Fill "half your child's plate with fruits and vegetables": Correlations with food-related practices and the home food environment

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Longitudinal changes in home food availability and concurrent associations with food and nutrient intake among children at 24-48 months

OBJECTIVES

To describe changes in home food availability during early childhood, including modified, developmentally sensitive obesogenic scores, and to determine whether home food availability is associated with food and nutrient intakes of children concurrently, over time.

DESIGN

Data were drawn from the STRONG Kids 2 longitudinal, birth cohort to achieve the study objectives. Home food availability was assessed with the Home Food Inventory (HFI) and included fifteen food groups (e.g. fruit and vegetables) and three obesogenic scores (one original and two modified). Food and nutrient intakes were measured using the Block FFQ and included twenty-seven food groups and eighteen nutrients (e.g. vitamins A and C, protein). HFI and FFQ were completed by trained researchers or mothers, respectively, at 24, 36 and 48 months. Repeated-measures ANOVA and Spearman's correlations were used to achieve the study objectives.

SETTING

Central Illinois, USA.

PARTICIPANTS

Participants were 468 children at 24, 36 and 48 months of age.

RESULTS

Availability of less nutritious foods and obesogenic foods and beverages increased as children aged, and availability of both nutritious and less nutritious foods were associated with child food and nutrient intake. The three obesogenic scores demonstrated similar, positive associations with the intake of energy, saturated fat, added sugars and kilocalories from sweets.

CONCLUSION

These findings offer novel insight into changes in home food availability and associations with food and nutrient intake during early childhood. Additional attention is needed examining antecedents (e.g. built environments, purchasing behaviours) and consequences (e.g. child diet quality and weight) of home food availability.

Obesity and malnutrition in children and adults: A clinical review

Background

In the U.S., children and adults are consuming more low-nutrient foods with added sugar and excess fats as compared to healthy, high-quality calories and micronutrients. This diet is increasing the prevalence of malnutrition and nutritional deficiencies, despite high calorie intake. This is a review of the common micronutrient deficiencies, the risk factors for malnutrition, dietary plans, and the health consequences in children and adults with obesity in the U.S.

Methods

This clinical review of literature was performed on the MEDLINE (PubMed) search engine. A total of 1391 articles were identified and after review, a total of 130 were found to be most pertinent.

Discussion

The most common micronutrient deficiencies found in patients with obesity were vitamin A, thiamine (B1), folate (B9), cobalamin (B12), vitamin D, iron, calcium, and magnesium, especially prior and after bariatric surgery. Diets that produced the most weight reduction also further puts these individuals at risk for worsening malnutrition. Malnutrition and micronutrient deficiencies can worsen health outcomes if not properly managed.

Conclusion

Adequate screening and awareness of malnutrition can improve the health outcomes in patients with obesity. Physiologic changes in response to increased adiposity and inadequate intake increase this population's risk of adverse health effects. Malnutrition affects the individual and contributes to worse public health outcomes. The recommendations for screening for malnutrition are not exclusive to individuals undergoing bariatric procedures and can improve the health outcomes of any patient with obesity. However, clearly, improved nutritional status can assist with metabolism and prevent adverse nutritional outcomes post-bariatric surgery. Clinicians should advise on proper nutrition and be aware of diets that worsen deficiencies.

Parent meal self-efficacy and practices in households with healthy home food environments in the face of economic hardship

Some families who experience economic hardship demonstrate remarkable strength and resourcefulness to sustain a healthy home food environment. This ability to navigate economic barriers could be associated with parent meal practices that promote children's healthful dietary intake. Therefore, this study aimed to examine 1) whether parent meal self-efficacy and practices were associated with economic assistance status and home fruit and vegetable (FV) availability and 2) how parent meal self-efficacy and practices differed by home FV availability and economic assistance status. Analyses utilized baseline data from 274 parent/child dyads from two childhood obesity prevention trials: HOME Plus (urban) and NU-HOME (rural). Parents in households with high FV availability (regardless of economic assistance) had significantly higher self-efficacy in preparing healthy foods, family dinner routines, frequency of child's plate being half filled with FV, frequency of family dinner and breakfast, and lower frequency of purchasing dinner from fast food restaurants. Economic assistance was not associated with parent meal self-efficacy and practices. Four family groups were created and defined by economic assistance (yes/no) and home FV availability (high/low). About 31% of families that received economic assistance and had high home FV availability were food insecure. Families (n = 39) receiving economic assistance and having high home FV availability had greater frequency of family dinners compared to those in households with economic assistance and low home FV availability (n = 47) (p = 0.001); no other parent meal self-efficacy or practices differed between groups. Our findings suggest some families can maintain healthy home food environments despite economic hardship and frequent family dinners may be an important strength for these families. More research is needed to investigate asset-based models to understand the family strengths that enable them to thrive during difficult times.

