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The roles of sleep and eating patterns in adiposity gain among
preschool-aged children
Amy R Goetz,1,2 Ishita Jindal,1,3 Jennette P Moreno,1 Maurice R Puyau,1 Anne L Adolph,1 Salma Musaad,1 Nancy F Butte,1
and Fida Bacha1,3
1 Department of Pediatrics, USDA and Agricultural Research Service Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA;
2 Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA; and 3 Division of Pediatric Endocrinology and Diabetes,

Texas Children’s Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA

ABSTRACT
Background: Short sleep durations are related to risks for obesity
in preschool children. However, the underlying mechanism or
mechanisms are not clear.
Objectives: We evaluated the relationships between sleep charac-
teristics and body composition, energetics, and weight-regulating
behaviors in preschool-aged children, as well as the longitudinal
associations between children’s sleep and eating patterns and body
composition at a 1-year follow-up.
Methods: Data were drawn from a longitudinal study of 118 children
aged 3–5 years. Sleep (duration, midpoint, regularity) and physical
activity (PA) were measured by accelerometry over 6 consecutive
days; total energy expenditure (TEE) was measured using the
doubly labeled water method; body composition (fat mass, fat-free
mass, and percent body fat) was measured by DXA; and dietary
intake (energy intake, timing) was measured using two 24-hour
recalls. Multivariable regression was used to estimate interindividual
associations of sleep parameters with body composition, PA,
TEE, and dietary outcomes and to examine the relationships
between sleep and dietary behaviors and body composition 1 year
later.
Results: Cross-sectionally, later sleep midpoint is associated with
having a greater fat mass (0.33; 95% CI: 0.05, 0.60) and a higher
percent body fat (0.92; 95% CI: 0.15, 1.70). Later sleep midpoint
was associated with delayed morning mealtimes (0.51; 95% CI:
0.28, 0.74) and evening mealtimes (0.41; 95% CI: 0.29, 0.53),
higher nighttime energy intakes (45.6; 95% CI: 19.7, 71.4), and
lower morning energy intakes (−44.8; 95% CI: −72.0, −17.6).
Longitudinally, shorter sleep duration (−0.02; 95% CI: −0.03, 0.00)
and later meal timing (0.83; 95% CI: 0.24, 1.42) were associated with
higher percent body fat measurements 1 year later.
Conclusions: Shorter sleep duration and later meal timing are
associated with adiposity gains in preschoolers. Am J Clin Nutr
2022;116:1334–1342.
Keywords: sleep, obesity, physical activity, dietary behaviors,
energy expenditure
Introduction
Short sleep duration has been linked to higher BMI z-scores
(BMIz values) and elevated risks for obesity in young children
(1–3). Furthermore, sleep duration has received the bulk of
attention in assessments of risks for obesity, despite being only
1 component of sleep. Other dimensions of sleep, such as day-to-
day regularity and timing, may impact the energy balance–related
behaviors of young children [e.g., dietary patterns, physical
activity (PA)]. Indeed, sleep patterns are maturing as children
transition from multiple sleep periods per day to 1 consolidated
sleep period at night. Moreover, the process of phasing out
daytime naps (4) may contribute to greater variability in sleep
schedules, as napping results in delayed sleep onset (5); thus,
there may be greater opportunity for day-to-day shifts in young
children’s sleep. Later sleep timing and greater variability in
sleep patterns may contribute to shorter sleep duration, especially
among young children, who often fail to compensate for later
bedtimes with later wake times (6–8).
It is possible that later sleep timing and greater day-to-day
variability in sleep timing may result in the mistiming of sleep
with the endogenous circadian clock, affecting the timing of other
energy balance–related behaviors, including dietary patterns and
PA. The misalignment of these behaviors with endogenous
rhythms may result in metabolic changes and weight gain in
This work was made possible with grant funding from the USDA and
Agricultural Research Service CRIS Awards 6250-5100-054 (to NFB) and
3092-5-001-057 (to FB).
The content is solely the responsibility of the authors and does not
necessarily represent the official views of the NIH or the USDA and
Agricultural Research Service.
Address correspondence to Fida Bacha (e-mail: fbacha@bcm.edu).
Abbreviations: BMIz, BMI z-score; MVPA, moderate to vigorous physical
activity; PA, physical activity; TEE, total energy expenditure.
Received February 23, 2022. Accepted for publication July 12, 2022.
First published online July 14, 2022; doi: https://doi.org/10.1093/ajcn/
nqac197.

