Repeated exposure and associative conditioning promote preschool children's liking of vegetables

Sweet and sour sips: No effect of repeated exposure to sweet or sour-tasting sugary drinks on children's sweetness preference and liking

Health agencies advocate reducing children's sweetness exposure to lower sweetness preference or liking to ultimately lower sugar intake. However, the relationship between sweetness exposure, preference, and liking remains unclear. This work investigated the influence of exposure to a sucrose-containing sweet or sour-tasting drink on sweetness preference and liking for sweet and sour products in 4-7-year-old children (n = 65). The children were randomized into three groups with one daily exposure to either the sweet drink, sour drink, or water (control group) for 14 days. Sweetness preference was assessed at baseline (t1), day 15 (t2), and two months after the intervention (t3), using a forced-choice, paired comparison test with five beverages varying in sweetness intensity. Hedonic liking for the intervention drinks, a sweet and sour yogurt, and a sweet and sour candy was evaluated using a 5-point pictorial scale. Linear mixed models revealed a significant increase in sweetness preference from t1 to t3 (F(2) = 7.46, p < 0.001). However, ANCOVA analysis indicated that this effect was not caused by the intervention. Based on linear mixed models, we observed that children's hedonic liking for sweet and sour products remained stable from t1 to t3 and was not influenced by the intervention. These findings suggest that 14 exposures to a sucrose-containing sweet or sour-tasting drink did not affect sweetness preference or liking in 4-7-year-old children.

Bean Consumption during Childhood Is Associated with Improved Nutritional Outcomes in the First Two Years of Life

Bean consumption during childhood may play a role in promoting early-life health given their high nutritional quality. To examine the associations of children's bean consumption with the socio-demographic characteristics of the child and mother and the child's nutrient intake, we analyzed data from the WIC-ITFPS-2, which followed children and their mothers at 1, 3, 5, 7, 9, 11, 13, 15, 18, and 24 months (m) following birth. Caregivers (mostly mothers) responded to an interview-administered 24 h recall on their child's dietary intake at each time point. The intake of dried beans, chili, yellow beans, and lima beans was quantified. Correlate measures included socio-demographic characteristics. Outcome measures of interest focused on the intake of macronutrients (grams and % kcals) and micronutrients at 11 (infancy) and 24 m (toddler) only. To ensure statistical power, we only examined the associations of dried beans and chili with socio-demographics (Chi-square tests) and nutritional outcomes (ANOVA) at 11 and 24 m. The proportion of children who consumed dried beans or chili was very low in the first 6 m of age, started to increase at 7 m (1.2% and 0.4%) and 11 m (4.9% and 2.3%), and reached a high level at 18 m (10.5%) and 24 m (5.9%), respectively. Consumption of yellow or lima beans was rare (<0.1%). At 11 and 24 m, dried bean consumption was higher in children who were White (vs. Black). Dried bean and chili consumption was higher in children who were of Hispanic or Latino ethnicity (vs. non-Hispanic or non-Latino ethnicity). Children who consumed dried beans and chili at 11 or 24 m had a higher intake of total energy, protein, total fiber, potassium, folate, and magnesium compared with non-consumers. The bean consumption was low amongst children, differed by race and ethnicity, and was associated with improved macro- and micronutrient intake in children at 11 and 24 m.

Systems map of interventions to improve dietary intake of pre-school aged children: A scoping review

Implementation and sustaining impact of early childhood nutrition interventions in practice remains a challenge. An understanding of the extent to which determinants across multiple levels of the food system are being addressed may improve success. This literature review aimed to synthesise the evidence on interventions targeting dietary intake and eating behaviours in preschool children using a systems approach. Eligible studies included intervention studies targeting the dietary intake of preschool children aged 2-5 years in high income countries, published in English after January 2000. Interventions were categorised to the Determinants of Nutrition and Eating (DONE) framework for children developed and evaluated by experts across multiple fields. The framework maps and ranks 411 factors driving eating behaviours and nutrition and can be used to systematically summarise determinants. DONE ranks each determinant for its perceived research priority. A total of 160 eligible studies were identified. Most interventions targeted interpersonal (n = 101, 63.1%) and individual (n = 85, 53.1%) level determinants, with fewer targeting environmental (n = 55, 34.4%) and policy level (n = 17, 10.6%) determinants. The most frequently addressed determinants were Parental Resources and Risk Factors (n = 85) and Children's Food Knowledge, Skills and Abilities (n = 67). These determinants had a Moderate research priority rating. Home Food Availability and Accessibility at the environmental level is classified as the highest research priority, however, only 15 of 160 interventions addressed this determinant. This review highlights home food availability and accessibility as potential leverage points for future interventions to improve children's dietary intake and eating behaviours.

Contribution of home garden vegetables on reducing stunting among 6- to 23-month-old children in South Tigray, northern Ethiopia

The study was conducted to analyze the contribution of home garden vegetables in reducing stunting among 6- to 23-month-old children from South Tigray, Northern Ethiopia. The quasi-experimental study design was used. Multistage sampling technique was used to select the districts and study communities. A total of 94 purposively selected vegetable producer (intervention) households and 260 randomly selected non-producer (control) households were included in the study (1:3 ratio). The recumbent length of children was measured using horizontal wooden board to the nearest 0.1 cm. The length-for-age Z-scores were computed using WHO-Anthro 2006 software. Propensity score-matching and difference-in-difference (DID) estimates were used to analyze data using STATA software version 12. Prevalence of child stunting was 19.8 (12.7-29.4) and 21.1 (16.4-26.7)% (baseline) and 43.5 (33.5-54.1) and 46.5 (45.7-47.2)% (end line) among intervention and control groups, respectively. Child stunting was higher for boys and older children from both intervention and control households. DID estimation revealed that there was no significant difference in child stunting between intervention and control households (DID = 1.7, p = .604). However, there was an intervention effect of -0.5, 2.5, and 1.7% in the prevalence of child stunting among females, males, and both sexes, respectively. Vegetable production as an intervention strategy reduced the prevalence of stunting in children aged 6-23 months. However, vegetable production needs to be well integrated with other nutrition-sensitive interventions to realize the objective of reducing child stunting.

Promoting vegetable acceptance in toddlers using a contingency management program: A cluster randomised trial

Children learn to accept novel foods by repeated exposure to these foods. In the current study, we investigated in toddlers whether a contingency management program (The Vegetable Box), comprising repeated vegetable taste exposure with contingent non-food rewards, is particularly potent at increasing recognition of and willingness to try vegetables. A total of 598 children (1-4 years old) recruited at 26 different day-care centres in the Netherlands took part. The day-care centres were randomly assigned to one of three conditions ('exposure/reward', 'exposure/no reward', or 'no exposure/no reward'). At the start and directly after the 3-month intervention period, all children were asked to identify various vegetables (recognition test; max score = 14) and whether they would like to taste and consume 1 or 2 bite-size pieces of tomato, cucumber, carrot, bell pepper, radish, and cauliflower (willingness to try test). Data were analysed with linear mixed-effects regression analyses (for recognition and willingness to try separately) with condition and time as independent variables, and adjusting for day-care centre clustering. Vegetable recognition significantly increased in both the 'exposure/reward' and the 'exposure/no reward' group, relative to the 'no exposure/no reward' control group. The willingness to try vegetables only increased significantly in the 'exposure/reward' group. Offering vegetables to children at day-care centres significantly increased toddlers' ability to identify various vegetables, but rewards contingent upon tasting vegetables appear particularly effective to also increase children's willingness to try (i.e., taste and consume) different vegetables. This result corroborates and strengthens previous findings demonstrating the efficacy of similar reward-based programs.

