JOURNAL OF PUBLIC HEALTH | Vol. 46, No. 3, pp. 392–402 | https://doi.org/10.

1093/pubmed/fdae033 | Advance Access Publication April 13, 2024

Changes over time of fruit, vegetable and sweets

consumption among European adolescents and associations
with sociodemographic characteristics: an HBSC study
Judit Queral1,2 , Annemieke Wargers3 , Lucia Tarro1,2 , Elisabet Llauradó1,2 ,
Rosa Solà1,2,4 , Wilma Jansen3,5
1
Institut d’Investigació Sanitària Pere Virgili (IISPV), Avda. Josep Laporte 2, 43204 Reus, Spain

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2
Functional Nutrition, Oxidation, and Cardiovascular Diseases Group (NFOC-Salut), Healthy Environment Chair, Facultat de Medicina i Ciències de la Salut, Universitat Rovira i Virgili,
Sant Llorenç21, 43201 Reus, Spain
3
Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40,3015 GD, Rotterdam, The Netherlands
4
Hospital Universitari Sant Joan de Reus, 43204 Reus, Spain
5
Department of Social Development, City of Rotterdam, Coolsingel 40, 3011 AD Rotterdam, The Netherlands

Address correspondence to Wilma Jansen, E-mail: [email protected].

ABSTRACT

Background European adolescents do not eat enough fruits and vegetables and have a high sweets consumption. This study aims to analyse
the changes in time of dietary behaviours related to sociodemographic characteristics, among European adolescents.
Methods Health Behaviour in School Age Children data (2013/14 to 2017/18), of European adolescents, aged 11- to15-year-old, were used.
Family Affluence Scale identified socioeconomic status (SES). Changes in time of dietary behaviours and associations with sociodemographic
characteristics were estimated by binary and multilevel logistic regression.
Results 182 719 adolescents were included, and 10/36 European countries showed a significant increase in daily fruit and vegetable
consumption and 12/36 countries a significant decrease in sweets consumption over 4 years. The multilevel analysis showed that 13- and
15-year-old adolescents consumed fewer daily fruits and vegetables (P < 0.001) and more daily sweets (P < 0.001) than 11-year-old
adolescents. Also, 15-year-old adolescents’ sweets consumption change over time was less favourable (P = 0.006). Girls consumed more daily
fruits, vegetables and sweets than boys (P < 0.001). Low SES adolescents consumed fewer daily fruits and vegetables than medium/high SES
adolescents. Additionally, the low SES adolescents’ vegetable consumption change over time was less favourable (P < 0.001).
Conclusions Dietary behaviour policy recommendations should be adapted for the sex, age and SES of the population.

Keywords dietary behaviour, socioeconomics factors, young people

Background socioeconomic status (SES), ethnicity, demographic charac-

teristics, sociocultural education and exposure to media, are
In 2017/18, more than half of 11- to 15-year-old European
important determinants of adolescents’ eating behaviours.5,6
adolescents did not eat fruits or vegetables daily (at least
According to data from the Health Behaviour in School
one time per day) and 25% consumed sweets daily (at least
Age Children (HBSC) study in 2010, older adolescents have
one time per day).1 These unhealthy behaviours can result in
less healthy lifestyles.7 Adolescents with lower SES generally
the development of non-communicable diseases (NCDs).2,3
Therefore, knowing insights into the establishment of healthy
behaviours is essential to designing effective prevention poli- J. Queral, PhD
cies.4 A. Wargers, MSc
The key factors that influence children’s dietary behaviours L. Tarro, PhD

can be divided into intrinsic (gender, age, genetics) and envi- E. Llauradó, PhD

ronmental factors. The environmental factors include family, R. Solà, Professor

W. Jansen, PhD
peers, community and social factors.5 Social factors, including

© The Author(s) 2024. Published by Oxford University Press on behalf of Faculty of Public Health.
392 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
[email protected]
 CHANGES OVER TIME OF FRUIT, VEGETABLE AND SWEETS CONSUMPTION 393

have worse dietary behaviours than higher SES adolescents.8 using HBSC data, from 2013/14 to 2017/18 in European
For example, regarding fruit and vegetable intake, previous adolescents.
studies with HBSC trend-time data (2001–10) highlighted that The present study hypothesizes that dietary behaviours
adolescents with a higher SES are more likely to consume will improve over time, that is fruit and vegetable consump-
daily vegetables and fruits than low SES adolescents.9,10 In tion increase and sweets consumption decrease. Also, older
these studies, the SES was assessed by the Family Affluence and low SES adolescents are expected to have worse dietary
Scale (FAS) based on the financial situation of the parents.11 behaviours than younger and medium/high SES adolescents.
Also, in a Dutch cross-sectional study with 8- to 12-year-
old children, children with a high education level of the
mother consumed more daily fruits and vegetables than the Methods

