Validity and feasibility of a digital diet estimation method for use with preschool children: a pilot study

Automated Artificial Intelligence-Based Thai Food Dietary Assessment System: Development and Validation

Background

Dietary assessment is a fundamental component of nutrition research and plays a pivotal role in managing chronic diseases. Traditional dietary assessment methods, particularly in the context of Thai cuisine, often require extensive training and may lead to estimation errors.

Objectives

To address these challenges, Institute of Nutrition, Mahidol University (INMU) iFood, an innovative artificial intelligence-based Thai food dietary assessment system, allows for estimating the nutritive values of dishes from food images.

Methods

INMU iFood leverages state-of-the-art technology and integrates a validated automated Thai food analysis system. Users can use 3 distinct input methods: food image recognition, manual input, and a convenient barcode scanner. This versatility simplifies the tracking of dietary intake while maximizing data quality at the individual level. The core improvement in INMU iFood can be attributed to 2 key factors, namely, the replacement of Yolov4-tiny with Yolov7 and the expansion of noncarbohydrate source foods in the training image data set.

Results

This combination significantly enhances the system's ability to identify food items, especially in scenarios with closely packed food images, thus improving accuracy. Validation results showcase the superior performance of the INMU iFood integrated V7-based system over its predecessor, V4-based, with notable improvements in protein and fat estimation. Furthermore, INMU iFood addresses limitations by offering users the option to import additional food products via a barcode scanner, thus providing access to a vast database of nutritional information through Open Food Facts. This integration ensures users can track their dietary intake effectively, with expanded access to over 3000 food items added to or updated in the Open Food Facts database covering a wide variety of dietary choices.

Conclusions

INMU iFood is a promising tool for researchers, health care professionals, and individuals seeking to monitor their dietary intake within the context of Thai cuisine and for ultimately promoting better health outcomes and facilitating nutrition-related research.

The Validity and Feasibility of Utilizing the Photo-Assisted Dietary Intake Assessment among College Students and Elderly Individuals in China

Dietary assessments hold significant importance within the field of public health. However, the current methods employed for dietary assessments face certain limitations and challenges that necessitate improvement. The aim of our study was to develop a reliable and practical dietary assessment tool known as photo-assisted dietary intake assessment (PAD). In order to evaluate its validity, we conducted an analysis on a sample of 71 college students' dinners at a buffet in a canteen. We compared estimates of food weights obtained through the 24-h recall (24 HR) or PAD method with those obtained through the weighing method; we also evaluated the feasibility of PAD for recording dinner intakes among a sample of college students (n = 76) and elderly individuals (n = 121). In addition, we successfully identified the dietary factors that have a significant impact on the bias observed in weight estimation. The findings of the study indicated that the PAD method exhibited a higher level of consistency with the weighing method compared to the 24 HR method. The discrepancy in D% values between cereals (14.28% vs. 40.59%, P < 0.05), vegetables (17.67% vs. 44.44%, P < 0.05), and meats (14.29% vs. 33.33%, P < 0.05) was clearly apparent. Moreover, a significant proportion of the food mass value acquired through the PAD method fell within the limits of agreement (LOAs), in closer proximity to the central horizontal line. Furthermore, vegetables, cereals, eggs, and meats, for which the primary importance lies in accuracy, exhibited a considerably higher bias with the 24 HR method compared to the PAD method (P < 0.05), implying that the PAD method has the potential to mitigate the quality bias associated with these food items in the 24 HR method. Additionally, the PAD method was well received and easily implemented by the college students and elderly individuals. In conclusion, the PAD method demonstrates a considerable level of accuracy and feasibility as a dietary assessment method that can be effectively employed across diverse populations.

Accuracy of dietary intake assessments using food records based on photographic images captured by visually impaired people

Traditional methods to assess dietary intake have limited and questionable application in visually impaired people since the lack of vision and low leading role in their diet make it difficult to quantify and detail the food consumed throughout the day. Thus, this study investigated whether it is possible to accurately identify foods and estimate their quantities using food records based on photographic images captured by visually impaired people. A panel of experts composed of nutritionists (n = 20) assessed these records comprising three standardized meals (breakfast; lunch/dinner; snack) from visually impaired people (n = 40) using two different protocols (frontal photo; aerial photo). Each nutritionist reported an estimated food record for each photographic image, which was compared to its respective weighed food record. For both frontal and aerial photos, experts were frequently correct for the number of food items in the meal (95.0% or over for breakfast, 100% for lunch/dinner, and 100% for snacks). All experts identified at least 11 of the 13 food items, but the majority correctly estimated the food amount only for 23% of the items. Compared to the weighed food record, the photographic records underestimated the amount of 61.5% of food items based on frontal photos, and of 76.9% of food items based on aerial photos. While most foods could be identified by photographic images captured by visually impaired people enabling a qualitative assessment of the diet, they could not be quantified accurately by nutritionists.

Development and validation of a photographic food atlas of Middle Eastern Mediterranean diet: Toward improved understanding of traditional healthy and sustainable diets

Background

Middle Eastern Mediterranean diet (MEMD) is a traditional plant-based diet that is commonly consumed and increasingly popular, but not well studied in nutrition research. To facilitate the dietary assessment of MEMD, we developed and validated a photographic food atlas depicting a variety of foods and dishes consumed in the MEM region.

Methods

The photographic food atlas included 1,002 photos of 400 types of foods and traditional dishes photographed characterizing MEMD. Foods and dishes were prepared by a professional cook and were subsequently photographed as a series of photos depicting portion size options. In a validation study, 45 individuals aged 20-50 years were recruited to assess portion size estimation of 25 representative food-photo series for each item. The validity of portion size estimation was assessed by comparing actual and reported estimates using Pearson or Spearman correlation tests. Sizes of the differences between estimated portions and the actual served portion sizes were calculate as mean differences and standard deviations.

Results

In the validation study, there was a strong correlation (r > 0.7) between estimated portion size of actual foods for 7 food items, such as pita bread, milk, labneh, and tomatoes, a moderate correlation (< 0.5 | r | < 0.7) for 12 items, such as meat, chicken, and grapes, and weak correlation (r < 0.3) for 6 items, such as seeds. Underestimation of portion sizes was more commonly observed for food items quantified when using "grams" or "milliliters" as a unit of measurement. In contrast, when household measurements were used, the participants tended to overestimate the portion sizes of respective foods and dishes.

Conclusion

We developed and validated a photographic food atlas depicting a wide variety of foods and dishes typical for the MEMD. The application of the photographic food atlas may facilitate the accurate assessment of adherence to MEMD and support the understanding of its health and sustainability aspects. Further methodological work is warranted to extend the list of food items and to evaluate the validity of the food atlas among larger and more heterogeneous groups of participants.

A Qualitative Analysis of the Remote Food Photography Method and the Automated Self-Administered 24-hour Dietary Assessment Tool for Assessing Children's Food Intake Reported by Parent Proxy

BACKGROUND

Accuracy and participant burden are two key considerations in the selection of a dietary assessment tool for assessing children's full-day dietary intake.

OBJECTIVE

The aim of this study was to identify barriers experienced by parents and burden when using two technology-based measures of dietary intake to report their child's intake: the Remote Food Photography Method (RFPM) and the Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24).

DESIGN

Qualitative, semistructured, focus groups were conducted with parents who served as proxy reporters of their child's dietary intake using the two different dietary assessment methods (ie, RFPM and ASA24) 1 week apart.

PARTICIPANTS/SETTING

This study was conducted in 2019 and included 32 parents of children aged 7 to 8 years in Colorado and Louisiana.

MAIN OUTCOME MEASURES

Barriers adhering to the protocol and burden with the RFPM and ASA24.

