Lower protein content in infant formula reduces BMI and obesity risk at school age: follow-up of a randomized trial

Growth and body composition of infants born moderate-to-late preterm fed a protein- and mineral-enriched postdischarge formula compared with a standard term formula until 6 months corrected age, a randomized controlled trial

BACKGROUND

Infants born moderate-to-late preterm (i.e., 32 wk-35 wk 6 d gestation) are, analogous to those born very preterm, at risk of later obesity, hypertension, and diabetes. Appropriate early life nutrition is key for ensuring optimal growth and body composition, thereby mitigating potential cardiometabolic risks.

OBJECTIVES

We aimed to compare growth and body composition between infants born moderate-to-late preterm fed isocaloric but protein- and mineral-enriched postdischarge formula (PDF) or standard term formula (STF) until 6 mo corrected age (CA; i.e., after term equivalent age [TEA]).

METHODS

After enrollment (≤7 d postpartum), infants received PDF if (fortified) mother's own milk (MOM) was insufficient. At TEA, those receiving >25% of intake as formula were randomized to either continue the same PDF (n = 47) or switch to STF (n = 50); those receiving ≥75% of intake as MOM (n = 60) served as references. At TEA and 6 mo CA, we assessed anthropometry and body composition using both dual-energy x-ray absorptiometry (DXA) and air displacement plethysmography (ADP).

RESULTS

Feeding groups had similar gestational age (median [25th percentile;75th percentile]: 34.3 [33.5; 35.1] wk), birthweight (mean ± standard deviation [SD]: 2175 ± 412 g), anthropometry, and body composition at TEA. At 6 mo CA, infants fed PDF had slightly, but significantly, greater length (67.6 ± 2.5 and 66.9 ± 2.6 cm, P < 0.05) and larger head circumference (43.9 ± 1.3 and 43.4 ± 1.5 cm, P < 0.05) compared to infants fed STF. Also, infants fed PDF had higher lean mass (LM) and bone mineral content estimated by DXA (4772 ± 675 and 4502 ± 741 g; 140 ± 20 and 131 ± 23 g, respectively; P < 0.05). ADP estimates, however, were not statistically different between feeding groups.

CONCLUSIONS

Infants born moderate-to-late preterm demonstrated modest increases in length, head circumference, LM, and bone mineral content when fed PDF compared to STF for 6 mo after TEA. This trial was registered at the International Clinical Trial Registry Platform as NTR5117 and NTR NL4979.

Personalized Nutrition with Banked Human Milk for Early Gut Microbiota Development: In Pursuit of the Perfect Match

The correct initial colonization and establishment of the gut microbiota during the early stages of life is a key step, with long-lasting consequences throughout the entire lifespan of the individual. This process is affected by several perinatal factors; among them, feeding mode is known to have a critical role. Breastfeeding is the optimal nutrition for neonates; however, it is not always possible, especially in cases of prematurity or early pathology. In such cases, most commonly babies are fed with infant formulas in spite of the official nutritional and health international organizations' recommendation on the use of donated human milk through milk banks for these cases. However, donated human milk still does not totally match maternal milk in terms of infant growth and gut microbiota development. The present review summarizes the practices of milk banks and hospitals regarding donated human milk, its safety and quality, and the health outcomes in infants fed with donated human milk. Additionally, we explore different alternatives to customize pasteurized donated human milk with the aim of finding the perfect match between each baby and banked milk for promoting the establishment of a beneficial gut microbiota from the early stages of life.

Nutritional counselling and risk factors for obesity: an observational study in toddlers

BACKGROUND

Nutrition exerts a fundamental role in the prevention of obesity (OB). The aim of this study was to assess the extent to which well recognized risk factors for early OB can be associated to overweight (OW) or OB under a standardized nutritional approach and surveillance in toddlers.

METHODS

The eligible population was represented by 676 toddlers aged 24-36 months, assigned to 18 primary care pediatricians trained on nutritional issues who shared a standardized nutritional approach. Six-hundred-twenty-nine children (333 boys), mean age 27.8 ± 4.2 months were effectively included in this observational study. Parents received nutritional advice with particular emphasis to proteins and sugar composition supported by leaflets and reinforced at each visit. Body mass index was assessed at the age of 24-36 months. The following individual and family risk factors were considered: gestational age, birth weight, eutocic/caesarean delivery, milk feeding history, household smoking or antibiotics exposure, parents' weight, height and educational level. Prevalence of OW/OB was compared to a group of 742 toddlers (373 boys) under usual care.

RESULTS

Under a standardized nutritional counselling, 28.1% toddlers were classified as OW/OB compared to 36.9% toddlers under usual care (p = 0.005). In unadjusted models, parental OW/OB was significantly associated to OW/OB in toddlers (p < 0.01), while high birth weight did not reach statistical significance (p = 0.07). In adjusted models, including all the explanatory variables studied, only paternal OW/OB vs. normal weight was significantly associated to OW/OB in toddlers (OR 2.035, 95% confidence interval 1.206-3.436). No protective effect of exclusive breast feeding during the first 6 months of age was demonstrated.

CONCLUSIONS

Toddlers under a standardized nutrition counselling focused to limit protein and simple sugars, showed lower prevalence of OW/OB compared to usual care. Healthy promotion activities should take into account the influence of paternal BMI on the offspring adiposity.

Childhood Transitions Between Weight Status Categories: Evidence from the UK Millennium Cohort Study

BACKGROUND

Assessing the cost-effectiveness of interventions targeting childhood excess weight requires estimates of the hazards of transitioning between weight status categories. Current estimates are based on studies characterized by insufficient sample sizes, a lack of national representativeness, and untested assumptions.

OBJECTIVES

We sought to (1) estimate transition probabilities and hazard ratios for transitioning between childhood weight status categories, (2) test the validity of the underlying assumption in the literature that transitions between childhood bodyweight categories are time-homogeneous, (3) account for complex sampling procedures when deriving nationally representative transition estimates, and (4) explore the impact of child, maternal, and sociodemographic characteristics.

METHODS

We applied a multistate transition modeling approach accounting for complex survey design to UK Millennium Cohort Study (MCS) data to predict transition probabilities and hazard ratios for weight status movements for children aged 3-17. Surveys were conducted at ages 3 (wave 2 in 2004), 5 (wave 3 in 2006), 7 (wave 4 in 2008), 11 (wave 5 in 2012), 14 (wave 6 in 2015), and 17 (wave 7 in 2018) years. We derived datasets that included repeated body mass index measurements across waves after excluding multiple births and children with missing or implausible bodyweight records. To account for the stratified cluster sample design of the MCS, we incorporated survey weights and jackknife replicates of survey weights. Using a validation dataset from the MCS, we tested the validity of our models. Finally, we estimated the relationships between state transitions and child, maternal, and sociodemographic factors.

RESULTS

The datasets for our primary analysis consisted of 10,399 children for waves 2-3, 10,729 for waves 3-4, 9685 for waves 4-5, 8593 for waves 5-6, and 7085 for waves 6-7. All datasets consisted of roughly equal splits of boys and girls. Under the assumption of time-heterogeneous transition rates (our base-case model), younger children (ages 3-5 and 5-7 years) had significantly higher annual transition probabilities of moving from healthy weight to overweight (0.033, 95% confidence interval [CI] 0.026-0.041, and 0.027, 95% CI 0.021-0.033, respectively) compared to older children (0.015, 95% CI 0.012-0.018, at ages 7-11; 0.018, 95% CI 0.013-0.023, at ages 11-14; and 0.018, 95% CI 0.013-0.025 at ages 14-17 years). However, the resolution of unhealthy weight was more strongly age-dependent than transitions from healthy weight to non-healthy weight states. Transition hazards differed by child, maternal, and sociodemographic factors.

CONCLUSIONS

Our models generated estimates of bodyweight status transitions in a representative UK childhood population. Compared to our scenario models (i.e., time-homogeneous transition rates), our base-case model fits the observed data best, indicating a non-time-homogeneous pattern in transitions between bodyweight categories during childhood. Transition hazards varied significantly by age and across subpopulations, suggesting that conducting subgroup-specific cost-effectiveness analyses of childhood weight management interventions will optimize decision-making.

Low-Protein Infant Formula Enriched with Alpha-Lactalbumin during Early Infancy May Reduce Insulin Resistance at 12 Months: A Follow-Up of a Randomized Controlled Trial

High protein intake during infancy results in accelerated early weight gain and potentially later obesity. The aim of this follow-up study at 12 months was to evaluate if modified low-protein formulas fed during early infancy have long-term effects on growth and metabolism. In a double-blinded RCT, the ALFoNS study, 245 healthy-term infants received low-protein formulas with either alpha-lactalbumin-enriched whey (α-lac-EW; 1.75 g protein/100 kcal), casein glycomacropeptide-reduced whey (CGMP-RW; 1.76 g protein/100 kcal), or standard infant formula (SF; 2.2 g protein/100 kcal) between 2 and 6 months of age. Breastfed (BF) infants served as a reference. At 12 months, anthropometrics and dietary intake were assessed, and serum was analyzed for insulin, C-peptide, and insulin-like growth factor 1 (IGF-1). Weight gain between 6 and 12 months and BMI at 12 months were higher in the SF than in the BF infants (p = 0.019; p < 0.001, respectively), but were not significantly different between the low-protein formula groups and the BF group. S-insulin and C-peptide were higher in the SF than in the BF group (p < 0.001; p = 0.003, respectively), but more alike in the low-protein formula groups and the BF group. Serum IGF-1 at 12 months was similar in all study groups. Conclusion: Feeding modified low-protein formula during early infancy seems to reduce insulin resistance, resulting in more similar growth, serum insulin, and C-peptide concentrations to BF infants at 6-months post intervention. Feeding modified low-protein formula during early infancy results in more similar growth, serum insulin, and C-peptide concentrations to BF infants 6-months post intervention, probably due to reduced insulin resistance in the low-protein groups.

