ABSTRACT This study aimed to describe dietary habits of Syrian adolescents attending secondary schools in Damascus and the surrounding areas. A descriptive, cross-sectional study was carried out on 3507 students in 2001. A stratified, 2-stage random cluster sample was used to sample the students. The consumption pattern of food items during the previous week was described. More than 50% of the students said that they had not consumed green vegetables and more than 35% had not consumed meat. More than 35% said that they consumed cheese and milk at least once a day. Only 11.8% consumed fruit 3 times or more daily. Potential determinants of the pattern of food consumption were analysed. Weight control practices and other eating habits were also described.

RÉSUMÉ Cette étude avait pour objectif de décrire les habitudes alimentaires d’adolescents syriens fréquentant des écoles secondaires à Damas et dans ses environs. Une étude transversale descriptive a été réalisée auprès de 3507 élèves en 2001. Un échantillonnage aléatoire en grappes stratifié à deux degrés a été utilisé pour répartir les élèves. Les caractéristiques de la consommation des aliments durant la semaine précédente ont été décrites. Plus de 50 % des élèves déclaraient n’avoir pas consommé de légumes verts et plus de 35 % n’avaient pas consommé de viande. Plus de 35 % déclaraient avoir consommé du fromage et des laitages au moins une fois par jour. Seuls 11,8 % des élèves consommaient des fruits trois fois par jour ou plus. Les déterminants potentiels de la consommation alimentaire ont été analysés. Les pratiques de contrôle du poids et les autres habitudes alimentaires ont également été décrites.

The quantity, strength, and consistency of evidence that relates dietary factors to chronic diseases, and the substantial impact of these conditions on health are reason enough to promote policies to increase the adoption of healthy diets [1,2].

The health of young people and adults is critically linked to the health-related behaviours they choose to adopt. Unhealthy dietary behaviour is one of those risky behaviours. Evidence from studies of the eating habits of young people raises concern about the implications on their future health [3].

The Syrian Arab Republic is a country witnessing great developments. It is also facing a clear epidemiological transition; chronic diseases are emerging as the main causes of death (Syrian Ministry of Health, unpublished report, 2000). The population of the country is rather young: the age group 10–19 years constitutes more than 25% of the total [4]. The net enrolment at secondary school is 40% for males and 45% for females [5].

Adolescents may not think of the long-term consequences of their health practices, rather, they consider only short-term consequences and assume they can alter their habits later for better health [3]. An analysis of dietary habits among adolescents would be useful in depicting prevalent habits, and also for designing relevant effective nutrition education recommendations. As far as is known, there are no previous studies in the Syrian Arab Republic that describe eating habits among adolescents, although other risky behaviours have been studied, e.g. smoking [6].

This study aimed to describe dietary habits of Syrian adolescents attending secondary schools in Damascus city and the surrounding areas.

The study was conducted in Damascus and surrounding areas. Damascus, the capital of the Syrian Arab Republic, has a population of > 1.5 million [4]. It constitutes one of the 14 provinces in the country and is surrounded by another province called Rural Damascus, with a population of < 2 million [4]. The total number of secondary schools (grades 7–12) in the 2 provinces approaches 400, the vast majority of them government schools.

This was a descriptive, cross-sectional study. A stratified, 2-stage, random, cluster sample was used to sample the students. In the first stage, schools were randomly selected from a sampling frame that included all schools (grades 7–12) in Damascus city and Rural Damascus (only 30 km around Damascus city). That frame was stratified by education level (2 strata), sex (2 strata) and place of residence (2 strata). Three schools from each stratum were randomly selected, i.e. 24 schools in total. Classes from each level of education in the selected schools were randomly chosen. Students in the 9th and 12th grades were not as well represented as other grades owing to the fact that some class teachers refused to allow any interruption in their classes since the students were registered for important exams in June of the same year. In the schools where this occurred (5/24 schools), we replaced that class with the class from the grade below. All students attending the selected classes were included. The sample size was estimated at 3380 taking into account: desirable confidence limit of 95%; an estimated prevalence of an unhealthy eating habit of 40%; the acceptable error; and the design effect of 1.5. Initial sample size was 3514 in-school adolescents; 5 students refused to participate and 2 questionnaires were returned blank. The total number of questionnaires analysed was 3507.

The questionnaire was developed and adapted from the questionnaire used for the behavioural risk factor surveillance system [7]. This modified questionnaire was piloted on 25 secondary students to check for ease of understanding and completion. The questionnaire consisted of 54 questions. Data collected included background information; food consumption and frequency of the main food items consumed in the past week; weight perception and weight control measures practised; reported weight and height if known by the student; habits of consuming products such as salt, coffee, tea, soft drinks and packaged food (e.g. biscuits, potato chips); and also snacking habits. A question on the perceived best authority to provide health education on nutrition was also included.

