Abstract
Context
Fast foods are quite popular among children owing to taste, appearance and hype created by mass media. However, the increased incidence of lifestyle disorders seen now-a-days at an early age could be attributed to fast foods.
Aim
This study was done to assess the awareness of health hazards, consumption pattern of fast foods and to find out its association with overweight among high school students.
Settings and Design
This cross-sectional study was done among boys of 3 private schools in Mangalore city in March 2012.
Materials and Methods
Data was collected using a semi-structured self-administered questionnaire.
Statistical Analysis
Chi-square test, one-way ANOVA and binary logistic regression analysis was used for analysis. P-value ≤ 0.05 was considered as statistically significant association.
Results
Mean age of boys was 13.5±0.9 years. Out of 300 participants, 41(13.7%) were overweight and 8 (2.7%) were obese. 292(97.3%) were fast food users of which 42(14.4%) consumed it every day. Majority of participants were introduced to fast foods through television commercials 193(64.3%). 73(57%) developed this habit as they were bored with home food. Awareness of harmful effects of fast food consumption was known to 186(62%) students and this was found to be associated with the perceived need to control its usage (p<0.001). Parental consumption of fast foods was found to influence fast food consumption among children (p=0.024). As many as 68(22.7%) and 206(68.7%) children were not eating vegetables and fruits respectively every day. Increased frequency of fast food consumption in a week was found to be associated with overweight or obesity among children after adjusting the effects of confounders (p=0.003).
Conclusion
Awareness on health hazards of fast foods needs to be taught at schools so as to minimize its consumption. Parents have to set an example themselves by not eating fast foods and improving home food to support discouragement of fast foods. This would minimize life style disorders among children to a greater extent.
Keywords: Awareness, Children, Junk foods, Obesity, Urban area
Introduction
Consumption of fast foods has become almost a global phenomenon. India’s fast-food industry is expanding at the rate of 40% every year. India ranks 10th in the fast food per capita spending figures with 2.1% of expenditure in annual total spending [1].
Popularity of these food stuffs in this age of urbanization has been attributed to quick preparation and convenience of finishing a meal within no time. Great taste, attractive appearance along with advertising has played a major role in attracting people particularly adolescents to the selling joints [2-4]. Unfortunately, the current world’s adaptation to a system of consumption of fast foods has resulted in several adverse effects on health. The energy density of fast foods had been found to be more than twice the recommended daily allowance for children [5]. Experts therefore attribute the current childhood obesity epidemic to fast foods [1]. This increase in childhood obesity has led to increase in life-threatening conditions particularly non communicable diseases in developing countries [1,6]. Dental cavities another common ailment in school children can result due to dense sugar content in fast foods [7]. Food additives used in these food stuffs are found to be carcinogenic and can be allergic causing asthma and rashes which are also seen frequently among children [1]. Added to this in developing countries there are problems like poor hygiene during preparation storage and handling of fast foods leading to contamination by microorganisms [8].
As food habits learnt in childhood tend to persist into adulthood it becomes important to educate children about healthy eating habits and make them aware about the health hazards of fast foods right Singh7from school level onwards. It becomes equally important to have a clear understanding of the factors influencing food choices so as to formulate appropriate nutritional educational strategies.
Therefore this study was done to find out the awareness of health hazards of fast foods, consumption pattern of fast foods and its association with overweight among high school students.
Materials and Methods
This cross-sectional study was done among high school students of 7th, 8th and 9th standard in three major private schools in Mangalore city in March 2012. The study protocol was approved by the ethics committee of the institution.
The sample size of 230 was obtained at 95% confidence level, 20% relative precision and reported proportion of fast food users among high school students to be 30.3% from a previous study [9].To make up the anticipated loss due to incompletely filled forms, an extra 50% were added to this number to get 345 as the final sample size. The permission to conduct study was obtained from the respective school principals. Written informed consent from the parents or guardians in addition to assent from each student was obtained through school diaries after providing them information and purpose of this study. Due to problems related with consenting only boys were included in this study.
