Abstract(resumo):

Objective: To evaluate the association between skipping and replacing meals with excess weight in adolescents. Method: Cross-sectional study among 382 students from public schools in Rio de Janeiro, Brazil, collecting sociodemographic data and dietary habits, focusing on skipping (breakfast, lunch, and dinner) and replacing meals with snacks. The Chi-square test assessed Body Mass Index for Age (overweight> +1 z-score), and logistic regression analyzed associations between meal skipping, replacing meals, and excess weight. Results: Girls who skipped breakfast had a higher excess weight frequency (50% vs 31.6%, p=0.025), while boys with excess weight skipped lunch (13.8% vs 4.8%, p=0.027) and dinner (15.5% vs 5.5%, p=0.020) more frequently. Boys skipping dinner were 3.13 times more likely to have excess weight (95%CI: 1.06-9.21), and girls skipping breakfast were 2.20 times more likely (95%CI: 1.10-4.41). No association was found between replacing meals and excess weight. Conclusion: Skipping dinner and breakfast increased the chances of excess weight in male and female adolescents, respectively.

Keywords(palavra-chave):

Excess weight, adolescents, snacks, breakfast, dinner.

Content(conteúdo):

Introduction
Excess weight (EW) is a public health problem with global relevance in developed and developing countries, with a significant increase in its prevalence in recent decades among adults and young individuals(1,2). Specifically in adolescents, EW has also shown an alarming increase in the international(3) and national(4) scenarios. According to the World Health Organization (WHO), the prevalence of obesity increased from 4.5% in 1975 to 12.8% in 2014 worldwide(5). Currently, 26.2% of adolescents aged between 10 and 19 years have some degree of EW(6).
Adolescence is the phase of life between 10 and 19 years of age and can be divided into two main phases: the first, which occurs between 10 and 14 years of age, in which sexual maturation starts, and the second, which occurs between 15 and 19 years of age, in which sexual maturation is completed.(7)In population studies, the body mass index for age (BMI/A), which combines information on age and sex, has been used as the main indicator for monitoring the nutritional status of adolescents(8). According to the Brazilian Ministry of Health, BMI/A values above z-score +1 and z-score +2 are recommended as cutoff points to classify adolescents as overweight and obese, respectively. EW is considered as the combination of overweight and obesity(9).
EW is a multifactorial, environmental, cultural, and dietary condition(10), which has been occurring concomitantly with changes in the Brazilian population's diet in recent decades, mainly characterized by the increase in the consumption of sugar, salt(4,11), and ultra-processed foods(12). A reduction in the consumption of basic foods such as rice and beans has also been observed, as well as a low consumption of fiber, fruits and vegetables and a high consumption of soft drinks and sugary drinks(4).
Scientific literature has explored the relationship between skipping meals and EW (13,16), yet significant controversies and gaps remain skipping breakfast and replacing meals (lunch and dinner) with quick snacks (18, 19, 20) are among the main eating habits related to the development of EW. Some authors associate skipping meals with EW (21,22). Not eating regular meals contributes to their replacement with unhealthy foods, increasing the energy density of the diet, which results in weight gain (23). Furthermore, existing research often highlights the shift towards unhealthy foods and increased energy density when regular meals are skipped, but it lacks a focus on adolescents specifically (19,23).
Studies highlight a decline in the quality of adolescents’ food choices, often associated with inadequate behaviors such as consuming energy-dense, nutrient-poor foods and skipping meals, in contrast to adults, who generally have more regular eating patterns (24, 25). Thus, these eating behaviors and meal replacement patterns observed among adolescents, which differ significantly from those of adults, suggest the need for more targeted studies focused on this age group.
To address these gaps and to contribute to a clearer understanding of these issues, this study aims to evaluate the relationship between meals skipping and replacement and EW in adolescents attending public schools in Rio de Janeiro, Brazil, considering the hypothesis that skipping and replacing meals with quick snacks are positively associated with being overweight.

