Right sizing prevention. Food portion size effects on children's eating and weight

Being well-fed in universal school lunches in Canada: avoiding a one-size-fits-all approach

As Canada is implementing a new national school food program with a long-term vision of every child having access to nutritious food in school, understanding student eating perspectives and food choices in universal programs is paramount. The purpose of this study was to understand how students in two low-income and culturally diverse elementary schools in Saskatoon, Canada, perceived and participated in a 2-year, universal school lunch pilot. This study was part of a larger case study of the Good Food for Learning program. Eleven focus groups with 65 students in grades 5-8 and participatory observation in the schools were conducted. Data analysis followed a reflexive thematic analysis approach Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport, Exer Health 2019;11:589-97. doi:10.1080/2159676 × .2019.1628806, Braun V, Clarke V. Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern-based qualitative analytic approaches. Counselling Psychother Res 2020;21:37-47. doi:10.1002/capr.12360) using NVivo 12 Plus. Student perspectives centered around being well-fed at lunch. Students saw participation in the pilot as a matter of personal choice: student decision to participate was encouraged by the pilot's flexible and free design; availability of well-liked food; and the perceived healthiness of the food. Offering culturally diverse and inclusive food was important to students. Mitigating future barriers to student participation in universal lunch programs will require attention to student choice, agency, and diversity, and offering diverse portion sizes, adequate meal lengths, and student-centered infrastructure. School lunch programs that are universal, health promoting, tasty, and free, and offer flexibility and choice to students, may be a socially desirable way to improve student nutrition and wellbeing.

Dietary and Physical Activity Habits of Children and Adolescents before and after the Implementation of a Personalized, Intervention Program for the Management of Obesity

BACKGROUND

Obesity in childhood and adolescence represents a major public health problem, mostly attributed to dietary and physical activity factors. We aimed to determine the dietary and physical activity habits of participants before and after the implementation of a personalized, multidisciplinary, lifestyle intervention program for the management of obesity in the context of the Horizon Research Project 'BigO: Big Data against Childhood Obesity'.

METHODS

Three hundred and eighty-six (n = 386) children and adolescents (mean age ± SD: 12.495 ± 1.988 years, 199 males and 187 females) participated in the study prospectively. Based on body mass index (BMI), subjects were classified as having obesity (n = 293, 75.9%) and overweight (n = 93, 24.1%) according to the International Obesity Task Force (IOTF) cut-off points. We implemented a personalized, multidisciplinary, lifestyle intervention program providing guidance on diet, sleep, and exercise, and utilized the BigO technology platform to objectively record data collected via a Smartphone and Smartwatch for each patient.

RESULTS

Following the intervention, a statistically significant decrease was noted in the consumption of cheese, cereal with added sugar, savory snacks, pasta, and fried potatoes across both BMI categories. Also, there was an increase in daily water intake between meals among all participants (p = 0.001) and a reduction in the consumption of evening snack or dinner while watching television (p < 0.05). Boys showed a decrease in the consumption of savory snacks, fried potato products, and pasta (p < 0.05), an increase in the consumption of sugar-free breakfast cereal (p < 0.05), and drank more water between meals daily (p < 0.001).

CONCLUSIONS

Our findings suggest that a personalized, multidisciplinary, lifestyle intervention improves the dietary habits of children and adolescents.

Child food portion sizes in the home environment: how do parents decide?

The consumption of larger portion sizes (PS) of food has been implicated in the increased prevalence of childhood obesity. The home is usually the first place children learn about food, however, little is known about how parents determine child PS in the home environment. This narrative review aimed to explore parental beliefs, decisions, strategies and barriers to the provision of appropriate food PS for children in the home environment. Results indicate that parental decisions on child food PS are based on the amounts they serve themselves, personal intuition and knowledge of child appetite. Owing to the habitual nature of food provision, parental decisions on child PS may be taken without conscious thought and/or could be part of a complex decision-making process influenced by several interlinked factors, including parental childhood mealtime experiences, other family members and child weight status. Strategies to determine child-appropriate PS include modelling the desired PS behaviour, use of unit-based food packaging and PS estimation aids, and providing the child with a degree of autonomy to rely on their own appetite cues. A lack of knowledge/awareness of PS guidance is a key barrier identified by parents to the provision of age-appropriate PS, warranting the inclusion of salient child-appropriate PS guidance within national dietary recommendations. Further home-based interventions to improve the provision of appropriate child PS are required, leveraged on parental strategies already in use, as outlined in this review.

Diet-Related Disparities and Childcare Food Environments for Vulnerable Children in South Korea: A Mixed-Methods Study

Diet-related disparities that have often been observed in vulnerable families may play a negative role in children's health and health-related quality of life. In South Korea, an afterschool care policy, called Community Childcare Center (CCC), was established in the 1960s to protect and educate vulnerable children; this role has expanded to provide meal services in recent times. Therefore, the CCCs' food environment has become a pivotal platform for observing children's nutrition and health-related disparities. Using a mixed-methods approach including a survey with self-reported questionnaires, field observation, and participant interviews, the food environment of CCC was explored alongside children's eating behaviors. Eating behaviors were not as healthy as expected. Although service providers and cooks reported in the survey responses that the centers' food environment was healthy, participant observations and interviews revealed a significant gap. Establishing a standardized food environment and improving the nutrition literacy of workers as a significant human resource at a CCC can promote healthy eating for vulnerable children. The findings suggest that in the absence of steps to improve the food environment of CCC, diet-related disparities may affect children's health in the future.

The big squeeze: a product content and labelling analysis of ready-to-use complementary infant food pouches in Australia

BACKGROUND

Encouraging the early development of healthy eating habits prevents diet-related chronic disease. It is well understood that highly processed foods with high amounts of sugars, salt and fats are a risk factor for non-communicable diseases. Commercial baby foods in ready-to-use squeeze pouches emerged in the global food market around 2012. The long-term effects of this now ubiquitous packaging on the quality of infant diets, baby food consumption and marketing are unknown. This study aimed to conduct a rigorous mixed-methods audit of squeeze pouches in Australia to inform product regulation and policy.

METHODS

Nutritional and marketing data were sourced from products available in Australian retailers. Analysis of nutritional content, texture and packaging labelling and serving size was conducted. Pouches were given a Nutrition Profile Index (NPI) score and compared with the Australian Infant Feeding Guidelines. Marketing text was thematically analysed and compared to existing infant nutrition policy around regulation of marketing claims.

RESULTS

276 products from 15 manufacturers were analysed, targeting infants from 4 + to 12 + months. Total sugar content ranged 0.8-17.5 g/100 g, 20% (n = 56) of products had added sugars, 17% (n = 46) had added fruit juice, 71% (n = 196) had added fruit puree. Saturated fat content ranged from 0.0 to 5.0 g/100 g, sodium 0.0-69 mg/100 g and dietary fibre 0.0-4.3 g/100 g. Only two products were nutritionally adequate according to a nutrient profiling tool. Marketing messages included ingredient premiumisation, nutrient absence claims, claims about infant development and health, good parenting, and convenience. Claims of 'no added sugar' were made for 59% of pouches, despite the addition of free sugars.

CONCLUSIONS

Squeeze pouch products available in Australia are nutritionally poor, high in sugars, not fortified with iron, and there is a clear risk of harm tothe health of infant and young children if these products are fed regularly. The marketing messages and labelling on squeeze pouches are misleading and do not support WHO or Australian NHMRC recommendations for breastfeeding or appropriate introduction of complementary foods and labelling of products. There is an urgent need for improved regulation of product composition, serving sizes and labelling to protect infants and young children aged 0-36 months and better inform parents.

Designing for downsizing: Home-based barriers and facilitators to reduce portion sizes for children

Evidence confirms that parents know that they should limit non-core foods for their children since these tend to be high in energy density (HED), fat, salt and sugar. However, it is unclear how knowledge of portion size limits, such as the 100 kcal guide from Public Health England are applied in practice. To observe in real-time children’s home food environment related to portion control and to explore with parents their reported portion size strategies, a mixed methods study was designed. Families with children aged 1–5 years were recruited (n = 21) to a three-part study: (1) to complete questionnaires and interviews on household food intake and portion control; (2) to report daily food intake for 4 days (n = 13) for one parent and their child(ren); (3) to observe home-based food provisioning via videorecording during dinner, breakfast and snack time (n = 6). Although the problem of large portion sizes of HED foods was recognised by mothers, strategies to downsize portions were not necessarily applied at home, as revealed in home observations and diaries. A mismatch between what was observed at home, what was reported in food diaries and what was said in interviews became apparent for some families. Mothers reported the need for greater support and guidance to downsize HED foods since they relied on pre-packaging as a guide to intake. Education and engagement were identified as important parameters for downsizing by mothers. One strategy which could be explored and applied by manufacturers is packaging design to faciliate the 100 kcal guidance using physical and engaging ways to assist parents in downsizing HED foods for their children. To facilitate effective government communication, innovative packaging design can be used to convey clear guidance and to tailor portion size messages for children. Packaging design, alongside government recommendations, can support parents’ goals to achieve healthy eating and can reinforce guidance for portion norms through innovation involving learning, playful engagement, and interaction.

Development of a conceptual framework of food and nutrition literacy in children

BACKGROUND

This study aimed to develop a conceptual framework to better understand food and nutrition literacy and its dimensions and components among Iranian children.

METHODS

The study included three sub-studies. First, two qualitative studies were conducted to explore experts' and students' perspectives and experiences regarding the topic. A comprehensive qualitative literature review was then conducted to identify food/nutrition literacy definitions and its components in the relevant literature. The data of the above three sub-studies were compiled as text data and were analyzed utilizing MAXQDA₂₀₁₀ software.

RESULTS

Two main domains, including cognitive and skill domains, emerged from the data analysis. The cognitive domain consisted of food- and nutrition-related knowledge included four subcategories "nutrition knowledge", "lifestyle knowledge", "food safety knowledge", and "knowledge of food and its preparation") as well as "food and nutrition understanding". The skill domain consisted of three dimensions: "functional", "interactive", and "critical" food and nutrition literacy.

CONCLUSIONS

The developed framework highlights the importance of integrated application of all dimensions of food and nutrition literacy among this population group. It can assist policymakers and curriculum developers in assessing education curricula and developing effective strategies for teaching and learning to increase students' food and nutrition literacy.

Where and when are portion sizes larger in young children? An analysis of eating occasion size among 1·5-5-year-olds in the UK National Diet and Nutrition Survey (2008-2017)

OBJECTIVE

To identify eating occasion-level and individual-level factors associated with the consumption of larger portions in young children and estimate their relative importance.

DESIGN

Cross-sectional.

SETTING

Data from parent-reported 4-d food diaries in the UK National Diet and Nutrition Survey (2008-2017) were analysed. Multilevel models explored variation in eating occasion size (kJ) within (n 48 419 occasions) and between children (n 1962) for all eating occasions. Eating contexts: location, eating companion, watching TV, and sitting at a table and individual characteristics: age, gender, ethnicity and parental socio-economic status were explored as potential correlates of eating occasion size.

PARTICIPANTS

Children aged 1·5-5 years.

RESULTS

Median eating occasion size was 657 kJ (IQR 356, 1117). Eating occasion size variation was primarily attributed (90 %) to differences between eating occasions. Most (73 %) eating occasions were consumed at home. In adjusted models, eating occasions in eateries were 377 kJ larger than at home. Eating occasions sitting at a table, v. not, were 197 kJ larger. Eating in childcare, with additional family members and friends, and whilst watching TV were other eating contexts associated with slightly larger eating occasion sizes.

CONCLUSIONS

Eating contexts that vary from one eating occasion to another are more important than demographic characteristics that vary between children in explaining variation in consumed portion sizes in young children. Strategies to promote consumption of age-appropriate portion sizes in young children should be developed, especially in the home environment, in eating contexts such as sitting at the table, eating with others and watching TV.

Portion size can be used strategically to increase intake of vegetables and fruits in young children over multiple days: a cluster-randomized crossover trial

BACKGROUND

Although dietary guidelines recommend that vegetables and fruits make up half the diet, it is unclear whether serving vegetables and fruits in larger portions will have sustained effects on children's intake over multiple days.

OBJECTIVES

This study tested the effects on children's intake of 2 strategies for increasing the proportion of vegetables and fruits: either adding or substituting extra portions as side dishes at meals and snacks over 5 d.

METHODS

In a cluster-randomized crossover design with 3 periods, we provided all meals and snacks for 5 d to 53 children aged 3-5 y in classrooms in their childcare centers. In the Control condition, we served typical portions for all food groups. In the Addition condition we increased portions of low-energy-dense vegetables and fruits by 50%, and in the Substitution condition we increased portions of vegetables and fruits by 50% and also reduced portions of other foods by an equivalent weight.

RESULTS

For vegetables, the Addition strategy increased daily intake compared with Control by 24% (mean ± SEM = 12 ± 3 g/d; P = 0.0002), and the Substitution strategy increased intake compared with Control by 41% (22 ± 3 g/d; P < 0.0001). For fruits, consumption increased by similar amounts: Addition by 33% (60 ± 6 g/d) and Substitution by 38% (69 ± 8 g/d; both P < 0.0001). Both strategies increased vegetable and fruit intakes compared with Control across all 5 days (all P < 0.004), although the increase in fruit consumption with Addition declined over time (P < 0.0001). Daily energy intake compared with Control increased by 5% with Addition (57 ± 17 kcal; P = 0.001) but decreased by 6% with Substitution (-64 ± 21 kcal; P = 0.004).

CONCLUSIONS

Both the Addition and Substitution strategies promoted increases in vegetable and fruit intake over 5 d in preschool children. When excess energy intake is a concern, substituting vegetables and fruits for other foods is a better option than simply serving more.This trial was registered at http://www.clinicaltrials.gov as NCT03242863 (https://clinicaltrials.gov/ct2/show/NCT03242863), where the protocol is available.

How Do French Parents Determine Portion Sizes for Their Pre-Schooler? A Qualitative Exploration of the Parent-Child Division of Responsibility and Influencing Factors

Large portion sizes can make children overeat, alter their self-regulation abilities and induce weight gain. However, little is known about how parents determine portion sizes for their children. Using semi-structured interviews with 5 fathers and 32 mothers of pre-schoolers, this study examined French parents' food portioning practices. The division of responsibility between parent and child in deciding portion sizes was explored, as well as the influencing factors and possible sources of information. Parents described a wide range of practices. For most, determining portion sizes is an intuitive action that depends on habits and mainly arises from experiences with feeding their child and his/her appetitive traits. Few parents grant autonomy to their child for portioning and serving food, especially for the first serving. Many influencing factors were identified, including child-related (e.g., appetite, food preferences), parent-related (e.g., avoiding food waste), and external factors (e.g., influence of siblings, French food culture). Most parents do not search for information/recommendations to guide their practices. Stimulating optimal self-regulation of eating in children is important and parents can play a crucial role in this. This study identified barriers and facilitators to guide parents in providing appropriate portion sizes and help include children in this decision process.

The Role of Dishware Size in the Perception of Portion Size in Children and Adolescents with Obesity

Purpose: The influence of dishware on portion size perception in children and adolescents is inconclusive. This study investigated how children and adolescents with both obesity and a normal weight perceived portion size in different sized and shaped dishware items. Methods: The study included 60 children and adolescents with overweight and obesity (OBE) and 27 children and adolescents with normal weight (NW) aged from 9 to 17 years. The participants estimated quantities in three pairs of drinking glasses, one pair of bowls and two pairs of plates which varied in size and shape. The children were instructed to state intuitively which portion they would choose for big or small thirst/hunger. Thereafter they were asked to determine the exact amount by answering which dishware item contained the larger/smaller portion (cognitive evaluation). Results: There were no substantial differences in the intuitive evaluation of portion sizes between OBE and NW. During the cognitive evaluation, OBE estimated the amount of water in the glasses more correctly compared to NW (61% vs. 43%; p = 0.008); OBE estimated the amount of lentils in the bowls and on the plates significantly less correctly (39%) compared to NW (56%; p = 0.013). Conclusions: Habit formation and environmental stimuli might play a greater role in estimating food amounts in dishware than the child’s and adolescent’s body weight.

Role of Dietary Factors, Food Habits, and Lifestyle in Childhood Obesity Development: A Position Paper From the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

ABSTRACT

Childhood obesity has high societal and economic impact but current treatment approaches are sub-optimal. In the last decade, important studies have been conducted aiming to identify strategies to prevent obesity during critical periods of life. Updated recommendations for childhood obesity prevention are needed. We present data from systematic reviews and meta- analysis, randomised controlled trials (RCTs) and large observational studies, published from 2011 onwards that consider the possible role of the following factors in obesity development: breast-feeding; macronutrient composition and method of complementary feeding; parenting style; dietary patterns; sugar-sweetened beverage consumption; eating behaviour (eg, skipping breakfast, family dinners. etc); meal frequency and composition (fast foods, snacking), portion size; dietary modulators of gut microbiota (including pre-, pro-, and synbiotics); physical activity and sedentary behaviour. We used the Medline database and the Cochrane Library to search for relevant publications. Important research gaps were also identified. This position paper provides recommendations on dietary factors, food habits, and lifestyle to prevent childhood obesity development, based on the available literature and expert opinion. Clinical research and high-quality trials are urgently needed to resolve numerous areas of uncertainty.

Development and validation of a food and nutrition literacy questionnaire for Chinese school-age children

Background

This study aimed to develop and validate the Food and Nutrition Literacy Questionnaire for Chinese School-age Children (FNLQ-SC).

Methods

A comprehensive literature review and qualitative study were initially performed to identify the dimensions and core components of food and nutrition literacy. A cross-sectional survey of 4359 school-age children was conducted, and junior middle school students were used to analyze the reliability and validity of the questionnaire (n = 2452). The reliability of the questionnaire was determined by internal consistency, the construct validity was assessed by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and the content validity was assessed by the Pearson correlation coefficient.

Results

From the literature review and qualitative methods, 19 core components of the FNLQ-SC were developed, including one dimension of food and nutrition knowledge and understanding, and four skill dimensions (ability of access, selection, preparing food and healthy eating). The overall FNLQ-SC questionnaire had acceptable internal consistency (Cronbach’s α = 0.698). The EFA of skill components extracted 5 factors that were included in the conceptual framework in a slightly different model, and the cumulative contribution of variance accounted for 50.60% of the overall variance. The CFA of skill components showed an acceptable fit in general and the root mean square error of approximation (RMSEA) was 0.070 (between 0.50 to 0.80). The communality was greater than 0.20 for all components. The Pearson correlation coefficients between each dimension and the overall questionnaire ranged from 0.370 to 0.877. The average FNLQ-SC score of all 4395 participants was 61.91 ± 9.22, and the score for the knowledge and understanding dimension was higher than that for the skill dimensions. Multiple linear regression analysis indicated that not only social demographic characteristics (being a girl, being an only child, living someplace other than at school, having an urban registered permanent residence status, being from an affluent family, and being cared for by parents/grandparents with a higher education level) but also the home food environment were predictors of food and nutrition literacy in school-age children (R² = 0.226, F = 81.401, P<0.05).

Conclusion

The Food and Nutrition Literacy Questionnaire (FNLQ-SC) developed here had good reliability, and it can potentially be a useful instrument for assessing food and nutrition literacy among Chinese school-age children.

Development of a Family-Based Nutrition Program Rooted in Food Parenting Literature

Family-based nutrition programs have been used to support healthy eating; however, few programs emphasize parental roles in regard to food. The purpose of this study was to develop and test a family-based curriculum with a parenting focus aimed at influencing child obesity risk. Qualitative data in the pilot implementation (cohort 1, n = 6 families with elementary-aged children) suggested parent value for: positive messages, hands-on learning, and group sharing. However, Family Nutrition and Physical Activity (FNPA) scores for cohorts 2-6 (n = 18 families) did not change significantly from pre- to post-program. Future implementations will consider more robust ways of assessing change and recruiting participants at various stages of change.

Nutrition Knowledge and Perspectives of Physical Activity for Pre-Schoolers amongst Early Childhood Education and Care Teachers

Caregivers’ nutrition and physical activity knowledge is recognised as being important for children’s health and body size. Identifying knowledge gaps amongst caregivers may inform professional development and obesity-prevention strategies in childcare settings. This cross-sectional validated online questionnaire aimed to measure current early childhood education and care (ECEC) teachers’ nutrition knowledge for pre-schoolers (2–5-year-olds) and related perspectives. Teachers’ (n = 386) knowledge of nutrition was lacking: The overall score was 22.56 ± 2.83 (mean ± SD), or 61% correct. Increased years of experience significantly predicted an increase in knowing that national nutrition and physical activity guidelines exist (B = 0.02 [95% CI, 0.00–0.03], r² = 0.13, p = 0.033). Teachers’ increased agreement in feeling they were confident talking about nutrition to parents significantly predicted an increase in overall nutrition knowledge scores (B = 0.34 [95% CI, 0.06–0.63], r² = 0.15, p = 0.019). The belief that ECEC teachers play a vital role in promoting pre-schoolers’ healthy eating and physical activity was widespread. Common knowledge barriers included a lack of staff training, confidence, and resources. ECEC teachers may lack nutrition knowledge for pre-schoolers, particularly in regard to basic nutrition recommendations (servings, food/beverage choices, and portion sizes).

What guidance is there on portion size for feeding preschool-aged children (1 to 5 years) in the United Kingdom and Ireland? A systematic grey literature review

Large portion sizes of food can lead to excessive energy intake and weight gain in young children. Although portion size guidance is available, parents are often unaware it exists. Our systematic grey literature review aimed to identify the portion size guidance resources in the United Kingdom and Ireland, aimed at users (e.g., parents and childcare providers) responsible for feeding preschool-aged children. We describe who the resources are aimed at, how they are informed and whether the recommended portion sizes are consistent across resources. Resources were identified via advanced Google searches, searching reference lists and contacting experts. Resources that provided quantifiable portion size information (e.g., grammes) were included. Portion sizes (g) were extracted and energy equivalents (kcal) were calculated. Portion sizes were analysed by food group and by eating occasion. Twenty-two resources were identified. Median portion sizes were consistent across resources for fruit (40 g [IQR = 40-50]) and vegetables (40 g [IQR = 30-40]). Variability was observed in portion size and/or energy content for dairy (60 g [IQR = 25-93]), protein (72 kcal [IQR = 44-106]) and starchy (41 g/71 kcal [IQR = 25-80/56-106]) food groups. The range in size of an average eating occasion was large (90-292 g). This review identifies resources that could help caregivers to choose appropriate portion sizes for preschool-aged children but also highlights how future resources could be improved.

A systematic review of recall errors associated with portion size estimation aids in children

To reduce errors in portion size estimation, a number of aids have been developed and tested. This systematic review synthesizes what is known about error associated with use of different portion size estimation aids (PSEAs) within self-reported dietary recall studies in children (aged ≤18 years). Eight electronic databases were searched using relevant keywords. From 8184 records identified and screened, 327 full texts were retrieved, with 10 records representing 9 studies meeting inclusion criteria. Studies using proxy reporting were excluded. Thirteen PSEAs were identified. To facilitate comparisons between different types of aids they were categorized into 'physical 2-dimensional (2D)', 'digital 2D' and '3-dimensional' PSEAs. Seven were physical 2D (e.g. food atlas), two were digital 2D (i.e. computer-based), and four were 3D (e.g. modelling clay, household items). Comparisons of PSEAs within studies found the smallest estimation errors for digital 2D and largest for 3D aids. Errors in relation to food type were varied, with portions of amorphous foods overestimated in multiple studies. No effects for recall interval time or sex were identified. One study reported a significant improvement in estimation error with increasing age. Across studies, large variations in study design and reporting of estimation error hindered the synthesis of evidence regarding the influence of different types of PSEAs on accuracy. While a definitive conclusion about the most accurate PSEA could not be drawn, a check-list to guide future PSEA development and testing has been proposed in the current review. This will assist comparability with future studies of PSEAs for children facilitate development of more accurate PSEAs in the future.

Do children with a high level of eating motivation consume less when foods are partitioned?

Eating behaviors, especially the control of intake, are modulated by both internal and external factors. The objective of our study was to examine the effect of the interaction between eating motivation (as an internal factor) and food partition (as an external factor) on chocolate intake in children, with the hypothesis, based on the paradigm of motivated perception, that the effect of partition, i.e. reduced intake, is higher for children with a high level of eating motivation than for other children. A mixed model design was used in which 80 children aged 8-11 yrs. were offered, in their natural setting, two standardized afternoon snacks that included, among other things, 100 g of chocolate presented once as a whole (one bar) and once segmented (six pieces). The amount of chocolate eaten was weighed and compared between conditions (Bar vs Pieces). Children completed questionnaires in order to assess two of their eating motivational features (appetite arousal, chocolate specific appetite). Results indicated no effect of Partition: children ate the same quantity of chocolate in the two conditions (Bar or Pieces). Only chocolate specific appetite was associated with the amount of chocolate eaten, with children with a higher level eating more than other children (+13 g). Contrary to adults, children are not influenced by the "many is more effect". Methodological and developmental interpretations were suggested, linked to the size of the portion, the network of attention and the sensibility to the external cues underlying the control of intake.

Using pictorial nudges of fruit and vegetables on tableware to increase children's fruit and vegetable consumption

Children's fruit and vegetable consumption is lower than recommended. Increasing consumption is important for children's health. Nudges influence children's eating behaviour, but less is known about the influence of a pictorial nudge on tableware on children's fruit and vegetable consumption. Two studies examined this. Study 1 examined whether a pictorial fruit nudge (a grape image) on a plate influenced children's fruit (grape) consumption relative to a control condition (no image). In a between-subjects design, children (n = 63, Mean age = 8.9 years, SD = 1.41, 38 females, 25 males, 73% had a healthy-weight) were randomly assigned to one of two conditions (fruit nudge vs. control). Study 2 examined the influence of a large portion pictorial nudge (a large portion carrot image) vs. a small portion pictorial nudge (a small portion carrot image) vs. control (no nudge) on children's vegetable (carrot) consumption. In a between-subjects design, children (n = 59, Mean age = 8.57 years, SD = 2.13, 31 females, 28 males, 85% had a healthy-weight) were randomly assigned to a condition. In Study 1 children consumed significantly more fruit in the pictorial nudge condition than the control condition. In Study 2 children ate significantly more vegetables in the large portion pictorial nudge condition than the other two conditions. The small portion pictorial nudge did not affect children's vegetable consumption relative to control. The results indicate that pictorial nudges on tableware influence children's fruit and vegetable consumption, and the portion size of this type of nudge may be key to whether it influences children's eating behaviour.

Portion size has sustained effects over 5 days in preschool children: a randomized trial

BACKGROUND

Although short-term studies have found that serving larger portions of food increases intake in preschool children, it is unknown whether this portion size effect persists over a longer period or whether energy intake is moderated through self-regulation.

OBJECTIVES

We tested whether the portion size effect is sustained in preschool children across 5 consecutive days, a period thought to be sufficient for regulatory systems to respond to the overconsumption of energy.

METHODS

With the use of a crossover design, over 2 periods we served the same 5 daily menus to 46 children aged 3-5 y in their childcare centers. In 1 period, all foods and milk were served in baseline portions, and in the other period, all portions were increased by 50%. The served items were weighed to determine intake.

RESULTS

Increasing the portion size of all foods and milk by 50% increased daily consumption: weighed intake increased by a mean ± SEM of 143 ± 21 g/d (16%) and energy intake increased by 167 ± 22 kcal/d (18%; both P < 0.0001). The trajectories of intake by weight and energy across the 5-day period were linear and the slopes did not differ between portion conditions (both P > 0.13), indicating that there were sustained increases in intake from larger portions without compensatory changes over time. Children differed in their response to increased portions: those with higher weight status, lower ratings for satiety responsiveness, or higher ratings for food responsiveness had greater increases in intake from larger portions (all P < 0.03).

CONCLUSIONS

This demonstration that preschool children failed to adjust their intake during prolonged exposure to larger portions challenges the suggestion that their self-regulatory behavior is sufficient to counter perturbations in energy intake. Furthermore, overconsumption from large portions may play a role in the development of overweight and obesity, as the magnitude of the effect was greater in children of higher weight status. This trial was registered at www.clinicaltrials.gov as NCT02963987.

Sprouts Growing Healthy Habits: Curriculum Development and Pilot Study

High rates of childhood obesity and the impact this has on children's health make it important to establish a healthy lifestyle during the early school years. This pilot study explored the impact of a newly developed healthy habits curriculum. The Sprouts: Growing Healthy Habits curriculum presents topics such as energy balance, healthy sleep habits, and food groups through short activities and interactive book-reading. A nonrandomized controlled experimental study design was used to assess impact. Fifty-seven children between 5 and 6 years of age participated from two elementary schools (36 from the intervention school, 21 from the control school). Knowledge was assessed pre- and post-intervention in five content areas (farm to table, bedtime routines, portion size, energy expenditure, sugar content of beverages) using card sorting, ranking, and sequence activities. Within- and between-school comparisons were conducted using differences between groups and mixed modeling approaches. Within the intervention school, significant increases in knowledge were observed for farm to table, sugar content of beverages, and bedtime routines. For the control school, there was a significant increase in knowledge of portion sizes. Considering between-schools, only change in knowledge of bedtime routines remained significant, with greater increases in the intervention school. Results seem promising given the short dosage of curriculum. Increases in knowledge of healthy habits in early childhood may help in promoting healthy behaviors and combatting the effects of obesity.

Evaluation of an eHealth intervention aiming to promote healthy food habits from infancy -the Norwegian randomized controlled trial Early Food for Future Health

BACKGROUND

Strategies to optimize early-life nutrition provide an important opportunity for primary prevention of childhood obesity. Interventions that can be efficiently scaled-up to the magnitude needed for sustainable childhood obesity prevention are needed. The objective of this study was to evaluate the effects of an eHealth intervention on parental feeding practices and infant eating behaviors.

METHODS

The Norwegian study Early Food for Future Health is a randomized controlled trial. Parents were recruited via social media and child health clinics during spring 2016 when their child was aged 3 to 5 months. In total 718 parents completed a web-based baseline questionnaire at child age 5.5 months. The intervention group had access to a webpage with monthly short video clips addressing specific infant feeding topics and age-appropriate baby food recipes from child age 6 to 12 months. The control group received routine care. The primary outcomes were child eating behaviors, dietary intake, mealtime routines and maternal feeding practices and feeding styles. The secondary outcomes were child anthropometry. This paper reports outcomes at child age 12 months.

RESULTS

More than 80% of the intervention group reported viewing all/most of the video clips addressing infant feeding topics and indicated that the films were well adapted to the child's age and easy to understand. Children in the intervention group were served vegetables/fruits more frequently (p = 0.035) and had tasted a wider variety of vegetables (p = 0.015) compared to controls. They were also more likely to eat family breakfast (p = 0.035) and dinner (p = 0.011) and less likely to be playing or watching TV/tablet during meals (p = 0.009) compared to control-group children. We found no group differences for child anthropometry or maternal feeding practices.

CONCLUSIONS

Our findings suggest that the eHealth intervention is an appropriate and feasible tool to propagate information on healthy infant feeding to Norwegian mothers. Our study also suggests that anticipatory guidance on early protective feeding practices by such a tool may increase young children's daily vegetable/fruit intake and promote beneficial mealtime routines.

TRIAL REGISTRATION

ISRCTN, ISRCTN13601567. Registered 29 February 2016, http://www.isrctn.com/ISRCTN13601567.

Shared Concerns and Opportunity for Joint Action in Creating a Food Environment That Supports Health

The food industry is a for-profit industry with high relevance to universal eating disorders prevention. To date, policy which targets the food industry and food environment has been underutilized in efforts to decrease the incidence of eating disorders and associated risk factors. In contrast, food policy has been extensively leveraged with the aim of reducing the incidence of obesity. While philosophical misalignments with these later efforts may have constituted an obstacle to identifying the food environment as a key target for eating disorders prevention, food policy is an area where shared interests can be found. Specifically, a shared goal of obesity and eating disorders prevention efforts is creating a food environment that supports health, while minimizing the influence of the food industry that profits from the sale of highly palatable, processed foods and “diet” foods and from increasing portions of foods served and eaten.

Diagnosis, treatment and prevention of pediatric obesity: consensus position statement of the Italian Society for Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics

The Italian Consensus Position Statement on Diagnosis, Treatment and Prevention of Obesity in Children and Adolescents integrates and updates the previous guidelines to deliver an evidence based approach to the disease. The following areas were reviewed: (1) obesity definition and causes of secondary obesity; (2) physical and psychosocial comorbidities; (3) treatment and care settings; (4) prevention.The main novelties deriving from the Italian experience lie in the definition, screening of the cardiometabolic and hepatic risk factors and the endorsement of a staged approach to treatment. The evidence based efficacy of behavioral intervention versus pharmacological or surgical treatments is reported. Lastly, the prevention by promoting healthful diet, physical activity, sleep pattern, and environment is strongly recommended since the intrauterine phase.

INSIGHT responsive parenting intervention and infant feeding practices: randomized clinical trial

Background

What, when, how, how much, and how often infants are fed have been associated with childhood obesity risk. The objective of this secondary analysis was to examine the effect of a responsive parenting (RP) intervention designed for obesity prevention on parents’ infant feeding practices in the first year after birth.

Methods

Primiparous mother-newborn dyads were randomized to the Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) Study RP intervention or child safety control. Research nurses delivered intervention content at home at infant age 3–4, 16, 28, and 40 weeks, and at a research center at 1 year. RP feeding guidance advised feeding that was contingent (i.e., feed in response to hunger and satiety signs, alternatives to using food to soothe), and developmentally appropriate (i.e., delaying introduction of solids, age-appropriate portion sizes). Infant feeding practices (i.e., bottle use, introduction of solids, food to soothe) were assessed by phone interviews and online surveys and dietary intake was assessed using a food frequency questionnaire.

Results

RP mothers were more likely to use of structure-based feeding practices including limit-setting (p < 0.05) and consistent feeding routines (p < 0.01) at age 1 year. RP group mothers were less likely to use non-responsive feeding practices such as pressuring their infant to finish the bottle/food (p < 0.001), and using food to soothe (p < 0.01), propping the bottle (p < 0.05) assessed between 4 and 8 months, and putting baby to bed with a bottle at age 1 year (p < 0.05). Few differences were seen between groups in what specific foods or food groups infants were fed.

Conclusions

Anticipatory guidance on RP in feeding can prevent the use of food to soothe and promote use of more sensitive, structure-based feeding which could reduce obesity risk by affecting how and when infants are fed during the first year.

Trial registration

The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) Study. www.clinicaltrials.gov . NCT01167270. Registered 21 July 2010.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0700-6) contains supplementary material, which is available to authorized users.

A latent class analysis of family eating habits in families with adolescents

The objectives of the present study were to identify adolescent classes based on perceptions of their family's eating habits and to determine whether these classes differ in terms of family meal frequency and source, parents and adolescent diet quality, nutritional status, satisfaction with life, family life and food-related life. Questionnaires were administered to a sample of 300 two-parent families with one child between 10 and 17 years in Chile. Questionnaires included the Satisfaction with Life Scale (SWLS), the Satisfaction with Food-related Life scale (SWFoL), the Satisfaction with Family Life scale (SWFaL) and the Adapted Healthy Eating Index (AHEI). Adolescents also answered the Family Eating Habits Questionnaire (FEHQ). Latent class (LC) analysis was used to estimate the number of classes associated with the adolescent's perceptions about their family's eating habits, based on the three factors detected in the FEHQ. The LC analysis yielded three classes: "medium cohesion around family meals/healthy food-related parenting practices" (Class 1, 50.4%), "high cohesion around family meals/healthy food-related parenting practices" (Class 2, 25.9%) and "high cohesion around family meals/unhealthy food-related parenting practices" (Class 3, 23.7%). Classes also differed in the adolescents AHEI score, frequency and source of family meals; body mass index, SWLS and SWFaL scores in mothers, fathers and adolescents, adolescent sex and household financial situation. These findings suggest that frequent and cohesive family meals improve the well-being in both parents and adolescents, but are not enough to achieve healthier diets and weight statuses in adolescents.

Research into food portion size: methodological aspects and applications

Portion sizes for certain foods have been increasing dramatically in recent years alongside obesity rates, concurring with the phenomenon of the portion size effect (more is consumed when more is offered). Portion size may be defined based on different purposes such as for dietary assessment, or therapeutic advice or food labelling, resulting in a variety of measurement methods and specifications. This situation has resulted in disagreements on establishing portion size recommendations by manufacturers, food distributors, restaurants, health professionals and policy makers, contributing to confusion amongst consumers on the amounts of food to be consumed, and potentially increasing the likelihood of overeating and other obesity-related behaviours. Such variability is also reflected in the research field making comparison across studies on portion size difficult. The aim of this review is to provide an overview of definitions and methods used in research to evaluate portion-size related outcomes, including methods to estimate amounts consumed by individuals as part of dietary assessment; methods to analyse cognitive mechanisms related to portion size behaviour; and methods to evaluate the impact of portion size manipulations as well as individual plus environmental factors on portion size behaviour. Special attention has been paid to behavioural studies exploring portion size cognitive processes given the lack of previous methodological reviews in this area. This information may help researchers, clinicians and other stakeholders to establish clearer definitions of portion size in their respective areas of work and to standardise methods to analyse portion size effects.

Meals for Good: An innovative community project to provide healthy meals to children in early care and education programs through food bank catering

Innovative approaches to childhood obesity prevention are warranted in early care and education (ECE) settings, since intervening early among youth is recommended to promote and maintain healthy behaviors. The objective of the Meals for Good pilot was to explore feasibility of implementing a food bank-based catering model to ECE programs to provide more nutritious meals, compared to meals brought from home (a parent-prepared model). In 2014-2015, a 12-month project was implemented by a food bank in central Florida in four privately-owned ECE programs. An explanatory sequential design of a mixed-methods evaluation approach was utilized, including a pre-post menu analysis comparing parent-prepared meals to the catered meals, and stakeholder interviews to determine benefits and barriers. The menu analysis of lunches showed daily reductions in calories, fat, and saturated fat, but an increase in sodium in catered meals when compared to parent-prepared meals. Interviews with ECE directors, teachers, parents, and food bank project staff, identified several benefits of the catered meals, including healthfulness of meals, convenience to parents, and the ECE program's ability to market this meal service. Barriers of the catered meals included the increased cost to parents, transportation and delivery logistics, and change from a 5 to a 2-week menu cycle during summer food service. This pilot demonstrated potential feasibility of a food bank-ECE program partnership, by capitalizing on the food bank's existing facilities and culinary programming, and interest in implementing strategies focused on younger children. The food bank has since leveraged lessons learned and expanded to additional ECE programs.

Parent packs, child eats: Surprising results of Lunch is in the Bag's efficacy trial

Early care and education (ECE) centers that require lunch brought from home provide an uncluttered view of parent-child dietary interactions in early childhood. Children's eating from parent-provided bag lunches was observed at 30 ECE centers in Texas, with 15 randomly assigned to the Lunch is in the Bag intervention to improve the lunch meal and 15 to a wait-list control condition. Study participants were parent and child aged 3-5 years (N = 633 dyads). Data were collected at baseline (pre-intervention) and follow-ups at weeks 6 (post-intervention), 22 (pre-booster), and 28 (post-booster). Changes effected in the children's lunch eating-e.g., increase of 14 percent in prevalence of children eating vegetables (SE = 5, P = 0.0063)-reciprocated changes in parent lunch-packing. Irrespective of intervention, however, the children consumed one-half to two-thirds of the amounts of whatever foods the parents packed, and the eat-to-pack ratio did not change across time. Thus, children's lunch eating at the ECE centers appeared to be regulated by perceptual cues of food availability rather than food preferences or internal cues of hunger and satiety.

Trends in Food and Beverage Portion Sizes in Australian Children; a Time-Series Analysis Comparing 2007 and 2011-2012 National Data

In 2011–2012 approximately 26% of Australian children aged between 5–17 years were reported to be overweight or obese. Furthermore, the increase in prevalence of overweight and obesity among US children parallels reported increases in energy intake and portion sizes of common foods, leading to the recognition that availability of larger portion sizes contributes to the rise in overweight and obesity prevalence. Thus, the aim of this time-series analysis was to investigate whether selected food portion sizes in Australian children aged 2–16 years changed between 2007 and 2011–2012. Portion size data from 24-h recalls collected in Australian nutrition surveys were compared between 2007 and 2011–2012. Portion sizes changed significantly in 23% of items with increases in 15% and decreases in 8%. Changes in portion sizes varied by age, sex, and food group. Changes occurred for many meat-based items, energy-dense, nutrient-poor food items, breads, cereals, and some fruits and vegetables. Vegetable and fruit portion sizes were below the respective serving sizes of 75 g and 150 g in the Australian Guide to Healthy Eating, while portion sizes of some energy-dense, nutrient-poor foods have increased. These findings suggest approaches to increasing consumption of nutrient-dense core foods and reducing energy-dense, nutrient-poor food items in children are warranted.

Developing and validating a scale to measure Food and Nutrition Literacy (FNLIT) in elementary school children in Iran

BACKGROUND

Food and nutrition literacy is an emerging term which is increasingly used in policy and research. Though research in this area is growing, progression is limited by the lack of an accepted method to measure food and nutrition literacy. The aim of this study is to develop a valid and reliable questionnaire to assess food and nutrition literacy in elementary school children in the city of Tehran.

METHODS

The study was conducted in three phases. To develop Food and Nutrition Literacy (FNLIT) questionnaire, a comprehensive literature review and a qualitative study were initially performed to identify food and nutrition literacy dimensions and its components. Content and face validity of the questionnaire were evaluated by an expert panel as well as students. In the second phase, construct validity of the scale was evaluated using Explanatory Factor Analyses (EFA) and Confirmatory Factor Analyses (CFA). In the last phase (confirmatory phase), the final version of the questionnaire was evaluated on 400 students.

