AWM: Eating Frequency and Patterns (2013)

Study Design:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:
To gain more knowledge about the breakfast habits of different groups of elderly people and to investigate the relationship between breakfast habits and maintenance of normal or excess body weight.
Inclusion Criteria:
  • residents of Madrid, Spain
  • between 65 and 95 years of age
  • living independently and institutionalized
Exclusion Criteria:
  • serious mental deterioration
  • neoplasms
  • liver malfunction
  • diabetes or other endocrine disorder
  • undergoing dietetic treatment to lose or gain weight
  • taking medication likely to alter appetite
Description of Study Protocol:

Recruitment Recruited elderly persons living in a home run by the State Social Security and persons living independently who attended a Social Security Health Center.

Design Subjects recorded their intake for 5 consecutive days (including a Sunday). Kitchen scales were provided for weighing. A food frequency was also completed and used to amplify and complement the records.  Breakfast was defined as all foods taken at the first meal of the day, always before 11 a.m.  Breakfast variety was scored by counting the number of foods and the number of food groups included in the breakfast meal.  Subjects also recorded their physical activity for what they considered one typical day during the experimental period. Measured weight and height were used to group the subjects into:  overweight and obese with BMI > 25 and normal with a BMI < 25. Subjects within each weight group were also divided into < 79 years and > 80 years.

Blinding used (if applicable) NA

Intervention (if applicable) NA

Statistical Analysis  Multiple regression analysis was used to determine the influence of age, sex, place of residence, and BMI.

Data Collection Summary:

Timing of Measurements  5 consecutive days (including a Sunday)

Dependent Variables

  • dietary records for 5 days, weighed food records reviewed by nutritionist 
  • physical activity record for one day, verified by observation
  • breakfast consumption (as % of intake)
  • variety of breakfast
  • time spent eating breakfast

Independent Variables

weight and height used to establish weight groups

Control Variables

none stated

Description of Actual Data Sample:

Initial N: 122 (51 NW, 71 OW), 65 men, 57 women

Attrition (final N): not mentioned

Age: NW: < 79 years = 70.8+/-4.7 years; >80 years=86.5+/-4.1 years.

        OW:  < 79 years = 71.0+/-5.2 years; >80 years=86.4+/-2.4 years

Ethnicity: not stated

Other relevant demographics: NW: < 79 years =58.3% male; >80 years=13.3% male.  OW: < 79 years =57.8% male; >80 years=30.8% male

Anthropometrics  not stated

Location: Madrid, Spain

Summary of Results:
  • Breakfast of NW subject included more variety (a greater number of foods and food groups).
  • NW subjects spent a greater length of time at breakfast (p<0.001).
  • NW subjects' breakfast made a greater contiribution to daily energy intake.
  • The % of subjects whose breakfasts provided less than 20% of their theoretical energy expenditure was higher among OW subjects (62% compared to 45% in NW subjects.
  • NW subjects consumed a greater quantity of sugar and fruit at breakfast than did OW subjects.
  • In OW subjects, breakfast provided a lower percentage of recommended intake of fiber, vitamin E, and iron.

NOTE: all Ps were < 0.05 unless otherwise reported.

Other Results:

  • All groups consumed milk products most often, followed by fruit, then cereal at breakfast 
  • Self-reported skipping breakfast was infrequenct (~0-6%) and not different between groups.
Author Conclusion:
"The shorter time spent at breakfast and the consumption of less varied and smaller meals at this time of day, as well as the differences seen in the composition of NW and O subjects' breakfasts, could indicate the existence of less healthy food habits among overweight and obese subjects."
Funding Source:
University/Hospital: Universidad Complutence of Madrid
Reviewer Comments:
This study contributes to the evidence that eating breakfast is associated with lower BMI, while also providing evidence that subjects who consumed breakfast had higher levels of some nutrients.  It is unclear why the authors divided their subjects into two age groups and the tables are more difficult to interpret because of that complication.
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? 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.) 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? 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.) Yes
  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? 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? 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? ???
  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? 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? Yes
  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? No
  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