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children with mothers with a low education level.12 That
Study design, population and database
is, the authors of the present manuscript highlight that the
This study used data from the HBSC study (2013/14 and
economic difficulties of families and poor knowledge about
2017/18). The HBSC study is a cross-national research
the beneficial aspects of consuming fruits and vegetables are
study into the health and well-being of adolescents across
two of the major reasons for the low consumption of fruits
Europe and North America conducted in collaboration with
and vegetables in low SES adolescents.
the World Health Organization (WHO). The present study
Evidence highlighted that despite the demographic charac-
followed ‘The Strengthening the Reporting of Observational
teristic and ethnic heritage, the European countries’ dietary
Studies in Epidemiology (STROBE) Statement: cross-
guidelines have key points in common: consume adequate
sectional studies’ (Additional file S1).
amounts of grains, vegetables and fruits with moderate intake
In 2013/14 and 2017/18, respectively, 42 and 48 countries
of fats, sugars, meats, caloric beverages and salt.13 However,
in Europe and North America took part in the survey.8,23
the report of HBSC of 2014 detected some variation between
Each country uses cluster sampling to select a proportion
countries and regions in the prevalence of many indicators
of young people aged 11, 13 and 15 every 4 years.23 Coun-
that reinforce the importance of country-level factors and
tries were provided with sampling guidance notes and were
cultural norms in young people’s health and well-being.14
required to submit a standardized sampling report with infor-
Getting a dynamic view of changes over time in fruit or
mation on the strategy employed. This report is part of the
vegetable consumption of adolescents is challenging, which
metadata attached to each country and international data file.
can be solved by using time-trend studies. Time-trend studies
It was then collated and made available to the HBSC network
are a type of time series design (observational design), specif-
by the Data Management Centre (MC) at the University
ically the simplest version where the purpose of the analysis
of Bergen, Norway.8,23 Data are collected in all participat-
is a descriptive account of a pattern over time in a specific
ing countries through school-based surveys.23 The HBSC
population.15 Moreover, this type of study as epidemiological
study protocol of 2013/14 and 2017/18 has been previously
approach has often been used successfully to inform public
explained in depth.8,23
health policy and practice.16
The present study included data from 2013/14 to 2017/18
Hence, the present study was designed to get insight into
about fruit, vegetable and sweets consumption, and related
the change over time in dietary behaviours in adolescents
sociodemographic characteristics (age, sex, SES) in 36 Euro-
and provide directions for adequate policy measures in the
pean countries. Countries that are not in the Europe region
future, considering the differences among populations in 36
or did not participate in both years’ surveys were excluded.
European countries. The literature showed dietary trends
A total of 182719 and 185245 European adolescents were
regarding sugary and soft drinks, breakfast, fruit and veg-
included in the analysis from 2013/14 and 2017/18, respec-
etable consumption, but these are from previous years17,18
tively.
focused on specific European countries19–21 or not consider-
The included participants have answered at least one of the
ing SES characteristics.22 The previous trend studies showed
principal outcomes (fruit, vegetable or sweets consumption)
an improvement in dietary behaviours such as an increase in
in both years’ surveys.
daily fruit and vegetable consumption and a decrease in the
consumption of sugar-sweetened beverages.18,19,22
For this reason, our present study aimed to analyse the Ethics
change over time in dietary behaviours, including fruit, veg- We used open data from the HBSC study, accordingly, all
etable and sweets consumption, and the associations with participating countries received ethical approval from their
sociodemographic characteristics such as sex, age and SES, respective medical ethical committees.8,23
394 JOURNAL OF PUBLIC HEALTH

Study participants, their schools and parents/guardians sex adjusted by country, age and FAS and (iii) for each age
were fully informed about the research and procedures adjusted by country, sex and FAS.
regarding confidentiality and anonymity, access to data and To know how the FAS, age and sex differences in dietary
data storage. Written and/or oral procedures for ‘informed’ behaviours have evolved (from 2013/14 to 2017/18), a mul-
consent were used.8,23 tilevel binary logistic regression was used.
Particularly, the present study was approved by the ethical Firstly, an empty model was built to calculate the ICC
committee of Erasmus Medical Center, the Medisch Ethische (Interclass Correlation Coefficient) and assess the log odds
Toetsings Commissie (METC) (Ref: MEC-2022-0771). between clusters. Then, intermediate models of each interac-
tion term (age∗year and sex∗year and FAS∗year) adjusted by
Outcomes and explanatory variables main effects (age, sex, FAS and time) were carried out to see

