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Original articles • J. Pediatr. (Rio J.) 92 (2) • Mar-Apr 2016 • https://doi.org/10.1016/j.jped.2015.05.009   copy

Association of eating frequency with anthropometric indices and blood pressure in children and adolescents: the CASPIAN-IV Study☆ ☆ Please cite this article as: Kelishadi R, Qorbani M, Motlagh ME, Heshmat R, Ardalan G, Bahreynian M. Association of eating frequency with anthropometric indices and blood pressure in children and adolescents: the CASPIAN-IV Study. J Pediatr (Rio J). 2016;92:156-67.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives:

This study was conducted to explore the association of eating frequency (EF) with anthropometric indices and blood pressure (BP) in children and adolescents.

Methods:

This nationwide cross-sectional study was performed on a multi-stage sample of 14,880 students, aged 6–18 years, living in 30 provinces in Iran. Parents were asked to report dietary intake of children as frequency of food groups and/or items. EF was defined as the sum of the daily consumption frequency of main meals and snacks. Association of EF with weight disorders, abdominal obesity, and elevated BP was assessed using different logistic regression models adjusted for potential confounding factors.

Results:

Eating more frequently (≥6 vs. ≤3) was found among students who were at younger age (11.91 vs. 13.29 years) (p < 0.001). Students who reported an EF of 4 (OR: 0.67, CI: 0.57–0.79), 5 (OR: 0.74, CI: 0.62–0.87), and 6 (OR: 0.54, CI: 0.44–0.65) had lower odds of being obese compared to those who had EF ≤ 3. Having EF of 4 (OR: 0.82, CI: 0.71–0.94), 5 (OR: 0.86, CI: 0.74–0.99), and ≥6 (OR: 0.73, CI: 0.63–0.85) was related to lower prevalence of abdominal adiposity.

Conclusion:

Higher EF was associated with lower mean values of anthropometric and BP measures, as well as with lower prevalence of generalized and abdominal obesity in children and adolescents. Longitudinal studies are needed to assess the long-term effects of EF on body composition in the pediatric age group.

Keywords
Eating frequency; Blood pressure; Anthropometric indices; Obesity; Children and adolescents

Resumo

Objetivos:

Este estudo foi feito para explorar a associação da frequência de alimentação (FA) com índices antropométricos e pressão arterial (PA) em crianças e adolescentes.

Métodos:

Este estudo transversal nacional foi feito em uma amostra de várias etapas de 14.880 estudantes entre seis e 18 anos de 30 províncias do Irã. Foi pedido que os pais relatassem o consumo alimentar das crianças, como a frequência de grupos e/ou itens alimentares. A FA foi definida como a soma da frequência de consumo diária das principais refeições e lanches. A associação entre FA e disfunções do peso, obesidade abdominal e PA elevada foi avaliada com diferentes modelos de regressão logística ajustados pelos possíveis fatores de confusão.

Resultados:

Foi constatada uma alimentação mais frequente (≥ 6 em comparação com ≤ 3) entre estudantes mais novos (11,91 em comparação com 3,29 anos) (P < 0,001). Estudantes que relataram quatro [razão de chance (RC): 0,67; intervalo de confiança (IC): 0,57-0,79], cinco (RC: 0,74; IC: 0,62-0,87) e seis (RC: 0,54; IC: 0,44-0.65) refeições apresentaram menores chances de se tornar obesos em comparação com os que apresentaram FAs ≤ 3. FA de quatro (RC: 0,82; IC: 0,71-0,94), cinco (RC: 0,86; IC: 0,74-0,99) e ≥ sei (RC: 0,73; IC: 0,63-0,85) foi associada a menor prevalência de adiposidade abdominal.

Conclusão:

A FA mais alta foi associada à redução nos valores médios das medidas antropométricas e de PA, bem como à menor prevalência de obesidade generalizada e abdominal em crianças e adolescentes. São necessários estudos longitudinais para avaliar os efeitos de longo prazo da FA sobre a composição corporal na faixa etária pediátrica.

Palavras-chave
Frequência de alimentação; Pressão arterial; Índices antropométricos; Obesidade; Crianças e adolescentes

Introduction

It is well documented that non-communicable diseases originate from early life,11 Kelishadi R, Poursafa P. A review on the genetic, environmental, and lifestyle aspects of the early-life origins of cardiovascular disease. Curr Probl Pediatr Adolesc Health Care. 2014;44:54-72. and that their major risk factors, such as elevated blood pressure (BP) and excess weight, track from childhood to adulthood.

Hypertension is recognized as one of the main possible leading cause for several forms of end-organ damage.22 Spagnolo A, Giussani M, Ambruzzi AM, Bianchetti M, Maringhini S, Matteucci MC, et al. Focus on prevention, diagnosis and treat-ment of hypertension in children and adolescents. Ital J Pediatr. 2013;39:20. Prevalence and new incidence of elevated BP are increasing among children and adolescents.33 Sorof JM, Lai D, Turner J, Poffenbarger T Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children Pediatrics. 2004;113:475-82. It has, however, been demonstrated that elevated BP in childhood increases the risk of pre-hypertension and hypertensive adulthood.44 Chen X, Wang Y.Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117:3171-80.

Body weight status is one of the strong risk factors contributing to hypertension.33 Sorof JM, Lai D, Turner J, Poffenbarger T Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children Pediatrics. 2004;113:475-82. The alarming rate in the prevalence of overweight and obesity is now becoming a serious public health issue worldwide.55 Kelishadi R, Haghdoost AA, Sadeghirad B, Khajehkazemi R. Trend in the prevalence of obesity and overweight among Iranian children and adolescents: a systematic review and meta--analysis. Nutrition. 2014;30:393-400.,66 Cavaco S, Eriksson T, Skalli A. Life cycle development of obesity and its determinants in six European countries. Econ Hum Biol. 2014;14:62-78.

Multiple underlying factors, such as the high interaction between genetics and environment, including dietary components, might affect the body weight status.77 Receveur O, Morou K, Gray-Donald K, Macaulay AC. Consump-tion of key food items is associated with excess weight among elementary-school-aged children in a Canadian first nations community. J Am Diet Assoc. 2008;108:362-6. Dietary approaches focused on specific nutrients and foods do not completely explain the establishment of childhood obesity and its associated complications. Thus, it is of great importance to concentrate on dietary patterns and eating behaviors, such as eating frequency (EF).88 Rodríguez G, Moreno LA. Is dietary intake able to explain diffe-rences in body fatness in children and adolescents? Nutr Metab Cardiovasc Dis. 2006;16:294-301.

Previous studies have indicated that greater EF is associated with a healthier body weight and lower likelihood of hypertension among adult population.99 Berg C, Lappas G, Wolk A, Strandhagen E, Torén K, Rosengren A, et al. Eating patterns and portion size associated with obesity in a Swedish population. Appetite. 2009;52:21-6.,1010 Kim S, Park GH, Yang JH, Chun SH, Yoon HJ, Park MS. Eating frequency is inversely associated with blood pressure and hypertension in Korean adults: analysis of the Third Korean National Health and Nutrition Examination Survey. Eur J Clin Nutr. 2014;68:481-9. However, current evidence on the relationship of EF and adiposity among children and adolescents is not conclusive.1111 Chinapaw MJ, Yildirim M, Altenburg TM, Singh AS, Kovács E, Molnár D, et al. Objective and self-rated sedentary time and indicators of metabolic health in Dutch and Hungarian 10-12 year olds: the Energy-Project. PLoS ONE. 2012;7:e36657.,1212 PayabM, Kelishadi R, Qorbani M, Motlagh ME, Ranjbar SH, Arda-lan G, et al. Association of junk food consumption with high blood pressure and obesity in Iranian children and adolescents: the Caspian-IV Study. J Pediatr (Rio J). 2015;91:196-205. Some associations are reported between skipping meals and increased risk of obesity in youth,1313 Koletzko B, Toschke AM. Meal patterns and frequencies: do they affect body weight in children and adolescents? Crit Rev Food Sci Nutr. 2010;50:100-5. whereas some other studies have not confirmed such a relationship.1414 Siega-Riz AM, Carson T, Popkin B. Three squares or mostly snacks - what do teens really eat? A sociodemographic study of meal patterns. J Adolesc Health. 1998;22:29-36. Therefore, this study aimed to explore the association of EF with anthropometric indexes and BP in a pediatric population.

Methods

This cross-sectional, multi-centric survey was conducted in 2011–2012 as the fourth phase of a nationwide surveillance program, entitled the Childhood and Adolescence Surveillance and PreventIon of Adult Non-communicable disease (CASPIAN-IV) study.

Study details and protocols have been described previously.1515 Kelishadi R, Ardalan G, Qorbani M, Ataie-Jafari A, Bahreynian M, Taslimi M, et al. Methodology and early findings of the Fourth Survey of Childhood and Adolescence Surveillance and Prevention of Adult Non-Communicable Disease in Iran: the Caspian-IV Study. Int J Prev Med. 2013;4:1451-60. In brief, the CASPIAN-IV survey was conducted on a stratified multi-stage probability sample of 14,880 children and adolescents, aged 6–18 years, living in urban and rural areas of 30 provinces in Iran. Ethical committees of the relevant national organizations approved the current study (Ethical committee code: 188092). Written informed consent and oral assent were obtained from parents and participants, respectively.

Trained health care providers measured anthropometric indices including height (Ht), weight (Wt), waist circumference (WC), and wrist and hip circumferences (HC) under standard protocols by using calibrated equipment. Standing height was measured using a wall-mounted stadiometer to the nearest 0.1 cm and weight was measured using a portable scale to the nearest 0.1 kg. WC measurement was recorded at the minimum circumference between the iliac crest and the rib cage, using a non-elastic tape. Body mass index (BMI) was then calculated via the ratio of Wt (kg) to Ht squared (m2). The World Health Organization (WHO) standard curves were used to define underweight, overweight, and obesity. Definition of underweight was based on BMI less than 5th percentile for age and gender. Overweight subjects were classified as BMI between 85th and 95th percentiles, and obesity was considered as BMI greater than the 95th percentile for age and gender. Waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were calculated by dividing WC by HC and Ht, respectively. WHtR more than 0.5 was considered as an indicator of abdominal obesity.1616 Li C, Ford ES, Mokdad AH, Cook S. Recent trends in waist circumference and waist-height ratio among US children and adolescents. Pediatrics. 2006;118:e1390-8. Assessment of dietary intake of children and adolescents was based on parental report as frequency of food groups and/or items. Schools in Iran are in session for half a day; therefore, school meal programs are unusual, and students have almost all their meals at home. Parents were asked about the consumption frequency of the three main meals (breakfast/lunch/dinner) of their children, whereas students were asked about snack items.1717 Kelishadi R, Majdzadeh R, Motlagh ME, Heshmat R, Aminaee T, Ardalan G, et al. Development and evaluation of a questionnaire for assessment of determinants of weight disorders among children and adolescents: the Caspian-IV Study. Int J Prev Med. 2012;3:699-705. The snack items were considered as follows: (a) cakes, cookies, biscuits, chocolates, candies; (b) corn-puffs, chips, pretzels; (c) cola, soda, and sugar-sweetened beverages; (d) fruits, natural fruit juices, dried fruits; (e) milk and dairy products; (f) sausages, pizza, and hamburgers. EF was defined as the summation of the main meals and snacks items consumed, which was between 1 and 9, categorized into four groups as EF ≤ 3, EF = 4, EF = 5, and EF ≥ 6 according to its distribution. Data on socio-demographics, physical activity, sleeping, screen time, and smoking habits were collected through an interview with students. Physical activity and screen time (including watching TV, and leisure time computer and internet use) were categorized as mild, moderate, and vigorous/high with cut-offs of >2 h or ≤2 h per day, respectively. The socioeconomic status (SES) score of participants was constructed using the principle component analysis method, including the variables "parents' education, parents' job, possessing private car, school type (public/private), type of home (owned/rented), and having a personal computer in home." The SES score was categorized into tertiles to construct three level of SES. The first level considered as "low SES," the second level as "moderate SES," and the third level as "high SES."

All interviews were performed in a calm and friendly atmosphere; the questionnaires were completed anonymously.

To measure systolic and diastolic BP (SBP, DBP), participants were asked to sit quietly and relaxed with limited movement, and to breathe normally. BP was measured twice, using a standardized and calibrated mercury sphygmomanometer on the right arm. The cuff had appropriate size for the children's upper arm and the average of measured values (in duplicate, with 5 min interval) was used to determine BP levels. The readings at the first Korotkoff sound were considered as the SBP, and at the fifth sound as DBP. The average of duplicate measurements was recorded and included in the analysis. The diagnosis of elevated BP in children was based on the 90th percentile of the distribution of SBP and/or DBP according to gender, age, and height.1818 Fallah Z, Qorbani M, Motlagh ME, Heshmat R, Ardalan G, Kelishadi R. Prevalence of prehypertension and hypertension in a nationally representative sample of Iranian children and adolescents: the Caspian-IV Study. Int J Prev Med. 2014;5: S57-64.

Statistical analysis

Data were analyzed using the STATA package (Release 12. College Station, STATA Corp LP, Package, TX, USA). All analyses were performed using survey analysis method. Mean, confidence intervals (95% CI), and percentages were calculated for continuous and categorical variables, respectively. Mean and prevalence of continuous and categorical variables across EF groups were assessed using the chi-squared and analysis of variance (ANOVA) tests. Association of EF with weight disorders, abdominal obesity, and high BP was assessed using different logistic regression models. In Model I, the crude association was assessed; in Model II, analysis was adjusted for age, gender, and living area; in Model III, screen time, physical activity, SES, and sleeping hours were additionally adjusted. BP analyses were adjusted for BMI in model IV. EF ≤ 3 was considered as reference group for all statistical models. The result of logistic regression is presented as odds ratio (OR) and 95% confidence interval (95% CI). Association of EF with anthropometric indices and BP level was assessed using different linear regression models. All adjustments were the same as logistic regression models. The result of linear regression is presented as beta (β) and 95% CI. The significant level was set at p-value of less than 0.05.

Results

Overall, 13,486 students completed the study (participation rate: 90.6%). The mean age of participants was 12.47 years (95% CI: 12.29, 12.65), 49.2% were girls, and 75.6% were from urban areas. Demographic and anthropometric characteristics of participants are presented in Table 1. No significant gender difference existed in the mean age (p = 0.20). The overall mean and 95% CI for BMI and WC were 18.85 (18.71, 18.99) kg/m2 and 67.03 (66.57, 67.48) cm, respectively. In total, 19.12% of students were abdominally obese and 11.89% were obese. Elevated BP was documented among 3.74% of students. Breakfast was determined as the main meal most skipped by children and adolescents (32.08% breakfast skippers vs. 8.90% lunch skippers vs. 10.90% dinner skippers). Anthropometric indices, leisure time activities, and frequency of elevated blood pressure are summarized in Table 2. As age increased, the frequency of eating decreased; 13.29 year old students ate ≤3 meals and/or snack, while 11.91 year old participants ate ≥6 meals and/or snacks during the day (p < 0.001). Similar results were observed for boys and girls, separately. Anthropometric indices, such as weight (45.95 vs. 39.66 kg), waist (68.75 vs. 65.56 cm), and BMI (19.61 vs. 18.17 kg/m2), were higher among those who had an EF of ≤3 compared to students with EF ≥ 6 (all p-values < 0.001). Lower EF was reported among obese subjects; in total, obesity was documented in 14.01% of students who reported EF ≤ 3, and in 9.51% of those with EF ≥ 6 (p < 0.001). The likelihood of being abdominally obese was higher among boys who had EF ≤ 3 (22.01%) compared to their counterparts with EF ≥ 6 (18.30%) (p = 0.030). Elevated SBP was documented among participants with lower EF than their peers reporting greater EF (p < 0.001). The same result was also observed for boys (p < 0.001) and girls (p < 0.001). Subjects with EF ≤ 3 were more likely to have higher DBP compared to those who consumed EF ≥ 6 daily (p < 0.001). Lower odds of elevated BP were observed among those who had higher EF (≥6) than those with fewer eating episodes (EF ≤ 3) (p = 0.040).

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Table 1
Demographic characteristics of the study participants: the CASPIAN-IV Study.
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Table 2
Anthropometric indices, leisure time activities, and frequency of elevated blood pressure in participants according to their eating frequency (EF): the CASPIAN-IV Study.

As shown in Table 3, consumption of pulses and soy was higher among those with 6 ≥ EF compared to those with ≤3 EF (p = 0.002). The same pattern was reported for boys (p = 0.08) and girls (p = 0.01).

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Table 3
Nutritional characteristics of participants according to their eating frequency: the CASPIAN-IV Study.

Table 4 presents the association of EF with abdominal obesity, weight disorders, and BP. A significant association was observed between EF and obesity; students who reported an EF of 4 (OR: 0.67, CI: 0.57–0.79), 5 (OR: 0.74, CI: 0.62–0.87), and 6 (OR: 0.54, CI: 0.44–0.65) had lower likelihood of being obese compared to those who had EF ≤ 3. The odds of central obesity had significant inverse association with EF; having an EF of 4 (OR: 0.82, CI: 0.71–0.94), 5 (OR: 0.86, CI: 0.74–0.99), and ≥6 (OR: 0.73, CI: 0.63–0.85) decreased the OR of abdominal adiposity. Eating five times per day was related to lower risk of elevated DBP (OR: 0.68, CI: 0.49–0.94) at first, but after controlling for confounders, this association was no longer significant (OR: 0.85, CI: 0.60–1.20). The same associations were observed for elevated BP and EF = 5 in Model 1 (OR: 0.71, CI: 0.53–0.95) and in the crude model of elevated BP and EF ≥ 6 (OR: 0.69, CI: 0.51–0.95); these associations were no longer significant after further adjustment for potential covariates.

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Table 4
Association between eating frequency, anthropometric indices, and blood pressure using different logistic regression models: the CASPIAN-IV Study.

Discussion

The current nationwide study, which is thought to be the first of its kind, found that higher EF was inversely associated with overweight, obesity, and anthropometric indices, as well as with mean and elevated BP. Many previous epidemiological studies among adults have reported favorable associations of frequent eating with BP; however, evidence is lacking in the pediatric age group.1010 Kim S, Park GH, Yang JH, Chun SH, Yoon HJ, Park MS. Eating frequency is inversely associated with blood pressure and hypertension in Korean adults: analysis of the Third Korean National Health and Nutrition Examination Survey. Eur J Clin Nutr. 2014;68:481-9.

Eating more frequently (≥6 vs. ≤3) was found among students with younger age. It might be because of the better control of parents regarding the food consumption of younger children and, therefore, higher adherence and compliance of young children to healthy dietary habits.1919 Arcan C, Neumark-Sztainer D, Hannan P. van den Berg P Story M, Larson N. Parental eating behaviours, home food environ-ment and adolescent intakes of fruits, vegetables and dairy foods: longitudinal findings from Project EAT. Public Health Nutr. 2007;10:1257-65.

By increasing EF, the estimated mean values of anthropometric measures including Wt and WC decreased, as well as the prevalence of overweight, obesity, and central obesity. Similar decreases were documented in the means of SBP, DBP, and the prevalence of elevated SBP and DBP. The association between frequent eating and lower obesity prevalence has also been proposed in previous studies.2020 Palmer MA, Capra S, Baines SK. Association between eating frequency, weight, and health. Nutr Rev. 2009;67:379-90. It has been assumed that low EF might promote weight gain and unfavorable health consequences that mimic features of metabolic syndrome among the adult population. However, higher EF could possibly lead to excess weight through higher calorie intake during a day. Although controversial, it is suggested that the reduction in hunger provided by regular eating might be another possible mechanism for weight management resulting from higher EF.2020 Palmer MA, Capra S, Baines SK. Association between eating frequency, weight, and health. Nutr Rev. 2009;67:379-90.,2121 Murakami K, Livingstone MB. Associations of eating frequency with adiposity measures, blood lipid profiles and blood pressure in British children and adolescents. Br J Nutr. 2014;111:2176-83. The proportion of distributed energy intake throughout the day appears to be a key factor for weight control. It is also proposed that the distribution of standardized daily energy intake throughout a range of EFs might not lead to an association between EF and weight, whereas a direct association has been observed in ad libitum intake.2222 Gregori D, Maffeis C. Snacking and obesity: urgency of a definition to explore such a relationship. J Am Diet Assoc. 2007;107:562-3.

The relationship of EF and BP is not fully understood. In the present study, lower EF was associated with both increased SBP and DBP compared to higher EF group. The same association was found for elevated BP. In a weight-maintenance trial, subjects with one meal per day had a 6% higher SBP and DBP compared to those who consumed three meals per day.2323 Stote KS, Baer DJ, Spears K, Paul DR, Harris GK, Rumpler WV, et al. A controlled trial of reduced meal frequency without calo-ric restriction in healthy, normal-weight, middle-aged adults. Am J Clin Nutr. 2007;85:981-8. No association of BP and a wide range of EF, from 1 to 9, was found in previous studies,2424 Bertéus Forslund H, Klingstrom S, Hagberg H, Londahl M, Torger-son JS, Lindroos AK. Should snacks be recommended in obesity treatment? A 1-year randomized clinical trial. Eur J Clin Nutr. 2008;62:1308-17.,2525 Poston WS, Haddock CK, Pinkston MM, Pace P Karakoc ND, Ree-ves RS, et al. Weight loss with meal replacement and meal replacement plus snacks: a randomized trial. Int J Obes (Lond). 2005;29:1107-14. whereas one study indicated that the relation of daily EF, especially snack frequency and BP in school-aged children, was inversely dependent on lean and fat mass of participants.2626 Barba G, Troiano E, Russo P Siani A, ARCA Project Study group. Total fat, fat distribution and blood pressure according to eating frequency in children living in southern Italy: the ARCA project. Int J Obes (Lond). 2006;30: 1166-9. However, in the present study, the relationships of EF with BP were adjusted for BMI and WC.

The underlying mechanisms responsible for the association of EF and BP remain to be determined, but they might be partly explained by the existing association of EF with general or central adiposity. Some evidence suggests that low EF is associated with obesity, particularly central obesity.2727 Bachman JL, Phelan S, Wing RR, Raynor HA. Eating fre-quency is higher in weight loss maintainers and normal-weight individuals than in overweight individuals. J Am Diet Assoc. 2011;111:1730-4. The present results are consistent with the findings of a recent study that showed lower EF was related to higher increase in the 10-year changes in BMI and WC of adolescent girls.2828 Ritchie LD. Less frequent eating predicts greater BMI and waist circumference in female adolescents. Am J Clin Nutr. 2012;95:290-6. Obesity is recognized as a contributing factor for hypertension morbidity.2929 Frisoli TM, Schmieder RE, Grodzicki T, Messerli FH. Beyond salt: lifestyle modifications and blood pressure. Eur Heart J. 2011;32:3081-7. The present study found significant associations of EF with generalized and central obesity. Furthermore, the relationship of EF and BP was attenuated after controlling for BMI and WC. These findings suggest that central obesity might be an underlying cause of the association between EF and elevated BP. It was found that individuals with higher EFs reported higher intake of pulses and soy protein, poultry and fish, rice, bread, fruits, and natural fruits. Likewise, previous findings have indicated that subjects who had higher EF were more likely to choose healthy food items, leading to improved quality of their diet,3030 Smith KJ, Blizzard L, McNaughton SA, Gall SL, Dwyer T, Venn AJ. Daily eating frequency and cardiometabolic risk factors in young Australian adults: cross-sectional analyses. Br J Nutr. 2012;108:1086-94. and increased daily intake of micronutrients including vitamin A, C, E, and β-carotene.1010 Kim S, Park GH, Yang JH, Chun SH, Yoon HJ, Park MS. Eating frequency is inversely associated with blood pressure and hypertension in Korean adults: analysis of the Third Korean National Health and Nutrition Examination Survey. Eur J Clin Nutr. 2014;68:481-9.

The limitations of the current study must be addressed. First, its cross-sectional nature precludes the assumption of cause and effect relationships. Moreover, recall bias of dietary intake due to the retrospective data collection may have occurred. Third, as a major limitation of studies on EF, a standard definition of key terms including eating occasions, EF, meals, and snacks is still lacking. Due to the substantial differences in definitions, the comparability of the results between studies may be difficult.2121 Murakami K, Livingstone MB. Associations of eating frequency with adiposity measures, blood lipid profiles and blood pressure in British children and adolescents. Br J Nutr. 2014;111:2176-83. Moreover, the exact energy intake and expenditure of participants was not determined. However, to the best of the authors' knowledge, this is the first study to explore the association between EF, BP, and anthropometric indices among a large, representative, nation-wide pediatric population.

In this study, higher EF was associated with decrease in the mean values of anthropometric measures and the prevalence of generalized and abdominal obesity, as well as with decrease in BP measures in children and adolescents. Longitudinal studies are necessary to identify the effects of EF on body composition, health condition, feelings of hunger and satiety, as well as on hormonal balance, particularly in obese children and adolescents.

  • ☆
    Please cite this article as: Kelishadi R, Qorbani M, Motlagh ME, Heshmat R, Ardalan G, Bahreynian M. Association of eating frequency with anthropometric indices and blood pressure in children and adolescents: the CASPIAN-IV Study. J Pediatr (Rio J). 2016;92:156-67.
  • Funding
    This study was conducted as part of a national surveillance program.

Acknowledgements

The authors would like to thank the large team working with this project, as well as the students, their parents, and school principals who willingly participated in the study.

References

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    Kelishadi R, Poursafa P. A review on the genetic, environmental, and lifestyle aspects of the early-life origins of cardiovascular disease. Curr Probl Pediatr Adolesc Health Care. 2014;44:54-72.
  • 2
    Spagnolo A, Giussani M, Ambruzzi AM, Bianchetti M, Maringhini S, Matteucci MC, et al. Focus on prevention, diagnosis and treat-ment of hypertension in children and adolescents. Ital J Pediatr. 2013;39:20.
  • 3
    Sorof JM, Lai D, Turner J, Poffenbarger T Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children Pediatrics. 2004;113:475-82.
  • 4
    Chen X, Wang Y.Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117:3171-80.
  • 5
    Kelishadi R, Haghdoost AA, Sadeghirad B, Khajehkazemi R. Trend in the prevalence of obesity and overweight among Iranian children and adolescents: a systematic review and meta--analysis. Nutrition. 2014;30:393-400.
  • 6
    Cavaco S, Eriksson T, Skalli A. Life cycle development of obesity and its determinants in six European countries. Econ Hum Biol. 2014;14:62-78.
  • 7
    Receveur O, Morou K, Gray-Donald K, Macaulay AC. Consump-tion of key food items is associated with excess weight among elementary-school-aged children in a Canadian first nations community. J Am Diet Assoc. 2008;108:362-6.
  • 8
    Rodríguez G, Moreno LA. Is dietary intake able to explain diffe-rences in body fatness in children and adolescents? Nutr Metab Cardiovasc Dis. 2006;16:294-301.
  • 9
    Berg C, Lappas G, Wolk A, Strandhagen E, Torén K, Rosengren A, et al. Eating patterns and portion size associated with obesity in a Swedish population. Appetite. 2009;52:21-6.
  • 10
    Kim S, Park GH, Yang JH, Chun SH, Yoon HJ, Park MS. Eating frequency is inversely associated with blood pressure and hypertension in Korean adults: analysis of the Third Korean National Health and Nutrition Examination Survey. Eur J Clin Nutr. 2014;68:481-9.
  • 11
    Chinapaw MJ, Yildirim M, Altenburg TM, Singh AS, Kovács E, Molnár D, et al. Objective and self-rated sedentary time and indicators of metabolic health in Dutch and Hungarian 10-12 year olds: the Energy-Project. PLoS ONE. 2012;7:e36657.
  • 12
    PayabM, Kelishadi R, Qorbani M, Motlagh ME, Ranjbar SH, Arda-lan G, et al. Association of junk food consumption with high blood pressure and obesity in Iranian children and adolescents: the Caspian-IV Study. J Pediatr (Rio J). 2015;91:196-205.
  • 13
    Koletzko B, Toschke AM. Meal patterns and frequencies: do they affect body weight in children and adolescents? Crit Rev Food Sci Nutr. 2010;50:100-5.
  • 14
    Siega-Riz AM, Carson T, Popkin B. Three squares or mostly snacks - what do teens really eat? A sociodemographic study of meal patterns. J Adolesc Health. 1998;22:29-36.
  • 15
    Kelishadi R, Ardalan G, Qorbani M, Ataie-Jafari A, Bahreynian M, Taslimi M, et al. Methodology and early findings of the Fourth Survey of Childhood and Adolescence Surveillance and Prevention of Adult Non-Communicable Disease in Iran: the Caspian-IV Study. Int J Prev Med. 2013;4:1451-60.
  • 16
    Li C, Ford ES, Mokdad AH, Cook S. Recent trends in waist circumference and waist-height ratio among US children and adolescents. Pediatrics. 2006;118:e1390-8.
  • 17
    Kelishadi R, Majdzadeh R, Motlagh ME, Heshmat R, Aminaee T, Ardalan G, et al. Development and evaluation of a questionnaire for assessment of determinants of weight disorders among children and adolescents: the Caspian-IV Study. Int J Prev Med. 2012;3:699-705.
  • 18
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Publication Dates

  • Publication in this collection
    Mar-Apr 2016

History

  • Received
    29 Dec 2014
  • Accepted
    27 May 2015
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