CHILDHOOD OBESITY

March 2020 j Volume 16, Number 2

REVIEW ARTICLE
ª Mary Ann Liebert, Inc.
DOI: 10.1089/chi.2019.0059

Dietary Patterns and Childhood Obesity Risk:

A Systematic Review
Rafaela Liberali, PhD,1 Emil Kupek, PhD,2 and Maria Alice Altenburg de Assis, PhD3

Abstract
Background: Childhood overweight and obesity are recognized as predictors of the risk of obesity in adulthood. The aim of this
systematic literature review was to determine the association between dietary pattern and obesity risk among children.
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Methods: Articles were selected from databases (Cochrane Library, Lilacs, Eric, Livivo, and PubMed/Medline), without limi-
tations regarding language or date. Database-specific search terms included the key words ‘‘obesity,’’ ‘‘diet,’’ ‘‘dietary pattern,’’
‘‘childhood,’’ ‘‘children,’’ ‘‘adolescents,’’ and relevant synonyms. The review included studies that reported the assessment of the
dietary pattern in childhood and that correlated eating patterns with the obesity risk through cluster analysis (CA) and/or factor
analysis and/or principal component analysis and presented odds ratios (ORs). The methodology of the selected studies was
evaluated using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Owing to the heterogeneity among the
assessments of the association of dietary patterns and obesity, the results are described narratively.
Results: Using a selection process in two phases, 16 articles were included. Fifteen studies used a cross-sectional design, and one
case–control study. The included studies showed variation in sample size (range = 232 to 10,187 children/adolescents) and age
(range = 1–19 years old). The studies reported between two and five dietary patterns each. The OR for the relationship between the
dietary pattern and the risk of childhood obesity ranged from OR = 1.02; confidence interval (95% CI) (0.91–1.15) to OR = 3.55; 95%
CI (1.80–7.03). In this study, the dietary patterns identified by the studies were given different names. The food intake patterns
identified could, in most factor or CA studies, be categorized as (1) potentially obesogenic foods that increased risk of becoming
overweight (including fatty cheeses, sugary drinks, processed foods, fast food, candies, snacks, cakes, animal products, whole milk,
and refined grains) or (2) food classified as healthy with the weakest association with the risk of becoming overweight or obese
(including low levels of sugar and fat and high levels of fruits, vegetables, whole grains, fish, nuts, legumes, and yogurt).
Conclusion: Overall, the results indicated from most studies that a diet with a lower percentage of obesogenic foods should be
effective in reducing the risk of developing obesity.

Keywords: childhood; dietary behavior; dietary pattern; dieting; obesity; overweight

Introduction obesity increased from 12.4% in 20105 to 30% in 2014,8

whereas in South Korea,6 it increased from 14.3% in 2010
mong the most serious public health problems of to 15.3% in 2013. In 2011, in China, the prevalence of

A the 21st century, both in developed and developing

countries, being overweight in childhood and
childhood obesity are recognized as predictors of the risk of
obesity in adulthood.1,2 Between 1980 and 2013, these
problems underwent a large increase in developing coun-
tries from 8.1% to 12.9% for boys and 8.4% to 13.4% for
girls3; in 2016, the WHO reported 41 million overweight
children aged <5 years worldwide.4
Childhood obesity has increased over time and has dif-
ferent prevalence rates among different countries. In the
United States, for example, the prevalence of childhood
obese children was 10.1%7 and the prevalence was 7% in
Portugal.9 Between 2012 and 2016, the increase in the
prevalence of obese children was 30%–35% in Mexico,10
12% in Indonesia, 11% in Thailand,11 and 5%–15% in
Latin American countries,12 with lower prevalence rates
in Asian countries, such as 5% in the Philippines, 3% in
Myanmar, 2% in Laos, and 2% in Cambodia.11
As a complex condition, childhood obesity is a risk
factor for several noncommunicable diseases, such as hy-
pertension, dyslipidemia, liver disease, diabetes, polycys-
tic ovary syndrome, and obstructive sleep apnea, as well as

1
Post-Graduation Program in Medical Sciences, Federal University of Santa Catarina, Florianopolis, SC, Brazil.
2
Department of Public Health, Federal University of Santa Catarina, Florianopolis, SC, Brazil.
3
Post-Graduate Program in Nutrition, Federal University of Santa Catarina, Florianopolis, SC, Brazil.

70
 CHILDHOOD OBESITY March 2020
psychosocial problems, including discrimination, social
isolation, and low self-esteem, which can affect health,
education, and quality of life.5,9
It is estimated that 40% to 60% of obese children will
become obese adults, with consequences for their health
and the world economy,1,9,13 thus it is necessary to develop
effective approaches to prevent childhood obesity as a
public health priority.14 As the lifestyle patterns adopted in
childhood are likely to continue in adulthood,8 analysis of
diet or dietary patterns is among the approaches that can be
performed.15
Because dietary intake, as a rule, follows a pattern of
consumption and diet itself is a modifiable risk factor,
understanding dietary patterns can provide useful infor-
mation about the associations between diet quality and its
influence on health, especially in relation to obesity.16,17
The analysis of dietary patterns has been identified as a
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more realistic representation of dietary habits,18 since it
takes into account the complex interactions between nu-
trients and other components of a diet, thus making inter-
ventions to change eating habits possible.16,17
However, Shi et al.19 suggested that the ideal is to in-
terpret an eating pattern as a predictor of the risk of being
overweight in childhood or childhood obesity, beyond
associating eating patterns with nutrient intake. Thus, this
study aimed to address this gap, with the purpose of this
article being to review the literature to determine the as-
sociation between dietary pattern and the risk of obesity
among children and adolescents.
Methods
Protocol and Registration
This systematic review followed the guidelines of the
Preferred Reporting Items for Systematic Reviews and
Meta-analysis checklist (PRISMA).20 The protocol under-
pinning this review is available through the PROSPERO
database (see registration number CRD42019132217).
Eligibility Criteria
Inclusion criteria. Cohort studies, surveys, and cross-
sectional and longitudinal studies that reported the dietary
pattern assessment in childhood and that correlated eating
patterns with obesity risk were included. Studies that were
published in any language or date were considered.
Population: studies with samples of children aged <11
years, and/or adolescents aged 12–18 years (or a mean
within these ranges) as subjects of study at baseline were
included. Dietary information was reported by the chil-
dren/adolescents aged >12 years or their parents, mother–
child pairs, participating families, or parents or caregivers
of children younger than 12 years.
This systematic review only included studies that reported
risk estimates [hazards ratios, odds ratios (ORs), and relative
risks] of obesity and measures of variability [effective sizes
(ESs) or confidence interval (95% CIs) from which these
could be derived] and studies that used validated instru-
71
ments to measure food and/or dietary patterns (rather than
nutrients) through cluster analysis (CA) and/or factor anal-
ysis (FA) and/or principal component analysis (PCA).
The studies reported that individuals were given factor
scores for each of the patterns. Factor scores were divided
into percentiles, tertiles, or quartiles on the basis of their
contribution to each pattern. The studies were included
when they reported dietary patterns for each food group,
first categorized into percentile, tertiles, or quartiles of
energy consumption and then classified into three cate-
gories: low consumption (first percentile, tertile, or quar-
tile), moderate consumption (second percentile, tertile, or
second and third quartile), and high consumption (third
percentile, tertile, or fourth quartile).
Studies that determined the correlation between eating
patterns and obesity risk, and used a variety of obesity
measures were included: weight status was determined us-
ing age- and gender-specific BMI percentiles, BMI z-scores,
BMI standard deviation scores (SDSs), BMI cutoff points,
or waist circumference (WC). BMI was calculated as
weight in kilograms divided by the square of height in
meters [BMI = weight (kg)/(height (m2))]. Abdominal obe-
sity was considered as waist-to-height ratio (WHR) >0.5.
The WC was measured midway between the lowest rib and
the superior border of the iliac crest with a measuring tape at
the end of normal expiration to the nearest 0.1 cm.
The primary criteria used to define overweight and obesity
include overweight: BMI or WC ‡85th percentile to 95th
percentile, BMI = 1 standard deviation above the average;
obesity: BMI or WC = 95th percentile, WHR >0.5, BMI = 2
standard deviations above the average, and overweight if
their BMI z-score was between the 85th and 95th percentile
and obese if their BMI z-score was >95th percentile.
Exclusion criteria. The following exclusion criteria
were applied: 1—studies that did not correlate eating pat-
terns with obesity through reported risk estimates [hazards
ratios, ORs, and relative risks]; 2—studies that did not
consider dietary patterns through CA and/or FA and/or
PCA; 3—participants who were not children and adoles-
cents; 4—studies that analyzed only one isolated macro-
nutrient or nutrient and not the entire diet; 5—studies with
well-defined/characterized samples of nonhealthy subjects
(e.g., people with type 2 diabetes, hypertension patients,
and eating disorders). Supplementary Appendix Table A1
contains the articles excluded and the reasons for exclusion.
Information Sources and Search Strategy
Detailed individual search strategies were performed in
each of the following electronic databases: Cochrane Li-
brary, Lilacs, Eric, Livivo, and PubMed/Medline. A gray
literature search was performed in Google Scholar. In ad-
dition to the electronic search, a hand search was made and
the reference lists of the selected articles were screened).
Search terms and Boolean operators of the medical subject
headings, keywords, and/or other controlled vocabulary
terms were used in searches of the PubMed and the others
 72
electronic databases. All electronic searches were con-
ducted from their earliest records up to March 29, 2018 and
updated to October 10, 2018. Database-specific search
terms included the key words ‘‘obesity,’’ ‘‘diet,’’ ‘‘dietary
pattern,’’ ‘‘childhood,’’ ‘‘children,’’ ‘‘adolescents,’’ and
relevant synonyms. Supplementary Appendix Table A2
contains the complete strategy search terms and databases.
Study Selection
The articles were selected in two phases. In phase 1, two
authors (R.L. and E.K.) independently reviewed the titles
and abstracts of all the references. During this phase, any
articles that did not meet the eligibility criteria already
described in the inclusion and exclusion criteria session
were excluded. In phase 2, they applied the same selection
criteria to the full text of the articles to determine which
articles to include. The same two authors independently
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reviewed the full texts of all the articles.
Data Collection Process and Data Items
One author (R.L.) extracted the data from the selected
studies, including study characteristics (author, year of
publication, study design, and location), population and
sample characteristics, diet assessment method, dietary
patterns identified, dietary patterns and their key compo-
nents, findings [factors adjusted for in the analyses (mul-
tivariable), OR, prevalence ratios, and 95% CI], and main
conclusion. A second author (E.K.) cross-checked all the
information retrieved.
Risk of Bias in Individual Studies
Risk of bias in the individual studies included was
conducted using the JBI-MAStARI ( JBI Meta Analysis of
Statistics Assessment and Review Instrument). The ques-
tionnaire consists of eight questions that were answered with
yes, no, unclear, or not applicable.54,55 In the JBI-MAStARI,
two criteria listed in the instrument were deemed irrelevant to
the nature of the studies. The studies were classified as fol-
lows: high methodological quality (>5 ‘‘yes’’ responses),
moderate methodological quality (3–4 ‘‘yes’’ responses), or
low methodological quality (0–2 ‘‘yes’’ responses).56 Sup-
plementary Appendix Table A3 contains the risk of bias of
the selected studies by JBI-MAStARI.
Summary Measures
The dietary patterns identified by CA and/or FA and/or
PCA and the association with obesity were considered as the
outcome. Risk estimates [hazards ratios, ORs, and relative
risks] of obesity and measures of variability (SEs or 95%
CIs from which these could be derived) for the outcome
measurement were considered in this review. The original
studies reported the results of dietary patterns in terms of
quartiles or tertiles of dietary factor scores and obesity risk.
Data Synthesis and Analysis
We created tables of evidence containing information
from the included studies. Owing to the heterogeneity
LIBERALI ET AL.
among the assessments of the association of dietary pat-
terns and BMI or obesity, it was not possible to perform a
meta-analysis; therefore, the results are described narra-
tively. It was not possible to assess publication bias
through funnel plots as no statistical data synthesis could
be performed.
Results
Study Selection
From the 1570 references initially identified, a com-
prehensive evaluation of the abstracts was performed
after removal of duplicates; 1411 articles were excluded,
resulting in finally 159 articles. After title and abstract
reading, 52 potentially useful studies were acquired. Of
these 36 articles were excluded for various reasons
(Supplementary Appendix Table A1). Thus, 16 studies
were retained for the final selection. A flowchart of the
process of study identification and selection is presented
in Figure 1.
Study Characteristics
The 16 studies were published between 2010 and 2018.
The studies were all cross-sectional studies, with the ex-
ception of one case–control study.70 The studies were con-
ducted in nine different countries and the majority of studies
were from Asian countries (Iran,70 China,61,65,66,69,71 and
Lebanon64,67), with four from American countries (Mex-
ico,58 Brazil,60,63 and Colombia62), two from European
countries (Norway57,59), one from Australia,19 and one from
Polynesia (Samoan island of Upolu68).
Most of the articles were published in English,19,57–59,61,64–71
two articles were published in Portuguese,60,63 and one article
was published in Spanish.62
Sample sizes ranged from 232 to 10,187 children and
adolescents. Mean age among the study participants ran-
ged from 1 to 19 years. Six studies were with children aged
between 1 and 6 years,58,61,62,65,69,70 five studies with
children aged between 5 and 18 years,19,60,67,68,71 two
studies with children aged between 9 and 13 years,57,59 and
three studies with adolescents in the age group between 11
and 19 years.63,64,66
Seven studies included >1000 participants.58,61,62,65,66,70,71
The total sample from the 16 selected studies included
44,793 children and adolescents. The total sample from
Asian countries was n = 22,263,61,64–67,69–71 the American
countries was n = 19,145,58,60,62,63 the European countries
was n = 1351,57,59 Australia was n = 288,19 and was n = 305
from the Samoan island of Upolu.68
The most popular used methods for deriving die-
tary patterns are PCA, FA, and CA. Of the 16 selected
studies, 1 used CA,58 7 used FA,19,61,64–67,71 and 8 used
PCA.57,59,60,62,63,68,69,70
Using PCA or FA or CA to identify dietary patterns, the
majority of the studies included in this review extracted
two,64,67–69,71 three,19,60,63,65,66,70 or four patterns.57,59,61
The cumulative proportion of the total variance in dietary
 CHILDHOOD OBESITY March 2020
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Figure 1. Flow diagram of search.
intake explained by the patterns of these studies ranged
from 16.36%69 to 38.18%,70 accounting for only a limited
portion of the between-person variance in diet. Of note, the
identification of three factors in the analysis by Yang
et al.66 that accounted for 65.6% of the cumulative pro-
portion of the total variance is out of the range of what was
reported in the aforementioned studies.
Because age, gender, socioeconomic status, demo-
graphic and environmental factors, and physical activity
level are associated with both the dietary patterns and the
risk of overweight and/or obesity in children and adoles-
cents, these confounders must be included in the adjusted
73
models. In addition, the risk of Ow/Ob in children might be
linked to parental weight status and child’s behavioral
factors such as sedentary activity and duration of sleep.
Regardless of the difference in confounding variables
and their characterization among the included studies,
statistical adjustments in the multivariate analysis varied
across the studies. This systematic review only included
studies that reported risk estimates (ORs). For the esti-
mative risk analysis and strategies to deal with confound-
ing factors stated (calculate unadjusted and adjusted ORs),
the studies used the following statistics: multiple logistic
regression,19,57,58–60,63,65–69,71 logistic regression random
 74
effects model,61 binomial regression model,62 multiple
linear regression,64 conditional logistic model.70
Possible confounding factors were controlled in the pat-
terns of regression and ORs were calculated by adjusting for
potential risk factors of obesity. The studies show many
confounders, however, the majority of studies considered the
age,19,58,61–65,67–71 gender,19,58,61–65,67–71 parental character-
istics (family education, family income, parental obesity, and
unhealthy behavior),19,57,59,61,63,64,67,69,71 and physical activ-
ity level,57,59,61,64–66,70 as important confounders.
The most important confounders associated with the
obesity risk are age,19,58,61,62,64,65,68–71 gen-
19,59,61,62,64,65,68–71
der, physical activity level,57,64,65,67,70
parental characteristics (parental BMI,57,58,64,67 educa-
tion,19,57,59,64,67 family income,59,65 and family history of
chronic diseases70), BMI,64,67,70 living area,65,68,70 screen
time,64,67,70 smoking status,64,67 and frequency of eating
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out per week.64,67 A summary of the descriptive charac-
teristics of the included studies is provided in Table 1.
Dietary Pattern
Table 1 presents the 16 studies that examined the rela-
tionship between the dietary pattern derived from CA and/
or FA and/or PCA and the risk of childhood obesity. In-
formation on dietary exposures was collected by various
methods.
The food frequency questionnaire (FFQ) was one of the
most commonly used methods to assess individual long-
term dietary intakes of foods and nutrients in the studies,
and is appropriate for investigating dietary patterns on the
basis of frequencies. The development of food lists
(ranging from 5 to 350 items) is crucial for the success of
an FFQ, with the median number being 79. The Food
Frequency Questionnaire for Adolescents (FFQA) adapted
from the FFQ was used to investigate dietary patterns on
the basis of frequencies from a list of foods and portion
sizes according to age (adolescents) and coherent with
dietary patterns and eating habits of this population
group. Dietary intake data were most commonly collected
using an FFQ,57,59,62,64,66–68,71 followed by multiple 24-
hour recalls,61,64–66,69 with two studies using FFQA,60,63
only one study used an eating habits questionnaire,70 and
one study using a 3-day weighed food diary.19
In all the studies, children and adolescents were classi-
fied as overweight or obese according to the BMI cutoff
points,57–59,68,69 BMI z-score,19,60–64,67 or BMI percen-
tiles,65,71 with only one study using WC (95th percentile)66
and one study using WHR (>0.5).70
The studies reported between two and five dietary pat-
terns each. The food items with high and low loadings in
each pattern are presented in Table 1.
In Norway, Oellingrath et al.57,59 reported four dietary
patterns: ‘‘snacking,’’ ‘‘junk/convenience,’’ ‘‘varied Nor-
wegian,’’ and ‘‘dieting.’’
Rodrı́guez-Ramı́rez et al.58 reported five dietary patterns
in the Mexican study: ‘‘rural,’’ ‘‘sweet cereal and corn
dishes,’’ ‘‘diverse,’’ ‘‘Western,’’ and ‘‘whole milk and
LIBERALI ET AL.
sweet,’’ and Ocampo et al.62 reported three dietary patterns
in the Colombian study: ‘‘Proteico/fibras,’’ ‘‘Bocadillo/
snack,’’ and ‘‘traditional/almidon.’’ In Brazil, Nobre
et al.60 and Pinho et al.63 reported three dietary patterns
each: ‘‘mixed diet;’’ ‘‘snack’’ and ‘‘unhealthy;’’60 and
‘‘junk food,’’ ‘‘healthy,’’ and ‘‘traditional.’’63
In Australia,19 three dietary patterns were reported:
‘‘traditional,’’ ‘‘processed,’’ and ‘‘health conscious.’’ In
Lebanon, two studies64,67 reported two dietary patterns:
‘‘traditional Lebanese’’ and ‘‘Western.’’64,67 Choy et al.68
reported two dietary patterns from the Samoan island of
Upolu: ‘‘modern’’ and ‘‘neotraditional.’’
Kelishadi et al.70 reported three patterns from Iran:
‘‘healthy,’’ ‘‘Western,’’ and ‘‘sweet.’’ In China, three
studies61,65,66 reported three dietary patterns: ‘‘healthy,’’
‘‘transitive,’’ and ‘‘Western’’61; ‘‘modern,’’ ‘‘traditional
north,’’ and ‘‘traditional south’’65; ‘‘Chinese wester,’’
‘‘Westernization,’’ and ‘‘meat diet’’66; and two studies69,71
reported two dietary patterns: ‘‘traditional Chinese’’ and
‘‘modern.’’69,71
Dietary Patterns Associated with Childhood
Obesity Risk
The studies that reported the association between dietary
patterns and a significantly higher likelihood of being
overweight or obese are given in Table 1. The OR for the
relationship between dietary pattern and childhood obesity
risk ranged from OR = 1.02; 95% CI (0.91–1.15) to
OR = 3.55; 95% CI (1.80–7.03).
From the European countries, in Norway, Oellingrath
et al.57,59 reported higher rates of obesity risk with a
‘‘dieting’’ diet, OR = 2.2; 95% CI (1.4–3.4) in children
aged 9–10 years57 and OR = 2.2; 95% CI (1.3–3.8) in
children aged 12–13 years.59
From the American countries, Mexican children adher-
ing to a ‘‘Western’’58 eating pattern had a significantly
higher likelihood of being overweight, OR = 1.53; 95% CI
(1.4–2.7). In Brazil, children adhering to a ‘‘snack’’ diet,60
OR = 1.29; 95% CI (0.5–2.8) and/or ‘‘junk food’’ diet,64
OR = 1.05; 95% CI (0.6–1.6) had a significantly higher
likelihood of being overweight. And in Colombia, Ocampo
et al.62 reported higher rates of obesity risk with a ‘‘Pro-
teico/fibra’’ diet, OR = 1.64; 95% CI (1.3–2.0).
From the countries of Oceania, in Australia,19 children
adhering to a ‘‘traditional’’ eating pattern had a signifi-
cantly higher likelihood of being overweight, OR = 3.12;
95% CI (1.1–1.7). On the Samoan island of Upolu,68 those
that followed the ‘‘neo-traditional’’ eating pattern pre-
sented a significantly higher likelihood of being over-
weight, OR = 3.43; 95% CI (1.03–11.4).
From the Asian countries, in Iran children adhering to a
‘‘sweet’’70 eating pattern had a significantly higher likeli-
hood of being overweight, OR = 1.29; 95% CI (1.01–1.66).
Lebanese children who presented a ‘‘Western’’64,67 eating
pattern had a significantly higher likelihood of being obese,
OR = 2.31; 95% CI (1.12–4.73). In China, children ad-
hering to a ‘‘Western’’ eating pattern had a significantly
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Table 1. Summary of the Characteristics of the Included Studies

Risk obesity—lowest and
Author (year) Factors adjusted for in highest by dietary Odds
Location Population and Diet assessment Dietary patterns identified analyses (multivariable) ratios (95% confidence
Study design sample method and their key components model (M) confounders interval), p value Conclusion
Oellingrath et al. 924 out of 1477 Short FFQ Snacking M1 (unadjusted) Tertile 1 (Ref eating patterns) Confounders associated with
(2010)57 9–10 years 39 food items, 11 types of Sugar-sweetened drinks M2 (parental BMI, Snacking the obesity risk:
Norway Primary dinks, 13 snack items, and consumed between meals, low maternal education and M1—1.3 (0.8–1.9) Parental characteristics
Cross-sectional School 5 main meals during breakfast and dinner frequency physical activity level of M2—1.0 (0.7–1.6) Physical activity
Dietary information the past 6 months and low intake of water, the child) Junk/convenient Lower likelihood of being
reported by their BMI cutoff points vegetables, and brown bread M1—0.6 (0.4–0.9) obese:
parents Junk/convenient M2—0.6 (0.4–0.9) ‘‘junk/convenient’’
High-fat, high-sugar processed, Varied Norwegian Obesity was most prevalent
fast foods, french fries, M1—1.7 (1.1–2.6) among children with the
processed pizza, processed M2—2.1 (1.3–3.2) dietary pattern:
meat products, sweets, ice Dieting ‘‘Varied Norwegian’’ or a
cream, and soft drinks M1—2.6 (1.7–4.0) ‘‘dieting’’
Varied Norwegian M2—2.2 (1.4–3.4)
Food items typical of a
traditional Norwegian diet,
fish, meat for dinner, brown
bread, regular white or brown
cheese, lean meat, fish spread,
fruit, and vegetables
Dieting
Artificially sweetened soft
drinks, fat cheese, and fat- and
sugar-reduced yoghurt

