Is food portion size a risk factor of childhood overweight?

Abstract

Food portion sizes have been increasing in industrialized countries and this is thought to be one of the risk factors of overweight. France is also facing the development of adiposity, particularly in its child population, where overweight rates are rising faster than in adults. Given this background, the objectives of the present study were, for each food category, to describe dietary intake in French children aged 3-11 years, and to assess the relationship between childhood overweight and portion size, adjusting for dietary energy density, physical activity and sedentary behaviour.
A representative sample of 748 French children aged 3-11 years was taken from the 1998-1999 cross-sectional French INCA1 (Enquête Individuelle et Nationale sur les Consommations Alimentaires) food consumption survey. Dietary intake was assessed using a 7-day food record. Portion sizes were estimated for 23 food categories. Weight and height, physical activity and sedentary behaviour were reported by parents or children in questionnaires.
In multivariate logistic regression adjusted models, overweight in children aged 3-6 years was positively correlated to portion sizes of croissant-like pastries and other sweetened pastries. Conversely, portion sizes of liquid dairy products were inversely associated with overweight in children aged 7-11 years.
At very young ages, the increase in overweight may be driven in part by a shift in eating patterns towards larger portion size of energy-dense and nutrient-poor foods.

Full text

ORIGINAL ARTICLE
Is food portion size a risk factor of childhood
overweight?
S Lioret
1
, J-L Volatier
1
, L Lafay
1
, M Touvier
1
and B Maire
2
1
French food safety agency (AFSSA), Dietary survey unit—Nutritional epidemiology, Maisons-Alfort, France and
2
Institut de recherche
pour le de
´
veloppement (IRD), UR106—Nutrition, food and society, WHO Collaborating Centre in Human Nutrition, Montpellier,
France
Background/Objectives: Food portion sizes have been increasing in industrialized countries and this is thought to be one of the
risk factors of overweight. France is also facing the development of adiposity, particularly in its child population, where
overweight rates are rising faster than in adults. Given this background, the objectives of the present study were, for each food
category, to describe dietary intake in French children aged 3–11 years, and to assess the relationship between childhood
overweight and portion size, adjusting for dietary energy density, physical activity and sedentary behaviour.
Subjects/Methods: A representative sample of 748 French children aged 3–11 years was taken from the 1998–1999 cross-
sectional French INCA1 (Enque
ˆ
te Individuelle et Nationale sur les Consommations Alimentaires) food consumption survey.
Dietary intake was assessed using a 7-day food record. Portion sizes were estimated for 23 food categories. Weight and height,
physical activity and sedentary behaviour were reported by parents or children in questionnaires.
Results: In multivariate logistic regression adjusted models, overweight in children aged 3–6 years was positively correlated to
portion sizes of croissant-like pastries and other sweetened pastries. Conversely, portion sizes of liquid dairy products were
inversely associated with overweight in children aged 7–11 years.
Conclusions: At very young ages, the increase in overweight may be driven in part by a shift in eating patterns towards larger
portion size of energy-dense and nutrient-poor foods.
European Journal of Clinical Nutrition (2009) 63, 382–391; doi:10.1038/sj.ejcn.1602958; published online 21 November 2007
Keywords: portion size; dietary patterns; energy density; food category; childhood overweight; France
Introduction
Portion sizes of many foods have been increasing in
countries with a well-established industrialized food supply.
Unlike in France, this trend has been well documented in the
United States (Nielsen and Popkin, 2003; Young and Nestle,
2003). It is part of the general change in lifestyle and dietary
shifts that have taken place over the last three decades, such
as greater away-from-home consumption (Guthrie et al.,
2002), the increasing prevalence of snacking (Jahns et al.,
2001; Zizza et al., 2001; Nielsen et al., 2002) and the
increasing consumption of snack foods and soft drinks
(Borrud et al., 1997; Putmann and Allshouse, 1999).
Since the trend towards larger portion sizes occurred at the
same time as the rise in the prevalence of obesity, it is worth
investigating this food consumption pattern as a potential
contributing risk factor of weight gain. In adults, positive
relationships between portion size and energy intake (EI)
have been demonstrated in short-term trials (Diliberti et al.,
2004; Rolls et al., 2006a). However, very few studies have
investigated the relationship between food portion size and
both EI and weight status in children (Huang et al., 2004;
McConahy et al., 2004). Even fewer studies also addressed
dietary energy density, a potential confounder for the
relationship between food portion size and adiposity (Kral
and Rolls, 2004; Ledikwe et al., 2005).
Received 15 February 2007; revised 16 October 2007; accepted 17 October
2007; published online 21 November 2007
Correspondence: S Lioret, French food safety agency (AFSSA), Direction of risk
assessment for nutrition and food safety (DERNS), Office of scientific support
for risk assessment (PASER), Dietary survey unit—Nutritional epidemiology
(OCA-EN), 27-31 Avenue du Ge
´
ne
´
ral Leclerc, Maisons-Alfort, 94701
MAISONS-ALFORT Cedex, France.
E-mail: s.lioret@afssa.fr
Contributors: SL designed the study, analysed and interpreted the data and
wrote the manuscript. BM contributed to the conceptualization of the study,
interpretation of the results, and editing of the manuscript. J-LV contributed to
the design of the survey and the data collection, and together with LL and MT,
supervised the analysis and helped to write the paper.
European Journal of Clinical Nutrition (2009) 63, 382–391
&
2009 Macmillan Publishers Limited All rights reserved 0954-3007/09 $
32.00
www.nature.com/ejcn

Given this background, the present study used data from
the French INCA1 (Enque
ˆ
te Individuelle et Nationale sur les
Consommations Alimentaires) food consumption survey to
describe dietary intake in each food category in French
children aged 3–11 years, and to assess the relationship
between childhood overweight (OW) and portion sizes of
food groups, taking into account dietary energy density,
physical activity and sedentary behaviour. To our knowl-
edge, no findings on these issues in children have been
published to date. We considered it relevant to study these
issues in France, where the child population is undergoing a
rapid increase in OW, with rates close to 20% in this age
range (Rolland-Cachera et al., 2002; Labeyrie and Niel, 2004;
Lioret et al., 2007), according to the International Obesity
Task Force (IOTF) definition (Cole et al., 2000).
Subjects and methods
Subjects
The French INCA1 food consumption survey was performed
between August 1998 and June 1999 by the Research centre
for the study and the observation of way of life (CREDOC)
and the French food safety agency (AFSSA). This cross-
sectional survey was primarily designed to assess the food
intake patterns of French children and adults (n ¼ 3003). A
complex sampling design was used to obtain a nationally
representative sample of members of French households.
The survey design and sampling frame have been described
in more detail elsewhere (Volatier, 2000; Lioret et al., 2007).
The present study focused on children aged 3–11 years
(n ¼ 748), who were separated into two age groups of similar
size, namely 3–6 years (n ¼ 340) and 7–11 years (n ¼ 408).
This stratification was based on the assumption that children
may respond differently to food cues and have different
eating patterns depending on their age (Birch and Fisher,
1998).
Measurements
A 7-day record was used to note all food and drink
consumption during the week of the survey. The other
variables, that is, anthropometrical, behavioural and socio-
demographical, were self-reported in questionnaires. These
documents were delivered at home by a trained and certified
investigator, who explained to the parents and their child
how to fill them out. At the end of the survey, he also
checked the accuracy of the information reported in both
the food record and the questionnaires in the presence of the
participants. If the child was under 10 years old, parents or
caregivers completed both documents together with the
child.
Dietary data. In the 7-day record, subjects reported the type
of eating occasion at which each food was consumed, that is,
meals and snacks. One line of the record corresponded to
one item consumed (food or drink), and thus to one eating
occasion for this specific item. Participants estimated portion
sizes of each item by comparing their actual consumption
with photographs in the Su.Vi.MAX (SUpple
´
mentation en
VItamines et en Mine
´
raux AntioXydants) food portion size
manual (Hercberg et al., 1994). These pictures represented
increasing portion sizes of each dish. Macronutrient intake
was evaluated with the CIQUAL (Centre d’information sur la
qualite
´
des aliments) food composition tables (Favier et al.,
1995). In the present study, we assessed the average daily
energy, food, sugar, fat and protein intakes (in kJ per day and
g per day, respectively).
Foods were separated into categories that were relatively
homogeneous with respect to their food origin, portion size
and energy density. This homogeneity constraint, together
with the fact that we wanted to limit the total number of
food categories, led us to a compromise of 23 food or drink
groups (Table 1). Some foods and drinks (that is, oleaginous
seeds, dried fruits, jam, honey, sugar, sea food and water)
were not included in our classification since neither their
energy density nor portion sizes were homogeneous with
any of the 23 groups described in Table 1. As they accounted
for only 2.4% of the EI, we considered that it was not worth
Table 1 Food classification
Sweet or savoury snacks: sugar or chocolate confectioneries, snack bars,
ice cream, chocolate spreads and all savoury appetizers.
Biscuits.
Sweetened pastries: cakes, pies and other sweetened desserts with no
(or very little) lactose.
Croissant-like pastries: French breakfast pastries made of flaky pastry.
Fast foods: rapid consumed savoury foods such as pizzas, sandwiches,
hamburgers, savoury pies and other savoury pastries.
Breakfast cereals.
Solid dairy products: yoghurt, heavy cream, cottage cheese, caramel
cream, whipped cream and other sweetened dairy desserts.
Solid fruits and vegetables: natural fruits, cooked fruits, compotes, raw
or cooked vegetables, but not including freshly squeezed fruit juices and
soups.
Starchy foods: bread, rice, pasta, potatoes (including roast or fried
potatoes), noodles, semolina and pulses.
Meat: beef, lamb, pork and offal.
Ham.
Meat products 1: such as chipolata and other sausages, small sausages
made of chitterlings, blood sausage and white sausage.
Meat products 2: cold cuts such as salami, chorizo, diced bacon, bacon
and ‘pa
ˆ
te
´
’.
Poultry and game.
Fish.
Eggs.
Cheese.
Mixed dishes: such as sauerkraut, stews, ‘couscous’, ‘paella’, ‘lasagne’
and ‘chilli con carne’.
Fat spreads: butter, margarine, oil and other fats, ketchup, mayonnaise
and other dressings.
Liquid dairy products: milk (regular and flavoured), milk shakes and
yoghurt drinks.
Freshly squeezed fruit juices and soups.
Noncarbonated sweetened beverages: including manufactured fruit
juices, but not including carbonated soft drinks and milk.
Carbonated soft drinks: nondiet sweetened and carbonated beverages.
Food portion size and childhood overweight
S Lioret et al
383
European Journal of Clinical Nutrition

increasing the total number of food groups to take them into
account.
We used an indirect measurement of portion size, using
methodology similar to that developed both by McConahy
et al. (2002) and Huang et al. (2004). The portion size of each
food group (g) was defined as the total intake (g) of items
included in the group and consumed during the week of the
survey, divided by the number of eating occasions of these
items. Energy density of the intake was also estimated at the
individual level, weighting the composition of each item
consumed (energy, in kJ) by its effective consumption over
the week (g). It was calculated in kJ per 100 g consumed, first
for the overall intake (ED) and second separately for each
food or drink category.
Physical activity data. The physical activity questionnaire
was derived from the French translation (Deheeger et al.,
1997) of the Modifiable Activity Questionnaire designed for
adolescents by Kriska et al. (1990) and adapted for children
(Fontvieille et al., 1993). It asked for the usual amount of
time spent in taking part in several sportive activities outside
school in an ordinary week. A physical activity indicator was
derived from the average time spent doing such activities (h
per week) and used as a proxy of leisure time physical activity
(LTPA). Sedentary behaviour (SED) was established from the
time spent either watching television or playing video games
in an ordinary week. An average daily time (h per day) was
calculated and weighted from the values reported for each
type of day, that is, school or nonschool days. Previous
findings have shown that these two behavioural variables are
independent patterns of physical activity (Platat et al., 2006;
Lioret et al., 2007).
Anthropometrical data. Self-reported weight and height were
used to calculate the child body mass index (BMI, in kg m
2
).
Obesity and OW were then estimated according to the IOTF
age- and gender-specific child BMI cut-off points (Cole et al.,
2000).
Statistical analysis
Data were analysed using SAS 8.2 software. Bivariate
descriptive analyses stratified by age category were per-
formed to describe dietary intake of French children. We
estimated the percentage of consumers and the energy
density of all food categories. For each food category, portion
sizes were estimated among children who had consumed at
least one item of the food group over the week. We assessed
the contributions of the groups to energy, sugar, fat and
protein intakes. The relationships between total EI and
portion size were also evaluated for each food category. All
statistical inferences were drawn at a significance level of 5%
with two-sided tests. Means were compared using Student’s
t-tests. w
2
-tests were used to compare frequencies and
Cramer’s V statistic was used to measure the strength of
the associations between ordinal variables.
Simple logistic regression analyses were first performed for
each food category to investigate the associations between
OW (including obesity) as the dependent variable and
portion size (Model 1). The analyses were conducted
separately in the two age classes and adjusted for sex and
age (introduced as a continuous variable to eliminate any
remaining potentially confounding effect of age within each
age category). We next computed multivariate stepwise
logistic regressions (Model 2) stratified on the two age classes
where OW was still the dependent variable and where
portion sizes of all food categories were introduced simulta-
neously. Critical P-values that selected food portion size
variables were established at P ¼ 0.15. The adjustment
variables, that is, sex, age, ED, LTPA and SED, were forced
in this multivariate model.
For these analyses, EI, food portion sizes, ED, LTPA and
SED were divided into tertiles. Since these variables are
strongly and positively correlated to age, the tertiles were
assessed within the age categories. The lowest tertile of each
discrete variable was taken as the reference group for
assessment of odds ratios. In order to limit potential
misreporting, we excluded five children from the data set
whose log-transformed value of EI was out of the range of the
mean value
±
3 s.d. within the age classes.
Results
Bivariate results
Of the 748 children included in the study, 29 observations
were eliminated in the analyses because of incomplete data
(behaviours: n ¼ 2; anthropometry: n ¼ 22) or potential
misreporting (n ¼ 5). Taken together, these children repre-
sented 3.6% of the initial sample and did not differ from the
others with regard to age, sex or socio-economic status
(determined from the head of household’s occupation).
Characteristics of the sample are presented by age in Table 2.
Prevalence of OW in children aged 3–6 years and 7–11 years
was 15.7 and 17.3%, respectively, without statistically
significant difference between the age classes. Conversely,
food intake, EI and ED of the diet were significantly higher
among the older children, as were LTPA and SED.
Characteristics of dietary intake differed between food
groups (Table 3 and Table 4). The percentage of consumers
was 460% for almost all food categories, except carbonated
soft drinks, freshly squeezed fruit juices and soups. Food
intake and food portion sizes were significantly higher
among the 7–11 year age group or similar across both age
categories for almost all food groups except dairy products,
whose consumption was significantly lower among the older
children. Sweet or savoury snacks, biscuits, croissant-like
pastries and sweetened pastries accounted for more than
20% of the energy, sugar and fat intakes. It should be noted
that these ‘sweet/fatty snack foods’ are both energy-dense
Food portion size and childhood overweight
S Lioret et al
384
European Journal of Clinical Nutrition

(energy density 4800 kJ per 100 g consumed) and low-
nutrient-dense products. Conversely, healthier products
with higher nutrient density, such as fruits and vegetables,
only contributed to 5% of the EI and 15% of sugar intake.
Lastly, among all food categories, pastries and fat spreads
were the most strongly correlated to total EI (Cramer’s
statistic 40.20, results not shown).
Multivariate results
The age- and sex-adjusted logistic regression models per-
formed for each food group (Model 1) showed that OW in
children aged 3–6 years was positively correlated to portion
sizes of biscuits (P ¼ 0.0392) and sweetened pastries
(P ¼ 0.0027) (Table 5). Almost significant positive trends
were also observed for portion sizes of croissant-like pastries
(P ¼ 0.0568) and meat (P ¼ 0.0574). Not all these relation-
ships were maintained in the multivariate regression ana-
lyses (Model 2) suggesting the presence of collinearity
between several food groups in terms of portion size. The
positive associations were confirmed in Model 2 for
croissant-like pastries (P ¼ 0.0522) and other sweetened
pastries (P ¼ 0.0051). In children aged 7–11 years, the former
age- and sex-adjusted logistic regressions (Model 1) indicated
a negative relationship between OW and portion size of
liquid dairy products (P ¼ 0.0003) (Table 6), which was
confirmed in the final multivariate model (Model 2). The
absence of significant interaction was checked between ED
and food portion sizes.
Discussion
Childhood obesity has reached epidemic proportions world-
wide. France is also involved, particularly in this age range
Table 3 Characteristics of dietary intakes by food category in children aged 3–6 years (n ¼ 338) and 7–11 years (n ¼ 405): percentage of consumers,
intake, food portion size and energy density
Food categories Percentage of
consumers (%)
Food intake (g per day) Food portion size among
consumers (g per portion)
Energy density (kJ per100 g)
3–6 years 7–11 years 3–6 years 7–11 years 3–6 years 7–11 years 3–6 years 7–11 years
Sweet or savoury snacks 83.4 86.2 14.7
±
15.7 16.8
±
16.6 25.8
±
17.3 32.8
±
19.2**** 1640.9
±
781.8 1736.4
±
742.0
Biscuits 91.1 84.4** 31.7
±
28.0 28.6
±
27.9 49.5
±
30.4 57.2
±
36.6** 1653.9
±
531.9 1531.3
±
669.2**
Sweetened pastries 69.8 75.6 25.7
±
30.3 35.4
±
40.8*** 116.1
±
73.8 134.5
±
89.2** 824.4
±
555.3 883.5
±
524.8
Croissant-like pastries 66.9 70.6 20.4
±
27.2 25.6
±
35.0* 68.7
±
32.7 79.0
±
41.6** 1099.8
±
777.2 1158.0
±
750.4
Fast foods 83.4 83.2 25.6
±
23.5 36.5
±
32.5**** 102.4
±
46.6 140.6
±
81.4**** 876.3
±
434.0 868.4
±
426.0
Breakfast cereals 63.0 69.9* 15.3
±
24.6 21.5
±
28.0*** 41.6
±
29.0 52.3
±
27.4**** 976.4
±
751.2 1071.8
±
709.8
Solid dairy products 97.9 96.1 125.6
±
68.2 113.8
±
71.1* 113.1
±
30.4 119.1
±
41.8* 508.1
±
239.8 495.1
±
246.1
Solid fruits and vegetables 98.8 99.0 157.5
±
111.8 191.7
±
125.6**** 92.2
±
34.2 110.1
±
40.5**** 181.6
±
66.1 171.2
±
61.1*
Starchy foods 100.0 100.0 138.9
±
68.3 196.9
±
91.1**** 74.4
±
27.0 98.4
±
36.2**** 662.9
±
143.1 689.7
±
143.1*
Meat 95.6 96.5 37.4
±
26.4 51.0
±
32.8**** 87.1
±
33.4 110.6
±
35.8**** 861.7
±
227.2 872.6
±
221.0
Ham 71.9 69.1 7.7
±
8.0 8.5
±
9.1 41.2
±
18.3 48.9
±
20.0 405.5
±
275.8 393.0
±
285.4
Meat products 1 62.7 53.1** 9.4
±
11.5 10.7
±
15.2 68.1
±
40.5 86.2
±
55.7**** 845.4
±
662.9 715.2
±
683.4**
Meat products 2 63.6 64.0 6.8
±
9.1 8.3
±
11.3 34.2
±
23.7 40.7
±
33.0* 940.4
±
737.8 951.3
±
743.7
Poultry and game 78.7 81.7 18.8
±
17.2 29.3
±
33.4**** 93.2
±
46.3 120.6
±
63.9**** 564.6
±
310.1 580.5
±
290.0
Fish 83.7 75.3** 19.3
±
17.3 22.1
±
24.8 87.1
±
52.3 110.5
±
77.8**** 547.4
±
315.5 483.8
±
342.3**
Eggs 61.8 60.0 10.6
±
11.5 12.3
±
14.0 76.0
±
38.3 100.0
±
56.0**** 421.0
±
336.1 411.0
±
339.0
Cheese 87.3 89.6 19.8
±
20.1 22.5
±
21.6 32.0
±
18.7 38.5
±
16.9**** 1174.3
±
466.2 1199.4
±
433.1
Mixed dishes 78.1 77.5 43.9
±
44.3 58.6
±
62.5*** 175.9
±
81.2 227.2
±
102.7**** 405.1
±
271.6 427.3
±
277.9
Fat spreads 100.0 100.0 16.9
±
10.2 21.9
±
10.5**** 5.4
±
2.8 6.8
±
3.1**** 2813.6
±
431.5 2829.1
±
454.5
Liquid dairy products 93.8 94.6 263.5
±
140.9 229.2
±
141.2*** 160.0
±
54.1 165.5
±
59.1 215.1
±
83.3 215.9
±
110.5
Freshly squeezed fruit
juices and soups
48.5 46.9 37.5
±
56.4 40.0
±
62.8 233.8
±
95.8 265.3
±
109.5** 64.0
±
67.0 60.7
±
66.1
Noncarbonated sweetened
beverages
87.9 78.5*** 125.6
±
145.6 113.6
±
129.8 153.9
±
72.3 185.9
±
87.7**** 229.3
±
244.4 177.9
±
216.8**
Carbonated soft drinks 53.9 59.3 51.9
±
84.2 69.4
±
112.4* 233.1
±
98.4 255.6
±
93.4* 90.0
±
83.3 98.8
±
82.4
Between-age comparisons: *Pp0.05; **Pp0.01; ***Pp0.001; ****Pp0.0001.
x
¯
±
s.d. (all such values).
Table 2 Demographical, anthropometrical and behavioural character-
istics of the sample
Age category
3–6 years (n ¼ 338)7–11 years (n ¼ 405)
Sex, male (%) 54.4 51.6
Overweight (including
obesity) (%)
15.7 17.3
Food intake (g per day) 1682.4
±
378  6 1880.0
±
457.9****
Energy intake (kJ per day) 6901
±
1754 8182
±
2143****
Dietary energy density
(kJ per 100 g)
556.2
±
98.3 592.2
±
93.7****
Leisure time physical activity
(h per week)
2.1
±
3.4 4.2
±
4.5****
Sedentary behaviour (h per day) 1.7
±
1.2 2.0
±
1.3***
Between-age comparisons: *Pp0.05; **Pp0.01; ***Pp0.001; ****Pp0.0001.
x
¯
±
s.d. (all such values).
Food portion size and childhood overweight
S Lioret et al
385
European Journal of Clinical Nutrition

where rates of OW are on average 17%, as already reported
based on the same data set (Lioret et al., 2007). Given this
background, our results provide useful insights into some
behavioural risk factors likely to be involved in weight gain.
To our knowledge, this study is the first to examine the
epidemiological relationships between portion size by food
group and childhood OW, taking into account potential
confounders, like dietary ED, LTPA and SED. This study also
provides useful descriptive values on portion size and dietary
intake by food group in French children aged 3–11 years at a
national scale, which has rarely been the case using
observational data.
We found that portion sizes of croissant-like pastries and
other sweetened pastries were positively correlated to OW in
children aged 3–6 years. These results are consistent with
findings from two cross-sectional studies in children linking
meal portion size to increased body weight using a similar
definition of portion size, that is, mean quantities in grams
consumed on one eating occasion (McConahy et al., 2002;
Huang et al., 2004). Additionally, our study shows that this
relationship could be attributed to specific food sources,
most of which belong to the category of ‘convenience foods’,
which are often packaged for single-serving consumption,
and whose portion sizes have been reported to be increasing
(Young and Nestle, 2002).
Most of the studies that focused on portion size investigated
its association with EI. Several well-controlled, laboratory-
based studies have shown that providing adults and children
(aged 4 years or more) with larger food portions can lead to
significant increases in EI (Rolls et al., 2000, 2002; Orlet Fisher
et al., 2003; McConahy et al., 2004; Ello-Martin et al., 2005).
This effect has been demonstrated for snacks and a variety of
single meals and shown to persist over a 2-day period (Rolls
et al., 2006b). Despite increases in intake, individuals
presented with large portions generally do not report or
respond to increased levels of satiety, suggesting that hunger
and satiety signals are ignored or overridden (Kral, 2006). It is
notable that the INCA1 food consumption data were collected
over seven days, which potentially allowed for compensatory
mechanisms, if any, following the intake of large portion sizes
on one or several eating occasions over the survey week to be
taken into account. In addition, the analyses performed on
the INCA1 data set confirmed that portion size of several food
categories was positively correlated to total EI, with the
strongest relationships observed for croissant-like pastries,
sweetened pastries and fat spreads (results not shown).
Table 4 Characteristics of dietary intakes by food category in children aged 3–6 years (n ¼ 338) and 7–11 years (n ¼ 405): contribution of each food
category to energy, sugar, fat and protein intakes
Food categories Contribution (%) of each food group to:
Energy intake Sugar intake Fat intake Protein intake
3–6 years 7–11 years 3–6 years 7–11 years 3–6 years 7–11 years 3–6 years 7–11 years
Sweet or savoury snacks 4.02
±
3.98 4.06
±
3.95 8.01
±
8.13 8.98
±
8.81 4.26
±
4.80 4.69
±
5.04 1.02
±
1.26 1.12
±
1.34
Biscuits 8.21
±
6.84 6.29
±
5.84**** 7.37
±
7.43 6.40
±
7.23 9.07
±
7.86 6.84
±
6.58**** 3.35
±
3.14 2.50
±
2.55****
Sweetened pastries 4.15
±
4.62 4.75
±
5.07 4.01
±
4.92 5.47
±
6.49*** 4.72
±
5.56 5.29
±
5.93 2.38
±
3.12 2.63
±
3.24
Croissant-like pastries 4.66
±
5.64 4.88
±
5.85 0.97
±
1.26 1.24
±
1.90* 5.60
±
6.66 5.79
±
6.77 2.81
±
3.87 2.82
±
3.73
Fast foods 4.01
±
3.57 4.70
±
4.20* 0.45
±
0.53 0.58
±
0.70** 5.09
±
4.96 5.65
±
5.11 4.59
±
4.26 5.40
±
5.16*
Breakfast cereals 3.38
±
4.89 4.07
±
4.86 2.80
±
5.40 4.09
±
6.21** 0.68
±
1.92 0.68
±
1.82 1.76
±
2.96 2.02
±
2.56
Solid dairy products 9.07
±
5.74 6.89
±
4.87**** 15.17
±
9.51 13.62
±
9.65* 9.15
±
6.91 6.87
±
5.69**** 9.24
±
5.53 6.62
±
4.49****
Solid fruits and
vegetables
4.26
±
3.09 4.13
±
2.88 12.70
±
9.80 14.14
±
10.78 0.77
±
1.57 0.96
±
1.81 1.91
±
1.42 2.05
±
1.39
Starchy foods 13.27
±
5.81 16.60
±
7.00**** 1.30
±
1.24 1.96
±
1.59**** 4.54
±
2.76 5.24
±
3.75** 9.75
±
4.81 11.93
±
5.70****
Meat 4.89
±
3.32 5.70
±
3.64** 0.00
±
0.00 0.00
±
0.00 6.95
±
5.14 7.91
±
5.23* 14.59
±
8.92 16.60
±
9.43**
Ham 0.63
±
0.68 0.61
±
0.72 0.00
±
0.02 0.00
±
0.01 0.78
±
0.93 0.74
±
0.91 2.27
±
2.28 2.11
±
2.40
Meat products 1 1.87
±
2.27 1.70
±
2.26 0.03
±
0.11 0.01
±
0.07 4.12
±
4.86 3.62
±
4.70 2.06
±
2.52 1.92
±
2.67
Meat products 2 1.46
±
1.95 1.54
±
2.24 0.03
±
0.08 0.04
±
0.15 3.03
±
3.95 3.13
±
4.32 1.87
±
2.42 1.92
±
2.68
Poultry and game 2.01
±
1.95 2.62
±
2.92** 0.00
±
0.00 0.00
±
0.00 2.07
±
2.43 2.62
±
3.28** 7.88
±
6.71 9.78
±
8.95***
Fish 1.81
±
1.67 1.76
±
2.40 0.01
±
0.07 0.02
±
0.08 1.90
±
2.01 1.84
±
2.62 5.33
±
4.79 4.79
±
4.95
Eggs 1.10
±
1.27 1.06
±
1.25 0.00
±
0.00 0.00
±
0.00 2.03
±
2.37 1.92
±
2.25 2.32
±
2.67 2.21
±
2.62
Cheese 3.72
±
3.49 3.64
±
3.25 0.08
±
0.21 0.06
±
0.14 7.15
±
6.56 6.91
±
5.96 6.37
±
5.77 6.19
±
5.39
Mixed dishes 3.19
±
3.36 4.06
±
4.48** 0.92
±
1.42 1.30
±
1.93** 4.04
±
4.60 5.20
±
6.02** 4.94
±
5.35 6.00
±
6.46*
Fat spreads 6.77
±
3.29 7.47
±
3.11** 0.17
±
0.44 0.16
±
0.30 17.99
±
8.13 19.63
±
7.60** 0.16
±
0.18 0.18
±
0.23
Liquid dairy products 9.28
±
6.22 6.41
±
4.18**** 19.42
±
12.68 15.93
±
10.86**** 5.22
±
3.58 3.54
±
2.30**** 13.70
±
8.08 9.53
±
5.64****
Freshly squeezed fruit
juices and soups
0.73
±
1.12 0.70
±
1.25 1.09
±
1.85 1.14
±
2.52 0.09
±
0.32 0.10
±
0.36 0.48
±
0.81 0.48
±
0.92
Noncarbonated
sweetened beverages
3.75
±
4.18 2.63
±
3.34**** 13.24
±
12.09 10.92
±
11.90** 0.01
±
0.11 0.00
±
0.00 0.01
±
0.17 0.00
±
0.00
Carbonated soft drinks 1.25
±
1.91 1.44
±
2.22 4.73
±
7.19 6.48
±
9.98** 0.00
±
0.00 0.00
±
0.00 0.00
±
0.00 0.00
±
0.00
Between-age comparisons: *Pp0.05; **Pp0.01; ***Pp0.001; ****Pp0.0001.
x
¯
±
s.d. (all such values).
Food portion size and childhood overweight
S Lioret et al
386
European Journal of Clinical Nutrition

Table 5 Age- and sex-adjusted and multivariable-adjusted odds ratios
(ORs) (and 95% CIs) for overweight (including obesity) by portion sizes
of food categories in children aged 3–6 years, using logistic regression
analysis (n ¼ 329)
Food groups Age- and
sex-adjusted ORs
a
Multivariable-adjusted
ORs
b
Sweet or savoury snacks
T1
c
1.00
T2
c
0.49 (0.23–1.05)
T3
c
0.99 (0.50–1.98)
P for trend
d
0.9101
Biscuits
T1 1.00
T2 1.47 (0.68–3.17)
T3 2.20 (1.03–4.68)
P for trend 0.0392
Sweetened pastries
e
T1 1.00 1.00
T2 1.41 (0.61–3.27) 1.38 (0.56–3.40)
T3 3.06 (1.43–6.56) 2.99 (1.31–6.84)
P for trend 0.0027 0.0051
Croissant-like pastries
e
T1 1.00 1.00
T2 1.37 (0.64–2.93) 1.43 (0.63–3.26)
T3 2.05 (0.98–4.30) 2.18 (0.96–4.96)
P for trend 0.0568 0.0522
Fast foods
T1 1.00
T2 0.74 (0.35–1.59)
T3 1.50 (0.74–3.03)
P for trend 0.2496
Breakfast cereals
e
T1 1.00
T2 0.53 (0.22–1.28)
T3 0.70 (0.37–1.33)
P for trend 0.2775
Solid dairy products
T1 1.00
T2 0.82 (0.39–1.73)
T3 1.18 (0.58–2.39)
P for trend 0.6585
Solid fruits and vegetables
T1 1.00
T2 1.07 (0.52–2.21)
T3 1.14 (0.55–2.35)
P for trend 0.7322
Starchy foods
T1 1.00
T2 1.22 (0.59–2.50)
T3 1.11 (0.53–2.32)
P for trend 0.7865
Meat
T1 1.00 1.00
T2 2.02 (0.95–4.29) 2.19 (0.96–4.99)
T3 2.10 (0.98–4.53) 1.70 (0.72–4.01)
P for trend 0.0574 0.1164
Table 5 Continued
Food groups Age- and
sex-adjusted ORs
a
Multivariable-adjusted
ORs
b
Ham
T1 1.00
T2 1.00 (0.46–2.18)
T3 1.48 (0.73–3.02)
P for trend 0.2636
Meat products 1
e
T1 1.00
T2 0.54 (0.25–1.15)
T3 0.74 (0.37–1.49)
P for trend 0.3577
Meat products 2
e
T1 1.00
T2 0.49 (0.19–1.22)
T3 1.33 (0.70–2.56)
P for trend 0.3659
Poultry and game
T1 1.00
T2 1.83 (0.84–3.96)
T3 2.04 (0.94–4.40)
P for trend 0.0741
Fish
T1 1.00
T2 1.84 (0.92–3.70)
T3 0.73 (0.32–1.68)
P for trend 0.5278
Eggs
e
T1 1.00
T2 0.38 (0.16–0.89)
T3 0.61 (0.31–1.17)
P for trend 0.1207
Cheese
T1 1.00
T2 1.47 (0.70–3.08)
T3 1.56 (0.75–3.24)
P for trend 0.2357
Mixed dishes
T1 1.00
T2 1.36 (0.65–2.88)
T3 1.48 (0.72–3.08)
P for trend 0.2929
Fat spreads
T1 1.00
T2 0.84 (0.41–1.74)
T3 0.91 (0.45–1.86)
P for trend 0.7918
Liquid dairy products
T1 1.00 1.00
T2 1.96 (1.00–3.83) 1.38 (0.65–2.91)
T3 0.48 (0.21–1.10) 0.38 (0.15–0.93)
P for trend 0.1582 0.0740
Freshly squeezed fruit juices and
soups
e
T1 1.00
T2 0.88 (0.37–2.07)
Food portion size and childhood overweight
S Lioret et al
387
European Journal of Clinical Nutrition

But children are also responsive to the increasing avail-
ability of highly palatable foods, which contribute to making
self-regulation of EI less operational (Rolls et al., 2006b). In
fact, it is not only portion size that increases EI, but rather,
large portions of energy-dense foods, known to be more
palatable (Kral and Rolls, 2004; Ledikwe et al., 2006). Energy
density and palatability of foods are directly related to their
fat content and, in the present study, croissant-like pastries
and the other sweetened pastries, which were shown to be
positively associated with OW in terms of portion size in
children aged 3–6 years, fall into the category of highly-
palatable energy-dense foods. Their energy density is
4800 kJ per 100 g consumed, and their contribution to EI,
fat and sugar intakes is relatively high. Conversely, their
nutrient density is very low. It should be underlined that
‘sweet/fatty snack foods’ might displace the child’s con-
sumption of other more nutritious and less energy-dense
foods, such as fruits and vegetables, dairy products, fish and
starchy foods (Bell et al., 2005). This food selection, when
associated with large portion sizes, could therefore contri-
bute to weight gain. Conversely, our results indicated that
portion size of liquid dairy products was inversely associated
with OW in children aged 7–11 years. In a recent review,
Zemel and Miller (2004) described the enhancing effect of
dairy calcium on lipolysis and thus on fat loss. It was also
Table 5 Continued
Food groups Age- and
sex-adjusted ORs
a
Multivariable-adjusted
ORs
b
T3 0.93 (0.48–1.81)
P for trend 0.8128
Noncarbonated sweetened
beverages
T1 1.00
T2 1.15 (0.53–2.49)
T3 1.69 (0.82–3.50)
P for trend 0.1491
Carbonated soft drinks
e
T1 1.00
T2 1.11 (0.55–2.27)
T3 1.00 (0.49–2.05)
P for trend 0.9691
a
Age- and sex-adjusted logistic regression analyses: there are 23 logistic
regression models (Model 1).
b
Stepwise multivariate logistic regression analysis adjusted for sex, age
(continuous), dietary energy density, leisure time physical activity and
sedentary behaviour (Model 2). Only the odds ratios of the food groups
selected by the stepwise logistic regression are given.
c
T1, tertile 1 of portion size distribution of food groups; T2, tertile 2; T3, tertile
3. Reference ¼ T1.
d
Tests for linear trend were performed using the ordinal score on categories of
each variable.
e
Since there was a high percentage of nonconsumers (433.3%), it was not
possible to obtain balanced tertiles for the portion sizes of these food groups.
The population was therefore split into three classes, the first corresponding to
nonconsumers (T1). The threshold that determined the two other categories
(T2 and T3) was the median of the portion size distribution among consumers
in each food category concerned.
Table 6 Age- and sex-adjusted and multivariable-adjusted odds ratios
(and 95% CIs) for overweight (including obesity) by portion sizes of food
categories in children aged 7–11 years, using logistic regression analysis
(n ¼ 390)
Food groups Age- and
sex-adjusted ORs
a
Multivariable-
adjusted ORs
b
Sweet or savoury snacks
T1
c
1.00
T2
c
1.03 (0.55–1.93)
T3
c
0.70 (0.37–1.34)
P for trend
d
0.2835
Biscuits
T1 1.00
T2 1.20 (0.63–2.29)
T3 1.24 (0.65–2.38)
P for trend 0.5188
Sweetened pastries
T1 1.00
T2 1.84 (0.95–3.58)
T3 1.66 (0.85–3.25)
P for trend 0.1530
Croissant-like pastries
T1 1.00
T2 0.87 (0.44–1.72)
T3 1.31 (0.70–2.44)
P for trend 0.3627
Fast foods
T1 1.00
T2 0.78 (0.39–1.53)
T3 1.51 (0.81–2.81)
P for trend 0.1763
Breakfast cereals
T1 1.00
T2 0.82 (0.44–1.53)
T3 0.60 (0.32–1.14)
P for trend 0.1202
Solid dairy products
T1 1.00
T2 0.99 (0.51–1.92)
T3 1.24 (0.66–2.34)
P for trend 0.4839
Solid fruits and vegetables
T1 1.00
T2 1.42 (0.74–2.72)
T3 1.22 (0.63–2.34)
P for trend 0.5781
Starchy foods
T1 1.00
T2 1.01 (0.51–1.96)
T3 1.52 (0.81–2.88)
P for trend 0.1845
Meat
T1 1.00
T2 1.12 (0.58–2.17)
T3 1.23 (0.65–2.35)
P for trend 0.5243
Ham
T1 1.00
Food portion size and childhood overweight
S Lioret et al
388
European Journal of Clinical Nutrition

suggested that bioactive components in milk proteins and
whey may act with calcium to attenuate lipogenesis (Shah,
2000). It is also likely that the consumption of large portion
sizes of liquid dairy product is an indicator of an overall
healthy lifestyle pattern regarding energy balance and
weight regulation. However, further research is needed to
confirm and explain the protective role of dairy intake
against OW in children (Huang and McCrory, 2005).