QUALITATIVE ANALYSES

Qualitative content analysis and Atlas.ti software were used to analyze and interpret focus group data.

RESULTS

For the RFPM, parents described missing photos due to unobserved intake, forgetting to capture images, disruption of mealtimes, and child embarrassment when meals were photographed at school. For the ASA24, parents described the time commitment as the main source of burden and the need to expand the food database to include additional ethnic foods and restaurant items. The main strengths were ease of use for the RFPM and the consolidated workload for the ASA24.

CONCLUSIONS

The barriers experienced by parents and burden differed by method, highlighting the importance of considering the unique characteristics of each assessment tool when designing a pediatric dietary assessment study and interpreting findings.

A comparison of the remote food photography method and the automated self-administered 24-h dietary assessment tool for measuring full-day dietary intake among school-age children

The limitations of self-report measures of dietary intake are well-known. Novel, technology-based measures of dietary intake may provide a more accurate, less burdensome alternative to existing tools. The first objective of this study was to compare participant burden for two technology-based measures of dietary intake among school-age children: the Automated-Self-Administered 24-hour Dietary Assessment Tool-2018 (ASA24-2018) and the Remote Food Photography Method (RFPM). The second objective was to compare reported energy intake for each method to the Estimated Energy Requirement for each child, as a benchmark for actual intake. Forty parent-child dyads participated in two, 3-d dietary assessments: a parent proxy-reported version of the ASA24 and the RFPM. A parent survey was subsequently administered to compare satisfaction, ease of use and burden with each method. A linear mixed model examined differences in total daily energy intake between assessments, and between each assessment method and the Estimated Energy Requirement (EER). Reported energy intake was 379 kcal higher with the ASA24 than the RFPM (P = 0·0002). Reported energy intake with the ASA24 was 231 kcal higher than the EER (P = 0·008). Reported energy intake with the RFPM did not differ significantly from the EER (difference in predicted means = -148 kcal, P = 0·09). Median satisfaction and ease of use scores were five out of six for both methods. A higher proportion of parents reported that the ASA24 was more time-consuming than the RFPM (74·4 % v. 25·6 %, P = 0·002). Utilisation of both methods is warranted given their high satisfaction among parents.

Comparison of the Diet Photograph Record to Weighed Dietary Record and 24 h Dietary Recall for Estimating Energy and Nutrient Intakes Among Chinese Preschoolers

This study aimed to assess the relative validity of the diet photograph record (DP) for measuring the energy and nutrient intakes against the weighed dietary record (WD) and the 24 h dietary recall (HR) in the Chinese preschoolers. In this study, 40 preschool children aged 4–6 years and their parents were recruited from a kindergarten in southwest China. Dietary intake of the preschoolers on a same day, as estimated by the DP and the HR were compared with the WD. These three methods were administered by the three group of investigators independently. The mean differences, correlation coefficients, cross-classifications, and weighted κ, as well as the Bland–Altman plots were performed to assess the differences and agreements among the estimates from the DP, the HR, and the WD. For the DP and the HR, the estimates of energy and nutrient intakes were moderate to high correlated with the WD, with the higher coefficients ranging from 0.73 to 0.94 for the DP. Both the methods tended to underestimate the dietary intake, but the differences from the known weights using the DP were significantly smaller than those using the HR. The weighed κ values ranking the preschoolers ranged from 0.48 to 0.80 for the DP and ranged from 0.28 to 0.64 for the HR. Furthermore, the Bland–Altman plots indicated a better agreement between the DP and the WD for estimating energy and nutrient intakes. This DP is a valid tool for measuring energy and nutrient intakes among the preschoolers.

Students choosing fat-free chocolate milk during school lunch consume more calories, total sugar, protein, minerals and vitamins at lunch

OBJECTIVE

To examine how milk consumption varies by milk choice and measure the association of milk choice on the nutritional and energetic content of National School Lunch Program (NSLP) lunches.

DESIGN

An observational plate waste study using the Digital Photography of Foods Method.

SETTING

Data were collected from two suburban South Carolina schools in one district during February and March 2013.

PARTICIPANTS

Totally, 968 NSLP lunches selected by 619 kindergarten to fifth grade students.

RESULTS

Most students chose chocolate milk (75 %). A multinomial logit model indicated milk choice varied significantly by sociodemographic characteristics. An ordinary least square regression indicated that consumption rates of low-fat white milk were 8·5 % lower than fat-free chocolate milk (P = 0·039) and milk consumption rates varied statistically by sociodemographic characteristics. Ordinary least square regressions found that the consumption of energies and nutrients from NSLP lunches varied with sociodemographic characteristics and milk choice; students selecting chocolate milk consumed 58 more energies (P < 0·001) and 10 more grams of total sugar (P < 0·001) than students selecting low-fat white milk from their NSLP lunches. Students consumed statistically similar energies and nutrients from the non-milk components of their meals.

CONCLUSIONS

Students selecting chocolate milk consumed more energies and nutrients from their NSLP lunches with the increases in consumption attributed to the milk component of the meal. The findings have implications for recent changes to NSLP guidelines that allow schools to offer both low-fat and fat-free flavoured milk, reversing the previous ban on low-fat flavoured milk under the Healthy, Hunger-Free Kids Act.

Development and validation of protocols for photographed food record by visually impaired people

OBJECTIVE

To develop and validate protocols for photographed food record directed to visually impaired people.

DESIGN

Photographic techniques were established for capturing food images using a smartphone, and written protocols were defined. Thereafter, visually impaired people made photographic records of three standardised meals (breakfast, lunch/dinner, and snack) following the previously developed protocols. These photographs were then evaluated by a panel of experts (nutritionists and photographer) to indicate whether the framing, focus and angle were suitable to identify the food type, food amount and portion size. Agreement between the experts was assessed using Fleiss' Kappa.

SETTING

Natal, the capital of Rio Grande do Norte, Brazil.

PARTICIPANTS

Visually impaired people (n 40); nutritionists (n 2); professional photographer (n 1).

RESULTS

Both protocols obtained a high proportion of satisfactory photos for all the items in the three dimensions investigated. When overall quality was assessed, the experts' agreement was a substantial that through the images it would be possible to identify the food type and portion size, both for Frontal Photos (k = 0·70 and k = 0·62, respectively) and Aerial Photos (k = 0·68 and k = 0·70, respectively). The degree of agreement that the photos presented a satisfactory global quality was moderate for the Frontal Photo (k = 0·43) and substantial for the Aerial Photo (k = 0·64). Participants who frequently used smartphone-type cell phones obtained better quality images for all these attributes for both protocols.

CONCLUSIONS

The protocols for photographed food record developed for visually impaired people in this study are feasible and present themselves as an alternative strategy to qualitatively assess their dietary intake.

Review of the validity and feasibility of image-assisted methods for dietary assessment

Accurately quantifying dietary intake is essential to understanding the effect of diet on health and evaluating the efficacy of dietary interventions. Self-report methods (e.g., food records) are frequently utilized despite evident inaccuracy of these methods at assessing energy and nutrient intake. Methods that assess food intake via images of foods have overcome many of the limitations of traditional self-report. In cafeteria settings, digital photography has proven to be unobtrusive and accurate and is the method of choice for assessing food provision, plate waste, and food intake. In free-living conditions, image capture of food selection and plate waste via the user's smartphone, is promising and can produce accurate energy intake estimates, though accuracy is not guaranteed. These methods foster (near) real-time transfer of data and eliminate the need for portion size estimation by the user since the food images are analyzed by trained raters. A limitation that remains, similar to self-report methods where participants must truthfully record all consumed foods, is intentional and/or unintentional underreporting of foods due to social desirability or forgetfulness. Methods that rely on passive image capture via wearable cameras are promising and aim to reduce user burden; however, only pilot data with limited validity are currently available and these methods remain obtrusive and cumbersome. To reduce analysis-related staff burden and to allow real-time feedback to the user, recent approaches have aimed to automate the analysis of food images. The technology to support automatic food recognition and portion size estimation is, however, still in its infancy and fully automated food intake assessment with acceptable precision not yet a reality. This review further evaluates the benefits and challenges of current image-assisted methods of food intake assessment and concludes that less burdensome methods are less accurate and that no current method is adequate in all settings.

