Fast Food Intake,Emotional and Behavioral Problems among Adolescents with Overweight and Obese Problems Participating in MyBFF@school Intervention Program

Abstract

The prevalence of fast food consumption and childhood obesity has increased rapidly. This study aimed to assess the association between the frequency of fast food consumption in the past week with emotional and behavioral problems of 624 adolescents with overweight and obese problems (mean age = 14.6). Frequency of fast food consumption was assessed through a pre-tested nutritional knowledge, attitude, and practice questionnaire. Meanwhile, the Youth Self-Report questionnaire was used to measure emotional and behavioral problems. Multiple linear regression was used to measure the strength of relationships. The strongest and significant positive correlation was reported between frequency of fast food consumption in the past week and aggressive behavior (r = .65, p < .001). Weak but significant positive correlations were demonstrated between frequency of fast food intake in the past week with somatic complaints (r = .328, p < .001) and attention problems (r = .356, p < .001). Therefore, adolescents with obese and overweight problems and their parents should be instilled awareness about the association between fast food consumption and emotional and behavioral problems to achieve their psychological well-being.

Keywords

adolescents behavioral problems emotional problems fast foods overweight and obese

Introduction

Fast food contains trans fatty acids that increases the ratio of low-density lipoprotein (LDL) to high-density lipoprotein (HDL) cholesterol and the risk of developing coronary heart disease (Brouwer et al., 2010; Mozaffarian et al., 2006). The World Health Organisation (WHO) advises reducing trans fatty acid consumption to less than 1% of total energy intake to lower the risk of non-communicable diseases. However, there is an increasing trend from 1977 to 2006 in the energy intake from fast foods among the US children (National Research Council, 1984; Poti & Popkin, 2011; U.S. Department of Agriculture ARS BHNRC, Food Surveys Research Group, n.d.). Between 2007 and 2008, 33% of children and 41% of adolescents take fast foods from restaurants on a typical day (Powell et al., 2012). During 2015 to 2018, there were 36.3% children and adolescents aged 2 to 19 taking fast food on a given day (Fryar et al., 2020).

The increasing trend is alarming as popular fast foods bought from 20 countries were found to have a very high amount (0.4%–40%) of trans fatty acids (Stender et al., 2006). Moreover, a recent study in China found that half of the children participating in their study consumed fast foods in the previous 3 months and more than 10% of the children were obese (Zhao et al., 2017). The fact that fast foods are potentially addictive in nature, couple with how little overweight and obese children have control over their eating behavior make these children more vulnerable to the detrimental effects of fast foods consumption (Garber & Lustig, 2011; Nederkoorn et al., 2006).

Apart from the effects on the physical health, food consumption could also affect psychological well-being. This warrants a different perspective on understanding the effects of fast food (Carabotti et al., 2015). Animal study found that rats exhibit mania-like behavior after prolonged consumption of trans fat (Trevizol et al.,2015). Further, in humans, consumption of fast food was found to be associated with a higher risk of depression (Sánchez-Villegas et al., 2012). Therefore, adolescents with overweight and obese problems who frequently consumed fast foods could also be exposed to the worsening of their psychological well-being. However, there is little information in the literature about the relationship of fast food consumption with a wide range of emotional and behavioral problems especially among adolescents with overweight and obese problems. Hence, this study aimed to elucidate the association of fast food with emotional and behavioral problem among secondary school adolescents of MyBFF@school intervention program.

Methods

This was the data of a school-based cluster randomized controlled trial, the “My Body is Fit and Fabulous at school” (MyBFF@school) intervention study. Trained personnel measured the BMI of 10,866 adolescents aged 13, 14, and 16 years old, with no medical condition from 15 secondary schools to screen for adolescents with overweight and obese problems. Adolescents aged 15 were excluded from this study because it is the policy of the Ministry of Education Malaysia not allowing these students to participate in any research. The main reason is they are involved in the public examination known as the Form Three Assessment (PT3). The adolescents were categorized as overweight if their BMI-for-age is more than +1SD and less than or equal to +2SD while adolescents with BMI-for-age exceeding +2SD were categorized as obese based on the WHO 2007 Growth Reference (“WHO | BMI-for-age (5–19 years),” n.d.). There were 2,910 (26.8%) adolescents who are either overweight or obese found from the screening process. They were approached for consents from parents or guardian to take part in the study and 1,041 (35.8%) adolescents submitted their informed written consents. The participating adolescents answered two self-reported questionnaires which were the nutritional knowledge, attitude and practice (KAP) questionnaire as well as the Youth Self-Report (YSR) questionnaire. Only 624 (59.9%) adolescents completed both questionnaires and have been considered in the analysis. Data were collected through a socio-demographic characteristics questionnaire that were answered by the adolescents’ parents.