Later 40 self-administered questionnaires were distributed to as many consenting students chosen simple randomly in each class. The questionnaire was in English and was pretested in a group of 10 students before its usage in the study. Content validation of the questionnaire was done by experts from Medical Education Unit of the institution. It contained semi-structured questions on food frequency intake of fast foods, vegetables and fruits per week. The list of common food stuffs labeled as fast foods was also mentioned in the questionnaire so as make this concept very clear to all participants. Other questions such as years of fast food consumption, source of information, reasons for consumption, awareness about its health hazards, amount spent in a week on fast foods and parental consumption of fast foods were also enquired. The type and duration of physical activity undertaken by the student was enquired and was compared with guidelines provided by the Centre for Disease Control (CDC), Atlanta, USA [10]. Physical activity of at least 60 minutes in a day was considered as of good level.
The students were asked to note down their recently recorded height and weight and their weight recorded two years ago from the school anthropometry register before handing over the questionnaire to the investigators. Grossly incompletely filled forms were excluded from analysis.
Age and male specific cut-offs for Body Mass Index (BMI) to screen for overweight and obesity among Indian children based on standard guidelines was used to categorize BMI [11]. At the end of data collection investigators educated students on health hazards associated with fast food usage using health educational posters.
Statistical Analysis
Data was entered and analysed using SPSS Inc., Chicago, IL, ver 11.0 Chi-square test and one-way ANOVA was used to test association. Binary logistic regression analysis was done to find out the independent predictors of overweight and obesity among children. p-value ≤ 0.05 was considered as statistically significant association.
Results
The response rate in this study was 83.3% with 300 out of 360 distributed questionnaires being satisfactorily filled by the participants. Mean age of boys was 13.5±0.9 years. Their mean height was 1.5±0.1 meters and mean weight was 42±9.5 kgs. 49(16.4%) children were either overweight or obese [Table/Fig-1].
[Table/Fig-1]:
Socio demographic distribution of school children
| Characteristics | Number | Percentage |
|---|---|---|
| Class | ||
| 7th standard | 96 | 32.0 |
| 8th standard | 112 | 37.3 |
| 9th standard | 92 | 30.7 |
| Age | ||
| 12 | 50 | 16.7 |
| 13 | 94 | 31.3 |
| 14 | 121 | 40.3 |
| 15 | 33 | 11.0 |
| 16 | 2 | 0.7 |
| Gender | ||
| Males | 300 | 100.0 |
| Body Mass Index | ||
| Normal/ underweight | 251 | 83.6 |
| Overweight | 41 | 13.7 |
| Obese | 8 | 2.7 |
| Total | 300 | 100.0 |
Almost all children 292(97.3%) were eating fast foods. Age of initiation of fast food consumption was answered by 216 participants. Among them majority 126(58.3%) were consumers since past 2 to 5 years. Commonest source of information about fast foods was television commercials 193(64.3%) followed by friends 161(53.7%) and parents 62(21.2%). As many as 64(21.9%) participants said that they preferred fast foods over usual meals [Table/Fig-2]. Reason for consumption was stated by 128 participants. The various reasons stated were being bored with home food 73(57%), curiosity 64(50%), favourite leisure time activity 32(25%), peer influence 30(23.4%), easy availability 10(7.8%), influence by television advertisements 10(3.3%) and quick to eat and finish as stated by two participants. Out of the 292 consumers of fast foods, 277(94.9%) said that their parents were aware about this habit.
