ORIGINAL RESEARCH

published: 03 February 2022

doi: 10.3389/fnut.2022.797415

Association Between Eating Habits

and Perceived School Performance:
A Cross-Sectional Study Among
46,455 Adolescents From 42
Countries
José Francisco López-Gil 1 , Arthur Eumann Mesas 1,2*, Celia Álvarez-Bueno 1 ,
Carlos Pascual-Morena 1 , Alicia Saz-Lara 1 and Iván Cavero-Redondo 1,3
1
Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain, 2 Postgraduate Program in Public
Health, Universidade Estadual de Londrina, Londrina, Brazil, 3 Rehabilitation in Health Research Center (CIRES), Universidad
de las Américas, Santiago, Chile

Purpose: This study analyzed the association between selected self-reported eating
habits and perceived school performance in adolescents by gender.

Edited by:
Methods: A cross-sectional analysis was conducted with data from a large
Diego Christofaro, representative sample of adolescents from 42 different countries. Participants answered
São Paulo State University, Brazil
questions about their weekly frequency of fruit, vegetable, sweets, and soft drink
Reviewed by:
consumption, as well as the frequency of breakfast consumption and family meals.
Elizabeth Yakes Jimenez,
University of New Mexico, The adolescents subjectively rated their school performance compared to that of their
United States classmates. Logistic regression models were adjusted for region, age, body mass
Maryam Amini,
National Nutrition and Food
index (z-score), socioeconomic status, physical activity, recreational screen time, and
Technology Research Institute, Iran sleep difficulties.
*Correspondence:
Results: Among the 46,455 (53.5% female, mean age of 13.7 ± 1.6 years) adolescents
Arthur Eumann Mesas
Arthur.EMesas@uclm.es studied, 20.6% of males and 25.5% of females reported high perceived school
performance. In the results of the fully adjusted analyses, the higher the frequency of all
Specialty section: healthy eating habits studied, the higher the perceived school performance in both males
This article was submitted to
Eating Behavior, and females. Specifically, both males and females reporting a higher frequency of fruit
a section of the journal and vegetable consumption, a lower frequency of sweets and soft drink consumption,
Frontiers in Nutrition
more frequent breakfast consumption, and more frequent family meals (breakfast and
Received: 18 October 2021
dinner) were more likely to perceive their school performance as higher compared to their
Accepted: 03 January 2022
Published: 03 February 2022 classmates. In addition, having breakfast regularly on weekends and the frequency of
Citation: family dinner were associated with better school performance in both males and females.
López-Gil JF, Mesas AE,
Álvarez-Bueno C, Pascual-Morena C,
Conclusions: In summary, this study provide cross-sectional evidence on the
Saz-Lara A and Cavero-Redondo I association between healthy eating habits and perceived school performance.
(2022) Association Between Eating
Considering that school performance is an indicator of healthy development in
Habits and Perceived School
Performance: A Cross-Sectional adolescence, our findings reinforce and extend the evidence on the importance of healthy
Study Among 46,455 Adolescents eating at this stage of life.
From 42 Countries.
Front. Nutr. 9:797415. Keywords: nutrition, healthy eating, diet quality, adolescence, youths, academic achievement, epidemiology,
doi: 10.3389/fnut.2022.797415 international study

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López-Gil et al. Eating Habits and School Performance

