Jonida STEFA1   , Migena GEGA1   , Brizida REFATLLARI1   , Grejd HYSKA2  
Gentiana QIRJAKO3,4   , Genc BURAZERI3,5* 
PREVALENCE AND SOCIODEMOGRAPHIC CORRELATES OF NUTRITIONAL 
HABITS AMONG SCHOOLCHILDREN AGED 11-15 YEARS IN ALBANIA
1 Faculty of Technical Medical Sciences, University of Medicine, Tirana, Albania
2 Global Studies Institute, University of Geneva, Geneva, Switzerland
3 Faculty of Medicine, University of Medicine, Tirana, Albania
4 Institute of Public Health, Tirana, Albania
5 Department of International Health, CAPHRI (Care and Public Health Research Institute),  
Maastricht University, Maastricht, The Netherlands
Received: Nov 27, 2024
Accepted: Mar 24, 2025
Original scientific article
*Correspondence: genc.burazeri@maastrichtuniversity.nl
10.2478/sjph-2025-0017 Zdr Varst. 2025;64(3):133-142
133
RAZŠIRJENOST IN SOCIODEMOGRAFSKI KORELATI PREHRANJEVALNIH 
NAVAD MED ŠOLARJI, STARIMI OD 11 DO 15 LET, V ALBANIJI
© National Institute of Public Health, Slovenia. 
Stefa J, Gega M, Refatllari B, Hyska G, Qirjako G, Burazeri G. Prevalence and sociodemographic correlates of nutritional habits among schoolchildren aged 11-15 years in Albania.  
Zdr Varst. 2025;64(3):133-142. doi: 10.2478/sjph-2025-0017.
ABSTRACT
Keywords 
Albania
Breakfast
Nutrition
Schoolchildren
Fruits and  
vegetables
IZVLEČEK
Ključne besede 
Albanija
zajtrki
prehranjevanje
šolarji
sadje in  
zelenjava
Objective 
Healthy nutritional habits during childhood promote healthy growth and development and foster psycho-emotional 
wellbeing.  Our aim was to assess the prevalence and sociodemographic correlates of selected nutritional habits among 
Albanian schoolchildren.
Methods
A cross-sectional study was conducted in Albania in 2022, in the framework of the Health Behaviour in School-aged 
Children survey, including a nationwide representative sample of 5,454 schoolchildren aged 11-15 years (≈52% girls; 
≈96% response). Data on nutritional habits were gathered, along with the children’s sociodemographic factors. Binary 
logistic regression was used to assess the associations of nutritional habits with sociodemographic factors.    
Results
In multivariable-adjusted analysis, the odds of daily breakfast consumption on weekdays were significantly higher 
among males (OR=1.3, 95%CI=1.2-1.5), younger children (OR=2.7, 95%CI=2.4-3.2) and those from more affluent families 
(OR=1.2, 95%CI=1.1-1.4). Conversely, the odds of daily consumption of fruits and/or vegetables were lower among males 
(OR=0.8, 95%CI=0.7-0.9 and OR=0.7, 95%CI=0.6-0.7, respectively), but higher in younger children (OR=1.5, 95%CI=1.3-
1.8 and OR=1.4, 95%CI=1.2-1.6, respectively) and those from wealthier families (OR=1.3, 95%CI=1.2-1.5 and OR=1.2, 
95%CI=1.0-1.3, respectively). Additionally, the odds of daily consumption of sweets were lower among males (OR=0.7, 
95%CI=0.6-0.8) and younger children (OR=0.5, 95%CI=0.5-0.6). Also, the odds of daily consumption of sugary soft drinks 
were lower in younger children (OR=0.6, 95%CI=0.5-0.6) and urban residents (OR=0.8, 95%CI=0.7-0.9).        
Conclusions
Our findings provide useful insights into the complex interplay of sociodemographic characteristics in shaping nutritional 
practices of children. There is a need for targeted nutritional interventions based on the specific sociodemographic 
backgrounds of children in Albania and elsewhere, ultimately supporting healthier nutritional habits.
Cilj
Zdrave prehranjevalne navade v otroštvu spodbujajo zdravo rast in razvoj ter krepijo psihično in čustveno dobro počutje. 
Naš cilj je bil oceniti razširjenost in sociodemografske korelate izbranih prehranjevalnih navad med albanskimi šolarji.
Metode 
V Albaniji je bila leta 2022 v okviru raziskave o vedenju šoloobveznih otrok v zvezi z zdravjem izvedena presečna 
študija, v katero je bil vključen reprezentativni vzorec 5.454 šolarjev, starih od 11 do 15 let (≈52 % deklet; ≈96-
% odziv). Zbrani so bili podatki o prehranjevalnih navadah in sociodemografski dejavniki otrok. Za oceno 
povezanosti prehranjevalnih navad s sociodemografskimi dejavniki je bila uporabljena binarna logistična regresija. 
