b
Socioeconomic score²
High	505.50 (493.94–517.07)^a,b	< 0.001	533.52 (523.29–543.74)^a,b	< 0.001
Medium	455.78 (449.94–461.62)^a,c		498.24 (492.64–503.84)^a,c
Low	385.30 (359.57–411.04)^b,c		417.73 (391.64–443.82)^b,c

Note: Equal letters represent statistically significant differences between categories. CI = Confidence Interval.

¹Test T of Student

²Anova and Bonferroni´s Test

Table 2 presents the results referring to the linear regression. It was observed that in the adjusted model by - gender, self-reported skin color, age, socioeconomic score, consumption of fresh and minimally processed foods (in grams), consumption of processed foods (in grams), total energy consumed, the practice of physical activity, body mass index z-score, smoking habit and alcohol consumption - adolescents who sleep less than 8 or more than 10 hours per night (inadequate sleep duration) exhibit an increase in UPF consumption (Table 2).

Table 2

Association between sleep duration and consumption of ultra-processed foods among adolescents participating in ERICA (Brazil, 2013–2014; n = 66,791).
Variable	Consumption of ultra-processed foods in grams
Variable	Beta (CI95%)^a	Beta (CI95%)^b
	Crude Model	Adjusted Model¹
Sleep Duration
8 to 10 hours	1	1
< 8 hours or > 10 hours	47.40 (32.16–62.64)*	37.20 (22.64–51.76)*
Note: CI = Confidence Interval

^aR²: 0.28% and Test F: p < 0.001; ^bR²: 2.87% and Test F: p < 0.001.

¹ Linear regression adjusted for gender, self-reported skin color, age, socioeconomic score, consumption of fresh and minimally processed foods (in grams), consumption of processed foods (in grams), total energy consumed, physical activity, z score of body mass index, smoking and alcohol consumption.

*p < 0.001

Adolescents with inadequate sleep duration (less than 8 hours or more than 10 hours) had higher UPF consumption than adolescents who met recommended sleep hours, consistent with the findings of previous studies [6, 12–14, 21–23]. Sleep duration can impact the quality of life, as adequate sleep duration is essential for the full development of adolescents. Otherwise, damage to psychosocial health is observed, affecting academic performance and even promoting the development of risk behaviors such as alcohol and tobacco use in adolescents with insufficient sleep duration [39, 39]. In addition, these studies suggest that sleep quality is also associated with higher UPF consumption among adolescents [6, 12–14], supporting the hypothesis that inadequate eating habits in adolescents may be associated with increased prevalence of obesity due to insufficient sleep duration [9, 12, 15–20].

UPFs have a high energy density, low nutrient density, high palatability, and large amounts of sugars, saturated fats, and sodium. Their high consumption has been associated with mood disturbances, the onset of depressive symptoms, satiety fluctuations, sleep disruption, and appetite changes [40–42]. Such changes could be related to the impairment of nutrients in UPAs in the serotonin synthesis [42], a hormone responsible for controlling hunger and satiety. In this sense, studies show that the increased consumption of UPA in adolescents with insufficient sleep duration may also be due to a hormonal imbalance of ghrelin and leptin [42]. Lin et al. [43] demonstrated that ghrelin levels were higher in the group that had less than the recommended hours of sleep. Ghrelin and leptin are hormones that regulate food intake and energy expenditure. When there is an imbalance (increase in ghrelin and decrease in leptin), there is an increase in appetite and storage of body fat.

Recognizing that food consumption is multifactorial, interventions to reduce UPF consumption should include multiple components that consider changes in the political, environmental, and individual settings. These measures should aim to reduce the availability of these foods in school and home environments through sale regulation of these foods in school settings, advertising and displays, taxation, and appropriate labeling. Also, at the individual level, it is pivotal to implement food and nutrition education activities to promote awareness of healthy lifestyle habits among young people and warn them of the harm caused by excessive UPF consumption.

In light of that, it is also essential to develop actions and strategies that promote sleep hygiene, i.e., which creates an environment that facilitates sleep, including this aspect in the routine of services and planning of health actions. Some strategies are building a daily routine, avoiding consuming products with caffeine before bed, avoiding using technology before bed, and adjusting the room temperature to provide a more comfortable environment [44]. Another factor that has been studied and associated with sleep quality and duration is the start time of classes, with morning students having a shorter sleep duration [45, 46]. Thus, a recommendation from the American Academy of Pediatrics to promote physical and mental health, as well as the best academic performance, is to start classes later, which may be a measure to be discussed and adopted in Brazil [47].

As a study limitation, it is noteworthy that the assessment of sleep duration was based on self-report and is therefore subject to error; however, this assessment method is widely used worldwide and is appropriate for measuring sleep hours in adolescents [48]. In addition, sleep quality may influence individual health and is associated with increased consumption of UPF, data that were not collected in the ERICA study. Finally, due to the cross-sectional design, it is not conceivable to establish a causal relationship between the variables analyzed. However, the representative sample allows a better generalization for the Brazilian population of adolescents aged 12–17 years living in cities with more than 100,000 inhabitants.

Based on the results presented in this study, it was possible to observe a positive association between inadequate sleep duration and UPF consumption, highlighting the need for multifactorial actions and strategies to promote healthy lifestyle habits. In this way, food and nutrition education actions, regulation of the sale and advertising of UPF, and incentives for sleep hygiene should be encouraged and implemented in the Brazilian scenario.

UPF

ultra-processed foods

ERICA

Study of Cardiovascular Risks in Adolescents

PDA

Personal Digital Assistant

24hR

24-hour food reminder

kcal

kilocalories

CCEB

Brazilian Economic Classification Criteria

ABEP

Brazilian Association of Research Enterprises

FAQ

Physical Activity Questionnaire for Adolescents

WHO

World Health Organization

PeNSE

National School Health Survey.

Ethics approval and consent to participate

This report was approved by the Research Ethics Committee of the Instituto de Estudos de Saúde Coletiva da Universidade Federal do Rio de Janeiro (IESC/UFRJ) which belongs to the report’s central coordination (IESC/UFRJ – Aprovation nº45/2008) and of each State. Informed consents were obtained from all subjects, parent and their legal guardian(s). The authors confirm that all methods were performed in accordance with the Declaration of Helsinki.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Author Contributions

LLR, LHAG and LLM conceived and designed the study. LLR, LHAG and MLCI analyzed the data. LLR, MLCI, LHAG, IGM, GJA, CFC, TAPRO, MCP and LLM contributed to the writing of the manuscript.

Consent for publication

Not applicable.

Funding

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq): 565037/2010–2 and 405.009/2012–7.

Availability of data and materials

The datasets used and/or analysed during the current study are available from corresponding author on reasonable request.

Acknowledgements

National Council for Scientific and Technological Development (CNPq–Research Productivity fellow [312979/2021-5]).

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No competing interests reported.

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Sleep duration and consumption of ultra-processed foods among Brazilian adolescents

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Introduction

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Experimental design

Participants

Outcome variable

Explanatory variable

Adjustment variables

Statistical analysis

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