From Birth to Weaning: A Window of Opportunity for Microbiota

(1) Background: The first 1000 days of life constitute a critical window of opportunity for microbiota development. Nutrients play a crucial role in enriching and diversifying the microbiota, derived not only from solid food but also from maternal dietary patterns during gestation. (2) Methods: We conducted a comprehensive literature review using the PubMed database, covering eleven years (2013-2023). We included English-language reviews, original research papers, and meta-analyses, while excluding case reports and letters. (3) Results: Consensus in the literature emphasizes that our interaction with a multitude of microorganisms begins in the intrauterine environment and continues throughout our lives. The existing data suggest that early nutritional education programs, initiated during pregnancy and guiding infant diets during development, may influence the shaping of the gut microbiota, promoting long-term health. (4) Conclusions: Further research is necessary in the coming years to assess potential interventions and early nutritional models aimed at modulating the pediatric microbiota, especially in vulnerable populations such as premature newborns.

A literature review of evidence for primary prevention of overweight and obesity in healthy weight children and adolescents: A report produced by a working group of the Danish Council on Health and Disease Prevention

Primary prevention targets development of overweight in individuals with healthy weight and is a great challenge. This paper summarizes the main findings of a working group of the Danish Council on Health and Disease Prevention that reviewed the literature on primary prevention of overweight and obesity among children and adolescents. The results were presented in a Danish report, in which a 2019 Cochrane review on childhood obesity prevention was complemented by searches in PubMed to include all relevant subsequent studies published from January 2018 until March 2020. In this paper, the review was updated until June 2023. Numerous childhood overweight prevention interventions have been developed during the past decades, primarily targeting diet and/or physical activity. Several of these interventions showed positive effects on diet and physical activity level but did not show effects on risk of developing overweight. The evidence foundation is inconsistent as four out of five interventions did not show positive effects. Previously observed intervention effects may not reflect excessive weight gain prevention among children with healthy weight but rather bodyweight reduction among those with overweight or obesity. We do not have sufficient knowledge about how to prevent children with healthy weight from developing overweight, and creative solutions are urgently needed.

Infant Milk Formula with Large, Milk Phospholipid-coated Lipid Droplets Enriched in Dairy Lipids Affects Body Mass Index Trajectories and Blood Pressure at School Age: Follow-up of a Randomized Controlled Trial

BACKGROUND

Human milk comprises large fat globules enveloped by a native phospholipid membrane, whereas infant formulas contain small, protein-coated lipid droplets. Previous experimental studies indicated that mimicking the architecture of human milk lipid droplets in infant milk formula (IMF) alters lipid metabolism with lasting beneficial impact on later metabolic health.

OBJECTIVES

To evaluate in a follow-up (FU) study of a randomized, controlled trial whether a Concept IMF with large, milk phospholipid-coated lipid droplets enriched with dairy lipids beneficially impacts long-term body mass index (BMI in kg/m2) trajectories and blood pressure at school age.

METHODS

Fully formula-fed infants were randomly assigned to Concept IMF (n = 115) or Control IMF with conventional, small lipid droplets containing vegetable oils (n = 108) for the first 4 mo of age. A group of 88 breastfed infants served as a reference. During FU, anthropometrics were collected at 1, 3, 4, and 5 y of age, and blood pressure only at the last visit.

RESULTS

Compared to Control, Concept group children had consistently lower mean BMI values during FU, with the most marked difference at 1 y of age (difference in means -0.71 kg/m2, 95% confidence interval (CI): -1.13, -0.29; P = 0.001); mean values were close to the breastfed group (P > 0.05). Contrary, the mean BMI values of the Control group were higher compared with the breastfed group during FU from 1 to 5 y of age (differences in means from 0.59 to 0.96 kg/m2, respectively; P < 0.02). At 5 y of age, the Concept group had a lower mean diastolic and arterial blood pressure compared with the Control group; -4.3mm Hg (95% CI: -7.3, -1.3; P = 0.005) and -3.7 mm Hg (95% CI: -6.5, -0.9; P = 0.01), respectively.

CONCLUSIONS

Early life feeding of an innovative IMF with large, milk phospholipid-coated lipid droplets enriched with dairy lipids results in a BMI trajectory closer to breastfed infants and a lower blood pressure at school age. This trial was registered at the Dutch Trial Register as NTR3683 and NTR5538.

Impact of Gestational Diabetes Detection Thresholds on Infant Growth and Body Composition: A Prospective Cohort Study Within a Randomized Trial

OBJECTIVE

Gestational diabetes mellitus (GDM) is associated with offspring metabolic disease, including childhood obesity, but causal mediators remain to be established. We assessed the impact of lower versus higher thresholds for detection and treatment of GDM on infant risk factors for obesity, including body composition, growth, nutrition, and appetite.

RESEARCH DESIGN AND METHODS

In this prospective cohort study within the Gestational Diabetes Mellitus Trial of Diagnostic Detection Thresholds (GEMS), pregnant women were randomly allocated to detection of GDM using the lower criteria of the International Association of Diabetes and Pregnancy Study Groups or higher New Zealand criteria (ACTRN12615000290594). Randomly selected control infants of women without GDM were compared with infants exposed to A) GDM by lower but not higher criteria, with usual treatment for diabetes in pregnancy; B) GDM by lower but not higher criteria, untreated; or C) GDM by higher criteria, treated. The primary outcome was whole-body fat mass at 5-6 months.

RESULTS

There were 760 infants enrolled, and 432 were assessed for the primary outcome. Fat mass was not significantly different between control infants (2.05 kg) and exposure groups: A) GDM by lower but not higher criteria, treated (1.96 kg), adjusted mean difference (aMD) -0.09 (95% CI -0.29, 0.10); B) GDM by lower but not higher criteria, untreated (1.94 kg), aMD -0.15 (95% CI -0.35, 0.06); and C) GDM detected and treated using higher thresholds (1.87 kg), aMD -0.17 (95% CI -0.37, 0.03).

CONCLUSIONS

GDM detected using lower but not higher criteria, was not associated with increased infant fat mass at 5-6 months, regardless of maternal treatment. GDM detected and treated using higher thresholds was also not associated with increased fat mass at 5-6 months.

Impact of an early 1000-day intervention for obesity prevention on adiposity and BMI at two years of age: A quasi-experimental study

Background

The 1000-day period encompassing pregnancy and the first two years of postnatal life is critical for preventing childhood obesity. Existing interventions targeting this period have been characterised by great variability in duration, objectives, and evaluation indicators. We aimed to evaluate the impact of an intervention developed during the entire 1000-day period on body mass index and body fat percentage at two years of age.

Methods

We designed a prospective, interventional, quasi-experimental study (ie, without randomisation or blinding of both groups) targeting mother-child pairs from the beginning of pregnancy up to two years of age belonging to the basic health area of Puerto Real (Cádiz). We developed and delivered an intervention from pregnancy to two years and assessed its effect.

Results

The duration of breastfeeding and vitamin D supplementation increased significantly after the intervention. The intervention group showed lowed skinfolds values, a significantly lower body fat percentage, as well as a lower accumulation of factor at two years than the control group.

Conclusions

The intervention has had an impact on body fat percentage at two years, potentially justified through its overall effect and the lower accumulation of early risk factors.

Causes of possible excessive weight gain in exclusively breastfed infants in the first six months of life

BACKGROUND

The aim of this study was to describe factors related to the infant, mother, and breastmilk composition that may be associated with excessive weight gain in a cohort of exclusively breastfed infants younger than 6 months of life with excessive weight gain, and to compare these findings with data from a group of normal-weight exclusively breastfed infants.

METHODS

Thirty-six exclusively breastfed infants younger than 6 months of life seen at two health-care centers between July 2016 and 2017 were enrolled in the study. The clinical features of the infants, their mothers, and the macronutrient composition of the breast milk were evaluated. We classified infants according to weight gain velocity between birth and 6 months of life into an excessive weight gain (EWG) and an adequate weight gain (AWG) group.

RESULTS

Mean age at protocol entry was 3.8 months. Thirteen patients were classified as EWG and 23 patients as AWG. Co-sleeping was more often observed in EWG than in AWG infants. Mothers in the EWG group were younger and more often had gained more than 18 kg during pregnancy than those in the AWG group. No significant differences were found in the macronutrient content of the breast milk between both groups.

CONCLUSIONS

Greater weight gain in infants under 6 months of age may be related to greater weight gain of the mother during pregnancy, younger age of the mother, and co-sleeping of the mother and child.

