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Abstract
Junk food consumption increases the risk of having symptoms of mental health problems. This study aimed to conduct a meta-analysis to assess the asso-
ciation between junk food and symptoms of mental health problems. The study was conducted by a systematic literature review from October to December
2020. The data sources were selected from PubMed and ScienceDirect articles published from 2010 to 2020. Those websites were check-marked for text
availability for original articles, using keywords for junk foods and mental health. This study had inclusion criteria for selecting articles and organizing articles
using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline. The full-text articles were selected for conducting a meta-
analysis using R Studio Software. The 5,079 article titles were obtained, seven of which met the relevant requirements for meta-analysis. The range of res -
pondents who experienced symptoms of mental illness was 1.38%–79.8%. There was no heterogeneity based on the tau-squared test. The correlation coef-
ficient was 0.11 (95% CI = 0.09–0.14), with no publication bias based on Egger’s regression test (0.602 or p-value > 0.05). The frequent consumption of junk
food can contribute to mental illness symptoms, even within minimal effects.
Keywords: children, junk food, mental health problems, meta-analysis
Junk Food Consumption and Symptoms of Mental Health
Problems: A Meta-Analysis for Public Health Awareness
Muhammad Hafizurrachman1*, Risky Kusuma Hartono1
1Department of Public Health, Sekolah Tinggi Ilmu Kesehatan Indonesia Maju, Jakarta, Indonesia
Introduction
Mental illness symptoms, such as stress, depression,
and anxiety, causes long-term nervousness and psycho-
logical problems,1weight loss,2drug abuse,3self-
torture,4suicide,5murder,6and premature mortality.7In
Indonesia, people with mental disorders were isolated us-
ing tied ropes or “dipasung,” to prevent them from en-
dangering the lives of others.8People in any age group
can have a mental illness, including children.9In fact,
children might have prolonged mental illness up to their
adulthood.10
A study showed that the risk factors for mental illness
are social environment, family issues, and violence.5
Several studies also revealed that a healthy diet con-
tributes to reducing the risk of mental illness.11 Con -
sumption of fruits and vegetables is believed to improve
mental health because micronutrients such as vitamins,
antioxidants, and minerals protect against mental ill-
ness.12 Unfortunately, the habit of fruit consumption has
been pushed aside by the increasing trend of high
salt/sugar-laden diets.
The habit of junk food consumption has increased
around the world.13 Foods with high sugar and salt con-
tent are widely recognized as causes of non-communica-
ble diseases such as diabetes, heart disease, and stroke.14
Recent evidence demonstrates an association between
junk food consumption and an increased risk of mental
disorders.15 Previous studies only applied meta-analysis
techniques between nutritious foods and mental prob-
lems. The results did not include junk foods to quantify
the findings.16
Method
The systematic literature review (SLR) was conduct-
ed by six authors, consisted of two primary authors and
four authors assistants, organized from October to early
December 2020. The SLR refers to the guidelines for sys-
tematic review and meta-analysis, called the Preferred
Reporting Items for Systematic reviews and Meta-
Analyses (PRISMA) guideline.17 This study has been
regis tered to the International Prospective Register of
Systematic Reviews, known as PROSPERO, with ID
CRD42020218992 and accepted as a type of systema tic
review and meta-analysis. PROSPERO is an international
database of prospectively registered systematic reviews,
rapid reviews, and umbrella reviews in health and social
Hafizurrachman et al. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public
Health Journal).2021; 16 (1): 1-8
DOI: 10.21109/kesmas.v16i1.4541
Correspondence*:
Muhammad Hafizurrachman, Department of Public Health,
Faculty of XX, Sekolah Tinggi Ilmu Kesehatan Indonesia Maju, Harapan Street
No. 50 Lenteng Agung, South Jakarta, Jakarta, Indonesia, Email: hafizurrach-
man@gmail.com, Phone: +62 818 120 663
Received : December 17, 2020
Accepted : January 03, 2021
Published: February 20, 2021
Copyright @ 2021, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited,
http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International
Kesmas: Jurnal Kesehatan Masyarakat Nasional
(National Public Health Journal)
2
care also does not accept scoping reviews or literature
scans. Key features from the review protocol are record-
ed and maintained as a permanent record in PROS-
PERO. The Ethics Committee has approved the study at
Sekolah Tinggi Ilmu Kesehatan Indonesia Maju, referen -
ce number: 2417/Sket/Ka-Dept/RE/STIKIM/IX/2020.
