724951

research-article2017
SJP0010.1177/1403494817724951Scandinavian Journal of Public HealthB.B. Nilsen et al.

Scandinavian Journal of Public Health, 1–9

Original Article

Reported habitual intake of breakfast and selected foods in relation to

overweight status among seven- to nine-year-old Swedish children

Bente B. Nilsen1,2, Agneta Yngve3, Celia Monteagudo3,4,

Richard Tellström1, Henrik Scander1 & Bo Werner1

1School of Hospitality, Culinary Arts and Meal Sciences, Örebro University, Grythyttan, Sweden, 2Department of Nursing

and Health Promotion, Oslo and Akershus University College, Oslo, Norway, 3Department of Food, Nutrition and Dietetics,
Uppsala University, Uppsala, Sweden, and 4Research Group Nutrition, Diet and Risk Assessment, Department of Nutrition
and Food Science, University of Granada, Granada, Spain

Abstract
Aim: The aim of this study was to examine the reported frequency of breakfast intake and selected food and beverages in
the investigated group of Swedish children in comparison with recommended intakes. Furthermore, the study analyses
these food habits and some demographic and lifestyle factors in relation to overweight and obesity. Methods: This cross-
sectional study builds on data collected in 2008 and 2010. Measured anthropometric data and parent questionnaire
data were collected. A total of 2620 Swedish children (52.1% boys) aged seven to nine years were included. Results: The
majority of parents reported that their children (95.4%) had breakfast every day. The majority of children had fresh fruit
(84.7%) and vegetables (83.9%) most days a week. Only 1.6% of the children were reported to have fast food and 6.0%
to have sugar containing soft drinks, four days a week or more. The prevalence of overweight including obesity (OW/OB)
was 17.8% for boys, 18.6% for girls. The odds of being OW/OB was higher among those not having breakfast every day
(odds ratio (OR) 1.9, 95% confidence interval (CI) 1.20–2.96), drinking diet soft drink (OR 2.6, 95% CI 1.52–4.42)
and skimmed/semi-skimmed milk (OR 1.8, 95% CI 1.37–2.36) four days a week or more. Parents being overweight
and having low education levels were also related to a higher risk of their children being overweight. Conclusions:
The parental reports of children’s food habits pointed at favourable eating patterns for most investigated
children. Breakfast skipping, diet soft drinks and low-fat milk consumption were more frequent among OW/
OB children. Longitudinal studies are needed to determine the causal relationships.

Key Words: Child growth, breakfast, food habits,WHO Childhood Obesity Surveillance Initiative

Introduction
The development of child overweight including
obesity (OW/OB) is complex and several factors
interplay, such as child birth weight and if the child
was breastfed [1], physical activity level [2], paren-
tal body mass index (BMI), education [2,3] and
area of residence [4]. Dietary habits certainly also
play a role in the development of child OW/OB
[3,5], and studies have shown a positive relationship
between breakfast skipping and OW/OB [6].
The breakfast habits of children/adolescents have
been described as being of importance for OW/OB
status, and having breakfast is recommended in the
Nordic countries [5,7]. In 2010, 72% and 66% 11-,
13- and 15-year-old Swedish boys and girls, respec-
tively, reported a daily breakfast intake [8]. However,
children, and in particular adolescents, are more likely
to skip breakfast than any other meal [6]. Regular
breakfast consumption has been associated with

Correspondence: Bente B. Nilsen, School of Hospitality, Culinary Arts and Meal Sciences, Örebro University, Campus Grythyttan, Box 1, Grythyttan, 712
60, Sweden. E-mail: bente.nilsen@oru.se

