AWM: Eating Frequency and Patterns (2013)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
To determine the prevalence and characteristics (i.e., energy and macronutrient intake) of snacking behavior in a French female obese sample and to identify those having a preference for CHO-rich protein-free snacks.
Inclusion Criteria:
Obese women who were admitted to an outpatient nutrition clinic.
Exclusion Criteria:
Women with bulimia nervosa, alcohol intoxication, endocrinological or major general disease, pregnancy, on weight-lowering medications, or on a special diet.
Description of Study Protocol:

Recruitment 273 consecutive admissions to the outpatient clinic of the Department of Nutrition at Hotel-Dieu, Paris.

Design Patients were classified to be in an ascending, stable, or descending phase of obesity (i.e., variation of > +/- 2 kg in the last 2 months). Food intakes and eating patterns were assessed by diet histories. Participants were identified as snackers when they ate between the usual times for meals and when snacking was responsible for at least 15% of the daily energy intake.  Reported snacks were analyzed by hour of consumption, foods most frequently eaten, and macronutrient composition, and the contributions of each macronutrient to snack energy intake was calculated.  Women self-reported their urge to eat a snack and those who reported a strong urge and followed up the urge with actual consumption were considered to be 'cravers'.

Blinding used (if applicable) NA

Intervention (if applicable) NA

Statistical Analysis Between group comparisons were done with Student's t-test and chi-squares.

Data Collection Summary:

Timing of Measurements 1 time

Dependent Variables energy and macronutrient intake

Independent Variables  snacking pattern

Control Variables None utilized

Description of Actual Data Sample:

Initial N:273

Attrition (final N): 273 (no attrition reported)

Age: 41 +/- 12 years, range = 18-65

Ethnicity:  not reported

Other relevant demographics: none reported


273 obese women

Snackers: BMI = 33 +/- 6 (27-61)

Non-snackers:  BMI = 33.6 +/-6 (27-59)

Location: Paris

Summary of Results:

Energy content and macronutrient composition (mean +/- SEM) of meals and snacks according to eating pattern
Snackers (n-163) Non-snackers (n=110)
Total daily intake
    Energy (MJ) 9.3+/-3.4 6.6+/-2.3*
    Protein (%) 18+/-3 21+/-6
    Carbohydrate (%) 41+/-7 39+/-8
    Fat (%)     41+/-6 38+/-8
Meals intake     
    Energy (MJ) 7.5+/-2.5 6.6+/-2.3*
    Protein (%)     19+/-4 21+/-6*
    Carbohydrate (%) 39+/-7 39+/-8
    Fat (%) 41+/-7 38+/-8*
Snacks intake
     Energy (MJ) 1.8+/-1.6
    Protein (%)  11+/-7
    Carbohydrate (%) 54+/-18
    Fat (%) 34+/-15

*P<0.05 as compared with snackers, by t-test

Snackers consumed signficantly:

  • more daily energy (9.3 +/- 3.4 MJ (2221.27 +/- 812.08 kcals) vs. 6.6 +/-2.3 MJ (1576.38 +/- 549.35 kcals), P<0.05)
  • less energy per meal (6.6 +/- 2.3 MJ (1576.38 +/- 549.35 kcals)vs. 7.5 +/- 2.5 MJ (1791.35 +/- 597.12), P<0.05)
  • less protein from meals ( 21+/-6% vs 19 +/-4%, P<0.05)
  • less fat from meals (38+/-8% vs. 41+/-7%,  P<0.05)

Other Findings

  • Snacking was found in 163 women (59.7%).
  • More non-snackers than snackers were losing weight (11% vs. 3%, P<0.05)
  • Snackers and non-snackers were not significantly different on BMI.
  • 86% of the snackers had 1 or 2 snacks per day, 13% had 3-4 snacks per day.
  • Snacking occurred predominantly in the afternoon.
  • Craving for food was reported by 68% of the snackers.
  • 12% of snackers were categorized as CHO cravers.
  • CHO cravers were younger (33+/-4 vs. 41 +/-12 years, p<0.01), had higher daily intake (p<0.01), and higher snack calorie intake (P<0.01) than other snackers.
Author Conclusion:
Snacking increases energy intake by obese patients but macronutrient specific snacking may be quite rare in the obese.
Funding Source:
University/Hospital: Hotel Dieu
Reviewer Comments:
Although this study provides interesting information regarding the effect of snacking on intake and weight loss in obese women, it does not provide information as to how obese and normal weight women differ in meal patterns.  Their finding that CHO craving does not exist in a very large percentage of their sample is interesting.  However, they do not appear to have measured craving behavior at meals.
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) Yes
  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) Yes
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? N/A
  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? 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? N/A
  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? N/A
  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? Yes
  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? Yes
  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)? N/A
  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? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes