Complementary feeding: Vegetables first, frequently and in variety

Prospective associations of infant food exposures and appetitive traits with early childhood diet quality

BACKGROUND

Early-life food exposures may influence food preferences and receptivity, thereby impacting long-term diet quality. Infant exposure to discretionary foods may be more detrimental for infants with high food approach traits; conversely, early exposure to fruits and vegetables may be more important for those with high food avoidance traits. This study investigated associations of infant food exposures with early childhood diet quality and whether these associations are modified by infant appetitive traits.

METHODS

Data are from the Pregnancy Eating Attributes Study (PEAS) and Sprouts follow-up study, a prospective cohort assessed from the first trimester of pregnancy through early childhood. Birthing parents completed the Baby Eating Behavior Questionnaire assessing food-approach and food-avoidance appetitive traits at 6 months and food frequency questionnaires assessing infant age at introduction to and frequency of consuming food groups at ages 6 months, 1 year, and 2 years. At child ages 3.5 and 5 years, parents provided two 24-h dietary recalls, from which the Healthy Eating Index-2020 was calculated to measure diet quality. Structural equation models using maximum likelihood estimation examined associations of age at introduction to, and intake frequency of, fruit/vegetables and discretionary foods, and their interactions with food-approach and food-avoidance appetitive traits, on child diet quality at ages 3.5 & 5 years, controlling for income, education, and breastfeeding duration.

RESULTS

Higher childhood diet quality was associated with later infant age at introduction to discretionary foods, lower intake of discretionary foods at ages 1 and 2 years, and greater intake of fruits and vegetables at age 2 years. Childhood diet quality was not associated with infant age at introduction to fruits and vegetables. Intake of fruits and vegetables at age 1 year interacted with food avoidance traits, indicating that the association of fruit and vegetable intake with childhood diet quality was magnified by greater food avoidance.

CONCLUSIONS

Exposure to discretionary food in the first two years of life was consistently associated with lower diet quality in early childhood regardless of the strength of appetitive traits. Findings suggest that improving child diet quality may require stronger efforts to limit exposure to discretionary foods in infancy.

Sugar Content and Sources in Commercial Infant Cereals in Spain

Instant infant cereals reconstituted with infant formula are the first complementary food for most Spanish infants. The main aim is to provide information on sugars in the formulation of infant cereals. Product information was collected from department stores, supermarkets, and pharmacies and completed with data from brand websites. A portion of the samples was selected for total sugars determination using the HPLC and Luff-Schoorl methods. The information regarding a total of 120 milk-free instant infant cereals marketed in Spain from 12 companies was summarized. The mean of total sugars was 23 ± 9 g/100 g (25–42%), providing 24% of the calories. Most of porridges are prepared with partially hydrolyzed flours providing free sugars (glucose and maltose). The most commonly added sugar is sucrose. A total of 43.3% of products contain added sucrose, and 16.7% contain fruits. Infant cereals analyzed with added sugars can have a sugar content similar to that found in products without added sugars. Consistent differences were found in sugars content between assayed methods and this label information. Although the European legislation of infant cereals establishes values for added sugars, the labeling reflects the content of total sugars, but not that of added sugars.

Supporting strategies for enhancing vegetable liking in the early years of life: an umbrella review of systematic reviews

BACKGROUND

Many children worldwide do not eat recommended amounts of vegetables. Disliking vegetables is a key factor associated with low intake.

OBJECTIVE

This umbrella review synthesized systematic reviews to determine the effectiveness of sensory and behavioral strategies to facilitate liking of vegetables (primary outcome) in young children up to 5 y of age, as key predictors of vegetable intake (secondary outcome).

METHODS

Nine databases were searched up to May 2019 (updated in September 2020). Two reviewers independently conducted study screening and selection, data extraction, and assessment of methodological quality using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Eleven reviews (n = 1 rated strong quality, n = 4 moderate quality, n = 6 low/critically low quality) examining 85 primary studies met the review criteria: systematic reviews and meta-analyses of primary studies (any quantitative design) that examined sensory or behavioral strategies on vegetable liking or intake (outcomes reported separately for children ≤5 y). Strategy effectiveness was synthesized into 3 categories based on evidence strength: 1) promising (large and consistent body of moderate quality evidence), 2) emerging (small to moderate body of mixed consistency and quality evidence), and 3) limited (small body of limited consistency and quality evidence).

RESULTS

Promising evidence was identified for repeated exposure to a single or a variety of vegetables. Emerging evidence was identified for several strategies that increase familiarity with vegetable flavors (e.g., via exposure in utero and through breast milk, and a "vegetable first" approach to complementary feeding) and/or willingness to try vegetables (e.g., via parental role modeling, nonfood rewards, and vegetable-based story books).

CONCLUSIONS

Current evidence supports incorporation of tailored advice into guideline documents for parents and carers to repeatedly expose their children to a variety of vegetables to increase vegetable intake. Ongoing robust research on strategies to facilitate children's liking of vegetables is warranted to strengthen the evidence base underpinning advice for parents and health professionals.

Identifying opportunities for strengthening advice to enhance vegetable liking in the early years of life: qualitative consensus and triangulation methods

OBJECTIVE

To prioritise and refine a set of evidence-informed statements into advice messages to promote vegetable liking in early childhood, and to determine applicability for dissemination of advice to relevant audiences.

DESIGN

A nominal group technique (NGT) workshop and a Delphi survey were conducted to prioritise and achieve consensus (≥70 % agreement) on thirty evidence-informed maternal (perinatal and lactation stage), infant (complementary feeding stage) and early years (family diet stage) vegetable-related advice messages. Messages were validated via triangulation analysis against the strength of evidence from an Umbrella review of strategies to increase children's vegetable liking, and gaps in advice from a Desktop review of vegetable feeding advice.

SETTING

Australia.

PARTICIPANTS

A purposeful sample of key stakeholders (NGT workshop, n 8 experts; Delphi survey, n 23 end users).

RESULTS

Participant consensus identified the most highly ranked priority messages associated with the strategies of: 'in-utero exposure' (perinatal and lactation, n 56 points) and 'vegetable variety' (complementary feeding, n 97 points; family diet, n 139 points). Triangulation revealed two strategies ('repeated exposure' and 'variety') and their associated advice messages suitable for policy and practice, twelve for research and four for food industry.

CONCLUSIONS

Supported by national and state feeding guideline documents and resources, the advice messages relating to 'repeated exposure' and 'variety' to increase vegetable liking can be communicated to families and caregivers by healthcare practitioners. The food industry provides a vehicle for advice promotion and product development. Further research, where stronger evidence is needed, could further inform strategies for policy and practice, and food industry application.

Associations between feeding practices in infancy and fruit and vegetable consumption in childhood

A diet rich in fruits and vegetables may reduce the risk of chronic diseases. However, in many countries, the majority of children do not eat the recommended quantities of fruits and vegetables. The present study aimed to understand associations between feeding practices in infancy (breast-feeding and first complementary food) and fruit and vegetable consumption in childhood (frequency and variety). Data were from the national, observational, cross-sectional Mothers and their Children’s Health study conducted in 2016/2017, a sub-study of the national Australian Longitudinal Study on Women’s Health. Mothers completed a written survey on feeding practices in infancy (breast-feeding duration, use of formula, first complementary food) and children’s fruit and vegetable frequency (number of times eaten) and variety (number of different types eaten) in the past 24 h, using the Children’s Dietary Questionnaire. Children (n 4981, mean 7·36 (sd 2·90) years) ate vegetables 2·10 (sd 1·11) times and fruits 2·35 (sd 1·14) times and ate 3·21 (sd 1·35) different vegetables and 2·40 (sd 1·18) different fruits, on average. Compared with breast-feeding for <6 months, breast-feeding for ≥6 months was associated with higher vegetable variety. Compared with cereal as the first complementary food, fruits or vegetables were associated with higher vegetable frequency and variety, and higher fruit frequency. Overall, infancy is a window of opportunity for dietary intervention. Guidance to parents should encourage the use of fruits and vegetables at the beginning of complementary feeding.

Baby's first bites: a randomized controlled trial to assess the effects of vegetable-exposure and sensitive feeding on vegetable acceptance, eating behavior and weight gain in infants and toddlers

BACKGROUND

The start of complementary feeding in infancy plays an essential role in promoting healthy eating habits. Evidence shows that it is important what infants are offered during this first introduction of solid foods: e.g. starting exclusively with vegetables is more successful for vegetable acceptance than starting with fruits. How infants are introduced to solid foods also matters: if parents are sensitive and responsive to infant cues during feeding, this may promote self-regulation of energy intake and a healthy weight. However, the effectiveness of the what and the how of complementary feeding has never been experimentally tested in the same study. In the current project the what and how (and their combination) are tested in one study to determine their relative importance for fostering vegetable acceptance and self-regulation of energy intake in infants.

METHODS

A four-arm randomized controlled trial (Baby's First Bites (BFB)) was designed for 240 first-time Dutch mothers and their infants, 60 per arm. In this trial, we compare the effectiveness of (a) a vegetable-exposure intervention focusing on the what in complementary feeding; (b) a sensitive feeding intervention focusing on the how in complementary feeding, (c) a combined intervention focusing on the what and how in complementary feeding; (d) an attention-control group. All mothers participate in five sessions spread over the first year of eating solid foods (child age 4-16 months). Primary outcomes are vegetable consumption, vegetable liking and self-regulation of energy intake. Secondary outcomes are child eating behaviors, child anthropometrics and maternal feeding behavior. Outcomes are assessed before, during and directly after the interventions (child age 18 months), and when children are 24 and 36 months old.

DISCUSSION

The outcomes are expected to assess the impact of the interventions and provide new insights into the mechanisms underlying the development of vegetable acceptance, self-regulation and healthy eating patterns in infants and toddlers, as well as the prevention of overweight. The results may be used to improve current dietary advice given to parents of their young children on complementary feeding.

TRIAL REGISTRATION

The trial was retrospectively registered during inclusion of participants at the Netherlands National Trial Register (identifier NTR6572 ) and at ClinicalTrials.gov ( NCT03348176 ). Protocol issue date: 1 April 2018; version number 1.

Home environment predictors of vegetable and fruit intakes among Australian children aged 18 months

Suboptimal vegetable and fruit consumption by young children is common. Identifying predictors of vegetable and fruit intakes is important for informing strategies to promote sufficient intakes of these foods from early life. The aim of the present study was to examine predictors of toddlers' vegetable and fruit intakes at age 18 months. This study involved secondary analysis of data from 361 child-mother dyads participating in the Melbourne Infant Feeding, Activity and Nutrition Trial in 2008-2010 at child ages four, nine and 18 months. Children's vegetable and fruit intakes were assessed at age 18 months using multiple 24-h dietary recalls. Data on potential predictor measures were collected via parent-completed questionnaires when children were four or nine months of age. Bivariate and multivariable linear regression models were used to test associations between children's average daily vegetable or fruit intake and potential predictors controlling for treatment arm and clustering by parent group. Multivariable models also controlled for covariates and potential confounders. Home availability of vegetables at age nine months was found to predict children's vegetable intake at age 18 months and remained significant (β = 20.19, 95% CI:7.23, 33.15, p = 0.003) in the multivariable model. Children's average daily fruit intake at age 18 months was predicted by maternal education at child age four months and the availability of fruits in their home at child age nine months. Maternal education remained significant (β = 30.83, 95% CI:12.17, 49.48, p = 0.002) in the multivariable model. Strategies to promote adequate vegetable and fruit intakes among young children should address known barriers to the availability of vegetables and fruits in the home from early in life. Additionally, messages encouraging fruit consumption may need to be tailored to mothers with lower levels of education.

Dietary intake in the early years and its relationship to BMI in a bi-ethnic group: the Born in Bradford 1000 study

OBJECTIVE

To assess relationships between dietary intake at age 12, 18 and 36 months and BMI Z-scores at age 36 months in a bi-ethnic group.

DESIGN

A prospective cohort study comparing cross-sectional and longitudinal data. Exposures included dietary intake at 12, 18 and 36 months (FFQ) with an outcome of BMI Z-score at age 36 months.

SETTING

Born in Bradford 1000 study, Bradford, UK.

SUBJECTS

Infants at age 12 months (n 722; 44 % White British, 56 % Pakistani), 18 months (n 779; 44 % White British, 56 % Pakistani) and 36 months (n 845; 45 % White British, 55 % Pakistani).

RESULTS

Diet at age 12 months was not associated with BMI Z-score at age 36 months. Higher consumption of vegetables at 18 and 36 months was associated with a lower BMI Z-score at 36 months (model coefficient (95 % CI): -0·20 (-0·36, -0·03) and -0·16 (-0·31, -0·02), respectively). Higher consumption of high-fat chips at age 36 months was associated with a lower BMI Z-score at age 36 months (-0·16 (-0·32, 0·00)). Overall, White British children had higher 36-month BMI Z-scores than Pakistani children (adjusted mean difference (95 % CI): 0·21 (0·02, 0·41)).

CONCLUSIONS

Our findings indicate that dietary intake at 18 and 36 months was somewhat related to BMI Z-score at age 36 months and suggest the importance of early interventions aimed at establishing healthy eating behaviours.