The source of this study used was from PubMed and
ScienceDirect website. The reason for choosing these two
databases was because they are well-known health data-
bases and their bibliometrics offer free and easy access to
verify work conducted by others. The first step is to go to
the address https://pubmed.ncbi.nlm.nih.gov/. Then en-
ter keywords into the website search engine, re presenting
study material to find relevant articles. On the PubMed
website, “check-mark” the text availability article (full
text and free full text), article type (book and documents,
clinical trial, and Randomized Control Trial), with the
publication of the last ten years (2010–2020). For
ScienceDirect: go to the address https://sciencedi -
rect.com. Do the same as with the PubMed website, by
specifying the article type or research article, “check-
mark” all categories for the publication title, and all sub-
ject areas.
The next step was following the PRISMA guideline.17
The guideline was: 1) Identifying: It was to identify the
titles of relevant journal articles in the search column on
the two website addresses for this study, the authors used
keywords for study themes by using quotation marks or
apostrophes. For two or more keywords, the authors
used the boolean symbol “AND” between keywords. The
keywords used to find articles related to junk food con-
sumption (as an exposure) and mental illness (as an out-
come) are: “junk food” and “mental health,” “Junk food”
and “mental disorders,” “Junk food” and “depression,”
“junk food” and “stress,” “junk food” and “sadness,”
“junk food” and “insomnia,” “junk food” and “anxiety;”
“mental health” and “snacks,” “mental health” and
“bread,” “mental health” and “ice cream,” “mental
health” and “chocolate,” “mental health” and “sweetened
food,” “mental disorder” and “snacks,” “mental disorder”
and “bread,” “mental disorder” and “ice cream,” “mental
disorder” and “chocolate,” and finally, “mental disorder”
and “sweetened food.” Additionally, junk food compo-
nents were defined as “canned food,” “chocolate,” “in-
stant noodles,” and “bread,” paired with “processed
cheese,” “frozen cake,” “ice cream,” “candy,” “baked
food,” and “dried sweet food”.18–20 Duplicate articles
that appeared several times during keyword searches
were not reused; 2) Screening: to screen journal articles'
titles, select the article title that matches the research
theme. All abstract identifications were read and re-
viewed based on the inclusion criteria. The inclusion cri-
teria are that they are original articles discussing junk
food and mental health. Study interviews were conducted
in person and written in English, and the study's method
was quantitative. Mental health inclusion criteria were
“depression,” “stress,” “sadness,” “insomnia,” and “anx-
iety” because these five disorders have a high prevalence
worldwide.18,19 Abstract articles that did not meet the
criteria were eliminated; 3) Eligibility: Selected journals
that meet the inclusion criteria should be downloaded
with full text. The criteria prevail to both open- and
closed-access journals. All journals are reviewed and se-
lected to find the association between junk food con-
sumption and symptoms of mental health problems.
Articles where no associations were found will not be
used; 4) Included: All journals articles at this phase that
meet all the inclusion criteria are arranged by author
year, country study, study design, study period, sample
size, number, respondents, average age, type of junk
food, consumption frequency, cases of mental problems,
sample case(s) of mental problems, percentages, covari-
ates, and OR values. This data is required to compute a
meta-analysis using R Studio Software, an open-source
software named “The Metaphor Package” (can be down-
loaded from https://cran.r-project.org/package=
metafor). The OR values of journals that were not found
were excluded.
The final step calculates the meta-analysis by showing
the three components: 1) heterogeneity figure (Q-statis-
tic, I-squared, tau-squared). It seeks to obtain whether
the data results on the selected journals are homogenous
or heterogeneous; 2) Looking at the publication bias fig-
ure (Funnel Plot, Egger's regression test) with the target
result that there is no publication bias; and 3) Visual
Effect size figure shows a significant target yield and no
bias. If the article found does not provide a 2x2 table in-
formation, then to calculate the meta-analysis it is neces-
sary to transform the OR value into the Pearson Product
Moment Value through Cohen's d Calculation.21
Results
Figure 1 shows the process of identification of eligible
articles for a meta-analysis of the association between
junk food consumption and symptoms of mental health
problems. A review of the database online journals found
1,889 articles that were necessarily removed due to du-
plication. On the o ther hand, 2,209 articles were exclud-
ed because 611 articles did not discuss junk food, 94 ar-
ticles did not use humans subjects, 141 and 987 articles
were comment and review articles, respectively, and 376
articles used a qualitative design. During the full-text ar-
ticle review, 82 articles were excluded for not reporting
the association test. Upon completion, seven eligible ar-
ticles relevant to the study remained.