Gender, Age, Family and Territorial Features of Dietary and Physical Activity Patterns in Russian Youths

OBJECTIVE

Identifying dietary and physical activity (PA) patterns in Russian youths and examining their dependence on gender, age, family characteristics and area of residence features. The research involved 783 school students 10-17 years of age and their parents living in the cities of Moscow and Murmansk. Using the principal component analysis, four integral indices were identified that characterized the habits and dietary patterns, PA and lifestyle. Boys, compared with girls, were more likely to consume unhealthy foods but less likely to practice malnutrition. Within the age ranges of 13-15 years old and 16-17 years old, the proportions of school students with a poor sleep pattern and low PA were higher than in children 10-12 years of age. In smoking families, children were less likely to consume healthy foods and more likely to eat unhealthy foods. In Murmansk school students, compared with their Moscow peers, a reduction in both sleep time and PA was observed less often. Our study demonstrated that the most significant factors of a balanced and healthy diet, rational daily routine and lifestyle in school students were their gender and age characteristics, as well as some contextual factors.

The Use of Portion Control Plates to Promote Healthy Eating and Diet-Related Outcomes: A Scoping Review

The role of portion control plates in achieving healthy diets is unclear. The aim of this scoping review was to systematically map findings from peer reviewed and grey literature to provide evidence for the use of portion control plates to promote healthy eating and nutrition-related knowledge in children and adults. A secondary aim was to review the design characteristics of portion control plates. The search was conducted in four databases, including Medline, CINAHL, Embase, and PsycInfo, and grey literature sources following the PRISMA scoping review guidelines. A total of 22 articles comprising 23 intervention studies and 8 from grey literature were included. It was found that the various two-dimensional and three-dimensional portion control plates examined were effective tools for better portion size selection in healthy children and adults. Most portion control plates dedicated half the plate to vegetables, a quarter to protein, and a quarter to carbohydrates. The use of portion control plates in nutrition interventions appears to promote weight loss among those with overweight and obesity and/or type 2 diabetes. However, portion control plates were mostly used as part of multicomponent interventions and the effectiveness of the portion control plate as a stand-alone educational resource or portion control tool alone was uncertain. Further interventional research is indicated to investigate portion plates as tools to improve dietary behaviours and food consumption at the population level.

Are patterns of family evening meal practices associated with child and parent diet quality and weight-related outcomes?

Family meal practices such as family member presence, fast food consumption and media usage have been associated with health outcomes. However, little is known about combinations of family meal practices and their effects on diet and health. This secondary data analysis aimed to identify patterns of family evening meal practices and examine their associations with family characteristics (e.g., demographics and chaos) and child and parent diet quality and weight-related outcomes. We used baseline data from a community-based randomized controlled trial with 7- to 10-year-old children and their parents in rural Minnesota (n = 114). Parent-reported structural (e.g. media usage) and interpersonal (e.g. mealtime routines) aspects of family evening meal practices were included in latent profile analyses to identify patterns. Diet quality was assessed by child Healthy Eating Index-2015 and parent fruit and vegetable intake. Weight-related outcomes were determined using measured body mass index (z-scores) and percent body fat. A 3-class model was the model of best-fit. The Unplanned Infrequent Family Evening Meals with Mixed Healthfulness class (C1) featured the least frequent family evening meals and the lowest scores for mealtime routines and planning skills. The Family Evening Meals with Fast Food class (C2) characterized having family evening meals four times a week, but fast food was often served. The Planful, Healthful and Frequent Family Evening Meals class (C3) reported the highest meal routine and planning scores as well as frequent family evening meals. Parents in C3 had higher consumption of fruits and vegetables and children in C3 had lower percent body fat, compared to those in other classes. Distinctly different patterns of family evening meal practices suggest a need for considering heterogeneity of family evening meal practices in developing tailored family-meal interventions.

Home availability of ultraprocessed foods in families who prepare meals at home

ABSTRACT Objective This study characterized the degree of processing of the food items available at home and the routine of shopping for food in families with children and/or teenagers and whose meals are usually prepared at home. Methods Mixed methods (interview, questionnaires, and food inventory). Interview’s transcripts were submitted to thematic analysis and the foods identified in the inventory were classified according to the degree of processing and analyzed for their availability and access in the home food environment. Results Results revealed the high availability of ultra-processed foods; that the supermarket was the main source of food acquisition; and that purchasing food is part of an organized routine where time and control of expenses are the most valued aspects. Conclusion Actions which focus on planning and executing the acquisition of unprocessed and minimally processed foods are needed to promote greater availability and increased intake of such foods, so that the composition of homemade meals may be in line with what is recommended by the national dietary guidelines.

Healthy and Sustainable Dietary Patterns in Children and Adolescents: A Systematic Review

The need for adherence to a healthy and sustainable dietary pattern in the pediatric stage is discussed worldwide, being linked to a progressive incidence of noncommunicable diseases in adulthood. The aims of this systematic review were to summarize the healthy and/or sustainable dietary patterns, defined a priori, described in the literature for use during the pediatric stage; to evaluate the adherence to these dietary patterns; and identify the health-related benefits associated with adherence to these patterns. A literature search was carried out on Medline, Scopus, and Web of Science from 2010 up to 2021, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 128 articles were included according to the following criteria: participants 2-17 y old, healthy and/or sustainable dietary patterns defined by an a priori methodology; articles written in English or Portuguese; and published since 2010. Fifty instruments with 14 adaptations that measure adherence to healthy and/or sustainable dietary patterns in children and adolescents were found. The Mediterranean Diet was the most studied dietary pattern. Adherence to healthy and/or sustainable dietary patterns has wide variations worldwide. Most of the instruments described have been little studied at pediatric ages, reducing the ability to extrapolate results. Higher adherence to these dietary patterns was associated with lower body fat, waist circumference, blood pressure, and metabolic risk. There is no consensus regarding the association with BMI. No studies have proofs of the sustainability characteristics of these instruments, it being necessary to produce a new sustainable instrument or test the association of the previous ones with, for example, the ecological footprint. Further validations of these instruments in each country and more prospective studies are needed to establish temporal relations with health-related outcomes. This systematic review was registered at www.crd.york.ac.uk/prospero/ as CRD42020221788.

Family Meals, Conviviality, and the Mediterranean Diet among Families with Adolescents

Two aspects that characterize the Mediterranean diet (MD) are "what" and "how" we eat. Conviviality relates to "how" we eat and to the pleasure of sharing meals with significant people. The most studied concept is "family meals", which includes conviviality, which involves "enjoying" family meals. Given the lack of research on convivial family meals in Mediterranean countries, the purpose of this qualitative study was to analyze the family meal representations and practices of families with 12- to 16-year-old adolescents to assess whether they responded to a pattern of conviviality, and to examine their association with MD adherence. Twelve semi-structured interviews were conducted and food frequency and family meal questionnaires were administered. A food pattern analysis was carried out and digital photos of meals were analyzed to examine eating habits and meal composition, respectively. The findings showed that parents believed family meals are a space for socialization and communication. Items relating to the conviviality of family meals identified in the study were meal frequency, meals at the table, lack of digital distractions, pleasant conversations, and time spent on family meals. Attention should be paid to conviviality in Mediterranean families when designing multi-approach strategies to promote healthy eating among adolescents.

Cross-Sectional Associations Between Mothers and Children's Breakfast Routine-The Feel4Diabetes-Study

Positive influences of family members have been associated with a high probability of children’s daily breakfast consumption. Therefore, the aim of this study was to scrutinize the association of breakfast routines between mothers and their children. The baseline data of the Feel4Diabetes-study was obtained in 9760 children (49.05% boys)–mother pairs in six European countries. A parental self-reported questionnaire gauging the frequency of breakfast consumption and of breakfast´ foods and beverages consumption was used. Agreement in routines of mothers and their children’s breakfast consumption was analyzed in sex-specific crosstabs. The relationship of breakfast routine and food groups’ consumption between mothers and their children was assessed with analysis of covariance. The highest proportion of children who always consumed breakfast were those whose mothers always consumed it. Children consuming breakfast regularly had a higher intake of milk or unsweetened dairy products and all kind of cereal products (low fiber and whole-grain) than occasional breakfast consumers (p < 0.05). The strong similarity between mothers and children suggests a transfer of breakfast routine from mothers to their children, as a high proportion of children who usually consume breakfast were from mothers also consuming breakfast. All breakfast foods and beverages consumption frequencies were similar between children and their mothers.

The Forbidden Reward. The Emergence of Parent-Child Conflicts About Food Over Time and the Influence of Parents' Communication Strategies and Feeding Practices

One of the most critical arenas for conflicts between parents and their children relates to food. Although parent-child conflicts about food are a real occurrence, this form of parent-child interaction has been rarely examined. Given the special role of parents in shaping children's diet, we especially focus on the impact of parental measures. This study investigates how parental communication strategies (i.e., active vs. restrictive) and feeding practices (i.e., overt control vs. covert control) affect the emergence of parent-child conflicts about food over time. Based on previous research, we assessed overt control through parents' use of food as a reward and restriction of their children's access to specific food types. We explored the impact of our predictors on both conflicts about unhealthy and healthy food with a two-wave panel study including parents and their children (N = 541; children aged between 5 and 11) in Austria between fall 2018 and spring 2019. Results of two multiple linear regressions indicated that predominantly parents' use of unhealthy food as a reward is connected to both healthy and unhealthy food conflicts. Furthermore, inconsistent parental educational styles increased the respective conflict potential. Active food-related mediation and covert control did not relate to food-related conflicts about unhealthy and healthy food. Parents' increased use of overtly controlling and restrictive feeding practices might not be only counterproductive for children's diet but also for food-related parent-child interactions. Instead, a “health discourse” (i.e., active food-related mediation) might prevent food-related conflicts and foster a healthy growth in the future.

