Reliability and Validity of Food Frequency Questions to Assess Beverage and Food Group Intakes among Low-Income 2- to 4-Year-Old Children

Development and validation of a short dietary questionnaire for assessing obesity-related dietary behaviours in young children

There are few short, validated tools to assess young children's obesity-related dietary behaviours, limiting the rapid screening of dietary behaviours in research and practice-based early obesity prevention. This study aimed to develop and assess the reliability and validity of a caregiver-reported short dietary questionnaire to rapidly assess obesity-related dietary behaviours in children aged 6 months to 5 years. The Early Prevention of Obesity in Childhood Dietary Questionnaire (EPOCH-DQ) was developed using a rigorous process to determine content and structural validity. Three age-appropriate versions were developed for (1) infants, aged 6-12 months, (2) toddlers, aged 1-2.9 years and (3) pre-schoolers, aged 3-5 years. The questionnaire (7-15 items) measures dietary behaviours, including diet risk from non-core food and beverage intake, diet quality from vegetable frequency, bread type and infant feeding practices. Test-retest reliability was assessed from repeated administrations 1 week apart (n = 126). Internal consistency, concurrent validity (against a comparison questionnaire, the InFANT Food Frequency Questionnaire), construct validity and interpretability were assessed (n = 209). Most scores were highly correlated and significantly associated (p < 0.05) for validity (rs: 0.45-0.89, percentage agreement 68%-100%) and reliability (intraclass correlation coefficient: 0.61-0.99) for diet risk, diet quality and feeding practice items. The EPOCH-DQ shows acceptable validity and reliability for screening of obesity-related behaviours of children under 5 years of age. The short length and, thus, low participant burden of the EPOCH-DQ allows for potential applications in various settings. Future testing of the EPOCH-DQ should evaluate culturally and socio-economically diverse populations and establish the predictive validity and sensitivity to detect change.

Any Infant Formula Amount, but Not Infant Formula Type, Is Associated with Less Healthful Subsequent Beverage Intake among Special Supplemental Nutrition Program for Women, Infants, and Children-Participating Children

Background

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to low-income households, including infant formula for infants not fully breastfeeding. Issuance of lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with elevated risk of obesity in early life, but associations between formula type and dietary intake have not been examined.

Objectives

To evaluate associations between infant formula (amount and type) issued by WIC with subsequent child diet at ages 12-59 mo.

Methods

Dietary data from 2014, 2017, and 2020 Los Angeles County WIC Survey respondents (n = 1339 children, 12-59 mo of age) were merged with WIC administrative data on infant feeding (amount and type of infant formula at ages 0-12 mo). Intake frequencies were available for sweetened beverages, sweets, juice, fast food, water, fruit, vegetables, and milk. Infant feeding was categorized by amount of WIC-issued formula (descending: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and issuance of a CSSF (any, none). Associations between infant feeding (infant formula amount and type) and child diet were evaluated in multivariable generalized estimating equation negative binomial regression models, stratified by child age (12 to <24 mo, 24 to <60 mo).

Results

Any infant formula issuance in the first year of life was adversely associated with subsequent dietary intake. This included 21%-23% higher 100% juice intake at 24 to <60 mo and 11%-13% (at 24 to <60 mo) or 20%-22% (at 12 to <24 mo) lower water intake. CSSF receipt compared with only other infant formula was not consistently associated with subsequent child diet.

Conclusions

Any infant formula amount, but not CSSF receipt compared with other formula types, was associated with less healthful beverage intake patterns among WIC-participating children. WIC nutrition education may have a stronger impact if tailored based on infant feeding practices.

The 7-day Beverage Intake Questionnaire for Latino Children: Validation of a Culturally Tailored Tool

OBJECTIVE

To validate a culturally tailored 7-day beverage intake questionnaire for Latino children (BIQ-L).

DESIGN

Cross-sectional.

SETTING

Federally qualified health center in San Francisco, CA.

PARTICIPANTS

Latino parents and their children aged 1-5 years (n = 105).

VARIABLES MEASURED

Parents completed the BIQ-L for each child and three 24-hour dietary recalls. Participants' height and weight were measured.

ANALYSIS

Correlations between the mean intake of beverages in 4 categories as determined by the BIQ-L and three 24-hour dietary recalls were assessed. Multivariable linear regression examined the association between sugar-sweetened beverages (SSB) servings as determined by the BIQ-L and child body mass index z-score.

RESULTS

Mean daily intake of SSB (r = 0.52, P < 0.001), 100% fruit juice (r = 0.45, P < 0.001), flavored milk (r = 0.7, P < 0.001), and unflavored milk (r = 0.7, P < 0.001) from the BIQ-L were correlated with intake assessed via three 24-hour dietary recalls. In the multivariable model, weekly servings of SSBs were associated with child body mass index z-score (β = 0.15, P = 0.02). Culturally specific beverages comprised 38% of the SSB intake reported on the BIQ-L.

CONCLUSIONS AND IMPLICATIONS

The BIQ-L is a valid tool for assessing beverage intake among Latino children aged 1-5 years. The inclusion of culturally specific beverages is critical for accurately assessing beverage intake among Latino children.

Comparing enhancements to well-child visits in the prevention of obesity: ENCIRCLE cluster-randomized controlled trial

BACKGROUND

Obesity disproportionally impacts rural, lower-income children in the United States. Primary care providers are well-positioned to engage parents in early obesity prevention, yet there is a lack of evidence regarding the most effective care delivery models. The ENCIRCLE study, a pragmatic cluster-randomized controlled trial, will respond to this gap by testing the comparative effectiveness of standard care well-child visits (WCV) versus two enhancements: adding a patient-reported outcome (PRO) measure (PRO WCV) and PRO WCV plus Food Care (telehealth coaching and a grocery store tour).

METHODS

A total of 2,025 parents and their preschool-aged children (20-60 months of age) will be recruited from 24 Geisinger primary care clinics, where providers are randomized to the standard WCV, PRO WCV, or PRO WCV plus Food Care intervention arms. The PRO WCV includes the standard WCV plus collection of the PRO-the Family Nutrition and Physical Activity (FNPA) risk assessment-from parents. Parents complete the PRO in the patient-portal or in the clinic (own device, tablet, or kiosk), receive real-time feedback, and select priority topics to discuss with the provider. These results are integrated into the child's electronic health record to inform personalized preventive counseling by providers. PRO WCV plus Food Care includes referrals to community health professionals who deliver evidence-based obesity prevention and food resource management interventions via telehealth following the WCV. The primary study outcome is change in child body mass index z-score (BMIz), based on the World Health Organization growth standards, 12 months post-baseline WCV. Additional outcomes include percent of children with overweight and obesity, raw BMI, BMI50, BMIz extended, parent involvement in counseling, health behaviors, food resource management, and implementation process measures.

DISCUSSION

Study findings will inform health care systems' choices about effective care delivery models to prevent childhood obesity among a high-risk population. Additionally, dissemination will be informed by an evaluation of mediating, moderating, and implementation factors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier (NCT04406441); Registered May 28, 2020.

Food insecurity and food consumption among children who receive federal food assistance

The objective of this study was to investigate the association between household food insecurity and food intake among children who participated in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), including a sub-sample who also participated in the Supplemental Nutrition Assistance Program (SNAP). Data came from the 2014 and 2017 Los Angeles County WIC Surveys, involving a random sample of WIC participating families in Los Angeles, California. Outcome variables were average daily consumption of fruit, 100% fruit juice, vegetables, milk, other juice, other sweetened drinks, and sweet foods, and frequency of fast-food consumption, as reported by the child's caregiver. Our predictor was household food insecurity, obtained from the 6-item Household Food Security Survey Module. Poisson regression (fruit, 100% fruit juice, vegetables, and milk), Negative Binomial regression (other juice, other sweetened drinks, and sweet foods) and multinomial logistic regression (frequency of fast food) models were run, adjusting for child's age and sex; maternal age, ethnicity and language, education, and employment; and type of WIC participation (WIC only vs. WIC + SNAP). In fully adjusted models, household food insecurity was associated with higher consumption of 100% fruit juice (RR = 1.08, 95%CI = 1.03-1.11), milk (RR = 1.04, 95%CI = 1.01-1.07), other juice (RR = 1.16, 95%CI = 1.08-1.26), other sweetened drinks (RR = 1.28, 95%CI = 1.12-1.46), and sweet foods (RR = 1.09, 95%CI = 1.04-1.14). No significant associations were found between household food insecurity and fruit and vegetable consumption. Nutrition education provided by WIC should continue to emphasize the importance of consuming fresh foods, while limiting foods high in sugar for this young population. Efforts should be made to identify food insecure families at the point of service delivery for enhanced nutrition education and social services referrals.

