EAL

DLM: Omega-3 Fatty Acids (2009-2010)

Citation:

Panagiotakos DB, Antonogeorgos G, Papadimitriou A, Anthracopoulos MB, Papadopoulos M, Konstantinidou M, Fretzayas A, Priftis KN. Breakfast cereal is associated with a lower prevalence of obesity among 10-12-year-old children: the PANACEA study. Nutr Metab Cardiovasc Dis. 2008 Nov;18(9):606-12.

PubMed ID: 18502106

Study Design:

Cross-sectional Study

Class:

D - Click here for explanation of classification scheme.

Quality Rating:

NEUTRAL: See Quality Criteria Checklist below.

Research Purpose:

To evaluate the association of cereal consumption for breakfast in relation to several other types of food as a diet pattern in overweight and obese boys and girls aged 10 to 12 years old from the greater area of Athens, Greece.

Inclusion Criteria:

School children with ages between 10 to 12 years old
Fourth and sixth grades schools
Pre-menstrual girls

Exclusion Criteria:

Excluded if not included above

Description of Study Protocol:

Recruitment : The children enrolled in the Physical activity, Nutritrion and Allergies in children examined in athens study (PANACEA) were recruited from schools located in several areas of Athens during 2005 to 2006.

Design: Cross-sectional Study

Blinding used (if applicable): not applicable

Intervention (if applicable): not applicable

Statistical Analysis:

Multiple logistic regression analysis
Relative risks of overweight or obesity based on the children's habits, was performed by calculating the odds ratios and the corresponding 95% confidence interval
Deviance residuals were calculated in order to evaluate the model's goodness-of-fit
Two sided tests, with cut off of 5% for significance level.

Data Collection Summary:

Timing of Measurements: One time measurements

Dependent Variables

Childhood obesity: Classification of BMI was based on IOFT (International Obesity Task Force)
Weight

Independent Variables

Physical activity - It was evaluated using a life style questionnaire (PALQ) on the frequency and duration of several sports, non-sports and sedentary activities. In the first part of the PALQ, the children answered 27 questions about their participation in physical activity during leisure, and in the second part the participation in physical activities during the last seven days. According to the evaluation of the PALQ for the last seven days, all children were classified as non-active (<3 MET/min) and active (>3 MET/min), where 1 MET=3.5ml/kg/min.
Breakfast Cereal and other foods - A semi-quantitative FFQ was used gathering information on a daily or weekly basis for 63 foods and beverages usually consumed in Greece, as well as the habits pertaining to mealtime behaviours. Cereals for breakfast were defined as the commercially availabe ready-to-eat cereals of any type (plain ready-to-eat cereals, whole-grain cereals, etc.). The FFQ was administered to all children who participated in the study and completed by their parents during face-to-face interviews. A quesiton about the frequency of breakfast consumption during the week (number of times per week) and another question to assess the food that children consumed most frequently for breakfast (close-type question with one of eight possible answers: milk, yogurt, cereals, fruit juice, honey/marmalade, bread/toast, butter/margarine, cake.

Control Variables

Parental BMI and educational level - data was collected using a questionnaire that included information regarding the social and economic status of the family

Description of Actual Data Sample:

Initial N: 700 (M:323; F:377)

Attrition (final N):700 (M:323; F:377)

Age: 10-12 years old

Ethnicity: not reported

Other relevant demographics:

Anthropometrics:

Location: Athens, Greece

Summary of Results:

Key Findings

Overall, 8.6% of boys and 9.0% of girls were obese, whereas 33.9% of boys and 2.1% of girls were overweight
The girls who most frequently consumed cereal for breaskfast were 2.4 times less likely to be overweight or obese; (OR=0.41, 95%CI: 0.21-0.79) P<0.01, while boys were 1.7 times less likely to be overweight or obese (OR=0.54, 95% CI: 0.45-1.29) ,P<0.1 after adjusting for various potential confounders, including physical activity status, number of meals per day and daily breakfast consumption
Girls who ate cereal breakfast and were physically active were 50% less likely to be overweight or obese (OR=0.41,95%CI:0.21-0.79; OR=0.54; 95%CI:0.31-0.94 respectively). No association was found among boys
Daily breakfast consumption was associated with much lower odds of being overweight or obese, regardeless of gender and other potential confounders (OR=0.27,95%CI:0.12-0.64 and OR=0.51,95%CI:0.25-1.05) for girls and boys, respectively

Other Findings

Cereal (16%) was the second most consumed breakfast, after milk (75%)
The boys (17.6%) and girls (13.6%) who were overweight or obese consumed more often cereal for breakfast
Overall, 50.9% of overweight or obese boys and 51.2% of the girls were physically active, but no significant association between obesity and physical activity status was found
Overweight or obese boys (72.2%, P<0.24) and girls (86.4%, P<0.001) had an overweight father, and 38.6%(P<0.03) of boys and 37.8% (P<0.1) of girls had also an overweight mother

Author Conclusion:

These data provide evidence that breaskfast cereal as a most frequent choice and daily consumption of breakfast were inveresely associated with the prevalence of overweight or obesity in 10-12 years-old children.

Reviewer Comments:

The study has multiple flaws. Self-questionnaire answered by the parents about children food habits can be subjected to recall bias, as well as the evaluation of physical acitivity made by the children with the help of a researcher. The main food for breakfast was milk rather than cereal which contributed to only sixteen per cent as a food choice for this meal. The tables and some of the results in the text were not consistent. Finally, BMI was the only indicator used to measure childhood obesity.

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?		No
	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?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	No
3.	Were study groups comparable?		???
	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?	???
	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.)	???
	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?		N/A
	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?	No
	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?	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?		No
	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?	No
	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?	No
	7.5.	Was the measurement of effect at an appropriate level of precision?	No
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	N/A
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?	No
	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?	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?		???
	10.1.	Were sources of funding and investigators' affiliations described?	No
	10.2.	Was the study free from apparent conflict of interest?	???