Date received 30 January 2017; reviewed 13 June 2017; accepted 7 July 2017

© Author(s) 2017
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DOI: 10.1177/1403494817724951
https://doi.org/10.1177/1403494817724951
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2    B.B. Nilsen et al.
positive health benefits [9]. Children who regularly
have breakfast have in other studies been shown to be
more likely to have a better diet quality and a higher
intake of key food groups, such as fruit, dairy and die-
tary fibre. Furthermore, they are also more likely to
meet the recommendations for micronutrients [10].
Children who skip breakfast tend to eat more
energy-dense food such as fast food and consume a
higher percentage of energy at subsequent meals.
When children are skipping breakfast, it can lead to
excess hunger, overeating and consequently eating
larger portion sizes [9].
Fruit and vegetables (f&v) are an essential part of a
healthy diet. A study from 10 European countries
showed that Swedish 11-year-olds had the highest f&v
intake (291 g/day) after Norway and Bulgaria [11].
Consumption of food such as processed food, French
fries, sweets and sugar-containing soft drinks is consid-
ered unhealthy [7,12]. Studies have shown that con-
sumption of these food items contributes to OW/OB
among children [3,5,12]. A decreasing trend was
observed for sweets and soft drink consumption for
Swedish adolescents from 2001 to 2010 [13]. Even if
milk is an important component of a child’s diet, there
are few studies that explore the association between
milk consumption and body mass among children [14].
World Health Organization Childhood Obesity
Surveillance Initiative (WHO COSI) study
On the recommendation from the World Health
Organization (WHO) [15], the World Health
Organization Childhood Obesity Surveillance
Initiative (WHO COSI) was developed in order to
monitor the development of childhood OW/OB in
Europe. In 2007/2008, the first data collection was
launched and 13 European countries including
Sweden participated, using a common standardized
protocol for measurement as well as equipment [16].
Aims of this paper
The first aim of this paper was to explore parental reports
of frequency of breakfast intake and selected food
items in relation to current recommendations among a
group of seven- to nine-year-old Swedish children. The
second aim was to analyse these reported food habits,
parental demographic and lifestyle factors in relation
to the children’s overweight and obesity status.
Material and methods
Study population
The selection of schools and data collection proce-
dure have been described previously [2,4]. The
Figure 1.  Overview of the inclusion and exclusion process in the
subset of Swedish WHO COSI study 2008 and 2010 of seven-
to nine-year-old children from the northern and eastern part of
Sweden.
measured children were given a lifestyle questionnaire
to be filled out by their parents or guardians. The
recruitment process is described in Figure 1.
Lifestyle questionnaires
The lifestyle questionnaire contained information
related to breakfast habits, as well as food and bever-
age intake. The question relating to breakfast habits
was formulated as follows: over a typical week, how
often does your child have breakfast? The food and
beverage questionnaire contained 17 items, and the
question was: how often does your child eat or drink
the following kinds of foods or beverages? The
options for breakfast, food items and beverages were
‘every day’, ‘most days (4–6 days)’, ‘some days (1–3
days)’ and ‘never’. For breakfast habits, the response
was dichotomized to ‘every day’ and ‘less than seven
days a week’. For the food items and beverages, the
responses were dichotomized into less than four days
a week and four or more days a week.
Anthropometric measurements
The height and weight of the children were measured
by trained staff using the WHO COSI protocol [17].
Age and gender-specific BMI cut-off points for thin-
ness (defined as BMI ≤ –1 standard deviation (SD)),
normal weight (defined as > –1 SD < +1 SD), over-
weight (defined as ≥ +1 SD < +2 SD) and obesity
(defined as ≥ +2 SD) are according to the Swedish
national growth reference from Werner [18]. To facil-
itate the identification of factors of importance for
OW/OB, children with different degrees of thinness,
defined as BMI ≤ –1 SD according to the growth ref-
erence from Werner [18] (n = 425 cases) were
excluded from the chi-square test and the regression

