Skipping breakfast, overconsumption of soft drinks and screen media: Longitudinal analysis of the combined influence on weight development in primary schoolchildren

Abstract

Background:
Regular breakfast and well-balanced soft drink, and screen media consumption are associated with a lower risk of overweight and obesity in schoolchildren. The aim of this research is the combined examination of these three parameters as influencing factors for longitudinal weight development in schoolchildren in order to adapt targeted preventive measures.

Methods:
In the course of the Baden-Württemberg Study, Germany, data from direct measurements (baseline (2010) and follow-up (2011)) at schools was available for 1733 primary schoolchildren aged 7.08 ± 0.6 years (50.8% boys). Anthropometric measurements of the children were taken according to ISAK-standards (International Standard for Anthropometric Assessment) by trained staff. Health and lifestyle characteristics of the children and their parents were assessed in questionnaires. A linear mixed effects regression analysis was conducted to examine influences on changes in waist-to-height-ratio (WHtR), weight, and body mass index (BMI) measures. A generalised linear mixed effects regression analysis was performed to identify the relationship between breakfast, soft drink and screen media consumption with the prevalence of overweight, obesity and abdominal obesity at follow-up.

Results:
According to the regression analyses, skipping breakfast led to increased changes in WHtR, weight and BMI measures. Skipping breakfast and the overconsumption of screen media at baseline led to higher odds of abdominal obesity and overweight at follow-up. No significant association between soft drink consumption and weight development was found.

Conclusion:
Targeted prevention for healthy weight status and development in primary schoolchildren should aim towards promoting balanced breakfast habits and a reduction in screen media consumption. Future research on soft drink consumption is needed. Health promoting interventions should synergistically involve children, parents, and schools.

Trial registration:
The Baden-Württemberg Study is registered at the German Clinical Trials Register (DRKS) under the DRKS-ID: DRKS00000494 .

Full text

R E S E A R C H A R T I C L E Open Access
Skipping breakfast, overconsumption of
soft drinks and screen media: longitudinal
analysis of the combined influence on
weight development in primary
schoolchildren
Meike Traub
1*
, Romy Lauer
1
, Tibor Kesztyüs
3,4
, Olivia Wartha
1
, Jürgen Michael Steinacker
1
,
Dorothea Kesztyüs
1,2
and the Research Group “Join the Healthy Boat”
Abstract
Background: Regular breakfast and well-balanced soft drink, and screen media consumption are associated with a
lower risk of overweight and obesity in schoolchildren. The aim of this research is the combined examination of
these three parameters as influencing factors for longitudinal weight development in schoolchildren in order to
adapt targeted preventive measures.
Methods: In the course of the Baden-Württemberg Study, Germany, data from direct measurements (baseline (2010)
and follow-up (2011)) at schools was available for 1733 primary schoolchildren aged 7.08 ± 0.6 years (50.8% boys).
Anthropometric measurements of the children were taken according to ISAK-standards (International Standard for
Anthropometric Assessment) by trained staff. Health and lifestyle characteristics of the children and their parents were
assessed in questionnaires. A linear mixed effects regression analysis was conducted to examine influences on changes
in waist-to-height-ratio (WHtR), weight, and body mass index (BMI) measures. A generalised linear mixed effects
regression analysis was performed to identify the relationship between breakfast, soft drink and screen media
consumption with the prevalence of overweight, obesity and abdominal obesity at follow-up.
Results: According to the regression analyses, skipping breakfast led to increased changes in WHtR, weight and BMI
measures. Skipping breakfast and the overconsumption of screen media at baseline led to higher odds of abdominal
obesity and overweight at follow-up. No significant association between soft drink consumption and weight development
was found.
Conclusion: Targeted prevention for healthy weight status and development in primary schoolchildren should aim
towards promoting balanced breakfast habits and a reduction in screen media consumption. Future research on soft
drink consumption is needed. Health promoting interventions should synergistically involve children, parents, and
schools.
Trial registration: The Baden-Württemberg Study is registered at the German Clinical Trials Register (DRKS) under the
DRKS-ID: DRKS00000494.
Keywords: Child, Soft drink, Breakfast, Screen media, Overweight, Obesity, Prevention & control
* Correspondence: meike.traub@uni-ulm.de
1
Medical Center, Division of Sports and Rehabilitation Medicine, University of
Ulm, Frauensteige 6, Haus 58/33, 89075 Ulm, Germany
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Traub et al. BMC Public Health (2018) 18:363
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Background
The increase in overweight and obesity in children and
adolescents as a worldwide health problem [1] has led
the World Health Organization (WHO), in the introduc-
tion of its World Health Report, to define overweight
and obesity as one of the future challenges [2]. In par-
ticular, childhood obesity has the longer-term risk that
overweight or obese children become overweight adults
and develop, e.g., cardiovascular diseases, diabetes or
orthopaedic problems [3]. Overweight and obesity are
most often the result of an unhealthy lifestyle, leading
to a rising prevalence of non-communicable diseases
(NCD) [4]. It is assumed that abdominal obesity has
the most risky influence on the development of NCDs
[5]. There are multiple and complex reasons for
overweight and obesity. However, in addition to gen-
etic and physiologic aspects, lifestyle patterns are the
most frequent causes of weight gain. In particular, a
sedentary lifestyle with a lot of screen media
consumption and reduced physical activity [6,7]skip-
ping breakfast [8], and a high energy intake, e.g.
overconsumption of high-calorie soft drinks [7]seem
to be relevant factors for weight gain and the devel-
opment of overweight in primary schoolchildren.
