Differential reporting of fruit and vegetable intake among youth in a randomized controlled trial of a behavioral nutrition intervention

Development and validation of the ASKFV-SE tool to measure children's self-efficacy for requesting fruits and vegetables

The aim of the present study was to develop the ASKFV-SE tool to measure self-efficacy (SE) towards requesting fruits and vegetables (FV) in the home and school environment with school-age children (grades 4-5) from urban, ethnically diverse, low-income households. Cognitive interviews reduced the tool from eleven items to seven. The 7-item questionnaire was tested with 444 children. The items loaded on two factors: home SE (four items) and school SE (two items) with one item was excluded (<0⋅40). The reduced 6-item, 2-factor structure was the best fit for the data (χ ² = 45⋅09; df = 9; CFI = 0⋅835; RMSEA = 0⋅147). Confirmatory factory analysis revealed that the 4-item home SE had high reliability (α = 0⋅73) and marginally acceptable reliability for the 2-item school SE (α = 0⋅53). The pre-COVID intra-class correlation coefficient (ICC) was 0⋅584 (P < 0⋅001; fair; n = 57) compared to 0⋅736 during-COVID (P < 0⋅001; good; n 50). The ASKFV-SE tool measures children's SE for asking for FVs with strong psychometric properties and low participant burden.

Effectiveness of medical nutrition therapy in adolescents with type 1 diabetes: a systematic review

BACKGROUND

Medical nutrition therapy (MNT) has an integral role in overall diabetes management. During adolescence, consideration of physiological and psychosocial changes is essential for implementing an optimal diabetes treatment.

OBJECTIVES

Our aim was to identify, summarize, and interpret the published literature about MNT in adolescents with type 1 diabetes.

METHODS

The Medline (PubMed) and EMBASE databases were searched from January 1959 to December 2021. The inclusion criteria were interventional studies with MNT in adolescents with type 1 diabetes with a disease duration over 1 year, including the following outcomes: dietary intake and daily eating patterns (assessed with validated tools, two or more 24 h dietary recall or 3-day dietary records), the diabetes self-management education and support (DSMES), glycemic control, lipid profile and body mass index (BMI). The exclusion criteria were studies without a control group (except for pre-post studies), the lack of randomization and those studies that assessed only a single nutrient, food or meal consumption, as well as reviews, and in-vitro/in-vivo studies. The risk of bias assessment was performed using the Cochrane risk-of-bias tool for randomized trials. A narrative synthesis was performed to present the results. The quality of evidence was assessed with the GRADE guidance.

RESULTS

From a total of 5377 records, 12 intervention studies (9 RCT and 3 pre-post intervention studies) were included. The data were assessed in order to perform a meta-analysis; however, the studies were too heterogeneous. The studies showed conflicting results about the effectiveness of MNT on dietary pattern, DSMES, glycemic control, lipid profile and BMI.

CONCLUSIONS

Clinical research studies on the effectiveness of MNT in adolescents with type 1 diabetes are scarce. The limited number of studies with a high risk of bias precludes establishing robust conclusions on this issue. Further research is warranted.

Intervention for promoting intake of fruits and vegetables in Brazilians: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a nutritional intervention to promote fruit and vegetable (FV) intake.

DESIGN

A randomised controlled community trial was conducted to evaluate the effectiveness of a 7-month nutritional intervention and to promote FV intake, separately and together. All participants attended physical exercise sessions. The intervention was based on the transtheoretical model and Paulo Freire's pedagogy. The interventions included group educational sessions, motivational cards and informational materials. The primary outcome was a change in FV intake (g/d), and secondary outcomes included stages of change, self-efficacy, decisional balance and knowledge on FV. All data were collected face-to-face; and FV intake was assessed using a validated brief questionnaire.

SETTING

Health promotion services of Brazilian Primary Health Care.

PARTICIPANTS

3414 users of Brazilian Primary Health Care (1931 in the control group and 1483 in the intervention group (IG)).

RESULTS

At baseline, the average daily FV intake was 370·4 g/d (95 % CI 364·2, 376·6). The increase in FV intake (23·4 g/d; 95 % CI 6·7, 40·0) and fruit intake (+17·3 g/d; 95 % CI 5·1, 29·4; P = 0·01) was greater in the IG among participants in the lowest baseline intake. Participants in the IG also showed progression in the stages of change (P < 0·001), increased self-efficacy (P < 0·001) and improved knowledge of FV crops (P < 0·001).

CONCLUSIONS

The nutritional intervention was effective in increasing FV intake and fruits intake among individuals with a lower intake at baseline and in maintaining FV intake among those who reported consuming FV as recommended (400 g/d).

Effects of differential measurement error in self-reported diet in longitudinal lifestyle intervention studies

Background

Lifestyle intervention studies often use self-reported measures of diet as an outcome variable to measure changes in dietary intake. The presence of measurement error in self-reported diet due to participant failure to accurately report their diet is well known. Less familiar to researchers is differential measurement error, where the nature of measurement error differs by treatment group and/or time. Differential measurement error is often present in intervention studies and can result in biased estimates of the treatment effect and reduced power to detect treatment effects. Investigators need to be aware of the impact of differential measurement error when designing intervention studies that use self-reported measures.

Methods

We use simulation to assess the consequences of differential measurement error on the ability to estimate treatment effects in a two-arm randomized trial with two time points. We simulate data under a variety of scenarios, focusing on how different factors affect power to detect a treatment effect, bias of the treatment effect, and coverage of the 95% confidence interval of the treatment effect. Simulations use realistic scenarios based on data from the Trials of Hypertension Prevention Study. Simulated sample sizes ranged from 110-380 per group.

