Snack consumption is decreasing in Colombia among the youngest, the most educated, and the wealthiest: results of two representative national surveys.

Background: A common recommendation is to reduce the consumption of snack food and replace this consumption with nutrient-dense foods. The objective was to establish whether there were changes in adherence to the consumption of the snack pattern (SP) in Colombian children and adults in the 2010-2015 quinquennium. In addition, this study aimed to establish the relationship between the SP and some biological, socioeconomic, and geographic variables in Colombia, Sur América. Methods: Based on a Food Frequency Questionnaire (FFQ) applied both in 2010 and 2015 in the national nutritional situation surveys, the adherence to the snack consumption pattern was established through factor analysis. The change in the adherence of consumption to the SP was established for the five-year period [2015 minus 2010], using multiple linear regression models. Crude and adjusted differences were estimated by the following covariables: sex, age, marital status, food security, wealth index, ethnicity, education of the head of the household, area and region. In total, 37,981 subjects were analyzed. In 2010, 10,150 children (5 to 17 years old) and 5,145 adults (18 to 64 years old) were included, and in 2015, 13,243 children and 9,443 adults. Results: In children, the adjusted difference in the adherence to SP was -0.37 (95% CI: -0.42, -0.32), p < 0.0001. In adults, the adjusted difference in the adherence to SP was -0.27 (95% CI: -0.31, -0.24), p < 0.0001. In all categories of covariables, consumption decreased, for all p < 0.0001. In children the decrease in consumption was inversely associated with body mass index (BMI) and height and was directly associated with the level of food security in the home and the wealth index. In adults the decrease in consumption was inversely related to age and BMI and directly related to the size, the level of food security of the household, wealth index, and education level. Conclusions: In the quinquennium there is a decrease in the adherence to the SP, the region, the wealthiest, the tallest, the best BMI and the most educated displayed the greatest decrease in the SP.

cardioprotective effects, such as the Mediterranean [10,11] or Eskimo or Inuit [12] diets, are the expression of what we now understand as traditional or ancestral food patterns. Evidence suggests that adhering to traditional dietary patterns -regardless of the geographical context -protects or delays the undesirable effects of ultraprocessed foods and other patterns in health, such as the socalled "western" diet, which consists of a high content of refined foods, sugar, saturated fat, ultraprocessed ingredients and, in general, items considered snack foods [13][14][15][16].
In countries with high and medium incomes, snack consumption contributes to between 20-40% of the total energy/day [17][18][19]. Snack consumption in children and adults has been associated with the development of adiposity, annual changes in body mass index (BMI), and subcutaneous fat (SCF) [20][21][22]; it is also positively associated with waist circumference and SCF thickness in overweight and obese men and women [23,24]. Contradictory evidence to these associations is apparently the result of reverse causality and the different ways in which snack consumption is defined and measured In 2010, the FFQ was applied to 7,138 subjects between 18 and 64 years old; in 2015, it was applied to 11,530 subjects. Of these subjects, we excluded pregnant women (in 2010, n = 1679; in 2015, n = 1134), those who practiced prescribed diets (in 2010, n = 255; in 2015, n = 304), and subjects measuring less than 100 cm or more than 200 cm or weighing less than 40 kg or more than 200 kg. In addition, in 2010, the FFQ was applied to 10,756 subjects between 5 and 17 years old, and in 2015, it was applied to 10,092 subjects. Of these, we excluded pregnant girls (in 2010, n = 257; in 2015, n = 159), those who practiced prescribed diets (in 2010, n = 128; in 2015, n = 126), and subjects measuring less than 80 cm or more than 200 cm or weighing less than 12 kg or more than 200 kg. In total, 37,981 records were analyzed. In 2010, 10,150 children (5 to 17 years old) and 5,145 adults (18 to 64 years old) were included, and in 2015, 13,243 children and 9,443 adults were included.
In 2010, the 10 responses in the FFQ regarding the frequency of consumption of 28 food items were converted to a continuous variable: "times/day". This variable was assessed using a factor analysis, and three consumption patterns were established.

Statistical analysis
All analyses were conducted using the analysis routines for complex sample designs of Stata software, version 14. 1 [35]. An analysis was conducted to estimate the average adherence to SP in the covariable categories. In addition, using a multiple linear regression with adherence to SP as the dependent variable, we estimated the adjusted differences for each of the categories in all covariates and their 95% confidence intervals (95% CIs). To obtain the adjusted differences, a new term was created as the cross product between the year and each category of the covariates (interaction). The adjusted differences incorporated the complex design of the sample, and the multiple regression model included the following covariates: sex, age, marital status, food security, wealth index, ethnicity, education of the head of household, area, and region. Finally, using a multiple linear regression, crude and adjusted differences and their respective 95% CIs were estimated between the frequency/day of consumption for the main items that compose the SP.

Institutional review board
The authors declare that all procedures that contributed to this work comply with the ethical

In children
In 2010, 49.3% of the subjects were girls. The mean age ± SE of the subjects was 11.8 ± 0.05 years, which differed by sex (p = 0.041). In 2015, 49.0% of the subjects were girls. The average age of the subjects was 11.0 ± 0.07 years, which differed by sex, with girls being an average of three months older (p = 0.001).
The adjusted difference in adherence to the SP was -0.37 (95% CI: -0.42, -0.32, p < 0.0001). In each year, age, height/age, and wealth index were directly associated with consumption. Those who live in urban areas consumed more. In all categories of variables, consumption decreased (p < 0.0001 for all). In this period, the decrease was greater in girls and in those who live in urban areas. The decrease in consumption was inversely associated with BMI and height and was directly associated with the level of food security in the home and the wealth index (Table 1).

In adults
In 2010, 55.2% of the subjects were women. The mean age ± SE of the subjects was 37.5 ± 0.24 years, which did not differ by sex. In 2015, 55.1% of the subjects were women. The mean age of the subjects was 37.8 ± 0.23 years, which differed by sex, with women being an average of two years older (p < 0.0001).
The adjusted difference in adherence to SP was -0.27 (95% CI: -0.31, -0.24, p < 0.0001). In each year, age and BMI were inversely associated with consumption and were directly associated with height and wealth index. Men, married people, and those who live in urban areas consumed more. In all categories of variables, consumption decreased (p < 0.0001 for all). In the period, the decrease was greater in men, single people, and those who live in urban areas. The decrease in consumption was inversely related to age and BMI and directly related to the size, the level of food security of the household, wealth index, and education level ( Table 2). Figure 1 illustrates the reduction in the pattern of snack consumption. tables 1 and 2 here Food determinants in the food transition. in the frequency/day of food consumption. In the SP, the most influential foods that decreased in consumption in children were candy, sweets, and packaged foods. The most influential foods that decreased in consumption in adults were candy, sweets, soda, SSB, and packaged foods. In both ENSINs, the decrease in snack consumption was greater in men. The consumption of snacks does not differ by sex, but in adults, snack consumption depends on the emotional state; for example, it increases in women with symptoms of depression, whereas it increases in men when they do not have symptoms of depression [38]. The above discussion is beyond the scope of this study. The greatest decrease was observed in the 18-to 24-year-old age group, which may have occurred because adolescents have the highest consumption of soda and snacks in general [39,40]. In addition, 18 to 24 years is the age group where messages and media actions have traditionally focused [41,42]. Clearly, as food habits are established with age, the decrease in the SP consumption is lower.
The finding that the SP consumption decreased more in tall subjects, those with a better BMI, households with food security, and the most educated and wealthiest illustrates several novel phenomena: a) inequality exists when incorporating better decisions regarding the purchase and consumption of foods that are negatively related to the state of health; b) subjects with greater "capacities/resources" translate information into better decisions [43,44]; c) it is possible that the consumption of the SP in the wealthiest and most educated is a result of having a sweet-tooth and therefore dispensable, whereas in the poorest, this consumption is part of the diet and therefore less expendable; d) the wealthy abandon snacks and likely increase their fruit-vegetable/fiber consumption; e) it is possible that in the poorest, the cost of the basic food basket increases significantly, which causes them to substitute snack foods for other foods more dense in nutrients, such as fruits, vegetables or milk, but which are also more expensive [45]; and finally f) the geographic region behaves as a proximal variable or cluster of economic and structural development and illustrates the same findings at the ecological level and the individual level: there is a gradient in the decrease in the SP consumption as the level of human and economic development in the regions increases.
Despite the effort made by the transnationals and snack producing and distributing companies to introduce snack consumption in rural areas [46], consumption still predominantly occurs in urban areas, which is why the greatest decrease was observed in those areas. This is corroborated indirectly by the result of snack consumption in the indigenous population (Table 1), which inhabits predominantly rural and dispersed areas.
The decrease in SP can be explained in part by a local and mediatic phenomenon derived from the attempt to reduce soda consumption [37] and, in general, by the incorporation of messages against the consumption of sugar, packaged foods, sweets, and candy in favor of a healthy diet, which do not escape globalization. Currently, due to the media, it is impossible to think that we do not have permanent campaigns against and in favor of a healthy diet [47]. The decrease in the consumption of some of the items that comprise the traditional pattern/starch, panela [unrefined whole cane sugar], sugar, honey, and tubers or bananas also suggests that the subjects associate snack and starch consumption with overweight and obesity, which is an association that, among others, was the axis of the aforementioned media campaigns.