Students filled in the questionnaires during regular class times, and questionnaires were also collected in class. The principal investigator visited all the selected schools between February and May 2001. Approval of the school principals was obtained before the start of the study, and written, informed consent was taken from all the students through the tool of data collection itself.

Questionnaires were checked and coded, and analysis of data was carried out using SPSS. Missing values were allowed for in the analysis. Descriptive statistics was carried out where frequencies were calculated for all questions. Comparisons between sexes and place of residence were also done. The chi-squared test to compare proportions and t-test to compare means were calculated. The level of significance was 0.05.

A total of 3509 students in 24 secondary schools in Damascus and surrounding areas received the questionnaire (5 adolescents had refused to participate). Partici- pation rate was extremely high, only 2 questionnaires were returned blank leaving a total of 3507 questionnaires. Table 1 summarizes the characteristics of the participants: 73.2% resided in urban areas, 41.7% were female, and age range was 13–18 years. More than 36% earned money through work; this proportion varied significantly between males and females (59.7% and 20.9% respectively).

When asked about sources of nutrition education, 33.1% of students indicated the family only as the best source of information; 6.4% indicated the school only and 5.1% indicated the media only. A total of 19.5% of adolescents indicated > 1 source.

This study identified a number of eating habits practised by in-school adolescents in Damascus city and the surrounding areas that are potentially harmful and unhealthy [2]. Food consumption and other dietary behaviours are influenced by many factors. These include culture, agriculture, socioeconomic factors and lifestyle. Our results are comparable with those of studies from neighbouring countries (A.M. Sibai, N. Kanaan, unpublished report, 1998) and western countries [9].

The study revealed that food consumption could be determined by economic factors such as fruit consumption as this is rather an expensive item on the market. Green vegetables, being a cheap item on the market, were consumed more by participants who reported low economic status of their families compared to more expensive items like fruit (Table 2).

Self-reported weight and height indicated that obesity and overweight were not prevalent among the study subjects. Nevertheless, Syrian adolescents did engage in weight control behaviours. Some of those who practised weight control measures, mainly females in this study, may be at risk of inadequate nutritional intake. Adolescents in particular can come under considerable pressure from the world at large to conform to current trends in fashion, body image, behaviour or foods. Recent developments in western dietary practices have tended to leave adolescents vulnerable to low intake of energy and of certain nutrients [10]. Studies of adolescents have noted the importance of psychosocial variables such as body image and self-perception in shaping dietary practices [11]. Nonetheless, our study revealed that nearly half the participants (46%) were not aware of their weight and height; this is another interesting finding that deserves note.

Snacking and light meal consumption was very common among study subjects. The food pattern was characterized by irregularity of meal consumption. Although snacks can be a source of needed nutrients, it is important that they do not substitute for regular meals. Snacking is an established eating pattern among adolescents worldwide. Snacking was more common in Nordic countries compared to southern European countries [12,13].

This study, like many others, has many limitations. First of all, using the food frequency questionnaire may be problematic. In spite of their inherent limitations, food frequency questionnaires have been used increasingly in research. Considerable research has been devoted to improving the validity and reproducibility of these questionnaires [14]. Secondly, our study has focused on in-school adolescents. Although secondary education is not universal in the country, a large proportion of adolescents attend schools. Additionally, our sample may have under-represented the rural areas. We embarked, for feasibility reasons, on sampling from schools close to Damascus city, within around 30 km of the city centre (the study was not intended to cover a national representative sample). In the cases where 9th and 12th grades were replaces by the grade below, we have no reason to think that this biased the results. Thirdly, self-administered questionnaires have some inherent problems and are subject to self-perceived measurements and reporting errors. But since our sample size was large, this should not affect the validity of the results very much, and the results compared well with similar studies. Further research is, however, needed to measure the nutritional status of Syrian adolescents objectively.

As far as is known, this study provided, for the first time in the country, data on the dietary habits of Syrian adolescents. It highlighted, despite some limitations, the urgent need to intervene and to promote healthy eating behaviour among those youngsters. Schools can help young people improve their eating habits by implementing effective policies and educational programmes that reach families and the community at large [15]. Interventions at school have a great potential to work positively. A study from the United Kingdom suggested how difficult it is to achieve sustained dietary changes in the eating habits of secondary school children [16]. However, our study revealed that families might have an important role to play since a high proportion of students felt their families would be a good source for nutrition education.

In conclusion, this study provided some baseline data for future research and for the use of policy makers. It also clearly supports the need for effective dietary education for adolescents, and even for children.

We express our sincere thanks to the authorities concerned at the Ministry of Education who kindly issued their approval to do the study. Great appreciation is extended to school principals and students for their participation. The Faculty of Medicine, University of Damascus, funded this study.