[Table/Fig-2]:
Fast food consumption habits among school children
| Characteristics | Number | Percentage |
|---|---|---|
| Current fast food consumption habit (n=300) | ||
| Yes | 292 | 97.3 |
| No | 8 | 2.7 |
| Type of fast foods | ||
| Vegetarian | 151 | 51.7 |
| Non vegetarian/ Mixed | 141 | 48.3 |
| Frequency of consumption per week | ||
| Once a week | 183 | 62.7 |
| Twice a week | 45 | 15.4 |
| Once on alternate days or on most days | 22 | 7.5 |
| Once almost everyday | 31 | 10.6 |
| More than once every day | 11 | 3.8 |
| Duration of consumption (n=216) | ||
| ≤ 1 year | 22 | 10.2 |
| 1 – 2 years | 31 | 14.4 |
| 2 – 3 years | 42 | 19.4 |
| 3 – 4 years | 42 | 19.4 |
| 4 – 5 years | 42 | 19.4 |
| >5 years | 37 | 17.1 |
| Preference of fast foods over usual meals | ||
| Yes | 64 | 21.9 |
| No | 228 | 78.1 |
| Preferred fast foods | ||
| Pizza | 89 | 30.5 |
| Burger | 35 | 12.0 |
| Samosa | 50 | 17.1 |
| Chocolate | 40 | 13.7 |
| Others | 78 | 26.7 |
| Preference for branded fast foods | ||
| Yes | 175 | 59.9 |
| No | 117 | 40.1 |
| Preference of aerated drinks over fresh fruit juices | ||
| Yes | 128 | 43.8 |
| No | 164 | 56.2 |
| Place of consumption | ||
| At home | 75 | 25.7 |
| School premises | 37 | 12.7 |
| Fast food stall | 180 | 61.6 |
| Total | 292 | 100.0 |
Reasons for non-consumption of fast foods stated by non-users were following parental advice stated by four, tendency of addiction stated by two and one each reported reasons like being aware of its ill effects, spicy to taste, not fresh foods and having fallen ill following consumption. Awareness of harmful effects of fast food consumption was noted in 186(62%) students. The various harmful effects reported were it contains harmful colouring agents 5(2.7%), contains harmful food additives/preservatives 12(6.5%), are unfresh foods 28(15.1%), contains high fat content (5.9%), causes rapid weight gain 31(22%), causes intestinal cancer 6(3.2%), same frying oil being used repeatedly is bad for health 2(1.1%) and poor in nutritive value as stated by two participants. There was no association of awareness of hazards of fast food usage with age of the participants (p=0.443).
One hundred and forty one (48.3%) of the total fast food consumers felt that there was a need to control their present fast food consumption practices. The reasons stated were associated health hazards 78(55.3%), tendency to cause weight gain 61(43.3%), parental pressure to quit 6(4.3%), waste of money 6(4.3%) and 15addiction tendency 3(2.1%). The perception to control usage was associated with awareness of health hazards of fast food usage among participants (p<0.001) [Table/Fig-3]. In this study 146(50%) boys spent less than 50Rs, 81(27.7%) spent 50Rs to 100Rs, 35(12%) spent 101Rs to 250Rs, 14(4.8%) spent 251Rs to 500Rs and 16(5.5%) spent more than 500Rs per week on fast foods.
[Table/Fig-3]:
Association between awareness of ill effects of fast food consumption with perception of need towards its control among participants
| Need to control | No need to control | Total | |
|---|---|---|---|
| Awareness of ill effects | 121(65.1%) | 65(34.9%) | 186 |
| Not aware of ill effects | 20(18.9%) | 86(81.1%) | 106 |
| Total | 141 | 151 | 292 |
| χ2=57.7, p<0.001 | |||
About one fourth and two third of students were not eating vegetables and fruits respectively every day. Consumption of fruits atleast once a day was reported by 94(31.3%) and vegetables by 232(77.4%) participants. Duration of physical activity either at school or at home was reported to be poor by 19(6.3%) of the total 300 participants.
Parental fast food consumption was reported to be present by 112(37.3%), absent by 43(14.3%) and the rest 145(48.4%) participants were not sure. Consumption of fast foods among parents was significantly associated with its usage among children (p=0.024) [Table/Fig-4]. The association between frequencies of consumption of fast foods with frequency of consumption of healthy foods like fruits (p=0.337) or vegetables (p=0.234) were not significant.
[Table/Fig-4]:
Association of various risk factors with consumption of fast foods among participants
| Characteristics | Consumes (%) | Do not consume (%) | Total |
|---|---|---|---|
| Age | |||
| 12 years | 49(98) | 1(2) | 50 |
| 13 years | 91(96.8) | 3(3.2) | 94 |
| 14 years | 117(96.7) | 4(3.3) | 121 |
| ≥15 years | 35(100) | 0(0) | 35 |
| χ2=1.33, p=0.721 | |||
| Type of diet | |||
| Vegetarian | 151(96.2) | 6(3.8) | 157 |
| Non vegetarian | 141(98.6) | 2(1.4) | 143 |
| χ2=1.693, p=0.193 | |||
| Parental consumption of fast foods (n=155) | |||
| Yes | 109(97.3) | 3(2.7) | 112 |
| No | 38(88.4) | 5(11.6) | 43 |
| χ2=5.08, p=0.024 | |||
| Awareness of health hazards | |||
| Yes | 179(96.2) | 7(3.8) | 186 |
| No | 113(99.1) | 1(0.9) | 114 |
| χ2=2.268, p=0.132 | |||
| Total | 292 | 8 | 300 |
Children who consumed fast foods once or more a day had greater proportion of being overweight or obese compared to less frequent consumers (p=0.035) [Table/Fig-5]. Although duration of physical activity was found to poor among greater proportion of students who ate fast food on most days a week, this association was not significant (p=0.339) [Table/Fig-6]. Association of duration of physical activity with BMI was also not found to be significant. (p=0.575) [Table/Fig-7]. Adjusted Odds Ratio of frequent consumption of fast foods per week with overweight or obesity status was found to be 1.339 (p=0.003) after controlling the confounding effect of physical activity. For calculating CI of AOR the consumers were divided into two groups namely less frequent users versus frequent users (daily and more than once daily users) of fast foods [Table/Fig-7].
[Table/Fig-5]:
Association of consumption of fast foods with body mass index
| Fast food consumption | Body mass index | Total | |
|---|---|---|---|
| Normal/ underweight (%) | Overweight/obese (%) | ||
| Yes | 244(83.6) | 48(16.4) | 292 |
| No | 7(87.5) | 1(12.5) | 8 |
| Total | 251 | 49 | 300 |
| χ2=0.088, p=0.766 | |||
| Frequency of fast food consumption | |||
| Once a week | 163(89.1) | 20(10.9) | 183 |
| Twice a week | 34(75.6) | 11(24.4) | 45 |
| Once on Alternate days | 17(77.3) | 5(22.7) | 22 |
| Most days a week | 12(75) | 4(25) | 16 |
| Once everyday | 11(73.3) | 4(26.7) | 15 |
| More than once every day | 7(63.6) | 4(36.4) | 11 |
| Total | 244 | 48 | 292 |
| χ2=11.953, p=0.035 | |||
[Table/Fig-6]:
Association between frequencies of fast food consumption with physical activity among students
| Fast food consumption | Duration of physical activity | Total | |
|---|---|---|---|
| Good | Poor | ||
| Yes | 273(93.5) | 19(6.5) | 292 |
| No | 8(100) | 0(0) | 8 |
| 281 | 19 | 300 | |
| χ2=0.556, p=0.456 | |||
| Frequency of fast food consumption | |||
| Once a week | 173(94.5) | 10(5.5) | 183 |
| Twice a week | 42(93.3) | 3(6.7) | 45 |
| Once on alternate days | 20(90.9) | 2(9.1) | 22 |
| Most days in a week | 13(81.2) | 3(18.8) | 16 |
| Once everyday | 15(100.0) | 0(0) | 15 |
| More than once every day | 10(90.9) | 1(9.1) | 11 |
| Total | 273 | 19 | 292 |
| χ2=5.677, p=0.339 | |||
[Table/Fig-7]:
Binary logistic regression analysis of association of duration of physical activity and frequent weekly consumption of fast foods with presence of overweight or obesity among fast food users (n=292)
| Characteristics | Unadjusted Odds Ratio (OR ) | 95% C.I for Unadjusted OR | p-value | Adjusted OR | 95% C.I for Adjusted OR | p-value | ||
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | Lower | Upper | |||||
| Physical activity | 1.388 | 0.440 | 4.379 | 0.575 | 1.297 | 0.402 | 4.183 | 0.664 |
| Frequent weekly fast food consumption | 2.511 | 1.023 | 6.165 | 0.035 | 1.339 | 1.105 | 1.623 | 0.003 |
Among the 163 users of fast food for 2 or more years, the mean weight gain over the same period was found to be more among frequent users (p=0.337) and those eating it for more than 5 years (p=0.954) [Table/Fig-8].
[Table/Fig-8]:
Association between frequency and duration of fast food consumption with weight gain over the past two years (n=163)
| Frequency of fast food consumption | Number | Mean±SD (Kg) |
|---|---|---|
| Once a week | 106 | 6.5±4.3 |
| Twice a week | 20 | 6.4±3.4 |
| Once on alternate/ most days a week | 17 | 7.5±5.9 |
| Once or more everyday | 20 | 8.5±6.9 |
| F=1.134, p=0.337 | ||
| Duration of fast food consumption | ||
| 3 years | 42 | 6.9±5.0 |
| 4 years | 42 | 7.3±6.7 |
| 5 years | 42 | 7.4±7.4 |
| More than 5 years | 37 | 7.7±5.6 |
| F=0.11, p=0.954 | ||
Discussion
Understanding of the faulty dietary habits and the factors responsible is very essential to develop effective intervention for promoting healthy eating and minimizing life style problems like obesity during adolescence which is a critical phase of developmental.
Fast food consumption was reported by 97.5% students in a study done in China [12], 98% in a study done in Lucknow, India [13] and by all students in a study done in Jammu Kashmir, India [14] which was more than our observations. However, in several other studies done worldwide, fast food consumption was seen between 30.3% to 93.5% children which was lower than our observations [9,15-18]. These findings infer that fast food consumption was predominant among children in these settings.
However, frequency of fast food usage almost every day varied from 3.7% to 70% of students in other studies in comparison to 14.4% reported in this study [6,17-23]. Consumption of fast foods thrice a week was reported ranging from 6.9% to 43.3% students elsewhere in comparison to 7.5% students in the present study [6,17,24-26]. This meant that pattern of fast food consumption was not as bad among students in this settings as reported elsewhere. Hence timely interventions in the form of early identification of fast food usage, focusing attention on frequent users by appropriate school and family based interventions might help to promote healthy food choices and avoidance of faulty eating habits.
In a study done in Chandigarh, 58.8% of the adolescents preferred fast food items over regular meals which were higher than the findings of this study [27]. Similar observations were made in other studies where young consumers rather than paying attention to the dietary value are instead preferring tasty and attractive food [12,14,22,27-30].
The preference over home diet among some students reported in this study indicate how tempting and pleasing these food stuffs are and is not easy for health educators to convince children to give up fast foods. Moreover a good number of students feeling bored of home foods indicate the need for familial support and nutritional counseling required at homes.
In a study done in Jammu Kashmir, India 7.4% students preferred branded fast foods which were much lower than our findings [14]. This vast difference could be because this study was done in affluent schools in Mangalore. In a study done in Australia, 25% students usually chose soft drinks instead of water or milk in comparison to the same reported by 43.8% students in this study [22].
In a study done in Saudi Arabia, 88.2% ate fast foods at restaurants in comparison to 61.6% in this study [17]. As majority of students were eating fast foods outside school and home environment it would be difficult to monitor their habits. Hence awareness generation about its health hazards and self-motivation to adopt healthy eating behaviour appears to be the best solution to this problem.
Television was the commonest source of information about fast foods in this study which was similar to observations made in a study done in China where children received information from advertisement on television (67.9%) followed by parents (9.02%) and newspapers or magazines (6.7%) [12].