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if there were significant differences between age, sex and FAS
The principal outcomes are daily fruit, vegetable and sweets
categories in comparison with the reference level (11-year-old,
(chocolate and candy) consumption by the sum of answer
boys and medium/high FAS) in each dietary behaviour and
options ‘once daily’ and ‘more than once daily’ from the
see the interaction effects over time. The results of the logistic
question of weekly consumption in the HBSC survey.8,23
regression analysis are presented as Odds Ratios (ORs) with
The sociodemographic characteristics were used as
99% confidence intervals (CIs).
explanatory variables.
To ensure the validity of the results, sensitivity analyses
were done for different cut-off points of the outcome (Addi-
SES scored by FAS III tional file S2). Statistical significance was set at P < 0.01.
The HBSC study developed FAS in 1998 and FAS III added Analyses were performed with SPSS (Version 28.0. Armonk,
more items in 2013/14.24 NY: IBM Corp).
In the 2013/14 and 2017/18 survey cycles, FAS III was
operationalized based on six items (car ownership, own
(bed)room, times per year of holidays with family abroad,
Results
computer/tablet ownership, number of bathrooms, owning
a dishwasher).8 Sample characteristics
In accordance with the total score, a relative measure was A total of 367964 participants were included in the analysis.
used to divide FAS into three categories indicating either low The participants’ characteristics and the descriptive results of
(lowest 20% of the sample, total score between 0 and 7), dietary behaviours by survey year and overall are described in
medium (middle 60% of the sample, total score between 8 and Table 1.
11) and high (highest 20% of the sample, total score between No significant differences were found in the distribution by
12 and 13) family affluence.8,11 Due to the low number of sex between the two survey years (P = 0.284). On the contrary,
participants classified in high FAS in the current study, two more 11-year-olds and fewer 15-year-olds were observed in
categories are used called low SES and medium/high SES 2017/2018 compared with 2013/2014 (P < 0.001). Also,
here-after. more adolescents from medium/high SES and fewer adoles-
cents from low SES were involved in 2017/2018 compared
Age and sex with 2013/2014 (P < 0.001).
In both surveys, participants were asked about their age and
sex. Related to age, the adolescents were classified into 3 Prevalence of dietary behaviours
categories: 11-year-old (from 11 to <13-year-old), 13-year-old
The prevalence of the daily consumption of fruit, vegetable
(from 13 to <15-year-old) and 15-year-old (≥15-year-old).
and sweets by age category and year split by sexes was shown
(Additional file S3).
Statistical analysis In comparison with the 2013/14 survey, the prevalence of
Descriptive statistics of sex, age, FAS and dietary behaviours fruit and vegetable consumption was significantly higher in
for each age category, sex and year of data collection were 2017/18 in all age and sex categories (P < 0.001), except
calculated as frequencies % (n). for fruit consumption in 15-year-old girls that showed a non-
The change over time of dietary behaviours was estimated significantly higher prevalence in 2017/18 (P = 0.217).
by binary logistic regression. Separate models were used (i) Regarding daily sweets consumption, the prevalence
for each country adjusted by sex, age and FAS; (ii) for each decreased significantly from 2013/14 to 2017/18 in boys
 CHANGES OVER TIME OF FRUIT, VEGETABLE AND SWEETS CONSUMPTION 395

Table 1 Participants’ characteristics separated by survey year and overall

2013/14 2017/18 Total

Included participants (n) 182719 185245 367964
Sex % (n) % (n) P-valuea

Girls 50.8 (92 874) 50.7 (93 831) 0.284 50.7 (186 705)
Boys 49.2 (89 845) 49.3 (91 414) 49.3 (181 259)
Age category
11 years old 32.3 (58 458) 34.2 (62 898) <0.001 33.2 (121 356)
13 years old 34.7 (62 904) 34.4 (63 331) 0.053 34.6 (126 235)

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15 years old 33.0 (59 825) 31.4 (57 804) <0.001 32.2 (117 629)
Family Affluence Scale
Low 41.4 (69 418) 36.0 (63 944) <0.001 38.6 (133 362)
Medium 50.8 (85 113) 54.1 (95 976) <0.001 52.5 (181 089)
High 7.9 (13 179) 9.9 (17 568) <0.001 8.9 (30 747)
Dietary behaviours
Fruit consumption % (n) % (n) % (n)
Never 2.9 (5262) 3.1 (5658) 3.0 (10 920)
Less than once a week 5.9 (10 694) 6.4 (11 777) 6.1 (22 471)
Once a week 9.8 (17 796) 9.6 (17 796) 9.7 (35 592)
2–4 days a week 28.7 (52 423) 25.9 (47 899) 27.3 (100 322)
5–6 days a week 15.2 (27 715) 15.8 (29 289) 15.5 (57 004)
Once daily 17.8 (32 560) 17.8 (32 865) 17.8 (65 425)
More than once daily 19.7 (35 979) 21.5 (39 754) 20.6 (75 733)
Vegetable consumption
Never 4.5 (8148) 4.7 (8681) 4.6 (16 829)
Less than once a week 5.6 (10 225) 5.8 (10 747) 5.7 (20 972)
Once a week 9.8 (17 898) 9.3 (17 224) 9.6 (35 122)
2–4 days a week 25.6 (46 572) 23.1 (42 635) 24.3 (89 207)
5–6 days a week 19.2 (34 945) 19.2 (35 382) 19.2 (70 327)
Once daily 19.1 (34 659) 19.7 (36 365) 19.4 (71 024)
More than once daily 16.2 (29 490) 18.2 (33 511) 17.2 (63 001)
Sweets consumption
Never 3.9 (7151) 4.0 (7315) 3.9 (14 466)
Less than once a week 11.8 (21 520) 12.2 (22 486) 12.0 (44 006)
Once a week 18.9 (34 306) 18.6 (34 393) 18.7 (68 699)
2–4 days a week 28.1 (51 217) 28.4 (52 381) 28.3 (103 598)
5–6 days a week 12.9 (23 551) 13.0 (24 048) 13.0 (47 599)
Once daily 12.6 (22 869) 12.8 (23 567) 12.7 (46 436)
More than once daily 11.7 (21 371) 11.0 (20 345) 11.4 (41 716)

a P-value obtained with Chi2 analysis.

