Association of Nutrient-Dense Snack Combinations WithCalories and Vegetable Intake

WHAT’S KNOWN ON THIS SUBJECT: The eating of non–nutrientdense snack foods is considered a major factor contributing tochildhood obesity. Parents are often ineffective at encouraginghealthier snacking habits.

WHAT THIS STUDY ADDS: Children consumed fewer calorieswhen snacking on nutrient-rich cheese and vegetables comparedwith when they were served potato chips.

abstractBACKGROUND: With other factors such as general diet and insufficientexercise, eating non–nutrient dense snack foods such as potato chipscontributes to childhood obesity. We examined whether children con-sumed fewer calories when offered high-nutrient dense snacksconsisting of cheese and vegetables than children who wereoffered non–nutrient dense snacks (ie, potato chips).

METHODS: Two hundred one children (115 girls) entering the third tosixth grades were randomly assigned to 1 of 4 snacking conditions:(1) potato chips only, (2) cheese-only, (3) vegetables only, and (4)cheese and vegetables. Children were allowed to eat snacks freelyprovided while watching 45-minute TV programs. Satiety wasmeasured before they started eating snacks, in the middle of thestudy, and 20 minutes after they finished eating the snacks. Parentscompleted a questionnaire regarding their family environment.

RESULTS: Children consumed 72% fewer calories when eating a com-bined snack compared with when they were served potato chips, P ,.001. Children who ate the combination snack needed significantlyfewer calories to achieve satiety than those who ate potato chips, P, .001. The effects of the snack conditions on caloric intake weremore pronounced among overweight or obese children (P = .02) andthose from low-involvement families (P = .049)

CONCLUSIONS: The combination snack of vegetables and cheese canbe an effective means for children to reduce caloric intake while snack-ing. The effect was more pronounced among children who were over-weight or obese and children from low-involvement families. Pediatrics2013;131:22–29

AUTHORS: Brian Wansink, PhD,a Mitsuru Shimizu, PhD,a

and Adam Brumberg, BSa

aFood and Brand Laboratory at the Charles H. Dyson School ofApplied Economics and Management, Cornell University, Ithaca,New York

KEY WORDSchildren, snack intake, combination snack, cheese, vegetable,family environment

ABBREVIATIONSANOVA—analysis of varianceH—hypothesisHND—high-nutrient denseNND—non–nutrient dense

Dr Wansink contributed to the conception and design ofexperiment, to analysis and interpretation of data, and to thedrafting and revision of the article. He gave final approval of theversion to be published. Dr Shimizu contributed to analysis andinterpretation of data and drafting and revision of the article.Mr Brumberg contributed to analysis and interpretation of dataand drafting and revision of the article.

www.pediatrics.org/cgi/doi/10.1542/peds.2011-3895

doi:10.1542/peds.2011-3895

Accepted for publication Sep 17, 2012

Address correspondence to Brian Wansink or Mitsuru Shimizu,Warren Hall, Ithaca, NY 14853. E-mail: wansink@cornell.edu orms925@cornell.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: Data collection was made possible by support fromBel Brands USA and the Cornell Food and Brand Laboratory.

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The increase in childhood obesity isa major health concern in the UnitedStates and around the world.1–5

According to NHANES, ∼32% of USchildren (aged 2–19 years old) areoverweight or obese (BMI $85th per-centile).5 Although there are othercontributing factors such as reducedphysical activity, the increase insnacking and the eating of non–nutrientdense (NND) snack foods (eg, potatochips, cookies, candy) in particular, areconsidered major factors associatedwith childhood obesity.6–8 According tothe US Department of Agriculture, chil-dren ate an average of 1 snack per day30 years ago, whereas today’s childreneat nearly 3.9

Several studies have examinedwhetherparental control, such as restrictingaccess to NND snack foods, could re-duce children’s intake of those foods.10–13

The results have been mixed. In somestudies, parents have been effective,10

but in others, they have not.11–13 Forinstance, Fisher and Birch offeredsnack foods to girls aged 3 to 6 yearsold (n = 30) without any restrictions onquantity. Those girls whose parentsenforced higher restrictions relating tosnacking actually ate more snacksthan those whose parents imposedfewer similar restrictions.13 Thus, al-though parental control can reduce theconsumption of restricted foods, pa-rental control can backfire in an un-restricted setting.

This research explores alternatives toparental control in reducing intake ofNND snack foods and increasing intakeof healthier snack foods. One possiblealternative can be adapted from exist-ing research on eating variety. In anexperimental study, children providedwith an assortment of snack foodsconsumed more total calories thanthose provided only with their favoritetype of snack food.14 Therefore, asEpstein et al speculated, increasing thevariety of high-nutrient dense (HND)

snacks instead of NND snacks couldreduce total caloric intake. How muchpeople eat depends not only on energyneeds but also on the psychologicalprocesses behind the sense of satiety.Because a variety of foods slow habit-uation, decrease in response (eg, eat-ing) due to a repeated exposure ofstimuli (eg, foods), a variety of foodsshould result in increased intake.14

This suggests that children providedwith a variety of HND rather than NNDsnack foods may consume morenutrients and fewer calories as theyachieve satiety.14

To test this logic, we examined whetherchildrenwould consume fewer caloriesif they were served 2 types of HNDsnacks (cheeseandvegetables) insteadof a NND snack (potato chips) whilewatching television (TV) cartoons. Weexamined snack intake during TVviewing to mimic typical snackingcontexts as well as to obscure the truepurpose of the experiment. Cheese andvegetables were chosen because theyare important sources of calcium,protein, vitamins, and fiber15 that alsorank high on the satiety index (ie, re-quired calories for satiety).16–18 In ad-dition, children’s intake of cheese andvegetables has been decreasing.19 Wehypothesized that children who ate thecombination snack of cheese and veg-etables would consume fewer caloriesthan those who ate potato chips.

Furthermore, we hypothesized that theeffect of the combination snack wouldbe especially pronounced amongoverweight children, consistent withprevious research that overweightchildren consume more than non-overweight children when providedfree snack foods.20 Finally, we hypoth-esized that the combination snackwould have a more pronounced effecton children from families with lowerfamilial involvement as previous re-search has found that maladaptivepatterns of familymealtime interactions

is associated with poor dietary hab-its.21 As in previous studies,21–23 wefocused on overall family involvementduring mealtime rather than parentalcontrol to examine whether the effectof the combination snack was ob-served children from low-involvementfamilies. In sum, we tested 4 hypotheses(H) in this research.

H1: Children eating a combinationsnack of vegetables and cheese willconsume fewer calories than chil-dren eating chips.

H2: Children eating the combinationsnack will require fewer calories toachieve satiety than those eatingchips.

H3: Heavier children eating the com-bination snack will consume fewercalories than healthier weight chil-dren.

H4: Children from low-involvementfamilies eating the combinationsnack will consume fewer caloriesthan those from higher-involvementfamilies.

METHODS

Participants were 201 (115 female)children entering the third to sixthgrades in the fall of 2011 from theChicago metropolitan area. A $70 in-centive was provided to the parents ofparticipating children. Participantswere screened for food allergies to thesnacks used in the study. The study hadCornell University’s Institutional ReviewBoard approval, and consent from boththe parents and children was obtainedbefore the study.

There were 24 experimental sessionsinvolving 5 to 11 participants. The ses-sions were conducted in 2 separaterooms, one where children completedthe experiment, and the other whereparents waited for their children tofinish. After arriving, parents were toldthe study’s purpose was to observe thebehaviors of children while watching

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TV. Children were told that the studywould ask them about characters inpopular TV shows and that they wouldbe given snacks to help them enjoy theprograms.

Once children arrived and were seated,theywereasked to indicatehowfull theyfelt (Time 1 Satiety) on 3 hunger-relateditems: (1) I feel full, (2) I could not eatanother bite, and (3) I am hungry; thesewere measured on 9-point scales (1 =strongly disagree, 9 = strongly agree).We believe that the face validity of theitems and the high internal consistency(a = .73) justified the use of this mea-sure.24

Children were then randomly assignedto 1 of 4 snacking conditions, with thesnacks being presented on a large plateor tray: (1) potato chips condition (eachindividual was given plain Pringles/Layschips in a tube and Crunchy Cheetos ina medium-size bag; ∼1500 kcal), (2)cheese-only condition (six 17-g cheesewedges and six 20-g cheese rounds;∼370 kcal), (3) vegetables-only condi-tion (2 cups of uncooked bite-sizebroccoli, 2 cups of baby carrots, and 2cups of bell pepper strips; ∼120 kcal),and (4) combo condition, cheese andvegetables (six 17-g cheese wedges andsix 20-g cheese rounds + 1 cup of eachof the 3 vegetables noted above; ∼490kcal). Cheese-only and vegetables-onlyconditions served as control groups toexamine how much children in thecombo condition consumed comparedwith those in control groups. All con-ditions included more than enoughsnack food for the duration of the TVshows; no child in any condition finishedall of the snacks offered.

Each child was given plates with theassigned snacks and a bottle of water.They were instructed to snack whilewatching 2 episodes (∼45 minutes intotal) of age-appropriate cartoons (eg,SpongeBob). After watching the firstepisode, children were encouraged to“eat all you wish” of the snacks. They

then indicated how full they were onthe same scale (Time 2 Satiety). Afterthe second 20-minute episode, snackswere removed. Children were askedhow much they liked the episode (1 =hated it; 9 = loved it) and how full theyfelt using the same scale (Time 3 Sati-ety). Thus, satiety was measured at 3time points to determine how theirsatiety increased. Finally, their age andgender were determined, and theirweight and heights were measured tocalculate their BMI.

The children were then thanked andreunited with their parents, and ques-tionnaires from both children andparents were collected. Each child’suneaten food was weighed and sub-tracted from the weight of the originalamount provided to calculate gramsconsumed.

As the primary dependent variable,grams consumed were converted tocalories consumed using the statedcaloric values on packaged foods (ie,cheeses and potato chips) For thevegetable snacks, average caloric val-ues per gram were retrieved online atcaloriecount.about.com. In addition, weindexed the total calories needed toachieve that level of satisfaction byadopting the satiety index used inprevious research.16–18 Specifically, oursatiety index was calculated by dividingtotal calories consumed by the satietyincrease from Time 1 to Time 3 to de-termine how many calories wereneeded to achieve the level of satietyattained.

The 20-item questionnaire completedby parents concerned the whole fam-ily’s mealtime habits by indicating howmany days they engage in mealtimeactivities related to family involvementin a typical week. Specifically, becausefamily involvement is often character-ized as the interactions between familymembers, parents were asked to re-spond to 3 questions “talk meaning-fully about their day,” “compliment

each other at dinner,” and “complimentthe person who made the dinner.” Anexploratory principal componentsanalysis revealed 6 factors with Eigenvalues.1 explaining 57.3% of the totalvariance. The first factor accounted for20.2% of explained variance consistingof the above 3 questions and 1 item,“eat with the whole family.” We createdan index for family involvement by av-eraging those 4 items, a = .68, suchthat higher scores indicate higherfamily involvement.

RESULTS

After excluding data from 18 childrenwho ate no snacks, the 183 remainingparticipants (104 female) had an av-erage age of 8.7 6 1.1 years anda mean BMI of 20.36 4.5. The excludedchildren did not differ from partic-ipants in terms of age (8.36 1.1 years)or BMI (19.8 6 3.8), Ps . .18. In-terestingly, the excluded childrenreported significantly higher baselinesatiety (Msatiety = 5.35, SD = 2.08) thanremaining participants (Msatiety = 4.21,SD = 1.38), P = .002. Additionally, theywere more likely to be from high-involvement families (Mfamily = 5.24,SD = 1.36) than remaining participants(Mfamily = 4.45, SD = 1.32), P = .02. Itmay be that these children did not eatsnacks because they ate regularmealsat home and were routinely asked bytheir parents not to eat snacks outsidethe home.

According to the Centers for DiseaseControl and Prevention BMI-for-agegrowth chart, 38 of the participantswere considered overweight (BMI$85th percentile), and 43 were con-sidered obese (BMI $95th percentile).There was no difference regarding theBMI spread of participants across the 4conditions (P = .59). There were 45participants in the potato chip condi-tion, 36 in the cheese-only condition, 59in the vegetables-only condition, and 43in the combo condition.

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A 1-way analysis of variance (ANOVA)was conducted to examine the effect ofthe snack conditions on caloric intake.This analysis revealed a significant ef-fect, F (3, 179) = 95.11, P, .001 (see the4 leftmost bars in Fig 1). Pos hocTukey’s honestly significant differencetests showed that children who wereoffered vegetables only (Mcalories = 60,SD = 30) or cheese only (Mcalories = 200,SD = 90) ate fewer calories than thosein the chip condition, Ps , .001. Moreimportant, children offered the com-bination snack also consumed signifi-cantly fewer calories (Mcalories = 170,SD = 70) than those offered potatochips (Mcalories = 620, SD = 330), P ,.001. Children offered the combinationsnack consumed approximately thesame amount of calories as those of-fered cheese only, P = .91, and theyconsumed significantly more caloriesthan those offered vegetables only, P,.01. It is worth noting that children of-fered the combination snack con-sumed about the same amount ofvegetables as those offered vegetablesonly (see the 2 rightmost bars in Fig 1).

To examine satiety levels across 3 timepoints, we conducted a mixed-modelANOVA in which the time wasa within-participant factor and thesnack condition was a between-participant factor. This analysisrevealed a significant main effect forthe time, F (2, 356) = 132.81, P , .001(see Fig 2), suggesting a linear in-crease in satiety. Importantly, thismain effect was qualified by a signifi-cant interaction effect, F (6, 356) = 3.41,P = .003, suggesting that the increasesin satiety depended on the condition.A follow-up ANOVA focusing on partic-ipants in each condition showed thatthe effect was strongest among thosewho ate potato chips, F (2,88) = 58.56,P , .001.

The ANOVA on the satiety index revealeda different picture. Figure 3 illustratesthat the effect of the snack conditionwas significant, F (3, 171) = 11.68, P,.001, and post hoc Tukey’s honestlysignificant difference tests showedthat children who ate the combinationsnack needed significantly fewer calo-ries to achieve satiety (Mcalories = 53.0,

SD = 186.4) than those who ate potatochips (Mcalories = 282.4, SD = 401.9), P,.001. Thus, the combination snack wasa more calorie-effective means to at-tain satiety than potato chips.

Finally, a series of 432 ANOVAs wereconducted to examine whether gen-der, age, BMI, or family involvementmoderated the effect of the snackconditions on caloric intake. Becausehow much they liked the episode didnot moderate the effect, we did notexplore this factor in this research.Before those analyses, the moderatingvariables were each divided into 2groups, male versus female children,children aged .9 years versus chil-dren ages ,9 years, overweight orobese children (BMI$85th percentile)versus healthy-weight children (BMI,85th percentile), and high versuslow in family involvement (mediansplit at 4.5). The analyses revealedsignificant moderation effects for thechildren’s weight status, F (3, 130) =3.38, P = .02, and for the family in-volvement factor, F (3, 171) = 2.67, P =.049 (Figs 4 and 5).

FIGURE 1The 4 leftmost bars represent total caloric intake as a function of snack condition. The 2 rightmost bars represent caloric intake of cheese and vegetables amongchildren in thecombosnackcondition.Children in thecombosnackconditionconsumedsignificantly fewercalories thanthose in thepotatochipscondition,P, .001.

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The effects of the snack conditions oncaloric intake were more pronouncedamong overweight or obese childrenand on those from low-involvementfamilies. Overweight or obese chil-dren ate more than normal weightchildren when they were offered chips,

but they consumed 16-points fewer(76% vs 60%) calories when the potatochips and combo conditions werecompared for each group. Similarly,children from low-involvement familiesate more than normal weight childrenwhen they were offered chips, but they

consumed 10-points fewer (77% vs67%) calories when the potato chipscondition and combo condition werecompared for each group.

It isworthnoting, however, that those 2interaction effects were not statisti-cally independent. A 3-way ANOVA

FIGURE 2Mean satiety ratings before (Time 1), immediately after (Time 2), and 20minutes after (Time 3) eating snacks. There is an overall increase in satiety, P, .001. Inaddition, the increase is strongest among children in the potato chips condition, P , .001.

FIGURE 3The total calories needed to achieve satiety as a function of snack condition. Children in the combo condition needed significantly fewer calories to achievesatiety, P , .001.

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revealed that neither the snack con-dition 3 BMI interaction nor thesnack condition3 family involvementinteraction reached conventional lev-els of significance, Ps . .11. Pre-sumably, this reflects the fact thatchildren from low-involvement fami-lies were more likely to be overweightor obese; the majority of overweight(55%) and obese (63%) children in oursample were from low-involvementfamilies.

DISCUSSION

Childrensnackmore today thantheydid30 years ago.6–8 With childhood obesity

a present and growing problem and

NND snacks a factor, strategies for

curbing their consumption are needed.

This research uncovers several key

insights regarding snack substitution.

First, a combination snack of cheeseand vegetables can be effective in re-ducing calorie consumption during

snacking. Children consumed 72%fewer calories when they were serveda combination snack compared withthose who were served potato chips.Given that children who were offeredcheese only consumed fewer caloriesthan those offered potato chips, simplyreplacing potato chipswith cheese wassufficient to decrease caloric intake.However, it is important to note that thecaloric intake of children in the comboconditionwas not significantly different

FIGURE 4The total caloric intake as a function of weight status and snack condition. The effect of the snack condition was moderated by the weight status, P = .02.

FIGURE 5The total caloric intake as a function of family involvement and snack condition. The effect of the snack conditionwasmoderated by the family involvement, P,.05.

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from the caloric intake of those in thecheese condition. Children who ate thecombination snack ate approximatelythe same amount of vegetables as thechildren served vegetables only. Thissuggests that the children did not re-place vegetables with cheese, butrather, they complemented their vege-table intakewithasourceofproteinandcalcium. If children were to eat cheeseand vegetables in place of NND snackfoods, snacking could be a good sourceof fiber, protein, and calcium.25 Thisobservation aligns with the findings ofother studies: the act of snacking canbe associated with reduced obesitywhen the snack foods are of thehealthier variety.25,26

Second, children who ate the combi-nation snackneeded significantly fewercalories to achieve satiety than thosewhoatechips. Thisunderscores the factthat eating snack foods higher on thesatiety index can help reduce caloricintake.16–18 Because no child finishedall the snacks available, we can as-sume that they ate snacks until they feltsated. Those who ate the combinationsnack required far fewer calories to

stop snacking than those who ate po-tato chips.

Third, the effect of the combinationsnack on caloric intake was especiallypronounced among those who wereoverweightorobeseandthose fromlowinvolvement families. This means thatthe combination snack was an espe-cially effectivemeans for thosewho aremost in need of weight reduction anda healthier diet.

Limitations and Future Research

This research did not examine specificprocesses underlying why the com-bination of HND snacks led to lesscaloric intake compared with the NNDsnack. Epstein et al demonstrated theslower rate of physiological habitua-tion, decrease in responding (eg,eating) due to a repeated exposure ofstimuli (eg, foods), when children,especially overweight children, wereprovided with a variety of snacks.14

Previous studies have shown that anincrease in the variety of foods of-fered leads to an increase in amountconsumed. This study’s innovationwas the use of that principle to re-

place a single NND snack food witha variety of HND snacks. Additionalresearch is needed not only to ap-preciate the underlying physiologicaland psychological processes but alsoto compare various combinations ofHND snacks. The impact of combina-tion snacks on intake over time alsoneeds to be explored.