Methods
Study design and population
This study is a cross-section of the project “Healthy Eating and Oral Hygiene: a Partnership with Good Taste!” (Notice FAPERJ/SESDEC/MS/CNPq/N. 35/2013), carried out in 2016. The sample consists of all eligible students enrolled from the 5th to the 9th years of public Elementary Schools and attended by the Family Health Clinic of Santa Marta (CFSM), located in the south of the city of Rio de Janeiro, state of Rio de Janeiro, Brazil.
From a total of 580 (100%) adolescents aged between 10 and 19 years old, 176 did not attend school on any of the data collection days carried out by the team, being excluded from the study. Of the 404 (69.6%) students who participated in the collection, 382 (65.8%) were anthropometrically evaluated and answered the structured questionnaire containing sociodemographic and nutritional information, thus constituting the sample for the present study.

Data collection
Data collection took place between the months of May and August 2016, and was carried out by nutritionists, interns, and undergraduate research students, previously trained after standardization to assess body composition measurements, and apply questionnaires, from the undergraduate course in Nutrition fromJosué de Castro Nutrition Institute (INJC) at Federal University of Rio de Janeiro(UFRJ).
Anthropometric measurements of weight (kg) and height (cm) were collected in a standardized way, according to the methodology recommended by Lohman et al. (1988). The adolescents were positioned in the center of the Tanita portable digital scale, with a capacity of 150 kg and accuracy of 0.1 kg, and weighed without accessories, coats, and shoes. To measure height, the adolescents were positioned upright, with their arms extended along their bodies and with their heads free of accessories, using a portable stadiometer made by Alturaexata. The analysis of these data was carried out using the AnthroPlus software version 1.0.4(26), aiming to characterize the students’ EW using the Body Mass Index for Age (BMI-A) and those with BMI-A > +1 z-score(26) were considered as having EW.
A structured questionnaire was applied to collect current sociodemographic data and usual dietary information about skipping and replacing meals with quick snacks. The questionnaire was filled out by the students themselves in the classroom, under the supervision of the interviewers, and reviewed by the interviewer immediately after finishing it. The obtained sociodemographic information included maternal informations [level of schooling (<9 years; ?9 years), maternal marital status (married; single/other), employment status (formal/registered; informal/self-employed/other), current maternal age (years) and number of children (<3 or ?3)] and questions about the student [sex (female; male), skin color (white/other; mixed/brown/black), resident of the Santa Marta community (yes; no), beneficiary of the Bolsa Família cash transfer program (yes; no).
Furthermore, the structured questionnaire included dietary questions about daily meals: Do you usually have a daily breakfast (yes or no)? Do you usually have a daily lunch (yes or no)? Do you usually have a daily dinner (yes or no)]? Also, students were asked about the dietary habit of replacing large meals with quick snacks: Do you usually replace large meals with quick snacks (yes or no)?
The chi-square and Student’s t tests were performed to analyze differences between proportions and average values of skipping and replacing meals frequencies and sociodemographic characteristics of adolescents according to their EW or without EW . The analyses were carried out using Stata software, and the significance level was set at 5%. Subsequently, a multivariate logistic regression analysis was performed to evaluate the association between skipping (breakfast, lunch and dinner) and replacing meals with EW (yes or not). The models were adjusted by the covariates associated with the outcomes (beneficiary of the Bolsa Família Program and maternal parity), using the method called Directed Acyclic Graph (DAG) (28) (FIGURE 1). The DAG facilitates the identification of causal relationships and reduces confounding biases by correctly selecting the factors to be controlled in statistical analysis. Also, using DAG it is possible to avoid overadjustment of the model and to include unnecessary covariables (28).


Ethical aspects
The project was submitted and approved by the Research Ethics Committee of the Municipal Department of Health and Civil Defense (CEP SMSDC-RJ) under protocol number 125/12. The objective of the study, voluntary participation and information about nutritional assessment were explained to the students and the Free and Informed Consent Form was sent to the students' parents or guardians.

Results
It was observed that 25.7% of female and 28.8% of male students were reported as overweight among the 382 adolescents (Table 1). Among male adolescents with EW, 89.7% were aged ?14 years compared to 71.7% of those without EW (p=0.006). The proportion of adolescent girls with EW was higher (78.3% versus 21.7%) among maternal civil status classified as married than those with single or other (p=0.020).
Regarding meal consumption, boys with EW skipped lunch and dinner, respectively, 13.8% and 15.5% (p= 0.020) more often than those without EW (4.8% and 5.5%). No differences were found in relation to breakfast. Among girls with EW, 50% skipped breakfast compared to 31.6% of those without EW (p=0.025), with no statistically significant differences found in relation to lunch and dinner. Also, there were no significant differences in relation to the replacement of lunch and dinner with quick snacks for boys and girls with and without EW (Table 2).
The logistic regression model adjusted for being a PBF beneficiary and maternal parity shows that the chance of male adolescents who skip dinner having EW is 3.13-fold (95% CI: 1.06-9.21) greater than those who do not skip this meal. For females, those who skip breakfast are 2.20-fold (95% CI: 1.10-4.41) more likely to have EW when compared to those who do not skip it (Table 3).

Discussion
The results of the present study show that skipping breakfast among female adolescents and skipping lunch and dinner among male adolescents is associated with having EW. It was not observed an association of replacing meals with quick snacks and EW. The prevalence of EW was 28.6% among boys and 25.7% among girls.
These findings about the prevalence of EW(31) and meal skipping among the adolescents of both sexes were similar to those reported in the literature(12, 24, 29, 30, 31, 32). The prevalence of EW found by the National School Health Survey (PeNSE, Pesquisa Nacional de Saúde Escolar) was 23.7% for females and 23.8% for males in 2015(31). Also, in accordance with both PeNSE carried out in 2015 and in 2019 with adolescents aged 13 to 17 years attending public and private schools in Brazil, the prevalence of the consumption of breakfast was 64.4% and 59.3%, respectively(31, 32). It is important to highlight that the data from 2015 were based on the students in the 9º grade of the elementary school in 2015(31).
According to a cross-sectional study conducted by Wadolowska et al.(23) with 1,566 students aged between 11 and 13 years old in Polony, students with EW are more likely to skip breakfast in comparison to students without overweight and obesity. Also, female gender was considered as a predictor of skipping breakfast(23). These similarities reinforce the significance of the current findings and suggest that meal skipping is a factor associated with EW in adolescents.
The risk of skipping breakfast among female adolescents with EW was also highlighted in the longitudinal study carried out by Hassan et al.(33) with 806 adolescents aged 10 to 16 years enrolled in public and private schools in the metropolitan region of Rio de Janeiro. In this study, the authors observed that at baseline, breakfast consumption was associated with normal BMI in female adolescents. After three years of follow-up, the authors observed that girls are 1.63 times more likely to skip breakfast than boys (33). The literature used for this article indicates that female adolescents are more likely to skip meals than male adolescents.(29, 35, 36) It is worth noting that breakfast was not offered in the schools where the present study was conducted. Furthermore, schools do not have a bar or canteen in their units. Only morning and afternoon snacks and lunch were available.
Among other factors related to skipping breakfast, it is observed that EW(24), little physical activity, low family income and inadequate diet would be associated with the risk of skipping breakfast(37, 38, 39). According to Hassan et al.(16), one of the hypotheses suggested for skipping breakfast among adolescents would be the objective of reducing energy intake to meet the aesthetic pressure that exists at this stage of life. Another possible cause to explain EW resulting from skipping meals would be the decrease in postprandial energy expenditure and changes in carbohydrate and lipid metabolism resulting from long periods of fasting(40). In this sense, there would be a reverse effect, as skipping this meal could lead to an increase in energy intake throughout the day and, consequently, weight gain.
Regarding the findings in relation to male adolescents, related to the association between skipping dinner and having EW, no studies were found that allowed the comparison of results. A possible explanation for boys skipping dinner and having EW would be the consumption of higher-calorie snacks prior to dinner, resulting in subsequent loss of appetite at dinner time. It is unlikely that foods considered as markers of healthy eating, such as grains and vegetables, be eaten at meals other than lunch and dinner. In 2008, around 83% of Brazilian adolescents consumed rice, 72% beans, 36% fruits, and in 2018 these frequencies decreased to 78%, 58% and 23% respectively(4). In 2008, Rodrigues et al.(23) carried out a study with 1,139 adolescents aged 14 to 19 years old, attending High School in the midwestern region of Brazil and found that 14% of the assessed adolescents’ diet showed a low consumption of fruits, vegetables, milk and dairy products, and high consumption of fats and sodium. Moreover, 47% skipped breakfast, 78% skipped lunch and 52% skipped dinner.(23) With adolescents increasingly consuming ultra-processed foods and decreasing their intake of in natura or minimally processed foods, it is crucial to investigate how these dietary changes could affect daily energy intake and, as a result, contribute to weight gain. For example, a rise in sugary snacks and packaged foods, coupled with a reduction in fruits and vegetables, may lead to higher calorie consumption and potentially cause weight gain over time.
Some studies report a greater number of skipped meals among adolescents than among children, as during this period there is an increase in food decisions and eating autonomy(41, 42, 43). Adolescents start making choices about when, where, and how to eat in a phase of life full of both biological and psychosocial changes. This increase in autonomy can contribute to an increase in the consumption of ultra-processed foods, sugary drinks, number of skipped meals, and the replacement of lunch and/or dinner with quick snacks (44). It is also important to understand that these food choices are significantly influenced by the individual's environment. Factors such as the living conditions, the neighborhood environment, local food-market availability and social environment(1,2). For instance, living in a neighborhood with limited access to fresh food might lead to a greater reliance on convenience foods, while peer influences can affect dietary preferences and eating habits(3,5).
Although the present study did not find any associations between replacing large meals with quick snacks and EW, the literature shows a possible association between these two factors(19, 41, 45). Teixeira et al.(40) carried out a cross-sectional study with 106 adolescents aged 15 to 19 years old, attending a technical school in the city of São Paulo, São Paulo, Brazil, where they found a prevalence of 40% of lunch replacement and 70% of dinner replacement among obese adolescents(39). According to the Family Budget Survey (POF, Pesquisa de Orçamentos Familiares) carried out in 2018(4), adolescents consumed more quick snacks like chips, pizzas, and sandwiches and less fruits and vegetables when compared to adults and the elderly.
As EW is a multifactorial condition, it is possible that aspects not addressed in this study may be related to the association between meal replacement and EW. This indicates a need for further exploration into the underlying reasons for this discrepancy. The National School Feeding Program (PNAE), for example, is a potentially protective factor against the substitution of main meals with snacks and consequently against being overweight. Future research should investigate the adherence to the meal school and the frequency of family meals. As well social and environmental determinants of the availability of fresh foods from local farmer-market. Other factors such as autonomy to cook their own meal, the proximity and affordability of fast-foods, and the influence of social networks on their eating habits.
As this is a cross-sectional study, the causal relationship between the associations is limited. Due to the results reported herein, it is important to carry out longitudinal studies aimed to confirm the observed associations with the effect of time. Another study limitation is the loss of 34.1% of adolescents initially indicated as eligible. However, it should be noted that the study considered all adolescents in the programmatic area 2.1 of the Santa Marta Family Clinic eligible and not just a sample. Furthermore, according to initial analyses, these losses occurred randomly, with no significant differences between study participants and non-participants.
The study shows the association of skipping breakfast among female students and skipping lunch and dinner among male students with EW. Further studies are recommended to explore the association of skipping meals with EW and the absence and lack of association observed between replacing meals with snacks and EW in children and adolescents in this study and in the scientific literature, respectively, with the goal of enriching the ongoing discussion on these topics. Given the multifactorial nature of obesity and the several determinants of eating habits, conducting studies that explore the environmental, social, economic, and cultural aspects could also help to understand this relationship.
The high prevalence of EW and the concerning eating habits reported by the adolescents underscore the urgent need for targeted health promotion interventions. Such interventions should focus on enhancing nutritional education at school, improving autonomy and access to healthy food options, and fostering supportive environments to mitigate EW. The National School Food Program and the School Health Program are healthy public strategies that can be more explored to improve and promote long-term health outcomes in Brazil.

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