Bold values show significant P-value (P < 0.01).

of 13-year-old (P = 0.006). Girls and other age categories From 2013/14 to 2017/18, 10 of 36 European countries
showed no significant difference. had a significant increase in daily fruit consumption and 16 of
36 countries showed a significant increase in daily vegetable
consumption. Additionally, 10 of 36 countries resulted in a
Change over time of dietary behaviours by country significant increase in both outcomes, with an OR range from
The change over time of each dietary behaviour from 1.109 to 1.859 in daily fruit consumption and an OR range
2013/14 to 2017/18 adjusted by age, sex and FAS split by from 1.124 to 1.588 in daily vegetable consumption. Albania
country are presented in Table 2. had the highest increase in daily fruit consumption [OR (99%
396 JOURNAL OF PUBLIC HEALTH

Table 2 Change over time of daily dietary behaviours consumption adjusted by age, sex and FAS split by country from 2013/14 to 2017/18

Country Daily fruit consumptiona,b Daily vegetable consumptiona,b Daily sweets consumptiona,b
OR (99% CI)c OR (99% CI)c OR (99% CI)c

Albania 1.859 (1.582, 2.185)∗∗ 1.430 (1.224, 1.670)∗∗ 1.157 (0.988, 1.355)
Austria 0.853 (0.750, 0.969)∗ 1.154 (1.007, 1.322)∗∗ 0.861 (0.749, 0.989)∗∗
Belgium (Flemish) 1.505 (1.329, 1.704)∗∗ 1.311 (1.165, 1.474)∗∗ 1.024 (0.893, 1.176)
Belgium (French) 0.915 (0.827, 1.012) 1.048 (0.947, 1.160) 0.733 (0.661, 0.813)∗∗
Bulgaria 1.008 (0.898, 1.132) 1.022 (0.912, 1.145) 0.750 (0.669, 0.841)∗∗
Croatia 0.966 (0.864, 1.081) 0.973 (0.865, 1.096) 0.744 (0.661, 0.838)∗∗

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Czech Republic 1.470 (1.340, 1.612)∗∗ 1.588 (1.439, 1.753)∗∗ 0.984 (0.882, 1.097)
Denmark 0.759 (0.663, 0.869)∗ 1.071 (0.937, 1.224) 0.995 (0.758, 1.306)
Estonia 1.437 (1.276, 1.620)∗∗ 1.466 (1.291, 1.666)∗∗ 0.943 (0.826, 1.077)
England 1.109 (0.981, 1.254) 1.036 (0.917, 1.171) 0.827 (0.713, 0.959)∗∗
France 0.935 (0.850, 1.029) 0.847 (0.771, 0.929)∗ 0.931 (0.835, 1.037)
Germany 1.001 (0.896, 1.118) 1.124 (0.995, 1.269)∗∗ 0.848 (0.750, 0.958)∗∗
Greece 0.934 (0.823, 1.061) 0.969 (0.856, 1.098) 1.005 (0.854, 1.183)
Hungary 0.811 (0.712, 0.923)∗ 0.835 (0.730, 0.955)∗ 0.678 (0.592, 0.776)∗∗
Iceland 1.042 (0.957, 1.135) 1.184 (1.083, 1.294)∗∗ 1.945 (1.530, 2.472)∗
Ireland 1.077 (0.949, 1.221) 0.957 (0.845, 1.085) 0.704 (0.606, 0.819)∗∗
Italy 0.914 (0.810, 1.032) 0.988 (0.865, 1.128) 0.890 (0.781, 1.015)
Latvia 0.979 (0.867, 1.105) 1.056 (0.936, 1.192) 0.770 (0.681, 0.871)∗∗
Luxembourg 1.005 (0.880, 1.149) 1.166 (1.017, 1.336)∗∗ 1.068 (0.920, 1.240)
Malta 0.991 (0.843, 1.164) 0.815 (0.685, 0.971)∗ 2.109 (1.771, 2.512)∗
Republic of Moldova 1.672 (1.495, 1.870)∗∗ 1.137 (1.017, 1.270)∗∗ 0.914 (0.811, 1.031)
Netherlands 0.950 (0.843, 1.071) 0.903 (0.806, 1.011) 0.866 (0.765, 0.980)∗∗
Norway 0.807 (0.701, 0.929)∗ 1.048 (0.911, 1.207) 1.099 (0.805, 1.501)
Poland 1.151 (1.026, 1.290)∗∗ 1.198 (1.065, 1.347)∗∗ 0.907 (0.802, 1.025)
Portugal 1.255 (1.129, 1.395)∗∗ 1.322 (1.179, 1.482)∗∗ 1.025 (0.885, 1.187)
Romania 1.060 (0.938, 1.198) 0.858 (0.756, 0.974)∗ 0.938 (0.830, 1.059)
Russia 1.001 (0.888, 1.129) 0.935 (0.830, 1.055) 0.983 (0.870, 1.112)
Slovakia 1.259 (1.118, 1.418)∗∗ 1.496 (1.322, 1.694)∗∗ 0.985 (0.873, 1.110)
Slovenia 1.134 (1.020, 1.261)∗∗ 1.583 (1.415, 1.771)∗∗ 1.150 (1.001, 1.321)∗
Spain 1.080 (0.972, 1.200) 1.387 (1.234, 1.559)∗∗ 1.106 (0.953, 1.282)
Sweden 0.993 (0.884, 1.116) 1.155(1.040, 1.282)∗∗ 1.604 (1.261, 2.040)∗
Switzerland 0.941 (0.860, 1.030) 1.024 (0.936, 1.120) 1.027 (0.931, 1.132)
Ukraine 0.812 (0.731, 0.901)∗ 0.926 (0.835, 1.028) 0.859 (0.772, 0.956)∗∗
Macedonia 1.182 (1.053, 1.327)∗∗ 1.194 (1.064, 1.340)∗∗ 0.966 (0.857, 1.090)
Scotland 0.862 (0.774, 0.960)∗ 0.885 (0.795, 0.985)∗ 0.729 (0.651, 0.815)∗∗
Wales 1.069 (0.976, 1.171) 0.977 (0.893, 1.068) 0.945 (0.854, 1.045)

