International Journal of Food Sciences and Nutrition,

May 2011; 62(3): 270275

Understanding the influence of the snack definition on the association

between snacking and obesity: a review
DARIO GREGORI1, FRANCESCA FOLTRAN2, MARCO GHIDINA3, & PAOLA BERCHIALLA4
1

Laboratory of Epidemiological Methods and Biostatistics, Department of Environmental Medicine and Public Health,
University of Padova, Italy, 2Department of Environmental Medicine and Public Health, University of Padova, Italy,
3
ZETA Research Ltd, Trieste, Italy, and 4Department of Public Health and Microbiology, University of Torino, Italy

Abstract
The aim of the present study is to understand how different definitions of snacking influence the estimated probability of obesity
in the presence of concurrent risk factors. Factors influencing obesity were evaluated by reviewing the relevant literature through
a PUBMED search. Six different modalities to define snack consumption were identified. A Bayesian network model in which
nodes represent the variables that the retrieved studies indicate as affecting the probability of obesity was implemented and used
to estimate the individual risk of developing obesity taking into account the concurrent effect of the considered risk factors. For a
subject with a given profile of factors, the probability of obesity varies according to the chosen definition of snacking, up to
maximum of 70%. The variability of the probability of obesity attributable to the chosen definition of snacking is very high and
may threaten any conclusion about the effect of snacking, which may be related to the specific definitions adopted in the study.

Keywords: Children, snacks, obesity, nutritional epidemiology

Introduction
Research on the determinants of obesity is fraught with
controversial issues, mostly because it is well recognized
as being a multi-factorial condition, resulting from an
imbalance between energy intake and expenditure.
In fact, genetic, cultural, socioeconomic, behavioral
and situational factors all play a role in eating and
weight control (Bray and Champagne 2005).
A number of studies examined the relationship
between obesity and diet in children, and, among
dietary patterns, snacks received great attention:
indeed, commercially available snack foods are, on
average, considerably more energetically dense than
most foods in the diet. Thus, snacks act with respect to
the average of the overall diet as major contributors to
calorie and saturated fat intake (Whybrow et al. 2007).
However, even if the percentage of energy from dietary
fat is widely believed to be an important determinant
of body fat accumulation, the existence of causal
relationships between single nutrients or foods and
obesity is controversial: prospective cohort studies

have frequently failed in finding a correlation, while

also factors other than dietary choices, including the
speed of ingestion and physical activity, seem to
influence obesity (Jordan et al. 1981; Hu et al. 1997;
Erkkila et al. 2008). Nevertheless, synthesizing the
existing knowledge about this topic is a difficult task,
given the enormous heterogeneity in scientific literature in describing and categorizing food dietary intake.
Particularly, snack is a generic word used to identify a
huge range of different foods, and the definition of the
snacking activity itself seems to be extremely variable
among studies (Gregori and Maffeis 2007). Indeed, at
least two strict concurrent definitions plus some
hybrids are present in the epidemiological research.
The first definition is based on food categories
(Wurtman et al. 1993) and consists of a taxonomy of
food, where snacks are identified by their quality and
composition. An alternative definition is based on time
criteria. In the time-based definition of snacking,
usually, foods consumed between 8:00 and 10:00 am,

Correspondence: Prof. Dario Gregori, Department of Environmental Medicine and Public Health, Via Loredan 18, 35151 Padova, Italy. Tel: 39
49 8275384. Fax: 39 2 700445089. E-mail: dario.gregori@unipd.it
ISSN 0963-7486 print/ISSN 1465-3478 online q 2011 Informa UK, Ltd.
DOI: 10.3109/09637486.2010.530597

