Early Childhood Vegetable, Fruit, and Discretionary Food Intakes Do Not Meet Dietary Guidelines, but Do Show Socioeconomic Differences and Tracking over Time

Driving Research and Advocacy for Healthy Infant and Toddler Diets: The Infant and Toddler Foods Research Alliance

Early childhood (0-36 months) is a critical time for the development of healthy dietary behaviours. This paper describes the establishment of the Infant and Toddler Foods Research Alliance in Australia and New Zealand, along with the development of the Alliance's priorities to guide research and advocacy activities for improved nutrition, health and well-being outcomes in early childhood. The multi-disciplinary Alliance includes a membership of academics, practitioners and advocates working in the fields of infant and toddler food and nutrition across Australia and New Zealand. The Alliance undertook a priority setting process across a series of member meetings with identified priorities subsequently refined by a core membership working group. Three priority themes, along with three cross-cutting impact areas were identified. The priority themes include commercial foods and milks for infants and toddlers; health and care settings and systems; and support for parents and carers. The cross-cutting impact areas include building evidence, translating evidence, and advocacy. This provides a framework to guide research, practice and advocacy, identify research gaps, and advance action to improve nutrition, health and well-being outcomes for infants and toddlers.

Breastfeeding Duration, Diet, and Sports Engagement in Immigrant Children: A Quantitative Study in the Lisbon Region, Portugal

Background: Being breastfed, following a healthy diet and staying active during childhood shape health trajectories across the life course, promoting long-term well-being. Despite the growing immigrant child population in Portugal, evidence on these behaviours, particularly among preschool-aged children, remains limited. In this context, this study examines the associations between migrant status and breastfeeding patterns, fruit and vegetable consumption, and participation in sports among children living in the Lisbon Metropolitan Area. Methods: A cross-sectional study nested within a cross-sequential cohort was carried out in the Lisbon region between May 2022 and April 2024. Approximately 760 children (49.4% immigrants) born in 2018 and 2020 were enrolled in the study. Data were collected through a face-to-face interview with parents, using a structured questionnaire with information on socioeconomic variables, migration history, breastfeeding habits, and children's diet (fruit and vegetable consumption) and physical activity. We used parametric and non-parametric tests to compare migrant and non-migrant children. To quantify factors associated with the main outcomes, we estimated a logistic regression model and calculated crude and adjusted odds ratios and their respective 95%CI. Results: Immigrant children were disproportionately represented in socioeconomically disadvantaged families. Breastfeeding initiation rates were higher among immigrant mothers (96.3% vs. 87.6%, p < 0.001). Additionally, immigrant mothers had a longer median duration of any breastfeeding (14 vs. 8 months, p < 0.001) and of exclusive breastfeeding (6 vs. 4 months, p < 0.001). Immigrant children had significantly lower odds of consuming three or more portions of fruit (aOR = 0.700; 95%CI: 0.511-0.959; p = 0.027) and two or more portions of vegetables per day (aOR = 0.489; 95%CI: 0.350-0.684; p < 0.001) compared with non-immigrant children. They were also twice as likely to not engage in sports (aOR = 2.185; 95%CI: 1.512-3.158; p < 0.001). Conclusions: Breastfeeding was better implemented in immigrant children. The findings highlight the need to address social determinants of health and the challenges faced by immigrant families in promoting a balanced diet and sports participation for their children. Multisectoral, culturally appropriate interventions that sustain and promote good breastfeeding practices, improve access to healthy food, and encourage sports are crucial to reducing health inequalities.

Zero vegetable or fruit consumption and its associated factors among children aged 6 to 23 months in Kenya: a multilevel analysis of a large population-based survey

Poor consumption of fruits and vegetables is associated with an increased risk of non-communicable diseases, micronutrient deficiency, and undernutrition. Fruit and vegetable consumption is generally low worldwide, particularly in rural regions of many low- and middle-income countries. This study aimed to determine the prevalence and determinants of zero vegetable or fruit consumption among children aged 6 to 23 months in Kenya using the most recent Kenya Demographic and Health Survey. A cross-sectional study was employed using data from the most recent nationally representative KDHS 2022. A weighted sample of 2,965 children aged between 6 to 23 months who were living with their mother was included in the study. Data extracted from the KDHS 2022 data sets were cleaned, recoded, and analyzed using STATA/SE version 14.0 statistical software. Multilevel logistic regression was used to determine the factors associated with the dependent variable. Finally, variables with a p-value less than 0.05 were declared statistically significant. The proportion of zero vegetable or fruit consumption among children aged 6 to 23 months in Kenya was 45.50% (95% CI: 43.71%-47.30%). Factors like maternal education [AOR = 0.59; 95% CI (0.37, 0.93)], maternal occupation [AOR = 0.60; 95% CI (0.47, 0.76)], media exposure [AOR = 0.59; 95% CI (0.43, 0.80)], wealth index [AOR = 0.68; 95% CI (0.49, 0.95)], place of delivery [AOR = 0.69; 95% CI (0.51, 0.94)], number of ANC visits [AOR = 1.30; 95% CI (1.05, 1.62)], child's age [AOR = 0.30; 95% CI (0.21, 0.41)], community media exposure [AOR = 0.30; 95% CI (0.21, 0.41)], community literacy [AOR = 0.29; 95% CI (0.20, 0.43)], and community poverty [AOR = 1.46; 95% CI (1.04, 2.05)] were significantly associated with zero vegetable or fruit consumption.

CONCLUSION

The proportion of zero vegetable or fruit consumption among children aged 6 to 23 months in Kenya was high. Zero vegetable or fruit consumption was significantly associated with maternal education, maternal occupation, media exposure, wealth index, place of delivery, number of ANC visits, child's age, community media exposure, community literacy, and community poverty. Giving attention to jobless, media-non-exposed mothers, poor wealth status, who gave birth at home, who had no formal education, attended < 4 ANC visits, and children aged 6 to 8 months is recommended.

WHAT IS KNOWN

• Dietary recommendations for fruit and vegetable consumption were not met by many children in low and middle-income countries.

WHAT IS NEW

• The proportion of zero vegetable or fruit consumption among children aged 6 to 23 months in Kenya was high.

Comparing Australian children's dietary intakes with the Eat-Lancet Commission Planetary Health Diet targets and Australian Dietary Guidelines: a cross-sectional study

PURPOSE

As healthy eating recommendations shift to incorporate environmentally sustainable eating principles, it becomes crucial to understand whether children's dietary intakes align with global recommendations such as the EAT-Lancet Commission Planetary Health Diet (PHD), in addition to national health-promoting guidelines, including the Australian Dietary Guidelines (ADG). This cross-sectional study aimed to assess the alignment of young Australian children's food intakes with these recommendations.

METHODS

Dietary data from the 2011-2012 National Nutrition and Physical Activity Survey for children aged 2-8 years were used and compared with, energy-adjusted target amounts of the PHD and ADG Foundation Diet. Usual energy intakes were calculated for two age groups (2-3; 4-8 years) and used to proportionally adjust the adult PHD target amounts for children. Mean intake of each food group (g/day) was determined through one 24-h dietary recall.

RESULTS

For both age groups (2-3-years: n = 463; 4-8-years: n = 776), the daily mean consumption of wholegrains, starchy vegetables, other vegetables, eggs, fish, legumes, nuts, and unsaturated oils was below the PHD targets, while the consumption of red meat, dairy products, poultry, and added sugars was above the targets. The ADG Foundation Diet trends were similar to the PHD for wholegrains, vegetables, nuts, and legumes but the daily mean consumption of dairy products and red meat was below ADG Foundation Diet targets and above PHD targets.

CONCLUSION

Australian children's diets do not align with the PHD and ADG Foundation Diet. Substantial changes are required to improve dietary practices, emphasizing the gap between current consumption and recommended guidelines.

Dietary fat intakes, food sources, and tracking across early childhood: results from the Melbourne InFANT Program

PURPOSE

Despite the important role of dietary fat in early childhood, our understanding of fat intake trends during this period is limited, particularly among Australian children. This study aimed to describe total and saturated fat (SFA) intake trends, food sources, and tracking in young Australian children.

METHODS

Data of children at ages 9 months (n = 393), 18 months (n = 284), 3.5 years (n = 244), and 5 years (n = 240) from the Melbourne InFANT Program were used. Dietary intakes were collected via three 24-hour recalls. Food groups and nutrient intakes were calculated using the 2007 AUSNUT Food Composition Database. Descriptive statistics were used to summarize fat intake and key food sources of fat. Tracking of fat intake was examined using Pearson correlations of residualized fat scores between time points.

RESULTS

Total and SFA intake (g/d) increased over time in early childhood. The percentage of energy from total fat decreased from 9 to 18 months but remained stable until 5 years of age. The percentage of energy from SFA decreased across early childhood. Milk and milk products were the primary sources of both total fat and SFA, followed by breads/cereals, and cakes/cookies. Slight to moderate tracking of fat was observed in most age groups.

CONCLUSION

This study described trends and food sources of young children's fat intakes and showed that early fat intakes track up to age 5 years. The study will contribute to the development and refinement of fat recommendations in young Australian children and inform the design of interventions to improve fat intake.

Development and evaluation of food-based dietary recommendations for New Zealand toddlers using linear and goal programming

PURPOSE

We designed and evaluated food-based dietary recommendations for 12-24-mo-old New Zealand children with linear and goal programming models taking into account intakes of all nutrients concurrently.

METHODS

Dietary data used to define model parameters (food list, food quantities consumed, and food consumption patterns from 3-d weighed food records) were collected from 12-24-mo-old New Zealand toddlers (n = 188). Linear and goal programming models were developed to design and evaluate three sets of recommendations: (1) using all foods consumed by toddlers; (2) excluding commercial infant/toddler foods; and (3) excluding both commercial infant/toddler foods and all iron-fortified foods.

RESULTS

Food-based dietary recommendations for toddlers were developed which aligned with observed food consumption patterns: Non-Sweet Cereals: 3 serves/d, Vegetables: 2 serves/d, Fruit: 2 serves/d, Dairy: 2 serves/d, and Meat/Fish/Poultry/Eggs/Legumes/Nuts: 2 serves/d. However, they only ensured adequate intakes of all nutrients modeled if ≈ 500 g/d of iron-fortified toddler milk was also recommended. Food-based dietary recommendations that excluded commercial infant/toddler foods or excluded both commercial infant/toddler foods and all iron-fortified foods would not ensure adequate intakes of iron and folate, for all children. The lowest intakes, in simulated intake distributions for these nutrients, were ≤ 29% and ≤ 38% of their nutrient reference values, respectively.

CONCLUSIONS

Food-based dietary recommendations which successfully promote the consumption of 3 serves/d of Non-Sweet Cereals, 2 serves/d of Vegetables, 2 serves/d of Fruit, 2 serves/d of Dairy (including ≈ 500 g/d of iron-fortified toddler milk), and 2 serves/d of Meat/Fish/Poultry/Eggs/Legumes/Nuts should ensure all New Zealand toddlers meet their requirements for the 15 nutrients modeled.

Carbohydrate intakes, food sources and tracking in Australian young children

Carbohydrate intake and key food sources of carbohydrates in early childhood are poorly understood. The present study described total carbohydrate intake and subtypes (i.e. starch, sugar), their primary food sources and their tracking among young Australian children. Data from children at ages 9 months (n 393), 18 months (n 284), 3·5 years (n 244) and 5 years (n 240) from the Melbourne InFANT Program were used. Three 24-hour recalls assessed dietary intakes. The 2007 AUSNUT Food Composition Database was used to calculate carbohydrates intake and food groups. Descriptive statistics summarised total carbohydrate and subtype intake and their main food sources. Tracking was examined using Pearson correlations of residualised scores between time points. Total carbohydrate, starch and sugar intakes (g/d) increased across early childhood. The percentage of energy from total carbohydrates (% E) remained stable overtime (48·4-50·5 %). From ages 9 months to 5 years, the %E from total sugar decreased from 29·4 % to 22·6 %, while the %E from starch increased from 16·7 % to 26·0 %. Sources of total carbohydrate intake changed from infant formula at 9 months to bread/cereals, fruits and milk/milk products at 18 months, 3·5 and 5 years. Across all time points, the primary sources of total sugar intake were fruit, milk/milk products and cakes/cookies, whereas main food groups for starch intake included bread/cereals, cakes/cookies and pasta. Weak to moderate tracking of total carbohydrates, total sugar and starch (g/d) was observed. These findings may have the potential to inform the refinement of carbohydrate intake recommendations and design of interventions to improve children's carbohydrate intake.

The contribution of dietary composition over 25 years to cardiovascular risk factors in childhood and adulthood: the Princeton Lipid Research Study

Diet is a contributing factor to CVD risk, but how diet quality changes over the long term and contributes to CVD risk is less well studied. Diet data were analysed from parents and offspring from the Princeton Lipid Research Study (24-h recall in the 1970s; Block FFQ in 1998). Diet quality was assessed using an 8-point Dietary Approaches to Stop Hypertension nutrient-based scoring index, including a new method for scoring in children, as well as examining twelve key macro/micronutrients. Outcomes included blood glucose, blood pressure, serum lipids and BMI. The analysis included 221 parents (39 % male, mean age 38·9 ± 6·5 at baseline and 66·6 ± 6·6 at follow-up) and 606 offspring (45 % male, 11·9 ± 3·2 at baseline and 38·5 ± 3·6 at follow-up). Parents' Dietary Approaches to Stop Hypertension score increased slightly from baseline to follow-up (1·4 ± 1·0 and 2·1 ± 1·3, respectively, P < 0·001), while offspring remained consistent (1·6 ± 0·9 and 1·6 ± 1·1, respectively, P = 0·58). Overall, the Dietary Approaches to Stop Hypertension score, adjusted for age, race, sex and BMI, was not significantly associated with any examined outcomes. Of the macro/micronutrients at follow-up, saturated and total fat were associated with increased diabetes and dyslipidaemia in parents, while the inverse was seen with niacin. Among offspring, niacin was associated with lower rates of hypertension and dyslipidaemia. In conclusion, no relationship was detected between Dietary Approaches to Stop Hypertension adherence and disease outcomes. However, both saturated fat and niacin were associated with components of CVD risk, highlighting the need for improved diet quality overall.

Repeated exposure to models' positive facial expressions whilst eating a raw vegetable increases children's consumption of the modelled vegetable

Exposing children to adults eating a raw vegetable with positive facial expressions ('positive modelling') increases children's consumption of the modelled vegetable. However, whether repeated versus a single exposure to positive modelling enhances this effect, and whether it generalises to a non-modelled vegetable, remains to be examined. Hence, this study examined the effect of a single exposure, versus repeated, exposure to positive modelling on children's acceptance and intake of a modelled and non-modelled vegetable. Children aged 5-6 years (N = 153; 81 males, 72 females) were randomised to one of three conditions in which they had i) a single or ii) repeated exposure to a video of adults eating raw broccoli with positive facial expressions or iii) were exposed to a no-food control video. Children's acceptance (measured as willingness to try and number of tastes), intake and liking of a modelled (raw broccoli) and non-modelled vegetable (raw mangetout) were measured. Children had greater raw broccoli consumption and liking if they had received repeated exposure to positive modelling, compared to children who had received a single exposure, but not compared to children in the control condition. Children's mangetout intake was greater in the single (versus repeated) positive condition, but this effect was not dependent on time. There was no effect on children's vegetable acceptance. Repeatedly exposing children to adults enjoying a vegetable encourages children's intake of the modelled vegetable in comparison to a single exposure. Thus, repeated exposure to others' food enjoyment may be a practical and useful strategy to encourage children's vegetable consumption.

Effectiveness of a food literacy and positive feeding practices program for parents of 0 to 5 years olds in Western Australia

ISSUE ADDRESSED

Lifelong eating behaviours are established in childhood. Improving parents' food literacy skills is essential, as parents play a fundamental role in establishing their children's healthy eating behaviours and preferences for nutritious food. This paper describes the development and evaluation of an innovative program that combines food literacy with positive parent feeding practices, targeting parents in disadvantaged areas of Western Australia.

METHODS

The Food Sensations® for Parents five-week program was delivered to participants from community-based parenting organisations during 2020 and 2021. Formative research and a pre-post evaluation design were adopted.

RESULTS

Pre- and post-evaluation data were collected from 224 participants (96% female). There was a statistically significant improvement in the mean score for 13 food literacy behaviours, 10 positive parenting feeding practices and a mean increase in parents' daily vegetable intake of 1/3 serve. Participants reported significantly greater net improvements in food literacy behaviours than feeding practices, the largest being the Use a nutrition information panel to make food choices (33.1%). Multivariate logistic regression analyses found English as a first language, being older than 35, and from a higher Socio-Economic Index for Areas resulted in a higher likelihood of positive changes in behaviours and practices.

CONCLUSIONS

The findings indicate that the program is effective in improving the frequency of use of food literacy behaviours, positive parenting feeding practices and increasing vegetable consumption. SO WHAT?: Analysing improvements in food literacy behaviours and feeding practices provides clarity on what change can be expected with a five-week parent program.

Western, Healthful, and Low-Preparation Diet Patterns in Preschoolers of the STRONG Kids2 Program

OBJECTIVE

Identify and describe diet patterns of children during early childhood using confirmatory factor analysis (CFA).

DESIGN

Longitudinal data were drawn from the STRONG Kids 2 program.

PARTICIPANTS

Mothers were surveyed about their child's diet at 24 (n = 337), 36 (n = 317), and 48 (n = 289) months old.

VARIABLES MEASURED

The Block Food Frequency Questionnaire for children aged 2-7 years was used to derive diet patterns; 23 food groups were created for analyses.

ANALYSIS

Principal component analysis was used to obtain preliminary factor loadings, and loadings were used to form a priori hypotheses for CFA-derived diet patterns. Independent samples t tests were used to compare food groups, nutrient intakes, and child and family characteristics by CFA pattern scores above vs at/below the median.

RESULTS

Three diet patterns consistently emerged: (1) processed meats, sweets, and fried foods; (2) vegetables, legumes, and starchy vegetables; and (3) grains, nuts/seeds, and condiments (only 24 and 36 months). Patterns were related to differences in added sugars, dietary fiber and potassium intakes, maternal education, and household income.

CONCLUSIONS AND IMPLICATIONS

Opposing healthful vs Western patterns, extant in child and adult literature, were observed across all ages. The third pattern differed between 24/36 and 48 months, representing a potential shift in food choices or offerings as children age.

Predictors of Free Sugars Intake Trajectories across Early Childhood-Results from the SMILE Birth Cohort Study

Foods and beverages high in free sugars can displace healthier choices and increase the risk of weight gain, dental caries, and noncommunicable diseases. Little is known about the intake of free sugars across early childhood. This study aimed to examine the longitudinal intake from 1 to 5 years of free sugars and identify the independent maternal and child-related predictors of intake in a cohort of Australian children participating in the Study of Mothers' and Infants' Life Events Affecting Oral Health (SMILE). Free sugars intake (FSI) was previously estimated at 1, 2, and 5 years of age, and three distinct FSI trajectories were determined using group-based trajectory modelling analysis. This study utilized multinomial logistic regression to identify the maternal and child-related predictors of the trajectories. The risk of following the 'high and increasing' trajectory of FSI compared to the 'low and fast increasing' trajectory was inversely associated with socio-economic disadvantage (aRRR 0.83; 95% CI 0.75-0.92; p < 0.001), lower for females (aRRR 0.56; 95% CI 0.32-0.98; p = 0.042), and higher in children with two or more older siblings at birth (aRRR 2.32; 95% CI 0.99-5.42; p = 0.052). Differences in trajectories of FSI were evident from an early age and a high trajectory of FSI was associated primarily with socio-economic disadvantage, providing another example of diet quality following a social gradient.

