F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.25303.1 Research Article Articles Poor eating habits and predictors of weight gain during the COVID-19 quarantine measures in Kuwait: a cross sectional study

[version 1; peer review: 2 approved with reservations]

 AlMughamis Nouf Conceptualization Investigation Methodology Project Administration Resources Supervision Visualization Writing – Review & Editing https://orcid.org/0000-0002-5285-6543 a 1 AlAsfour Shaimaa Conceptualization Methodology Resources Writing – Original Draft Preparation 1 Mehmood Shariq Formal Analysis Writing – Original Draft Preparation Writing – Review & Editing 2 Ministry of Health, Kuwait, Kuwait Postgraduate Medical Institute, Lahore, Pakistan nalmughamis@moh.gov.kw

No competing interests were disclosed.

 5 8 2020 2020 9 914 30 7 2020 Copyright: © 2020 AlMughamis N et al. 2020 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Despite the public health importance of documenting the burden of physical inactivity and weight gain, there is a paucity of such data in Kuwait during the lockdown for Covid-19 pandemic. Therefore, this survey was designed to estimate: the burden of poor eating habits particularly binge eating habits, fluctuations in weight and its predictors among the Kuwaiti public.

Methods: This cross-sectional survey was conducted from 2 nd to 12 th April 2020 among the general public in Kuwait. All data were collected through a social media platform (WhatsApp groups), through convenience and snowball sampling methods. The survey comprised three sections: a) demographic characteristics of respondents, b) eating habits particularly binge eating, consumption of snacks and beverages c) subjective feelings of anxiety and d) weight before and during the pandemic. All data were analyzed using SPSS (v.25).

Results: There was a total of 522 valid respondents, with a mean age of 41.78 (11.75) years. There was a significant increase in weight of respondents during the quarantine (mean difference= -1.13, SD 5.39, t= -4.52, p < 0.001). Those with reporting unhealthy diets were 4.5 times more likely to report an increase in weight. Those reporting having anxiety throughout the day were 2.45 times more likely and those consuming snacks excessively were associated with 3.27 times higher odds of increase in weight than those not consuming it.

Conclusions: We recommend that authorities develop a strategic plan to counter harmful effects of this pandemic on health that are originating from sedentary lifestyle, unhealthy eating patterns and psychological issues.

 weight gain COVID-19 quarantine binge-eating anxiety Kuwait The author(s) declared that no grants were involved in supporting this work. Introduction

These are unusual times, as the coronavirus disease 2019 (COVID-19) pandemic of has drastically affected daily lives of millions of people around the world. The concept of quarantine is practically new for the general public, and has influenced social, economic and psychological threads of our life 1, 2 . Due to changes in our habits including socializing, physical work, eating and entertainment, it is natural that level of anxiety and depression is on the rise among people in quarantine 3 . The psychological impact of quarantine has also been associated with post-traumatic stress, confusion and aggression 1 .

Among the general public, poor information pertaining to the COVID-19 and the rationale for lockdown has given birth to fear toward infection, frustration, boredom, financial loss and stigma 1 . These stressors may lead to people being homebound and lead a sedentary lifestyle and develop poor eating habits. This poor lifestyle can be detrimental to the health structure of Middle Eastern countries, especially Kuwait, where obesity has a high prevalence and a large proportion of Kuwaiti national meet the World Health Organization’s definition of ‘obesity’ 4 . According to Al-Nohair, the prevalence of obesity among Kuwaiti males is 36% and in females is 48% 4, 5 . This high rate of obesity in Kuwait has been attributed to a plethora of biopsychosocial risk factors and a polygenic etiology 4 . The current pandemic and associated quarantine may further exacerbate the situation 1 .

Due to the disrupted daily routine of adults and children, less social contact and rising psychological distress, the health of Kuwaiti residents can further deteriorate both physically and mentally 1 . All of these factors have been documented to particularly affect healthy eating habits 6 . Over-eating and the resulting weight gain during the COVID-19 quarantine, may result in an increase in incidence of chronic diseases such as diabetes, cardiovascular diseases and psychiatric illnesses. Epidemiological and public health studies focusing on nutrition and weight gain among the general masses are needed to develop strategies and devise interventions countering these.

Despite the public health importance of documenting the burden of physical inactivity and weight gain, there is a paucity of such data in Kuwait. Therefore, this survey was designed to estimate the burden of poor eating habits particularly binge eating habits, fluctuations in weight and its predictors among the Kuwaiti public.

 Methods Study background

This cross-sectional survey was conducted from 2 nd to 12 th April 2020 among the general public in Kuwait City, Kuwait. The country reported its first case on 24 th February 2020, and the country went into partial lockdown since 22 nd March, and on 10 th May, the country was placed in full curfew based on Ministry of Health’s assessment 7 (at the time of writing, on 4 th August 2020 Kuwait will remain under curfew 9pm-3am). All data were collected through a social media platform (WhatsApp groups), where first participants were chosen through convenience sampling and the rest through snowball sampling methods. Attempts were made to exclude non-Kuwaiti nationals by distributing the questionnaire to Kuwaiti nationals and screening the datasets after collection of data. Inclusion criteria included participants being Kuwaiti nationals residing in Kuwait. There were no specific exclusion criteria pertaining to age, language, gender or occupation of the respondents. After providing written informed consent, the respondents were briefed about the objectives of the survey, ensured anonymity and that the group findings will be reported. Respondents could leave the study at any time if they felt uncomfortable. Approval for this study was provided by the Ethical Review Board of Ministry of Health of Kuwait, Kuwait (Approval #2020/1477).

 Survey

The minimum sample size required for this survey was calculated to answer out primary research objective of documenting prevalence of poor eating habits among Kuwaitis. Based on a statistical power of 80%, confidence level 95%, margin of error 5% and a population size of 1.3 million Kuwaitis, a minimum sample size of 385 was required. All data were collected using an electronic version of a bilingual questionnaire in Arabic and English languages. The questionnaire was pre-piloted among a few participants before distribution; however, no factor validity or reliability testing was done due to categorical and open-ended nature of the responses. Participants were encouraged to provide their responses in either of the languages. The questionnaire comprised of three sections 20 : a) demographic characteristics of respondents, b) eating habits particularly binge eating, consumption of snacks and beverages c) subjective feelings of anxiety and d) weight before and during the pandemic. Demographic characteristics included gender, age, nationality, marital status, parity and housing of the respondents. Several questions were asked regarding binge eating habits documenting change in nutrition habits, time of increased food consumption, number and type of snack foods consumed during the day, water and coffee intake. Physical activity during the day was inquired using two questions: a) a trichotomous question documenting change in physical activity when compared with normal routine before the quarantine and number of hours spent in a sedentary manner per day in the last week. Symptoms of anxiety were measured subjectively using a three-point Likert scale. Participants were asked the extent to which they experienced anxiety every day in last 7 days. Responses were given on a three point scale ranging from never to always. Participants were instructed to respond with their weights measured using a weight scale (digital or analogue) if they had measured it. Similarly, they were instructed to input their current weight status using a digital or analogue weighing scale, if available. The question regarding weight of the respondents before and during the lockdown, yielded 462 (88.50%) valid responses. The remaining participants could not input their weights due to unavailability of weighing scales.

 Statistical analysis

All data were analyzed using SPSS (v25). Descriptive statistics were calculated for all variables where quantitative variables were presented as mean (SD) and categorical ones as frequency and percentage. Statistical significance for difference between weight of respondents during the COVID-19 pandemic and before it was assessed using t-test for dependent samples. To delineate predictors of weight gain, it was planned a priori to run multiple regression; however, due to the non-normalized nature of the data, logistic regression analysis was performed.

Thereafter, the respondents were categorized in to two groups: participants with weight gain and participants with negative or no change in weight. To identify the predictors of experience in weight gain among the Kuwaitis, binary logistic regression (stepwise method) was employed. Theoretically sound factors showing relationship with weight gain in previous literature were added as predictors in the logistic regression model 8 . These predictors included demographic characteristics of respondents, eating habits c) subjective feelings of anxiety and d) questions pertaining to physical inactivity. The final model reported significant predictors of weight, with statistical significance set at ≤0.05 and the variance in the model was assessed using the Negelkerke R 2.

 Results Characteristics of respondents

There was a total of 522 valid respondents, with a mean age of 41.78 (11.75) years. More of the respondents were females (380, 72.8%) than males (142, 27.2%). A higher proportion of the respondents were married (379, 72.6%) than single (97, 18.6%). A total of 201 (38.5%) respondents reported having 1–3 children, followed by >3–6 (170, 32.6%), no children (124, 23.8%) and more than 6 children 27 (5.2%). More than half of the respondents lived in their own houses 297 (56.9%), followed by at parents’ house 128 (24.5%), and apartment 97 (18.6%).

 Weight and eating patterns before the COVID-19 pandemic

A higher proportion of the respondents’ families were assisted by a cook (299, 57.3%) to prepare meals than themselves (223, 42.7%). A change in nutritional habits was reported by 387 (74.1%) respondents, with 214 reporting that their eating pattern had improved to a healthier one (214, 41%) than unhealthy one (24.3%). Respondents tend to consume more food at night (232, 44.4%) than during daytime. A total of 352 respondents (67.4%) reported consuming snacks more than twice per day. Water intake was self-reported as enough (287, 55.0%) and 300 (57.5%) respondents reported having 1-3 cups of coffee a day.

For the question regarding weight of the respondents before and during the lockdown, there were 462 (88.50%) valid responses. We did not impute the missing data for responses regarding weight measurements, and excluded participants with missing data in the logistic regression model. Mean weight of respondents before the pandemic was 75.03 (16.85) kg and 75.74 (17.54) kg during the pandemic ( Figure 1). There was a significant increase in weight of respondents during the quarantine (mean difference= -1.13, SD 5.39, t= -4.52, p < 0.001). A higher proportion of respondents reported that their weight will stabilize after the pandemic (n=305, 58.4%) while 217 (41.6%) reported that it would increase. A total of 333 (63.8%) of the respondents reported feeling anxious sometimes during the day, 133 (25.5%) always and 56 (10.7%) never. Over 69% of the respondents reported that their physical activity had reduced than before. Mean number of hours spent being sedentary at home were 9.56 (5.64) ( Table 1).

Distribution of weight of respondents before and after COVID-19 quarantine. Eating habits during COVID-19.
Statement Response Frequency Percentage
Who cooks at home? Cook 298 57.2%
Self or family member 223 42.8%
Have you changed your nutritional habits at home? No 135 25.9%
To an extent 174 33.3%
Yes 213 40.8%
How has your eating habit changed? Became unhealthy 127 24.3%
No change 181 34.7%
Became healthier 214 41.0%
When do you tend to consume more food? Eat more at day 82 15.8%
Eat more at night 232 44.6%
Eat more at night and day 12 2.3%
No change 194 37.3%
Main meals during COVID-19 Breakfast 28 5.36%
Breakfast & Dinner 43 8.24%
Breakfast & Lunch 50 9.58%
Breakfast, Lunch and Dinner 153 29.31%
Dinner 47 9.0%
Lunch 95 18.20%
Lunch & Dinner 106 20.31%
Snack during COVID None 38 7.3%
Once a day 132 25.3%
Twice a day 166 31.8%
Thrice a day 89 17.0%
More than 3 times a day 97 18.6%
Water intake during COVID-19 Not enough 233 44.8%
Enough 287 55.2%
Coffee during COVID-19 No coffee 141 27.1%
1–3 cups 300 57.6%
>3 cups 80 15.4%
Physical activity As it was 85 16.3%
Less 363 69.5%
More 74 14.2%
What will happen to weight after covid-19 Decrease 0 0.0%
Stabilise 304 58.3%
Increase 217 41.7%
I feel anxious Never 56 10.7%
Sometimes 333 63.8%
Always 133 25.5%
Predictors of weight increase among the Kuwaitis

Logistic regression (stepwise method) was used to analyze statistically significant predictors of increase in weight among the Kuwaitis during the COVID-19 quarantine. It yielded a significant model (X 2= 90.43, df= 8, p< 0.001). The model explained 24.9% of variance in weight changes among Kuwaitis (Nagelkerke R 2) and correctly classified 71.6% of the cases, whereas the sensitivity of this particular model was 65.8% and specificity 78% in predicting the increase in weight among Kuwaiti respondents. According to this model, when compared with respondents who changed their diet pattern to healthier, those with reporting unhealthy diets were 4.5 times (95% CI= 2.45 to 8.23) more likely to report an increase in weight. Those reporting having anxiety throughout the day were 2.45 times more likely to have an increase in weight than those never experiencing it. Consuming snacks excessively

(>3 times a day) was associated with 3.27 times higher odds of increase in weight than those not consuming it. Those that consumed moderate amounts of snacks (1–3 times a day) did not differ to their counterparts who never consumed snacks throughout the day ( Table 2).

Predictors itis (n= 462).
Variable B S.E. P Odds ratio 95% C.I.
Lower Upper
how has your eating habit changed? <0.001
Became healthy
Became unhealthier 1.505 0.311 <0.001 4.506 2.448 8.295
No change 0.057 0.235 .809 1.058 0.668 1.677
Snack during COVID <0.001
None
Once a day -0.403 0.445 0.365 0.668 0.279 1.600
Twice a day -0.276 0.434 0.525 0.759 0.324 1.778
Thrice a day 0.369 0.477 0.440 1.446 0.568 3.681
More than 3 times a day 1.186 0.494 0.016 3.273 1.244 8.613
I feel anxious 0.085
Never
Sometimes 0.626 0.361 0.083 1.870 0.921 3.796
Always 0.896 0.404 0.026 2.451 1.110 5.410
Constant -0.945 0.501 0.059 0.389
Discussion

The present study documents change in dietary patterns among Kuwait residents during the COVID-19 pandemic. According to our results, a high proportion of Kuwaitis reported binge eating habits, a sedentary lifestyle and an increase in their weight during the quarantine. Significant predictors of weight gain among the Kuwaitis included unhealthy diet pattern, excessive consumption of snacks and subjective feelings of anxiety.

Our study reports a high prevalence of unhealthy eating habits and sedentary lifestyle during the pandemic, which contributed to a significant weight increase among the Kuwaitis. Although in the past, several studies have reported high rates of unhealthy habits and obesity among the Kuwaiti public, this situation may have worsened during the lockdown. This time of pandemic and quarantine has affected almost all aspects of life and the pattern of unhealthy eating habits have become more prevalent including excessive consumption of snacks, predicting an increase in weight of the studied population. Our study also showed that a higher proportion of respondents assume that their eating pattern has become healthier but at the same time the frequency of snacks binge eating, and night-time consumption of food showed statistical significance, leading to unhealthy patterns of food consumption. An increase in weight gain and development of unhealthy eating habits will present as a challenge in the post-COVID era, and policies must be devised to strengthen health systems to tackle this.

Another important predictor of weight included subjective feelings of anxiety during this era, which not only carry negative physical and mental health implication but also contribute to ‘stress-eating’ and ‘food cravings’ 9– 14 . Feeling anxious during this era of pandemic is natural and eating more carbohydrates and binge eating likely improves mood in the short term, but leads to gain of weight and chronic diseases incidence also contribute to poorer body image 9– 14 . This double burden of poor mental health and obesity thus presents a great challenge to the public health professionals and interventions must be devised to ensure good mental health during these trying times. Several interventions, especially psychoeducation related to this pandemic and meditation interventions, can be provided to ease off worry and stress and reduce anxiety levels among the general public.

