Can Reduced Intake Associated with Downsizing a High Energy Dense Meal Item be Offset by Increased Vegetable Variety in 3⁻5-year-old Children?

'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.

Children with lower ratings of executive functions have a greater response to the portion size effect

Deficits in executive functions (EFs), a set of cognitive processes related to self-regulation, are associated with the development of obesity. Prior studies from our group showed that lower food-cue related activation in brain regions implicated in self-regulation was related to a larger portion size effect. We tested the hypothesis that lower EFs in children would be positively related to the portion size effect. Healthy weight children aged 7-8 y (n = 88), who varied by maternal obesity status, participated in a prospective study. At baseline, the parent primarily in charge of feeding completed the Behavior Rating Inventory of Executive Function (BRIEF2) to assess child EFs, including Behavioral (BRI), Emotional (ERI), and Cognitive (CRI) indices. At 4 baseline sessions, children consumed meals in which the portion sizes of foods (pasta, chicken nuggets, broccoli, and grapes) varied by visit (total meal weight of 769, 1011, 1256, or 1492g). Intake increased with increasing portions in a linear trajectory (p < 0.001). EFs moderated the portion size effect such that lower BRI (p = 0.003) and ERI (p = 0.006) were associated with steeper increases in intake as portions increased. As amount of food increased, children in the lowest functioning tertiles for BRI and ERI increased intake by 35% and 36%, respectively, compared to children in the higher tertiles. Increases in intake among children with lower EFs were for higher- but not lower-energy-dense foods. Thus, in healthy weight children who varied by obesity risk, lower parentally reported EFs were associated with a larger portion size effect, and these results were independent of child and parent weight status. Therefore, EFs may be target behaviors that could be strengthened to help children moderate excess intake in response to large portions of energy-dense foods.

Food-Evoked Emotions and Optimal Portion Sizes of Meat and Vegetables for Men and Women across Five Familiar Dutch Meals: An Online Study

Portion size manipulation is well known to be effective in increasing vegetable intake in adults, whereas less is known about the effects of portion size manipulation on reducing meat intake. This online study investigated the effects of recommended and regularly consumed portion sizes of vegetables and meat in five familiar Dutch meals. Participants evaluated 60 food pictures of five meals and used a 100 mm VAS to measure expected liking, satiety, food-evoked emotions, and the perceived normal portion size. The results show that both regular and recommended portions scored above 55 on the 100 mm VAS on expected liking and satiety. Similarly, both portion sizes scored high (55–70 on the 100 mm VAS) in positive emotions (i.e., happy, relaxed, and satisfied). Regarding the perceived amount of meat, men consistently preferred larger portions of meat than women. However, the optimal portion sizes of vegetables were similar for men and women. Furthermore, the recommended portion sizes led to positive food-evoked emotions, implying that the effective implementation of portion size strategies for increasing vegetable and limiting meat intake requires a careful, holistic approach focusing on the sensory characteristics of food products as well as the emotions evoked by the total food experience.

Predictors of vegetable consumption in children and adolescents: analyses of the UK National Diet and Nutrition Survey (2008-2017)

Children's vegetable consumption is generally below national recommendations in the UK. This study examined predictors of vegetable intake by children aged 1·5-18 years using counts and portion sizes derived from 4-d UK National Diet and Nutrition Survey food diaries. Data from 6548 children were examined using linear and logit multilevel models. Specifically, we examined whether demographic variables predicted vegetable consumption, whether environmental context influenced portion sizes of vegetables consumed and which food groups predicted the presence (or absence) of vegetables at an eating occasion (EO). Larger average daily intake of vegetables (g) was predicted by age, ethnicity, equivalised income, variety of vegetables eaten and average energy intake per d (R2 0·549). At a single EO, vegetables were consumed in larger portion sizes at home, with family members and at evening mealtimes (Conditional R2 0·308). Within EO, certain configurations of food groups such as carbohydrates and protein predicted higher odds of vegetables being present (OR 12·85, 95 % CI 9·42, 17·54), whereas foods high in fats, sugars and salt predicted a lower likelihood of vegetable presence (OR 0·03, 95 % CI 0·02, 0·04). Vegetables were rarely eaten alone without other food groups. These findings demonstrate that only one portion of vegetables was eaten per d (median) and this was consumed at a single EO, therefore falling below recommendations. Future research should investigate ways to encourage vegetable intake at times when vegetables are not regularly eaten, such as for breakfast and as snacks, whilst considering which other, potentially competing, foods are presented alongside vegetables.