INTRODUCTION Greenland, Greece, Croatia, Hungary, Ireland, Israel, Iceland,

Italy, Lithuania, Luxembourg, Latvia, Republic of Moldova,
Adolescence is characterized by rapid physical, cognitive, and North Macedonia, Malta, Netherlands, Norway, Poland,
psychosocial growth, which affects how they deal with their own Portugal, Romania, Russian Federation, Scotland, Sweden,
feelings, thoughts, decision-making processes, and interactions Slovenia, Slovakia, Ukraine, Wales) from the 2013/2014 wave
with the world around them (1). The biological and psychosocial of the ongoing international Health Behavior in School-Aged
changes that occur at this stage of life produce one of the greatest Children (HBSC) study, which includes nationally representative
needs for nutrients throughout the life cycle (2). However, samples of adolescents aged 10–17 years (14). Adolescents
because of the transition to greater independence from their were randomly selected from their schools and anonymously
parents regarding food choices, adolescents are more vulnerable completed a standardized questionnaire, which had been
in terms of nutrition than younger children (3). Similarly, during translated into their local language. Students were free to leave
adolescence, peer, and media influences exert a considerably any question unanswered. Institutional ethical authorization was
greater impact on food choices, frequently in favor of foods with received from each participating country. Moreover, both the
less healthy nutritional content (2). schools and the adolescents and their parents or legal guardians
Furthermore, adolescence is a crucial phase for brain received and signed written informed consent forms.
maturation, as myelination, synaptic pruning and several neural The present analysis includes data from all the countries
connections develop, particularly in the prefrontal cortex (4, that provided information on diet habits, school performance,
5). This brain maturation is accompanied by the emergence and the covariates considered. The total number of participants
of increasingly sophisticated cognitive abilities, which, in turn, was 214,175, of whom 167,720 (78.3%) were excluded because
are bidirectionally associated with school performance (6). In of missing data on some of the study variables, resulting in
addition, nutrition is one of the most modifiable aspects of a final sample of 46,455 (53.5% females) adolescents from 42
lifestyle that can influence brain maturation and, consequently, different countries.
cognition and school performance (7). In this regard, a previous
longitudinal study conducted over a 3-year period showed that Procedures
lifestyle habits (e.g., eating breakfast) were related to cognitive Perceived School Performance
control and school performance in adolescents (8). Likewise, Perceived school performance was evaluated using the following
a systematic review showed moderate relationships of school question: “In your opinion, what does your class teacher(s)
performance with better overall diet quality, as well as with think about your classroom performance compared to your
healthier eating habits, such as regular breakfast consumption classmates?” For this question, the response options were very
and lower consumption of energy-dense foods and foods with good, good, average, and below average. Subsequently, the
poor nutritional value (9). different options were collapsed into high perceived school
Given the above, a deeper understanding of whether eating performance (very good) and not high perceived school
habits are related to school performance could be crucial for performance (good, average, and below average).
parents/legal guardians, public health researchers, and policy-
makers (10). However, research on the association between Eating Habits
dietary patterns and school performance is still developing and Four different eating habits were measured using variations of
has certain limitations (9). For instance, some studies analyzed the following basic question: “How many times a week do you
the relationship between school performance and eating habits consume fruits?” (Response options were never, less than once a
among adolescents, but only in a single country [e.g., Canada week, 2–4 times a week, 5–6 times a week, once daily, more than
(11) or Australia (12)]. Furthermore, although most studies once daily). This question format and the same response options
examining the association between school performance and were then used to assess the consumption of vegetables, sweets,
eating habits have focused on breakfast consumption (9, 13), and soft drinks. Additionally, breakfast habits were evaluated by
studies assessing the relationship with other eating habits (e.g., the following question: “How often do you usually have breakfast
family meals) are scarce (11). Thus, the present study examined (more than a glass of milk or fruit juice)?” (Response options
the association between multiple eating habits (including fruit, for weekdays were 1—never to 5—every weekday; and response
vegetable, sweets, and soft drink consumption, as well as options for weekends were 1—never to 3—both days). Family
having breakfast and family meals) and school performance meals habits were assessed by the following questions: “How
among a large, representative sample of adolescents from 42 often do you eat breakfast together with your mother or father?”
different countries. and “How often do you eat dinner together with your family?”
Possible responses ranged from never to 7 days for each of
METHODS the questions.