The results from this study can serve as a guiding tool for shaping health strategy during this pandemic by health authorities. As Gulf countries grew enormously in wealth, living standards were raised, albeit at a cost of more sedentary and comfortable life routine 5, 15, 16 . Kuwait had previously developed a ‘Kuwait National Programme for Healthy Living (2013-2017)’ 17 ; authorities can develop a strategic plan to counter harmful effects of this pandemic on health that are originating from sedentary lifestyle, unhealthy eating patterns and psychological issues.

Limitations

Despite its large sample size, this study has several limitations which need to be considered for careful interpretation of its results. Most important limitations include a convenience and snowballing approach for collection of data as opposed to random sampling. Cross-sectional nature of this study limits inferences related to causality and temporality and use of a subjective question for estimating anxiety levels limit validity of these results and also introduce recall bias. Future studies should consider a prospective study design and use of valid and reliable questionnaires like the Generalized Anxiety Disorder 7-item scale 18 .

 Data availability Underlying data

Figshare: Diet Kuwait.csv, https://doi.org/10.6084/m9.figshare.12706223.v1 19 .

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

 Extended data

Figshare: CovidKuwaitWt-Survey.pdf, https://doi.org/10.6084/m9.figshare.12709631.v1 20 .

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Acknowledgements

The authors thank Dr. Ahmed Waqas, doctoral fellow at the University of Liverpool, Liverpool, UK, for providing assistance in data analysis.

 Brooks SK Webster RK Smith LE : The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20. 32112714 10.1016/S0140-6736(20)30460-8 7158942 Kaplan J Frias L McFall-Johnsen M : A third of the global population is on coronavirus lockdown — here’s our constantly updated list of countries locking down and opening up. 2020. Reference Source Zohn Rosen SA Cheskie Rosenzweig WL Rosmarin DH : Anxiety and distress among the first community quarantined in the U.S due to COVID-19: Psychological implications for the unfolding crisis. J Chem Inf Model. 2020;53:1689–99. 10.31234/osf.io/7eq8c Alnohair S : Obesity in Gulf Countries. Int J Health Sci (Qassim). 2014;8(1):79–83. 24899882 10.12816/0006074 4039587 Badr HE : Differences in physical activity, eating habits and risk of obesity among Kuwaiti adolescent boys and girls : a population-based study. 2017;1–9. 10.1515/ijamh-2016-0138 Muscogiuri G Barrea L Savastano S : Nutritional recommendations for CoVID-19 quarantine. Eur J Clin Nutr. 2020;74(6):850–851. 32286533 10.1038/s41430-020-0635-2 7155155 State of kuwait: COVID-19 updates. 2020. Reference Source Zachary Z Brianna F Brianna L : Self-quarantine and weight gain related risk factors during the COVID-19 pandemic. Obes Res Clin Pract. 2020;14(3):210–6. 32460966 10.1016/j.orcp.2020.05.004 7241331 Vidovi V Henigsberg N Jure V : Anxiety and Defense Styles in Eating Disorders. 2003;1:125–34. Reference Source Aoun C Nassar L Soumi S : The Cognitive, Behavioral, and Emotional Aspects of Eating Habits and Association With Impulsivity, Chronotype, Anxiety, and Depression: A Cross-Sectional Study. Front Behav Neurosci. 2019;13:204. 31555108 10.3389/fnbeh.2019.00204 6742717 Higgins DM Dorflinger L MacGregor KL : Binge eating behavior among a national sample of overweight and obese veterans. Obesity (Silver Spring). 2013;21(5):900–3. 23784891 10.1002/oby.20160 Verplanken B : Beyond frequency: Habit as mental construct. Br J Soc Psychol. 2006;45(Pt 3):639–56. 16984725 10.1348/014466605X49122 Yannakoulia M Panagiotakos DB Pitsavos C : Eating habits in relations to anxiety symptoms among apparently healthy adults. A pattern analysis from the ATTICA Study. Appetite. 2008;51(3):519–25. 18495296 10.1016/j.appet.2008.04.002 Schulz S Laessle RG : Associations of negative affect and eating behaviour in obese women with and without binge eating disorder. Eat Weight Disord. 2010;15(4):e287–93. 21406953 10.1007/BF03325311 Musaiger AO : Consumption, Health Attitudes and Perception Toward Fast Food Among Arab Consumers in Kuwait: Gender Differences. Glob J Health Sci. 2014;6(6):136–43. 25363129 10.5539/gjhs.v6n6p136 4825490 Balhareth A Meertens R Kremers S : Overweight and obesity among adults in the Gulf States: A systematic literature review of correlates of weight, weight-related behaviours, and interventions. Obes Rev. 2019;20(5):763–93. 30653803 10.1111/obr.12826 6850146 Behbehani K : Kuwait National Programme for Healthy Living : First 5-Year Plan ( 2013 – 2017 ). Med Princ Pract. 2017;23 suppl 1(Suppl 1):32–42. 24662472 10.1159/000358884 5586954 Spitzer RL Kroenke K Williams JBW : A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med. 2006;166(10):1092–7. 16717171 10.1001/archinte.166.10.1092 Al Mughaimis N : Diet Kuwait.csv. figshare. Dataset.2020. http://www.doi.org/10.6084/m9.figshare.12706223.v1 AlMughamis N : CovidKuwaitWt-Survey.pdf. figshare. Preprint.2020. http://www.doi.org/10.6084/m9.figshare.12709631.v1 10.5256/f1000research.27925.r80146 Reviewer response for version 1 Maric Gorica 1 Referee Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

Competing interests: No competing interests were disclosed.

 8 3 2021 Copyright: © 2021 Maric G 2021 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

First, I would like to thank the Editorial Team for providing me chance to review an article for F1000 Research.

The manuscript entitled "Poor eating habits and predictors of weight gain during the COVID-19 quarantine measures in Kuwait: a cross sectional study“ presents data on eating habits and changes in body weight along with its predictors in the population of  Kuwait city. Although the topic is very actual and important from many aspects, there are some methodological issues that need to be clarified:

Using Whatsapp groups for reaching participants in my opinion represents significant sampling bias, maybe some people don’t use this app, other (elderly) are not so familiar with its use, etc.

The questionnaire: The data on the questionnaire development is scarce. Did the authors use some pre-existing questionnaire or developed the new one? If so, how did they make it, based on which sources? What were the results of pre-pilot testing, did the questionnaire undergo any changes after that?

How many people were invited for the participation in the survey, and how many of them accepted and how many refused participation in the study?

Please, add the age distribution by categories as well.

Are the age and gender distribution in study sample in accordance with the age and gender of Kuwait city population?

Self-measurement of the body weight should also be stated as a study limitation.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Epidemiology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

 10.5256/f1000research.27925.r79339 Reviewer response for version 1 Alhussain Maha H. 1 Referee https://orcid.org/0000-0003-0168-6721 Department of Nutrition and Food Sciences, College of Agricultural and Food Sciences, King Saud University, Riyadh, Saudi Arabia

Competing interests: No competing interests were disclosed.

 4 3 2021 Copyright: © 2021 Alhussain MH 2021 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The study was estimating the burden of poor eating habits, fluctuations in weight and its predictors among 522 Kuwaiti public. The main finding is that people with reporting unhealthy diets were 4.5 times more likely to report an increase in weight.

There are several comments/suggestions that must improve this work: 

Inadequate methods description. For example, does the study sample include children? If so, was the informed consent provided from parents/guardians? The authors mentioned that attempts were made to exclude non-Kuwaiti nationals. It is not clear whether all non-Kuwaiti national have been excluded or not.

Data were analysed by SPSS, but were the data cleaned? What cleaning was done, should be included.

Were the numerical data tested for normality?

What was the response rate? 

Self-assessment body weight measures should acknowledge as a limitation.

The conclusion is inadequate and need to be expanded according to the study results.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Meal pattern, obesity, Energy balance.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.