Systematic reviews show that in schoolchildren skip-
ping breakfast is associated with an increase in body
mass index (BMI) and a higher risk of becoming
overweight or obese [8,9]. In addition, there exists
the general view that prolonged use of screen media
is associated with childhood obesity [10]. On the one
hand, time spent with screen media leads to physical
inactivity, and on the other hand, it contributes to an
increased energy intake through snacking and con-
suming soft drinks in front of the screen [10]. A
study of Krahnstoever Davison et al. shows that 7-
year-old girls who exceed the recommendations of
the tolerable time watching TV are more likely to be
overweight at age 11 [11]. Due to the high calorific
density of soft drinks, there is a special interest in
the association of soft drink consumption and obesity
[12]. Two recent reviews conclude that the consumption
of soft drinks is related to obesity [13,14]. Additionally,
the association between soft drink consumption and
various weight parameters is consistent [15]. For example,
Lee et al. confirm a link between high soft drink consump-
tion and higher waist circumference (WC) and BMI
z-scores [16].
The aim of the present study is to investigate the
longitudinal associations of skipping breakfast, the
consumption of soft drinks, and screen media as com-
bined factors for longitudinal weight development in
schoolchildren. New information for multicomponent
and targeted interventions for obesity prevention in
schoolchildren could be derived from these findings.
Methods
Study design
The Baden-Württemberg Study is a prospective, cluster-
randomized and longitudinal study with a waitlist
control group to evaluate the school-based health pro-
motion programme “Join the Healthy Boat”.The
programme is included in the curriculum of grades one
to four at primary schools in Baden-Württemberg,
south-west Germany. A detailed description of the
evaluation design and the programme can be found
elsewhere [17]. The aim of the programme is to support
children to develop a healthy lifestyle in the terms of
physical activity, reduction in consumption of soft drinks
and in screen media. Behavioural and environmental
components are combined equally. In order to analyse
the success of the programme and its effects, data
collection was conducted for baseline measurements in
autumn 2010, and for follow-up in autumn 2011.
Ethics, consent and permissions
Besides the agreement of schools and teachers to partici-
pate in the study, parents had to give their written, in-
formed consent for their child. The trial protocol was
approved by the ethics committee of Ulm University
(Application No. 126/10). The Baden-Württemberg
Study is registered at the German Clinical Trials Register
(DRKS) under the DRKS-ID: DRKS00000494.
Participants and data
At baseline and follow-up, data from 1733 children from
first and second grade was collected. Anthropometric
data of the children such as height, weight, and waist
circumference were assessed in schools by trained staff.
Data from parental questionnaires was available for 1545
children (89%) at baseline and follow-up. Parents gave
information about their own anthropometric data as well
as health and living conditions. They also provided
details about their child’s health behaviour, lifestyle and
socioeconomic background.
Demographics
The parental education level was assigned on the basis of
the CASMIN classification (Comparative Analysis of
Social Mobility in Industrial Nations) [18], and family
education level was defined as the highest level of two
parents or a single parent. Family education level was
dichotomized for analysis into elementary and intermedi-
ate level, on the one side, compared with tertiary level on
the other side. A child’s migration background was defined
as at least having one parent being born abroad, or at least
one parent having mainly spoken a foreign language and
not German during the child’s first years of life. House-
hold income was assessed according to the categories used
in the KiGGS survey (German Health Interview and
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Examination Survey for Children and Adolescents) [19]
and dichotomized for analysis into two groups: Families
with a household income of €1750 or less per month, and
families with more than €1750 per month.
Health and lifestyle characteristics
Parents were asked to give information on their
children’s health and health behaviour. Relevant ques-
tions were taken from the validated questionnaires of
the German KiGGS survey [20]. Frequency of consum-
ing soft drinks at school and outside school (several
times a day, every day, several times a week, once a
week, less than once a week, never) was assessed on a 6-
point Likert scale. Time spent with screen media on
school days and at weekends, as well as playing outside
(never, about 30 min/day, about 30–60 min/day, about
1–2 h/day, about 2–3 h/day, about 3–4 h/day, more
than 4 h/day) was assessed on a 7-point Likert scale.
Variables were dichotomized for analysis (soft drinks
> 1/week, playing outside > 60 min/day, screen media
> 1 h/day). On a 4-point Likert scale, parents stated how
often their children ate breakfast before going to school.
The answers also were dichotomized: “Never and rarely”
versus “often and always”. Furthermore, they stated the
number of days per week during which their children
were physically active at a moderate to vigorous level for
at least 60 min a day, as recommended by the World
Health Organization (WHO) [21]. This item was dichot-
omized for analysis at the middle category (physically
active ≥4 days/week ≥60 min/day). Moreover, parents
were asked whether and how long their children were
breastfed, and whether their mother had smoked during
pregnancy. Finally, parents stated self-assessed informa-
tion about their height, weight and WC, from which
their weight status could be derived.
Anthropometric measurements
Trained staff took the anthropometric measurements of
the children according to ISAK-standards [22]. Height
was measured to the nearest 0.1 cm and body weight
was assessed to the nearest 0.1 kg using a stadiometer
(Stadiometer, Seca®, Germany) and an electric calibrated
and balanced scale (Seca®, Germany). WC was measured
midway between iliac crest and lower costal arch to the
nearest 0.1 cm using a flexible metal tape (Lufkin
Industries Inc., Texas, USA). The children’s BMI was
computed as weight divided by height squared (kg/m
2
).
According to German reference data, cut-off points for
overweight children were set above the 90th age- and
gender-specific BMI percentile; for obese children above
the 97th percentile [23]. WC divided by height in centi-
metres was used to calculate the waist-to-height-ratio
(WHtR). According to Ashwell & Hsieh, participants
with a WHtR ≥0.5 were categorized as abdominally
obese [24]. Parental BMI was determined based on the
self-reported weight and height data from the question-
naires and was categorized as overweight (BMI ≥25.0) or
obese (BMI ≥30.0) [25]. Parental WHtR was calculated
as the ratio of self-reported WC to height in centi-
metres, and the cut-off point for abdominal obesity was
defined as WHtR ≥0.5 [24].
Missing data
In observational studies the problem of missing data
often occurs, possibly leading to biased results [26].
Therefore, baseline differences between cases with and
without missing values for the final regression model
were statistically tested and reported.