analyses, leaving a total sample of n = 2195 children,
1129 boys (51.4%). Overweight and obesity were
merged into OW/OB.
Demographic and lifestyle factors
The place of residence was categorized as ‘urban/
semi-urban’ or ‘rural’ [17]. For both parents, the self-
reported BMI were calculated and weight status was
determined according to the international cut-off for
adults, BMI ≥ 25 kg/m2 for overweight and BMI ≥ 30
kg/m2 for obesity [19], and dichotomized into ‘both
parents normal weight’ and ‘one or both parents
overweight (including obesity)’. The education level
of parents was dichotomized into ‘at least one parent
educated at university level’ or ‘both parents below
university level’.
Statistical analysis
Body size characteristics of the children were
described using the means (SD) of all anthropomet-
ric variables. The chi-square test was performed to
identify significant independent variables followed by
the binary logistic regression models to establish
associations between all independent variables and
the outcome variable (OW/OB). Odds ratios (ORs)
with 95% confidence intervals (CIs) were computed
to estimate the association between variables. All
p-values reported were based on two-tailed compari-
sons and the level of significance set at 0.05. All sta-
tistical analyses were performed using Statistical
Package of Social Sciences (SPSS), Version 23.0
(SPSS Inc., Chicago, IL, USA).
Ethical considerations
The regional Ethics Committee in Stockholm
reviewed and approved this project (number 2008/5:4
and protocol 2010/5:5). For the 2008 data collection,
a passive consent was used for parents. For the 2010
data collection, an active informed written consent
was requested from the parents. Before both data
collections, oral consent was obtained from the child.
Results
Breakfast frequency and food and beverage
consumption
As shown in Table I, a majority of the children were
having breakfast every day (95.4%).
Fruit was reported to be eaten by 84.7% of the chil-
dren, and vegetables, by 83.9% four days or more per
week. For both f&v, we found a significant (p < 0.001)
Reported habitual intake of breakfast   3
gender difference, whereas boys more commonly were
reported as having f&v less than four days a week (data
not shown).
The vast majority of the children (≥ 95.5%) had
snacks, sweets or chocolate, sweet bakery products
and fast food (pizza, French fries, hamburgers, sau-
sages or meat pies) less than four days a week (Table
I). We also found a significant gender difference (p =
0.023) for fast food; the boys were reporting having
fast food items four days a week or more frequently
than the girls (data not shown).
For beverages, the majority of children were
reported having soft drinks containing sugar (94.0%),
diet soft drinks (97.2%) and fruit juice (75.7%) less
than four days a week. For skimmed/semi-skimmed
milk and whole-fat milk, 84.8% and 82.9%, respec-
tively, of the children were reported to consume these
types of milk less than four days a week (Table I).
Children’s characteristics
Table II shows the mean and SD for age, weight,
height and BMI for three different age groups and by
gender. We found no significant gender difference in
height, weight and BMI, except for the eight-year-old
boys that were significantly taller (p < 0.001). The
boys were thinner and more obese than the girls. The
prevalence of weight categories according to the
growth reference by Werner [18] were calculated and
presented (Table II).
Table III shows the association between OW/OB
and reported breakfast consumption as well as
selected foods and beverages. We found a significant
positive association between OW/OB and reports of
not having breakfast every day, drinking diet soft
drinks and drinking skimmed/semi-skimmed milk
four days or more.
In the unadjusted regression model (Table IV),
the risk of being OW/OB was higher if the child was
reported not to have breakfast every day, if the child
had diet soft drinks or skimmed/semi-skimmed milk.
For whole-fat milk, we found an inverse association
with OW/OB. Adjusting for gender, parental weight
status, parents’ education level and area of living
attenuated the model only slightly. Breakfast, diet
soft drinks, skimmed/semi-skimmed milk remained
significant. The risk of being OW/OB was higher if
one of both parents was OW/OB and if the parental
education level was below university degree.
Discussion
We found that the vast majority of the children were
reported to have breakfast daily and f&v four days a
week or more. For food items like snacks, sweets or
4    B.B. Nilsen et al.
Table I.  Consumption frequency of breakfast, food and beverages for Swedish seven- to nine-year-old children during a regular week.

All* Every day Most days Some days Never

n n (%) (4–6 days) (1–3 days) n (%)
n (%) n (%)

Breakfast consumption frequency 2187 2087 (95.4) 71 (3.2) 25 (1.1) 4 (0.2)