Study Design and Population Sample Covariates

This is a cross-sectional study using data from 42 countries Region, gender, age, weight, and height were self-reported by the
(Albania, Armenia, Austria, Belgium (Flemish), Belgium adolescents. Height and weight values were used to determine
(French), Bulgaria, Canada, Switzerland, Czech Republic, the body mass index (kg/m2 ). The body mass index z-score
Germany, Denmark, Estonia, England, Spain, Finland, France, was determined following the specific International Obesity Task

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López-Gil et al. Eating Habits and School Performance

Force (IOTF) criteria (15) and, therefore, the prevalence of vegetables, sweets, and soft drinks. In both males and females,
excess weight (≥1 SD) was determined. The Family Affluence the highest likelihood of reporting high perceived school
Scale (FAS) (16) was used to assess socioeconomic status. The performance was observed among those who consumed fruits
FAS includes questions on material goods (e.g., computers) and (males: OR = 1.44; 95% CI: 1.17–1.78; females: OR = 2.87;
vacations to estimate socioeconomic status. Physical activity was 95% CI: 2.16–3.81) and vegetables (males: OR = 1.60; 95% CI:
measured with the following question: “Over a typical or usual 1.33–1.93; females: OR = 2.07; 95% CI: 1.70–2.53) more than
week, on how many days are you physically active for a total once a day. Conversely, in general, the likelihood of reporting
of at least 60 min per day?” (Responses varied from 0 to 7 days high performance was lower in both males and females as the
per week) (17). Recreational screen time was evaluated by the frequency of sweets consumption increased. Similarly, in both
following three questions: (1) “How many hours a day, in your males and females, it was observed that the higher the frequency
free time, do you usually spend using electronic devices such of soft drink consumption, the lower the probability of reporting
computers, tablets (like an iPad) or smartphones for purposes high performance.
such as homework, e-mailing, tweeting, using Facebook, chatting, As shown in Figure 2, the dietary habit of eating breakfast
surfing the internet?,” (2) “How many hours a day, in your free daily on weekdays was associated with better school performance
time, do you usually spend playing games on a computer, game in both males (OR = 1.17; 95% CI: 1.05–1.30), and females (OR =
console, tablet (like an iPad), smartphone, or other electronic 1.37; 95% CI: 1.26–1.49). Having breakfast regularly on weekends
device (not including moving or fitness games)?,” and (3) “How was associated with better school performance in both males
many hours a day, in your free time, do you usually spend (OR = 1.15; 95% CI: 1.00–1.31) and females (OR = 1.44; 95%
watching TV, videos (including YouTube or similar services), CI: 1.26–1.65).
DVDs, and other entertainment on a screen?” All questions The relationship between high perceived school performance
included nine answer options (responses ranged from 0 to and the frequency of family meals (breakfast and dinner) is
more than 7 h per day). Participants answered these questions shown in Figure 3. In general, adolescents of both males and
separately for weekdays and weekends. Similarly, adolescents females who had breakfast with their families more frequently
were asked to report the frequency of sleep difficulties using a were more likely to report high school performance (males: OR =
five-point scale ranging from rarely or never to almost every day. 1.34; 95% CI: 1.20–1.49; females: OR = 1.54; 95% CI: 1.39–1.69).
The selection of these covariates was based on scientific evidence Furthermore, although the habit of eating dinner with the family
of their potential confounding effect on the association between daily was associated with high school performance in both males
school performance and eating habits (9, 18–21). (OR = 1.45; 95% CI: 1.23–1.71) and females (OR = 2.01; 95%
CI: 1.73–2.33), the pattern of association between the frequency
Statistical Analysis of family dinner and school performance was clearer in females
Data for categorical and continuous variables were expressed than in males.
as numbers and percentages and as the mean and standard
deviation, respectively. Odds ratios were interpreted as the
DISCUSSION
likelihood of achieving “high performance” (“very good”)
or “not high performance” (“good,” “average,” and “below Summary of the Main Results
average”) according to the different eating habits. For this The main finding of the present study was that in adolescents
purpose, multilevel mixed effects logistic regression analyses from several countries, all the healthy eating habits analyzed
were performed including different eating habits and covariates were associated with high perceived school performance. More
described above in addition to country-specific random effects. specifically, in both males and females, it was found that the
Data analyses were conducted using the software Statistical higher the frequency of healthier eating habits, the higher
Package for Social Sciences (SPSS) (Version 25.0). A p-value of the perceived school performance reported. These results were
0.05 was used to establish statistical significance. All analyses consistent overall for the reported consumption of fruits,
were adjusted by region, age, body mass index (z-score), vegetables, sweets, and soft drinks and for having breakfast and
socioeconomic status, physical activity, recreational screen time, family meals (breakfast and dinner).
and sleep difficulties.
Fruit and Vegetable Consumption and High
RESULTS Perceived School Performance
Our results indicate that a more frequent consumption of fruits
Table 1 shows the characteristics of the sample analyzed for and vegetables was related to high perceived school performance
males and females. The mean age was 13.7 years (SD = 1.6) in both males and females. These findings are in agreement
for both males and females. The prevalence of excess weight with the conclusions from the systematic review conducted by
(overweight and obesity) was higher in males (29.5%) than in Burrows et al. (9). Similarly, Tapia-Serrano et al. (22) found
females (19.2%) (p < 0.001). The proportion of adolescents that adherence to the Mediterranean diet, which is characterized
reporting a high (“very good”) perceived school performance was by frequent intake of a large number of healthy foods [e.g.,
higher in females (25.5%) than in males (20.6%) (p < 0.001). vegetables and fruits (23)], was cross-sectionally associated with
Figure 1 shows the fully adjusted association between high higher school performance in Spanish adolescents regardless
perceived school performance and the consumption of fruits, of their nutritional status. Among the possible mechanisms