Higher versus lower protein intake in formula-fed term infants

BACKGROUND

Many infants are fed infant formulas to promote growth. Some formulas have a high protein content (≥ 2.5 g per 100 kcal) to accelerate weight gain during the first year of life. The risk-benefit balance of these formulas is unclear.

OBJECTIVES

To evaluate the benefits and harms of higher protein intake versus lower protein intake in healthy, formula-fed term infants.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, OpenGrey, clinical trial registries, and conference proceedings in October 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of healthy formula-fed infants (those fed only formula and those given formula as a complementary food). We included infants of any sex or ethnicity who were fed infant formula for at least three consecutive months at any time from birth. We excluded quasi-randomized trials, observational studies, and infants with congenital malformations or serious underlying diseases. We defined high protein content as 2.5 g or more per 100 kcal, and low protein content as less than 1.8 g per 100 kcal (for exclusive formula feeding) or less than 1.7 g per 100 kcal (for complementary formula feeding).

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed the risk of bias and extracted data from trials, and a fifth review author resolved discrepancies. We performed random-effects meta-analyses, calculating risk ratios (RRs) or Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) with 95% CIs for continuous outcomes. We used the GRADE approach to evaluate the certainty of the evidence.

MAIN RESULTS

We included 11 RCTs (1185 infants) conducted in high-income countries. Seven trials (1629 infants) compared high-protein formula against standard-protein formula, and four trials (256 infants) compared standard-protein formula against low-protein formula. The longest follow-up was 11 years. High-protein formula versus standard-protein formula We found very low-certainty evidence that feeding healthy term infants high-protein formula compared to standard-protein formula has little or no effect on underweight (MD in weight-for-age z-score 0.05 SDs, 95% CI -0.09 to 0.19; P = 0.51, I2 = 61%; 7 studies, 1629 participants), stunting (MD in height-for-age z-score 0.15 SDs, 95% CI -0.05 to 0.35; P = 0.14, I2 = 73%; 7 studies, 1629 participants), and wasting (MD in weight-for-height z-score -0.12 SDs, 95% CI -0.31 to 0.07; P = 0.20, I2 = 94%; 7 studies, 1629 participants) in the first year of life. We found very low-certainty evidence that feeding healthy infants high-protein formula compared to standard-protein formula has little or no effect on the occurrence of overweight (RR 1.26, 95% CI 0.63 to 2.51; P = 0.51; 1 study, 1090 participants) or obesity (RR 1.96, 95% CI 0.59 to 6.48; P = 0.27; 1 study, 1090 participants) at five years of follow-up. No studies reported all-cause mortality. Feeding healthy infants high-protein formula compared to standard-protein formula may have little or no effect on the occurrence of adverse events such as diarrhea, vomiting, or milk hypersensitivity (RR 0.93, 95% CI 0.76 to 1.13; P = 0.44, I2 = 0%; 4 studies, 445 participants; low-certainty evidence) in the first year of life. Standard-protein formula versus low-protein formula We found very low-certainty evidence that feeding healthy infants standard-protein formula compared to low-protein formula has little or no effect on underweight (MD in weight-for-age z-score 0.0, 95% CI -0.43 to 0.43; P = 0.99, I2 = 81%; 4 studies, 256 participants), stunting (MD in height-for-age z-score -0.01, 95% CI -0.36 to 0.35; P = 0.96, I2 = 73%; 4 studies, 256 participants), and wasting (MD in weight-for-height z-score 0.13, 95% CI -0.29 to 0.56; P = 0.54, I2 = 95%; 4 studies, 256 participants) in the first year of life. No studies reported overweight, obesity, or all-cause mortality. Feeding healthy infants standard-protein formula compared to low-protein formula may have little or no effect on the occurrence of adverse events such as diarrhea, vomiting, or milk hypersensitivity (Peto OR 1.55, 95% CI 0.70 to 3.40; P = 0.28, I2 = 0%; 2 studies, 206 participants; low-certainty evidence) in the first four months of life.

AUTHORS' CONCLUSIONS

We are unsure if feeding healthy infants high-protein formula compared to standard-protein formula has an effect on undernutrition, overweight, or obesity. There may be little or no difference in the risk of adverse effects between infants fed with high-protein formula versus those fed with standard-protein formula. We are unsure if feeding healthy infants standard-protein formula compared to low-protein formula has any effect on undernutrition. There may be little or no difference in the risk of adverse effects between infants fed with standard-protein formula versus those fed with low-protein formula. The findings of six ongoing studies and two studies awaiting classification studies may change the conclusions of this review.

Cardiovascular Risk in Pediatrics: A Dynamic Process during the First 1000 Days of Life

The early childhood period, encompassing prenatal and early stages, assumes a pivotal role in shaping cardiovascular risk factors. We conducted a narrative review, presenting a non-systematic summation and analysis of the available literature, focusing on cardiovascular risk from prenatal development to the first 1000 days of life. Elements such as maternal health, genetic predisposition, inadequate fetal nutrition, and rapid postnatal growth contribute to this risk. Specifically, maternal obesity and antibiotic use during pregnancy can influence transgenerational risk factors. Conditions at birth, such as fetal growth restriction and low birth weight, set the stage for potential cardiovascular challenges. To consider cardiovascular risk in early childhood as a dynamic process is useful when adopting a personalized prevention for future healthcare and providing recommendations for management throughout their journey from infancy to early adulthood. A comprehensive approach is paramount in addressing early childhood cardiovascular risks. By targeting critical periods and implementing preventive strategies, healthcare professionals and policymakers can pave the way for improved cardiovascular outcomes. Investing in children's health during their early years holds the key to alleviating the burden of cardiovascular diseases for future generations.

Protein appetite as an integrator in the obesity system: the protein leverage hypothesis

Despite the large volume and extensive range of obesity research, there is substantial disagreement on the causes and effective preventative strategies. We suggest the field will benefit from greater emphasis on integrative approaches that examine how various potential contributors interact, rather than regarding them as competing explanations. We demonstrate the application of nutritional geometry, a multi-nutrient integrative framework developed in the ecological sciences, to obesity research. Such studies have shown that humans, like many other species, regulate protein intake more strongly than other dietary components, and consequently if dietary protein is diluted there is a compensatory increase in food intake-a process called protein leverage. The protein leverage hypothesis (PLH) proposes that the dilution of protein in modern food supplies by fat and carbohydrate-rich highly processed foods has resulted in increased energy intake through protein leverage. We present evidence for the PLH from a variety of sources (mechanistic, experimental and observational), and show that this mechanism is compatible with many other findings and theories in obesity research. This article is part of a discussion meeting issue 'Causes of obesity: theories, conjectures and evidence (Part II)'.

Infant body composition: A comprehensive overview of assessment techniques, nutrition factors, and health outcomes

Body composition assessment is a valuable tool for clinical assessment and research that has implications for long-term health. Unlike traditional measurements such as anthropometrics or body mass index, body composition assessments provide more accurate measures of body fatness and lean mass. Moreover, depending on the technique, they can offer insight into regional body composition, bone mineral density, and brown adipose tissue. Various methods of body composition assessment exist, including air displacement plethysmography, dual-energy x-ray absorptiometry, bioelectrical impedance, magnetic resonance imaging, D3 creatine, ultrasound, and skinfold thickness, each with its own strengths and limitations. In infants, several feeding practices and nutrition factors are associated with body composition outcomes, such as breast milk vs formula feeding, protein intake, breast milk composition, and postdischarge formulas for preterm infants. Longitudinal studies suggest that body composition in infancy predicts later body composition, obesity, and other cardiometabolic outcomes in childhood, making it a useful early marker of cardiometabolic health in both term and preterm infants. Emerging evidence also suggests that body composition during infancy predicts neurodevelopmental outcomes, particularly in preterm infants at high risk of neurodevelopmental impairment. The purpose of this narrative review is to provide clinicians and researchers with a comprehensive overview of body composition assessment techniques, summarize the links between specific nutrition practices and body composition in infancy, and describe the neurodevelopmental and cardiometabolic outcomes associated with body composition patterns in term and preterm infants.

Protein and growth during the first year of life: a systematic review and meta-analysis

Dietary protein intake in the first year of life might influence later growth. We conducted a systematic review to investigate the growth effects of interventions based on infant formula composition providing different amounts of protein within the first year of life of healthy term infants; in the absence of other comparable information over the investigated period, a meta-analysis further compared weight or length gain at 120 days from high- (>2.0 g/100 kcal) and low-protein (≤2.0 g/100 kcal) content formula groups. Twelve papers (n = 2275) were included and five of them (n = 677) contributed to the meta-analysis. Most studies compared a high-protein formula, a low-protein formula, and breastfeeding. Evidence from the systematic review was inconclusive due to heterogeneity in design and treatments. In the presence of modest heterogeneity but in the absence of publication bias, the weighted mean difference for weight gain at 120 days was -0.02 g/day (95% CI: -1.41, 1.45); with higher heterogeneity, the weighted MD estimate of length gain at 120 days was 0.004 cm/month (95% CI: -0.26, 0.27). Although limited and underpowered, evidence from the meta-analysis does not support the assumption that high- vs. low-protein content formulas during exclusive milk-feeding lead to different growth outcomes in the first months of life. Prospero registration number: CRD42017058535. IMPACT: The optimal amount of dietary protein that should be given to healthy full-term infants early in life is still debated. Despite heterogeneity in study design, treatments, and outcomes, this systematic review showed that there is no clear-cut effect on the growth of different amounts of protein intake from formulas or complementary feeding. Evidence from the meta-analysis based on the five articles enrolling infants <1 month of life does not support the previous assumption that high- vs. low-protein content formulas during exclusive milk-feeding lead to different growth outcomes in the first 4 months of life.