Statistical analysis
Group differences in baseline data between boys and
girls, as well as between participants with and without
missing values, were tested. The Mann-Whitney-U test
was used for continuous data, and Fisher’s exact test for
categorical data. Statistical analyses were performed
using the statistical software packages IBM SPSS Release
21.0 for Windows (SPSSInc, Chicago, IL, USA) with a
significance level set at α= 0.05 for two-sided tests.
To account for the clustering of data in schools, general-
ised linear mixed effects models were calculated for the
prevalence of abdominal obesity, overweight and obesity
at follow-up. Changes in WHtR, weight in kg and BMI
measureswere analysed in linear mixed effects regression
analyses. Variables from models derived in previous inves-
tigations were included in the analyses [27,28]. The
variables of interest were included in the respective model
for each outcome parameter and were tested for their
significance. Because of multiple testing and the accumu-
lation of α-error, a Bonferroni-Holm correction was ap-
plied [29]. For this purpose, the ascending ordered
quantity k (= number of single hypotheses) of the p-values
were subjected to the rule of significance p<α/k,where
k has been reduced by 1 in each further step.
Results
Baseline characteristics
Table 1shows a summary of baseline participants’
anthropometric, health and lifestyle characteristics.
Primary schoolchildren who took part in the research
had a mean age of 7.08 ± 0.6 years, 50.8% of them were
boys. Boys were significantly heavier and less abdomin-
ally obese than girls, but on average had a higher WC.
Significantly more mothers of girls refrained from smok-
ing than did mothers of boys Boys played outside signifi-
cantly more often, reached significantly higher levels of
physical activity, and spent significantly more time with
screen media than did girls.Girls skipped breakfast sig-
nificantly more often than did boys.
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Regression analysis of changes in WHtR, weight and BMI
measures
Previous investigations of the same study were taken as
the basis for the regression model used here [27,28]. A
linear mixed effects regression model was formed for
each outcome parameter and the variables of interest
were tested for their statistical significance. Table 2
shows the longitudinal correlations of skipping breakfast,
and the overconsumption of soft drinks and screen
media with changes in WHtR, weight in kg and BMI
percentiles, adjusted for the respective baseline measures,
for socio-economic (migration background, household
Table 1 Baseline characteristics of participants in the Baden-Württemberg Study (2010-2011)
Missing Girls Boys Total
Values (n=852) (n=881) (n=1733)
Child characteristics
Age, years [m (sd)] 7.07 (0.64) 7.09 (0.63) 7.08 (0.63)
Migration background, n (%) 244 235 (31.6) 227 (30.5) 462 (31.0)
Control group, n (%) 371 (43.5) 407 (46.2) 778 (44.9)
Weight in kg [m (sd)] 24.45 (4.50)** 24.88 (4.82) 24.67 (4.91)
BMI, [m (sd)] 15.99 (2.19) 15.97 (2.08) 15.98 (2.14)
BMIPERC, [m (sd)] 48.96 (27.74) 48.15 (27.57) 48.55 (27.65)
Overweight, n (%) 82 (9.6) 83 (9.4) 165 (9.5)
Obesity, n (%) 30 (3.5) 38 (4.3) 68 (3.9)
WC, cm [m (sd)] 55.15 (5.91)* 55.79 (5.54) 55.48 (5.73)
WHtR, [m (sd)] 0.45 (0.04) 0.45 (0.04) 0.45 (0.04)
Abdominal obesity, n (%) 78 (9.2)* 57 (6.5) 135 (7.8)
Parental characteristics
Single parent, n (%) 218 85 (11.3) 71 (9.3) 156 (10.3)
Maternal smoking during pregnancy, n (%) 196 65 (8.5)* 91 (11.8) 156 (10.1)
Breastfeeding, n (%) 194 651 (85.1) 535 (82.0) 1286 (83.6)
Breastfeeding months [m (sd)] 462 5.55 (3.46) 5.68 (4.05) 5.61 (3.76)
Tertiary family educational level, n (%) 269 237 (32.6) 238 (32.3) 475 (32.4)
Household income ≤1750 €, n (%) 381 88 (13.1) 83 (12.2) 171 (12.6)
Overweight (mother), n (%) 300 223 (31.4) 217 (30.1) 440 (30.7)
Overweight (father), n (%) 392 417 (62.8) 400 (59.1) 817 (60.9)
Abdominal obesity (mother), n (%) 788 228 (48.1) 219 (46.5) 447 (47.3)
Abdominal obesity (father), n (%) 871 325 (76.3) 317 (72.7) 642 (74.5)
Health and lifestyle characteristics
Playing outside > 60 min/day, n (%) 248 462 (62.9)*** 558 (74.4) 1020 (68.7)
Physically active ≥4 days/week ≥60 min/day, n (%) 263 161 (22.1)*** 238 (32.1) 399 (27.1)
Screen media > 1 h/day, n (%) 205 86 (11.3)* 119 (15.5) 205 (13.4)
PC on school days > 1 h/day, n (%) 246 2 (0.3)** 14 (1.9) 16 (1.1)
PC at weekends > 1 h/day, n (%) 236 28 (3.7)*** 72 (9.6) 100 (6.7)
TV on school days > 1 h/day, n (%) 217 89 (11.8)* 124 (16.3) 213 (14.1)
TV at weekends > 1 h/day, n (%) 228 362 (48.1) 390 (51.8) 752 (50.0)
Soft drinks > 1 time per week n (%) 197 178 (23.3) 198 (25.7) 376 (24.5)
At school, n (%) 226 57 (7.5) 52 (6.9) 109 (7.2)
Outside school, n (%) 224 174 (23.3) 192 (25.2) 366 (24.3)
Skipping breakfast, n (%) 195 116 (15.2)** 82 (10.6) 198 (12.9)
m (sd) mean (standard deviation), BMI body mass index, BMIPERC BMI percentiles, WHtR waist-to-height-ratio, WC waist circumference
*** p< 0.001, ** p< 0.01, * p< 0.05
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income, and family education level) and individual (age
and gender) variables, and assignment to the intervention
or control group of the underlying programme evaluation
and school. Children who skipped breakfast were signifi-
cantly more likely to show increases in WHtR, in weight,
and in BMI percentiles.