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia and Educational Planning and Research Division (EPRD), and Ministry of Education Malaysia (ethical code: NMRR-13-439-16563). Written informed consent was obtained from the parents or guardian of all subjects and written informed assent was obtained from all subjects.

Instrument

Nutritional KAP questionnaire developed by the researchers has been used to gather data on frequency of fast food consumption. The questionnaire obtains information on how many days adolescents eat fast foods for the past 7 days, attitudes toward fast food intakes and knowledge about fast food. Fast foods in this study refer to foods purchased from fast food restaurants such as burger, pizza, fried chicken, and French fries. Symptoms of emotional and behavioral problems among the adolescents has been measured via the Youth Self-Report (YSR) questionnaire by Achenbach (1991). The questionnaire consists of 112 likert-scaled items with 8 subscales namely anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior (Achenbach, 1991; Achenbach & Rescorla, 2001). The questionnaire has gone through back-to-back translation from English to Malay Language. Nutritional KAP and YSR have been pre-tested during the pilot study on adolescents with overweight and obese problems from Putrajaya in 2015. YSR achieved Cronbach alpha of .95 for its reliability.

Statistical Analysis

Chi-square test was used to quantify the association between categorical variables. The relationship between fast food consumption in the past 7 days and the symptoms of emotional and behavioral problems was assessed via multiple linear regression. All statistical tests were conducted at 5% significance level. IBM Statistical Package for the Social Sciences (SPSS) version 20 was applied for all data analysis.

Result

There were 624 adolescents with a mean age (SD) of 14.6 (1.3) years old who completed both the nutritional KAP and YSR questionnaire. Gender distribution were found to be statistically significant different at baseline between the two arms (χ²(1) = 8.362, p = .004). The number of girls in this study was greater than the number of boys as shown in Table 1.

Table 1.

Demography of Participants.

Characteristic of respondents	Overweight	Obese	Chi-square	p-Value
Sex, n(%)
Boy	95 (41.3)	135 (58.7)	8.362*	0.004
Girl	210 (53.3)	184 (46.7)
Age groups, n(%)
13 years	92 (49.2)	95 (50.8)	0.649	0.723
14 years	73 (46.2)	85 (53.8)
16 years	140 (50.2)	139 (49.8)
Location, n(%)
Rural	93 (46.0)	109 (54.0)	0.963	0.326
Urban	212 (50.2)	210 (49.8)
Ethnicity, n(%)
Malay	230 (47.0)	259 (53.0)	3.570	0.312
Chinese	28 (56.0)	22 (44.0)
Indian	42 (56.8)	32 (43.2)
Others	5 (45.5)	6 (54.5)

p < .01.

Table 2 reported fast food consumption for the past 7 days by the adolescents according to their body weight. Most of the overweight adolescents have fast food once a week whereas most of the obese adolescents don’t eat fast food for the past 7 days. The number of adolescent have fast food for 7 days for the past 7 days is the lowest for both weight category.

Table 2.

Tabulation of Fast Food Consumption for the Past 7 days Across Body Weight.