75
Rodrı́guez-Ramı́rez 8252 out of 9383 7-day FFQ Rural
et al. (2011)58 5–11 years 102 food items Corn tortilla, legume, low
Mexican Mexican school BMI cutoff points intake of sweets and some
Cross-sectional Dietary information cereals such as white bread,
reported by their whole-wheat bread, rice, and
mother or guardian noodles
Sweet cereal and corn dishes
Sweet cereals, corn dishes,
low-fat milk, sweets, cereals in
general, dairy products
Diverse
Sweetened beverages, meat
and poultry, dairy products,
vegetables and fruits, corn
tortillas
Western
Soft drinks, cakes, dishes with
fat, and salty snacks.
Whole milk and sweet
Whole milk, sweet groups,
lower proportion of corn
tortilla, cereals, sweetened
beverages, and low-fiber
cereals
M1 (unadjusted) Rural (percentiles) (Ref Lower likelihood of being
M2 (age) eating patterns) obese:
M3 (age, área) Sweet cereal and corn dishes ‘‘rural’’
M1—1.34 (1.16–2.06) Obesity was most prevalent
p < 0.05 among children with the
M2—1.43 (1.30–2.27) dietary pattern:
p < 0.05 ‘‘Western’’ or a ‘‘sweet
M3—1.29 (1.09–1.94) cereal and corn dishes’’
p < 0.05
Diverse
M1—1.28 (1.06–1.92)
p < 0.05
M2—1.34 (1.13–2.05)
p < 0.05
M3—1.21 (0.97–1.76)
Western
M1—1.45 (1.33–2.47)
p < 0.05
M2—1.53 (1.49–2.72)
p < 0.05
M3—1.35 (1.17–2.19)
p < 0.05
Whole milk and sweet
M1—1.23 (0.99–1.80)
M2—1.35 (1.14–2.04)
M3—1.17 (0.91–1.67)
continued on page 76
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Table 1. Summary of the Characteristics of the Included Studies continued

Risk obesity—lowest and
Author (year) Factors adjusted for in highest by dietary Odds
Location Population and Diet assessment Dietary patterns identified analyses (multivariable) ratios (95% confidence
Study design sample method and their key components model (M) confounders interval), p value Conclusion
Oellingrath et al. 1.789 out of 2980 FFQ Snacking M1 (unadjusted) Results from 7th grade— Confounders associated with
(2011)59 (924–4th grade) and 40 food items, 11 types Snack, sugar-sweetened drinks, M2 (maternal and (691 children) the obesity risk:
Norway 865–7th grade) of dinks, 13 snack items, low intake of water, vegetables paternal overweight, and Tertile 1 Parental characteristics
Cross-sectional 9–13 years and 5 main meals during and brown bread. education, family income, (Ref eating patterns) Physical activity
Primary School the past 6 months Junk/convenient child physical activity, Snacking Gender
Dietary information BMI cutoff points High-fat and high-sugar sedentary and gender) M1—0.9 (0.5–1.5) Lower likelihood of being
reported by their processed fast foods, french M2—1.0 (0.6–1.6) obese:
parents fries, hamburger or kebab, Junk/convenient ‘‘Varied Norwegian’’
french fries, biscuits, cakes, M1—0.8 (0.5–1.3) Obesity was most prevalent
sausages, hot dog, processed M2—0.8 (0.5–1.4) among children with the
pizza and meat, waffles, sweets, varied Norwegian dietary pattern:
salty snacks, white bread, ice M1—0.5 (0.3–0.8) ‘‘dieting’’
cream. M2—0.6 (0.4–0.9)
varied Norwegian Dieting
Fish and meat, brown bread, M1—2.1 (1.3–3.4)
regular white or brown cheese, M2—2.2 (1.3–3.8)
lean meat, fish spread, fruit and
vegetables
Dieting

76
Cereals without sugar, juice
between meals, artificially
sweetened soft drinks,
carbonated and
noncarbonated, fat- and sugar-
reduced yoghurt
Nobre et al. 232 out of 310 FFQA Mixed diet M1 (unadjusted) Mixed diet Lower likelihood of being
(2012)60 1–4 years 24 food items Beef and pork, cooked beans, Normal weight M1—0.57 (0.24–1.37) ns obese:
Brazil Preschool children BMI z-score milk and dairy products, rice (Ref eating patterns) Snack ‘‘Mixed diet’’
Cross-sectional Dietary information and roots, farinaceous, sweet M1—1.29 (0.59–2.83) ns Obesity was most prevalent
reported by their and savory cookies, cakes, leafy Unhealthy among children with the
mother–child pairs vegetables, fruits, natural juices M1—0.97 (0.44–2.14) ns dietary pattern:
Snack ‘‘snack’’
Milk and dairy products, sweet
and savory biscuits, fruits,
natural juices, breads,
margarine, chocolate milk
Unhealthy
Sweets, artificial juices, soft
drinks, sweets and desserts,
stuffed biscuit, fried or boiled
eggs
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Table 1. Summary of the Characteristics of the Included Studies continued

Risk obesity—lowest and
Author (year) Factors adjusted for in highest by dietary Odds
Location Population and Diet assessment Dietary patterns identified analyses (multivariable) ratios (95% confidence
Study design sample method and their key components model (M) confounders interval), p value Conclusion
Shang et al. 5.267 out of 7500 24 hours-recall 3 Healthy M1 (gender, age) Healthy (percentiles) Confounders associated with
(2012)61 6–13 years consecutive days Milk, yogurt, eggs, fruit, and M2 (M1+feeding types, (Ref eating patterns) the obesity risk:
China Primary schools Foods to 28 groups vegetables and low intake of birth weight, parents’ Transitive Gender
Cross-sectional Dietary information BMI z-score meat such as pork, poultry, weight, parents’ M1—1.21 (0.98–1.48) ns Age
reported by their parents organ meat, and beef/lamb/ educational level, average M2—1.17 (0.96–1.44) ns Lower likelihood of being
other red meat family income per month M3—1.11 (0.89–1.38) ns obese:
Transitive per capita and school in Western ‘‘Healthy’’
organ meat, pork, seafood, center) M1—2.04 (1.38–3.02) Obesity was most prevalent
processed meat, edible fungi M3 (M2+total energy p < 0.001 among children with the
and algae, light vegetables intake (kcal/day) and M2—1.79 (1.20–2.67) dietary pattern:
Western physical activity energy p < 0.004 ‘‘Western’’
rice, refined grains, deep color expenditure) M3—1.80 (1.15–2.81)
vegetables, pork, sugar, fish, p < 0.009
and shrimp, beef, lamb, and red
meat, wheat, starch tubers,
light color vegetables
Ocampo et al. 10.187 out of 17.897 FFQ Proteico/Fibra M1 (unadjusted) Quartile 1 (Ref eating Confounders associated with
(2014)62 5–17 years 28 food items Fruits, cheese, yogurt, cream M2 (age, gender) patterns) obesity risk:
Colombian Instituto Colombiano BMI z-score cheese, vegetables, cooked M3 (age, gender, level of Proteico/Fibra Age
Cross-sectional de Bienestar Familiar (ICBF) vegetables, whole fruits, bread, wealth) M1—1.64 (1.32–2.00) Gender
Dietary information whole foods, chicken, beef p < 0.001 Level of wealth
reported by adolescents viscera, butter, tuna or M2—1.64 (1.23–2.04) Lower likelihood of being

