Validation of food diary method for assessment of dietary energy and macronutrient intake in infants and children aged 6-24 months

Capacity for Regulation of Energy Intake in Infancy

Importance

The capacity for regulation of energy intake (REI) to match energy needs is thought to contribute to differences in weight gain, and preventing excess infant weight gain is a priority.

Objective

To determine capacity for REI across infancy.

Design, Setting, and Participants

For this cohort study, a convenience sample of mother-infant dyads was recruited from the community in Michigan between 2015 and 2019. Inclusion criteria were healthy, full-term infants with weight appropriate for gestational age; biological mothers who were 18 years or older, English speaking, and a legal and custodial guardian; and infant having had consumed 2 oz or more in 1 feeding from an artificial nipple at least once per week. Infants were followed in the home setting with staff support for up to 12 months.

Interventions

Mother-infant dyads participated at infant age 1, 2.5, 5, 7, 10, and 12 months. In the intervention condition, mothers offered a feeding every hour for 6 hours. In the control condition, mothers fed infants as they typically would for 6 hours. Intake was recorded and kilocalories calculated.

Main Outcomes and Measures

Capacity for REI was indexed as the difference in intake in kilocalories per kilogram of body weight (intervention minus control condition); a value of 0 indicated perfect REI. Maternal and infant characteristics were obtained by questionnaire, and anthropometry was measured. Using multiple imputation, the intercept and slope for difference in kilocalories per kilogram across the 6 age points were estimated using mixed models accounting for repeated measures within participants. Statistical analyses were conducted between September 2021 and February 2023.

Results

The sample included 175 infants (87 [49.71%] female, 88 [50.29%] male; 494 pairs of intervention and control conditions and 4630 feedings). The mean (SD) 12-month weight-for-age z score was 0.1 (0.8). Mean (SD) gestational age as 39.55 (1.05) weeks, and mean (SD) birth weight was 3.43 (0.41) kg. Mean (SD) breastfeeding duration for those who reported stopping by 12 months was 17.83 (12.03) weeks. As designed, the intervention (compared with control) condition included more feedings at shorter intervals. After collapsing the data across age points in a mixed model accounting for repeated measures within participants, the REI estimate at 1 month differed from 0. On average, infants ate 5.21 kcal/kg (95% CI, 2.89-7.54 kcal/kg) more in the frequent feeding intervention condition than in the ad lib feeding control condition. This difference did not significantly change over 12 months of infancy (REI slope = -0.01 kcal/kg per month; 95% CI, -0.02 to 0.03 kcal/kg per month).

Conclusions and Relevance

The study's findings suggested that, on average, when offered more frequent feedings, healthy, full-term infants may overeat. The results provide support for responsive feeding as a strategy for preventing excess infant weight gain.

Noninvasive Reflection Spectroscopy Measurement of Skin Carotenoid Score in Infants Is Feasible and Reliable

BACKGROUND

Skin carotenoid measurement by reflection spectroscopy (RS) offers a noninvasive biomarker of carotenoid intake, but feasibility, reliability, and validity are not established in infants.

OBJECTIVES

In this study we aimed to determine the feasibility and reliability of 4-mo-old infant skin carotenoid score (SCS) measurement and its correlation with total carotenoid intake and plasma concentrations.

METHODS

SCSs were measured in a prospective, observational study with a modified, portable RS device at the index finger and heel of the foot in 4-mo-olds (n = 21). Infant plasma, human milk, and formula carotenoid concentrations were measured by HPLC-photodiode array, and carotenoid intake was estimated from 7-d food diaries corrected for actual milk carotenoid content. Mean SCS, time to acquire measurements, replicate intraclass correlations, and bivariate correlations between SCS, carotenoid intake, and plasma carotenoids were examined. Exploratory analyses of returning 6- (n = 12) and 8-mo-old (n = 9) infants were conducted.

RESULTS

Mean ± SD finger and heel SCSs in 4-, 6-, and 8-mo-olds were 92 ± 57 and 92 ± 51; 109 ± 41 and 119 ± 44; and 161 ± 89 and 197 ± 128 units, respectively. Replicate SCS measurements were reliable, with high intraclass correlation (≥0.70) of within-subject visit measurements. Finger SCSs in 4-mo-olds were correlated with carotenoid intake (ρ = 0.48, P = 0.0033), and finger and heel SCS were correlated with total plasma carotenoid concentrations (ρ = 0.71, P < 0.0001 and ρ = 0.57, P = 0.0006, respectively). Eight-mo-olds' finger and heel SCSs were correlated with total carotenoid intake (ρ = 0.73, P < 0.001; ρ = 0.58, P = 0.0014, respectively), whereas SCSs in 6-mo-olds, in transition from exclusive milk to complementary feeding, did not correlate with plasma carotenoid or dietary carotenoids, despite correlation between plasma and dietary carotenoid intake (ρ = 0.86, P = 0.0137). Mixed models suggest plasma total carotenoid concentration, age, carotenoid intake, and age × carotenoid intake, but not measurement site, are determinants of infant SCS.

CONCLUSIONS

Infant skin carotenoids are feasibly and reliably measured by RS and may provide a biomarker of carotenoid intake in 4-mo-olds. This trial was registered at clinicaltrials.gov as NCT03996395.

Breastfeeding duration is associated with higher adiposity at 6-8 months of age

Breastfeeding (BF) has been identified as a protective factor against childhood obesity. However, evidence of the association between BF duration and adiposity remains inconclusive. Few studies have been conducted among Southeast Asian infants that have measured body composition during infancy using the gold standard stable isotope method. This study aimed to evaluate the association between BF duration and body composition during infancy. Healthy full-term Thai infants aged 6-8 months (n = 60) receiving exclusive or predominant BF for at least 3 months were recruited. Skinfold thickness (SFT) was measured by well-trained investigators. Body composition was assessed by the deuterium dilution technique. Infants with longer BF duration (>6 months; mean 7.5 ± 0.5 months, n = 29) had a higher subscapular SFT z-score than those with shorter BF duration (≤6 months; mean 5.3± 0.9 months, n = 31) by 0.48 (95% confidence interval [CI]: 0.01-0.94). After adjustment for age and sex, BF duration and age at introduction of complementary feeding (CF) were positively associated with fat mass and fat mass index at 6-8 months. One month increase in BF duration and CF age was associated with a 0.37 (95% CI: 0.05, 0.69) kg/m² and 0.76 (95% CI: 0.18, 1.34) kg/m² increase in the fat mass index, respectively. After adjusting for infant body mass index (BMI) during the earlier infancy period, the strength of the association was attenuated. This finding may reflect reverse causality where infants with lower BMI received formula or CF earlier. A longitudinal study with follow-up into childhood is warranted to confirm the effects of BF on adiposity in infancy and childhood.

Validation of a food-frequency questionnaire to assess methyl-group donor intake in preschoolers

A good assessment of dietary methyl-group donor intake (folate, choline, betaine, methionine) is needed to investigate the effect of methyl-group donor intake on children's health. The aim is to develop and validate a food-frequency questionnaire (FFQ) to estimate the daily intake of methyl-group donors in preschoolers. For the relative validity and reproducibility of the FFQ, a 7-day estimated dietary record (7d EDR) and repeated measurements 6 weeks apart (n = 77) were used respectively. For the validity (n = 75), a moderate ranking ability was obtained (de-attenuated Pearson correlation = 0.43-0.70; weighted ƙ 0.10-0.40), but the FFQ tends to overestimate the real intake. Cross-classification analysis showed that 38% (choline) and 28% (betaine) of the subjects were misclassified. The FFQ shows a moderate to good reproducibility, intra-class correlation coefficients range between 0.67 (betaine) and 0.76 (choline) with a maximal misclassification of 6.5% for betaine (weighted ƙ 0.37-0.69) (n = 77).

CONCLUSION

The FFQ is a tool with a moderate validity and reproducibility to estimate the consumption of dietary methyl-group donors in preschoolers. This tool might be used in future research epidemiological studies including preschoolers.

