The quality of breakfast and healthy diet in school-aged adolescents and their association wi

nutrients Article The Quality of Breakfast and Healthy Diet in School-aged Adolescents and Their Association with BMI, Weight Loss Diets and the Practice of Physical Activity Raquel M. Guevara , JoséD. Urchaga * , Antonio S. Cabaco and JoséE. Moral-García Faculty of Education, C/Henry Collet, Pontifical University of Salamanca, 37007 Salamanca, Spain; [email protected] (R.M.G.); [email protected] (A.S.C.); [email protected] (J.E.M.-G.) *Correspondence: [email protected]; Tel.: +(34)-923-125-027 Received: 14 June 2020; Accepted: 27 July 2020; Published: 30 July 2020   Abstract: Dietary habits are an important factor in the protection of adolescent health. The quality and frequency of breakfast and the various food groups can affect the wellbeing of this population group in both the short and long term. Research indicates that there is a range of relevant variables in the study of diet at this stage: following a weight loss diet, body mass index and the practice of physical exercise, amongst others. In this paper, all three variables are analysed, together with others of a demographic nature (sex and age). This is a descriptive cross-sectional survey that was carried out on 1318 adolescents aged 11 to 18. The Health Behaviour in School-Aged Children (HBSC) international study questionnaire, sponsored by the World Health Organisation, was used. In general terms, the data revealed that the majority of adolescents do not have adequate eating patterns. The quality and frequency of breakfast and the consumption of food types are associated with almost all the variables under study; additionally, there are significant differences by sex and school year. Finally, proposals are made to prevent eating disorders, which are appearing at an increasingly young age. Keywords: dietary habits/diet; breakfast; weight loss diet; BMI; physical activity; eating disorders 1. Introduction Our diet, together with physical activity (PA), are the main factors contributing to the protection of our health in all stages of life. Therefore, adopting and maintaining healthy habits in both spheres provides numerous benefits and contributes to the maintenance or improvement of our quality of life [ 1 , 2 ]. During adolescence, the adoption of adequate dietary and exercise habits can protect against obesity and prevent chronic diseases, such as diabetes mellitus, heart disease or stroke [3,4]. In Spain, overweight and obesity affect 34.4% of the young population between 5 and 19 years of age [ 5 ], making it a public health priority on account of the consequences this may have in the later stages of life [6,7]. The World Health Organisation’s (WHO) dietary recommendations for adolescents [ 2 ] indicate that their diet must be varied and rich in nutrients. Additionally, international agencies think it is relevant to take into account the weekly and/or daily frequency with which the various food groups need to be consumed in order to achieve a balanced diet. Recent research studies undertaken by experts in the field indicate that the number of young people who have eating disorders or unbalanced eating habits is high [ 8 , 9 ]. The WHO [ 10 ] and various international agencies recommend for three or more pieces of fruit and vegetables to be eaten daily, the rotation between white meats and fish, and only an occasional consumption of red meats, snacks, confectionery and soft drinks. Research studies [ 11 – 13 ] highlight that the percentage of young people who maintain eating patterns that are not consistent with a healthy diet is Nutrients 2020,12, 2294; doi:10.3390/nu12082294 www.mdpi.com/journal/nutrients Nutrients 2020,12, 2294 2 of 15 high (low consumption of fruit and vegetables, frequent consumption of snacks, confectionery and soft drinks, reduction in the consumption of dairy products as they grow up, etc.). The ENALIA research, carried out by the Spanish Agency for Consumption, Food Safety and Nutrition, points out that less than half of Spanish adolescents follow the nutritional recommendations [ 14 ]. Only 18.2% of the young population consume fruit with optimal frequency (every day, more than once), whereas 13.6% consume vegetables; 26.2% consume confectionery within the recommended frequency (occasionally, less than once a week) and 34.5% of adolescents have soft drinks occasionally (according to recommendations) [ 15 ]. There are differences in the