Skipping breakfast also influenced changes in BMI
(0.21 ± 0.01, p= 0.006) and BMI z-scores (0.09 ± 0.03,
p= 0.001).
Regression model for prevalent abdominal obesity,
overweight and obesity at follow-up
Table 3shows the results of the generalised linear mixed
regression analysis for the possible influences of skipping
breakfast, and the overconsumption of soft drinks and
screen media on abdominal obesity, overweight and
obesity at follow-up. Adjustments were made for socio-
economic (migration background, household income,
and family education level) and individual (age and gen-
der) variables, assignment to intervention or control
group of the underlying program evaluation, and
school.Skipping breakfast and the overconsumption of
screen media were more highly associated with abdom-
inal obesity (odds ratio 3.36 and 2.46, respectively).
Children who skipped breakfast and those who over-
consumed screen media at baseline were more likely to
be overweight at follow up (odds ratio 2.30 and 2.28,
respectively).
Missing data
Children whose records contained missing data were sig-
nificantly more likely to have a history of migration in
their backgrounds, and were significantly more likely to
be overweight, obese, or abdominally obese than
children whose records contained complete data. On
average, children whose records had missing data
weighed less than children whose records contained
complete data. Children whose records had missing data
were more often living in single-parent homes and were
more often in homes with a household income less than
Table 2 Linear mixed regression models of longitudinal changes in WHtR, weight in kg and BMI percentiles
Changes in WHtR*
1¶
Changes in weight*
2
[kg] Changes in BMI percentiles*
3
(n= 1252) (n= 1251) (n= 1250)
B(SE) p-value B(SE) p-value B(SE) p-value
Skipping breakfast 0.50 (0.19) 0.007** 0.39 (0.12) <0.001*** 2.01 (0.90) 0.027*
Soft drinks > 1 time per week -0.01 (0.15) 0.966 -0.08 (0.09) 0.385 -0.75 (0.70) 0.282
Screen media > 1 h/day 0.29 (0.16) 0.074 0.19 (0.10) 0.054 0.70 (0.78) 0.373
B(SE) Bregression coefficient (standard error),
¶
multiplied by 10
2
for better interpretability, *adjusted for school, migration background, family education level,
household income, age, gender, participation in the intervention, and
1
baseline WHtR,
2
baseline weight,
3
baseline BMI percentiles
*** p< 0.001, ** p< 0.01, * p< 0.05
Table 3 Generalised linear mixed regression model for abdominal obesity, overweight and obesity at follow-up
Unadjusted Adjusted*
Missing Values OR 95% CI OR 95% CI p-value
Abdominal obesity
(n = 1253)
Skipping breakfast 196 3.36 (2.23; 5.07) 2.06 (1.23; 3.47) 0.006**
Soft drinks > 1 time per week 198 1.78 (1.22; 2.61) 1.46 (0.92; 2.32) 0.108
Screen media > 1 h/day 1 2.46 (1.76; 3.45) 2.00 (1.23; 3.23) 0.005**
Overweight
(n = 1251)
Skipping breakfast 201 2.30 (1.54; 3.45) 1.71 (1.04; 2.80) 0.034*
Soft drinks > 1 time per week 203 1.65 (1.16; 2.35) 1.29 (0.84; 1.96) 0.246
Screen media > 1 h/day 6 2.28 (1.67; 3.13) 2.01 (1.33; 3.03) 0.001***
Obesity
(n = 1251)
Skipping breakfast 201 1.81 (0.94; 3.47) 0.90 [0.39; 2.07) 0.799
Soft drinks > 1 time per week 203 1.80 (1.04; 3.11) 1.57 (0.82; 3.03) 0.177
Screen media > 1 h/day 6 2.16 (1.34; 3.49) 1.87 (0.96; 3.67) 0.068
* adjusted for school, migration background, family education level, household income, age, gender, participation in the intervention, OR Odds Ratio, CI Confidence Interval
*** p< 0.001, ** p< 0.01, * p< 0.05
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or equal to €1750. Furthermore, children whose records
lacked complete data were less likely to live in a home
with a tertiary family education level and were less likely
to have been breastfed than were children whose records
were complete. Moreover, children whose records had
missing data spent more time with a PC on school days
and were more likely to skip breakfast than their
counterparts.
A sensitivity analysis was added to investigate possible
differences between complete case analysis and analysis
of datasets comprising multiple imputations. The results
are shown in Table 4.
Discussion
This study shows that children skipping breakfast ex-
perience increased changes in WHtR, weight and BMI
measures. Skipping breakfast and the overconsumption
of screen media at baseline contributed to abdominal
obesity at follow-up. Skipping breakfast and the overcon-
sumption of screen media also influenced overweight at
follow-up. No significant associations were found for the
consumption of soft drinks with longitudinal weight de-
velopment or weight status at follow-up.
Obesity and abdominal obesity
Children participating in the present study were identi-
fied to be abdominally obese according to the threshold
of WHtR ≥0.5. From these children, 18% were of normal
weight, based on the BMI definition. This is in line with
recent research literature saying that a considerable
number of people are of normal or low weight according
to the BMI definition, but are abdominally obese with a
higher risk of mortality [30,31]. For children, rising
numbers of abdominal obesity were detected, while rates
of overweight and obesity, defined by BMI, seemed to
stabilize, thus underestimating changes in weight
development [32]. These results correspond with data
which show that BMI fails to identify obesity in more
than a quarter of children [33]. While BMI measures the
general body structure as relative weight for height,
WHtR provides information about body fat distribution.