Fast food intake for past 7 days	Weight category
Fast food intake for past 7 days	Overweight	Obese	Total
0	76	95	171
0	24.92	29.78	27.40
1	89	73	162
1	29.18	22.88	25.96
2	66	72	138
2	21.64	22.57	22.12
3	38	49	87
3	12.46	15.36	13.94
4	18	17	35
4	5.90	5.33	5.61
5	10	6	16
5	3.28	1.88	2.56
6	5	6	11
6	1.64	1.88	1.76
7	3	1	4
7	0.98	0.31	0,64
Total	305	319	624
Total	100.00	100.00	100.00

The strongest and significant positive correlation was reported between frequency of fast food consumption in the past week and aggressive behavior (r = .65, p < .001). On the other hand, weak but significant positive correlations were demonstrated between frequency of fast food intake in the past week with somatic complaints (r = .328, p < .001) and attention problems (r = .356, p < .001) as shown in Table 3.

Table 3.

Correlation Between YSR Subscales and Frequency of Fast Food Consumption.

YSR subscales	Adjusted beta coefficient	95% CI	p-Value
Withdrawn/depressed	.153	[0.006, 0.301]	.041
Anxious/depressed	.377	[0.151, 0.604]	.001
Somatic complaints	.328	[0.155, 0.501]	<.001
Social problems	.310	[0.133, 0.486]	.001
Thought problems	.348	[0.148, 0.547]	.001
Attention problems	.356	[0.196, 0.517]	<.001
Rule-breaking behavior	.297	[0.115, 0.479]	.001
Aggressive behavior	.650	[0.380, 0.920]	<.001
Total behavior	2.85	[1.397, 4.304]	<.001

Each model is adjusted for gender, age, ethnicity, and school location.

Discussion

The positive associations between the frequency of fast food consumption with the symptoms of emotional and behavioral problems imply that higher frequency of fast food consumption is associated with worse emotional and behavioral problems among adolescents with overweight and obese problems. Obese children and adolescents have been reported to have impaired health-related quality of life similar with children and adolescents diagnosed having cancer (Schwimmer et al., 2003). However, the findings do not reveal if fast food intake causes emotional and behavioral problems among these adolescents or vice versa. The nutritional contents of fast food have not been determined as the focus of this study is no the frequency of fast food consumption.

We hypothesize that the relationships between them may exist mainly due to the mechanism of the gut-brain axis. Changes in the species of microbiome that resides in our gastrointestinal tract can influence stress-related behavior (Foster & McVey Neufeld, 2013). The microbiota is responsible in the regulation of hypothalamic–pituitary–adrenal (HPA) axis at early age as well as in the reaction of our body toward stress throughout our life (Foster & McVey Neufeld, 2013). The HPA axis plays a role in modulating stress and changes in its activity have been associated with depression (Belvederi Murri et al., 2014; Wasserman et al., 2010). Research on humans has discovered a correlation between fecal mirobiota and depression (Naseribafrouei et al., 2014). This is because changes in our diet can influence the gut microbiota composition which could eventually influence stress related behavior (Flint et al., 2015). Evidences from research on mice have shown that high-fat diet can increase anxious and depressive behaviors (Luna & Foster, 2015). These evidences coincide with the significant association between fast food and the symptoms of anxious/depressed among adolescents with overweight and obese problems found in this study.

Even though the cause of somatic symptoms is medically unexplainable, they are often regarded as the effects of stress as well as other factors such as biological and interpersonal factors (Mayou & Farmer, 2002). An experimental study discovered that stressed emotional eaters would usually consume energy-dense foods that are high in sugar, salts, and fats as these types of food could alleviate their mood due to the release of dopamine in their brain (Horsch et al., 2015; Leigh Gibson, 2006; Oliver et al., 2000). Thus, fast foods might be one of their best options when they were stressed since these foods typically contains high sodium, sugar, total fat, and trans-fat (Dunford et al., 2010; Stender et al., 2006). Therefore, stress could be the potential mediator of frequent consumption of fast foods and the prevalence of somatic symptoms which are in accordance with the result of our study.

A range of emotional and behavioral problems such as social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior faced by adolescents with overweight and obese problems in this study may be related to the development of mania like behavior and hyperactive behavior due to the trans-fat in the fast foods consumed by the adolescents. A study on rats found that their brain cortex would assimilate trans-fat under prolonged consumption which would eventually leads to mania-like behavior that includes hyperactive behavior (Trevizol et al., 2015). The development of these behaviors is expected to be due to the declining level of brain-derived neurotrophic factor (BDNF) as there is a correlation between the level of BDNF with the development of bipolar disorder (Cunha et al., 2006; Trevizol et al., 2015). Mania-like behavior could worsen interpersonal relationship due to impairment of facial emotion which would cause social problems (Lembke & Ketter, 2002). The inability to accurately determine facial emotion is also associated with thought problems (Wickline et al., 2012). Amid, hyperactivity behavior is characterized by restless, inattentive, and impulsive behavior that could lead to attention problems, aggressive behavior as well as social problems such as peer rejection (Schachar, 1991; Spira & Fischel, 2005). On top of that, it also has a strong link with rule breaking behavior (McArdle et al., 1995).

The high fat and salt content in fast food may cause it to become potentially addictive (Garber & Lustig, 2011). The amount of sugar in soda that often comes with fast foods is usually 10 times the normal amount which can cause the release of excessive dopamine in the brain (Avena et al., 2009; Garber & Lustig, 2011). The effect is similar to that of drug abuse where addictive-like behavior would likely to occur (Avena et al., 2009). To make it worse, obese children usually have resistance to hormones that control appetite and limit reward compared to children with normal body weight who have no problem in receiving normal hunger and satiety signals (Garber & Lustig, 2011; Mietus-Snyder & Lustig, 2008). Thus, it would be harder for obese individuals to reduce their weight especially when they are addicted to fast foods. Children who are not satisfied with their body image are likely to perpetrate bullying (Rech et al., 2013). This could exacerbate social problems, aggressive behavior, and rule-breaking behavior. Studies have found that the two most-preferred fast foods by Malaysian adolescents contain also contain trans-fat which could cause them to be hyperactive under prolonged consumption (Habib et al., 2011; Stender et al., 2006; Trevizol et al., 2015).

It is utmost important for parents to know the positive associations between the frequency of fast food consumption with the symptoms of emotional and behavioral problems among the overweight and obese adolescents. This is because excessive fast food consumptions not only relates to psychological problems, also result in many health-related issues and make obese adolescents face more challenges in reducing their weight. Ultimately, obese children reveal behavioral and social problems due to unsatisfactory body image. Parents have to monitor their children’s food intake and ensure they are eating healthy diet. In addition, parents should practice healthy dietary habits because parental food intakes are highly correlated with their children’s food intakes especially among young children (Tang et al., 2020). Parents also have great impacts on their children’s eating behaviors (Patel et al., 2018).

One of the limitations to this study is the respondents’ understanding on the items of the questionnaire due to their command of Malay Language. Their difficulties in answering the questionnaire have challenged the validity of their responses and data collection process. Nevertheless, as the data is obtained via a self-reported questionnaire, it relies on the respondents’ ability to recall their past behavior. Besides that, completing the large number of items in the questionnaire required respondents’ great patience, too. Another limitation is this study applies cross-sectional design where data is collected at one time, there is not follow-up with the respondents to have further information on their eating habits and obesity after the study.

Conclusion

Fast food consumption significantly associated with a range of emotional and behavioral problems which include the symptoms of somatic complaints, attention problems, and aggressive behavior among adolescents with overweight and obese problems. Therefore, WHO guidelines on fast food consumption should be adhered strictly by discouraging its consumption especially among adolescents with overweight and obese problems. Hence, nutrition education is of paramount importance to adolescents with overweight and obese problems, primarily in the topics related to appetite control, the addictive nature of fast food and the health effects that it would bring to them. Furthermore, parents must be aware of the importance of providing their children with healthy food and reduce fast food intake. Parents need to monitor their children’s dairy diet and be a role model to them by applying healthy dietary habits.

Footnotes

Acknowledgements

The authors would like to thank the Director General of Health Malaysia for his permission to publish this article, the Ministry of Education for giving the approval for us to undertake this study, and all researchers, staff of Ministry of Health, participants, and teachers for helping in data collection. Special thanks to Dr. Hj. Tahir Bin Aris as the coordinator of MyBFF@school project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by a grant from the Ministry of Health Malaysia [grant number NMRR-13-439-16563].

Ethical Approval

ORCID iDs

Zahari Ishak

Wan Abdul Hakim Wan Ibrahim

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