The influential role of parents' socioeconomic status and diet quality on their children's dietary behavior: results from the LIPOKAP study among the Iranian population

PURPOSE

There is a paucity of evidence regarding the influential factors on Iranian children's diet quality. To assess this issue, we explore the relationship between parental diet quality, socioeconomic status (SES), and nutritional knowledge with their children's diet quality using a cross-sectional sample of the Iranian population.

METHODS

In this study, paired parents along with one of their children (aged 6-18 years old) who lived with them were included. Dietary intake was assessed using a food frequency questionnaire (FFQ) and diet quality was determined using an Alternative Healthy Eating Index-2010 (AHEI). Nutritional knowledge and SES were also explored using validated questionnaires. Multiple linear regression analysis was used and beta (β) and corresponding 95% confidence interval (CI) were reported.

RESULTS

After controlling for potential confounders, the parents' AHEI was significantly associated with their children's diet quality (β = 12.34, 95% CI: 10.75, 13.93; P < 0.001). The nutritional knowledge of parents was significantly associated with children's AHEI after controlling for potential confounders (β = 1.63, 95% CI: 0.14, 3.11; P = 0.032). Moreover, the parents' SES was inversely associated with the AHEI of children (β=-3.76, 95% CI: -5.40, -2.11; P < 0.001); however, further adjustment for confounders attenuated this relationship (Model 3: β = 0.87, 95% CI: -0.76, 2.34; P = 0.269).

CONCLUSIONS

We found that the children's diet quality could be influenced by their parents' SES, nutritional knowledge, and diet quality. Our findings suggest that improving the nutritional knowledge of parents not only may improve the healthy eating pattern of parents but also could influence their children's diet quality.

The role of saliva in taste and food intake

Saliva is well-described in oral food processing, but its role in taste responsiveness remains understudied. Taste stimuli must dissolve in saliva to reach their receptor targets. This allows the constituents of saliva the opportunity to interact with taste stimuli and their receptors at the most fundamental level. Yet, despite years of correlational data suggesting a role for salivary proteins in food preference, there were few experimental models to test the role of salivary proteins in taste-driven behaviors. Here we review our experimental contributions to the hypothesis that salivary proteins can alter taste function. We have developed a rodent model to test how diet alters salivary protein expression, and how salivary proteins alter diet acceptance and taste. We have found that salivary protein expression is modified by diet, and these diet-induced proteins can, in turn, increase the acceptance of a bitter diet. The change in acceptance is in part mediated by a change in taste signaling. Critically, we have documented increased detection threshold, decreased taste nerve signaling, and decreased oromotor responding to quinine when animals have increases in a subset of salivary proteins compared to control conditions.

Impact of a Montessori-Based Nutrition Program on Children's Knowledge and Eating Behaviors

BACKGROUND

Poor dietary habits in childhood can lead to obesity and chronic diseases later in life. Increasing children's nutrition knowledge and liking of fruits and vegetables are key factors in improving diet quality. The purpose of this study was to assess the effects of a nutrition program on knowledge, liking and intake of fruits and vegetables in Montessori students.

METHODS

Clustered-randomized control trial conducted in a Southeastern US Montessori school. Children aged 4-6 years old (intervention, n = 22; control, n = 29) participated in a 4-week nutrition education with taste testing of 12 fruits and vegetables. Nutrition knowledge, fruit and vegetable liking, and intake were measured with questionnaires, and analyzed using repeated measures analysis of covariance and descriptive analyses (SPSS v.23); significance defined as p < 0.05.

RESULTS

Controlling for covariates, significant between group effects for nutrition knowledge (F = 24.16, p < 0.001) and liking tomatoes (F = 7.01, p = 0.01) were found. The intervention group increased vegetable intake (Hedges' g = 1.01) compared to the control, although it was not significant between groups (F = 1.95, p = 0.17).

CONCLUSIONS

Initial examination of this program indicates that it was effective in increasing knowledge, vegetable liking and intake for young children in the sample. More research is needed to compare outcomes between educational delivery methods.

Contribution of home availability, parental child-feeding practices and health beliefs on children's sweets and salty snacks consumption in Europe: Feel4Diabetes-Study

Adoption of healthy dietary and snacking habits could support optimum physical and mental development in children as they define health in adulthood. This study assessed parameters associated with children's snacking such as food home availability, parenting practices, and parents' health beliefs. In this cross-sectional study 12 039 children, 49·4% boys 5-12 years, participating in the European Feel4Diabetes-Study were included. Children's weekly consumption of sweets and salty snacks, home availability of snacks, food parenting practices, and health beliefs were assessed via questionnaires. Logistic regression was applied to explore associations of a) home availability of snacks, b) food parenting practices (permissiveness and rewarding with snacks) and c) parent's opinions on deterministic health beliefs with children's consumption of sweets and salty snacks. Results showed that home availability (sweets: OR_adj: 4·76, 95 % CI: 4·32, 5·23; salty snacks: OR_adj: 6·56, 95 % CI: 5·64, 7·61), allowing to consume (sweets: OR_adj: 3·29, 95 % CI: 2·95, 3·67; salty snacks: OR_adj: 3·41, 95 % CI: 2·98, 3·90) and rewarding with sweets/salty snacks (sweets: OR_adj: 2·69, 95 % CI: 2·23, 3·24; salty snacks: OR_adj: 4·34, 95 % CI: 3·57, 5·28) 'sometimes/or less frequently' compared to 'always/or often' were associated with lower weekly consumption of sweets and snacks. Parents' disagreement compared to agreement with deterministic health beliefs and inattentive eating were associated with lower consumption of salty snacks and sweets in children. Overall, the findings of this study indicate that attempts to promote healthy snacking habits in children should aim to improve parental dietary habits, food parenting practices, health beliefs, and reducing home availability of unhealthy foods and snacks.

Dietary Environment in Early Care and Education Settings and Young Children's Eating Behavior: A Systematic Review of Literature

OBJECTIVES

An increasing number of young children spend time and eat at least one meal per day in childcare programs, highlighting the significance of early care and education (ECE) settings in promoting children's healthy dietary behaviors. The purpose of this review was to summarize quantitative studies on the relationship between the dietary environment in ECE settings and the eating behaviors of children aged 0-6 years.

METHODS

We consulted Web of Science, PsycInfo, ProQuest, and Emerald electronic databases, searching for empirical studies from 2000 to 2022.

RESULTS

Ultimately, we included 38 studies. Measures of the dietary environment varied considerably across studies. Following healthy diet regulations and nutrition-related activities were positively correlated with children's intake of healthy foods. Strategies such as serving fruits and vegetables in advance, serving small portion sizes, and providing children a variety of vegetables increased children's intake of healthy foods. Results on caregivers' feeding practices remained mixed.

CONCLUSIONS

These findings reveal the necessity and importance of paying attention to different aspects of the dietary environment and to take a comprehensive approach to understanding the role that environment plays in cultivating children's dietary behaviors.

From food preference development to responsive feeding - Selective studies to commemorate the life and work of Dr Leann Birch

Dr Leann Birch was a pioneer in conducting research on infant and child eating behaviour. At the beginning of her research career, Leann recognised a significant gap in the developmental psychology literature, namely that few studies had been conducted to understand infant eating and feeding behaviours. This seems an unusual omission given that food intake is essential and that developmental milestones from milk to solids, and from being fed to becoming an autonomous eater, are obvious to most caregivers. Leann paved the way for interdisciplinary research from psychology, paediatrics and public health to explore and apply this knowledge to infant and child appetite, eating behaviour, dietary patterns, food preferences, and obesity risk. Early studies in her laboratory demonstrated that children form food preferences through experience and socialisation. Experiments published in 1979 tested the role of familiarisation through repeat exposure, and the impact of instrumental and social learning on the acquisition of food preferences. In 1984, a presentation given to the British Feeding and Drinking Group (BFDG) in Brighton set out three organising principles for understanding how children acquire food preferences: genetically pre-programmed behavioural propensities; social constraints on experience with food; and social transmission resulting from direct social interaction. Building on these three organising principles, research on child eating behaviour has flourished, including the intersection between individual differences, food experience and environmental influences on children's food preferences, energy regulation, and weight outcomes. In this review, the initial groundwork set out by Leann Birch on food preference development in children is considered followed by a discussion of how this has since inspired an interdisciplinary, international and expanding field of research on children's food intake, appetite and body weight regulation.

Impact of a Farm-to-School Nutrition and Gardening Intervention for Native American Families from the FRESH Study: A Randomized Wait-List Controlled Trial

Establishing healthy eating habits during childhood is critical to prevent chronic diseases that develop in adulthood. Tribally owned Early Childhood and Education (ECE) programs signify fundamental influence in childhood obesity disparities. A strategy to improve diet is the use of school gardens; however, few studies have used rigorous methods to assess diet and health outcomes. The purpose of this manuscript is to describe results from the six-month Food Resource Equity for Sustainable Health (FRESH) study among Native American families. We aimed to recruit 176 families of children attending Osage Nation ECE programs in four communities. Two communities received the intervention and two served as wait-list controls. Outcomes included change in dietary intake, body mass index, health status, systolic blood pressure (adults only), and food insecurity in children and parents. There were 193 children (n = 106 intervention; n = 87 control) and 170 adults (n = 93 intervention; n = 77 control) enrolled. Vegetable intake significantly increased in intervention children compared to controls for squash (p = 0.0007) and beans (p = 0.0002). Willingness to try scores increased for beans in intervention children (p = 0.049) and tomatoes in both groups (p = 0.01). FRESH is the first study to implement a farm-to-school intervention in rural, tribally owned ECEs. Future interventions that target healthy dietary intake among children should incorporate a comprehensive parent component in order to support healthy eating for all household members.

Sleep duration and eating behaviours are associated with body composition in 5-year-old children: findings from the ROLO longitudinal birth cohort study

Inadequate sleep and poor eating behaviours are associated with higher risk of childhood overweight and obesity. Less is known about the influence sleep has on eating behaviours and consequently body composition. Furthermore, whether associations differ in boys and girls has not been investigated extensively. We investigate associations between sleep, eating behaviours and body composition in cross-sectional analysis of 5-year-old children. Weight, height, BMI, mid upper arm circumference (MUAC), abdominal circumference (AC) and skinfold measurements were obtained. Maternal reported information on child's eating behaviour and sleep habits were collected using validated questionnaires. Multiple linear regression examined associations between sleep, eating behaviours and body composition. Sleep duration was negatively associated with BMI, with 1-h greater sleep duration associated with 0·24 kg/m² (B = 0·24, CI -0·42, -0·03, P = 0·026) lower BMI and 0·21 cm lower (B = -0·21, CI -0·41, -0·02, P = 0·035) MUAC. When stratified by sex, girls showed stronger inverse associations between sleep duration (h) and BMI (kg/m²) (B = -0·32; CI -0·60, -0·04, P = 0·024), MUAC (cm) (B = -0·29; CI -0·58, 0·000, P = 0·05) and AC (cm) (B = -1·10; CI -1·85, -0·21, P = 0·014) than boys. Positive associations for 'Enjoys Food' and 'Food Responsiveness' with BMI, MUAC and AC were observed in girls only. Inverse associations between sleep duration and 'Emotional Undereating' and 'Food Fussiness' were observed in both sexes, although stronger in boys. Sleep duration did not mediate the relationship between eating behaviours and BMI. Further exploration is required to understand how sleep impacts eating behaviours and consequently body composition and how sex influences this relationship.

Obesity prevention practices in early care and education settings: an adaptive implementation trial

Background

Despite the potential for Early Care and Education (ECE) settings to promote healthy habits, a gap exists between current practices and evidence-based practices (EBPs) for obesity prevention in childhood.

Methods

We will use an enhanced non-responder trial design to determine the effectiveness and incremental cost-effectiveness of an adaptive implementation strategy for Together, We Inspire Smart Eating (WISE), while examining moderators and mediators of the strategy effect. WISE is a curriculum that aims to increase children’s intake of carotenoid-rich fruits and vegetables through four evidence-based practices in the early care and education setting. In this trial, we will randomize sites that do not respond to low-intensity strategies to either (a) continue receiving low-intensity strategies or (b) receive high-intensity strategies. This design will determine the effect of an adaptive implementation strategy that adds high-intensity versus one that continues with low-intensity among non-responder sites. We will also apply explanatory, sequential mixed methods to provide a nuanced understanding of implementation mechanisms, contextual factors, and characteristics of sites that respond to differing intensities of implementation strategies. Finally, we will conduct a cost effectiveness analysis to estimate the incremental effect of augmenting implementation with high-intensity strategies compared to continuing low-intensity strategies on costs, fidelity, and child health outcomes.

Discussion

We expect our study to contribute to an evidence base for structuring implementation support in real-world ECE contexts, ultimately providing a guide for applying the adaptive implementation strategy in ECE for WISE scale-up. Our work will also provide data to guide implementation decisions of other interventions in ECE. Finally, we will provide the first estimate of relative value for different implementation strategies in this setting.

Trial registration

NCT05050539; 9/20/21.

Outcomes of a Multi-Component School-Based Nutrition Program

BACKGROUND

This paper presents the effectiveness of a multi-component elementary school-based nutrition education program, the Integrated Nutrition Education Program (INEP), which has been in existence for over 25 years. INEP includes components to address multiple layers of influence: hands-on nutrition education lessons in the classroom (student-level), parent education, and outreach (home-level), and facilitation of a planning process to implement policy, system, and environmental (PSE) school changes (school-level).

METHODS

Three evaluation tools assessed the effectiveness of the program: (1) classroom plate waste measurement in intervention (N = 149 students) and demographically-matched comparison schools (N = 131 students), (2) pre/post classroom surveys completed by students who participated in INEP (N = 204), and (3) PSE change data from participating schools (N = 47 schools).

RESULTS

Students who participated in the nutrition education program were more likely to consume vegetable-based recipes and vegetables included in classroom nutrition lessons compared to students in comparison classrooms (Chinese vegetable salad: p < .001; couscous salad: p < .001; snap peas: p = .001). Classroom survey analyses showed improvements in student self-efficacy (p < .001), preference for vegetables (p = .005), and knowledge (p < .001). In addition, through a wellness planning process, schools implemented an average of 3.7 PSE changes per school.

CONCLUSIONS

Results demonstrate a multi-component school-based nutrition education program improves student nutrition-related outcomes.

Associations between mother-child dyad dietary patterns and child anthropometric measures among 6-year-old children

The goals of this study were to study relationships between maternal and children's dietary patterns (DPs) and to assess how children's DP was associated with child anthropometry. This cross-sectional study included 788 pairs of 6-year-old girls and mothers in health centers in Tehran, Iran. Information on dietary intake was collected with a 168-item food frequency questionnaire. Principal component factor analysis was performed to label different data-driven dietary patterns. Three different binary logistic regression models were used to evaluate the associations between child's DPs and child anthropometry. A positive correlation was found between all maternal patterns and child's Western DP (p < 0.001). Maternal prudent and Western DPs were correlated with child's high-protein DP (p < 0.001). Children's high-protein DP was negatively correlated with maternal high fat DP (p < 0.001). Maternal prudent and high fat DPs were correlated with prudent DP in children (p < 0.001). In adjusted models, a child being in the highest compared to the first quartile of the high-protein DP was associated with decreased odds of underweight and wasting (OR 0.43; 95% CI 0.23-0.80).Conclusion: The present study showed inverse associations between a high-protein DP in children and being underweight and wasted. Also, a positive correlation was found between all maternal DPs and children's Western DPs. This correlation should be taken into account while managing child nutrition by means of educating parents on the influence of their own dietary pattern on their children. Moreover, getting enough protein through a balanced diet should be considered in children. What is Known: • Some research exists on the intake of specific foods in relation to risk of abnormal growth in children. • Less is known about the relationship between mothers' and children's food intake. What is New: • Better adherence to a high-protein dietary pattern was significantly associated with lower risk of being both underweight and wasted. • This study suggests that correlation between mothers' and their children's dietary patterns exists, which should be taken into consideration when managing child nutrition.

Maternal Diet During Pregnancy and Lactation and Child Food Preferences, Dietary Patterns, and Weight Outcomes: a Review of Recent Research

PURPOSE OF REVIEW

Efforts to promote children's preferences for healthy foods hold much potential for improving diet quality and preventing obesity. The purpose of this review was to summarize recent evidence for associations between maternal diet during pregnancy and lactation and child food preferences, dietary patterns, and weight outcomes.

RECENT FINDINGS

Recent research illustrates greater maternal vegetable intakes during pregnancy and lactation predict greater child preferences for and intakes of vegetables. Recent randomized clinical trials to improve maternal weight outcomes during the perinatal period via behavioral lifestyle interventions that included dietary components have yielded mixed findings for effects on child weight outcomes. There is strong evidence that maternal diet during pregnancy and lactation shapes flavor preferences during infancy; more research is needed to understand factors that facilitate versus hinder the translation of these preferences to later dietary patterns and weight outcomes.

Does social modeling increase infants' willingness to accept unfamiliar foods?

Despite a rich knowledge base about infants' social learning and studies observing social referencing in other species in food contexts, we know surprisingly little about social learning about food among human infants. This gap in the literature is particularly surprising considering that feeding unfamiliar foods to infants is a very common experience as infants begin to eat solid foods. The present study examines whether parental social modeling influences infants' willingness to accept unfamiliar foods. In two Zoom sessions, parents will be asked to feed unfamiliar foods to their 6- to 24-month-old infants (different unfamiliar foods in each session). In both sessions, infants' food acceptance and rejection will be measured. In the first session, parents will be asked to do what they would typically do; spontaneous social modeling will be recorded. In the second session, parents will be instructed to model eating the unfamiliar food. We will examine associations between infants' willingness to eat unfamiliar foods, parent social modeling, and extant parent and infant characteristics.

A Pavlovian Intervention to Condition Comforting Effects of Fruits

OBJECTIVE

Perceived stress, lower fruit intake, and comfort eating are all risk factors for chronic disease. The present pilot study aimed to simultaneously mitigate all three risk factors by applying Pavlovian conditioning to change the nature of comfort eating. Specifically, stressed participants underwent a Pavlovian conditioning intervention designed to elicit comforting effects of fruit intake and thereby reduce negative mood while promoting fruit intake.

METHODS

We developed a seven-dose Pavlovian conditioning intervention wherein participants temporally paired together Progressive Muscle Relaxation (unconditioned stimulus) with fruit intake (conditioned stimulus) daily for 1 week. Participants (N = 100, mean [standard deviation] age = 20.7 [4.6] years; 74% female) with moderate to high levels of baseline perceived stress were randomized to the intervention or an active explicitly unpaired control group, wherein the Progressive Muscle Relaxation and fruit intake also occurred but were not temporally paired together. After the intervention, participants' negative mood was assessed immediately before and after fruit intake to assess conditioning effects. Then, participants logged their regular food intake for 4 days using the MyFitnessPal smartphone app.

RESULTS

After the intervention, fruit intake acutely improved negative mood to a greater extent among the intervention versus control group (F(1,98) = 3.99, p = .048, = 0.039). However, there was not a significant between-group difference in intake of fruit or traditional comfort foods at postintervention.

CONCLUSIONS

Repeated pairing of fruit intake with a reliable distress-reducing activity led to the conditioning of comforting effects of fruit intake. Further refinement of the intervention design is necessary to translate this conditioned association to actual intake of fruit and other foods.

Preference for fruits and vegetables is linked to plate waste among preschool children

BACKGROUND

A large portion of preschool-aged children in the United States (US) do not consume enough fruits and vegetables (FV). It is important for childcare providers to know what food choices children in their care are making at mealtime and how to encourage them to eat more FV. The objective of this pilot study was to examine the relationship between FV preference and plate waste among pre-school aged children in a childcare setting using a rapid assessment tool.

METHODS

The rapid assessment tool was first pilot tested with 23 children and revised. A repeated cross-sectional design was carried out for three days during fall 2016 in one childcare center. Over three days, the research team collected 100 FV plate waste observations from 30 children who were surveyed simultaneously about their preference (did not try, tried, liked, loved) towards FV.

RESULTS

Food preference for FV by preschool children is significantly (p < 0.05) related to plate waste and age. Children that indicated they loved a fruit or vegetable generated the least plate waste. Children that indicated that they did not try a fruit or vegetable generated the most plate waste.

CONCLUSIONS

FV preference and plate waste are significantly and inversely correlated. The rapid assessment tool developed should be validated to be used in implementing strategies that increase child preferences and consumption of FV that support lifelong healthy eating behaviors.

Dietary Intakes of Children Enrolled in US Early Child-Care Programs During Child-Care and Non-Child-Care Days

BACKGROUND

Early-child-care (ECE) programs may substantially influence child diet quality.

OBJECTIVE

The Study of Nutrition and Activity in Child Care Settings describes the usual food group intake of preschool-aged children attending ECE programs relative to Dietary Guidelines for Americans (DGA) recommendations, comparing intakes during child-care and non-child-care days.

DESIGN

Meal observations and parent-completed food diaries in a cross-sectional nationally representative multistage cluster sample of Child and Adult Care Food Program-participating ECE programs.

PARTICIPANTS/SETTING

One thousand four hundred sixty-eight children aged 3 to 5 years attending 217 Child and Adult Care Food Program-participating ECE programs (eg, child-care centers and Head Start) during 2017.

MAIN OUTCOME MEASURES

Daily energy intake, daily US Department of Agriculture Food Pattern Food Group intakes, and percentage of daily intakes meeting 2015-2020 DGA Food Pattern recommendations.

STATISTICAL ANALYSES PERFORMED

Regression-adjusted usual intakes and percentage of children meeting recommendations were estimated using the National Cancer Institute method. Single-day mean intakes were used to test for statistical differences between child-care and non-child-care days.

RESULTS

Mean usual energy intake was 1,524 ± 19.3 kcal during child-care days and exceeded the recommended range at 1,702 ± 30.2 kcal during non-child-care days; single-day means indicated significantly lower energy intake on child-care days (P < 0.001). The percent of children meeting DGA recommendations on a child-care day varied by DGA food group: fruits (51.4%), grains (50.1%), dairy (42.5%), vegetables (6.5%), whole grains (4.6%), and protein foods (0.1%). Recommended limits on calories from added sugar and solid fats were met by 28.2% and 14.6% of children, respectively. Compared with mean food group intakes during a single child-care day, non-child-care day intakes were similar for fruits and vegetables, lower for dairy and whole grains, and higher for total grains, protein foods, and calories from added sugars and solid fats.

CONCLUSIONS

Although there is room to increase nutrient density inside and outside of child care, intakes on child-care days more closely align to DGAs.

Mealtime behaviours of young children with sensory food aversions: An observational study

INTRODUCTION

Children with sensory food aversions (SFAs) are at risk for nutritional problems and occupational dysfunction during daily meals. To facilitate optimal occupational performance for children with SFAs, it is critical that clinicians understand child behaviour and caregiver strategy use to manage child behaviour during meals. The purpose of this paper is to examine the reliability of a novel coding scheme, the Behavioural Mealtime Coding System (BMCS) and identify associations among child acceptance of preferred and targeted foods, child food exploration and caregiver use of strategies to manage child behaviour.

METHODS

Twenty-one children (aged 18-60 months) with SFAs and their caregivers were recruited using a convenience sample. An observational video coding system was developed to code mealtime behaviour in 63 typical mealtime videos recorded by caregivers in the home environment. Inter-rater reliability, descriptive statistics and bivariate correlations were calculated.

RESULTS

The BMCS demonstrated excellent inter-rater reliability (ICC = .95). Child bites of targeted foods were associated with mealtime duration (rs  = .51, p = .02) and events of the child licking food (rs  = .57, p = .007). Caregiver use of threats was positively associated with child age (rs  = .48, p = .03) and negatively associated with caregiver education level (rs  = -.49, p = .03).

CONCLUSION

For children with SFAs, increasing mealtime duration by embedding positive activities to encourage food exploration may improve acceptance of healthy targeted foods. Future research is needed to better understand the complex relationships among caregiver strategy use, mealtime duration and child mealtime behaviour.

Obesity prevention in early care and education: a comparison of licensing regulations across Canadian provinces and territories

BACKGROUND

Early care and education (ECE) settings represent an important point of intervention for childhood obesity prevention efforts. The objective of this paper was to compare ECE licensing regulations for each Canadian province/territory to evidence-based, obesity prevention standards.

METHODS

Two authors reviewed existing ECE regulations for each province/territory and examined whether the regulatory text supported standards for nutrition (n = 11), physical activity (n = 5) and screen time (n = 4). Provinces/territories were evaluated on the strength of regulatory language for each standard (i.e. fully, partially, or not addressed) and a total comprehensiveness score (maximum score of 20). ECE centres and homes were examined separately.

RESULTS

The majority of provinces/territories required providers to follow Canada's Food Guide, but few had regulations for specific foods or beverages. Most provinces/territories included standards related to written menus and drinking water, but the strength of these standards was weak. Many provinces/territories required physical activity and outdoor opportunities to be provided daily, but few included a time requirement. Only two provinces included any screen time standards. Total comprehensiveness scores averaged 5.7 for centres and 5.4 for homes.

CONCLUSIONS

Canadian provinces/territories have insufficient obesity prevention regulations in ECE settings, highlighting a potential point of intervention to prevent obesity.

How to promote healthy eating in preschool children: Evidence from an associative conditioning procedure with non-food stimuli

Given the increasing rates and severe consequences of childhood obesity, how to encourage children to eat low-calorie and healthy foods is an important question. Building on evaluative conditioning research, this study investigated how associating fruits and vegetables with positive, non-food stimuli influences preschool children's food choice and consumption. Consistent with this idea, it was found in two experiments that 3- to 6-year-old children's healthy food choice and consumption increased by pairing a healthy food's picture systematically with a positive, non-food image. These findings highlight a simple yet effective means of changing young children's eating behavior, which may complement existing intervention procedures.

Utilising an integrated approach to developing liking for and consumption of vegetables in children

Children eat too few vegetables and this is attributed to disliked flavours and texture as well as low energy density. Vegetables confer selective health benefits over other foods and so children are encouraged to eat them. Parents and caregivers face a challenge in incorporating vegetables into their child's habitual diet. However, liking and intake may be increased through different forms of learning. Children learn about vegetables across development from exposure to some vegetable flavours in utero, through breastmilk, complementary feeding and transitioning to family diets. Infants aged between 5 and 7 m are most amenable to accepting vegetables. However, a range of biological, social, environmental and individual factors may act independently and in tandem to reduce the appeal of eating vegetables. By applying aspects of learning theory, including social learning, liking and intake of vegetables can be increased. We propose taking an integrated and individualised approach to child feeding in order to achieve optimal learning in the early years. Simple techniques such as repeated exposure, modelling, social praise and creating social norms for eating vegetables can contribute to positive feeding experiences which in turn, contributes to increased acceptance of vegetables. However, there is a mismatch between experimental studies and the ways that children eat vegetables in real world settings. Therefore, current knowledge of the best strategies to increase vegetable liking and intake gained from experimental studies must be adapted and integrated for application to home and care settings, while responding to individual differences.

Examining Nutrition and Food Waste Trade-offs Using an Obesity Prevention Context

Obesity and food waste are related issues, both exacerbated by an overabundance of food. Efforts to reduce food waste can have varying unintended, obesity-related consequences, which further underscores the need for a systems approach to food waste reduction. Yet, these 2 issues are rarely examined together. It is the authors' point of view that for nutrition educators and other public health practitioners to develop interventions that simultaneously address food waste and obesity, they need to understand how actions at the consumer-level may impact waste and its related food system consequences earlier in the supply chain.

The Relative Reinforcing Value of Cookies Is Higher Among Head Start Preschoolers With Obesity

The relative reinforcing value (RRV) of food measures how hard someone will work for a high-energy-dense (HED) food when an alternative reward is concurrently available. Higher RRV for HED food has been linked to obesity, yet this association has not been examined in low-income preschool-age children. Further, the development of individual differences in the RRV of food in early childhood is poorly understood. This cross-sectional study tested the hypothesis that the RRV of HED (cookies) to low-energy-dense (LED; fruit) food would be greater in children with obesity compared to children without obesity in a sample of 130 low-income 3- to 5-year-olds enrolled in Head Start classrooms in Central Pennsylvania. In addition, we examined individual differences in the RRV of food by child characteristics (i.e., age, sex, and reward sensitivity) and food security status. The RRV of food was measured on concurrent progressive-ratio schedules of reinforcement. RRV outcomes included the last schedule reached (breakpoint) for cookies (cookie Pmax) and fruit (fruit Pmax), the breakpoint for cookies in proportion to the total breakpoint for cookies and fruit combined (RRV cookie), and response rates (responses per minute). Parents completed the 18-item food security module to assess household food security status and the Behavioral Activation System scale to assess reward sensitivity. Pearson's correlations and mixed models assessed associations between continuous and discrete child characteristics with RRV outcomes, respectively. Two-way mixed effects interaction models examined age and sex as moderators of the association between RRV and Body Mass Index z-scores (BMIZ). Statistical significance was defined as p < 0.05. Children with obesity (17%) had a greater cookie Pmax [F (1, 121) = 4.95, p = 0.03], higher RRV cookie [F (1, 121) = 4.28, p = 0.04], and responded at a faster rate for cookies [F (1, 121) = 17.27, p < 0.001] compared to children without obesity. Children with higher cookie response rates had higher BMIZ (r = 0.26, p < 0.01); and RRV cookie was positively associated with BMIZ for older children (5-year-olds: t = 2.40, p = 0.02) and boys (t = 2.55, p = 0.01), but not younger children or girls. The RRV of food did not differ by household food security status. Low-income children with obesity showed greater motivation to work for cookies than fruit compared to their peers without obesity. The RRV of HED food may be an important contributor to increased weight status in boys and future research is needed to better understand developmental trajectories of the RRV of food across childhood.

Optimising Repeated Exposure: Determining Optimal Stimulus Shape for Introducing a Novel Vegetable among Children

Although it is well evident that a healthy diet rich in fruit and vegetables could prevent a number of major chronic diseases, national and international guidelines concerning their intake are not being reached by a large percentage of the population, including children. Thus, it is of interest to investigate how the consumption of this food group by children could be increased. The aim of this study was to examine the impact of serving style on the consumption of a raw snack vegetable (daikon) and the influence of its exposure on liking and intake of the vegetable. A group of 185 children 3–5 years old participated in the study. Two kindergartens served as intervention groups, while the third was assigned to be the control group of the study (n = 50). The intervention groups were repeatedly exposed to one of three different serving styles of daikon: sticks (n = 42), triangles (n = 46) or grated (n = 47), and they were all visited 7 times during the exposure period, on the same frequency (twice per week). Familiarity and liking of the target vegetable, daikon, and six other vegetables (cucumber, celery, celeriac, broccoli, cauliflower and beetroot) were measured at baseline, post-intervention and two follow up sessions (3- and 6-month) to investigate the likelihood of generalisation effects. Intake of daikon was measured at all control sessions and exposures. Moreover, children were asked to rank their favourite serving style of daikon and beetroot, among triangle, stick and grated, towards understanding the influence of shape on the efficacy of the exposure. The results revealed significant changes between liking and intake of daikon for the groups of triangles and sticks and the control group (p < 0.05). The group that received grated daikon did not show significant differences in liking and at intake levels during the exposures but performed well in the long-term. Throughout the exposure period, intake levels followed an overall increasing pattern, with all the groups to demonstrate a decrease of their intake at the last session, which was not found significant for the triangle group. Mere exposure was efficient towards increasing liking and intake of the novel vegetable with all the shapes to deliver positive results, but based on this study no particular serving style can be recommended.

Optimising Repeated Exposure: Determining Optimal Exposure Frequency for Introducing a Novel Vegetable among Children

Fruit and vegetables are important components of a healthy diet, but unfortunately many children are not consuming enough to meet the recommendations. Therefore, it is crucial to develop strategies towards increasing the acceptance of this food group. This study aims to investigate the effect of different repeated exposure frequencies on fruit and vegetable acceptance using a novel vegetable, daikon, among 3–6-year-old children. One hundred and fifty-nine children participated in this study. Eight kindergarten teams were assigned to one of the following groups: Three different intervention groups with varying exposure frequencies, but all receiving seven exposures: Twice a week (n = 47), once a week (n = 32) and once every second week (n = 30), and a control group (n = 50). Liking and familiarity of daikon and other vegetables (cucumber, celery, celeriac, broccoli, cauliflower and beetroot) were assessed at baseline, post-intervention and two follow up sessions (3 and 6 months) to test for potential generalisation effects and observe the longevity of the obtained effects. Intake of daikon was measured at all exposures and test sessions. Results showed significant increases (p ≤ 0.05) in liking and intake of daikon for all three frequencies and the control group. Over the exposures, intake of daikon increased until the 4th exposure for all the groups, where a plateau was reached. No systematic generalisation effects were found. Repeated exposure was a successful approach to increase liking and intake of a novel vegetable with all exposure frequencies to be effective, and no particular exposure frequency can be recommended. Even the few exposures the control group received were found to be sufficient to improve intake and liking over 6 months (p ≤ 0.05), indicating that exposures to low quantities of an unfamiliar vegetable may be sufficient.

A qualitative study of cognitive, behavioral, and environmental influences on Hispanic mothers' early childhood feeding practices

Young children's lifestyle behaviors are largely shaped by their parents. There are socioeconomic risk factors particular to Hispanic populations that influence the way parents feed their children. As obesity continues to be a public health issue with substantial inequities across race and ethnicity, it is critical to understand Hispanic parents' food choices and feeding practices. The objective of this qualitative study is to identify the behavioral, environmental, and cognitive factors that influence the parental food choices and feeding behaviors of Hispanic mothers of children ages 0-5 years. Snowball sampling was used to recruit participants from the community (n = 30) who were 1) female; 2) Hispanic; 3) over the age of 18; and 4) a mother to child(ren) between the ages zero and five. Each interview consisted of a brief demographic survey and a set of open-ended questions based on Social Cognitive Theory constructs. A thematic analysis using a combined deductive and inductive approach was used to analyze transcriptions. Results indicated that mothers' attitudes around breastfeeding were connected with their challenges, while their attitudes around solid foods were expressed in their feeding strategies. Mothers used strategies of modeling, repeated exposure, and practices of "sneaking" in healthy foods and bribing to promote healthy eating. Mothers were most likely to seek out information from (1) pediatricians, (2) female family members, and (3) the internet. Hispanic mothers actively seek out information from many different sources that impact how they feed their young children. Understanding their trusted sources and how it influences the SCT constructs is an important step in preventing early childhood obesity.

Rewarding behavior with a sweet food strengthens its valuation

Sweet foods are commonly used as rewards for desirable behavior, specifically among children. This study examines whether such practice may contribute to reinforce the valuation of these foods. Two experiments were conducted, one with children, the other with rats. The first study, conducted with first graders (n = 214), shows that children who receive a food reward for performing a cognitive task subsequently value the food more compared to a control group who received the same food without performing any task. The second study, conducted on rats (n = 64), shows that rewarding with food also translates into higher calorie intake over a 24-hour period. These results suggest that the common practice of rewarding children with calorie-dense sweet foods is a plausible contributing factor to obesity and might therefore be ill advised.

Opportunities to Promote Healthy Weight Through Child Care Licensing Regulations: Trends in the United States, 2016-2020

BACKGROUND

Policies that support healthy nutrition and physical activity environments in early care and education (ECE) settings can help promote healthy weight in children. State child care licensing regulations are a critical mechanism for setting such policies.

OBJECTIVES

To develop a research instrument to evaluate the promotion of healthy child weight in state child care licensing regulations and assess the strength of the regulations over time.

DESIGN

For measure development, systematic reviews of evidence on the impact of healthy weight strategies relevant to the ECE environment were combined with expert stakeholder input to identify 15 healthy weight promotion policy standards and a coding tool to measure the strength and comprehensiveness of regulatory language matching these standards. For assessing the strength of regulations, the coding tool was applied to child care regulations nationwide in 2016 and again in 2020.

SUBJECTS/SETTING

Child care licensing regulations in 2016 and 2020 for all 50 US states plus Washington DC.

OUTCOME MEASURES

Strength and comprehensiveness scores for state licensing regulations.

STATISTICAL ANALYSES

Intraclass correlation coefficients were calculated to estimate interrater reliability of the coding tool. Paired t tests were used to compare scores within states from 2016 to 2020.

RESULTS

Interrater reliability for the coding tool had intraclass correlation coefficients of 0.81 for strength and 0.87 for comprehensiveness scores. Strength and comprehensiveness of states' healthy weight promotion policies increased significantly over time (P < .001). However, most states still lack important healthy weight policies in their licensing regulations, such as prohibiting serving sugary drinks.

CONCLUSIONS

This study presents a reliable research instrument for measuring the strength and comprehensiveness of healthy weight promotion standards in child care licensing regulations. States have increased their incorporation of strategies for healthy weight into state policy.

