DIETARY PATTERNS IN YOUNG ADULTS FROM TIMIS COUNTY

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2012 vol. 116, no. 4 PREVENTIVE MEDICINE - LABORATORY ORIGINAL PAPERS DIETARY PATTERNS IN YOUNG ADULTS FROM TIMIS COUNTY Ioana Tuţă-Sas 1, Brigitha Vlaicu 1, Sorina Doroftei 1, Cristina Petrescu 1, Corneluţa Fira-Mladinescu 1, Salomeia Putnoky 1, Oana Suciu 1, R. Bagiu 1, S. Ursoniu 2, D. Şerban 3 Victor Babeş University of Medicine and Pharmacy Timişoara Faculty of Medicine 1. Discipline of Hygiene 2. Discipline of Public Health 3. Discipline of Microbiology DIETARY PATTERNS IN YOUNG ADULTS FROM TIMIS COUNTY (Abstract): Dietary patterns present at the age of the young adult have great probability to remain unchanged for the rest of the life and may contribute to eating disorders later in life. The aim of this study is the analysis of the intake patterns for fruits and vegetables in students from Timis County. Material and methods: We conducted a cross sectional study using a stratified cluster sa m- ple design to produce a representative sample of students for the Timis County. The st u- dents sample totalized 2076 students from the universities in Timis County. Results: A large of the young people participating in the study (41.9%) does not consume fresh juices. For the consumption of fresh fruits, the present results back up the international di s- coveries, only 32.8% of the young people consuming fruits daily, which is a smaller that the medium value reported by other countries. The frequency of consumption for fruits differs according to gender, being higher for girls. For salads, the of young people consuming this type of foods at least once a day is 17.0%, much lower compared to 32.8% of the young people consuming fresh fruits at least once a day. Conclusions: The examination of the dietary patterns related to the intake of fruits and vegetables helped us to determine priority areas for future interventions. Keywords: FRUITS, VEGETABLES, YOUNG ADULTS, DIETARY PATTERNS Diet and physical activity, alongside genetic factors, have important roles in determining the individual status of health. The habits related to diet and physical activity start to form during childhood and continue to shape until the adult age. While the time of childhood is characterized by resistance to new culinary experiences, the young adults will use more often new culinary products to declare their independence, not always in a beneficial manner. In the context of the young adult distancing from the known family environment and creating a new social entourage, this will influence in a variable proportion the diet. The frequency of obesity in all age groups increased 2 to 3 times in the last two decades (1). The results of the Behavioral Risk Factor Surveillance System study (BRFSS) conducted between 1991 and 1998 show the most important increase for the obesity rates in the age group 19 to 29 years, also for those with higher educational degree (2). 1150

