The Journal of Nutrition

Nutritional Epidemiology

Obesity-Related Eating Behaviors Are

Associated with Low Physical Activity and Poor
Diet Quality in Spain1–3
Arthur Eumann Mesas,* Pilar Guallar-Castillón, Luz M. León-Muñoz, Auxiliadora Graciani,
Esther López-Garcı́a, Juan Luis Gutiérrez-Fisac, José R. Banegas, and Fernando Rodrı́guez-Artalejo

Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid⁄IdiPAZ–CIBER in

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Epidemiology and Public Health (CIBERESP), Madrid, Spain

Abstract
This study examined the association of obesity-related eating behaviors (OREB) with physical activity, sedentariness, and
diet quality. Data were taken from a cross-sectional study in 10,791 persons representative of the Spanish population who
were $18 y of age in 2008–2010. The following self-reported information was collected on 12 OREB: not planning how
much to eat before sitting down, not deciding the amount of food on the plate, skipping breakfast, eating precooked/
canned food or snacks bought at vending machines or at fast-food restaurants, not choosing low-energy foods, not
removing visible fat from meat or skin from chicken, eating while watching television or seated on a sofa or an
armchair, and taking a short time for meals. Analyses were performed with linear or logistic regression, as appropriate,
and adjusted for the main confounders. In comparison to participants with #1 OREB, those with $5 OREB performed
less physical activity [b: 22.61 (95% CI: 24.44, 20.78); P-trend , 0.001] and spent more time watching television
[b: 2.17 (95% CI: 1.39, 2.95); P-trend , 0.001]; furthermore, they had greater total energy intake [b: 160 (95% CI:
115, 210); P-trend , 0.001] and were less likely to follow a Mediterranean diet [OR: 0.55 (95% CI: 0.41, 0.73);
P-trend , 0.001]. In conclusion, the association between OREB and obesity is biologically plausible because OREB
are associated with energy intake and poor accordance with the Mediterranean diet. Studies on the association between
OREB and obesity should control for the confounding effect of physical activity and sedentariness. J. Nutr. 142: 1321–
1328, 2012.

Introduction
The main guidelines for weight control recommend avoiding or
moderating certain eating behaviors that may lead to weight gain,
including skipping breakfast, eating fast-foods, and snacking (1–
4). In addition, other behaviors have been promoted for healthy
eating and weight control, such as choosing low-energy foods
1
Data for this study were from the Study on Nutrition and Cardiovascular Risk in
Spain (ENRICA), which was funded by Sanofi-Aventis. Additional support was
obtained from Fondo de Investigación Sanitaria grants PI09-1626, PI08-0166, and
PI09-00104 and from the Cátedra UAM de Epidemiologı́a y Control del Riesgo
Cardiovascular. A.E.M. was supported by grant 2010/006 from the National Plan
on Drug Addiction. The funders had no role in the design, implementation,
analysis, or interpretation of the data.
2
Author disclosures: A. E. Mesas, P. Guallar-Castillón, L. M. León-Muñoz, A. Graciani,
E. López-Garcı́a, J. L. Gutiérrez-Fisac, J. R. Banegas, and F. Rodrı́guez-Artalejo, no
conflicts of interest.
3
Supplemental Table 1 is available from the “Online Supporting Material” link in
the online posting of the article and from the same link in the online table of
contents at http://jn.nutrition.org.
4
Abbreviations used: ENRICA, Study on Nutrition and Cardiovascular Risk in
Spain; MD, Mediterranean diet; MEDAS, Mediterranean Diet Adherence
Screener; OmniHeart, Optimal Macronutrient Intake Trial to Prevent Heart
Disease; OREB, obesity-related eating behavior; TV, television.
* To whom correspondence should be addressed. E-mail: aemesas@hotmail.
com.
ã 2012 American Society for Nutrition.
Manuscript received January 13, 2012. Initial review completed February 19, 2012. Revision accepted April 16, 2012.
First published online May 23, 2012; doi:10.3945/jn.112.158154.
(e.g., light foods and/or dairy products), removing visible fat from
meat, eating slowly, having meals while seated at a table without
distractions from television (TV)4 viewing, and deciding the
amount of food to be eaten before sitting down (1–4).
Unfortunately, the relationship between most of these obesity-
related eating behaviors (OREB) and excess weight is still uncertain
because OREB may simply be a marker of an unhealthy lifestyle
(e.g., low physical activity, sedentariness), which leads to obesity
rather than exerting a direct obesogenic effect (5). However, to our
knowledge, no previous population-based study has systematically
assessed the association between the most common OREB and
physical activity and sedentariness.
Moreover, information on the potential mechanisms of the
effect of these OREB on body weight is sparse (5). OREB may
reflect the joint effect of several foods and nutrients that may
influence energy balance. However, we are not aware of any
previous work that comprehensively analyzes the association
between OREB, energy intake, and diet quality, nor are we
aware of studies on the association between OREB and the
Mediterranean diet (MD), a culturally rooted model for healthy
eating that has shown a protective effect against obesity (6,7)
and its consequences (8).
1321
 Accordingly, this study systematically examined the associ-
ation of 12 OREB with physical activity, sedentariness, energy
intake, and diet quality, as represented by accordance with the
MD in the adult population of Spain.
Participants and Methods
Study design and participants
Data were taken from the Study on Nutrition and Cardiovascular Risk in
Spain (ENRICA), whose methods have been reported elsewhere (9).
Briefly, ENRICA is a cross-sectional study conducted from June 2008 to
October 2010 in 12,948 persons representative of the noninstitutional-
ized population aged $18 y in Spain. Information was collected by
telephone interview on sociodemographic variables, lifestyle, perceived
health, and diagnosed morbidity. Data were subsequently obtained by a
face-to-face interview in the participants’ households where we used a
structured questionnaire to assess OREB and a diet history to obtain
food consumption information; a physical examination was also conducted
in the households. The final response rate was 51%.
ENRICA participants gave their written informed consent. The study
protocol was approved by the clinical research ethics committee of the
University Hospital La Paz in Madrid and the Hospital Clinic in
Barcelona.
Study variables
OREB. We used information on 12 self-reported OREB. First, we asked
participants the following 2 questions about planning and controlling
the amount of food served on the plate: 1) “Before sitting down at the
table, do you think about how much you intend to eat?” and 2) “Do you
decide the amount of food served on your plate?” We also assessed 3) the
consumption of any amount of food at breakfast. Skipping breakfast was
defined as never eating anything on this occasion. Moreover, we inquired
about 4) consuming precooked and/or canned foods, 5) buying choco-
lates or other snacks in vending machines, and 6) eating in fast-food
restaurants. Participants also reported whether they had some mindful
eating behaviors such as 7) “selecting low-energy foods,” 8) “removing
visible fat from meat,” and 9) “taking the skin off the chicken” before
eating. To assess meal context, study participants were asked 10) how
often they had lunch or dinner while watching TV and 11) how often
they did so while sitting in a sofa or armchair. Last, we asked about 12)
the time, in minutes, that the person usually took to eat breakfast, lunch,
and dinner. The cutoffs used to define a short meal were 5 min for
breakfast and 15 min for lunch and dinner.
Physical activity and sedentariness. Physical activity was assessed
during leisure time by using a validated questionnaire developed for the
European Prospective Investigation into Cancer and Nutrition (EPIC)-
Spain cohort study (10), which allowed for estimating energy expenditure
in metabolic equivalent hours/wk (11). As an indicator of sedentariness,
we asked participants to report the average time (h/wk) that they spent
watching TV in a typical week over the last year. This question has been
used in well-known prospective studies (12) and has been shown to be
reliable (13) and to have criterion validity (14).
Diet. A computerized diet history, developed from the one used in the
EPIC-Spain cohort study (15,16), was used to assess habitual food
consumption in the previous year. The diet history asked about the food
consumed in a typical week, and all foods consumed at least once every
15 d were recorded (e.g., one food might be consumed once per week
during 2 seasons in the last year, which is equivalent to consuming this
food once every 15 d during the whole year). Nutrient intake was
estimated by using food-composition tables for Spanish and interna-
tional foods (17–21).
Accordance with the MD was evaluated with the Mediterranean Diet
Adherence Screener (MEDAS) score (22), which represents the tradi-
tional MD consumed in Spain at around 1960 (23). This is important
because the average diet in Spain has substantially departed from the
MD over the last decades. The MEDAS score ranges from 0 to 14, so that
1322 Mesas et al.
a higher value indicates better MD accordance (Supplemental Table 1).
We considered that an MEDAS score $9 represents a modest accordance
with the MD (22).
Given that there is no standard definition of the nutrient composition
of the MD, we used the nutrient intake targets of the higher unsaturated
fat variant of the Optimal Macronutrient Intake Trial to Prevent Heart
Disease (OmniHeart) diet (24,25) as indicative of the nutrient profile of
the traditional MD (26) (Supplemental Table 1). The OmniHeart diet
score ranges from 0 to 12. A higher value represents better accordance,
and score of $4 (median in the study population) was deemed to indicate
modest accordance with the nutrient composition of the MD (25).
Other variables. In addition to age, sex, education, and occupation-
based social class, we used information on other variables that have been
shown to be associated with eating behaviors or with physical activity,
sedentariness, and diet quality, such as tobacco smoking, alcohol intake,
and physical activity at work. Information was also used on physician-
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diagnosed morbidity reported by the participant, including coronary
disease, stroke, cancer at any site, and osteomuscular disease (osteoar-
thritis, rheumatoid arthritis, and hip fracture).
Last, height and weight were measured in standardized conditions
(27). BMI was calculated as weight in kilograms divided by squared
height in meters.
Statistical analysis
Of the 12,948 study participants, we excluded the following individuals
because of missing data on some study variables: 1117 were missing data
on at least one OREB, 46 were missing data on physical activity or time
watching television, 86 were missing data on diet or had extreme values
for total energy intake (men: #800 or $5000 kcal/d; women: #500 or
$4000 kcal/d), and 908 had potential confounders. Thus, the analyses
were conducted in 10,791 individuals.
The relationship between each OREB and energy spent in physical
activity, time watching TV, and energy intake was summarized with b
coefficients and their 95% CI obtained from linear regression models.
The association between each OREB and accordance with the Mediter-
ranean dietary pattern was estimated with OR and 95% CI obtained
from logistic regression. Last, analyses were repeated by using the
number of OREB (range: 0–12) instead of each isolated OREB as the
main independent variable. To allow for a sufficient number of
individuals in each category, the number of OREB was grouped into 5
categories: #1, 2, 3, 4 and $5. We tested for linear trend by modeling the
number of OREB as a continuous variable. Analyses were adjusted for
age, sex, education, social class, smoking, alcohol consumption, binge
drinking, physical activity at work, BMI, and reported morbidity.
Significance was set at P , 0.05. To take the sampling design into
account, all analyses were performed by using the survey procedures in
Stata, version 11.1 (2009; StataCorp LP).
Results
Approximately one-half of the individuals included in the
present analyses were women, .70% had completed secondary
or university studies, and almost two-thirds were overweight or
obese (Table 1). The most frequent OREB were eating while
watching TV, not planning how much to eat before sitting down,
not choosing low-energy foods, and consuming precooked and/
or canned foods (Table 2). In contrast, other OREB were
infrequent, such as buying snacks at vending machines and
skipping breakfast (Table 2).
Rarely choosing low-energy foods and rarely removing visible
fat from meat showed a significant association with lower energy
spent in leisure-time physical activity (Table 3). The rest of the
OREB, with the exception of deciding the amount of food on the
plate and eating while seated on a sofa or armchair, showed
associations in the same direction, although they did not reach
significance. Moreover, frequently eating precooked/canned food
TABLE 1 Characteristics of the study participants1 TABLE 2 Eating behaviors, leisure-time physical activity, time
watching television, energy intake, and accordance
Total with the Mediterranean diet (MEDAS and OmniHeart
diet scores) among study participants1
Women, % 50.2
Age, y 46.3 6 0.3 Total
Educational level, %
Primary or lower 28.9 Eating behaviors, %
Secondary 42.3 Not planning how much to eat before sitting down 72.4
University 28.8 Never deciding the amount of food on the plate 14.9
Social class based on occupation, % Always skipping breakfast 1.4
I–II (nonmanual workers) 64.7 Consuming precooked and/or canned foods 1 time/wk 43.2
III–IV (manual workers) 35.3 Buying snacks at vending machines 1 time/wk 4.2
Smoking, % Eating at fast-food restaurants 1 time/wk 9.3
Never smoker 47.4 Never or almost never choosing low-energy foods 46.1
Former smoker 24.8 Never or almost never removing visible fat from meat2 15.7