Mothers' Perceptions and Attitudes towards Children's Vegetable Consumption-A Qualitative, Cross-cultural Study of Chilean, Chinese and American Mothers Living in Northern California

This exploratory research focused on the cultural variables involved in children’s vegetable consumption, through the analysis of mothers’ perceptions, attitudes, and feeding practices regarding their children’s intake, using qualitative consumer research methods. Twelve focus groups of mothers with children between 2–12 years old (Euro-Americans n = 20, Chinese n = 19, and Chilean n = 19) were conducted. All participants lived in Northern California, had higher education, and incomes that did not limit their vegetable purchase. Intercultural differences in vegetable preferences and consumption habits were found. Mothers across all groups agreed on the importance of children’s vegetable consumption, the influence that mothers have over their children’s vegetable intake, and how challenging it is to get children to eat a variety of vegetables. The ethnic groups differed regarding how they perceived the level of mothers’ responsibility over children’s vegetable intake, the way that mothers defined the amount of vegetables that children should eat, the constraints that mothers had on increasing their children’s vegetable intake and mothers’ recommendations to encourage vegetable consumption. Our study suggests that under similar socio-economic and parental education levels, culture-specific strategies should be considered to foster healthy dietary habits in children.

School-based gardening, cooking and nutrition intervention increased vegetable intake but did not reduce BMI: Texas sprouts - a cluster randomized controlled trial

BACKGROUND

Although school garden programs have been shown to improve dietary behaviors, there has not been a cluster-randomized controlled trial (RCT) conducted to examine the effects of school garden programs on obesity or other health outcomes. The goal of this study was to evaluate the effects of a one-year school-based gardening, nutrition, and cooking intervention (called Texas Sprouts) on dietary intake, obesity outcomes, and blood pressure in elementary school children.

METHODS

This study was a school-based cluster RCT with 16 elementary schools that were randomly assigned to either the Texas Sprouts intervention (n = 8 schools) or to control (delayed intervention, n = 8 schools). The intervention was one school year long (9 months) and consisted of: a) Garden Leadership Committee formation; b) a 0.25-acre outdoor teaching garden; c) 18 student gardening, nutrition, and cooking lessons taught by trained educators throughout the school-year; and d) nine monthly parent lessons. The delayed intervention was implemented the following academic year and received the same protocol as the intervention arm. Child outcomes measured were anthropometrics (i.e., BMI parameters, waist circumference, and body fat percentage via bioelectrical impedance), blood pressure, and dietary intake (i.e., vegetable, fruit, and sugar sweetened beverages) via survey. Data were analyzed with complete cases and with imputations at random. Generalized weighted linear mixed models were used to test the intervention effects and to account for clustering effect of sampling by school.

RESULTS

A total of 3135 children were enrolled in the study (intervention n = 1412, 45%). Average age was 9.2 years, 64% Hispanic, 47% male, and 69% eligible for free and reduced lunch. The intervention compared to control resulted in increased vegetable intake (+ 0.48 vs. + 0.04 frequency/day, p = 0.02). There were no effects of the intervention compared to control on fruit intake, sugar sweetened beverages, any of the obesity measures or blood pressure.

CONCLUSION

While this school-based gardening, nutrition, and cooking program did not reduce obesity markers or blood pressure, it did result in increased vegetable intake. It is possible that a longer and more sustained effect of increased vegetable intake is needed to lead to reductions in obesity markers and blood pressure.

CLINICAL TRIALS NUMBER

NCT02668744 .

A Nutrition Intervention to Promote the Consumption of Pulse-Based Foods in Childcare Centers: Protocol for a Multimethod Study

Background

Plant-based foods, including pulses (dry beans, lentils, chickpeas, and peas), have gained worldwide attention owing to their health and environmental benefits. Despite high production, the consumption of pulses is low in Canada. Behavior change interventions systematically designed to promote the consumption of pulse-based foods are scarce.

Objective

We describe the utilization of intervention mapping (IM) in the development of a multicomponent nutrition intervention aimed at promoting consumption of pulse-based foods among preschool children in childcare centers in Saskatchewan, Canada.

Methods

The Pulse Discovery Toolkit intervention was developed following the six steps of the IM protocol. Decisions at each step were either based upon literature review, expert consultation, pretesting, or a combination of these. Following the initial phase of the study, which focused on intervention development, phases II and III of the study were concerned with pilot testing and roll-out of the intervention, respectively. In total, one, two, and four childcare centers participated in phases I, II, and III, respectively. A multimethod approach was designed to evaluate the intervention during pilot testing and roll-out.

Results

The application of IM steps 1 to 3 in phase I resulted in the creation of performance objectives at different levels, including at the individual level (preschool children), and the social and environmental levels (parents, early childhood educators, and cooks). These objectives were then used to create a matrix of objectives matching the constructs of the social cognitive theory while taking Piaget cognitive development into consideration. This step was followed by defining program components, implementation, adoption, and evaluation strategies, which were utilized in phases II and III. Data have been collected from 2015 to 2018 and analyzed. The results will be reported elsewhere.

Conclusions

The IM protocol provided a rigorous framework for the development of a multicomponent evidence-based intervention to promote pulse-based foods in childcare centers.

International Registered Report Identifier (IRRID)

RR1-10.2196/22775

A positive deviance-based qualitative study of stress, coping, and feeding practices among low-income, Hispanic mothers whose children do versus do not meet guidelines for fruit and vegetable intake

Less than 1% of children in the United States concurrently meet guidelines for fruit/vegetable intake, physical activity, screen time, and sugar-sweetened beverages. Prior evidence suggests that parents of this 1% potentially cope with stress differently. This qualitative study used a positive deviance-based approach to locate mothers whose children avoided negative feeding outcomes despite being 'high-risk' for obesity. Semi-structured interviews were conducted in Spanish for two groups: low-income, Hispanic mothers whose children were normal weight and met recommendations for fruits/vegetables and physical activity (n = 5); and a comparison group whose children had obesity and did not meet guidelines (n = 8). Topics included weight-related parenting practices, attitudes toward health, and stress management. Interviews were transcribed, translated, and coded using NVivo for theoretically driven thematic analysis. Results suggested that mothers viewed stress differently. Mothers of healthy weight children believed stress could be prevented, such as by paying children more attention or directing one's attention away from stressors; comparison group mothers tended to report stress about managing their child's eating and about financial worries. Future research is needed to understand the underlying sources of these differences (e.g. personality traits, coping practices) and test whether stress prevention interventions can promote healthy parental feeding practices.

Invited review: Maintaining and growing fluid milk consumption by children in school lunch programs in the United States

Fluid milk consumption among children has declined for decades. Adequate consumption of milk and dairy products, especially during childhood, has beneficial health outcomes for growth, development, and reduced risk of osteoporosis, hypertension, obesity, and cancer during adulthood. Satisfaction with milk flavor, perceived health benefits derived from milk, and habit are primary drivers of lifelong milk consumption. Child preferences and attitudes for milk may differ from those of adults, and as such, understanding and fulfilling the needs of children is crucial to reverse the decline in milk consumption. School meal programs make fluid milk accessible to millions of children each day; however, regulations and school lunch procurement systems in the United States sometimes make it difficult to provide novel or value-added milk products in these programs. Total consumption of all milk types in US schools declined by 14.2% from 2008 to 2017, and the percentage of children participating in the school lunch program has also declined. This decline has also been driven by declining average daily participation in the school meal program and may also reflect children's dissatisfaction with the sensory characteristics and the form of milk offered in schools. The change in form of milk offered in schools to lower fat and lower added sugar content in the United States has been driven by government-mandated school lunch calorie and fat requirements. This review describes the current milk consumption trends among children; the structure and basic requirements of the school lunch program in total and for milk; and the intrinsic, extrinsic, and environmental factors that influence child perception, preference, and consumption of fluid milk in the US school system.

