Pediatric Weight Management

PWM: Eating Behaviors of Children (2006)

Citation:
Nicklas TA, Yang SJ, Baranowski T, Zakeri I, Berenson G. Eating patterns and obesity in children. The Bogalusa Heart Study. Am J Prev Med. 2003 Jul;25(1):9-16. PubMed ID: 12818304
 
Study Design:
Cross-Sectional Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To analyze children’s eating patterns over 2 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, LA, school system
  • At risk of overweight: BMI = 85th percentile but less than the 95th percentile.
  • Overweight: BMI = 95th percentile
  • However, all at-risk for overweight and overweight were combined.
Exclusion Criteria:
Not stated
Description of Study Protocol:

Recruitment

Fifth grade students (age 10 years) in the Bogalusa, LA, school system

Design

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.

A food-grouping scheme identified four large food categories: FJV (fruit, fruit juices, vegetables), meats, sweets, and dairy.  High- and low-quality food groups were also created (high quality: food consumed at least once from meats, dairy, breads/grains, fruits/fruit juices, and vegetable groups; low-quality: foods consumed at least once from salty snacks, candy, desserts, fats/oils, and sweetened beverage groups). 

Eating patterns: food consumption patterns, total gram amount of food/beverages consumed by meal period, total eating episodes, number of meals and snacks consumed, and total gram amount of high- and low-quality foods.

One of the quality controls of the study was a product identification notebook for probing of snack consumption and products researched in the field to obtain updated information on their ingredients and weights, primarily snack foods, candy, and fast foods.  No further definition of snack food or snacking episode was defined.

Statistical Analysis

Multivariate logistic regression (association between eating patterns and being overweight)

Data Collection Summary:

Timing of Measurements

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

Dependent Variables

Body mass index

Independent Variables

Eating patterns (gram amount from meals, number of eating episodes, food group consumption, gram amount of high and low quality foods)

Control Variables

Total calorie intake, age, study year, ethnicity, gender, ethnicity x gender interaction

Description of Actual Data Sample:

Initial N: 1562

Attrition (final N): 1562

Age: 10 years

Ethnicity: Ethnicity distributions of the seven cohorts were similar: 60% to 65% White, 35% to 45% African American, representative of the total population

Duration: 21 years (1973-1994) 

Location: Bogalusa, LA

Summary of Results:

The percentage of children with BMI in the <50th percentile significantly decreased (p<0.0001) from 55% in 1973 to 34% in 1994.

There was a twofold increase (p<0.0001) in the percentage of children with a BMI >= 85th and <95th percentile and a five-fold increase (p<0.0001) in the percentage of children with a BMI>=95th percentile (4% to 20%) over 2 decades. 

Overall percentage of overweight among 10-year-olds was 24% (equally distributed by gender and ethnicity).  There was a significant (p<0.0001) difference in the ethnic x gender distribution of overweight status. 

White males had the highest prevalence of overweight (27%) and black males had the lowest prevalence (19%). 

The likelihood to be overweight for white males was 1.2 time higher than black females at 10 years of age. 

The percentage of overweight among 10 year olds in Bogalusa (24%) was slightly higher than among 6 to 11 year olds in NHANES (225), particularly for white males.

Total gram amount of food/beverage consumed, particularly from snacks (p<0.05), and total gram consumption of low-quality foods (p<0.01) were positively associated with overweight status.  Consumption of sweets (p<0.001), specifically sweetened beverages (p<0.001), and meats (p=0.051) was positively associated with overweight status.

Sweetened beverages: OR of 1.33 (95%CI 1.12-1.57), p<0.001 with a mean gram amount 299.0, for example of food weight: 8 oz Coke (235.2 g).  Sweetened beverages were only significant for white males (OR 1.68, 95%CI 1.21-2.33, p<0.05) and females (OR 1.53, 95%CI 1.05-2.22, p<0.05) and not significant for black males and females

For white males, consumption of sweets (p<0.05), especially sweetened beverages (p<0.01); total gram amount of food/beverages consumed (p<0.05), particularly from the dinner meal (p<0.05); and total gram amount of low quality foods consumed (p<0.05) were positively associated with obesity. 

For white females, consumption of seafood (p<0.05) and sweets (p<0.05), particularly sweetened beverages (p<0.05), were positively associated with obesity.

Total gram amount of food consumed (p<0.05), particularly low-quality foods (p<0.05), was positively associated with obesity.

For black females, consumption of fruits/fruit juices (p<0.01); FJV (p<0.01); total gram amount of breakfast consumed (p<0.05); and total number of meals consumed (p<0.05) were negatively associated with obesity. 

Overall, the percent of variance explained (range 4% to 8%) by the model was low for all ethnic x gender groups.

Soft drink consumption accounted for 50% of the sweetened beverages consumed, with the remaining percentage reflecting consumption of tea or coffee with sugar, and fruit drinks. 

Researchers found no association between milk or dairy consumption and overweight.

Author Conclusion:

Overall, several eating patterns were positively associated with weight status: consumption of sweetened beverages, sweets, and meats, and total gram consumption of low-quality foods. Total gram amount of food/beverages consumed, particularly from snacks, were also positively associated.  These results have important implications for obesity-prevention research targeting children.  These associations were poorly explained by a single eating patter and the patter of significant relationships varied by ethnicity and gender.

Funding Source:
Government: NHLBI
Reviewer Comments:

Strengths:

  • One 24-hour recall is sufficient for characterizing the eating patterns of large groups of children.
  • Sample size is relatively large
  • Dietary intakes are comparable to national surveys
  • Percentage of children overweight in this study (11%) is comparable to the national average (11%)

Limitations:

  • Cross-sectional analysis (causal inferences cannot be made)
  • One 24-hour recall is not adequate for characterizing usual eating patterns
  • Findings are specific to 10 year olds in Bogalusa and may not be representative of the nation as a whole
  • Lack of physical activity data and energy expenditure
  • Overweight group is defined as those who are at-risk for overweight and overweight – may not be able to replicate well in larger studies.
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? ???