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Current smoker 27.8 Never or almost never removing skin from chicken3 15.5
Alcohol consumption, % Eating while watching TV .2 times/wk 74.1
Never drinkers 45.0 Eating while seated on a sofa or an armchair .2 times/wk 23.1
Former drinkers 27.5 Taking a short time to have breakfast, lunch, and dinner4 11.6
,1 time/wk 21.4 Number of obesity-related eating behaviors 3.28 6 0.02
$1 time/wk 6.1 Physical activity in leisure time, MET-h/wk 28.4 6 0.3
Binge drinking in last month2, % 5.9 Time spent watching TV, h/wk 13.5 6 0.1
Physical activity at work, % Total energy intake, kcal/d 2180 6 9
Unemployed 24.1 Mediterranean diet accordance
Sedentary work 30.6 MEDAS score 6.34 6 0.02
Standing work 39.0 MEDAS score $9, % 11.8
Manual or heavy work 6.3 OmniHeart diet score 3.99 6 0.01
BMI, % OmniHeart diet score $4, % 55.2
,25 kg/m2 37.9 1
Values are means 6 SE or percentages obtained by sampling correction procedures;
25–29.9 kg/m2 39.6 n = 10,791. MEDAS, Mediterranean Diet Adherence Screener (score range: 0–14);
$30 kg/m2 22.5 MET-h, metabolic equivalent hours; OmniHeart, Optimal Macronutrient Intake Trial to
Prevent Heart Disease (score range: 0–12); TV, television.
Morbidity, % 2
Analyses based on 9606 participants who ate meat.
Coronary disease 0.6 3
Analyses based on 9249 participants who ate chicken.
Stroke 0.4 4
Eating breakfast in #5 min and lunch and dinner in #15 min.
Asthma 6.3
Cancer at any site 0.8
Osteomuscular disease3 20.0 for total energy intake or when the MEDAS and OmniHeart
1
Values are means 6 SE or percentages obtained by sampling correction procedures; diet scores were modeled as a continuous variable using linear
n = 10,791. regression (data not shown).
2
Intake of $8 standard units of alcohol in men and $6 in women during a single Last, an increasing number of OREB were associated with
drinking occasion (1 standard unit has 10 g of alcohol). decreasing physical activity, more time watching TV, an
3
Osteoarthritis, rheumatoid arthritis, or hip fracture.
increasing total energy intake, and a decreasing frequency of
MD accordance, either with MEDAS or OmniHeart diet scores
or at fast-food restaurants, eating while watching TV, and eating (P-trend , 0.001 in all cases) (Table 5). Results were similar
while seated on a sofa or armchair were significantly related to a when analyses were restricted to the 4 most frequent (.40% in
longer time watching TV (Table 3). the study sample) OREB (data not shown).
OREB were associated with a higher energy intake, with the
exception of never deciding the amount of food on the plate,
skipping breakfast, eating while seated in a sofa or armchair,
Discussion
and taking a short time to eat, which were associated with
lower energy intake (Table 4). Moreover, each OREB, with the Our results showed that a greater number of OREB are
exception of deciding the amount of food on plate, skipping associated with lower physical activity, more time viewing TV, a
breakfast, and eating precooked/canned food, was associated higher energy intake, and a lower frequency of a healthy diet, as
with a lower frequency of MD accordance, as assessed by the represented by the MD.
MEDAS score. Results were unchanged when MD accordance Most observed associations were of modest magnitude
was defined as MEDAS $7, which is the median in the study because, compared with individuals with only #1 OREB, those
sample (data not shown). with $5 OREB spent 2.6 metabolic equivalent hours/wk less in
Those individuals who did not plan how much to eat before physical activity, watched TV for only 2.2 h/wk more, and
sitting, who chose low-energy foods, and who rarely removed fat ingested an additional 163 kcal/d. However, if maintained over
from meat or the skin from chicken were significantly less likely time, only a small energy imbalance is required to produce
to have a diet whose nutrient profile was accordant with the substantial weight changes. For instance, each 25-kcal/d change
MD, as assessed with the OmniHeart diet score (Table 4). in energy intake could lead to an eventual bodyweight change of
Results were similar when analyses were additionally adjusted about 1 kg over 3 y in an average overweight adult (28).
Eating behavior, physical activity, and diet quality 1323
 TABLE 3 Association between eating behaviors, leisure-time physical activity, and time spent
watching TV1

Leisure-time physical Time spent watching

activity, MET-h/wk TV, h/wk

Planning how much to eat before sitting down

Yes Reference Reference
No 20.78 (21.85, 0.29) 20.30 (20.78, 0.18)
Deciding the amount of food on plate
Always/habitually/occasionally Reference Reference
Never 1.38 (20.18, 2.95) 20.37 (20.97, 0.21)
Skipping breakfast
No Reference Reference
Yes 20.42 (25.46, 4.61) 1.36 (20.31, 3.04)
Eating precooked/canned foods

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,1 time/wk Reference Reference
$1 time/wk 20.47 (21.45, 0.50) 0.51 (0.12, 0.89)*
Buying snacks at vending machines
,1 time/wk Reference Reference
$1 time/wk 20.19 (22.60, 2.21) 0.24 (20.58, 1.06)
Eating at fast-food restaurants
,1 time/wk Reference Reference
$1 time/wk 21.88 (23.86, 0.09) 1.53 (0.79, 2.26)‡
Choosing low-energy foods
Frequently/always/sometimes Reference Reference
Never/almost never 21.48 (22.51, 20.45)y 20.12 (20.53, 0.28)
Removing visible fat from meat2
Frequently/always/sometimes Reference Reference
Never/almost never 21.79 (23.15, 20.44)y 0.12 (20.44, 0.68)
Removing skin from chicken3
Frequently/always/sometimes Reference Reference
Never/almost never 21.23 (22.73, 0.26) 0.16 (20.40, 0.73)
Eating while watching TV
#2 times/wk Reference Reference
.2 times/wk 20.77 (21.82, 0.27) 2.34 (1.92, 2.76)‡
Eating while seated on a sofa or an armchair
#2 times/wk Reference Reference
.2 times/wk 0.53 (20.62, 1.67) 1.85 (1.34, 2.36)‡
Taking a short time to eat4
No Reference Reference
Yes 20.74 (22.00, 0.52) 0.60 (20.07, 1.28)
1
Values are b (95% CI) obtained by linear regression and adjusted for age, sex, educational level (primary or lower, secondary,
university), social class [I–II (nonmanual), III–IV (manual)], smoking (never smoker, former smoker, current smoker), alcohol
consumption (former drinker, abstainer, ,1 time/wk, $1 time/wk), binge drinking (yes, no), physical activity at work
(unemployed, sedentary work, standing work, manual or heavy work), BMI (,25, 25–29.9, $30 kg/m2), and morbidity
(coronary disease, stroke, asthma, cancer at any site, osteomuscular disease); (n = 10,791). *P , 0.05, yP , 0.01, ‡P , 0.001.
MET-h, metabolic equivalent hours; TV, television.
2
Analyses based on 9606 participants who ate meat.
3
Analyses based on 9249 participants who ate chicken.
4
Eating breakfast in #5 min and lunch and dinner in #15 min.

Our results could also have public health importance because
several OREB are very frequent in the population. In fact, the
study associations were observed even when analyses were
restricted to the following 4 OREB that had a population
prevalence .40%: eating while watching TV, not planning how
much to eat, not choosing low-energy foods, and consuming
precooked and/or canned foods. Of note is that the first 3
behaviors on this list are conceptually easy to modify with
appropriate educational interventions. Moreover, these behav-
iors tend to cluster, because 33% of the population presents 3
of these factors simultaneously and 12% present all 4. This
observation may stimulate research into the underlying influ-
ences responsible for the observed behavioral clusters. Also, it
1324 Mesas et al.
suggests that interventions that address several OREB together
might be more efficient than those directed to individual OREB.
One interesting finding is the dose-response inverse associa-
tion between the number of OREB and accordance with the
MD. It raises the possibility that the health effects of the studied
OREB could go beyond excess weight to include other outcomes
related to the MD, such as hypertension (26), coronary disease
(29), cancer (30), and total mortality (31).
Our results are consistent with previous research on some
specific OREB behaviors. Keski-Rahkonen et al. (32) reported
that skipping breakfast had a modest association with a
sedentary lifestyle in both adults and adolescents in Finland.
Also, adult breakfast eaters performed regular exercise more
 TABLE 4 Association between eating behaviors and energy intake and accordance with the
Mediterranean diet (MEDAS score $9 or OmniHeart diet score $4)1

Total energy MEDAS OmniHeart diet

intake2, kcal/d score $93 score $43

Planning how much to eat before sitting down

Yes Reference Reference Reference
No 50 (20, 80)y 1.15 (0.97, 1.35) 0.73 (0.65, 0.81)‡
Deciding the amount of food on plate
Always/habitually/occasionally Reference Reference Reference
Never 2210 (2250, 2170)‡ 1.06 (0.87, 1.29) 0.91 (0.79, 1.04)
Skipping breakfast
No Reference Reference Reference
Yes 2250 (2380, 2125)‡ 0.68 (0.30, 1.53) 0.66 (0.44, 1.00)
Eating precooked/canned foods

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,1 time/wk Reference Reference Reference
$1 time/wk 160 (130, 180)‡ 0.98 (0.86, 1.13) 1.08 (0.98, 1.19)
Buying snacks at vending machines
,1 time/wk Reference Reference Reference
$1 time/wk 140 (80, 200)‡ 0.61 (0.41, 0.90)* 0.87 (0.71, 1.06)
Eating at fast-food restaurants
,1 time/wk Reference Reference Reference
$1 time/wk 50 (1, 95)* 0.57 (0.40, 0.82)y 0.94 (0.79, 1.12)
Choosing low-energy foods
Frequently/always/sometimes Reference Reference Reference
Never/almost never 150 (120, 180)‡ 0.69 (0.59, 0.80)‡ 0.68 (0.62, 0.75)‡
Removing visible fat from meat4
Frequently/always/sometimes Reference Reference Reference
Never/almost never 70 (35, 110)‡ 0.71 (0.57, 0.89)y 0.70 (0.62, 0.80)‡
Removing skin from chicken5
Frequently/always/sometimes Reference Reference Reference
Never/almost never 90 (55, 125)‡ 0.74 (0.60, 0.92)y 0.80 (0.59, 0.77)y
Eating while watching TV
#2 times/wk Reference Reference Reference
.2 times/wk 35 (9, 60)y 0.80 (0.69, 0.92)y 0.97 (0.87, 1.07)
Eating while seated on a sofa or an armchair
#2 times/wk Reference Reference Reference
.2 times/wk 245 (275, 215)y 0.70 (0.59, 0.85)‡ 0.91 (0.82, 1.02)
Taking a short time to eat6
No Reference Reference Reference
Yes 270 (2110, 230)‡ 0.74 (0.59, 0.92)y 0.91 (0.79, 1.05)
1
n = 10,791; *P , 0.05, yP , 0.01, ‡P , 0.001. MEDAS, Mediterranean Diet Adherence Screener (score range: 0–14);
OmniHeart, Optimal Macronutrient Intake Trial to Prevent Heart Disease (score range: 0–12); TV, television.
2
Values are b (95% CI) obtained by linear regression and adjusted for age, sex, educational level (primary or lower, secondary,
university), social class [I–II (nonmanual), III–IV (manual)], smoking (never smoker, former smoker, current smoker), alcohol
consumption (former drinkers, abstainers, ,1 time/wk, $1 time/wk), binge drinking (yes, no), physical activity at work
(unemployed, sedentary work, standing work, manual or heavy work), BMI (,25, 25–29.9, $30 kg/m2), and morbidity
(coronary disease, stroke, asthma, cancer at any site, osteomuscular disease).
3
Values are OR (95% CI) by logistic regression and adjusted for the same variables as in the linear regression.
4
Analyses based on 9606 participants who ate meat.
5
Analyses based on 9249 participants who ate chicken.
6
Eating breakfast in #5 min and lunch and dinner in #15 min.

frequently than did breakfast skippers in the United States (33)
and Taiwan (34). Moreover, the dietary energy density intake
was lower among breakfast reporters than among nonreporters
in US adults participating in NHANES 1999–2004 (35).
Snacking has been associated with an additional 1.5 h/wk of
TV viewing compared with not snacking in Spanish adults (36).
Energy-dense snack intake and snacking behavior have also been
linked to more TV viewing time in young adults in Canada (37).
In addition, several, but not all (38), studies have found that
snacking is associated with poorer diet quality. Snacking has
been linked to a higher intake of total energy, total fat, animal
and vegetable fat (36) and to a greater consumption of fast-
foods, sweets, and sugar-sweetened beverages (39). In Finland a
snack-dominated eating pattern was associated with a higher
sucrose and lower fiber intake in women (40). Last, Smith et al.
(41) found that eating takeaway food twice or more a week was
associated with poorer diet quality and more time watching TV
and sitting in young men and women. Fast-food consumption
was also inversely associated with diet quality both in Spain (42)
and in the United States (43).
The mechanisms of some of the observed associations are
easy to guess. For instance, eating while watching TV or eating
while seated on a sofa or an armchair could naturally be as-
sociated with more time watching TV. This is also the case for
Eating behavior, physical activity, and diet quality 1325
TABLE 5 Association of the number of obesity-related eating behaviors with leisure-time physical activity, time spent watching
television, and energy intake and accordance with the Mediterranean diet (MEDAS score $9 or OmniHeart diet score $4)1

Number of obesity-related eating behaviors2

#1 (n = 1179) 2 (n = 2479) 3 (n = 3154) 4 (n = 2498) $5 (n = 2226) P-trend

Leisure time physical activity, MET-h/wk 27.5 6 0.7 27.4 6 0.6 27.5 6 0.5 28.4 6 0.6 31.4 6 0.7
b (95% CI)3 Reference 20.88 (22.54, 0.76) 21.43 (23.02, 0.15) 22.56 (24.24, 20.88)y 22.61 (24.44, 20.78)y 0.001
Time watching TV, h/wk 12.8 6 0.3 13.1 6 0.2 14.0 6 0.2 13.4 6 0.2 13.6 6 0.3
b (95% CI)3 Reference 0.10 (20.59, 0.79) 1.18 (0.48; 1.88)y 1.23 (0.50, 1.96)y 2.17 (1.39, 2.95)‡ ,0.001
Total energy intake, kcal/d 1930 6 20 2110 6 15 2150 6 15 2270 6 15 2360 6 15
b (95% CI)3 Reference 115 (75, 160)‡ 124 (80, 165)‡ 170 (125, 215)‡ 160 (115, 210)‡ ,0.001
MEDAS score $9 (95% CI), % 15.5 (13.0, 18.0) 15.4 (13.7, 17.0) 12.3 (11.0, 13.7) 9.8 (8.5, 11.2) 7.0 (5.8, 8.2)
OR (95% CI)4 Reference 1.02 (0.81, 1.29) 0.80 (0.64, 1.01) 0.67 (0.52, 0.87)y 0.55 (0.41, 0.73)‡ ,0.001
OmniHeart score $4 (95% CI), % 66.3 (63.0, 69.5) 63.6 (61.2, 65.9) 57.0 (54.9, 59.2) 50.0 (47.5, 52.5) 42.9 (40.4, 45.5)
OR (95% CI)4 Reference 0.96 (0.80, 1.15) 0.76 (0.64, 0.90)* 0.63 (0.53, 0.76)‡ 0.57 (0.47, 0.68)‡ ,0.001

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y ‡
1
Values are means 6 SD unless otherwise indicated; n = 10,791. *P , 0.05, P , 0.01, P , 0.001. MEDAS, Mediterranean Diet Adherence Screener (score range: 0–14);
MET-h, metabolic equivalent hours; OmniHeart, Optimal Macronutrient Intake Trial to Prevent Heart Disease (score range: 0–12); TV, television.
2
Obesity-related eating behaviors are as follows: not planning how much to eat before sitting down, never deciding the amount of food on the plate, always skipping breakfast,
consuming precooked and/or canned foods $1 time/wk, buying snacks at vending machines $1 time/wk, eating at fast-food restaurants $1 time/wk, never or almost never
choosing low-energy foods, never or almost never removing visible fat from meat, never or almost never removing skin from chicken, eating while watching TV . 2 times/wk,
eating while seated on a sofa or an armchair .2 times/wk, and taking a short time to have breakfast, lunch and dinner.
3
Values are b (95% CI) obtained from linear regression and adjusted for age, sex, educational level (primary or lower, secondary, university), social class [I–II (nonmanual), III–IV
(manual)], smoking (never smoker, former smoker, current smoker), alcohol consumption (former drinkers, abstainers, ,1 time/wk, $1 time/wk), binge drinking (yes, no), physical
activity at work (unemployed, sedentary work, standing work, manual or heavy work), BMI (,25, 25–29.9, $30 kg/m2), and morbidity (coronary disease, stroke, asthma, cancer at
any site, osteomuscular disease).
4
Values are OR (95% CI) obtained from logistic regression and adjusted for the same variables as in the linear regression.