Abbreviations: OR, Odds Ratio; CI, Confidence Interval. a Positive change over time: an increase over time in daily fruit and vegetable consumption and a
decrease in daily sweet consumption.
b Negative change over time: decrease over time in daily fruit and vegetable consumption and an increase in daily sweet consumption.
c Binary logistic regression of dietary outcomes adjusted by sex, gender, age and FAS split by country.
∗ Negative and significant change over time (P < 0.01).
∗∗ Positive and significant change over time (P < 0.01).

CI) = 1.859 (1.582, 2.185), P < 0.001], whereas the Czech Regarding the daily sweets’ consumption, from 2013/14
Republic had the highest increase in daily vegetable consump- to 2017/18, 12 of 36 European countries had a significant
tion [OR (99% CI) = 1.588 (1.439, 1.753), P < 0.001]. decrease with an OR range from 0.678 to 0.907. The Nether-
 CHANGES OVER TIME OF FRUIT, VEGETABLE AND SWEETS CONSUMPTION 397

Table 3 Change over time in dietary behaviours daily consumption by age, sex and FAS from 2013/14 to 2017/18

Daily fruit consumption Daily vegetable consumption Daily sweets consumption

OR (99% CI) change over timea OR (99% CI) change over timea OR (99% CI) change over timea

Age
11 years old 1.062 (1.028, 1.096)∗ 1.089 (1.054, 1.125)∗ 0.948 (0.912, 0.986)∗
13 years old 1.061 (1.027, 1.096)∗ 1.115 (1.079, 1.152)∗ 0.908 (0.876, 0.942)∗
15 years old 1.045 (1.010, 1.081)∗ 1.081 (1.045, 1.118)∗ 0.906 (0.873, 0.940)∗
Sex
Girls 1.044 (1.017, 1.071)∗ 1.095 (1.067, 1.124)∗ 0.927 (0.900, 0.955)∗

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Boys 1.066 (1.038, 1.096)∗ 1.093 (1.063, 1.124)∗ 0.911 (0.882, 0.940)∗
FAS
Low FAS 1.071 (1.038, 1.105)∗ 1.056 (1.024,1.090)∗ 0.917 (0.887, 0.948)∗
Medium/High FAS 1.045 (1.020, 1.070)∗ 1.119 (1.092, 1.146)∗ 0.921 (0.895, 0.947)∗

This table shows the change over time from 2013/14 to 2017/18 in each dietary behaviour adjusted by age and/or sex and/or FAS and country split by
age categories, sex and FAS categories. Abbreviations: OR, Odds Ratio; CI, Confidence Interval
a Binary logistic regression of dietary outcomes adjusted by sex, age, FAS and country.
∗ P-value < 0.01.