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López-Gil et al. Eating Habits and School Performance

TABLE 1 | Characteristics of the study participants (N = 46,455).

Variables Males (n = 21,591; 46.5%) Females (n = 24,864; 53.5%) p

n/M (%/SD) n/M (%/SD)

Age (years) 13.7 (1.6) 13.7 (1.6) 0.210

Weight (kg) 54.4 (15.0) 50.0 (11.4) <0.001
Height (cm) 163.9 (13.5) 159.5 (9.5) <0.001
BMI (z-score)a 0.40 (1.15) 0.10 (1.09) <0.001
Excess weighta 6,376 (29.5) 4,781 (19.2) <0.001
FAS-III (score) 5.9 (2.0) 5.8 (2.0) <0.001
High SES 556 (2.6) 483 (1.9) <0.001
Medium SES 8,244 (38.2) 9,834 (35.9)
Low SES 12,792 (59.2) 15,447 (62.1)
Physical activity
≥60 min MVPA (days) 4.4 (2.0) 3.7 (2.0) <0.001
Recreational screen time
TV/DVD/Video on weekdays (>2 h) 12,935 (59.9) 14,264 (57.4) <0.001
TV/DVD/Video on weekends (>2 h) 16,398 (75.9) 18,649 (75.0) <0.001
Computer games on weekdays (>2 h) 10,398 (48.2) 6,650 (26.7) <0.001
Computer games on weekends (>2 h) 14,379 (66.6) 9,764 (39.3) <0.001
Computer use on weekdays (>2 h) 9,569 (44.3) 11,860 (47.7) <0.001
Computer use on weekends (>2 h) 11,766 (54.5) 14,409 (58.0) <0.001
Sleep difficulties
About every day 1,620 (7.5) 2,760 (11.1) <0.001
Perceived academic performance
Very good 4,440 (20.6) 6,332 (25.5) <0.001
Good 9181 (42.5) 10,395 (41.8)
Average 6,666 (30.9) 7,123 (28.6)
Below average 1,181 (5.5) 918 (3.7)

BMI, body mass index; MVPA, moderate-to-vigorous physical activity; SES, socioeconomic status.
a According to the international obesity task force criteria (15).

underlying the relationship between a higher consumption of higher consumption of unhealthy foods was related to self-
fruits and vegetables and school performance is the high density reported learning difficulties in math. Similarly, Nyaradi et
of vitamin C, which cooperates with vitamin E (also known as al. (12) reported that the “Western” dietary pattern, which
tocopherol) as an antioxidant (24). In this regard, Alghadir et includes a higher consumption of soft drinks and ultra-
al. (25) found a positive correlation between two subtypes of processed food (among others) than other dietary patterns,
tocopherol (α- and γ-tocopherol) and executive function and was related to significantly lower school performance in
school performance in adolescents. These same authors pointed Australian adolescents. One of the possible reasons for
out that adolescents with learning difficulties could benefit from this finding is that sweets and soft drinks contain high
a well-balanced diet that provides adequate levels of vitamin amounts of saturated fats and free sugars, which have been
E and other antioxidants. Additionally, increased consumption associated with impaired functioning of the hippocampus,
of fruits and vegetables may also increase the intake of some a brain structure involved in learning and memory (29).
micronutrients, such as folate or iron, which have been associated This fact is especially relevant during adolescence, since
with improved school performance (26, 27). the hippocampus expands its volume at this stage of
development (30).

Sweets and Soft Drink Consumption and Breakfast Consumption and High
High Perceived School Performance Perceived School Performance
Furthermore, considering that sweets and soft drinks are In addition, our results showed that a higher frequency of
known for their low nutritional value and high caloric breakfast consumption was related to higher perceived school
value, a higher frequency of consumption of these unhealthy performance, which is consistent with the scientific literature
foods was associated with lower rates of self-reported high among adolescents (9, 13). Breakfast may improve neuronal
academic achievement. Supporting this finding, one study activity (31) and cognitive control (e.g., working memory and
of Norwegian adolescents by Øverby et al. (28) showed that attentional capacities) (32), which in turn can influence school

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López-Gil et al. Eating Habits and School Performance

FIGURE 1 | Association between high perceived academic performance and fruit, vegetable, sweets, and soft drink consumption among adolescents. Odds ratios
generated using logistic regression models adjusted by region, age, body mass index (z-score), socioeconomic status, physical activity, recreational screen time, and
sleep difficulties.

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López-Gil et al. Eating Habits and School Performance

FIGURE 2 | Association between high perceived academic performance and breakfast consumption (on both weekdays and weekends) among adolescents. Odds
ratios generated using logistic regression models adjusted by region, age, body mass index (z-score), socioeconomic status, physical activity, recreational screen
time, and sleep difficulties.

performance. In line with this association, Adolphus et al. has been associated with higher diet quality (9, 34), not
(33) showed in a systematic review of studies with children skipping breakfast may help adolescents achieve a high-quality
and adolescents that, breakfast intake positively influences diet (38), which could then explain their high perceived
cognitive function compared to skipping breakfast. Likewise, school performance.
Masoomi et al. (34) and Kawabata et al. (35) demonstrated that
breakfast consumption had a positive influence on students’ Regular Family Meal Consumption and
cognitive functions and school performance. Furthermore, High Perceived School Performance
Peña-Jorquera et al. (36) indicated that adolescents who Regarding regular consumption of family meals, we found an
eat breakfast before cognitively demanding activities and association between a higher frequency of family meals (breakfast
who regularly include a high-quality breakfast have higher and dinner) and higher perceived school performance. Although
cognitive performance than their counterparts who do the consumption of family meals has been shown to be beneficial
not. A possible reason for these findings could lie in the for the health and psychosocial well-being of adolescents (39)
association between skipping breakfast and an increased (which could be key factors in improving school performance),
likelihood of depression, anxiety, psychological distress, and we found only a single study that examined this eating behavior
stress in adolescence (37), which can negatively affect school in terms of school performance among Canadian adolescents
performance. Finally, because regular meal consumption (11). These same authors showed that healthy eating habits (e.g.,

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López-Gil et al. Eating Habits and School Performance

FIGURE 3 | Association between high perceived academic performance and frequency of family meals (breakfast and dinner) among adolescents. Odds ratios
generated using logistic regression models adjusted by region, age, body mass index (z-score), socioeconomic status, physical activity, recreational screen time, and
sleep difficulties.