Pilot Intervention Enhances Preschoolers' Self-Regulation and Food Liking

OBJECTIVE

The goal of this study was to develop and evaluate a 5-week intervention that targeted self-regulation and healthy food liking through mindfulness and classroom-based games with exposure to fruits and vegetables.

METHODS

Children (mean age, 3.6 ± 0.05 years) in 1 Head Start center received the classroom-based intervention (n = 24) and children in a second did not (n = 15). Assessments of self-regulation and liking of fruits and vegetables were administered pre- and postintervention.

RESULTS

Children in the intervention, but not the comparison group, experienced significant improvements in behavioral regulation (P = 0.003) and liking of fruits and vegetables (P = 0.02).

CONCLUSIONS AND IMPLICATIONS

This study lays a foundation for future research that replicates findings with a larger sample using a randomized controlled design, incorporates more typical mindful eating practices, and includes additional, broader measures of food liking.

Measuring commissioners' willingness-to-pay for community based childhood obesity prevention programmes using a discrete choice experiment

BACKGROUND

In the UK, rates of childhood obesity remain high. Community based programmes for child obesity prevention are available to be commissioned by local authorities. However, there is a lack of evidence regarding how programmes are commissioned and which attributes of programmes are valued most by commissioners. The aim of this study was to determine the factors that decision-makers prioritise when commissioning programmes that target childhood obesity prevention.

METHODS

An online discrete choice experiment (DCE) was used to survey commissioners and decision makers in the UK to assess their willingness-to-pay for childhood obesity programmes.

RESULTS

A total of 64 commissioners and other decision makers completed the DCE. The impact of programmes on behavioural outcomes was prioritised, with participants willing to pay an extra £16,600/year if average daily fruit and vegetable intake increased for each child by one additional portion. Participants also prioritised programmes that had greater number of parents fully completing them, and were willing to pay an extra £4810/year for every additional parent completing a programme. The number of parents enrolling in a programme (holding the number completing fixed) and hours of staff time required did not significantly influence choices.

CONCLUSIONS

Emphasis on high programme completion rates and success increasing children's fruit and vegetable intake has potential to increase commissioning of community based obesity prevention programmes.

The effects of taste sensitivity and repeated taste exposure on children's intake and liking of turnip (Brassica rapa subsp. rapa); a bitter Brassica vegetable

Low consumption of vegetables in children is a concern around the world, hence approaches aimed at increasing intake are highly relevant. Previous studies have shown that repeated taste exposure is an effective strategy to increase vegetable acceptance. However, few studies have examined the effect of repeated taste exposure on children varying in bitter taste sensitivity. This study investigated the influence of taste genotypes and phenotypes on the effects of repeated taste exposure to a Brassica vegetable. 172 preschool children aged 3-5 years were recruited into this study. Turnip was selected as the target vegetable and parents completed a questionnaire to ensure unfamiliarity. During the intervention, children were exposed to steamed-pureed turnip for 10 days (once/day). Intake and liking were measured before, during and after the intervention, and a follow-up was done 3 months post-intervention. Taste genotypes (TAS2R38 and gustin (CA6) genotypes) and taste phenotypes (PROP taster status and fungiform papillae density) were determined. There was a significant effect of exposure shown by significant increases in intake (p < 0.001) and liking (p = 0.008) post-intervention; however, there were no significant effects of taste genotypes or phenotypes on intake and liking. In summary, repeated taste exposure is confirmed to be a good strategy to increase vegetable acceptance in children, regardless of bitter taste sensitivity.

Examining associative conditioning with a positive peer context as a strategy to increase children's vegetable acceptance

BACKGROUND

Children's vegetable acceptance increases following repeated exposure and associative conditioning pairing a target vegetable with a well-liked food. Yet traditional pairings may increase energy intake when well-liked foods are calorie-rich.

OBJECTIVES

To examine whether pairing a non-food stimulus with target vegetables increases children's vegetable acceptance and whether effects exceed those of repeated exposure.

METHODS

Twenty-three 6-to-8-year-old children participated in twice-weekly sessions across 6 weeks of a summer camp serving children from low-income families. First- and second-grade camp classrooms were randomly assigned to associative conditioning and repeated exposure groups, respectively. Liking and preference were assessed for seven vegetables at pre/post-test. For each child, two non-preferred vegetables were randomly assigned as the target or control. During exposures, associative conditioning group children experienced a positive peer context (involving group games) paired with tasting their target vegetable. The repeated exposure group received only taste exposures; target vegetable liking was assessed.

RESULTS

Preferences for target vegetables increased from pre- (Median = 6.00) to post-test (Median = 3.00) overall (P = .007), but did not differ by group (P = .59). Group, time and interaction effects on vegetable liking were non-significant overall (P ≥ .29), with some evidence of group differences when examining select time points.

CONCLUSIONS

Findings can inform future research aiming to increase vegetable preferences in community settings.

Implementation of a Multi-Component School Lunch Environmental Change Intervention to Improve Child Fruit and Vegetable Intake: A Mixed-Methods Study

Nudge interventions are widely used to promote health in schools, yet implementation metrics are seldom used to understand intervention outcomes. A multi-component intervention consisting of cafeteria decorations, creative names, social norming taste tests, and flavor station components was implemented in three rural elementary school cafeterias by school nutrition services (SNS) and extension staff. Selection and consumption of fruits and vegetables at lunch were measured through monthly plate waste assessments over eight months (n = 1255 trays). Interviews were conducted with SNS staff (n = 3) upon completion of the intervention to assess implementation outcomes using validated acceptability and feasibility metrics. Consumption findings were generally inconsistent across schools and time points, yet fruit consumption increased at School 1 (p < 0.05) during the taste test and flavor station intervention months and School 2 (p < 0.001) during the creative names intervention months compared to baseline. Odds of selecting a vegetable at School 3 were three times higher than baseline during the taste test intervention months (odds ratio (OR), 3.0; 95% confidence interval (CI), 1.3–6.5). Cafeteria decorations and taste tests had higher reported implementation metrics for acceptability and feasibility than other interventions. Thematic analysis underscored the facilitating role of extension support, as well as systems factors, which served as facilitators and barriers across schools and interventions. These findings suggest that nudge interventions are a promising strategy to improve vegetable selection and fruit consumption in school meal programs.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Improving Willingness to Try Fruits and Vegetables Among Low-Income Children Through Use of Characters

Purpose: Low-income children are disproportionately affected by high rates of food insecurity and obesity, placing them at risk for poor health outcomes. Diets that are rich in fruits and vegetables (FV) are associated with health benefits such as reducing the risk of obesity. Despite these benefits, American children do not consume nationally recommended amounts of fruits (63%) and vegetables (90%) per day. Data reveal that young children exhibit increased food neophobia toward vegetables. One way to decrease food neophobia is to introduce FV to young children via recipe tasting. The purpose of the study was to increase willingness to try FV among low-income children using live characters at Summer Food Service Program Sites.

Methods: The study design was a small-scale pilot study to conduct taste tests of recipes with 125 low-income children. Researchers created recipe-tasting stations at two different sites. At Site 1, characters promoting FV characters were present at the recipe-tasting station. At Site 2, researchers presented recipes without characters being present. Taste tests were conducted once per week for a period of 4 weeks using two previously validated instruments, Taste Test Tool and the Taste and Rate Questionnaire.

Results: Results demonstrated that introducing FV recipes with characters showed a trend toward increasing willingness to try FV among low-income children. Data also suggested that low-income children had limited exposure to specific FV before recipe tastings.

Conclusion: The use of characters is a promising approach to increase willingness to try FV among low-income children.