Does human milk composition predict later risk of obesity? A systematic review

BACKGROUND

Possible mechanisms behind the association of breastfeeding with a lower risk of later obesity are unknown but one possibility is the unique composition of human milk. Here, we systematically reviewed the evidence linking breast-milk macronutrient and hormonal composition with later obesity.

METHODS

We searched 7 databases for studies that included infants predominantly breast-fed for the first 3 months and which analysed associations between a measure of breast-milk composition and later (> 6 months) measures of obesity or body composition.

RESULTS

47 publications were identified for full-text screening, of which 10 were eligible and only 3 found significant associations. Higher leptin concentration in breast milk at age 1 month was associated with lower infant BMI at 12, 18 and 24 months of age (1 study). Higher breast-milk adiponectin concentration at 6 weeks and 4 months were associated with adiposity at age 12 and 24 months (1 study). In 1 study, breast-milk carbohydrate content was positively associated, and fat content negatively associated, with adiposity at age 12 months. No significant associations were found between other hormones or macronutrients in human milk and later risk of obesity or body composition.

CONCLUSIONS

The evidence linking breast-milk composition with later obesity was inconsistent and confined to single, individual studies. Our review highlights the methodological limitations of previous studies and the need for further research in this area.

Obesity in Early Life: Its Causes, Prevention and Risks in Later Life

Being overweight or obese at the end of the first year of life is associated with an increased risk of obesity in later life and an increased risk of developing other diseases, like type 1 diabetes mellitus, cardiovascular disorders and psycho-social problems [...].

Child and adolescent obesity

The prevalence of child and adolescent obesity has plateaued at high levels in most high-income countries and is increasing in many low-income and middle-income countries. Obesity arises when a mix of genetic and epigenetic factors, behavioural risk patterns and broader environmental and sociocultural influences affect the two body weight regulation systems: energy homeostasis, including leptin and gastrointestinal tract signals, operating predominantly at an unconscious level, and cognitive-emotional control that is regulated by higher brain centres, operating at a conscious level. Health-related quality of life is reduced in those with obesity. Comorbidities of obesity, including type 2 diabetes mellitus, fatty liver disease and depression, are more likely in adolescents and in those with severe obesity. Treatment incorporates a respectful, stigma-free and family-based approach involving multiple components, and addresses dietary, physical activity, sedentary and sleep behaviours. In adolescents in particular, adjunctive therapies can be valuable, such as more intensive dietary therapies, pharmacotherapy and bariatric surgery. Prevention of obesity requires a whole-system approach and joined-up policy initiatives across government departments. Development and implementation of interventions to prevent paediatric obesity in children should focus on interventions that are feasible, effective and likely to reduce gaps in health inequalities.

Effects of early introduction of solid foods on nutrient intake in preterm infants during their 1st year of life: a secondary outcome analysis of a prospective, randomized intervention study

Very low birth weight (VLBW) infants have higher nutritional needs even after hospital discharge. However, data concerning current nutrient intakes at different time points after the introduction of solid foods and whether dietary reference values are being met are scarce. To adress this issue, this secondary analysis of a prospective, two-arm interventional study in 177 VLBW infants 21 investigates dietary intake comparing early and late (early: 10-12 weeks corrected for gestational age, late: 16-18 weeks corrected for gestational age) introduction of standardized complementary food during the first year of life. Nutritional intake was assessed using self-reported monthly 3-day dietary records from 3 until 12 months, corrected for gestational age. The time point of the introduction of solid foods did not influence nutrient intake, but the early introduction of solids tended toward a higher proportional intake of protein and carbohydrates and a lower intake of fat as a percentage of total energy) during the 1st year of life, corrected for gestational age. The results of this study indicate that this standardized feeding concept was sufficient for zinc, calcium, and phosphorus intake. However, dietary iron and vitamin D intakes did not meet the recommendations. Thus, prolonged iron supplementation should be considered beyond the introduction of meat and vitamin D supplementation at least until 12 months, corrected for gestational age.

Trial registration number

ClinicalTrials.gov: NCT01809548.

Growth, Nutritional Status, and Dietary Intake Patterns Associated With Prolonged Breastfeeding in Young Korean Children: A Nationwide Cross-Sectional Study

BACKGROUND

Although the optimal duration of breastfeeding remains unclear, breastfeeding is generally recommended exclusively for the first 6 months of life, which continues into late infancy. However, the awareness regarding the effects of long-term breastfeeding is relatively low compared with that of breastfeeding in early infancy. We aimed to investigate the growth and nutritional characteristics of the children with prolonged breastfeeding (PBF) over 1 year.

METHODS

This cross-sectional study was based on the data of children aged 12 to 23 months from the National Health and Nutrition Examination Survey (2010-2020) conducted by the Korean Center for Disease Control and Prevention. Data on anthropometric measurements, dietary behavior, and food and nutrient intake were extracted, and the association between PBF and growth, nutritional status, and dietary patterns were analyzed.

RESULTS

Of the 872 children with a birth weight of ≥ 2.5 kg in the final analysis, 34.2% continued breastfeeding over 12 months of age, and their median breastfeeding duration was 14.2 months. Children with PBF were more likely to have lower current body weight (P < 0.001) and weight gain (P < 0.001), lower daily protein (P = 0.012), calcium (P < 0.001), and iron (P < 0.001) intake per calorie compared with children weaned by 12 months of age or those who were never breastfed. Furthermore, they were started on complementary food at 6 months or later rather than 4-5 months (P < 0.001), consumed cow's milk earlier (P = 0.012), and consumed probiotics as dietary supplements (P < 0.001) significantly less commonly. When comparing the intake of food groups, children with PBF had a significantly higher intake of cereals and grains (P = 0.023) and fruits (P = 0.020) and a significantly lower intake of bean products (P = 0.020) and milk and dairy products (P = 0.003).

CONCLUSION

Korean children who continued breastfeeding over 12 months of age showed distinct characteristics in terms of growth, nutritional status, and dietary patterns in the second year of life compared to children who did not. Long-term additional research on their growth and nutritional status may be needed; however, these findings are significant as important fundamental data for nutritional counseling to establish healthy PBF.

Micronutrient Deficiency in Children and Adolescents with Obesity-A Narrative Review

Childhood obesity represents a serious public health burden. Despite excessive dietary consumption, children with obesity present high rates of micronutrient deficiencies, such as deficiencies in minerals and specific vitamins; micronutrient deficiencies may have a pathogenic role in obesity-related metabolic comorbidities. In this narrative review, we analyzed the main deficiencies associated with obesity, their clinical consequences, and the evidence about a possible supplementation. Iron; vitamins A, B, C, D, and E; folic acid; zinc; and copper deficiencies represent the most common deficient microelements. The relationship between obesity and multiple micronutrient deficiencies remains unclear, and different mechanisms have been proposed. The medical care plan for pediatric obesity should include food choices with high nutritional content as part of a crucial approach to obesity-related complications. Unfortunately, only a few studies are available regarding the efficacy of oral supplementation or weight loss for treating them; thus, continuous nutritional monitoring is necessary.

Is It Time to Revise the Current Nutrient Requirements for Infant Formulas Principally Established in 1980?

Because of the production of nutrient-deficient infant formulas (IFs), the United States Congress passed regulations on the composition and production of IF, referred to as the Infant Formula Act (IFA), in 1980, which was amended in 1986. More detailed FDA rules have been created since then, specifying the ranges or minimum intakes of nutrients and providing details for the safe production and evaluation of infant formulas. Although generally effective in ensuring safe IF, recent events have made it clear that a re-evaluation of aspects of all the nutrient composition regulations for IF is needed, including consideration of adding requirements related to bioactive nutrients not mentioned in the IFA. We propose that, as principal examples, the requirement for iron content needs to be re-evaluated and that DHA and AA should be considered for addition to the nutrient requirements after scientific review by a panel such as those established by the National Academies of Sciences, Engineering, and Medicine. Additionally, there is no specific requirement in current FDA regulations for the energy density of IF, and this should be added alongside potential revisions of the protein requirement. It would also be ideal to have specific FDA rules on nutrient intakes for premature infants as these are exempted from the specific nutrient regulations of the amended IFA.

Prevalence of nutritional inadequacy in children aged 12-36 months: EPACI Portugal 2012

Adequate nutritional intake in the first years of life is crucial for future health. The purpose of this study is to assess the adequacy of nutritional intake in Portuguese toddlers. The EPACI Portugal 2012 is a cross-sectional study of a representative sample of toddlers (n = 2230), aged between 12 and 36 months. Data on diets were collected by trained interviewers. The current analysis included 853 children with full data from 3-day food diaries completed by parents/caregivers. Intakes of energy, macro- and micronutrients were estimated through Statistical Program to Assess Dietary Exposure (SPADE). Nutritional adequacy was evaluated using Dietary Reference Values established by the European Food Safety Authority. A large proportion of children exceeded the recommended energy intake. The median daily protein intake was 4.7 g/kg/day, five times more than that recommended. About 9% and 90% of the children consumed a lower proportion of energy than the lower limit of the Reference Intake range for carbohydrates and fat, respectively. Around a third consumed less fibre and magnesium and 100% less vitamin D than the recommended Adequate Intake (AI). Almost a third consumed less vitamin A than the recommended Average Requirement (AR) and 86% of the children showed excessive sodium consumption. Portuguese toddlers consumed a low proportion of energy from fat, had energy and protein intakes above the recommendations and excessive intakes of sodium, and inadequate intakes of vitamin A. Every child consumed less than the recommended AI for vitamin D.

Eating Frequency in European Children from 1 to 96 Months of Age: Results of the Childhood Obesity Project Study

We aimed to investigate the eating frequency (EF) in children over age, and examined the influence of country, sex, feeding mode and weight status on EF. We used the dietary data of the Childhood Obesity Project, which comprised European children from five countries. Dietary data of 3-days weighed and estimated records were available monthly from 1 to 9 and at 12-, 24-, 36-, 48-, 60-, 72- and 96-months old. Generalized additive mixed effects models were used to estimate EF trajectories with EF as outcome and applying age splines. Additionally, the models were further adjusted for country, feeding mode, sex or weight status. Data from 1244 children were analysed. EF was highest at 1 month with on average 7.3 ± 1.9 feeds per day, and fell to 5.1 ± 1.1 eating occasions at the age 96 months. Night feeding was similarly often than day feeding at 1 month but declined thereafter. Significant differences in EF were observed between countries (p < 0.05), with the highest EF in Poland, and between infant feeding modes, with a higher EF in breastfed than non-breastfed infants (p < 0.05). Sex and body weight were not associated with EF. Despite the importance of EF towards total energy intake, no association with weight status was found.

Distribution of energy and macronutrient intakes across eating occasions in European children from 3 to 8 years of age: The EU Childhood Obesity Project Study

PURPOSE

We aimed to characterize the distribution of energy and macronutrient intakes across eating occasions (EO) in European children from preschool to school age.

METHODS

Data from 3-day weighed food records were collected from children at ages 3, 4, 5, 6 and 8 years from Belgium, Germany, Italy, Poland and Spain. Food intakes were assigned to EO based on country-specific daytimes for breakfast, lunch, supper and snacks (morning, afternoon). The average energy and nutrient intakes were expressed as percentage of total energy intake (%E). Nutrients were additionally expressed as percentage per EO (%E_EO). Foods were assigned to food groups; variation in intake was calculated via coefficient of variation (CV). We analyzed age trends in diurnal intake using mixed-effects beta regression.

RESULTS

The 740 healthy children included in the analysis consumed the largest proportion of daily energy at lunch (31%E ± 8, M ± SD) and supper (26%E ± 8), followed by breakfast (19%E ± 7) and snacks [afternoon (16%E ± 8); morning (8%E ± 7)], with the most variable intake at morning snack (CV = 0.9). The nutrient composition at lunch and supper was highest for fat (36 ± 9%E_Lunch; 39 ± 11%E_Supper) and protein (18 ± 5%E_Lunch; 18 ± 6%E_Supper) and at breakfast and snacks for carbohydrates (54 ± 12%E_Breakfast; 62 ± 12%E_Snacks). High-sugar content foods were consumed in relatively large proportions at breakfast and snacks. Food intakes varied significantly with age, with lower snack intakes at later ages (p < 0.001).

CONCLUSION

Possibly unhealthy EOs with high-fat intakes and high-sugar-content foods were observed. Changes in nutrient composition of EOs may be beneficial for health.

TRIAL REGISTRY

ClinicalTrials.gov: NCT00338689; 19/June/2006.

Effects of a Novel Infant Formula on Weight Gain, Body Composition, Safety and Tolerability to Infants: The INNOVA 2020 Study

Exclusive breastfeeding is recommended for the first six months of life to promote adequate infant growth and development, and to reduce infant morbidity and mortality. However, whenever some mothers are not able to breastfeed their infants, infant formulas mimicking human milk are needed, and the safety and efficacy of each formula should be tested. Here, we report the results of a multicenter, randomized, blinded, controlled clinical trial that aimed to evaluate a novel starting formula on weight gain and body composition of infants up to 6 and 12 months, as well as safety and tolerability. For the intervention period, infants were divided into three groups: group 1 received formula 1 (Nutribén® Innova 1 (Alter Farmacia S.A., Madrid, Spain) or INN (n = 70)), with a lower amount of protein, a lower casein to whey protein ratio by increasing the content of α-lactalbumin, and a double amount of docosahexaenoic acid/arachidonic acid than the standard formula; it also contained a thermally inactivated postbiotic (Bifidobacterium animalis subsp. lactis, BPL1TM HT). Group 2 received the standard formula or formula 2 (Nutriben® Natal (Alter Farmacia S.A., Madrid, Spain) or STD (n = 70)) and the third group was exclusively breastfed for exploratory analysis and used as a reference (BFD group (n = 70)). During the study, visits were made at 21 days and 2, 4, 6, and 12 months of age. Weight gain was higher in both formula groups than in the BFD group at 6 and 12 months, whereas no differences were found between STD and INN groups either at 6 or at 12 months. Likewise, body mass index was higher in infants fed the two formulas compared with the BFD group. Regarding body composition, length, head circumference and tricipital/subscapular skinfolds were alike between groups. The INN formula was considered safe as weight gain and body composition were within the normal limits, according to WHO standards. The BFD group exhibited more liquid consistency in the stools compared to both formula groups. All groups showed similar digestive tolerance and infant behavior. However, a higher frequency of gastrointestinal symptoms was reported by the STD formula group (n = 291), followed by the INN formula (n = 282), and the BFD groups (n = 227). There were fewer respiratory, thoracic, and mediastinal disorders among BFD children. Additionally, infants receiving the INN formula experienced significantly fewer general disorders and disturbances than those receiving the STD formula. Indeed, atopic dermatitis, bronchitis, and bronchiolitis were significantly more prevalent among infants who were fed the STD formula compared to those fed the INN formula or breastfed. To evaluate whether there were significant differences between formula treatments, beyond growth parameters, it would seem necessary to examine more precise health biomarkers and to carry out long-term longitudinal studies.

Interventions in the first 1000 days to prevent childhood obesity: a systematic review and quantitative content analysis

BACKGROUND

Childhood obesity poses a global health challenge. In recent years, there has been an increase in interventions that begin in pregnancy, putting the concept of early programming and early risk factors into practice. The present study aims to update the findings regarding interventions in the first 1000 days of life.

METHODS

A systematic review based on the PRISMA guidelines was carried out in PubMed, WoS, Scopus and CINAHL to obtain the articles to be analysed. We included those studies published between 2016 and 2021. Human interventions that started within the first 1000 days of life and acted on at least one programming factor were included. Once selected, coding and quantitative content analysis was carried out to obtain a profile of the interventions during the first 1000 days.

RESULTS

From all screened articles, 51 unique interventions, which met the selection criteria, were included. The majority of interventions (81%) took place in high-income areas. Almost all (86%) were targeted at the general population. The majority (54%) started in the second trimester of pregnancy. A clear majority (61%) ended at the time of birth. 44% of the interventions included all pregnant women. Only 48% of these interventions were focused on improving the nutritional status of the offspring in the short term. Most interventions collected the baby's weight at birth (68%).

CONCLUSIONS

It can be concluded that current interventions are not covering as many aspects as they should. Future research should be conducted more frequently in developing countries and target disadvantaged groups. These interventions should include all pregnant women, regardless of their nutritional status, aiming to cover as many programming factors as possible and extending through the first 1000 days of life, with body mass index or skinfolds as measures of effectiveness during this period.

Different protein intake in the first year and its effects on adiposity rebound and obesity throughout childhood: 11 years follow-up of a randomized controlled trial

BACKGROUND AND OBJECTIVES

Infant feeding affects child growth and later obesity risk. We examined whether protein supply in infancy affects the adiposity rebound, body mass index (BMI) and overweight and obesity up to 11 years of age.

METHODS

We enrolled healthy term infants from five European countries in a double blind randomized trial, with anticipated 16 examinations within 11 years follow-up. Formula-fed infants (n = 1090) were randomized to isoenergetic formula with higher or lower protein content within the range stipulated by EU legislation in 2001. A breastfed reference group (n = 588) was included. Adiposity rebound and BMI trajectories were estimated by generalized additive mixed models in 917 children, with 712 participating in the 11 year follow-up.