Australian Stakeholder Perspectives on Healthier Retail Food Environments for Toddlers-The Era of "Band Aids and Small Inroads"

Background

A healthy diet in young children is crucial for optimal growth and development. However, many toddlers (1-3 y) consume suboptimal diets, and as a result, are at a high risk of experiencing negative health outcomes. Moreover, minimal progress has been made to improve the healthiness of retail food environments for toddlers to date despite the potential and advocacy for the issue.

Objectives

To gain insight into stakeholder perceptions and opinions on the healthiness of Australian retail food environments for toddlers, as well as perspectives on the options and barriers to improve their healthiness.

Methods

Qualitative, online study utilizing semi-structured individual interviews with 27 key stakeholders from food industry, academia, nongovernment organizations, public health, and government in Australia.

Results

Most stakeholders agreed that retail food environments for toddlers were not health promoting. Stakeholders identified that a multifaceted approach including nutrition education and strong government mandated regulation were essential to improve the healthiness of retail food environments for toddlers. Interviews also highlighted the main perceived barriers to progress, and reasons for policy inaction in this area are the food industry and government support. Many stakeholders were concerned that child health is being undermined due to the government favoring business needs over public health.

Conclusions

Stakeholders in this study overwhelmingly agreed that there is more that can and should be done to create health promoting retail food environments for toddlers in Australia. Stakeholders identified a range of strategies that can be used to improve the healthiness of toddler food environments, but advocacy efforts are being undermined due to government inaction. Stakeholders believed that strong governance is required to create equitable, sustainable healthy retail food environments for young children. Improving the healthiness of retail food environments for young children will not only reduce diet related disease across the lifespan but will help to address financial and societal costs of a poor diet.

Mothers' experiences of reducing family mealtime screen use in Australian households with young children

OBJECTIVE

Screen use at mealtimes is associated with poor dietary and psychosocial outcomes in children and is disproportionately prevalent among families of low socio-economic position (SEP). This study aimed to explore experiences of reducing mealtime screen use in mothers of low SEP with young children.

DESIGN

Motivational interviews, conducted via Zoom or telephone, addressed barriers and facilitators to reducing mealtime screen use. Following motivational interviews, participants co-designed mealtime screen use reduction strategies and trialled these for 3-4 weeks. Follow-up semi-structured interviews then explored maternal experiences of implementing strategies, including successes and difficulties. Transcripts were analysed thematically.

SETTING

Australia.

PARTICIPANTS

Fourteen mothers who had no university education and a child between six months and six years old.

RESULTS

A range of strategies aimed to reduce mealtime screen use were co-designed. The most widely used strategies included changing mealtime location and parental modelling of expected behaviours. Experiences were influenced by mothers' levels of parenting self-efficacy and mealtime consistency, included changes to mealtime foods and an increased value of mealtimes. Experiences were reportedly easier, more beneficial and offered more opportunities for family communication, than anticipated. Change required considerable effort. However, effort decreased with consistency.

CONCLUSIONS

The diverse strategies co-designed by mothers highlight the importance of understanding why families engage in mealtime screen use and providing tailored advice for reduction. Although promising themes were identified, in this motivated sample, changing established mealtime screen use habits still required substantial effort. Embedding screen-free mealtime messaging into nutrition promotion from the inception of eating will be important.

Assessing the scalability of healthy eating interventions within the early childhood education and care setting: secondary analysis of a Cochrane systematic review

OBJECTIVE

Early childhood education and care (ECEC) is a recommended setting for the delivery of health eating interventions 'at scale' (i.e. to large numbers of childcare services) to improve child public health nutrition. Appraisal of the 'scalability' (suitability for delivery at scale) of interventions is recommended to guide public health decision-making. This study describes the extent to which factors required to assess scalability are reported among ECEC-based healthy eating interventions.

DESIGN

Studies from a recent Cochrane systematic review assessing the effectiveness of healthy eating interventions delivered in ECEC for improving child dietary intake were included. The reporting of factors of scalability was assessed against domains outlined within the Intervention Scalability Assessment Tool (ISAT). The tool recommends decision makers consider the problem, the intervention, strategic and political context, effectiveness, costs, fidelity and adaptation, reach and acceptability, delivery setting and workforce, implementation infrastructure and sustainability. Data were extracted by one reviewer and checked by a second reviewer.

SETTING

ECEC.

PARTICIPANTS

Children 6 months to 6 years.

RESULTS

Of thirty-eight included studies, none reported all factors within the ISAT. All studies reported the problem, the intervention, effectiveness and the delivery workforce and setting. The lowest reported domains were intervention costs (13 % of studies) and sustainability (16 % of studies).

CONCLUSIONS

Findings indicate there is a lack of reporting of some key factors of scalability for ECEC-based healthy eating interventions. Future studies should measure and report such factors to support policy and practice decision makers when selecting interventions to be scaled-up.

Remembered childhood mealtime experiences influence on early childcare and education staff

Parent feeding styles, behaviors, beliefs, and practices are associated with developing children's eating behaviors. However, many children spend considerable time in childcare; thus, are exposed to child-feeding practices of other adults, e.g., early care and education (ECE) staff. Limited research exists on how and whether current classroom feeding practices of ECE staff associate with their own childhood experiences. The About Feeding Children survey, conducted in 2005, examined self-reported feeding practices and beliefs and personal characteristics of ECE staff in Western United States. An exploratory factor analysis of questions related to childhood experiences (N = 1189), revealed two Mealtime Factors: Remembered Adult Control and Remembered Child Autonomy Support. Structural equation modeling was conducted to examine the hypothesis that these remembered experiences would be associated with current feeding practices (Structural Mealtime Strategies, Verbal Mealtime Strategies, and Beliefs about Mealtimes). For each outcome, models had good to moderate fit. Across models, Remembered Autonomy Support was associated with less control, bribing, autonomy undermining, and concern-based control beliefs and greater support at meals and autonomy promoting beliefs in teachers' classroom feeding practices. More research is called for to consider whether reflection on remembered childhood experiences might be beneficial to consider during ECE staff training related to feeding young children.

Commercially available foods for young children (<36 months) in Australia: An assessment of how they compare to a proposed nutrient profile model

ISSUE ADDRESSED

To assess the nutritional composition of commercially available foods (CAFs) for infants and toddlers sold in Australia to determine whether they meet World Health Organization (WHO) Europe's proposed standards for nutritionally appropriate foods for children <36 months.

METHODS

A cross-sectional retail audit of infant (n = 177) and toddler (n = 73) foods found in-store and online at three major Victorian supermarkets was conducted in August/September 2019. Products were grouped according to WHO Europe's food categories and their nutrient content assessed against specific composition standards applicable to their category. The presence of added sugar in each product was also recorded.

RESULTS

Most infant products (71%) were soft-wet spoon-able, ready-to-eat foods whereas the most prevalent category for toddler products was dry finger foods and snacks (71%). Overall, just one-third of CAFs met all the nutrient recommendations for their category, with infant foods more likely to be compliant than toddler foods (43% vs. 10%; P < .001). Around 9 in 10 infant (93%) and toddler (89%) CAFs contained added sugar according to the Public Health England definition of 'free' sugars.

CONCLUSIONS

There is considerable scope to improve the nutritional composition of Australian CAFs for both infants and toddlers, to reduce harmful sugars in these foods and to improve the energy density of them. For CAFs marketed as suitable for toddlers there is also considerable scope to reduce the sodium content. SO WHAT?: These findings support the need for stronger regulation of CAFs for infants and toddlers to better promote healthy eating patterns and taste preferences in young children.

Iron Nutrition of Pre-Schoolers in High-Income Countries: A Review

Pre-schoolers are vulnerable to iron deficiency, which, in high-resource countries, is mainly caused by suboptimal or poorly absorbable iron intakes. This review examines the prevalence of inadequate iron intakes and status, and the non-dietary factors associated with these, among children aged between 2 and 5 years within high-income countries. It then considers the quality of the pre-schooler diet in terms of dietary factors, dietary patterns, and iron intakes. Additionally, it discusses the assessment of iron bioavailability and examines the various methods used to estimate the amount of absorbable iron in pre-schooler diets. Knowledge of the adequacy of iron intakes and bioavailability of iron intakes, and dietary patterns associated with iron intakes can facilitate the design and implementation of effectively targeted community-based intervention studies to improve iron intakes and iron bioavailability to minimise the risk of iron deficiency.

A qualitative study exploring the perceptions of health among pre-teen girls from disadvantaged communities in Dublin

There are disparities in health outcomes between youth from higher and lower socioeconomic backgrounds, and girls are especially vulnerable to changes in health-related behaviours as they develop. Therefore, this study explored how girls from disadvantaged communities in Dublin, Ireland, make sense of 'being healthy.' A phenomenological qualitative design was implemented. Three focus groups were conducted (n = 22, 10-12 years) and data were analysed using thematic analysis. Food and physical appearance featured prominently within the girls' definitions of health. Girls and their families from low-SES backgrounds may experience more difficulties with time scarcity as well as environmental barriers to a healthy lifestyle.

