Taste the feeling or feel the tasting: Tactile exposure to food texture promotes food acceptance

Technological tools for the measurement of sensory characteristics in food: A review

The use of technological tools, in the food industry, has allowed a quick and reliable identification and measurement of the sensory characteristics of food matrices is of great importance, since they emulate the functioning of the five senses (smell, taste, sight, touch, and hearing). Therefore, industry and academia have been conducting research focused on developing and using these instruments which is evidenced in various studies that have been reported in the scientific literature. In this review, several of these technological tools are documented, such as the e-nose, e-tongue, colorimeter, artificial vision systems, and instruments that allow texture measurement (texture analyzer, electromyography, others). These allow us to carry out processes of analysis, review, and evaluation of food to determine essential characteristics such as quality, composition, maturity, authenticity, and origin. The determination of these characteristics allows the standardization of food matrices, achieving the improvement of existing foods and encouraging the development of new products that satisfy the sensory experiences of the consumer, driving growth in the food sector. However, the tools discussed have some limitations such as acquisition cost, calibration and maintenance cost, and in some cases, they are designed to work with a specific food matrix.

The influence of food sensory properties on eating behaviours in children with Down syndrome

Developing new food products for children is challenging, particularly in vulnerable groups including children with Down syndrome (DS). Focusing on children with DS, the aim of this study was to study the influence of parent liking on acceptance of food products by children with DS and demonstrate the influence of food sensory properties on indicators of food acceptance, food rejection, and challenging eating behaviours. Children (ages 1158 months) with DS (n = 111) participated in a home use test evaluating snack products with varying sensory properties as profiled by a trained sensory panel. Parents recorded their children's reactions to each food product; trained coders coded videos for eating behaviours. To understand the influence of each sensory modality on eating behaviour, ordered probit regression models were run. Results found a significant correlation between the parent liking and overall child disposition to the food (p < 0.05). From the regression analysis, the inclusion of all food sensory properties, including texture, flavour, taste, product shape and size, improved the percentage of variance explained in child mealtime behaviours and overall disposition over the base model (containing no sensory modalities), with texture having the largest influence. Overstuffing the mouth, a challenging eating behaviour, was most influenced by product texture (children ≥ 30 months), and product texture and size (children < 30 months). In both age groups, coughing/choking/gagging was most influenced by food texture and was associated with a product that was grainy and angular (sharp corners). In both age groups, product acceptance was associated with a product that was dissolvable, crispy, and savoury while rejection was associated with a dense, gummy and fruity product. These results suggest that a dissolvable, crispy texture, with a cheesy or buttery flavour are the sensory properties important in a desirable flavoured commercial snack product for children with DS; however, overall disposition must be balanced against mouth overstuffing.

[Sensory food aversion in the context of a modern approach to eating disorders in early childhood]

Sensory food aversion, an early childhood eating disorder, is a serious, permanent form of picky eating, in which the infant or the child consistently and persistently refuses certain foods based on specific characteristics, following one or more previous aversive experiences. Biological (sensory processing disorder, taste sensitivity) and environmental factors contribute to its development. Due to limited diet, specific dietary deficiencies may occur but weight gain is usually normal. Behavioral problems, anxiety disorder, autism spectrum disorder are often associated. Diagnosis can usually be made based on a detailed history, but further assessment may include pediatric examination, nutritionist consultation, and psychologic and occupational therapy assessment. Treatment is based on parent education and support in order to minimize mealtime battles and anxiety and to think together about strategies for expanding the child's diet and to help them to accept new foods. As part of the interdisciplinary team, the pediatrician's role is to monitor appropriate growth and development, exclude dietary deficiencies or prescribe supplementation if necessary. In our article, the screening and treatment of sensory processing disorder as part of the assessment of eating problems are introduced as an example of good clinical practice at the Early Childhood Eating and Sleep Disorder Outpatient Clinic at the Heim Pál National Institute of Pediatrics. Orv Hetil. 2023; 164(45): 1767-1777.

Child characteristic correlates of food rejection in preschool children: A narrative review

Dietary habits formed in early childhood are key for establishing a healthy diet later in life. Picky eating and food neophobia - the two main forms of food rejection in young children - form an important barricade to establishing such healthy habits. Understanding these types of food rejection is thus essential for promoting healthy eating behaviour in both children and adults. To this end, the present narrative review aims to provide an overview of food rejection research in preschool-aged children, focusing on recent advances in the cognitive literature. Specifically, we evaluate the link between children's cognitive development, chemosensory perception and affective evaluation of food, food knowledge, decision-making strategies, anxiety and disgust sensitivity, and food rejection behaviour. Longitudinal and experimental studies are necessary to establish how the relationships between food rejection and cognitive processes develop over time and to determine their causal directions.

Food oral processing and eating behavior from infancy to childhood: evidence on the role of food texture in the development of healthy eating behavior

Eating behaviors develop in early life and refine during childhood, shaping long-term food choice and dietary habits, which underpin optimum growth and health. The development of Food Oral Processing (FOP) is of major importance in the establishment of eating behaviors at two scale levels: for the initial acceptance of food texture and for the longer-term development of eating behaviors associated to food intake. To date, both processes have been studied as independent topics and the current review proposes a parallel vision on their development from the onset of complementary feeding to later childhood. Individual factors affecting these FOP-related behaviors as they relate to food texture acceptance are discussed, alongside examples of interventions aiming at modifying them. Opportunity to better consider food textures when designing foods for children is addressed. Altogether, the review demonstrates the critical role of food texture in the development of a child's FOP skills, eating habits, and dietary patterns. These scientific knowledges need to be considered for the development of healthier eating behavior. We identify research gaps that need to be addressed and highlight the need to design foods that can support the development of healthy oral processing and eating behaviors among infants and children.

11- to 13-Year-Old Children's Rejection and Acceptance of Unfamiliar Food: The Role of Food Play and Animalness

Promoting children's healthy food behavior is important in reducing the risk of developing obesity; it is therefore relevant to investigate methods to promote healthy food choices. This study's aim was to investigate differences in rejection-acceptance mechanisms related to unfamiliar foods depending on the inclusion of tactile exercises prior to cooking and food origin. Participant observation was applied in a school setting. Eight fifth and sixth grade classes were recruited from four Danish schools (n = 129). The classes were divided into two groups: animal (AG; quail) and nonanimal (NAG; bladderwrack). AG and NAG were subdivided into two groups: food print (FP) and no food print (NFP). Applied thematic analysis was applied. During preparation/cooking, NFP displayed disgust-related rejection, whereas FP displayed inappropriateness-related rejection. FP exhibited more playful behavior. Inappropriateness and animalness drove AG rejection. NAG rejection was driven by the slimy texture of the food and the perception of it 'not being food'. Acceptance was driven by taste and familiarity. In conclusion, the inclusion of tactile exercises could increase children's exploratory food behavior, and the promotion of children's healthy food behavior should not solely focus on choosing foods deemed safe and familiar, since, despite rejection during cooking, acceptance is ultimately possible.

The clinicians' view of food-related obstacles for treating eating disorders: A qualitative study

Background

Good health requires healthy eating. However, individuals with eating disorders, such as anorexia nervosa, require treatment to modify their dietary behaviours and prevent health complications. There is no consensus on the best treatment practices and treatment outcomes are usually poor. While normalising eating behaviour is a cornerstone in treatment, few studies have focused on eating and food-related obstacles to treatment.

Objective

The aim of the study was to investigate clinicians' perceived food-related obstacles to treatment of eating disorders (EDs).

Design

Qualitative focus group discussions were conducted with clinicians involved in eating disorder treatment to get an understanding of their perceptions and beliefs regarding food and eating among eating disorder patients. Thematic analysis was used to find common patterns in the collected material.

Results

From the thematic analysis the following five themes were identified: (1) ideas about healthy and unhealthy food, (2) calculating with calories, (3) taste, texture, and temperature as an excuse, (4) the problems with hidden ingredients and (5) the challenges of extra food.

