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958
KEY WORDS
eating frequency, obesity, children
ABBREVIATIONS
CIcondence interval
ORodds ratio
Ms Kaisari searched the literature and extracted data, drafted
the manuscript, and contributed to the interpretation of the
results; Dr Yannakoulia conceptualized the analysis, searched
the literature and extracted data, contributed to the
interpretation of the results, and critically reviewed the
manuscript; Dr Panagiotakos conceptualized the analysis,
performed the statistical analysis, contributed to the
interpretation of the results, and reviewed and revised the
manuscript; and all authors approved the nal manuscript as
submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-3241
doi:10.1542/peds.2012-3241
Accepted for publication Jan 22, 2013
Address correspondence to Mary Yannakoulia, PhD, Department
of Nutrition and Dietetics, Harokopio University, El. Venizelou 70,
Athens 17671, Greece. E-mail: myiannak@hua.gr
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
FUNDING: No external funding.
KAISARI et al
REVIEW ARTICLE
METHODS
Search Strategy
Original research, observational studies
published until October 2011, examining
the association between eating frequency and overweight/obesity status in
children and adolescents, were selected
through a literature search in the
PubMed database. Specic key words
were used for this search: eating frequency, meal frequency, meals, and
eating episodes, in combination with
the term overweight or obesity. In
addition, the reference list of the retrieved and eligible articles was used
to identify relevant articles that were
not extracted through the searching
procedure. The initial search resulted
in 1069 entries in PubMed on eating frequency and obesity/overweight,
155 entries on meal frequency and
overweight/obesity, 414 entries on meals
and overweight/obesity, and 69 entries
on eating episodes and overweight/
obesity.
Study Selection
The relevance of studies was assessed
by using a hierarchical approach based
on title, abstract, and full manuscript.
Studies eligible for inclusion were those
959
RESULTS
Study Selection
Figure 1 shows results from the literature search and study-selection process. Overall, 11 studies were nally
included in this meta-analysis, after
screening 1707 titles and abstracts and
reviewing 30 full articles. A manual
search of references cited in these
articles did not yield new eligible articles. Among these 11 studies, some
studies presented their results according to participants sex,14,15,2123
ethnic origin,14 and age group.22 Moreover, the report of Toschke et al16 included separate results of OR for
overweight and for obesity. Therefore,
960
FIGURE 1
Flow diagram for selection of studies.
KAISARI et al
Portugal,
2008
Brazil,
2003
Italy,
2006
Turkey,
2006
Neutzling et al27
Barba et al19
(ARCA project)
Turkkahraman
et al29
Germany,
2005
Toschke et al16
Mota et al15
US, 2003
Country,
Year
Nicklas et al
(The Bogalusa
Heart Study)
14
Reference/ Name
of the Study
461
2070
3668
508
513 EA/279 AA
Girls
425
2300
497 EA/273 AA
Boys
Sample, n
617
611
1519
1317
57
10
Age
Cross-sectional
Cross-sectional
Case-control
Cross-sectional
Cross-sectional
Cross-sectional
Type of Study
Parental questionnaire
Parental questionnaire
(Yes or No)
Standardized and
pre-coded questionnaire
self-reported
(Number of daily meals)
Self-reported questionnaire
(possible answers:1/2/3/4/5/6)
Age
Frequency and amount of
physical activity
Hours of sleep
Hours of watching television,
playing video games, and using
a computer per day
Dietary habits
Number of daily meals
Sex, maturity
Smoking
Dieting for weight-loss reasons
Socioeconomic status
Total breastfeeding duration
Birth wt
Wt, height, BMI, and
Schooling of Parents
Body wt, height, waist
circumference and BP
Parental clinical history,
demographics and lifestyle
Demographic variables
Birth wt
Breakfast skipping
Parental education
Parental obesity
Watching television or
playing video games
Breastfeeding
Physical activity
Smoking during pregnancy
Eating snacks while watching television
Physical activity
Parameters Evaluated
Evaluation of Eating
Frequency
TABLE 1 Basic Characteristics of the Studies Included in the Meta-analysis (Chronological Order)
Not specied
Overweight/Obesity
Denition
REVIEW ARTICLE
961
962
KAISARI et al
Greece,
2010
Greece,
2011
Kontogianni
et al22
Cassimos
et al31
344
334
544
987
Girls
335
633
346
265
581
1021
Boys
Sample, n
1112
312
1318
1012
610
1217
Age
Cross-sectional
Cross-sectional
Cross-sectional
Cross-sectional
Cross-sectional
Type of Study
Questionnaire
completed by parents
Interviewer-administered
questionnaire (number of
eating occasions)
Evaluation of Eating
Frequency
Body wt, height
Dietary habits
Physical activities
Sedentary activities
(watching television, working
on a computer, playing video games)
Body wt, height, upper arm,
waist circumference
Triceps skinfold
Birth wt
Duration of breast-feeding
Dietary habits
Parents wt, height
Sociodemographic variables
Birth order
Paternal education
Dietary patterns
Energy intake
Physical activity
Sedentary activities (watching
television, working on a
computer, playing video games)
Sociodemographic variables
Parental education
Dietary intake
Eating behaviors
Adherence to the Mediterranean diet
guidelines
Energy intake/ BMR: for the
assessment of low energy reporting
Physical activity
Sedentary activities (watching
television, working on a computer,
playing video games)
Body wt, height
Blood pressure
Parents wt, height
Socioeconomic status
Parents educational status
Dietary habits
Time sleeping and time watching
television of the children
Parameters Evaluated
AA, African American; BMR, basal metabolic rate; BP, blood pressure; CDC, Centers for Disease Control and Prevention; EA, European American; IOTF, International Obesity Task Force; wt, weight.
Greece,
2008
Portugal,
2008
Ferreira &
MarquezVidal21
Lagiou &
Parava28
Greece,
2007
Country,
Year
Kosti et al
(The Vyronas
study)
23
Reference/ Name
of the Study
TABLE 1 Continued
Overweight/Obesity
Denition
REVIEW ARTICLE
TABLE 2 ORs and 95% CIs Between Number of Meals and Overweight/Obesity Status, as Reported in the Studies Included in the Meta-analysis
ID
Reference
14
1
2
3
4
5
Toschke et al 200516
7
Mota et al 2008 (girls)15
8
Neutzling et al 200327
OR
95% CI
Comments
0.97
1.23
0.70
0.56
#3 meals: 1
4 meals: 0.73
$5 meals: 0.56
#3 meals: 1
4 meals: 0.73
$5 meals: 0.51
#3 meals: 1
4 meals: 1.97
$5 meals: 1.33
#3 meals: 1
4 meals: 2.75
$5 meals: 1.44
.3 meals: 0.54
0.631.50
0.801.89
0.381.33
0.330.95
1
0.560.96
0.420.75
1
0.441.21
0.290.89
1
1.003.96
0.752.36
1
1.295.83
0.862.97
0.291.00
497
513
273
279
4370
425
508
10
Barba et al 200619
#3 meals: 1
4 meals: 0.78
$5 meals: 0.48
1
0.581.04
0.360.64
3668
11
Turkkahraman et al 200629
15
16
1.563.98
0.340.84
0.212.62
0.360.86
0.461.30
1
0.461.64
0.572.13
1
0.632.83
0.894.09
0.480.76
2465
12
13
14
2 meals: 2.49
3 meals: 0.54
$ 4 meals: 0.59
$ 3 meals: 0.55
$ 3 meals: 0.77
#3 meals: 1
4 meals: 0.87
$5 meals: 1.01
#3 meals: 1
4 meals: 1.34
$5 meals:1.90
0.61
17
Kontogianni et al 2010
(Children: 312, boys)22
18
Kontogianni et al 2010
(Children: 312, girls)22
19
Kontogianni et al 2010
(Adolescents:1318, boys)22
20
Kontogianni et al 2010
(Adolescents:1318, girls)22
21
Cassimos et al 201131
#3 meals: 1
4 meals: 1.30
$5 meals: 0.66
#3 meals: 1
4 meals: 1.02
$5 meals: 1.20
#3 meals: 1
4 meals: 0.90
$5 meals: 0.82
#3 meals: 1
4 meals: 0.47
$5 meals: 0.51
#3 meals: 1.74
1
0.463.68
0.251.75
1
0.362.90
0.453.20
1
0.421.95
0.371.79
1
0.191.15
0.221.21
1.032.94
1021
987
581
544
633
346
344
265
334
335
AA, African American; EA, European American; ID, identication number; wt, weight; n, number.
DISCUSSION
Summary and Interpretation of
Findings
FIGURE 2
Eating frequency and overweight/obesity status in children and adolescents. Forest plot of studies that
evaluated the effect of eating frequency on the overweight/obesity status in children and adolescents
(squares and diamonds represent effect size; extended lines show 95% CIs). Increased eating frequency,
as compared with the reference category, was associated with a benecial effect regarding the body
weight status. Numbers in brackets are the study identication numbers, presented in Table 2.
964
KAISARI et al
REVIEW ARTICLE
FIGURE 3
Eating frequency and overweight/obesity in children and adolescents, by sex. Forest plot of studies that
evaluated the effect of eating frequency on the overweight/obesity status in children and adolescents
(separate data for boys and girls; squares and diamonds represent effect size; extended lines show 95%
CIs). Increased frequency of meal consumption, as compared with the reference category, was associated with a signicant benecial effect regarding body weight status in boys, but not in girls.
Numbers in brackets are the study identication numbers, presented in Table 2.
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