consumption levels of some foods by sex: girls eat fruit and vegetables more often, but also more confectionery, whereas boys have soft drinks more often [ 15 ]. By age group, the consumption of fruit and vegetables compared with the optimal level decreases as age increases and, whereas the consumption of confectionery and snacks remains the same with age, the consumption of soft drinks increases. The association between the food adolescents eat and the body mass index (BMI) is clear, with those individuals with the best dietary habits showing lower BMIs [ 11 , 16 ]. Following a weight loss diet affects and limits the consumption of certain types of food, frequently removing fats, confectionery, fried food and sweetened drinks from the diet. In this sense, following a specific weight loss diet tends to involve the consumption of natural and healthy food, such as fruit and vegetables [ 17 ], although at this stage of development diets are mostly associated with an obsession with thinness or a sense of dissatisfaction with one’s own body, which leads adolescents to follow such diets without medical supervision. Food restrictions or skipping meals without adequate supervision can lead to negative health consequences for young people and cause eating disorders such as anorexia, bulimia, etc. [ 18 , 19 ]. Given that adolescence is a period of time where many changes occur, it is relevant for young boys and girls to learn to accept their bodies [ 20 ]. However, when young people do not adhere to adequate eating patterns, their physical self-concept decreases, especially in girls, which in turn derives relational or academic difficulties [ 20 ]. Other studies, for example, state that skipping meals in adolescence affects the ovarian and uterine functions in girls [ 21 ]. In Spain, 13.1% of adolescents state that they are on some type of weight loss diet or other, although this is more frequent in girls and at younger ages [ 15 ]. Physical activity also affects the dietary habits of adolescents [ 22 , 23 ], with boys who eat better practicing more physical activity. Breakfast is the first meal of the day and breaks up the long period of fasting taking place while we sleep. It is consumed within 2 to 3 h from waking up. It is made of food and drinks from at least one food group and can be eaten anywhere [ 24 ]. This meal helps reorganise the metabolic changes taking place at night time, prevents the effects of a long fasting period and, on many occasions, it includes the first liquid that is consumed after a long period of time, which means that it contributes to maintaining adequate water levels [ 25 ]. The quality and frequency of breakfast is also very relevant when considering a healthy diet. In spite of the fact that it is currently necessary to reach more solid scientific consensus in terms of the food that must be included in breakfast [ 26 , 27 ], at least three of the following main food groups are proposed as essential: dairy products, cereal and fruit, which need to be consumed every day of the week [ 28 ]. The breakfast that is most frequently consumed in Spain consists of a dairy product—specifically skimmed or semi-skimmed milk and a cereal—especially bread, which may differ from other European countries [ 29 – 32 ]. Research shows that this type of breakfast is a good indicator of a healthy lifestyle [ 33 ], associating adherence to it with a better quality diet [ 27 , 34 ]. There is plenty of research that indicates this is essential in the prevention of disease. In Huasan’s study, for example, this is considered to be an essential practice to prevent type II diabetes [35]. On the other hand, skipping breakfast has been associated with poor-quality diets, lower cognitive performance and various other negative impacts on health [ 26 , 36 ]. In spite of the importance of breakfast, skipping breakfast or having a poor-quality breakfast is frequent in adolescents [ 37 ]. Research such as that of Monzani or Wadoloska associate skipping breakfast with general and central obesity [ 38 , 39 ]. In girls it is also associated with more frequent dysmenorrhea and irregular menstruation [ 21 ]. In Spain, the percentage of high school boys going to class without having had breakfast is 16.9% [ 15 ]. If we take into account social-demographic variables such as sex, the national data indicate that girls tend to skip breakfast more frequently, with the boys having healthier habits in this Nutrients 2020,12, 2294 3 of 15 regard. Age is