lands showed the highest decrease [OR (99% CI) = 0.866 old adolescents (P < 0.001). In addition, the interaction effect
(0.765, 0.980), P = 0.003]. showed that 15-year-old adolescents had a significantly less
The change over time by country highlighted that daily favourable change over time in sweets consumption than 11-
fruit and/or vegetable consumption showed a positive and year-old adolescents (P = 0.006).
significant change in most Eastern Europe countries. On the Related to sex, girls consumed more daily fruits, vegetables
contrary, daily sweets consumption was reduced in mostly and sweets than boys (P < 0.001). However, the interaction
Western European countries. However, in both Western and effect indicated a similar change over time between sex cate-
Eastern Europe, a negative and significant change of dietary gories in fruits (P = 0.077); vegetables (P = 0.888) and sweets
behaviours (fruit, vegetable and sweets consumption) was (P = 0.967) consumption.
observed (Table 2). Regarding FAS categories, low SES adolescents consumed
fewer daily fruits and vegetables than adolescents with medi-
Change over time of dietary behaviours by age, um/high SES (P < 0.001). Additionally, the interaction effect
sex and FAS categories showed a less favourable change over time in daily vegetable
From 2013/14 to 2017/18, the change over time by age, sex consumption in low SES adolescents than medium/high SES
and FAS showed a significant increase in daily fruit and veg- (P < 0.001), but a similar change over time between FAS
etable consumption and a significant decrease in daily sweets categories in daily fruit consumption (P = 0.195). However,
consumption in all age, sex and FAS categories (Table 3). no significant differences were found for main effects and
interaction effects over time in daily sweets consumption
Multilevel analysis: main effects and interaction between FAS categories.
effects over time between sociodemographic
characteristics in dietary behaviours Sensitivity analysis
The multilevel analysis showed main effect differences and In the sensitivity analysis, the selected cut-off points were (i)
interaction effects over time (from 2013/14 to 2017/18) in more than once daily fruit and vegetable consumption and
dietary behaviours between sociodemographic characteristics (ii) weekly sweets consumption (Additional file S2). Regarding
(Table 4). Focussing on age categories, 13- and 15-year-old change over time by country, five extra countries showed
adolescents consumed fewer daily fruits and vegetables than significantly positive results in fruit and sweets consumption,
11-year-old adolescents (P < 0.001). However, the interac- and six extra countries in vegetable consumption. However,
tion effects did not show significant change over time (from five countries, showing positive and significant changes in
2013/14 to 2017/18) differences (P > 0.01). Furthermore, time in the main analysis, do not show this in the sensitivity
13- and 15-year-old consumed more daily sweets than 11-year- analysis.
398 JOURNAL OF PUBLIC HEALTH

Table 4 Multilevel analysis: main effects differences and Interaction effects in dietary behaviours between sociodemographic characteristics over time
(from 2013/14 to 2017/18)

Daily fruit consumption Daily vegetables consumption Daily sweets consumption

OR (99% CI) main OR (99 CI) OR (99% CI) main OR (99 CI) OR (99% CI) main OR (99 CI)
effectsa interactionb effectsa interactionb effectsa interactionb

Age
11 years old Ref Ref Ref Ref Ref Ref
13 years old 0.729 (0.706, 1.000 (0.956, 0.847 (0.820, 1.024 (0.979, 1.208 (1.163, 0.962 (0.913,

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0.752)∗ 1.045) 0.875)∗ 1.072) 1.254)∗ 1.013)
15 years old 0.611 (0.592, 0.963 (0.920, 0.809 (0.782, 0.976 (0.932, 1.213 (1.168, 0.946 (0.897,
0.632)∗ 1.008) 0.836)∗ 1.022) 1.260)∗ 0.997)∗
Sex
Girls 1.375 (1.339, 0.975 (0.940, 1.379 (1.342, 0.998 (0.961, 1.201 (1.165, 0.999 (0.958,
1.412)∗ 1.012) 1.416)∗ 1.036) 1.238)∗ 1.043)
Boys Ref Ref Ref Ref Ref Ref
FAS
Low FAS 0.712 (0.692, 1.020 (0.981, 0.767 (0.745, 0.941 (0.905, 0.983 (0.952, 0.998 (0.956,
0.733)∗ 1.059) 0.790)∗ 0.979)∗ 1.016) 1.042)
Medium/High FAS Ref Ref Ref Ref Ref Ref

This table shows the main effects difference between sociodemographic characteristics categories and interaction effects over time (2013/14 versus
2017/18) between sociodemographic categories in each dietary behaviour in comparison with the reference category (11-year-old and medium + high
FAS participants). Abbreviation: Ref, Reference level category; OR, Odds Ratio; CI, Confidence Interval.
a Main effects differences between age, sex and FAS categories in dietary behaviours by the multilevel binary logistic regression with country as a level.
b Interaction effects of age, sex and FAS categories over time (from 2013/14 to 2017/18) by multilevel binary logistic regression with country as a level.
∗ P-value < 0.01.

Focussing on multilevel analysis, the main effects differ- prevalence of 36.3% in daily fruit consumption and of 33.0%
ences showed the same results as the original cut-off, except in vegetable consumption.25 However, these improvements
for low SES adolescents that had less sweets consumption are not enough, as many adolescents still do not consume
(more than once daily) than medium/high SES. fruits and vegetables every day. Additionally, the prevalence of
Related to the interaction effect, the low SES adolescents daily sweets consumption (chocolate and candy) was 23.8% in
showed a significantly more favourable change over time than 2017/18. A HBSC trend study from 2002 to 2014 showed that
medium/high SES adolescents in fruit consumption. More- in 2014 21% of adolescents from the Czech Republic con-
over, 13- to 15-year-old adolescent showed a less favourable sumed sweets daily, but in the present study, this percentage
change over time than 11-year-old adolescents in fruit and is higher because is considering all European adolescents.26
vegetable consumption. According to the recommendation of the European
Finally, in weekly sweets consumption, low SES adoles- Society for Paediatric Gastroenterology, Hepatology and the
cents showed a significantly less favourable change over time Nutrition Committee on Nutrition, children and adolescents
than medium/high SES adolescents. should reduce their sugar intake to <5% daily energy, meaning
daily 27–32 g of added sugar for adolescents between 13 and
15 years old.27 For example, 50 g of chocolate (two squares)
Discussion
contains 27 g of added sugar, making it easy to exceed the
Main findings of this study and what is already recommendation of daily added sugar, also in the 23.8% of
known on this topic adolescents in this study.
In 2017/18, respectively, 39.3% and 37.3% of 11- to 15-year- Focussing on country specific change over time of fruit
old adolescents of 36 European countries consumed fruits and vegetable consumption, a significant increase in daily fruit
and vegetables every day. This is an increase compared with consumption is shown in 10 of 36 European countries, as well
the previous HBSC report from 2009/10, which showed a as a significant increase in daily vegetable consumption in 16
 CHANGES OVER TIME OF FRUIT, VEGETABLE AND SWEETS CONSUMPTION 399

