Associations of Less Healthy Snack Food Consumption with Infant Weight-for-Length Z-Score Trajectories: Findings from the Nurture Cohort Study

Environmental Scan of Online Government Complementary Feeding Resources in the United States

BACKGROUND

Parents commonly seek online sources of information on the important complementary feeding period, but the accuracy of these sources varies. The 21st Century Integrated Digital Experience Act (IDEA) states federal government resources should be accurate and user-friendly; however, the quantity, quality, and accuracy of federal resources on complementary feeding is unknown.

METHODS

An environmental scan of online federal, parent-facing resources about complementary feeding was conducted. The authors reviewed federal resources for concordance of information with the Dietary Guidelines for Americans (DGA). Quality was evaluated using the Patient Education Materials Assessment Tool.

RESULTS

A total of 112 resources across 2 federal government departments. Overall quality was high as was concordance with recommendations from the DGA for age of complementary food introduction, foods to introduce, and foods to avoid. Allergenic food introduction and textured food progression recommendations were less consistent. Recommendations for improvements to federal resources are made.

CLINICAL IMPLICATIONS

This environmental scan only included federal resources for CF. Parents may be accessing other, non-federal resources online. However, given the enactment of IDEA, it is expected that these federal resources will be up-to-date and user-friendly, which was not always the case. Nurses should review the DGA guidelines for complementary feeding and provide evidence-based anticipatory guidance to families, focusing especially on allergenic food introduction and textured food progression. Future complementary feeding interventions may benefit from directing families to online exemplars from federal sources.

Benchmarking the nutrient composition and labelling practices of finger foods and snacks for older infants and young children across seven Southeast Asian countries

Ensuring consumption of nutrient-dense, safe and appropriate complementary foods among older infants and young children (IYC) 6-36 months of age is critical for enabling optimal growth and development. The ubiquitous availability of and high demand for commercially packaged snack foods has culminated in a growing trend of snack food products specifically produced and promoted for older IYC. Commercially produced complementary foods (CPCF) that are finger foods/snacks often contain added sugars, excessive sodium content and high total sugar content, making them inappropriate for this young population. This study benchmarked the nutrient composition and labelling practices of CPCF finger foods/snacks available for purchase in seven countries in Southeast Asia. The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older IYC. Of the total 606 products identified, 8.2% were automatically categorized as not suitable because they were confectionery items. Of the remaining 556 products assessed, over 85% failed to meet all nutrient composition requirements, with the presence of added sugars/sweeteners and excessive sodium and total sugar contents the primary reasons for failure. Products also demonstrated concerning labelling practices, with all of the products (98.6%) displaying an inappropriate claim on the label. These findings reveal major concerns with the nutrient composition and labelling practices of CPCF finger foods/snacks in the SEA region and should serve as an alarm bell for regulatory action. National binding legal measures, such as mandatory standards for composition and labelling are urgently needed.

Baby, children, and adult biscuits. Differences in nutritional quality and naturalness

This study examined and compared the nutritional quality and degree of naturalness between baby biscuits (<3 years), children biscuits (>3 years), and adult biscuits. Mintel's Global New Products Database was searched for "Baby Biscuits & Rusks" and "Sweet Biscuits/Cookies" (re)launched between July 2019 and July 2022 in four European countries (Germany, the Netherlands, Spain, and the United Kingdom), which resulted in 1280 products to be analyzed. Nutritional quality was measured by means of nutrient values per 100 g, and baby biscuits were assessed for compliance with the World Health Organization's latest Nutrient and Promotion Profile Model (NPPM). Degree of naturalness was measured using the food naturalness index (FNI). Baby biscuits had the best nutritional quality and were the most natural as compared to children and adult biscuits, but their energy density and sugar content require further attention. Nutritional quality was comparably poor in children and adult biscuits, and children biscuits were the least natural of the three groups. The NPPM requirements of not adding any free sugar at all to baby biscuits may drive parents to purchase alternative sweeter biscuits originally formulated and meant for children and adults. Reasonable regulations are needed to support product (re)formulations and to improve the current market food offer for babies and children.

Caregiver feeding decisions and sociodemographic characteristics are associated with snack food intake during infancy and toddlerhood

Snacking starts early in childhood, yet little is known about child versus family influences on snacking during infancy and toddlerhood. This secondary analysis of baseline data examined associations of child characteristics (e.g., appetitive traits, temperament), caregiver feeding decisions, and sociodemographic characteristics with the mean frequency of (times/day) and mean energy from (kcal/day) child snack food intake. Caregivers and their children (ages 9-15 months) were recruited in Buffalo, NY from 2017 to 2019. Caregivers reported on sociodemographics, child appetitive traits (Baby Eating Behaviour Questionnaire), and child temperament (Infant Behavior Questionnaire-Revised). Three 24-h dietary recalls were collected, and USDA food categories were used to categorize snack foods (e.g., cookies, chips, and puffs). Hierarchical multiple linear regression models examined associations of child characteristics (Step 1: age, sex, baseline weight-for-length z-score, appetitive traits, and temperament), caregiver feeding decisions (Step 2: breastfeeding duration and age of solid food introduction), and caregiver sociodemographic characteristics (Step 3: caregiver age, prepregnancy BMI, education, and household size) with mean child snack food intake. Caregivers (n = 141) were on average 32.6 years of age, predominantly white (89.1%), and college-educated (84.2%). Age of solid food introduction (B = -0.21, p = 0.03), prepregnancy BMI (B = 0.03, p = 0.04), and household size (B = 0.23, p = 0.02) were significantly associated with the mean frequency of (times/day) snack food intake, over and above other variables of interest. Child age (B = 15.96, p = 0.002) was significantly associated with mean energy from (kcal/day) snack food intake. Household size (B = 28.51, p = 0.006) was significantly associated with mean energy from (kcal/day) snack food intake, over and above other variables of interest. There were no significant associations of other child characteristics with snack food intake. Findings show that child snack food intake is more closely associated with caregiver feeding decisions and sociodemographic characteristics than child characteristics. TRIAL REGISTRATION: National Institute on Child Health and Human Development, Grant/Award Number R01HD087082-01.

Parental food selection questionnaire - Infant version

PURPOSE

Complementary feeding practices (CFPs) are associated with health outcomes (e.g., obesity and food allergies). Understanding how parents select foods for their infant is limited. This study's purpose was to develop a psychometrically sound measure of parents' food selection motives for their infant during the complementary feeding period.

METHODS

Development and testing of the Parental Food Slection Questionnaire-Infant Version (PFSQ-I) occurred in three phases. English-speaking, U.S. mothers of healthy infants, aged 6-19 months old participated in a semi-structured, face-to-face interview (Phase 1) or a web-based survey (Phases 2 & 3). Phase 1 was a qualitative study of maternal beliefs and motives surrounding complementary feeding. Phase 2 involved adaptation and exploratory factor analysis of the original Food Choice Questionnaire (Steptoe et al., 1995). Phase 3 involved validity testing of the relationships among PFSQ-I factors and CFPs (timing/type of complementary food introduction, frequency of feeding method, usual texture intake, and allergenic food introduction) using bivariate analyses, and multiple linear and logistic regression analyses.

RESULTS

Mean maternal age was 30.4 years and infant age was 14.1 months (n = 381). The final structure of the PFSQ-I included 30 items and 7 factors: Behavioral Influence, Health Promotion, Ingredients, Affordability, Sensory Appeal, Convenience, and Perceived Threats (Cronbach's α = 0.68-0.83). Associations of factors with CFPs supported construct validity.

DISCUSSION

The PFSQ-I demonstrated strong initial psychometric properties in a sample of mothers from the U.S. Mothers who rated Behavioral Influence as more important were more likely to report suboptimal CFPs (e.g., earlier than recommended complementary food introduction, delayed allergenic food introduction, and prolonged use of spoon-feeding). Additional psychometric testing in a larger, more heterogenous sample is needed, along with examination of relationships between PFSQ-I factors and health outcomes.

Unhealthy Food and Beverage Consumption in Children and Risk of Overweight and Obesity: A Systematic Review and Meta-Analysis

This WHO-commissioned review contributed to the update of complementary feeding recommendations, synthesizing evidence on effects of unhealthy food and beverage consumption in children on overweight and obesity. We searched PubMed (Medline), Cochrane CENTRAL, and Embase for articles, irrespective of language or geography. Inclusion criteria were: 1) randomized controlled trials (RCTs), non-RCTs, cohort studies, and pre/post studies with control; 2) participants aged ≤10.9 y at exposure; 3) studies reporting greater consumption of unhealthy foods/beverages compared with no or low consumption; 4) studies assessing anthropometric and/or body composition; and 5) publication date ≥1971. Unhealthy foods and beverages were defined using nutrient- and food-based approaches. Risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions version I) and RoB2 [Cochrane RoB (version 2)] tools for nonrandomized and randomized studies, respectively. Narrative synthesis was complemented by meta-analyses where appropriate. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Of 26,542 identified citations, 60 studies from 71 articles were included. Most studies were observational (59/60), and no included studies were from low-income countries. The evidence base was low quality, as assessed by ROBINS-I and RoB2 tools. Evidence synthesis was limited by the different interventions and comparators across studies. Evidence indicated that consumption of sugar-sweetened beverages (SSBs) and unhealthy foods in childhood may increase BMI/BMI z-score, percentage body fat, or odds of overweight/obesity (low certainty of evidence). Artificially sweetened beverages and 100% fruit juice consumption make little/no difference to BMI, percentage body fat, or overweight/obesity outcomes (low certainty of evidence). Meta-analyses of a subset of studies indicated a positive association between SSB intake and percentage body fat, but no association with change in BMI and BMI z-score. High-quality epidemiological studies that are designed to assess the effects of unhealthy food consumption during childhood on risk of overweight/obesity are needed to contribute to a more robust evidence base upon which to design policy recommendations. This protocol was registered at https://www.crd.york.ac.uk/PROSPERO as CRD42020218109.

Frequency of sweet and salty snack food consumption is associated with higher intakes of overconsumed nutrients and weight-for-length z-scores during infancy and toddlerhood

BACKGROUND

Current dietary guidelines recommend avoiding foods and beverages with added sugars and higher sodium before age 2 years.

OBJECTIVE

The aim was to describe daily snack food intake (frequency and total energy) and the associations with overconsumed nutrients (added sugars, sodium, and saturated fats) and child weight-for-length z scores.

DESIGN

A cross-sectional, secondary analysis of baseline data from an ongoing longitudinal intervention was conducted.

PARTICIPANTS AND SETTING

A sample of 141 caregivers with infants (aged 9 to 11 months) and toddlers (aged 12 to 15 months) was recruited in Buffalo, NY, between 2017 and 2019.

MAIN OUTCOME MEASURES

Three 24-hour dietary recalls were used to categorize 'sweet and salty snack foods' or 'commercial baby snack foods' based on the US Department of Agriculture What We Eat in America food group classifications and estimate nutrient intakes. Child recumbent length and weight were measured by trained researchers.

STATISTICAL ANALYSIS

Daily frequency (times/day), energy (kcal/day), and overconsumed nutrients from snack food intake were calculated. Multivariable regression models examined associations between the frequency of and energy from snack food intake with overconsumed nutrients and child weight-for-length z scores.

RESULTS

Infants consumed snack foods on average 1.2 times/day contributing 5.6% of total daily energy, 19.6% of added sugars, and 6.8% of sodium. Toddlers consumed snack foods on average 1.4 times/day contributing 8.9% of total daily energy, 40.0% of added sugars, and 7.2% of sodium. In adjusted models including all children, greater frequency of sweet and salty snack food intake, but not commercial baby snack foods, was associated with higher weight-for-length z scores.

CONCLUSIONS

Snack foods are frequently consumed by infants and toddlers and contribute to the intake of overconsumed nutrients such as added sugars and sodium. Given the current guidelines to avoid added sugars and higher sodium before age 2 years, additional recommendations related to nutrient-dense snack intake may be beneficial.

Choking, allergic reactions, and pickiness: A qualitative study of maternal perceived threats and risk avoidance strategies during complementary feeding

An infant's early eating experiences influence later growth and health. However, motivators for mothers' complementary feeding decisions for their infants, such as the process of introducing solid foods, remains unclear. This qualitative study identified maternal perceived threats surrounding complementary feeding and strategies mothers use to mitigate perceived threats of adverse feeding-related health outcomes for their infants. Twenty-seven mothers participated in private, semi-structured interviews. Inductive and deductive qualitative content analysis revealed three primary themes of maternal perceived threats: a) choking, b) allergic reaction, and c) pickiness. Within each primary theme were sub-themes that further delineated the perceived threats and outlined specific and focused complementary feeding practices (CFPs) mothers used for each type of perceived threat. Findings suggest mothers have difficulty with estimating the likelihood and severity of risks and rely on elevated threat perception to guide their feeding decisions. CFPs used to prevent perceived threats were disproportionate to risks, and, at times, actually introduced additional, alternative risks.