Food items and beverages frequency:  
Fruit* 2184 1376 (63.0) 474 (21.7) 290 (13.3) 44 (2.0)
Vegetables (excluding potatoes)** 2184 1201 (55.0) 631 (28.9) 325 (14.9) 27 (1.2)
Fruit juice (100%) 2172 251 (11.6) 277 (12.8) 1121 (51.6) 523 (24.1)
Soft drinks containing sugar 2184 19 (0.9) 111 (5.1) 1751 (80.2) 303 (13.9)
Diet soft drinks 2183 13 (0.6) 48 (2.2) 622 (28.5) 1500 (68.7)
Skimmed/semi-skimmed milk (0.1–0.5% fat) 2167 230 (10.6) 100 (4.6) 184 (8.5) 1653 (76.3)
Low-fat milk (1.5% fat) 2169 998 (46.0) 410 (18.9) 370 (17.1) 391 (18.0)
Whole-fat milk (3% fat) 2144 299 (10.7) 137 (6.4) 352 (16.4) 1426 (66.5)
Flavoured milk 2178 113 (5.2) 150 (6.9) 1038 (47.7) 877 (40.3)
Cheese 2173 252 (11.6) 492 (22.6) 1009 (46.4) 420 (19.3)
Yoghurt, milk pudding, cream cheese/quark 2185 603 (27.6) 644 (29.5) 791 (36.2) 147 (6.7)
or other dairy products
Meat 2187 167 (7.6) 1394 (63.7) 605 (27.7) 21 (1.0)
Fish 2191 9 (0.4) 264 (12.0) 1850 (84.4) 68 (3.1)
Snacksa 2188 2 (0.1) 10 (0.5) 1821 (83.2) 355 (16.2)
Sweets or chocolate 2191 3 (0.1) 20 (0.9) 2043 (93.2) 125 (5.7)
Sweet bakery products 2187 7 (0.3) 92 (4.2) 1815 (83.0) 273 (12.5)
Fast foodb*** 2191 5 (0.2) 31 (1.4) 1964 (89.6) 191 (8.7)

aPotatocrisps, corn crisps, popcorn or peanuts.

bPizza,French fries, hamburgers, sausages or meat pies.
*Boys had fruit less than four times a week more frequently than girls (p < 0.001).
**Boys had vegetables less than four times a week more frequently than girls (p < 0.001).
***Boys had fast food four days a week or more, more frequently than girls (p < 0.023).

chocolate, sweet bakery products, fast food and soft
drinks containing sugar, the majority of children had
these food items less than four days a week. The chil-
dren were more likely to be OW/OB if the children
did not have breakfast every day, had diet soft drinks
and skimmed/semi-skimmed milk four days a week
or more, if one or both parents was overweight/obese
or if their education level was below university.
Breakfast habits
We found that the vast majority, 95.4% of the chil-
dren, had breakfast daily. In a study from Norway,
91% of the children age 9–10 years were reported to
have breakfast every day [20] which is in agreement
with our study. In another a study on breakfast con-
sumption among 11-, 13- and 15-year-old children
and adolescents from 31 European countries, 69.4%
of the Swedish children reported having breakfast
daily [8], which was lower than our findings. A pos-
sible explanation to the high breakfast frequency in
our study is the children’s age, since breakfast skip-
ping has been identified as a problem more related to
older children [6,8,9].
Breakfast can be defined as the first meal of the
day, eaten before or at the start of daily activities
within two hours of waking, typically no later than
10:00 am and containing a calorie level between 20%
and 35% of daily energy need [21]. Even if we did
not have information on what food items the children
had for breakfast, a traditional Swedish breakfast
usually contains food items such as bread or cereal,
fruit (fruit juice) and low-fat milk products or other
calcium sources [22], food items that are included in
National dietary guidelines [22] as a part of a healthy
breakfast for children [21]. In a study of Swedish
11–12-year-old children on dietary patterns reported
that the reason for skipping breakfast was not enough
time in the morning or that they were too tired [23].
Among the children not having breakfast every day,
we also found a lower consumption frequency of f&v,
a higher consumption frequency of soft drinks con-
taining sugar, sweet bakery products, sweets and choc-
olate and slightly more fast food compared with the
children having breakfast every day (data not shown).
In the Nordic nutrition recommendations for a
healthy dietary pattern for children [7], a regular
intake of breakfast is recommended [8].
Even if only 4.6% of the children did not have
breakfast every day, findings from the current study
indicated an increased risk of OW/OB among chil-
dren who were reported not to have breakfast daily
(OR 1.9, 95% CI 1.20–2.96), and also when adjust-
ing for gender, parents’ weight status education and
 Reported habitual intake of breakfast   5
Table II. Anthropometric data according to age groups, prevalence of thinness, normal weight, overweight and obesity for the Swedish
seven- to nine-year-old children.

Boys and girls Boys Girls p-value* (CI)

Mean (SD) Mean (SD) Mean (SD)

7–7.99 years n = 792 n = 408 n = 384  

Age (years) 7.6 (0.2) 7.7 (0.2) 7.6 (0.2) 0.119 (−0.01–0.60)
Weight (kg) 27.0 (4.5) 27.1 (4.4) 27.0 (4.6) 0.603 (−0.46–0.80)
Height (cm) 128.8 (5.6) 129.2 (5.4) 128.5 (6.1) 0.078 (−0.08–1.53)
BMI (kg/m²) 16.2 (2.1) 16.2 (2.0) 16.2 (2.1) 0.574 (−0.37–0.20)
8–8.99 years n = 1174 n = 624 n = 550  
Age (years 8.5 (0.3) 8.5 (0.3) 8.5 (0.3) 0.945 (−0.33–0.04)
Weight (kg) 29.6 (5.2) 29.9 (5.2) 29.3 (5.2) 0.074 (−0.05–1.14)
Height (cm) 133.3 (6.0) 133.9 (6.0) 132.7 (6.0) 0.001 (0.54–1.92)
BMI (kg/m²) 16.6 (2.1) 16.6 (2.1) 16.6 (2.2) 0.991 (−0.24–0.25)
9–9.99 years n = 654 n = 333 n = 321  
Age (years) 9.3 (0.3) 9.3 (0.3) 9.3 (0.3) 0.772 (−0.05–0.44)
Weight (kg) 32.5 (5.9) 32.6 (5.6) 32.5 (6.1) 0.869 (−0.82–0.97)
Height (cm) 137.9 (5.9) 138.2 (5.7) 137.5 (6.0) 0.135 (−0.21–1.59)
BMI (kg/m²) 17.0 (2.3) 17.0 (2.2) 17.1 (2.4) 0.516 (−0.47–0.24)
Weight category** n (%) n (%) n (%)  
Thina 425 (16.2) 236 (17.3) 189 (15.1)  
Normal weightb 1718 (65.5) 885 (64.8) 833 (66.4)  
Overweightc 356 (13.6) 172 (12.6) 184 (14.7)  
Obesityd 121 (4.6) 72 (5.2) 49 (3.9) 0.070
Overweighte 477 (18.2) 244 (17.8) 233 (18.6)  
(including obesity)

SD: standard deviation; BMI: body mass index.

*p-value for gender difference.
**Weight category according to Swedish national growth reference from Werner [18].
aThin defined as BMI ≤ –1 SD.
bNormal weight defined as BMI > –1 SD < +1 SD.
cOverweight defined as BMI ≥ +1 SD < +2 SD.
dObesity defined as BMI ≥ +2 SD.
eOverweight (including obesity) defined as BMI ≥ +1 SD.

area of residence. These results are consistent with
previous findings [2,5,9]. In a previous study from
the US (2010), the prevalence of breakfast skipping
for 9–13-year-old children was 20.6% for boys and
19.7% for girls. The prevalence of obesity was also
higher among the breakfast skippers compared with
those who had breakfast [9].
Reported frequency of intake of fruit and
vegetables (f&v)
The parents reported that 84.7% and 83.9% of the
children had f&v four days a week or more (Table I).
In a food survey based on a four-day food registration
by parents of Swedish children (Riksmaten Barn)
[24], the fruit consumption for eight-year-olds was
reported as 5.5 times a week for boys and girls, and
the vegetable consumption frequency was 5.6 times a
week for boys and six times a week for girls [24]. In
another study on f&v consumption among 11-year-
old children in 10 European countries, about 40%
and 60% of the Swedish children reported having f&v
every day, respectively [11]. For comparison, in our
study, the parents reported a higher daily consump-
tion of fruit among their children (63%), while the
daily vegetable consumption in our study (55.0%)
corresponded reasonably well (Table I). We also found
a significant (p < 0.001) gender difference in f&v con-
sumption, with boys more frequently having f&v less
than four days a week. The same gender difference in
consumption of f&v was also observed in a study of
Swedish 11-year-old children [11]. The recom-
mended intake of f&v for children in Sweden is 400 g
per day, with no reference to frequency of intake [22].
It is not possible to determine if the children in our
study meet the recommended intake of f&v due to
limitations in our data.
Even if we did not find any association between
intake of f&v and overweight and obesity (Table III),
other studies have indicated that overweight children
consume less f&v than normal-weight children [3].
Consumption of beverages
The majority of children (≤ 82.9%) had the different
types of milk less than four days a week, except for
6    B.B. Nilsen et al.
Table III.  Consumption frequency of breakfast, food and beverage for normal weight and OW/OB in Swedish seven- to nine-year-old children.

Characteristics All Normal weight* OW/OB* p-value**

n (%) n (%) n (%)

Breakfast  
Every day 2087 (95.4) 1646 (96.2) 441 (92.6)  
Less than 7 days a week 100 (4.6) 65 (3.8) 35 (7.4) 0.001
Fruit  
Less than 4 days a week 334 (15.3) 268 (15.7) 66 (13.8)  
4 days a week or more 1850 (84.7) 1439 (84.3) 411 (86.2) 0.317
Vegetables (excluding potatoes)  
Less than 4 days a week 352 (16.1) 269 (15.7) 83 (17.5)  
4 days a week or more 1832 (83.9) 1440 (84.3) 392 (82.5) 0.363
Fruit juice 100%  
Less than 4 days a week 1644 (75.7) 1266 (74.5) 378 (79.9)  
4 days a week or more 528 (24.3) 433 (25.5) 95 (20.1) 0.015
Soft drinks containing sugar  
Less than 4 days a week 2054 (94.0) 1606 (93.9) 448 (94.5)  
4 days a week or more 130 (6.0) 104 (6.1) 26 (5.5) 0.627
Diet soft drinks  
Less than 4 days a week 2122 (97.2) 1672 (97.9) 450 (94.5)  
4 days a week or more 61 (2.8) 35 (2.1) 26 (5.5) < 0.001
Skimmed/semi-skimmedmilk (0.1–0.5% fat)  
Less than 4 days a week 1837 (84.8) 1473 (86.9) 364 (77.3)  
4 days a week or more 330 (15.2) 223 (13.1) 107 (22.7) < 0.001
Low-fat milk (1.5% fat)  
Less than 4 days a week 761 (35.1) 601 (35.4) 160 (34.0)  
4 days a week or more 1408 (64.9) 1098 (64.6) 310 (66.0) 0.593
Whole-fat milk (3% fat)  
Less than 4 days a week 1778 (82.9) 1371 (81.5) 407 (88.3)  
4 days a week or more 366 (17.1) 312 (18.5) 54 (11.7) 0.001
Flavoured milk  
Less than 4 days a week 1915 (87.9) 1497 (87.9) 418 (88.2)  
4 days a week or more 263 (12.1) 207 (12.1) 56 (11.8) 0.844
Cheese  
Less than 4 days a week 1429 (65.8) 1127 (66.3) 302 (64.0)  
4 days a week or more 744 (34.2) 574 (33.7) 170 (36.0) 0.357
Yoghurt, milk pudding, cream cheese/quark or other dairy products  
Less than 4 days a week 938 (42.9) 725 (42.4) 213 (44.7)  
4 days a week or more 1247 (57.1) 984 (57.6) 263 (55.3) 0.365
Meat  
Less than 4 days a week 626 (28.6) 479 (28.0) 147 (30.9)  
4 days a week or more 1561 (71.4) 1232 (72.0) 329 (69.1) 0.218
Fish  
Less than 4 days a week 1918 (87.5) 1503 (87.7) 415 (87.0)  
4 days a week or more 273 (12.5) 211 (12.3) 62 (13.0) 0.688
Snacksa  
Less than 4 days a week 2176 (99.5) 1700 (99.4) 476 (99.8)  
4 days a week or more 12 (0.5) 11 (0.6) 1 (0.2) 0.257
Sweets or chocolate  
Less than 4 days a week 2168 (99.0) 1700 (99.1) 468 (98.3)  
4 days a week or more 23 (1.0) 15 (0.9) 8 (1.7) 0.127
Sweet bakery products  
Less than 4 days a week 2088 (95.5) 1629 (95.3) 459 (96.2)  
4 days a week or more 99 (4.5) 81 (4.7) 18 (3.8) 0.371
Fast foodb  
Less than 4 days a week 2155 (98.4) 1686 (98.4) 469 (98.3)  
4 days a week or more 36 (1.6) 28 (1.6) 8 (1.7) 0.947

OW/OB: overweight including obesity.

*Normal weight and OW/OB according to Swedish national growth reference by Werner [18] (thin (BMI ≤ –1 SD) children are excluded).
**Pearson’s chi-square tests.
aPotato chips (crisps), corn chips, popcorn or peanuts.
bPizza, French fries (chips), hamburgers, sausages or meat pies.
 Reported habitual intake of breakfast   7
Table IV.  Binary logistic regression for unadjusted and adjusted odds ratios (ORs) of OW/OB for Swedish seven- to nine-year-old children.

Unadjusted model Adjusted model

Predictors OR (95% CI) p-value OR (95% CI) p-value

Breakfast consumption frequency  

Every day Reference* Reference*  
Less than 7 days a week 1.9 (1.20–2.96) 0.006 1.9 (1.18–3.13) 0.008
Fruit juice (100%)  
Less than 4 days a week Reference* Reference*  
4 days a week or more 0.8 (0.61–1.02) 0.067 0.9 (0.67–1.18) 0.430
Diet soft drinks  
Less than 4 days a week Reference* Reference*  
4 days or more a week 2.6 (1.52–4.42) <0.001 2.4 (1.37–4.27) 0.002
Skimmed/semi-skimmed milk (0.1–0.5% fat)  
Less than 4 days a week Reference* Reference*  
4 days or more a week 1.8 (1.37–2.36) <0.001 1.9 (1.40–2.48) <0.001
Whole-fat milk (3% fat)  
Less than 4 days a week Reference* Reference*  
4 days or more a week 0.6 (0.43–0.83) 0.002 0.6 (0.39–0.78) 0.001
Child sex  
Boy Reference*  
Girl 1.0 (0.80–1.23) 0.977
Parents weight status  
Normal weight Reference*  
One or both parents overweight/obese 1.9 (1.49–2.50) <0.001
Parents’ education level  
One or both parents have university education Reference*  
Below university education 1.3 (1.01–1.61) 0.040
Area of living  
Urban Reference*  
Rural 1.2 (0.96–1.55) 0.105

*Reference category.