Rezultati
V multivariatno prilagojeni analizi je bila verjetnost vsakodnevnega uživanja zajtrka ob delavnikih znatno večja pri fantih 
(RO = 1,3, 95-% IZ = 1,2–1,5), mlajših otrocih (RO = 2,7, 95-% IZ = 2,4–3,2) in otrocih iz premožnejših družin (RO = 1,2, 95-% IZ 
= 1,1–1,4). Nasprotno je bila verjetnost dnevnega uživanja sadja in/ali zelenjave nižja pri fantih (RO = 0,8, 95-% IZ = 0,7–0,9 
oziroma RO = 0,7, 95-% IZ = 0,6–0,7), višja pa pri mlajših otrocih (RO = 1,5, 95-% IZ = 1,3–1,8 oziroma RO = 1,4, 95-% IZ = 
1,2–1,6) in otrocih iz premožnejših družin (RO = 1,3, 95-% IZ = 1,2–1,5 oziroma RO = 1,2, 95-% IZ = 1,0–1,3). Poleg tega je bila 
verjetnost dnevnega uživanja sladkarij manjša pri fantih (RO = 0,7, 95-% IZ = 0,6–0,8) in mlajših otrocih (RO = 0,5, 95-% IZ = 
0,5–0,6). Tudi verjetnost dnevnega uživanja sladkih brezalkoholnih pijač je bila manjša pri mlajših otrocih (RO = 0,6, 95-% 
IZ = 0,5–0,6) in živečih v mestih (RO = 0,8, 95-% IZ = 0,7–0,9).
Zaključki
Naše ugotovitve ponujajo koristen vpogled v zapleten preplet sociodemografskih značilnosti pri oblikovanju prehranjevalnih 
navad otrok. Potrebni so ciljno usmerjeni prehranski ukrepi, ki temeljijo na posebnih sociodemografskih značilnostih otrok v 
Albaniji in drugod, kar bi na koncu prispevalo k bolj zdravim prehranjevalnim navadam.
1 INTRODUCTION 
Poor nutritional habits constitute an important risk factor 
for ill-health and premature mortality (1). Inducement to 
healthy nutritional practices starting from an early age is 
crucial, as behavioural patterns developed in childhood 
and adolescence often carry over into adulthood (2, 3). 
Unhealthy dietary patterns and practices during childhood 
and adolescence contribute to the development of obesity 
and increased body fat (4, 5), a higher incidence of dental 
caries (6), increased blood pressure, poorer mental health 
and a lower quality of life (5, 7, 8). Conversely, healthy 
nutritional habits during childhood and adolescence not 
only reduce the risk of developing chronic conditions 
and noncommunicable diseases later in life (1), but also 
promote healthy growth and development (9, 10), and 
foster psycho-emotional wellbeing (5, 7, 8).   
Regular breakfast consumption is one of the main 
indicators of healthy nutritional practices in children 
(11) and has been convincingly linked to a healthier body 
mass index (BMI), better mental health, improved school 
performance and improved overall diet quality (11-14). 
Indeed, a comprehensive systematic review including 
about 290,000 children and adolescents in 33 countries (15) 
has reported that breakfast consumption among children 
and adolescents is associated with a lower BMI, better 
nutritional intake (16) and better cognitive status (17).
Regarding specific food items, consumption of fruit and 
vegetables is essential for the good physical and mental 
health of children (11, 18). Therefore, the World Health 
Organization (WHO) recommends consumption of at least 
five portions of fruit and vegetables per day and reduction 
of the consumption of free sugars to less than 10% of daily 
energy intake (11, 18). 
Reports from many countries have linked various 
sociodemographic factors with the eating habits of children 
(11, 18). Thus, fairly recent evidence indicates that breakfast 
consumption levels are higher among boys, younger children 
(11 years) and those from more affluent families (11). 
Conversely, daily consumption of fruit and/or vegetables has 
been reported to be higher among girls, younger children 
and those from more affluent families (11). Furthermore, 
daily consumption of sweets has been reported to be 
higher among girls, whereas the association with other 
sociodemographic factors is seemingly not consistent (11). 
Regarding daily consumption of sugary soft drinks, the 
available evidence indicates a higher level of consumption 
among boys and children from less affluent families (11). 
The Health Behaviour in School-aged Children (HBSC) study 
is a large school-based survey conducted every four years 
in many countries in Europe, Central Asia and Canada (11, 
19). The HBSC survey collects important information on 
several health behaviours, health outcomes and the social 
environments of children aged 11, 13 and 15 years (11, 19). 
10.2478/sjph-2025-0017 Zdr Varst. 2025;64(3):133-142
134
The last round of the HBSC survey was conducted in 2021-
2022 in 44 countries including Albania (11, 19, 20). In addition 
to many health outcomes and behavioural factors, the survey 
included a set of questions measuring selected nutritional 
habits among schoolchildren aged 11-15 years (11, 19). 
Fairly recent evidence from Albania indicates that almost 
1/3 of schoolchildren aged 12-15 years do not exhibit the best 
attitudes towards health promotion, including the ability to 
maintain and improve health (21). Furthermore, a previous 
study reported a strong and consistent positive relationship 
between breakfast skipping and obesity, but not overweight 
among Albanian children aged 7-10 years (22).
In this framework, the objective of our study was to 
assess the prevalence and sociodemographic correlates of 
selected nutritional habits among schoolchildren, based on 
the data obtained from the last round of the HBSC survey 
conducted in Albania in 2022 (20). In line with the evidence 
obtained from the previous rounds of HBSC surveys (11, 
19), we hypothesised a higher prevalence of breakfast 
consumption among boys, younger children and those 
from more affluent families. Conversely, we hypothesised 
a higher consumption of fruits and vegetables among girls, 
younger children and those from more affluent families, 
based on indications from previous HBSC rounds (11, 19). 
Additionally, we hypothesised a higher consumption of 
sweets among girls, but a higher consumption of sugary 
soft drinks in boys and children from less affluent families 
(11, 19). On the other hand, in the absence of supporting 
literature, we did not formulate any hypotheses regarding 
the association of eating habits with place of residence or 
parental employment status.        
2 METHODS 
2.1 Design and study population 
The data presented in this article were obtained from a 
cross-sectional study corresponding to the last round of 
the HBSC survey, which was carried out in Albania and 
in many other countries in Europe and beyond during the 
period 2021-2022 (11, 19). 
The study population comprised a nationwide 
representative sample of schoolchildren aged 11, 13 
and 15 years (stratified multistage cluster sampling with 
probability proportional to size) (20). Stratification was 
based on prefectures (regions) of Albania, which ensured 
an adequate representativeness of the sample at a national 
level. Overall, of 5,700 targeted children for inclusion 
in the study, the sample included 5,454 schoolchildren 
aged 11, 13 and 15 years (2,844 girls, or ≈52% of the total 
sample). The overall response rate was: 5,454/5,700≈96% 
(20). There was no need for weighting the data as the 
distribution of gender, age and geographical region in the 
final study sample corresponded to the target population 
(i.e., the overall number of schoolchildren in Albania).
10.2478/sjph-2025-0017 Zdr Varst. 2025;64(3):133-142
2.2 Data collection 
Data collection was conducted in May 2022. A structured 
self-administered and anonymous internationally 
standardised questionnaire included, among other health 
behavioural characteristics, assessment of nutritional 
habits (breakfast consumption and consumption of 
selected food items) and information on sociodemographic 
factors of schoolchildren (11, 19). 
Measurement of breakfast consumption on weekdays was 
based on the following question (19): “During weekdays, 
how often do you usually have breakfast (more than a glass 
of milk or fruit juice)?”. Potential response categories 
were as follows: “never”, “one day”, “two days”, “three 
days”, “four days”, “five days”. In the analysis, breakfast 
consumption was dichotomised into: “daily” (5 days) vs. 
“non-daily” (0-4 days).  
Conversely, measurement of the frequency of consumption 
of selected food items was based on the following 
questions (19): “How many times a week do you usually 
eat or drink: fruits, vegetables, sweets, and sugary soft 
drinks?”. Potential response categories for each food item 
were as follows: “never”, “less than once a week”, “once 
a week”, “2-4 days a week”, “5-6 days a week”, “once a 
day, every day”, and “every day, more than once”. In the 
analysis, the frequency of consumption of each food item 
was dichotomized into: “daily” (≥1/day) vs. “non-daily” 
(≤5-6/week) (19).  
Sociodemographic characteristics included children’s 
gender (boys vs. girls), age (11, 13 and 15 years), place of 
residence (urban vs. rural areas), mother’s and father’s 
current employment status (for each: yes vs. no), and 
family affluence scale (dichotomised into: less affluent 
[below median scores] vs. more affluent families [above 
median scores]) (19). 
2.3 Ethical aspects 
The study was approved by the Ethics Committee of 
Tirana Medical University (approval ID: No.700/1). All 
schoolchildren were informed about the objectives and 
procedures of the study, as well as the aspects regarding 
the anonymity of the survey and the subsequent 
aggregated data analysis. Furthermore, passive consent 
was sought from the parents through the teachers from 
each respective school.