also influential on the habit of eating breakfast, with older adolescents’ habits being worse. Thus, the percentage of high school boys going to class without having had any breakfast at all increases from 8.2% at 11–12 years of age to 24.6% at 17–18 years of age [ 15 ]. Numerous studies point out that regular consumption of breakfast has also been associated with lower BMI [ 40 – 43 ]. Adherence to a weight loss diet can lead to skipping breakfast altogether or having an unhealthy breakfast, mainly as a result of wanting to stay in shape or lose weight, with this habit being more frequent amongst girls [ 44 ]. Lastly, research reveals that young people skipping breakfast tend to have a higher BMI and tend to practice less physical activity [45–47]. In this context, this study intends to analyse the range of variables previously mentioned (i.e., sex, age, weight loss diet, BMI and PA) and their effect on the dietary habits of adolescents. The specific objectives of this study are to: (a) understand the quality of breakfast and the diet of adolescents by sex, school year, weight loss diet adherence, BMI and the practice of physical activity; (b) analyse how frequently they tend to have breakfast (on weekdays, on the weekend and for the entire week) and the various food groups during the other daily meals by sex, school year, diet adherence, BMI and PA that adolescents have; and (c) understand which of the variables (sex, school year, diet adherence, BMI and physical activity) is the most influential in predicting breakfast habits and the daily or occasional consumption of food groups during the other daily meals. 2. Materials and Methods 2.1. Design and Participants This is a cross-sectional descriptive survey carried out in the city of Salamanca. The sample was taken through stratified multistage random sampling by conglomerates. The 16 participating schools were selected taking into account the social districts as defined by the town council of Salamanca and also the healthcare districts into which the Castilla y Leon Regional Council divides the city. We made sure that each district included a state school and a semi-private school. Amongst the schools that expressed an interest in the research study, 16 were selected for their location in a way that every neighbourhood in the city would be represented. A Consort chart (Figure 1) is included in order to explain the sampling. The sample consisted of 1318 adolescents (50.98% female), between 11 and 18 years of age (14.76 ± 1.61 years old). The total population was 3592, and therefore the range of error was 2.1% (p=q=5; Z=2). Nutrients 2020, 12, x FOR PEER REVIEW 3 of 15 BMI [40–43]. Adherence to a weight loss diet can lead to skipping breakfast altogether or having an unhealthy breakfast, mainly as a result of wanting to stay in shape or lose weight, with this habit being more frequent amongst girls [44]. Lastly, research reveals that young people skipping breakfast tend to have a higher BMI and tend to practice less physical activity [45–47]. In this context, this study intends to analyse the range of variables previously mentioned (i.e., sex, age, weight loss diet, BMI and PA) and their effect on the dietary habits of adolescents. The specific objectives of this study are to: (a) understand the quality of breakfast and the diet of adolescents by sex, school year, weight loss diet adherence, BMI and the practice of physical activity; (b) analyse how frequently they tend to have breakfast (on weekdays, on the weekend and for the entire week) and the various food groups during the other daily meals by sex, school year, diet adherence, BMI and PA that adolescents have; and (c) understand which of the variables (sex, school year, diet adherence, BMI and physical activity) is the most influential in predicting breakfast habits and the daily or occasional consumption of food groups during the other daily meals. 