Table 1 shows the resulting characteristics of the eli-
gible article for the systematic review. Most of the studies
were carried out in developed countries such as the
Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2021; 16 (1): 1-8
3
United Kingdom,19,22 and Norway,23 from continental
Europe, Korea,24 and China,25 from Asia. All studies
used a cross-sectional design. One article from the publi-
cation year fell within the inclusion time frame of this
study. The study used data from 2006 and 2009.22 All
articles used large sample sizes. The least was 334 re-
spondents,26 and the most were 105,061 respondents.27
The age groups of respondents varied from children to
15–19 year-old,15 adolescents,24 and all age ranges. The
lowest age group was 12 years.22,23 The oldest was 58
years.26
Table 2 shows, in the eligible articles, that the various
types of junk food were salty and unhealthy snacks,15,19
cakes, biscuits, sugary products, sweetened food, and piz-
za.27 All studies mentioned that daily junk food con-
sumption is associated with developing symptoms of
mental health problems. The other frequent categories
were “high frequency”,24 and “always consuming” junk
food.22 In general, mental health problems were com-
prised of poor mental health,22 and mental health ill-
ness.15,22–25,27 They also included psychiatric disor-
ders,15,23 sleep dissatis fact ion,24 stress,25 and suicide at-
tempts.27
The proportions of respondents suffering from mental
health problems ranged from 1.38%,24 to 79.8%.27
Covariates of the study were sociodemographic condi-
tions (age, gender, level of education, hostile behaviors
such as smoking,15,18,19,22 alcohol use,19,24 and body
mass index (BMI).15,18,22 The control variables to reduce
the adverse mental health effects were routine fruit and
vegetable,27 consumption and physical activity.22,27
All of the articles produced OR ranged from 1.31 to
1.9.25,27 Nor did all of the articles present the total cases
of respondents with mental health problems,19,26 as pre-
sented in Table 2. Because there is no 2x2 table informa-
tion in Table 2, the OR value of the seven selected articles
must be transformed into a Pearson Product moment va -
lue that shown in Figure 2.
The meta-analysis based on R Studio Software, the
random effect model's heterogeneity analysis results
show that the estimated amount of total heterogeneity
using the tau-squared test was equal to 0.0008 and Q-
statistic with a p-value equal to 0.0001. Furthermore, the
calculation of the I-squared result was 93.91%. The three
Table 1. Eligible Articles Characteristic
Author Year Country Study Study Design Study Period Sample Size Respondents Age (Mean in Years)
Zahedi, et al.,15 2014 Iran Cross-sectional 2011–2012 13,486 Children 15–19
Zahra, et al.,22 2014 United Kingdom Cross-sectional 2006 and 2009 10,645 Participants 12–14
Oelingrath, et al.,23 2014 Norway Cross-sectional 2010 789 Participants 12–13
Park, et al.,24 2016 Korea Cross-sectional 2015 68,043 Adolescents 15.07
Xu H, et al.,25 2020 Chinese Cross-sectional 2017– 2018 14,500 Middle schools 14.9
Jacob, et al.,27 2020 32 Countries Cross-sectional 2009–2015 105,061 Adolescents 13–15
Chaplin, et al.,19 2011 United Kingdom Cross-sectional 2011 870 Participants 45
Figure 1. Flowchart of PRISMA Guideline Figure 2. Forest Plot between Junk Food Consumption and the Symptoms of
Mental Health Problems
Hafizurrachman et al, Junk Food Consumption and Symptoms of Mental Health Problems
4
tests above resulted in different statuses of heterogeneity.
Two tests said the study had heterogeneity (Q-statistic
and I-squared), one study said no heterogeneity (tau-
squared). It was caused by a range of sample sizes among
the selected articles.
Figure 2 shows the magnitude of association mea -
sured by the correlation coefficient showed a small asso-
ciation between junk food consumption and the symp-
toms of mental health problems (0.11 with 95% CI =
0.09–0.14).
