Development and Application of the Remote Food Photography Method to Measure Food Intake in Exclusively Milk Fed Infants: A Laboratory-Based Study

Adaptation of the Remote Food Photography Method to Assess Infant Intake During Bottle-Feeding of Ready-to-Feed Formula

Bottle-fed infants are at a higher risk for obesity, yet interventions to modify bottle-feeding patterns have shown limited success. Accurate assessment of bottle-feeding patterns is an important basis for targeted interventions. Caregiver reports are susceptible to bias, highlighting the need for more robust methods. One promising approach is the Remote Food Photography Method (RFPM), which involves analysis of digital photographs to objectively assess intake. The purpose of this study was to adapt RFPM to measure the amount of ready-to-feed formula in bottles. Research assistants took digital photographs of bottles with varying amounts of formula and assessed bottle weight to create a predictive model data set (n = 100) and an external validation data set (n = 100). Image processing software was used to determine the area of formula in pixels. Formula area was regressed on actual bottle weight and the resulting regression parameters were used to calculate estimated bottle weights. Predictive models were validated by applying them to the external validation data set. Within the predictive model data set, the mean difference between estimated and actual bottle weight was equivalent within ±10% equivalence bounds (0.0005 g [90% CI, -0.45, 0.45]). Within the external validation data set, the mean difference between estimated and actual bottle weight was also equivalent within ±10% equivalence bounds (-17.0 g [90% CI, -18.85, -15.17]). Findings were similar when bottle weight was converted to calories. In sum, the present study provided preliminary evidence for the feasibility and accuracy of an adapted RFPM to assess changes in the amount and caloric content of ready-to-feed formula in bottles.

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

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

Modifications to Infant Formula Instructions Improve the Accuracy of Formula Dispensing

Readability of infant formula preparation instructions is universally poor, which may result in inaccurate infant feeding. Given that inaccurate formula dispensing can lead to altered infant growth and increased adiposity, there is an increased need for easy to follow instructions for formula preparation. We hypothesize that altering infant formula instruction labels using feedback from iterative focus groups will improve the preparation accuracy of powdered infant formula in a randomized controlled trial. Participants were recruited from the community, 18 years of age or older, willing to disclose demographic information for focus group matching, and willing to participate freely in the first (n = 21) or second (n = 150) phase of the study. In the second phase, participants were randomized to use the standard manufacturer instructions or to use the modified instructions created in the first phase. Accuracy was defined as the percent error between manufacturer-intended powder formula quantity and the amount dispensed by the participant. Participants who were assigned to the modified instructions were able to dispense the powdered formula more accurately than participants who used the standard manufacturer instructions (−0.67 ± 0.76 vs. −4.66 ± 0.74% error; p < 0.0001). Accuracy in powdered formula dispensing was influenced by bottle size (p = 0.02) but not by body mass index (p = 0.17), education level (p = 0.75), income (p = 0.7), age (p = 0.89) or caregiver status (p = 0.18). Percent error of water measurement was not different between the groups (standard: −1.4 ± 0.6 vs. modified: 0.7 ± 0.6%; p = 0.38). Thus, caloric density was more accurate in the modified instructions group compared to the standard manufacturer instructions group (−0.3 ± 0.6 vs.−2.9 ± 0.9%; p = 0.03). Infant formula label modifications using focus group feedback increased infant formula preparation accuracy.

Unintentional error in formula preparation and its simulated impact on infant weight and adiposity

BACKGROUND

Accelerated weight gain in infancy is a public health issue and is likely due to feeding behaviours.

OBJECTIVES

To test the accuracy of individuals to dispense infant formula as compared with recommended serving sizes and to estimate the effect of dispensing inaccuracy on infant growth.

METHODS

Fifty-three adults dispensed infant formula powder for three servings of 2, 4, 6, and 8 fl oz bottles, in random order. The weight of dispensed infant formula powder was compared with the recommended serving size weight on the nutrition label. A novel mathematical model was used to estimate the impact of formula dispensing on infant weight and adiposity.

RESULTS

Nineteen percent of bottles (20 of 636) prepared contained the recommended amount of infant formula powder. Three percent were underdispensed, and 78% of bottles were overdispensed, resulting in 11% additional infant formula powder. Mathematical modelling feeding 11% above energy requirements exclusively for 6 months for male and female infants suggested infants at the 50th percentile for weight at birth would reach the 75th percentile with increased adiposity by 6 months.

CONCLUSIONS

Inaccurate measurement of infant formula powder and overdispensing, which is highly prevalent, specifically, may contribute to rapid weight gain and increased adiposity in formula-fed infants.

Snap-N-Send: A valid and reliable method for assessing the energy intake of elite adolescent athletes

To ensure that elite adolescent athletes meet their unique training, growth and maturation demands, it is imperative to have access to valid measures of energy intake. Contemporary methods demand close attention-to-detail, meaning that athletes often do not fully adhere to real-time protocols. This study represents the first investigation of a real-time dietary assessment designed using a comprehensive behaviour change framework (COM-B). In a crossover design, 12 elite adolescent male rugby players recorded their energy intake via an estimated food diary (est-FD) and photography-based mobile assessment ('Snap-n-Send'), combined with a 24-h dietary recall interview. Two 4-day assessment periods were divided into three separate recording environments: 96 h free-living and researcher-observed; 72 h free-living and 10 h researcher-observed. Assessment periods were one month apart. All foods and beverages were provided and weighed by the research team to quantify actual intakes. 'Snap-n-Send' reported a small mean bias for under-reporting across 96 h (-0.75 MJ day^-1; 95% confidence interval [CI] for bias = -5.7% to -2.2%, p < .001), 72 h (-0.76 MJ day^-1; 95% CI for bias = -5.6% to -2.1%, p = .004) and 10 h (-0.72 MJ day^-1; 95% CI for bias = -8.1% to -0.1%; p = .067) environments. The est-FD reported a moderate mean bias for under-reporting across 96 h (-2.89 MJ day^-1; 95% CI for bias = -17.9% to -10.2%; p < .001), 72 h (-2.88 MJ day^-1; 95% CI for bias = -17.9% to -10.1%; p < .001) and 10 h (-2.52 MJ day^-1;-26.1% to -5.3%; p = .023) environments. Results evidence the ability of 'Snap-n-Send' to accurately assess the diet of elite adolescent athletes, signalling the exciting promise of this comprehensive and theoretical behavioural approach within valid dietary assessment.