Results

Realistic differential measurement error seen in lifestyle intervention studies can require an increased sample size to achieve 80% power to detect a treatment effect and may result in a biased estimate of the treatment effect.

Conclusions

Investigators designing intervention studies that use self-reported measures should take differential measurement error into account by increasing their sample size, incorporating an internal validation study, and/or identifying statistical methods to correct for differential measurement error.

The association of diet and depression: an analysis of dietary measures in depressed, non-depressed, and healthy youth

BACKGROUND

The association of diet quality with depression among the pediatric age group has been inconsistent. This may be due, in part, to varying dietary assessment methods. The current study sought to examine this association, and its reliability, using four dietary measures previously studied in children and adolescents.

METHODS

Dietary habits among 139 children and adolescents (10-18 years, 66% female) with major depressive disorder [MDD (n = 77)], non-MDD psychiatric conditions (PSYCH; n = 31), or without psychiatric illness (healthy controls [HC]; n = 31) were examined. Using self-reported dietary intake, diet quality was characterized using the Youth Healthy Eating Index (YHEI), Dietary Questionnaire (DQ), Health Behaviour of Teenagers (HBT), and the Healthy Eating Habits Scale (HEHS). Multivariate Analysis of Covariances examined the association between depression status and dietary habits across measures controlling for participant age.

RESULTS

The multivariate effect was significant by diet measures, F (16, 256) = 1.9, p = .02, partial η² = 0.12, with significant differences across groups on consumption of healthy dietary practices and minimal variability across measures. In subgroup analyses, MDD children had decreased consumption of healthy foods compared with PSYCH and HC children on three out of four measures. There was no difference in consumption of unhealthy foods across diagnostic groups.

LIMITATIONS

Cross-sectional design.

CONCLUSIONS

Children with MDD consume fewer healthy foods than non-MDD children, with little variation by dietary measure. Research examining the directionality of this association and specific dietary deficits among MDD youth is needed to elucidate potential preventative targets for intervention.

Fruit and Vegetable Intake Assessed by Repeat 24 h Recalls, but Not by A Dietary Screener, Is Associated with Skin Carotenoid Measurements in Children

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute’s All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2–12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p < 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/−1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data; and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted.

Supporting families of children with overweight and obesity to live healthy lifestyles: Design and rationale for the Fitline cluster randomized controlled pediatric practice-based trial

BACKGROUND

Over a third of preadolescent children with overweight or obesity. The American Academy of Pediatrics (AAP) recommends pediatric providers help families make changes in eating and activity to improve body mass index (BMI). However, implementation is challenging given limited time and referral sources, and family burden to access in-person weight management programs.

PURPOSE

To describe the design of a National Heart Blood and Lung Institute sponsored cluster randomized controlled pediatric-based trial evaluating the effectiveness of the Fitline pediatric practice-based referral program to reduce BMI and improve diet and physical activity in children with overweight or obesity. Comparison will be made between brief provider intervention plus referral to (1) eight weekly nutritionist-delivered coaching calls with workbook to help families make AAP-recommended lifestyle changes (Fitline-Coaching), vs. (2) the same workbook in eight mailings without coaching (Fitline-Workbook).

METHODS

Twenty practices are pair-matched and randomized to one of the two conditions; 494 parents and their children ages 8-12 with a BMI of ≥85th percentile are being recruited. The primary outcome is child BMI; secondary outcomes are child's diet and physical activity at baseline and 6- and 12-months post-baseline. Cost-effectiveness of the two interventions also will be examined.

CONCLUSION

This is the first randomized controlled trial to examine use of a centrally located telephonic coaching service to support families of children with overweight and obesity in making AAP-recommended lifestyle changes. If effective, the Fitline program will provide an innovative model for widespread dissemination, setting new standards for weight management care in pediatric practice.

TRIAL REGISTRATION

The ClinicalTrials.gov registration number is NCT03143660.

Characterizing Measurement Error in Dietary Sodium in Longitudinal Intervention Studies

Background: Previous measurement error work that investigates the relationship between a nutritional biomarker and self-reported intake levels has typically been at a single time point, in a single treatment group, or with respect to basic patient demographics. Few studies have examined the measurement error structure in longitudinal randomized trials, and whether the error varies across time or group. This structure is crucial to understand, however, in order to correct for measurement error in self-reported outcomes and properly interpret the longitudinal effects of dietary interventions. Methods: Using two longitudinal randomized controlled trials with internal longitudinal validation data (urinary biomarkers and self-reported values), we examine the relationship between urinary sodium and self-reported sodium and whether this relationship changes as a function of time and/or treatment condition. We do this by building a mixed effects regression model, allowing for a flexible error variance-covariance structure, and testing all possible interactions between time, treatment condition, and self-reported intake. Results: Using a backward selection approach, we arrived at the same final model for both validation data sets. We found no evidence that measurement error changes as a function of self-reported sodium. However, we did find evidence that urinary sodium can differ by time or treatment condition even when conditioning on self-reported values. Conclusion: In longitudinal nutritional intervention trials it is possible that measurement error differs across time and treatment groups. It is important for researchers to consider this possibility and not just assume non-differential measurement error. Future studies should consider data collection strategies to account for the potential dynamic nature of measurement error, such as collecting internal validation data across time and treatment groups when possible.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.