Confectionery consumption and overweight, obesity, and related
outcomes in children and adolescents: a systematic review and
meta-analysis1,2
Constantine E Gasser,3,4* Fiona K Mensah,3–5 Melissa Russell,3,4 Sophie E Dunn,3,4 and Melissa Wake3–5
3
The University of Melbourne, Melbourne, Australia; 4Murdoch Childrens Research Institute, Melbourne, Australia; and 5The Royal Children’s Hospital,
Melbourne, Australia
ABSTRACT
Background: Many calorie-rich dietary components contribute to
obesity. However, the contribution of confectionery to obesity in
children and adolescents has not been well established.
Objective: In this systematic review and meta-analysis, we hy-
pothesized that higher total, chocolate, and nonchocolate confec-
tionery consumption would be associated with higher odds
of overweight, obesity, and other obesity-related outcomes
[body mass index (BMI), BMI z score, body composition,
waist circumference, and percentage body fat] in children
and adolescents.
Design: We searched Scopus, PubMed, and reference lists of
pertinent reviews, supplemented by expert contact, for random-
ized controlled trials (RCTs) and observational studies published
between 1990 and 31 March 2015, and we conducted separate
meta-analyses for categorical and continuous ORs and for total,
chocolate, and nonchocolate confectioneries with the use of a
random-effects model.
Results: A total of 19 studies were included in the systematic re-
view, and the cross-sectional results of 11 studies (w177,260 par-
ticipants) were included in the meta-analysis. In the meta-analysis,
which examined the combined outcome of overweight and obe-
sity, the odds of overweight or obesity were 18% lower (OR:
0.82; 95% CI: 0.69, 0.97) for subjects in the highest category
of consumption than for a reference category of consumption. Thus,
a 1-time/wk or a 1-U increase in consumption was associated
with a 13% (OR: 0.87; 95% CI: 0.85, 0.88) decrease in the odds
of overweight or obesity. Associations were similarly inverse
for chocolate and nonchocolate confectioneries. In the longitu-
dinal studies and the RCT included in the review, no associa-
tions were observed between confectionery consumption and
overweight, obesity, or obesity-related outcomes.
Conclusions: Instead of overweight and obese children and ado-
lescents having higher confectionery intakes, this review shows
the reverse effect. This result might reflect a true inverse associ-
ation, reverse causality, or differential underreporting in heavier
individuals. Interventions may need to focus on dietary elements
other than confectionery to tackle obesity. Am J Clin Nutr
2016;103:1344–56.
Keywords: adolescent, candy, child, obesity, overweight
1344 Am J Clin Nutr 2016;103:1344–56. Printed in USA. Ó 2016 American Society for Nutrition
INTRODUCTION
Obesity is a major health issue for children and adolescents in
developed and developing countries. A child or adolescent who is
obese has increased risk of obesity in adult life (1). Many lifestyle
factors (2, 3), including diet and physical activity, contribute to
obesity.
Sugar is an important component of the human diet that comes in
a variety of vehicles. However, the contribution of only some of
these vehicles to obesity has been thoroughly examined. Some
previous systematic reviews or studies have shown associations
between the consumption of sugar-sweetened beverages and weight
gain (4, 5), a higher prevalence of obesity (6), or higher BMI (7, 8)
or adiposity (9, 10) in children and/or adults. Likewise, the re-
placement of sugar-sweetened beverages with other drinks has been
shown to be inversely associated with weight gain (11). This re-
search is extremely important because soft drinks and soda col-
lectively comprise the highest sources of carbohydrate, total sugar,
and added sugar in the diets of 2- to 18-y-old US children (12).
One sugar-laden food that has not been thoroughly examined
in relation to obesity is confectionery. This examination is im-
portant from a public health point of view because confectionery
is ubiquitous in many societies. On the one hand, candy alone is
the fifth highest source of added sugar (13) and the ninth highest
source of carbohydrate (14) in the diets of 2- to 18-y-old US
children (13, 14). Furthermore, chocolate confectionery is often
high in fat including in saturated fat (15). On the other hand,
chocolate consumption may have real health benefits (16–18). A
1
The authors reported no funding received for this study. MW is supported
by an Australian National Health and Medical Research Council (NHMRC)
Senior Research Fellowship (1046518), and FM is supported by an NHMRC
Early Career Fellowship (1037449). Research at the Murdoch Childrens
Research Institute is supported by the Victorian Government’s Operational
Infrastructure Support Program.
2
Supplemental Tables 1–3 are available from the “Online Supporting Ma-
terial” link in the online posting of the article and from the same link in the
online table of contents at http://ajcn.nutrition.org.
*To whom correspondence should be addressed. E-mail: constantine.
gasser@mcri.edu.au.
Received July 29, 2015. Accepted for publication March 15, 2016.
First published online April 13, 2016; doi: 10.3945/ajcn.115.119883.
 CONFECTIONERY CONSUMPTION AND OBESITY
systematic review and meta-analysis revealed an association
between the consumption of chocolate and reduced risks of
cardiovascular disease and stroke (16). Moreover, the con-
sumption of flavonoid-rich cocoa, which is a component in
chocolate, has been associated with decreased systolic blood
pressure, whereas it has not been associated with BMI (18).
Higher intake of chocolate or cocoa, which is an ingredient in
confectionery, has been associated with lower diastolic blood
pressure and LDL cholesterol and slightly higher HDL cho-
lesterol (17). However, all of these systematic reviews (16–18)
have been conducted in adults, and none of the reviews con-
sidered nonchocolate confectionery.
Globally, many individual studies have explored the associ-
ation between confectionery consumption and obesity-related
outcomes, which have yielded conflicting results (19–24) in
terms of positive (19, 20), inverse (21, 22), or null (23, 24) re-
lations. However, to our knowledge, no previous systematic
review has examined the link between confectionery consump-
tion and obesity-related outcomes in children and adolescents.
The aim of this systematic review and meta-analysis was to
investigate the hypothesis that higher confectionery consump-
tion would predict higher odds of overweight, obesity, and other
obesity-related outcomes in children and adolescents. A sec-
ondary aim was to determine whether this association differed
depending on the type of confectionery (chocolate or non-
chocolate, which differ greatly in sugar and fat concentrations)
that children or adolescents consumed.
METHODS
Literature search
Scopus (http://www.scopus.com/) and PubMed (http://www.
ncbi.nlm.nih.gov/pubmed) were searched to identify relevant
articles published up until 31 March 2015. Synonyms for candy
or confectionery were used for the exposure variable or in-
tervention group, and overweight, obesity, and related synonyms
were used for the outcome variables. The final search strategy for
both databases is shown in Supplemental Table 1. In addition,
CEG hand searched the reference lists of relevant reviews and
contacted an expert in the field. Finally, CEG searched the ref-
erence list of an article (24) provided by an expert in the field
and for references that cited this article. CEG undertook all
searches after a consultation with a librarian and a consultation
and review by FKM, MR, and MW to devise a comprehensive
search strategy. SED blindly rescreened a sample of 500 ab-
stracts (w20%). None of the 447 articles that SED excluded on
the basis of their title or abstract were included in the systematic
review.
Study selection
Randomized controlled trial (RCT) and observational (pro-
spective cohort, case-control, and cross-sectional) studies were
included in the systematic review. Eligible RCTs included $1
intervention group who received confectionery, which was de-
fined as candy, chocolate, lollies, soft sweets, jellies, and/or
chewing gum (provided that this was not the only exposure), and
a control group who did not receive an alternative snack. Eligible
observational studies were those that included confectionery as an
1345
exposure and any obesity-related outcome (overweight, obesity,
BMI, BMI z score, body composition, waist circumference, and/
or percentage of body fat) and 1) reported a measure of the effect
between the exposure and one or more of the outcomes or 2)
compared proportions of people of different weights (e.g., normal
weight, overweight, and obese) who consumed confectionery.
Possible exposures included the percentages of daily energy or
calories from confectionery provided that the other inclusion
criteria were also met.
The following publications were excluded from the systematic
review and meta-analysis: nonhuman studies; non-English
studies; studies published before January 1990 (generally con-
sidered to predate the child obesity epidemic); studies that were
only conducted in adults (all participants $18 y of age) or in