1334 Am J Clin Nutr 2022;116:1334–1342. Printed in USA. © The Author(s) 2022. Published by Oxford University Press on behalf of the American
Society for Nutrition. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
 Sleep and energetics among preschoolers 1335
children (9). Recent reviews have found that shorter duration is
associated with poorer diets (10) but inconsistently related to PA
in young children (11–13). Among adults, later sleep timing has
been shown to contribute to a higher energy intake, adiposity,

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and having a greater fat mass (14–17). Because children’s eating
patterns (i.e., timing, energy intakes) are in part controlled by
parental influences (e.g., food availability, timing of meals), it is
unknown whether similar associations between later sleep timing
and meal patterns are present among preschool-aged children.
We previously found that shorter sleep duration is associated
with changes in fat mass over a 1-year period in preschool-
aged children. The current study expands upon this previous
observation (18) by considering novel pathways through which
different dimensions of sleep may influence energetics, as well
as the contributions of the timing of children’s sleep and dietary
patterns to changes in adiposity over time. We specifically aimed
to examine the following: 1) the relationships between different
components of sleep (duration, timing, and day-to day regularity)
and children’s body composition; total energy expenditure (TEE),
measured by the doubly labeled water method; PA, measured by
accelerometry; and energy intake and meal timing, measured by
dietary recall; and 2) the longitudinal associations of different
sleep components and dietary patterns with children’s adiposity at FIGURE 1 Flowchart of participant enrollment in the study.
a 1-year follow-up. Our primary hypothesis was that shorter sleep
duration, later sleep timing, and more irregular sleep schedules
would be associated cross-sectionally with having a greater fat family was asked to have the child wear an accelerometer for the
mass and higher percent body fat measurements. Furthermore, week following the visit. The second 24-hour dietary recall was
our secondary hypothesis was that poorer sleep characteristics completed during the week. At the end of the week following the
would be associated with less PA, TEE, higher energy intake, and visit, the urine samples were collected and the accelerometer data
later meal timing. An additional secondary hypothesis was that were downloaded. Children were studied throughout the year.
shorter sleep duration, later sleep timing, and more irregular sleep Thirty-six were studied in the summer, 33 in the winter, 18 in
schedules would relate to greater 1-year increases in fat mass and the spring, and 28 in the fall. One year later, anthropometric and
percent body fat. body composition measures were repeated.

