Appetite 157 (2021) 105007

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Appetite
journal homepage: www.elsevier.com/locate/appet

Eating context and its association with ultra-processed food consumption

by British children
Bianca M. Onita a, Catarina M. Azeredo b, c, Patrícia C. Jaime a, b, Renata B. Levy b, d,
Fernanda Rauber a, b, d, *
a
Departamento de Nutrição, Faculdade de Saúde Pública, Universidade de São Paulo, Av. Dr. Arnaldo 715, 01246-904, São Paulo, Brazil
b
Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde, Universidade de São Paulo, Av. Dr. Arnaldo 715, 01246-904, São Paulo, Brazil
c
Faculdade de Medicina, Universidade Federal de Uberlândia, Av. Pará, 1720, Bloco 2H – Campus Umuarama Campus, 38400-902, Uberlândia, Brazil
d
Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Arnaldo 455, Cerqueira César, 01246-903, São Paulo, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: This study aimed to investigate the patterns of eating context and its association with ultra-processed food
Ultra-processed foods consumption by British children. This cross-sectional study was conducted with a representative sample of UK
Eating occasion children aged 4–10 years old (n = 1772) from the National Diet and Nutrition Survey 2008/2014. Data on food
United Kingdom
consumption, meal context and ultra-processed food consumption were assessed through a four-day food diary.
Diet
Children
Exploratory factor analysis was used to identify the patterns of eating context and these patterns’ association
with the daily consumption of ultra-processed food was verified by linear regression analyses. Ultra-processed
foods comprised 65.4% of the total daily energy intake. At lunch, higher ultra-processed food consumption
was associated with the patterns “Eating with family while watching TV” (64.9% in the lowest tertile to 68.1% in
the highest tertile) and “Eating away from home” (65.2%–67.7%, respectively), while the eating pattern “Eating
at school with friends” was associated with lower ultra-processed food consumption (66.6%–64.7%, respec­
tively). At dinner, higher ultra-processed food consumption was associated with the patterns “Eating with family
while watching TV” (64.6%–67.1%, respectively) and “Eating alone in the bedroom” (63.9%–66.5%, respec­
tively). Eating alone, eating whilst watching TV, and eating away from home stood out as patterns of eating
context associated with the increased consumption of ultra-processed food.

1. Introduction
The food environment is an important determinant of eating habits
(HLPE, 2017). Children are exposed to different food environments,
including the physical environment, such as school, home, neighbour­
hood, restaurants, and fast foods, and the social environment related to
different people, such as parents, caregivers, relatives, and friends
(Contento, 2015). These environments influence the development of
children’s eating habits and behaviours, which are shaped at a young
age and tend to remain throughout their lives (Arcan et al., 2007; Branen
& Fletcher, 1999; Mais et al., 2018).
Parents and caregivers shape the children’s familiar food environ­
ment (Savage et al., 2007; Ventura & Birch, 2008) and their eating
habits during meals are seen as examples of consumption patterns,
especially for younger children in development (Jaime et al., 2017;
Patrick & Nicklas, 2005). Children generally choose more available, or
easily accessible food (Ding et al., 2012; Leite et al., 2018; Santiago-­
Torres et al., 2014; Talip et al., 2017). Thus, food availability and
accessibility in places like the household, school environment, or even in
external environments (such as places regularly frequented by children)
also strongly influence on food consumption.
Ultra-processed foods (UPF) are industrial formulations made,
mainly, of food-derived substances and often include ingredients not
used in culinary preparations, such as additives (e.g. flavourings, col­
ourings, emulsifiers). UPF usually contains little, if any, intact food in its
composition (Monteiro et al., 2019). Children’s eating habits have been
characterized by high UPF intake (Costa, Rauber, et al., 2019; Karnopp
et al., 2017; Neri et al., 2019; Rauber et al., 2015, Rauber et al., 2019).
These products have replaced freshly prepared dishes and meals, leading
to changes in eating patterns and behaviours, such as preparing and

* Corresponding author. Núcleo de Pesquisas Epidemiológicas em Nutrição e Saúde, Universidade de São Paulo, Av. Dr. Arnaldo 715, 01246-904, São Paulo, Brazil.
E-mail addresses: bianca.onita@usp.br (B.M. Onita), catarina.azeredo@ufu.br (C.M. Azeredo), constant@usp.br (P.C. Jaime), rlevy@usp.br (R.B. Levy), rauber.
fernanda@gmail.com, rauber@usp.br (F. Rauber).