which the outcomes were only studied in adults; studies that
looked at different exposures and/or outcomes or lacked expo-
sures and/or outcomes; any publication types apart from original
articles; studies in which confectionery was grouped with other
foods or drinks such as chocolate powders or chocolate spreads;
studies in which confectionery was grouped with other foods
and/or drinks in a food pattern; studies that looked at Bengali
sweets; trials with no control group; and studies in which
chewing gum was the only exposure. In some articles, the term
sweets or confectionery was used without definition; in these
cases, it was not clear whether the terms referred to dessert-type
foods or to the candy type confectionery of interest to this review.
To resolve these discrepancies, CEG contacted the corresponding
or other authors of these articles by e-mail. Eleven articles, in
which there was either a discrepancy in the term sweets or con-
fectionery after e-mail contact or no reply received from any of
the authors, were excluded from the systematic review.
Data extraction
For observational studies, the following information was
extracted when provided: first author; year of publication; study
population; sample size; ages of participants (mean 6 SD
baseline age or age range); study duration (for prospective co-
hort studies); dietary assessment method [food-frequency ques-
tionnaire (FFQ), other questionnaire or survey, dietary recalls,
or food diary]; outcome assessment method; covariates and
stratification (if applicable); type of confectionery (for studies
in the meta-analysis); and categories compared or the interpretation
of continuous ORs (for studies in the meta-analysis). When
possible, we preferentially extracted ORs with adjustment
for the maximum possible number of variables that assessed
the association between confectionery consumption and over-
weight and/or obesity. When available, ORs from any sub-
group analyses that the researchers performed were also
extracted.
For RCTs, the following information was extracted: first
author; year of publication; study population; sample size;
age range of participants; baseline BMI, waist circumfer-
ence, and percentage of body fat; study duration; study de-
sign; intervention; control; outcome assessment method; and
covariates. A single rater (CEG) extracted all data with close
supervision and review by FKM, MR, and MW. SED blind
duplicated the data-extraction process by re-extracting data from
100% of included studies, and discrepancies were resolved
through consultation with a third party (FKM).
1346 GASSER ET AL.
Data synthesis and analysis
The meta-analyses investigated how confectionery con-
sumption was associated with the combined outcome of over-
weight and obesity. Because of the variation in the types of results
provided in the included publications, only cross-sectional
studies that provided ORs or cross-sectional results from cohort
studies that provided ORs (25) (n = 11) were combined in the
meta-analyses because these were the most-common measures
of effect. We performed separate meta-analyses for ORs for
categorical exposures (categorical ORs) and ORs for continuous
exposures (continuous ORs). If separate ORs were provided for
overweight and obesity, both ORs were included in the meta-
analysis. For categorical ORs, we estimated combined ORs,
specifically for chocolate and nonchocolate confectioneries, in
2 additional meta-analyses.
Because of the heterogeneity in study designs, longitudinal
ORs from a prospective cohort study (25) and an OR from a case-
control study (26) were not combined with those of the other
studies. However, in sensitivity analyses, we repeated the meta-
analyses and also included the relevant additional ORs from
a prospective cohort study (25) and a case-control study (26),
which were excluded from the main analyses because of the
added heterogeneity in the study design. We also performed
sensitivity analyses separately for categorical and continuous
ORs in which only studies that looked at chocolate and non-
chocolate confectioneries combined were included.
Stata/IC 14.0 software (StataCorp LP) was used to perform all
statistical analyses. The random-effects model was used for all
meta-analyses because of the heterogeneity in the included
studies (27) with the use of the metan command. Furthermore,
publication bias was investigated with the use of Funnel plots
and Egger’s test to test for small-study effects with the use of
the metafunnel and metabias commands (StataCorp LP),
respectively.
Finally, meta-regression analyses were performed to in-
vestigate possible sources of heterogeneity with the use of the
metareg command (StataCorp LP). I2 percentages (percentages
of between-study heterogeneity that were due to the variation in
the true treatment effect instead of a sampling variability) and t 2
values (between-study variance) were used to measure hetero-
geneity. Possible sources of heterogeneity that were considered
were as follows: whether overweight or obesity was measured or
self-reported; the continent of publication; the year of publica-
tion (before or after 2010); whether parental education, social
class, and/or family income was adjusted for; the sex of par-
ticipants; whether adjustment for sex or stratification by sex was
performed; how the exposure was measured (FFQ, other ques-
tionnaire or survey, dietary recalls, or food diary); whether ad-
justment for age was performed; whether adjustment for
underreporting was performed (for categorical ORs); and, for
continuous ORs, the interpretation of the OR (specifically,
whether the OR was for a 1-U increase or a 1-time/wk increase
in confectionery consumption).
RESULTS
Literature search
The search strategy identified 2690 citations from the data-
bases (Figure 1). Of these citations, 140 of them were dupli-
cates, and 2368 citations were irrelevant, on the basis of their
titles or abstracts. Another 7 articles were located from the
reference lists of reviews, and one article (24) was identified
from an expert in the field, which left 190 articles for the full-
text review. Ultimately, the systematic review included 19
studies, whereas the meta-analyses included 10 cross-sectional
studies plus results from the cross-sectional component of one
prospective cohort study (25).
Characteristics of the 11 studies included in the meta-
analyses
The characteristics of the 11 studies (2, 3, 15, 21–23, 25, 28–
31) included in the meta-analyses (n $ 177,260) are shown in
Table 1. Six studies (3, 21, 22, 25, 29, 30) were performed in
Europe, 3 studies (23, 28, 31) were conducted in the Middle
East, one study (15) was performed in the United States, and one
study (2) was conducted in 34 different countries. Ten studies (2,
3, 15, 21, 22, 25, 28–31) included both sexes, and one study (23)
only included male subjects. The ages of children and adoles-
cents ranged from 2 to 18 y across the studies. Three studies (23,
28, 31) only considered chocolate consumption; the other
studies (2, 3, 15, 21, 22, 25, 29, 30) also considered non-
chocolate confectionery. Researchers used FFQs in 6 studies (2,
3, 23, 25, 29, 31), other self-report questionnaires or surveys in 3
studies (22, 28, 30), a precoded food diary in one study (21), and
in-person 24-h dietary recalls in one study (15). Three studies (2,
22, 31) reported continuous ORs, whereas the other 8 studies (3,
15, 21, 23, 25, 28–30) reported categorical ORs. The 8 studies
(3, 15, 21, 23, 25, 28–30) that reported categorical ORs all had
different exposure categories for confectionery consumption.
The specific definitions of overweight and obesity varied
slightly between studies (Table 1). Furthermore, 8 studies con-
sidered the combined outcome of overweight and obesity (2, 3,
23, 25, 28–31), 2 studies considered overweight and obesity
separately (15, 22), and one study (21) only considered over-
weight. Moreover, for the determination of whether participants
were overweight or obese, only 7 studies (3, 15, 22, 23, 28, 29,
31) used measured height and weight, whereas the remaining 4
studies (2, 21, 25, 30) relied on self-reported height and weight.
Included covariates, when studying the association between
confectionery consumption and overweight and/or obesity, dif-
fered between studies. Three studies (3, 23, 28) presented un-
adjusted results [only for girls in Santiago et al. (3)]. Only 4
studies (21, 22, 25, 29) adjusted for variables related to socio-
economic status, specifically for parental education, social class,
or family income. Five studies (2, 15, 21, 22, 30) adjusted for sex,
3 studies (3, 23, 28) presented results that were stratified by sex,
and the remaining 3 studies (25, 29, 31) presented results that
were neither stratified by nor adjusted for sex. Four studies (2, 15,
21, 22) controlled for age or the age group, and only one study
(29) controlled for the underreporting of energy intake, which
was determined by the ratio of total energy intake to the basal
metabolic rate (29).
Association between confectionery consumption and the
combined outcome of overweight and obesity
All meta-analyses showed inverse associations between con-
fectionery consumption and the combined outcome of overweight
 CONFECTIONERY CONSUMPTION AND OBESITY 1347