Effect of food variety on intake of a meal: a systematic review and meta-analysis

BACKGROUND

Many studies have shown that food variety-the presence of multiple foods and/or sensory characteristics within and across meals-increases intake. However, studies report mixed findings, and effect size remains unclear.

OBJECTIVES

A systematic review and meta-analysis were conducted to 1) synthesize data across experimental studies that examined effects of variety on total meal intake, relative to a control condition with comparatively less variety; 2) quantify support for this effect; and 3) assist in the identification of important moderating factors (registration: CRD42019153585).

METHODS

In November 2019, we searched the following databases for relevant experimental studies, published in English from 1980, with human participants: PubMed, Cochrane Library, Web of Science, ClinicalTrials.gov, PsycINFO, and OpenGrey. This search was updated in September 2020. Means, standard deviations, and sample sizes were extracted from included articles, and Hedges' g was used to calculate effect sizes. Risk of bias was assessed using the Cochrane Collaboration's tool.

RESULTS

Of 7259 references identified in an initial search, 34 articles consisting of 37 studies contained sufficient information for review, and data from 30 studies (39 comparisons) were included in the meta-analysis. Results from a random-effects model showed a significant small to medium effect of variety on intake (in weight and energy), with greater variety being associated with increased consumption (Hedges' g = 0.405; 95% CI: 0.259, 0.552). However, heterogeneity was considerable across studies (I2 = 84%), and this was unexplained by subgroup analyses based on form of variety, test foods, sensory characteristics, age, sex, and body weight.

CONCLUSIONS

Our findings support the conclusion that variety is a robust driver of food intake. However, risk of bias was high across studies, and this review highlights methodologic limitations of studies. It is recommended that further attention is given to the development of preregistered, well-powered randomized controlled studies in eating behavior research.

What guidance is there on portion size for feeding preschool-aged children (1 to 5 years) in the United Kingdom and Ireland? A systematic grey literature review

Large portion sizes of food can lead to excessive energy intake and weight gain in young children. Although portion size guidance is available, parents are often unaware it exists. Our systematic grey literature review aimed to identify the portion size guidance resources in the United Kingdom and Ireland, aimed at users (e.g., parents and childcare providers) responsible for feeding preschool-aged children. We describe who the resources are aimed at, how they are informed and whether the recommended portion sizes are consistent across resources. Resources were identified via advanced Google searches, searching reference lists and contacting experts. Resources that provided quantifiable portion size information (e.g., grammes) were included. Portion sizes (g) were extracted and energy equivalents (kcal) were calculated. Portion sizes were analysed by food group and by eating occasion. Twenty-two resources were identified. Median portion sizes were consistent across resources for fruit (40 g [IQR = 40-50]) and vegetables (40 g [IQR = 30-40]). Variability was observed in portion size and/or energy content for dairy (60 g [IQR = 25-93]), protein (72 kcal [IQR = 44-106]) and starchy (41 g/71 kcal [IQR = 25-80/56-106]) food groups. The range in size of an average eating occasion was large (90-292 g). This review identifies resources that could help caregivers to choose appropriate portion sizes for preschool-aged children but also highlights how future resources could be improved.

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.

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.

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.

Portion size normality and additional within-meal food intake: two crossover laboratory experiments

Reducing food portion size could reduce energy intake. However, it is unclear at what point consumers respond to reductions by increasing intake of other foods. We predicted that a change in served portion size would only result in significant additional eating within the same meal if the resulting portion size was no longer visually perceived as 'normal'. Participants in two crossover experiments (Study 1: n 45; Study 2: n 37; adults, 51 % female) were served different-sized lunchtime portions on three occasions that were perceived by a previous sample of participants as 'large-normal', 'small-normal' and 'smaller than normal', respectively. Participants were able to serve themselves additional helpings of the same food (Study 1) or dessert items (Study 2). In Study 1 there was a small but significant increase in additional intake when participants were served the 'smaller than normal' compared with the 'small-normal' portion (m difference = 161 kJ, P = 0·002, d = 0·35), but there was no significant difference between the 'small-normal' and 'large-normal' conditions (m difference = 88 kJ, P = 0·08, d = 0·24). A similar pattern was observed in Study 2 (m difference = 149 kJ, P = 0·06, d = 0·18; m difference = 83 kJ, P = 0·26, d = 0·10). However, smaller portion sizes were each associated with a significant reduction in total meal intake. The findings provide preliminary evidence that reductions that result in portions appearing 'normal' in size may limit additional eating, but confirmatory research is needed.

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.