2. Materials and Methods 2.1. Design and Participants This is a cross-sectional descriptive survey carried out in the city of Salamanca. The sample was taken through stratified multistage random sampling by conglomerates. The 16 participating schools were selected taking into account the social districts as defined by the town council of Salamanca and also the healthcare districts into which the Castilla y Leon Regional Council divides the city. We made sure that each district included a state school and a semi-private school. Amongst the schools that expressed an interest in the research study, 16 were selected for their location in a way that every neighbourhood in the city would be represented. A Consort chart (Figure 1) is included in order to explain the sampling. The sample consisted of 1318 adolescents (50.98% female), between 11 and 18 years of age (14.76 ± 1.61 years old). The total population was 3592, and therefore the range of error was 2.1% (p = q = 5; Z = 2). Figure 1. CONSORT chart for sampling selection. The description of the sample, according to the level of practice of physical activity, reveals that 64.5% were classified as active (adolescents who feel active exercised at least 60 min a day), whereas 35.5% were sedentary (the remaining); the BMI reveals that 9% were underweight, 76.9% were within the normal weight range, 12.7% were overweight and 1.4% were obese, a lower percentage than that found at the national level because in this study adolescents were between 11 and 18 years old, while national data collects data on children between 5 and 19 years old. With regards to weight loss diet adherence, 65.3% did not follow a specific weight loss diet, whilst 34.7% did. Figure 1. CONSORT chart for sampling selection. The description of the sample, according to the level of practice of physical activity, reveals that 64.5% were classified as active (adolescents who feel active exercised at least 60 min a day), whereas 35.5% were sedentary (the remaining); the BMI reveals that 9% were underweight, 76.9% were within the normal weight range, 12.7% were overweight and 1.4% were obese, a lower percentage than Nutrients 2020,12, 2294 4 of 15 that found at the national level because in this study adolescents were between 11 and 18 years old, while national data collects data on children between 5 and 19 years old. With regards to weight loss diet adherence, 65.3% did not follow a specific weight loss diet, whilst 34.7% did. 2.2. Instruments Socio-demographic questionnaire, which compiled information on the sex of the respondents (male and female) as well as age. Questionnaire on eating habits. The international survey Health Behaviour in School-Aged Children (HBSC) questionnaire [ 48 ], sponsored by the WHO, was used [ 49 ] which contains questions about having a full breakfast and how frequently during the week they consumed certain basic foods. This questionnaire about dietary habits has two dimensions that are interpreted in the following way: (a) Full breakfast: when in addition to a glass of milk or a piece of fruit, the respondent eats something else. The days per week when the respondent had a full breakfast were quantified (0 to 7 days). Following the recommendations [ 26 ] for having a full breakfast, the result “good” was allocated when a full breakfast was eaten every day of the week, “medium” when it was eaten 6 days a week and “poor” when it was eaten five days a week or less. These considerations were based on research studies dealing with the food consumed during childhood and adolescence [ 25 – 27 , 50 ] which state the importance of nutrients and energy for individuals to deal with a long school day. (b) Weekly consumption frequency by food type. Food was classified as basic (fruit, vegetables, meat and fish) and not very healthy (snacks, soft drinks or sweetened drinks and confectionery). The times a week that these foods were consumed was quantified. The answer options were placed on a scale from 1 to 7: never (1), less than once a week (2), once a week (3), 2–4 days a week (4), 5–6 days a week (5), once a day, every day (6) and every day more than once (7). Questionnaire on weight loss diet adherence. The following question was asked “Are you following a weight loss diet or doing anything to lose weight at present?” There were 4 answer options: (1) no, I think I am at my ideal weight; (2) no, but I should lose some weight; (3) no, because I need to gain weight and (4) yes. Questionnaire on the practice of physical activity. In order to analyse the level of practice of PA, we used the Moderate to Vigorous Physical Activity (MVP) questionnaire [ 51 ], consisting of two items which report the number of days a week that the individuals practice at least 60 min of moderate to vigorous PA, both in the previous week and in an average week. The answer scale for both was the same ( 0=none , 1=once , 2=twice, 3 =three days, 4 =four days, 5 =five days, 6=six days , and 7 =seven days). Following the recommendations of the World Health Organisation [ 52 ], adolescents who exercised at least 60 min a day were considered to be active and the remaining were considered to have a sedentary lifestyle. Body composition was analysed through the BMI (kg/m 2 ratio). Weight and height measurements were self-reported by the participants themselves and BMI was calculated. The validity of self-reported data in obtaining BMI in studies with children and youth has already been supported in previous research [20]. BMI was adjusted according to sex and age, using the international reference tables for underweight, normal weight range, overweight and obesity [49,50]. The study strictly complied with all the ethical criteria contained in the Helsinki declaration in its amendment of 2013 for this type of research. The study was approved by the Ethics Committee of Pontifical University of Salamanca (20/07/2020). Before beginning to collect the data, the 16 participating school centres were contacted for approval and consent of the parents or legal custodians of the students. They were informed of the type of survey proposed and assured them that participation was absolutely voluntary. The students who took part in this survey did not receive financial or academic compensation whatsoever. In the same way, the anonymity and confidentiality of the participants and their data were assured. At the data collection stage, all the questionnaires were distributed during school time. Four interviewers were trained by one main researcher and they were put in charge of distributing the various questionnaires with the various instruments used. Nutrients 2020,12, 2294 5 of 15 The participation requirements were voluntary participation, signed authorisation by the parents or legal custodian, and reporting on whether the student was following any kind of nutritional plan or weight loss diet at the time of the study, or during the previous 6 months. Thus, the exclusion criteria were providing incorrect or incomplete answers to any of the items making up the various questionnaires, failure to provide the authorisation by the parents or legal custodian and showing some type of condition during the study (have an injury, be in a cast, remain at rest due to operation, etc.) that might prevent the habitual practice of moderate to vigorous PA. In these cases, participants with these situations did not participate in the survey. No medical evaluation of any student was required. 2.3. Data Analysis The data were analysed using the SPSS version 24.0 statistical piece of software. For the purposes of the statistical study, descriptors, chi-square, Bonferroni post hoc test and the ANOVA analysis as well linear regression were used, taking breakfast and the type of food consumed as dependent variables; and BMI, weigh loss diet and the practice of PA as independent variables; and finally, the co-variables were sex and age. 3. Results 3.1. Descriptors of the Quality of Breakfast, the Daily Healthy Food Diet and the Occasional Healthy Food Diet Table 1analyses the quality of breakfast and the food diet according to sex, age, weight loss diet adherence, BMI and practice of PA. As Table 1shows, the quality of breakfast reveals significant differences in all the variables under analysis. For example, boys tend to have a good breakfast (in terms of frequency and consistency) to a greater extent than girls (75.9% against 66.2%); having a poor breakfast (skipping it two or more days a week) is more frequent as adolescents are older (14.7% at 11–12 years of age against 38.6% at 17–18 years of age); students who have a good breakfast (every day and consisting of something more than just a glass of milk) are to a greater extent those who do not follow a weight loss diet (76.2% against 61.1%); breakfast quality worsens as the BMI of the adolescents increases (16.8% are underweight against 29.4% who are obese); practice of PA is a conditioning factor for active students to have a good breakfast in a higher percentage than sedentary students (75.6% against 68.6%). Analysing the quality of the daily diet, sex, age and practice of PA bring about significant differences. In fact, females have a better and healthier diet in comparison to males (24.7% against 22%) and the diet is better amongst adolescents aged 15–16 (26.2%) compared with adolescents aged 11–12 (19.1%); on the other hand, sedentary adolescents (53.5%) have a poor daily diet compared to the more active adolescents (46%). With regards to the healthy consumption of the food types that should be consumed only occasionally, significant differences are only found by age. Specifically, its consumption improves with age, thus older adolescents (14.5% at 17–18 years of age) have extensively better diets than the others. 3.2. Comparison of Averages (ANOVA) for the Frequency of Consumption of Daily Breakfast on Weekends, Weekdays and during the Entire Week Figure 2analyses the daily consumption frequency of breakfast, with significant differences becoming evident on the weekends (p<0.05), weekdays ( p<0.01 ) and during the entire week ( p<0.01) . There is a significantly more frequent daily consumption of breakfast over the three analysis points in adolescents between 11 and 12 years of age, those who do not follow a weight loss diet and those who are physically active. Significant differences were found by sex, which pointed at boys showing better results during weekdays and during the entire week. On the other hand, the BMI does not show significant differences. Nutrients 2020,12, 2294 6 of 15 Nutrients 2020, 12, x FOR PEER REVIEW 6 of 15 Adherence to a weight loss diet reveals significant differences, with those who do not follow a weight loss diet consuming more vegetables (p < 0.05; 4.7 against 4.4), confectionery (p < 0.001; 3.9 against 3.3) and nuts (p < 0.001; 3.6 against 3.1) than those who follow one. The level of practice of PA determines that active adolescents compared to sedentary students consume bread and cereal (p < 0.001; 5.1 against 5.3), fruit (p < 0.001; 5.0 against 4.7), vegetables (p < 0.01; 4.5 against 4.3), fish and seafood (p < 0.001; 4.0 against 3.7) and soft drinks (p < 0.001; 3.9 against 3.5) more frequently. Age reveals significant differences in the consumption of dairy products with 15–16 year old students consuming more than 17–18 years old students (p < 0.01; 6.1 against 5.7); fruit, with 11–12 year old students consuming more than 17–18 year old students in particular (p < 0.05; 5.0 against 4.7); confectionery is more consumed by 15–16 year old students compared to 11–12 year old students (p < 0.01; 3.9 against 3.6); and soft drinks, with 17–18 year old students consuming them more frequently than 11–12 year old students (p < 0.01; 4.1 against 3.5). The BMI reveals significant differences with greater consumption of fruit in students with normal weight compared to the overweight students in particular (p < 0.05; 5.0 against 4.6) greater consumption of bread amongst the obese students compared to overweight students (p < 0.05; 5.3 against 5.0) and greater consumption of confectionery in underweight students when compared to obese students (p < 0.001; 4.3 against 3.5). 3.4. Linear Regression between Quality of Breakfast, Daily Healthy Diet, Foods the Consumption of Which Should Be Only Occasional and the Remaining Variables under Analysis A linear regression analysis was applied using the Enter method. Quality of breakfast, daily healthy diet and the healthy consumption of foods that should only be consumed occasionally were introduced as dependent variables; weight loss diet, BMI and practice of PA as independent variables; sex and age acted as co-variables (Table 3). The One-Way ANOVA test shows significant influence on the quality of breakfast (F = 13.230; p < 0.001). Specifically, a significant influence in terms of sex (B = 0.154; standard error = 0.049; t = 3.129; p = 0.002), with boys having a better quality breakfast than girls; age also has a significant impact, in fact, the quality of breakfast decreases as age increases in adolescents (B = −0.167; standard error = 0.059; t= −2.822; p = 0.005). In the same way, the adherence to a weight loss diet has a significant impact, with the individuals following a weight loss diet eating a lesser-quality breakfast (B = −0.194; standard error = 0.056; t= −3.490; p < 0.001). The BMI also has significant influence (B = −0.019; standard error = 0.009; t= −2.137; p < 0.05), associating a better-quality breakfast with lower BMI values. Figure 2. Frequency of breakfast consumption during the entire week, on weekdays and on weekends by sex, age, weight loss diet adherence, body mass index (BMI) and level of physical activity (PA). A dot represents the group with the highest and most significant difference. Figure 2. Frequency of breakfast consumption during the entire week, on weekdays and on weekends by sex, age, weight loss diet adherence, body mass index (BMI) and level of physical activity (PA). A dot represents the group with the highest and most significant difference. 