135
2.4 Statistical analysis    
Binary logistic regression was used to assess the 
association of nutritional habits with sociodemographic 
characteristics of schoolchildren. Initially, crude 
(unadjusted) models were run (Table 2). Odds ratios (ORs) 
and their respective 95% confidence intervals (95%CIs) 
and p-values (P) were calculated for each nutritional 
habit. Next, all sociodemographic factors (gender, age, 
residence, mother’s and father’s employment status, and 
family affluence scale) were entered simultaneously into 
the logistic regression models (Table 3). Multivariable-
adjusted ORs and their respective 95%CIs and p-values were 
calculated for each of the nutritional habits (breakfast 
intake, and consumption of fruits, vegetables, sweets 
and sugary soft drinks). For all the multivariable-adjusted 
logistic regression models, a Hosmer-Lemeshow test 
was used to assess the goodness-of-fit; all multivariable-
adjusted models fit the Hosmer-Lemeshow criterion (23). 
For all statistical tests employed, P≤0.05 was considered 
statistically significant. Statistical Package for the Social 
Sciences (SPSS, version 19.0) was used for all the statistical 
analyses.
3 RESULTS
Table 1 presents the distribution of nutritional habits by 
sociodemographic characteristics of the schoolchildren. 
The overall prevalence of daily breakfast consumption was 
about 48%. 
Daily breakfast consumption was more frequent among 
boys, 11-year-olds, children living in urban areas, those 
whose parents were both employed and children from 
more affluent families. The overall prevalence of daily 
fruit and/or vegetable consumption was around 59% and 
47%, respectively. Fruit and/or vegetable consumption was 
more frequent among girls, youngest children, those whose 
fathers were employed and in children from more affluent 
families. The overall prevalence of daily consumption of 
sweets was about 36%. Consumption of sweets was more 
frequent for girls among the oldest children, in those from 
rural areas and in children with unemployed fathers. The 
overall prevalence of daily consumption of sugary soft 
drinks was around 29%. Consumption of sugary soft drinks 
was more frequent among the oldest children, in those 
from rural areas and in schoolchildren whose mothers 
were unemployed.
Table 2 presents the crude/unadjusted associations of 
nutritional habits with sociodemographic characteristics 
of the schoolchildren. 
10.2478/sjph-2025-0017 Zdr Varst. 2025;64(3):133-142
136
Distribution of selected nutritional habits by sociodemographic characteristics in a nationwide sample of Albanian 
schoolchildren, HBSC 2022.  
Legend: a Absolute numbers and their respective percentages (in parentheses). For nutritional habits, there were the following missing 
values: breakfast consumption (n=349), fruit consumption (n=53), vegetable consumption (n=70), consumption of sweets (n=68), and 
consumption of sugary soft drinks (n=70). In addition, there were the following missing values for sociodemographic factors: age of 
schoolchildren (n=8), father’s employment status (n=47); mother’s employment status (n=68); and family affluence score (n=139).
Sociodemographic 
characteristics Breakfast Vegetables
Daily consumption
Fruit Sweets Sugary soft drinks
Table 1.
Total sample (n=5454)
Gender:
Boys (n=2610)
Girls (n=2844)
Age:
11 years (n=1784)
13 years (n=1785)
15 years (n=1877)
Residence:
Urban areas (n=3648)
Rural areas (n=1806)
Father’s employment:
Yes (n=4928)
No (n=479)
Mother’s employment:
Yes (n=3676)
No (n=1710)
Family affluence:
Less affluent (n=2600)
More affluent (n=2715)
2461 (48.2) a
1265 (52.1)
1196 (44.7)
1023 (62.2)
754 (45.6)
681 (37.9)
1676 (48.8)
785 (46.9)
2260 (49.0)
190 (42.0)
1701 (49.3)
734 (45.9)
1113 (45.8)
1290 (50.4)
1911 (35.5)
791 (30.9)
1120 (39.7)
495 (28.1)
631 (35.9)
782 (42.1)
1253 (34.8)
658 (36.9)
1697 (34.8)
193 (40.8)
1259 (34.6)
623 (36.9)
898 (34.9)
962 (35.9)
3174 (58.8)
1434 (55.7)
1740 (61.5)
1145 (64.7)
1004 (57.0)
1021 (54.8)
2125 (58.7)
1049 (58.9)
2897 (59.3)
248 (52.2)
2164 (59.4)
975 (57.6)
1434 (55.5)
1657 (61.7)
2549 (47.3)
1072 (41.9)
1477 (52.3)
946 (53.5)
759 (43.3)
841 (45.3)
1701 (47.2)
848 (47.6)
2327 (47.8)
204 (43.3)
1710 (47.1)
814 (48.3)
1179 (45.9)
1303 (48.6)
1582 (29.4)
766 (29.9)
816 (28.9)
409 (23.2)
524 (29.9)
647 (34.8)
1007 (27.9)
575 (32.3)
1424 (29.2)
142 (30.1)
1033 (28.4)
528 (31.3)
747 (29.1)
798 (29.8)
137
10.2478/sjph-2025-0017 Zdr Varst. 2025;64(3):133-142
Associations of nutritional habits with sociodemographic characteristics of schoolchildren; results from unadjusted binary 
logistic regression models. 