Prevalence and maternal determinants of early and late introduction of complementary foods: results from the Growing Up in New Zealand cohort study

A nationally generalisable cohort (n 5770) was used to determine the prevalence of non-timely (early/late) introduction of complementary food and core food groups and associations with maternal sociodemographic and health behaviours in New Zealand (NZ). Variables describing maternal characteristics and infant food introduction were sourced, respectively, from interviews completed antenatally and during late infancy. The NZ Infant Feeding Guidelines were used to define early (≤ 4 months) and late (≥ 7 months) introduction. Associations were examined using multivariable multinomial regression, presented as adjusted relative risk ratios and 95 % confidence intervals (RRR; 95% CI). Complementary food introduction was early for 40·2 % and late for 3·2 %. The prevalence of early food group introduction were fruit/vegetables (23·8 %), breads/cereals (36·3 %), iron-rich foods (34·1 %) and of late were meat/meat alternatives (45·9 %), dairy products (46·2 %) and fruits/vegetables (9·9 %). Compared with infants with timely food introduction, risk of early food introduction was increased for infants: breastfed < 6months (2·52; 2·19-2·90), whose mothers were < 30 years old (1·69; 1·46-1·94), had a diploma/trade certificate v. tertiary education (1·39; 1·1-1·70), of Māori v. European ethnicity (1·40; 1·12-1·75) or smoked during pregnancy (1·88; 1·44-2·46). Risk of late food introduction decreased for infants breastfed < 6 months (0·47; 0.27-0·80) and increased for infants whose mothers had secondary v. tertiary education (2·04; 1·16-3·60) were of Asian v. European ethnicity (2·22; 1·35, 3·63) or did not attend childbirth preparation classes (2·23; 1·24-4·01). Non-timely food introduction, specifically early food introduction, is prevalent in NZ. Interventions to improve food introduction timeliness should be ethnic-specific and support longer breast-feeding.

Correlates of children's dietary intake, physical activity and sedentary behavior in home-based childcare: A systematic review

This systematic review assessed the correlates of children's dietary intake, physical activity and sedentary behavior in home-based childcare. A systematic search of five databases with articles published between January 2000 and July 2021 was conducted. Articles were included if they contained data from a home-based childcare (birth-5 years) setting; were a quantitative study that reported children's dietary intake, physical activity or sedentary behavior; included variables associated with children's dietary intake, physical activity or sedentary behavior; and were published in English. Correlates were categorized using McLeroy’s social ecological framework. Risk of bias was assessed using the Office of Health Assessment and Translation (OHAT) Risk of Bias Rating Tool. Fifteen studies met the inclusion criteria; six assessed children's dietary intake, and nine assessed physical activity and/or sedentary behaviors. Studies were conducted in the USA (n = 12) and Canada (n = 3). Seventy-three correlates were identified, for children's dietary intake (n = 11), physical activity (n = 35) and sedentary behavior (n = 27). Ethnicity and the food provided to children were associated with children's dietary intake in two studies; both from the same study sample. Indoor play space was positively associated with physical activity in two separate studies. No consistent associations for children's dietary intake, physical activity, or sedentary behavior outcomes were found between studies, however few studies assessed the same correlates. High-quality studies conducted in different countries that assess the nutrition and physical activity environments in home-based childcare using reliable and consistent methods are needed. This review was registered with PROSPERO, no. CRD42019103429.

Parent-reported barriers to establishing a healthy diet with young children in Australia

BACKGROUND

Parents' beliefs and behaviours affect children's nutrition, eating behaviours, and health outcomes; however, little is known about parents' experiences and perspectives on establishing a healthy diet with young children.

METHODS

A community-recruited sample of 391 parents of young children (under age 5) completed an anonymous cross-sectional online survey assessing the degree to which their children met recommendations outlined in Australian nutrition guidelines, perceived barriers to establishing a healthy diet with their child, and interest in receiving tips/information about establishing healthy eating habits with their children. Descriptive statistics illustrated proportions of children adhering to recommendations. Thematic analysis was used to analyse qualitative data.

RESULTS

Adherence to recommended nutrition guidelines varied across age groups. Most children across all age groups had water as their main drink, routinely consumed a variety of fruit, and consumed sweet drinks or fast foods only rarely. In contrast, less than half of 2- and 3-year-olds regularly consumed a variety of vegetables. The proportion of children consuming discretionary "treat" foods increased sharply over the first 2 years of life, and two thirds of 2-, 3-, and 4-year-olds consumed treat foods a few days per week or more. Parent-reported barriers to establishing a healthy diet with young children included child behavioural factors (e.g., dislike of vegetables), parental influences (e.g., lack of time), family dynamics (e.g., influence of extended family) and external influences (e.g., external environment). Parents were most often interested in ways to modify child behaviour and information about child nutrition.

CONCLUSIONS

Parents cite child behavioural issues as a major barrier to establishing a healthy diet with young children. Behavioural interventions that provide parents with information and support on how to establish a healthy diet with young children, as opposed to educational interventions focusing mainly on what children should be eating, may better meet families' needs.

Predictors of sustainment of two distinct nutrition and physical activity programs in early care and education

Introduction

The goal of the present study was to investigate factors associated with sustainment of two evidence-based programs for nutrition promotion in early care and education (ECE) settings - Food Friends (FF) and Together, We Inspire Smart Eating (WISE).

Materials and methods

In a cross-sectional study design, ECE directors (N = 55) from centers that had previously been trained in WISE or FF completed a survey. Program-specific measures included Steckler's Perception of Innovations, the Program Sustainability Assessment Tool (PSAT), and the Organizational Readiness for Change Assessment (ORCA). For our primary outcomes, two measures of sustainment were examined: Nutrition Continued Practice (i.e., the use of or general focus on nutrition programs) and Program Fidelity (i.e., how well centers used specific evidence-based practices of WISE or FF). Multiple regression was used to determine the association of these outcomes with program, years since last implementation, and overall scores on predictors. Follow-up correlation analyses were used to investigate outcome relationships with context submeasures due to high intercorrelations between predictor submeasures.

Results

Nutrition Continued Practice was significantly predicted by program and overall PSAT score. WISE programs had significantly higher Nutrition Continued Practice scores than FF program (p = 0.03). All subscales of the PSAT (e.g., environmental support, funding stability, organizational capacity, program adaptation, communications, and strategic planning) were significantly correlated with Nutrition Continued Practice (all rs > 0.30, all ps < 0.03). Program Fidelity was significantly predicted by PSAT and Steckler Perception of Innovation scores. All subscales of the PSAT were strongly positively correlated with Program Fidelity (all rs > 0.48, all ps < 0.001); relative advantage (r = 0.54, p < 0.001) and level of institutionalization (r = 0.61, p < 0.001) were positively correlated with Program Fidelity.

Conclusion

This study suggests that factors associated with the continued practice of program principles are partially distinct from those that are associated with the sustainment of specific practices driving program fidelity. Results suggest capacity building strategies may be important for both continued attention to nutrition and physical activity as well as sustaining fidelity to specific evidence-based practices.

Nurturing children's development through healthy eating and active living: Time for policies to support effective interventions in the context of responsive emotional support and early learning

Fostering the growth, development, health, and wellbeing of children is a global priority. The early childhood period presents a critical window to influence lifelong trajectories, however urgent multisectoral action is needed to ensure that families are adequately supported to nurture their children's growth and development. With a shared vision to give every child the best start in life, thus helping them reach their full developmental potential, we have formed the International Healthy Eating Active Living Matters (HEALing Matters) Alliance. Together, we form a global network of academics and practitioners working across child health and development, and who are dedicated to improving health equity for children and their families. Our goal is to ensure that all families are free from structural inequality and oppression and are empowered to nurture their children's growth and development through healthy eating and physical activity within the context of responsive emotional support, safety and security, and opportunities for early learning. To date, there have been disparate approaches to promoting these objectives across the health, community service, and education sectors. The crucial importance of our collective work is to bring these priorities for early childhood together through multisectoral interventions, and in so doing tackle head on siloed approaches. In this Policy paper, we draw upon extensive research and call for collective action to promote equity and foster positive developmental trajectories for all children. We call for the delivery of evidence-based programs, policies, and services that are co-designed to meet the needs of all children and families and address structural and systemic inequalities. Moving beyond the "what" is needed to foster the best start to life for all children, we provide recommendations of "how" we can do this. Such collective impact will facilitate intergenerational progression that builds human capital in future generations.

Parental work hours and household income as determinants of unhealthy food and beverage intake in young Australian children

OBJECTIVE

This study examined parental work hours and household income as determinants of discretionary (energy-dense, nutrient-poor) food and beverage intake in young children, including differences by eating occasion.

DESIGN

Secondary analysis of cross-sectional data. Three hierarchical regression models were conducted with percentage of energy from discretionary food and beverages across the day, at main meals and at snack times being the outcomes. Dietary intake was assessed by 1 × 24-h recall and 1-2 × 24-h food record(s). Both maternal and paternal work hours were included, along with total household income. Covariates included household, parent and child factors.

SETTING

Data from the NOURISH/South Australian Infants Dietary Intake studies were collected between 2008 and 2013.

PARTICIPANTS

Participants included 526 mother-child dyads (median (interquartile range) child age 1·99 (1·96, 2·03) years). Forty-one percentage of mothers did not work while 57 % of fathers worked 35-40 h/week. Most (85 %) households had an income of ≥$50 k AUD/year.

RESULTS

Household income was consistently inversely associated with discretionary energy intake (β = -0·12 to -0·15). Maternal part-time employment (21-35 h/week) predicted child consumption of discretionary energy at main meals (β = 0·10, P = 0·04). Paternal unemployment predicted a lower proportion of discretionary energy at snacks (β = -0·09, P = 0·047).