3.3. Comparison of Averages in the Weekly Frequency for the Consumption of the Various Food Types, both Daily Recommended or Occasionally Recommended Table 2analyses the frequency of consumption of food types according to sex, age, weight loss diet, BMI and PA. On examination of the findings by sex, females reveal a significantly higher consumption of vegetables (p<0.05; 4.5 against 4.3) and confectionery (p<0.01; 3.9 against 3.7) than males; however, males consume more soft drinks (p<0.001; 4.0 against 3.5). Adherence to a weight loss diet reveals significant differences, with those who do not follow a weight loss diet consuming more vegetables (p<0.05; 4.7 against 4.4), confectionery (p<0.001; 3.9 against 3.3) and nuts (p<0.001; 3.6 against 3.1) than those who follow one. The level of practice of PA determines that active adolescents compared to sedentary students consume bread and cereal (p<0.001; 5.1 against 5.3), fruit (p<0.001; 5.0 against 4.7), vegetables ( p<0.01 ; 4.5 against 4.3), fish and seafood (p<0.001; 4.0 against 3.7) and soft drinks (p<0.001; 3.9 against 3.5) more frequently. Age reveals significant differences in the consumption of dairy products with 15–16 year old students consuming more than 17–18 years old students (p<0.01; 6.1 against 5.7); fruit, with 11–12 year old students consuming more than 17–18 year old students in particular (p<0.05; 5.0 against 4.7); confectionery is more consumed by 15–16 year old students compared to 11–12 year old students ( p<0.01 ; 3.9 against 3.6); and soft drinks, with 17–18 year old students consuming them more frequently than 11–12 year old students (p<0.01; 4.1 against 3.5). The BMI reveals significant differences with greater consumption of fruit in students with normal weight compared to the overweight students in particular (p<0.05; 5.0 against 4.6) greater consumption of bread amongst the obese students compared to overweight students (p<0.05; 5.3 against 5.0) and greater consumption of confectionery in underweight students when compared to obese students (p<0.001; 4.3 against 3.5). 3.4. Linear Regression between Quality of Breakfast, Daily Healthy Diet, Foods the Consumption of Which Should Be Only Occasional and the Remaining Variables under Analysis A linear regression analysis was applied using the Enter method. Quality of breakfast, daily healthy diet and the healthy consumption of foods that should only be consumed occasionally were introduced as dependent variables; weight loss diet, BMI and practice of PA as independent variables; sex and age acted as co-variables (Table 3). Nutrients 2020,12, 2294 7 of 15 Table 1. Comparison of quality of breakfast and type of healthy diet by sex, age, weight loss diet adherence, BMI and practice of PA. Quality of Breakfast 1Quality of Healthy Diet Daily Consumption 2Quality of Healthy Diet Occasional Consumption 3 Variable Classification Poor (n=323) Medium (n=60) Good (n=935) PValue 4Poor (n=672) Medium (n=494) Good (n=152) PValue 4Poor (n=801) Medium (n=401) Good (n=116) PValue 4 Sex Man % 19.5 4.6 75.9 <0.001 *** 49.4 28.6 22.0 0.47 63.8 28.6 7.6 0.069 Woman % 29.3 4.5 66.2 52.5 22.8 24.7 57.9 32.1 3.7 Age 11–12 y.o. % 14.7 3.5 81.8 <0.001 *** 51.2 29.7 19.1 0.018 55.5 36.4 8.1 0.029 * 13–14 y.o. % 29.2 5.7 65.1 55.5 19.9 24.6 62.3 28.8 8.9 15–16 y.o. % 28.1 4.3 67.6 47.5 26.4 26.2 64.1 27.3 8.5 17–18 y.o. % 38.6 6.0 55.4 55.4 20.5 24.1 60.2 25.3 14.5 Weight Loss Diet Adherence No % 19.6 4.2 76.2 <0.001 *** 49.8 26.3 23.9 0.462 62.3 29.8 7.9 0.149 Yes % 33.7 5.3 61.1 53.4 24.1 22.5 57.5 31.9 10.5 BMI Underweight % 16.8 6.7 76.5 <0.001 *** 52.9 19.3 27.7 0.071 63.9 27.7 8.4 0.604 Normal weight % 24.9 3.8 71.3 50.7 25.9 23.4 60.8 30.6 8.6 Overweight % 27.2 7.1 65.7 52.4 29.8 17.9 59.5 29.8 10.7 Obesity % 29.4 5.9 64.7 35.3 17.6 47.1 52.9 47.1 0.0 Practice of PA Sedentary % 26.0 5.3 68.6 0.017 * 53.5 23.6 23.0 0.019 59.1 31.9 8.9 0.194 Active % 21.4 3.0 75.6 46.0 29.9 24.1 64.1 27.4 8.5 1 . Answer scale: Poor (when breakfast was consumed 5 days a week or less frequently); Medium (when breakfast was consumed 6 days a week); Good (when breakfast was consumed every day of the week). 2 . Answer scale: Poor (has 1–2 healthy eating habits a day); Medium (has 3–4 healthy eating habits a day); Good (has 5–7 healthy eating habits a day); 3 . Answer scale: Poor (does not follow the recommendations as to consumption of confectionery and soft drinks); Medium (does not follow the recommendations as to consumption of confectionery or soft drinks); Good (does follow the recommendations as to consumption of confectionery and soft drinks). * p<0.01; *** p<0.001. 