Scope and limitations of the study
The results of this study are unable to establish causal relationships; therefore, the decrease in the consumption of SP, panela, sugar, honey, tubers, and plantains may be due to a systematic information bias. However, given the independence in food patterns and that the results are consistent with other food transitions -where the richest migrate toward consumptions valued as healthy, such as fruits and vegetables, and are coherent with the phenomenon of the nutritional transition that was recently explained for this same population -obesity increases faster in the urban poor and residents [48] -the occurrence of this bias is unlikely. The main strength of this study is that it used data on dietary consumption that were comparable between periods and obtained in two representative national surveys.

Conclusions
In summary, there are three food consumption patterns in Colombia, and we demonstrate the transition that occurs in the SP. Both at an individual and ecological level, the region, the wealthiest, the tallest, the best BMI and the most educated displayed the greatest decrease in the SP. It is plausible that both local and global media messages and campaigns, which did not obey state policies, have influenced this decrease in SP consumption in Colombia. Identifying the causes and the context in which this decrease occurred can help develop adequate policies and interventions to sustain this decline. Authors' contribution.

List Of Abbreviations
OFH designed the study, obtained the databases of the ICBF, prepared the databases and conducted and led statistical analyzes. OFH, EV and DCQ-L interpreted the results, prepared, reviewed and wrote the manuscript finally submitted. All authors reviewed the manuscript and approved the final version.

Acknowledgement.
Not applicable Authors' information.
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The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported. The reporting of this work is compliant with STROBE guidelines. The lead author affirms that no important aspects of the study have been omitted. In addition, this study is a product of analysis of secondary information anonymized, public and available in different web pages properly reported within the main text and the references section.   -0.49) -0.42 (-0.51, -0.33) * In 2010 n may be less than 10150 for missing values. In 2015 n may be less than 13243 for missing values. † Adjusted difference and 95% confidence interval achieved in a linear regression model with the score of adherence (Z score) to the snack pattern as a dependent variable and predictors that include indicator variables for each sociodemographic correlates, year 2015 (2010 as reference) and cross-product (interaction) terms between year and indicator variables of the correlate. In addition, the linear regression model was adjusted by the following covariables; sex, age, food security, wealth index, ethnicity, area and region. The complex sampling survey design was taken into account in all multivariate regression models. ‡ Based on equivalent cutoff points using the IOFT classification. §The rural category included suburban population centers close to small cities, towns in rural areas distant from small towns, and disperses or very distant from rural towns.  -0.22) * In 2010 n may be less than 5145 for missing values. In 2015 n may be less than 9443 for missing values. † Adjusted difference and 95% confidence interval achieved in a linear regression model with the score of adherence (Z score) to the snack pattern as a dependent variable and predictors that include indicator variables for each sociodemographic correlates, year 2015 (2010 as reference) and cross-product (interaction) terms between year and indicator variables of the correlate. In addition, the linear regression model was adjusted by the following covariables; sex, age, marital status, food security, wealth index, ethnicity, education of the head, area and region. The complex sampling survey design was taken into account in all multivariate regression models. ‡ The rural category included suburban population centers close to small cities, towns in rural areas distant from small towns, and disperses or very distant from rural towns. Figure 1 Adherence to Snack food consumption pattern (Z) in Children 5 to 17y (a) and Colombian