Discussion

All identified themes showed not only connections to each other but also some overlap. All themes were associated with a requirement of control, where food may be perceived as a threat, with the effects of food consumption resulting in a perceived net loss, rather than a gain. This mindset can greatly influence decision making.

Conclusions

The results of this study are based on experience and practical knowledge that could improve future ED treatments by enhancing our understanding the challenges certain foods pose for patients. The results may also help to improve dietary plans by including and explaining challenges for patients at different stages of treatment. Future studies could further investigate the causes and best treatment practices for people suffering from EDs and other eating disturbances.

A review on children's oral texture perception and preferences in foods

Texture properties of foods are particular drivers for food acceptance and rejection in children. The texture preferences follow the developmental progression of the child and these changes modulate the present and future food habits. This paper reviews the development and factors influencing texture preferences in children and the methods in food texture research with children. The child's acceptance of more complex food textures is age-dependent. The progression is indorsed by the development of oral processing skills at an early age and bolstered by repeated exposures to foods with varying textures. Children generally reject foods containing pieces or bits (i.e., geometrical textural properties); however, the impact of mechanical textural properties on food acceptance is less clear. Child characteristics such as food neophobia, picky eating, and tactile over-responsivity, negatively affect the acceptance of more diverse food textures. Depending on the child's age, the prevailing methods of characterizing food texture preferences in children include observational techniques and self-reported questionnaires. Despite knowledge of children's development of masticatory skills, learning, and cognitive abilities, the relationships of these changes to food texture acceptance and the recommended test methodology for evaluating product texture acceptance in this period of life are still limited.

Eating behaviors in children with down syndrome: Results of a home-use test

Children with Down syndrome (DS) display a disproportionate number of health challenges, including feeding and swallowing difficulties and food texture sensitivities. To start addressing food texture challenges early in life, the aim of this research was to understand mealtime behaviors and identify preferred food textures of children with DS. Children (aged 11 to 58 months) with DS (n = 111) and without (typically developing, TD; n = 107) participated in a home use test evaluating snack products of varying textures. Parents recorded their children's reactions to each food product; a panel of trained coders coded videos for mealtime behaviors. Children were also identified as food texture sensitive (TS) or non-texture sensitive (NTS). Results showed that age, TS, the presence of a DS diagnosis and the TS*DS interaction influenced the child's behaviors to the food products. Children with DS were more likely to increase distance from the food, mouth/suck on the food, and less likely to chew/much on the food compared to children TD. Children with DS also ate significantly less than typically developing children. Similar mealtime behaviors were observed between the children with TD/<30 months of age and children with DS regardless of age (p < .05). While children with DS/TS had a higher disposition for the dissolvable texture, along with products that were salty and cheesy, children with DS/NTS had a greater tolerance for more textures in general, including crunchy and grainy. Overall, this research identified mealtime behaviors in children with DS, determined overall disposition of children with DS to foods of differences sensory properties, and demonstrated the influence of TS on a child's disposition to a food. This research will be extended to develop acceptable and innovative food products for children with DS/TS.

Promoting Routines of Exploration and Play during Mealtime: Estimated Effects and Identified Barriers

Promoting Routines of Exploration and Play during Mealtime (Mealtime PREP) is an intervention designed to support healthy dietary variety in children. To estimate the effects of this intervention, we recruited 20 parents and children (aged 1-5 years) with sensory food aversions to participate in a pilot study. Parents were coached to enhance daily child meals using Mealtime PREP. Our primary outcome was acceptance of targeted food (number of bites) over time. Descriptive statistics and effect sizes are reported. Moderate effects were observed for acceptance of targeted food. Mealtime PREP warrants additional research to examine effects in larger, more diverse samples.

Food texture experiences across age groups in 4- to 36-month-old children in the United States

The question of what to feed becomes a new challenge as an infant reaches the transition to complementary foods. Limited information is available that provides a texture progression map for complementary food introduction. Thus, the objective of this study was to determine the relationship between age and food texture experiences (FTE) in young children aged 4-36 months in the United States. A parent-reported survey was fielded with 328 children categorized into five age groups (AGs): 4-8 months (AG1), 9-12 months (AG2), 13-18 months (AG3), 19-24 months (AG4), and 25-36 months (AG5). The present study analyzed four questions focused on FTE, with statistical analyses including probit and logit models, and analysis of variance. Results showed that all 16 food textures were tried at least once (>50%) by AG3. The question answered by participants, "How well does your child manage a specific texture," showed that significant differences existed among AGs for the management of 10 food textures (including chewy, hard, soft), whereas teething alone had no effect. The most refused textures by the children were AG1-crispy (27%), AG2-leafy (23%), AG3-leafy (40%), AG4-tough meat (52%), and AG5-leafy (51%). With increasing AG, the refusal probability of nine food textures, including chewy, leafy, and rubbery, also increased (p < .05). The refusal probability of cold food temperatures decreased with increasing age (p < .05). This study observed FTE in children across AGs and provides useful information to parents and practitioners as they introduce food textures into children's diets.

A quasi-experimental intervention protocol to characterize the factors that influence the acceptance of new foods by infants: mothers' diet and weaning method. Dastatuz project

BACKGROUND

Children usually refuse to eat and taste fruits and vegetables; and turning unhealthy eating habits around is an important social challenge in industrialized countries. The Dastatuz project aims to study children food neophobia and to enhance fruit and vegetable acceptance.

METHODS

A quasi-experimental, multicentre, controlled and prospective intervention study is proposed, in which early factors influencing new food acceptance will be studied. Mothers in the third trimester of pregnancy (n = 144) and their infants will be the study population. Experimental groups will be established based on mothers´ fruit and vegetable intake (standard or high intake) and weaning method (baby lead weaning vs spoon feeding). The project will assess the possible impact of maternal diet and complementary feeding on infants eating behaviour until 18 months of age. Outcome measures will comprise maternal diet and psychological features during pregnancy and breast-feeding (validated questionnaires). Compositional and physicochemical analysis of milk during breastfeeding will also be carried out. During weaning, until 18 months of age, children's diet will be assessed with 24 h recalls and acceptance of new fruits and vegetables will be studied using video recording.

DISCUSSION

If the intervention is effective, this research work would have a high potential to be transferred to future public health programs or nutrition guidelines, as a feasible solution to achieve a higher intake of fruits and vegetables among children.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov. Identifier: NCT04262102 . Registration date: February 10, 2020 - Retrospectively registered.

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.

Development of a home-use method for the evaluation of food products by children with and without Down syndrome

This article describes the development of a method to evaluate the acceptance of different snack food textures by children with food texture sensitivities, including children with and without Down syndrome (DS). An in-home use test (HUT) was developed to reflect recent taste study and allow greater recruitment. In this study, parents with children (ages 11-60 months) with DS (CWDS) and without (typically developing, CTD) were recruited and based on responses to several questions, children were categorized as food texture sensitive (TS) or nontexture sensitive (NTS). In total, 111 CWDS (49 TS and 62 NTS) and 107 CTD (42 TS and 65 NTS) participated. To select the food products for assessment, a trained panel profiled commercially available infant and toddler solid snack foods (n = 41), from which 16 products were selected and sorted into four flavor groupings. For the HUT, participating children evaluated each food product once per day for 6 days. Parents recorded their children's reactions to each food product; a panel of trained coders coded each video for verbal and nonverbal behaviors using a novel coding scheme. Parent prompts were also coded. Several challenges were experienced during this study, including poor-quality videos, and standardization of the home environment during the feeding sessions. However, the high degree of successful completion of the HUT (96%) was attributed to the high motivation of the parents involved, as well as the close interaction between the experimenters and the participants on an individual family level.

Factors Associated With Food Texture Acceptance in 4- to 36-Month-Old French Children: Findings From a Survey Study

Food texture plays an important role in food acceptance by young children, especially during the complementary feeding period. The factors driving infant acceptance of a variety of food textures are not well-known. This study summarizes maternal reports of children's ability to eat foods of different textures (here: acceptance) and associated factors. Mothers of 4- to 36-month-old children (n = 2,999) answered an online survey listing 188 food-texture combinations representing three texture levels: purees (T1), soft small pieces (T2), hard/large pieces, and double textures (T3). For each offered combination, they reported whether it was spat out or eaten with or without difficulty by the child. A global food texture acceptance score (TextAcc) was calculated for each child as an indicator of their ability to eat the offered textured foods. The results were computed by age class from 4-5 to 30-36 months. The ability to eat foods without difficulty increased with age and was ranked as follows: T1> T2 > T3 at all ages. TextAcc was positively associated with exposure to T2 (in the age classes between 6 and 18 months old) and T3 (6-29 months) and negatively associated with exposure to T1 (9-36 months). Children's developmental characteristics, as well as maternal feeding practices and feelings with regard to the introduction of solids, were associated with texture acceptance either directly or indirectly by modulating exposure. Children's ability to eat with their fingers, gagging frequency, and to a lesser extent, dentition as well as maternal feelings with regard to the introduction of solids were the major factors associated with acceptance. This survey provides a detailed description of the development of food texture acceptance over the complementary feeding period, confirms the importance of exposure to a variety of textures and identifies a number of additional person-related associated factors.

Children overcoming picky eating (COPE) - A cluster randomised controlled trial

OBJECTIVES

Food neophobia limits dietary variety in children and adults. Interventions to alleviate the impact of neophobia on children's dietary variety have had varying success. The potential effectiveness of mindfulness, a process of bringing awareness to the present moment, has received little attention. This trial aimed to explore the effectiveness of two mindfulness exercises on novel food acceptance for children.

METHODS

A cluster-randomised controlled trial with three trial arms compared the impact of two mindfulness exercises (mindful breathing and mindful raisin-eating) and a non-mindful control task on anticipated liking and intake of a novel fruit. Seventy-one children aged 10-12 years engaged in one of the three tasks at school over five days and were offered a novel fruit at the end of the intervention. Children self-reported mindfulness, food neophobia and anxiety at baseline and follow-up.

RESULTS

Two mixed-effects models showed that, controlling for school effects and covariates (including mindfulness, food neophobia and anxiety), children in the mindful raisin-eating arm reported greater anticipated liking of a novel fruit and children in both mindfulness arms consumed greater amounts of a novel fruit than children in the control arm. Mixed-design ANOVAs indicated that mindfulness, food neophobia and anxiety did not change over time in each trial arm.

CONCLUSIONS

The results provide promising evidence for the potential effectiveness of mindfulness interventions in encouraging children to try new foods. The mechanisms underlying effectiveness remain unclear and further research, exploring long-term effects and the possibility to generalise these findings to other food groups such as vegetables, is needed.

Play with Your Food and Cook It! Tactile Play with Fish as a Way of Promoting Acceptance of Fish in 11- to 13-Year-Old Children in a School Setting-A Qualitative Study

Despite a tradition of consuming fish in Denmark and despite the health benefits of eating fish, Danish children consume only one-third of the officially recommended amount of fish. The objective of this study was to explore an experiential and sensory-based exercise in a school setting with focus on tactile play and cooking as a way of promoting 11- to 13-year-old children’s acceptance of fish. The design was a qualitative exploratory multiple-case design using participant observation in a school setting. Six classes were recruited from the Eastern part of Denmark (n = 132). Based on an exercise with cooking fish and gyotaku (fish print), four meta-themes were identified by applying applied thematic analysis: rejection, acceptance, craftsmanship, and interaction. Rejection and acceptance appeared along a rejection–acceptance continuum related to how the fish was categorised (animal, non-animal, food) in different phases of the experiment. Rejection was promoted by mucus, smell, animalness, and texture, whereas helping each other, tactile play, and craftsmanship promoted acceptance. In conclusion, this study found that tactile play combined with cooking could be a way of promoting acceptance of fish. The findings also support a school setting as a potential gateway in promoting healthy food behaviour.