One strong point of the INCA1 survey is taking into
account the comprehensive variables related to the three
components of the energy balance equation, that is, dietary
intake, energy expenditure and weight status. However, in
such a large-scale study, precision and accuracy cannot be
optimal for all measurements. Compared to other methods
(for example 24-h recall), the 7-day food record is more
suitable for taking the day-to-day variability of food intake in
children into account, which is approximately twice of that
observed in adults (Livingstone and Robson, 2000). More-
over, recent studies have demonstrated the ability of
children to report food portion size accurately using food
photographs (Lillegaard et al., 2005; Foster et al., 2006).
However, people may grow tired of filling out a prolonged
food record, which may result in food intake being under-
reported (Livingstone and Robson, 2000). Potential bias due
to under-reporting of body weight or food intake (Brener
et al., 2003; Rennie et al., 2005) should not be excluded, even
though this has mainly been described in obese adolescents
and adults (Bandini et al., 1990; Strauss, 1999). Finally the
associations observed between OW status and food portion
Table 6 Continued
Food groups Age- and
sex-adjusted ORs
a
Multivariable-
adjusted ORs
b
T2 0.58 (0.29–1.17)
T3 0.85 (0.47–1.53)
P for trend 0.5910
Meat products 1
e
T1 1.00
T2 0.53 (0.25–1.13)
T3 1.01 (0.56–1.81)
P for trend 0.8891
Meat products 2
e
T1 1.00
T2 0.65 (0.34–1.24)
T3 0.83 (0.45–1.53)
P for trend 0.4952
Poultry and game
T1 1.00
T2 0.73 (0.38–1.39)
T3 0.84 (0.45–1.58)
P for trend 0.5981
Fish
T1 1.00
T2 1.02 (0.55–1.88)
T3 0.78 (0.40–1.51)
P for trend 0.4664
Eggs
e
T1 1.00
T2 0.68 (0.36–1.29)
T3 0.86 (0.46–1.60)
P for trend 0.5705
Cheese
T1 1.00
T2 0.70 (0.36–1.39)
T3 1.42 (0.77–2.65)
P for trend 0.2302
Mixed dishes
T1 1.00
T2 0.79 (0.41–1.51)
T3 1.05 (0.56–1.96)
P for trend 0.8870
Fat spreads
T1 1.00
T2 0.69 (0.36–1.31)
T3 0.81 (0.44–1.51)
P for trend 0.5182
Liquid dairy products
T1 1.00 1.00
T2 0.54 (0.28–1.04) 0.57 (0.29–1.11)
T3 0.30 (0.15–0.59) 0.30 (0.14–0.60)
P for trend 0.0003 0.0006
Freshly squeezed fruit juices and soups
e
T1 1.00 1.00
T2 0.56 (0.28–1.13) 0.55 (0.26–1.16)
T3 0.66 (0.34–1.28) 0.61 (0.31–1.22)
P for trend 0.1351 0.1107
Noncarbonated sweetened beverages
T1 1.00
Table 6 Continued
Food groups Age- and
sex-adjusted ORs
a
Multivariable-
adjusted ORs
b
T2 0.89 (0.47–1.69)
T3 1.03 (0.55–1.96)
P for trend 0.9148
Carbonated soft drinks
e
T1 1.00
T2 0.79 (0.39–1.60)
T3 1.38 (0.76–2.49)
P for trend 0.2982
a
Age- and sex-adjusted logistic regression analyses: there are 23 logistic
regression models (Model 1).
b
Stepwise multivariate logistic regression analysis adjusted for sex, age
(continuous), dietary energy density, leisure time physical activity and
sedentary behaviour (Model 2). Only the odds ratios of the food groups
selected by the stepwise logistic regression are given.
c
T1, tertile 1 of portion size distribution of food groups; T2, tertile 2; T3, tertile
3. Reference ¼ T1.
d
Tests for linear trend were performed using the ordinal score on categories of
each variable.
e
Since there was a high percentage of nonconsumers (433.3%), it was not
possible to obtain balanced tertiles for the portion sizes of these food groups.
The population was therefore split into three classes, the first corresponding to
nonconsumers (T1). The threshold that determined the two other categories
(T2 and T3) was the median of the portion size distribution among consumers
in each food category concerned.
Food portion size and childhood overweight
S Lioret et al
389
European Journal of Clinical Nutrition

size were based on cross-sectional data and therefore
causality cannot be directly inferred. One cannot exclude
the possibility that some OW children who were willing to
lose weight deliberately changed the portion size of certain
foods they consumed, which might have weakened certain
relationships. Therefore, additional studies based on long-
itudinal design are needed to confirm our results and
conclude in causality.
Conclusion
This study suggests that the current worldwide increase in
childhood OW, which has also been described in France,
may be driven not only by increased sedentary behaviour
and consumption of particular foods, but also by the shift in
eating patterns towards larger portion sizes of specific foods,
notably energy-dense and nutrient-poor products. The
precocity of these harmful choices and behaviours towards
food needs to be taken seriously as, once established, eating
habits are actually difficult to change (Nicklaus et al., 2005).
Consequently, although these cross-sectional observations
need to be confirmed by further longitudinal studies, there is
a need to deliver public health messages that consider
portion sizes and energy density of foods together. Con-
sumption of large portion sizes of palatable energy-dense
foods should be discouraged both inside and outside home,
while nutritious low-energy-dense foods, such as grains,
some dairy products, fish, fruits and vegetables should be
promoted in the context of a balanced diet.
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