CONCLUSIONS

This work suggests that household income should be addressed as a key opportunity-related barrier to healthy food provision in families of young children. Strategies to reduce the time burden of healthy main meal provision may be required in families where mothers juggle longer part-time working hours with caregiving and domestic duties. The need to consider the role of fathers and other parents/caregivers in shaping children's intake was also highlighted.

Does Food Intake of Australian Toddlers 12–24 Months Align with Recommendations: Findings from the Australian Feeding Infants and Toddlers Study (OzFITS) 2021

(1) Background: Food-based dietary guidelines promote population health and well-being through dietary patterns that reduce chronic disease risk while providing adequate energy and nutrients. In Australia, recommended dietary patterns based on servings per day from the five food groups—fruits, vegetables, cereals and grains, meats and alternatives, and dairy—have been developed for toddlers 1–2 years of age. However, no study has assessed the intake of the five food groups in this age group nationally. (2) Aim: To compare daily servings and the percentage of energy from the five food groups and discretionary foods in toddlers 1–2 years old to the Australian Dietary Guidelines. (3) Methods: Dietary intake was assessed using a one-day food record for 475 toddlers. (4) Results: Apart from fruit and dairy, servings of the five food groups were below the recommendations. Two-thirds of toddlers did not consume enough vegetables, and only 10% consumed the recommended number of servings for cereals and grains. On average, toddlers consumed only half the recommended servings of meat and alternatives. Nearly all toddlers (89%) consumed discretionary foods, which accounted for ~12% of total energy. Forty-five percent of toddlers received breastmilk. On average, breastfed toddlers consumed fewer servings from the five food groups than non-breastfed toddlers. Dairy contributed 20% of daily energy in all toddlers; however, this food group accounted for 13% in breastfed and 32% in non-breastfed toddlers on the day of the food record. (4) Conclusions: Compared to the recommendations, alignment with the servings of the five food group foods was not achieved by most toddlers, except for fruit and dairy. Discretionary foods may have displaced nutritious family foods. Consistent with Australian Infant Feeding Guidelines, many toddlers in this study continued to receive breastmilk but the recommended dietary patterns do not include breastmilk. Dietary modeling, including breastmilk as the primary milk source, is urgently needed, along with practical advice on incorporating breastmilk in a toddler’s diet while optimizing food consumption.

Mealtime TV Use Is Associated with Higher Discretionary Food Intakes in Young Australian Children: A Two-Year Prospective Study

Background: Mealtime television use has been cross-sectionally associated with suboptimal diets in children. This study aimed to assess the two-year prospective association between baseline mealtime television use and subsequent diets in young children, and identify socioeconomic differences. Methods: Parents reported their child’s television use at meals, and fruit, vegetable, and discretionary food intakes. Multivariable linear and logistic regression analyses assessed the association between baseline mealtime television use and follow-up diet outcomes. Differences were assessed by socioeconomic position. Results: Participants were 352 Australian parents of children aged six months to six years. Daily mealtime television use (average frequency/day) was associated with higher daily frequency of discretionary food intakes (β 0.2, 95% confidence interval (CI) 0.07–0.67) at the 2-year follow-up. Individually, television use during breakfast and dinner (1–2 days/week compared to never) predicted higher daily intake frequency of discretionary food, β 0.36 (95% CI 0.12–0.60) and β 0.19 (95% CI 0.00–0.39), respectively. Similarly, 3–7 days/week of television use during breakfast and lunch predicted higher frequency of discretionary food intake, β 0.18 (95% CI 0.02–0.37) and β 0.31 (95% CI 0.07–0.55), respectively. Associations were not socioeconomically patterned. Conclusions: Investigating mealtime television use motivators across the socioeconomic spectrum could inform interventions targeting the high consumption of discretionary foods in children.

Identification and Evaluation of Tools Utilised for Measuring Food Provision in Childcare Centres and Primary Schools: A Systematic Review

BACKGROUND

Children aged 2-11 years spend significant hours per week in early childhood education and care (ECEC) and primary schools. Whilst considered important environments to influence children's food intake, there is heterogeneity in the tools utilised to assess food provision in these settings. This systematic review aimed to identify and evaluate tools used to measure food provision in ECEC and primary schools.

METHODS

The Preferred Reporting Items for Systematic Reviews (PRISMA) was followed. Publications (2003-2020) that implemented, validated, or developed measurement tools to assess food provision within ECEC or primary schools were included. Two reviewers extracted and evaluated studies, cross checked by a third reviewer and verified by all authors. The Academy of Nutrition and Dietetics Quality Criteria Checklist (QCC) was used to critically appraise each study.

RESULTS

Eighty-two studies were included in the review. Seven measurement tools were identified, namely, Menu review; Observation; Weighed food protocol; Questionnaire/survey; Digital photography; Quick menu audit; and Web-based menu assessment. An evidence-based evaluation was conducted for each tool.

CONCLUSIONS

The weighed food protocol was found to be the most popular and accurate measurement tool to assess individual-level intake. Future research is recommended to develop and validate a tool to assess service-level food provision.

Associations of socioeconomic status indicators and migrant status with risk of a low vegetable and fruit consumption in children

Background

It is important to provide insight in potential target groups for interventions to reduce socioeconomic inequalities in children's vegetable/fruit consumption. In earlier studies often single indicators of socioeconomic status (SES) or migrant status have been used. However, SES is a multidimensional concept and different indicators may measure different SES dimensions. Our objective is to explore multiple associations of SES indicators and migrant status with risk of a low vegetable/fruit consumption in a large multi-ethnic and socioeconomically diverse sample of children.

Methods

We included 5,010 parents of 4- to 12-year-olds from a Dutch public health survey administered in 2018. Cross-sectional associations of parental education, material deprivation, perceived financial difficulties, neighbourhood socioeconomic status (NSES) and migrant status with low (≤4 days a week) vegetable and fruit consumption in children were assessed using multilevel multivariable logistic regression models. Results are displayed as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the 4- to 12-year-olds, 22.1% had a low vegetable consumption and 11.9% a low fruit consumption. Low (OR 2.51; 95%CI: 2.05, 3.07) and intermediate (OR 1.83; 95%CI: 1.54, 2.17) parental education, material deprivation (OR 1.45; 95%CI: 1.19, 1.76), low NSES (OR 1.28; 95%CI: 1.04, 1.58) and a non-Western migrant status (OR 1.94; 95%CI: 1.66, 2.26) were associated with a higher risk of a low vegetable consumption. Low (OR 1.68; 95%CI: 1.31, 2.17) and intermediate (OR 1.39; 95%CI: 1.12, 1.72) parental education and material deprivation (OR 1.63; 95%CI: 11.27, 2.08) were also associated with a higher risk of a low fruit consumption.

Conclusion

Our findings indicate associations of multiple SES indicators and migrant status with a higher risk of a low vegetable/fruit consumption in children and thus help to identify potential target groups.

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Vegetable and fruit consumptions on 4 days or less a week is reported for respectively 22.1% and 11.9% of children.

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Children's vegetable but not fruit consumption differs between neighbourhoods.

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A non-Western migrant status and a low socio-economic status of the neighbourhood are associated with low vegetable consumption.

•

Low/intermediate education and material deprivation are associated with low vegetable and fruit consumption.

•

This study provides clues to potential entry points for reducing inequalities in vegetable and fruit consumption.

The Nutritional Profile and On-Pack Marketing of Toddler-Specific Food Products Launched in Australia between 1996 and 2020

With the food system evolving, it is not clear how the nutrition and on-pack claims of toddler foods have been impacted. Data on the trends in Australia are lacking, so we sought to determine the changes in the nutrition and on-pack claims of toddler-specific packaged foods over time. A retrospective cross-sectional analysis was conducted using the Mintel Global New Products Database. The number of toddler-specific foods increased from 1996 to 2020. Over time, a lower proportion of meals and snacks were classified as “ultra-processed”, but a higher proportion of snacks were classified as “discretionary”. Meals launched after 2014 had higher median values for energy, saturated fat, and sugar than those in earlier years. Toddler snacks launched after 2014 had lower median values for sodium, and higher median values for fat, saturated fat, and sugar than those in earlier years. The mean number of total claims per package increased over time for snacks, with an increase in unregulated claims for both meals and snacks. Public health action is needed to ensure that the retail food environment for young children is health-promoting, including stringent and clear regulations for on-pack claims, and compositional guidelines and guidance on how to reduce the number of ultra-processed foods for toddlers.

The Australian Feeding Infants and Toddlers Study (OzFITS) 2021: Study Design, Methods and Sample Description

(1) Background: Caregiver feeding practices during the first two years of a child's life influence nutrition, growth, and development, as well as long term taste preferences and dietary patterns. Suboptimal feeding practices lead to poorer health outcomes, such as obesity, that persist into adulthood. Although the importance of early life nutrition is well-established, there are no Australia-wide surveys of dietary intakes of children under two years of age. The 2021 Australian Feeding Infants and Toddlers Study (OzFITS) aims to fill this gap. This paper describes the methods and study sample of OzFITS 2021. (2) Methods: OzFITS 2021 is a cross-sectional study of children aged 0 to 23.9 months of age and their caregiver across Australia. Data were collected between April 2020 and April 2021. A telephone-based survey was completed with a caregiver to obtain information on child and caregiver characteristics and feeding practices. For exclusively breastfed infants, the number of breastfeeds in a 24 h period was reported. Dietary intakes for mixed fed children were estimated using a one-day food record, with 30% of caregivers completing a second food record on a non-consecutive day. (3) Results: We enrolled 1140 caregiver and child dyads. Of those eligible to complete a food record, 853 (87%) completed the food record. Compared to the Australian population, caregivers were more likely to be university-educated (>75%), married or in a de facto relationship (94%), and have a household income >$100,000/y (60%). (4) Conclusions: OzFITS 2021 is the first national study to examine food and nutrient intake in Australian children aged under 2 years. The study will provide information on breastfeeding rates and duration, use of breast milk substitutes, and timing of solid food introduction. Dietary intake data will allow the comparison of core food groups and discretionary food intake to Australian guidelines and estimate the prevalence of inadequate intake of key nutrients, like iron. Healthcare practitioners and policymakers can use the study findings as a source of evidence to inform the next iteration of infant feeding guidelines.

