The Feasibility and Acceptability of Two Methods of Snack Portion Control in United Kingdom (UK) Preschool Children: Reduction and Replacement

Examining parents' experiences and challenges of feeding preschool children with avid eating behaviour

Avid eating behaviours, including greater responsiveness to food cues and emotional over-eating, have been linked to child overweight and obesity. Parental feeding practices are modifiable components of a child's food environment and may be key levers for behaviour change in tailored interventions to support parents of children with avid eating behaviour. However, there is a lack of research examining parents' experiences in this context. This study aimed to explore parents' experiences of feeding children with avid eating behaviour and to understand any challenges experienced in this context. Semi-structured interviews with parents (N = 15) of a preschool child (3-5 years) identified as having an avid eating behaviour profile explored how children's avid eating manifests, the parental feeding practices used to manage avid eating, and the perceived effectiveness of these strategies. Data were analysed using reflexive thematic analysis. Four core themes were generated. Theme one, 'Have they got worms? Children's insatiable hunger', captures parents' interpretation of the complex ways in which avid eating behaviour manifests. Theme two, 'Parenthood as a duty', illustrates how parents' perceived responsibilities shape their feeding practices. Theme three, 'Lifelong habits', captures parents' use of responsive feeding practices to support children's healthy relationship with food. Theme four, 'Picking battles', captures the structure- and coercive-based feeding strategies commonly used to manage children's avid eating. This novel study provides an in-depth understanding of the complex ways that children's avid eating behaviour manifests, and the strategic and creative parental feeding practices used to manage these behaviours. Such findings are valuable for informing the development of future support resources for parents/caregivers to help their children with avid eating behaviours to develop a healthy relationship with food.

'You just eyeball it': Parent and nursery staff perceptions and influences on child portion size: A reflexive thematic analysis

Background: Childhood obesity is one of the most serious public health epidemics of the 21st century. Observational studies report that increases in portion size (PS) have occurred in parallel with levels of obesity. Increased PSs of high-energy-dense foods can promote overeating, and without compensatory behaviours, can contribute to childhood obesity. Caregivers make decisions about PSs for children in the home and nursery environment, thus are gatekeepers to child food intake. Understanding caregiver PS decisions can aid in the best practice of PS provision to young children. The aim of this study was to explore parent and nursery staff influences on child PS selection and their suggestions for useful tools/strategies in PS decisions. Methods: A qualitative design was employed using focus group discussions (FGDs) with parents and nursery staff of children aged 3-5 years. FGDs were employed given their ability to generate rich data, as well as permit the exploration of collective perceptions, attitudes, behaviours and experiences. Data were analysed using an inductive, semantic approach to reflexive thematic analysis. Results: Four FGDs were conducted: two with parents (n = 13), two with nursery staff (n = 17). Four overarching themes were derived: (i) awareness of PS guidelines; (ii) control over PS; (iii) social influences on children's eating behaviours; (iv) child-specific, social and external factors influencing parent and nursery staff PS decisions. Additionally, participants discussed tools/strategies they believe would be useful in PS decisions. Conclusion: Data from the themes suggest that caregiver control, social, child-specific and external factors are more influential than PS guidelines in both parent and nursery staff PS decisions for young children aged 3-5 years. These findings can inform future childhood obesity prevention initiatives focussed on improving parent and nursery staff provision/use of age-appropriate PSs.

Systems map of interventions to improve dietary intake of pre-school aged children: A scoping review