https://doi.org/10.1016/j.appet.2020.105007
Received 19 April 2020; Received in revised form 11 October 2020; Accepted 12 October 2020
Available online 17 October 2020
0195-6663/© 2020 Elsevier Ltd. All rights reserved.
B.M. Onita et al.
sharing meals with family and friends (Monteiro et al., 2011). In addi­
tion, UPF exhibit specific characteristics that favour excessive calorie
intake, such as practicality, omnipresence, and hyper-palatability,
which facilitates the nibbling habit as well as the aggressive marketing
specifically targeting children (Monteiro et al., 2013, Monteiro et al.,
2016; Vandevijvere et al., 2017). Higher UPF consumption is associated
with lower diet quality (Louzada et al., 2018; Moubarac et al., 2017;
Rauber et al., 2018) and negative health outcomes in all life stages. For
children, lipid profile changes (Rauber et al., 2015) and increased
abdominal circumference have been reported (Costa, Rauber, et al.,
2019). Moreover the occurrence of Metabolic Syndrome (Tavares et al.,
2012) and asthma have been reported in adolescents (Melo et al., 2018).
Finally, there are reports of increased risk of obesity (Mendonça et al.,
2016) and other chronic diseases in adults (Fiolet et al., 2018; Mendonça
et al., 2017; Srour et al., 2020).
There is a lack of studies evaluating the association between eating
context patterns and ultra-processed food consumption in children.
Thus, to better understand the food environment in its physical and
social context, this study aimed to investigate the eating context patterns
and assess its association with ultra-processed food consumption by
British children.
2. Methods
2.1. Sampling and data collection
We used data from the National Diet and Nutrition Survey Rolling
Program (NDNS), years 1–6 (2008/09–2009/10, 2010/11–2011/12,
2012/13–2013/14) (Public Health England, 2014, Public Health En­
gland, 2016), a national survey held in the United Kingdom (England,
Wales, Scotland and Northern Ireland). Documentation files and general
data for this study were obtained respecting the UK Data Archive license,
available at http://www.esds.ac.uk. All participants provided written
informed consent. For children aged under 16 years old, consent was
sought from their parents for the interview along with assent from the
child. For children who were unable to sign their assent, provided they
did not appear to verbally disagree with the procedure, written consent
was sought from the parent only. Ethical approval for the NDNS was
obtained from the Oxfordshire A Research Ethics Committee (years 1–5)
and the Cambridge South NRES Committee (year 6) (Public Health
England, 2016).
In short, the survey sample was randomly selected from the UK
postcode address file, which contains a list of all British addresses from
the four countries. A child (between 1.5 and 18 years old), or a child and
an adult (aged 19 years old or more), were selected from each of the
addresses drawn. Either participants or their parents/caregivers (in case
of children under 11 years old), completed a detailed computer-assisted
interview. For this study, data from children aged 4–10 years old were
used, resulting in a total sample of 1772 children.
Food consumption was recorded using a four-day food diary
completed by parents/caregivers, which included weekdays and week­
ends. Parents/caregivers were instructed to register all food and drink
consumed by the child on that day, inside and outside their home.
Trained interviewers followed a protocol to explain the method, eluci­
dating the different sections of the document for the participants,
including the instruction page, how to describe details of foods, drinks,
and portion sizes, and a one-day food diary example. Portion sizes were
estimated using household measurements or weights from labels. For
homemade dishes, participants recorded recipes on a separate page.
Information related to eating context was also recorded for each con­
sumption occasion, such as meal location, who was present, if the tele­
vision was on, and if the child ate at the table. All the collected diaries
were checked for descriptions of items consumed by trained
interviewers.
Data on food consumption was coded from the complete records and
edited using the DINO Program (Diet In, Nutrients Out) (Fitt et al.,
2
Appetite 157 (2021) 105007
2015), and energy intake was estimated based on the NDNS food
nutrition database (Nutrient Databank) (Widdowson & McCance, 2015).
2.2. Dietary context
Parents/caregivers were asked to record where the child was, who
they were with, whether the TV was on, and whether the child was
eating at the table, for each food consumption occasion. The information
was reported in a four-day diary and was used to assess the eating
context at lunch (four occasions) and at dinner (four occasions). To
define meals, we applied an approach based on the time of the day in
which foods were consumed – corresponding to lunch (11 a.m. - 3 p.m.)
and dinner (6 p.m.–9 p.m.) (Huseinovic et al., 2019). If the child ate
more than one meal at those time frames, the one with the highest
caloric intake was selected as the main meal (lunch or dinner) (Leech
et al., 2015). At each meal, the eating context components were orga­
nized into: 1) Where the child ate: at school, at home, in the bedroom
(house), at a friends’ house, at another place to eat or another place; 2)
Who the child ate with: alone, with family, or with friends; and 3) How
the child ate: watching TV, or sitting at the table.
For each component and at each meal, we considered “no” when the
behaviour was not reported in the food diaries and “yes” when the
behaviour was reported on at least one of the four days. Table S1
(Supplementary Table 1) presents all eating context components
included in the analyses, displaying 11 components for lunch and 10
components for dinner.
2.3. Food classification according to processing
All items present in the food diaries were classified according to the
NOVA classification, a food classification system based on the nature,
extent, and purposes of the industrial processing undertaken by the food
(Monteiro et al., 2019). This classification includes four groups: 1) un­
processed or minimally processed foods (MPF), such as beans, rice, fresh
or frozen meat, and milk; 2) processed culinary ingredients (PI),
including vegetable oils, butter, and table sugar; 3) processed foods (PF),
such as vegetables in brine, cheeses, and bread made from flour, water,
and salt; and 4) ultra-processed foods. The latter encompasses foods with
industrial formulations made entirely/mostly of substances extracted
from food (such as fats, sugar and starch), derived from food constitu­
ents (such as hydrogenated fats and modified starch), or synthesized in
the laboratory based on organic materials such as oil and coal (e.g.
chemical additives). Examples of UPF are cookies, ice cream, candies,
sugary breakfast cereals, instant noodles and spices, snacks, soft drinks,
sugar-sweetened drinks, sweetened yogurts and dairy drinks, con­
sumption ready or semi-ready meals, sausage, and other sausages,
among others (Monteiro et al., 2018). A more detailed NOVA classifi­
cation description can be found in a previous publication (Monteiro
et al., 2019).
All foods presented in the NDNS database are coded as a food number
and grouped into subsidiary food groups (n = 155). When possible,
subsidiary food groups were classified directly according to NOVA. For
the subsidiary food groups, including food items belonging to different
NOVA groups (n = 52), the food codes were individually classified
instead of categorizing the entire group. Thus, a classification of each
underlying ingredient of homemade preparations was feasible within its
corresponding NOVA group. The NDNS database presented most food
items systematically broken down into their individual components (Fitt
et al., 2010). Notwithstanding, certain preparations have not been
broken down into constituent ingredients (less than 4%). In this case,
homemade preparations were categorized according to the main con­
stituent ingredient. It is noteworthy that details on food items classifi­
cation are well documented in previously published articles (Rauber
et al., 2018).
B.M. Onita et al. Appetite 157 (2021) 105007

