Meal and snack frequency in relation to diet quality in US children and adolescents: the National Health and Nutrition Examination Survey 2003-2012

Objective: To examine the associations of meal frequency (MF) and snack frequency (SF) with diet quality. Design: Dietary intake was assessed using two 24 h dietary recalls. All eating occasions providing >= 210 kJ of energy were divided into meals or snacks on the basis of contribution to energy intake (>= 15% or < 15 %), self-report and time (06.00-09.00, 12.00-14.00 and 17.00-20.00 hours, or others). Diet quality was assessed using the Healthy Eating Index (HEI)-2010. Setting: Nationally representative sample of the US population. Subjects: Children aged 6-11 years (n 4269) and adolescents aged 12-19 years (n 6193) in the National Health and Nutrition Examination Survey 2003-2012. Results: Irrespective of the definition of meals, higher MF was associated with higher HEI-2010 in both children and adolescents. One additional meal per day increased HEI-2010 by 1.45-3.59 points (all P < 0.005). Conversely, the associations for SF were inconsistent. While SF based on energy contribution was positively associated with HEI-2010 in both children and adolescents (0.70 (P = 0.001) and 1.00 (P < 0.0001) point increase by one additional snack, respectively), there were no associations for SF based on self-report or time. In analyses in which only plausible energy reporters (3425 children and 3753 adolescents) were included, similar results were obtained. Conclusions: In a representative sample of US children and adolescents, MF was associated with better diet quality, while the associations for SF varied depending on the definition of snacks. The findings highlight the importance of applying different definitions of meals and snacks when assessing the impact of dietary patterns on health.