Implementation and sustaining impact of early childhood nutrition interventions in practice remains a challenge. An understanding of the extent to which determinants across multiple levels of the food system are being addressed may improve success. This literature review aimed to synthesise the evidence on interventions targeting dietary intake and eating behaviours in preschool children using a systems approach. Eligible studies included intervention studies targeting the dietary intake of preschool children aged 2-5 years in high income countries, published in English after January 2000. Interventions were categorised to the Determinants of Nutrition and Eating (DONE) framework for children developed and evaluated by experts across multiple fields. The framework maps and ranks 411 factors driving eating behaviours and nutrition and can be used to systematically summarise determinants. DONE ranks each determinant for its perceived research priority. A total of 160 eligible studies were identified. Most interventions targeted interpersonal (n = 101, 63.1%) and individual (n = 85, 53.1%) level determinants, with fewer targeting environmental (n = 55, 34.4%) and policy level (n = 17, 10.6%) determinants. The most frequently addressed determinants were Parental Resources and Risk Factors (n = 85) and Children's Food Knowledge, Skills and Abilities (n = 67). These determinants had a Moderate research priority rating. Home Food Availability and Accessibility at the environmental level is classified as the highest research priority, however, only 15 of 160 interventions addressed this determinant. This review highlights home food availability and accessibility as potential leverage points for future interventions to improve children's dietary intake and eating behaviours.

Child food portion sizes in the home environment: how do parents decide?

The consumption of larger portion sizes (PS) of food has been implicated in the increased prevalence of childhood obesity. The home is usually the first place children learn about food, however, little is known about how parents determine child PS in the home environment. This narrative review aimed to explore parental beliefs, decisions, strategies and barriers to the provision of appropriate food PS for children in the home environment. Results indicate that parental decisions on child food PS are based on the amounts they serve themselves, personal intuition and knowledge of child appetite. Owing to the habitual nature of food provision, parental decisions on child PS may be taken without conscious thought and/or could be part of a complex decision-making process influenced by several interlinked factors, including parental childhood mealtime experiences, other family members and child weight status. Strategies to determine child-appropriate PS include modelling the desired PS behaviour, use of unit-based food packaging and PS estimation aids, and providing the child with a degree of autonomy to rely on their own appetite cues. A lack of knowledge/awareness of PS guidance is a key barrier identified by parents to the provision of age-appropriate PS, warranting the inclusion of salient child-appropriate PS guidance within national dietary recommendations. Further home-based interventions to improve the provision of appropriate child PS are required, leveraged on parental strategies already in use, as outlined in this review.

Free sugar intake from snacks and beverages in Canadian preschool- and toddler-aged children: a cross-sectional study

BACKGROUND

Excess consumption of free sugar (FS) increases the risk of dental caries and unhealthy weight gain. However, the contribution of snacks and beverages to young children's FS intake is not well understood. The purpose of this study was to determine FS intake from snacks and beverages among preschool-aged Canadian children.

METHODS

This cross-sectional study examined baseline data from 267 children 1.5 to 5 y enrolled in the Guelph Family Health Study. Dietary assessment was completed over a 24-h period using ASA24-Canada-2016 to, 1) estimate the proportion of children whose FS intake from snacks and beverages consumed exceeded 5% total energy intake (TE) and 10% TE, and 2) identify the top snack and beverage sources of FS.

RESULTS

FS contributed 10.6 ± 6.9% TE (mean ± SD). 30 and 8% of children consumed ≥ 5% TE and ≥ 10% TE from snack FS, respectively. Furthermore, 17 and 7% of children consumed ≥ 5% TE and ≥ 10% TE from beverages FS, respectively. Snacks and beverages accounted for 49 ± 30.9% of FS energy. Top snack sources of FS (% children, children's %TE from FS) were bakery products (55%, 2.4%), candy and sweet condiments (21%, 3.0%), and sugar-containing beverages (20%, 4.1%). Top sugar-containing beverage sources of FS (48%, 5.3%) were 100% fruit juice (22%, 4.6%) and flavored milk (11%, 3.1%).

CONCLUSIONS

Snacks and beverages contributed nearly half of FS intake among a sample of young children in Canada. Thus, long-term monitoring of snacking behavior and consumption of FS is warranted. These findings may help inform nutritional strategies and public policies to improve diet quality and FS intake in preschool-aged children.

TRIAL REGISTRATION

The Clinical Trial Registry number is NCT02939261 from clinicaltrials.gov. Date of Registration: October 20, 2016.