To our knowledge, the majority of studies examine
selected parameters, e.g. the association of skipping
breakfast, or soft drink consumption or screen media
consumption with predominantly one weight parameter,
mostly BMI. The present study considers the influence
of these critical behaviours on the longitudinal develop-
ment in WHtR, weight and BMI measures and the
presence of abdominal obesity, obesity and overweight at
follow-up. Due to the short observation period of one
year, and because of the rather gradual development of
obesity, results were not as clearly significant as
expected, especially for obesity at follow-up. Further-
more, yet not statistically significant, the intervention
may have influenced the results. Another reason may be
the relatively small number of obese children at follow-
up that inhibits proof of significance. Therefore, longer
observation periods are necessary to detect further
associations.
Skipping breakfast
Results of the present study are consistent with previous
research. Eating behaviours such as consuming un-
healthy food or skipping breakfast in children have been
Table 4 Differences between analyses with datasets containing complete data (CD) and imputed data (ID)
Skipping breakfast Soft drinks > 1 time per week Screen media > 1h/day
OR 95% CI OR 95% CI OR 95% CI
Abdominal obesity CD 2.06 (1.23; 3.47)** 1.46 (0.92; 2.32) 2.00 (1.23; 3.23)**
ID 1.87 (1.19; 2.96)** 1.37 (0.92; 2.04) 1.81 (1.19; 2.75)**
Overweight CD 1.71 (1.04; 2.80)* 1.29 (0.84; 1.96) 2.01 (1.33; 3.03)***
ID 1.60 (1.02; 2.50)* 1.38 (0.94; 2.01) 1.76 (1.18; 2.61)**
Obesity CD 0.90 (0.39; 2.07) 1.57 (0.82; 3.03) 1.87 (0.96; 3.67)
ID 1.02 (0.50; 2.07) 1.56 (0.87; 2.80) 1.65 (0.90; 3.01)
B(SE) p-value B(SE) p-value B(SE) p-value
Changes in WHtR
a,b,c
CD 0.50 (0.19) 0.007** -0.01 (0.15) 0.966 0.29 (0.16) 0.074
ID 0.51 (0.17) 0.003** -0.07 (0.13) 0.600 0.17 (0.15) 0.240
Changes in weight [kg]
b,d
CD 0.39 (0.12) 0.001*** -0.08 (0.09) 0.385 0.19 (0.10) 0.054
ID 0.51 (0.17) 0.003** -0.07 (0.13) 0.600 0.17 (0.15) 0.240
Changes in BMI percentiles
b,e
CD 2.01 (0.90) 0.027* -0.75 (0.70) 0.282 0.70 (0.78) 0.373
ID 2.58 (0.83) 0.002** -1.12 (0.64) 0.083 0.21 (0.72) 0.780
OR odds ratio, CI confidence interval, B(SE) Bregression coefficient (standard error),
a
multiplied by 10
2
for better interpretability, badjusted for school, migration
background, family education level, household income, age, gender, participation in the intervention, and
c
baseline WHtR,
d
baseline weight,
e
baseline BMI percentiles
*** p< 0.001, ** p< 0.01, * p< 0.05
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reported to be associated with higher odds for over-
weight [34]. A recent study showed that skipping break-
fast was one modifiable factor for developing abdominal
obesity in primary schoolchildren [27]. In a study with
overweight Latino youth, Alexander et al. reported that
higher visceral adiposity was associated with skipping
breakfast [35].
Screen media consumption
Chaput et al. show that sedentary behaviour is associated
with higher BMI, weight gain, and obesity in children
[36]. Children’s usage time of computers or TVs is in-
creasing, and is associated with adverse health outcomes
such as overweight or obesity [37]. Moreover, children
having a TV in their bedroom are more likely to have
sleep problems and long-term negative consequences on
their health [38]. In our study it can be supposed that
the identified effects intensify if enlarging the observa-
tional period, and children grow older. A study of
American schoolchildren found that children who had
screen media times of ≥2 h/day had double the odds of
being overweight than do children with < 2 h/day [37].
In the present study, we were able to show that already
> 1 h/day screen time is sufficient for having at least
twice the odds for becoming overweight or abdominally
obese.
Soft drink consumption
In general literature, there is no doubt about the positive
association between soft drinks and overweight in
children [13–15]. However, no significant association be-
tween soft drink consumption and weight development
was found in the present study, this may be due to the
young age of the children and the generally low con-
sumption of soft drinks in this sample. In preschool
children, Newby et al. also found no association between
soft drink consumption and changes in weight and BMI
[39]. They speculate that the low intakes and limited
variations of soft drink consumption limited the results
[39]. Low intakes could also be one reason for not find-
ing significant results in the present study, as in primary
schools vending machines are not as widespread as in
secondary schools and the availability, and thus the
consumption of soft drinks, is automatically reduced.
Additionally, providing water to children in primary
schools is widespread. Besides, Baden-Württemberg is a
wealthy federal state with lower rates of social inequality
and overweight than other parts of the country. Another
reason possibly lies in the way soft drink consumption
was assessed, and parents may have replied to the ques-
tionnaire in a socially desired manner. The questionnaire
did not give information about the frequency of con-
sumption of fruit nectars and of flavoured or chocolate
milk drinks that contain high amounts of added sugar.
Overall, soft drink consumption was very limited in this
sample.
Implications for families, future interventions and
decision makers
Accordingly, interventions influencing positive weight
status in schoolchildren have to include lifestyle
patterns, such as having regular breakfast, and a respon-
sible consumption of screen media and soft drinks. First
of all, parents should be informed about the advantages
and importance of a healthy lifestyle, and health-conscious
behaviour. Second, institutions such as schools should be
involved in the behaviour change. Finally, for obesity pre-
vention, policy makers have to note that healthy eating and
lifestyle habits are required at all times, but the cornerstone
has to be laid early.
Parents who demonstrate and offer their children
healthy and regular breakfast habits fulfil their function
as role models. At institutional level, schools that ensure
daily breakfast consumption at the start of the school
day will reach all children and avoid the problem of
skipping breakfast [40]. On a political level, the time of
the start of school day should be discussed: A later start
of classes might allow families to have breakfast
together.