Aversive textures and their role in food rejection

Texture is a prominent feature in foods and consequently can be the reason a food is accepted or rejected. However, other sensory attributes, such as flavor/taste, aroma, sound, and appearance may also lead to the rejection of food and motivations other than unpleasantness exist in unacceptance. To date, these motivations for food rejection have been studied in isolation and their relationships with psychological factors have not been tested. This study measured reasons people reject a food and probed into the specifics of texture rejection. A large U.S. sample (N = 473) was asked to rate their motivations for rejecting a food, list foods that were disliked due to unpleasant sensory attributes, specify the unpleasant sensory attribute(s), and complete an assessment of general touch sensitivity. Results showed 94% of individuals reject a food due to its texture, a rate comparable to flavor-based rejection. Looking at the number of foods being rejected, flavor was the most common food attribute, followed by texture and then aroma. From a linguistic standpoint, aversive textures encompass a large vocabulary, larger than liked textures, and the same food may be rejected due to a single or combination of texture terms. Viscosity (e.g., slimy) and hardness (e.g., mushy) are the most common aversive texture types, but through cluster analysis subsets of individuals were identified that are more aversive to other textures. This study emphasizes the role of aversive textures in food rejection and provides many avenues for future investigations.

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.

A Serious Game Approach to Improve Food Behavior in Families-A Pilot Study

The objective of this pilot study was to investigate the effect of a specially developed serious game to improve food behavior in families with children aged 5-13 years using mixed methods. Fourteen families were randomized into a game-group and a non-game-group and divided into age groups (game-children (GC), game-parents (GP), non-game-children (nGC), and non-game-parents (nGP)). The families completed a baseline test, a three-week intervention period with or without a game element, and a follow-up test. Qualitative results showed a positive change in food behavior in all families. Quantitative results mainly showed an effect in food neophobia as a decrease was seen in all groups; however, it was only significant (p < 0.05) in three groups (GP, nGC, nGP). No changes were seen in willingness to taste, and only limited changes in liking and number of words used to describe the stimuli. In conclusion, qualitative results showed positive change in the children's food behavior in most families, indicating a positive effect of performing tastings and tasks together as a family-regardless of the presence of a game element. However, this was not as clear in the quantitative data, indicating that current quantitative tools are less suited to measure complex concepts like willingness to taste.

A longitudinal examination of the role of sensory exploratory behaviors in young children's acceptance of new foods

OBJECTIVE

Prompted engagement with a new food's sensory properties (smell, texture) has been associated with young children's acceptance of new foods. However, little is known about the prevalence and stability of children's sensory exploratory behaviors exhibited spontaneously when trying new foods. The aim of this analysis was to examine developmental trajectories of sensory exploratory behaviors (i.e., smelling, licking, spitting) in response to new foods.

METHOD

This 3-year longitudinal study included observational data collected from 244 preschoolers. At age 4 years, children were asked to taste four novel foods. An experimenter recorded the child's displays of smelling, licking, spitting, refusals, and acceptance. Assessments were repeated at 4.5, 5.5, and 6.5 years of age. Summary scores were created for each child by totaling the number of foods smelled, licked, spit out, refused, and accepted at each time point. A series of growth models were fit to the summary scores to examine individual sensory behavior trajectories and associations between trajectories of sensory behaviors and acceptance.

RESULTS

Linear growth model parameters indicated that spitting and refusals decreased over time (p-values < 0.01), whereas acceptances increased (p < 0.01). Licking and smelling showed non-significant change (p-values > 0.01) Furthermore, decreases in licking, spitting, and refusals were associated with increases in acceptance across the study period (p-values < 0.01).

DISCUSSION

The decline in young children's sensory exploratory behaviors in response to new foods was associated with increases in food acceptance. Our findings suggest that sensory exploratory behaviors may promote familiarity and help children learn that new foods are acceptable and safe to consume.

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. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing 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 August 2019. We searched Proquest Dissertations and Theses in May 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 78 trials with 214 trial arms and 13,746 participants. Forty-eight 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 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 20 of the 78 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 very 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 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per 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 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 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) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. 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.

Early influencing factors on the development of sensory and food preferences

PURPOSE OF REVIEW

The current review focuses on studies investigating the factors related to the development of preferences for foods and sensory inputs (tastes, odours, and food textures) in the first years of life, which constitutes a specific window for food learning.