Evaluation of an Alimentary Education Intervention on School Canteen Waste at a Primary School in Bari, Italy

The “Love Food, Not Waste” project was conducted to train students on good food choices and evaluate food waste in school canteens. Teachers, parents and students were surveyed before and after training. Weights of both the served and wasted food were recorded for one week both before the educational intervention in February 2019 and after the educational intervention in March 2019, using the same menu. Students completed a food satisfaction questionnaire on the days the data were collected. For the first dish, the mean wastes per school were 1199 g before training and 1054 g after training. For the second dish, the mean wastes per school were 246 g before training and 220 g after training. For the side course, the means wastes per school were 663 g before training and 747 g after training. The results did not significantly differ among weeks or schools. Less food was wasted when boys judged the food’s general aspects like smell, taste and appearance as positive; more food was wasted when girls judged these factors as negative. Food waste monitoring is mandatory but does not always occur. Analyzing food waste relative to students’ food perceptions can help determine whether educational interventions can help reduce waste. Students’ satisfaction must also be considered.

Snack Portion Sizes for Preschool Children Are Predicted by Caregiver Portion Size, Caregiver Feeding Practices and Children's Eating Traits

Caregivers are mostly responsible for the foods young children consume; however, it is unknown how caregivers determine what portion sizes to serve. This study examined factors which predict smaller or larger than recommended snack portion sizes in an online survey. Caregivers of children aged 2 to 4 years were presented with 10 snack images, each photographed in six portion sizes. Caregivers (n = 659) selected the portion they would usually serve themselves and their child for an afternoon snack. Information on child eating traits, parental feeding practices and demographics were provided by caregivers. Most caregivers selected portions in line with recommended amounts for preschool children, demonstrating their ability to match portion sizes to their child's energy requirements. However, 16% of caregivers selected smaller than recommended low energy-dense (LED, e.g., fruits and vegetables) snacks for their child which was associated with smaller caregiver's own portion size, reduced child food liking and increased satiety responsiveness. In contrast, 28% of caregivers selected larger than recommended amounts of high energy-dense (HED, e.g., cookies, crisps) snacks for their child which were associated with larger caregiver's own portion size, greater frequency of consumption, higher child body mass index (BMI), greater pressure to eat and lower child food liking. These findings suggest that most caregivers in this study select portions adjusted to suit their child's age and stage of development. Future interventions could provide support to caregivers regarding the energy and nutrient density of foods given the relatively small portion sizes of LED and large portions of HED snacks offered to some children.

Assessing dinner meals offered at home among preschoolers from low-income families with the Remote Food Photography Method

BACKGROUND

The high prevalence of obesity among preschoolers may be partially explained by the type and quantity of foods offered by parents and left unconsumed by preschoolers.

OBJECTIVES

(a) To compare foods offered and consumed at dinner to the Dietary Guidelines for Americans (DGAs) and the Child and Adult Care Food Program (CACFP) standards and (b) to examine the types, quantities, and nutrient composition of foods offered to and consumed by preschoolers and their plate waste.

METHODS

Participants were recruited from six Head Start/preschool centres. The Remote Food Photography Method was used to document dinner meals over 1 week (n = 153 meals). Energy and nutrients for foods offered, consumed, and plate waste were calculated. Foods offered and consumed were compared with the DGAs and CACFP standards.

RESULTS

Foods and beverages offered at dinner equaled 506 kcal, which is 36% of the DGA-recommended total daily energy intake. Meals offered and consumed were high in fat and sodium and low in fibre. Adherence to CACFP standards was low for fruits (25%) and milk (2%) and moderate for vegetables (63%). Mean plate waste (29%) was similar across food types.

CONCLUSIONS

Opportunities exist to improve preschoolers' adherence to the DGAs and CACFP standards by enhancing the quality of dinner meals offered to them.

Child-care self-assessment to improve physical activity, oral health and nutrition for 2- to 4-year-olds: a feasibility cluster RCT

Background

The Nutrition And Physical Activity Self Assessment for Child Care (NAP SACC) intervention has shown evidence of effectiveness in the USA but not been adapted or assessed for effectiveness in the UK.

Objectives

To evaluate the feasibility and acceptability of implementing NAP SACC in the UK.

Design

Adaptation and development of NAP SACC and feasibility cluster randomised controlled trial (RCT) including process and economic evaluations. Substudies assessed mediator questionnaire test–retest reliability and feasibility of food photography methods.

Setting

Nurseries, staff and parents in North Somerset, Cardiff, Gloucestershire and Bristol.

Participants

Development – 15 early years/public health staff and health visitors, 12 nursery managers and 31 parents. RCT – 12 nurseries and 31 staff, four partners and 168 children/parents. Mediator substudy – 82 parents and 69 nursery staff. Food photography substudy – four nurseries, 18 staff and 51 children.

Intervention

NAP SACC UK partners supported nurseries to review policies and practices and set goals to improve nutrition, oral health and physical activity (PA) over 5 months. Two workshops were delivered to nursery staff by local experts. A home component [website, short message service (SMS) and e-mails] supported parents. The control arm continued with usual practice.

Main outcome measures

Feasibility and acceptability of the intervention and methods according to prespecified criteria.

Data sources

Qualitative data to adapt the intervention. Measurements with children, parents and staff at baseline and post intervention (8–10 months after baseline). Interviews with nursery managers, staff, parents and NAP SACC UK partners; observations of training, workshops and meetings. Nursery environment observation, nursery Review and Reflect score, and resource log. Child height and weight, accelerometer-determined PA and sedentary time, screen time and dietary outcomes using the Child and Diet Evaluation Tool. Staff and parent questionnaires of knowledge, motivation and self-efficacy. Child quality of life and nursery, family and health-care costs. Food photography of everything consumed by individual children and staff questionnaire to assess acceptability.

Results

Thirty-two per cent (12/38) of nurseries and 35.3% (168/476) of children were recruited; no nurseries withdrew. The intervention was delivered in five out of six nurseries, with high levels of fidelity and acceptability. Partners found it feasible but had concerns about workload. The child loss to follow-up rate was 14.2%. There was suggestion of promise in intervention compared with control nurseries post intervention for snacks, screen time, proportion overweight or obese and accelerometer-measured total PA and moderate to vigorous PA. Many parental and nursery knowledge and motivation mediators improved. The average cost of delivering the intervention was £1184 per nursery excluding partner training, and the average cost per child was £27. Fourteen per cent of parents used the home component and the mediator questionnaire had good internal consistency and test–retest reliability. Photography of food was acceptable and feasible.

Limitations

Following nursery leavers was difficult. Accelerometer data, diet data and environmental assessment would have been more reliable with 2 days of data.

Conclusions

The NAP SACC UK intervention and methods were found to be feasible and acceptable to participants, except for the home component. There was sufficient suggestion of promise to justify a definitive trial.

Future work

A multicentre cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of NAP SACC UK has been funded by NIHR and will start in July 2019 (PHR NIHR 127551).

Trial registration

Current Controlled Trials ISRCTN16287377.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 13. See the NIHR Journals Library website for further project information. Funding was also provided by the North Somerset and Gloucestershire Councils, Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer) (MR/KO232331/1), and the Elizabeth Blackwell Institute.

Beyond Nutrient Intake: Use of Digital Food Photography Methodology to Examine Family Dinnertime

OBJECTIVE

To explore the feasibility of using an image-based food photography methodology (Remote Food Photography Method) in a rural, low-resource audience and use the photos to examine the context of family dinner.

DESIGN

Parents used the SmartIntake app on study-issued tablets to take before and after photos of their and their child's dinner for about 7 nights and participated in a mini-focus group to discuss their experience with the Remote Food Photography Method.

SETTING

Six Head Start/preschool centers in rural Colorado.

PARTICIPANTS

Mother-child dyads (n = 31).

VARIABLES MEASURED

Number and quality of photos received, participant feedback, meal timing, concordance, location, preparation, and quality.

ANALYSIS

The researchers assessed feasibility via practicality (percent photos received) and acceptability (general inductive approach used to analyze mini-focus group transcripts for participant feedback); time stamps, meal quality, and food preparation scales were used to analyze dinner photos.

RESULTS

The majority of photographs (738 of 864) were received. Participants reacted favorably to the methodology; for some, it led to greater self-reflection about mealtime. Mother-child dyads usually ate dinner at the same time and often ate the same food. Children were frequently served protein and refined grains and were rarely served whole grains or fruit. Many families relied on convenience foods.

CONCLUSIONS AND IMPLICATIONS

Digital food photography was feasible in this audience. Photos yielded a holistic picture of family dinnertime: meal timing, location, concordance in parent-child meals, level of preparation, and meal quality.

Observations of Toddlers' sensory-based exploratory behaviors with a novel food

BACKGROUND

Food neophobia hinders the acceptance of healthy foods in young children, and may be overcome by repeated food exposure. Prevalent literature states that children exhibit five sensory-based exploratory behaviors (SBEBs): smelling, licking, spitting, manipulating and/or swallowing as they progress towards accepting a novel food, yet there is a paucity of research on these behaviors. This study aimed to use direct observations of SBEBs across first-time exposures to hummus to (1) determine the prevalence of five SBEBs (smelling, licking, spitting, manipulating and swallowing) in 12-35 month olds, (2) quantify the psychometric properties of the SBEB assessment; and (3) examine the association of SBEBs with parent-assessed food fussiness, and consumption of the novel food.

METHODS

Direct observations of SBEBs during a 15-20 min snack time were conducted by trained staff members for 55 hummus-naïve toddlers ages 12-35 months, across 16 exposures to a novel food (hummus). Parents completed the child eating behavior questionnaire. Hummus consumption was measured using digital plate waste method.

RESULTS

Very low base rates of spitting (0.06%), smelling (0.97%) and licking (1.95%) were observed but manipulation (26.36%) and swallowing (62.15%) were more prevalent. Observation data on two behaviors over 16 occasions gave rise to a reliability coefficient from our G study portion of our generalizability analyses of Eρ² = 0.65. SBEBs did not significantly associate with parent-assessed food fussiness, nor hummus consumption.

CONCLUSIONS

Although literature refers to the prevalence of SBEBs, we did not observe this for three proposed behaviors. We did observe manipulation, but more research is needed to determine if there are additional SBEBs not noted in the literature, and to better delineate the process that leads to acceptance/rejection of novel food.

Sensory-based food education in early childhood education and care, willingness to choose and eat fruit and vegetables, and the moderating role of maternal education and food neophobia

Objective

To investigate the association between sensory-based food education implemented in early childhood education and care (ECEC) centres and children’s willingness to choose and eat vegetables, berries and fruit, and whether the mother’s education level and children’s food neophobia moderate the linkage.

Design

The cross-sectional study involved six ECEC centres that provide sensory-based food education and three reference centres. A snack buffet containing eleven different vegetables, berries and fruit was used to assess children’s willingness to choose and eat the food items. The children’s parents completed the Food Neophobia Scale questionnaire to assess their children’s food neophobia.

Setting

ECEC centres that provide sensory-based food education and reference ECEC centres in Finland.

Subjects

Children aged 3–5 years in ECEC (n 130) and their parents.

Results

Sensory-based food education was associated with children’s willingness to choose and eat vegetables, berries and fruit. This association was stronger among the children of mothers with a low education level. A high average level of neophobia in the child group reduced the children’s willingness to choose vegetables, berries and fruit. No similar tendency was observed in the group that had received sensory-based food education. Children’s individual food neophobia had a negative association with their willingness to choose and eat the vegetables, berries and fruit.

Conclusions

Child-oriented sensory-based food education seems to provide a promising method for promoting children’s adoption of vegetables, berries and fruit in their diets. In future sensory food education research, more focus should be placed on the effects of the education at the group level.

Validity of assessing child feeding with virtual reality

Assessment of parents' child feeding behavior is challenging, and there is need for additional methodological approaches. Virtual reality technology allows for the creation of behavioral measures, and its implementation overcomes several limitations of existing methods. This report evaluates the validity and usability of the Virtual Reality (VR) Buffet among a sample of 52 parents of children aged 3-7. Participants served a meal of pasta and apple juice in both a virtual setting and real-world setting (counterbalanced and separated by a distractor task). They then created another meal for their child, this time choosing from the full set of food options in the VR Buffet. Finally, participants completed a food estimation task followed by a questionnaire, which assessed their perceptions of the VR Buffet. Results revealed that the amount of virtual pasta served by parents correlated significantly with the amount of real pasta they served, rs = 0.613, p < .0001, as did served amounts of virtual and real apple juice, rs = 0.822, p < .0001. Furthermore, parents' perception of the calorie content of chosen foods was significantly correlated with observed calorie content (rs = 0.438, p = .002), and parents agreed that they would feed the meal they created to their child (M = 4.43, SD = 0.82 on a 1-5 scale). The data presented here demonstrate that parent behavior in the VR Buffet is highly related to real-world behavior, and that the tool is well-rated by parents. Given the data presented and the potential benefits of the abundant behavioral data the VR Buffet can provide, we conclude that it is a valid and needed addition to the array of tools for assessing feeding behavior.

Validity of a Digital Diet Estimation Method for Use with Preschool Children

BACKGROUND

The validity of using the Remote Food Photography Method (RFPM) for measuring food intake of minority preschool children's intake is not well documented.

OBJECTIVE

Our aim was to determine the validity of intake estimations made by human raters using the RFPM compared with those obtained by weighing all foods and beverages consumed by 3- to 5-year-old children (weighed method).

DESIGN

We conducted a cross-sectional observational study.

PARTICIPANTS/SETTINGS

A convenience sample of 54 3- to 5-year-old Hispanic and African-American children were observed during a 12-hour period at Baylor Metabolic Research Unit between June 2013 and January 2014.

MAIN OUTCOME MEASURES

All foods/beverages consumed by the children were provided by Baylor research coordinators who took and wirelessly transmitted before-and-after pictures of the trays to trained human raters at the Pennington Biomedical Research Center who estimated grams consumed. Energy and macronutrients were calculated using the Food and Nutrient Database for Dietary Studies or food facts data provided by manufacturers.

STATISTICAL ANALYSES

Paired t test, mean differences, and Bland-Altman limits of agreement were performed.

RESULTS

Compared to the weighed method, the rater method significantly overestimated total intake by 34±71 g (P<0.0001), with a mean percent error of 2.9% (root mean square error=7.1%), and total energy intake by 75±102 kcal (P<0.0001), with a mean percent error of 7.5% (root mean square error=12.3%). The standard error for the macronutrient intakes ranged from 11.0% to 20.2%. The Bland-Altman approach demonstrated a positive slope for the rater method relative to the weighed method for total intake in grams (P=0.006), carbohydrate (P=0.01), and protein (P=0.01) (ie, magnitude of the bias increased with increasing intakes).