eating precooked/canned food and snacks, because it is known
that this type of food is frequently consumed while watching TV.
In fact, there is some evidence that it is the type and amount of
food consumed while viewing TV that is responsible for the
association between TV viewing and excess weight (44). For
other OREB (e.g., not planning how much food to eat or not
removing fat from meat), their mechanistic links with low
physical activity and sedentary lifestyle are as yet unknown, but
they may simply represent one manifestation of the widely
reported tendency of unhealthy behaviors to cluster (45). In fact,
recent evidence suggests that a neurocognitive link might con-
tribute to the clustering, because eating behaviors and physical
activity share a decision-making process that involves self-
regulation mediated by the neural system (46).
Some research has been done on the mechanisms of the
association between several OREB and energy intake. Breakfast
skipping may lead to increased ghrelin secretion and hunger,
resulting in overeating during the day (47). Moreover, low-energy
foods usually have lower energy density than their regular
counterparts. Also fast-foods, snack foods, and red meat with
visible fat are highly palatable, energy-dense foods. Experimental
studies have also shown that watching TV may be a distraction
while eating and result in a delay in normal mealtime satiation and
a reduction in internal satiety signals (48,49). Last, eating quickly
may lead to consumption of larger amounts of food.
Several methodologic aspects of this study should be
discussed. First, the response rate (51%) in the ENRICA study
and the number of missing data for some important variables
(OREB and potential confounders) are a cause for concern. It
should be noted that although the response rate was somewhat
lower than in the NHANES III, which was conducted in 2007–
2008 in the United States (50), it was among the highest rates
in the National Health Interview and Examination Surveys
conducted in Europe (51). Moreover, the composition of the
analytical sample in this study closely resembled the age, sex,
and educational level distribution of the population of Spain in
2009. Last, we found no suggestion that the missing data could
1326 Mesas et al.
be related to the study variables, so that it is likely that these
missing data just reduced the strength of the observed associ-
ations. Second, the cross-sectional design did not allow for
establishing causality. In fact, some unexpected findings could be
due to this design. For instance, the lower energy intake of those
not deciding the amount of food on their plate may result from
their being overweight or needing dietary therapy (i.e., someone
else may take care of them and decide on their diet). Likewise,
the lower energy intake of breakfast skippers may be a form of
dieting to control body weight. Nevertheless, in this study not
deciding the amount of food on the plate and skipping breakfast
were associated with taking a short time to eat [OR (95% CI):
1.53 (1.01, 2.32) and 1.21 (1.03, 1.43), respectively], which may
account for these individuals’ lower energy intake. Third, OREB
were self-reported. Thus, our results could be subject to some
recall bias and to the natural tendency of individuals to report
more socially desirable behaviors. Accordingly, it is possible
that the magnitude of many observed study associations is even
smaller than reported.
We conclude that the association between OREB and obesity
has certain biological plausibility because OREB are associated
with higher energy intake and poorer diet quality. Studies on
the association between OREB and obesity should control for
the confounding effect of physical activity and sedentariness.
However, given that OREB are also associated with low physical
activity and sedentariness, the latter variables may act as
confounders of the association between OREB and obesity,
and should be controlled for in future research.
Acknowledgments
A.E.M., P.G.-C., L.M.L.-M., A.G., E.L.-G., J.R.B., and F.R.-A.
designed the study; A.E.M. and F.R.A. analyzed the data and
drafted the manuscript; A.E.M., P.G.-C., L.M.L.-M., A.G.,
E.L.-G., J.L.G.-F., J.R.B., and F.R.-A. reviewed the manuscript
for important intellectual content; and F.R.-A. and A.E.M. had
primary responsibility for the final content. All authors read and
approved the final manuscript.
Literature Cited
1. Dapcich V, Salvador Castell G, Ribas Barba L, Pérez Rodrigo C,
Aranceta Bartrina J, Serra Majem L. Guı́a de la alimentación saludable.
Madrid: Sociedad Española de Nutrición Comunitaria; 2004.
2. Ministerio de Sanidad y Consumo. Alimentación saludable. Guia para
las familias. Madrid: Ministerio de Sanidad y Consumo; 2007.
3. Katzen M, Willett W. Eat, drink, and weigh less. New York: Hyperion;
2006.
4. Gidding SS, Lichtenstein AH, Faith MS, Karpyn A, Mennella JA,
Popkin B, Rowe J, Van Horn L, Whitsel L. Implementing American
Heart Association pediatric and adult nutrition guidelines: a scientific
statement from the American Heart Association Nutrition Committee
of the Council on Nutrition, Physical Activity and Metabolism, Council
on Cardiovascular Disease in the Young, Council on Arteriosclerosis,
Thrombosis and Vascular Biology, Council on Cardiovascular Nursing,
Council on Epidemiology and Prevention, and Council for High Blood
Pressure Research. Circulation. 2009;119:1161–75.
5. Mesas AE, Munoz-Pareja M, Lopez-Garcia E, Rodriguez-Artalejo F.
Selected eating behaviours and excess body weight: a systematic review.
Obes Rev. 2012;13:106–35.
6. Buckland G, Bach A, Serra-Majem L. Obesity and the Mediterranean
diet: a systematic review of observational and intervention studies. Obes
Rev. 2008;9:582–93.
7. Romaguera D, Norat T, Vergnaud AC, Mouw T, May AM, Agudo A,
Buckland G, Slimani N, Rinaldi S, Couto E, et al. Mediterranean dietary
patterns and prospective weight change in participants of the EPIC-
PANACEA project. Am J Clin Nutr. 2010;92:912–21.
8. Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Ruiz-
Gutierrez V, Covas MI, Fiol M, Gomez-Gracia E, Lopez-Sabater MC,
Vinyoles E, et al. Effects of a Mediterranean-style diet on cardiovascular
risk factors: a randomized trial. Ann Intern Med. 2006;145:1–11.
9. Rodrı́guez-Artalejo F, Graciani A, Guallar-Castillon P, Leon-Munoz
LM, Zuluaga MC, Lopez-Garcia E, Gutierrez-Fisac JL, Taboada JM,
Aguilera MT, Regidor E, et al. Rationale and methods of the Study
on Nutrition and Cardiovascular Risk in Spain (ENRICA). Rev Esp
Cardiol. 2011;64:876–82.
10. Pols MA, Peeters PH, Ocke MC, Slimani N, Bueno-de-Mesquita HB,
Collette HJ. Estimation of reproducibility and relative validity of the
questions included in the EPIC Physical Activity Questionnaire. Int J
Epidemiol. 1997;26(Suppl 1):S181–9.
11. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath
SJ, O’Brien WL, Bassett DR Jr, Schmitz KH, Emplaincourt PO, et al.
Compendium of physical activities: an update of activity codes and
MET intensities. Med Sci Sports Exerc. 2000;32:S498–504.
12. Hu FB, Li TY, Colditz GA, Willett WC, Manson JE. Television watching
and other sedentary behaviors in relation to risk of obesity and type 2
diabetes mellitus in women. JAMA. 2003;289:1785–91.
13. Clark BK, Sugiyama T, Healy GN, Salmon J, Dunstan DW, Owen N.
Validity and reliability of measures of television viewing time and other
non-occupational sedentary behaviour of adults: a review. Obes Rev.
2009;10:7–16.