FIGURE 1 Flowchart showing the search strategy and selection of studies for inclusion in the systematic review and meta-analysis. Data-
bases used were as follows: Scopus (http://www.scopus.com/) and PubMed (http://www.ncbi.nlm.nih.gov/pubmed). RCT, randomized controlled
trial.

and obesity. In other words, individuals who reported higher
confectionery intakes had lower odds of overweight and/or
obesity. The findings were highly consistent in the size and
direction for all analyses conducted. The pooled categorical OR
for overweight and obesity for the comparison of the highest
category of total confectionery consumption with a reference
category [or, in the study by Ramos et al. (30), the comparison
of the daily or medium consumption of sweets in overweight or
obese dieters with the daily or medium consumption of sweets
in nonoverweight dieters] was 0.82 (95% CI: 0.69, 0.97)
(Figure 2).
Sex (I2 = 42.34%, t 2 = 0.01) and sex adjustment (I2 = 42.89%,
t = 0.02) appeared to explain a substantial proportion of the
2
heterogeneity (compared with I2 = 66.64% and t2 = 0.07 from
the unadjusted regression). None of the other listed covariates
explained a substantial proportion of the heterogeneity (results
not shown).
The pooled continuous OR for overweight and obesity that was
associated with a 1-time/wk (22, 31) [or 1-U (2)] increase in
confectionery consumption was 0.87 (95% CI: 0.85, 0.88)
(Figure 3). For meta-regression analyses for all continuous ORs,
none of the listed covariates explained a substantial proportion
of the heterogeneity (results not shown).
The pooled categorical OR for overweight and obesity for the
comparison of the highest category of chocolate consumption
with a reference category was 0.80 (95% CI: 0.71, 0.92) (Figure
4). Finally, the pooled categorical OR for overweight and obe-
sity for the comparison of the highest category of nonchocolate
confectionery consumption with a reference category was 0.78
(95% CI: 0.71, 0.86) (Figure 5).
After sensitivity analyses were performed, in which the rel-
evant additional ORs from a prospective cohort study (25) and
a case-control study (26) were added into each meta-analysis,
we observed inverse associations of similar magnitudes for all
TABLE 1
Characteristics and summary of all observational studies included in the meta-analysis1
1348

Study population,
Study including Dietary assessment Outcome-assessment Covariates; Type of
(reference) sample size Baseline age, y2 method method stratification confectionery Categorical or continuous
3
Musaiger et al., 735 students (339 15–18 Prevalidated self- Obesity [including Unadjusted; stratified Chocolate Categorical ($4
2014 (28) males; 396 females) report questionnaire overweight and by sex compared with
from levels 10–12, obese adolescents ,4 times/wk)
governmental (i.e., those with
secondary schools, BMI $85th
Bahrain percentile for their
age and sex)];
measured by
investigators
Amin et al., 1139 Saudi Arabian 10–14 Interview of students Overweight (BMI No adjustments Chocolate Categorical ($1 time/d
2008 (23) males, grades 5–6, 16 with the use of $85th percentile) compared with
public primary items from the and obesity (BMI 1–2 times/wk)
schools, Al Hassa validated Youth and .95th percentile)
governate, Saudi Adolescence FFQ (combined
Arabia (32, 33) outcome) as
defined by Cole
et al. (34);
measured by
investigators
Andersen et al., 1432 grade 4 and 8 Eighth grade: girls, 18-page precoded Overweight as defined Adjusted for age, sex, Chocolate and Categorical (fourth
2005 (21) pupils. Random 12.9 [13.0] (13.0, food diary with 277 by Cole et al. (34); social class, nonchocolate, compared with first
sample from 13.0)4; boys, 12.9 items used on 4 self-reported height watching television collectively quartiles of
GASSER ET AL.

countrywide cross- [13.0] (13.0, 13.0) consecutive days and weight and/or with the use consumption of
sectional dietary Fourth grade: girls, confirmed by of the computer, sweets)
survey, 2000, Norway 8.9 [9.0] (9.0, 9.0); validation studies energy, and eating
boys, 8.9 [9.0] (9.0, breakfast
9.0)
Chacar and 2547 adolescents (1416 11–18 FFQ Overweight, including Adjusted for food Chocolate Continuous (1-time/wk
Salameh, females; 1131 males) obesity, as defined frequency increase in
2011 (31) from a random by Cole et al. (34); consumption)
sample of 16 public measured by
schools, Lebanon investigators
(Continued)
TABLE 1 (Continued )

Study population,
Study including Dietary assessment Outcome-assessment Covariates; Type of
(reference) sample size Baseline age, y2 method method stratification confectionery Categorical or continuous

Pei et al., 2565 school-aged 122.5 6 2.75 82-item FFQ Overweight Adjusted for energy Chocolate and Categorical (highest
2014 (29) children (1308 males completed by [including obesity intake from other nonchocolate, compared with
and 1257 females) in parents (i.e., children with groups, city, family collectively and lowest tertiles of
the GINIplus and a BMI z score .1 income, parental separately total, chocolate, and
LISAplus studies, SD)]; measured by education and screen nonchocolate
Germany physicians time, and confectioneries)
underreporter
compared with
plausible energy
intake reported for
total confectionery
consumption;
stratified by
chocolate or
chocolate bars
compared with soft
sweets in one analysis
Kristiansen Bergen Growth Study, 6–15.5 Questionnaire Overweight [BMI (in Adjusted for age Chocolate and Continuous (1-time/wk
et al., 2013 Norway; n = 2778 completed by kg/m2) .25] and group, sex, and nonchocolate, increase in
(22) parents obesity (BMI .30) parental education collectively consumption)
as defined by Cole
et al. (34); measured
by investigators
Santiago et al., 2814 children (1418 6–12 FFQ Overweight and Unadjusted (girls) and Chocolate and Categorical ($1
2013 (3) boys; 1396 girls) obesity (combined adjusted for sports nonchocolate, compared with
participating in the outcome) as defined activities, breakfast collectively ,1 time/d)
“Feed their health” by Cole et al. (34); every day, fruit
program, Spain measured by consumption, bun
pharmacists consumption, and
CONFECTIONERY CONSUMPTION AND OBESITY

fast-food
consumption (boys);
stratified by sex
Huus et al., ABIS study, Sweden; 2.5 and 5 30-item FFQ at 2.5 y Overweight and obesity Adjusted for mother’s Chocolate and Categorical (daily
2009 (25)6 n $ 50327 of age; 34-item FFQ (combined outcome) education, father’s nonchocolate, compared with
at 5 y of age as defined by Cole education, mother’s separately 1–2 times/wk of
et al. (34); weight BMI, father’s BMI, candy and chocolate
and height self- and heredity for consumption)
reported by parents; diabetes
weight and height at
5 y of age validated
by information from
the Child Health
Clinics
(Continued)
1349
TABLE 1 (Continued ) 1350

Study population,
Study including Dietary assessment Outcome-assessment Covariates; Type of
(reference) sample size Baseline age, y2 method method stratification confectionery Categorical or continuous

Ramos et al., 9444 school students 13.78 (children aged HBSC survey Overweight and Adjusted for country Chocolate and Categorical (daily or
2013 (30) participating in the 11, 13, and 15) obesity (combined and sex nonchocolate, medium consumption
HBSC, England and outcome), as collectively of sweets in
Spain defined by Cole overweight or obese
et al. (34); self- dieters compared with
reported that in nonoverweight
dieters)
O’Neil et al., 7049 children and 4132 2–18 In-person 24-h dietary Overweight (sex-and- Adjusted for sex, age, Chocolate and Categorical (consumers
2011 (15) adolescents recalls specific BMI ethnicity, and nonchocolate, compared with
(n = 11,181) who between 85th and energy; analyses collectively and nonconsumers of total,
participated in the 95th percentiles) stratified by separately chocolate, and
1999–2000, 2001– and obesity (sex- chocolate candy nonchocolate
2002, 2003–2004 and-specific BMI and sugar candy confectioneries)
NHANES, United $95th percentile); consumption
States measured by
investigators
Janssen et al., 137,593 adolescents 10–16 FFQ Overweight and Adjusted for age, sex, Chocolate and Continuous [1-U increase
2005 (2) from school classes, obesity (combined currently trying to nonchocolate, in intake (moving from
participating in the outcome) as defined lose weight, fruit collectively one category to the
2001–2002 HBSC, by Cole et al. (34); intake, vegetable next defined as a 1-U
35 countries (31 self-reported intake, soft-drink increase)] compared
European countries intake, physical with lowest intake.
GASSER ET AL.

plus Russia, Canada, activity level, Categories: never,

Israel, and United television-viewing ,1 time/wk, 1 time/wk,
States) time, and computer 2–4 d/wk, 5–6 d/wk,
use 1 time/d, and .1
time/d
1
ABIS, All Babies in Southeast Sweden; FFQ, food-frequency questionnaire; GINIplus, German Infant Nutritional Intervention Plus Environmental and Genetic Influences on Allergy Development; HBSC,
Health Behavior in School-Aged Children Study; LISAplus, Influences of Lifestyle-Related Factors on the Immune System and the Development of Allergies in Childhood Plus Air Pollution and Genetics.
2
All ages are expressed in years unless otherwise specified.
3
Range (all such values).
4
Mean; median in brackets; 25th percentile, 75th percentile in parentheses (all such values).
5
Mean 6 SD months.
6
Study duration of 5 y.
7
For associations between chocolate and candy consumption at 5 y of age and overweight and obesity at 5 y of age, which were of interest for the meta-analyses.
8
Mean.
 CONFECTIONERY CONSUMPTION AND OBESITY 1351

FIGURE 2 Forest plot showing the pooled effect of total confectionery consumption on overweight and obesity for studies that reported categorical ORs
with the use of the random-effects model (n $ 34,342). The pooled effect of confectionery consumption on overweight and obesity is shown for the highest
category of consumption compared with a reference category of consumption. Solid diamonds denote individual ORs, shaded squares denote relative sizes of
the weights, reflecting study sizes, horizontal lines denote individual 95% CIs, the dotted vertical line denotes the point estimate for the pooled OR, the open
diamond corresponds to the pooled OR including its 95% CI, and the black vertical line indicates the line of no effect.