Legend: a Odds ratios and their respective 95% confidence intervals (in parentheses), as well as p-values from crude (unadjusted) binary 
logistic regression models. Reference groups for nutritional habits were as follows: “non-daily” (0-4 days) for breakfast consumption 
during weekdays, and “non-daily” (≤5-6/week) for the other dietary practices. b Compared to age 15.  
Daily consumption
Daily consumption
              Male
OR (95%CI) a
       Father employed
OR (95%CI) a
P a
P a
P
P
P
P
            Urban areas
OR (95%CI)
            More affluent
OR (95%CI)
Demographic variables
Socioeconomic variables
             Age 11 b
OR (95%CI)
       Mother employed
OR (95%CI)
Table 2.
Breakfast
Nagelkerke R²
Area under the curve (AUC)
Fruit
Nagelkerke R²
AUC
Vegetables
Nagelkerke R²
AUC
Sweets
Nagelkerke R²
AUC
Sugary soft drinks
Nagelkerke R²
AUC
Breakfast
Nagelkerke R²
Area under the curve (AUC)
Fruit
Nagelkerke R²
AUC
Vegetables
Nagelkerke R²
AUC
Sweets
Nagelkerke R²
AUC
Sugary soft drinks
Nagelkerke R²
AUC
1.35 (1.21-1.51)
0.01
54%
0.79 (0.71-0.88)
0.01
47%
0.66 (0.59-0.73)
0.02
45%
0.68 (0.61-0.76)
0.01
46%
1.05 (0.93-1.18)
<0.01
51%
1.32 (1.09-1.61)
<0.01
54%
1.34 (1.11-1.61)
<0.01
54%
1.20 (0.99-1.45)
<0.01
52%
0.78 (0.64-0.94)
<0.01
47%
0.96 (0.78-1.18)
<0.01
50%
<0.001
<0.001
<0.001
<0.001
<0.001
0.005
0.003
0.064
0.010
0.700
<0.001
<0.001
<0.001
<0.001
<0.001
0.024
0.210
0.416
0.112
0.030
0.199
0.917
0.759
0.114
<0.001
0.001
<0.001
0.047
0.463
0.578
2.70 (2.35-3.09)
0.05
60%
1.51 (1.32-1.73)
0.01
54%
1.39 (1.22-1.59)
0.01
55%
0.54 (0.47-0.62)
0.02
45%
0.57 (0.49-0.65)
0.02
45%
1.15 (1.02-1.29)
<0.01
52%
1.08 (0.96-1.21)
<0.01
51%
0.95 (0.85-1.07)
<0.01
49%
0.91 (0.80-1.02)
<0.01
49%
0.87 (0.77-0.99)
<0.01
49%
1.08 (0.96-1.21)
<0.01
51%
0.99 (0.89-1.12)
<0.01
50%
0.98 (0.88-1.10)
<0.01
50%
0.91 (0.81-1.02)
<0.01
49%
0.81 (0.72-0.92)
<0.01
48%
1.21 (1.08-1.35)
<0.01
52%
1.29 (1.16-1.44)
0.01
53%
1.12 (1.00-1.24)
<0.01
51%
1.04 (0.93-1.17)
<0.01
51%
1.03 (0.92-1.17)
<0.01
50%
138
10.2478/sjph-2025-0017 Zdr Varst. 2025;64(3):133-142
Independent associations of sociodemographic factors with nutritional habits; results from multivariable-adjusted binary 
logistic regression models.  
Legend: a Odds ratios and their respective 95% confidence intervals (in parentheses), as well as p-values from crude (unadjusted) binary 
logistic regression models. Reference groups for nutritional habits were as follows: “non-daily” (0-4 days) for breakfast consumption 
during weekdays, and “non-daily” (≤5-6/week) for the other dietary practices. b Compared to age 15.  
Daily consumption
Daily consumption
              Male
OR (95%CI) a
       Father employed
OR (95%CI) a
P a
P a
P
P
P
P
            Urban areas
OR (95%CI)
            More affluent
OR (95%CI)
Demographic variables
Socioeconomic variables
             Age 11 b
OR (95%CI)
       Mother employed
OR (95%CI)
Table 3.
Breakfast
Fruit
Vegetables
Sweets
Sugary soft drinks
Breakfast
Fruit
Vegetables
Sweets
Sugary soft drinks
1.30 (1.16-1.46)
0.76 (0.68-0.85)
0.65 (0.58-0.72)
0.68 (0.61-0.77)
1.08 (0.95-1.22)
1.18 (0.96-1.45)
1.21 (0.99-1.47)
1.16 (0.95-1.42)
0.82 (0.67-1.01)
1.02 (0.83-1.27)
<0.001
<0.001
<0.001
<0.001
0.228
0.116
0.062
0.141
0.056
0.834
<0.001
<0.001
<0.001
<0.001
<0.001
0.113
0.379
0.437
0.237
0.078
0.229
0.809
0.974
0.086
<0.001
0.002
<0.001
0.009
0.258
0.601
2.73 (2.37-3.15)
1.52 (1.33-1.75)
1.40 (1.22-1.60)
0.54 (0.47-0.62)
0.55 (0.48-0.64)
1.11 (0.98-1.25)
1.06 (0.94-1.19)
0.95 (0.85-1.08)
0.93 (0.82-1.05)
0.89 (0.78-1.01)
1.08 (0.95-1.22)
0.99 (0.87-1.11)
0.99 (0.89-1.12)
0.90 (0.79-1.02)
0.79 (0.70-0.90)
1.21 (1.08-1.36)
1.33 (1.18-1.49)
1.16 (1.04-1.30)
1.07 (0.95-1.21)
1.03 (0.91-1.17)
The odds of daily breakfast consumption were significantly 
higher among males (OR=1.4, 95%CI=1.2-1.5), in the 
youngest children (OR=2.7, 95%CI=2.4-3.1), in those whose 
fathers and/or mothers were employed (OR=1.3, 95%CI=1.1-
1.6 and OR=1.2, 95%CI=1.0-1.3, respectively), and among 
children from more affluent families (OR=1.2, 95%CI=1.1-
1.4). Conversely, the odds of daily fruit consumption were 
significantly lower among males (OR=0.8, 95%CI=0.7-0.9), 
but higher among younger children (OR=1.5, 95%CI=1.3-
1.7), in those whose fathers were employed (OR=1.3, 
95%CI=1.3-1.6) and among children from more affluent 
families (OR=1.3, 95%CI=1.2-1.4). Likewise, the odds of 
daily vegetable consumption were significantly lower 
among males (OR=0.7, 95%CI=0.6-0.7), but higher among 
younger children (OR=1.4, 95%CI=1.2-1.6) and those from 
more affluent families (OR=1.1, 95%CI=1.0-1.2). In turn, 
the odds of daily consumption of sweets were significantly 
lower among males (OR=0.7, 95%CI=0.6-0.8), children 
aged 11 (OR=0.5, 95%CI=0.5-0.6) and those whose fathers 
were employed (OR=0.8, 95%CI=0.6-0.9). Furthermore, 
the odds of daily consumption of sugary soft drinks were 
significantly lower among the youngest children (OR=0.6, 
95%CI=0.5-0.7), urban residents (OR=0.8, 95%CI=0.7-
0.9) and those whose mothers were employed (OR=0.9, 
95%CI=0.8-1.0).  
In multivariable-adjusted binary logistic regression models 
(Table 3), the odds of daily breakfast consumption were 
significantly higher among males (OR=1.3, 95%CI=1.2-1.5), 
children aged 11 (OR=2.7, 95%CI=2.4-3.2) and those from 
more affluent families (OR=1.2, 95%CI=1.1-1.4). 
Conversely, the odds of daily fruit intake were significantly 
lower among males (OR=0.8, 95%CI=0.7-0.9), but higher 
in children aged 11 (OR=1.5, 95%CI=1.3-1.8) and those 
from more affluent families (OR=1.3, 95%CI=1.2-1.5). 
Furthermore, the odds of daily vegetable intake were 
significantly lower among males (OR=0.7, 95%CI=0.6-0.7), 
but higher in younger children (OR=1.4, 95%CI=1.2-1.6) and 
those from more wealthy families (OR=1.2, 95%CI=1.0-1.3). 
Additionally, upon multivariable adjustment, the odds 
of daily consumption of sweets were significantly lower 
among males (OR=0.7, 95%CI=0.6-0.8) and children aged 
11 (OR=0.5, 95%CI=0.5-0.6). In turn, the odds of daily 
consumption of sugary soft drinks were significantly lower 
in younger children (OR=0.6, 95%CI=0.5-0.6) and urban 
residents (OR=0.8, 95%CI=0.7-0.9).        
4 DISCUSSION 
In our study, daily breakfast consumption among Albanian 
schoolchildren aged 11-15 years was more frequent among 
boys, younger individuals and those from more affluent 
families, highlighting the role of socioeconomic factors in 
dietary habits. In contrast, fruit and vegetable intake were 
more frequent among girls, younger children and those 
from more affluent families. Daily sweets consumption was 
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more frequent among girls and younger children, whereas 
sugary soft drink intake was more prevalent among older 
children and those from rural areas.