In Figure 3, the results of publication bias analysis us-
ing a Funnel Plot showed asymmetric results since the
distribution of dots has no balance. There is another test,
Egger’s regression test, which aims to compare the
Funnel Plot result. The results of Egger’s regression test
analysis showed a value of 0.602 or a p-value of more
than 0.05, which indicates that there is no publication
bias.
Discussion
The results of the meta-analysis of this study indicate
a significant positive association between the frequency
of junk food consumption and symptoms of mental
health problems (0.11 with 95% CI = 0.09–0.14).
Several previous systematic review articles between nu-
trient food and mental illness suggest that it is better to
reduce the consumption of high fat and high sugar foods
to prevent mental illness symptoms.16 Polat, et al.,28 re-
vealed that frequent junk food consumption leads to an
increase in testosterone and estrogen production, which
might cause specific problems, including stress triggers.
Palacios, et al.,29 added that junk food substances from
nuts trigger phytoestrogens' development, which can
Table 2. Type of Junk Food and Mental Health Problems in the Eligible Article
Author Type of Junk Food Consumption Case of Mental Problem n % Covariate OR
Frequency
Zahedi, et al.,15 Salty Snacks, Sweets, Daily Psychiatric distress (worry, 5,352 39.86 Family size, father’s occupation, mother’s occu- 1.37
Sweetened Beverage, depression, confusion, in- pation, father’s education, mother’s education,
Fast Food somnia, anxiety, aggression, sedentary lifestyle, screen time, physical activity,
and feelings of worthless- socio-economic status, family history, body mass
ness) and violent behaviors index (BMI), body image, passive smoking,
(physical fighting, victim- current smoking.
izing, and bullying)
Zahra, et al.,22 Hamburger, chips, Always Poor mental health 1,836 17.24 Eat at irregular times, eat junk food daily, gender, 1.59
crisps, fizzy drinks, age, ethnicity, overcrowded, free school meal,
sweets special educational needs, smoking, parenting
style, poor physical health.
Oelingrath, Junk foods Daily Psychiatric disoders 72 9.1 Child’s BMI category, maternal education, family 1.6
et al.,23 income, family structure, child’s gender, child’s
gender, child’s physical activity, inactivity of child.
Park, et al.,24 Energy drinks and High Sleep dissactifaction, perceiv- 945 1.38 Males, high school, rural residence, non-residence 1.65
junk food frequency ed stress, persistent depress- with family, high academic achievement, lifetime
ive mood, suicidal ideation, alcohol use, physically active, age.
suicide plan, suicide attempt(s)
Xu H, et al.,25 Western junk food, During last Severe stress, depressive mood, 432 3.1 Age, gender, residence, boarding school, being 1.9
Chinese junk food, week, 1-2 suicidal ideation, suicide plans, the only child in the family, father’s education
takeaway junk food, times suicide attempts, and sleep level, mother’s education level, the number of
hot food packed in dissatisfaction close friends, sports, and self-perceived socio-
disposable fastfood box economic status.
Jacob, et al.,27 Adherence to Western Daily Suicide attempts NA 26.7- Sex, age, food insecurity (a proxy of socioecono- 1.31
dietary patterns 79.8 mic status), alcohol consumption, smoking, phy-
(snacks, pizza, sweets, sical activity, obesity, carbonated soft drink con-
and desserts) sumption, fruit, and vegetable consumption.
Chaplin, Unhealthy snacks More than Life stress NA NA Alcohol consumption, smoking, difficulty sleeping, 1.59
et al.,19 three times (Only showed gender, age, neuroticism, total negative job score.
a week the association)
Note: OR = Odds Ratio; NA = Not Available
Figure 3. Funnel Plot of Junk Food Consumption and the Symptoms of
Mental Health Problems
Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2021; 16 (1): 1-8
5
cause stress. This condition will increase with high caloric
content, high salt, high saturated fat, high sugar, and low
fiber in junk food.30 Perfluoroalkyl substances (PFASs)
found in foods such as hamburgers, sausages, and pizza
can interfere with the function of testosterone and other
steroid hormones.31 This condition is worrying because
the quick reaction to these substances can cause in-
creased risks of anemia, anxiety, and insomnia as triggers
for mental health problems.32 These quick reaction
symptoms were clearly shown in the selected articles,
which use the cross-sectional design in this study. It is
differs from the effects of non-communicable diseases
such as heart disease, diabetes, stroke, and cancer, which
take a long time to manifest after junk food consump-
tion.33,34 The reaction will stimulate a higher impact if
junk food is consumed in large quantities, exceeding the
standard daily dose of health, and consumed frequently.