meta-analyses (results not shown). Furthermore, the results of RCTs

sensitivity analyses, which only included studies that looked at
chocolate confectionery and nonchocolate confectionery com-
bined in the meta-analyses for categorical and continuous ORs,
did not materially differ (results not shown).
Publication bias
It did not appear that there was strong evidence of publication
bias for any of the meta-analyses. All funnel plots were rea-
sonably symmetrical about the pooled OR with most ORs
contained within the 95% confidence limits (Figure 6). P values
from Egger’s test that correspond to Figure 6A–D were 0.38,
0.16, 0.08, and 0.72, respectively, indicating that there was not
strong evidence of publication bias. However, for the meta-
analyses performed on categorical ORs (Figures 2, 4, and 5),
note that the relatively small number of studies reduced the
power and suggested caution should be taken when interpreting
these values.
Review of studies not included in the meta-analyses
Results of 9 of the 19 studies (one RCT and 8 observational
studies) were not included in the meta-analyses (Supplemental
Tables 2 and 3).
In an Australian school-based RCT, Chan et al. (24) observed
no associations between dark-chocolate consumption and obesity-
related outcomes. After adjustment for age, sex, parent education,
and the corresponding baseline measure and after accounting for
clustering by class, the mean BMI after the 7-wk study was 0.02 U
lower (95% CI: 20.3, 0.2 U; P = 0.9) in the intervention
(chocolate) group than in the control (no-chocolate) group (24).
However, the mean waist circumference after the study was 0.3 U
higher (95% CI: 20.5, 1.1 U; P = 0.4) in the intervention group
than in the control group after adjustment for the same vari-
ables (24). Finally, the mean percentage of body fat after the
study was 0.2 U higher (95% CI: 21.4, 1.7 U; P = 0.8) in the in-
tervention than in the control group, after adjustment for the same
variables (24).
Cohort studies
In the All Babies in Southeast Sweden study, Huus et al. (25)
showed that, after adjustment for mother’s and father’s edu-
cation and BMI and heredity for diabetes, the OR for over-
weight and obesity at 5 y of age for the comparison of subjects
who consumed chocolate daily with those who consumed
chocolate 1–2 times/wk at 2.5 y of age was 1.20 (95% CI: 0.21,
6.87; P = 0.84) (25). Similarly, after adjustment for the same var-
iables, the OR for overweight and obesity at 5 y of age for the
1352 GASSER ET AL.

FIGURE 3 Forest plot showing the pooled effect of total confectionery consumption on overweight and obesity for studies that reported continuous ORs
with the use of the random-effects model (n = 142,918). The pooled effect of confectionery consumption on overweight and obesity is shown for a 1-time/wk
(22, 31) [or 1-U (2)] increase in consumption. The study by Chacar and Salameh (31) only considered chocolate confectionery; all other studies considered
chocolate and nonchocolate confectioneries, collectively. Solid diamonds denote individual ORs, shaded squares denote relative sizes of the weights, reflecting
study sizes, horizontal lines denote individual 95% CIs, the dotted vertical line denotes the point estimate for the pooled OR, the open diamond corresponds to
the pooled OR including its 95% CI, and the black vertical line indicates the line of no effect.

comparison of subjects who consumed candy daily with those who
consumed candy 1–2 times/wk at 2.5 y of age was 2.13 (95% CI:
0.59, 7.68; P = 0.25) (25).
In addition, with the use of linear mixed-effects modeling and
adjustment for parental overweight, servings of fruit and vege-
tables, and age at menarche, Phillips et al. (35) observed little
evidence of an association between candy consumption and BMI
z scores over a 10-y period (P-trend = 0.09). Also, after ad-
justment for parental overweight and the percentage of calories
from protein, Phillips et al. (35) showed no association between
candy consumption and the percentage of body fat over the same
period (P-trend = 0.35).
Case-control studies
In a Polish study, Jodkowska et al. (36) showed an inverse
association between the consumption of sweets (chocolates,
candies, lollipops, and jellies) and overweight. Overall, 39.4%,
45.4%, and 15.1% of overweight adolescents consumed sweets
#1, 2–6, and 7 times/wk, respectively, compared with 21.0%,
50.0%, and 29.0%, respectively, for their nonoverweight coun-
terparts (for comparison of the 2 groups, P-overall , 0.001)
(36). Conversely, in a recent Iranian study, Baygi et al. (26) reported
no association between chocolate consumption and obesity. After
age, sex, physical activity, and energy intake were controlled for,
the OR for obesity associated with a 1-time/mo increase in choc-
olate consumption was 1.03 (95% CI: 0.99, 1.08) (26).
Cross-sectional studies
Four cross-sectional studies (19, 20, 37, 38) were excluded
from the meta-analysis because they did not provide ORs
(Supplemental Table 3). In the Arab Teens Lifestyle Study, Al-
Haifi et al. (20) showed no associations between waist circum-
ference and the consumption of sweets (candy or chocolate) in
both sexes and between BMI and the consumption of sweets in
boys. The proportions of variances in waist circumference ex-
plained by sweets were 0.001 (P = 0.50) and 0.005 (P = 0.14)
for boys and girls, respectively. The proportion of variance in
BMI explained by sweets was 0.006 (P = 0.11) for boys. In
contrast, Al-Haifi et al. observed a positive association between
the consumption of sweets and BMI in girls. The proportion of
variance in BMI explained by sweets was 0.015 (P = 0.01) in
girls (20).
 CONFECTIONERY CONSUMPTION AND OBESITY 1353

FIGURE 4 Forest plot showing the pooled effect of chocolate confectionery consumption on overweight and obesity for studies that reported categorical
ORs with the use of the random-effects model (n $ 20,652). The pooled effect of chocolate consumption on overweight and obesity is shown for the highest
category of consumption compared with a reference category of consumption. Solid diamonds denote individual ORs, shaded squares denote relative sizes of
the weights, reflecting study sizes, horizontal lines denote individual 95% CIs, the dotted vertical line denotes the point estimate for the pooled OR, the open
diamond corresponds to the pooled OR including its 95% CI, and the black vertical line indicates the line of no effect.