14. Fung TT, Hu FB, Yu J, Chu NF, Spiegelman D, Tofler GH, Willett WC,
Rimm EB. Leisure-time physical activity, television watching, and
plasma biomarkers of obesity and cardiovascular disease risk. Am J
Epidemiol. 2000;152:1171–8.
15. EPIC Group of Spain. Relative validity and reproducibility of a diet
history questionnaire in Spain. I. Foods. Int J Epidemiol. 1997;26(Suppl
1):S91–9.
16. EPIC Group of Spain. Relative validity and reproducibility of a diet
history questionnaire in Spain. II. Nutrients. Int J Epidemiol. 1997;26
(Suppl 1):S100–9.
17. Farrán A, Zamora R, Cervera P. Centre d’Ensenyament Superior de
Nutrició i Dietética (CESNID). Barcelona: McGraw-Hill/Interamerica-
na de Espàña, S.A.U. Edicions Universitat de Barcelona; 2004.
18. Moreiras O, Carvajal A, Cabrera L, Cuadrado C. Tablas de composición
de alimentos. 11th ed. Madrid: Ediciones Pirámide; 2007.
19. Ortega Anta RM, López Sobaler AM, Carvajales PA, Requejo Marcos
AM, Molinero Casares LM. Programa DIAL. 2007 [cited 12 May
2011]. Available from: http://www.alceingenieria.net/nutricion.htm.
20. U.S. Department of Agriculture, Agricultural Research Service. Na-
tional Nutrient Database for Standard Reference. 2010 [cited 12 May
2011]. Available from: http://www.ars.usda.gov/Services/docs.htm?doc-
id=8964.
21. Jiménez Cruz A, Cervera Ral P, Bacardı́ Gascón M. Tabla de composición
de alimentos. 1st ed. Barcelona: Wander-Sandoz Nutrition; 1990.
22. Schröder H, Fito M, Estruch R, Martinez-Gonzalez MA, Corella D,
Salas-Salvado J, Lamuela-Raventos R, Ros E, Salaverria I, Fiol M, et al.
A short screener is valid for assessing Mediterranean diet adherence
among older Spanish men and women. J Nutr. 2011;141:1140–5.
23. Helsing E. Traditional diets and disease patterns of the Mediterranean,
circa 1960. Am J Clin Nutr. 1995; 61(6, Suppl):1329S–37S.
24. Swain JF, McCarron PB, Hamilton EF, Sacks FM, Appel LJ. Charac-
teristics of the diet patterns tested in the optimal macronutrient intake
trial to prevent heart disease (OmniHeart): options for a heart-healthy
diet. J Am Diet Assoc. 2008;108:257–65.
25. Mellen PB, Gao SK, Vitolins MZ, Goff DC Jr. Deteriorating dietary habits
among adults with hypertension: DASH dietary accordance, NHANES
1988–1994 and 1999–2004. Arch Intern Med. 2008;168:308–14.
Downloaded from https://academic.oup.com/jn/article-abstract/142/7/1321/4630859 by guest on 10 July 2019
26. Sacks FM, Campos H. Dietary therapy in hypertension. N Engl J Med.
2010;362:2102–12.
27. Gutiérrez-Fisac JL, Guallar-Castillón P, León-Muñoz LM, Graciani A,
Banegas JR, Rodrı́guez-Artalejo F. Prevalence of general and abdominal
obesity in the adult population of Spain, 2008–2010: the ENRICA
Study. Obes Rev. 2012;13:388–92.
28. Hall KD, Sacks G, Chandramohan D, Chow CC, Wang YC, Gortmaker
SL, Swinburn BA. Quantification of the effect of energy imbalance on
bodyweight. Lancet. 2011;378:826–37.
29. Buckland G, Gonzalez CA, Agudo A, Vilardell M, Berenguer A, Amiano
P, Ardanaz E, Arriola L, Barricarte A, Basterretxea M, et al. Adherence
to the Mediterranean diet and risk of coronary heart disease in the
Spanish EPIC Cohort Study. Am J Epidemiol. 2009;170:1518–29.
30. Benetou V, Trichopoulou A, Orfanos P, Naska A, Lagiou P, Boffetta P,
Trichopoulos D. Conformity to traditional Mediterranean diet and
cancer incidence: the Greek EPIC cohort. Br J Cancer. 2008;99:191–5.
31. Trichopoulou A, Costacou T, Bamia C, Trichopoulos D. Adherence to a
Mediterranean diet and survival in a Greek population. N Engl J Med.
2003;348:2599–608.
32. Keski-Rahkonen A, Kaprio J, Rissanen A, Virkkunen M, Rose RJ.
Breakfast skipping and health-compromising behaviors in adolescents
and adults. Eur J Clin Nutr. 2003;57:842–53.
33. Song WO, Chun OK, Obayashi S, Cho S, Chung CE. Is consumption of
breakfast associated with body mass index in US adults? J Am Diet
Assoc. 2005;105:1373–82.
34. Huang CJ, Hu HT, Fan YC, Liao YM, Tsai PS. Associations of breakfast
skipping with obesity and health-related quality of life: evidence from a
national survey in Taiwan. Int J Obes (Lond). 2010;34:720–5.
35. Kant AK, Andon MB, Angelopoulos TJ, Rippe JM. Association of
breakfast energy density with diet quality and body mass index in
American adults: National Health and Nutrition Examination Surveys,
1999–2004. Am J Clin Nutr. 2008;88:1396–404.
36. Sánchez-Villegas A, Martinez-Gonzalez MA, Toledo E, de Irala-Estevez
J, Martinez JA. Relative role of physical inactivity and snacking
between meals in weight gain. Med Clin (Barc). 2002;119:46–52.
37. Thomson M, Spence JC, Raine K, Laing L. The association of television
viewing with snacking behavior and body weight of young adults. Am J
Health Promot. 2008;22:329–35.
38. Zizza CA, Xu B. Snacking is associated with overall diet quality among
adults. J Am Diet Assoc. 2011.
39. Bes-Rastrollo M, Sanchez-Villegas A, Basterra-Gortari FJ, Nunez-
Cordoba JM, Toledo E, Serrano-Martinez M. Prospective study of
self-reported usual snacking and weight gain in a Mediterranean cohort:
the SUN project. Clin Nutr. 2010;29:323–30.
40. Ovaskainen ML, Tapanainen H, Pakkala H. Changes in the contribu-
tion of snacks to the daily energy intake of Finnish adults. Appetite.
2010;54:623–6.
41. Smith KJ, McNaughton SA, Gall SL, Blizzard L, Dwyer T, Venn AJ.
Takeaway food consumption and its associations with diet quality and
abdominal obesity: a cross-sectional study of young adults. Int J Behav
Nutr Phys Act. 2009;6:29.
42. Schröder H, Fito M, Covas MI. Association of fast food consumption
with energy intake, diet quality, body mass index and the risk of obesity in
a representative Mediterranean population. Br J Nutr. 2007;98:1274–80.
Eating behavior, physical activity, and diet quality 1327
43. French SA, Harnack L, Jeffery RW. Fast food restaurant use among
women in the Pound of Prevention Study: dietary, behavioral and
demographic correlates. Int J Obes Relat Metab Disord. 2000;24:1353–9.
44. Cleland VJ, Schmidt MD, Dwyer T, Venn AJ. Television viewing and
abdominal obesity in young adults: is the association mediated by food
and beverage consumption during viewing time or reduced leisure-time
physical activity? Am J Clin Nutr. 2008;87:1148–55.
45. Galán I, Rodriguez-Artalejo F, Tobias A, Diez-Ganan L, Gandarillas A,
Zorrilla B. Clustering of behavior-related risk factors and its association
with subjective health. Gac Sanit. 2005;19:370–8.
46. Joseph RJ, Alonso-Alonso M, Bond DS, Pascual-Leone A, Blackburn
GL. The neurocognitive connection between physical activity and eating
behaviour. Obes Rev. 2011;12:800–12.
1328 Mesas et al.
47. Timlin MT, Pereira MA. Breakfast frequency and quality in the etiology
of adult obesity and chronic diseases. Nutr Rev. 2007;65:268–81.
48. Blass EM, Anderson DR, Kirkorian HL, Pempek TA, Price I, Koleini
MF. On the road to obesity: television viewing increases intake of high-
density foods. Physiol Behav. 2006;88:597–604.
49. Bellissimo N, Pencharz PB, Thomas SG, Anderson GH. Effect of
television viewing at mealtime on food intake after a glucose preload in
boys. Pediatr Res. 2007;61:745–9.
50. Centers for Disease Control and Prevention. NHANES response rates
and CPS totals [cited27 Feb 2012]. Available from: http://www.cdc.gov/
nchs/nhanes/response_rates_CPS.htm
51. Aromaa A, Koponen P, Tafforeau J, Vermeire C. Evaluation of Health
Interview Surveys and Health Examination Surveys in the European
Union. Eur J Public Health. 2003;13:67–72.
Downloaded from https://academic.oup.com/jn/article-abstract/142/7/1321/4630859 by guest on 10 July 2019