Pediatric Weight Management


Rodríguez-Artalejo F, García EL, Gorgojo L, Garcés C, Royo MA, Martín Moreno JM, Benavente M, Macías A, De Oya M; On behalf of the investigators of the Four Provinces Study.  Consumption of bakery products, sweetened soft drinks and yogurt among children aged 6-7 years: association with nutrient intake and overall diet quality.  Br J Nutr 2003;89:419-29. PubMed ID: 12628036
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To test the hypothesis that higher consumption of bakery products, sweetened soft drinks and yogurt is associated with higher intake of energy, saturated fats, sugars and worse overall diet quality among Spanish children.

Inclusion Criteria:
Not specified, children selected through random cluster-sampling of schools, stratified by sex and SES; 6 schools selected per city and in each school almost all 6-7 year-old children invited to participate (response rate 85%).
Exclusion Criteria:
not specified
Description of Study Protocol:

Recruitment - Representative sample of 6-7 y children in 4 Spanish cities (Cadiz, Murcia, Madrid & Orense) over 1998-99.

Measurements - Field team (MD & nurse) conducted interviews & measurements (location not described, but may be at child’s home as FFQ was administered to mother or other caregiver)

Statistical Analysis - Compared difference between fifth and first quintile of consumption (test not described, p<.01); for nutrient intake and food consumption (but not healthy eating index), differences were adjusted for energy intake and BMI using linear regression models

Data Collection Summary:

(no blinding)

Dependent variables – BMI (measured wt & ht)

Independent variables – Intake, expressed as quintiles of consumption (g):

  • Bakery products (biscuits, buns, donuts, croissants, cakes, pastries, churros, chocolates, cookies, shortbread)
  • Sweetened soft drinks (carbonated and non-carbonated, excluding 100% fruit juice)
  • Yogurt (all varieties, e.g., skimmed, whole-milk, with fruit and with cereals)
  • (77 item FFQ [adjusted for and piloted, but not fully validated with children] – administered to mother or person in charge of child’s food)
  • Diet quality (healthy eating index [HEI])
Control variables – gender (examined, but no change in results so genders combined); no others for sweetened beverage intake
Description of Actual Data Sample:

N - 1112 children (557 boys, 555 girls)

Age - 6-7 years

Ethnicity - not specified, but all Spanish

Other demographics - not specified

Summary of Results:


  • Bakery products:  no association
  • Sweetened soft drinks:  no association
  • Yogurt:  no association

Energy intake

  • Bakery products: + association (also + with sugar & - with fruit/vegetables)
  • Sweetened soft drinks:  + association (also – with Ca and milk)
  • Yogurt:  + association (also + with sugar and saturated fats)


  • Bakery products: no association
  • Sweetened soft drinks:  - association
  • Yogurt:  no association
Note:  magnitude of most associations were small
Author Conclusion:

We conclude that the impact of the consumption of bakery products, sweetened soft drinks and yogurt on the quality of the diet of Spanish children is only modest, although it may contribute to aggravating certain unhealthy characteristics of their diet, particularly excess energy, saturated fats and sugars. Therefore, consumption of bakery products and sweetened soft drinks should be moderated, and priority given to consumption of low-fat, low-sugar yogurt.

Funding Source:
Consejo Oleicola Internacional
Commodity Group:
Foundation associated with industry:
Reviewer Comments:


  • Representative sample;
  • large sample size


  • No control for physical activity or other potential confounding variables;
  • Statistical methods not well described;
  • Demographics of participants & discussion of subjects who refused to participate not provided;
  • Unclear definition of ‘sweetened soft drink’
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? No
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? No
  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? No
  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? No
  8.1. Were statistical analyses adequately described and the results reported appropriately? No
  8.2. Were correct statistical tests used and assumptions of test not violated? ???
  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)? No
  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? No