A Narrative Review of Dietary Assessment Tools for Preschool-Aged Children in the Home Environment

Preschool-aged children in the U.S. have suboptimal diets. Interventions to improve child nutrition focus on parents and their role in shaping social and physical home environments, which influence children's eating behaviors. Dietary assessment tools selected to measure intervention objectives, and how results are interpreted in key findings, are essential when examining children's diets. The objectives of this review were to (1) describe dietary assessment tools used in intervention studies in young children focused within the home environment; and (2) examine how the application of these dietary assessment tools addressed intervention objectives. PubMed and Web of Science were searched for English-language nutrition intervention studies that included children aged 2-5 years, had a home environment component, used a dietary assessment tool, and reported on diet-related outcomes. Seventeen studies were included. Intervention objectives focused on overall diet, specific food groups, eating occasions, and obesity prevention/treatment. Concordance of key findings with intervention objectives, type of tool used, and multiple tools within the same study varied with 8 studies aligning in objective and tool, 1 discordant in both, and 8 partially concordant or too broad to determine. This review highlights current challenges in measuring dietary intake in preschoolers and provides recommendations for alternative applications and strategies.

A comparison between parent and grandparent dietary provision, feeding styles and feeding practices when caring for preschool-aged children

Grandparents are frequently called upon to provide childcare to young children. Consequently, grandparents may influence the development of children's eating habits and preferences and may require support with their approach to feeding young children. However, research into grandparental feeding behaviours is scarce. Understanding how grandparental feeding behaviours compare to parental feeding behaviours will further help to establish whether grandparents require specific interventions unique to the grandparental role or if current strategies that target parental feeding behaviour are also appropriate for grandparents. The aim of the present study was to explore the similarities and differences between parent and grandparent dietary provision, feeding practices and feeding styles to preschool-aged children. 72 parents and 44 unrelated grandparents of children aged 2-4 years old took part in an online study and completed an online 24-h dietary recall using myfood24® to assess dietary provision. Parents and grandparents were providing meals high in saturated fat and sodium and providing below recommended amounts of fruit and vegetables. Overall, feeding practices were similar between parents and grandparents. Although, grandparents scored lower on using food as a reward (p < 0.05) and creating a healthy food environment (p < 0.05) compared to parents. Whereas, parents scored higher for promoting balance and variety (p < 0.05). A range of feeding styles were found within each caregiver type, with no significant associations found between caregiver type and feeding style (p > 0.05). Strategies to promote healthy eating in young children should be expanded to also target grandparents who act as informal caregivers to preschool-aged children. However, since very few differences in feeding behaviour were reported the content of such strategies may not need to be adapted specifically for grandparents.

Breaking habits or breaking habitual behaviours? Old habits as a neglected factor in weight loss maintenance

Maintaining weight loss requires long-term behaviour change. Theory and evidence around habitual behaviour - i.e., action triggered by impulses that are automatically activated upon exposure to cues, due to learned cue-action associations - can aid development of interventions to support weight loss maintenance. Specifically, weight loss is more likely to be sustained where people develop new habits that support weight management, and break old habits that may undermine such efforts. Interventions seeking to break 'bad' weight-related habits have focused on inhibiting unwanted impulses or avoiding cues. This paper draws attention to the possibility that while such approaches may discontinue habitual behaviour, underlying habit associations may remain. We use evidence from existing qualitative studies to demonstrate that, left unchecked, unwanted habit associations can render people prone to lapsing into old patterns of unhealthy behaviours when motivation or willpower is momentarily weakened, or when returning to familiar settings following temporarily discontinued exposure. We highlight six behaviour change techniques especially suited to disrupting habit associations, but show that these techniques have been underused in weight loss maintenance interventions to date. We call for intervention developers and practitioners to adopt techniques conducive to forming new habit associations to directly override old habits, and to use the persistence of unwanted habit associations as a potential indicator of long-term weight loss intervention effectiveness.

Reductions to main meal portion sizes reduce daily energy intake regardless of perceived normality of portion size: a 5 day cross-over laboratory experiment

BACKGROUND

Smaller portions may help to reduce energy intake. However, there may be a limit to the magnitude of the portion size reduction that can be made before consumers respond by increasing intake of other food immediately or at later meals. We tested the theoretical prediction that reductions to portion size would result in a significant reduction to daily energy intake when the resulting portion was visually perceived as 'normal' in size, but that a reduction resulting in a 'smaller than normal' portion size would cause immediate or later additional eating.

