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Bell L, Manson A, Zarnowiecki D, Tan SN, Byrne R, Taylor R, Zheng M, Wen LM, Golley R. Development and validation of a short dietary questionnaire for assessing obesity-related dietary behaviours in young children. MATERNAL & CHILD NUTRITION 2024; 20:e13613. [PMID: 38192050 PMCID: PMC10981485 DOI: 10.1111/mcn.13613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 11/07/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Abstract
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.
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Affiliation(s)
- Lucinda Bell
- Flinders University, College of Nursing and Health Sciences, Caring Futures InstituteAdelaideSouth AustraliaAustralia
| | - Alexandra Manson
- Flinders University, College of Nursing and Health Sciences, Caring Futures InstituteAdelaideSouth AustraliaAustralia
| | - Dorota Zarnowiecki
- Flinders University, College of Nursing and Health Sciences, Caring Futures InstituteAdelaideSouth AustraliaAustralia
| | - Shi Ning Tan
- Flinders University, College of Nursing and Health Sciences, Caring Futures InstituteAdelaideSouth AustraliaAustralia
| | - Rebecca Byrne
- School of Exercise and Nutrition Sciences, Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
| | - Rachael Taylor
- Department of MedicineUniversity of OtagoDunedinNew Zealand
| | - Miaobing Zheng
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition SciencesDeakin UniversityGeelongVictoriaAustralia
| | - Li Ming Wen
- Sydney School of Public Health, Faculty of Medicine and HealthSydneyNew South WalesAustralia
| | - Rebecca Golley
- Flinders University, College of Nursing and Health Sciences, Caring Futures InstituteAdelaideSouth AustraliaAustralia
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Bell LK, Leemaqz S, Devenish-Coleman G, Do LG, Ha D, Scott JA, Golley RK. Development and internal validation of the SMILE-FSS: a Free Sugars Screener for Australian children aged 2 and 5 years. Public Health Nutr 2023; 26:2691-2703. [PMID: 37905405 PMCID: PMC10755434 DOI: 10.1017/s1368980023002380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To develop and internally validate a Free Sugars Screener (FSS) for Australian children aged 2 and 5 years. DESIGN Using data collected from a ninety-nine-item (2-year-olds) and ninety-eight-item (5-year-olds) FFQ in the Study of Mothers' and Infants' Life Events affecting oral health (SMILE-FFQ), a regression-based prediction modelling approach was employed to identify a subset of items that accurately estimate total free sugars intake (FSI). The predictors were grams of free sugars (FSg) for individual items in the SMILE-FFQ and child's age and sex. The outcome variable was total FSI per person. To internally validate the SMILE-FSS items, the estimated FSg was converted to percent energy from free sugars (%EFS) for comparison to the WHO free sugars guideline categories (< 5 %, 5-< 10 % and ≥ 10 %EFS) using cross-classification analysis. SETTING Australia. PARTICIPANTS 858 and 652 2- and 5-year-old children, respectively, with complete dietary (< 5 % missing) and sociodemographic data. RESULTS Twenty-two and twenty-six items were important in predicting FSI at 2 and 5 years, respectively. Items were similar between ages with more discretionary beverage items (e.g. sugar-sweetened beverages) at 5 years. %EFS was overestimated by 4·4 % and 2·6 %. Most children (75 % and 82 %) were categorised into the same WHO free sugars category with most (87 % and 95 %) correctly identified as having < 10 %EFS in line with the WHO recommendation. CONCLUSIONS The SMILE-FSS has good internal validity and can be used in research and practice to estimate young Australian children's FSI and compare to the WHO free sugars guidelines to identify those 'at risk'.
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Affiliation(s)
- Lucinda K Bell
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide5001, Australia
| | - Shalem Leemaqz
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | | | - Loc G Do
- School of Dentistry, The University of Queensland, Brisbane, QLD, 4072Australia
| | - Diep Ha
- School of Dentistry, The University of Queensland, Brisbane, QLD, 4072Australia
| | - Jane A Scott
- School of Population Health, Curtin University, Perth, WA6102, Australia
| | - Rebecca K Golley
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide5001, Australia
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Townsend MS, Shilts MK, Lanoue L, Drake C, Díaz Rios LK, Keim NL, Styne DM, Ontai LL. Obesity Risk Assessment for Spanish-Speaking Immigrant Families with Young Children in the United States: Reliability and Validity with Nutrient Values. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050868. [PMID: 37238415 DOI: 10.3390/children10050868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/20/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
The purpose is to examine validity and reliability for an obesity risk assessment tool developed in Spanish for immigrant families with children, 3-5 years old using an 8-week cross-sectional design with data collected over 1 year at Head Start and Special Supplemental Nutrition Program for Women, Infants and Children [WIC]. Parent/child dyads (206) provided a child obesity risk assessment, three child modified 24 h dietary recalls, three child 36+ h activity logs and one parent food behavior checklist. Main outcome measures were convergent validity with nutrients, cup equivalents, and diet quality and three assessments of reliability that included item difficulty index, item discrimination index, and coefficient of variation. Validity was demonstrated for assessment tool, named Niños Sanos. Scales were significantly related to variables in direction hypothesized [p ≤ 0.05]: Healthy Eating Index, fruit/vegetable cup equivalents, folate, dairy cup equivalents, vitamins D, β-carotene, fiber, saturated fat, sugar, time at screen/ sleep/physical activity and parent behaviors. Three measures of reliability were acceptable. The addition of nutrient values as an analytical validation approach adds strength and consistency to previously reported Niños Sanos validation results using children's blood biomarkers and body mass index. This tool can be used by health professionals as an assessment of obesity risk in several capacities: (1) screener for counseling in a clinic, (2) large survey, (3) guide for participant goal setting and tailoring interventions, and (4) evaluation.
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Affiliation(s)
| | - Mical K Shilts
- Department of Family and Consumer Sciences, Nutrition, Food & Dietetics Program, California State University, Sacramento, CA 95819, USA
| | - Louise Lanoue
- Department of Nutrition, University of California, Davis, CA 95616, USA
| | - Christiana Drake
- Department of Statistics, University of California, Davis, CA 95616, USA
| | - L Karina Díaz Rios
- Division of Agriculture and Natural Resources, Public Health Department, University of California, Merced, CA 95343, USA
| | - Nancy L Keim
- USDA Western Human Nutrition and Research Center, University of California, Davis, CA 95616, USA
| | - Dennis M Styne
- Department of Pediatrics, University of California Medical Center, Davis, CA 95817, USA
| | - Lenna L Ontai
- Department of Human Ecology, University of California, Davis, CA 95616, USA
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Bautista T, Fogelman N, Lartigue S, Silverman WK, Jastreboff AM, Sinha R. Association between specific types of parent stressors and fast-food consumption among parents and children. Eat Behav 2023; 49:101724. [PMID: 37054487 PMCID: PMC10247538 DOI: 10.1016/j.eatbeh.2023.101724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Although stress has been associated with eating behaviors, such as overeating and eating less healthy foods, the relationships between specific types of parent stressors and fast-food consumption in parents and young children have not been well studied. We hypothesized that parent perceived stress, parenting stress, and household chaos would be positively associated with fast-food consumption for parents and their young children. METHODS Parents of 2-5 year olds and with Body Mass Index >27 kg/m2 (N = 234, parent mean age: 34.3 (±5.7); child age: 44.9 (±13.8) months; 65.8 % from two parent households) completed surveys on parent perceived stress, parenting stress, household chaos, and their fast-food intake and that of their child. RESULTS In separate regression models, controlling for covariates, parent perceived stress (β = 0.21, p < 0.01; R2 = 0.10, p < 0.01), parenting stress (β = 0.26, p < 0.01; R2 = 0.13, p < 0.01), and household chaos (β = 0.25, p < 0.01; R2 = 0.12, p < 0.01) were each significantly associated with parent fast-food consumption, and separately with child fast-food consumption [Parent perceived stress (β = 0.05, p = 0.02; R2 = 0.14, p < 0.01); parenting stress (β = 0.14, p = 0.03; R2 = 0.14, p < 0.01); parent fast-food consumption (β = 0.40, p < 0.01; R2 = 0.27, p < 0.01)]. However, combined final models showed parenting stress (p < 0.01) as the only significant predictor of parent fast-food consumption, which in turn was the only significant predictor of child fast-food consumption (p < 0.01). DISCUSSION The findings support the inclusion of parenting stress interventions that target fast-food eating behaviors in parents, which may in turn, reduce fast-food intake in their young children.
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Affiliation(s)
- Tara Bautista
- Psychological Science, Northern Arizona University, United States of America
| | - Nia Fogelman
- Department of Psychiatry, Yale University School of Medicine, United States of America
| | | | - Wendy K Silverman
- Child Study Center, Yale University School of Medicine, United States of America
| | - Ania M Jastreboff
- Department of Pediatrics (Pediatric Endocrinology), Yale University School of Medicine, United States of America; Department of Internal Medicine (Endocrinology and Metabolism), Yale University School of Medicine, United States of America
| | - Rajita Sinha
- Department of Psychiatry, Yale University School of Medicine, United States of America.
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Palacios C, Bolton J, Wang W, Gatto A, Concepción L, Sadjadi M, Varella M, Hannan J. Development and pilot testing of the Baby-Feed web application for healthcare professionals and parents to improve infant diets. Int J Med Inform 2023; 174:105047. [PMID: 36948062 DOI: 10.1016/j.ijmedinf.2023.105047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/30/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Diet is key in preventing rapid infant weight gain but adherence to infant dietary recommendations is difficult to follow and low in adherence. OBJECTIVE Develop and pilot test the "Baby-Feed" web application for parents and healthcare professionals to easily evaluate infant diets and provide immediate feedback to promote adherence to current infant dietary recommendations. METHODS Baby-Feed was developed following the ADDIE (analysis, design, development, implementation, and evaluation) model. It was pilot tested among two clinicians and 25 parents of infants aged 4 to 12 months that had a scheduled well-child visit at a community health center in Miami. After 2 weeks of using Baby-Feed, parents completed a feasibility, acceptability, satisfaction, and usability questionnaire. Parents and clinicians were also asked to suggest improvements. Descriptive analysis included frequency and median (25th, 75th percentiles). One-sample binomial tests was used to evaluate if feasible, acceptable, satisfactory, and usable. RESULTS Twenty-three parents completed the evaluation (all were mothers), 31.0 (26.0, 33.0) years-old, 96% Hispanic, 83% had ≥ high school education, with 1.5 (1.0, 2.0) children. Infants' age was 6.1 (4.0, 9.0) months and 57% were boys. Binomial tests indicated that most parents (greater than87%) agreed that Baby-Feed was easy to use, learn, quick, would use it again, rated it as 4/5 stars. They used it greater than 1 times per week (p < 0.001). Parents suggested improving the visuals (more icons, colors, and pictures) and images of portion sizes, highlighting missing fields, being able to view/open it on their phones, and adding recipes and more information. The two clinicians (a pediatrician and a physician assistant) suggested to be open-access and to add more infant nutrition information. CONCLUSION Baby-Feed was feasible, usable, satisfactory, and acceptable. It could be used as a tool to easily evaluate infant diets in the healthcare setting to provide immediate feedback.
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Affiliation(s)
- Cristina Palacios
- Department of Dietetics and Nutrition, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA.
| | - Jennifer Bolton
- Department of Dietetics and Nutrition, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
| | - Wenjia Wang
- Vertically Integrated Projects, School of Computing and Information Sciences, Florida International University, Miami, FL, USA
| | - Alayne Gatto
- Department of Dietetics and Nutrition, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
| | - Lourdes Concepción
- Department of Dietetics and Nutrition, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
| | - Masoud Sadjadi
- Vertically Integrated Projects, School of Computing and Information Sciences, Florida International University, Miami, FL, USA
| | - Marcia Varella
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Jean Hannan
- Nicole Wertheim College of Nursing & Health Sciences, Florida International University, Miami, FL, USA
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Bellows LL, Lou Y, Nelson R, Reyes LI, Brown RC, Mena NZ, Boles RE. A Narrative Review of Dietary Assessment Tools for Preschool-Aged Children in the Home Environment. Nutrients 2022; 14:nu14224793. [PMID: 36432478 PMCID: PMC9694043 DOI: 10.3390/nu14224793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Preschool-aged children in the U.S. have suboptimal diets. Interventions to improve child nutrition focus on parents and their role in shaping social and physical home environments, which influence children's eating behaviors. Dietary assessment tools selected to measure intervention objectives, and how results are interpreted in key findings, are essential when examining children's diets. The objectives of this review were to (1) describe dietary assessment tools used in intervention studies in young children focused within the home environment; and (2) examine how the application of these dietary assessment tools addressed intervention objectives. PubMed and Web of Science were searched for English-language nutrition intervention studies that included children aged 2-5 years, had a home environment component, used a dietary assessment tool, and reported on diet-related outcomes. Seventeen studies were included. Intervention objectives focused on overall diet, specific food groups, eating occasions, and obesity prevention/treatment. Concordance of key findings with intervention objectives, type of tool used, and multiple tools within the same study varied with 8 studies aligning in objective and tool, 1 discordant in both, and 8 partially concordant or too broad to determine. This review highlights current challenges in measuring dietary intake in preschoolers and provides recommendations for alternative applications and strategies.
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Affiliation(s)
- Laura L. Bellows
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA
- Correspondence:
| | - Yuanying Lou
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA
| | - Rachel Nelson
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA
| | - Ligia I. Reyes
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA
| | - Renae C. Brown
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA
| | - Noereem Z. Mena
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA
- Department of Agriculture, Nutrition and Food Systems, University of New Hampshire, Durham, NH 03842, USA
| | - Richard E. Boles
- Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA
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Diet quality of Norwegian children at 3 and 7 years: changes, predictors and longitudinal association with weight. Int J Obes (Lond) 2022; 46:10-20. [PMID: 34462565 DOI: 10.1038/s41366-021-00951-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/28/2021] [Accepted: 08/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Poor diet quality in early life can have long-term health effects, but the evidence is largely from cross-sectional studies. Our objective was to examine diet quality of Norwegian children by applying a-priori diet quality indices, identify early life determinants and examine prospective associations with overweight. SUBJECTS/METHODS We included 34,074 preschoolers (3-year-olds) and 18,350 school-aged children (7-years-olds) from the prospective, population-based Norwegian Mother, Father and Child Cohort Study. Diet quality was assessed as (i) adherence to a Mediterranean diet, estimated by the food frequency-based Mediterranean Diet Score (fMDS, score range: 0-6) and (ii) by the diet quality index (DQI, score range: -33% to 100%), reflecting compliance to food-based dietary guidelines. In multivariate analyses we explored perinatal and childhood characteristics as potential determinants of diet quality. We used logistic regression to examine the associations between diet quality at 3 years and BMI status at 8 years, adjusting for relevant confounders and diet quality at 7 years. RESULTS One in three children had high MD adherence at 3 and 8 years, and DQI (mean 60%) at 3 and 7 years was strongly correlated (r = 0.48, p < 0.001). Short breastfeeding duration, physical activity and sleep duration and long screentime at 18 months were associated with 2-3% lower DQI at 3 years. At both ages, maternal diet quality was the strongest prospective predictor of DQI (beta = 5%, 95% CI = 4.7, 5.2 and beta = 3.1%, 95% CI = 2.8, 3.4), and screentime was the strongest cross-sectional predictor (beta = -5.2%, 95% CI = -5.9, -4.5 and beta = -4.1%, 95% CI = -5.0, -3.2). High DQI score at 3 years, but not MD adherence, was associated with a lower risk for overweight (including obesity) at 8 years, compared to low DQI (lower tertile) (adjusted OR = 0.77, 95% CI = 0.62, 0.96). CONCLUSIONS Our study provides evidences that high diet quality in early childhood may reduce the risk for overweight in later childhood, independent of the current dietary behaviors.
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Hernández-Ruiz Á, Díaz-Jereda LA, Madrigal C, Soto-Méndez MJ, Kuijsten A, Gil Á. Methodological Aspects of Diet Quality Indicators in Childhood: A Mapping Review. Adv Nutr 2021; 12:2435-2494. [PMID: 34192740 PMCID: PMC8634546 DOI: 10.1093/advances/nmab053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/12/2021] [Accepted: 04/02/2021] [Indexed: 01/16/2023] Open
Abstract
Diet quality indicators (DQIns) are tools that aim to assess an individual's overall diet quality. Previous reviews focused mainly on health-related outcomes but did not provide detailed information about components, assessment variables, or important methodological issues for the development and application of DQIns in the pediatric age. The current mapping review aims to provide comprehensive guidance regarding DQIns developed through a priori methodology in children aged ≤14 y that have been applied worldwide. A mapping review was conducted, whereby 1665 original articles describing the development, modifications, and updates of DQIns, published up to June 26, 2020, in English and Spanish, were retrieved. A total of 139 articles were identified and classified into 13 subgroups. There were 10 overall DQIns: Healthy Eating Indexes (n = 25), Dietary Diversity Scores (n = 20), Diet Quality Indexes (n = 16), Food Variety Scores (n = 11), Healthy and Unhealthy Scores (n = 11), Feeding and Eating Indexes (n = 10), Diet Quality Scores (n = 5), Nutritional Adequacy and Micronutrients Indexes (n = 5), Dietary Guidelines Indexes (n = 5), and Other Healthy Diet Indexes (n = 13). Three additional subgroups of dietary and lifestyle indicators found were Mediterranean Diet Indexes (n = 10), Diet-Lifestyle Indexes (n = 5), and Breakfast Quality Indexes (n = 3). This compilation of DQIns will help researchers select the most appropriate tool for future epidemiological studies by considering a careful selection of information about the assessment components, scoring methods, and key methodological issues. The main limitations of this review are that, due to its nature, a risk-of-bias assessment was not performed and the article screening was completed in 2 databases (PubMed/MEDLINE and Scopus). More research is needed to identify health-related outcomes associated with DQIns in the pediatric population, using clearer and more standardized methodological criteria.
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Affiliation(s)
| | | | - Casandra Madrigal
- Iberoamerican Nutrition Foundation (FINUT), Granada, Spain
- Department of Nutrition and Food Science, Faculty of Pharmacy, University of Granada, Granada, Spain
| | | | - Anneleen Kuijsten
- Division of Human Nutrition and Health, Wageningen University, Wageningen, Netherlands
| | - Ángel Gil
- Iberoamerican Nutrition Foundation (FINUT), Granada, Spain
- Department of Biochemistry and Molecular Biology II, University of Granada, Granada, Spain
- Institute of Nutrition and Food Technology “José Mataix,” Biomedical Research Center, University of Granada, Granada, Spain
- Biosanitary Research Institute ibs.GRANADA, Granada University Hospital Complex, Granada, Spain
- CIBEROBN (Physiopathology of Obesity and Nutrition), Instituto de Salud Carlos III, Madrid, Spain
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Development of a Food-Based Diet Quality Scale for Brazilian Schoolchildren Using Item Response Theory. Nutrients 2021; 13:nu13093175. [PMID: 34579052 PMCID: PMC8469312 DOI: 10.3390/nu13093175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022] Open
Abstract
Item response theory (IRT) is a psychometric method that provides probabilistic model-based measurements. Its use is relatively recent in the assessment of food consumption, especially through dietary assessment tools. This study aims (1) to develop a food-based diet quality scale for Brazilian schoolchildren using IRT, and (2) to apply the scale to a representative sample of schoolchildren from a Southern Brazilian city. The scale was developed with daily consumption frequency of foods from 835 students who completed the Food Intake and Physical Activity of Schoolchildren questionnaire. Questionnaire foods were grouped into 10 items according to their nutritional similarities and were evaluated by full-information factor analysis that indicated a dominant factor explaining 28% of the variance. Psychometric item analysis was performed using Samejima’s model. The scale covered all levels of diet quality, from “very poor” (scores < 95) to “very good” (scores ≥ 130). Children who had higher diet quality scores consumed beans, meat, fish, eggs, fruits, vegetables, dairy products, and water more frequently, while reducing the consumption of ultraprocessed sugary foods, ultraprocessed savoury snacks and sausages, and sugary drinks. Of 6323 children, an average of less than 10% consumed the highest diet quality scores (good or very good diet quality) and about 60% of children consumed low diet quality scores. The scale can be applied to other schoolchildren with the same measure precision.
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10
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Shanks CB, Milodragovich A, Smith E, Izumi B, Stephens L, Ahmed S. Preference for fruits and vegetables is linked to plate waste among preschool children. SSM Popul Health 2021; 15:100908. [PMID: 34541282 PMCID: PMC8436058 DOI: 10.1016/j.ssmph.2021.100908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND A large portion of preschool-aged children in the United States (US) do not consume enough fruits and vegetables (FV). It is important for childcare providers to know what food choices children in their care are making at mealtime and how to encourage them to eat more FV. The objective of this pilot study was to examine the relationship between FV preference and plate waste among pre-school aged children in a childcare setting using a rapid assessment tool. METHODS The rapid assessment tool was first pilot tested with 23 children and revised. A repeated cross-sectional design was carried out for three days during fall 2016 in one childcare center. Over three days, the research team collected 100 FV plate waste observations from 30 children who were surveyed simultaneously about their preference (did not try, tried, liked, loved) towards FV. RESULTS Food preference for FV by preschool children is significantly (p < 0.05) related to plate waste and age. Children that indicated they loved a fruit or vegetable generated the least plate waste. Children that indicated that they did not try a fruit or vegetable generated the most plate waste. CONCLUSIONS FV preference and plate waste are significantly and inversely correlated. The rapid assessment tool developed should be validated to be used in implementing strategies that increase child preferences and consumption of FV that support lifelong healthy eating behaviors.
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Affiliation(s)
- Carmen Byker Shanks
- Montana State University, Bozeman, MT, USA
- Gretchen Swanson Center for Nutrition, Omaha, NE, USA
| | | | - Erin Smith
- Montana State University, Bozeman, MT, USA
| | - Betty Izumi
- OHSU Portland State University, Portland, OR, USA
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Zachary M, Sisley S. The Pediatric Obesity Encounter: Literature and Resources to Help with 4 Common Issues. Curr Nutr Rep 2021; 9:94-100. [PMID: 32350815 DOI: 10.1007/s13668-020-00308-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW We review here best practices and resources for pediatricians providing pediatric obesity management in 4 key areas: how to assess all of the relevant factors contributing to obesity, how to provide nutrition education, how to counsel families who eat out regularly, and what to do with patients who frequently make poor eating choices. RECENT FINDINGS While there are many resources indicating recommendations for the physical exam and laboratory tests, there are very few resources that give pragmatic advice on the counseling aspects of the pediatric obesity encounter. We note new nutrition research showing the importance of avoiding ultra-processed foods. Most importantly, we list several resources regarding useful questionnaires, nutrition guidance, and even further training for pediatricians. There is a need for more curation of resources in different aspects of obesity care. We hope that this review and list of resources are helpful for pediatricians and will empower families and can be expanded in the future.
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Affiliation(s)
- Montgomery Zachary
- Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. #10068, Houston, TX, 77030, USA
| | - Stephanie Sisley
- Department of Pediatrics, Baylor College of Medicine, 1100 Bates St. #10068, Houston, TX, 77030, USA.
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Hörmann-Wallner M, Krause R, Alfaro B, Jilani H, Laureati M, Almli VL, Sandell M, Sandvik P, Zeinstra GG, Methven L. Intake of Fibre-Associated Foods and Texture Preferences in Relation to Weight Status Among 9-12 Years Old Children in 6 European Countries. Front Nutr 2021; 8:633807. [PMID: 33681278 PMCID: PMC7935542 DOI: 10.3389/fnut.2021.633807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/25/2021] [Indexed: 12/17/2022] Open
Abstract
Plant foods, rich in fibre, can offer textures that children find difficult to orally manipulate, resulting in low preferences but are important for a healthy diet and prevention of overweight in children. Our aim was to investigate preferences for food texture, intake of fibre-associated foods and the relation to BMI. Three hundred thirty European children (9-12 years, 54% female) indicated their texture preferences using the Child-Food-Texture-Preference- Questionnaire (CFTPQ), and their parents responded on fibre-associated food consumption and anthropometric information. BMI was significantly lower for children with higher intake of wholegrain alternatives of common foods; in addition to being significantly influenced by country and the wearing of a dental brace. Overall BMI-for-age-percentiles (BMI_pct) were negatively associated with the consumption of wholegrain cereals, white pasta and wholemeal products and positively associated with the intake of legumes and white biscuits. In males, BMI_pct were negatively associated with wholegrain products and dried fruits, and in females, positively with legume consumption. A few country-related associations were found for BMI_pct and wholegrain biscuits, seeds and nuts and refined products. No overall correlation was found between BMI_pct and the texture preference of soft/hard foods by CFTPQ, except in Austria. We conclude that this study revealed evidence of a connection between fibre-associated foods and children's BMI at a cross-cultural level and that sex is an important determinant of fibre-associated food intake and the development of overweight in childhood.
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Affiliation(s)
- Marlies Hörmann-Wallner
- Institute of Dietetics and Nutrition, University of Applied Sciences FH JOANNEUM, Graz, Austria
| | - Raphaela Krause
- Institute of Dietetics and Nutrition, University of Applied Sciences FH JOANNEUM, Graz, Austria
| | - Begoña Alfaro
- Food Research Division, Expert Technology Centre in Marine and Food Innovation (AZTI), Derio Bizkaia, Spain
| | - Hannah Jilani
- Institute for Public Health and Nursing Research– Leibniz Institute for Prevention Research and Epidemiology, University of Bremen and Institute for Preventions Research and Epidemiology– Instituts für Public Health und Pflegeforschung, Bremen, Germany
| | - Monica Laureati
- Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Valérie L. Almli
- Department of Innovation, Consumer and Sensory Sciences, Nofima, Aas, Norway
| | - Mari Sandell
- Functional Foods Forum, University of Turku, Turku, Finland
- Department of Food and Nutrition, University of Helsinki, Helsinki, Finland
| | - Pernilla Sandvik
- Department of Food Studies, Nutrition and Dietetics, Uppsala University, Uppsala, Sweden
| | - Gertrude G. Zeinstra
- Food, Health & Consumer Research Group, Wageningen Food & Biobased Research, Wageningen, Netherlands
| | - Lisa Methven
- Department of Food and Nutritional Sciences, University of Reading, Reading, United Kingdom
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13
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Indexes to assess feeding practices of children under 2 years old: a systematic review. Public Health Nutr 2021; 24:2033-2049. [PMID: 33504386 DOI: 10.1017/s1368980021000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To systematically review studies that used indexes to assess feeding practices of children under 2 years. DESIGN Seven databases were searched with no limit on language or publication date. SETTING The reviewed studies included thirteen Asian, ten Latin American, four European, four North American, three Oceanian and three African. PARTICIPANTS Children under 2 years. RESULTS We analysed thirty-six studies: twenty-two presenting original indexes and fourteen using adapted indexes. Among the original indexes, thirteen assess breast-feeding, fourteen food consumption, ten food groups, and ten other feeding practices. Original indexes were mainly adapted to fit the data available in the study, to update for current nutritional recommendations or to add components not present in the original indexes. Seven studies evaluated the associations between the indexes and nutrient intake or nutritional status. The main limitations cited by the authors were: flaws in the definition of the index components, criteria for cut-off points and weighting of the evaluated index components. CONCLUSIONS The assessment of feeding practices for young children and its comparison across countries remains a challenge, especially due to the lack of consensus on the construction of indexes and regional differences in dietary recommendations and practices. Lack of validation for some indexes also makes it difficult to choose the most appropriate index for a given objective. Adapting existing indexes is a viable option. We point out relevant recommendations that may contribute to future research. Validation and longitudinal studies in diverse populations are favourable to qualify the assessment of feeding practices in this group.
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14
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Bestle SMS, Christensen BJ, Trolle E, Biltoft-Jensen AP, Matthiessen J, Gibbons SJ, Ersbøll BK, Lassen AD. Reducing Young Schoolchildren's Intake of Sugar-Rich Food and Drinks: Study Protocol and Intervention Design for "Are You Too Sweet?" A Multicomponent 3.5-Month Cluster Randomised Family-Based Intervention Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249580. [PMID: 33561071 PMCID: PMC7767356 DOI: 10.3390/ijerph17249580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022]
Abstract
A high consumption of sugar-rich discretionary food and drinks has several health implications, which have been traced from childhood into adulthood. Parents act as primary mediators shaping children's dietary habits, and interventions that engage parents have shown to result in positive outcomes. Further, collaboration with local school health nurses and dentists provides an effective structural frame to support behaviour change and anchor new initiatives. The multicomponent 3.5-month cluster randomised family-focused intervention "Are you too Sweet?" aims to evaluate the effectiveness of communicating new Danish guidelines for sugar-rich discretionary food and drinks for school starters (5-7 years). This paper describes the development, outcomes and process evaluation of the intervention that includes three main components: extended dialogue during a school health nurse consultation, a box with home-use materials, and a social media platform to facilitate interaction among participants. Children (n = 160) and their parents were scheduled for a baseline interview at six different schools. The intervention was developed to increase self-efficacy, knowledge about guidelines, observational learning and reduce impediments for behavioural change. The desired primary outcome was a reduction in intake of sugar-rich food measured through a 7-day dietary record. The results contribute to the evidence on effective health promotion strategies.
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Affiliation(s)
- Sidse Marie Sidenius Bestle
- Division of Food Technology, National Food Institute, Technical University of Denmark, Kemitorvet Building 201, 2800 Kongens Lyngby, Denmark; (B.J.C.); (E.T.); (A.P.B.-J.); (J.M.); (S.J.G.); (A.D.L.)
- Correspondence:
| | - Bodil Just Christensen
- Division of Food Technology, National Food Institute, Technical University of Denmark, Kemitorvet Building 201, 2800 Kongens Lyngby, Denmark; (B.J.C.); (E.T.); (A.P.B.-J.); (J.M.); (S.J.G.); (A.D.L.)
| | - Ellen Trolle
- Division of Food Technology, National Food Institute, Technical University of Denmark, Kemitorvet Building 201, 2800 Kongens Lyngby, Denmark; (B.J.C.); (E.T.); (A.P.B.-J.); (J.M.); (S.J.G.); (A.D.L.)
| | - Anja Pia Biltoft-Jensen
- Division of Food Technology, National Food Institute, Technical University of Denmark, Kemitorvet Building 201, 2800 Kongens Lyngby, Denmark; (B.J.C.); (E.T.); (A.P.B.-J.); (J.M.); (S.J.G.); (A.D.L.)
| | - Jeppe Matthiessen
- Division of Food Technology, National Food Institute, Technical University of Denmark, Kemitorvet Building 201, 2800 Kongens Lyngby, Denmark; (B.J.C.); (E.T.); (A.P.B.-J.); (J.M.); (S.J.G.); (A.D.L.)
| | - Sarah Jegsmark Gibbons
- Division of Food Technology, National Food Institute, Technical University of Denmark, Kemitorvet Building 201, 2800 Kongens Lyngby, Denmark; (B.J.C.); (E.T.); (A.P.B.-J.); (J.M.); (S.J.G.); (A.D.L.)
| | - Bjarne Kjær Ersbøll
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, 2800 Kongens Lyngby, Denmark;
| | - Anne Dahl Lassen
- Division of Food Technology, National Food Institute, Technical University of Denmark, Kemitorvet Building 201, 2800 Kongens Lyngby, Denmark; (B.J.C.); (E.T.); (A.P.B.-J.); (J.M.); (S.J.G.); (A.D.L.)
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15
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Montagut-Martínez P, Pérez-Cruzado D, García-Arenas JJ. Nutritional Status Measurement Instruments for Diabetes: A Systematic Psychometric Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165719. [PMID: 32784695 PMCID: PMC7460259 DOI: 10.3390/ijerph17165719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 12/18/2022]
Abstract
Background: Diabetes is a serious chronic disease associated with a large number of complications and an increased risk of premature death. A dietary evaluation is of utmost importance for health promotion, disease prevention and individual treatment plans in patients with diabetes. Methods: An exhaustive search was carried out in various databases—Medline, Web of Science, Open Gray Cochrane Library and Consensus-based Standards for the selection of health status Measurement Instruments (COSMIN)—for systematic review of the measurement properties of instruments that evaluate the dietary intake of people with diabetes mellitus type 1 and/or 2 according to COSMIN standards. Results: Seven instruments were identified. There was no instrument measuring nutritional status for which all the psychometric properties were evaluated. The methodological quality for each of the psychometric properties evaluated was ‘inadequate’ or ‘doubtful’ for all instruments. The Food Frequency Questionnaire (FFQ) evaluated the most psychometric characteristics and with a better score in terms of quality of the evidence. Conclusions: Several instruments have been developed for the evaluation of dietary intake in people with diabetes. Evaluation of this construct is very useful, both in clinical practice and in research, requiring new knowledge in this area. The FFQ is the best instrument available to assess dietary intake in people with diabetes.
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Affiliation(s)
- Pedro Montagut-Martínez
- Health Sciences PhD Program, Campus de los Jerónimos, Universidad Católica de Murcia UCAM, 30107 Murcia, Spain;
| | - David Pérez-Cruzado
- Department of Occupational Therapy, Campus de los Jerónimos, Universidad Catolica de Murcia UCAM, 30107 Murcia, Spain;
- Institute of Biomedicine of Malaga (IBIMA), 29071 Málaga, Spain
- Correspondence: ; Tel.: +34-6-5314-1109
| | - José Joaquín García-Arenas
- Department of Occupational Therapy, Campus de los Jerónimos, Universidad Catolica de Murcia UCAM, 30107 Murcia, Spain;
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16
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Burnett AJ, Lamb KE, McCann J, Worsley A, Lacy KE. Parenting styles and the dietary intake of pre-school children: a systematic review. Psychol Health 2020; 35:1326-1345. [DOI: 10.1080/08870446.2020.1743842] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Alissa J. Burnett
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Karen E. Lamb
- Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Jennifer McCann
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Anthony Worsley
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Kathleen E. Lacy
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
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17
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Zheng M, Campbell KJ, Scanlan E, McNaughton SA. Development and evaluation of a food frequency questionnaire for use among young children. PLoS One 2020; 15:e0230669. [PMID: 32210467 PMCID: PMC7094848 DOI: 10.1371/journal.pone.0230669] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 03/05/2020] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Miaobing Zheng
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition (IPAN), Deakin University, Burwood, Victoria, Australia
- * E-mail:
| | - Karen J. Campbell
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition (IPAN), Deakin University, Burwood, Victoria, Australia
| | - Emily Scanlan
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition (IPAN), Deakin University, Burwood, Victoria, Australia
| | - Sarah A. McNaughton
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition (IPAN), Deakin University, Burwood, Victoria, Australia
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18
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Adaptation, acceptability and feasibility of a Short Food Survey to assess the dietary intake of children during attendance at childcare. Public Health Nutr 2020; 23:1484-1494. [PMID: 32178751 PMCID: PMC7196734 DOI: 10.1017/s136898001900404x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: To (i) describe the adaptation of the Short Food Survey (SFS) for assessing the dietary intake of children (2–5 years) during attendance at Early Childhood Education and Care (SFS-ECEC); (ii) determine the acceptability and feasibility of the SFS-ECEC; and (iii) compare the SFS-ECEC to direct observations for assessing dietary intake of children in care. Design: The adapted forty-seven-item SFS-ECEC was completed by childcare educators to capture individual child’s usual intake over the past month. Acceptability and feasibility were assessed via educator self-report and completion rates. Mean servings of food groups consumed in accordance with dietary guidelines reported in the SFS-ECEC were compared to those obtained by a single-day direct observation via visual estimation conducted by trained personnel. Mean differences, intra-class correlations, Bland–Altman plots, percentage agreement and Cohen’s κ were examined. Setting: Early Childhood Education and Care, NSW, Australia. Participants: Educators and children. Results: 213 (98·61 %) SFS-ECECs were returned. Acceptability was high with 86·54 % of educators reporting the tool as easy to understand. Mean differences in servings of food groups between the SFS-ECEC and direct observation were statistically significantly different for five out of six foods and ranged 0·08–1·07, with intra-class correlations ranging 0·00–0·21. Agreement between the methods in the classification of children meeting or not meeting dietary guidelines ranged 42·78–93·01 %, with Cohen’s κ ranging −0·03 to 0·14. Conclusions: The SFS-ECEC is acceptable and feasible for completion by childcare educators. While tool refinement and further validation is warranted, small mean differences suggest the tool may be useful in estimating group-level intakes.
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19
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Bush LA, Hutchinson J, Hooson J, Warthon-Medina M, Hancock N, Greathead K, Knowles B, Vargas-Garcia EJ, Gibson LE, Margetts B, Robinson S, Ness A, Alwan NA, Wark PA, Roe M, Finglas P, Steer T, Page P, Johnson L, Roberts K, Amoutzopoulos B, Greenwood DC, Cade JE. Measuring energy, macro and micronutrient intake in UK children and adolescents: a comparison of validated dietary assessment tools. BMC Nutr 2019; 5:53. [PMID: 32153966 PMCID: PMC7050749 DOI: 10.1186/s40795-019-0312-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/30/2019] [Indexed: 12/15/2022] Open
Abstract
Background Measuring dietary intake in children and adolescents can be challenging due to misreporting, difficulties in establishing portion size and reliance on recording dietary data via proxy reporters. The aim of this review was to present results from a recent systematic review of reviews reporting and comparing validated dietary assessment tools used in younger populations in the UK. Methods Validation data for dietary assessment tools used in younger populations (≤18 years) were extracted and summarised using results from a systematic review of reviews of validated dietary assessment tools. Mean differences and Bland-Altman limits of agreement (LOA) between the test and reference tool were extracted or calculated and compared for energy, macronutrients and micronutrients. Results Seventeen studies which reported validation of 14 dietary assessment tools (DATs) were identified with relevant nutrition information. The most commonly validated nutrients were energy, carbohydrate, protein, fat, calcium, iron, folate and vitamin C. There were no validated DATs reporting assessment of zinc, iodine or selenium intake. The most frequently used reference method was the weighed food diary, followed by doubly labelled water and 24 h recall. Summary plots were created to facilitate comparison between tools. On average, the test tools reported higher mean intakes than the reference methods with some studies consistently reporting wide LOA. Out of the 14 DATs, absolute values for LOA and mean difference were obtained for 11 DATs for EI. From the 24 validation results assessing EI, 16 (67%) reported higher mean intakes than the reference. Of the seven (29%) validation studies using doubly labelled water (DLW) as the reference, results for the test DATs were not substantially better or worse than those using other reference measures. Further information on the studies from this review is available on the www.nutritools.org website. Conclusions Validated dietary assessment tools for use with children and adolescents in the UK have been identified and compared. Whilst tools are generally validated for macronutrient intakes, micronutrients are poorly evaluated. Validation studies that include estimates of zinc, selenium, dietary fibre, sugars and sodium are needed.
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Affiliation(s)
- Linda A Bush
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Jayne Hutchinson
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Jozef Hooson
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Marisol Warthon-Medina
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK.,2Quadram Institute Bioscience, Norwich, NR4 7UA UK.,3EuroFIR AISBL, 40 Rue Washington, 1050 Brussels, Belgium
| | - Neil Hancock
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Katharine Greathead
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Bethany Knowles
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Elisa J Vargas-Garcia
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Lauren E Gibson
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
| | - Barrie Margetts
- School of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD UK
| | - Sian Robinson
- 5NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK.,6National Institute of Health (NIHR) Bristol Biomedical Research Centre, Nutrition Theme, University, Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, BS2 8AE UK
| | - Andy Ness
- 7NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital, Southampton NHS Foundation Trust, Southampton, UK
| | - Nisreen A Alwan
- School of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD UK.,8Centre for Innovative Research Across the Life Course (CIRAL), Faculty of Health and Life Sciences, Coventry University, Coventry, CV1 5FB UK
| | - Petra A Wark
- 9Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, SW7 2AZ UK.,10AGE Research Group, Newcastle University, Newcastle, UK
| | - Mark Roe
- 2Quadram Institute Bioscience, Norwich, NR4 7UA UK.,3EuroFIR AISBL, 40 Rue Washington, 1050 Brussels, Belgium
| | - Paul Finglas
- 2Quadram Institute Bioscience, Norwich, NR4 7UA UK.,3EuroFIR AISBL, 40 Rue Washington, 1050 Brussels, Belgium
| | - Toni Steer
- 11MRC Elsie Widdowson Laboratory, Cambridge, CB1 9NL UK
| | - Polly Page
- 11MRC Elsie Widdowson Laboratory, Cambridge, CB1 9NL UK
| | - Laura Johnson
- 12Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, BS8 1TH UK.,11MRC Elsie Widdowson Laboratory, Cambridge, CB1 9NL UK
| | - Katharine Roberts
- 13Public Health Section, School of Health and Related Research (ScHARR), University of Sheffield, S10 2TN, Sheffield, UK.,14Public Health England, London, SE1 8UG UK
| | | | - Darren C Greenwood
- 15Faculty of Medicine and Health, Division of Biostatistics, University of Leeds, Leeds, LS2 9JT UK
| | - Janet E Cade
- 1Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, LS2, 9JT, Leeds, UK
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20
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Judd AL, Beck KL, McKinlay C, Jackson A, Conlon CA. Validation of a Complementary Food Frequency Questionnaire to assess infant nutrient intake. MATERNAL AND CHILD NUTRITION 2019; 16:e12879. [PMID: 31343830 PMCID: PMC7038889 DOI: 10.1111/mcn.12879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 11/26/2022]
Abstract
Dietary assessment in infants is challenging but necessary to understand the relationship between nutrition and growth and development. Currently no simple, validated methods exist to assess nutrient intake in New Zealand (NZ) infants. Therefore, this study aimed to assess the relative validity and reproducibility of a Complementary Food Frequency Questionnaire (CFFQ) to determine nutrient intakes of NZ infants. Ninety-five parent-infant pairs (infant age 10 ± 1 months) completed the CFFQ twice (CFFQ-1 and CFFQ-2), 4 weeks apart (to assess reproducibility). A 4-day weighed food record (4dWFR) was collected between CFFQ administrations (to assess validity). Validity and reproducibility were assessed for intakes of energy and 18 nutrients using Bland-Altman analysis, Pearson's correlation coefficients, cross-classification, and weighted Kappa (κ). The CFFQ showed acceptable validity: Nutrients from the CFFQ were comparable with the 4dWFR (bias, 9-28%), correlation between methods ranged from r = .18 (saturated fat) to r = .81 (iron; mean r = .52), 54% (mean) of participants were correctly classified (range 39% to 67%), and 7.1% (mean) misclassified into opposite tertiles (range 2.1% to 14.7%). There was acceptable agreement between the CFFQ and 4dWFR (κ = 0.20-0.60). The CFFQ showed good reproducibility: Correlations ranged from r = .34 (folate) to r = .80 (zinc); for 16 nutrients, >50% of participants were correctly classified, and for all nutrients, <10% of participants were grossly misclassified. All nutrients showed acceptable to good agreement (κ > 0.20). The CFFQ has acceptable relative validity and good reproducibility for assessing nutrient intake in NZ infants aged 9-12 months, making it a useful tool for use in future research.
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Affiliation(s)
- Amy L Judd
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
| | - Kathryn L Beck
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
| | | | - Ashleigh Jackson
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
| | - Cathryn A Conlon
- School of Sport, Exercise and Nutrition, Massey University, Auckland, New Zealand
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21
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Hooson Jzh J, Hutchinson Jyh J, Warthon-Medina M, Hancock N, Greathead K, Knowles B, Vargas-Garcia E, Gibson LE, Bush LA, Margetts B, Robinson S, Ness A, Alwan NA, Wark PA, Roe M, Finglas P, Steer T, Page P, Johnson L, Roberts K, Amoutzopoulos B, Burley VJ, Greenwood DC, Cade JE. A systematic review of reviews identifying UK validated dietary assessment tools for inclusion on an interactive guided website for researchers: www.nutritools.org. Crit Rev Food Sci Nutr 2019; 60:1265-1289. [PMID: 30882230 PMCID: PMC7114915 DOI: 10.1080/10408398.2019.1566207] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Health researchers may struggle to choose suitable validated dietary assessment tools (DATs) for their target population. The aim of this review was to identify and collate information on validated UK DATs and validation studies for inclusion on a website to support researchers to choose appropriate DATs.Design: A systematic review of reviews of DATs was undertaken. DATs validated in UK populations were extracted from the studies identified. A searchable website was designed to display these data. Additionally, mean differences and limits of agreement between test and comparison methods were summarized by a method, weighting by sample size.Results: Over 900 validation results covering 5 life stages, 18 nutrients, 6 dietary assessment methods, and 9 validation method types were extracted from 63 validated DATs which were identified from 68 reviews. These were incorporated into www.nutritools.org. Limits of agreement were determined for about half of validations. Thirty four DATs were FFQs. Only 17 DATs were validated against biomarkers, and only 19 DATs were validated in infant/children/adolescents.Conclusions: The interactive www.nutritools.org website holds extensive validation data identified from this review and can be used to guide researchers to critically compare and choose a suitable DAT for their research question, leading to improvement of nutritional epidemiology research.
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Affiliation(s)
- Jozef Hooson Jzh
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Jayne Hutchinson Jyh
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Marisol Warthon-Medina
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK.,Food Databanks National Capability, Quadram Institute Bioscience, Norwich, UK
| | - Neil Hancock
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Katharine Greathead
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Bethany Knowles
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Elisa Vargas-Garcia
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Lauren E Gibson
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Linda A Bush
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Barrie Margetts
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sian Robinson
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University of Southampton & University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andy Ness
- NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Nisreen A Alwan
- NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle, University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, UK.,Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Petra A Wark
- Centre for Innovative Research Across the Life Course (CIRAL), Faculty of Health and Life Sciences, Coventry University, Coventry, UK.,Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Mark Roe
- Food Databanks National Capability, Quadram Institute Bioscience, Norwich, UK.,EuroFIR AISBL, Brussels, Belgium
| | - Paul Finglas
- Food Databanks National Capability, Quadram Institute Bioscience, Norwich, UK
| | - Toni Steer
- MRC Elsie Widdowson Laboratory, Cambridge, UK
| | - Polly Page
- MRC Elsie Widdowson Laboratory, Cambridge, UK
| | - Laura Johnson
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
| | - Katharine Roberts
- Public Health Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.,Public Health England, London, UK
| | | | - Victoria J Burley
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Darren C Greenwood
- Faculty of Medicine and Health Division of Biostatistics, University of Leeds, Leeds, UK
| | - Janet E Cade
- Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds, UK
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22
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Byrne R, Bell L, Taylor RW, Mauch C, Mihrshahi S, Zarnowiecki D, Hesketh KD, Wen LM, Trost SG, Golley R. Brief tools to measure obesity-related behaviours in children under 5 years of age: A systematic review. Obes Rev 2019; 20:432-447. [PMID: 30468286 DOI: 10.1111/obr.12801] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/24/2018] [Accepted: 10/04/2018] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Rebecca Byrne
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, Brisbane, Australia.,NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Lucy Bell
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Rachael W Taylor
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Chelsea Mauch
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Seema Mihrshahi
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Dorota Zarnowiecki
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Kylie D Hesketh
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,School of Exercise and Nutrition Science, Deakin University, Institute for Physical Activity and Nutrition, Geelong, Australia
| | - Li Ming Wen
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Stewart G Trost
- Institute of Health and Biomedical Innovation, Centre for Children's Health Research, Queensland University of Technology, Brisbane, Australia.,NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Rebecca Golley
- NHMRC Centre of Research Excellence in the Early Prevention of Obesity in Childhood, Sydney School of Public Health, Level 6, Charles Perkins Centre, University of Sydney, Sydney, Australia.,College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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23
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Delshad M, Beck KL, von Hurst PR, Mugridge O, Conlon CA. The validity and reliability of the Dietary Index for a Child's Eating in 2-8-year old children living in New Zealand. MATERNAL AND CHILD NUTRITION 2019; 15:e12758. [PMID: 30499635 DOI: 10.1111/mcn.12758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 10/19/2018] [Accepted: 11/09/2018] [Indexed: 11/29/2022]
Abstract
This study aimed to examine the validity and reliability of the Dietary Index for a Child's Eating (DICE) in children living in New Zealand (NZ). Caregivers of healthy children aged 2-8 years completed a 4-day estimated food record (4DFR) for their child and completed the DICE online on two separate occasions, 8 weeks apart. Relative validity was assessed by comparing the DICE and 4DFR total score and component subscores using the Wilcoxon test, Spearman rank correlation coefficients, cross-classification, and weighted kappa (ĸ) statistic. For evaluating construct validity, the DICE total score was compared with energy and nutrient intake from the 4DFR using linear contrast analysis. Intraclass correlation coefficients (Cronbach's α) and Bland-Altman plots were used to assess the reliability of DICE. From a possible score of 100, the mean ± standard deviation of DICE was 78.2 ± 11.5 and from the 4DFR, was 73.8 ± 10.8, with a positive correlation (r = 0.72; p < 0.001) and moderate agreement (ĸ = 0.49). Cross-classification showed 61.9% were correctly categorised into the same tertile group from DICE and the 4DFR. Participants in the highest tertile of DICE had higher intakes of fibre, vitamin C, vitamin A, vitamin D, folate, and calcium. Good agreement (α = 0.87) was found for reliability. DICE is a valid and reliable tool for the assessment of children's adherence to a healthy diet, as recommended by the NZ Ministry of Health Food and Nutrition guidelines.
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Affiliation(s)
- Maryam Delshad
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Auckland, New Zealand
| | - Kathryn L Beck
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Auckland, New Zealand
| | - Pamela R von Hurst
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Auckland, New Zealand
| | - Owen Mugridge
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Auckland, New Zealand
| | - Cathryn A Conlon
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Auckland, New Zealand
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24
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The Relative Validity of the Menzies Remote Short-Item Dietary Assessment Tool (MRSDAT) in Aboriginal Australian Children Aged 6⁻36 Months. Nutrients 2018; 10:nu10050590. [PMID: 29748493 PMCID: PMC5986470 DOI: 10.3390/nu10050590] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 01/21/2023] Open
Abstract
The Menzies Remote Short-item Dietary Assessment Tool (MRSDAT) can be used to derive a dietary index score, which measures the degree of compliance with the Australian Dietary Guidelines. This study aimed to determine the relative validity of a dietary index score for children aged 6–24 months, living in a Remote Aboriginal Community (RAC), derived using MRSDAT. This validation study compared dietary index scores derived using MRSDAT with those derived from the average of three 24-h recalls. Participants were aged 6–36 months at the first dietary assessment and were living in a RAC. The level of agreement between the two methods was explored using Lin’s concordance correlation coefficient (CCC), Bland-Altman plots, weighted Cohen’s kappa, and Fischer’s exact and paired t-tests. Forty participants were recruited. The CCC was poor between methods (R = 0.35, 95% CI 0.06, 0.58), with MRSDAT estimating higher dietary intake scores for all food groups except fruit, and higher dietary quality scores by an average of 4.78 points/100. Community-based Aboriginal researchers were central to this validation study. MRSDAT was within the performance range of other short-item dietary assessment tools developed for young children, and shows promise for use with very young children in RACs.
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25
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26
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Tugault-Lafleur CN, Black JL, Barr SI. A Systematic Review of Methods to Assess Children's Diets in the School Context. Adv Nutr 2017; 8:63-79. [PMID: 28096128 PMCID: PMC5227974 DOI: 10.3945/an.116.013144] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
To evaluate the impact of school-based nutrition interventions, accurate and reliable methods are needed to assess what children eat at school. The primary objective of this study was to systematically review methodological evidence on the relative accuracy and reliability of dietary assessment methods used in the school context. The secondary objective was to assess the frequency of methods and analytical approaches used in studies reporting in-school dietary outcomes. Three health databases were searched for full-text English-language studies. Twenty-two methodological studies were reviewed. For school meal recalls, the majority of studies (n = 8 of 12) reported poor accuracy when accuracy was measured by using frequencies of misreported foods. However, when energy report rates were used as a measure of accuracy, studies suggested that children were able to accurately report energy intake as a group. Results regarding the accuracy of food-frequency questionnaires (FFQs) and food records (FRs) were promising but limited to a single study each. Meal observations offered consistently good interrater reliability across all studies reviewed (n = 11). Studies reporting in-school dietary outcomes (n = 47) used a broad range of methods, but the most frequently used methods included weighed FRs (n = 12), school meal recalls (n = 10), meal observations by trained raters (n = 8), and estimated FRs (n = 7). The range of dietary components was greater among studies relying on school meal recalls and FRs than among studies using FFQs. Overall, few studies have measured the accuracy of dietary assessment methods in the school context. Understanding the methodological characteristics associated with dietary instruments is vital for improving the quality of the evidence used to inform and evaluate the impact of school-based nutrition policies and programs.
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Affiliation(s)
- Claire N Tugault-Lafleur
- Food, Nutrition and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer L Black
- Food, Nutrition and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan I Barr
- Food, Nutrition and Health, Faculty of Land and Food Systems, University of British Columbia, Vancouver, British Columbia, Canada
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27
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Bohman B, Rasmussen F, Ghaderi A. Development and psychometric evaluation of a context-based parental self-efficacy instrument for healthy dietary and physical activity behaviors in preschool children. Int J Behav Nutr Phys Act 2016; 13:110. [PMID: 27765049 PMCID: PMC5072306 DOI: 10.1186/s12966-016-0438-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022] Open
Abstract
Background Parental self-efficacy (PSE) refers to beliefs of parents to effectively engage in behaviors that result in desired outcomes for their children. There are several instruments of PSE for promoting healthy dietary or physical activity (PA) behaviors in children. These measures typically assess PSE in relation to some quantity or frequency of behavior, for example, number of servings or times per week. However, measuring PSE in relation to contextual circumstances, for example, psychological states and situational demands, may be a more informative approach. The purpose of the present study was to develop and psychometrically evaluate a context-based PSE instrument. Methods Swedish mothers of five-year-old children (n = 698) responded to the Parental Self-Efficacy for Healthy Dietary and Physical Activity Behaviors in Preschoolers Scale (PDAP) and a questionnaire on dietary and PA behaviors in children. Interviews were conducted to explore participant perceptions of the quality of the PDAP items. Psychometric evaluation was conducted using exploratory and confirmatory factor analyses. Spearman correlations between PSE and child behaviors were examined. Results Twenty-seven interviews were conducted with participants, who perceived the items as highly comprehensible, relevant and acceptable. A four-factor model of a revised 21-item version of the PDAP fitted the data, with different factors of PSE for promoting healthy dietary or PA behaviors in children depending on whether circumstances were facilitating or impeding successful performance. Internal consistency was excellent for total scale (Cronbach’s α = .94), and good for factors (α = .84–.88). Correlations were in the expected direction: positive correlations between PSE and healthy behaviors, and negative correlations between PSE and unhealthy behaviors (all rss ≤ .32). Conclusions Psychometric evaluation of the PDAP provided preliminary support of construct validity and internal consistency.
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Affiliation(s)
- Benjamin Bohman
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden. .,Centre for Psychiatric Research, Stockholm Health Care Services, Stockholm County Council, Liljeholmstorget 7 B, SE-117 63, Stockholm, Sweden.
| | - Finn Rasmussen
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Centre for Epidemiology and Community Medicine, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Ata Ghaderi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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28
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Avis JLS, Komarnicki A, Farmer AP, Holt NL, Perez A, Spence N, Ball GDC. Tools and resources for preventing childhood obesity in primary care: A method of evaluation and preliminary assessment. PATIENT EDUCATION AND COUNSELING 2016; 99:769-775. [PMID: 26742609 DOI: 10.1016/j.pec.2015.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/30/2015] [Accepted: 12/10/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To pilot-test a mixed methods approach to evaluate tools and resources (TRs) that healthcare providers (HCPs) use for preventing childhood obesity in primary care, and report a preliminary descriptive assessment of commonly-used TRs. METHODS This mixed methods study included individual, semi-structured interviews with purposefully-sampled HCPs in Alberta, Canada; interviews were digitally recorded and analyzed thematically (phase I). Two independent reviewers used three assessment checklists to evaluate commonly-used TRs (phase II). HCPs provided feedback on our coding scheme and checklist data (phase III). RESULTS Three themes described how HCPs (n=19) used TRs: purpose of use (e.g., clinical support), logistical factors (e.g., accessibility), and decision to use (e.g., suitability). The latter theme overlapped with constructs of suitability on the checklists. Overall, participants used 15 TRs, most of which scored 'average' on the checklists. CONCLUSION Phases I and II provided unique insights on the evaluation of TRs used for preventing childhood obesity. Criteria on the checklists overlapped with HCPs' perceptions of TR suitability, but did not reflect logistical factors that influenced their use of TRs. PRACTICE IMPLICATIONS Developers of TRs should collaborate with HCPs to ensure that subjective and objective criteria are used to optimize TR suitability in the primary care setting.
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Affiliation(s)
- Jillian L S Avis
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Angela Komarnicki
- Department of Agricultural, Food & Nutrition Science, Faculty of Agricultural, Life & Environmental Sciences, University of Alberta, Edmonton, AB, Canada
| | - Anna P Farmer
- Department of Agricultural, Food & Nutrition Science, Faculty of Agricultural, Life & Environmental Sciences, University of Alberta, Edmonton, AB, Canada; School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Nicholas L Holt
- Faculty of Physical Education & Recreation, University of Alberta, Edmonton, AB, Canada
| | - Arnaldo Perez
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nicholas Spence
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Geoff D C Ball
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada; Department of Agricultural, Food & Nutrition Science, Faculty of Agricultural, Life & Environmental Sciences, University of Alberta, Edmonton, AB, Canada; Pediatric Centre for Weight and Health, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada.
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29
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Maresca MM, Hoepner LA, Hassoun A, Oberfield SE, Mooney SJ, Calafat AM, Ramirez J, Freyer G, Perera FP, Whyatt RM, Rundle AG. Prenatal Exposure to Phthalates and Childhood Body Size in an Urban Cohort. ENVIRONMENTAL HEALTH PERSPECTIVES 2016; 124:514-20. [PMID: 26069025 PMCID: PMC4829975 DOI: 10.1289/ehp.1408750] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 06/08/2015] [Indexed: 05/20/2023]
Abstract
BACKGROUND Phthalate exposures are hypothesized to increase obesity; however, prior research has been largely cross-sectional. OBJECTIVE We evaluated associations between prenatal phthalate exposures and body mass index (BMI) at child ages 5 and 7 years. METHODS Nine metabolites of six phthalates-di(2-ethylhexyl) phthalate (DEHP), di-n-octyl-, di-iso-butyl-, di-n-butyl-, butylbenzyl-, and diethyl phthalates-were measured in spot urine samples collected from pregnant African-American and Dominican women during their third trimester, and from their children at ages 3 and 5 years. To reduce multiple comparison issues, we initially used principal component analysis (PCA) to identify major patterns of natural log (ln)-transformed metabolite concentrations. Height and weight were assessed at ages 5 and 7 years, and fat mass and waist circumference at age 7. Linearized generalized estimating equation analyses related maternal component scores to child anthropometric outcomes at ages 5 (n = 326) and 7 (n = 330) years. RESULTS PCA identified a DEHP component and a non-DEHP component. In boys, higher maternal non-DEHP, but not DEHP, component scores were associated with lower BMI z-score (β = -0.30; 95% CI: -0.50, -0.10, n = 156), lower fat percentage (β = -1.62; 95% CI: -2.91, -0.34, n = 142), and smaller waist circumference (β = -2.02; 95% CI: -3.71, -0.32, n = 124). No significant associations with anthropometric outcomes were seen in girls (for BMI z-score, β = 0.07; 95% CI: -0.18, 0.31, n = 181). Interactions between sex and non-DEHP component association with outcomes were statistically significant (p < 0.01). CONCLUSIONS Contrary to hypotheses, prenatal non-DEHP phthalate exposures were associated with lower BMI z-score, waist circumference, and fat mass in boys during early childhood. CITATION Maresca MM, Hoepner LA, Hassoun A, Oberfield SE, Mooney SJ, Calafat AM, Ramirez J, Freyer G, Perera FP, Whyatt RM, Rundle AG. 2016. Prenatal exposure to phthalates and childhood body size in an urban cohort. Environ Health Perspect 124:514-520; http://dx.doi.org/10.1289/ehp.1408750.
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Affiliation(s)
- Michelle M. Maresca
- Division of Pediatric Endocrinology, Diabetes and Metabolism, Department of Pediatrics, New York-Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Lori A. Hoepner
- Columbia Center for Children’s Environmental Health, Department of Environmental Health Sciences, and
| | - Abeer Hassoun
- Division of Pediatric Endocrinology, Diabetes and Metabolism, Department of Pediatrics, New York-Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Sharon E. Oberfield
- Division of Pediatric Endocrinology, Diabetes and Metabolism, Department of Pediatrics, New York-Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Stephen J. Mooney
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Antonia M. Calafat
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Judyth Ramirez
- Columbia Center for Children’s Environmental Health, Department of Environmental Health Sciences, and
| | - Greg Freyer
- Columbia Center for Children’s Environmental Health, Department of Environmental Health Sciences, and
| | - Frederica P. Perera
- Columbia Center for Children’s Environmental Health, Department of Environmental Health Sciences, and
| | - Robin M. Whyatt
- Columbia Center for Children’s Environmental Health, Department of Environmental Health Sciences, and
| | - Andrew G. Rundle
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- Address correspondence to A.G. Rundle, Department of Epidemiology, Mailman School of Public Health, 722 West 168th St., Room 730, New York, NY 10032 USA. Telephone: (212) 305-7619. E-mail:
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30
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Sharafi M, Peracchio H, Scarmo S, Huedo-Medina TB, Mayne ST, Cartmel B, Duffy VB. Preschool-Adapted Liking Survey (PALS): A Brief and Valid Method To Assess Dietary Quality of Preschoolers. Child Obes 2015; 11:530-40. [PMID: 26322657 DOI: 10.1089/chi.2015.0037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Feasible, valid, and reliable tools are needed to assess dietary quality among preschoolers. We aimed to test construct-/criterion-related validity and reliability of a dietary quality index generated from a liking survey and novel dietary patterns for characterizing food hedonism and parental feeding practices. METHODS Participants included 416 economically disadvantaged, diverse preschoolers (41% overweight/obese) from educational centers and their parents. Parents completed liking and frequency surveys; the liking survey took half as long to complete. Preschoolers' skin carotenoid status (measured by Resonance Raman spectroscopy) and BMI percentile (measured weight/height) were assessed. The Healthy Eating Preference Index (HEPI) was constructed from weighted averages of liking scores for food groups and healthy variety score and Healthy Eating Index 2010 (HEI) from nutrient analysis of the frequency survey. RESULTS The HEPI was normally distributed and showed construct validity and adequate internal reliability. In hierarchical regression analyses, the HEPI explained carotenoid status and adiposity as alternative or value-added predictors to HEI, supporting criterion-related validity of HEPI. Parental reporting of children's liking of high-fat/sweet/salty foods in excess of pleasurable activities (food hedonism) predicted heavier preschoolers, as did discord between HEI and HEPI (potential parental pressure toward healthy eating). HEPI alone or with HEI explained variability in carotenoid status and adiposity in path models with adequate to good fits. CONCLUSIONS With simple collection and processing, the liking survey can generate a valid/reliable dietary quality index in child care settings to identify preschoolers at risk for lower nutritional status. Using liking and frequency-based screeners could improve understanding of parental feeding behaviors and precision of predicting nutritional status.
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Affiliation(s)
- Mastaneh Sharafi
- 1 Department of Allied Health Sciences, College of Agriculture, Health and Natural Resources, University of Connecticut , Storrs, CT
| | - Heather Peracchio
- 2 Department of Extension, College of Agriculture, Health and Natural Resources, University of Connecticut , Storrs, CT
| | - Stephanie Scarmo
- 3 Kids' Safe and Healthful Foods , Government Performance, The Pew Charitable Trusts, Washington, DC
| | - Tania B Huedo-Medina
- 1 Department of Allied Health Sciences, College of Agriculture, Health and Natural Resources, University of Connecticut , Storrs, CT
| | - Susan T Mayne
- 4 Chronic Disease Epidemiology, Yale School of Public Health , New Haven, CT
| | - Brenda Cartmel
- 4 Chronic Disease Epidemiology, Yale School of Public Health , New Haven, CT
| | - Valerie B Duffy
- 1 Department of Allied Health Sciences, College of Agriculture, Health and Natural Resources, University of Connecticut , Storrs, CT
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31
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Dietary Assessment on a Mobile Phone Using Image Processing and Pattern Recognition Techniques: Algorithm Design and System Prototyping. Nutrients 2015. [PMID: 26225994 PMCID: PMC4555113 DOI: 10.3390/nu7085274] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Dietary assessment, while traditionally based on pen-and-paper, is rapidly moving towards automatic approaches. This study describes an Australian automatic food record method and its prototype for dietary assessment via the use of a mobile phone and techniques of image processing and pattern recognition. Common visual features including scale invariant feature transformation (SIFT), local binary patterns (LBP), and colour are used for describing food images. The popular bag-of-words (BoW) model is employed for recognizing the images taken by a mobile phone for dietary assessment. Technical details are provided together with discussions on the issues and future work.
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32
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Interrelationships of More Healthful and Less Healthful Aspects of Diet Quality in a Low-Income Community Sample of Preschool-Aged Children. Matern Child Health J 2015; 19:2663-72. [DOI: 10.1007/s10995-015-1788-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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33
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Bell LK, Golley RK, Magarey AM. Dietary risk scores of toddlers are associated with nutrient intakes and socio-demographic factors, but not weight status. Nutr Diet 2015. [DOI: 10.1111/1747-0080.12208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Lucinda K. Bell
- Nutrition and Dietetics, Faculty of Medicine, Nursing and Health Sciences; Flinders University; Adelaide South Australia Australia
| | - Rebecca K. Golley
- Sansom Institute for Health Research; Division of Health Sciences; University of South Australia; Adelaide South Australia Australia
| | - Anthea M. Magarey
- Nutrition and Dietetics, Faculty of Medicine, Nursing and Health Sciences; Flinders University; Adelaide South Australia Australia
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34
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Perry CP, Keane E, Layte R, Fitzgerald AP, Perry IJ, Harrington JM. The use of a dietary quality score as a predictor of childhood overweight and obesity. BMC Public Health 2015; 15:581. [PMID: 26100985 PMCID: PMC4477494 DOI: 10.1186/s12889-015-1907-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 06/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of dietary quality scores/indices to describe diet quality in children has increased in the past decade. However, to date, few studies have focused on the use of these scores on disease outcomes such as childhood obesity and most are developed from detailed dietary assessments. Therefore, the aims of this study were: firstly to construct a diet quality score (DQS) from a brief dietary assessment tool; secondly to examine the association between diet quality and childhood overweight or obesity; thirdly we also aim to examine the associations between individual DQS components and childhood overweight or obesity. METHODS A secondary analysis of cross sectional data of a sample of 8,568 9-year-old children and their families as part of the Growing Up in Ireland (GUI) study. Subjects were drawn from a probability proportionate to size sampling of primary schools throughout Ireland over the school year 2007-2008. Height and weight were measured by trained researchers using standardised methods and BMI was classified using the International Obesity Taskforce cut-points. The DQS (un-weighted) was developed using a 20-item, parent reported, food frequency questionnaire of foods consumed over the past 24 h. Adjusted odds ratios for overweight and obesity were examined by DQS quintile, using the first quintile (highest diet quality) as the reference category. RESULTS The prevalence of normal weight, overweight and obese was 75, 19 and 6% respectively. DQS ranged from -5 to 25, higher scores indicated higher diet quality in the continuous score. In analyses adjusted for gender, parent's education, physical activity and T.V. viewing, child obesity but not overweight was significantly associated with poor diet quality: OR of 1.56 (95% CI 1.02 2.38) in the 5th compared to the 1st DQS quintile. Findings from individual food items were inconsistent. CONCLUSIONS The findings suggest that diet quality may be an important factor in childhood obesity. A simple DQS developed from a short dietary assessment tool is significantly associated with childhood obesity.
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Affiliation(s)
- Catherine P Perry
- Department of Epidemiology and Public Health, University College Cork, 4th Floor Western Gateway Building, Western Rd, Cork, Ireland.
| | - Eimear Keane
- Department of Epidemiology and Public Health, University College Cork, 4th Floor Western Gateway Building, Western Rd, Cork, Ireland.
| | - Richard Layte
- Economic and Social Research Institute (ESRI), Sir John Rogerson's Quay, Dublin 2, Ireland. .,Department of Sociology, Trinity College Dublin, 3 College Green Dublin 2, Dublin 2, Ireland.
| | - Anthony P Fitzgerald
- Department of Epidemiology and Public Health, University College Cork, 4th Floor Western Gateway Building, Western Rd, Cork, Ireland. .,School of Mathematical sciences 1st floor Western Gateway Building, Western Rd, Cork, Ireland.
| | - Ivan J Perry
- Department of Epidemiology and Public Health, University College Cork, 4th Floor Western Gateway Building, Western Rd, Cork, Ireland.
| | - Janas M Harrington
- Department of Epidemiology and Public Health, University College Cork, 4th Floor Western Gateway Building, Western Rd, Cork, Ireland.
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Development and evaluation of a stand-alone index for the assessment of small children’s diet quality. Public Health Nutr 2015; 18:1941-9. [DOI: 10.1017/s1368980014002535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AbstractObjectiveTo construct and evaluate an independent Children’s Index of Diet Quality (CIDQ).DesignA food consumption questionnaire, which contained twenty-five multiple-item questions on eating and food intake, was formulated and evaluated against 7 d food records. Key questions that best reflected a healthy diet, defined in criteria set by the nutrient recommendations, were searched and validated by correlation and analyses of receiver-operating characteristic curves.SettingsA cohort of a young population of South-West Finland.SubjectsParticipants (n 400) were 2–6-year-old children.ResultsFifteen questions were identified to best depict the children’s diet quality in reference to the recommendations. These questions were scored, summarized and further constructed into a three-class index (good, moderate and poor dietary quality) where higher scores depicted better diet quality. The CIDQ cut-off score of 14 points for good dietary quality had a sensitivity of 0·59 and a specificity of 0·82 and the cut-off score of 10 points, for at least moderate dietary quality, had a sensitivity of 0·77 and a specificity of 0·69. Higher index scores were related to higher dietary intakes of several vitamins, lower dietary intakes of SFA and cholesterol, and further with lower serum cholesterol and higher serum vitamin C concentrations.ConclusionsThe three-class food index was found to represent diet quality as defined in recommendations and evaluated against nutrient intakes from food diaries and biochemical markers. This self-standing index could provide an effective and low-burden method to obtain information about diet quality and guide future recommendations.
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A short food-group-based dietary questionnaire is reliable and valid for assessing toddlers' dietary risk in relatively advantaged samples. Br J Nutr 2014; 112:627-37. [DOI: 10.1017/s0007114514001184] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Identifying toddlers at dietary risk is crucial for determining who requires intervention to improve dietary patterns and reduce health consequences. The objectives of the present study were to develop a simple tool that assesses toddlers' dietary risk and investigate its reliability and validity. The nineteen-item Toddler Dietary Questionnaire (TDQ) is informed by dietary patterns observed in Australian children aged 14 (n552) and 24 (n493) months and the Australian dietary guidelines. It assesses the intake of ‘core’ food groups (e.g. fruit, vegetables and dairy products) and ‘non-core’ food groups (e.g. high-fat, high-sugar and/or high-salt foods and sweetened beverages) over the previous 7 d, which is then scored against a dietary risk criterion (0–100; higher score = higher risk). Parents of toddlers aged 12–36 months (Socio-Economic Index for Areas decile range 5–9) were asked to complete the TDQ for their child (n111) on two occasions, 3·2 (sd1·8) weeks apart, to assess test–retest reliability. They were also asked to complete a validated FFQ from which the risk score was calculated and compared with the TDQ-derived risk score (relative validity). Mean scores were highly correlated and not significantly different for reliability (intra-class correlation = 0·90, TDQ1 30·2 (sd8·6)v. TDQ2 30·9 (sd8·9);P= 0·14) and validity (r0·83, average TDQ ((TDQ1+TDQ2)/2) 30·5 (sd8·4)v. FFQ 31·4 (sd8·1);P= 0·05). All the participants were classified into the same (reliability 75 %; validity 79 %) or adjacent (reliability 25 %; validity 21 %) risk category (low (0–24), moderate (25–49), high (50–74) and very high (75–100)). Overall, the TDQ is a valid and reliable screening tool for identifying at-risk toddlers in relatively advantaged samples.
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