Influence of the snack definition in obesity research

between 12:00 and 2:00 pm and between 6:00 and
8:00 pm are considered meals. Every food item
consumed between meals is thus considered a snack
(Toornvliet et al. 1996). Hybrid definitions are also
presented in the literature, like the complex Food
Based Classification of Eating Episodes.
Although some authors (Gregori and Maffeis 2007)
pointed out that the usage of such definitions is not
always clearly stated in the papers, making the overall
understanding of the effect of snacking troublesome,
the actual influence of the adoption in a research study
of one or the other definition has never been estimated.
Indeed, empirical studies use only one specific
definition of snacking in their studies, so comparative
data are not available for the competing definitions.
The aim of the present paper is to understand how
the choice of different snack definitions is impacting
the probability of obesity, in the presence of
concurrent risk factors. In order to accomplish this
goal, we systematically reviewed existing evidence and
implemented a Bayesian network (BN). BNs rely on
Bayes theorem, in which probability distributions for
prior beliefs are modified by new information (the
likelihood function) in developing posterior inferences
(Spiegelhalter et al. 1999). An advantage of this
approach is that prior knowledge and beliefs can be
systematically incorporated, allowing one to fully take
into account the complex relationships between risk
factors related with obesity, as emerging from the
scientific literature.
In the following sections, the literature search
strategy aiming to identify all papers investigating the
relationship between snacks and obesity will be
described. Then, a short introduction to BNs will be
presented and the implementation of a BN model
incorporating the information coming from the
retrieved papers will be proposed and discussed.
Materials and methods
Search strategy and variables definition
A PubMed search based on the terms snack* and
obes*, limited to English-language papers published
between 1 January 2003 and 31 December 2007, was
carried out. A total of 228 cross-sectional, cohort and
randomized controlled trial studies were found and
included in the analysis.
In the articles identified through the PubMed search,
the following risk factors were recognized as being
related to obesity: physical activity, residence, television
viewing, PC/PlayStation usage, parental education,
smoking status of the parents, snacking behavior.
For our purposes, all of these variables were defined
in a precise operational way on the basis of the
literature, as extensively illustrated in the Appendix
(see Supplementary material; online version only),
and they were categorized as shown in Table I.
Moreover, as recognized in the literature, snack
consumption could be defined according to two main

271

Table I. Definitions of variables, their abbreviations and categories.

Variable (abbreviation)

Category

Gender (Gender)

Male
Female
Yes
No
Underweight/normal
Overweight/obese
Urban
Suburban
Rural
Yes
No
Yes
No
Primary
Secondary
University
Primary
Secondary
University
Underweight/normal
Overweight/obese
Underweight/normal
Overweight/obese
Yes
No

Physical activity (PA)

Weight status (Obesity)
Residence (Residence)

Television viewing (TV)

Computer use (PC)
Paternal education (P_edu)

Maternal education (M_edu)

Paternal weight status (P_obes)

Maternal weight status (M_obes)
Parental smoking habits (Smoker)

criteria: (I) the type of the snack, or (II) the time when
the snack was eaten. In the first case, a snack consumer
could be a subject eating (IA) sweet snack, (IB) savory
snack or (IC) generic snack. According to the second
criterion, the consumer of the snack could be a subject
eating food (IIA) in the morning, (IIB) in the
afternoon or (IIC) between meals. Therefore, overall
six different modalities to define snack consumption
were identified.
Statistical analysis
Bayesian network. A BN is a graphical model
(Jensen 2001) that represents the joint probability
distributions over a set of random variables. It consists
of a graphical structure, probability tables and an
inference algorithm. The graphical structure is a series
of nodes representing variables and connected by
arrows, forming a graph that has no cycles. Arcs
encode the conditional dependence relationships
among variables. The direction of each arc indicates
a possible causal relationship between the nodes it
joins. Each arc implies a state of conditional
dependence; that is, linked nodes directly influence
each other, possibly in the form of a causal
relationship between the joined nodes. The absence
of an arc represents conditional independence. Each
node is a data structure that contains an enumeration
of possible values it can assume (states) and is
associated with a probability table that quantifies the
probability of each state depending on the values of the
incoming nodes.
Basically, there are three ways to build a BN: both
the structure and the probability tables can be

272 D. Gregori et al.

the concurrent effect of all factors is taken into account
in such a model, the BN was used to estimate the
probability of being obese for some subject profiles,
which are constructed randomly choosing a limited set
of covariates combinations, including gender, physical
activity, television viewing, using a PC, snack
consumption, parental smoke habits, maternal weight
status. Moreover, in order to study the effect of the
different snacking definitions, for every considered
profile we calculate six obesity probabilities, each of
them estimated assuming to describe the subject
snacking activity adopting one of the six modalities
previously identified.
The NETICA modeling environment (Norsys
Software Corporation 2006) was used for both the
BN implementation and the inference task.

elicited from experts; they can be learned from data by

means of learning algorithms; or both the structure
and the numerical probabilities can be a mixture of
expert knowledge, measurements and objective frequency data (Pearl 2000). When both the structure
and probabilities are established, the BN is able to
calculate the probability of developing obesity based
upon available information about other conditionally
dependent nodes using an inference algorithm that
relies on the principles of probabilistic reasoning and
Bayes theorem.
Information extraction and BN model implementation. We
implemented a BN model in which nodes represent
the variables that the studies identified in the literature
indicate as affecting the probability of obesity;
moreover, we adopted the first strategy to build the
BN model, among those described above: therefore,
structure and probability tables were both elicited
using the evidence coming from the articles yielded
by the PubMed search, considered as experts.
The probability tables are simple contingency tables
relating the risk factor (e.g. snack consumption) with
the outcome of interest (i.e. obesity), populated by the
numbers extracted from each single paper reviewed.
In the case of concurrent sources of information (as in
cases when more than one paper is providing
information to the given contingency table), all
values were retained in the model and treated as
coming from different experts.
The BN model we implemented allowed the
calculation of the marginal probabilities of obesity
according to the presence of each considered risk
factor. Particularly, the marginal probability to
become obese was computed for every modality used
to define the snack consumption. In order to show how

Results
The BN based on the data extracted from the 228
papers is presented in Figure 1. All factors are strictly
inter-correlated except for mothers and fathers
weights, which act as independent factors.
The marginal probability of obesity (i.e. averaging
over the observed distribution of the other risk factors)
is presented in Table II. Snacking and television
viewing are the factors that, assuming all of the other
factors are equally distributed among subjects, are the
most relevant, being associated with a two-fold greater
probability of obesity as compared with the other risk
factors.
In Table III, the probability of obesity is estimated
for a set of covariates combinations: in this analysis,
the concurrent effect of all factors is taken into
account, and the effect of the different definitions of
snacking is presented.

P_edu
PA

M_edu

Smoker
PC
Residence

P_obes
Gender

Obesity
TV

M_obese
Snack

Figure 1. Bayesian network structure. Labeled rectangles represent nodes, and arrows represent conditional dependence relationships.

17.75
3.54
16.85
18.29
13.46
3.13
15.79
12.62
13.1
3.72
12.29
15.56
9.64
3.36
11.48
11.18
11.38
6.36
13.52
11.99
12
4.91
16.35
10.98
12.25
6.2
14.9
13.91
11.46
4.62
12.84
12.62
12.77
6.65
14.27
14.8
12.88
7.45
13.4
11.37
10.48
4.86
15.64
15.71
13.06
4.89
15.06
13.3
Normal
Normal
Normal
Obese
Normal
Normal
Obese
Normal

Yes
Yes
No

Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes

Snack IIA
Snack IC
Snack IB
Snack IA
Maternal weight status
Smoker

No
Yes
No
No
Yes
No
No
Yes
Female
Male
Male
Female
Male
Female
Male
Female

The increased prevalence of overweight and obesity

particularly among children and adolescents is a severe
public health problem shared by the developed and the
developing world, making strategies to identify risk
factors indispensable. The contribution of snacking
toward overweight in children has gained popularity
over the past decade: particularly, the wide availability
of energy-dense snack foods (Farley et al. 2009) and
the empirical observation that the prevalence of
obesity increased contemporarily with the snacking
habits (Bes-Rastrollo et al. 2009) seem to justify this
growing attention on the issue.
Snack foods tend to be energy dense, including in
the definition items such as sweet bakery goods,
sweets, and chocolate and savory snacks. Thus, the
potential effect of between-meal snacking on obesity
could be driven by an extra energy intake. Moreover,
subjects seem not to compensate energy intake after
snacking, especially if they consume snacks on an
irregular basis. However, the relationship between
snacking and body weight remains controversial
(Bes-Rastrollo et al. 2009), mainly because obesity is
a multifactor phenomenon and the quantification of
the contribution made by individual dietary components to this condition could be difficult to estimate.
Numerous determinants of food intake patterns and
consequent weight gain have been described in
scientific literature: they include factors such as
genetics, psychological factors such as disinhibition
and restraint, physical activity levels, home economics
and sociodemographic characteristics (Perez-Cueto
et al. 2009).
Taking into account the concurrent effect of
multiple risk factors is a task even more difficult
when data are extracted from published papers; and
indeed, meta-analytic approaches to multifactorial

Snack

Discussion

Using PC

12.63 (12.1313.31)
12.85 (12.5913.32)
13.13 (12.9413.38)
13.63 (13.1814.08)
12.18 (11.6412.73)
14.03 (13.2614.8)

TV viewing

(6.296.89)
(7.518.16)
(4.364.84)
(3.624.07)
(6.837.48)

Physical activity

6.59
7.84
4.61
3.84
7.15

P (Obesity) (%)

4.61 (4.334.86)

Gender

9.12 (8.759.5)
4.64 (4.394.89)

Table III. Concurrent effects of different risk factors on estimated probability of obesity according to some randomly constructed subject profiles.

Television viewing (Yes)

Paternal weight status
(Overweight)
Maternal weight status
(Overweight)
Residence (Urban)
Physical activity (No)
Paternal education (Primary)
Maternal education (Primary)
Using computer (Yes)
Snack
IA
IB
IC
IIA
IIB
IIC

Snack IIB

Percentage probability of obesity

(95% confidence interval)

Yes
Yes
No
Yes
No
Yes
No
Yes

Table II. Marginal probabilities of obesity according to the

presence of known risk factors as emerging from the BN model.

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Snack IIC

Influence of the snack definition in obesity research

273

274 D. Gregori et al.

studies are rarely conducted, due to such methodological difficulties.
The approach that we propose is based on BNs and
treats the information extracted from the published
papers as expert opinions, using it to derive
probabilistic scenarios that are eventually used for
providing the estimates. We found 228 articles,
published during a 5-year period and aiming to
describe the relationship between snack consumption
and obesity. Consistent with the literature, we
implemented a BN model giving an overall picture of
the inter-relationships among factors contributing to
obesity in which dietary habits interact with behavioral
and environmental factors.
According to the estimated probability of obesity,
computed for each risk factor, snack consumption and
television viewing seem to make a non-negligible
contribution. These behaviors are usually considered
to have a negative effect per se, the first one increasing
energy intake and the second one decreasing energy
expenditure, but are also believed to act together given
the childrens habits to eat snacks while watching
television. Prospective studies have shown that
television viewing during childhood is associated with
later adult body mass index (Viner and Cole 2005) and
that television viewing time is also associated with the
number of food items requested by children (Marquis
et al. 2005; Chamberlain et al. 2006).
However, despite the existing amount of studies
finalized to evaluate the effect of snack consumption,
alone or in combination with other factors, the
concept of snacking is not unambiguous. Authors
employ this term to identify various consumer profiles
that could be dramatically different with regard to food
eaten (sweet or savory snacks) and the time at which
food is eaten.
We retrieved in published papers almost six different
modalities to describe and define the consumption of
snacks; moreover, we showed that for a subject with a
given profile of the other factors, the probability of
obesity varies according to the chosen definition, with
a relative percentage difference among values of up to
70%. This fact is not surprising given the heterogeneity of elements that are commonly encompassed
under the definition of snack.
This finding could be useful in explaining the
enormous uncertainty existing at the present about the
contribution of snacking to obesity. Moreover, we
need to underline the fact that we directly observed
and studied the dramatic effect of differences in risk
factor definitions, but it is also important to underline
that the definition of obesity is also not univocal;
deficiencies in adopting a common and well-established definition of obesity have been stressed elsewhere (Gregori and Maffeis 2007), and obviously
differences in the definition of obesity could affect the
estimation of the effect of snacking as well as the effects
of all other risk factors.

In conclusion, variability such as that observed in

our analysis, where the probability of obesity can take a
large range of values according to the definition of
snacking adopted, potentially threatens any conclusion about the role of snacking in inducing obesity.
In this sense, any effect could be related mainly to the
specific definition adopted in a given study, preventing
any possible generalization of the conceptual categorization of snacking itself.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper of interest.

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