2 Dietary patterns in young adults from Timis County Overweight and obesity are some of the most challenging and steadily rising public health problems worldwide. Strategies to effectively reduce and maintain a healthy body weight are urgently required. A number of national and international bodies recommend an increased intake of fruits and vegetables in order to decrease the risk of developing lifestyle-related diseases including overweight and obesity. The risk-reducing effect of fruits and vegetables on overweight and obesity may in part be exerted through their possible reduction upon the total energy intake. This may be explained by various factors. Fruits and vegetables are low in energy density, high in water content and they contain a considerable amount of dietary fibers, soluble dietary fibers in particular (3). A number of observational and interventional studies have investigated the possible association between fruit and vegetable intake and body weight. Most of these studies find an inverse association. In a review (3), emphasis is given to the role of fruits alone and the risk of developing overweight and obesity. The rationales for this are several: fruits are typically consumed at other occasions than vegetables as they can be obtained in various physical forms, such as fresh, dried, canned, pureed, making them convenient as between-meal snacks, potentially substituting more energy-dense snacks; the culinary use of fruits differs from that of vegetables. For example, because of the various physical forms and commonly sweet taste, they are suitable as deserts. Also, here they may act as the relatively healthier alternative to the traditionally more energy dense deserts and fruits are frequently consumed raw, whereas vegetables are often prepared by addition of fatty substances, which diminishes the low energy-dense characteristics of vegetables. Although, to the best knowledge of the authors, the plausible differential physiological mechanisms of fruit and vegetables have not been explored, fruits possess a distinct physical profile, which may be manifested differently in relation to body weight status. Fructose, the main sugar in fruits, has a relatively low glycaemic index (4), producing a slow increase in postprandial blood glucose followed by a possible increase in satiety. The slow absorption may also increase satiety as a result of extended contact time with the gastrointestinal receptors that produce satiety signals. Another factor that may connect fructose to satiety involves incomplete absorption of fructose with subsequent hyperosmolar environment in the colon (5). This results in attraction of fluids into the gut lumen, causing a feeling of indisposition and lost interest in further food consumption. Based on these and other as yet unknown probable factors, the authors find it appropriate to distinguish between fruits and vegetables in relation to overweight and obesity (3). Previous literature revealed that young adults tend to consume excess amounts of total fat, saturated fat, cholesterol and sodium. Other studies have found inadequate intakes of essential micronutrients, such as calcium, iron, zinc, folate, and vitamins A, B 6 and C, as well as low consumption of fruits and vegetables. Promotion of dietary change among young adults, who are currently healthy, could be especially challenging. Potential future health benefits of a balanced diet, which are the principal emphases in many of the current guidelines, may not seem as appealing to this particular population as immediate physical and psychological benefits (6). 1151

3 Ioana Tuţă-Sas et al. The aim of this study is to analyze dietary patterns among young adults from the urban area in Timis County. MATERIAL AND METHODS This study is based on the grant The evaluation of risk behavior dimension in high school students and young people from vocational schools and universities in Timis County (CORT 2004), carried out between , cod CNCSIS 1167, attained at The University for Medicine and Pharmacy Timisoara. The CORT 2004 study is a transversal epidemiologic survey assessing risk behavior in a group of young people attending the colleges and universities in Timis County. We conducted a cross-sectional study using a stratified cluster sample design to produce a representative sample of students for the Timis County, Romania. A 126- item questionnaire was developed to investigate health-risk behaviors of young adults. Some of the questionnaire items were modified from other instruments, including the 1999 Youth Risk Behavior Survey (YRBS) (7) and the European School Survey Project on Alcohol and Other Drugs (ESPAD) (8). The survey focused on health risk behaviors established during the period of young adulthood that results in the most significant mortality, morbidity, disability, and social problems for youths and, later, adults. The following issues were examined: family environment, out-of-family entourage, tobacco use, alcohol use, illicit drug use, violence-related behaviors and schoolrelated violent behaviors, suicide ideation, attempted suicides, and the seriousness of those attempts, preventive conduct in road traffic, sexual behaviors, dietary behaviors, overweight and weight control, physical activity, medical attendance. In total, 30 items were dedicated to dietary behaviors. A pilot test was conducted to establish the validity and reliability of the instrument. The participants were included in this study based on their free consent. The questionnaire was administered in a regular classroom setting and took students 60 minutes to complete. No filter questions were used. By doing this, comparable amounts of time are required to complete the questionnaire, regardless of risk behavior status and students cannot detect the risk behaviors of their colleagues simply by looking at the pattern of the responses. Only students present the day of the survey were eligible for participation. Trained public health residents and undergraduate students conducted the survey. The data collectors read aloud scripts that explained the survey procedures. Students were told that they do not have to put their names on answer sheets, and that obtained data would be used only for general assessment of the situation in the county. The data processing and interpretation used modern methods of advanced medical statistics. Data were filed using EpiInfo, version 6.0, 2001 and processed using Epi- Info, version 3.5.1, The values of the statistical significance level p<0.05 were considered statistically significant, and p<0.01 were considered very significant statistically. The following statistical tests were applied: chi-square test, Mann- Whitney test, Kruskal-Wallis test, Pearson correlation and Kendall correlation. Factorial exploratory analysis was also used in order to group the association of the risk behaviors. RESULTS AND DISCUSSION The students sample from Timis County 1152