low-fat milk where 64.9% of the children consumed
low-fat milk four days a week or more (Table I). In
Riksmaten Barn [20], the eight-year-old children’s
consumption frequency of whole-fat milk (3% fat)
was 2.7 times a week, low-fat milk (1.5% fat) 7.4
times and semi-skimmed milk (0.5% fat) 2.8 times a
week. The Swedish National Food Agency recom-
mend children in all ages to consume low-fat milk
daily [22]; however, only 64.9% of the children in
our study meet this recommendation.
We found that the majority of children, 94% and
97.2%, had sugar containing soft drinks and diet soft
drinks, respectively, less than four days a week. A low
consumption frequency of soft drinks was also found
in the Riksmaten study; children aged eight had sugar
containing soft drinks 2.7 times per week and diet
soft drinks 0.21 times a week [24].
Reported beverage intake and overweight/
obesity
We found that children who were reported having
diet soft drinks and skimmed/semi-skimmed milk
four days a week were 2.6 (95% CI 1.52–4.42) and
1.8 times (95% CI 1.37–2.36) more likely to be over-
weight (including obesity). When we adjusted for
gender, parent’s weight status, education and area of
residence, the results only attenuated slightly (Table
IV). A possible explanation is that parents of over-
weight children report that their child is drinking diet
soft drinks as a weight-controlling measure. Foreyt
et  al. [25] found a similar association between the
consumption of low-calorie sweeteners and over-
weight and obesity among children and adolescents.
In regards to our findings concerning the increased
risk of being overweight (including obesity) among
children having skimmed/semi-skimmed milk four
days a week, a study by Berkey et al. (2005) indicated
that consumption of skimmed and low-fat milk (1%
fat) may provide some children with excess energy
that results in excess weight gain [26]. On the other
hand, as for diet soft drinks, the parents of overweight
children may have reported that their child was
drinking skimmed/semi-skimmed milk as a weight
controlling measurement or maybe as a more socially
desirable response.
For whole-fat milk, we found an inverse associa-
tion with overweight and obesity; children having
8    B.B. Nilsen et al.
whole-fat milk four days a week or more were less
likely to be overweight and obese. Studies on milk
consumption and association with overweight and
obesity are inconclusive. A study on children from
Italy (2005) also found an inverse association
between whole-fat milk consumption and overweight
and obesity [14], while the opposite effect was
observed in a study on seven-, nine- and 13-year-old
children, where a three-year excess weight gain was
also associated with the intake of whole-fat milk [12].
In our study, 94.0% of the children had sugar
containing soft drinks less than four days a week,
but we found no significant association between
sugar-containing soft drinks and OW/OB. However,
other studies have identified a relationship between
soft-drink consumption and OW/OB development
among children [12,27].
Fast food and snacks, sweets and sweet bakery
products
The parents reported that the vast majority (≥ 95.5%)
of the children had fast food items, snacks, sweets
and sweet bakery products less than four days a week,
while avoidance is recommended [22].
Even if we did not find any association between
OW/OB and consumption of fast food items,
snacks, sweets and sweet bakery products, a study
of seven-, nine- and 13-year-old children from the
UK found that excess weight gain over a three-year
period was associated with the consumption of
food items such as potato crisps, French fries,
sweets, desserts, full- and low-fat milk and sugar
containing beverages [12].
Children’s overweight status and socio-
demographic factors
In the adjusted regression model we found that if one
or both parents was overweight or obese and if the
parents’ education level was below university level,
the children’s risk of being OW/OB increased; this
has previously been reported from the full Swedish
WHO COSI material from 2008 [2].
Strengths and limitations
One of the major strengths of this study was the thor-
ough collection of height and weight data, using the
WHO COSI protocol [4]. We could also see that the
prevalence of normal weight, overweight and obesity
was in line with previous findings from 2008 when
the total Swedish WHO COSI sample was included
[28]. Also, the food intake frequencies were consist-
ent with previous findings from a National food
survey [24]. Another strength of this study was that
the findings were adjusted for a selection of potential
confounders, which allowed for confidence in the
study results.
There are several limitations to be noted. As this
is a cross-sectional study, it is not possible to infer a
causal relation. The self-reported questionnaire
answered by parents may have been affected by lim-
itations related to memory or misreporting of expo-
sure. Parents who were concerned about their
child’s weight status might have been more likely to
over-report more favourable behaviours, for exam-
ple breakfast habits and f&v consumption, and to
under-report less favourable behaviours such as
consumption of sugar-containing soft drinks, cook-
ies and sweets [29] and more likely to take steps to
improve their child’s diet [30]. In this material, we
had no information on portion size or what food
items the children had for breakfast. Bread and
cereal products were not included in the question-
naire. It would have been an advantage to have one
or more open-ended questions regarding other
foods. This was not included due to the interna-
tional data collection and the need to simplify all
data collection methods.
Conclusion
The majority of the children in this study were
reported to have a rather favourable food intake pat-
tern. However, the children were more likely to be
OW/OB when reported to skip breakfast and if the
children consumed diet soft drinks and skimmed
milk/semi-skimmed milk more than four days a
week, which could be interpreted as an effect rather
than a cause.
Acknowledgements
The authors are grateful to Eric Poortvliet, Usama
Al-Ansari and Manzur Kader at Karolinska Institutet
for their contribution to the data collection and han-
dling. We are also grateful to all the staff and students,
children, parents and teachers who helped out with
the data collection and Trudy Wijnhoven and Joao
Breda at the WHO European Region for coordinat-
ing the COSI study.
Declaration of conflicting interests
None declared.
Funding
This work was supported by funds from The Swedish
Council for Working Life and Social Research and
Karolinska Institutet.

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