of 36 European countries. A similar study of HBSC data from dom) implemented taxes on SSB and/or sugar consumption
2002 to 2010 resulted in a significant increase in daily fruit between 2009 and 2018.33 This can explain why most of these
consumption in 22 of 33 European countries and in daily veg- countries presented a positive and significant change over
etable consumption in 18 of 33 countries.18 These increases in time in the present study. Nevertheless, this recommended
fruit and vegetable consumption in more countries compared sugar reduction is still important, as the present study showed
with the present study could be explained by the higher sample that ≥20% of adolescents still consume sweets daily.
size and/or the more survey years analysed: 3 waves of the Recently, the European Programme of Work 2020–25 was
HBSC survey (2002/03, 2006/07 and 2010/11) instead of 2 agreed upon by all 53 Member States of the WHO European
waves (2013/14 and 2017/18).18 Region, aiming to promote healthy and sustainable diets,
Most countries that increased daily fruit and vegetable tackle the growing rates of obesity, and ensure good nutrition

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consumption are from Eastern Europe. This observation is and food security through a range of activities. Among others,
supported by a recent narrative review that highlighted the activities consist of (i) promoting school nutrition policies,
improvement of dietary patterns, including fruit and veg- (ii) restricting digital marketing of unhealthy foods and non-
etable consumption, evident since 1990 in Western European alcoholic beverages to children and adolescents, (iii) promot-
countries, also being visible in Eastern European countries ing policies to reduce salt, fats and sugars in diet, including
in the last two decades, since 2000.28 A previous study on food product reformulation and (iv) supporting fiscal policies
fruit and vegetable consumption showed that the majority of including sugar-sweetened beverage tax and front-of-pack
countries with higher prevalence in 2010 were from Western labelling.34 These initiatives provide a good opportunity to
Europe, whereas the majority of Eastern countries showed a improve the dietary behaviours of children and adolescents
lower prevalence of fruit and vegetable consumption. Possi- taking into account the relevant results of the present study.
bly in the present study, most Eastern countries had a signifi- The present study showed that older adolescents consumed
cant positive catch-up as they set off with a lower prevalence.18 fewer daily fruits and vegetables than younger adolescents.
Currently, the WHO is implementing some policy rec- These results are in line with a European trend from 2002
ommendations to address fruit and vegetable consumption, to 2010.35 Additionally, the present study demonstrated that
e.g. EU school scheme: distribution of fruit, vegetables and older adolescents consumed more daily sweets with a less
milk from nursery to secondary school across the European favourable change over time than younger adolescents. A
Union.29 Nevertheless, it is necessary to expand policy rec- study from Germany between 1985 and 2016 showed the
ommendations because the initiative of the school scheme opposite; older children consuming less sugar than younger
did not involve all European countries (only 27 countries) children.36 Justifying that the results differ among countries
and, in the present study, only 11 of these 27 countries and the present study analyses the overall European level.
showed a positive significant change over time in at least Focussing on SES inequality, low SES adolescents con-
fruit and vegetable consumption. Moreover, reinforcing this sumed fewer daily fruits and vegetables than medium/high
policy is necessary in low SES high schools considering that SES adolescents. Also, the change over time in daily vegetable
adolescents of low SES consume fewer fruits and vegetables consumption was less favourable in low SES adolescents.
than their peers with higher SES. These results are in line with a study among Nordic ado-
The country-specific change over time in sweets consump- lescents that showed that high SES students are more likely
tion showed that the daily sweets consumption in adolescents to report eating daily fruits and vegetables compared with
decreased in 14 of 36 Europe countries. A previous study low/medium SES adolescents. On the contrary, trends (from
from Germany (1985–2016) also showed a decrease in the 2001/02 to 2009/10) in SES inequality in fruit and vegetable
total sugar intake in children and adolescents since 2010.30 consumption did not differ across survey years.9 The study
The decrease in sugar consumption in the present study did not show any significant associations between SES and
might be explained by 2015 recommended WHO guideline sweets consumption.9 Those less favourable changes over
about the reduction of sugar intake to less than 10% of time for low SES groups means that inequities are increasing
total energy.31 Due to this recommendation, some policy over time and probably reflect the devastating effects of the
recommendations were carried out in Europe to restrict or economic crisis on European society.37 In future research, this
eliminate the choice of sugar-added food or beverages and potentially widening gap should be monitored and addressed.
introduce the recommendation of fiscal measures such as Related to sex inequity, girls consumed more daily fruits,
the taxation of sugar-sweetened beverages (SSB) and sugar- vegetables and sweets than boys, as was also found in a
rich products.32 Some European countries (Belgium, Finland, previous trend study on dietary behaviour among European
France, Hungary, Ireland, Norway, Portugal and United King- adolescents.35
400 JOURNAL OF PUBLIC HEALTH