One possible idea for the prevention of overconsump-
tion of screen media is to define determined times of the
day for playing computer games or watching TV that
regulate the duration of daily media consumption, e.g. in
the form of an agreement between parents and children
[41]. At all times, health-promoting programmes should
offer and enhance various options against using screen
media for schoolchildren. Thus, children’s decision
making-ability will be strengthened and children will
learn and internalize a healthy lifestyle for permanent
appropriation [42]. Times of sedentary behaviour are to
be replaced with active and meaningful leisure activities.
One promising approach in the reduction of soft drink
consumption is being practised via schools. The removal
of soft drink vending machines limits the availability of
these drinks as well as limiting their consumption by
children [43]. One possibility is the installation of water
dispensers in schools, or offering water or unsweetened
tea for free in classrooms. Furthermore, in primary
school, children’s parents should be involved: The regu-
lar provision of water, organized by parents, constitutes
a suitable measurement for changing the environment.
Strengths and limitations
This study provides valuable insights into the connection
between skipping breakfast, soft drink and screen media
consumption with weight development in schoolchil-
dren. There are some strengths and limitations that
should be taken into consideration when interpreting
Traub et al. BMC Public Health (2018) 18:363 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

these results. One strength of this research is the strict
protocol of a longitudinal trial. A second strength is the
large sample size and the fact that the study includes
data from an entire state of Germany, although the study
is not representative for the whole of Germany. All an-
thropometric data were objectively measured by trained
staff in a standardized procedure and are of high quality.
Furthermore, the Institute of Epidemiology and Medical
Biometry at Ulm University managed data professionally,
and advised in statistical issues. Finally, to our know-
ledge, this the first study to specifically investigate these
three weight-influencing parameters in primary school-
children in combination. However, there are also some
limitations: First, the observational character of the
study may have led to some biased results. Due to the
young age of the children, parental report measures were
used to assess health and lifestyle characteristics, and
some of the questions might have been answered in a
socially desired way or show the Hawthorne effect,
which describes that participants in observational studies
behave differently. Moreover, the investigated variables
on children’s weight development could have been com-
plemented by chronobiological aspects. Information on
the children’s sleep was not collected, but may also be
relevant for their health [44]. As far as school schedules
as a further influencing factor on chronobiological
aspects are concerned, the included primary schools
started between half past seven and eight o’clock and
included one or two break times per morning. At the
time of the assessment in 2010, all-day school was not
yet very common in primary schools in Baden-
Württemberg, so most children went home after school
at noon.
Furthermore, participation in this study was voluntary
and only teachers and parents who gave their agreement
were included. Thus, it seems reasonable that teachers
and parents who were motivated and health conscious
were more likely to take part. Parental breakfast and soft
drink intake were not assessed in the present investiga-
tion, but in future research these parameters should be
included. Another problem of observational studies are
missing values which may, in the worst case lead to
biased results [26]. Therefore, a missing data analysis
and additionally a sensitivity analysis with imputed data
were performed. The latter confirmed the significance of
the investigated influence of skipping breakfast and
screen media use on weight development.
Conclusion
Soft drink consumption was not associated with weight
status in this sample, but should be investigated in more
detail in future research. The skipping of breakfast and the
overconsumption of screen media influence weight devel-
opment in primary schoolchildren. Dietary improvements
and restriction in screen times are promising approaches
in obesity prevention in schoolchildren. Especially with
regard to the high prevalence of overweight and abdom-
inal obesity in parents, healthy breakfast habits both at
home or in schools and an awareness of screen media
consumption may not only improve children’shealthbut
that of their parents, too. Children, parents, schools and
governments should be involved in behavioural and struc-
tural prevention. Finally, further research should examine
the combined effects of these crucial variables on weight
development for a longer period, at least over the period
of four school years in primary school.
Abbreviations
BMI: Body mass index; CASMIN classification: Comparative Analysis of Social
Mobility in Industrial Nations; DRKS: German Clinical Trials Register;
ISAK: International Standards for Anthropometric Assessment; KiGGS
survey: German Health Interview and Examination Survey for Children and
Adolescents; NCD: Non-communicable diseases; OR: Odds ratio; WC: Waist
circumference; WHO: World Health Organization; WHtR: Waist-to-height ratio
Acknowledgments
Thanks to Ileana Briegel, Jens Dreyhaupt, Eva-Maria Friedemann, Anne Kelso,
Lina Hermeling, Eleana Georgiou, Ekaterine Goosmann, Christine Lämmle,
Rainer Muche, Olga Pollatos, Luise Steeb, Belinda Hoffmann, Susanne Kobel,
Tamara Wirt of the “Join the Healthy Boat –primary school”research group
for their input. Most of all, we thank the teachers, pupils and their parents
who participated in the Baden-Württemberg Study. Finally, we thank Sinéad
McLaughlin for her language assistance.
Funding
The programme “Join the Healthy Boat –primary school”is financed by the
Baden-Württemberg Stiftung. The Baden-Württemberg Stiftung had no
influence on the content of the manuscript.
Availability of data and materials
The datasets generated and analysed during the current study are not
publicly available due to reasons of data protection but are available from
the Institute of Epidemiology and Medical Biometry, Ulm University, on
reasonable request.
Authors’contributions
DK, OW and other members of the research group planned and organized
the Baden-Württemberg study. DK and other members of the research group
were involved in carrying out the measurements. MT and DK performed the
statistical analyses. JMS is the director of the programme “Join the Healthy
Boat –primary school”and principal investigator of the Baden-Württemberg
Study. MT, RL, and DK drafted the manuscript. TK, OW and JMS revised the
manuscript drafts. All authors have read and approved the final version of
the manuscript.
Ethics approval and consent to participate
The study protocol was approved by the ethics committee of Ulm University
in June 2009 (Application No. 126/10). The Baden-Württemberg Study is
registered at the German Clinical Trials Register (DRKS) under the DRKS-ID:
DRKS00000494. Written informed consent was obtained from parents and
teachers.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Traub et al. BMC Public Health (2018) 18:363 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Author details
1
Medical Center, Division of Sports and Rehabilitation Medicine, University of
Ulm, Frauensteige 6, Haus 58/33, 89075 Ulm, Germany.