2.4. Data analysis energy intake.

Table 2 displays the factor loads for each of the eating context pat­
Exploratory factor analysis (EFA) by principal components was terns identified in the two main meals. At lunch, three context patterns
performed to identify the eating context patterns, through the correla­ were retained: 1) “Eating with family while watching TV” – positive for
tion matrix applied to the 11 components of lunch, and the 10 compo­ eating the meal watching TV, sitting at the table, with the family, and at
nents of dinner. All components were expressed as binary variables (‘no’ home and negative for eating the meal at school (eigenvalue = 2.47). 2)
and ‘yes’) and examined separately for lunch and dinner. Due to the “Eating at school with friends” – positive for having a meal at the table,
limited number of variables describing the eating contexts, we have with friends, and at school (eigenvalue = 1.35). 3) “Eating away from
combined the eigenvalue criteria (eigenvalues above 1), scree test and home” – positive for eating at a friend’s house, or at the food outlets, and
the interpretability of the retained factors, prevailing the interpretability negative for eating alone and in the bedroom (at home) (eigenvalue =
over the other criteria. The minimum component loading to be included 1.23). At dinner, two patterns were retained: 1) “Eating with family
in a factor was 0.30 and orthogonal rotation was applied to simplify the while watching TV” – positive for eating the meal watching TV, sitting at
data structure (Hair Jr. et al., 2005). The sample adequacy was assessed the table, with the family, and at home (eigenvalue = 1.73). 2) “Eat
by the Kaiser - Meyer - Olkin (KMO) criteria. These criteria can assume alone in the bedroom” – positive for eating alone and in the bedroom (at
values between 0 and 1 and values below 0.5 are considered unac­ home) (eigenvalue = 1.43).
ceptable. In the present study, a KMO >0.5 was obtained (0.5745 at Crude and adjusted association analyses between the eating context
lunch and 0.5338 at dinner). Scores for each pattern were predicted by patterns and UPF consumption are presented in Table 3. At lunch, the
regression analysis and attributed to each individual in the sample. highest UPF consumption was associated with the patterns “Eating with
These values represent the child’s adherence to each eating context family while watching TV” (from 64.9% in the lowest tertile to 68.1% in
pattern and have been transformed into tertiles for analyses, wherein the the highest tertile) and “Eating away from home” (from 65.2% to 67.7%,
first tertile was represented by the children presenting the least adher­ respectively). On the other hand, the pattern “Eating at school with
ence to the pattern. friends” was associated with the lowest UPF consumption (from 66.6%
The mean of all available days of the food diary was used for each to 64.7%, respectively). At dinner, the highest UPF consumption was
child to estimate the dietary contribution of ultra-processed foods (as a
percentage of the total energy intake). The association between UPF
consumption and dietary context patterns (tertiles) was assessed by Table 2
linear regression analysis. A crude model was firstly fitted and, there­ Eating context patterns according to main meals of British children, identified
after, a multivariable model adjusted for sex (female or male), age through Analysis by Principal Components, NDNS (2008–2014).
(years), income (equivalent family income), ethnicity (white and non- Eating context patterns
white) and region (North of England, Central England, South of En­ Lunch Eating with family Eating at school Eating away
gland, Scotland, Wales, and Northern Ireland). watching TV with friends from home
Statistical analyses were performed on the STATA software, version How
14, considering the research sample design, its weighting factors, and Watching TV 0.5458 − 0.2517 − 0.2911
the significance level (p < 0.05). Sitting at the 0.3151 0.5398 0.2052
table
With whom
3. Results Alone 0.1810 − 0.1643 ¡0.6062
With family 0.8064 − 0.1546 0.2347
Table 1 presents the population characteristics. More than half were With friends − 0.1466 0.7898 0.0691
boys, aged 4–7 years old, white, and residing in the south of England. Where
At school ¡0.3077 0.7788 − 0.0996
Ultra-processed food consumption represented 65.4% of the total daily At home 0.8413 − 0.0995 − 0.1736
In the bedroom − 0.0165 − 0.1526 ¡0.4745
Table 1 (home)
Characteristics of British children aged 4–10 years old, UK NDNS (2008–2014). At friends’ 0.0603 − 0.2196 0.3949
house
Sex, % Food outlets a 0.1085 − 0.1793 0.5597
Other place b 0.0829 − 0.1904 0.2082
Female 48.8
Male 51.2 Dinner c Eating with family Eating alone in
Age, % watching TV the bedroom
4–7 years 58.8
8–10 years 41.3 How
Ethnicity, % Watching TV 0.3090 0.2745
White 82.1 Sitting at the 0.5596 − 0.2206
Non white 18.0 table
Region, % With whom
Northern England 24.2 Alone 0.0452 0.8013
Midlands 14.6 With family 0.7914 0.0017
Southern England (London) 45.6 With friends 0.0492 − 0.1927
Scotland 7.7 Where
Wales 4.7 At home 0.8062 − 0.0088
Northern Ireland 3.2 In the bedroom − 0.1179 0.7770
Household income (quintile)*, mean (home)
1◦ quintile £7876.8 At friends’ 0.0434 − 0.2048
2◦ quintile £14,815.8 house
3◦ quintile £21,827.2 Food outlets a 0.0491 − 0.2111
4◦ quintile £33,465.4 Other places b − 0.0536 − 0.0028
5◦ quintile £59,452.0 a
Food outlets include coffee shops, deli, restaurants and fast-food.
Ultra-processed food consumption, mean b
Other places include “on the go” (bus, car, train) and leisure places (sports
% of total energy intake 65.4
clubs, sports leisure venues, leisure activity places, cinema, shopping centre).
c
* Equalised for different household sizes and composition using the McClements The variable “at school” was not included at nights meals due to the fact that
equivalence scale. children do not have night classes.

3
B.M. Onita et al. Appetite 157 (2021) 105007

Table 3
Association between ultra-processed food consumption and patterns of eating context among British children, NDNS (2008–2014).
Eating context patterns Ultra-processed food consumption (% of total energy intake)

Mean (SE) Coefficient Crude (CI 95%) Coefficient Adjusted a (CI 95%)

Lunch Tertile 1 Tertile 2 Tertile 3 Tertile 1 Tertile 2 Tertile 3 Tertile 1 Tertile 2 Tertile 3

