EAL

NGHC: Childhood Nutrition and Lifestyle Factors (2013)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To further investigate the effect of television food advertisements on food intake of children and whether obesity is related to greater susceptibility to food promotion.

Inclusion Criteria:

Children recruited from two classes within a United Kingdom school were included.

Exclusion Criteria:

All potential subjects agreed to participate and no other potential exclusion characteristics were described.

Description of Study Protocol:

Recruitment

Fifty-nine children in two classes of a United Kingdom school were recruited via flyers sent home to parents.

Design

Non-randomized crossover trial. Within-subject counterbalance design with all subjects participating in both treatment and non-treatment conditions on separate study points.

Blinding

Not used.

Intervention

Subjects were analyzed and categorized for existing weight status so that effects could be compared to status
Subjects watched a cartoon video with 10 advertisements. The treatment-group advertisements were for food items. The advertisements shown to the non-treatment group were for toys.
Subjects were offered a variety of snacks after watching the video and consumption levels were monitored.

Statistical Analysis

Analysis of variance (ANOVA and MANOVA), t tests, post hoc comparisons
Statistical Package for the Social Sciences statistical software package, version 14 for personal computer (SPSS Inc, Chicago, IL).

Data Collection Summary:

Timing of Measurements

Participants were recruited two weeks prior to first study date
Study dates were two weeks apart, same time of day
Height and weight records collected after test period on final study date.

Dependent Variables

Weight status (normal weight, overweight, obese), %BMI
Food consumption type: low-fat savory (cheese crackers), low-fat sweet (jelly sweets), high-fat sweet (chocolate), high-fat savory (potato crisps), low-energy density (grapes)
Food consumption amount.

Independent Variables

Subjects watched a cartoon video with 10 advertisements. The treatment group advertisements were for food items. The advertisements shown to the non-treatment group were for toys.

Control Variables

Age
Sex.

Description of Actual Data Sample:

Initial N

59 children (32 male, 27 female).

Attrition (final N)

Same.

Age

Nine years and six months to eleven years and two months (mean ten years and two months).

Ethnicity

Not indicated.

Other relevant demographics

Not indicated.

Anthropometrics

Normal weight=33 (56%)
Overweight=15 (25%)
Obese=11 (19%).

Location

United Kingdom.

Summary of Results:

Key Findings

Total energy intake was significantly greater after exposure to food advertisements than after toy advertisements (P<0.001) in all children, increasingly by obesity status:
- Normal weight, 89% (250kcal, P<0.001)
- Overweight, 100% (306kcal, P<0.001)
- Obese, 155% (471kcal, P<0.001).
All children increased their consumption of high-fat and/or sweet energy-dense snacks in response to the advertisements (P<0.001)
In the food advertisement condition, total intake and the intake of these specific snack items correlated with the children’s modified age- and sex-specific BMI score
Intake was not different between weight status groups after exposure to toy advertisements (P=0.004).

Other Findings

Table of mean intake (grams±standard error of the mean) of each food item in both conditions (NW=Normal weight, OW=Overweight, OB=Obese)

Advertisement Exposure	Toy	Toy	Toy	Toy	Food	Food	Food	Food	Significance
Food Item/Weight group	NW	OW	OB	All	NW	OW	OB	All	(Toy to Food All)
Potato Crisps	6.4±1.1	8.8±2.0	10.2±2.7	7.7±1.0	12.4±1.5	15.2±2.8	22.3±3.0	14.9±1.3	P<0.001
Snack Jacks	3.3±0.6	1.7±0.4	7.5±1.9	3.7±0.5	4.0±0.7	2.9±0.8	9.3±3.0	4.7±0.7	NS, P=0.052
Chocolate	18.7±2.7	20.9±4.5	17.7±3.3	19.1±2.0	42.9±3.7	42.5±7.6	71.9±9.8	48.2±3.6	P<0.001
Jelly Sweets	33.3±3.4	30.4±5.9	28.7±7.5	31.7±2.8	55.7±4.9	72.2±8.2	58.8±8.7	60.5±3.8	P<0.001
Grapes	48.1±6.5	61.7±9.8	45.5 ±13.1	51.0±5.0	76.7±10.8	77.7±2.4	64.4±17.2	74.7±7.5	P<0.001

Author Conclusion:

Food advertisement exposure had greater impact on obese and overweight children compared with the impact on normal-weight children. This study replicates previous findings that food advertisements increase intake in all children.

Funding Source:

University/Hospital:

University of Liverpool, United Kingdom

Reviewer Comments:

Almost all groups consumed the highest total volume (by weight) of grapes. It would be interesting to assess whether children would consume more fruit and less sweets or snacks if a larger variety of fruits were offered.

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)	Yes
	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?	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?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	No
	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.)	No
	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?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	Yes
	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?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	No
	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?	Yes
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?	No
	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?		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?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes