Nicklas TA, Morales M, Linares A, Yang SJ, Baranowski T, De Moor C, Berenson G. Children's meal patterns have changed over a 21-year period: the Bogalusa Heart Study. J Am Diet Assoc. 2004; 104(5): 753-61

PubMed ID: 15127060
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 analyze children’s meal patterns over two decades by collecting one 24-hour dietary recall on each child who participated in one of seven cross-sectional surveys.

Inclusion Criteria:
  • Fifth grade (age 10 years) in the Bogalusa, Louisiana, school system
  • At risk of overweight: BMI equal to or greater than the 85th percentile, but less than the 95th percentile.
  • Overweight: BMI equal to or greater than the 95th percentile.
Exclusion Criteria:

Children who were interviewed on Monday regarding their intake on Sunday.

Description of Study Protocol:


  • Children attending the fifth grade (age 10 years) in the Bogalusa, Louisiana, school system.


  • The 24-hour dietary recall method was adapted for use in interviewing children. Quality controls were included. All interviewers participated in rigorous training sessions and pilot studies before the field surveys to minimize interviewer effects. One 24-hour dietary recall was collected on each study participant. Duplicated recalls were obtained from 10% random subsamples of each study population to assess interviewer variability.
  • Breakfast and meal frequency are not defined. Eating episode was defined as any eating or drinking occasion that was separated by at least 15 minutes from other events.

Statistical Analysis

  • One-way analysis of variance adjusting for gender and ethnicity (test for differences in meal patterns), analysis of linear trends (for year of study), logistic regression model analysis (relationship between BMI and meal patterns).
Data Collection Summary:

Timing of Measurements

  • Data was collected during seven cross-sectional surveys in Bogalusa.

Dependent Variables

  • Body mass index.

Independent Variables

  • Dietary intake
  • Meal pattern (meal frequency, source of meal, eating episodes and mealtime span).

Control Variables

  • Study year
  • Total energy intake
  • Ethnicity
  • Gender
  • Ethnicity x gender.
Description of Actual Data Sample:

  • Initial N: 1,655
  • Attrition (final N): 1,584
  • Age: 10 years
  • Ethnicity: Ethnicity distributions of the seven cohorts were similar (60% to 65% W, 35% to 45% AA, representative of the total population)
  • Duration: 21 years (1973-1994)
  • Location: Bogalusa, Louisiana.
Summary of Results:


  • Marked increase (P<0.0001) in the percentage of children who skipped breakfast, from 8.2% to 29.6%. When school breakfast was introduced in 1981, the proportion of children skipping breakfast declined to 12.5% (P<0.01).

From 1973-1974 to 1993-1994

  • The percentage of children eating a school lunch decreased from 89.7% to 78.2% (P<0.001)
  • Eating lunch brought from home increased from 5.9% to 11.1% (P<0.01)
  • Consuming a home dinner decreased from 89.2% to 75.9% (P<0.01)
  • Eating a dinner prepared outside the home increased from 5.4% to 19.0% (P<0.01)
  • Consuming a meal at a restaurant increased from 0.3% to 5.4% (P<0.0001)
  • Consuming snacks decreased (P<0.0001)
  • Total eating episodes decreased from 6.6 to 5.2 (P<0.0001)
  • Eating time span significantly decreased from 12.4 hours to 11.5 hours (P<0.0001).

No associations were found between meal patterns and overweight status.

Association between eating episodes and overweight status is not examined. Any other data associated with eating episodes are not shown, but are described as above (the mean number of total eating episodes decreased from 6.6 to 5.2 over the 21-year period).

Fast food is included under “source of meal” as part of “meal pattern” and, as above, no significant associations were found between meal patterns and overweight status.

Author Conclusion:

Children’s meal patterns have changed much over a two-decade period. Consumption of school lunch and snacks decreased and the number of dinners consumed outside the home increased. Total eating episodes and eating time span decreased. The findings from this study provide new information on specific meal patterns that may be potential determinants of overall dietary adequacy and dietary quality. Despite the changes found in meal patterns of children, there were no associations found between meal patterns and overweight status.

Funding Source:
Government: USDA
Reviewer Comments:


  • Unique contribution: Identification of eating episodes and mealtime span in the diets of children over time. Both mean number of total eating episodes and mean mealtime span decreased from 1973 to 1994. The decrease in mean eating episodes reflects the decrease in snacking occasions.


  • Population (10-year-olds from a single city)
  • Dietary methodology (24-hour recall)
  • Lack of physical activity data
  • Self-reported meal pattern
  • 24-hour dietary recall.

Other Comments

[Note: Self-reports by 10 year olds and only one 24-hour recall used.]

  • Should the authors have controlled for energy intake? This may be how meal patterns affect BMI.
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? Yes
  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? Yes
  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? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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? Yes
  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? Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  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? ???
  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.) ???
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? ???
  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? Yes
  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? N/A
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? ???
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? ???