WHAT IS KNOWN

• Poor dietary habits during childhood have been associated with chronic disease in adulthood. • Methyl-group donors are important for DNA methylation, which is the underlying mechanism of disease development.

WHAT IS NEW

• For the first time, a food-frequency questionnaire that can assess the intake of methione, folate, choline, and betaine has been developed and validated for the use in preschoolers.

An Active Image-Based Mobile Food Record Is Feasible for Capturing Eating Occasions among Infants Ages 3–12 Months Old in Hawai‘i

The ability to comprehensively assess the diet of infants is essential for monitoring adequate growth; however, it is challenging to assess dietary intake with a high level of accuracy. Infants rely on surrogate reporting by caregivers. This study aimed to determine if surrogate reporters (e.g., caregivers) could use an image-based mobile food record adapted (baby mFR) to record infants’ eating occasions, and via caregiver feedback, could assess the usability and feasibility of the baby mFR in recording infants’ diets. This was a cross-sectional study in which surrogate reporters (e.g., caregivers) recorded all food and beverage intake (including human milk) of the infant over a 4-day period. Trained research staff evaluated all images submitted during data collection for different indicators of quality. All surrogate reporters were asked to complete a usability questionnaire at the end of the 4-day data collection period. Basic descriptive analyses were performed on the infants 3–12 months of age (n = 70). A total of 91% (n = 64) of surrogate reporters used the baby mFR to record their infants’ eating occasions. The mean number of images submitted daily per participant via the mFR was 4.2 (SD 0.2). A majority of submitted images contained the fiducial marker and the food and/or beverage was completely visible. The mFR was found to be easy to use; however, suggestions were provided to increase utility of the application such as the inclusion of a bottle button and reminders. An image-based dietary assessment method using a mobile app was found to be feasible for surrogate reporters to record an infant’s food and beverage intake throughout the day.

Comparison of 24-Hour Recall and 3-Day Food Records during the Complementary Feeding Period in Thai Infants and Evaluation of Plasma Amino Acids as Markers of Protein Intake

Background: An accurate and reliable measurement of nutrient intake is the first and foremost step in order to optimise infant nutrition and evaluate its impact on health outcomes. However, research on the validity of dietary assessment tools used during the weaning period is limited, especially in lower-middle income countries. The primary aim of this study was to evaluate relative validity of a 24-h recall method (24-HR) using a 3-day food record (3-DFR). A secondary aim was to investigate association between protein intake from 3-DFR and plasma amino acids as a potential protein biomarker. Methods A multicentre, prospective cohort study was conducted in Chiang Mai, Thailand from June 2018 to May 2019. Food consumption data were collected in healthy infants using 24-HR and 3-DFR at 9 and 12 months of age. Blood samples were obtained at 12 months (M). Plasma amino acids were analysed using high performance liquid chromatography. Results Of 145 infants, 49% were female. At group level, paired t-tests/Wilcoxon signed rank tests did not show significant differences between average nutrient intakes from the 2 dietary assessment methods, except for vitamin A and vitamin C. Weighted kappa (Kw) was acceptable for all nutrients, except for vitamin A intake at 9 M (Kw = 0.15). The Bland–Altman analyses were unbiased for most nutrients with variable limits of agreement. At individual level, correlation coefficients (r) ranged from acceptable to excellent (r = 0.37–0.87) while cross-classifications showed acceptable outcomes, except for vitamin A. Multivariate analyses showed significant associations between protein intake at 12 M from the 3-DFR and plasma concentrations of branched-chain amino acids (BCAA) and essential amino acids (EAA), even after adjusting for gender, milk feeding type and energy intake. Conclusions For infants aged 9–12 M, a 24-HR can be used as a more practical alternative to a 3-DFR for most nutrients although caution is required for some micronutrients, especially vitamin A. A repeated interview might further improve the accuracy. Furthermore, protein intake, particularly animal-based protein, significantly predicted plasma BCAA and EAA concentrations regardless of gender, type of milk feeding and energy consumption.