Although it proved a significant positive association,
the results of this study's meta-analysis showed that dif-
ferences are resulting in the heterogeneity of the associa-
tion between junk food consumption and the symptoms
of mental health problems. Heterogeneity might occur
due to the various outcomes and sample sizes of mental
health problems, including mental disorders, psychiatric
disorders, sleep dissatisfaction, stress, autistic fantasy,
and suicide attempts.15,20,22–27 However, based on the
tau-squared test, the heterogeneity has no occurred that
one of the requirements for further analysis in this study.
A meta-analysis study meets high qualifications if the cal-
culation results do not have heterogeneity of measure-
ment values.
Another prerequisite for better meta-analysis is that
there be no publication bias in any of the measurement
tests. In this study, publication bias was calculated by
two measurements–the Funnel Plot and the Egger’s re-
gression test. Both measurements yielded different re-
sults. The Funnel Plot showed a publication bias, while
the Egger’s regression test showed none. Since this study
included only seven articles, the Egger’s regression test
proved more robust or suitable.35 It can be said that there
was no publication bias for this study.
Under real conditions, various types of mental disor-
ders might cause heterogeneity of the result.36 These re-
sults provide strong evidence for a connection between
junk food consumption and the occurrence of problem-
atic mental health issues.
The systematic review showed that children are sus-
ceptible to symptoms of mental health problems,23,25
such as depression, anxiety, and low self-esteem due to
anatomical and physiological conditions.37,38 Moreover,
junk food such as chips and fries, chocolate, cookies, piz-
za, and burgers are more consumed by children than
adults.39 Junk food, especially the type that contains ex-
cessive sweet or salty taste, can inhibit information pro-
cessing in the brain. Therefore, children and adolescent
who consumes a lot of junk food usually have concentra-
tion difficulties at school.40 Junk food also exacerbates
existing mental disorders. In Indonesia, schools provide
Unit Kesehatan Sekolah or School Health Unit to pre-
vent mental illness in children. However, it is still a pilot
project, and controlling junk food has not been deter-
mined as the program's aim.41 In India, there is a High
in Fat, Sugar, and Salt (HFSS) guideline, regulating chil-
dren’s excessive consumption of junk food because of its
association with higher body mass index. However, these
guidelines do not address the risks of developing mental
illness.42
Based on the discussion above, the association be-
tween junk food and mental health problems is sufficient-
ly acute. Even minimal but frequent consumption of junk
food could contribute to aggravated mental health symp-
toms. A regular public education awareness campaign to
prevent mental illness through improvements to diet and
lifestyle is warranted. The community must be aware of
policy makers' issues through guidelines, rules, and pub-
licity campaigns. The community needs to ramp up
awareness of junk food consumption risks, mainly to pre-
vent long-lasting mental health problems for children.
The findings from several eligible articles showed that
negative behaviors, such as smoking, and drinking were
significant determinants of poor mental health condi-
tions.19,26,27 These findings were consistent with the oth-
er studies.43 Both sugar and fat nutrients and nicotine
exposure may activate stressors in the body.44 Further
study is required to support this finding.
Body mass index is also considered a covariate in se -
veral eligible studies.15,18,23 Obesity affects stress be-
cause it strains emotional function, causes depression,
and delays the development of teeth, bones, and mus-
cles.45 Therefore, maintaining an ideal BMI, smoking,
and alcohol cessation are also necessary to prevent the
aggravation of mental illness symptoms.
Food is not the only risk factor for poor mental con-
ditions. It can be seen from the covariate variations that
affect the associations between junk food consumption
and the incidence of mental illness in all eligible studies
for meta-analysis in this study. However, the potential
for mental illness from junk food consumption has not
received much awareness from public health personnel
and medical personnel.46 The efforts of mental illness
prevention implemented by health personnel have includ-
ed junk food consumption control.47 Some nutritionists
have implemented campaigns against junk food con-
sumption in patients because of the risk of mental illness,
but it has not been implemented by other health person-
nel.48 For example, nurses in primary health care have
not actively advertised the importance of controlling junk
food consumption to prevent stress symptoms in their
Hafizurrachman et al, Junk Food Consumption and Symptoms of Mental Health Problems
6
patients.49 Treatment of mental illness in health services
should include encouraging the consumption of vegeta-
bles and fruit instead of junk food. Public health person-
nel as the front liners in preventing mental illness should
campaign on junk food consumption restriction.
The existing health policy has linked the consumption
of junk food with malnutrition. However, it has not em-
phasized the potential risks of developing mental ill-
ness.50–52 Developing and developed countries such as
the United States, France, Mexico, Chile, Brazil, and
South Africa have imposed taxes on food and sweetened
drinks to limit the consumption of foods that pose a
health risk.53–55 Other countries might need to imple-
ment a similar policy.
Regular consumption of fruits and vegetables, instead
of junk food, can prevent mental illness. Fruits and ve -
getables provide a wide variety of vitamins, minerals,
fiber, and phytochemicals that the body needs to keep
healthy, while junk food provides abundant calories that
harm health.56,57 Promoting regular consumption of fruit
and vegetable have been routinely encouraged by health
personnel to patients and the community. However, pol-
icy needs to be developed especially for children, to reg-
ularly eat fruits and vegetables to avoid various mental
health problems.58–60
This study's novelty is that it is the first meta-analysis
conducted to determine the positive relation between
junk food consumption and the symptoms of mental
health problems by using two well-known health data-
bases. The existing meta-analysis research method ap-
proaches the subject from a less comprehensive point of
view. This approach is to the importance of healthy food
intake to improve the symptoms of mental health prob-
lems.16 Simply the result of this first meta-analysis will
allow future researchers around the world to examine the
different effects of junk food consumption and the symp-
toms of mental problems by using observatory data from
their own countries. Using combination of two databases
that are sufficiently strong for SLR study such as journal
searches becomes less time-consuming and efficient. It
obtains high index articles without having to identify oth-
er well-known databases. These two databases have ad-
vanced the search, facilitating the specific journal search
process.
Limitations of this study only used five categories of
mental health problems and did not include other symp-
toms such as schizophrenia. Meanwhile, junk food cate-
gories did not measure fried foods (gorengan) that con-
tain unhealthy carbohydrates and fats and are widely con-
sumed by society. The source of the meta-analysis comes
from just two databases. It might still be possible to find
a stronger association between exposure and outcome.
Therefore, other researchers could investigate more var-
ied types of junk food and mental health problems for
the next SLR research and use more databases and web-
site resources.
Conclusion
This systematic review and meta-analysis study
demonstrated a significant positive association between
frequent junk food consumption and the potential for
symptoms of mental health problems. These problems
can be suffered by all age categories, including children
and adolescence. On the other hand, routine junk food
consumption coupled with negative behaviors such as
smoking and drinking alcohol, and being overweight or
obese, contribute to the growth of mental health prob-
lems. Therefore, society and policymakers together must
be made aware of the outcomes of this study and the
need to develop junk food consumption controls, espe-
cially for children, to raise public health awareness to-
ward the negative outcome of mental health problems.
Abbreviations
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-
Analysis; SLR: Systematic Literature Review; PROSPERO:
International Prospective Register of Systematic Reviews; BMI: Body
Mass Index; CI: Confident Interval; NA: Not Available; OR: Odds
Ratio; PFASs: Perfluoroalkyl Subtances; HFSS: High in Fat, Sugar, and
Salt.
Ethics Approval and Consent to Participate
The analysis used an online database journal from PubMed and
ScienceDirect. Ethics approval was obtained by the Ethics Committee
of Sekolah Tinggi Ilmu Kesehatan Indonesia Maju, reference number:
2417/Sket/Ka-Dept/RE/STIKIM/IX/2020.
Competing Interest
The author declares that there are no significant competing financial,
professional, or personal interests that might have affected the per-
formance or presentation of the work described in this manuscript.
Availability of Data and Materials
The data is publicly available from Pubmed and Science Direct from
October 2010 to October 2020. The data of this study can be obtained
from seven eligible articles that have been included in references. Also,
the reader may contact the corresponding author for further informa-
tion.
Authors’ Contribution
MH contributed to the conception, data screening, supervising, and
writing of the manuscript. RKH participated in the conception and
writing of the manuscript.
Acknowledgment
The author would like to extend special gratitude to Gunanti
Khairunnisa, Putri Candaika, and Margaretha Josephine Mantrono,
supporting and collecting the data. Adi Wijaya contributed to the data
Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2021; 16 (1): 1-8
7
analysis.
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