What this study adds Related to SES inequality, low SES adolescents consumed
The present study provides new actual evidence about fewer daily fruits and vegetables than adolescents with medi-
the change over time of dietary behaviours in European um/high SES. In low SES adolescents, a less favourable
adolescents and the association with sociodemographic change over time for vegetable consumption was shown.
characteristics. These findings are very important to further
underpin the development of public health policies to Supplementary data
improve the diet of European adolescents.
Supplementary data are available at the Journal of Public Health
online.
Limitations of this study
Acknowledgements

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As more recent data are not freely available yet, the data on
the study are limited to the 2013/14 to 2017/18 period. Authors acknowledge the schools, students participating in
Related to future perspectives, studies with longer time- the study and the International Coordinator and Principal
trend comparisons between European countries including Investigators for providing the HBSC data for 2013/14 and
more social factors (ethnicity, demographic characteristics, 2017/18. HBSC is an international study carried out in collab-
sociocultural education and exposure to media), and more oration with WHO/EURO. The International Coordinator
details on consumed quantities might provide further evi- of the 2013/14 survey was Prof. Candace Currie, and of
dence. 2017/18 survey was Prof. Jo Inchley, and the Data Bank
Furthermore, European policy recommendations aiming Manager was Prof. Oddrun Samdal. The survey 2013/14 and
to prevent NCDs and improve dietary behaviour should 2017/18 was conducted by Principal Investigators in the 36
reflect on the differences in age, sex and SES regarding daily countries are: Albania (Gentiana Qirjako); Austria (Rosemarie
fruit and vegetable consumption, which is a protective factor Felder-Puig); Belgium: Flemish (Carine Vereecke (to 2012)
for NCDs. Key points to adapt policy recommendations Anne Hublet (from 2012)); Belgium: French (Danielle Piette);
should be, first, to offer fruits and vegetables in schools or Bulgaria (Lidiya Vasileva); Croatia (Marina Kuzman (to 2013),
high schools at the European level considering the SES of Ivana Pavic Simetin (from 2013)); Czech Republic (Michal
families. Secondly, educational strategies should be imple- Kalman); Denmark (Pernille Due (to 2012) Mette Rasmussen
mented to improve the knowledge about the importance of (from 2012)); Estonia (Katrin Aasvee); France (Emmanuelle
fruit and vegetable consumption: reaching low SES families Godeau); Germany (Petra Kolip (to 2015), Matthias Richter
to enable them to attain fruit and vegetable recommendations. (from 2015)); Greece (Anna Kokkevi); Hungary (Ágnes
Lastly, fruit and vegetable recommendations should be Németh); Iceland (Arsaell Arnarsson); Ireland (Saoirse Nic
specified to sub-age categories such as younger adolescents Gabhainn and Michal Molcho); Italy (Franco Cavallo);
(10–12 years old), middle adolescents (12–14 years old) and Latvia (Iveta Pudule); Luxembourg (Yolande Wagener); Malta
older adolescents (15–18 years old), not only divided by (Charmaine Gauci); Netherlands (Wilma Vollebergh and
children or adolescents in general. Tom ter Bogt); Norway (Oddrun Samdal); Poland (Joanna
Mazur); Portugal (Margarida Gaspar de Matos); Republic of
Moldova (Galina Lesco); Romania (Adriana Baban); Russian
Conclusions Federation, (Oleg Churganov); Slovakia (Andrea Madarasová
Gecková); Slovenia (Helena Jericek); Spain (Carmen Moreno
From 2013/14 to 2017/18, a significant and positive change Rodriguez); Sweden (Lilly Augustine (to 2015), Petra Lofstedt
over time, an increase was shown in the daily fruit and veg- (from 2015)); Switzerland (Emmanuel Kuntsche); The
etable consumption and a decrease in sweets consumption former Yugoslav Republic of Macedonia (Lina Kostarova
of 11- to 15-year-old adolescents in 36 European countries. Unkovska); Ukraine (Olga Balakireva); United Kingdom:
Especially in Eastern European countries, an increase in daily England (Antony Morgan (to 2015) Fiona Brooks); United
fruit and vegetables was perceived, whereas in Western Euro- Kingdom: Scotland (Candace Currie (to 2015), Jo Inchley
pean countries, a decrease in daily sweet consumption was (from 2015)); United Kingdom: Wales (Chris Roberts). For
observed. details, see http://www.hbsc.org.
Notably, older adolescents consumed fewer daily fruits and
vegetables and more daily sweets than younger adolescents.
Conflict of interest
In addition, girls consumed more daily fruits, vegetables and
sweets than boys. The authors declare that they have no competing interests.
 CHANGES OVER TIME OF FRUIT, VEGETABLE AND SWEETS CONSUMPTION 401

Authors’ contributions diets. Food Nutr Bull 2020;41:59S–73S. Available from: https://journa
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