Association between the Sociodemographic Characteristics of Parents with Health-Related and Lifestyle Markers of Children in Three Different Spanish-Speaking Countries: An Inter-Continental Study at OECD Country Level

The purpose of this cross-cultural study was to determine the association between the sociodemographic background of a child’s parents (i.e., their socioeconomic level, marital status, and educational level) with the child’s lifestyle (i.e., Mediterranean diet (MD), physical activity (PA) and screen time (ST)), and health markers. Material: This cross-sectional study included 1273 children, from Chile (n = 496), Colombia (n = 340), and Spain (n = 437). The sociodemographic information together with the lifestyle and health markers of the children were measured. There was an inverse association between a low or medium-low socioeconomic level for the parents of Chilean children and handgrip strength (β −0.61, p < 0.001); meanwhile, for Spanish children, an inverse association between a low or medium-low socioeconomic level and PA after school (β −0.58, p = 0.016), lifestyle (β −0.74, p = 0.015), and with MD adherence (β −0.86, p = 0.004) was found. The risk (i.e., by odd ratios (OR)) of being divorced/separated parents marital status showed an inverse association with abdominal obesity (OR 0.21, p = 0.045) in Spanish children; however, the parent’s marital status and a low educational level were risk factors for the suffering of a low nutritional level in Colombian children (OR 2.02, p = 0.048; OR 2.49, p < 0.001, respectively). On the other hand, a low educational level for parents reported for Chilean children had a positive association with ST of ≥4 h per day (OR 1.82, p = 0.020). In conclusion, in Spanish-speaking children, the lifestyle and health markers of the children are affected by the sociodemographic background of their parents; however, these effects could be moderated by the socio-cultural and economic status of their countries as members of the OCDE; therefore, it is essential to develop policies that decrease these gaps, so that children who are under-resourced can reach their full potential.

Commercially Available Apps to Support Healthy Family Meals: User Testing of App Utility, Acceptability, and Engagement

Background

Parents juggling caregiving and paid employment encounter a range of barriers in providing healthy food to their families. Mobile apps have the potential to help parents in planning, purchasing, and preparing healthy family food. The utility and acceptability of apps for supporting parents are unknown. User perspectives of existing technology, such as commercially available apps, can guide the development of evidence-based apps in the future.

Objective

This study aims to determine the feasibility of existing commercially available apps for supporting the healthy food provision practices of working parents.

Methods

Working parents (N=133) were recruited via the web and completed a 10-item Capability, Opportunity, Motivation, and Behavior (COM-B) self-evaluation survey assessing their needs in relation to the provision of healthy family meals. A total of 5 apps were selected for testing, including a meal planning app, recipe app, recipe manager app, family organizer app, and barcode scanning app. Survey items were mapped to app features, with a subsample of parents (67/133, 50.4%) allocated 2 apps each to trial simultaneously over 4 weeks. A semistructured interview exploring app utility and acceptability and a web-based survey, including the System Usability Scale and the user version of the Mobile App Rating Scale, followed app testing. The interview data were analyzed using a theoretical thematic approach.

Results

Survey participants (N=133; mean age 34 years, SD 4 years) were mainly mothers (130/133, 97.7%) and partnered (122/133, 91.7%). Participants identified a need for healthy recipes (109/133, 82% agreed or strongly agreed) and time for food provision processes (107/133, 80.5%). Engagement quality was the lowest rated domain of the user version of the Mobile App Rating Scale across all 5 apps (mean score per app ranging from 3.0 to 3.7 out of a maximum of 5). The family organizer, requiring a high level of user input, was rated the lowest for usability (median 48, IQR 34-73). In the interviews, participants weighed the benefits of the apps (ie, time saving) against the effort involved in using them in determining their acceptability. Organization was a subtheme emerging from interviews, associated with the use of meal planners and shopping lists. Meal planners and shopping lists were used in time, while behavior was occurring.

Conclusions

Meal planning apps and features promoting organization present feasible, time-saving solutions to support healthy food provision practices. Attention must be paid to enhancing app automation and integration, as well as recipe and nutrition content, to ensure that apps do not add to the time burden of food provision and are supportive of healthy food provision behavior in time.

Identifying opportunities for strengthening advice to enhance vegetable liking in the early years of life: qualitative consensus and triangulation methods

OBJECTIVE

To prioritise and refine a set of evidence-informed statements into advice messages to promote vegetable liking in early childhood, and to determine applicability for dissemination of advice to relevant audiences.

DESIGN

A nominal group technique (NGT) workshop and a Delphi survey were conducted to prioritise and achieve consensus (≥70 % agreement) on thirty evidence-informed maternal (perinatal and lactation stage), infant (complementary feeding stage) and early years (family diet stage) vegetable-related advice messages. Messages were validated via triangulation analysis against the strength of evidence from an Umbrella review of strategies to increase children's vegetable liking, and gaps in advice from a Desktop review of vegetable feeding advice.

SETTING

Australia.

PARTICIPANTS

A purposeful sample of key stakeholders (NGT workshop, n 8 experts; Delphi survey, n 23 end users).

RESULTS

Participant consensus identified the most highly ranked priority messages associated with the strategies of: 'in-utero exposure' (perinatal and lactation, n 56 points) and 'vegetable variety' (complementary feeding, n 97 points; family diet, n 139 points). Triangulation revealed two strategies ('repeated exposure' and 'variety') and their associated advice messages suitable for policy and practice, twelve for research and four for food industry.

CONCLUSIONS

Supported by national and state feeding guideline documents and resources, the advice messages relating to 'repeated exposure' and 'variety' to increase vegetable liking can be communicated to families and caregivers by healthcare practitioners. The food industry provides a vehicle for advice promotion and product development. Further research, where stronger evidence is needed, could further inform strategies for policy and practice, and food industry application.

Foods provided to children in family day care: an observational study

OBJECTIVE

To assess the quality and quantity of foods and beverages provided to children aged 0-5 years in family day care and identify structural and sociodemographic factors associated with the nutritional quality of food provided.

DESIGN

A cross-sectional study measured the food and beverages provided to children using weighed food records. The number of serves from different food groups was calculated according to the Australian Guide to Healthy Eating, and a healthy food provision index score was created. Associations between structural and sociodemographic factors and healthy food provision index scores were analysed using linear mixed models.

SETTING

Family day care services in two large geographic areas in New South Wales, Australia.

PARTICIPANTS

One hundred and four children in thirty-three family day care services.

RESULTS

During attendance at childcare, most children met recommended servings of fruit but not dairy, vegetables, lean meat and meat alternatives and wholegrains. Discretionary foods exceeded recommendations. Children's age, socio-economic status and the type of main meal provided were significantly associated with the healthy food provision index score.

CONCLUSIONS

Foods provided to children in family day care are aligned with dietary recommendations for fruit but not vegetables, dairy, lean meat and meat alternatives, wholegrains or discretionary foods. Interventions to promote healthy eating are needed to support families and educators to improve the nutritional quality of food provided to children.

Nutrition and oral health in early childhood: associations with formal and informal childcare

OBJECTIVE

To examine associations between childcare type and nutrition and oral health indicators.

DESIGN

Cross-sectional data extracted from a longitudinal birth cohort. Parent-completed FFQ and questions regarding oral health and childcare use. The associations between childcare type, classified into four groups: parent care only (PCO), formal childcare only (FCO), informal childcare only (ICO) or combination of care (F&I), and nutrition and oral health indicators were examined.

SETTING

Home and childcare.

PARTICIPANTS

Families with children aged 3 years (n 273) and 4 years (n 249) in Victoria, Australia.

RESULTS

No associations were observed between childcare type and core food/beverage consumption or oral health indicators. For discretionary beverages, compared with children receiving PCO at age 3 years, children in FCO or F&I were less likely to frequently consume fruit juice/drinks (FCO: adjusted OR (AOR) 0·41, 95 % CI 0·17, 0·96, P = 0·04; F&I: AOR 0·32, 95 % CI 0·14, 0·74, P = 0·008). At age 4 years, children receiving FCO or ICO were less likely to consume sweet beverages frequently compared with children receiving PCO: fruit juice/drink (ICO: AOR 0·42, 95 % CI 0·19, 0·94, P = 0·03; FCO: AOR 0·35, 95 % CI 0·14, 0·88, P = 0·03) and soft drink (ICO: AOR 0·23, 95 % CI 0·07, 0·74, P = 0·01; FCO: AOR 0·14, 95 % CI 0·03, 0·76, P = 0·02).

CONCLUSIONS

Associations between childcare type and discretionary beverage intake were observed. Investigation into knowledge, attitudes and activities in formal and informal childcare settings is required to explore different health promotion practices that may influence nutrition and oral health.

Effect of a Parent-Focused eHealth Intervention on Children's Fruit, Vegetable, and Discretionary Food Intake (Food4toddlers): Randomized Controlled Trial

Background

In Western countries, children’s diets are often low in fruits and vegetables and high in discretionary foods. Diet in early life tends to track through childhood and youth and even into adulthood. Interventions should, therefore, be delivered in periods when habitual traits are established, as in toddlerhood when children adapt to their family’s diet.

Objective

In this study, we assessed the effect of the Food4toddlers eHealth intervention, which aimed to enhance toddlers’ diets by shaping their food and eating environment.

Methods

The Food4toddlers randomized controlled trial was conducted in Norway in 2017-2018. Parent-child dyads were recruited through social media. In total, 298 parents completed an online questionnaire at baseline (mean child age 10.9 months, SD 1.2). Postintervention questionnaires were completed immediately after the intervention (ie, follow-up 1; mean child age 17.8 months, SD 1.3) and 6 months after the intervention (ie, follow-up 2; mean child age 24.2 months, SD 1.9). The intervention was guided by social cognitive theory, which targets the linked relationship between the person, the behavior, and the environment. The intervention group (148/298, 49.7%) got access to the Food4toddlers website for 6 months from baseline. The website included information on diet and on how to create a healthy food and eating environment as well as activities, recipes, and collaboration opportunities. To assess intervention effects on child diet from baseline to follow-up 1 and from baseline to follow-up 2, we used generalized estimating equations and a time × group interaction term. Between-group differences in changes over time for frequency and variety of fruits and vegetables and frequency of discretionary foods were assessed.

Results

At follow-up 1, a significant time × group interaction was observed for the frequency of vegetable intake (P=.02). The difference between groups in the change from baseline to follow-up 1 was 0.46 vegetable items per day (95% CI 0.06-0.86) in favor of the intervention group. No other significant between-group differences in dietary changes from baseline to follow-up 1 or follow-up 2 were observed. However, there is a clear time trend showing that the intake of discretionary foods increases by time from less than 1 item per week at baseline to more than 4 items per week at 2 years of age (P<.001), regardless of group.

Conclusions

A positive intervention effect was observed for the frequency of vegetable intake at follow-up 1 but not at follow-up 2. No other between-group effects on diet were observed. eHealth interventions of longer duration, including reminders after the main content of the intervention has been delivered, may be needed to obtain long-terms effects, along with tailoring in a digital or a personal form.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 92980420; https://doi.org/10.1186/ISRCTN92980420

Preschoolers will drink their GREENS! Children accept, like, and drink novel smoothies containing dark green vegetables (DGVs)

Dark green vegetables (DGVs; e.g., spinach) are a nutrient rich source of essential vitamins and minerals; yet, children's intakes of DGVs fall well below dietary recommendations and creative solutions are needed. This study describes preschoolers (3-5 y) willingness to taste, liking, and intake of fruit-based smoothies containing DGVs (i.e., spinach, collards, kale), commonly referred to as "green smoothies," and explores individual differences in children's eating responses. Using a between-subjects design, preschoolers were randomized to either a FRUIT ONLY smoothie condition (n = 36) or FRUIT+DGV smoothie condition (n = 32). Children's acceptance and intake were collected in one tasting session and one ad libitum snack session, respectively. Parents reported on child food pickiness, food responsiveness, and approach, and children's intake of fruits and DGVs. Children self-reported on previous experience with the study fruits and DGVs. The initial tasting session revealed that the majority of children (84.3%) in the FRUIT+DGV condition willingly tasted all five green smoothies and rated the green smoothies as moderately liked (2.3 ± 0.1). Children in the FRUIT+DGV condition consumed 225.7 ± 31.4 g (9.0 ± 1.3 oz; 1.1 ± 0.2 cups; 91.9 ± 12.9 kcals) of their most preferred green smoothie, providing 18.3 ± 3.7 g (or 0.7 ± 0.1 cups) of DGVs. Children's willingness to try, liking, and intake did not differ by smoothie condition. Individual differences in children's intake are reported. In conclusion, children were willing to try fruit smoothies supplemented with DGVs. Children rated the green smoothies as moderately-liked and children's intake during snack met 31% of their weekly USDA recommendations for DGVs. Adding DGVs to fruit-based smoothies may compliment other effective feeding strategies for increasing children's vegetable consumption.

Exploring Feeding Practices and Food Literacy in Parents with Young Children from Disadvantaged Areas

Early childhood provides an opportunity to optimize growth and development and parents play a fundamental role in forming healthy eating habits in their children. A healthy diet improves quality of life and wellbeing and reduces the risk of chronic disease. The aim of this research was to explore parents' experiences of feeding 0-5-year-old children and food literacy behaviors. This qualitative study employed a general inductive inquiry approach. Participants were recruited through community-based parenting organizations in disadvantaged areas. Eight focus groups were conducted with 67 parents (92.5% female) living in socially disadvantaged areas within metropolitan Perth of Western Australia. Ten themes emerged from the preliminary analysis and were aligned with domains of relatedness, autonomy, and competence within the self-determination theory. Themes included relatedness (1) feeding is emotional, (2) variations in routine and feeding structures, (3) external influences, autonomy (4) power struggles, (5) it must be quick and easy, (6) lack of strategies for feeding autonomy, competency (7) whatever works, (8) healthy is important but for some unattainable, (9) improvements in food literacy skills, and (10) conflicting information overload. This research informed the development of a food literacy program for parents. Parents faced many challenges when trying to provide healthy food. This research has shown parents would benefit from support to achieve healthy eating practices for their families.

Tracking Preschoolers' Lifestyle Behaviors and Testing Maternal Sociodemographics and BMI in Predicting Child Obesity Risk

BACKGROUND

Longitudinal data investigating tracking of children's lifestyle behaviors and predictors of childhood obesity are limited.

OBJECTIVES

We examined changes in children's lifestyle behaviors (dietary, physical activity, and screen time) from ages 2-5 y to determine if maternal sociodemographic factors and BMI predict child obesity at 3.5 y and 5 y.

METHODS

Data were obtained from 667 first-time mothers who were recruited into the Healthy Beginnings Trial at 24-34 weeks of gestation in Sydney, Australia. Child lifestyle behaviors were assessed using face-to-face questionnaire interviews with mothers. To measure child and maternal anthropometry, BMI (in kg/m2) was calculated using measured height and weight. Children were categorized as overweight or obese based on the International Obesity Task Force criteria. We used 1-factor repeated-measures ANOVA to track preschoolers' lifestyle behaviors and multiple logistic regression to determine obesity predictors.

RESULTS

In children aged 2-5 y, consumption of vegetables (ηp2 = 0.06; P < 0.005) and milk (ηp2 = 0.02; P < 0.001) decreased, whereas physical activity (ηp2 = 0.07; P < 0.001) increased. Discretionary foods (sweet snacks, fast foods, salty snacks, processed meats, confectionary) (ηp2 = 0.03-0.25; P ≤ 0.01) and screen time (ηp2 = 0.39; P < 0.001) increased. Maternal BMI (in kg/m2) (Exp β: 1.06; 95% CI:1.01, 1.12 ; P=0.02), marital status (married/de facto compared with single) (Exp β: 0.06; 95% CI:0.01, 0.26; P < 0.001), and child BMI at 2 y (Exp β: 1.82; 95% CI: 1.46, 2.27; P < 0.001) predicted overweight/obesity at 3.5 y. Child BMI at 3.5 y (Exp β: 3.51; 95% CI: 2.50, 4.93; P < 0.001) predicted obesity at 5 y.

CONCLUSIONS

Poor dietary and lifestyle behaviours track in early childhood, with maternal single-parent status and high maternal and child BMI at 2 y predicting earlier obesity onset.

Nutrition and packaging characteristics of toddler foods and milks in Australia

OBJECTIVE

To analyse nutritional and packaging characteristics of toddler-specific foods and milks in the Australian retail food environment to identify how such products fit within the Australian Dietary Guidelines (ADG) and the NOVA classification.

DESIGN

Cross-sectional retail audit of toddler foods and milks. On-pack product attributes were recorded. Products were categorised as (1) food or milk; (2) snack food or meal and (3) snacks sub-categorised depending on main ingredients. Products were classified as a discretionary or core food as per the ADG and level of processing according to NOVA classification.

SETTING

Supermarkets and pharmacies in Australia.

RESULTS

A total of 154 foods and thirty-two milks were identified. Eighty percentage of foods were snacks, and 60 % of foods were classified as core foods, while 85 % were ultraprocessed (UP). Per 100 g, discretionary foods provided significantly more energy, protein, total and saturated fat, carbohydrate, total sugar and Na (P < 0·001) than core foods. Total sugars were significantly higher (P < 0·001) and Na significantly lower (P < 0·001) in minimally processed foods than in UP foods. All toddler milks (n 32) were found to have higher energy, carbohydrate and total sugar levels than full-fat cow's milk per 100 ml. Claims and messages were present on 99 % of foods and all milks.

CONCLUSIONS

The majority of toddler foods available in Australia are UP snack foods and do not align with the ADG. Toddler milks, despite being UP, do align with the ADG. A strengthened regulatory approach may address this issue.

Factors Influencing the Early Introduction of Sugar Sweetened Beverages among Infants: Findings from the HSHK Birth Cohort Study

Understanding the determinants of early introduction of sugar sweetened beverages (SSBs) may assist in designing effective public health interventions to prevent childhood weight related conditions (obesity). This study explores the relationship between family/infant characteristics and the early introduction of SSBs among infants in Sydney, Australia. Mothers (n = 934) from an ongoing birth cohort study were interviewed at 8, 17, 34, and 52 weeks postpartum. Multivariable logistic regression analysis was used to identify family/infant factors independently associated with the likelihood of early introduction of SSBs (<52 weeks of age). Of the 934 mothers interviewed, 42.7% (n = 399) of infants were introduced to SSBs before 52 weeks. Mothers who were born in Vietnam (adjusted Odds Ratio (AOR) = 2.14; 95% confidence interval (CI) 1.33, 3.47), other Asian countries (AOR = 1.62; 95% CI 1.02, 2.58) as well as single mothers (AOR = 3.72; 95% CI 2.46, 5.62) had higher odds of introducing SSBs early to their infants. Mothers from highly advantaged socioeconomic background (AOR = 0.43; 95% CI 0.28, 0.68), those who breastfed their baby for 17–25 weeks (AOR = 0.60; 95% CI 0.37, 0.99), 26–51 weeks (AOR = 0.65; 95% CI 0.45, 0.94), and 52 weeks or more (AOR = 0.62; 95% CI 0.43, 0.90); and those who introduced solids between 17–25 weeks (AOR = 0.58; 95% CI 0.36, 0.91) and 26 weeks or more (AOR = 0.55; 95% CI 0.34, 0.91) had reduced odds of introducing SSBs early. Tailoring health promotion programs for these vulnerable groups may delay the introduction of SSBs.

Associations between parental food choice motives, health-promoting feeding practices, and infants' fruit and vegetable intakes: the Food4toddlers study

Background

Parents influence their infants’ diets and are the providers of healthy foods such as fruit and vegetables. Parental motives can influence infant’s diets directly or through parental feeding practices.

Objective

This study aimed to assess the associations between parental food choice motives and infants’ fruit and vegetable intakes and to examine whether parental feeding practices mediated these associations.

Design

A total of 298 parents participated in the Norwegian Food4toddlers study. Before the child’s first birthday (mean age = 10.9 months), the parents completed an online baseline questionnaire. Five parental food choice motives were assessed: health, convenience, sensory appeal, price, and familiarity. Infants’ fruit and vegetable intakes and three health-promoting feeding practices were also assessed. For each food choice motive and its relation to fruit or vegetable intake, three single mediation models were conducted. Mediation effects were examined using MacKinnon’s product of coefficients procedure, and bootstrap confidence intervals (CIs) were used for inferential testing.

Results

Higher scores on the motive of health were positively associated with infants’ vegetable intake (τ = 0.394, P < 0.001). No other significant associations were found between food choice motives and fruit or vegetable intake. The feeding practice of shaping a healthy environment mediated the relationships between health motive and both fruit (αβ = 0.067, CI: 0.001–0.146) and vegetable (αβ = 0.105, CI: 0.042–0.186) intakes. The feeding practice of encouraging balance and variety mediated the relationships between health motive and vegetable (αβ = 0.085, CI: 0.030–0.150) intake and between sensory appeal motive and vegetable intake (αβ = 0.047, CI: 0.005–0.103).

Conclusion

High levels of parental health motive are associated with higher infant vegetable intake. Our study contributes to understand the structure of parental feeding behaviors that may have implication for nutrition interventions targeting parents.

Childcare Food Provision Recommendations Vary across Australia: Jurisdictional Comparison and Nutrition Expert Perspectives

Early childhood is a critical stage for nutrition promotion, and childcare settings have the potential for wide-reaching impact on food intake. There are currently no Australian national guidelines for childcare food provision, and the comparability of existing guidelines across jurisdictions is unknown. This project aimed to map and compare childcare food provision guidelines and to explore perspectives amongst early childhood nutrition experts for alignment of jurisdictional childcare food provision guidelines with the Australian Dietary Guidelines (ADG). A desktop review was conducted and formed the basis of an online survey. A national convenience sample of childhood nutrition experts was surveyed. Existing guideline recommendations for food group serving quantities were similar across jurisdictions but contained many minor differences. Of the 49 survey respondents, most (84-100%) agreed with aligning food group provision recommendations to provide at least 50% of the recommended ADG serves for children. Most (94%) agreed that discretionary foods should be offered less than once per month or never. Jurisdictional childcare food provision guidelines do not currently align, raising challenges for national accreditation and the provision of support and resources for services across jurisdictions. Childhood nutrition experts support national alignment of food provision guidelines with the ADG.

A cross-sectional study of packed lunchbox foods and their consumption by children in early childhood education and care services

AIM

To (a) describe lunchbox foods packed and consumed by children attending early childhood education and care services; (b) compare the serves of foods packed and consumed with nutrition guideline recommendations; and (c) explore associations between parent characteristics and serves of food groups packed in lunchboxes.

METHODS

A cross sectional study was conducted on a sample of early childhood education and care services where parents provide food in the Hunter New England region of NSW, Australia. Lunchbox contents were assessed using photography and pre- and post-meal weights. Descriptive statistics were used to describe packing and consumption of core food groups and discretionary foods.

RESULTS

Data on food packed and consumed were collected for 355 children's lunchboxes from 17 services (preschools n = 14, long day care services n = 3). Less than half (44%) of lunchboxes contained vegetables, and 54% contained at least one serve of discretionary foods. Less than 1% of lunchboxes met all setting-specific nutrition guidelines. On average, children consumed 68% of lunchbox contents, with the lowest consumption rate being for vegetables. An association was found between parent education level and packing of discretionary foods (-0.36, P = <.01) but not for packing of fruit or vegetables.

CONCLUSIONS

Lunchboxes contained an over-representation of discretionary foods and under-representation of vegetables, and children had a low preference for consuming vegetables compared with other food groups. Interventions to support parent packing of lunchboxes in line with nutrition guidelines and strategies to expand child preference for foods such as vegetables are warranted.

Long-term outcomes (2 and 3.5 years post-intervention) of the INFANT early childhood intervention to improve health behaviors and reduce obesity: cluster randomised controlled trial follow-up

Background

The few health behavior interventions commencing in infancy have shown promising effects. Greater insight into their longer-term benefits is required. This study aimed to assess post-intervention effects of the Melbourne INFANT Program to child age 5y on diet, movement and adiposity.

Methods

Two and 3.5y post-intervention follow-up (2011–13; analyses completed 2019) of participants retained in the Melbourne INFANT Program at its conclusion (child age ~ 19 m; 2008–10) was conducted. The Melbourne INFANT Program is a 15-month, six session program delivered within first-time parent groups in Melbourne, Australia, between child age 4-19 m. It involves strategies to help parents promote healthy diet, physical activity and reduced sedentary behavior in their infants. No intervention was delivered during the follow-up period reported in this paper. At all time points height, weight and waist circumference were measured by researchers, children wore Actigraph and activPAL accelerometers for 8-days, mothers reported children’s television viewing and use of health services. Children’s dietary intake was reported by mothers in three unscheduled telephone-administered 24-h recalls.

Results

Of those retained at program conclusion (child age 18 m, n = 480; 89%), 361 families (75% retention) participated in the first follow-up (2y post-intervention; age 3.6y) and 337 (70% retention) in the second follow-up (3.5y post-intervention; age 5y). At 3.6y children in the intervention group had higher fruit (adjusted mean difference [MD] = 25.34 g; CI₉₅:1.68,48.99), vegetable (MD = 19.41; CI₉₅:3.15,35.67) and water intake (MD = 113.33; CI₉₅:40.42,186.25), than controls. At 5y they consumed less non-core drinks (MD = -27.60; CI₉₅:-54.58,-0.62). Sweet snack intake was lower for intervention children at both 3.6y (MD = -5.70; CI₉₅:-9.75,-1.65) and 5y (MD = -6.84; CI₉₅:-12.47,-1.21). Intervention group children viewed approximately 10 min/day less television than controls at both follow-ups, although the confidence intervals spanned zero (MD = -9.63; CI₉₅:-30.79,11.53; MD = -11.34; CI₉₅:-25.02,2.34, respectively). There was no evidence for effect on zBMI, waist circumference z-score or physical activity.

Conclusions

The impact of this low-dose intervention delivered during infancy was still evident up to school commencement age for several targeted health behaviors but not adiposity. Some of these effects were only observed after the conclusion of the intervention, demonstrating the importance of long-term follow-up of interventions delivered during early childhood.

Trial registration

ISRCTN Register ISRCTN81847050, registered 7th November 2007.

Process Evaluation of an eHealth Intervention (Food4toddlers) to Improve Toddlers' Diet: Randomized Controlled Trial

BACKGROUND

Parents seek trustworthy information online to promote healthy eating for their toddlers. Such information must be perceived as relevant and easy to implement and use.

OBJECTIVE

The objectives of this study were to conduct a process evaluation of the electronic health (eHealth) intervention (Food4toddlers) targeting food environment, parental feeding practices, and toddlers' diet and to examine possible differences in these areas according to education and family composition.

METHODS

A 2-armed randomized controlled trial, including 298 parent-toddler dyads from Norway, was conducted in 2017. In total, 148 parents in the intervention group received access to an intervention website for 6 months. Data on website usage were retrieved from the learning management platform used (NEO). Participants' satisfaction with the intervention was asked for in a postintervention questionnaire. Chi-square and t tests were used to examine differences in usage and satisfaction between education and family composition groups.

RESULTS

Most participants were mothers (144/148, 97.2%), lived in two-adult households (148/148, 100%), and were born in Norway (132/148, 89.1%). Mean parental age was 31.5 years (SD 4.2). More than 87.8% (129/147) had a university education degree and 56.5% (83/147) had over 4 years of university education. Most (128/148, 86.5%) intervention participants entered the website at least once (mean days of access 7.4 [SD 7.1]). Most parents reported the website as appropriate to the child's age (71/83, 86%) and self-explanatory (79/83, 95%) and appreciated the interface (52/83, 63%) and layout (46/83, 55%). In total, 61% (51/83) stated that they learned something new from the intervention. Parents with over 4 years of university education and in 1-child households used the intervention website more than those with 4 years or less of university education (8.4 vs 5.9 days in total, P=.04) and households with more than 1 child (8.3 vs 5.8 days in total, P=.04), respectively.

CONCLUSIONS

The Food4toddlers intervention website was found to be relevant by most participants in the intervention group, although usage of the website differed according to educational level and family composition. For eHealth interventions to be effective, intervention materials such as websites must be used by the target group. Our results highlight the need to include users from different groups when developing interventions.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN92980420; http://www.isrctn.com/ISRCTN92980420.