In a US study, Bandini et al. (37) showed that, in the unadjusted
analysis, mean 6 SD intakes of candy were 31 6 36 and 113 6
110 kcal/d in obese and nonobese adolescents, respectively (for
comparison of the 2 groups, P , 0.01). Moreover, in the un-
adjusted analysis, the mean 6 SD percentages of daily intakes
from candy were 2.0% 6 2.5% and 4.5% 6 3.5% in obese and
nonobese adolescents, respectively (P , 0.01) (37). By contrast,
after adjustment for the degree of underreporting, Bandini et al.
(37) showed no association between the percentage of daily
energy intake from candy and obesity status. Similarly, in the
National Diet and Nutrition Survey of Children in the United
Kingdom, Gibson (38) reported no association between the
percentage of dietary energy from confectionery and BMI.
Finally, in a cross-sectional study performed in Greek ado-
lescents, Hassapidou et al. (19) showed that the mean 6 SD
frequencies for the weekly consumption of milk chocolate
were 1.87 6 0.30 and 0.50 6 0.80 for overweight and non-
overweight adolescents, respectively (for comparison of the 2

FIGURE 5 Forest plot showing the pooled effect of nonchocolate confectionery consumption on overweight and obesity for studies that reported
categorical ORs with the use of the random-effects model (n $ 18,778). The pooled effect of nonchocolate confectionery consumption on overweight and
obesity is shown for the highest category of consumption compared with a reference category of consumption. Solid diamonds denote individual ORs, shaded
squares denote relative sizes of the weights, reflecting study sizes, horizontal lines denote individual 95% CIs, the dotted vertical line denotes the point
estimate for the pooled OR, the open diamond corresponds to the pooled OR including its 95% CI, and the black vertical line indicates the line of no effect.
1354 GASSER ET AL.

FIGURE 6 Funnel plots with pseudo 95% confidence limits for the meta-analysis of studies that reported categorical ORs and studied the association
between total confectionery consumption and overweight and/or obesity (A), studies that reported continuous ORs and studied the association between total
confectionery consumption and overweight and/or obesity (B), studies that reported categorical ORs and studied the association between chocolate con-
sumption and overweight and/or obesity (C), and studies that reported categorical ORs and studied the association between nonchocolate confectionery
consumption and overweight and/or obesity (D). Solid vertical lines correspond to pooled ORs, dotted lines correspond to the pseudo 95% confidence limits,
and solid dots correspond to each of the ORs from the included studies. Log and loge both refer to loge for these funnel plots.

