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Socioeconomic Status and Lifestyle Factors Modifies the Association Mirmiran et al. Nutr J (2021) 20:70 https://doi.org/10.1186/s12937-021-00728-y RESEARCH Open Access Socioeconomic status and lifestyle factors modifes the association between snack foods intake and incidence of metabolic syndrome Parvin Mirmiran1, Maryam Aghayan2, Bahar Bakhshi2, Somayeh Hosseinpour‑Niazi2* and Fereidoun Azizi3 Abstract Background: Intake of snack foods has been previously associated with an elevated risk of chronic disease; however, studies on snack foods and metabolic syndrome (MetS) while considering the modifying efect of socioeconomic status (SES) and lifestyle factors on this association are lacking. We aimed to investigate the association between snack foods intake and the MetS risk, and the mediatory efects of SES and lifestyle factors on the forenamed association among adults who participated in the Tehran Lipid and Glucose Study (2006–2018). Methods: This is a prospective study of 1915 participants (male, 40.5%), aged 19–74 year who were free of MetS at baseline. Dietary intakes were gathered using a validated, semi‑quantitative food frequency questionnaire at baseline (2006–2008), and with 3‑year intervals afterwards. Alternative approach was used for snack foods from all available questionnaires during follow‑up. Snack foods were divided into 4 categories, including total snacks, biscuits and cakes, candies and chocolate, and salty snacks. Total snack foods intake and its subgroup (serving/week) were modeled as tertiles. MetS was diagnosed according to the Joint Interim Statement criteria. Physical activity level (PAL) categorized as low/medium and high levels. Information regarding smoking (Smoker/Non‑smoker), education (higher/lower edu‑ cation), and occupation (employed/non‑employed) was gathered using questionnaire. The Cox regression was used, regarding interaction between snack foods, SES, and PAL on the MetS risk. Results: A total of 591 incident MetS cases were diagnosed during 8.9 years of follow‑up. The median total snack foods intake was 5.2 serving/week (IQR: 3.0–9.1). Total snack foods intake was positively associated with the MetS risk after adjusting for potential confounders (adjusted for age and gender, energy intake, total fber intake, smoking sta‑ tus, PAL, education levels, family history of diabetes, family history of CVD events, and BMI). After adjustment for con‑ founders, among snacks’ subgroups, candies and chocolate intake was positively associated with MetS risk. Moreover, among lower‑educated and non‑employed participants, candies and chocolate intake was positively associated with the MetS risk, by 38 and 43% respectively. Stratifcation based on PAL resulted a positive association between intake of total snack foods and candies and chocolates and risk of MetS among participants with low PAL. Conclusion: Snack foods, especially candies and chocolate, increased the risk of MetS, among individuals with a low PAL. Keywords: Snack, Candies and chocolate, Metabolic syndrome, Socio‑economic status, Adults Introduction *Correspondence: [email protected]; [email protected] 2 Nutrition and Endocrine Research Center, Research Institute It is well established that metabolic syndrome (MetS), for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, a cluster of interrelated metabolic abnormalities, No 24, A’rabi St, Yeman Av, Velenjak, P.O.Box: 19395‑4763, Tehran, Iran can occur from early childhood to late adulthood [1]. Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mirmiran et al. Nutr J (2021) 20:70 Page 2 of 12 Te National Cholesterol Education Program Adult of snack foods and MetS, among adult population dur- Treatment Panel III has stated MetS as a promoter of ing 8.9 years of follow-up. cardiovascular disease (CVD) risk factors, which sub- sequently increases the risk of morbidity and all-cause Material and methods mortality [2]. To reduce the burden of MetS, it is neces- General characteristics sary to explore the efect of modifable lifestyle factors, Tis study was conducted within the framework of the such as physical activity levels (PAL), that might have Tehran Lipid and Glucose Study (TLGS), a long-term a preventing efect against the disease occurrence [3]. prospective population-based study initiated in 1998 to As indicated in several studies, the increasing trend of determine the prevalence of non-communicable disease MetS is known to be associated with sedentary lifestyle risk factors and its outcomes among the urban Tehranian behaviors, in addition to an ongoing nutrition transi- population. Te design and other details of TLGS were tion, as a result of modernization that manifest itself described elsewhere [16]. Briefy, the frst survey phase through a higher intake of industrial and processed initiated in 1999, with > 15,000 participants aged ≥ 3 years foods and is a major factor in the development of non- enrolling from district 13 of Tehran, the capital of Iran, communicable diseases among populations [4, 5]. using a multistage cluster random sampling method. Snack foods intake has recently been emphasized Beginning in 1999 with 3-year intervals afterwards, par- as a potentially unhealthy eating habit [6]. Intake of ticipants were assessed for anthropometric measures, energy-dense nutrient poor snacks from 1 serving per medication use, medical history of CVD risk factors, day to ≥ 2 serving per week, which are high in simple demographic, lifestyle factors and SES. To update all sugars, sodium, saturated and trans fatty acids, impose previous data, this information were documented every individuals to a higher risk of CVD and MetS [7]. Addi- 3 years during face-to-face visits by the local research tionally, a 20% increase in the frequency of snacks team. Phases II, III, IV, V, VI were prospective follow- intake was associated with weight gain and dysglycemia up studies conducted between 2002–2005, 2006–2008, [8], and metabolically unhealthy obese subjects had a 2009–2011, 2012–2015, 2016–2018, respectively. higher frequency of salty snacks, compared with meta- Te current study used baseline examination data from bolically healthy obese subjects [9]. Furthermore, snack phase III of the TLGS (2006–2008) and followed par- foods was associated with imbalance energy intake and ticipants up to phase VI of TLGS (2016–2018), during poor diet quality, which leads to weight gain as well as an 8.91 (Interquartile Range: (IQR): 7.98–9.69) year fol- oxidative stress and infammation [10, 11]. low-up. During the phase III of the TLGS, a representa- It is also well known that lifestyle factors alongside tive sample of 4920 participants was randomly selected, the diet may play an important role in the incidence for gathering their dietary information. From the 4920 of chronic diseases [3]. Socioeconomic status (SES), selected participants in the present study, 3462 number including education, occupation, and some lifestyle fac- of individuals, agreed to complete the FFQ. For the cur- tors, such as PAL and smoking, are related to the MetS rent study, 3265 adults aged 19–74 years with complete [12–14]. Two cross-sectional studies that have investi- demographic, anthropometric, biochemical, and dietary gated the association between MetS and SES, measured data were selected. Te characteristics of participants by income and education, found that lower education who completed the dietary assessment were similar to levels as well as lower income were associated with those of the total population in the phase III of TLGS MetS risk in both young and older adults [12, 13]. In [17]. Te mean age and BMI of participants who com- another cross-sectional study, physical activity pattern pleted the FFQ were 36.5 years and 25.6 kg/m2, com- was independently associated with the MetS in adults pared with 35.4 years and 26.1 kg/m2 in participants who [14]. In a prospective study with 4 years of follow-up did not have nutritional data, in the phase III of the study. never smokers had lower risk of MetS compared to Among non-included participants, 32.9% had academic continual smokers among middle-aged adults [15]. education and 21.5% were smokers, compared with 29.5 To our knowledge, no prospective studies have con- and 21.7% subjects who completed the FFQ. sidered SES and lifestyle factors (including education, We excluded those with MetS at baseline (n = 872), occupation, PAL, and smoking) as mediators of the those who were pregnant or lactating at baseline and relation between snack foods intake and MetS risk. during follow-up (n = 28), those with under-or over- Because of that, the current study aimed to, frstly, reporting of energy intakes (daily energy intake < 800 investigate the association between snack foods intake and > 4200 kcal per day) (n = 115), those were on any and risk of MetS, and secondly, investigate the media- specifc diets as result of diabetes, hypertension or tory efect of SES and lifestyle factors on the association hyperlipidemia (n = 26), and participants with miss- ing biochemical and anthropometric measures related Mirmiran et al.
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