77
and their parentes sardinas, fish or seafood p < 0.001 obese:
(either mother or father) Bocadillo/snack M3—1.26 (1.00–1.58) ‘‘Tradicional/Almidón’’
Packaged foods, candy or p < 0.001 Obesity was most prevalent
sweets, soft drinks, fast food, Bocadillo/snack among children with the
sausages M1—1.18 (0.91–1.52) ns dietary pattern:
Tradicional/Almidón M2—1.13 (0.87–1.46) ns ‘‘Proteico/Fibra’’
Sugar, honey, rice, or pasta, M3—0.84 (0.64–1.09) ns
fried foods dry grains tubers or Tradicional/Almidón
bananas, eggs, beef, veal, pork, M1—0.56 (0.46–0.69)
rabbit, goat, coffee or tea, p < 0.001
chicken noodles M2—0.58 (0.47–0.71)
p < 0.001
M3—0.65 (0.53–0.80)
p < 0.001
Pinho et al. 474 out of 535 FFQA Junk food M1 (unadjusted) Normal weight (percentiles) Confounders associated with
(2014)63 11–17 years 26 food items pasta, whole dairy products, M2 (gender) (Ref eating patterns) the obesity risk:
Brazil Public schools BMI z-score margarine, breads, chocolate M3 (age, family income) Junk food gender
Cross-sectional Dietary information milk powder, sweets, and M1—1.05 (0.68–1.63) Lower likelihood of being
reported by their desserts, sugar, filled biscuits, Healthy obese:
parents fatty foods, and mayonnaise M2—0.56 (0.35–0.91) ‘‘Healthy’’
Healthy Traditional Obesity was most prevalent
skim dairy products, cereals, M1—0.76 (0.50–1.20) among children with the
leafy vegetables, fruits, and dietary pattern:
natural juices ‘‘junk food’’
Traditional
rice, tuberous roots, beans,
red and white meat, eggs,
processed meats, and artificial
juices
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Table 1. Summary of the Characteristics of the Included Studies continued

Risk obesity—lowest and
Author (year) Factors adjusted for in highest by dietary Odds
Location Population and Diet assessment Dietary patterns identified analyses (multivariable) ratios (95% confidence
Study design sample method and their key components model (M) confounders interval), p value Conclusion
Naja et al. (2015)64 446 out of 3636 Single multiple-pass Traditional Lebanese M1 (gender, age) Tertile 1 (Ref eating patterns) Confounders associated with
Lebanese 13–19 years 24-hours recall vegetables, legumes, bread, M2 (m1+mother’s Traditional Lebanese the obesity risk:
Cross-sectional Lebanese adolescents Semiquantitative rice, pasta, and cereals, bulgur, education, working M1—1.60 (0.92–2.77) Physical activity
Dietary information FFQ fruits, fish, and vegetable oils status, parental obesity, M2—1.41 (0.64–3.13) Frequency of breakfast
reported by adolescents BMI z-score Western smoking status, physical Western consumption
and their parents (either poultry and eggs, red meat, activity level, frequency of M1—2.12 (1.24–3.63) Lower likelihood of being
mother or father) mayonnaise, fast-food eating while watching M2—2.31 (1.12–4.73) obese:
sandwiches, pizza, and pies television per week, ‘‘Traditional Lebanese’’
frequency of eating out Obesity was most prevalent
per week, BMI and total among children with the
energy intake) dietary pattern:
‘‘Western’’
Zhang et al. 1282 Three consecutive Modern M1 (age, gender, living Quartile 1 Confounders associated with
(2015)65 7–17 years 24 hours recall Milk, fast foods, eggs, other area, annual household (Ref eating patterns) the obesity risk:
China from the 2011 China Health 20 food items livestock meat, poultry, and income, physical activity) Modern age, gender, living area,
Cross-sectional and Nutrition Survey (CHNS) BMI percentile cake M2 (M1+energy intake) M1—3.55 (1.80–7.03) physical activity, annual
Dietary information reported Traditional north p < 0.000 household income per family
by children ‡12 years wheat flour products and M2—3.10 (1.52–6.32) member, and energy intake
and their mother for children other cereals, combined with p < 0.000 Lower likelihood of being
younger than 12 years. low consumption of rice, pork, Traditional north obese:
and poultry M1—2.45 (1.35–4.44) ‘‘Traditional south’’
Traditional south p < 0.000 Obesity was most prevalent

78
Yang et al. (2016)66 1590 out of 2214
China 11–17 years
Cross-sectional From urban and rural primary
and middle schools
Dietary information
reported by adolescents
vegetables, rice, pork, and
legumes
FFQ Chinese and Western
25 food items Rice, flour, whole grains, fresh
24 hours recall vegetables, fresh fruit, poultry,
BMI WC eggs, freshwater fishes, and
shrimps, deep-sea fish, milk and
dairy products, beans and bean
products, nuts, snacks, sugar,
and barbecue
Western
rice and rice products, flour
and flour products, fresh fruit,
fat meat, hamburgers and fried
foods, processed products,
snacks, coke, sprite, coffee, ice
cream, instant noodles, and
barbecue
Meat diet
fat meat, beef and mutton,
poultry, animal liver,
freshwater fishes and shrimps
and deep-sea fish.
M1 (unadjusted)
M2 (gender, passive
smoking, drinking,
calcium supplements,
body mass index)
M3 (physical activity)
M2—2.42 (1.34–4.39) among children with the
p < 0.000 dietary pattern:
Traditional south ‘‘Modern’’ or a ‘‘Traditional
M1—1.44 (0.81–2.57) ns north’’
M2—1.15 (0.62–2.11) ns
Tertile 1 (Ref eating patterns) Lower likelihood of being
Chinese and Western obese:
M1—0.89 (0.62–1.29) ‘‘Chinese and Western’’
p < 0.005 Obesity was most prevalent
M2—1.07(0.69–1.65) ns among children with the
M3—1.08(0.70–1.68) ns dietary pattern:
Westernization ‘‘Westernization’’
M1—1.76(1.15–2.73)
p < 0.000
M2—1.76 (1.14–2.73)
p < 0.000
M3—1.92 (1.29–2.85)
p < 0.000
Meat diet
M1—1.45 (1.00–2.14)
p < 0.000
M2—1.23 (1.02–1.52)
p < 0.000
M3—1.11 (0.81–1.51) ns
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Table 1. Summary of the Characteristics of the Included Studies continued

Risk obesity—lowest and
Author (year) Factors adjusted for in highest by dietary Odds
Location Population and Diet assessment Dietary patterns identified analyses (multivariable) ratios (95% confidence
Study design sample method and their key components model (M) confounders interval), p value Conclusion
Nasreddine et al. 525 out of 531 5-Step Multiple Traditional Lebanese M1 (age, gender) Tertile 1 Confounders associated with
(2017)67 2–5 years pass FFQ Vegetables, legumes, bread, M2 (mother’s education, (Ref eating patterns) the obesity risk:
Lebanese From preschoolers 15 foods/food groups rice, pasta, and cereals, bulgur, working status of the Traditional Lebanese Mother’s education
Cross-sectional Dietary information BMI z-score fruits, fish, and vegetable oils mother, parental obesity, M1—1.60 (0.92–2.77) Weekly frequency of Meals
reported by their Western smoking status, physical p < 0.000 Age
mother poultry and eggs, red meat, activity level, frequency M2—1.41 (0.64–3.13) ns Gender
mayonnaise, fast-food of eating while watching Western Lower likelihood of being
sandwiches, and pizza and pies television per week, M1—2.12 (1.24–3.63) obese:
frequency of eating out p < 0.000 ‘‘Traditional Lebanese’’
per week, BMI and total M2—2.31 (1.12–4.73) Obesity was most prevalent
energy intake) p < 0.000 among children with the
dietary pattern:
‘‘Western’’
Choy et al. (2018)68 305 117-item FFQ with a Modern M1 (unadjusted) Quartile 1 Confounders associated with
Samoan island of 2–5 years 30 day reference period. Unprocessed red meats, whole M2 (age, gender, total (Ref eating patterns) the obesity risk
Upolu From 10 villages on the BMI cutoff points grains (which are not energy intake, census Modern age, gender, total energy
Cross-sectional Samoan island of Upolu traditional to Samoa), corn, region and material M1—1.00 (0.38–2.61) ns intake, census region and
Dietary information French fries, butter, lifestyle score (quartiles) M2—0.71 (0.74–2.08) ns lifestyle
reported by their mayonnaise, nuts, and snack Neo Traditional Lower likelihood of being