A fairly recent report indicating the same nutritional 
habits among all 44 participating countries in the last 
HBSC survey round conducted in 2021-22 (11) indicates 
that only half of adolescents (51%) eat breakfast daily on 
weekdays, which is slightly higher than our finding related 
to Albanian children of the same age group (48%). Daily 
breakfast consumption has been reported as low as 8% 
among 15-year-old girls in North Macedonia to 86% among 
11-year-old boys in the Netherlands (11). Generally, 
a significant decline between 2018 and 2002 in daily 
breakfast consumption was observed in more than half 
of the countries included in the last HBSC round (11). In 
Albania, there is evidence of a small decline. Conversely, 
the largest decrease is evident in North Macedonia (29% 
and 28% decreases among boys and girls respectively), 
whereas Serbia is the only country with an increase in 
daily breakfast consumption across all gender and age 
groups (11).
Furthermore, according to the multi-country HBSC 2021-
22 report (11), a higher proportion of boys (56%) reported 
daily breakfast consumption compared to girls (46%), a 
gender-difference which is similar to our findings (52% in 
boys vs. 45% in girls). 
Our finding regarding an inverse relationship of breakfast 
consumption with age is in line with a fairly recent 
systematic review which has convincingly documented 
that the frequency of breakfast consumption decreases 
across the primary-school transition (24). According to this 
review, it may be possible that, as children transition into 
adolescence, their daily sleep patterns evolve, which may 
lead to a reduced sense of hunger upon waking in the 
morning (24, 25). Other influencing factors for skipping 
breakfast among older children may include their growing 
autonomy and increased peer pressure (24, 26).  
In our study, boys and girls from more affluent families 
were more likely to eat breakfast daily, a finding which is 
compatible with the multi-country HBSC 2021-22 report 
(11). It has been convincingly shown that parents from 
wealthier families, among other things, play a significant 
role as a positive model for their children in acquir¬ing 
and adopting healthy dietary patterns (27). Also, in the 
Albanian context, this may be presumably due to a greater 
awareness about the importance of breakfast intake 
among children from a wealthier background, or due to 
a more structured family routine as parents from affluent 
backgrounds often have more flexible work schedules, 
allowing for a more organised morning routine that includes 
breakfast. Conversely, Albanian children from less affluent 
families may skip breakfast due to economic hardship, or 
lack of time and/or limited parental supervision.
The recent multi-country HBSC report indicates that only 
38% of children consume fruits and vegetables daily (11), 
which is lower than our findings in Albania (59% for fruits 
and 47% for vegetables). Regarding the relationship with 
gender and age, in our study, consumption of fruits and 
vegetables was higher in girls than in boys and declined 
with age in both genders – findings which are compatible 
with the multi-country HBSC 2021-22 report (11). Also, 
we found the same social gradient in daily consumption 
of fruits and/or vegetables as evidenced in the recent 
multi-country HBSC report, with higher levels among 
schoolchildren from more affluent families (11). Daily 
fruit and vegetable consumption may be higher among 
schoolchildren from more affluent families in Albania due 
to greater financial ability to purchase these products, 
higher parental education levels, and an increased 
awareness of healthy eating habits. In contrast, less 
affluent families in Albania may rely more on cheaper, 
calorie-dense foods, leading to lower intake of fruits and 
vegetables among their children. 
In 2018-2022, on average, fruit and vegetable consumption 
remained almost stable in HBSC participating countries, 
which is also the case of Albania and several neighbouring 
countries except North Macedonia, which exhibited a 
notable decrease in daily vegetable consumption (11).   
In our study, more than 1/3 of children (36%) reported 
daily consumption of sweets, which is higher than the 
average estimate of the recent multi-country HBSC report 
(25%) (11). Generally, girls reported eating sweets more 
often than boys in countries which participated in the last 
HBSC round (11), which is in line with our findings. On the 
other hand, daily consumption of sweets was generally 
higher among schoolchildren from high-affluence families 
according to the HBSC multi-country report (11), a finding 
which was not evident in our study. On the other hand, 
between 2018 and 2022, daily consumption of sweets 
decreased in Albania (4% in boys and 5% in girls), a 
reduction which was higher than in Serbia, Croatia, North 
Macedonia, or the Republic of Moldova (11).   
The overall prevalence of daily consumption of sugary 
soft drinks in our study (29%) was almost twice as high 
as the multi-country average (15%). Generally, boys were 
more likely than girls to consume sugary soft drinks daily 
in countries which participated in the last HBSC round 
(11), a finding which was not also evident in our study. 
Furthermore, we did not find an association of sugary soft 
drinks with family wealth, in contrast to several former 
communist countries (including the Republic of Moldova 
and Poland) where the consumption was more frequent 
among children from more affluent families (11).     
In our study, there was no evidence of significant 
associations between place of residence and nutritional 
habits, except for sugary soft drinks. This may be due to 
the relatively homogeneous food environment across urban 
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10.2478/sjph-2025-0017 Zdr Varst. 2025;64(3):133-142
and rural settings in Albania, where access to food options 
does not differ substantially. Furthermore, we did not find 
any significant associations between parental employment 
status and nutritional habits of schoolchildren. Seemingly, 
employment status does not strongly influence children’s 
dietary patterns in the Albanian context, probably due 
to the extended family structures and strong cultural 
norms around family meals which likely reduce the direct 
impact of parental employment on children’s dietary 
patterns, as grandparents or other family members often 
take responsibility for meal preparation and supervision. 
However, our findings related to parental employment and 
place of residence should be confirmed in future studies.  
A major strength of our study consists of the large 
nationwide representative sample of schoolchildren and 
the use of an internationally standardised instrument (19). 
Yet, regarding external validity, a potential limitation of 
this study may include the lack of generalisability to out-
of-school Albanian children aged 11-15 years. Furthermore, 
there is a possibility of information bias including in 
particular social desirability bias (over-reporting of fruit and 
vegetable intake and/or under-reporting of consumption of 
sweets and sugary soft drinks), or intentional misreporting. 
Additionally, validation studies in Belgian and Italian 
schoolchildren have indicated that overestimation must 
be considered while estimating consumption frequencies 
in the HBSC surveys (28). Also, the cross-sectional study 
design may constitute another limitation, preventing the 
establishment of causal relationships. 
Nonetheless, our study provides useful evidence on 
the prevalence and sociodemographic distribution of 
several important nutritional habits among Albanian 
schoolchildren. Targeted interventions need to be 
implemented in Albania and elsewhere to help children 
develop healthier behaviours and prevent habits that could 
impact their current health and well-being, as well as their 
future health outcomes as adults (11). In any case, a variety 
of public health approaches are essential to effectively 
address the intricate factors influencing positive changes 
in nutritional habits among children (11). In the context 
of Albania, the government should act swiftly to limit the 
marketing of unhealthy foods and beverages, especially 
when such marketing is aimed at children and adolescents 
(11). Also, introduction of school-based programmes 
should be considered to encourage breakfast consumption 
among older children and those from less wealthy families. 
Furthermore, school-based programmes in Albania should 
consider the provision of free or subsidised fruits and 
vegetables, combined with interactive nutrition education 
and parental engagement, which can effectively increase 
their consumption among schoolchildren.
5 CONCLUSIONS  
In conclusion, our study conducted in Albania provides useful 
insights into the complex interplay of sociodemographic 
characteristics in shaping nutritional practices of children. 
There is a need for targeted nutritional interventions 
based on specific sociodemographic backgrounds of 
children in Albania and in other countries, ultimately 
supporting healthier nutritional habits.
ACKNOWLEDGMENT
This study was conducted by the Faculty of Medicine, 
University of Medicine, Tirana, Albania.
INFORMED CONSENT
Written informed consent was obtained from all 
individual participants included in the study. This study 
was approved by the Ethics Committee of Tirana Medical 
University (approval ID: No.700/1, date: 05-04-2022), and 
all procedures were conducted in accordance with the 
Declaration of Helsinki.
CONFLICTS OF INTERESTS 
None declared. 
FUNDING
This study was funded by the following agencies: the 
United Nations Population Fund (UNFPA) Office in Albania, 
the United Nations Children’s Fund (UNICEF) Office in 
Albania, and the Swiss Development and Cooperation 
(SDC) Agency through the project “Schools for Health” 
implemented in Albania. 
ETHICAL APPROVAL
This study was approved by the Ethics Committee of 
Tirana Medical University (approval ID: No.700/1, date: 
05-04-2022).
AVAILABILITY OF DATA AND MATERIALS
All data and materials used in this study are available 
upon reasonable request. 
AUTHORS’ CONTRIBUTIONS
Jonida Stefa, Gentiana Qirjako and Genc Burazeri 
contributed to the study conceptualisation and design, 
analysis and interpretation of the data and writing of the 
article. Migena Gega, Brizida Refatllari and Grejd Hyska 
commented comprehensively on the manuscript. All 
authors have read and approved the submitted manuscript. 
ORCID  
Jonida Stefa: 
http://orcid.org/0009-0006-2868-3837
Migena Gega: 
http://orcid.org/0009-0009-7568-6012
Brizida Refatllari: 
http://orcid.org/0009-0008-3157-0731
Grejd Hyska: 
http://orcid.org/0009-0000-3775-0858
Gentiana Qirjako: 
http://orcid.org/0000-0003-3179-9006 
Genc Burazeri: 
http://orcid.org/0000-0003-4813-4000
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