CONCLUSIONS

The rater method overestimated total intake in grams and energy in kilocalories in minority preschool children in a well-controlled condition and needs to be further tested in a free-living environment.

Association Between Sleep Duration and Body Mass Index Among US Low-Income Preschoolers

OBJECTIVE

To verify whether sleep duration was related to body mass index z scores (zBMI) and whether bedtimes or ethnicity was a moderator of the sleep duration-zBMI association among preschoolers from low-income families.

METHODS

Two hundred twenty-eight African American and Hispanic parents and their preschoolers were recruited from Head Start Centers. Parents reported their preschoolers' sleep duration and bedtimes (using the Children's Sleep Habits Questionnaire) and their television watching. Food intake was measured using multiple days of digital photography to estimate energy intake at dinner. The Parenting Stress Index and the Center for Epidemiologic Studies Depression Scale were used to measure stress and depression. Parents' and preschoolers' height and weight were measured by trained staff.

RESULTS

Longer sleep duration was significantly associated with lower zBMI when controlling for demographics, bedtimes, energy intake at dinner, and television watching, but not when also controlling for parents' demographics, BMI, stress, and depression. Preschoolers' sleep duration-zBMI association was not moderated by bedtimes or ethnicity.

CONCLUSIONS

Longer sleep duration was associated with lower zBMI among low-income preschoolers when controlling for preschoolers' characteristics, but this was no longer the case when also controlling for parents' characteristics. Additional studies are needed on the moderators of the sleep duration-zBMI association among low-income preschoolers.

Validity of the Remote Food Photography Method Against Doubly Labeled Water Among Minority Preschoolers

OBJECTIVE

The aim of this study was to determine the validity of energy intake (EI) estimations made using the remote food photography method (RFPM) compared to the doubly labeled water (DLW) method in minority preschool children in a free-living environment.

METHODS

Seven days of food intake and spot urine samples excluding first void collections for DLW analysis were obtained on thirty-nine 3- to 5-year-old Hispanic and African American children. Using an iPhone, caregivers captured before and after pictures of each child's intake, pictures were wirelessly transmitted to trained raters who estimated portion size using existing visual estimation procedures, and energy and macronutrients were calculated. Paired t tests, mean differences, and Bland-Altman limits of agreement were performed.

RESULTS

The mean EI was 1,191 ± 256 kcal/d using the RFPM and 1,412 ± 220 kcal/d using the DLW method, resulting in a mean underestimate of 222 kcal/d (-15.6%; P < 0.0001) that was consistent regardless of intake. The RFPM underestimated EI by -28.5% in 34 children and overestimated EI by 15.6% in 5 children.

CONCLUSIONS

The RFPM underestimated total EI when compared to the DLW method among preschoolers. Further refinement of the RFPM is needed for assessing the EI of young children.

Food and Nutrients Intake in the School Lunch Program among School Children in Shanghai, China

This study aimed to evaluate the intake of food and nutrients among primary, middle, and high schools students in Shanghai, and provide recommendations for possible amendments in new school lunch standards of Shanghai. Twenty schools were included in the school lunch menu survey. Of those, seven schools enrolled 5389 students and conducted physical measurement of plate waste and a questionnaire survey. The amount of food and nutrients was compared according to the new China National Dietary Guideline for School Children (2016) and Chinese Dietary Reference Intakes (2013). The provision of livestock and poultry meat in menus was almost 5-8 times the recommended amount. The amount of seafood was less than the recommended amount, and mostly came from half-processed food. The average percentage of energy from fat was more than 30% in students of all grades. The greatest amount of food wasted was vegetables with 53%, 42%, and 31%, respectively, among primary, middle and high school students. Intake of Vitamin A, Vitamin B₂, calcium, and iron was about 50% of the recommended proportion. Only 24.0% students were satisfied with the taste of school lunches. Higher proportions of livestock and poultry meat and low intake of vegetables have become integral problems in school lunch programs. Additionally, more attention needs to be paid to the serving size in primary schools with five age groups.

Developing a digital photography-based method for dietary analysis in self-serve dining settings

Current population-based methods for assessing dietary intake, including food frequency questionnaires, food diaries, and 24-h dietary recall, are limited in their ability to objectively measure food intake. Digital photography has been identified as a promising addition to these techniques but has rarely been assessed in self-serve settings. We utilized digital photography to examine university students' food choices and consumption in a self-serve dining hall setting. Research assistants took pre- and post-photos of students' plates during lunch and dinner to assess selection (presence), servings, and consumption of MyPlate food groups. Four coders rated the same set of approximately 180 meals for inter-rater reliability analyses; approximately 50 additional meals were coded twice by each coder to assess intra-rater agreement. Inter-rater agreement on the selection, servings, and consumption of food groups was high at 93.5%; intra-rater agreement was similarly high with an average of 95.6% agreement. Coders achieved the highest rates of agreement in assessing if a food group was present on the plate (95-99% inter-rater agreement, depending on food group) and estimating the servings of food selected (81-98% inter-rater agreement). Estimating consumption, particularly for items such as beans and cheese that were often in mixed dishes, was more challenging (77-94% inter-rater agreement). Results suggest that the digital photography method presented is feasible for large studies in real-world environments and can provide an objective measure of food selection, servings, and consumption with a high degree of agreement between coders; however, to make accurate claims about the state of dietary intake in all-you-can-eat, self-serve settings, researchers will need to account for the possibility of diners taking multiple trips through the serving line.

Design and Evaluation of a Training Protocol for a Photographic Method of Visual Estimation of Fruit and Vegetable Intake among Kindergarten Through Second-Grade Students

OBJECTIVE

To design a replicable training protocol for visual estimation of fruit and vegetable (FV) intake of kindergarten through second-grade students through digital photography of lunch trays that results in reliable data for FV served and consumed.

METHODS

Protocol development through literature and researcher input was followed by 3 laboratory-based trainings of 3 trainees. Lunchroom data collection sessions were done at 2 elementary schools for kindergarten through second-graders. Intraclass correlation coefficients (ICCs) were used.

RESULTS

By training 3, ICC was substantial for amount of FV served and consumed (0.86 and 0.95, respectively; P < .05). The ICC was moderate for percentage of fruits consumed (0.67; P = .06). In-school estimates for ICCs were all significant for amounts served at school 1 and percentage of FV consumed at both schools.

CONCLUSIONS AND IMPLICATIONS

The protocol resulted in reliable estimation of combined FV served and consumed using digital photography. The ability to estimate FV intake accurately will benefit intervention development and evaluation.

Motivational theater to increase consumption of vegetable dishes by preschool children

Background

By 3 years of age, many children have developed a dislike for certain foods, particularly vegetables. Seventy-five percent of young children consume less than the recommended levels for vegetables. The objective of this randomized feasibility intervention was to demonstrate the impact of an innovative approach to increase consumption of vegetable dishes by minority preschool children attending Head Start. The specific aims included the collection of data to assess feasibility and efficacy of the intervention.

Methods

Both qualitative and quantitative assessments were conducted. Qualitative data was used for development of the intervention and for program feedback at post assessments. Two hundred fifty-three preschool children (49% boys; 66% Hispanics and 34% African-Americans; mean age 4.4 years) were randomized either to the intervention (n = 128) or the control group (n = 125). The teacher/parent intervention group showed the children videotaped (DVD) puppet shows. Based on the theoretical framework “transportation into a narrative world”, three professionally developed characters, unique storylines and an engaging, repetitious song were incorporated in four 20-min DVD puppet shows. Prior to lunch each show was shown for five consecutive days in school and a minimum of once in the home. Digital photography was used in school to assess consumption of vegetable dishes at the lunch meal (quantitative assessment). At home parents were asked to complete the booklet questions corresponding to each DVD; questions could be answered correctly only if parents watched the DVD with their child. A multilevel mixed-effect model was used to analyze the data, adjusting for age, gender, and ethnicity.

Results

Children in the intervention group significantly (p < 0.0001) increased consumption of vegetable dishes from baseline to follow-up compared to no change in the control group. At follow-up, the intervention group continued to have significantly (p = 0.022) higher intake of vegetable dishes compared to the control group. Sixty percent of the mothers completed the booklet’s questions with 76 to 98% correct responses.

Conclusion

Using theory-based motivational theater with multiple exposures may be an effective behavioral intervention to increase consumption of vegetable dishes by preschool children that can be easily disseminated to a large sample.

Trial Registration

ClinicalTrials.gov; Identifier: NCT02216968

Development and Validation of a Photographic Method to Use for Dietary Assessment in School Settings

OBJECTIVE

To develop and validate a photographic method aimed at making assessment of dietary intake in school canteens non-obstrusive, practical and feasible.

METHODS

The study was conducted in two elementary schools representing two different school canteen systems; main dish being served by canteen staff (Iceland), and complete self-serving (Sweden). Food items in serving and leftovers were weighed and photographed. Trained researchers estimated weights of food items by viewing the photographs and comparing them with pictures of half and full reference portions with known weights. Plates of servings and leftovers from 48 children during five school days (n = 448 plates) and a total of 5967 food items were estimated. The researchers' estimates were then compared with the true weight of the foods and the energy content calculated.

RESULTS

Weighed and estimated amounts correlated across meals both in grams and as total energy (0.853-0.977, p<0.001). The agreement between estimated energy content in school meals was close to the true measurement from weighed records; on average 4-19 kcal below true values. Organisation of meal service impacted the efficacy of the method as seen in the difference between countries; with Iceland (served by canteen staff) having higher rate of acceptable estimates than Sweden (self-serving), being 95% vs 73% for total amount (g) in serving. Iceland more often had serving size between or above the half and full reference plates compared with Sweden.

CONCLUSIONS

The photographic method provides acceptable estimates of food and energy intake in school canteens. However, greater accuracy can be expected when foods are served by canteen staff compared with self-serving.

Validity of energy intake estimated by digital photography plus recall in overweight and obese young adults

BACKGROUND

Recent reports have questioned the adequacy of self-report measures of dietary intake as the basis for scientific conclusions regarding the associations of dietary intake and health, and reports have recommended the development and evaluation of better methods for the assessment of dietary intake in free-living individuals. We developed a procedure that used pre- and post-meal digital photographs in combination with dietary recalls (DP+R) to assess energy intake during ad libitum eating in a cafeteria setting.

OBJECTIVE

To compare mean daily energy intake of overweight and obese young adults assessed by a DP+R method with mean total daily energy expenditure assessed by doubly labeled water (TDEE(DLW)).

METHODS

Energy intake was assessed using the DP+R method in 91 overweight and obese young adults (age = 22.9±3.2 years, body mass index [BMI; calculated as kg/m(2)]=31.2±5.6, female=49%) over 7 days of ad libitum eating in a university cafeteria. Foods consumed outside the cafeteria (ie, snacks, non-cafeteria meals) were assessed using multiple-pass recall procedures, using food models and standardized, neutral probing questions. TDEE(DLW) was assessed in all participants over the 14-day period.

RESULTS

The mean energy intakes estimated by DP+R and TDEE(DLW) were not significantly different (DP+R=2912±661 kcal/d; TDEE(DLW)=2849±748 kcal/d, P=0.42). The DP+R method overestimated TDEE(DLW) by 63±750 kcal/d (6.8±28%).

CONCLUSION

Results suggest that the DP+R method provides estimates of energy intake comparable to those obtained by TDEE(DLW).

Use of electronic visual recording to aid assessment of dietary intake of Australian Aboriginal children living in remote communities

OBJECTIVE

To assess the feasibility of using electronic visual recording in combination with food records to evaluate dietary intake in Aboriginal infants and children.

METHODS

All foods and drinks consumed by the child over four consecutive days were recorded in daily food records and pictures or videos. Feasibility was assessed by determining i) proportion of meals reported to be consumed; ii) cost of data collection; iii) day-to-day variation in energy intake and; iv) acceptability of the method.

RESULTS

Dietary intake data was collected from three girls and five boys aged 11 months to eight years, five over four days and three during one day, at a cost of $3,300 per child. One-third of the 89 meals reported to be consumed through the food records were electronically recorded. Most photographs were taken in the first two days with the number of meals electronically recorded decreasing each day over the four-day period. There was a large day-to-day variation in energy intake.

CONCLUSIONS

Use of electronic recording to aid individual usual dietary intake data collection was feasible. Collection periods spread over 1-2 weeks may be more appropriate due to the large variance in day-to-day dietary intake.

How willing are adolescents to record their dietary intake? The mobile food record

Background

Accurately assessing the diets of children and adolescents can be problematic. Use of technologies, such as mobile apps designed to capture food and beverages consumed at eating occasions with images taken using device-embedded cameras, may address many of the barriers to gathering accurate dietary intake data from adolescents.

Objective

The objectives of this study were to assess the willingness of adolescents to take images of food and beverages at their eating occasions using a novel mobile food record (mFR) and to evaluate the usability of the user confirmation component of the mFR app, referred to as the “review process.”

Methods

Mixed methods combining quantitative and qualitative protocols were used in this study. Adolescents (11-15-year olds) attending a summer camp were recruited to participate in the study. First, the participants were asked to take images of foods and beverages consumed as meals and snacks for 2 consecutive days using the mFR app running on an iPhone and the number of images taken was noted. This was followed by focus group sessions to evaluate usability, which was analyzed by content and themes. After using the mFR, a think-aloud method was used to evaluate the usability of the mFR method for reviewing system-identified foods (ie, the review process). A usability questionnaire was administered at the end of all activities.

Results

The mFR was accepted by the majority of the 24 boys and 17 girls (n=41) but varied according to gender and eating occasion. Girls were significantly more likely than boys to capture images of their eating occasions (Fisher exact test, P=.03). Participants were more likely to take images of their breakfasts (90%, 36/40) and lunches (90%, 72/80) and least likely to capture afternoon and evening snacks, 54% (43/80) and 40% (32/80), respectively. The major themes from the focus groups with regard to using the mFR were games, rewards, and the need to know more about why they were using the app. Results of the usability questionnaire indicated that including a game component would be important to increase willingness to use the mFR, and a high majority of the participants indicated a willingness to use the mFR for 7 days or more. The image review process was found to be easy to use except for some confusion with overlapping markers on the screen.

Conclusions

The adolescents’ experiences with and feedback about the mFR highlighted the importance of increased training, reminders, entertainment (eg, games), and training with practice in using the device to capture complete dietary intake as part of their active lifestyles.

A new mobile phone-based tool for assessing energy and certain food intakes in young children: a validation study

Background

Childhood obesity is an increasing health problem globally. Obesity may be established already at pre-school age. Further research in this area requires accurate and easy-to-use methods for assessing the intake of energy and foods. Traditional methods have limited accuracy, and place large demands on the study participants and researchers. Mobile phones offer possibilities for methodological advancements in this area since they are readily available, enable instant digitalization of collected data, and also contain a camera to photograph pre- and post-meal food items. We have recently developed a new tool for assessing energy and food intake in children using mobile phones called the Tool for Energy Balance in Children (TECH).

Objective

The main aims of our study are to (1) compare energy intake by means of TECH with total energy expenditure (TEE) measured using a criterion method, the doubly labeled water (DLW) method, and (2) to compare intakes of fruits and berries, vegetables, juice, and sweetened beverages assessed by means of TECH with intakes obtained using a Web-based food frequency questionnaire (KidMeal-Q) in 3 year olds.

Methods

In this study, 30 Swedish 3 year olds were included. Energy intake using TECH was compared to TEE measured using the DLW method. Intakes of vegetables, fruits and berries, juice, as well as sweetened beverages were assessed using TECH and compared to the corresponding intakes assessed using KidMeal-Q. Wilcoxon matched pairs test, Spearman rank order correlations, and the Bland-Altman procedure were applied.

Results

The mean energy intake, assessed by TECH, was 5400 kJ/24h (SD 1500). This value was not significantly different (P=.23) from TEE (5070 kJ/24h, SD 600). However, the limits of agreement (2 standard deviations) in the Bland-Altman plot for energy intake estimated using TECH compared to TEE were wide (2990 kJ/24h), and TECH overestimated high and underestimated low energy intakes. The Bland-Altman plots for foods showed similar patterns. The mean intakes of vegetables, fruits and berries, juice, and sweetened beverages estimated using TECH were not significantly different from the corresponding intakes estimated using KidMeal-Q. Moderate but statistically significant correlations (ρ=.42-.46, P=.01-.02) between TECH and KidMeal-Q were observed for intakes of vegetables, fruits and berries, and juice, but not for sweetened beverages.

Conclusion

We found that one day of recordings using TECH was not able to accurately estimate intakes of energy or certain foods in 3 year old children.

Determination of plate waste in primary school lunches by weighing and visual estimation methods: a validation study

The aim of this study was to validate the visual estimation method for aggregated plate waste of main dish at Portuguese primary school canteens. For this purpose plate waste at school lunch was measured for 505 individual servings, using weighing individual servings and plate waste and visual estimation method by a 6-point scale, as developed by Comstock et al. (1981). A high variability of initial serving weights was found with serving sizes ranging from 88.9 to 283.3g and with a coefficient of variation ranging from 5.5% to 24.7%. Mean plate waste was 27.5% according to the weighing method. There was a significant bias in the conversion of the visual waste estimations to actual waste, being overestimated by an average of 8.0 g (ranging from -12.9 g to 41.4 g). According to Bland and Altman plot, the mean difference between methods was of 8.0 g and the amplitude interval was 102.6g. The study showed that the visual estimation method is not as accurate as the weighing method in assessing nonselective aggregated plate waste at primary school canteens. Our findings are thus very important on considering plate waste assessment, since the wide variation on initial servings introduces a relevant bias when considering standard portions or a random sample of initial servings. Although, greater convenience, time-saving and the possibility to monitor plate waste of large groups, make the visual estimation method an important method to assess plate waste at school canteens, these results highlighted the need of portions standardization and control of initial servings to allow for its use.

Development of an estimated food record for 9-36-month-old toddlers

OBJECTIVES

Adequacy of dietary intake in the sensitive period of toddler development is a key determinant of health in a short- and long-term perspective. Therefore, studies focussing the nutrition of toddlers are of importance. For this purpose, tailored dietary record methods are an important prerequisite. The objective of this work is to develop a toddler-specific estimated food record (EFR) in a booklet providing photographs of age-specific foods and portion sizes that should be accurate and simple.

SUBJECTS/METHODS

For a toddler study in Germany, a 7-day consecutive EFR was developed. Data were obtained from a sample of toddlers in Germany. The basis is an evaluation of 3-day weighing food records on food choice and portion size of the DONALD (Dortmund Nutritional and Anthropometric Longitudinally Designed) study for 227 toddlers (118 boys) aged 9-36 months from January 2004 to March 2008.

RESULTS

In the analysed food records, a total of 15.147 eating occasions with 24.820 dishes were reported and grouped in 17 food groups. To estimate the portion size, the median consumption amounts of the 194 most frequently consumed dishes were calculated and photographed. Formula and commercial complementary food are collected separately. EFR was structured into seven eating occasions of the day: before breakfast, breakfast, mid-morning, lunch, mid-afternoon, dinner, and before bed.

CONCLUSIONS

The EFR booklet provides a simple, feasible and validated instrument that can be used to update information on dietary habits during the transition from infant to childhood diet for families in different social classes.

Reliability and validity of digital imaging as a measure of schoolchildren's fruit and vegetable consumption

BACKGROUND

As more and more interventions aim to increase schoolchildren's fruit and vegetable (FV) consumption, less resource-intensive yet valid alternatives to weighed plate waste (WPW) are needed for assessing dietary intake.

OBJECTIVES

We aimed to test the reliability and validity of digital imaging (DI) and digital imaging with observation (DI+O) in assessing children's FV consumption during school lunch.

DESIGN

FV consumption (in grams) was assessed on lunch trays from third- to fifth-grade children over eight visits (31 to 68 trays collected per visit) to compare WPW with DI and DI+O.

SETTING

Two elementary schools (327 and 631 students enrolled, respectively).

MAIN OUTCOME MEASURES

Interobserver reliability of DI. Validity of DI and DI+O compared against WPW.

STATISTICAL ANALYSES

Reliability was assessed by percent agreement and intraclass correlation coefficients (ICCs). Validity was assessed by Pearson correlations, paired t tests, and Bland-Altman plots.

RESULTS

Reliability was acceptable for DI; percent agreement was 96% and the ICC was 0.92. FV consumption assessments by DI and WPW (n=159) were highly correlated (r=0.96; P<0.001). Mean FV consumption using DI (96.7 g) was within 1.0 g of WPW and not significantly different from WPW (P=0.56), and Bland-Altman limits of agreement for individual-tray FV consumption were -32.9 to 31.3 g. FV consumption assessments by DI+O and WPW were highly correlated (r=0.98; P<0.001). Mean FV consumption using DI+O (99.3 g) was within 1.0 g of WPW and not significantly different from WPW (P=0.38), and limits of agreement for individual-tray FV consumption were -25.0 to 26.8 g.

CONCLUSIONS

DI was reliable for assessing children's FV consumption during school lunch. DI and DI+O were valid for assessing mean consumption but less precise for estimating individual-tray consumption. Valid estimations of mean FV consumption were achieved using DI without cafeteria observations, thereby reducing labor and time. Thus, DI is especially promising for assessing children's mean FV consumption during school lunch.

Portion sizes for children are predicted by parental characteristics and the amounts parents serve themselves

BACKGROUND

Children's energy intakes are influenced by the portions they are served. Factors influencing the amounts adults offer children are not well described.

OBJECTIVE

We assessed whether the amounts that were served to and consumed by children at meals were related to amounts that parents served themselves.

DESIGN

In this repeated-measures, cross-sectional observational study, 145 parents and their preschoolers (82 Hispanic, 57 African American, 6 unidentified) were recruited from Head Start settings in Houston, TX. The amounts served to and consumed by children and parents during 3 at-home evening meals were measured and analyzed. We assessed children's and parents' heights and weights, and body mass indexes (BMIs) were calculated. Associations between portions served for parents and children and between amounts served to and consumed by children were evaluated. Multiple linear regression was used to determine whether maternal characteristics (race-ethnicity, sociodemographic factors, and caregivers' BMIs) predicted the amounts caregivers served to children.