groups, P , 0.001). Moreover, the mean 6 SD frequencies for
the weekly consumption of chocolate bars were 3.78 6 1.65 and
2.50 6 0.35 for overweight and nonoverweight adolescents, re-
spectively (for comparison of the 2 groups, P , 0.001) (19).
Studies not included in the systematic review
Finally, CEG scanned the results of the 11 studies that were
excluded from the systematic review because of a discrepancy in
the term sweets or confectionery. Again, mostly inverse (n = 7
studies) associations were observed with only 3 of the 11 studies
reporting increased odds of obesity-related outcomes in subjects
who ate more confectionery.
DISCUSSION
All meta-analyses pointed to consistent inverse associations of
confectionery consumption with overweight and obesity (de-
creased odds of overweight and/or obesity for higher confec-
tionery consumption). Similarly, we also mostly observed either
null or inverse relations between confectionery consumption and
obesity-related outcomes for the studies that were further
included in the systematic review.
Just like expected findings, unexpected findings can reflect the
truth, bias, residual confounding, and/or chance. We think that
chance was unlikely because of the large sample size and the high
degree of consistency across studies and designs, which yielded
a high degree of precision in the findings of this review. Residual
confounding is later discussed as a limitation.
One possible explanation for the results is that there is a true,
directly causal, inverse association in the population. People who
consume more confectionery or sugar may consume less fat (2).
This possibility might lead to their lower weight because con-
fectionery is high in sugar, which is lower in kilojoules than fat (2).
Furthermore, the consumption of confectionery, which is high in
sugar, may lead to an increased sense of satiety (39). It is possible
that increased satiety results in a lower consumption of other foods
and, therefore, a lower weight or BMI (29). Another possibility
reflects the fact that, in contrast with other foods such as sugar-
sweetened beverages, confectionery may be a relatively smaller
and more-discretionary aspect of the diet. In some of the included
studies, confectionery was not a major contributor of energy to the
diets of participants (15, 29). For example, in the study by Pei et al.
(29), confectionery accounted for only w3.0% of the daily energy
of participants (29). Moreover, in the diets of US children and
adolescents, candy comprises only 2.8% of energy (40) and 6.8%
of added sugar (a mean daily intake of 24.9 kcal) (13). In contrast,
soda, energy, and sports drinks comprise 31.8% of added sugar
(13) in the diets of US children and adolescents.
Another possible explanation, because of the cross-sectional
nature of most included studies, is reverse causality (2, 22, 25, 29,
30, 38). Overweight or obese children or adolescents may reduce
their confectionery intake more than do nonoverweight children
or adolescents if overweight or obese children or parents believe
that it is contributing to their weight gain (2, 22, 25, 29, 30, 38).
This phenomenon might also explain why previous cross-sectional
studies have observed null associations between the consumption of
soft drinks or energy drinks and obesity-related outcomes (2, 20, 22).
 CONFECTIONERY CONSUMPTION AND OBESITY
However, reverse causality may occur to a greater extent for con-
fectionery than for other foods, such as soft drinks, if people per-
ceive confectionery to be unhealthier than other foods and/or if it is
relatively easier for them to cut out confectionery.
However, it seems equally plausible that bias in reporting was
at play in our results, possibly coexisting with reverse causality.
This likelihood would have resulted in differential underreporting
between overweight and nonoverweight individuals (41, 42). In
other words, overweight children or adolescents may underreport
their intake of confectionery to a greater extent than do those of
normal weight (41, 42). Underreporting might also explain the
absence of associations between soft-drink consumption and
obesity in previous cross-sectional studies (2, 22).
Because obesity is strongly linked to cardiometabolic disorders
(43), these findings are consistent with those of previous systematic
reviews (16–18) that have shown that higher consumption of
chocolate or cocoa, which is an ingredient in confectionery, is
associated with lower risks of cardiometabolic disorders (16) or
risk factors (17, 18). The results also complement findings by
Shrime et al. (18), which showed that the consumption of flavonoid-
rich cocoa, which is a component in chocolate, was not posi-
tively related to BMI. However, although confectionery is high
in sugar, the findings contrast with those of recent systematic
reviews, which showed positive associations between sugar-
sweetened beverages and weight gain (4, 5). Therefore, it ap-
pears that, although both confectionery and sugar-sweetened
beverages are high in sugar, they do not have the same effect
on obesity-related outcomes. This difference may be due to
the relative difference in the amount of overall energy pro-
vided from sugar-sweetened beverages and confectionery (40),
the different food form, or another factor that has not been
identified.
This systematic review has a number of strengths. First, we
searched a wide range of databases and sources in an attempt to
include all of the available evidence on the topic that has been
published since 1990. Second, the large sample size (n $
177,260) in the meta-analyses provided both power and pre-
cision that supported our conclusions. Third, only cross-sectional
results were combined in the meta-analyses. The resulting low
amount of heterogeneity in study designs means that results
were comparable between studies.
A limitation of this review is that all of the results included in
the meta-analyses and 14 studies included in the systematic
review (2, 3, 15, 19–23, 28–31, 37, 38) only assessed cross-
sectional associations. A weakness of cross-sectional designs is
that they preclude the establishment of temporality, which
means that reverse causality is possible. This possibility was
rendered less likely because there was no supporting evidence
for reverse causality in the 2 longitudinal studies (25, 35) and
the RCT (24), which were included in the systematic review.
An additional limitation was the heterogeneity in the cate-
gories of categorical ORs and interpretations of continuous ORs
that were combined in the meta-analyses. Therefore, it is important
to be cautious in interpreting the findings of the meta-analyses in
a dose-response manner. Nevertheless, the combination of these
ORs provided an insight into the association between overweight
and obesity and high confectionery consumption compared with
low confectionery consumption. Another potential limitation is
that ORs for overweight and obesity from some studies (15, 22)
were combined, which may have falsely reduced heterogeneity
1355
because more than one OR from the same study was included.
However, in making this choice, we had to balance this limitation
against the benefits of including a larger sample size and being able
to undertake fewer subgroup analyses.
Residual confounding may have occurred in the 18 observa-
tional studies, which also could have influenced the results be-
cause the studies controlled for different numbers of confounding
variables. It might also be important to collect additional data
on the physical activity and dietary patterns of participants
(15). Finally, another limitation of many of the studies was that
the researchers did not consider the quantities of confectionery
that participants consumed, only the frequency of consumption (2,
20, 25).
Typically, cross-sectional studies overestimate risk-outcome
(i.e., harmful) associations, which leads to recommendations for
additional longitudinal studies and/or RCTs. These studies could
confirm temporality and provide firmer estimates of effect sizes,
which are usually smaller than the observed cross-sectional as-
sociations. Because of the inverse associations shown in this
review, it seems unlikely that longitudinal studies would yield
greatly different conclusions. Nonetheless, this literature would
be strengthened if additional longitudinal studies and RCTs
became available. Additional research could also probe differ-
ential impacts of chocolate and nonchocolate confectioneries
(because chocolate is generally high in fat, including in saturated
fat (15), whereas nonchocolate candy is generally high in sugar
but lower in fat), the quantity of confectionery that participants
consume, and the broader dietary habits of participants (15),
which could improve the understanding of dietary patterns that
may be related to confectionery consumption and to obesity.
In conclusion, this systematic review and meta-analysis does
not reveal evidence of positive associations between confec-
tionery consumption and overweight, obesity, or other obesity-
related outcomes in children and adolescents. This review suggests
that, whatever its adverse contribution to other aspects of human
health, confectionery is not a major driver of obesity. Therefore,
it might be better to focus interventions that aim to reduce
obesity on other components of daily dietary intake.
The authors’ responsibilities were as follows—CEG: designed the re-
search, analyzed the data, and wrote the manuscript; CEG and SED: con-
ducted the research; CEG and MW: had primary responsibility for the final
content of the manuscript; FKM, MR, and MW: provided input concerning
the design of the research and supervised the analysis of the data; and all
authors: read and approved the final manuscript. The views expressed in this
article are those of the authors. None of the authors reported a conflict of
interest related to the study.
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