4 Dietary patterns in young adults from Timis County was composed of 2076 students from universities in the urban environment. Among this sample, the distribution was as it follows: 62.49% (1296) girls and 37.51% (778) boys. The individuals participating in this study were young adults, meaning their age was between 18 years (0.3%) and 25 years (3%). In Great Britain, in the year 1994, the Cardiovascular Review Group recommended a daily intake of 5 to 6 portions of fruits and vegetables, twice as much as the medium intake of the average British citizen, although the consumption pattern vary in different areas and in different social layers (9). Among multiple factors influencing the intake of these food classes, the pleasure of consuming them is one of the most important internal factors, and their availability, cost and time necessary for cooking them are maybe the most important external factors (10). For people leading an active life reaching the recommended ratio of these foods may be challenging. One way to consume them during the day is in the form of juice. As to the intake of fresh fruits juices, most of the young people participating in the study declared they do not consume it, 41.9% (858), or they consume it 1-3 times per week, 37.9% (775). Only 7.1% (145) admitted they drink fresh fruits juices once a day, and 5.5% (113) twice or more times per day. The contribution of fruit juices to the fibers intake is very poor and in this aspect it is more indicated the intake of fresh fruits (tab. I). The studies conducted on national level in the United States showed that young adults with the age between 18 and 24 years consume insufficient quantities of fruits and vegetables (11, 12, 13). TABLE I The students distribution according to the frequency of consumption for juices prepared from fresh fruits The frequency of consumption for juices prepared from fresh fruits Frequency Percent Valid Cumulated 2 or more times per day Once per day times per week times per week never Total Missing data Total The studies conducted by WHO uncovered that, on average, only 30% of the boys and 37% of the girls report daily fruits intake. The consumption was highest in Israel (49% of the boys and 54% of the girls) and lowest in Estonia (17% of the boys and 23% of the girls). In 16 different countries and regions, more than 25% of 1153

5 Ioana Tuţă-Sas et al. the young people consume only rarely fruits (once per week or less). In almost all the countries and regions, mostly girls reported daily fruits intake, although there is a considerable geographic variation present (14). Of the young adults participating in the present study, 41.13% (844) reported fruits intake 1-3 times per week, and 23% (472) consume fruits 4-6 times per week. Only 3.07% (63) of the participants to this study declared they never eat fruits. 16.0% (329) of the young adults included in the study eat fresh fruits 2 or more times per day, intake pattern comparable to the international recommendations (tab. II). TABLE II Students distribution related to the frequency of intake for fresh fruits Frequency of intake for fresh fruits Frequency Percent Valid Cumulated 2 or more times per day Once per day times per week times per week Never Total Missing data Total The results of the present study corroborate the results of other international studies showing that most of the young people do not consume the recommended quantities of fruits (15, 16). The sample of 844 young adults reporting fruits intake 1-3 times per week, is composed of 497 girls (38.7% of the female respondents) and 347 boys (45.4% of the male respondents). For the different fresh fruits intake frequencies, the males and females s are similar. Nevertheless, the girls, 17.4% (223) is higher than the boys, 15.7% (120), which consume fresh fruits once per day. The same, in case of consumption 2 or more times per day of these aliments, the of girls reporting this intake pattern, 18.2% (234), was higher than the boys, 12.4% (95) (tab. III). These results suggest that the consumption frequency for fruits differs related to gender, being higher for girls, conclusion reached by other authors too (16). Salads are consumed by the young adults: 52.0% (1067) 1-3 times per week, 16.8% (345) never, and 6.3% (130) consumes salads 2 or more times per day, but in this case also the intake is low (tab. IV). In the fast-food restaurants accessible to students, there is a less diversified offer of salads, and for the most part they are missing. As the young adults prefer this way to procure food, the reduced intake of these foods can be explained. 1154