Longer Family Participation in WIC is Associated With Lower Childhood Sugar-Sweetened Beverage Intake

OBJECTIVE

To evaluate if children of families with a longer duration of participation in the Special Supplementation Nutrition Program for Women, Infants, and Children (WIC) consume fewer sugar-sweetened beverages (SSB) and more water.

DESIGN

A repeated cross-sectional study.

SETTING

Conducted among representative samples of WIC-participating families in Los Angeles County, California, in 2014, 2017, and 2020.

PARTICIPANTS

Children aged 4-59 months participating in WIC.

MAIN OUTCOME MEASURES

Daily servings of total SSBs, daily servings of specific types of SSBs, and daily servings of water.

ANALYSIS

Multivariable count regression models were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for associations of the duration of family WIC participation with daily servings of total SSBs, water, and specific types of SSBs. Zero-inflated negative binomial regression models were used for total SSBs and specific types of SSBs, and Poisson regression was used for water.

RESULTS

Children of families with 2 years of WIC participation consumed significantly fewer daily servings of total SSBs (IRR, 0.95; 95% CI, 0.93-0.98; P = 0.002), fruit-flavored SSBs (IRR, 0.95; 95% CI, 0.91-0.99; P = 0.02), soda (IRR, 0.86; 95% CI, 0.76-0.98; P = 0.02), and water (IRR, 0.99; 95% CI, 0.98 to < 1.00; P = 0.03) than children of families with 1 year of WIC participation. Protective associations for total SSBs, fruit-flavored SSBs, and soda remained statistically significant and increased in magnitude through 10 years of family WIC participation.

CONCLUSIONS AND IMPLICATIONS

Duration of WIC participation was associated with decreased SSB intake by young children. Given the role that increasing water intake in lieu of SSBs plays in child obesity, improving the effectiveness of WIC nutrition education on parental perceptions and provision of fruit-flavored SSBs and water to their children merits detailed evaluation.

Longer Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children Is Not Associated with Reduced Sugar-Sweetened Beverage Intake among Black Participants

This study assessed relationships of duration of family Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participation with racial/ethnic disparities in child sugar-sweetened beverage (SSB) and water intake. Child beverage intake and family duration on WIC were collected during three cross-sectional surveys of WIC-participating families in Los Angeles County, California (2014, 2017 and 2020; n = 11,482). The associations of family duration of WIC participation, a proxy for the amount of WIC services received, with daily intake of total SSBs, fruit-flavored SSBs and water were assessed in race/ethnicity strata with multivariable negative binomial and Poisson regression models. Among English-speaking Hispanic children, those of families reporting 10 years of WIC participation consumed 33% and 27% fewer servings of total and fruit-flavored SSBs compared to those of families reporting 1 year on WIC. Among Black children, those from families reporting 5 and 10 years of participation in WIC consumed 33% and 45% more daily servings of fruit-flavored SSBs than those from families reporting 1 year on WIC. Disparities in daily total and fruit-flavored SSB intake between Black and White children increased with longer family duration on WIC. Duration of family WIC participation is associated with healthier beverage choices for infants and children, but does not appear to be equally beneficial across racial/ethnic groups in Los Angeles County.

Development of a National Dietary Behaviors Questionnaire for EFNEP Adult Participants

OBJECTIVE

Develop and establish the reliability and validity of dietary behavior evaluation questions for the Expanded Food and Nutrition Education Program (EFNEP).

DESIGN

A mixed-methods study using cognitive interviews, expert panels, test/retest reliability, and pretests/posttests.

SETTING

14 states across the US.

PARTICIPANTS

A convenience sample of low-income EFNEP or EFNEP-eligible participants for cognitive interviews (n = 111), reliability testing (n = 181), and sensitivity to change testing (n = 382).

MAIN OUTCOMES MEASURES

Indicators of face and content validity, temporal reliability, and sensitivity to change.

ANALYSIS

Questions interpreted as intended in cognitive interviews, intraclass correlation coefficient and Spearman rank-order correlation for reliability testing; paired t tests or Wilcoxon signed-rank tests for sensitivity to change; and exploratory factor analyses to identify possible scales.

RESULTS

Cognitive interviews resulted in 3 rounds of question revisions; reliability value ranges were 0.48-0.77 for intraclass correlation coefficient and 0.43-0.77 for Spearman rank-order correlation. For sensitivity to change, 9 items had evidence of change (P < 0.05) between pretests and posttests, whereas 5 items had evidence for change after removing those with little room to change. Two scales were identified: diet quality and non-cheese dairy.

CONCLUSIONS AND IMPLICATIONS

The EFNEP's new dietary behavior evaluation questions demonstrated face and content validity, moderate to strong reliability, and sensitivity to detect self-reported behavior changes among low-income, diverse populations (culturally, racially/ethnically, and level of education) across 14 states. Nutrition education programs targeting similar behaviors with English speaking clients could consider this dietary behavior questionnaire.

Development of a measure of the relative reinforcing value of food versus parent-child interaction for young children

The relative reinforcing value (RRV) of food captures individual differences in the motivation to eat and is associated with weight status among infants, children, and adults. Currently, there is no concurrent measure of the RRV of food versus a non-food alternative for 4-to-5-year-old children. The present study aimed to develop and validate a measure of the RRV of food versus time spent interacting with a parent in the context of reading among 4-to-5-year-old children. The first phase of the study involved an online survey. Parents of 4-to-5 year olds (n = 102) reported their children's consumption frequency and liking for thirty-six snack foods. A priori criteria were used to identify snacks that were well-liked and served at least sometimes for use in the subsequent laboratory study. Then, a validation study was conducted in the laboratory to examine the construct validity of the finalized RRV task. Thirty-one parent-child dyads completed a laboratory visit, in which children's RRV of food versus time spent reading with a parent was measured concurrently on a progressive ratio reward schedule. Linear regression was used to assess validity of the task. Children's RRV of food positively and significantly predicted BMI z-scores among children with complete data (B = 0.41, p < 0.05, n = 28). Maximum schedules reached for food also positively and significantly predicted BMI z-scores (B = 0.30, p < 0.05). The relationship between maximum schedules reached for parent-child reading and BMI z-scores was in the expected direction, but this relationship was non-significant. Results support the validity and feasibility of the RRV paradigm used in the present study. Future research could continue to examine the measurement properties of this paradigm, as well as the potential for positive parent-child interactions to serve as a novel alternative to food.

Development and evaluation of a food frequency questionnaire for use among young children

Background/Objectives

This study described the development of a parent food frequency questionnaire (FFQ) for measuring diets of young children over the past month and the validation of this FFQ against three non-consecutive 24 hour recalls.

Subjects/Methods

Food and nutrient intakes from a 68-item FFQ were compared with three non-consecutive 24 hour recalls in a follow-up cohort of children aged 1.5, 3.5 and 5.0 years old. Data from both methods were available for 231, 172 and 187 participants at ages 1.5, 3.5 and 5.0 years, respectively.

Results

Out of 11 nutrients, four (protein, fat, fibre, iron), two (Vitamin C, folate) and three (protein, vitamin C and folate) nutrients showed good-acceptable outcome for 2 out of 3 group-level validation tests at ages 1.5, 3.5 and 5.0 years, respectively. Of 26 food groups, good-acceptable outcome for 2 out of 3 group-level validation tests was revealed for two, four and six food groups at ages 1.5, 3.5 and 5.0 years, respectively. For individual-level validation tests, all nutrients showed good-acceptable outcome for 2 out of 3 individual level tests across three time points, except for folate at age 1.5 years and energy intake at age 3.5 years. Most food groups (22 out of 26) at age 1.5 years and all food groups at both ages 3.5 and 5.0 years showed good-acceptable outcome for 2 out of 3 individual-level validation tests.

Conclusions

At all three time points, the FFQ demonstrated good-acceptable validity for some nutrients and food groups at group-level, and good-acceptable validity for most nutrients and food groups at individual-level. This quantitative FFQ is a valid and robust tool for assessing total diet of young children and ranking individuals according to nutrient and food intakes.

Association of breastfeeding and early exposure to sugar-sweetened beverages with obesity prevalence in offspring born to mothers with and without gestational diabetes mellitus

BACKGROUND

The relationship of gestational diabetes mellitus (GDM), exclusive breastfeeding (EBF), and sugar-sweetened beverages (SSBs) on obesity prevalence in children has rarely been evaluated.

OBJECTIVE

This study examined the association of GDM status, EBF, and SSB with obesity prevalence in children (1-5 y).

METHODS

Data are from the 2014 Los Angeles County WIC Survey, which included 3707 mothers and their children (1-5 y).

RESULTS

Compared with GDM offspring who were not EBF, GDM offspring who were EBF had lower odds of obesity, as did non-GDM offspring who were and were not EBF. Compared with GDM offspring with high-concurrent SSB intake (>3 servings/d) and no EBF, GDM offspring with high SSB intake and EBF did not have lower odds of obesity, whereas those with GDM, low SSB (≤1 serving/d), and EBF had lower odds of obesity. Using non-GDM, EBF, and low SSB as referent, non-GDM offspring who were not EBF, with either high or low SSB, had approximately a fourfold increase in odds of obesity.

CONCLUSIONS

In GDM offspring, EBF is only associated with lower obesity levels if later SSB intake is also low, whereas EBF is protective against obesity in non-GDM offspring regardless of high or low later SSBs intake.

A feasibility cluster randomised controlled trial of a preschool obesity prevention intervention: ToyBox-Scotland

BACKGROUND

High levels of childhood obesity have been observed globally over the last three decades. Preschools are promising settings to implement obesity prevention interventions in the early years. The aim of this study was to test the feasibility of a cluster randomised controlled trial of the ToyBox-Scotland preschool obesity prevention intervention.

METHODS

Six preschools in predominantly deprived areas of Glasgow, UK, were randomised to either the ToyBox intervention (n = 3) or usual curriculum control group (n = 3). The intervention ran for 18 weeks from March-June 2018, and consisted of practitioner-led physical activity and sedentary behaviour sessions in preschools, with an additional interactive home component. Primary outcome measures were intervention fidelity, recruitment rates, attrition rates, and compliance with trial procedures. Secondary outcomes were body mass index (BMI) z-score, bioelectrical impedance analysis (BIA), objectively measured physical activity and sedentary time via activPAL accelerometer, and parent-reported home eating, snacking, and water consumption.

RESULTS

The preschool component of the intervention was implemented with high fidelity (64%), while the home component was implemented with low fidelity (41%). A cluster-level recruitment rate of 10% was achieved, and the individual-level recruitment rate was 18% (42/233 children, mean age 4.4 years; 17 girls). The attrition rate was 14%, and compliance rates varied considerably by the outcome. Compliance was highest for BMI (86%), while 19% of the sample returned valid accelerometer data for both baseline and follow-up and the parental questionnaire response rate was 23%. Both intervention and control groups showed small increases in BMI z-scores at follow-up of 0.02 and 0.06, respectively. Both groups had small decreases in physical activity and increases in sedentary time at follow-up.

CONCLUSIONS

Before progression to an effectiveness trial, additional procedures should be considered to improve recruitment rates, compliance with outcome measures, and implementation of the home-based component of the ToyBox-Scotland intervention.

TRIAL REGISTRATION

ISRCTN12831555.

Brief tools to measure obesity-related behaviours in children under 5 years of age: A systematic review

INTRODUCTION

Valid and reliable tools for measuring obesity-related behaviours in young children that are brief and can be administered quickly and cost-effectively in large-scale population studies are needed. The objectives of this systematic review were to describe brief tools that measure dietary intake, physical activity, sedentary behaviour, and sleep in young children.

METHODS

A systematic review of studies published in English in six databases (CINAHL, Medline, Embase, PsycINFO, HaPI, and Cochrane) prior to April 2018 was undertaken using the PROSPERO protocol and PRISMA guidelines. Included studies were those reporting the psychometric properties of brief (≤15 items) tools that measure dietary, activity, or sleep-related behaviours, alone or in combination, in children birth to 4.9 years of age.

RESULTS

The search identified 11 379 papers, 200 full-text articles were screened for eligibility, and 12 met the inclusion criteria. Three studies measured two behavioural domains, while most assessed a single behaviour (three diet, five physical activity, one sleep, and none sedentary behaviour). Only two (one diet, one sleep) focused on the under 2 age group. Few studies assessed reliability, and validity and findings were mixed.

CONCLUSIONS

There is a need to develop brief tools to measure early life obesity-related behaviours, particularly those assessing sedentary behaviour and sleep and tools that cover multiple domains.

Severe housing-cost burden and obesity among preschool-aged low-income children in Los Angeles County

Despite high rates of housing-cost burden in the United States, little is known regarding its impact on childhood obesity. In this article, we determine whether low-income 2–5-year-olds living in housing-cost burdened households are more likely to be obese and examine the potential moderators and behavioral and psychosocial mediators of this relationship. We used data from a triennial survey (2011, 2014) of a random sample of Los Angeles County participants of the Special Supplemental Nutrition Program for Women, Infants and Children (n = 2307). Logistic regression was used to examine the association between child's obesity status (Body Mass Index for age and sex ≥ 95th percentile) and severe housing-cost burden (finding it very difficult to pay for housing). Mother's depressive symptoms and child's diet and screen time were tested for mediation. We found that 16% of children lived in severe housing-cost burdened households. Severe housing-cost burden was associated with an increase in the odds of childhood obesity [aOR (95%CI) = 1.33 (1.00, 1.78)] and household size moderated this relationship. Child's diet and screen time and mother's depressive symptoms were not mediators. Given the high and vacillating rates of early childhood obesity and the increasing burden of housing costs in low-income populations, there is an urgency to better understand the role of housing-cost burden in epidemiologic investigations of early childhood obesity.

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Children in severe housing-cost burdened households had more chronic stressors.

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Severe housing-cost burden was associated with greater odds of childhood obesity.

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Child's behavior and mother's mental well-being were not mediators of the relationship.

Relative validity of a semi-quantitative food frequency questionnaire for Singaporean toddlers aged 15-36 months

Background

There is presently no simple tool for use in large epidemiological studies to understand the food and nutrient intakes of Asian toddlers. This study aimed to assess the relative validity of a semi-quantitative food frequency questionnaire (sqFFQ) developed for multi-ethnic Singaporean toddlers aged 15–36 months.

Methods

Ninety-one parents completed the sqFFQ and a 2-day weighed food record as the reference method. Intake of energy and 25 nutrients were determined for each method and compared using Pearson correlations corrected for attenuation, Bland-Altman plots, and weighted kappa according to quartiles; sqFFQ calibration was performed using multivariable linear regression.

Results

Deattenuated correlations for energy and all nutrients were acceptable (r = ≥0.30, p < 0.001). The sqFFQ was highly reproducible, but significantly overestimated intake of energy and all nutrients except vitamin A. Bland-Altman plots showed wide limits of agreement for energy and all nutrients. Weighted kappa ranged from 0.12 (slight) to 0.53 (moderate). After calibration, deattenuated correlations improved for energy and 10/25 nutrients, with no change or a slight decline for the remainder, including one falling to r = 0.27. Limits of agreement narrowed for energy and all nutrients, and except for DHA, median intakes were not significantly different except for vitamin A, enabling population estimates of absolute intakes. Weighted kappa improved overall; energy and 16 nutrients now had moderate agreement (0.41–0.60), while 9 nutrients had fair agreement (0.21–0.40).

Conclusions

The Singaporean toddler semi-quantitative food frequency questionnaire is suitable for ranking nutrient intakes of Singaporean toddlers in larger epidemiological studies. However, for population estimates of absolute nutrient intakes, it is recommended that a subsample within a cohort complete weighed food records for calibration purposes.

Trial registration

This study was registered retrospectively on clinicaltrials.gov on 3rd May 2017 (identifier code: NCT03138330).

Challenges in the assessment of total fluid intake in children and adolescents: a discussion paper

Purpose

In recent years, evidence has emerged about the importance of healthy fluid intake in children for physical and mental performance and health, and in the prevention of obesity. Accurate data on water intake are needed to inform researchers and policymakers and for setting dietary reference values. However, to date, there are few published data on fluid or water intakes in children. This is due partly to the fact that drinking water is not always reported in dietary surveys. The aim of this paper is to review the current status of the literature and highlight the challenges of assessing total fluid intake in children and adolescents.

Results

From the dietary assessment literature it is apparent that children present unique challenges to assessing intake due to ongoing cognitive capacity development, limited literacy skills, difficulties in estimating portion sizes and multiple caregivers during any 1 day making it difficult to track intakes. As such, many issues should be considered when assessing total fluid intakes in children or adolescents. Various methods to assess fluid intakes exist, each with its own strengths and weaknesses; the ultimate choice of method depends on the research question and resources available. Based on the literature review, it is apparent that if the research focus is to assess only fluid intake, a fluid-specific method, such as a diary or record, appears to be a feasible approach to provide an accurate estimate of intakes.