Validity and Reproducibility of a Semi-Quantitative Food-Frequency Questionnaire Designed to Measure the Nutrient Intakes of Canadian South Asian Infants at 12 Months of Age

Purpose: Validated methods to assess diet of non-European infants are sparse. We assessed the validity and reliability of a semi-quantitative food-frequency questionnaire (FFQ) for South Asian infants in Canada.Methods: We developed an 80-item FFQ to assess infant nutrient intake in the South Asian Birth Cohort study (START). Caregivers completed the FFQ twice along with two 24-hour diet recalls. We measured infant plasma ferritin to cross-validate reported iron intake. We evaluated validity using Spearman's rho (ρ), and reliability using the intraclass correlation coefficient.Results: Seventy-six caregivers provided 2 FFQs and 2 24-hour diet recalls. Energy-adjusted, de-attenuated correlations between the FFQs and 24-hour diet recalls ranged from -0.29 (monounsaturated fat) through 1.00 (cholesterol). The FFQ overestimated energy intake by 128%. Iron intake by 24-hour diet recalls correlated with plasma ferritin (r = 0.41; P = 0.01; n = 37), but iron intake by FFQ did not. The average reproducibility coefficient of the FFQ ranged from 0.24 (macronutrients) to 0.65 (minerals).Conclusions: Among South Asian infants living in Canada, at least 2 days of diet recall completed with the primary caregiver yields more valid and reproducible estimates of nutrient intakes than a semi-quantitative FFQ, and it highlights that careful selection of FFQ portion sizes is important for assessing dietary intake with an FFQ.

The Impact of Dietary Protein in Complementary Foods on Infant Growth and Body Composition in a Population Facing the Double Burden of Malnutrition: Protocol for a Multicenter, Prospective Cohort Study

BACKGROUND

Protein is an essential macronutrient with an important role during complementary feeding. Low protein intake contributes to undernutrition while high intake, especially from animal sources, may increase obesity risk. However, the influences of different protein sources (dairy, meat, and plants) on growth, and underlying mechanisms for these effects, are poorly understood. Animal-sourced foods provide both high-quality protein and iron and are recommended to improve iron status. However, it is unclear whether current dietary recommendations are adequate to support healthy growth and optimize iron status. These issues are of particular concern in countries facing the double burden of malnutrition, the coexistence of all forms of malnutrition. More evidence is needed to develop appropriate recommendations for these countries.

OBJECTIVE

This study will investigate associations between protein intake during complementary feeding and growth, body composition, and iron status of infants in Thailand, a country facing the double burden of malnutrition. The study will also explore how different protein sources influence growth via the growth hormone-insulin-like growth factor I (IGF-1) axis and plasma amino acids.

METHODS

A multicenter cohort study will be conducted in Chiang Mai, Thailand, in 150 healthy term infants aged 4-6 months with birth weight ≥2500 g. Demographic data, dietary intake, and anthropometry will be collected at 6, 9, and 12 months. Dietary intake will be assessed using 24-hour dietary recalls, 3-day food records, and food frequency questionnaires. Blood samples for iron status, growth hormone, IGF-1, insulin-like growth factor-binding protein III (IGFBP-3), and plasma amino acids and urine samples for body composition analysis using stable isotope dilution will be obtained at 12 months.

RESULTS

The recruitment of study participants and data collection was undertaken from June 2018 to May 2019. Data and laboratory analyses are ongoing and are expected to be completed by December 2020. A total of 150 participants were enrolled, and 146 completed the study. We hypothesized that protein intake from animal-sourced foods in recommended quantities could support normal weight and length gain and lower the risk of undernutrition associated with similar amounts of plant-based protein. However, higher protein intake, especially from milk protein, may be linked to increased body fat via plasma amino acids and the growth hormone-IGF axis.

CONCLUSIONS

The results of this study will provide data on current complementary feeding practices, focusing on protein and iron intake in Thai infants. This information, combined with data on associations with infant growth and iron status, will help inform complementary feeding recommendations for this population and may be found relevant to other settings experiencing the double burden of malnutrition.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18112.