Implications

For parents, eliminating snacking al-together is impractical and, in somecases, can backfire. However, parentscould potentially replace some NNDsnacks with HND snacks such asa cheese and vegetable combinationwith less fear of backlash than if NNDsnacks were removed altogether. Forhealthprofessionals, thefindingsof thisresearch as they relate to family in-volvement could potentially help inidentifying families who might benefitmost from a move toward of “combi-nation snack substitution.” The linkbetween HND snacks and satiety canhelp dieticians craft diets that allow forboth choice and enjoyment while alsocontrolling calories.

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12. Fisher JO, Birch LL. Restricting access topalatable foods affects children’s behav-ioral response, food selection, and intake.Am J Clin Nutr. 1999;69(6):1264–1272

13. Fisher JO, Birch LL. Restricting access tofoods and children’s eating. Appetite. 1999;32(3):405–419

14. Epstein LH, Robinson JL, Temple JL, RoemmichJN, Marusewski AL, Nadbrzuch RL. Varietyinfluences habituation of motivated behav-ior for food and energy intake in children.Am J Clin Nutr. 2009;89(3):746–754

15. Subar AF, Krebs-Smith SM, Cook A, Kahle LL.Dietary sources of nutrients among USchildren, 1989–1991. Pediatrics. 1998;102(4pt 1):913–923

16. Rolls BJ, Hetherington M, Burley VJ. Thespecificity of satiety: the influence of foodsof different macronutrient content on thedevelopment of satiety. Physiol Behav. 1988;43(2):145–153

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17. Holt SHA, Miller JCB, Petocz P, FarmakalidisE. A satiety index of common foods. Eur JClin Nutr. 1995;49(9):675–690

18. Holt SH, Brand Miller JC, Petocz P. Inter-relationships among postprandial satiety,glucose and insulin responses and changesin subsequent food intake. Eur J Clin Nutr.1996;50(12):788–797

19. Siega-Riz AM, Popkin BM, Carson T. Trendsin breakfast consumption for children inthe United States from 1965–1991. Am JClin Nutr. 1998;67(4):748S–756S

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23. Moens E, Braet C, Soetens B. Observationof family functioning at mealtime: a com-parison between families of children withand without overweight. J Pediatr Psychol.2007;32(1):52–63

24. van Kleef E, Shimizu M, Wansink B. Justa bite: Considerable smaller snack por-tions satisfy delayed hunger and craving. JNutr Educ Behav. In Press.

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DRUG TESTING IN MIDDLE SCHOOL: My four children attended the combinedelementary and middle school in our home town. They played soccer, basketball,and lacrosse, and participated in a variety of after-school programs and activ-ities. During the entire time my children were there, approximately 36 schoolyears, never were they asked to submit a urine sample for drug testing. Amaz-ingly, however, drug testing has now seeped into middle school life. According toan article in The New York Times (Sports: September 22, 2012), while the exactnumbers of middle schools are hard to calculate, districts in Delaware, Florida,Alabama, Missouri, West Virginia, Arkansas, Ohio, New Jersey and Texas nowrequire drug testing for children in middle school. Drug testing is most oftena requirement for students participating in sports or other extra-curricularactivities. The testing is designed to find those who are using any types of drugsincluding alcohol, marijuana, and performance-enhancing drugs. Officials fromparticipating schools report that the majority of parents support the initiativeand that drug testing may increase awareness of drug problems and act asa deterrent. Others take a different approach and have filed lawsuits claimingthat requiring a middle-school student to submit a urine sample for drug testingbefore he or she can participate in nonathletic activities infringes on personalliberty. While the Supreme Court has upheld the right of high schools to requiredrug testing in athletes, whether this extends to students in any extra-curricularactivity—particularly those so young—is not known. To date, there are noreports of a middle school child testing positive for performance-enhancingsteroids or human growth hormone. Reports of urine samples positive formarijuana are rare. What to do with the test results, whether positive or negative,is often not known. Maybe I am naïve or possibly even nostalgic, but mandatorydrug testing of middle school children seems a step too far.

Noted by WVR, MD

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