High intake of added sugars is linked to rapid weight gain in infancy, breastfeeding ≥12 months may protect against this: A preliminary investigation

BACKGROUND

Consumption of added sugars is linked to excess adiposity in older age groups and breastfeeding has been shown to protect against later obesity.

OBJECTIVES

This investigation aimed to determine whether intake of added sugars associates with rapid weight gain in individuals under 2 years of age, if intake of added sugars associates with breastfeeding duration, and how both influence body weight.

METHODS

A cross-sectional analysis of data from three 24-hours dietary recalls collected from 141 infants/toddlers (age 11.9 ± 1.9 months, 44.7% male) was performed. Multivariable regressions assessed relationships between added sugar intakes, breastfeeding duration, and weight status. Hierarchical regressions examined added variance accounted for in rapid weight gain (specifically, upward weight-for-age percentile [WFA %tile] crossing) through the interaction of added sugars * breastfeeding duration.

RESULTS

Added sugars correlated positively with upward WFA %tile crossing (r = 0.280, P < .001) and negatively with breastfeeding duration (r = -0.468, P < .001). Consumption of added sugars was a significant predictor of rapid weight gain when breastfeeding duration was short (<12 months, β = 0.020, P = .029), but not long (≥12 months, β = 0.001, P = .875).

CONCLUSIONS

A high intake of added sugars in individuals below age 2 associates with rapid weight gain, though breastfeeding ≥12 months appears protective against this. Further studies are necessary to substantiate these findings and provide insight into underlying mechanisms.

A recurrent cross-sectional qualitative study exploring how low-income mothers define snacks and reasons for offering snacks during infancy

Despite rapid increases in snacking in recent decades, little is known about snacking during infancy. This study explored how low-income mothers define snacks and their reasons for offering snacks during infancy. A recurrent cross-sectional qualitative approach was used to identify themes from semi-structured interviews with low-income mothers when their infants were 6 and 12 months of age. A purposive sample of mothers (N = 15) was recruited from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices and childcare centers serving low-income families in Rhode Island. Mothers also completed demographic and infant feeding questionnaires. Independent thematic analyses were conducted to identify themes from the 6 and 12 month interviews. Themes from the 6 month interviews for how mothers defined snacks were: snacks are consumed between meals, snacks are smaller portions, and snacks are sweet. Themes from the 12 month interviews also included snacks are consumed between meals and snacks are smaller portions with one additional theme: snacks do not include all food groups. Themes from the 6 month interviews for the reasons mothers offered snacks were: infants seemed hungry, infants showed interest, and snacks help manage behavior. Themes from 12 month interviews also included snacks help manage behavior with two additional themes: snacks expose infants to different flavors and snacks expose infants to different textures. Findings suggest that snacks are commonly offered during infancy and that mothers define snacks as smaller portions that help with hunger between meals. However, during early infancy mothers describe snacks as sweet, and across infancy report using snacks to manage behavior, underscoring the importance of providing parents with guidance on healthy snacking during the first year of life.

Grow well/Crecer bien: a protocol for research on infant feeding practices in low-income families

BACKGROUND

The prevalence of obesity among children remains high. Given obesity's significant lifelong consequences, there is great interest in preventing obesity early in life. There is a need to better understand the relation of common infant feeding styles and practices to obesity in infants using longitudinal study designs. There is also an urgent need to understand the role of caregivers other than mothers in feeding. A better understanding of variation in feeding styles and practices can inform the identification of risk groups and the tailoring of interventions to them.

METHODS

In partnership with Early Head Start programs across four counties in southern California, mothers and infants will be enrolled in a two-year longitudinal study collecting survey and anthropometric data. A subsample of mothers and their selected other caregivers will participate in qualitative research involving feeding diaries and dyadic interviews. The results will be used to develop and test an enhanced nutrition education program.

DISCUSSION

We outline a study methodology to examine feeding styles and practices and their association with early childhood obesity risk and enhance an existing intervention to promote healthy infant feeding and growth among children in low-income families.