2
Institute of General
Medicine, Ulm University, 89081 Ulm, Germany.
3
Department of Computer
Science, Ulm University of Applied Sciences, 89081 Ulm, Germany.
4
Institute
of Medical Systems Biology, Ulm University, 89081 Ulm, Germany.
Received: 13 November 2017 Accepted: 6 March 2018
References
1. Pigeot I, Buck C, Herrmann D, Ahrens W. Übergewicht und Adipositas bei
Kindern und Jugendlichen. Die weltweite Situation [Overweight and obesity
in children and adolescents. The worldwide situation].
Bundesgesundheitsblatt Gesundheitsforsch Gesundheitsschutz. 2010;53(7):
653–65.
2. World Health Organisation. The world health report 2002: Reducing risk,
Promoting healthy life. WHO Press. 2002. http://www.who.int/whr/2002/en/
whr02_en.pdf?ua=1. Accessed 17 Oct 2017.
3. Daniels S. Complications of obesity in children and adolescents. Int J Obes.
2009;33:60–5.
4. Bloom DE, Cafiero E, Jané-Llopis E, Abrahams-Gessel S, Reddy Bloom L,
Fathima S, et al. The global economic burden of Noncommunicable
diseases. 2011. http://apps.who.int/medicinedocs/documents/s18806en/
s18806en.pdf. Accessed 17 Oct 2017.
5. Hainer V, Aldhoon-Hainerova I. Obesity paradox does exist. Diabetes Care.
2013;36(Suppl 2):276–S281.
6. Steele RM, Van Sluijs EMF, Cassidy A, Griffin SJ, Ekelund U. Targeting
sedentary time or moderate- and vigorous-intensity activity: independent
relations with adiposity in a population-based sample of 10-y-old British
children. Am J Cl Nutr. 2009;90:1185–92.
7. Funk MB, Bausback-Schomakers S, Hanschmann KM, Gerhards B, Kuhn K,
Krackhardt B. Gewichtsentwicklung im frühen Grundschulalter. Prävalenz, Inzidenz
und Risikofaktoren für Übergewicht und Adipositas [Overweight in primary
school-age children. Prevalence and risk factors]. Bundesgesundheitsblatt
Gesundheitsforsch Gesundheitsschutz. 2015;58(10):1110–7.
8. Szajewska H, Ruszczyński M. Systematic review demonstrating that breakfast
consumption influences body weight outcomes in children and adolescents
in Europe. Crit Rev Food Sci Nutr. 2010;50(2):113–9.
9. de la Hunty A, Gibson S, Ashwell M. Does regular breakfast cereal
consumption help children and adolescents stay slimmer? A systematic
review and meta-analysis. Obes Facts. 2013;6(1):70–85.
10. Rosiek A, Maciejewska NF, Leksowski K, Rosiek-Kryszewska A, Leksowski L.
Effect of television on obesity and excess of weight and consequences of
health. Int J Environ Res Public Health. 2015;12(8):9408–26.
11. Krahnstoever Davison K, Marshall SJ, Birch LL. Cross-sectional and
longitudinal associations between TV viewing and girls’body mass index,
overweight status, and percentage of body fat. J Pediatr. 2006;149(1):32–7.
12. Katzmarzyk P, Broyles S, Champagne C, Chaput J-P, Fogelholm M, Hu G, et
al. Relationship between soft drink consumption and obesity in 9–11 years
old children in a multi-national study. Nutrients. 2016;8(12):1–13.
13. Bes-Rastrollo M, Sayon-Orea C, Ruiz-Canela M, Martinez-Gonzalez MA.
Impact of sugars and sugar taxation on body weight control: a
comprehensive literature review. Obesity. 2016;24(7):1410–26.
14. Keller A. Bucher Della Torre S. Sugar-sweetened beverages and obesity
among children and adolescents: a review of systematic literature reviews.
Child Obes. 2015;11(4):338–46.
15. Vos MB, Kaar JL, Welsh JA, van Horn LV, Feig DI, Anderson CAM, et al.
Added sugars and cardiovascular disease risk in children: a scientific
statement from the American heart Asscociation. Circulation. 2016;134:1–32.
16. Lee AK, Chowdhury R, Welsh JA. Sugars and adiposity: the long-term effects
of consuming added and naturally occurring sugars in foods and in
beverages. Obes Sci Pract. 2015;1(1):41–9.
17. Dreyhaupt J, Koch B, Wirt T, Schreiber A, Brandstetter S, Kesztyues D, et al.
Evaluation of a health promotion program in children: study protocol and
design of the cluster-randomized Baden-Wuerttemberg primary school
study. BMC Public Health. 2012;12(1):157.
18. Brauns H, Steinmann S. Educational reform in France, West-Germany and
the United Kingdom: updating the CASMIN educational classification. ZUMA
Nachrichten. 1999;23:7–44.
19. Lange M, Kamtsiuris P, Lange C, Schaffrath Rosario A, Stolzenberg H, Lampert
T. Messung soziodemographischer Merkmale im Kinder- und
Jugendgesundheitssurvey (KiGGS) und ihre Bedeutung am Beispiel der
Einschätzung des allgemeinen Gesundheitszustands. Bundesgesundheitsblatt
Gesundheitsforsch Gesundheitsschutz. 2007;50(5–6):578–89.
20. Kurth B-M. Der Kinder- und Jugendgesundheitssurvey (KiGGS): Ein Überblick
über Planung, Durchführung und Ergebnisse unter Berücksichtigung von
Aspekten eines Qualitätsmanagements TL - 50. Bundesgesundheitsblatt
Gesundheitsforsch Gesundheitsschutz. 2007;50(5/6):533–46.