Modifications to Infant Formula Instructions Improve the Accuracy of Formula Dispensing

Readability of infant formula preparation instructions is universally poor, which may result in inaccurate infant feeding. Given that inaccurate formula dispensing can lead to altered infant growth and increased adiposity, there is an increased need for easy to follow instructions for formula preparation. We hypothesize that altering infant formula instruction labels using feedback from iterative focus groups will improve the preparation accuracy of powdered infant formula in a randomized controlled trial. Participants were recruited from the community, 18 years of age or older, willing to disclose demographic information for focus group matching, and willing to participate freely in the first (n = 21) or second (n = 150) phase of the study. In the second phase, participants were randomized to use the standard manufacturer instructions or to use the modified instructions created in the first phase. Accuracy was defined as the percent error between manufacturer-intended powder formula quantity and the amount dispensed by the participant. Participants who were assigned to the modified instructions were able to dispense the powdered formula more accurately than participants who used the standard manufacturer instructions (−0.67 ± 0.76 vs. −4.66 ± 0.74% error; p < 0.0001). Accuracy in powdered formula dispensing was influenced by bottle size (p = 0.02) but not by body mass index (p = 0.17), education level (p = 0.75), income (p = 0.7), age (p = 0.89) or caregiver status (p = 0.18). Percent error of water measurement was not different between the groups (standard: −1.4 ± 0.6 vs. modified: 0.7 ± 0.6%; p = 0.38). Thus, caloric density was more accurate in the modified instructions group compared to the standard manufacturer instructions group (−0.3 ± 0.6 vs.−2.9 ± 0.9%; p = 0.03). Infant formula label modifications using focus group feedback increased infant formula preparation accuracy.

Measuring energy, macro and micronutrient intake in UK children and adolescents: a comparison of validated dietary assessment tools

Background

Measuring dietary intake in children and adolescents can be challenging due to misreporting, difficulties in establishing portion size and reliance on recording dietary data via proxy reporters. The aim of this review was to present results from a recent systematic review of reviews reporting and comparing validated dietary assessment tools used in younger populations in the UK.

Methods

Validation data for dietary assessment tools used in younger populations (≤18 years) were extracted and summarised using results from a systematic review of reviews of validated dietary assessment tools. Mean differences and Bland-Altman limits of agreement (LOA) between the test and reference tool were extracted or calculated and compared for energy, macronutrients and micronutrients.

Results

Seventeen studies which reported validation of 14 dietary assessment tools (DATs) were identified with relevant nutrition information. The most commonly validated nutrients were energy, carbohydrate, protein, fat, calcium, iron, folate and vitamin C. There were no validated DATs reporting assessment of zinc, iodine or selenium intake. The most frequently used reference method was the weighed food diary, followed by doubly labelled water and 24 h recall. Summary plots were created to facilitate comparison between tools. On average, the test tools reported higher mean intakes than the reference methods with some studies consistently reporting wide LOA. Out of the 14 DATs, absolute values for LOA and mean difference were obtained for 11 DATs for EI. From the 24 validation results assessing EI, 16 (67%) reported higher mean intakes than the reference. Of the seven (29%) validation studies using doubly labelled water (DLW) as the reference, results for the test DATs were not substantially better or worse than those using other reference measures. Further information on the studies from this review is available on the www.nutritools.org website.

Conclusions

Validated dietary assessment tools for use with children and adolescents in the UK have been identified and compared. Whilst tools are generally validated for macronutrient intakes, micronutrients are poorly evaluated. Validation studies that include estimates of zinc, selenium, dietary fibre, sugars and sodium are needed.