Methods Demographics questionnaire

Study population
Healthy children aged 3 to 5 years who were without a major
medical illness and living in the greater Houston area were
recruited into this study. Flyers were posted at local clinics
and preschool centers, and interested families contacted the
study team to obtain information on the study opportunity.
Children who were diagnosed with a chronic disease or had
been prescribed medications that may affect growth or limit
activity were excluded (Figure 1) (18). Preterm children were
excluded due to differences in postnatal growth trajectories.
The Institutional Review Board at Baylor College of Medicine
approved the study protocol, and parents provided written
informed consent to participate in this study.
Procedures
Parent-child dyads completed baseline and 1-year follow-up
visits in the Children’s Nutrition Research Center Metabolic
Research Unit. At baseline, parents completed a demographics
questionnaire and the first of two 24-hour dietary recalls for
the child. Child anthropometric data were collected and a body
composition assessment was completed. Detailed procedures for
collecting urine samples each day over 1 week were described, in
order to assess TEE via the doubly labeled water method, and the
Data on each child’s age, sex, race and ethnicity, and time spent
in childcare settings were obtained based on the parents’ report.
The mother’s age, height and weight (used to derive maternal
BMI; kg/m2 ), family income, and number of people living in
the home were also reported. The income-to-needs ratio was
calculated, with values ≤1.0 considered to indicate the household
was at or below the poverty level (19).
Anthropometrics and body composition
Child weight and height were measured using standardized
procedures (18). Age- and sex-specific BMIz values and BMI
percentiles were calculated using US growth references (20).
Having a healthy weight was defined as having a BMI <85th
percentile and having overweight or obesity was defined as
having a BMI ≥85th percentile for age and sex (20). The
fat-free and fat masses were measured using DXA (Delphi-A;
Hologic).
Sleep and PA
Sleep and PA data were collected using the ActiGraph GT3X+
accelerometer (ActiGraph LLC) and an Actiheart monitor
(CamNtech Ltd.). The accelerometer was worn on the child’s
right hip and the Actiheart was worn on the chest and secured
1336 Goetz et al.
with electrodes. Families were asked to have the child wear both
monitors for 7 days and remove them for bathing and swimming.
During the week of accelerometry data collection, the parents
completed a sleep log to note the times the child went to bed
and woke in the morning, as well as the periods of the day the
device was removed for water-based activities. Upon return, data
from both monitors were downloaded in 1-minute epochs and
analyzed for missing wear time. A day was defined as the time
from sleep onset of 1 day to sleep onset on the next day. A
valid day required ≥1000 minutes of wear time—consistent with
the criteria described by others (21, 22)—and having complete
data was defined as having ≥4 valid days, including 1 weekend
day. The last day of wear was excluded from analyses due to
incomplete data. Approximately 89% of the sample had 6 days
of complete data. The average wear time was 1410 ± 35 min/d
(range: 1293–1527 min/d).
Sleep onset, offset, and nap times were identified by the parent-
completed sleep log, visual inspection of 24-hour daily plots,
and the epoch-by-epoch data. Sleep onset was defined as having
≥5 minutes of inactivity (vector magnitude counts at 0) and a
gradual decline in heart rate, and sleep offset was defined as
an abrupt increase in vector magnitude activity and heart rate.
During visual inspection of the daily plots, we identified and
removed periods of nonwear time. Wake after sleep onset was
determined using the Sadeh algorithm (23, 24), which was also
used to confirm observations of sleep onset and offset.. The
sleep duration was defined as the period between sleep onset
and sleep offset minus wake times after sleep onset. The sleep
midpoint was defined as the halfway point between sleep onset
and sleep offset for the nighttime sleep period. Mean values of
sleep duration and midpoints were used in this study. The sleep
regularity index—the probability of being asleep or awake at any
2 times that were 24 hours apart on any 2 consecutive days—
was computed using Python code developed by Avery-Lunsford
et al. (25). Values on the sleep regularity index range from 0–
100, with higher scores indicating more consistent sleep-wake
timing.
Minutes spent sedentary, doing light PA, and doing moderate
to vigorous PA (MVPA) were defined according to published
vector magnitude cut points (26). Similar to the sleep duration
and midpoint values, mean values of the time spent sedentary,
doing light PA, and doing MVPA were calculated.
Energy intake and meal timing by dietary recall
Two 24-hour recalls using the multiple-pass method were
conducted and analyzed using the Nutrition Data Systems for
Research software (Nutrition Coordinating Center, University
of Minnesota). Parents were queried on their child’s food and
beverage intake. Recalls were analyzed to obtain the average
daily energy consumption and the times of the first and last eating
events. Although over-reporting of energy intake has been noted
in studies of young children (27), 24-hour dietary recall was
a more accurate method to estimate energy intake in children
compared with the doubly labeled water method (28). Average
energy intakes in the morning (06:00 to <10:00) and at night
(19:00 to <06:00) were calculated using defined criteria (29).
Energy expenditure by doubly labeled water
TEE was measured over a 7-day period using the doubly
labeled water method and was expressed as kilocalories per day,
as described previously (18, 26).
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Statistical analysis plan
Descriptive statistics, including means (SDs) and frequencies
(%), were calculated to describe children’s sleep, energetics, PA,
and dietary behaviors. Linear relationships between dependent
variables and the residuals, normality, and homogeneity of
variance were examined. There was no collinearity between
the 3 sleep predictor variables included in the model. Bivariate
correlations were used to explore the relationships between
sleep duration, sleep midpoints, and sleep regularity. Multiple
regression was conducted to examine the cross-sectional rela-
tionships at baseline between all 3 sleep variables and body
composition (i.e., fat mass and percent body fat). To better
understand how children’s sleep patterns influence energetics,
we used multiple regression to model the associations between
sleep duration, midpoint, and regularity together with TEE and
minutes in sedentary, light, and MVPA as separate outcomes.
We additionally examined the mean total energy intake, energy
intakes in the morning and night, and the timing of the first and
last eating events of the day as outcomes in separate models.
Finally, multiple regression was used to test the longitudinal
associations between children’s sleep parameters and dietary
patterns and body composition (fat mass and percent body fat)
1 year later while controlling for baseline fat mass and percent
body fat in separate models.
Age, sex, race and ethnicity, income-to-needs ratio, childcare
attendance, and BMIz data were included as covariates in the
above models. Fat-free mass and fat mass were included as
covariates in place of BMIz in the model that tested TEE as
the outcome. The accelerometer wear time was controlled for
in the analyses of sedentary, light PA, and MVPA times. The
models were tested in Mplus Version 8.1 (Muthen & Muthen)
and constructed using full-information maximum likelihood
estimation.
Using multiple regression and power conditional on the model
R2 , a sample size of 65 was considered to be the minimum
sample size necessary to achieve 80% power to detect an R2 of
0.08 attributed to the 3 independent variables (sleep duration,
midpoints, and regularity) using an F-test with a significance
level (alpha) of 0.05. The models were adjusted for additional
covariates that increased the explained proportions of variance in
the dependent variables.
Results
A total of 118 children were included in this study, with a
mean ± SD age of 4.6 ± 0.9 years (Table 1). Half were male and
29% were non-Hispanic white, 29% were non-Hispanic black,
35% were Hispanic, and 7% were of another race and ethnicity.
The majority were considered to have healthy weight. The mean
sleep onset, offset, and midpoint times were at the following times
of day: 22:16 (±1:32 hours), 07:42 (±1:20 hours), and 03:01
(±1:18 hours), respectively (Table 2). Nearly 79% of children
 Sleep and energetics among preschoolers 1337
TABLE 1 Baseline characteristics for children and families for the total sample and by child age1