family meals) were positively associated with higher academic child’s life, with could provide additional support for academic
achievement, which is consistent with our study results. In achievement (42).
this sense, Eisenberg et al. (39) suggested that family meals
could provide a formal/informal time during which parents Methodological Considerations
could connect with their children’s emotional well-being, which The main strength of the study is the large and representative
could at least partially explain the associations found in our sample of adolescents analyzed from 42 countries, which confers
analysis. Another rationale could be related to the association substantial external validity to our findings. Although the
between family meals and higher quality of diet. Family meals statistical significance of small effect sizes can be demonstrated
are associated with a higher consumption of healthy foods, such in studies analyzing large datasets, the results from this study
as fruits and vegetables (40, 41), and with a better overall diet provide evidence of the association between eating habits
as assessed with the Healthy Eating Index (40), which may and perceived school performance. Nevertheless, because of
be related to high perceived school performance. Furthermore, the cross-sectional study design, we cannot establish a cause-
another possible explanation is that family meals may be an effect relationship. Thus, future prospective observational and
overall proxy for parental availability and involvement in their experimental studies based on objective measures are required to

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López-Gil et al. Eating Habits and School Performance

examine whether an increased frequency of healthy dietary eating students, it is necessary to continue to raise awareness and
habits leads to improved school performance in adolescents. develop intervention programs that consider the promotion of
Although the measures used have been previously validated, healthy eating habits.
the questions asked were brief—intended to reduce the burden
of questions on participants—and did not provide in-depth DATA AVAILABILITY STATEMENT
data on the variables analyzed. A more detailed measurement
would provide additional information for each item, as well The datasets presented in this study can be found in online
as information about other healthy foods such as nuts, seeds, repositories. The names of the repository/repositories and
pulses, or diaries. Also, the assessment of cognitive ability accession number(s) can be found below: https://www.uib.no/en/
would be interesting, since it has been related to healthier hbscdata.
lifestyle habits (e.g., eating habits) (43). Likewise, weight and
height were parent-reported which could introduce error and ETHICS STATEMENT
bias to the results obtained (44). Moreover, information on
dietary patterns and school performance may result in some Ethical review and approval was not required for the current
differential bias because of information and recall bias, social study in accordance with the local legislation and institutional
desirability bias or overestimation by adolescents. Furthermore, requirements. Written informed consent from the participants
the question on perceived school performance asked the was not required for the current study in accordance with the
participants to speculate about what their teacher thought national legislation and the institutional requirements. For the
about them, relative to their classmates, which may lead to datasets on which this study is based, each participant country
different interpretations. In addition, although we controlled is responsible for researching under their ethical guidelines,
our analysis for the effect of important confounders, including consequently, consent to carry out the research was given by
sociodemographic, anthropometric, and lifestyle variables related school administrators in each country. Moreover, both the
to movement, such as physical activity, screen use, and sleep, schools and the adolescents and their parents or legal guardians
residual confounding is still possible. Lastly, for the present study received and signed written informed consent forms.
we used data collected in 2013/2014. However, the most recent
information from the HBSC study is not publicly available (at AUTHOR CONTRIBUTIONS
this time).
JL-G designed the study, contributed to the interpretation of
CONCLUSIONS the data, and to the analysis and writing of the draft. AM,
CÁ-B, CP-M, AS-L, and IC-R contributed to the revision
In conclusion, this study provides cross-sectional evidence that of the manuscript. All authors approved the final version of
selected healthy eating habits, such as a higher frequency the manuscript.
of fruit and vegetable consumption, a lower frequency of
sweets and soft drink consumption, more frequent breakfast ACKNOWLEDGMENTS
consumption, and more frequent family meals (breakfast and
dinner), are associated with high perceived school performance JL-G is a Postdoctoral Fellow (Universidad de Castilla-La
among adolescents, regardless of the main confounding factors. Mancha – ID 2021-UNIVERS-10414). AM was supported by
Considering the importance of school performance for the a Beatriz Galindo contract (BEAGAL18/00093) by the Spanish
cognitive, emotional and physical development of adolescent Ministry of Education, Culture and Sport.

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Frontiers in Nutrition | www.frontiersin.org 9 February 2022 | Volume 9 | Article 797415