Validation of a Complementary Food Frequency Questionnaire to assess infant nutrient intake

Dietary assessment in infants is challenging but necessary to understand the relationship between nutrition and growth and development. Currently no simple, validated methods exist to assess nutrient intake in New Zealand (NZ) infants. Therefore, this study aimed to assess the relative validity and reproducibility of a Complementary Food Frequency Questionnaire (CFFQ) to determine nutrient intakes of NZ infants. Ninety-five parent-infant pairs (infant age 10 ± 1 months) completed the CFFQ twice (CFFQ-1 and CFFQ-2), 4 weeks apart (to assess reproducibility). A 4-day weighed food record (4dWFR) was collected between CFFQ administrations (to assess validity). Validity and reproducibility were assessed for intakes of energy and 18 nutrients using Bland-Altman analysis, Pearson's correlation coefficients, cross-classification, and weighted Kappa (κ). The CFFQ showed acceptable validity: Nutrients from the CFFQ were comparable with the 4dWFR (bias, 9-28%), correlation between methods ranged from r = .18 (saturated fat) to r = .81 (iron; mean r = .52), 54% (mean) of participants were correctly classified (range 39% to 67%), and 7.1% (mean) misclassified into opposite tertiles (range 2.1% to 14.7%). There was acceptable agreement between the CFFQ and 4dWFR (κ = 0.20-0.60). The CFFQ showed good reproducibility: Correlations ranged from r = .34 (folate) to r = .80 (zinc); for 16 nutrients, >50% of participants were correctly classified, and for all nutrients, <10% of participants were grossly misclassified. All nutrients showed acceptable to good agreement (κ > 0.20). The CFFQ has acceptable relative validity and good reproducibility for assessing nutrient intake in NZ infants aged 9-12 months, making it a useful tool for use in future research.

A systematic review of reviews identifying UK validated dietary assessment tools for inclusion on an interactive guided website for researchers: www.nutritools.org

Background: Health researchers may struggle to choose suitable validated dietary assessment tools (DATs) for their target population. The aim of this review was to identify and collate information on validated UK DATs and validation studies for inclusion on a website to support researchers to choose appropriate DATs.Design: A systematic review of reviews of DATs was undertaken. DATs validated in UK populations were extracted from the studies identified. A searchable website was designed to display these data. Additionally, mean differences and limits of agreement between test and comparison methods were summarized by a method, weighting by sample size.Results: Over 900 validation results covering 5 life stages, 18 nutrients, 6 dietary assessment methods, and 9 validation method types were extracted from 63 validated DATs which were identified from 68 reviews. These were incorporated into www.nutritools.org. Limits of agreement were determined for about half of validations. Thirty four DATs were FFQs. Only 17 DATs were validated against biomarkers, and only 19 DATs were validated in infant/children/adolescents.Conclusions: The interactive www.nutritools.org website holds extensive validation data identified from this review and can be used to guide researchers to critically compare and choose a suitable DAT for their research question, leading to improvement of nutritional epidemiology research.

Active Image-Assisted Food Records in Comparison to Regular Food Records: A Validation Study against Doubly Labeled Water in 12-Month-Old Infants

Overreporting of dietary intake in infants is a problem when using food records (FR), distorting possible relationships between diet and health outcomes. Image-assisted dietary assessment may improve the accuracy, but to date, evaluation in the pediatric setting is limited. The aim of the study was to compare macronutrient and energy intake by using an active image-assisted five-day FR against a regular five-day FR, and to validate image-assistance with total energy expenditure (TEE), was measured using doubly labeled water. Participants in this validation study were 22 healthy infants randomly selected from the control group of a larger, randomized intervention trial. The parents reported the infants’ dietary intake, and supplied images of main course meals taken from standardized flat-surfaced plates before and after eating episodes. Energy and nutrient intakes were calculated separately using regular FR and image-assisted FRs. The mean (± standard deviations) energy intake (EI) was 3902 ± 476 kJ/day from the regular FR, and 3905 ± 476 kJ/day from the FR using active image-assistance. The mean EI from main-course meals when image-assistance was used did not differ (1.7 ± 55 kJ, p = 0.89) compared to regular FRs nor did the intake of macronutrients. Compared to TEE, image-assisted FR overestimated EI by 10%. Without validation, commercially available software to aid in the volume estimations, food item identification, and automation of the image processing, image-assisted methods remain a more costly and burdensome alternative to regular FRs in infants. The image-assisted method did, however, identify leftovers better than did regular FR, where such information is usually not readily available.