79
mother–child pairs
Shi et al. (2018)19 288
Australia 1–4 years
Cross-sectional From the FINS (Food
Intake and Nutritional
Status of preschool children)
Dietary information
reported by their parents
foods such as potato chips
Neotraditional
Vegetables, local starchy crops
such as taro and breadfruit,
coconut, fish, poultry and a low
intake of desserts, pizza, dairy
products (milk, cheese ice
cream) and infant food items
3-day weighed food diary Traditional
25 food items Grains, fruit, vegetables, and
BMI z-score red meat
Processed
snack foods, processed meats,
beverages, and confessionary
Health conscious
Polyunsaturated margarines,
low-fat dairy products, fish,
eggs, and composite foods that
contain vegetables as a key
ingredient
M1 (unadjusted)
M2 (age, gender, duration
of breastfeeding,
mother’s education and
other dietary patterns)
M3 (M2+energy and
protein intake)
M1—1.80 (0.61–5.30) ns obese:
M2—3.43 (1.03–11.39) ns ‘‘Modern’’
Obesity was most prevalent
among children with the
dietary pattern:
‘‘Neotraditional’’
Tertile 1 Confounders associated with
(Ref eating patterns) the obesity risk
T3—traditional age, gender, duration of
M1—2.74 (1.08–6.94) p.03 breastfeeding, mother’s
M2—3.12 (1.11–8.74) p.03 education, and other dietary
M3—1.78 (0.59–5.43) ns patterns
T3—Processed Lower likelihood of being
M1—0.81(0.33–1.98) ns obese:
M2—1.05(0.37–2.99) ns ‘‘Processed’’ or a ‘‘Health
M3—1.06 (0.35–3.24) ns conscious’’
T3—Health conscious Obesity was most prevalent
M1—1.55 (0.68–3.53) ns among children with the
M2—1.80 (0.75–4.31) ns dietary pattern:
M3—1.84 (0.75–4.52) ns ‘‘Traditional’’ was positively
associated with protein
intake
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Table 1. Summary of the Characteristics of the Included Studies continued

Risk obesity—lowest and
Author (year) Factors adjusted for in highest by dietary Odds
Location Population and Diet assessment Dietary patterns identified analyses (multivariable) ratios (95% confidence
Study design sample method and their key components model (M) confounders interval), p value Conclusion
Zhen et al. 489 out of 736 24 hours recall Traditional Chinese M1 (gender, age) Quartile 1 Confounders associated with
(2018)69 6–14 years 28 food groups Rice, red meat, pork, poultry, M2 (M1+residency, (Ref eating patterns) the obesity risk
China China Health and BMI cutoff points vegetables (leafy) and fish highest level of parental Traditional Chinese Age, gender
Cross-sectional Nutrition Survey (CHNS) Modern education, region, M1—0.28 (0.11–0.70) Lower likelihood of being
Dietary information Wheat buns, cakes, legume physical activity and M2—0.19 (0.07–0.49) obese:
reported by children products, nuts, pickled and energy intake) M3—0.19 (0.09–0.40) ‘‘traditional Chinese’’
‡12 years salted vegetables, fruit, red M3 (M2+geographical Modern Obesity was most prevalent
and their parents for meat, processed meats, regions) M1—2.17 (0.99–4.77) among children with the
children younger poultry, eggs, fish, milk, and fast M2—2.02 (0.88–4.65) dietary pattern:
than 12 years food M3—2.02 (1.17–3.48) ‘‘Modern’’
Kelishadi et al. 3843 out of 4200 Questionnaire eating habits Healthy Diet M1 (age, gender, living Healthy Diet Lower likelihood of being
(2018)70 7–18 years, Provinces in Iran 16 food groups Fresh fruit, dried fruit, fresh area, SES, parent M1—1.22 (0.95–1.56) obese:
Iran Dietary information Abdominal obesity fruit juice, vegetables, milk, perception about student Western ‘‘Western’’
Case–control reported by their parents yogurt, and cheese body image, weigh M1—0.84 (0.65–1.08) Obesity was most prevalent
Western satisfaction, physical Sweet among children with the
Salty snacks (cheese puffs, activity, sleep duration, M1—1.29 (1.01–1.66) dietary pattern:
chips and pretzels), beer, fast family history of chronic ‘‘Sweet’’
foods (sausages, burgers and diseases, parents’ BMI,
pizza) and coffee screen time).
Sweet
Sweet snacks (cakes, cookies,
pastries, biscuits, chocolate),

80
soft drinks, packaged fruit juice,
tea, cubed sugar, and sugar
Rutayisire et al. 8900 out of 9100 FFQ Traditional Chinese M1 (gender, age, sibling) Tertile 1 Lower likelihood of being
(2018)71 3–6 years 36 food groups Wheat and other cereals, M2 (maternal education, (Ref eating patterns) obese:
China Cities in eastern China BMI percentiles tubers, legumes, fruits, paternal smoking status, Traditional Chinese ‘‘Modern’’
Cross-sectional Dietary information vegetables, fresh juices, eggs, parental BMI). M1—1.02 (0.91–1.15) ns Obesity was most prevalent
reported by their low-fat dairy products, poultry, M2—1.02 (0.90–1.15) ns among children with the
parents or caretaker and fish Modern dietary pattern:
Modern M1—0.91 (0.81–1.03) ns ‘‘Traditional Chinese’’
Western fast food, Chinese fast M2—0.92 (0.82–1.04) ns
food, preserved food, fried
vegetables, fried meats, sweet
course, sugary foods,
chocolates/ice cream,
carbonated beverages, flavored
milk drinks and synthesized
fruit/vegetable juice
a
Abdominal obesity was considered as WHR >0.5. WHR waist-to-height ratio.
BMI was calculated as weight in kilograms divided by the square of height in meters [BMI = weight (kg)/(height (m2))]. We included studies that determine the correlated eating patterns with obesity
risk, and used variety of obesity measures: body weight status was determined using age- and gender-specific BMI percentiles, BMI z-scores, BMI SDSs, BMI cutoff points or WC. BMI was calculated
as weight in kilograms divided by the square of height in meters [BMI = weight (kg)/(height (m2))]. Abdominal obesity was considered as WHR >0.5. WHR waist-to-height ratio. And WC measured
midway between the lowest rib and the superior border of the iliac crest with an inelastic measuring tape at the end of normal expiration to the nearest 0.1 cm. The primary criteria used to define
overweight and obesity include overweight: BMI or WC ‡85th percentile to 95th percentile, BMI = 1 standard deviation above the average; obesity: BMI or WC = 95th percentile, BMI = 2 standard
deviations above the average. Children were classified as overweight if their BMI z-score was between the 85th and 95th percentile and obese if their BMI z-score was above the 95th percentile.
24 hour recall, 24 hour dietary recall method; DP, dietary patterns; FFQ, food frequency questionnaire; FFQA, Food Frequency Questionnaire for Adolescents; ns, not significant; SDSs, standard
deviation scores; WC, waist circumference; WHR, waist-to-height ratio.
 CHILDHOOD OBESITY March 2020
higher likelihood of being overweight, OR = 2.04; 95% CI
(1.38–3.02),61 as well as those who presented a ‘‘modern,’’
OR = 3.55; 95% CI (1.8–7.03),65 and OR = 2.17; 95% CI
(0.99–4.77),69 ‘‘Westernization,’’ OR = 1.92; 95% CI
(1.29–2.85),66 and ‘‘traditional Chinese’’ eating pattern,
OR = 1.02; 95% CI (0.9–1.1).71
Mapping of High Positive Loadings Dietary
Patterns and Their Key Components Associated
with Childhood Obesity Risk
The studies that reported the association between dietary
patterns and obesity risk are given in Table 1. A higher and
lower likelihood of being overweight or obese and the
relationship between the dietary patterns and their key
components and the risk of childhood obesity were seen in
the following dietary patterns.
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Higher likelihood of being overweight or obese. From
European countries: ‘‘dieting,’’ in Norway57,59 (cereals
without sugar, juice between meals, artificially sweetened,
carbonated, and noncarbonated soft drinks, and fat- and
sugar-reduced yoghurt).
From the Asia countries: in China, ‘‘modern,’’69 ‘‘Wes-
tern,’’61 ‘‘Westernization,’’66 and ‘‘traditional north’’65
(milk, sugar, coke, sprite, coffee, ice cream, fast foods,
snacks, eggs, poultry, red meat, fatty meat, processed meats,
pork, fish and shrimp, lamb, hamburgers and fried foods,
wheat buns, processed products wheat, cakes, legume
products, tubers, nuts, pickled and salted vegetables, starch
tubers and light colored vegetables, fruit and fresh fruit, rice
and rice products, refined grains, flour and flour products,
and barbecued foods) and ‘‘traditional Chinese’’71 (wheat
and other cereals, tubers, legumes, fruits, vegetables, fresh
juices, eggs, low-fat dairy products, poultry, and fish).
‘‘Sweet’’ in Iran70 (sweet snacks, cakes, cookies, pastries,
biscuits, chocolate, soft drinks, packaged fruit juice, tea,
cubed sugar, and granulated sugar); ‘‘Western’’ in Leba-
non64,67 (poultry and eggs, red meat, mayonnaise, fast-food
sandwiches, pizza, and pies).
From the America countries: in Brazil, ‘‘snack,’’60
‘‘junk food’’64 (milk and dairy products, chocolate milk
powder, sweet, savory biscuits, desserts, sugar, and filled
biscuits, fruits, natural juices, breads, pasta, margarine,
mayonnaise, whole dairy products, sweets, and fatty
foods); ‘‘Proteico/fibra’’ in Colombia62 (fruits, cheese,
yogurt, cream cheese, vegetables, cooked vegetables,
whole fruits, bread, whole foods, chicken, beef viscera,
butter, tuna or sardines, fish, or seafood); ‘‘Western’’ in
Mexico58 (soft drinks, sugar, cakes, wheat, starch tubers,
dishes with fat, salty snacks, fish and shrimp, beef, lamb
and red meat, pork, poultry and eggs, mayonnaise, fast-
food sandwiches, pizza and pies, rice, refined grains, and
dark and light colored vegetables).
From the Oceania countries: ‘‘neotraditional,’’ on the
Samoan island of Upolu68 (vegetables, local starchy crops
such as taro and breadfruit, coconut, fish, poultry and a low
81
intake of desserts, pizza, and dairy products (milk, cheese,
and ice cream) and infant food items (infant formula,
breast milk, infant packaged food purées, and prepared
meals)); and ‘‘traditional’’ in Australia19 (grains, fruit,
vegetables, and red meat).
Children aged from 1 to 6 years, adhering to a
‘‘snack,’’60 ‘‘Western,’’67 ‘‘neotraditional,’’68 ‘‘tradition-
al,’’19 and ‘‘traditional Chinese’’71 diet; children aged from
5 to 18 years, adhering to a ‘‘Western,’’58,61 ‘‘Proteico/
Fibra,’’62 ‘‘modern,’’ or a ‘‘traditional north,’’65 ‘‘mod-
ern,’’69 and ‘‘sweet’’70 diet; children from 9 to 13 years,
adhering to a ‘‘varied Norwegian’’ or a ‘‘dieting’’57,59 diet
and adolescents from 11 to 18 years, adhering to a ‘‘junk
food,’’63 ‘‘Western,’’64 and ‘‘Westernization’’66 diet had a
significantly higher likelihood of being overweight.
The studies show that, regardless of age, children aged
11 years, and/or adolescents aged 12–19 years, if the
subjects had a diet based on obesogenic products (e.g.,
poultry and eggs, red meat, pasta, whole dairy products,
margarine, breads, chocolate milk powder, sweets and
desserts, sugar, filled biscuits, fatty foods, pizza and pies,
fatty meat, hamburgers and fried foods, processed prod-
ucts, mayonnaise snacks, coke, sprite, coffee, ice cream,
instant noodles, and barbecued food), they were at risk of
developing obesity.
Lower likelihood of being overweight or obese. From
European countries: in Norway ‘‘junk/convenience’’57
(high-fat, high-sugar processed, fast foods such as french
fries, processed pizza, processed meat products, sweets, ice
cream, and soft drinks) and ‘‘varied Norwegian’’59 (fish
and meat, brown bread, regular white or brown cheese,
lean meat, fish spread, fruit, and vegetables).
From the Asia countries: in China, ‘‘healthy’’61 (milk,
yogurt, eggs, fruit, and vegetables), ‘‘traditional south,’’65
and ‘‘traditional Chinese’’69 [vegetables, rice, pork, and
legumes rice, red meat, pork, poultry, vegetables (leafy),
and fish], ‘‘Chinese and Western’’66 and modern71 (rice,
flour, whole grains, fresh vegetables, fresh fruit, poultry,
eggs, freshwater fish and shrimps, sea fish, milk and dairy
products, beans and bean products, nuts, snacks, sugar, and
barbecued foods). ‘‘Western’’ in Iran70 [salty snacks
(cheese puffs, chips, and pretzels), beer, fast foods (sau-
sages, burgers, and pizza), and coffee]; ‘‘traditional Le-
banese’’ in Lebanon64,67 (vegetables, legumes, bread, rice,
pasta and cereals, bulgur, fruits, fish, and vegetable oils).
From the America countries: ‘‘rural’’ in Mexico,58 (corn
tortilla, legumes, low intake of sweets and some cereals
such as white bread, whole-wheat bread, rice, and noodles);
in Brazil, ‘‘mixed diet’’60 (beef and pork, cooked beans,
milk and dairy products, rice and tubers, farinaceous foods,
sweet and savory cookies, cakes, leafy vegetables, fruits,
and natural juices) and ‘‘healthy’’63 (skimmed dairy prod-
ucts, cereals, leafy vegetables, fruits, and natural juices);
‘‘traditional/Almidón’’ in Colombia62 (sugar, honey, rice or
pasta, fried foods dry grains, tubers or bananas, eggs, beef,
veal, pork, rabbit, goat, coffee or tea, and chicken noodles).
 82
From the Oceania countries: ‘‘modern’’ on the Samoan
island of Upolu68 (unprocessed red meats, whole grains,
which are not traditional to Samoa, corn, french fries,
butter, mayonnaise, nuts, and snack foods such as potato
chips); ‘‘processed’’ in Australia19 (snack foods, processed
meats, beverages, and confectionary).
Risk of Bias in Individual Studies
The quality assessment of the included studies is pre-
sented in Supplementary Appendix Table A3. Of the 16
selected studies, 15 used a cross-sectional design, and 1
was a case–control study.70 The selected studies were ho-
mogeneous, and all studies presented high quality ac-
cording to the JBI-MAStARI.
Discussion
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The results of this review indicate a positive association
between certain eating patterns and the development of
being overweight and obesity in children and adolescents in
various parts of the world. These findings show that the
analysis of dietary patterns and standards classifies foods
into groups, taking into account the entire diet, describing
eating behaviors72 and the interactive effects of foods and
nutrients consumed together,27 thus monitoring these dietary
patterns among children as a predictor of adult diseases.73
It was decided to synthesize studies that analyzed dietary
patterns through PCA, CA, or FA, since these allow the
risk of developing diseases to be predicted,74 groups of
children with consistently healthy or unhealthy diets to be
identified, and to provide a perception of the dietary impact
on changes in body composition.73
Different studies may give the same name to a dietary
pattern, although this does not mean that the food items
observed in these patterns are the same. They may vary due
to the heterogeneity and specificity of the population (such
as geographic, economic, and cultural characteristics), al-
though several similarities can be observed.57
For example, the specificity of the ins-and-outs of school
dietary patterns analyzed was observed in the study by
Vieira et al.,45 with 2979 Brazilian children, aged 1 to
6 years, in the southeast region. In this study, the ‘‘tradi-
tional’’ pattern within the school was associated with lower
income and better nutritional quality (essentially composed
of typical Brazilian foods such as rice, beans, high-fiber
foods, vitamins, minerals, vegetables, cereals, processed
meat, and sausages) and the ‘‘traditional’’ pattern outside
the school (similar to the food patterns identified within the
school), with a higher intake of saturated and trans fats,
sodium, and fiber).
Morris and Northstone82 also found differences in the
analysis of dietary patterns of 11,868 children 10 years of
age in the United Kingdom, where the traditional diet of
children living in rural areas was healthier and had less
‘‘packed lunch/snack’’ consumption, whereas the traditional
diet of children residing in urban areas presented high con-
sumption of processed foods and ‘‘packed lunches/snacks.’’
LIBERALI ET AL.
Also in the present review, the dietary patterns identified
by the studies (Table 4) were given different names. Some,
however, presented similarities in the food groups and,
independent of geographical region, indicate that children
adhering to eating patterns characterized by frequent in-
gestion of unhealthy potentially obesogenic foods (in-
cluding fatty cheeses, sugary drinks, processed foods, fast
food, candies, snacks, cakes, animal products, whole milk,
and refined grains) are at increased risk of becoming
overweight.19,57,59–62,64–66,68–70
Most studies in this systematic review presented results
in keeping with the worldwide trend highlighted by the
WHO,81 which reported that currently the greatest frequency
is in the consumption of foods that are rich in lipids, refined
carbohydrates, bakery products, food of animal origin, and
sugar-rich foods, with increasing obesity mainly due to the
dependence on soft drinks and sweets, combined with the
reduced consumption of fruits and vegetables in many coun-
tries.75 A study by Kelly et al.76 conducted in China, In-
donesia, Malaysia, and South Korea attempted to determine
the reach of television advertising and marketing of food for
children. They found that the products most frequently ad-
vertised in all these countries were sugary drinks, with low
rates of advertising of vegetables and fruits observed.77
Some studies with children in different parts of the world
also show this trend of consuming potentially obesogenic
foods (baked goods, rich in sugar, such as breads, cakes,
and cookies), such as that of Aranceta et al.78 with 3534
children and adolescents in Spain, Ritchie et al.79 in the
United States with 2371 children aged 9 to 10 years,
Fernández-Alvira73 with 8341 European children (regions
in Italy, Estonia, Cyprus, Belgium, Sweden, Hungary,
Germany, and Spain), and Santos et al.83 with 1247 children
aged 6 to 12 years in Brazil. Romero-Polvo et al.26 reported
an association between the Western diet (high carbohydrates
intake, soft drinks, snacks, and corn tortillas, and lower in-
take of fresh fruits and orange juice), with the risk of insulin
resistance in 916 Mexican children and adolescents.
In this study, the dietary patterns that presented the
weakest association with the risk of becoming overweight
or obese were those in which children consumed more
nonobesogenic foods (fruits, vegetables, whole grains, fish,
nuts, legumes, and yogurt), that is, food classified as
healthy with low levels of sugar and fat.59,61,63,64,66,67
Dietary patterns may also vary depending on the cultural
and economic context,52 as well as other factors, such as
lifestyle and level of physical activity. Alshammari et al.44
highlighted that, currently, living standards are on the rise,
leading to complex changes in diet, lifestyle, and health.
In this review, some studies showed dietary patterns that
are part of the local culture, with a low risk of obesity, such
as the ‘‘mix-diet,’’ with foods from Brazilian culture60; a
rural diet; Mexican food58; the diets of traditional South-
east Asia65 and Chinese,66 with traditional Chinese foods;
and various Norwegian traditional foods.59
Similar to the present review, several studies have as-
sociated dietary patterns with some other patterns. For
 CHILDHOOD OBESITY March 2020
example, in France, Lioret et al.80 reported physical inac-
tivity combined with the consumption of fried snacks as
being a predictor of childhood obesity. Magriplis et al.15
demonstrated that obese children in Greece are those who
consume obesogenic foods, sleep less, and spend more
hours per day studying. Hebestreit et al.42 evaluated the
availability of soft drinks during meals in Sweden, Ger-
many, Hungary, Italy, Cyprus, Spain, Belgium, and Esto-
nia and highlighted that parents are important predictors of
sweet and fatty food intake in children. Conversely, some
studies analyzed in Table 4 show that children who adhere
to an obesogenic diet do not present a risk of developing
obesity.19,57,58,60,62,70
One of the main strengths of this review was the analysis
of studies that analyzed, through PCA, FA, and/or CA, the
grouping of dietary patterns in children and adolescents
and their associations with overweight and obesity,
Downloaded by 200.57.23.180 from www.liebertpub.com at 07/10/22. For personal use only.
showing that these statistical methods provide an alterna-
tive for analysis of the effect of the diet as a whole instead
of isolated nutrients.
Another strength of this review is that it allows the
combinations of nutrients and/or foods to be demonstrated
through these multivariate methods and the similarities and
differences between countries to be highlighted, while si-
multaneously understanding that obesogenic behaviors are
not unique. This premise provides support for future die-
tary interventions to be tailored to these specific groups,
taking into account behavioral and cultural differences.
This review has several limitations. First, it is well known
that the use of a cross-sectional design does not reach the
confidence level of meta-analyses of randomized clinical
trials. Another limitation in the included studies is that the
dietary exposures were assessed using self-reports through
food frequency questionnaires or 24-hour recall, both rely-
ing on memory and are, therefore, susceptible to inherent
measurement errors and misclassifications. Finally, the
studies included in this review were heterogeneous.
Conclusions
This systematic review suggests that children and
adolescents who adhere to dietary patterns composed of
obesogenic foods are more likely to develop obesity. Ad-
ditional confounders, such as parental eating patterns and
child physical activity, should be considered.
Acknowledgments
We are grateful to the Post-Doctoral National Program-
CAPES (PNPD/CAPES) (Programa Nacional de Pós
Doutorado, PNPD-CAPES) that granted Rafaela Liberali a
postdoctoral scholarship.
Authors’ Contributions
All authors were involved in analyzing the studies, re-
viewing and interpreting the results, and writing the article;
no divergencies exist between any two authors.
83
Funding Information
This research did not receive any specific grant from
funding agencies from the public, commercial, or not-for-
profit sectors.
Author Disclosure Statement
No competing financial interests exist.
Supplementary Material
Supplementary Appendix Table S1
Supplementary Appendix Table S2
Supplementary Appendix Table S3
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Address correspondence to:
Rafaela Liberali, PhD
Post-Graduation Program in Medical Sciences
Federal University of Santa Catarina
Florianopolis, SC 88036-800
Brazil
E-mail: rafaelametodologia@gmail.com