Eating with family watching 64.9 63.7 68.1* REF − 1.8 (− 3.5; 2.9 (1.1; 4.7) REF − 1.2 (− 2.8; 0.5) 3.2 (1.4; 5.0)
TV (0.6) (0.6) (0.7) − 0.1)
Eating at school with friends 66.6 65.3 64.7* REF 0.0 (− 1.9; 1.9) − 0.5 (− 2.4; REF − 1.4 (− 3.2; 0.5) − 1.9 (− 3.7;
(0.7) (0.6) (0.6) 1.4) − 0.1)
Eating away from home 65.2 62.9 67.7* REF − 3.0 (− 4.9; 2.0 (0.3; 3.6) REF − 2.3 (− 4.1; 2.5 (0.9; 4.1)
(0.6) (0.8) (0.6) − 1.1) − 0.5)

Dinner

Eating with family watching 64.6 65.9 67.1* REF 0.3 (− 1.3; 2.0) 3.3 (1.3; 5.2) REF 1.4 (− 0.2; 3.0) 2.5 (0.5; 4.6)
TV (0.6) (0.6) (0.9)
Eating alone in the bedroom 63.9 66.3 66.5 (0.8) REF 2.4 (0.7; 4.1) 3.7 (1.8, 5.6) REF 2.4 (0.7; 4.0) 2.6 (0.6; 4.5)
(0.6) (0.6)

*p < 0.05 for linear trend of the terciles adjusted for the variables sex, age, equivalised household income, ethnicity, and region.
SE = Standard error.
a
Adjusted for the variables sex, age, equivalised household income, ethnicity, and region.

associated with the patterns “Eating with family while watching TV”
(from 64.6% to 67.1%, respectively) and “Eating alone in the bedroom”
(from 63.9% to 66.5%, respectively).
The dietary contribution of UPF types according to the eating context
patterns are presented in Tables 4 and 5. At lunch, the pattern “Eating
with family while watching TV” was associated with higher consump­
tion of sweets/candies/ice cream and soft drinks/sweetened drinks/fruit
juices, and lower breakfast cereals’ consumption. The pattern “Eating at
school with friends” was associated with lower consumption of chips,
sweets/candies/ice cream, and soft drinks/sweetened drinks/fruit jui­
ces. The pattern “Eating away from home” was associated with greater
consumption of chips, sweets/candies/ice cream, soft drinks/sweetened
drinks/fruit juices, and other ultra-processed foods, as well as with
lower ultra-processed bread consumption.
At dinner, the pattern “Eating with family while watching TV” was
associated with higher soft drinks/sweetened drinks/fruit juices con­
sumption. Furthermore, the pattern “Eating alone in the bedroom” was
associated with a greater intake of dairy drinks.
4. Discussion
This study evaluated the association between eating context patterns
and ultra-processed food consumption in a representative sample of the
British children. The findings show that the patterns “Eating with family
while watching TV”, “Eating away from home ", and “Eating alone in the
bedroom” were associated with higher UPF consumption, whilst the
pattern “Eating at school with friends” was associated with lower con­
sumption of these products. We highlighted that, apart from the pattern
“Eating at School with friends”, the other eating context patterns shared
a mix of characteristics, some associated with healthy eating habits, such
as eating with the family (Dallacker et al., 2018), and others with un­
healthy eating habits, such as eating while watching TV (Avery et al.,
2017).
Moreover, our results highlight that UPF significantly contributed to
the British children’s diet. The mean UPF dietary share observed in our
study is similar to values observed among American children aged 6–11
years old, around 66% of the total energy intake (Neri et al., 2019). The
mean was also higher than the reported among Colombian children aged
2–9 years old (19%) (Khandpur et al., 2020), Belgian children aged 3–9
years old (33%) (Vandevijvere et al., 2019), and Brazilian children aged

Table 4
Types of ultra-processed food consumption according to patterns of eating context at lunch among British children, NDNS (2008–2014).
Eating context patterns at lunch

Ultra-processed subgroups (% of total energy Eating with family watching TV Eating at school with friends Eating away from home
intake)
Tertile 1 Tertile 2 Tertile 3 Tertile 1 Tertile 2 Tertile 3 Tertile 1 Tertile 2 Tertile 3

Meana Meana Meana Meana Meana Meana Meana Meana Meana

(SE) (SE) (SE) (SE) (SE) (SE) (SE) (SE) (SE)

Ultra-processed bread 10.9 (0.3) 11.0 (0.3) 11.6 (0.3) 11.2 (0.3) 11.0 (0.3) 11.3 (0.4) 11.6 (0.3) 11.4 (0.4) 10.4*
(0.3)
Breakfast cereals 6.0 (0.2) 6.1 (0.2) 5.3* (0.2) 5.5 (0.3) 6.3 (0.2) 5.6 (0.2) 5.8 (0.2) 6.6 (0.3) 5.3 (0.2)
Pizza (ready/frozen) 2.4 (0.2) 2.3 (0.2) 2.8 (0.3) 2.4 (0.3) 2.8 (0.3) 2.4 (0.2) 2.6 (0.2) 1.9 (0.3) 2.9 (0.3)
French fries 3.4 (0.2) 2.6 (0.2) 3.2 (0.2) 3.3 (0.2) 3.2 (0.2) 2.7* (0.2) 2.9 (0.2) 2.4 (0.2) 3.7* (0.2)
Packaged salty snacks and biscuits 8.6 (0.3) 7.7 (0.3) 7.9 (0.3) 7.4 (0.3) 8.7 (0.3) 8.0 (0.3) 8.3 (0.3) 7.3 (0.4) 8.2 (0.3)
Packaged ready meals 6.3 (0.3) 6.6 (0.3) 7.1 (0.3) 7.3 (0.4) 5.8 (0.3) 7.0 (0.3) 6.7 (0.3) 7.0 (0.4) 6.4 (0.3)
Margarine, spreads and sauces 3.4 (0.2) 3.5 (0.2) 3.8 (0.2) 3.4 (0.2) 3.8 (0.2) 3.5 (0.2) 3.6 (0.1) 3.7 (0.2) 3.5 (0.2)
Confectionary 5.3 (0.3) 6.3 (0.3) 6.5* (0.3) 6.6 (0.3) 5.9 (0.2) 5.6* (0.3) 5.5 (0.2) 5.6 (0.3) 7.1* (0.3)
Pastries, buns and cakes 5.6 (0.3) 5.5 (0.3) 5.6 (0.4) 5.2 (0.4) 5.3 (0.2) 6.2 (0.3) 5.4 (0.3) 5.5 (0.4) 5.8 (0.3)
Soft drinks and fruit juices 2.5 (0.2) 2.3 (0.2) 3.2* (0.2) 3.3 (0.2) 2.4 (0.1) 2.3* (0.2) 2.5 (0.2) 2.2 (0.2) 3.2* (0.2)
Milk-based drinks 4.2 (0.2) 3.4 (0.2) 4.0 (0.3) 4.1 (0.3) 3.6 (0.2) 3.9 (0.2) 4.1 (0.2) 3.3 (0.3) 3.8 (0.2)
Other ultra-processed foods b 2.2 (0.2) 2.1 (0.2) 2.5 (0.2) 2.4 (0.2) 2.2 (0.1) 2.1 (0.2) 2.1 (0.1) 1.9 (0.2) 2.7* (0.2)

SE = Standard Error.
*p < 0,05 for linear trend.
a
Adjusted for the variables sex, age, equivalised household income, ethnicity, and region.
b
Include alternative meats (e.g. quorn and soy protein), soy-based drinks or others milk substitutes, artificial sweeteners.

4
B.M. Onita et al. Appetite 157 (2021) 105007

Table 5 as vegetables (parents serve as examples), and transmission of

Types of ultra-processed foods consumption according to patterns of eating food-associated values (Santiago-Torres et al., 2014; Scaglioni et al.,
context at dinner among British children, NDNS (2008–2014). 2018). Another possible explanation for this pattern is intrinsically
Eating context patterns at dinner related to UPF characteristics, which is its convenience and portability,
Ultra-processed Eating with family watching Eating alone in the bedroom
facilitating these foods consumption anywhere and without the use of
subgroups (% of TV cutlery, or other utensils necessary to enable culinary preparations
total energy (FAO, 2019; Monteiro et al., 2013; Monteiro et al., 2018).
Tertile Tertile Tertile Tertile Tertile Tertile
intake)
1 2 3 1 2 3 Eating away from home was also associated with higher UPF con­
sumption, a result corroborated by previous studies (Andrade et al.,
Meana Meana Meana Meana Meana Meana
(SE) (SE) (SE) (SE) (SE) (SE)
2020; Bes-Rastrollo et al., 2010; Nago et al., 2010). A possible expla­
nation could be that the ultra-processed foods, such as French fries,
Ultra-processed 11.6 10.6 11.4 11.6 10.7 11.2
hamburgers, nuggets, frozen pizzas, soft drinks, and artificial juices are
bread (0.3) (0.3) (0.4) (0.3) (0.3) (0.3)
Breakfast 5.9 5.9 5.4 5.9 5.6 5.9 widely marketed, not only in fast-food chains (Ziauddeen et al., 2015),
cereals (0.2) (0.2) (0.3) (0.2) (0.2) (0.2) but also in bars, cafeterias, restaurants, convenience stores and bakeries
Pizza (ready/ 2.3 2.6 2.9 2.1 2.7 2.8 (Leite et al., 2018; Machado et al., 2018). In these places, there is a wide
frozen) (0.2) (0.3) (0.4) (0.2) (0.3) (0.3)
UPF availability, as well as an appealing marketing of these products
French fries 3.0 3.1 3.3 3.0 3.2 3.0
(0.2) (0.2) (0.3) (0.2) (0.2) (0.2)
(Monteiro et al., 2013, Monteiro et al., 2018), strongly influencing food
Packaged salty 8.2 8.0 7.6 7.6 8.4 8.2 choices (Moore et al., 2009).
snacks and (0.3) (0.3) (0.4) (0.3) (0.3) (0.3) Eating at school with friends was the only pattern associated with
biscuits lower UPF consumption, probably due to the provision of meals by the
Packaged ready 6.7 6.6 6.8 6.2 6.8 7.1
school. The introduction of school food standards in the UK has resulted
meals (0.3) (0.3) (0.4) (0.3) (0.3) (0.4)
Margarine, 3.6 3.4 3.9 3.6 3.5 3.7 in ‘healthy’ food options being provided, leading to improved food and
spreads and (0.1) (0.2) (0.2) (0.1) (0.2) (0.2) nutrients’ intake among schoolchildren having school lunches, as well as
sauces an apparent impact on total diet (Adamson et al., 2013). These standards
Confectionary 5.5 6.6 6.3* 6.0 6.2 5.8 include the routine presence of fresh and minimally processed foods,
(0.2) (0.3) (0.4) (0.3) (0.3) (0.3)
Pastries, buns 5.1 6.1 5.5 5.8 5.6 5.2
such as fruits, vegetables, legumes, and meats in the food offered to
and cakes (0.2) (0.4) (0.4) (0.3) (0.3) (0.4) students; and banned some ultra-processed foods, such as sweets and
Soft drinks and 2.5 2.6 3.1 2.4 2.8 2.8 treats (EDUCATION, ENGLAND, 2007). Moreover, the school food
fruit juices (0.2) (0.2) (0.2) (0.2) (0.2) (0.2) environment protects young children through the uptake of govern­
Milk-based 3.8 3.8 3.9 3.4 3.9 4.3*
mental policies, such as free school meals for low-income children and
drinks (0.3) (0.2) (0.3) (0.2) (0.2) (0.3)
Other ultra- 2.1 2.3 2.5 2.2 2.3 2.3 free fruit and vegetable snacks for all children aged 4–6 years old
processed (0.1) (0.2) (0.2) (0.1) (0.2) (0.2) (Ziauddeen et al., 2018). Studies have shown that there is an improve­
foods b ment in British children diet quality who usually consumes ready-to-eat
SE = Standard Error. or ready-to-heat meals (Adamson et al., 2013; Evans et al., 2016; Lucas
*p < 0,05 for linear trend. et al., 2017). This evidence corroborates our findings that children who
a
Adjusted for the variables sex, age, equivalised household income, ethnicity, eat at school consumed less sweets, treats, chips, soft drinks, and arti­
and region. ficial juices.
b
Include alternative meats (e.g. quorn and soy protein), soy-based drinks or Given the endemic presence of ultra-processed foods in the UK,
others milk substitutes, artificial sweeteners. mainly among children since UPF represents 65% of the total caloric
intake, our findings may be used to enhance the understanding on the
2–10 years old (variation between 41% and 48%) (Costa, Rauber, et al., eating contexts that are associated with UPF consumption. For instance,
2019; Leffa et al., 2020). parents and practitioners may be encouraged to avoid promoting
The positive association found in our study between watching tele­ negative social/eating environments for children, such as eating whilst
vision during meals and UPF consumption is corroborated by previous watching TV or eating alone in the bedroom. Researchers should also
studies. These studies suggest that eating whilst watching TV can be consider eating contexts when designing future programmes and in­
related to children’s poor-quality diet, assessed through elevated intake terventions that target dietary behaviours and food consumption.
of both sugary drinks and sweetened foods (Avery et al., 2017; Hare-­ Although the differences in UPF consumption may appear small, they
Bruun et al., 2011; Ogden et al., 2013). A recent study carried out with are meaningful because reflect daily basis behaviours. We emphasize
British children demonstrated that having main meals (lunch and din­ that eating habits once formed in childhood are generally tracked
ner) whilst watching TV was associated with higher UPF consumption through adulthood (Movassagh et al., 2017). This is even more relevant
(Martines et al., 2019). In this context, the apparent benefits of having a if we consider that increases in UPF dietary share is linked to deterio­
meal with the family (Dallacker et al., 2018; Martins et al., 2019; Sca­ ration of the overall diet nutritional quality (Neri et al., 2019; Rauber
gliusi et al., 2016) were outweighed by the negative effects of having the et al., 2018) and negative health outcomes (Costa, Rauber, et al., 2019;
television on during meals, as observed in a study performed by Fitz­ Leffa et al., 2020; Melo et al., 2018; Rauber et al., 2015). Thus, under­
Patrick et al. (2007) and by Avery et al. (2017). Furthermore, we standing the eating occasion-specific opportunities early could help to
observed the association between this eating pattern and greater con­ identify potential aspects to reduce the UPF consumption among UK
sumption of specific UPF types, such as breakfast cereals, sweets and children.
candies, soft drinks, and artificial fruit juices. This suggests a replace­
ment of meals and dishes based on fresh and minimally processed foods 4.1. Study limitations and strengths
by snacks, which can be eaten anywhere, e.g. on the sofa and/or
watching TV. Potential limitations and strengths of the study should be considered.
The higher UPF consumption among children eating alone in the This is the first population-based study to analyse the relationship be­
bedroom can be justified by family members’ absence at the mealtime, tween eating context patterns and UPF consumption in British children.
considering their role in the child’s eating habits development (Dal­ The use of the NOVA classification is one of its strengths when classi­
lacker et al., 2018; Martins et al., 2019). Having meals with the family is fying foods according to industrial processing degree, using standard­
associated to meals’ better structuring, healthy food introduction, such ized and objective criteria, besides being recognized as a valid tool for

5
B.M. Onita et al.
public health and both nutrition research and policy (FAO, 2015;
Moubarac, 2015). In addition, we used data from the NDNS – a
well-characterized and nationally representative survey of the UK pop­
ulation. NDNS dietary data were obtained through a four-day food diary
using standardized methods and checked by trained interviewers (Public
Health England, 2014), which enhances the information reliability and
enables intrapersonal variability apprehension. Among the limitations,
it is noteworthy that the food data used were self-reported and might be
subject to errors. A constant limitation of dietary assessment methods is
the underreporting of certain foods, mainly unhealthy foods, although
food recalls are recognized as one of the most comprehensive methods
for assessing food consumption. In addition, information regarding the
meal type was not available and, therefore, some degree of misclassifi­
cation is expected. However, we have used objective methods to classify
the meals of interest (lunch and dinner), which reduces the likelihood of
measurement error. Finally, this study could not determine the effects
direction between the eating context and UPF consumption, and if the
effects were causal, because of the NDNS survey cross-sectional design.
For instance, it is possible that UPF consumption is driven by the eating
contexts, such as the location of the meal, but there may also be cir­
cumstances where eating contexts are driven by food choices or con­
sumption. Hence, further research should be carried out with a
longitudinal design to enable clearer conclusions on causality.
5. Conclusion
In conclusion, this study highlights that ultra-processed foods
contribute, on average, with two-thirds of the total calories consumed by
British children. For the main meals, eating context patterns that include
eating alone, eating watching television and eating away from home
were associated with increased UPF consumption. Thus, interventions
focused on promoting healthy eating habits should consider aspects
related to the eating context. Furthermore, food environment impor­
tance must be recognized as a tool to mitigate UPF consumption. This
can also serve as baseline for future public health policies that require
integrated policy action across different intervention levels (individual,
community, and society), as well as throughout the entire life course
(starting with the childhood).
Availability of data and material
This study is based on open data of the UK population that is avail­
able in the UK Data Archive website (http://www.esds.ac.uk). Details of
how food item classification was accomplished are further explained in
previously published papers (Rauber et al., Nutrients. 2018 - see Sup­
plementary Table S1 http://www.mdpi.com/2072-6643/10
/5/587/s1).
Financial support
This work was supported by the Brazilian National Council for Sci­
entific and Technological Development (CNPq), grant number PIBIC
119751-4 (BMO is a beneficiary of a scholarship) and the Fundação de
Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant numbers
2016/14302-7 (FR is a beneficiary of a postdoctoral fellowship). CNPq
and FAPESP had no role in the design, analysis or writing of this
manuscript.
Author contributions
BMO took care of data management and analyses, interpreted the
data and wrote the first draft of the manuscript; FR: designed the
research, took care of data analyses and interpreted the data; All authors
read, edited and approved the final manuscript.
6
Appetite 157 (2021) 105007
Ethical statement
Documentation files and general data for this study were obtained
respecting the UK Data Archive license, available at http://www.esds.
ac.uk. This research was approved by the ethics committees of each of
the four countries
Declaration of competing interest
The authors declare that they have no conflict of interest.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.appet.2020.105007.
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