Studies have also found that youngsters who watch more television are more susceptible to unhealthy eating habits and unhealthy conceptions about food substances compared to others who watch minimally [31]. This is because the current food advertising rarely promotes healthy choices and rather promotes frequent consumption of unhealthy foods making it even difficult for most parents to promote healthy eating at home [32]. Therefore advertisement guidelines related to quality of food products in mass media needs formulation and strict implementation [8].
In this study fast food consumption as a favourite leisure time activity was reported by one fourth of the students. Eating during emotional states such as eating while feeling bored (56.2%), while feeling depressed (28.8%) and while feeling worried (24.7%) were other reasons for fast food consumption stated by participants in Syria [24] and physiological and psychological factors stated by participants in China [12]. Therefore, psychological factors could also play a role in making children habituated with fast food consumption.
Peer influence stated as a reason for consumption was also mentioned in other studies done in USA [25] and Iran [33]. This is because fast food selling joints are epicenters for socializing with peer group among adolescents when away from their families and a less restricting environment in comparison to schools [34,35].Easy availability of fast foods at any time of the day as reason for fast food usage stated by few in this study was also mentioned in other studies [14,22,34]. In a study done in Jammu Kashmir, India, influence of media was a cause for eating fast foods in urban areas among 80% respondents which was much more than our findings [14]. The television advertisements on fast foods are known to mislead the viewers and discourage the concept of healthy foods.
Awareness of health hazards associated with fast foods use among 62% participants observed in this study was similar to that of the study done in Chandigarh, India [27] as reported by 64.8% adolescents but was more than that reported in the study done at Beijing, China [12]. We noticed a big gap between knowledge and practice of students in this study. Almost 96% of those aware of health hazards continued to eat fast foods and only 65.1% of them felt the need to control its usage. A study done in Baroda, India found that children despite knowing the harmful effects continued to eat fast foods and for reasons like taste preferences, strong desire to do so and quick to eat [16]. Nutrition counseling could help to reduce this gap between knowledge and practice.
In this study half of the respondents spent less than 50Rs per week on fast foods which was lesser than that reported in the study done in Jammu Kashmir, India where majority of the adolescents spent 20-50 Rs per day [14]. Parents need to be very careful in not giving liberal pocket money to children.
History of fast food consumption among family members was significantly associated with fast food usage among children in this study and in other studies done in Iran [33] and China [12]. This proves that familial influences has a major role to play in shaping the eating behaviour of children. Dietary habits are therefore largely determined by familial and cultural factors rooted in childhood and adolescence period [36]. Fast foods which are presently gaining popularity in nuclear families as working parents have less time for meal preparation at home could hence be detrimental in the long run as children pick up these faulty habits early in life [8,37].
In this study greater proportion of students who were overweight or obese were significantly more among most frequent users of fast foods (once or more in a day) which was similar to findings of studies by Li M et al., [21] and Savige et al., [38]. This substantiates the role of fast foods as a risk factor for childhood obesity.Although weight gain over the past two years was found to be most among frequent fast food users in this study it was not statistically significant.
Limitations
School girls could not be included in this study due to nonconsenting issues raised by majority of their guardians. There could also be a possibility of recall bias of students with respect to their dietary habits.
Conclusion
Fast food consumption was reported by most students in this study. Commonest source of information was from television advertisements. Therefore, legislations to regulate marketing of fast foods need to be more stringent. Statutory warning about hazards should also accompany television advertisements promoting fast foods. More than half of the fast food users said that they were eating it because of being bored with home food. Therefore, the views of children on factors at home which affect their desire to eat healthy foods need to be understood and addressed appropriately.
In spite of good number of participants being of health hazards of fast foods, the need to control its usage was felt by 65.1% only. There is thus a need for nutrition counseling to bridge the gap between knowledge and practice about healthy eating behaviour. This would also solve the problem of overweight among children which was found significantly more among fast food users in this study.
Acknowledgement
The authors of this study would like to thank MBBS students, Mr.Chinmaya R. Kamat, Ms. SuttopaTalukdar, Mr. Rohan Naik and Ms. Divya Buchireddy for their help in data collection. No source of funding was acquired for this study.
Financial or Other Competing Interests
None.
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