METHODS

Over three 5-day periods, daily energy intake was measured in a controlled laboratory study using a randomized crossover design (N = 30). The served portion size of the main meal component of lunch and dinner was manipulated in three conditions: 'large-normal' (747 kcal), 'small-normal' (543 kcal), and 'smaller than normal' (339 kcal). Perceived 'normality' of portion sizes was determined by two pilot studies. Ad libitum daily energy intake from all meals and snacks was measured.

RESULTS

Daily energy intake in the 'large-normal' condition was 2543 kcals. Daily energy intake was significantly lower in the 'small-normal' portion size condition (mean difference - 95 kcal/d, 95% CI [- 184, - 6], p = .04); and was also significantly lower in the 'smaller than normal' than the 'small-normal' condition (mean difference - 210 kcal/d, 95% CI [- 309, - 111], p < .001). Contrary to predictions, there was no evidence that the degree of additional food consumption observed was greater when portions were reduced past the point of appearing normal in size.

CONCLUSIONS

Reductions to the portion size of main-meal foods resulted in significant decreases in daily energy intake. Additional food consumption did not offset this effect, even when portions were reduced to the point that they were no longer perceived as being normal in size.

TRIAL REGISTRATION

Prospectively registered protocol and analysis plan: https://osf.io/natws/; retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03811210.

Snack Portion Sizes for Preschool Children Are Predicted by Caregiver Portion Size, Caregiver Feeding Practices and Children's Eating Traits

Caregivers are mostly responsible for the foods young children consume; however, it is unknown how caregivers determine what portion sizes to serve. This study examined factors which predict smaller or larger than recommended snack portion sizes in an online survey. Caregivers of children aged 2 to 4 years were presented with 10 snack images, each photographed in six portion sizes. Caregivers (n = 659) selected the portion they would usually serve themselves and their child for an afternoon snack. Information on child eating traits, parental feeding practices and demographics were provided by caregivers. Most caregivers selected portions in line with recommended amounts for preschool children, demonstrating their ability to match portion sizes to their child's energy requirements. However, 16% of caregivers selected smaller than recommended low energy-dense (LED, e.g., fruits and vegetables) snacks for their child which was associated with smaller caregiver's own portion size, reduced child food liking and increased satiety responsiveness. In contrast, 28% of caregivers selected larger than recommended amounts of high energy-dense (HED, e.g., cookies, crisps) snacks for their child which were associated with larger caregiver's own portion size, greater frequency of consumption, higher child body mass index (BMI), greater pressure to eat and lower child food liking. These findings suggest that most caregivers in this study select portions adjusted to suit their child's age and stage of development. Future interventions could provide support to caregivers regarding the energy and nutrient density of foods given the relatively small portion sizes of LED and large portions of HED snacks offered to some children.

Maternal Decisions on Portion Size and Portion Control Strategies for Snacks in Preschool Children

Caregivers are responsible for the type and amount of food young children are served. However, it remains unclear what considerations caregivers make when serving snacks to children. The aim of the study was to explore mothers' decisions and portion control strategies during snack preparation in the home environment. Forty mothers of children aged 24-48 months participated in the study. Mothers prepared five snack foods for themselves and their child whilst verbalizing their actions and thoughts. Mothers were then asked about their portion size decisions in a semi-structured interview. Transcripts were imported into NVivo and analyzed thematically. Three key themes were identified: (1) portion size considerations, (2) portion control methods, and (3) awareness and use of portion size recommendations. Transient, food-related situational influences influenced mothers and disrupted planning and portion control. Food packaging and dishware size were used as visual cues for portion control; however, these vary widely in their size, thus emphasizing mothers' uncertainty regarding appropriate portion sizes. Mothers called for portion size information to be accessible, child-centered, and simple. These findings reveal multiple considerations when deciding on the correct snack portion sizes for children. These decisions are complex and vary across situations and time, and according to the types of snacks offered.