4. Chi-square. Nutrients 2020,12, 2294 8 of 15 Table 2. Frequency of consumption of the various types of food, both daily recommended and occasionally recommended according to sex, diet adherence, level of PA, age and BMI. % (n) Dairy Products Bread, Cereals Fruit Lean Meats Vegetables Fish and Seafood Sweet Soft Drinks Nuts Factors M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) Sex Male 50.1 6.0 (1.2) 5.2 (1.5) 4.8 (1.6) 4.8 (1.1) 4.3 (1.3) 3.9 (1.3) 3.7 (1.5) 4.0 (1.7) 3.6 (1.1) Female 49.9 5.9 (1.4) 5.3 (1.4) 4.9 (1.6) 4.7 (1.0) 4.5 (1.3) 3.8 (1.1) 3.9 (1.5) 3.5 (1.6) 3.5 (1.2) Total 5.9 (1.3) 5.2 (1.4) 4.9 (1.6) 4.7 (1.1) 4.4 (1.3) 3.8 (1.2) 3.8 (1.5) 3.8 (1.7) 3.5 (1.2) pa0.053 0.712 0.281 0.223 0.016 * 0.008 * 0.008 ** <0.001 *** 0.350 Diet Yes 11.9 5.8 (1.5) 5.1(1.6) 5.0 (1.6) 4.7 (1.1) 4.7 (1.4) 3.8 (1.3) 3.3 (1.5) 3.7 (1.6) 3.1 (1.2) No 88.1 6.0 (1.3) 5.3 (1.4) 4.9 (1.6) 4.7 (1.0) 4.4 (1.3) 3.8 (1.1) 3.9 (1.5) 3.8 (1.7) 3.6 (1.2) pa0.129 0.184 0.203 0.559 0.016 * 0.699 <0.001 *** 0.518 <0.001 *** Physical Activity Sedentary 35.5 5.9 (1.3) 5.1 (1.4) 4.7 (1.7) 4.7 (1.0) 4.3 (1.3) 3.7 (1.1) 3.8 (1.5) 3.5 (1.7) 3.5 (1.1) Active 64.5 6.0 (1.3) 5.3 (1.4) 5.0 (1.6) 4.8 (1.1) 4.5 (1.3) 4.0 (1.2) 3.8 (1.5) 3.9 (1.7) 3.6 (1.2) pa0.192 0.001 ** <0.001 *** 0.116 0.005 ** <0.001 ** 0.540 <0.001 *** 0.263 Age 11–12 (a) 33.0 6.0 (1.3) 5.3 (1.4) 5.0 (1.5) 4.7 (1.0) 4.5 (1.2) 3.9 (1.1) 3.6 (1.4) 3.5 (1.6) 3.4 (1.2) 13–14 (b) 21.4 5.8 (1.4) 5.2 (1.5) 4.7 (1.7) 4.7 (1.1) 4.4 (1.4) 3.8 (1.4) 3.9 (1.7) 4.1 (1.8) 3.5 (1.2) 15–16 (c) 39.3 6.1 (1.2) 5.3 (1.4) 4.9 (1.6) 4.8 (1.0) 4.5 (1.2) 3.8 (1.0) 3.9 (1.4) 3.7 (1.6) 3.5 (1.1) 17–18 (d) 6.3 5.7 (1.4) 5.1 (1.3) 4.6 (1.7) 4.7 (1.1) 4.4 (1.3) 3.8 (1.2) 3.9 (1.7) 4.1(1.8) 3.7 (1.4) pb0.002 ** 0.632 0.008 ** 0.213 0.734 0.460 0.002 ** <0.001 *** 0.252 Multiple comparision cb=d<c * a * >b=da<b * a<c ** a ** <b=d b>c ** BMI Underweight a) 9.0 6.0 (1.3) 5.3 (1.5) 4.8 (1.6) 4.8 (1.2) 4.5 (1.4) 3.8 (1.3) 4.3(1.8)) 3.7 (1.6) 3.6 (1.4) Normal weigh (b) 76.9 6.0 (1.3) 5.3 (1.4) 5.0 (1.6) 4.8 (1.0) 4.5 (1.3) 3.9 (1.2) 3.8 (1.5) 3.7 (1.7) 3.5 (1.1) Overweight (c) 12.7 5.8 (1.3) 5.0 (1.4) 4.6 (1.7) 4.7 (1.0) 4.3 (1.2) 3.8 (1.2) 3.5 (1.4) 3.9 (1.6) 3.4 (1.2) Obesity (d) 1.4 5.8 (1.1) 5.3 (1.2) 4.7 (1.9) 4.2 (1.5) 4.8 (1.5) 3.2 (1.1) 3.3 (1.1 4.3 (1.8) 3.5 (1.5) pb0.491 0.041 * 0.025 * 0.114 0.322 0.057 <0.001 *** 0.388 0.317 Multiple comparision cb>c * b >c * a>b ** a>c *** a>d * b ** >c=d Note: a: Student´s t; b: ANOVA; c: Bonferroni; * p<0.05; ** p<0.01; *** p<0.001. Nutrients 2020,12, 2294 9 of 15 Table 3. Regression analysis: quality of breakfast, occasional healthy diet and daily healthy diet (dependent variables) and weight loss diet adherence, body mass index and level of practice of physical activity (independent variables), adjusted to co-variables of sex and age. Unstandardised Coefficients Standardised Coefficients OneWay ANOVA BStandard Error BtpSum of Squares RG(RS) MS RG(RS) F p BREAKFAST Cons. 1.798 0.180 - 10.013 <0.001 46.716 (918.093) 9.343 (0.706) 13.230 <0.001 Sex 0.154 0.049 0.090 3.129 0.002 Age −0.167 0.059 −0.079 −2.822 0.005 WL Diet −0.194 0.056 −0.107 −3.490 <0.001 BMI −0.019 0.009 −0.067 −2.137 0.033 PA 0.017 0.013 0.040 1.383 0.167 R: 0.220 - R2: 0.048 - Adjusted R2: 0.045 - df: 5. 1305 - Durbin-Watson: 0.89 DAILY DIET Cons. 0.257 0.146 - 1.762 0.078 3.726 (607.980) 0.745 (0.468) 1.593 0.159 Sex 0.008 0.040 0.006 0.208 0.835 Age −0.041 0.048 −0.024 −0.844 0.399 WL Diet −0.075 0.045 −0.052 −1.662 0.097 BMI −0.016 0.007 0.072 −2.237 0.025 PA 0.012 0.10 0.034 1.171 0.242 R: 0.078 - K2: 0.006 - Adjusted R2: 0.002 - df:5. 1305 - Durbin-Watson: 0.013 OCCASIONAL DIET Cons. 0.508 0.139 - 3.641 <0.001 4.596 (553.425) 0.919 (0.426) 2.159 0.056 Sex −0.068 0.038 −0.052 −1.785 0.074 Age −0.064 0.046 −0.040 −1.382 0.167 Wl Diet 0.060 0.043 0.044 1.398 0.162 BMI 0.002 0.007 0.008 0.262 0.793 PA −0.009 0.010 −0.026 −0.870 0.384 R: 0.091 - R2: 0.008 - Adjusted R2: 0.004 - df: 5. 1305 - Durbin-Watson: 0.190 Cons.: constant term; Sex (0 =girl and 1 =boy); Age: continuous value (12 to 16); Diet: no weigh loss diet adherence (0) and weight loss diet adherence (1); BMI: body mass index (0 =underweight, 1 =normal weight, 2 =overweight and 3 =obesity); PA: physical activity (0 =sedentary and 1 =active); RG: Regression; RS: Residual.