RESULTS

Findings show Content Validity Ratio (CVR) and Content Validity Index (CVI) of the 62-item questionnaire at acceptable levels of 0.87 and 0.92, respectively. EFA suggested a six-factor construct, namely, understanding food and nutrition information, knowledge, functional, interactive, food choice, and critical. The results of CFA indicated acceptable fit indices for the proposed models. All subscales demonstrated satisfactory internal consistency (Cronbach's alpha≥0.70), except for critical skill subscale (0.48). The intraclass correlation coefficient (ICC = 0.90, CI: 0.83-0.94) indicated that Food and Nutrition Literacy (FNLIT) scale had satisfactory stability. Each phase of development progressively improved the questionnaire, which resulted in a 46-item (42 likert-type items and 4 true-false items) Food and Nutrition Literacy (FNLIT) scale. The questionnaire measured two domains with 6 subscales, including: 1) cognitive domain: understanding and knowledge; 2) skill domain: functional, food choice, interactive, and critical skills.

CONCLUSION

The developed food and nutrition literacy scale is a valid and reliable instrument to measure food and nutrition literacy in children. This measure lays a solid empirical and theoretical foundation for future research and tailored interventions to promote food and nutrition literacy in this age group.

The Financial Costs, Behaviour and Psychology of Obesity: A One Health Analysis

People who are overweight or have obesity are estimated to comprise 30% of the global population and up to 59% of companion dogs and cats are estimated to be above their optimal body weight. The prevalence of human and companion obesity is increasing. The direct and indirect costs of obesity and associated comorbidities are significant for human and veterinary healthcare. There are numerous similarities between obesity in people and companion animals, likely related to the shared environmental and lifestyle elements of this multifactorial disease. While the study of human obesity is relatively robust, research conducted in pets is generally limited to small studies, studies with cross-sectional designs or reports that have yet to be replicated. Greater understanding of human obesity may elucidate some of the factors driving the more recent rise in pet obesity. In particular, there are overlapping features of obesity in children and pets that are, in part, related to dependency on their 'parents' for care and feeding. When feeding is used in a coercive and controlling fashion, it may lead to undesirable feeding behaviour and increase the risk for obesity. A 'responsive parenting' intervention teaches parents to respond appropriately to hunger-satiety cues and to recognize and respond to others' distress. Such interventions may impact on childhood overweight and obesity and have the potential to be adapted for use with companion animals. Social behaviour towards people with obesity or owners of pets with obesity is often driven by beliefs about the cause of the obesity. Educating healthcare professionals and the public about the multifactorial nature of this complex disease process is a fundamental step in reducing the bias and stigma associated with obesity. Children living in low-income households have particularly high rates of obesity and as household income falls, rates of obesity also rise in pets and their owners. There are risk regulators (i.e. dynamic components of interconnected systems that influence obesity-related behaviours) and internal factors (i.e. biological determinants of obesity) that may influence the development of both childhood and pet obesity, and poverty may intersect with these variables to exacerbate obesity in low-income environments. This review discusses the costs, behaviours and psychology related to obesity in people and pets, and also proposes potential techniques that can be considered for prevention and treatment of this disease in pets. A 'One Health' approach to obesity suggests that an understanding of human obesity may elucidate some of the factors driving the more recent rise in pet obesity.

Home Food Rules in Relation to Youth Eating Behaviors, Body Mass Index, Waist Circumference, and Percent Body Fat

PURPOSE

To investigate agreement and associations between parent and youth acknowledgment of home food rules, youth eating behaviors, and measures of body composition and excess weight.

METHODS

Parent-youth dyads (N = 413) completed the "rules for eating at home" scale (Active Where Survey) and reported dietary intake. Trained research staff obtained anthropometric data. Linear regression analyses separately evaluated relationships between youth and parent acknowledgment of rules and youth-reported eating behaviors and anthropometric outcomes. Food rules were evaluated as a 12-item scale and individually.

RESULTS

Score on the food rule scale was positively associated with fruit and vegetable servings by youth acknowledgment only (β = .09, p = .006), and not with anthropometric outcomes. The rule "no desserts except fruit" was positively associated with fruit and vegetable servings by youth (β = .72, p = .002) and parent (β = .53, p = .03) acknowledgment. The rules "no second helpings at meals" and "limited fast food" were positively associated with body mass index z-score by youth (β = .38, p = .002; β = .32, p = .02, respectively) and parent (β = .74, p < .001; β = .41, p = .006, respectively) acknowledgment, with similar results for waist circumference z-score and percent body fat.

CONCLUSIONS

Inverse associations between specific food rules and healthful eating behaviors but positive associations with anthropometric outcomes suggest potentially bidirectional relationships between food rule implementation and youth weight. Future studies should disentangle how food rules guide youth behavior in the context of youth weight status.

Development of a theory-based questionnaire to assess structure and control in parent feeding (SCPF)

Background

Parents shape children’s eating environments and act as powerful socialization agents, impacting young children’s behavioral controls of food intake. Most feeding measures assess parents’ use of control to manage children’s intake of energy dense foods. The Structure and Control in Parent Feeding (SCPF) questionnaire was developed to assess more positive aspects of feeding practices with their young children —setting limits, providing routines—that promote self-regulation, as well as controlling feeding practices.

Methods

A mixed method approach was used to develop the SCPF. In 2013, cognitive interviews informed the modification, deletion and/or replacement of items. In 2014, the survey was distributed statewide to mothers of toddlers aged 12 to 36 months participating in the Women, Infants, and Children program. In 2016, exploratory factor analyses was conducted to test our theoretical parenting model and content validity and criterion validity were assessed (n = 334).

Results

Exploratory factor analysis (EFA) and second-order EFA revealed a 2-factor, 22-item Structure model and a 2-factor, 12-item Control model. Internal consistencies for all factors exceeded 0.70. As predicted, the Structure superfactor was positivity associated with responsiveness, whereas the Control superfactor was positively associated with demandingness on the Caregiver’s Feeding Styles Questionnaire. The Structure subscales were also positively associated with mealtime behaviors and Control subscales were positively associated with control-oriented feeding measures from the Control in Parent Feeding Practices questionnaire.

Conclusion

The SCPF questionnaire is a reliable tool that can be used to assess aspects of structure- and control-based feeding practices to better understand how parents feed their toddlers.