RESULTS

BMI trajectories were elevated in the higher compared to the lower protein group, with significantly different BMI at adiposity rebound (0.24 kg/m², 0.01-0.47, p = 0.040), and an increased risk for overweight at 11 years (adjusted Odds Ratio 1.70; 1.06-2.73; p = 0.027) but no significant difference for obesity (adjusted Odds Ratio 1.47; 0.66-3.27). The two formula groups did not differ in the timing of adiposity rebound, but all children with obesity at 11 years had an early adiposity rebound before four years.

CONCLUSIONS

Compared to conventional high protein formula, feeding lower protein formula in infancy lowers BMI trajectories up to 11 years and achieves similar BMI values at adiposity rebound as observed in breastfed infants.

The Effects of Breastfeeding for Four Months on Thinness, Overweight, and Obesity in Children Aged 3 to 6 Years: A Retrospective Cohort Study from National Physical Fitness Surveillance of Jiangsu Province, China

Objective: To explore the effects of breastfeeding during the first four months of life on thinness, overweight, and obesity and to analyze the influential factors in children aged three to six years in eastern China. Methods: This study was designed as a retrospective cohort study, and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed. A total of 8053 subjects were included in this secondary analysis of data from the 2015 “Physical Fitness Surveillance data of Jiangsu, China”. The subjects were classified into three groups on the basis of feeding patterns: breastfeeding, mixed feeding, and formula feeding. The International Obesity Task Force (IOTF) definitions of BMI were used to define thinness, overweight, and obesity. Multivariate logistic regression models and subgroup analysis were used to assess the association between feeding patterns and childhood thinness, overweight, obesity, and overweight/obesity, adjusted for potential confounders (sex, age grade, area, region/economy, gestational age, birthweight, childbearing age, mother’s education, and caretaker). Results: The prevalence of breastfeeding was 63.8%, and the prevalence of thinness, overweight, obesity, and overweight/obesity reached 2.7%, 11.2%, 4.7%, and 15.9%, respectively. Breastfeeding participants had a lower risk of overweight and overweight/obesity with adjusted ORs of 0.652 (95% CI: 0.533, 0.797; p < 0.001) and 0.721 (95% CI: 0.602, 0.862; p < 0.001), respectively; however, there was no difference in thinness and obesity (both p > 0.05) compared with formula feeding. There was no statistical difference between mixed and formula feeding, in terms of thinness, overweight, obesity, or overweight/obesity (all p > 0.05). Subgroup analysis showed that breastfeeding for three years, preterm, and a childbearing age of 25−29 years had higher adjusted ORs for thinness, and in 5−6 years, urban areas, southern/developed economy regions, post-mature, childbearing age ≥ 25 years, and other caretakers had higher and invalid breastfeeding-adjusted ORs (all p > 0.05 except overweight in the urban grade) for both overweight and overweight/obesity. Conclusions: Breastfeeding during the first four months was not associated with the thinness of children aged 3−6 years in eastern China, and the protective effect of breastfeeding against overweight or overweight/obesity could be confirmed. However, the effects of breastfeeding on thinness, overweight, and obesity may change or become invalid in some subgroups, suggesting that there may be potential interactions between feeding patterns and influential factors.

Impact of Weight Status Reporting on Childhood Body Mass Index

Background: Many states have adopted school-based BMI screening or surveillance programs in an effort to address high rates of childhood obesity, some of which involve provision of confidential BMI reports to parents. While there is evidence that parents are attuned to information in the reports, there is less evidence showing that the reports are effective in preventing excess childhood weight gain. Methods: Data from Arkansas, the state with the nation's first and longest running and BMI screening program, were used to measure the impact of BMI reports. This was done through a regression discontinuity design that compared future BMI z-scores among children falling within a narrow band around the obese and overweight thresholds. We derived the effects of BMI reports by comparing students who received different types of reports around the relevant threshold. Results: While we are unable to detect any differences in BMI z-scores between the children who received the overweight report and the children who received the healthy weight report, we detected some differences between children who received the obese report and children who received the overweight report. These findings hold across subsamples by age, minority status, and school meal status. Conclusions: Based on these data, overweight or obese reports to do not meaningfully impact future BMI z-scores. This may be due, in part, to the format of parental reports, which may dampen the surprise element of an overweight or obese report.

Quantity and Source of Protein during Complementary Feeding and Infant Growth: Evidence from a Population Facing Double Burden of Malnutrition

BACKGROUND

While high protein intake during infancy may increase obesity risk, low qualities and quantities of protein contribute to undernutrition. This study aimed to investigate the impact of the amount and source of protein on infant growth during complementary feeding (CF) in a country where under- and overnutrition co-exist as the so-called the double burden of malnutrition.

METHODS

A multicenter, prospective cohort was conducted. Healthy term infants were enrolled with dietary and anthropometric assessments at 6, 9 and 12 months (M). Blood samples were collected at 12M for IGF-1, IGFBP-3 and insulin analyses.

RESULTS

A total of 145 infants were enrolled (49.7% female). Animal source foods (ASFs) were the main protein source and showed a positive, dose-response relationship with weight-for-age, weight-for-length and BMI z-scores after adjusting for potential confounders. However, dairy protein had a greater impact on those parameters than non-dairy ASFs, while plant-based protein had no effect. These findings were supported by higher levels of IGF-1, IGFBP-3 and insulin following a higher intake of dairy protein. None of the protein sources were associated with linear growth.

CONCLUSIONS

This study showed the distinctive impact of different protein sources during CF on infant growth. A high intake of dairy protein, mainly from infant formula, had a greater impact on weight gain and growth-related hormones.

Infant Feeding Choices during the First Post-Natal Months and Anthropometry at Age Seven Years: Follow-Up of a Randomized Clinical Trial

The Belgrade–Munich Infant Milk Trial (BeMIM) randomized healthy term infants into either a protein-reduced intervention infant formula (IF) group, with an α-lactalbumin-enriched whey and long-chain polyunsaturated fatty acids, or a control infant formula (CF) group. A non-randomized breastfed group (BF) was studied for reference. We assessed the long-term effects of these infant feeding choices on growth measures until the age of seven years. Weight, standing height, head circumference, and percent body fat (using skinfolds and bioelectrical impedance) were determined with standardized methods. A total of 161 children out of the 256 completers of the initial study (63%) participated in the seven-year follow-up. Children in the three study groups did not differ in their anthropometric measures, including body mass index (IF 16.1 ± 2.6, CF: 15.6 ± 1.7, BF: 15.6 ± 2.5 kg/m², mean ± SD). IGF-1 serum concentrations determined at the age of 4 months contributed to explaining the variances in weight (p = 0.001), height (p = 0.001) and BMI (p = 0.035) z-scores at the age of seven years, whereas insulin levels at four months did not. Different feeding choices during the first four months of life leading to higher energy efficiency and increased growth with IF did not affect later growth outcomes at an early school age. Diet-induced modulation of IGF-1 in the first months of life may have lasting programming effects on later growth.

Association of dietary macronutrient intake with adiposity during childhood according to sex: Findings from the generation XXI birth cohort

BACKGROUND/OBJECTIVES

Few studies have assessed the independent and longitudinal effects of each macronutrient intake on adiposity throughout childhood. We aimed to prospectively assess the independent associations between each macronutrient intake at 4, 7, and 10 years (protein, carbohydrates, fat, and fibre) and each measure of adiposity from 7 to 10 years of age by sex.

METHODS

Data from the population-based birth cohort Generation XXI was used (n = 3999). At 4, 7, and 10 years old, dietary, anthropometric and sociodemographic data were collected. The dietary intake of the children was evaluated by a validated food frequency questionnaire. Age- and sex-specific body mass index z-scores (zBMI), percentage of body fat (%FM) from bio-impedance, and waist-to-hip ratio (Whr) were used as measures of adiposity. Path analysis tested the independent associations between each macronutrient intake (protein, carbohydrates, fat, and fibre) and each measure of adiposity from 7 to 10 years of age.

RESULTS

In fully adjusted models, an increase in energy from fibre intake at the age of 7 was associated with lower zBMI at the same age (β = -0.073; 95%CI [-0.127,-0.019]) and at 10 years (β = -0.083; 95%CI [-0.137,-0.029]). Similar results were found for %FM and Whr, and in each sex separately. At the age of 10, an increase in energy from fibre intake was associated with lower %FM and Whr, while an increase in energy from protein was associated with an increase in Whr (β = 0.061; 95%CI [0.014, 0.107]).

CONCLUSIONS

Our study supports the protective effect of fibre intake on adiposity development during childhood in both sexes.

Childhood obesity and adverse cardiometabolic risk in large for gestational age infants and potential early preventive strategies: a narrative review

Accumulating evidence indicates that obesity and cardiometabolic risks become established early in life due to developmental programming and infants born as large for gestational age (LGA) are particularly at risk. This review summarizes the recent literature connecting LGA infants and early childhood obesity and cardiometabolic risk and explores potential preventive interventions in early infancy. With the rising obesity rates in women of childbearing age, the LGA birth rate is about 10%. Recent literature continues to support the higher rates of obesity in LGA infants. However, there is a knowledge gap for their lifetime risk for adverse cardiometabolic outcomes. Potential factors that may modify the risk in early infancy include catch-down early postnatal growth, reduction in body fat growth trajectory, longer breastfeeding duration, and presence of a healthy gut microbiome. The early postnatal period may be a critical window of opportunity for active interventions to mitigate or prevent obesity and potential adverse metabolic consequences in later life. A variety of promising candidate biomarkers for the early identification of metabolic alterations in LGA infants is also discussed. IMPACT: LGA infants are the greatest risk category for future obesity, especially if they experience rapid postnatal growth during infancy. Potential risk modifying secondary prevention strategies in early infancy in LGA infants include catch-down early postnatal growth, reduction in body fat growth trajectory, longer breastfeeding duration, and presence of a healthy gut microbiome. LGA infants may be potential low-hanging fruit targets for early preventive interventions in the fight against childhood obesity.

Exploring the Potential of Human Milk and Formula Milk on Infants’ Gut and Health

Early-life gut microbiota plays a role in determining the health and risk of developing diseases in later life. Various perinatal factors have been shown to contribute to the development and establishment of infant gut microbiota. One of the important factors influencing the infant gut microbial colonization and composition is the mode of infant feeding. While infant formula milk has been designed to resemble human milk as much as possible, the gut microbiome of infants who receive formula milk differs from that of infants who are fed human milk. A diverse microbial population in human milk and the microbes seed the infant gut microbiome. Human milk contains nutritional components that promote infant growth and bioactive components, such as human milk oligosaccharides, lactoferrin, and immunoglobulins, which contribute to immunological development. In an attempt to encourage the formation of a healthy gut microbiome comparable to that of a breastfed infant, manufacturers often supplement infant formula with prebiotics or probiotics, which are known to have a bifidogenic effect and can modulate the immune system. This review aims to elucidate the roles of human milk and formula milk on infants’ gut and health.

LIMIT: LIfestyle and Microbiome InTeraction Early Adiposity Rebound in Children, a Study Protocol

Childhood obesity is a strong predictor of adult obesity with health and economic consequences for individuals and society. Adiposity rebound (AR) is a rise in the Body Mass Index occurring between 3 and 7 years. Early adiposity rebound (EAR) occurs at a median age of 2 years and predisposes to a later onset of obesity. Since obesity has been associated with intestinal dysbiosis, we hypothesize that EAR could be related to early microbiome changes due to maternal/lifestyle changes and environmental exposures, which can increase the unhealthy consequences of childhood obesity. LIMIT is a prospective cohort study that aims at identifying the longitudinal interplay between infant gut microbiome, infant/maternal lifestyle, and environmental variables, in children with EAR vs. AR. Methods. The study evaluated 272 mother-infant pairs, enrolled at an Italian neonatal unit, at different time points (T0, at delivery; T1, 1 month; T2, 6 months; T3, 12 months; T4, 24 months; T5, 36 months after birth). The variables that were collected include maternal/infant anthropometric measurements, lifestyle habits, maternal environmental endocrine disruptor exposure, as well as infant AR. The LIMIT results will provide the basis for early identification of those maternal and infant modifiable factors on which to act for an effective and personalized prevention of childhood obesity.

Infancy Dietary Patterns, Development, and Health: An Extensive Narrative Review

Correct dietary patterns are important for a child’s health from birth to adulthood. Understanding a child’s health as a state of entire physical, mental, and social well-being is essential. However, reaching adulthood in a complete health proper state is determined by feeding and dietary habits during preconception, pregnancy, or children infancy. Different factors, such as the mother’s lifestyle, culture, or socioeconomic status, are crucial during all these phases. In this review, we aimed to assess the long-term associations between infancy dietary patterns and health and their influence on development and growth. To reach this objective, a consensus critical review was carried out using primary sources such as scientific articles, and secondary bibliographic indexes, databases, and web pages. PubMed, SciELO, and Google Scholar were the tools used to complete this research. We found that high-income countries promote high-calorie foods and, consequently, obesity problems among children are rising. However, undernutrition is a global health issue concerning children in low- and middle-income countries; thus, parental socioeconomic status in early life is essential to children’s health and development, showing that biological, social, and environmental influences are increased risk factors for chronic diseases. This narrative review is aimed to collect evidence for early nutritional intervention and future disease prevention.

Low-Protein Infant Formula and Obesity Risk

Infant formulas have been designed to mimic human milk for infants who cannot be breastfed. The overall goal is to establish similar functional outcomes to assure optimal growth, development, maturation of the immune system, and programming of the metabolic system. However, after decades of improving infant formula, growth patterns and body composition development are still different in formula-fed infants compared to breastfed infants, which could contribute to an increased risk of obesity among formula-fed infants. It has been hypothesized that the lower protein concentration of breast milk compared to infant formula influences infants’ growth and body composition. Thus, several trials in formula-fed infants with different protein intake levels have been performed to test this hypothesis. In this review, we discuss the current evidence on low-protein infant formula and obesity risk, including future perspectives and implications.

The Association of Formula Protein Content and Growth in Early Infancy: A Systematic Review and Meta-Analysis

This systematic review aimed to examine differences in growth outcomes between breastfed infants and infants fed with formula with different protein/energy ratios during the first six months of life. We conducted a systematic review in the PubMed, Web of Science, and Springer databases. Twenty clinical trials qualified for inclusion. We extracted data about the growth outcomes of infants who were exclusive breastfed or exclusively infant formula fed in the first six months and used a meta-analysis to pool the finding data. We categorized study formulas into four groups according to their protein content: <1.8, 1.8−2.0, 2.1−2.2, and >2.2 g/100 kcal. In the first month of life, growth was not different between formula- and breastfed infants. During 2−3 months of life, growth was faster in infants who consumed formulas with protein contents higher than 2.0 g/100 kcal. After 3 months, formula-fed infants grew faster than breastfed infants. Our meta-analysis indicated that the growth outcomes of infants fed with infant formula with a relatively low protein/energy ratios, compared with that a relatively high protein/energy ratio, were close to those of breastfed infants.

An integrative approach to dietary balance across the life course

Animals require specific blends of nutrients that vary across the life course and with circumstances, e.g., health and activity levels. Underpinning and complicating these requirements is that individual traits may be optimized on different dietary compositions leading to nutrition-mediated trade-offs among outcomes. Additionally, the food environment may constrain which nutrient mixtures are achievable. Natural selection has equipped animals for solving such multi-dimensional, dynamic challenges of nutrition, but little is understood about the details and their theoretical and practical implications. We present an integrative framework, nutritional geometry, which models complex nutritional interactions in the context of multiple nutrients and across levels of biological organization (e.g., cellular, individual, and population) and levels of analysis (e.g., mechanistic, developmental, ecological, and evolutionary). The framework is generalizable across different situations and taxa. We illustrate this using examples spanning insects to primates and settings (laboratory, and the wild), and demonstrate its relevance for human health.

Comprehensiveness of infant formula and bottle feeding resources: A review of information from Australian healthcare organisations

The use of infant formula is widespread internationally. In Australia, 55% of infants receive formula before 6 months of age, with higher rates among disadvantaged communities. Infant formula use can contribute to childhood overweight and obesity, through formula composition and feeding behaviours, such as adding cereal to bottles and parental feeding style. While information abounds to promote and support breastfeeding, formula‐feeding parents report a paucity of advice and support; many rely on formula packaging for information. This study systematically searched and reviewed online resources for infant formula and bottle feeding from Australian governments, health services, hospitals, and not‐for‐profit parenting organisations. A comprehensive search strategy located 74 current resources, mostly for parents. Researchers evaluated the resources against best practice criteria derived from Australian government and UNICEF guidelines on six topics. They assessed how comprehensively the resources addressed each topic and whether the resources provided all the information necessary for parents to understand each topic. The mean ‘comprehensiveness’ rating for topics across all resources was 54.36%. However, some topics were addressed more fully than others. Information on ‘discussing infant formula with health workers’ and on ‘preparing infant formula’ was more frequently accurate and comprehensive. However, there was much less comprehensive information on ‘using infant formula’, including amounts of formula to feed, use of bottle teats, appropriate bottle‐feeding practice and responsiveness to infant satiety cues. Over half the resources were written at an acceptable reading level.

Insufficient formula‐feeding support from health services can lead to parents relying on formula packaging or other commercial information.

Most formula‐feeding resources from Australian healthcare organisations focus on preparing infant formula and using infant formula. However, comprehensiveness of information varies—on average, information on preparing infant formula was more comprehensive than that on using infant formula.

Many resources do not address responsive bottle‐feeding practices, which impacts risk of infant overweight and obesity.

The Australian government infant feeding guidelines should be revised to include more comprehensive best‐practice formula‐feeding recommendations; subsequently, this should be reflected in formula‐feeding information from health organisations.

Effects of high dairy protein intake and vitamin D supplementation on body composition and cardiometabolic markers in 6-8-y-old children-the D-pro trial

BACKGROUND

Increasing evidence suggests that prevention of lifestyle diseases should begin early. Dairy protein and vitamin D can affect body composition and cardiometabolic markers, yet evidence among well-nourished children is sparse.

OBJECTIVES

We investigated combined and separate effects of high dairy protein intake and vitamin D on body composition and cardiometabolic markers in children.

METHODS

In a 2 × 2-factorial, randomized trial, 200 white, Danish, 6-8-y-old children substituted 260 g/d dairy in their diet with high-protein (HP; 10 g protein/100 g) or normal-protein (NP; 3.5 g protein/100 g) yogurt and received blinded tablets with 20 µg/d vitamin D3 or placebo for 24 wk during winter. We measured body composition (by DXA), blood pressure, and fasting blood glucose, insulin, C-peptide, and lipids.

RESULTS

In total, 184 children (92%) completed the study. Baseline median (25th-75th percentile) dairy protein intake was median: 3.7 (25th-75th percentile: 2.5-5.1) energy percentage (E%) and increased to median: 7.2 (25th-75th percentile: 4.7-8.8) E% and median: 4.2 (25th-75th percentile: 3.1-5.3) E% with HP and NP. Mean ± SD serum 25-hydroxyvitamin D concentration changed from 81 ± 17 to 89 ± 18 nmol/L and 48 ± 13 nmol/L with vitamin D and placebo, respectively. There were no combined effects of dairy protein and vitamin D, except for plasma glucose, with the largest increase in the NP-vitamin D group (Pinteraction = 0.005). There were smaller increases in fat mass index (P = 0.04) with HP than with NP, and the same pattern was seen for insulin, HOMA-IR, and C-peptide (all P = 0.06). LDL cholesterol was reduced with vitamin D compared with placebo (P < 0.05). Fat-free mass and blood pressure were unaffected.

CONCLUSIONS

High compared with normal dairy protein intake hampered an increase in fat mass index. Vitamin D supplementation counteracted the winter decline in 25-hydroxyvitamin D and the increase in LDL cholesterol observed with placebo. This study adds to the sparse evidence on dairy protein in well-nourished children and supports a vitamin D intake of ∼20 µg/d during winter. This trial was registered at clinicaltrials.gov as NCT03956732.

Burden of Early Life Obesity and Its Relationship with Protein Intake in Infancy: The Middle East Expert Consensus

Adequate nutrition in early life is proposed to shape a child's future health by launching the growth trajectory in the proper direction, which helps to avoid negative metabolic programming effects. Protein intake during infancy and early childhood is of great importance, as it plays a key role in infant metabolic programming and the future risk of obesity. Breastfeeding provides the best nutrition in early life, with many benefits tailored for the baby, including the appropriate quantity and quality of proteins. Considering the high prevalence of childhood, and subsequent adult, obesity in the region, a virtual Middle East expert consensus meeting was held to discuss an effective approach for managing childhood obesity. Leading pediatric experts from Bahrain, Egypt, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates participated in the meeting. The experts discussed, debated, and agreed on certain directions, including the importance of educating parents, endorsing breastfeeding, and ensuring optimum quantity and quality intake of proteins in early life. This expert consensus may serve as the starting point for healthcare professionals in the region who are interested in shaping a healthy future for the generations to come.

Detailed knowledge of maternal and infant factors and human milk composition could inform recommendations for optimal composition

Breastfeeding is best for infants, but quantitative associations between specific milk components and infant biomarkers remain unclear. Methodological limitations include missing milk volume intake, variable milk composition and that standardised, fasted state blood sampling is impossible in infants. Milk protein and fat content appear marginally related to infant serum amino acid and phospholipid concentrations, with some association between milk fatty acid composition and lipid species levels. CONCLUSION: Detailed simultaneous examinations of maternal factors, milk composition and infant biomarkers or outcomes could identify the mechanistic basis of human milk effects and help develop dietary recommendations for optimal human milk composition.

A new partially hydrolyzed whey-based follow-on formula with age-adapted protein content supports healthy growth during the first year of life

BACKGROUND

Standard infant formulae often have higher protein content than breastmilk in order to compensate for potentially lower digestibility; excess protein intake may promote adverse effects later in life. A new partially hydrolyzed whey-based (pHF-W) follow-on formula (FoF) with age-adapted protein content was evaluated for growth and gastrointestinal (GI) tolerance in healthy infants.

METHODS

Formula-fed (FF) infants (n = 108) received standard pHF-W formula (1.9 g protein/100 kcal) from enrollment (age ≤ 30 days) until age 120 days followed by new pHF-W FoF (1.6 g protein/100 kcal) until 360 days. Weight gain velocity (WGV) (mean daily WG from enrollment to age 180 days) was compared to WHO growth standards and a breastfed (BF) reference group (n = 86) (non-inferiority margin -3 g/day). GI tolerance was assessed using a validated questionnaire (scale range 13-65).

RESULTS

WGV in FF infants (mean ± SD 24.0 ± 4.4 g/day) was non-inferior to BF (23.7 ± 3.9 g/day) and WHO standards (all p ≤ 0.013). Weight-for-age, length-for-age, weight-for-length, and head circumference-for-age z-scores of FF infants were not significantly different from BF at any timepoint. Symptoms of GI intolerance were low (≤23) at all timepoints and similar between groups.

CONCLUSION

A new pHF-W FoF with age-adapted protein content fed sequentially after standard pHF-W infant formula is safe, well-tolerated, and promotes a healthy growth pattern consistent with BF infants and WHO standards during the first year of life.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/], identifier [NCT03276663].

Molecular mechanisms of dietary restriction promoting health and longevity

Dietary restriction with adequate nutrition is the gold standard for delaying ageing and extending healthspan and lifespan in diverse species, including rodents and non-human primates. In this Review, we discuss the effects of dietary restriction in these mammalian model organisms and discuss accumulating data that suggest that dietary restriction results in many of the same physiological, metabolic and molecular changes responsible for the prevention of multiple ageing-associated diseases in humans. We further discuss how different forms of fasting, protein restriction and specific reductions in the levels of essential amino acids such as methionine and the branched-chain amino acids selectively impact the activity of AKT, FOXO, mTOR, nicotinamide adenine dinucleotide (NAD⁺), AMP-activated protein kinase (AMPK) and fibroblast growth factor 21 (FGF21), which are key components of some of the most important nutrient-sensing geroprotective signalling pathways that promote healthy longevity.

Parental Perception of Body Weight Status of Their 8-year-old Children: Findings from the European CHOP Study

BACKGROUND

Maternal perception of child weight status in children with overweight or obesity has received a lot of attention but data on paternal perception of children from presumably healthy cohorts are lacking.

OBJECTIVE

We aimed to investigate paternal and maternal perception of child weight status at the age of 8 years in a cohort of 591 children from 5 European countries.

MATERIAL AND METHODS

Included were 8-year-old children and their parents participating in the European Childhood Obesity Project (EU CHOP). Weight and height of children and parents were measured and Body Mass Index (BMI, kg/m²) was calculated. Both parents were asked to assess their perception of child weight status using Eckstein scales and their concern about child overweight. The agreement between mother and father perceptions was assessed by Cohen kappa coefficient and their relationship was analyzed by linear mixed effects models based on ordinal logistic regression, accounting for country, child gender and BMI, parental BMI, level of education, concern and type of feeding during first year of life.

RESULTS

Data from children and both parents were available for 432 girls and boys. Mean BMI was comparable in boys and girls (16.7 ± 2.31 vs. 16.9 ± 2.87 kg/m², P = 0.55). In total, 172 children (29.3%) were overweight or obese. There was a high degree of agreement between mother and father perceptions of their child's weight status (Cohen kappa 0.77). Multivariate modelling showed that perception levels significantly increased with child BMI but were globally lower than assessed. They differed between countries, gender and types of feeding during first year of life, were influenced by education level of the father but were not related to parental BMI and concern about childhood overweight.

CONCLUSIONS

The study showed no overall differences between mothers and fathers in rating their child's weight status but both parents had a propensity to underestimate their child's actual weight, particularly in boys. The EU CHOP trial registered at clinicaltrials.gov as NCT00338689.

Sleep duration and problem behaviour in 8-year-old children in the Childhood Obesity Project

There is growing evidence that insufficient sleep has negative effects on the mental health of children. The aim of this study is to examine the associations between device-measured sleep duration and internalizing and externalizing problems in 8-year-old children. The study is a secondary analysis of data from the Childhood Obesity Project conducted in five European countries. Nocturnal sleep duration was measured with the SenseWear™ Armband 2. Parents rated their child's internalizing and externalizing problems on the Child Behaviour Checklist. Behaviour scores were dichotomized at the 90th percentile based on sex- and country-specific z-scores. Logistic regression models were applied to test the associations between sleep duration and behaviour. Data were available for 406 8-year-old children. The average sleep duration was 9.25 h per night (SD: 0.67) with 1464 nights measured in total. The sleep duration recommendation of the American Academy of Sleep Medicine for school-aged children (9-12 h) was met by 66.7% of children. One hour of additional sleep per night significantly reduced the risk of having internalizing problems (adjusted OR = 0.51; 95% CI 0.29-0.91). Children who adhered to the sleep duration recommendation had a lower risk for internalizing problems (adjusted OR = 0.45; 95% CI 0.21-0.99). Sleep duration and externalizing problems showed no significant association. Longer sleep duration was associated with a reduced risk of having internalizing problems but not externalizing problems. Results highlight that it is important to ensure adequate sleep duration throughout primary-school years for the optimal emotional health of children. Trial registration number: NCT00338689. Registered: June 19, 2006.