FNCE 2023
Session 357. Providing MNT for the Pediatric Type 1 Diabetes Population: What Does the Evidence Show?
Monday, October 9, 8:30 AM - 9:30 AM

See session information ♦ See EAL review results

PWM: Eating Behaviors of Children (2006)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

To evaluate:

  1. associations of type and number of eating occasions with nutrient intakes,
  2. influence of OW status and prior participation in intervention or control groups in CATCH on them,
  3. patterns and sources of meals and snacks by sex and race/ethnicity.
Inclusion Criteria:

2,075 eligible as completed 24-hr recall in 3rd or 5th grades; 1,543 (74% of original cohort) completed addition 24-hr recall in 8th grade

Exclusion Criteria:

50 excluded from analysis because portions beyond 99th percentile

Description of Study Protocol:

Recruitment – Details reported elsewhere; drawn from 96 public schools in 4 locations (San Diego, CA, New Orleans, LA Minneapolis, MN, Austin, TX)

Design – Multicomponent (heart-healthy diet & PA) intervention in 3rd -5th graders (CATCH Main Trial, 1991-1994) with tracking through 8th grade (CATCH Cohort Study, 1997); 883 from intervention group, 610 from control group

Statistical Analysis – Multiple logistic regression analysis
Data Collection Summary:

(no blinding)

Independent variables: (24-hr recall – from 8th grade?)

  • Meals (breakfast, lunch, dinner; defined by students’ self-reports)
  • Snacks (defined by students’ self-reports)
  • Total eating occasions

Dependent variables:

  • BMI (measured) classification:  Not OW (<85th%; n=991), OW (>85th%, n=502) using NHANES I cut-off points

Other variables:

  • Nutrient intake (24-hr recall)
  • Energy
  • Total & saturated fat
  • Protein
  • Total CHO
  • Sugar
  • Sodium (not including discretionary salt)

Control variables:

  • Gender
  • Site
  • CATCH intervention group
  • Random inter-school variation
Description of Actual Data Sample:

N –1,493 (736 boys, 757 girls)

Age – Mean 14.1 y (13.1-16.4 y)

Ethnicity – 70% white, 12% black, 14% Hispanic, 4% other

Other demographics – not provided (SES measure not available)

Summary of Results:

Eating Meals & Snacks

  • Breakfast eating – inversely related to OW status (70% OW, 80% not OW,  p =.0004)
  • Lunch – NS
  • Dinner – NS
  • Snacks – trend toward being inversely related to OW status (85% OW, 89% not OW, p=.07)
  • OW had lower energy, fat, protein, CHO, sugar intakes and higher Na intakes than not OW
  • As number of eating occasions increased, so did intake of energy, CHO,  & sugar; Na intake decreased (confusing for others due to difference in results and discussion section)

Other Results

  • 77% ate breakfast (most likely meal to be skipped)
  • 69% ate 3 meals/day
  • 87% ate snacks (average 2/day)
  • Fewer meals associated with more snacks (p=<.003)
  • Nutrient content of meals and snacks provided (Table 2 & Figure)
  • Some maintenance of intervention effects (lower total and saturated fat and Na, higher CHO and sugar in intervention vs. control group; no difference in meal or snack patterns between groups)
  • Most lunches eaten at school, breakfast & dinner at home
Author Conclusion:

Both eating patterns and eating occasions should be considered in promoting healthy eating behaviors.

Funding Source:
University/Hospital: Tufts University
Reviewer Comments:

Strengths: Large sample size, ethnically diverse sample.

Weaknesses: Did not control for SES, PA or other diet measures in eating breakfast analysis

Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? ???
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes