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Delahunt A, Killeen SL, O'Brien EC, Geraghty AA, O'Reilly SL, McDonnell CM, Cushion R, Mehegan J, McAuliffe FM. Stability of child appetitive traits and association with diet quality at 5 years and 9-11 years old: Findings from the ROLO longitudinal birth cohort study. Eur J Clin Nutr 2024; 78:607-614. [PMID: 38575724 PMCID: PMC11230891 DOI: 10.1038/s41430-024-01436-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND We explored change in child appetitive traits from 5 to 9-11 years old and examined associations between appetitive traits at both timepoints and child diet quality. METHODS This is secondary analyses of the ROLO longitudinal birth cohort study, including mother-child dyads from the 5 and 9-11-year old follow-up. The Children's Eating Behaviour Questionnaire measured child appetitive traits, with 167 children having matched data for both timepoints. The Healthy Eating Index (HEI) measured diet quality. Linear mixed models and multiple linear regression were completed. RESULTS Mean (SD) score for 'Emotional Overeating' (1.63 (0.51) vs. 1.99 (0.57), p = <0.001) and 'Enjoyment of Food' (3.79 (0.72) vs. 3.98 (0.66), p = <0.001) increased from 5 to 9-11 years. Mean score for 'Desire to Drink' (2.63 (0.94) vs. 2.45 (0.85), p = 0.01), 'Satiety Responsiveness (3.07 (0.66) vs. 2.71 (0.66), p = <0.001), 'Slowness Eating' (3.02 (0.77) vs. 2.64 (0.78), p = <0.001), and 'Food Fussiness' (3.00 (1.04) vs. 2.81 (0.96), p = 0.001) decreased. At 5-years-old, 'Food Responsiveness' and 'Enjoyment of Food' were positively associated with HEI and 'Desire to Drink', 'Satiety Responsiveness' and 'Food Fussiness' were negatively associated with HEI. At 9-11-years, 'Enjoyment of Food' was positively and 'Desire to Drink' and 'Food 'Fussiness' were negatively associated with HEI. CONCLUSIONS Food approach appetitive traits increased over time, whereas food avoidant appetitive traits tended to decrease. At both time points 'Food Fussiness' and 'Desire to Drink" were inversely associated with HEI. Further research on how appetitive traits track over childhood and how this relates to dietary quality and weight is warranted.
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Affiliation(s)
- Anna Delahunt
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
| | - Sarah Louise Killeen
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
| | - Eileen C O'Brien
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
- School of Biological, Health and Sport Science, Technological University Dublin, Dublin, Ireland
| | - Aisling A Geraghty
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
| | - Sharleen L O'Reilly
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
- School of Agriculture and Food Science, University College Dublin, Dublin, 4, Ireland
| | - Ciara M McDonnell
- Department of Paediatric Endocrinology & Diabetes, Children's Health Ireland Temple St & Tallaght, Dublin, Ireland
- Trinity Research in Childhood Centre (TRICC), Discipline of Paediatrics, School of Medicine, Trinity College, Dublin, Ireland
| | - Rosemary Cushion
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
| | - John Mehegan
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
- School of Public Health, Physiotherapy and Sport Science, University College Dublin, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland.
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Sleiman R, Abdelkader W, AlTannir D. Assessing the Body Composition of "Picky Eaters" Using Body Impedance Analysis: An Experience From a Tertiary Care Center. Cureus 2024; 16:e60538. [PMID: 38887328 PMCID: PMC11181006 DOI: 10.7759/cureus.60538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Picky eating might be associated with a higher risk of being underweight and poor growth. This study aimed to investigate if picky eaters aged between three and 12 years showed differences in height, weight, and body composition compared to their non-picky peers using a body impedance analysis (BIA). METHODS This cross-sectional study was conducted between March 1, 2022, and July 31, 2022, on children aged three to 12 years who presented to the outpatient pediatric clinics at Al Habib Ar Rayyan in Riyadh, Saudi Arabia. Body composition was measured using BIA after manually inserting the height, gender, and age into the machine, where body mass index (BMI), fat mass, and skeletal muscle mass were recorded. Participants were classified as under/normal/over for each body composition measurement. RESULTS A total of 2234 children were entered into the final data analysis. Our analysis showed that 1917 (85.8%) were Saudis and 1117 (50%) were males. The mean age of participants was 6.08±2.01 years and 1151 (51.5%) were in the pre-school age. The reported prevalence of picky eaters was 1684 (75.4%), of whom, 606 (27.0%) were selective eaters, 365 (16.2%) were low appetite eaters, and 723 (32.2%) were both selective and low appetite eaters. Being underweight was significantly more common among the picky eaters 487 (28.9%) compared to those non-picky eaters 55 (10.0%) (p<0.001). Significantly, 1280 (76%) picky eaters had below-average skeletal muscle mass compared to 151 non-picky eaters (27.5%) (p<0.001). The low appetite picky eater group had more under skeletal muscle mass children 277 (75.9%) compared to the selective picky eater group 412 (68.0%) (p=0.009). Additionally, the low appetite group possessed lower muscle ratios (p=0.012) and were more underweight than the selective group (p<0.001). Furthermore, the low appetite group showed a higher percentage of children below the 3rd percentile in the height for age category (p=0.003) compared to the selective group. CONCLUSION This study is the first of its kind in Saudi and globally to evaluate body composition using BIA among children. The study showed that picky eating is more associated with underweight children and low muscular mass. Despite the normal BMI, height, and weight of a picky eater, their skeletal muscle mass might be less than average, which could be associated with an increased risk of morbidity.
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Affiliation(s)
- Rola Sleiman
- Pediatrics, Dr. Sulaiman Al Habib Medical Group, Riyadh, SAU
| | | | - Dana AlTannir
- Pediatric Medicine, Alfaisal University College of Medicine, Riyadh, SAU
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Olwi DI, Day FR, Cheng TS, Olga L, Petry CJ, Hughes IA, Smith AD, Ong KK. Associations of appetitive traits with growth velocities from infancy to childhood. Sci Rep 2023; 13:16056. [PMID: 37749117 PMCID: PMC10520028 DOI: 10.1038/s41598-023-42899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023] Open
Abstract
Several studies have reported associations between appetitive traits and weight gain during infancy or childhood, but none have directly compared these associations across both age periods. Here, we tested the associations between appetitive traits and growth velocities from birth to childhood. Appetitive trait data were collected using the Children's Eating Behaviour Questionnaire (CEBQ) in 149 children from the Cambridge Baby Growth Study at age 9-17 years. These participants also provided anthropometric measurements during infancy (birth, 3, 12, 18, and 24 months) and childhood (5 to 11 years). Standardized growth velocities (in weight, length/height, BMI, and body fat percentage) for 0-3 months, 3-24 months, and 24 months to childhood were estimated using individual linear-spline models. Associations between each of the eight CEBQ traits and each growth velocity were tested in separate multilevel linear regression models, adjusted for sex, age at CEBQ completion, and the corresponding birth measurement (weight, length, BMI, or body fat percentage). The three food-approach traits (food responsiveness, enjoyment of food and emotional overeating) were positively associated with infancy and childhood growth velocities in weight, BMI, and body fat percentage. By contrast, only one of the food-avoidant traits, satiety responsiveness, was negatively associated with all growth velocities. Significant associations were mostly of similar magnitude across all age periods. These findings reveal a broadly consistent relationship between appetitive traits with gains in weight and adiposity throughout infancy and childhood. Future interventions and strategies to prevent obesity may benefit from measuring appetitive traits in infants and children and targeting these as part of their programs.
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Affiliation(s)
- Duaa Ibrahim Olwi
- MRC Epidemiology Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK.
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
- King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
| | - Felix R Day
- MRC Epidemiology Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
| | - Tuck Seng Cheng
- MRC Epidemiology Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
| | - Laurentya Olga
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Clive J Petry
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Andrea D Smith
- MRC Epidemiology Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
| | - Ken K Ong
- MRC Epidemiology Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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Ferreira P, Warkentin S, Oliveira A. Appetitive traits and food groups consumption in school-aged children: prospective associations from the Generation XXI birth cohort. Eat Weight Disord 2023; 28:67. [PMID: 37542554 PMCID: PMC10404169 DOI: 10.1007/s40519-023-01586-9] [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: 09/15/2022] [Accepted: 11/25/2022] [Indexed: 08/07/2023] Open
Abstract
PURPOSE Appetite can influence children's dietary choices; however, this relationship in school-aged children is still unclear. We aimed to explore the prospective associations between child appetitive traits at age 7 and food consumption at 10 years of age. METHODS The study included 3860 children from the Generation XXI birth cohort, recruited in 2005/2006 in Porto, Portugal. The Children's Eating Behaviour Questionnaire was used to evaluate children's appetitive traits at 7 years. Food consumption was measured at 10 years through a validated Food Frequency Questionnaire. Logistic regression models were performed and adjusted for possible confounders. RESULTS Children with greater Enjoyment of Food at 7 years were 36% more likely to eat fruits ≥ 2 times/day and 54% more likely to eat vegetables > 2.5 times/day at 10 years compared to those with less frequent consumption. Children who ate more in response to negative emotions had higher odds of consuming energy-dense foods (OR = 1.33; 99% CI 1.13-1.58) and salty snacks (OR = 1.28; 99% CI 1.08-1.51) 3 years later. Those with less ability to adjust intake (higher Satiety Responsiveness) and more selective about foods (higher Food Fussiness) at 7 years were less likely to consume vegetables frequently, and were more likely to consume energy-dense foods and sugar-sweetened beverages. CONCLUSIONS Children's appetitive traits at 7 years were associated with the consumption of several food groups at 10 years of age. Eating more in response to negative emotions (Emotional Eating), with less ability to adjust intake (Satiety Responsiveness) and more food selectivity (Food Fussiness) were associated with worse dietary choices (in general, lower fruit and vegetables, and higher energy-dense foods and sugar-sweetened beverages consumption). LEVEL OF EVIDENCE Level III: Evidence obtained from well-designed cohort or case-control analytic studies.
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Affiliation(s)
- Pedro Ferreira
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], University of Porto, Rua das Taipas nº135, 4050-600, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health [ITR], University of Porto, Rua das Taipas nº135, 4050-600, Porto, Portugal
| | - Sarah Warkentin
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], University of Porto, Rua das Taipas nº135, 4050-600, Porto, Portugal
- Laboratory for Integrative and Translational Research in Population Health [ITR], University of Porto, Rua das Taipas nº135, 4050-600, Porto, Portugal
| | - Andreia Oliveira
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], University of Porto, Rua das Taipas nº135, 4050-600, Porto, Portugal.
- Laboratory for Integrative and Translational Research in Population Health [ITR], University of Porto, Rua das Taipas nº135, 4050-600, Porto, Portugal.
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
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Thorsteinsdottir S, Bjarnason R, Eliasdottir HG, Olafsdottir AS. Body Composition in Fussy-Eating Children, with and without Neurodevelopmental Disorders, and Their Parents, Following a Taste Education Intervention. Nutrients 2023; 15:2788. [PMID: 37375692 DOI: 10.3390/nu15122788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
Fussy eaters may have an increased risk of becoming overweight or obese as adolescents, with fussy eating and weight status also correlating with neurodevelopmental disorders (NDs) such as autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD). Further, maternal and children's weight status relationships are well-established. In this study, we analyzed the body composition of parent-child dyads using bioelectrical impedance analysis (BIA). Fifty-one children aged 8-12 years, with an ND (n = 18) and without (n = 33), and their parents, participated in a 7-week food-based Taste Education intervention with 6-month follow-up. The paired t-test was used to compare differences in body composition based on children's ND status. In logistic regression analysis, odds of children being in the overweight/obese or overfat/obese categories increased by a factor of 9.1 and 10.6, respectively, when having NDs, adjusting for parents' BMI (body mass index) or fat percentage (FAT%). Children with NDs and their parents had significantly higher mean BMI-SDS (BMI standard deviation score) and FAT% at pre-intervention than children without NDs and their parents. Mean BMI-SDS and FAT% lowered significantly between time points for children with NDs and their parents but not for children without NDs or their parents. The findings underline the need for additional exploration into the relationships between children's and parents' body composition based on children's ND status.
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Affiliation(s)
- Sigrun Thorsteinsdottir
- Faculty of Health Promotion, Sport and Leisure Studies, School of Education, University of Iceland, Stakkahlid, 105 Reykjavik, Iceland
| | - Ragnar Bjarnason
- Faculty of Medicine, School of Health Sciences, University of Iceland, Laeknagardur 4th Floor, Vatnsmyrarvegur 16, 101 Reykjavik, Iceland
- Department of Pediatrics, National University Hospital, Hringbraut, 101 Reykjavik, Iceland
| | - Helga G Eliasdottir
- Faculty of Health Promotion, Sport and Leisure Studies, School of Education, University of Iceland, Stakkahlid, 105 Reykjavik, Iceland
| | - Anna S Olafsdottir
- Faculty of Health Promotion, Sport and Leisure Studies, School of Education, University of Iceland, Stakkahlid, 105 Reykjavik, Iceland
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Garcia-Iborra M, Castanys-Munoz E, Oliveros E, Ramirez M. Optimal Protein Intake in Healthy Children and Adolescents: Evaluating Current Evidence. Nutrients 2023; 15:nu15071683. [PMID: 37049523 PMCID: PMC10097334 DOI: 10.3390/nu15071683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023] Open
Abstract
High protein intake might elicit beneficial or detrimental effects, depending on life stages and populations. While high protein intake in elder individuals can promote beneficial health effects, elevated protein intakes in infancy are discouraged, since they have been associated with obesity risks later in life. However, in children and adolescents (4–18 years), there is a scarcity of data assessing the effects of high protein intake later in life, despite protein intake being usually two- to three-fold higher than the recommendations in developed countries. This narrative review aimed to revise the available evidence on the long-term effects of protein intake in children and adolescents aged 4–18 years. Additionally, it discusses emerging techniques to assess protein metabolism in children, which suggest a need to reevaluate current recommendations. While the optimal range is yet to be firmly established, available evidence suggests a link between high protein intake and increased Body Mass Index (BMI), which might be driven by an increase in Fat-Free Mass Index (FFMI), as opposed to Fat Mass Index (FMI).
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Affiliation(s)
- Maria Garcia-Iborra
- Abbott Nutrition R & D, Granada University Science Park, 18016 Granada, Spain; (M.G.-I.); (E.C.-M.)
| | - Esther Castanys-Munoz
- Abbott Nutrition R & D, Granada University Science Park, 18016 Granada, Spain; (M.G.-I.); (E.C.-M.)
| | - Elena Oliveros
- Abbott Nutrition R & D, Abbott Laboratories, 18004 Granada, Spain;
| | - Maria Ramirez
- Abbott Nutrition R & D, Abbott Laboratories, 18004 Granada, Spain;
- Correspondence: ; Tel.: +34-669127998
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Calderón García A, Alaminos-Torres A, Pedrero Tomé R, Prado Martínez C, Martínez Álvarez JR, Villarino Marín A, Marrodán Serrano MD. Eating Behavior and Obesity in a Sample of Spanish Schoolchildren. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4186. [PMID: 36901196 PMCID: PMC10001860 DOI: 10.3390/ijerph20054186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 06/18/2023]
Abstract
From the point of view of prevention, it is convenient to explore the association between eating behavior and the obese phenotype during school and adolescent age. The aim of the present study was to identify eating behavior patterns associated with nutritional status in Spanish schoolchildren. A cross-sectional study of 283 boys and girls (aged 6 to 16 years) was carried out. The sample was evaluated anthropometrically by Body Mass Index (BMI), waist-to-height ratio (WHtR) and body fat percentage (%BF). Eating behavior was analyzed using the CEBQ "Children's Eating Behavior Questionnaire". The subscales of the CEBQ were significantly associated with BMI, WHtR and %BF. Pro-intake subscales (enjoyment of food, food responsiveness, emotional overeating, desire for drinks) were positively related to excess weight by BMI (β = 0.812 to 0.869; p = 0.002 to <0.001), abdominal obesity (β = 0.543-0.640; p = 0.02 to <0.009) and high adiposity (β = 0.508 to 0.595; p = 0.037 to 0.01). Anti-intake subscales (satiety responsiveness, slowness in eating, food fussiness) were negatively related to BMI (β = -0.661 to -0.719; p = 0.009 to 0.006) and % BF (β = -0.17 to -0.46; p = 0.042 to p = 0.016).
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Affiliation(s)
- Andrea Calderón García
- Research Group EPINUT (Nutritional Epidemiology), Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Nursing and Nutrition, Faculty of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain
- Department of Biology, Faculty of Sciences, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Ana Alaminos-Torres
- Research Group EPINUT (Nutritional Epidemiology), Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Biodiversity, Ecology and Evolution, Faculty of Biology, Complutense University of Madrid, 28040 Madrid, Spain
| | - Roberto Pedrero Tomé
- Research Group EPINUT (Nutritional Epidemiology), Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Biodiversity, Ecology and Evolution, Faculty of Biology, Complutense University of Madrid, 28040 Madrid, Spain
| | - Consuelo Prado Martínez
- Research Group EPINUT (Nutritional Epidemiology), Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Biology, Faculty of Sciences, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Jesús Román Martínez Álvarez
- Research Group EPINUT (Nutritional Epidemiology), Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - Antonio Villarino Marín
- Research Group EPINUT (Nutritional Epidemiology), Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - María Dolores Marrodán Serrano
- Research Group EPINUT (Nutritional Epidemiology), Faculty of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Department of Biodiversity, Ecology and Evolution, Faculty of Biology, Complutense University of Madrid, 28040 Madrid, Spain
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Kamarudin MS, Shahril MR, Haron H, Kadar M, Safii NS, Hamzaid NH. Interventions for Picky Eaters among Typically Developed Children-A Scoping Review. Nutrients 2023; 15:nu15010242. [PMID: 36615899 PMCID: PMC9824123 DOI: 10.3390/nu15010242] [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: 11/15/2022] [Revised: 12/09/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023] Open
Abstract
Picky eating in children is often a major source of concern for many parents and caregivers. Picky eaters (PEs) consume limited foods, demonstrate food aversion, and have a limited food repertoire, which hinders their growth and health. These behaviours are common in children with special health care needs despite the rise in typically developing children. This leads to less attention being given to intervention programmes for typically developing children. Therefore, this scoping review aims to investigate the key concept of an existing intervention programme for PE among typically developing children, primarily on the types and approaches selected. A thorough literature search was conducted on three primary databases (PubMed, Emerald In-sight, and Web of Science) using predefined keywords. The literature was then appraised using the Joanna Briggs Institute's guidelines and protocols, and the PRISMScR checklist. Inclusion and exclusion criteria were also specified in the screening procedure. Results showed that the majority of the interventions in these studies were single-component interventions, with the sensory approach being the type that was most frequently utilised, followed by the nutrition approach and parenting approach. Single and multiple intervention components improved the assessed outcome, with a note that other components may or may not show a similar outcome, as they were not assessed in the single-component intervention. Given the evidence that picky eating is influenced by various factors, a multi-component intervention can provide a substantial impact on future programmes. In addition, defining picky eaters using standardised tools is also essential for a more inclusive subject selection.
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Affiliation(s)
- Mohd Shah Kamarudin
- Center for Rehabilitation & Special Needs Studies (iCaRehab), Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur 56000, Malaysia
| | - Mohd Razif Shahril
- Center for Healthy Ageing & Wellness (H-CARE), Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur 56000, Malaysia
| | - Hasnah Haron
- Center for Healthy Ageing & Wellness (H-CARE), Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur 56000, Malaysia
| | - Masne Kadar
- Center for Rehabilitation & Special Needs Studies (iCaRehab), Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur 56000, Malaysia
| | - Nik Shanita Safii
- Center for Community Health Studies (ReaCH), Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur 56000, Malaysia
| | - Nur Hana Hamzaid
- Center for Rehabilitation & Special Needs Studies (iCaRehab), Faculty of Health Sciences, National University of Malaysia, Kuala Lumpur 56000, Malaysia
- Correspondence:
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Venkatesh S, DeJesus JM. Can children report on their own picky eating? Similarities and differences with parent report. Appetite 2022; 177:106155. [PMID: 35779643 DOI: 10.1016/j.appet.2022.106155] [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: 02/15/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 11/02/2022]
Abstract
Picky eating in childhood is associated with children's dietary outcomes and parental feeding experiences. The Child Eating Behavior Questionnaire (CEBQ) is a frequently-used parent-report survey that measures children's eating behaviors, including picky eating. Limited work has adapted the CEBQ into a child-friendly format to measure children's ability to report directly on their own picky eating behavior. We sought to extend previous research by adapting the Food Fussiness subscale of the CEBQ into a child self-report format and measuring parent-child resemblance in scores, with children as young as 3 years. Our final sample included 3- to 10-year-old children (n = 95) and their parents, who were assessed at a local children's museum. The internal consistency of parent-report on the CEBQ FF was α = 0.9 and child-report was α = 0.7, with parent scores predicting child scores when controlling for child age and child gender. The largest difference between parent and child scores on child picky eating (with parents reporting higher scores) was for 3- to 4-year-old children. Children are able to report on their own picky eating and with age their reports converge with those of their parents, highlighting the potential benefit of collecting picky eating scores from multiple informants (parent and child). We suggest future directions for the validation and extension of this measure.
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Walton K, McGee M, Sato J, Law N, Hopperton KE, Bando N, Kiss A, Unger S, O'Connor DL. Social-Emotional Functioning and Dietary Intake among Children Born with a Very Low Birth Weight. Appl Physiol Nutr Metab 2022; 47:737-748. [PMID: 35196153 DOI: 10.1139/apnm-2021-0434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Very low birth weight infants (VLBW, <1500g) are at elevated risk of neurodevelopmental disorders, later obesity and cardiometabolic disease; if and how neurodevelopmental disorders impact chronic disease risk is poorly understood. The most common neurodevelopmental disorders experienced by VLBW children are those of social-emotional functioning. We compared dietary patterns and body composition between VLBW children with poor vs. typical social-emotional functioning using linear mixed models adjusted for sex, gestational age, cognitive impairment, parental education and BMI. VLBW children (n=158) attending the Donor Milk for Improved Neurodevelopmental Outcomes trial 5.5-year follow-up participated. Poor social-emotional functioning was based on standardized parent-rated questionnaires and/or parent-reported physician diagnosis of autism spectrum or attention-deficit/hyperactivity disorders. Most children had diets categorized as 'needs improvement' (67%) or 'poor' (27%) and 29% of children exhibited poor social-emotional functioning. Poor social-emotional functioning was positively associated with 100% fruit juice (β=0.3 cup equivalents/day; 95% CI 0.1, 0.5) and energy intake (β=118.1 kcals/day; 95% CI 0.9, 235.2). Children with poor social-emotional functioning were more likely to have a limited food repertoire (p=0.02), but less likely to exceed dietary fat recommendations (p=0.04). No differences in overall diet quality or body composition were observed. Diet counselling and research are essential to improving the nutrition of VLBW children to mitigate chronic disease risk. Novelty: • Overall diet quality and body composition did not differ between VLBW children with poor vs. typical social-emotional functioning. • Most had diets "needing improvement" or "poor" according to the HEI 2010. • Diet counselling may help mitigate chronic disease risk in this vulnerable population.
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Affiliation(s)
- Kathryn Walton
- The Hospital for Sick Children, 7979, Translational Medicine, Toronto, Ontario, Canada;
| | - Meghan McGee
- The Hospital for Sick Children, 7979, Translational Medicine, Toronto, Ontario, Canada.,University of Toronto Dalla Lana School of Public Health, 274071, Toronto, Ontario, Canada.,University of Toronto Temerty Faculty of Medicine, 12366, Nutritional Sciences, Toronto, Ontario, Canada;
| | - Julie Sato
- The Hospital for Sick Children, 7979, Neurosciences & Mental Health, Toronto, Ontario, Canada.,The Hospital for Sick Children, 7979, Diagnostic Imaging , Toronto, Ontario, Canada.,University of Toronto, 7938, Psychology, Toronto, Ontario, Canada;
| | - Nicole Law
- The Hospital for Sick Children, 7979, Translational Medicine, Toronto, Ontario, Canada;
| | - Kathryn E Hopperton
- The Hospital for Sick Children, 7979, Translational Medicine, Toronto, Ontario, Canada;
| | - Nicole Bando
- The Hospital for Sick Children, 7979, Translational Medicine, Toronto, Ontario, Canada.,University of Toronto Temerty Faculty of Medicine, 12366, Nutritional Sciences, Toronto, Ontario, Canada;
| | - Alex Kiss
- University of Toronto Institute of Health Policy Management and Evaluation, 206712, Toronto, Ontario, Canada.,Sunnybrook Research Institute, 282299, Evaluative and Clinical Sciences, Toronto, Ontario, Canada;
| | - Sharon Unger
- Sinai Health System, 518775, Department of Paediatrics, Toronto, Ontario, Canada.,University of Toronto Temerty Faculty of Medicine, 12366, Department of Pediatrics, Toronto, Ontario, Canada.,The Hospital for Sick Children, 7979, Neonatology, Toronto, Ontario, Canada;
| | - Deborah L O'Connor
- The Hospital for Sick Children, 7979, Translational Medicine, Toronto, Ontario, Canada.,University of Toronto Temerty Faculty of Medicine, 12366, Nutritional Sciences, Toronto, Ontario, Canada.,Sinai Health System, 518775, Paediatrics, Toronto, Ontario, Canada;
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11
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Grulichova M, Kuruczova D, Svancara J, Pikhart H, Bienertova-Vasku J. Association of Picky Eating with Weight and Height—The European Longitudinal Study of Pregnancy and Childhood (ELSPAC–CZ). Nutrients 2022; 14:nu14030444. [PMID: 35276803 PMCID: PMC8839058 DOI: 10.3390/nu14030444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: This study aimed to evaluate whether preschool children identified as picky eaters showed differences in anthropometric characteristics (weight and height) from their non-picky peers at 15 years of age. Design: This study was performed among the cohort members of the EL- SPAC–CZ study, a longitudinal study of pregnancy and childhood. The analysis included 2068 children (997 girls and 1071 boys) followed between births and 15 years of age. Picky eaters were identified at 1.5, 3, and 5 years of age. Anthropometric characteristics were measured at 15 years of age (15 years). Results: Picky eaters (n = 346; 16.7%) had a lower weight and height than non-picky eaters (n = 1722; 83.3%) at 15 years. This difference in weight and height was maintained after controlling for sex of the child, birth weight, birth length, maternal education, family structure at 15 years, and maternal age at childbirth. The picky children were on average 2.3 kg lighter and 0.8 cm shorter than non- picky children at 15 years. Conclusions: Persistent picky eating in preschool children is related to lower weight and height at 15 years of age in ELSPAC–CZ study.
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Affiliation(s)
- Marketa Grulichova
- Department of Pathological Physiology, Faculty of Medicine, Masaryk University, 601 77 Brno, Czech Republic;
- Research Centre for Toxic Compounds in the Environment (RECETOX), Masaryk University, 601 77 Brno, Czech Republic; (D.K.); (J.S.); (H.P.)
| | - Daniela Kuruczova
- Research Centre for Toxic Compounds in the Environment (RECETOX), Masaryk University, 601 77 Brno, Czech Republic; (D.K.); (J.S.); (H.P.)
- Department of Food Technology, Mendel University, 601 77 Brno, Czech Republic
| | - Jan Svancara
- Research Centre for Toxic Compounds in the Environment (RECETOX), Masaryk University, 601 77 Brno, Czech Republic; (D.K.); (J.S.); (H.P.)
| | - Hynek Pikhart
- Research Centre for Toxic Compounds in the Environment (RECETOX), Masaryk University, 601 77 Brno, Czech Republic; (D.K.); (J.S.); (H.P.)
- Research Department of Epidemiology and Public Health, University College London, London WC1E6BT, UK
| | - Julie Bienertova-Vasku
- Research Centre for Toxic Compounds in the Environment (RECETOX), Masaryk University, 601 77 Brno, Czech Republic; (D.K.); (J.S.); (H.P.)
- Correspondence: ; Tel.: +420-739-300-485
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12
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Warkentin S, Fildes A, Oliveira A. Appetitive behaviors and body composition in school-age years: Bi-directional analyses in a population-based birth cohort. Appetite 2021; 168:105770. [PMID: 34687825 DOI: 10.1016/j.appet.2021.105770] [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: 05/10/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022]
Abstract
Cross-sectional studies have consistently associated appetitive behaviors with child body mass index. However, few prospective studies have investigated the association between appetite and other measures of body composition and its directionality. We aimed to investigate the bi-directional relationship between appetitive behaviors and body composition in school-aged children. Data from 3668 children of the Generation XXI birth cohort were analyzed. Appetitive behaviors were assessed at 7 and 10 years through the Children's Eating Behavior Questionnaire. Higher fat mass and fat-free mass were measured through tetrapolar bioelectric impedance and waist-to-weight and waist-to-height ratios were calculated. Fat and fat-free mass indexes, waist-to-weight and waist-to-height age- and sex-specific z-scores were then calculated. Cross-lagged analyses were performed (body composition at 7 to appetitive behaviors at 10 and the reverse) to measure the magnitude and direction of associations. Fat mass and waist-to-height ratio at 7y predicted greater food approach behaviors at 10y (Enjoyment of Food, Food Responsiveness, Desire to Drink and Emotional Overeating), but not waist-to-weight, which seems to be consequence of child's avid appetite (e.g. Enjoyment of Food at 7y: βstandardized = 0.085, 95%CI = 0.041; 0.128, p < 0.001). Child scores on food avoidant behaviors, such as Satiety Responsiveness (βstandardized = -0.073, 95%CI = -0.110;-0.034, p < 0.001) and Slowness in Eating (βstandardized = -0.080, 95% CI = -0.120;-0.041, p < 0.001) at 7y predicted lower fat-free mass at 10. Appetitive behaviors may not solely predict weight status, but the path of association between body composition and later appetitive behavior may also be true, especially for food approaching behaviors and adipose tissue. Interventions aiming to prevent excess weight should focus on appetitive behaviors. Moreover, in children with higher adiposity, other pathways also seem to regulate appetite and need to be considered in interventions.
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Affiliation(s)
- Sarah Warkentin
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal.
| | - Alison Fildes
- School of Psychology, University of Leeds, Leeds, LS2 9JT, England, Portugal
| | - Andreia Oliveira
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health (ITR), Porto, Portugal; Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
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13
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Hübel C, Herle M, Santos Ferreira DL, Abdulkadir M, Bryant-Waugh R, Loos RJF, Bulik CM, Lawlor DA, Micali N. Childhood overeating is associated with adverse cardiometabolic and inflammatory profiles in adolescence. Sci Rep 2021; 11:12478. [PMID: 34127697 PMCID: PMC8203659 DOI: 10.1038/s41598-021-90644-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 05/07/2021] [Indexed: 12/15/2022] Open
Abstract
Childhood eating behaviour contributes to the rise of obesity and related noncommunicable disease worldwide. However, we lack a deep understanding of biochemical alterations that can arise from aberrant eating behaviour. In this study, we prospectively associate longitudinal trajectories of childhood overeating, undereating, and fussy eating with metabolic markers at age 16 years to explore adolescent metabolic alterations related to specific eating patterns in the first 10 years of life. Data are from the Avon Longitudinal Study of Parents and Children (n = 3104). We measure 158 metabolic markers with a high-throughput (1H) NMR metabolomics platform. Increasing childhood overeating is prospectively associated with an adverse cardiometabolic profile (i.e., hyperlipidemia, hypercholesterolemia, hyperlipoproteinemia) in adolescence; whereas undereating and fussy eating are associated with lower concentrations of the amino acids glutamine and valine, suggesting a potential lack of micronutrients. Here, we show associations between early behavioural indicators of eating and metabolic markers.
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Affiliation(s)
- Christopher Hübel
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- UK National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health, South London and Maudsley Hospital, London, UK
- National Centre for Register-Based Research, Department of Economics and Business Economics, Aarhus University, Aarhus, Denmark
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Moritz Herle
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Diana L Santos Ferreira
- Medical Research Council Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mohamed Abdulkadir
- Department of Pediatrics Gynaecology and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Rachel Bryant-Waugh
- Maudsley Centre for Child and Adolescent Eating Disorders, Michael Rutter Centre for Children and Young People, Maudsley Hospital, London, UK
| | - Ruth J F Loos
- Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Cynthia M Bulik
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychiatry, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
- Department of Nutrition, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Deborah A Lawlor
- Medical Research Council Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol National Institute of Health Research Biomedical Research Centre, Bristol, UK
| | - Nadia Micali
- Department of Pediatrics Gynaecology and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Great Ormond Street Institute of Child Health, University College London, London, UK.
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14
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Gan K, Tithecott C, Neilson L, Seabrook JA, Dworatzek P. Picky Eating Is Associated with Lower Nutrient Intakes from Children's Home-Packed School Lunches. Nutrients 2021; 13:nu13061759. [PMID: 34064118 PMCID: PMC8224271 DOI: 10.3390/nu13061759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/12/2021] [Accepted: 05/19/2021] [Indexed: 11/23/2022] Open
Abstract
The objective was to assess the relationship between children’s picky eating (PE) status and nutrient intake from home-packed school lunches. The lunches of 321 students, aged 7–10 years, were quantified via cross-sectional direct observation. Children were classified as having PE (n = 155) or not (non-PE; n = 166) based on food neophobia scores and parental perceptions of PE. The PE group consumed significantly less protein, folate, magnesium, potassium, zinc, and vitamins B1, B2, B3, B6, D, and E than the non-PE group; however, both groups consumed amounts exceeding Dietary Reference Intakes (DRIs) for protein, carbohydrates, sugar, sodium, iron, and vitamins B1, B2, B3, B6, B12, and C. Conversely, both groups consumed amounts significantly lower than DRIs for calcium, fibre, folate, magnesium, potassium, zinc, and vitamins A, D, E, and K. The PE group ate significantly less meat and alternatives, vegetables and fruit, and fruit than the non-PE group, and did not meet any of Canada’s Food Guide (2007) recommendations. The non-PE group met recommendations for meat and alternatives only. PE impacts the dietary intake of children’s home-packed lunches; however, many packed lunches were of low nutritional quality. Focus should be placed on provision of nutritionally complete school lunches for all children.
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Affiliation(s)
- Kellseigh Gan
- School of Food and Nutritional Sciences, Brescia University College at Western University, 1285 Western Road, London, ON N6G 1H2, Canada; (K.G.); (C.T.); (L.N.); (J.A.S.)
| | - Carly Tithecott
- School of Food and Nutritional Sciences, Brescia University College at Western University, 1285 Western Road, London, ON N6G 1H2, Canada; (K.G.); (C.T.); (L.N.); (J.A.S.)
| | - Lisa Neilson
- School of Food and Nutritional Sciences, Brescia University College at Western University, 1285 Western Road, London, ON N6G 1H2, Canada; (K.G.); (C.T.); (L.N.); (J.A.S.)
| | - Jamie A. Seabrook
- School of Food and Nutritional Sciences, Brescia University College at Western University, 1285 Western Road, London, ON N6G 1H2, Canada; (K.G.); (C.T.); (L.N.); (J.A.S.)
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada
- Department of Epidemiology & Biostatistics, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada
- Human Environments Analysis Laboratory, Western University, 1151 Richmond Street, London, ON N6A 3K7, Canada
- Children′s Health Research Institute, 800 Commissioners Road East, London, ON N6C 2V5, Canada
- Lawson Health Research Institute, 750 Base Line Road East, Suite 300, London, ON N6C 2R5, Canada
| | - Paula Dworatzek
- School of Food and Nutritional Sciences, Brescia University College at Western University, 1285 Western Road, London, ON N6G 1H2, Canada; (K.G.); (C.T.); (L.N.); (J.A.S.)
- Schulich Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, Western University, 1465 Richmond St., London, ON N6G 2M1, Canada
- Correspondence: ; Tel.: +1-519-432-8353
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15
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Abstract
Eating behaviors may be expressions of genetic risk for obesity and are potential antecedents of later eating disorders. However, childhood eating behaviors are heterogeneous and transient. Here we show associations between polygenic scores for body mass index (BMI-PGS) and anorexia nervosa (AN-PGS) with eating behavior trajectories during the first ten years of life using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), N=7,825. Results indicated that one standard deviation (SD) increase in the BMI-PGS was associated with a 30-37% increased risk for early- and mid-childhood overeating. In contrast, one SD increase in BMI-PGS was associated with a 20% decrease in risk of persistent high levels of undereating and a 15% decrease in risk of persistent fussy eating. There was no evidence for a significant association between AN-PGS and eating behavior trajectories. Our results support the notion that child eating behavior share common genetic variants associated with BMI.
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16
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Jansen PW, Derks IPM, Mou Y, van Rijen EHM, Gaillard R, Micali N, Voortman T, Hillegers MHJ. Associations of parents' use of food as reward with children's eating behaviour and BMI in a population-based cohort. Pediatr Obes 2020; 15:e12662. [PMID: 32548949 PMCID: PMC7583369 DOI: 10.1111/ijpo.12662] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Parents' use of food as reward has been linked to children's dietary intake, but the association with children's eating behaviour and overweight risk is less clear. OBJECTIVES To examine the temporal association of using food as reward with eating behaviour, body mass index (BMI) and weight status of children. METHODS Participants were 3642 children of the population-based Generation R Study in the Netherlands (8.3% overweight/obese). Repeated assessments were collected at child ages 4 and 9 years, including measured anthropometrics and parent reports on feeding practises and eating behaviour. RESULTS Linear regressions and cross-lagged models indicated that parents' use of food as reward at child age 4 years predicted Emotional Overeating and Picky Eating at age 9 years. Reversely, higher Emotional Overeating and Food Responsiveness scores were associated with more use of food as reward over time. Using food as reward was not associated with children's satiety response, BMI or overweight risk. CONCLUSIONS A vicious cycle may appear in which children who display food approach behaviour are rewarded with food by their parents, which in turn might contribute to the development of unhealthy eating habits (emotional eating, fussiness). These findings warrant further research, to facilitate evidence-based recommendations for parents.
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Affiliation(s)
- Pauline W. Jansen
- Department of Child and Adolescent Psychiatry/PsychologyErasmus MC‐University Medical Centre RotterdamRotterdamThe Netherlands,Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
| | - Ivonne P. M. Derks
- Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
| | - Yuchan Mou
- The Generation R Study GroupErasmus MC‐University Medical Centre RotterdamRotterdamThe Netherlands,Department of EpidemiologyErasmus MC‐University Medical Centre RotterdamRotterdamThe Netherlands
| | - Elisabeth H. M. van Rijen
- Department of Psychology, Education and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
| | - Romy Gaillard
- Department of PaediatricsErasmus MC‐University Medical Centre RotterdamRotterdamThe Netherlands
| | - Nadia Micali
- Department of Psychiatry, Faculty of MedicineUniversity of GenevaGenevaSwitzerland,Department of PsychiatryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA,Institute of Child Health, University College LondonLondonUK
| | - Trudy Voortman
- Department of EpidemiologyErasmus MC‐University Medical Centre RotterdamRotterdamThe Netherlands
| | - Manon H. J. Hillegers
- Department of Child and Adolescent Psychiatry/PsychologyErasmus MC‐University Medical Centre RotterdamRotterdamThe Netherlands
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17
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Thomas R, Siliquini R, Hillegers MH, Jansen PW. The association of adverse life events with children's emotional overeating and restrained eating in a population-based cohort. Int J Eat Disord 2020; 53:1709-1718. [PMID: 32702148 PMCID: PMC7589411 DOI: 10.1002/eat.23351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/28/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Life adversities are recognized risk factors for eating disorders, in adolescents and adults, but whether such adversities are also associated with particular eating behaviors earlier in life is still unclear. Our aim was to assess whether experiencing adverse life events in early childhood is associated with emotional overeating and restrained eating at age 10. METHODS Emotional overeating and restrained eating were assessed in 4,653 10-years-old children using the mother-reported Children's Eating Behavior Questionnaire and Dutch Eating Behavior Questionnaire. Mothers also reported on 24 different life events during childhood, those with moderate or severe impact being categorized as adverse life events. Regression analyses were performed to investigate relationships between adverse life events and eating behaviors in the total sample. RESULTS Adjusted for covariates, adverse life events were associated with more emotional overeating and restrained eating in children (p-values for trend <.01). Specifically, mothers who reported that their child experienced 3+ adverse life events, also reported significantly higher emotional overeating (B = 0.20; 95% confidence interval [CI], 0.06-0.33) and restrained eating (B = 0.21; 95% CI, 0.08-0.33) in their children relative to children who did not experience adverse life events. These results did not differ by sex. DISCUSSION Our results based on mother-reported data suggest that children's experiences of life adversities are associated with emotional overeating and restrained eating at age 10 years. We recommend future prospective studies using multi-informant assessments of both adverse life events and eating behaviors to further describe the nature and developmental course of this relationship.
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Affiliation(s)
- Robin Thomas
- Department of Child and Adolescent Psychiatry/PsychologyErasmus MC‐University Medical CenterRotterdamThe Netherlands,Department of Public HealthUniversity of TorinoTorinoItaly
| | | | - Manon H. Hillegers
- Department of Child and Adolescent Psychiatry/PsychologyErasmus MC‐University Medical CenterRotterdamThe Netherlands
| | - Pauline W. Jansen
- Department of Child and Adolescent Psychiatry/PsychologyErasmus MC‐University Medical CenterRotterdamThe Netherlands,Department of Psychology, Education, and Child StudiesErasmus University RotterdamRotterdamThe Netherlands
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18
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Herle M, Stavola BD, Hübel C, Ferreira DLS, Abdulkadir M, Yilmaz Z, Loos RJF, Bryant-Waugh R, Bulik CM, Micali N. Eating behavior trajectories in the first 10 years of life and their relationship with BMI. Int J Obes (Lond) 2020; 44:1766-1775. [PMID: 32461555 PMCID: PMC7610465 DOI: 10.1038/s41366-020-0581-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 03/03/2020] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
Background Child eating behaviors are highly heterogeneous and their longitudinal impact on childhood weight is unclear. The objective of this study was to characterize eating behaviors during the first ten years of life and evaluate associations with BMI at age 11 years. Method Data were parental reports of eating behaviors from 15 months to age 10 years (n=12,048) and standardized body mass index (zBMI) at age 11 years (n=4884) from the Avon Longitudinal Study of Parents and Children. Latent class growth analysis was used to derive latent classes of over-, under-, and fussy eating. Linear regression models for zBMI at 11 years on each set of classes were fitted to assess associations with eating behavior trajectories. Results We identified four classes of overeating; “low stable” (70%), “low transient” (15%), “late increasing” (11%), and “early increasing” (6%). The “early increasing” class was associated with higher zBMI (boys: β=0.83, 95%CI:0.65, 1.02; girls: β=1.1; 0.92, 1.28) compared to “low stable”. Six classes were found for undereating; “low stable” (25%), “low transient” (37%), “low decreasing” (21%), “high transient” (11%), “high decreasing” (4%), and “high stable” (2%). The latter was associated with lower zBMI (boys: β=-0.79; -1.15, -0.42; girls: β=-0.76; -1.06, -0.45). Six classes were found for fussy eating; “low stable” (23%), “low transient” (15%), “low increasing” (28%), “high decreasing” (14%), “low increasing” (13%), “high stable” (8%). The “high stable”class was associated with lower zBMI(boys: β =-0.49; -0.68 -0.30; girls: β =-0.35;-0.52, -0.18). Conclusions Early increasing overeating during childhoodis associated with higher zBMI at age 11. High persistent levels of undereating and fussy eating are associated with lower zBMI. Longitudinal trajectories of eating behaviors may help identify children potentially at risk of adverse weight outcomes.
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Affiliation(s)
- Moritz Herle
- Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Bianca De Stavola
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Christopher Hübel
- Social, Genetic & Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,UK National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health, South London and Maudsley Hospital, London, UK.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Diana L Santos Ferreira
- Medical Research Council Integrative Epidemiology, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mohamed Abdulkadir
- Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Zeynep Yilmaz
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ruth J F Loos
- Icahn Mount Sinai School of Medicine, New York, NY, USA
| | - Rachel Bryant-Waugh
- Maudsley Centre for Child and Adolescent Eating Disorders, Michael Rutter Centre for Children and Young People, Maudsley Hospital, London, UK
| | - Cynthia M Bulik
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nadia Micali
- Great Ormond Street Institute of Child Health, University College London, London, UK. .,Department of Psychiatry, Faculty of Medicine, University of Geneva, Geneva, Switzerland. .,Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Child and Adolescent Psychiatry Division, Department of Child and Adolescent Health, Geneva University Hospital, Geneva, Switzerland.
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19
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Warkentin S, Santos AC, Oliveira A. Associations of appetitive behaviors in 7-year-old children with their cardiometabolic health at 10 years of age. Nutr Metab Cardiovasc Dis 2020; 30:810-821. [PMID: 32143895 DOI: 10.1016/j.numecd.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Atherosclerosis begins early in life, thus optimal cardiovascular health needs to be promoted early. We investigated whether appetitive behaviors among 7 year olds are associated with their cardiometabolic health years later. METHODS AND RESULTS A sample of 2951 children from a Portuguese birth cohort was analyzed. The Children's Eating Behavior Questionnaire assessed eating behaviors, and a measure of cardiometabolic risk (higher risk group: those in the upper quartile of triglycerides, homeostatic model assessment-insulin resistance, waist circumference and systolic blood pressure and in the lower quartile of high-density lipoprotein cholesterol z-scores) was created. Linear and logistic regressions were run. Children with more food avoidant behaviors had lower cardiometabolic risk (Satiety Responsiveness - boys: OR = 0.39, 95% CI 0.16; 0.93, girls: OR=0.37, 95% CI 0.17; 0.82 and Slowness in eating - boys: OR = 0.49, 95% CI 0.25; 0.95, girls: OR = 0.49, 95% CI 0.27; 0.91). Food approach behaviors (Food responsiveness (CEBQ-FR), Enjoyment of food (CEBQ-EF) and Emotional overeating (CEBQ-EOE)) increased cardiometabolic risks (e.g. CEBQ-FR: boys: OR = 2.50, 95% CI 1.45; 4.32, girls: OR = 2.33, 95% CI 1.46; 3.71). CEBQ-EF had stronger effects in boys, while CEBQ-EOE was positively associated with cardiometabolic risk among girls. When adjusting for BMIz at 7y, associations did not remain significant. Appetitive behaviors were also associated with isolated cardiometabolic parameters; the strongest association being with waist circumference. CONCLUSIONS Appetitive behaviors at 7-years are associated with cardiometabolic risk at age 10. While 'food avoidant' behaviors protect against cardiometabolic risk and 'food approach' behaviors increase cardiometabolic risk, these associations are largely dependent of child's adiposity.
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Affiliation(s)
- Sarah Warkentin
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], Porto, Portugal.
| | - Ana Cristina Santos
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], Porto, Portugal; Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Andreia Oliveira
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto [Institute of Public Health, University of Porto], Porto, Portugal; Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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20
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Costa A, Severo M, Vilela S, Fildes A, Oliveira A. Bidirectional relationships between appetitive behaviours and body mass index in childhood: a cross-lagged analysis in the Generation XXI birth cohort. Eur J Nutr 2020; 60:239-247. [PMID: 32270288 DOI: 10.1007/s00394-020-02238-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 03/25/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Appetitive behaviours have been associated with body mass index (BMI). However, existing data were largely derived from cross-sectional studies and cannot provide insight into the direction of associations. We aimed to explore the bidirectionality of these associations in school-age children. METHODS Participants are from the Generation XXI birth cohort, assessed at both 7 and 10 years of age (n = 4264; twins excluded). The Children's Eating Behaviour Questionnaire (CEBQ) was used to measure appetitive behaviours (8 subscales). Anthropometrics were measured and WHO BMI z-score was calculated. Cross-lagged analyses were performed to compare the magnitude and direction of the associations (behaviours at 7 years to BMI z-score at 10 years and the reverse) (covariates: child's sex, physical exercise, maternal age and education; plus BMI z-score at age 7 or, in the reverse direction, the subscale score). RESULTS In cross-lagged analyses, appetitive behaviours at 10 years of age (apart from emotional undereating) were shown to be reactive to the child BMI z-score at 7 years of age. Only slowness in eating was significantly related to subsequent BMI. However, the strongest association was from the child BMI z-score to the behaviour (βstandardized = - 0.028 compared with βstandardized = - 0.103, likelihood ratio test p < 0.001). CONCLUSIONS BMI at age 7 was related to appetitive behaviours at 10 years of age, rather than the reverse. This suggests that children with a higher BMI in middle childhood are at increased risk of developing an avid appetite over time.
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Affiliation(s)
- Alexandra Costa
- EPIUnit-Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - Milton Severo
- EPIUnit-Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sofia Vilela
- EPIUnit-Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - Alison Fildes
- School of Psychology, University of Leeds, Leeds, LS2 9JT, England
| | - Andreia Oliveira
- EPIUnit-Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal.
- Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal.
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21
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Power TG, Hidalgo-Mendez J, Fisher JO, O’Connor TM, Micheli N, Hughes SO. Obesity risk in Hispanic children: Bidirectional associations between child eating behavior and child weight status over time. Eat Behav 2020; 36:101366. [PMID: 31962209 PMCID: PMC7044049 DOI: 10.1016/j.eatbeh.2020.101366] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 02/08/2023]
Abstract
Individual differences in eating behaviors have been associated with obesity among young children. Food responsiveness tends to be positively associated with childhood obesity, satiety responsiveness tends to show a negative association, and the results for emotional overeating are mixed. Previous studies in this area, however, have generally employed cross-sectional designs. The purpose of the present study was to examine, in a sample of Hispanic children from families with low-income levels, the degree to which individual differences in child eating behaviors in the preschool years predicted changes in child weight into the early elementary school years. Parent/child dyads (n = 113) were seen on three separate occasions starting when the children were 4-years-old and ending when they were 8-years-old. Separate cross-lag panel analyses were conducted for food responsiveness, satiety responsiveness, and emotional overeating in examining the relationships between child eating behavior and child weight status over time. Consistent with previous cross-sectional studies, at all three time points, food responsiveness was positively associated with concurrent child weight status and satiety responsiveness showed a negative relationship. No concurrent relationship with child weight status was found for emotional overeating until the third time point when children were eight-years-old. Only two cross-lag associations between child eating behavior and child weight status were significant: emotional overeating and child weight status showed a bidirectional relationship between the second and third time points. Future longitudinal studies should examine these relationships in other populations.
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Affiliation(s)
- Thomas G. Power
- Department of Human Development, Washington State University, PO Box 644852, Pullman WA 99164, USA
| | - Jackelyn Hidalgo-Mendez
- Department of Human Development, Washington State University, PO Box 644852, Pullman, WA 99164, USA.
| | - Jennifer Orlet Fisher
- Center for Obesity Research and Education, Temple University, 3223 N. Broad Street, Suite 175, Philadelphia, PA 19140, USA.
| | - Teresia M. O’Connor
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates Street, Houston TX 77030, USA
| | - Nilda Micheli
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates Street, Houston, TX 77030, USA.
| | - Sheryl O. Hughes
- USDA/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, 1100 Bates Street, Houston TX 77030, USA
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22
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Taylor CM, Steer CD, Hays NP, Emmett PM. Growth and body composition in children who are picky eaters: a longitudinal view. Eur J Clin Nutr 2019; 73:869-878. [PMID: 29995831 PMCID: PMC6215483 DOI: 10.1038/s41430-018-0250-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND/OBJECTIVES Picky eating may be associated with higher risk of being underweight and poor growth over time or conversely, being overweight. Our aim was to investigate if children identified as picky eaters showed differences in height, weight and body composition from their non-picky peers. SUBJECTS/METHODS Picky eaters were identified in the Avon Longitudinal Study of Parents and Children cohort at 3 years of age. Height and weight were measured on seven occasions (age 7-17 years). Body composition was measured on five occasions by dual-energy x-ray absorptiometry (age 9-17 years). Participants were classified as thin/normal/overweight or obese at each age point using body mass index (BMI) classifications. Data were analysed with adjusted multiple regression analysis and mixed-design repeated measures ANOVA. RESULTS There was a main effect of being a picky child on height and weight (and on BMI and lean mass index (LMI) in boys) (lower in the picky children, all p ≤ 0.044), but not on percentage body fat or fat mass index (and not on BMI and LMI in girls) (all p > 0.2). The mean heights, weights and BMIs of picky eaters were consistently above the 50th centiles of reference growth charts. More than two-thirds of picky eaters were not thin at any age point. However, being a picky eater was predictive of being thin at a few age points. CONCLUSIONS The growth trajectories of children who were picky eaters were reassuring. The prevalence of thinness amongst some picky eaters is notable, suggesting that some children may need specific early identification, intervention and growth surveillance.
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Affiliation(s)
- Caroline M Taylor
- Centre for Child and Adolescent Health, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Colin D Steer
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Pauline M Emmett
- Centre for Child and Adolescent Health, Bristol Medical School, University of Bristol, Bristol, UK
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23
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de Lauzon-Guillain B, Koudou YA, Botton J, Forhan A, Carles S, Pelloux V, Clément K, Ong KK, Charles MA, Heude B. Association between genetic obesity susceptibility and mother-reported eating behaviour in children up to 5 years. Pediatr Obes 2019; 14:e12496. [PMID: 30702799 DOI: 10.1111/ijpo.12496] [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: 05/25/2018] [Accepted: 11/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Many genetic polymorphisms identified by genome-wide association studies for adult body mass index (BMI) have been suggested to regulate food intake. OBJECTIVE The objective was to study the associations between a genetic obesity risk score, appetitive traits, and growth of children up to age 5 years, with a longitudinal design. METHODS In 1142 children from the Etude des Déterminants pre et post natals de la santé de l'ENfant (EDEN) birth cohort, a combined obesity risk-allele score (BMI genetic risk score [GRS]) was related to appetitive traits (energy intake up to 12 mo, a single item on appetite from 4 mo to 3 y, a validated appetite score at 5 y) using Poisson regressions with robust standard errors. The potential mediation of appetitive traits on the association between BMI-GRS and growth was assessed by the Sobel test. RESULTS Children with a high BMI-GRS were more likely to have high energy intake at 1 year and high appetite at 2 and 5 years. High energy intake in infancy and high appetite from 1 year were related to higher subsequent BMI. High 2-year appetite seemed to partially mediate the associations between BMI-GRS and BMI from 2 to 5 years (all P ≤ 0.05). CONCLUSIONS Genetic susceptibility to childhood obesity seems to be partially explained by appetitive traits in infancy, followed by an early childhood rise in BMI.
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Affiliation(s)
- Blandine de Lauzon-Guillain
- INSERM, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France.,Paris Descartes University, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Paris, France.,INRA, U1125 Epidemiology and Biostatistics Sorbonne Paris Cité Center (CRESS), Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France
| | - Yves Akoli Koudou
- INSERM, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France
| | - Jérémie Botton
- INSERM, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France.,Faculty of Pharmacy, University of Paris-Sud, Université Paris-Saclay, France
| | - Anne Forhan
- INSERM, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France.,Paris Descartes University, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Paris, France
| | - Sophie Carles
- INSERM, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France
| | - Véronique Pelloux
- Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.,INSERM, UMRS 1166, Nutriomic Team 6, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, UMRS1166, Paris, France
| | - Karine Clément
- Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.,INSERM, UMRS 1166, Nutriomic Team 6, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, UMRS1166, Paris, France
| | - Ken K Ong
- Medical Research Council Epidemiology Unit and Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Marie Aline Charles
- INSERM, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France.,Paris Descartes University, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Paris, France
| | - Barbara Heude
- INSERM, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Early Origin of the Child's Health and Development Team (ORCHAD), Paris, France.,Paris Descartes University, UMR1153 Epidemiology and Biostatistics Sorbonne Paris Cité Center, Paris, France
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24
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Taylor CM, Hays NP, Emmett PM. Diet at Age 10 and 13 Years in Children Identified as Picky Eaters at Age 3 Years and in Children Who Are Persistent Picky Eaters in A Longitudinal Birth Cohort Study. Nutrients 2019; 11:E807. [PMID: 30974806 PMCID: PMC6521015 DOI: 10.3390/nu11040807] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/21/2019] [Accepted: 04/04/2019] [Indexed: 02/01/2023] Open
Abstract
Picky eating has been associated with lower intakes of some nutrients and foods during preschool ages but there is little known about the longer-term diet. The aim of this study was to characterise the diets of children aged 10 and 13 years who had been identified as: (1) picky eaters at age 3 years (cross-sectional); and (2) picky eaters at 2-5.5 years old (longitudinal). Picky eating behaviour (PE) was identified in the Avon Longitudinal Study of Parents and Children (ALSPAC) from parental/caregiver questionnaires. Dietary intake was assessed at age 3.5 years and repeated at 10 and 13 years. For cross-sectional PE compared with non-PE there were differences at age 10 years that were similar to those at 3.5 years: lower intakes of protein (-5%) and fibre (-7%) and of meat (-15%), fruit (-10%) and vegetables (-33%). At 13 years, differences in vegetable (-23%), fruit (-14%) and meat (-8%) intakes were evident. For longitudinal (persistent) PE, differences were more pronounced at each age. More effective strategies to help parents to widen the food choices of their children at early ages need to be developed, focusing particularly on vegetable and fruit intakes.
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Affiliation(s)
- Caroline M Taylor
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol BS8 1NU, UK.
| | - Nicholas P Hays
- Nestlé Product Technology Center-Nutrition, La Tour-de-Peilz, 1800 Vevey, Switzerland.
| | - Pauline M Emmett
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol BS8 1NU, UK.
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25
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A Narrative Review of Childhood Picky Eating and Its Relationship to Food Intakes, Nutritional Status, and Growth. Nutrients 2018; 10:nu10121992. [PMID: 30558328 PMCID: PMC6316224 DOI: 10.3390/nu10121992] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 11/18/2022] Open
Abstract
A main characteristic of children perceived as picky eaters is their tendency to avoid certain foods or food groups. The goal of this narrative review is to provide an overview of published studies that have examined whether picky eating in childhood is in fact associated with measurable differences in food and/or nutrient intakes and growth. While picky eaters appear to consume less vegetables compared to non-picky eaters, no consistent differences were observed for the intakes of other food groups or the intakes of energy, macronutrients and dietary fiber. Although, in some studies, picky eaters had lower intakes of certain vitamins and minerals, the levels consumed generally exceeded the recommended values, suggesting nutritional requirements are being met. No consistent relationship between childhood picky eating and growth status was observed, although significant differences in body weight/growth between picky and non-picky eaters were most discernible in studies where multiple defining criteria were used to identify picky eating. The research area would benefit from the adoption of a uniform definition of picky eating. More longitudinal assessments are also required to understand the long-term impact of picky eating on nutritional status and growth.
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26
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Ellis JM, Zickgraf HF, Galloway AT, Essayli JH, Whited MC. A functional description of adult picky eating using latent profile analysis. Int J Behav Nutr Phys Act 2018; 15:109. [PMID: 30400944 PMCID: PMC6220498 DOI: 10.1186/s12966-018-0743-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Research has indicated that adult picky eating (PE) is associated with elevated psychosocial impairment and limited dietary variety and fruit and vegetable intake; however, research operationalizing PE behaviors is limited. Previous research identified a PE profile in children, marked by high food avoidance (satiety responsiveness, fussiness, and slow eating) and low food approach (food enjoyment and responsiveness) appetitive traits. The present study aimed to replicate a similar latent eating behavior profile in an adult sample. METHODS A sample of 1339 US adults recruited through Amazon's MTurk completed an online survey that included a modified self-report version of the Child Eating Behavior Questionnaire (CEBQ-A). Latent profile analysis was employed to identify eating profiles using the CEBQ-A subscales, ANCOVAs were employed to examine profile differences on various self-report measures, and eating profiles were compared across BMI classifications. RESULTS Analyses converged on a four-profile solution, and a picky eater profile that closely resembled the past child profile emerged. Participants in the picky eater profile (18.1%) scored higher on measures of adult PE and social eating anxiety compared to all other profiles, scored higher on eating-related impairment and depression than moderate eating profiles, and were more likely to be of normal weight. DISCUSSION A distinct adult PE profile was observed, indicating childhood PE and appetitive behaviors may carry over into adulthood. Research identifying meaningful groups of picky eaters will help to shed light on the conditions under which picky eating is a risk factor for significant psychosocial impairment or distress, or weight-related problems.
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Affiliation(s)
- Jordan M Ellis
- Department of Psychology, East Carolina University, East Fifth Street, 104 Rawl Building, Greenville, NC, 27858-4353, USA.
| | - Hana F Zickgraf
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Amy T Galloway
- Department of Psychology, Appalachian State University, 222 Joyce Lawrence Ln, P.O. Box 32109, Boone, NC, 28608, USA
| | - Jamal H Essayli
- Department of Psychiatry, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA, 17033, USA
| | - Matthew C Whited
- Department of Psychology, East Carolina University, East Fifth Street, 104 Rawl Building, Greenville, NC, 27858-4353, USA
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27
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Abstract
Picky eating is a common behaviour in early childhood. There is neither a universally accepted definition of picky eating, nor is there agreement on the best tool to identify it. Causes of picky eating include early feeding difficulties, late introduction of lumpy foods at weaning, pressure to eat and early choosiness, especially if the mother is worried by this; protective factors include the provision of fresh foods and eating the same meal as the child. The consequences for the child's diet include poor dietary variety and a possible distortion of nutrient intakes, with low intakes of iron and zinc (associated with low intakes of meat, and fruit and vegetables) being of particular concern. Low intakes of dietary fibre, as a result of low intakes of fruit and vegetables, are associated with constipation in picky eaters. There may be developmental difficulties in some children with persistent picky eating. There is little evidence, however, for a consistent effect of being a picky eater on growth trajectories. There may be a small subgroup of children in whom picky eating does not resolve who might be at risk of thinness during adolescence, or of developing an eating disorder or adult picky eating: these children need to be identified at an early age to enable support, monitoring and advice to be offered to parents. Strategies for avoiding or ameliorating picky eating include repeated exposures to unfamiliar foods, parental modelling of eating fruit and vegetables and unfamiliar foods, and the creation of positive social experiences around mealtimes.
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28
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Emmett PM, Hays NP, Taylor CM. Antecedents of picky eating behaviour in young children. Appetite 2018; 130:163-173. [PMID: 30099068 PMCID: PMC6173797 DOI: 10.1016/j.appet.2018.07.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/16/2018] [Accepted: 07/27/2018] [Indexed: 01/15/2023]
Abstract
Background Picky eating behaviour in young children is a common concern for parents. Objective To investigate early life factors which are associated with a child becoming a picky eater. Design Singleton children from the Avon Longitudinal Study of Parents and Children were studied prospectively (n = 5758–6608). Parental-completion questionnaires were used to define ‘picky eating’ status at age 3 years, and child and parental feeding behaviours and practices throughout the first 2 years of life. Multinomial logistic regression models with 3 levels of picky eating (not, somewhat and very picky) as the dependant variables tested associations with antecedent variables, from pregnancy, and the first and second year of life, separately, then combining all significant variables in a final model. Results Feeding difficulties during complementary feeding and late introduction of lumpy foods (after 9 months) were associated with increased likelihood of the child being very picky. A strong predictor was the child being choosy at 15 months, particularly if the mother was worried about this behaviour. Many children (56%) were considered to be choosy at 15 months: 17% went on to be very picky at 3 years if the mother was not worried, compared with 50% if the mother was very worried by the choosiness. The mother providing fresh fruit and eating the same meal as the child were protective against later ‘picky eating’, while feeding ready-prepared food was predictive. Conclusion Advice and support to parents could help to reduce picky eating behaviour. Parents should be encouraged to introduce lumpy foods by 9 months, to feed fresh foods particularly fruit, and to eat with their children. Parents should be reassured that choosiness is normal and to continue to provide a variety of foods.
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Affiliation(s)
- Pauline M Emmett
- Centre for Child and Adolescent Health, Bristol Medical School, University of Bristol, UK.
| | - Nicholas P Hays
- Nestlé Product Technology Center - Nutrition, La Tour-de-Peilz, Switzerland
| | - Caroline M Taylor
- Centre for Child and Adolescent Health, Bristol Medical School, University of Bristol, UK
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29
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Zickgraf HF, Rigby A. The Adult Eating Behaviour Questionnaire in a bariatric surgery-seeking sample: Factor structure, convergent validity, and associations with BMI. EUROPEAN EATING DISORDERS REVIEW 2018; 27:97-104. [PMID: 30039633 DOI: 10.1002/erv.2628] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/25/2018] [Accepted: 07/01/2018] [Indexed: 11/07/2022]
Abstract
The aim of this study was to validate the Adult Eating Behaviour Questionnaire (AEBQ), a measure of food approach and avoidant traits, for use in bariatric surgery candidates. Participants were 337 bariatric surgery candidates in the Mid-Atlantic United States. Confirmatory factor analysis suggested that one item did not load onto its original factor. A 34-item, eight-factor model had better fit than a seven-factor model; dropping the Hunger factor, as previously suggested, did not improve fit. The factors had good internal consistency and showed convergent/divergent validity with an existing measure of food approach traits. The emotional overeating scale was positively correlated with BMI at programme entry, whereas the slow eating scale was negatively correlated with baseline weight. The AEBQ scales had the same pattern of intercorrelations and similar means to those of two previously published samples. The AEBQ is a valid measure of appetitive traits in bariatric candidates.
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Affiliation(s)
- Hana F Zickgraf
- Penn State College of Medicine, Hershey Medical Center, Hershey, PA, USA
| | - Andrea Rigby
- Penn State College of Medicine, Hershey Medical Center, Hershey, PA, USA
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30
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Abstract
OBJECTIVE Few studies on child feeding have focused on family dynamics or disadvantaged families, yet feeding occurs in the complex social, economic, and relational context of the family. We examined how the level (high vs low) and concordance (concordant vs discordant) of nonresponsive feeding practices of mothers and fathers are associated with child fussy eating, in a socioeconomically disadvantaged Australian sample. METHODS Mother-father pairs (N = 208) of children aged 2 to 5 years old independently completed validated questionnaires reporting their "persuasive feeding," "reward for eating," "reward for behavior," and child's "food fussiness." The fussiness scores did not differ between mother-father pairs and were averaged to derive a single dependent variable. K-means cluster analyses were used to assign mother-father pairs to clusters for each feeding practice, based on mean scores. Three ANCOVAs, corresponding to each feeding practice, tested differences in child fussiness across clusters while controlling for covariates. RESULTS Four clusters were identified for each feeding practice-concordant: (1) high (MHi/FHi) for both parents and (2) low (MLo/FLo) for both parents; and discordant: (3) high for mother but low for father (MHi/FLo); and (4) low for mother but high for father (MLo/FHi). For "persuasive feeding," MLo/FLo reported lower levels of fussiness compared with MHi/FLo, MHi/FHi, and MLo/FHi (p values < 0.05). For "reward for eating," MLo/FLo reported lower levels of fussiness than did MHi/FHi (p < 0.05). Child fussiness did not differ across "reward for behavior" clusters. CONCLUSION In socioeconomically disadvantaged families, when parents are concordant in avoiding nonresponsive feeding practices, less child "food fussiness" is reported. Findings suggest that feeding interventions should consider inclusion of both parents in 2-parent households.
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31
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Costa S, Pinto A, Santos AC, Oliveira A. The association of problematic eating behaviours with food quality and body mass index at 7 years of age. Eur J Clin Nutr 2018; 73:549-557. [PMID: 29748660 DOI: 10.1038/s41430-018-0169-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES There is scarce evidence of how certain eating behaviours compromise the compliance with dietary guidelines and weight status in school-aged children. This study aims to evaluate the association of children's problematic eating behaviours with food quality and body mass index at 7 years of age. SUBJECTS/METHODS Participants were children aged 7 years old from a population-based cohort study from Porto, Portugal-Generation XXI. Children's quantity and speed of ingestion, food refusal at the table and food rewards requesting were evaluated by caregiver's perception. Food consumption was evaluated by a food frequency questionnaire and compared with age-appropriate guidelines. Children's weight status was assessed by objective measurements and parent's perceptions. Associations were estimated by logistic regressions (odds ratio (OR), 95% confidence intervals (95% CI)) adjusted for maternal age, education, smoking during pregnancy, birth type, child's sex, weight-for-gestational age and sports (n = 3801). RESULTS Children eating small amounts of food, refusing to eat at the table with the rest of the family during meals and asking for food rewards showed a higher consumption of energy-dense foods (OR = 1.51; 95% CI:1.23-1.86; OR = 1.58; 95% CI:1.16-2.16; OR = 1.56; 95% CI:1.14-2.12) and presented higher odds of consuming fruit and vegetables below recommendations (OR = 1.41; 95% CI:1.22-1.64; OR = 1.20; 95% CI:1.00-1.45; OR = 1.28; 95% CI:1.05-1.55). Children displaying these eating behaviours were less likely to be overweight/obese, hence their parents were less likely to show concern with their weight. Including food quality as covariate in the final models with obesity status did not change the associations. CONCLUSIONS Problematic eating behaviours were associated with poorer food quality (more energy-dense foods and low fruit and vegetables), but food quality does not seem to explain the association with obesity status. Parents were less likely to be concerned about their child's weight if the child ate slowly or poorly, and accordingly the odds of them being overweight or obese were lower.
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Affiliation(s)
- Sara Costa
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Andreia Pinto
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Ana Cristina Santos
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Unit of Epidemiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Andreia Oliveira
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal. .,Department of Public Health and Forensic Sciences, and Medical Education, Unit of Epidemiology, Faculty of Medicine, University of Porto, Porto, Portugal.
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What’s the fuss about? Parent presentations of fussy eating to a parenting support helpline. Public Health Nutr 2018; 21:1520-1528. [DOI: 10.1017/s1368980017004049] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveTo characterise parent presentations of fussy eating and mealtime interactions at a point of crisis, through analyses of real-time recordings of calls to a parenting helpline.DesignQualitative analysis included an inductive thematic approach to examine clinical parent presentations of fussy eating and derive underlying themes relating to mealtime interactions.SettingCalls made to the Child Health Line regarding feeding concerns were recorded and transcribed verbatim.SubjectsFrom a corpus of 723 calls made during a 4-week period in 2009, twelve were from parents of children aged 6–48 months.ResultsParents of infants (≤12 months, n 6) presented feeding concerns as learning challenges in the process of transitioning from a milk-based to a solid-based diet, while parents of toddlers (13–48 months, n 6) presented emotional accounts of feeding as an intractable problem. Parents presented their child’s eating behaviour as a battle (conflict), in which their children’s agency over limited intake and variety of foods (child control) was constructed as ‘bad’ or ‘wrong’. Escalating parent anxiety (parent concern) had evoked parent non-responsive feeding practices or provision of foods the child preferred.ConclusionsReal-time descriptions of young children’s fussy eating at a time of crisis that initiated parents’ call for help have captured the highly charged emotional underpinnings of mealtime interactions associated with fussy eating. Importantly, they show the child’s emerging assertion of food autonomy can escalate parents’ emotional distress that, in the short term, initiates non-responsive feeding practices. The current study identifies the importance of educational and emotional support for parents across the period of introducing solids.
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Maranhão HDS, Aguiar RCD, Lira DTJD, Sales MÚF, Nóbrega NÁDN. DIFICULDADES ALIMENTARES EM PRÉ-ESCOLARES, PRÁTICAS ALIMENTARES PREGRESSAS E ESTADO NUTRICIONAL. REVISTA PAULISTA DE PEDIATRIA 2017; 36:7. [PMID: 29091129 PMCID: PMC5849369 DOI: 10.1590/1984-0462/;2018;36;1;00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/24/2017] [Indexed: 08/29/2023]
Abstract
Objective: To identify the prevalence of feeding difficulties in preschoolers, its
association with epidemiological factors and previous eating habits, and
repercussion on nutritional status. Methods: Cross-sectional study with a questionnaire given to the mothers of 301 children
aged 2-6 years enrolled in public and private kindergartens in Natal, Northeast
Brazil, conducted in 2014-2015. Feeding difficulty was assessed according to
Kerzner’s criteria, resulting in the profiles “highly selective intake”, “active
child with small appetite”, “fear of feeding”, and “child with psychological
disorder or neglected”. Association with the following independent variables was
analyzed by logistic regression: breastfeeding time, age of cows’ milk and
complementary feeding introduction, age range, family income, type of school,
mothers’ profile (responsive or nonresponsive), and body mass index (BMI). Results: Feeding difficulty was found in 37.2% of cases, with predominance of “highly
selective intake” (25.4%). It was not associated with infancy feeding practices,
family income or type of school. There were no differences between the BMI Z score
means for the groups with and without feeding difficulty (1.0±1.5 SD and 1.1±1.4
SD, respectively). The five-to-six age range had more occurrences (OR 1.8; 95%CI
1.1-2.9). Children of responsive mothers were less likely to have feeding
difficulties (OR 0.4; 95%CI 0.2-0.8). Conclusions: Feeding difficulties were very frequent. Nutritional status was not impacted by
it, and infancy eating habits were not associated with it. Responsive mothers’
profile is a protective factor against eating difficulties and reinforces the
importance of behavioral factors and mother-child interaction.
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Parent-child mealtime interactions associated with toddlers' refusals of novel and familiar foods. Physiol Behav 2017; 176:93-100. [DOI: 10.1016/j.physbeh.2017.03.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/17/2017] [Accepted: 03/02/2017] [Indexed: 01/22/2023]
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Monnereau C, Jansen PW, Tiemeier H, Jaddoe VWV, Felix JF. Influence of genetic variants associated with body mass index on eating behavior in childhood. Obesity (Silver Spring) 2017; 25:765-772. [PMID: 28245097 PMCID: PMC5496668 DOI: 10.1002/oby.21778] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/23/2016] [Accepted: 12/26/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Childhood eating behaviors are associated with body mass index (BMI). Recent genome-wide association studies have identified many single-nucleotide polymorphisms (SNPs) associated with adult and childhood BMI. This study hypothesized that these SNPs also influence eating behavior. METHODS In a population-based prospective cohort study among 3,031 children (mean age [standard deviation]: 4.0 [0.1] years), two weighted genetic risk scores, based on 15 childhood and 97 adult BMI SNPs, and ten individual appetite- and/or satiety-related SNPs were tested for association with food fussiness, food responsiveness, enjoyment of food, satiety responsiveness, and slowness in eating. RESULTS The 15 SNP-based childhood BMI genetic risk score was not associated with the eating behavior subscales. The 97 SNP-based adult BMI genetic risk score was nominally associated with satiety responsiveness (β: -0.007 standard deviation, 95% confidence interval [CI] -0.013, 0.000). Of the 10 individual SNPs, rs11030104 in BDNF and rs10733682 in LMX1B were nominally associated with satiety responsiveness (β: -0.057 standard deviation, 95% CI -0.112, -0.002). CONCLUSIONS These findings do not strongly support the hypothesis that BMI-associated SNPs also influence eating behavior at this age. A potential role for BMI SNPs in satiety responsiveness during childhood was observed; however, no associations with the other eating behavior subscales were found.
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Affiliation(s)
- Claire Monnereau
- The Generation R Study Group, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Pauline W Jansen
- Institute of Psychology, Erasmus University, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Henning Tiemeier
- Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Psychiatry, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Vincent W V Jaddoe
- The Generation R Study Group, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Janine F Felix
- The Generation R Study Group, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Rohde JF, Händel MN, Stougaard M, Olsen NJ, Trærup M, Mortensen EL, Heitmann BL. Relationship between pickiness and subsequent development in body mass index and diet intake in obesity prone normal weight preschool children. PLoS One 2017; 12:e0172772. [PMID: 28296896 PMCID: PMC5351873 DOI: 10.1371/journal.pone.0172772] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 02/09/2017] [Indexed: 11/18/2022] Open
Abstract
Background Most children have periods in their life where they reject familiar as well as non-familiar food items and this is often referred to as pickiness. The consequences of pickiness may be malnutrition and, if prolonged, potentially lower body weight. However, studies investigating the consequence of pickiness on subsequent changes in diet intake and weight are limited. Objectives To examine whether pickiness influences body mass index as well as diet intake over subsequent 15 months among obesity prone normal weight children aged 2–6 years. Methods Data was obtained from the “Healthy Start” intervention study which included 271 children aged 2–6 years susceptible to overweight later in life. Information on pickiness was obtained from a parental questionnaire. Dietary habits were collected by 4-day dietary records filled in by the parents and height and weight were measured by trained health professionals and both measured twice over a 15 month period. Linear regression models were performed to assess the influence of pickiness on body mass index and diet with adjustments for possible confounders. Results No differences in mean BMI Z-score were seen between picky/non-picky (P = 0.68) and little picky/non-picky (P = 0.68) children at 15 month follow-up. Picky children had a lower intake of protein (P = 0.01) than non-picky children despite no differences in total energy intake (P = 0.74), or in the other macronutrients, or the intake of fruit and vegetables, though children being a little picky had a lower intake of starch compared to non-picky children (P = 0.05). Results were essentially similar before and after adjustment for key covariates. Conclusion Our study showed that BMI Z-score after 15 months follow-up was similar for picky and non-picky children. Picky children seemed to develop a lower protein intake despite similar total energy intake and diet composition.
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Affiliation(s)
- Jeanett Friis Rohde
- Research Unit for Dietary Studies at The Parker Institute, Bispebjerg and Frederiksberg University Hospital, The Capital Region, Frederiksberg, Denmark
- National Institute of Public health, University of Southern Denmark, Copenhagen, Denmark
- * E-mail:
| | - Mina Nicole Händel
- Research Unit for Dietary Studies at The Parker Institute, Bispebjerg and Frederiksberg University Hospital, The Capital Region, Frederiksberg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Maria Stougaard
- Research Unit for Dietary Studies at The Parker Institute, Bispebjerg and Frederiksberg University Hospital, The Capital Region, Frederiksberg, Denmark
| | - Nanna Julie Olsen
- Research Unit for Dietary Studies at The Parker Institute, Bispebjerg and Frederiksberg University Hospital, The Capital Region, Frederiksberg, Denmark
| | - Maria Trærup
- Research Unit for Dietary Studies at The Parker Institute, Bispebjerg and Frederiksberg University Hospital, The Capital Region, Frederiksberg, Denmark
| | - Erik Lykke Mortensen
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Berit Lilienthal Heitmann
- Research Unit for Dietary Studies at The Parker Institute, Bispebjerg and Frederiksberg University Hospital, The Capital Region, Frederiksberg, Denmark
- National Institute of Public health, University of Southern Denmark, Copenhagen, Denmark
- Boden Institute of Obesity, Nutrition Exercise & Eating Disorders, University of Sydney, Camperdown, New South Wales, Australia
- Department of Public health, Section for General Medicine, University of Copenhagen, Copenhagen, Denmark
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Gibson EL, Cooke L. Understanding Food Fussiness and Its Implications for Food Choice, Health, Weight and Interventions in Young Children: The Impact of Professor Jane Wardle. Curr Obes Rep 2017; 6:46-56. [PMID: 28205158 DOI: 10.1007/s13679-017-0248-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW This review examines the concepts of fussy eating and food neophobia in the context of key determinants of the development of children's food preferences. We discuss the evidence for genetic versus parental and other environmental influences on the ontogeny of these behavioural traits and the implications of current knowledge for interventions that attempt to lessen the impact of these traits on children's diets. Finally, we consider whether these traits increase the risk of a child becoming obese, or alternatively, underweight and malnourished. RECENT FINDINGS Fussy eating and neophobia are related concepts with both genetic and environmental aetiologies. Parent-child correlations and heritability estimates are moderate to high for both traits, but aspects of the family environment remain influential in young children, although no longer in young adults. Parental strategies based around repeat tasting opportunities can improve acceptance of disliked foods in even the fussiest children. Fussy eating and neophobia are not risk factors for obesity but could limit growth in severe cases. Fussy eating and food neophobia are common concerns for parents, though health risks are low. Dissemination of evidence-based strategies to parents that can encourage a more varied diet in young children would be helpful.
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Affiliation(s)
- E Leigh Gibson
- Department of Psychology, Whitelands College, University of Roehampton, Holybourne Avenue, London, SW15 4JD, UK.
| | - Lucy Cooke
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, UCL, London, UK
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Jansen PW, de Barse LM, Jaddoe VWV, Verhulst FC, Franco OH, Tiemeier H. Bi-directional associations between child fussy eating and parents' pressure to eat: Who influences whom? Physiol Behav 2017; 176:101-106. [PMID: 28215424 PMCID: PMC5436628 DOI: 10.1016/j.physbeh.2017.02.015] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/03/2017] [Accepted: 02/15/2017] [Indexed: 12/12/2022]
Abstract
Background Fussy eating is common in young children, often raising concerns among parents. The use of pressuring feeding practices may provoke or worsen child fussiness, but these practices could equally be a parent’s response to child fussy eating. Objective In longitudinal analyses, we assessed directionality in the relation between fussy eating and parent’s pressure to eat across childhood. Methods Study participants were 4845 mother-child dyads from the population-based Generation R cohort in the Netherlands. The Child Behavior Checklist was used to assess fussy eating (2 items) at child ages 1½, 3 and 6 years. Parents’ pressure to eat was assessed with the Child Feeding Questionnaire (4 items) when children were 4 years old. All scale scores were standardized. Results Linear regression analyses indicated that preschoolers’ fussy eating prospectively predicted higher levels of parents’ pressure to eat at child age 4 years, independently of confounders (adjusted B=0.24, 95% CI: 0.21, 0.27). Pressure to eat at 4 years also predicted more fussiness in children at age 6 years, independently of confounders and of fussy eating at baseline (adjusted B=0.14, 95% CI: 0.11, 0.17). Path analyses indicated that the relation from fussy eating at 3 years to parenting one year later was stronger than from pressure at 4 years to fussy eating two years later (p<0.001). Conclusions Our findings suggest bi-directional associations with parental pressuring feeding strategies being developed in response to children’s food avoidant behaviors, but also seemingly having a counterproductive effect on fussiness. Thus, the use of pressure to eat should be reconsidered, while providing parents alternative techniques to deal with their child’s fussy eating.
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Affiliation(s)
- Pauline W Jansen
- Institute of Psychology, Erasmus University Rotterdam, Netherlands; Department of Child and Adolescent Psychiatry, Psychology, Erasmus MC-Sophia, Netherlands.
| | - Lisanne M de Barse
- The Generation R Study Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Vincent W V Jaddoe
- The Generation R Study Group, Erasmus MC, University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC-Sophia, Netherlands
| | - Frank C Verhulst
- Department of Child and Adolescent Psychiatry, Psychology, Erasmus MC-Sophia, Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Henning Tiemeier
- Department of Child and Adolescent Psychiatry, Psychology, Erasmus MC-Sophia, Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center, Rotterdam, Netherlands; Department of Psychiatry, Erasmus MC, University Medical Center, Rotterdam, Netherlands
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Steinsbekk S, Sveen TH, Fildes A, Llewellyn C, Wichstrøm L. Screening for pickiness - a validation study. Int J Behav Nutr Phys Act 2017; 14:2. [PMID: 28061793 PMCID: PMC5219775 DOI: 10.1186/s12966-016-0458-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 12/20/2016] [Indexed: 11/17/2022] Open
Abstract
Picky eating is prevalent in childhood and is associated with negative health outcomes. Therefore early detection of pickiness is pertinent. Because no psychometric measure of picky/fussy eating has been validated, we aimed to examine the screening efficiency of the 6-item ‘Food Fussiness’ (FF) scale from the Children’s Eating Behavior Questionnaire using structured psychiatric interviews (the Preschool Age Psychiatric Interview), providing meaningful cut-off values based on a large, representative sample of Norwegian 6 year olds (n = 752). Screening efficiency was evaluated using receiver operating characteristic curve analysis, revealing excellent discrimination. The cut-point maximizing the sum of sensitivity and specificity for the scale was found at a score of 3.33 for severe cases and 3.00 when both moderate and severe pickiness were included. The results suggest that the FF scale may provide a tool for identification of clinically significant picky eating, although further assessment may be needed to separate moderate from severe cases.
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Affiliation(s)
- Silje Steinsbekk
- Department of Psychology, Norwegian University of Science and Technology (NTNU) Social Science, Dragvoll, 7491, Trondheim, Norway.
| | - Trude Hamre Sveen
- Department of Psychology, Norwegian University of Science and Technology (NTNU) Social Science, Dragvoll, 7491, Trondheim, Norway
| | - Alison Fildes
- School of Psychology, University of Leeds, Leeds, LS2 9JT, UK
| | - Clare Llewellyn
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK
| | - Lars Wichstrøm
- Department of Psychology, Norwegian University of Science and Technology (NTNU) Social Science, Dragvoll, 7491, Trondheim, Norway
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Berger PK, Hohman EE, Marini ME, Savage JS, Birch LL. Girls' picky eating in childhood is associated with normal weight status from ages 5 to 15 y. Am J Clin Nutr 2016; 104:1577-1582. [PMID: 27797710 PMCID: PMC5118736 DOI: 10.3945/ajcn.116.142430] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/20/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Picky eating has been associated with lower weight status and limited food intake and variety in childhood. Little is known about how the persistence of picky eating in childhood is associated with changes in weight and food intake from childhood into adolescence. OBJECTIVE We determined whether picky eating identified in childhood was related to growth, nutrition, and parental use of pressure over a 10-y period. DESIGN Non-Hispanic white girls (n = 181) participated in a longitudinal study and were assessed biannually from ages 5 to 15 y. The Child Feeding Questionnaire was used to classify girls as persistent picky eaters or nonpicky eaters and to assess parental use of pressure to eat. Height and weight were measured to calculate body mass index (BMI) z scores at each occasion. Three 24-h dietary recalls obtained at each occasion were used to determine intakes of fruit and vegetables. With the use of repeated-measures analyses, differences between persistent picky eaters and nonpicky eaters in BMI z scores, dietary intake, and use of pressure were examined. RESULTS From ages 5 to 15 y, persistent picky eaters (n = 33; 18%) had lower BMI (tracking at the 50th percentile) than did nonpicky eaters (n = 148; tracking at the 65th percentile) (P = 0.02). Persistent picky eaters were less likely to be overweight into adolescence. Both groups consumed less than the recommended amounts of fruit and vegetables, although persistent picky eaters had lower intakes of vegetables than did nonpicky eaters at all time points (P = 0.02). Persistent picky eaters also received higher amounts of pressure (P = 0.01). CONCLUSIONS Findings that persistent picky eaters were within the normal weight range, were less likely to be overweight, and had similar fruit intakes to those of nonpicky eaters suggest that higher parental concerns about persistent picky eaters are unwarranted. All parents and children could benefit from evidence-based anticipatory guidance on alternatives to coercive feeding practices to increase fruit and vegetable consumption.
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Affiliation(s)
- Paige K Berger
- Department of Foods and Nutrition, University of Georgia, Athens, GA; and
| | - Emily E Hohman
- Center for Childhood Obesity Research, Pennsylvania State University, State College, PA
| | - Michele E Marini
- Center for Childhood Obesity Research, Pennsylvania State University, State College, PA
| | - Jennifer S Savage
- Center for Childhood Obesity Research, Pennsylvania State University, State College, PA
| | - Leann L Birch
- Department of Foods and Nutrition, University of Georgia, Athens, GA; and
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Li Z, van der Horst K, Edelson-Fries LR, Yu K, You L, Zhang Y, Vinyes-Pares G, Wang P, Ma D, Yang X, Qin L, Wang J. Perceptions of food intake and weight status among parents of picky eating infants and toddlers in China: A cross-sectional study. Appetite 2016; 108:456-463. [PMID: 27825943 DOI: 10.1016/j.appet.2016.11.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/24/2016] [Accepted: 11/03/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Previous studies have suggested that children that are picky eaters may have a different and less varied diet than non-picky children, but the literature on picky eating in Chinese children is limited. OBJECTIVES To assess the prevalence of picky eating in 6-35 month-old Chinese children, and to explore how parents' perceptions of picky eating relate to children's intake and body composition. METHODS 1414 6-35 month-old infants and toddlers from 8 Chinese cities were included in this study. Questionnaires were used to collect information on family demographic factors, child picky eating behaviors, food group rejection, and parents' perception of child weight status. Dietary intake data was collected via 24-h recall. Children's length/height and weight were measured. RESULTS The reported prevalence of picky eating was higher in 24-35 month-olds (36% of children) compared to 6-11 month-olds (12%). There were no consistent significant differences in dietary intakes of nutrients between picky and non-picky eaters. Picky eating children whose parents indicated that they avoided eggs had lower intake of this food group compared to non-picky eaters, whereas those reported to avoid grains or meat had higher intakes of those food groups. Weight status was underestimated by parents of both picky and non-picky children. CONCLUSIONS Picky eating seems to occur at similar prevalence rates in China as has been reported in other countries. Parents' perceptions of food refusal do not reflect actual intakes, nor do nutrient intakes of picky eaters show additional gaps compared to non-picky eating children. In healthy children with typical growth patterns, picky eating seems to be a normal phase of development experienced by some children, without substantial consequences on their nutrient or food group intakes.
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Affiliation(s)
- Ziyi Li
- Department of Social Medicine and Health Education, School of Public Health, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing 100191, People's Republic of China
| | - Klazine van der Horst
- Nestlé Research Center Lausanne, Vers-chez-les-Blanc, PO Box 44, 1000 Lausanne 26, Switzerland
| | - Lisa R Edelson-Fries
- Nestlé Research Center Lausanne, Vers-chez-les-Blanc, PO Box 44, 1000 Lausanne 26, Switzerland.
| | - Kai Yu
- Nestlé Research Center Beijing, Building E-F, No.5 Dijin Road, Haidian District, Beijing 100095, People's Republic of China; Department of Nutrition and Food Hygiene, School of Public Health, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing 100191, People's Republic of China
| | - Lili You
- Department of Social Medicine and Health Education, School of Public Health, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing 100191, People's Republic of China
| | - Yumei Zhang
- Department of Nutrition and Food Hygiene, School of Public Health, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing 100191, People's Republic of China
| | - Gerard Vinyes-Pares
- Nestlé Research Center Beijing, Building E-F, No.5 Dijin Road, Haidian District, Beijing 100095, People's Republic of China
| | - Peiyu Wang
- Department of Social Medicine and Health Education, School of Public Health, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing 100191, People's Republic of China
| | - Defu Ma
- Department of Social Medicine and Health Education, School of Public Health, Peking University Health Science Center, No.38 Xueyuan Road, Haidian District, Beijing 100191, People's Republic of China
| | - Xiaoguang Yang
- Department of Nutrition and Food Hygiene, Chinese Center for Disease Control and Prevention, No. 155 Changbai Road, Changping District, Beijing 102206, People's Republic of China
| | - Liqiang Qin
- Department of Health Education, School of Public Health, Soochow University, No.199 Renai Road, Suzhou Industrial Park, Suzhou 215325, Jiangsu, People's Republic of China
| | - Jiaji Wang
- School of Public Health and General Medicine, Guangzhou Medical University, No.195 Dongfeng West Road, Guangzhou 510182, Guangdong, People's Republic of China
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Tovar A, Vaughn AE, Fallon M, Hennessy E, Burney R, Østbye T, Ward DS. Providers' response to child eating behaviors: A direct observation study. Appetite 2016; 105:534-41. [PMID: 27328098 PMCID: PMC5067159 DOI: 10.1016/j.appet.2016.06.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 04/22/2016] [Accepted: 06/15/2016] [Indexed: 11/18/2022]
Abstract
Child care providers play an important role in feeding young children, yet little is known about children's influence on providers' feeding practices. This qualitative study examines provider and child (18 months -4 years) feeding interactions. Trained data collectors observed 200 eating occasions in 48 family child care homes and recorded providers' responses to children's meal and snack time behaviors. Child behaviors initiating provider feeding practices were identified and practices were coded according to higher order constructs identified in a recent feeding practices content map. Analysis examined the most common feeding practices providers used to respond to each child behavior. Providers were predominately female (100%), African-American (75%), and obese (77%) and a third of children were overweight/obese (33%). Commonly observed child behaviors were: verbal and non-verbal refusals, verbal and non-verbal acceptance, being "all done", attempts for praise/attention, and asking for seconds. Children's acceptance of food elicited more autonomy supportive practices vs. coercive controlling. Requests for seconds was the most common behavior, resulting in coercive controlling practices (e.g., insisting child eat certain food or clean plate). Future interventions should train providers on responding to children's behaviors and helping children become more aware of internal satiety and hunger cues.
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Affiliation(s)
- Alison Tovar
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI 02881, USA.
| | - Amber E Vaughn
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd, CB 7426, Chapel Hill 27599-7426, NC, USA.
| | - Megan Fallon
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI 02881, USA.
| | - Erin Hennessy
- ChildObesity180, Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Avenue, Boston, MA 02111, USA.
| | - Regan Burney
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd, CB 7426, Chapel Hill 27599-7426, NC, USA.
| | - Truls Østbye
- Duke University Medical Center, 310 Trent Drive, Durham, NC 27710, USA.
| | - Dianne S Ward
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin L. King Jr. Blvd, CB 7426, Chapel Hill 27599-7426, NC, USA.
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Brown CL, Vander Schaaf EB, Cohen GM, Irby MB, Skelton JA. Association of Picky Eating and Food Neophobia with Weight: A Systematic Review. Child Obes 2016; 12:247-62. [PMID: 27135525 PMCID: PMC4964761 DOI: 10.1089/chi.2015.0189] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Picky eating and food neophobia are common during childhood. Childhood eating behaviors are often predictive of adult eating behaviors. OBJECTIVES Determine if childhood picky eating or food neophobia is associated with childhood weight status, or with becoming underweight, overweight, or obese later in childhood. DATA SOURCES We identified relevant studies from searches of PubMed, PsycINFO, and NEOHAL, as well as citations from identified studies. Study Eligibility Criteria and Participants: Inclusion criteria were original research articles examining a relationship between picky eating and/or food neophobia with childhood weight status. We summarized definitions and prevalence of picky eating or food neophobia and association with weight status. STUDY APPRAISAL Two independent investigators assessed bias and confounding using the Agency for Healthcare Research and Quality's RTI Item Bank. RESULTS Forty-one studies met inclusion criteria. Picky eating was defined inconsistently, and a large variation in prevalence was found (5.8%-59%). Food neophobia was consistently defined as an unwillingness to try new foods, with a prevalence between 40% and 60%. No association existed between childhood weight status and food neophobia, and results were unclear for picky eating. LIMITATIONS Risk of bias and confounding were moderate. Parental report was commonly used to assess picky eating, height, and weight and parental weight, feeding styles, and community characteristics were infrequently considered. CONCLUSIONS AND IMPLICATIONS Heterogeneous definitions used for picky eating led to a wide range of reported prevalence and an unclear relationship with weight. Consistent definitions and an improved understanding of such a relationship could help clinicians provide appropriate anticipatory guidance.
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Affiliation(s)
- Callie L. Brown
- Department of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Emily B. Vander Schaaf
- Department of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gail M. Cohen
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC.,Brenner FIT Program, Brenner Children's Hospital, Winston-Salem, NC
| | - Megan B. Irby
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC.,Brenner FIT Program, Brenner Children's Hospital, Winston-Salem, NC
| | - Joseph A. Skelton
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC.,Brenner FIT Program, Brenner Children's Hospital, Winston-Salem, NC.,Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
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