PWM: Eating Behaviors of Children (2006)

Sampson AE, Dixit S, Meyers AF, Houser R Jr. The nutritional impact of breakfast consumption on the diets of inner-city African-American elementary school children.  J Natl Med Assoc 1995;87:195-202. PubMed ID: 7731069
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 determine the contribution of breakfast-eating behavior to dietary adequacy among low-income African-American children.
Inclusion Criteria:

For schools:

  • similar proportion of low-income children,
  • similar numbers in study grades,
  • located in comparable neighborhoods with demographically similar student bodies
Exclusion Criteria:

For students:

  • special education,
  • emotionally disturbed,
  • neurologically disabled,
  • bilingual
Description of Study Protocol:

Recruitment – Sent home consent forms to all 2nd-5th grade students in selected 4 of 9 elementary schools in East Orange, New Jersey (predominantly black and low SES area); 1401 eligible for study; 161 (11%) declined to participate, 1151 (82%) had completed two 24-hour recalls

Design – In Sept. 1989 a self-administered eating-behavior survey was distributed by classroom teachers to all study children on 4 random days over a 2-week period (4 sections; 1 for each day) with 2 questions: Did you have anything to eat before coming to school?  Did you eat a snack on the way to school?

In Oct. 1989 24-hour recalls obtained from all children.

Statistical Analysis – how weight and breakfast habits compared was not described

Data Collection Summary:

(no blinding)

Independent variables

  • Two 24-hour recalls
  • Breakfast and or morning snack consumption:  breakfast & breakfast + snack = ‘breakfast eaters’; no breakfast or snack or snack only = ‘breakfast skippers’

Dependent variables

  • Weight-for-age and height-for age (measured)
  • BMI classification:  obese (>85th%, prevalence = 18%), super-obese, (>95th%, prevalence = 18% (using criteria of Must, 1991)

Other variables

  • Physical activity (questionnaire)
  • SES (parent’s occupation & characteristics of home?)

Control variables

  • Gender
  • Degree of under- or overestimation of intake (based on reported intake vs. estimation of energy requirement given reported PA using WHO equations)
Description of Actual Data Sample:

N: 1151 (585 boys, 566 girls)

Age: Grades 2-5 (21% in grade 2, 79% in grades 3-5)

Ethnicity: 97% black

Other demographics: low SES (79% of all elementary grade children in study schools qualified for free or reduced price school meals)

Summary of Results:

Breakfast eating

  • No relation with breakfast eating behavior and weight-for-age, height-for-age, prevalence of obesity or super-obesity

Other Results

  • 12-26% skip breakfast (varies between 4 days and 24-hour recalls)
  • Significantly more of the breakfast skippers than eaters failed to achieve dietary adequacy for nearly every nutrient studied
Author Conclusion:

Not eating breakfast results in substantial deficits in dietary intake of a variety of essential nutrients among low-income African-American school children. Efforts to improve the nutritional status of children should include nutrition education to promote breakfast.

Funding Source:
General Mills Inc
Food Company:
University/Hospital: Tufts University School of Nutrition, Boston University and Boston City Hospital
Reviewer Comments:

Strengths: Extensive dietary data collection, large sample size

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

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? No
  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? No
  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? No
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? No