Supplemental Material can be found at:

http://jn.nutrition.org/content/suppl/2015/09/16/jn.115.21316
5.DCSupplemental.html

The Journa l of Nutrit ion

CommunityandInternationalNutrition

Increased Snacking and Eating OccasionsAre

Associatedwith Higher EnergyIntake among
MexicanChildrenAged213Years 1
4
5
4
Lindsey Smith T aillie,
Myriam C A feiche,
Alison L Eldri d g5 e,
a n d Ba r r y M P op
kin*
4

Departmen t of Nutri tion, Uni versity of North Carolina, Chapel Hi ll, NC;
Nes
and
t l e Research Center, La usan ne, S wi tzerland

Abstract
Background:Little is known about the dietary behaviors of Mexican children with regard to frequency, amount, and
quality of foods consumed at eating occasions and their impact on total daily energy intake.
Objectives:The objectives were to
1) describ e foods consume d across eating occasions
2) examine
and
whether the

number or type of total eating occasions was associated with increased total daily energy intake and differed between 2-Downloaded
to
from
5-y-old and 6- to 13-y-old Mexican children.
Methods: A nationally representative sample of 5031 children from the 2012 ENSANUT (Encuesta Nacional de Salud y
Nutrici on) was used to examine the percentage of meals and snacks consumed, mean energy intake from meals and
snacks, and the top food groups contribut ing to meals and snacks . Multivariate linear regression was used to examine the

association between meals, snacks, and total eating occasions with daily energy intake for 2- to 5-y-old and 6- to 13-y-old jn.nutrition.org
children.
Results:Eating patterns were similar across age groups (per capita mean intake of 3 meals and 1.4.6 snacks/d). Each
additional snack was associated with greater increases in mean daily energy for older children (+191
P < 0.01)
9 kcal/d;
relative to younger children (+102 0 kcal/d;
P < 0.01). Likewise, each additional eating occasion was associated
b ywith
guest on November 18, 2015
great e r increases in mean daily e nergy for older childre n (+32
P < 0.01
3 kcal/d;
) relative to you nger children (+16 6 61 kcal/d;
P < 0.01). In both younger and older children, snacking was prevalent (75% and 68%, respectively). Top food contributors
to snacks included fruit, salty snacks, candy, sweetene d breads, and cookies. Among older children , whole milk as a snack
was partially replaced with soda and sweetened fruit drinks.
Conclusion:Snacks represent an area for potential improvement in the diets of Mexican children , especial ly among those
aged 6 to 13 y, for whom each additional snack or eating occasio n was linked to even greater increases in total daily energy
intake. JNutr 2015;145:2570.

Keywords:

snacks, sugar-sweetened beverages, energy intake, dietary behavior, child diets, preschooler diets,

Latin America

Introduction

snackinghas becomea predominantway of eatingamong

Public healthexpertsincreasinglyseekto understanddietary Mexicanchildren,similarto increasesin snackingacross the
determinants of excess energy intake and obesity in Mexican
globe (2). One recent article showed that snacking increased
children. In addition to high-caloric foods and beverages
(1),99 to 20 12 , wi th 79 % of 2- to 18 - y- ol d c hi ld r e n c on f ro m 19
s um insgna c ks
(5 ).In n or thw e stMe
e rn
x ic o,
>8 6%of ft hg ra d er s co n su me d a t le a st 1 sw ee t sn a ck a nd 8 5% co n su me d a t
1
e Resea rch Center, Lausanne, Switzerl
Supported by Nestl
and.
This
i s -f
a free
le a st
1 hi
gh
a t sn a ck (6 ) w ee k ly. Ot h er w or k fo un d th a t fe ed i ng
acces sarticle,distributedunderterms (http://wwwhi
.nutrition.org/pu
gh -f a t sn blications
a ck s a /nd sw ee te n ed b ev er a g es st a rt s ea rl y in li fe (< 6 mo
guidelines -and-policies /license/)ptehramtui nt r e s t r i c t e d noncomm ercial use,
of a g e), w ith >60% of 12- to 2 4-mo-olds consuming hi g h - fat
d i str i bution,
and r eproduction
in any mediu m, p ro vide
t hdeor iginalwork is
snacks and s weetened drinks at leas t once p er week (7).
p r operly cited.
2
Au thor disclosure s: LS Taillie, MC Afeiche, AL Eldridge,
no w a r din c r e a s e dsn acking is p o tentially p roblemT and
h i BM
strPopk
e nin,dto
conic ts of interest.
atic. Whereas snacking and i nc r e ased meal fr equency h ave been
3
Suppleme ntal
Tables 1 and 2 are availablefrom th eOnlin eSupporting
linked to i ncreased energy intake in US chi ldren and adul ts (8
Materi al link in the on line posting of the artic le and fro m the same link in the
10), the literature on e ating f re quency and weight is mixed : some
online table of contents at http://jn.nutr ition.org.
* To whom correspondenc e should be a ddres sed. E-mail: popkin@ unc.edu.
studies found n o l ink bet ween me al patterns, s nacking, and
2570

2015Am erican Society for Nutrition.

Manusc ript received March 23, 2015. Initial review complete d May 31, 2015. Revision accepted August 17, 2015.
First publish ed online September 16, 2015; doi:10.3945/ j n.115.213165.

childrenprovidingconrmat ion
of foodsconsumedwhile not in the
overweight status (11), whereas others found that increased
snackingwas positivelyassociated
with overweight(14, 15). presence of the primary meal preparer (i.e., while at school). Participants
reported the type and amount of foods and beverages consumed over the
There are severalpossibleexplanationsfor theseconicting
past
24 h and detailed information about food characteris tics, including
ndings: although increases in both the energy density of
snacks
place of consumption (home, restauran t, school), and method of preand increased portion sizes of snacks may contribute to excess
paration (i.e., raw , processed, package d, frozen, etc.). Interviewers used
energyintake (16, 17), other work (primarilyin adults)is
tools to aid in portion-size estimation, including photos of commonly
suggestive but inconclusive that frequent
eating
throughout
c on s u m
e d f oo
d s , a fo odthe
s ca l e, m e a s u r in g cu p , a nd s er v i n g s p oo n . G r a m s
day can help with appetitecontrol and promote energy or mi l li l it of
e rs
f o ods/ d ishe s /b e ve r age s c oimput
nsum
e by
de d
age
were
regulation (18, 19). One recent study in British
group,and
areaAmerican
an d r e g ion of r esi d e n ce , and e a t i ng o c c a sion whe n the w e i g ht
adults found that
$ 6 eating occasions was associated with lower
o r v o lu m e wa s n o t r ep o r te d b y t h e pa r ti ci pa n t.
Whole foods were reported as consumed (i.e., banana, yogurt) and
total energy , lower mean BMI, and a higher nutrient-rich foods
mixed dishes were reported as a single item and then disaggregated into
index (20).
component
Thus, one major question is whether eating occasions
(meals ingredien ts by using either a standard recipe (when the food
was
consume d away from home or the specic proportion of ingredients
compared with snacks) are linked to shifts in total daily energy
and the quality of foods consumed. Y et, virtually no workwas
haspartially or wholly unknown) or a consumer recipe (when ingredients were known) . The food groups used in this study were based on the
examined the link between snacking or other eating occasions
food groups used in the Feeding Infants and T oddlers Study (33).T wo
and t otal daily energy intake in a r epre sentative sample
of
trained Mexicandietaryresearchspecial ists
modied existing groups
Mexican s chool-aged
chi l dren.
The one studyto examine and created additional groups to reect foods consumed by children in
associatio ns between meal fre quency and en ergy wasMexico,
a smallsuch as the addition of tortillas (
). Our
SupplementalTable1
stud yn(= 45 ) conducted in a geographically limited region
f the most recent food-composition
study oused
table, which was based on
ru ralMexico in t he early 1990s,
which found that among a combinati on of pre-existing Mexican food-composition tables (67% of
foods) (32) and the food-composition tables from the
s Food
USDAand
children < 5 y old, increased e ating f requency was associated
Database for Dietary Studies (33% of foods) (34).
Downloaded from
with increased energy intake (2 1). Of particular interestNutrient
are
Participants were asked to report the eating occasion an d name of the
evening snacks, because these have been linked to i ncreased
eating
energy intake (22) and overweight in adults, as well
as oa c c a si on in which they con sumed each food o r dish. Sp ec i call y,
p articipants could r eport t hat a n i t e m was con s u m ed at 1 o f 4 custo m ary
fourth meal called
almuerzo
, wh i ch is consumed in the late
me alt ime s, in cl ud in g bre ak fa st ( rst me al of th e day ), lu nc h (of te n the
morningb eforelunch and rep resents
a potentiallymajor
ma in me al, con sum ed bet we en no on and mid af ter no on ), di nn er (ev en in g
unexplor ed contributor to Mexican diets.
me al) , and
, almuerzo
whi ch is a me al tha t occ ur s af ter bre ak fas t (ty pi ca ll y
jn.nutrition.org
Finally , understandingdifferencesbetweenpreschoolers
la te mor ni ng or no on ), or as a sna ck . Sna ck s we re de ned as an y fo od or
(childrenaged2 y) and older children(ages6
y) rag
is e co ntr ib ut in g >0 kc al th at wa s con sum ed be tw een th e cus to ma ry
be ve
important, considering that although younger children
s intake me alt imeins,cl ud inthgefo ll ow in be
g: fo re -br ea kf
sna
ast
ckmor
,
ni ng
at individual eating occasions tends to be sn
more
ac k,variable,
aft er no their
on sna ck, and ev en in g sna ck (a ft er di nn er ). Eat in g oc ca sio ns
re cod ed as un iq ue ea ti ng occ as io ns if the y oc cur re d >6 0 min af ter the
daily energyintaketendsto be lessvariable(25), we
indicating
guest
18, 2015
re cen t ea ti ng occ as io n. On th e bas is of thbey qu
es on
tioNovember
nn air e des
ign ,
betterenergyself-regulation
(26, 27). Converselyolder
, mo st
chilpa rtsatiety
ici pan and
ts co ul d re po rt up to 4 sna cks fo r the mo rni ng and af te rno on
drens food intake may be driven less by hunger and
sn ac ks,
more inuencedby social and environmental
cues,such
as bu t onl y 1 sn ack bef ore bre ak fa st or af ter di nn er. W at er wa s no t
co de a
ds a me alor sna ck,be cau se
wa te is
r es se nt for
ial phy si ol ogi c
portion size or eating patterns (26, 28). Older children also have
fu nc tio n and sho ul d be co nsu me d ad li bi tu m (3 5) .
increasedautonomyin choosing,purchasing,and consuming
The Internation al Obesity T ask Force cutoffs were used to classify
foods, especially outside the home (29).
overweigh t and obesity using BMI by age and sex (36, 37). This method
2
The objectivesof this studywere rst to describeenergy extrapo lates to childhood the BMI (in kg/m
) in young adulthood of
intakeand top foods consumedacrosseatingoccasionsin a
$ 25 for overweight and
$ 30 for obesity , thereby creating cutoffs at
nationallyrepresentative
sampleof 2- to 13-y-old Mexican every age by sex.
children and explore sociodemographic correlates. Second, we
examinedwhetherconsumingduring key eating occasions Statistical analysis.Statistical analysis was conducted by using Stata,
version
(snacks,almuerzo
) or incre as ed to t a l eat ing oc cas ions
we 13
re (Stata Corporatio n). First, we examined the differences in the
percentage
of consumers and mean per capita consumption of eating
as s o ciate d with i n cr e a s e d t otal dai ly en e r gy i n take
a nd whether
occasions by key demogra phic characteristics using chi-square tests and
this differ e d b etween 2- to 5-y-old a nd 6- to 13-y-old children.
t tests,respectivelywith
, signica nce
denedat P < 0.05. W ealso
descrip tively examined per capita energy intake across eating occasions
and total daily energy intake by age group, as well as by consumer . W e
Methods
then examined the top 5 food groups consumed at each eating occasion
asde
well as their mean energy contribution to that eating occasion and
Studypopulation. This study used data from the Encuesta Nacional
to toNational
ta l da ilHealth
y en erand
gy i nt a ke . Fi na ll y, u si ng m ul ti v ar i at e li n ea r r eg re s s io n ,
Salud y Nutrici on (ENSANUT ) 2012 (Mexican
w eex -a m inth
edea ss oc i atbe
i on
tw eethneco ns um p ti
o on
fke yea ti n g
Nutrition Survey), a cross-sectio nal, multistage, stratied, and cluster
[ br
s e a k faalmuerzo
s t,
(o r l at e- m o rnminea
g l)m
, o rn in g /
sampled representative survey conducted bys Mexico
Instituto Nacional o c ca si on
a ft er no on / evs en
na in
ckg], tosn
ta al ckasnd
, to taeal ti ng oc ca san
io dn s
de Salud Publica (National Institute of Public Health) between October
l il yen er giny ta kead
, ju s te
fodrke ys oc io de m og rfaap
cthiorcs ,
2011 and May 2012. The surveymethodolo gy
has beendescribed to ta da
i nc lu di50,528
n g aghouseholds
e (c on ti nu ou s) , se x , we i gh t s ta tu s (n or m a l we i gh t co m pa r ed
elsewhere, but, in brief, ENSAN UT 2012 surveyed
w it h ov er we ig ht /o be s it y ), ur ba ni ci ty (r ur al co m pa re d wi th u r ba n) , an d
with a response rate of 87% (30, 31).
te r ti loes
fs oc i oe co n som
ta ic
tu(Ss ES a; cc or dito
ng
h ou s eh a
o ss
ld et s ).
A n al on
ys es
we r e s tr a ti e d by a g e g ro up (2 5 co m pa r ed w it h 6 13 y) an d
a random
Dietary assessment.Dietary intake data were collected
edus in g
su rv ey
co m m anads
ndad ju s te
todbe na ti o na ll y
subsampleacrossall ages(n = 9937)by usinga single24-h recall co nd u ctby
r ep m
r es
en ta ti vhe.asFo r th e m u lt iv a ri at e a na ly si s , we us ed m ar g in s co m m a nd s
administe red
via t heautomated5-st epmultiple-pass
ethod,which
to prded
eaest
n en
ta k e fo r ea ch le v el o f co n su m pt io n s ta tu s of ea ch
been ad apted to t he Mexican c ontext a nd foun
to ibct
em
tter
i mer
atgy
e einnergy
k children
ey ea ti a
ngged
oc betwe
ca s ioen
n ,2a dj us te d fo r th e af o re m en ti on ed v a ri ab le s . S ig ni intake than the t radition al 24-h rec all (32). For
ca ncthe
e fo r m ul ti v ar ia te a na ly se sP wa
<0.s 0d 1e. ne d at
and 13 y, the primary household m eal p reparer re porte d intake, with
Eating occasions in Mexican children
2571

children (
), although older children had higher absolute
Figure1
energy intake
at each meal and snack as well as higher total daily
Sociodemographic characteristics and associations with energy . Although
almuerzocontributed only 11% and 13% of
eating and snacking occasions.Our analytic sample com- per capita daily energy for younger and older children, respecprised 5093 children, 47% of whom were girls. A total of 16%
tively a
, mongthosewho consumedalmuerzo
, it contributed
were overweight and 7% were obese. Most (61%) children25%
livedand 28% of daily energy for younger and older children
in urban areas of Mexico.
(
. T otal snacks contributed 19% and 16%
SupplementalTable2)
Y oungerchildrenhad slightlymoretotal eatingoccasions of
per capita total daily energy for younger and older children,
than did older children due to increased snacking (; P < respectively , primarily in the form of morning snacks (8% of per
Table1On average,
0.05), in particular in the afternoon and evening.
capita daily energy) and afternoon snacks (8% of per capita
younger children consumed 3 meals and 1.6 snacks (resulting
daily in
energy) T
. he p erc a pita
contribu tionof energyfrom
4.6total eating occasions/d), whereas older children consumed
eveni 3ngsnack swas small ( 1 2% but
), amongth osewho
meals and 1.2 snacks (resulting in 4.2 total eating occasions/d).
consumedeveningsnacks,it represented
12% of total daily
W e observed regional and socioeconomic variations inenergy
eating intake for both age groups.
occasions. The percentage of consumers
almuerzo
of was higher
in rural than in urban areas (55% compared with 40%) and
in
Topfoods
consumed acrosssnacking occasions. Fo r 2 - t o
south and central Mexico (49% in both regions) compared
with
5-y-old children, top sou r c es of foods a n d beverages con s u me d as
northern Mexico and Mexico City (40% and 32%, respectively)
snac k were
s
cons i s tent
acrosssnac k i ng
occ a sions
To.p snacks
(P < 0. 05 ) . On th e o th er ha nd , ch il dr en in uinrbc a
n ar ea
s acsandy
we l ,l salty
as in snacks, cookies , sweetened breads (i. e . ,
l uded
fruit,
no rt h er n M ex ic o a nd Me x ic o Ci ty we re mo bread
re li k o
elrybaker
to co yns
um e s that have been swe e tened, also known a s
product
sn a ck s, in cl ud in g a ft er no on a nd ev en in
g
sn
a
ck
s.
C
hi
l
dr
en
fr om
pan d ul c e ), and d airy
(whole milk , yo g urt, lac t o s e -free milk, and
fa mi li es wi th h ig he r S ES we re a ls o mo re l ik el y tofortied
co ns um
e
sn
milk) ( a ck).s The evenin g snack, in particular, comth a n
ch il d refrnomfa mi l ie
in sth elo we st te rtoilfSE
e S(7 5 % prised mostlyTable2
from
milk-basedbeveragesa n dsome ca n Downloaded
dyand
co mp a re d w it h 6 4% fo r hi g he st co
mp
a
re d breads.
wi th lo Fwe
sweetened
o rst6te
- trto il1es
3 -, y - o l d c h i l d r e n , t o p s n a c k f o o d s
re sp ec ti ve
P <l 0.
y; 0 5) . Th er e we re n o si gn i inc
ca nt
di ff er
s insnac
th e k s , candy , cookies , and sweete n ed breads.
l uded
f r en
uit,ce
salty
nu mb er o f ea ti ng o cc as i on s be tw ee n o ve rw
ei
g
h
t/
ob
es
e
ch
However , at morning ils dr
n aen
ck, car b onated s o da p a r tially replace d
an d no rm a l- w ei g ht ch
P =il 0.
dr16
en)(o r by P
se=x0.
( 2 2)
.
whole
m ilk as the caloric be v er a ge of c h oice. For eve n ing snacks,

Results

swee t ene d t e a and coffee were t h e bi gg est con tri bu t or s t o energ y

nd cand y .
Meanenergyintakesacrosseatingandsnackingoccasions. int a ke, follo wed b y fruit, salty snacks, w hole milk, a jn.nutrition.org
For both age groups,
almuerzowas characterized predomiThe relative contribution of meals and snacks remained fairly
productsand
consistentbetween2- to 5-y-oldchildrenand 6- to 13-y-old nantlyby sandwichesand othersandwich-type
b y guest
onnumber
November
2015
TABLE1
Sociodemographic associations with percentage of consumers for eating occasions and mean per
capita
of18,
eating
1
occasions among children aged 2 y participating in the Mexican National Healt h and Nutrition Survey (ENSANUT), 2012
3

Consumers,%
Characteristic

Any Morning Afternoon Evening

2
Breakfast Almuerzo Lunch Dinner snack snack
snack
snack Totalmeals

Age
2y(ref)
2039
86
6y
2992
83*
Sex
Male(ref)
2564
84
Female
2467
84
Region
South(ref)
1795
86
Central
1847
81*
North
1148
79*
MexicoCity
241
93*
Urbanicity
Rural(ref)
1952
79
Urban
3079
86*
Weightstatus
Normalweight(ref)
3644
84
Overweight/obese
1133
84
Socioeconomic status
Lowesttertile(ref)1886
83
Middletertile
1785
83
Highesttertile
1360
87
1

Numberofeatingoccasionspercapita

44
45

92
91

82
82

75
68*

48
41*

55
45*

16
8*

3.0 6 0.02
3.0 6 0.02

Totalsnacks

Totaleating
occasions

1.66 0.05
1.26 0.03*

4.66 0.05
4.26 0.04*

45
44

90
92*

82
83

68
72

43
44

46
50

11
10

3.06 0.02
3.06 0.02

1.36 0.04
1.36 0.03

4.36 0.04
4.36 0.04

49
49
40*
32*

88
94*
91
93*

79
82
87*
82

63
69
77*
78*

42
42
46
47

42
48
56*
53*

7
10
14*
14

3.06
3.16
3.06
3.06

1.26
1.26
1.46
1.56

4.26
4.36
4.46
4.56

55
40*

88
92*

78
84*

64
73*

39
45*

44
50*

8
11*

3.06 0.02
3.06 0.02

1.26 0.05
1.36 0.03*

4.26 0.05
4.46 0.04*

45
45

91
90

83
81

70
71

43
44

49
45

11
8

3.06 0.02
3.06 0.03

1.36 0.03
1.26 0.05

4.36 0.04
4.26 0.05

48
43
42

90
90
93

78
83
86*

64
71*
75*

40
45
46

44
49*
52*

10
11
10

3.06 0.02
3.06 0.03
3.16 0.03*

1.26 0.04
1.36 0.04*
1.46 0.05*

4.26 0.05
4.36 0.05
4.56 0.06*

0.03
0.03
0.03
0.06

0.05
0.04
0.04*
0.10*

0.05
0.05
0.04*
0.12

n = 5093. *Different from referent group,

P , 0.05(chi-square test for percentage of consumers
t test
andfor mean number of eating occasions). ENSANUT, Encuesta Nacional
on; ref, referent.
de Salud y Nutrici
2
Almuerzois a late-morning meal in Mexico.
3
6 SEs.
Values are means

2572 Taillie et al.

with 75% and 68% of younger and older children consuming

snacks, respectively , and a mean per capita snack consumption
of 1.2.6 snacks/d. The mean number of snacks and percentage
of consumers of snacks were slightly lower than recent estimates
b y Duffey e t a l. (5), wh o found that 79%2-o to
f 5 - y-old
M e x i can children were c onsu m in g snacks, with a per capita
consumptiono f 2.0 snacks/d,an d76% o f 6- to 11-y-olds
wereco nsuming
snacks,with a per capitacon s umption
of
s na c k s/1.5
d . Th i s d if fe re n ce i s pr im a ri l y d u e to Du ff sey et a l.
classic ation of
almuerzoas a s nack, w h e r eas we cla ssied
almuerzoas a me a l.
In de ed , th e cl a ss i ca ti o n of sn a ck s co mp a re d w it h me a ls po se s
a n i m po rtant
c o m plexity
f or analyzingeating pa t terns,
b e c a udenitions
se
are sometimesbut not alwaysbasedon
cultural and social norms about what constitutes a main eating
occasion(i.e.,

meal)ratherthan an eatingoccasionthat is
typically smallerand occurs outsideof thesemain eating
occasions (i.e., snack) (38, 3 9 ) . F o r e x a m p l e , i n t h e P h ilippine s,
meriendai sa c o m monly
consumedfourth mealin the late
afternoon,similar to British tea, in which peopleconsume
substantial foods such as sandwiches, spaghetti, or fast food (L
Adair, Universityof North Carolina, Chapel Hill, personal
Downloaded from
communication,2015) (40). In this study ,almuerzowas
; b
co ns %
um
ofed
ch
45
il yd re n a n d, am o ng th os e wh o co n su me d
;ut2ly
i t, co
5%nto ri
f db ai
edca lo ri es , su g g es t in g th a t th is ea ti ng
FIGURE1
Mean energy intake by eating occasion for 2- to 5-y-olds
o cc as io n is a ma jo r co nttrioM
b ue txoi rc ca hn i l d sdi
ren
ets,
(n 2039)and 6- to 13-y-olds(n 2992)in the 2012 ENSANUT
especially among child ren living in r u r al areas or in th e south.

(Encuesta Nacional de Salud y Nutrici

on).
M o r e o v e r , t h o s e w h oalmuerzo
consumed
consumed the same
jn.nutrition.org
ofan
snacks
to rti lla s (w hic h to get he r co mp ri sed 25% an d 36number
% of me
pe r but more total meals relative to nonconsumers
(datanot
shown),suggesting
that this mealis an additional
cap it a en erg y in tak e fo r 2- to 5- an d 6- to 13- y- old s,
res pe ct
ive ly) ,
o t sati m p l y a s n a c k r e p l a c e m e n t . O n t h e
fo llo we d by egg s an d egg dis he s, so upeating
s an d occasion
ste ws (2and
y),n me
o t gr
h eoup
r h sand,
almuerzotended
ed at
t o b e more
tac os (6 3 y), an d le gu mes (b ot h ag e gr oup s). Fo od
at foods consu m
other
meals
legu mes, sandwiches)
lun ch we re si mil ar, alt ho ug h so da was a to p co ntsimilar
ri bu tot ro of
en erg
y (tortilla s, soups,
b y guest on November 18, 2015
andfas
l ess
s imilar
fo r old er ch ild re n bu t not you ng er ch ild ren . At br eak
t, who
le to snacks. Future work should examine how
mi lk, swe et en br
edead s,
an d rea dy -to -ecer
at ealwe reto the
p c onsumption of this late-mo rning meal a ffects hunger and
s
a
t
i
e
t y es
a nan
d energy
across th e d ay in order t o understan d
co nt ri but ors fo r bo th ag e gr ou ps , whe rea s co oki
d egg diregulation
sh es
whd ether
this
tio nal
mealis a p o t e n tc ioanl t r i b tuoo
t orr
we re to p co nt ri but ors of en erg y fo r 2- to 5- y-o lds an
sa nd
wiaddi
ch es
p ol
otential
an d to rt ill as we re to p co nt ri but ors fo r 6- to 13 -yds . s trategy against ex ce ss inta ke and w eight gain. It
m a y a l s o b e i m p o r t a n t f o r U S nutritional surveys such as the
Eating occasions with total daily energy intake.For older NHANES to consider adding a late-morning meal to the meal
children, the consumption almuerzo
of
was associated with a denitions, to understand how common this behavior is in the
i nu n der stan
i tdsp
i no gt e n t i a l
193-kcal/d increase in mean daily energy
P < 0.05),
(
but this wasUnited Statesa n dt o h e l p
implications
for
weight
gain.
not the case in younger children
P = 0.97)
(
(
). Morning,
Table3
Notably ,yo ungerand o lderchildrenh adsimilareating
afternoon, and evening snacks were associated
with increased
p atternsan dpercentage
of contributionof energyintake
daily energy for both younger and older children (+144, +197,
and +140 kcal/d, respectively , for younger children andacross
+240,eating occasions, with 81% and 84% of energy co ming
+353, and +432 kcal/d, respectively , for older Pchildren;
< 0.01 from mealsa nd19% a nd16% of energyf roms nacksf or
for comparison of snack consumers with nonconsumersyounger
within and older ch ildren, resp ectively . T hese results were
s owith
me greater
wh at surp risi ng, bec a use we wo uld h ave expe cted so me
age group). Each additional snack was associated
inl/d
eating f requency a s c hildren s h ift from presch ool
increases i n mean daily energy f o r older childr e n (+1changes
91 k c a
to
elementary
school. In add ition, some work indicates that
per a ddition al snack) relative to you n ger children (+10 20 k cal/d
o lder c hild ren and adolescent s snack more frequently , which
per additional snack)
P <( 0.01 for each additional snack within
i n t urn,associatedwith increasedmeal skipping( 41).
age group). Likewise, each additional eating occasion wasis,
associatedwith greaterincreasesin meandaily energyfor older One possibility i s that t he 4-me al stru cture, coupled with the
pd
re va lence
o f s nack ing
over time, has createda
children (+323kcal/d for each additionaleatingoccasion) in cr ea se
social norm i n wh i ch eating frequently throu ghou t t he day is
relativeto youngerchildren(+166
kcal/dfor eachadditional eatingoccasion)(P < 0.01 for eachadditionaleatingacceptable a cross a ges. One question f or future research is to
b e tter understand whether a ny shifts in eating occasions have
occasion within age group).
o c curred
alo n gside
other shiftsin the eatingenviron ment,
such as eatin g in front o f t he television (42), or shifts in where
childrena re getting s nack
(i.e.,
s from school, ven d ing maDiscussion
chines, c orner s tores), b ecause s ome wo rk suggests t hat t he
source
In this study , we found consistent eating patterns between
2- toof food is linked t o i ncre as ed empty calor ies in kids
I n3
c mea
o nside
ration of mounting e vidence that f amily meals
5-an d 6- to 13- y-o ld ch ild ren , pri mar ily enc omp(43).
as sing
ls/ d,
Eating occasions in Mexican children
2573

TABLE2
Per capita percentage of energy contributed from the
TABLE 2
top 5 food groups by age group at each eating occasion among
children aged 2 y participating in the Mexican National Health
1
and Nutrition Survey (ENSANUT), 2012
Contribution,%
Rank
2-to5-y-olds
Breakfast
1
2
3
4
5
Almuerzo
1
2
3
4
5
Lunch
1
2
3
4
5

Foodgroups

1.18
1.17
0.74
0.98
0.69

4.36
3.06
2.36
2.16
1.76

0.34
0.31
0.23
0.24
0.21

Sandwiches, tortas,lledrolls
13.36
Tortillas
11.76
Eggsandeggdishes
9.46
Soupsandstews
5.96
Legumes
5.96

1.81
1.04
1.03
1.12
0.85

3.46
3.06
2.16
1.66
1.56

0.45
0.26
0.26
0.45
0.23

17.46
11.96
5.66
5.26
4.26

0.79
0.77
0.47
0.62
0.71

4.86
3.26
1.66
1.86
1.56

0.23
0.26
0.15
0.29
0.28

1.04
1.06
0.98
0.82
0.45

3.46
2.76
1.46
2.26
1.26

0.22
0.29
0.20
0.29
0.13

1.68
1.44
1.03
1.33
0.82

2.66
2.96
1.46
0.56
0.96

0.35
0.41
0.20
0.08
0.14

1.75
1.50
1.24
0.98
0.98

2.26
1.66
2.46
1.56
1.46

Tortillas
Soupsandstews
Legumes
Poultry
Sandwiches, tortas,
lledrolls

Dinner
1
Wholemilk
15.96
2
Sweetenedbreads
9.86
3
Ready-to-eatcereal
7.56
4
Sandwiches, tortas,lledrolls
7.26
5
Tortillas
4.96
Morningsnack
1
Fruit,freshandfrozen
18.76
2
Wholemilk
13.86
3
Saltysnacks
8.06
4
Candy
6.66
5
Babyyogurt
5.26
Afternoonsnack
1
Fruit,freshandfrozen
20.96
2
Candy
15.76
3
Saltysnacks
12.36
4
Cookies
6.66
5
Sweetenedbreads
4.96
Eveningsnack
1
Wholemilk
46.66
2
Fortiedmilk
5.26
3
Sweetenedbreads
4.66
4
Waterandmilk-based
atoles 3.96
5
Candy
3.86
6-to13-y-olds
Breakfast
1
Wholemilk
13.06
2
Sweetenedbreads
12.26
3
Tortillas
8.66
4
Sandwiches, tortas,lledrolls
7.66
5
Ready-to-eatcereal
7.66
Almuerzo
1
2

4.46
1.65
1.53
2.02
1.66

0.93
0.91
0.56
0.68
0.92

Sandwiches, tortas,lledrolls
19.06 1.35
Tortillas
16.56 1.12

2574 Taillie et al.

0.19
0.22
0.24
0.22
0.50

Contribution,%
Foodgroups

Toeating Tototaldaily
occasion
energy

3
Eggsandeggdishes
5.76
4
Meattacos
5.56
5
Legumes
4.76
Lunch
1
Tortillas
24.96
2
Soupsandstews
7.86
3
Legumes
6.86
4
Sandwiches,tortas,lledrolls
4.76
5
Carbonatedsodas
4.66
Dinner
1
Sweetenedbreads
10.96
2
Tortillas
10.06
3
Wholemilk
9.16
4
Sandwiches, tortas,lledrolls
7.06
5
Ready-to-eat cereal
6.16
Morningsnack
1
Fruit,freshandfrozen
18.76
2
Saltysnacks
16.26
3
Candy
8.46
4
Sandwiches, tortas,
7.76

Toeating Tototaldaily
occasion
energy

18.16
10.36
9.06
8.66
6.26

Wholemilk
Sweetenedbreads
Eggsandeggdishes
Ready-to-eatcereal
Cookies

Rank

Continued

0.63
0.75
0.62

1.46 0.14
1.46 0.22
1.46 0.16

0.83
0.69
0.55
0.48
0.33

8.36
2.26
2.26
1.86
1.56

0.32
0.18
0.24
0.20
0.09

0.92
0.69
0.70
0.61
0.68

2.96
2.96
1.86
2.06
1.46

0.24
0.20
0.14
0.19
0.16

1.41
1.50
1.19
1.60

1.96
3.26
0.56
2.56

0.23
Downloaded from
0.41
0.08
0.87

lledrolls
5
Carbonated sodas
4.76 0.94 0.56 0.10
Afternoonsnack
jn.nutrition.org
1
Saltysnacks
24.36 1.62 4.86 0.43
2
Fruit,freshandfrozen
16.96 1.38 1.66 0.16
3
Candy
13.46 1.28 1.06 0.10
4
Cookies
5.86 0.80 1.56 0.26
guest0.7
on6November
18, 2015
5
Sweetenedbreads
3.26b y0.60
0.15
Eveningsnack
1
Sweetenedteaandcoffee 12.06 4.03 0.46 0.12
2
Fruit,freshandfrozen
11.76 3.4
0.96 0.52
3
Saltysnacks
10.46 2.96 1.36 0.32
4
Sweetenedbreads
10.06 2.72 1.46 0.42
5
Wholemilk
8.66 2.15 0.96 0.22
1

Values are means 6 SEs, n = 5093. ENSANUT, EncuestaNacionalde Salud y

Nutrici on.

with appropriate parental modeling are linke d to improved

intak e of fruit, vegetables, an d key n utrients such as calcium
and i ro n ( 4 4 ), t his c o uld be one potential area for future
interve ntions.
5.66 0.71
One key difference between older and younger children is
0.56 0.19
that
younger
children were twice as likely to consume an evening
6
1.2 0.40
snack,which
contributed; 12% of daily energyintake,on
0.66 0.36
average,
for
those
who consumed it. Although the consumption
0.36 0.12
of evening snacks could be problematic for some segments of the
populationgiventhe associationsbetweennight eatingand
increased
intake of energy-dense and unhealthy foods, younger
2.76 0.19
children
s
evening
snacks mostly consisted of milk-based bever 3.36 0.25
ages,
so
this
snacking
occasion may not pose cause for concern in
2.96 0.21
young children.
2.46 0.24
Among both younger and older children, however, consump1.56 0.17
tion at any particular eating occasion or of additional snacks or
number of total eating occasions was positively and signicantly
5.16 0.39
associatedwith increasesin total energyFor
. older children,
5.26 0.35
these results were consistent with a US study , which showed that
(Continued) among children ages 9 y each additional reported meal and

replaced, a t least in part, by s u gar -sweetened beverages i ncludin g

TABLE 3 Multivariate associations between eating occasions
and total energy intake among children aged 2 y participating
so da , f ru i t dr in ks , and swee ten ed coffee .
in the Mexican National Health and Nutrition Survey (ENSANUT),The relativelygreaterincreasesin daily energyassociated
1
2012
with eating occasions for older compared with younger children

may be due to older children

s overall greater energy intake, such
that each additional eating occasion
makes a bigger absolute
n
n
Mean(99%CI)
Mean(99%CI)
difference
intotaldailyenergyforolderkids.Sustainedover
time, if this e n e rgy
i ntak eis in excesso f daily energy
Breakfast
r
e
q
u
i
r
e
m
ad
e
n
di
t
ti
s
on
, sn
alac kco
s ul d
b ea po te nt iama
ll yjo r
Nonconsumer (ref)313 1646(1371,1922) 543 1606(1448,1764)
contri butorto wei g hgain
t as c hil dren
becomeadolescents,
Consumer
1726 1855*(1631,2079)
2449 1844*(1771,1917)
especiall
cons
y
forum
t hinose
gle s s - h e a l t h ys n a c k s .Onth e
Almuerzo
other hand, th is cross-sectional w ork c annot rule ou t reverse
Nonconsumer (ref)
1124 1838(1603,2074)1554 1718(1631,1805)
causality:increaseds nackin cg ouldsimplyreectthe e ating
Consumer
915 1840(1607,2073)1438 1911*(1817,2006)
ha
b
its of those w ho ea t m ore i n general (38). I n t he present
Morningsnack
study
,
w e di d no t nd an associ a t ion between eati ng occasion
Nonconsumer (ref)
1023 1803(1580,2026)1786 1706(1626,1786)
a
n
d
o
v
e rwei ght/obesity . Thi s m ay be due i n part to the c rossConsumer
1016 1947*(1717,2186)
1206 1946*(1837,2054)
sectional design of t his study . It is also po s sible that chi ldren
Afternoonsnack
wh o h a v e hig her physica l act ivity have more ea t ing oc casions
Nonconsumer (ref)943 1754(1536,1972)1629 1647(1567,1728)
a n d h i g h e r total energy i ntake bu t lower weight, lea d i ng to a
Consumer
1096 1951*(1690,2218)
1363 2000*(1900,2100)
lack of a n association between eating occasion and overweight
Eveningsnack
a
n
d
obesi
ty . Du e to data limita t ions on physi cal a cti v i ty in thi s
Nonconsumer (ref)
1715 1858*(1635,2082)
2774 1769(1702,1837)
sample,
w e w ere u na b l e t o e xami ne this. Longitudinal s tudies
Consumer
324 1999(1738,2259) 218 2201*(1897,2505)
Downloaded
from
in
Mexican
chi ldren a re needed to understand how
mea l and
Totalmeals
snackingfrequency
a
ff
ec
ene
ts
r
g
int
y
a
k
a
e
n
d
w
e
ight
s
tat
us
#3 (ref)
1608 1770(1530,2010)2362 1708(1635,1780)
ov e trime, i ncl uding
whethert hisassociationva r ies
by the
$4
431 1958*(1724,2190)630 2133*(2008,2258)
source
and
quality
of
foods
consumed.
Totalsnacks
Foods consumed at snack t ime a ppear to be one potential
0 (ref)
500 1750(1503,1998) 986 1564(1475,1654)
key
area for future intervention. Although f rui t was t he top
1
582 1880(1658,2102)1038 1779*(1674,1884)
snack
for both o lder and yo unger children, other t jn.nutrition.org
op sn acks
2
481 1992*(1744,2239)641 1970*(1839,2101)
included
salty
sn
acks,
c
andy
,
sweetened
breads,
and
cookies.
$3
476 2094*(1807,2381)327 2259*(2033,2485)
Among ol d e r c h i ldren, nonnutriti ve caloric bev erages, includTotaleatingoccasions
ing s odaand sweetened
coffeeand tea, were consu m ed
at
#3
495 1612(1362,1862) 938 1459(1368,1549)
snacks,a
lthough,
n
otably
,
w
e
also
did
not
capturew
ater
4
537 1873*(1643,2102)989 1782*(1673,1891)
b y guest on November 18, 2015
intake and so we c annot ascertain the proportion of beverage
$5
1007 2039*(1803,2275)
1065 2105*(1996,2213)
intake constitutedby t heseb e vera ges.
Breakfastwa sals o
1
Values are predictedadjustedmeans (99% CIs) from linearregressionmodels
no tab l y c haracterized by a number of high-carbohydrate f oods
controllingfor child age, weight status (normal,overweight/obe sity),
urbanicity,
s uchas sweetened
br e ads,
ready-to-ea cereal,and
t
a mong
socioeconomic status, and sex;
n = 5093. *Different from referent group,
P , 0.01.
youngerchil dren,cookies.Thesecharacteristicps otenti ally

ENSANUT, Encuesta Nacional de Salud y Nutrici

on; ref, referent.
a r e c a u s e f o r concern, because previous work has shown that
amongMexican children,a sweetcereal (i.e.,

bread and
snack was associated with an 18.5% and a 9.4% increase
cookies)
in
and corn dishes dietary pattern (characterized by a high
total energyintake, respectively(8). However f,or younger intake of sugary cereals, tortillas, and maize products) and a
children, these results were slightly surprising, because previous
W estern
pattern(a high intakeof sweetened
beverages,
fried
US-basedresearchhas shown that preschoolchildren self- snacks,industrials n a ccka k e as n
, ds u g a cr y
e r e awl se)r e
regulateenergyintake acrossthe day (44), suggestingthat a s s o c i a
w ti et h
o
d v e r weight and obesity in Mexican
children
(47). More work will be needed to understand the association
additional eating occasions would not necessarily be associated
with increases in total daily energy intake. More work, including
between breakfast, key foods consumed at breakfast, and diet
laboratory-based
studies,will be neededto understandhow quality .
Mexican children compensate for additional snacks or eating
In January 20 14, Me x ico instituted a 1 peso p e r liter sales
occasions(as well as other potentiallyimportant dietarytax o n sugar -s weetened beverages together w ith a n 8 % a d
valorem
behaviors such as portion size or energy density), and how
this tax on nonessenti al foo ds wi th an en ergy d en si ty
changes as children age.
$ 275 kcal/100 g, which is meant to target foods high in a dded
Notably i,ncr easeins daily e n e rgy
by eatingoccasionwe re sugars or solid fats. O ne ke y question f or future research will be
greater f o r older than f or younger children. For example,
h ow a
t his
single
tax ch anges t he types of food s children c o nsu me across
snack per day was associ ated with o n ly a 1 30-kcal, n o nsignicant
all eat ing occ as ions , es pecia lly snac ks.
increasefor y ounger
children(P = 0.05),but with a 215-kcal
This work is not without limitations.This study was
incr easfor
e olde rchildr en(P < 0.01), relativet o no n snack primarilycross-sectional
and thusrepresents
a descriptionof
consumers.
This d i fference
wa s exacerbated
fo rtop snackcon - eatingoccasionsand energyintake, rather than seekingto
sum ers: wher eas e$a3snacks/d
ting
was associated with a 344-kcal
establish a causal link between patterns of eating throughout the
incr eas e f o r younger childr en r elat ive to nonsnac
P<
k consume
day and rs
energy
(
intake. Future studies should look longitudinally
to understand how patterns of eating across the day affect total
0.01), eating$ 3 s n acks/d was associated with a 695-kcal increase
for o lder children
P <( 0 .01). I n a dd iti on, older children consumed
energy and subsequent changes in weight status.
co salty
n cl us i on , th i s st u dy de sc ri be s p at te rn s o f sn a ck in g an d
fewerh ealthy sn acks
relative to younger children,Inbecause
snacks were more commonly cons umed and milk beverages
me
were
a ls
am o ng
a n at i on al
relypr es en tasa
ti mp
v e le
of Me x ic a n
2-to5-y-olds

6-to13-y-olds

Eating occasions in Mexican children

2575

P ie
CP ,opk
in of
B M. I n c r ease
po rtdio si
n z es f rom en er gy -de ns e
ch il dr en a g es 2 5 an d 6 13 y ol d . T he p a tt er n o17.
f co
n rn
suas
mp
ti on
f oo
tota
e ne
rgyth
i nta ke at ea ti ng o c c a s io ns i n US ch i l dre n
sn a ck s a n d me al s wa s co n si st en t ac ro ss a ge
g dros aff
up ec
s, tan
d lfo
r bo
a nd adol esc en ts: pa tte rn s a n d tre nd s by ag e g ro up and so ciode m oyounger a n d older children a dditional e a t ing occasions
were
g raphi c char a cteri stics, 1 977 06 . A m J Cl in N utr 2 011 ;9 4: 132 4
linked t o increases in total daily ener gy . Fruit and m ilk-based
32.
beverages were c ommonly c onsum ed as sn a c ks. H owever,
l ess18. M cCror
yMA, CampbellWW. Effec tsof eati ngfrequencysnacking
,
,
nu trien t-d ense
snacks,s uchas ca n dycookies,
,
sweetened
and breakfastskippingon energyregulation symposium
:
overview .
breads, a nd salty snacks, which were commonly consumed JinN utr 2011;141:14 4.
19. Lof
eid y H J, Campbell
WW. T he effect of eating frequency
on appetite
this sam ple, r epresent a key ar ea for imp r oving the diets
controland foodintake:brief synop sis of controlled
fe eding
studies.
Mexican c hildren .

J N utr 2011;141:15 4.
20. A ljuraibanG S,Chan Q, Oude Griep LM, B rownIJ, DaviglusML,
Acknowledgments
StamlerJ, V anH orn L, Elliott P, Frost G S.The impactof eating
W ethank Phil Bardsleyfor excellentdata management
and
frequency and time of intake on n utrient quality and body m ass index:
programmingassistance,
Nancy Lopez for her assistancein
the INTERMAP study a
, p opulation-bas study
ed
J. Acad Nutr Diet
2015;1 15:528.e1.
understanding Mexico nutrition survey data collection, and Lily
21. G arcia SE, K aiser L, D ewey K. The relationship of eating frequency and
Pedraza and T ania Alburto for assistance with food grouping.
cal oricdensityto energyintake among rural Mexican prescho ol
LST, MCA, ALE, and BMP designed the research and edited the
chil dren. Eur J Clin Nutr 1990;44:381 .
manuscript; LST analyzed the data and wrote the manuscript
22. Stunkar d AJ, Alli son KC, OReardon JP. The night eating syndrome: a
with contributions from all coauthors; and BMP had primary progres s report. Appetite 2005;4 5(2):182.
responsibility for nal content. All authors read and approved
23. Stunkar d AJ. N ight eating syndrome. In: Fairbur n CG, Brownell KD,
the nal manuscript.
editors. Eating disord ers and obesity: a comprehensive handb ook. 2nd
ed.New Y ork: The Guilford Press; 2005. p. 183 .
24. C olles SL, D ixon J, OBrien P. Night eating syndro me and nocturnal
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