RESULTS

The amounts that parents served themselves were significantly associated with the amounts that they served to their children (r = 0.51, P < 0.0001). Multiple regression analysis showed that African American parents (compared with Hispanics) served more food to themselves and to their children (P < 0.01, R² = 6.9%) and that employed (compared with unemployed) parents served more food to their children (P = 0.025, R² = 3.3%). The amounts served to children were strongly associated with the amounts children consumed (r = 0.88, P < 0.0001). When parents served more to themselves, they also served more to their children (P < 0.001).

CONCLUSIONS

These findings underscore the strong relation between portions offered by caregivers and the amounts children consume at a meal and suggest that factors unrelated to the child (such as the amount a parent serves himself or herself) are important predictors of children's consumption. Efforts aimed at improving parents' recognition of developmentally appropriate portions for young children could be useful for future obesity-prevention efforts.

Evaluating the reliability of assessing home-packed food items using digital photographs and dietary log sheets

OBJECTIVE

To assess the reliability of manual data entry for home-packed food items by using digital photographs and dietary log sheets.

METHODS

Data from 60 lunches were entered by researcher A and B independently. Researcher B re-entered researcher A's items within 1 week. Researcher B then re-entered her items 4 weeks from the initial entry point.

RESULTS

The inter-rater reliability intraclass correlation coefficient (ICC) was 0.83 for total kilocalories and ranged from 0.75-0.87 for macronutrients. The intra-rater reliability ICC was 0.92 for total kcal and ranged from 0.90-0.92 for macronutrients. The inter-rater ICCs for the 5 selected micronutrients ranged from 0.33-0.83, whereas the intra-rater ICCs for these micronutrients ranged from 0.65-0.98.

CONCLUSIONS AND IMPLICATIONS

This method of data entry is feasible and its reliability is promising for macronutrient investigations. Continued assessment of this method for investigations related to micronutrient content is recommended.

Measuring food intake with digital photography

The digital photography of foods method accurately estimates the food intake of adults and children in cafeterias. When using this method, images of food selection and leftovers are quickly captured in the cafeteria. These images are later compared with images of 'standard' portions of food using computer software. The amount of food selected and discarded is estimated based upon this comparison, and the application automatically calculates energy and nutrient intake. In the present review, we describe this method, as well as a related method called the Remote Food Photography Method (RFPM), which relies on smartphones to estimate food intake in near real-time in free-living conditions. When using the RFPM, participants capture images of food selection and leftovers using a smartphone and these images are wirelessly transmitted in near real-time to a server for analysis. Because data are transferred and analysed in near real-time, the RFPM provides a platform for participants to quickly receive feedback about their food intake behaviour and to receive dietary recommendations for achieving weight loss and health promotion goals. The reliability and validity of measuring food intake with the RFPM in adults and children is also reviewed. In sum, the body of research reviewed demonstrates that digital imaging accurately estimates food intake in many environments and it has many advantages over other methods, including reduced participant burden, elimination of the need for participants to estimate portion size, and the incorporation of computer automation to improve the accuracy, efficiency and cost-effectiveness of the method.

Characterizing lunch meals served and consumed by pre-school children in Head Start

OBJECTIVE

To examine the variability of food portions served and consumed by African-American and Hispanic-American pre-school children attending Head Start.

DESIGN

Cross-sectional.

SETTING

Food consumption by pre-schoolers (n 796) enrolled in sixteen Head Start centres in Houston, Texas (51 % boys, 42 % African-American, mean age 4 years) were assessed during 3 d of lunch meals using digital photography. Descriptive statistics and multilevel regression models, adjusting for classroom and school clustering effects, were determined.

SUBJECTS

Head Start pre-schoolers aged 3–5 years.

RESULTS

Mean amount served was 2428 kJ (580 kcal) and 572 g. Mean intake was 1421 kJ (339 kcal) and 331 g: 20 % protein, 46 % carbohydrate and 34 % fat. Plate waste was 43 % (range: 38 % (fruit) to 61 % (vegetables)). Mean CV of food served was 29 %: 33 % for entrées, 44 % for vegetables, 60 % for fruit and 76 % for starches. Mean CV of food consumed was 46 %: 58 % for entrées, 86 % for fruit, 96 % for vegetables and 111 % for starches. Total gram amount of food served was positively correlated with consumption (r = 0·43, P < 0·001).

CONCLUSIONS

Plate waste and variation in amounts served and consumed were substantial; amounts served were associated with amounts consumed. Large portion sizes may contribute to paediatric obesity by promoting excessive intake at meals. Understanding factors influencing portion sizes provides insight about specific intervention strategies that can be used in obesity prevention programmes.

Characterizing dinner meals served and consumed by low-income preschool children

BACKGROUND

A dinner meal is consumed by approximately 95% of preschool children, yet few studies have characterized the dinner meal within a broader environmental context. The primary goal of this study was to identify the average quantities of foods served and consumed at the dinner meal by preschool children. A secondary goal was to look at factors that influenced the total amounts of food and energy consumed among preschoolers at the dinner meal.

METHOD

Food intake at a family dinner meal was measured using digital photography in African-American and Hispanic-American preschool children (n = 231). Pictorial records were converted to gram and energy estimates of food served and consumed; grams were converted to kilocalories for each food using Nutrition Data System for Research (NDSR) nutritional software. Foods were categorized by groups/subgroups. Comparison of means and coefficient of variation was examined overall and by food groups for food grams (and energy) served, consumed, and wasted. The relationship of mother/child characteristics to amounts served and consumed were analyzed by regression and analysis of variance (ANOVA).

RESULTS

Plate waste was high; 30% of the foods served to the child at the dinner meal were not consumed. The amounts of food and beverage served and consumed varied within and among the food groups studied. The proportion of children served a major food group at the dinner meal varied considerably: 44% fruit/juice, 97% vegetables, 99% grains, 97% meats, 74% dairy, 66% sweetened beverages, 92% fat and oils, and 40% sweets and sugars. The amount of food served was positively associated with the amount consumed (p < 0.0001). Energy density of the dinner meal was positively associated with energy intake consumed (p < 0.0001).

CONCLUSIONS

Plate waste and variation in amounts served and consumed was substantial. The amount of food served was positively associated with the amount of food consumed by preschool children.

Validity of the Remote Food Photography Method (RFPM) for estimating energy and nutrient intake in near real-time

Two studies are reported; a pilot study to demonstrate feasibility followed by a larger validity study. Study 1's objective was to test the effect of two ecological momentary assessment (EMA) approaches that varied in intensity on the validity/accuracy of estimating energy intake (EI) with the Remote Food Photography Method (RFPM) over 6 days in free-living conditions. When using the RFPM, Smartphones are used to capture images of food selection and plate waste and to send the images to a server for food intake estimation. Consistent with EMA, prompts are sent to the Smartphones reminding participants to capture food images. During Study 1, EI estimated with the RFPM and the gold standard, doubly labeled water (DLW), were compared. Participants were assigned to receive Standard EMA Prompts (n = 24) or Customized Prompts (n = 16) (the latter received more reminders delivered at personalized meal times). The RFPM differed significantly from DLW at estimating EI when Standard (mean ± s.d. = -895 ± 770 kcal/day, P < 0.0001), but not Customized Prompts (-270 ± 748 kcal/day, P = 0.22) were used. Error (EI from the RFPM minus that from DLW) was significantly smaller with Customized vs. Standard Prompts. The objectives of Study 2 included testing the RFPM's ability to accurately estimate EI in free-living adults (N = 50) over 6 days, and energy and nutrient intake in laboratory-based meals. The RFPM did not differ significantly from DLW at estimating free-living EI (-152 ± 694 kcal/day, P = 0.16). During laboratory-based meals, estimating energy and macronutrient intake with the RFPM did not differ significantly compared to directly weighed intake.