3 years (n = 38) 4 years (n = 41) 5 years (n = 39) Total (N = 118)

Age, years 3.6 ± 0.3 4.5 ± 0.3 5.6 ± 0.3 4.6 ± 0.9

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Sex, % male 53% 49% 49% 50%
Race and ethnicity
Non-Hispanic White 18% 37% 31% 29%
Non-Hispanic Black 35% 22% 31% 29%
Hispanic 37% 39% 28% 35%
Other or mixed race 11% 2% 10% 7%
Out of home childcare, % 53% 67% 78% 65%
Daycare, h/wk 18.1 ± 19.5 21.0 ± 18.0 27.2 ± 16.7 22.1 ± 18.3
BMI z-score 0.2 ± 1.0 0.2 ± 1.1 0.2 ± 1.0 0.2 ± 1.0
Weight status, % with 16% 20% 18% 18%
overweight or obesity
Fat-free mass, kg 11.2 ± 1.6 13.4 ± 2.1 15.1 ± 2.6 13.3 ± 2.7
Fat mass, kg 4.8 ± 1.8 5.1 ± 2.2 5.5 ± 2.0 5.1 ± 2.0
Mother’s age, y 34.4 ± 8.2 34.1 ± 6.4 35.7 ± 7.2 34.7 ± 7.3
Maternal BMI, kg/m2 29.9 ± 7.0 27.9 ± 5.5 29.1 ± 7.3 29.9 ± 6.6
Income-to-needs ratio, % 16% 18% 26% 20%
poverty
1 Values are presented as means ± SDs or percentages.

took at least 1 nap and napped, on average, 39 ± 28 minutes.
One-half of the sample met the National Sleep Foundation (30)
recommendations for 10 to 13 hours of sleep based on the time in
bed (duration from sleep onset to offset) plus nap duration. Later
sleep midpoints were associated with poorer sleep regularity
(r = −0.30; P < 0.05). There was a significant relationship
between season and sleep onset, such that children studied in
the summer had later sleep onset compared to children studied in
the fall [F(3,114) = 3.85; P < 0.05], with a significant pairwise
difference between youth studied during the summer (M = 22:79;
SD: 1.91) relative to those who provided sleep data in the fall
(M = 21:71; SD: 0.99).
The relationship of children’s sleep patterns with body
composition
Age was associated with having a greater fat mass ( B = 0.47;
95% CI: 0.11, 0.82) but lower percent body fat (−1.3; 95%
CI: −2.38, −0.23). At baseline, being female was associated
with having a greater fat mass (0.84; 95% CI: 0.28, 1.40) and
a higher percent body fat (5.40; 95% CI: 3.67, 7.13). Relative
to white children, black children had a lower fat mass (−1.34;
95% CI: −2.23, −0.46) and a lower percent body fat (−5.83;
95% CI: 8.25, −3.39), while the fat mass and percent body
fat measurements of white and Hispanic children did not differ.
Later sleep midpoints were associated with having a greater

TABLE 2 Mean sleep parameters, physical activity, energy expenditure, and dietary intake behaviors for the total sample and by child age1