21. World Health Organization. Global recommendations on physical activity for
health. Geneva. 2010. https://www.ncbi.nlm.nih.gov/books/NBK305057/pdf/
Bookshelf_NBK305057.pdf. Accessed 17 Oct 2017.
22. Stewart A, Marfell-Jones M, Olds T, De Ridder H. International standards for
anthropometric assessment. In: International Standards for Anthropometric
Assessment. International Society for the Advancement of Kinanthropemetry. 2011.
http://www.ceap.br/material/MAT17032011184632.pdf. Accessed 17 Oct 2017.
23. Kromeyer-Hauschild K, Wabitsch M, Kunze D, Geller F, Geiß HC, Hesse V,
et al. Perzentile für den Body-mass- Index für das Kindes- und Jugend- alter
unter Heranziehung verschiedener deutscher Stichproben [Percentiles of
bodymass index in children and adolescents evaluated from different
regional German studies]. Monatsschrift Kinderheilkd. 2001;149:807–18.
24. Ashwell M, Hsieh SD. Six reasons why the waist-to-height ratio is a rapid
and effective global indicator for health risks of obesity and how its use
could simplify the international public health message on obesity. Int J
Food Sci Nutr. 2005;56(5):303–7.
25. World Health Organisation. Physical status: the use and interpretation of
anthropometry. In: Report of a WHO Expert Committee. WHO Technical
Report Series 854. 1995. http://apps.who.int/iris/bitstream/10665/37003/1/
WHO_TRS_854.pdf. Accessed 17 Oct 2017.
26. Vandenbroucke JP, Von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock
SJ, et al. Strengthening the reporting of observational studies in epidemiology
(STROBE): explanation and elaboration. PLoS Med. 2007;4(10):1628–54.
27. Kesztyüs D, Traub M, Lauer R, Kesztyüs T, Steinacker JM. Correlates of
longitudinal changes in the waist-to-height ratio of primary school children:
implications for prevention. Prev Med Reports. 2016;3:1–6.
28. Kesztyüs D, Lauer R, Kesztyüs T, Kilian R, Steinacker JM. Costs and effects of
a state-wide health promotion program in primary schools in Germany -
the Baden-Württemberg study: a cluster-randomized, controlled trial. PLoS
One. 2017;12(2):1–18.
29. Holm S. A simple sequentially Rejective multiple test procedure. Scand J
Stat. 1979;6(2):65–70.
30. Coutinho T, Goel K, Corrêa De Sá D, Carter RE, Hodge DO, Kragelund C, et
al. Combining body mass index with measures of central obesity in the
assessment of mortality in subjects with coronary disease: role of “normal
weight central obesity.”. J Am Coll Cardiol. 2013;61(5):553–60.
31. Pischon T, Boeing H, Hoffmann K, Bergmann M, Schulze M, Overvad K, et al.
General and abdominal adiposity and risk of death in Europe. N Engl J Med.
2008;359(20):2105–20.
32. Griffiths C, Gately P, Marchant PR, Cooke CB. A five year longitudinal study
investigating the prevalence of childhood obesity: comparison of BMI and
waist circumference. Public Health. 2013;127(12):1090–6.
33. Javed A, Jumean M, Murad MH, Okorodudu D, Kumar S, Somers VK, et al.
Diagnostic performance of body mass index to identify obesity as defined by
body adiposity in children and adolescents. Pediatr Obes. 2015;10(3):234–44.
34. Brug J, Van Stralen MM, te Velde SJ, Chinapaw MJM, De Bourdeauhuij I, Lien
N, et al. Differences in weight status and energy-balance related behaviors
among schoolchildren across Europe : the ENERGY-project. PLoS One.
2012;7(4):1–13.
35. Alexander KE, Ventura EE, Spruijt-Metz D, Weigensberg MJ, Goran MI, Davis
JN. Indices in overweight Latino youth. Obesity. 2010;17(8):1528–33.
36. Chaput J-P, Leduc G, Boyer C, Belanger P, LeBlanc A, Borghese M, et al.
Objectively measured physical activity , sedentary time and sleep duration:
independent and combined associations with adiposity in Canadian
children. Nutr Diabetes. 2014;4:1–5.
37. Steffen LM, Dai S, Fulton JE, Labarthe DR. Overweight in children and
adolescents associated with TV viewing and parental weight: project
HeartBeat! Am J Prev Med. 2009;37(Suppl 1):1–12.
38. Garrison MM, Liekweg K, Christakis D. Media use and child Sleep : the
impact of content , timing , and environment. Pediatrics. 2011;128(1):29–35.
39. Newby PK, Peterson KE, Berkey CS, Leppert J, Willett WC, Colditz GA.
Beverage consumption is not associated with changes in weight and body
Traub et al. BMC Public Health (2018) 18:363 Page 9 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

mass index among low-income preschool children in North Dakota. J Am
Diet Assoc. 2004;104(7):1086–94.
40. Kesztyüs D, Traub M, Lauer R, Kesztyüs T, Steinacker JM. Skipping breakfast is
detrimental for primary school children: cross-sectional analysis of
determinants for targeted prevention. BMC Public Health BMC Public
Health. 2017;17(1):258.
41. Beck A, Eichner M. Empfehlungen für jedes Alter –gegen den Sitzenden
Lebensstil von Kindern. B&G Bewegungstherapie und Gesundheitssport.
2014;30(3):113–4.
42. Seufert T, Muche R, Steinacker JM. Gesundheitsförderung in der
Grundschule. Komm mit in das gesunde Boot-Grundschule. Schriftenreihe
der Baden Württemberg Stiftung. 2012;63:1–61.
43. Welsh JA, Lundeen EA, Stein AD. The sugar-sweetend beverege wars: public
health and the role of the beverege industry. Curr Opin Endocrinol Diabetes
Obes. 2013;20(5):401–6.
44. Carissimi A, Dresch F, Martins A, Levandovski RM, Adan A, Natale V, et al.
The influence of school time on sleep patterns of children and adolescents.
Sleep Med. 2016;19:33–9.
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