Considering Nature and Nurture in the Etiology and Prevention of Picky Eating: A Narrative Review

Children are often categorized as picky eaters by parents and caregivers for their rejection of foods, such as vegetables, and for exhibiting other difficult mealtime behaviors. However, there are several factors that contribute to these mealtime behaviors, including early feeding practices (i.e., breastfeeding, introduction to solid food), repeated exposure to novel foods, and genetic taste sensitivity to certain compounds. Using the online database of PubMed, a review of the literature on the development of picky eating in children, its outcomes, and intervention strategies was conducted. This review groups the developmental contributors to picky eating into the categories of nature and nurture and explores the interaction between the two. This paper will also summarize the potential outcomes of picky eating and the various strategies that are currently recommended to mitigate picky eating in young children. However, there is a lack of longitudinal work targeting consistent picky eating behaviors that have the potential to impact long-term food preferences and dietary variety. Future intervention strategies should address the factors that influence the development of picky eating on an individual level.

Family meal frequency and its association with food consumption and nutritional status in adolescents: A systematic review

This systematic review evaluated the association between frequency of family meals (FFM) and nutritional status (NS) and/or food consumption (FC) in adolescents. The protocol was registered with PROSPERO (CRD42017062180) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. No publication date, language, or meal type restrictions were imposed. Only full-text original articles were included; qualitative studies were excluded. Studies were identified by searching 5 electronic databases (PubMed, Web of Science, Scopus, BVS Brazil, and Adolec) and gray literature (Google Scholar) and by scanning reference lists of included articles. Risk of bias was assessed using the Newcastle-Ottawa scale for cohort and cross-sectional studies. Initial search yielded 2001 results and 47 articles were included. An updated literature search added 3 articles. Of the 50 studies included, 25 studied the association between FFM and NS, 32 investigated the association between FFM and FC, being that seven studies analyzed both outcomes. Thirty-four were cross-sectional studies, 12 were longitudinal studies, and 4 studies analyzed both cross-sectional and longitudinal data. Thirty-five studies were rated as having good quality, whereas 19 were of fair quality. Sample size ranged from 140 to 102 072 participants. Most investigations evaluated the frequency of breakfast, lunch, and/or dinner/supper/evening meals over a 1-week period. Seventeen studies identified a positive relationship between high FFM and better NS, and 26 found a positive association between high FFM and better FC. In conclusion, this review showed an association between FFM and healthy dietary patterns, such as increased consumption of fruits and vegetables. Further research is needed to understand the association between FFM and NS, since some studies showed a protective role of family meals against obesity in this age group, whereas other studies identified no significant association between these variables.

Development of a Parental Feeding Goal Measure: The Family Mealtime Goals Questionnaire

It is well established that parents' feeding practices predict children's eating behaviors. However, there has been little research into parents' mealtime goals-their desired outcomes for family mealtimes. These goals, and potential conflicts between them, may be important both in explaining parents' feeding practices and improving children's eating behaviors, as health behavior change is more likely to be achieved by programmes and interventions that are aligned with an individual's goals. The objectives of this study were to develop a reliable and valid measure that captures parental mealtime goals, and to describe parents' endorsement of these goals. Online questionnaire methods were used to design and test the Family Mealtime Goals Questionnaire with 1,140 parents and carers of at least one child aged from 1 to 16 years. Exploratory qualitative analysis, Principal Components Analysis, Confirmatory Factor Analysis, and test-retest analysis (using intraclass correlations) were conducted to establish the psychometric properties of the instrument. An 18-item questionnaire was produced with seven dimensions: stress/conflict avoidance, homemade food, shared family food, family involvement in mealtimes, price, occasional treats, and high/low fat regulation. Some differences were found in the goal structure of parents of children of different ages but stress/conflict avoidance was the most strongly endorsed mealtime goal for all age groups. The Family Mealtime Goals Questionnaire provides a useful measure of parents' feeding motivations. It will facilitate large-scale research into the relationships between parents' feeding goals and practices and could inform the design of more effective healthy eating interventions that target specific feeding goals.