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Food Away from Home, Sugar-Sweetened Drink Consumption and Juvenile Obesity

Children’s Exercise & Nutrition Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada

Address reprint requests to: Linda Gillis, Children’s Exercise and Nutrition Centre, Evel 4, Room 464A, Chedoke Division, Hamilton Health Sciences, Hamilton, Ontario, L8N 3Z5, CANADA. E-mail: gillisl{at}hhsc.ca

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Objective: To identify if particular foods or food groups may be associated with obesity in children and adolescents and to determine if consuming food away from home (FAFH) has an effect on the nutritional quality of their diets.

Design: One-year cross-sectional study.

Setting/Subjects: The obese subjects (n = 91) were on the waiting list for a hospital-based weight control treatment program. The non-obese subjects (n = 90) were recruited from community advertisements.

Measures of Outcome: Information on food intake was obtained using the dietary history method by a Registered Dietitian. Body fat was determined by bioelectrical impedance analysis.

Results: Obese children and adolescents consumed significantly more servings of meat and alternatives, grain products, FAFH, sugar-sweetened drinks and potato chips which contributed to a higher calorie, fat and sugar intake compared to non-obese children and adolescents. Sugar-sweetened drinks were only significantly greater in boys. The consumption of meat servings, sugar-sweetened drinks and FAFH was positively correlated with percent body fat. The frequency of food consumed outside of the Canada’s Food Guide To Healthy Eating was not different between the two groups.

Conclusions: Obese children and adolescents need to limit their access to food consumed away from home and sugar-sweetened drinks as there is a relationship between these foods and body fatness.

Key words: juvenile obesity, food away from home, sugar-sweetened drinks

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Obesity is becoming a worldwide problem affecting all levels of society and is being described as a global epidemic [1]. Between 1981 and 1996 in Canada, the prevalence of overweight (Body Mass Index (BMI) greater than the 85^th percentile for age and gender) among boys increased from 15% to 28.8% and among girls from 15% to 23.6%. The prevalence of obesity (BMI greater than the 95^th percentile for age and gender) in children more than doubled over that time, from 5% to 13.5% for boys and 11.8% for girls [2].

Over the last decade, there has been a change in the environment of children. Physical activity has decreased and sedentary activities such as television, video games and computer use have increased [3]. This reduction in energy expenditure combined with an increase in the availability of high energy, high fat foods has likely contributed to the dramatic increase in the prevalence of overweight and obese children [4]. There has been a shift from consuming food prepared at home to the purchasing of food away from home [5]. Restaurants serve larger portions that tend to be higher in fat and calories compared to meals prepared at home [6]. In adults, this has been shown to contribute to the increased rates of obesity seen in the United States [7].

In order for clinicians to treat obesity effectively and educate overweight families, it is important to know what particular foods or food groups may be contributing to obesity. Giving blanket statements about decreasing dietary fat may not be successful, as these are often misinterpreted [8–10]. Despite the wide availability of "low fat", "lite" and "no-fat" foods, obesity continues to increase. Indeed, it has been shown that dietary fat intake may not be solely responsible for obesity [7,11,12].

The current nutrition recommendations for children and adolescents include an emphasis on cereals, breads and other grain products and vegetables and fruit. Lower fat dairy products and lean meats and foods prepared with little or no fat should be chosen such that no more than 30% of calories comes from fat [13–14]. Researchers have shown that the dietary intakes of children and adolescents in general do not meet these recommendations. Their diets contain more than 30% of calories from fat [15]. A diet high in fat is generally low in fruits and vegetables and complex carbohydrates [16]. To teach the above nutrition recommendations to the public, Canada’s Food Guide To Healthy Eating has been used as a nutrition education tool. A healthy diet should be based on recommended servings from each food group [14]. In the United States, using a similar education tool, children are not meeting these food group recommendations. They consume an excessive amount of energy from fats, oils and sweets, and the number of servings from all other groups, except grains, is below recommendations [17]. Snacks chosen by adolescents are not nutrient dense, and the most popular ones include candy, cake, ice cream and soda pop [18].

Thus the purpose of this study was first to identify if the frequency of consumption of particular foods, such as foods outside of the Canada’s Food Guide to Healthy Eating, was greater in obese children and adolescents compared to non-obese and whether this frequency was associated with percent body fat. The second purpose was to determine if consuming food away from home (FAFH) had a negative effect on the nutritional intake of the diets of children and adolescents.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Subjects
One hundred and ninety-five Caucasian children and adolescents ages four to 16 years participated in this cross-sectional study over the year 2001. Those children with eating disorders including dieting, genetic disorders of obesity, physical limitations such as spina bifida, cerebral palsy or muscular dystrophy, other co-morbid conditions that might affect eating, or treated by medications that could affect eating such as psychiatric disorders or attention deficit disorder had been excluded. Eleven children were excluded from the data as their BMI percentile was between the 76^th to 94^th and thus did not meet the weight criteria for either of the two study groups. Another three were excluded because it was determined during the assessment that one was showing symptoms of an eating disorder, one was found to be on an appetite altering medication and the third was on a weight reducing diet. Therefore, 181 subjects were included in the results.

The obese group was on a one to two month waiting list at the Children’s Exercise and Nutrition Centre, which is a clinic that uses an inter-disciplinary behavior modification approach to the treatment of juvenile obesity. The only information that they received prior to the study was a general overview of obesity such as the risks associated with obesity, prevalence, and the like. They were instructed on the importance of accuracy of dietary recall in order to receive the best treatment. This group of 91 children (40 males, 51 females) was defined as obese because they had a BMI greater than the 95^th percentile of the reference values for age and gender. The non-obese subjects were recruited from community advertisements. The research was described to them as a study looking at the differences in eating patterns between healthy weight and overweight children. Parents received reimbursement for parking, and the participants received a T-shirt for their involvement. This group of 90 children (35 males, 55 females) were defined as non-obese because their weights were in a healthy weight range (BMI less than the 75^th percentile of the reference values for age and gender). The BMI cut-offs for the two groups were based on National Health and Nutrition Examination Survey definition of obesity [19]. A parent was asked the family’s yearly gross income to determine socioeconomic level. To control for seasonal variation in food intake, the obese and non-obese subjects were recruited evenly throughout the year with equal numbers from both subject groups from the four different seasons.

This study was approved by the Hamilton Health Sciences Corporation Ethics Review Board. The parent and the child, if 12 years of age and over, signed an informed consent. Those less than 12 years of age gave a verbal assent to participate.

Measurements
The subject, with at least one parent, was invited to the clinic and basic demographic material was obtained including age, gender and income level. Standing height was measured in stocking feet using a Harpenden Stadiometer (London, U.K.) with a precision of 0.1 cm. Weight was measured to the nearest 10 grams in a standard hospital gown or T-shirt and shorts using an Ancaster electronic scale (Brantford, Ontario). Percent body fat was assessed by bioelectrical impedance analysis (BIA) with a body composition analyzer, BIA-101A (RJL Systems Inc., Detroit, MI), using a right sided four surface electrode placement [20]. Equations were based on Houtkooper’s body composition formulas adjusted for children [21]. An earlier study in our clinic has demonstrated a good validity of this method in obese children and adolescents, compared with underwater weighing [22]. BMI was calculated as weight in kg divided by height squared in meters. Percent BMI was calculated as actual BMI divided by median BMI for age and gender. Two trained investigators performed all anthropometric measurements.

A dietary history interview was performed with each subject by the same registered dietitian. Reed and Burke examined this method with children and determined that it gave reliable and valid results [23]. The dietary history included a 24-hour recall of usual dietary intake of all meals and snacks, a modified food frequency questionnaire (FFQ) of high calorie foods, and questions to verify intake including portion sizes, food preparation techniques and place of consumption [24]. If foods were consumed in an alternate setting, for example a daycare facility or home of another caregiver, they were asked to provide written information from that facility on what and how much was consumed. Graduated food models were used to aid in portion size delineation. The food frequency questionnaire included twelve high calorie foods usually consumed per week or per month by children and adolescents. These foods (potato chips, peanut butter, cheese, regular soda pop, sugar-sweetened drinks, granola bars, baked goods, cookies, candy, chocolate, doughnuts, ice cream) were chosen based on clinical experience at our treatment center with 80 dietary assessments (unpublished data). To determine the amount of FAFH that was consumed, the subjects were asked how many times per week they ordered food into the home, had take-out food, went to a fast food or family type restaurant, had theme days at school or bought food at school. A three-day record sheet of intake recorded by the parent in the week prior to the clinic was brought at this visit. It included two weekdays and one weekend day. The record was reviewed with the family for correctness, and explanations were requested if different from the 24-hour recall. For children eight years of age and older, the 24-hour recall was performed by asking the child directly with the participation of the parent for portion sizes, cooking methods or omissions. For the younger children, the 24-hour recall was completed with the parent only. With the food frequency questionnaire, the parent was asked directly with help from the child, when needed. This approach has been used successfully by others [25,26]. If any of the subjects had made dietary changes in the one to two months prior to the study, these changes were reflected in the dietary assessment.

From the reviewed three-day food records, the total dietary energy, macronutrient intake and number of food groups servings were calculated from tables of food composition in the computerized analysis program Nutritionist V (First Data Banks, San Bruno, CA, 1995). Composite food items such as pizza were broken down to primary ingredients and placed into food groups by the computer program.

Data Analysis
The results are expressed as mean and standard deviation. To determine if there were differences in age, income, weight, height, BMI, percent BMI and percent body fat between the obese and non-obese subjects, t tests were performed. Chi-square tests were used to test for differences in gender and socioeconomic status.

The t tests were used to test for differences in intake between the two groups. These included total energy intake in kcal and as a percentage of Recommended Nutrient Intake (RNI) for age and gender [27]; fat in grams and as a percentage of Health and Welfare Canada Guidelines for age [13]; fat as a percentage of total energy, sugar in grams; sugar as a percentage of total energy; each food group in Canada’s Food Guide To Healthy Eating (servings of fruit including fruit juice, vegetables, fruit and vegetables combined, grains, milk and milk products, meat and alternatives); each food group as a percentage of total energy; foods determined to be consumed routinely by children and adolescents from the FFQ data (peanut butter; cheese; regular soda pop, sugar-sweetened drinks which included, powerades, lemonade, iced tea, koolaide, fruit punch with low or no fruit juice; regular soda pop and sugar-sweetened drinks combined; granola bars or "fruit" bars that contain little or no fruit; baked goods such as cake and pie; cookies; chocolate; doughnuts; ice cream; a composite of the above foods (not found in Canada’s Food Guide To Healthy Eating)); and FAFH including ordering in, take out, restaurants, theme days at schools and food bought at school (pizza, french fries, hamburgers, fried chicken, etc). If a food or food group was significantly different between the two subject groups, a correlation was used to determine if it contributed to the overall calories, fat and sugar intake. To determine if there was a gender effect between the two groups, a two-way ANOVA was also run on each of the above food variables

The type of milk or milk products consumed (no fat, low fat or regular fat) was also compared using chi-square tests.

In order to determine if percent body fat was correlated with the frequency in consumption of any particular food or food group, correlations were calculated using a step-wise multiple regression analysis. The dependent variable was percent body fat as measured by BIA and the independent variables were the individual food groups and FFQ data as listed above. To determine if eating FAFH affected the nutritional quality of the diet, correlations were used to determine if there was a relationship between the frequency of FAFH consumed and each food group. The results were rejected at p > 0.05 using the SPSS statistical package.

In a preliminary analysis, subjects were subdivided into two age categories, 4 to 11 years and 12 to 16 years. This was to determine whether the adolescents would consume different foods than younger children, as adolescents may have more freedom to purchase food away from the home and thus have more of an access to unhealthier foods. However, no age-related differences were seen, and thus these sub-groups were collapsed into one group for further statistical analysis.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Anthropometric characteristics of the subjects are described in Table 1. There were no significant differences in age, gender or income between the two groups. Subjects represented all socioeconomic levels but the majority were middle class families (net earning of $20 000 to $49 000 Canadian). The two groups were significantly different in weight, height, BMI, percent BMI and percent body fat.

	DISCUSSION

Only a few recent studies have been done that have compared food group consumption between obese and non-obese youth. Generally, obese and non-obese youth eat similar number of servings from the food groups which are below current recommendations [26,28,29]. In the current study the obese consumed more grain products and meat than did the non-obese, perhaps because of the amount of FAFH consumed. This is likely in the form of hamburgers, pizza or chicken, or the like. In the Bogalusa Heart Study [15], children who consumed diets with a fat intake greater than 40% of total calories had more meat than those with less fat in the diet as a percentage of calories. In our study, this high meat and alternative intake was associated with a high percent body fat which has also been shown in adults [30]. It is unclear why cheese was negatively correlated with percent body fat, as cheese is a food high in calories [14]. One possible reason is that the non-obese children consumed more snacks such as cheese and crackers whereas the obese consumed more snacks such as potato chips or meat sandwiches, which may be higher in calories. Although fruit was negatively correlated with percent body fat, this food group also contained fruit juice. Unfortunately, this is a limitation to our study as the computer program did not differentiate between fruit derived from a solid or liquid form. Other studies have shown that fruit juice is linked with obesity in younger children [31].

As seen in other studies, it is a misconception that obese children and adolescents consume more "junk food" than the non-obese [26,28,29]. Our study confirms this for high calorie foods, not found in Canada’s Food Guide, as a whole, but did show that potato chips are consumed significantly more often by obese youth. This amount of extra high calorie foods is likely replacing more nutrient dense foods in the diets of obese and non-obese children and adolescents, as shown by the low fruit, vegetable and milk and milk products intake. Data from a U.S. National Survey [32] revealed that children and adolescents with a high soft drink intake consume more calories and less milk and fruit juice. Thus they consume less of the key nutrients needed for growth and development such as protein, riboflavin, vitamin A, calcium, phosphorous, vitamin C and folate.

One other research group has studied the association between sugar-sweetened drinks and weight in children [11]. The authors concluded that a change in the BMI of children was associated with the consumption of sugar-sweetened drinks. They hypothesized that this contributes to obesity because energy is not compensated for at later meals when a liquid, as opposed to a solid, is consumed. In our study this consumption of sugar-sweetened drinks was also positively associated with percent body fat.

On average the obese subjects in this study ate FAFH eight times per month as opposed to five per month for the non-obese. This has been shown to contribute to a significant amount of extra calories and fat in the diets of obese adults [6,33]. In a study with obese and non-obese adults [34], the obese were observed to consume more food and calories at a fast food shop. Consumption of FAFH may have long-term detrimental effects in obese individuals. The risk factors for chronic diseases start in childhood, and there is a correlation between cholesterol levels and the number of times that students report eating out [35].

There are some limitations in this study. The analysis was not adjusted for ethnicity, education level, socio-economic status, rural or urban dwelling or gender so our findings may not be applicable across all sectors of the population. Secondly, this study was cross-sectional and thus described the diet patterns of the children and adolescents at one point in time and did not answer the question about the development or etiology of obesity. Finally, the non-obese group may not have been representative of all non-obese children as individuals who respond to advertisements may be more committed to healthy lifestyles. Perhaps had the non-obese been randomly recruited from a school setting, they would have been more representative of all non-obese children and adolescents. The strengths of this study included a large sample size in which dietary histories were performed by the same registered dietitian, over all seasons, with the parent and the child present.

	CONCLUSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
In comparison to non-obese children and adolescents, obese children and adolescents consume significantly more FAFH and sugar-sweetened drinks which contribute to a higher calorie, fat and sugar intake which positively correlates with percent body fat. More research is needed to determine if strategies that help parents change shopping habits, given in either a clinical or community setting, will increase the number of nutritious foods in the diets of youth, decrease consumption of FAFH and ultimately reduce obesity prevalence.

Received December 24, 2002. Accepted July 9, 2003.

	REFERENCES

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 

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This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gillis, L. J Articles by Bar-Or, O. Search for Related Content PubMed PubMed Citation Articles by Gillis, L. J Articles by Bar-Or, O.