3 years 4 years 5 years Total

n = 38 n = 41 n = 39 N = 118
Sleep
Sleep onset, h:min 22:28 ± 1:29 22:00 ± 1:30 22:24 ± 1:35 22:16 ± 1:32
Sleep midpoint, h:min 3:10 ± 1:18 2:50 ± 1:26 3:06 ± 1:28 3:01 ± 1:18
Sleep offset, h:min 7:49 ± 1:17 7:31 ± 1:23 7:49 ± 1:23 7:42 ± 1:20
Time in bed, min 557.8 ± 54.3 573.3 ± 44.8 566.6 ± 46.5 565.8 ± 48.7
Wake after sleep onset, min 56.5 ± 21.3 57.2 ± 22.4 46.7 ± 19.9 53.5 ± 21.6
Total sleep duration, min 551.2 ± 40.6 543.5 ± 43.4 535.2 ± 41.1 543.4 ± 41.8
Sleep regularity index 65.9 ± 8.5 70.3 ± 7.4 73.7 ± 8.5 69.9 ± 8.7
Physical activity and energy expenditure
Sedentary, min/d 361.7 ± 75.0 369.9 ± 80.4 394.3 ± 56.0 375.2 ± 72.0
Light physical activity, min/d 385.6 ± 64.9 381.8 ± 53.4 381.1 ± 47.9 382.8 ± 55.5
Moderate to vigorous physical 52.8 ± 22.6 54.4 ± 30.0 53.4 ± 22.2 53.5 ± 24.9
activity, min/d
Total energy expenditure, kcal/d 1079 ± 143 1239 ± 176 1277 ± 176 1197 ± 186
Dietary intake
Total energy intake, kcal/d 1360 ± 326 1374 ± 277 1489 ± 316 1405 ± 308
Morning energy intake, kcal/d 294 ± 117 293 ± 116 307 ± 127 299 ± 119
Nighttime energy intake, kcal/d 352 ± 177 387 ± 202 409 ± 233 379 ± 207
Time of first eating event, h:min 8:49 ± 1:58 8:23 ± 1:38 8:31 ± 1:30 8:34 ± 1:38
Time of last eating event, h:min 19:19 ± 1:00 19:04 ± 1:08 19:11 ± 1:04 19:11 ± 1:04
1 Values are presented as means ± SDs.
1338 Goetz et al.

TABLE 3 Parameter estimates for the associations between sleep duration, midpoint, and regularity with body composition at baseline (N = 118)1

Predictors Fat mass, kg Percent body fat

Effect estimate (95% CI)
− 0.03 (−0.06, −0.01)

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Sleep duration, min/d 0.00 (−0.01, 0.01)
Sleep midpoint, hours/d 0.33 (0.05, 0.60)2 0.92 (0.15, 1.70)2
Sleep regularity,3 units 0.00 (−0.04, 0.04) 0.10 (−0.04, 0.24)
1 All regression models were adjusted for age, sex, race and ethnicity, childcare attendance, and income-to-needs ratio, as well as sleep duration,

midpoint, and regularity.

2 P < 0.05
3 The index scores range from 0 to 100, with higher scores reflecting more consistent sleep and wake timing.

fat mass (0.33; 95% CI: 0.05, 0.60) and a higher percent body
fat (0.92; 95% CI: 0.15, 1.70); (Table 3). Sleep duration and
sleep regularity were not associated with measures of body
composition.
The association between children’s sleep patterns and other
energy balance–related behaviors
Shorter sleep duration (−0.71; 95% CI: −1.20, −0.21)
and later sleep midpoints (25.00; 95% CI: 9.20, 40.79) were
associated with greater TEE (Table 4). Shorter sleep duration
(−0.45; 95% CI: −0.69, −0.22) and greater sleep regularity
(2.80; 95% CI: 1.65, 3.95) were associated with more time spent
doing light PA. For every 1-hour decrease in sleep duration,
an estimated 27 additional minutes was spent doing light PA,
and a 1-unit increase in sleep regularity was associated with
approximately 2–3 additional minutes of light PA. Later sleep
midpoints were related to having a higher nighttime energy intake
(45.58; 95% CI: 19.72, 71.43), a lower morning energy intake
(−44.78; 95% CI: −71.97, −17.58), and delayed timing for both
the first (0.51; 95% CI: 0.28, 0.74) and last (0.41; 95% CI: 0.29,
0.53) eating events in the day. Furthermore, a 1-hour delay in
the sleep midpoint was associated with an estimated consumption
increase of 46 calories at night and with consumption of 45 fewer
calories in the morning. Additionally, for every 1-hour delay in
the sleep midpoint, eating events were delayed by 25–31 minutes.
Sensitivity analyses were conducted to examine each sleep
predictor variable with each outcome, excluding mutual adjust-
ment for the other sleep variables. Results were unchanged when
sleep variables were examined in isolation of each other (data not
shown). In addition, the sleep onset was substituted for the sleep
midpoint in all analyses. The estimates between sleep onset and
outcome variables were comparable to the estimates between the
sleep midpoint and these variables. The only variable in which
the magnitude of effect decreased was between sleep onset and
fat mass (0.29; 95% CI: 0.02, 0.56).

TABLE 4 Parameter estimates for the average interindividual associations between sleep duration, midpoint, and regularity with energy expenditure,
physical activity, and dietary intake (N = 118)1

Sleep midpoint,
Outcomes Sleep duration, min/d hours/d Sleep regularity units2
Effect estimate (95% CI)
Total energy expenditure,3 − 0.71 (−1.20, −0.21)4 25.00 (9.20, 40.79)4 2.45 (−0.11, 5.01)
kcal/d
Sedentary time,5 min/d − 0.31 (−0.61, 0.00) − 5.24 (−14.51, 4.02) − 0.52 (−1.99, 0.95)
Light physical activity,5 min/d − 0.45 (−0.69, −0.22)6 4.09 (−2.40, 10.57) 2.80 (1.65, 3.95)4
Moderate to vigorous physical − 0.09 (−0.21, 0.04) 0.30 (−3.69, 4.29) 0.11 (−0.41, 0.33)
activity,5 min/d
Total energy intake, kcal/d − 1.19 (−2.50, 0.11) − 7.70 (−50.19, 34.80) 2.90 (−4.93, 10.74)
Morning energy intake, kcal/d − 0.29 (−0.87, 0.28) − 44.78 (−71.97, −17.58)6 0.24 (−3.14, 3.62)
Nighttime energy intake, − 0.23 (−1.23, 0.78) 45.58 (19.72, 71.43)6 2.33 (−2.41, 7.07)
kcal/d
Time of first eating event, 0.00 (−0.01, 0.01) 0.51 (0.28, 0.74)4 0.02 (−0.01, 0.06)
hours/d
Time of last eating event, − 0.01 (−0.01, 0.00) 0.41 (0.29, 0.53)4 0.00 (−0.02, 0.03)
hours/d
1 Allregression models were adjusted for age, sex, race and ethnicity, childcare attendance, income-to-needs ratio, and BMI z-score, as well as sleep
duration, midpoint, and regularity.
2 The index ranges from 0–100 with higher scores reflecting more consistent sleep and wake timing.
3 Adjusted for fat and fat-free masses but not BMI z-score.
4 P < 0.01.
5 Adjusted for accelerometer wear time.
6 P < 0.05.
 Sleep and energetics among preschoolers
TABLE 5 Parameter estimates for the longitudinal associations between sleep, dietary patterns, and body composition (N = 116)1
Predictors
Effect estimate (95% CI)
Baseline fat mass, kg
Baseline percent body fat
Sleep duration, min/d
Sleep midpoint, hours/d
Sleep regularity,4 units
Total Energy Intake, kcal/d
Morning Energy Intake, kcal/d
Nighttime Energy Intake, kcal/d
Time of First Eating Event, hours/d
Time of Last Eating Event, hours/d
1 Allregression models were adjusted for age, sex, race and ethnicity, childcare attendance, and income-to-needs ratio.
2P < 0.01.
3 P < 0.05.
4 The index scores range from 0 to 100, with higher scores reflecting more consistent sleep and wake timing.
The longitudinal relationship of children’s sleep and dietary
patterns to body composition
When examining the longitudinal associations between chil-
dren’s sleep and dietary patterns and body composition, only the
fat mass at baseline was associated with the fat mass 1 year later
(1.21; 95% CI: 1.12, 1.30; Table 5). In a similar model with
percent body fat as the dependent variable, shorter sleep duration
(−0.02; 95% CI: −0.03, 0.00) and later timing of the last meal
of the day (0.83; 95% CI: 0.24, 1.42) at baseline independently
contributed to percent body fat measurements 1 year later.
Discussion
The current study examined pathways through which the
duration, timing, and regularity of preschoolers sleep patterns
may be related to the risks for childhood obesity. Cross-
sectionally, later sleep timing was associated with adiposity
(fat mass and percent body fat); longitudinally, both shorter
sleep duration and later meal timing were associated with
greater adiposity 1 year later. These results are consistent
with those previously observed by our research group (24).
Sleep midpoints and regularity did not account for unique
variance in change in children’s adiposity, although we found
an association between meal timing and percent body fat 1 year
later.
The current study sought to expand upon our understanding
of the relationship between sleep and adiposity by examining
multiple dimensions of sleep behavior. We first explored the
connections between sleep duration, sleep timing, and sleep
regularity [as assessed by the sleep regularity index (35)]. Later
sleep midpoints were related to lower sleep regularity. In addition,
we observed that later sleep midpoints were linked with greater
nighttime and lower morning energy intakes, as well as delayed
timing of both the first and last eating occasions of the day.
Furthermore, the relationships between sleep midpoints and eat-
ing behaviors demonstrated the largest effect sizes in the current
study. Other relationships, such as the association between sleep
regularity and doing light PA, while statistically significant, may
not be clinically meaningful. Interestingly, meal patterns were
not associated with sleep duration or sleep regularity, and later
1339
Fat mass, kg Percent body fat
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1.21 (1.12, 1.30)2 —
— 0.97 (0.89, 1.04)2
− 0.04 (−0.09, 0.00) − 0.02 (−0.03, 0.00)3
− 0.04 (−0.19, 0.10) − 0.23 (−0.69, 0.23)
0.01 (−0.01, 0.02) 0.03 (−0.03, 0.08)
0.00 (−0.01, 0.00) 0.01 (−0.01, 0.03)
0.00 (−0.02, 0.02) − 0.03 (−0.09, 0.03)
0.00 (−0.01, 0.01) − 0.01 (−0.04, 0.02)
− 0.01 (−0.14, 0.11) − 0.12 (−0.50, 0.27)
0.17 (0.02, 0.33) 0.83 (0.24, 1.42)∗
sleep midpoints were not associated with higher overall energy
intakes. Though we cannot discern the directionality of these
relationships, these cross-sectional findings underscore the inter-
relatedness of sleep midpoints and the timing of eating behaviors
(31–34).
Later bedtimes have been correlated with breakfast skipping
(35, 36), delayed meals (37), and higher evening energy
consumption (37) in children. Several studies have reported
that having a higher energy intake later in the day—as a
proportion of total energy intake—is related to having a higher
body fat percentage (38) and to prospective increases in BMIz
values (39). The additional time awake in the evening due to
later bedtimes likely provides more opportunities to eat, as
was observed when children’s energy intakes were compared
between conditions of sleep restriction and sleep extension
(40).
Though the exact mechanisms through which sleep and meal
timing in the absence of increased total energy intake are
related to adiposity gains is beyond the scope of the current
study, we speculate that chronodisruption (i.e., the misalignment
between the behavioral rhythms of sleep and meal patterns with
endogenous circadian rhythms) may explain these associations
(9, 14, 41–43). Eating later in the biological day may lead
to changes in metabolism, resulting in exposure to higher
evening blood glucose levels, with effects persisting through
the next morning (44, 45). This may affect substrate utilization.
Furthermore, diet-induced thermogenesis has been shown to
be lower after later eating events (14, 46–49), suggesting that
eating later may contribute to greater weight gain; however,
these relationships have only been delineated in adults. Overall,
the mechanisms through which shorter sleep and later meal
timing affect adiposity among preschoolers is in need of further
research.
Interestingly, shorter sleep duration was associated with
greater TEE and more time spent doing light PA. While this may
be due to time reallocation (i.e., the additional time awake may
account for the higher energy expenditure), it is also possible that
sleep restriction elevates energy expenditure through increased
PA (50–52). In our recent work with youth, shorter sleep duration
was similarly associated with higher activity energy expenditure
1340 Goetz et al.
by doubly labeled water (24). However, sleep duration was
positively related to basal metabolic rates (BMRs; i.e., the
major component of energy expenditure) evaluated by room
calorimetry, such that shorter sleep duration was associated with
having lower BMRs. Though the BMR was not assessed here,
its relationship with sleep offers 1 possibility for the association
between shorter sleep duration and greater weight gain. Future
studies should examine the impact of sleep duration on BMR,
and its impact on body composition.
In comparison, we found that sleep regularity was associated
with more time spent doing light PA. The sleep regularity index
is a novel measure used to characterize the consistency of sleep-
wake schedules (25, 53–57). Greater intraindividual variability
in children’s sleep duration—a similar but distinct construct
to sleep regularity—was related to greater energy, fat, and
carbohydrate intakes (58) and consumption of sugar-sweetened
beverages (59). In the current study, more consistent sleep
patterns were associated with greater engagement in light PA,
which parallels the positive associations between sleep regularity
and PA in older adults (25) and school-aged children (60).
Furthermore, in older adults, sleep irregularity correlated with
10-year risks of obesity, cardiometabolic disease, and dysg-
lycemia (25).
The strengths of this study include its robust measurements
and the recruitment of families from diverse backgrounds. In
addition, we embraced a multidimensional approach to sleep
health by studying 3 sleep characteristics in tandem. To this end,
we calculated the novel sleep regularity index, a measure of day-
to-day consistency of sleep-wake timing. Although this metric
has not been validated with preschoolers, it allowed us to account
for daytime napping and address the variability in sleep schedules
inherent within this developmental period. A limitation of this
work is that our analyses were conducted from the standpoint that
poor sleep promotes obesogenic behaviors, which ultimately lead
to greater weight gain. The reverse pattern of weight influencing
sleep and relevant behaviors is equally important to consider.
Second, our data are limited to a select sample of preschoolers,
and research is needed to understand the generalizability of these
findings. Third, it is possible that the use of a 1-minute epoch
influenced the allocation of times spent in different levels of
PA intensity. The use of a longer epoch may have incorrectly
classified youth as participating in light PA while actually
engaged in short bouts of MVPA. That said, a 1-minute epoch
has been validated in preschoolers when comparing actigraphy
to videosomnography (61). Fourth, residual confounding may
account for some of the observed relationships. While we
controlled for several important covariates, there are many factors
(e.g., bedroom environment, food availability) that may be
implicated in the relationships between sleep, PA, and eating
behaviors that warrant rigorous statistical controls. In addition,
we conducted a large number of statistical tests, which may have
inflated our type 1 error rate. Fifth, the average sleep onset time
of our sample was later, and SDs were larger, than those of
estimates obtained by parent reports (62) or accelerometry (63–
65) in other preschool samples, though our mean was consistent
with at least 1 study that used accelerometry (66). We did find
a significant relationship between season and sleep onset, such
that children studied during summer had later sleep onset times
compared to those studied during the fall. However, only one-
third of children were studied in the summer, so it is unlikely
that seasonality is the only driver of the late sleep onset times
observed here. Although half of our sample met sleep duration
Downloaded from https://academic.oup.com/ajcn/article/116/5/1334/6643558 by Mahidol University, Faculty of Medicine, Ramathibodi Hospital user on 15 January 2023
recommendations based on accelerometry, the mean total sleep
duration does appear comparable to other actigraphy estimates
obtained for preschoolers (63, 65). Finally, while gold-standard
assessments of dietary intake were utilized, these relied on parent
reports, which are prone to error (28, 67). This may have limited
our ability to fully understand the impacts of eating patterns on
adiposity gains.
In summary, among healthy preschoolers, later sleep timing
was associated with increased adiposity cross-sectionally. Addi-
tionally, going to bed later portended having a higher nighttime
energy intake, lower morning energy intake, and delayed timing
of both the first and last eating occasions of the day. Moreover,
greater sleep regularity is linked to more time spent doing light
PA. Longitudinally, shorter sleep duration and later meal timing
were associated with having a higher percent body fat 1 year later.
Overall, our findings suggest that earlier bedtimes may promote
earlier meal timings, which may be protective of adiposity gain.
Taken together, these results suggest promoting specific sleep
patterns (e.g., adequate duration, earlier bedtimes to ensure the
optimal timing of food intake) is of critical importance for obesity
prevention efforts and is worthy of further research.
The authors’ responsibilities were as follows—ARG: analyzed the data
and wrote the first draft of the manuscript; IJ: contributed to the data
analyses and writing of the first draft of the manuscript; NFB, MRP, and
ALA: conducted the research; JPM: contributed to the data interpretation,
conceptual development of the research question, and writing of the
manuscript; MRP and SM: contributed to the data analyses; FB: designed
the research, oversaw the analysis plan and data interpretation, contributed to
writing and editing of the manuscript, and had primary responsibility for the
final content; and all authors; read and approved the final manuscript.
Author disclosures: JPM receives support from the Eunice Kennedy
Shriver National Institute of Child Health & Human Development of the NIH
(R00 HD091396). FB and NB report funding from the USDA/ Agricultural
Research Services (FB and NB). FB received funding from AstraZeneca and
Takeda through her institution for research not related to this work. All other
authors report no conflicts of interest.
Data Availability
Data described in the manuscript, code book, and analytic code
will be made available upon request pending application and
approval.
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