6 Dietary patterns in young adults from Timis County TABLE III Students distribution according to the fresh fruits frequency of intake, by gender Fresh fruits frequency of intake female sex male Total Number Percent Number Percent Number Percent Twice or more times per day Once per day times per week times per week Never Total TABLE IV Students distribution related to the salads intake frequency Salads intake frequency Frequency Percent Valid Cumulated Twice or more times per day Once per day times per week times per week Never Total Missing data Total CONCLUSIONS Dietary patterns may seem not as acute a risk behavior compared with behaviors producing more dramatic results (violence, addiction etc.), but on a long term is just as damaging as the others. There are always difficulties in adequate assessing nutrition intake with a limited number of items. The present study corroborates the findings of other authors, namely the young adults intake of fruit and vegetables is lower than the recommended ratio. There are a number of reasons we can think off in order to explain this situation: the students prefer to eat in fast-food restaurants, where the offer for fresh salads and fruits is usually not very diversified; the cost of these foods can represent a barrier to higher intake because they are more expensive than highly processed foods; during an active 1155

7 Ioana Tuţă-Sas et al. day it may be difficult to consume these particular aliments (an option is represented by juices); fruits are usually ready to be eaten, but vegetables necessitate more time to prepare; the food choices are usually influenced by entourage and publicity. The insufficient intake of fruits and vegetables situates the young adults at risk for future chronic diseases (cardiovascular diseases, diabetes, obesity). In the future, strategies to increase the intake of fruits and vegetables must be developed for this age group, taking into account the particularities of the young adults. REFERENCES 1. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, JAMA 2004; 291: ***. American College Health Association National College Health Assessment spring J Am Coll Health 2008; 56: Alinia S, Hels O, Tetens I. International Association for the Study of Obesity, Obesity Reviews Riby JE, Fujisawa T, Kretchmer N. Fructose absorption. Amer J Clin Nutrit 1993; 58(5 Suppl): 748S- 753S. 5. Kneepkens CMF, Vonk RJ, Fernandes J. Incomplete intestinal absorption of fructose. Arch Dis Childhood 1984; 59(8): Ma J, Betts MN, Horacek T, Georgiou C, White A. Assessing stages of change for fruit and vegetable intake in young adults: a combination of traditional staging algorithms and food-frequency questionnaires. Health Educ Res 2003; 18(2): ***. The Youth Risk Behavior Surveillance System, Department of Health and Human Services, Centers for Disease Control and Prevention, USA, Hibell B, Ansersson B, Bjarnason T, Ahlström S, Balakireva O, Kokkevi A, Morgan M. The ESPAD Report 2003 Alcohol and Other Drug Use Among Students in 35 European Countries. The Swedish Council for Information on Alcohol and Other Drugs, The Pompidou Group at the Council of Europe and the authors, Sweden, modintryckoffset AB, Stockholm, Jeyanthi HJ, Ziebland S. Reported barriers to eating more fruit and vegetables before and after participation in a randomized controlled trial: a qualitative study. Health Educ Res 2004; 19(2): Ziebland S, Thorogood M, Yudkin P, Jones L, Coulter A. Lack of willpower or lack of wherewithal? Internal and external barriers to changing diet and exercise in a three year follow-up of participants in a health check. Soc Sci Med 1998; 46: Skinner JD. Changes in students' dietary behavior during a college nutrition course. J Nutrit Educ 1991; 4: Mitchell PJ, Hertzler AA, Webb RE. The consumption levels of fruits, vegetables and antioxidants by college students. J Amer Diet Assoc 1994, 94: A Ma J, Betts NM. Servings of grain products, vegetables and fruits influence nutrient quality of young adults diets. J Amer Diet Assoc 1998; 98(9): A Vereecken C, Ojala K, Jordan MD. Eating habits, Young people's health in context. WHO, Vereecken CA, De Henauw S, Maes L. Adolescent's food habits: results of the Health Behavior in School-aged Children survey. Brit J Nutrit 2005; 94: Scully M, Dixon H, White V, Beckmann K. Dietary, physical activity and sedentary behavior among Australian secondary students in Health Promotion International 2007; 22(3):