RECENT FINDINGS

Foetal nutrition, intrauterine growth, and prematurity influence food preferences; this topic warrants more research to broaden our understanding of the 1000 days phenomenon. Although it is less studied than other sensory inputs, food texture acceptance, and the related sensitive period for texture introduction are attracting more attention, as is the impact of fat acceptance. Research should focus not on vegetables alone but on diverse foods whose consumption is encouraged (e.g., fishes and legumes). The role of parental feeding practices, as another major determinant, continues to inspire research exploring the bidirectional influences between children and caregivers. New interventions have confirmed the strong positive influence of repeated exposure to foods through familiarization via taste lessons, cooking, or play activities on acceptance. Interventions that consider individuals traits are necessary.

SUMMARY

Although new evidence is available, it remains a challenge to consider both individual traits and bidirectional influences between parents and children and to investigate this issue worldwide and in all socioeconomic status groups.

Special series on "effects of board games on health education and promotion" board games as a promising tool for health promotion: a review of recent literature

Board games are played by moving game pieces in particular ways on special boards marked with patterns. To clarify the possible roles of board game use in psychosomatic medicine, the present review evaluated studies that investigated the effects of this activity on health education and treatment. A literature search conducted between January 2012 and August 2018 identified 83 relevant articles; 56 (67%) targeted education or training for health-related problems, six (7%) examined basic brain mechanisms, five (6%) evaluated preventative measures for dementia or contributions to healthy aging, and three (4%) assessed social communication or public health policies. The results of several randomized controlled trials indicated that the playing of traditional board games (e.g., chess, Go, and Shogi) helps to improve cognitive impairment and depression, and that the playing of newly developed board games is beneficial for behavioral modifications, such as the promotion of healthy eating, smoking cessation, and safe sex. Although the number of studies that have evaluated board game use in terms of mental health remains limited, many studies have provided interesting findings regarding brain function, cognitive effects, and the modification of health-related lifestyle factors.

Effect of Taste Enhancement on Consumer Acceptance of Pureed Cucumber and Green Capsicum

Vegetables have low taste intensities, which might contribute to low acceptance. The aim of this study was to investigate the effect of taste (sweetness, sourness, bitterness, umami, and saltiness) and fattiness enhancement on consumer acceptance of cucumber and green capsicum purees. Three concentrations of sugar, citric acid, caffeine, mono-sodium glutamate, NaCl, and sunflower oil were added to pureed cucumber and green capsicum. Subjects (n = 66, 35.6 ± 17.7 y) rated taste and fattiness intensity. Different subjects (n = 100, 33.2 ± 16.5 years) evaluated acceptance of all pureed vegetables. Taste intensities of vegetable purees were significantly different (P < 0.05) between the three tastant concentrations except for umami in both vegetable purees, sourness in green capsicum puree, and fattiness in cucumber puree. Only enhancement of sweetness significantly (P < 0.05) increased acceptance of both vegetable purees compared to unmodified purees. In cucumber purees, relatively small amounts of added sucrose (2%) increased acceptance already significantly, whereas in green capsicum acceptance increased significantly only with addition of 5% sucrose. Enhancement of other taste modalities did not significantly increase acceptance of both vegetable purees. Enhancing saltiness and bitterness significantly decreased acceptance of both vegetable purees. We conclude that the effect of taste enhancement on acceptance of vegetable purees differs between tastants and depends on tastant concentration and vegetable type. With the exception of sweetness, taste enhancement of taste modalities such as sourness, bitterness, umami, and saltiness was insufficient to increase acceptance of vegetable purees. We suggest that more complex taste, flavor, or texture modifications are required to enhance acceptance of vegetables.

PRACTICAL APPLICATION

Results can be used by cultivators to select and grow vegetable varieties with enhanced taste and flavor. Especially for cucumber, relatively small sweetness enhancement is sufficient to increase acceptance.

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. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing 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 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies 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 studies; 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 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 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 studies.There is very 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 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per 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 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up 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.