Identifying Barriers to Reducing Portion Size: A Qualitative Focus Group Study of British Men and Women

Reducing portion size might reduce meal satisfaction, which could minimize adherence to portion size interventions. The present study sought to identify the perceived barriers for consumers to eat smaller portions. A secondary aim explored the relative contribution of enjoyment of taste and post-meal fullness as determinants of meal satisfaction. Focus groups (N = 42) evaluated consumers' feelings toward a small reduction in portion size. Thematic analysis of written free association tasks and open-ended group discussions revealed that most participants expected to feel hungry and unsatisfied, which motivated them to consume something else. However, others expected to feel comfortable, healthy, and virtuous. The acceptability of the reduced portion was also determined by meal characteristics (e.g., time and setting) and individual characteristics (e.g., predicted energy requirements). Compared to post-meal fullness, enjoyment of taste was perceived to be the more important determinant of meal satisfaction. In conclusion, interventions should present portion reduction as a marginal modification with little physiological consequence to energy reserves, while emphasizing the positive feelings (e.g., comfort, satisfaction, and self-worth) experienced after consuming a smaller portion. Additionally, focusing on taste enjoyment (rather than fullness) might be a useful strategy to maintain meal satisfaction despite a reduction in meal size.

The effect of food type on the portion size effect in children aged 2-12 years: A systematic review and meta-analysis

Visual cues such as plate size, amount of food served and packaging are known to influence the effects of portion size on food intake. Unit bias is a well characterised heuristic and helps to determine consumption norms. In an obesogenic environment where large portions are common place, the unit or segmentation bias may be overridden promoting overconsumption of both amorphous or unit foods. The aim of this review was to investigate the impact of offering unit or amorphous food on the portion size effect (PSE) in children aged 2-12 years. A systematic search for literature was conducted in Medline, PsycInfo and Web of Science in February 2018. A total of 1197 papers were retrieved following the searches. Twenty-one papers were included in the systematic review, of which 15 provided requisite statistical information for inclusion in a random effects meta-analysis. Increasing children's food portion size by 51-100% led to a significant increase in intake (SMD = 0.47, 95% CI: 0.39-0.55). There was no evidence to suggest that increases in consumption were related to food type (p = 0.33), child age (p = 0.47) or initial portion size served (p=0.14). Residual heterogeneity was not significant (p=0.24). The PSE was demonstrated in children aged 2-12 years when offered both unit and amorphous food items. The effect was not restricted by food type, child age or influenced by initial portion size served. Of the studies included in the meta-analysis between study heterogeneity was low suggesting minimal variation in treatment effects between studies, however, more research is required to understand the mechanisms of the PSE in preschool children. Future research should determine feasible methods to downsize portion sizes served to children.

Binge-Type Eating in Rats is Facilitated by Neuromedin U Receptor 2 in the Nucleus Accumbens and Ventral Tegmental Area

Binge-eating disorder (BED) is the most common eating disorder, characterized by rapid, recurrent overconsumption of highly palatable food in a short time frame. BED shares an overlapping behavioral phenotype with obesity, which is also linked to the overconsumption of highly palatable foods. The reinforcing properties of highly palatable foods are mediated by the nucleus accumbens (NAc) and the ventral tegmental area (VTA), which have been implicated in the overconsumption behavior observed in BED and obesity. A potential regulator of binge-type eating behavior is the G protein-coupled receptor neuromedin U receptor 2 (NMUR2). Previous research demonstrated that NMUR2 knockdown potentiates binge-type consumption of high-fat food. We correlated binge-type consumption across a spectrum of fat and carbohydrate mixtures with synaptosomal NMUR2 protein expression in the NAc and VTA of rats. Synaptosomal NMUR2 protein in the NAc demonstrated a strong positive correlation with binge intake of a “lower”-fat (higher carbohydrate) mixture, whereas synaptosomal NMUR2 protein in the VTA demonstrated a strong negative correlation with binge intake of an “extreme” high-fat (0% carbohydrate) mixture. Taken together, these data suggest that NMUR2 may differentially regulate binge-type eating within the NAc and the VTA.