Nutritional disorders resulting from food allergy in children

The elimination of food allergens that contribute essential nutrients in paediatrics may lead to the development of nutritional disorders. The most common nutritional disorders include poor growth, micronutrient deficiencies and feeding difficulties. Of the aforementioned, growth faltering has been well studied and is seen as a common presenting factor in paediatric food allergy. However, the use of different criteria and cut-off values makes it difficult to establish the overall effect. The impact of number and type of foods eliminated and comorbidities has yielded varying results, although there seems to be a trend towards worsening growth with atopic dermatitis and the avoidance of cow's milk. Low micronutrient intake is common in paediatric food allergy; however, a low intake does not necessarily translate into a deficiency as measured by biomarkers. Vitamin D and calcium have been well studied, and a long-lasting impact on bone mineral density has been found. However, other micronutrient deficiencies have also been found and should also be considered. Feeding difficulties is a common complaint in clinical practice, but limited data have been published in food allergy. Poor growth and reflux/vomiting have been shown to be associated with feeding difficulties, in particular in non-IgE-mediated food allergies. There seems to be a long-lasting effect on feeding, in particular in cow's milk allergy, which needs to be taken into account with dietary input. The interplay between growth, feeding difficulties and micronutrient deficiencies has been implied in some studies, but cause and effect is not well established and requires further research.

Sources and pattern of protein intake and risk of overweight or obesity in young UK twins

High protein intake in young children is associated with excess gains in weight and body fat, but the specific role of different protein sources has yet to be described. The study aimed to investigate the role of different types of protein in the post-weaning stage on weight, BMI and overweight/obesity at 60 months. Intakes of animal, dairy and plant protein and a dietary pattern characterising variation in protein types at 21 months of age were estimated using a 3-d diet diary in a cohort of 2154 twins; weight and height were recorded every 3 months from birth to 60 months. Longitudinal mixed-effect models investigated the associations between sources of protein intake or dietary pattern scores and BMI, weight and overweight/obesity from 21 months up to 60 months. Adjusting for confounders, dairy protein intake at 21 months was positively associated with greater weight (46 (95 % CI 21, 71) g and BMI up to 60 months (0·04 (95 % CI 0·004, 0·070) kg/m2) and the odds of overweight/obesity at 3 years (OR 1·12; 95 % CI 1·00, 1·24). Milk showed associations of similar magnitude. A dietary pattern low in dairy protein and high in plant protein was associated with lower weight gain up to 60 months, but not overweight/obesity. Intake of dairy products in early childhood is most strongly associated with weight gain, compared with other protein sources. A dietary pattern characterised by lower protein intake and greater protein source diversity at 2 years may confer a lower risk of excess weight gain.

Feasibility of an estimated method using graduated utensils to estimate food portion size in infants aged 4 to 18 months

The Diet and Nutrition Survey of Infants and Young Children (DNSIYC) was carried out in 2011 to assess the nutrient intakes of 4 to 18 month old infants in the UK. Prior to the main stage of DNSIYC, pilot work was undertaken to determine the impact of using graduated utensils to estimate portion sizes. The aims were to assess whether the provision of graduated utensils altered either the foods given to infants or the amount consumed by comparing estimated intakes to weighed intakes. Parents completed two 4-day food diaries over a two week period; an estimated diary using graduated utensils and a weighed diary. Two estimated diary formats were tested; half the participants completed estimated diaries in which they recorded the amount of food/drink served and the amount left over, and the other half recorded the amount of food/drink consumed only. Median daily food intake for the estimated and the weighed method were similar; 980g and 928g respectively. There was a small (6.6%) but statistically significant difference in energy intake reported by the estimated and the weighed method; 3189kJ and 2978kJ respectively. There were no statistically significant differences between estimated intakes from the served and left over diaries and weighed intakes (p>0.05). Estimated intakes from the amount consumed diaries were significantly different to weighed intakes (food weight (g) p = 0.02; energy (kJ) p = 0.01). There were no differences in intakes of amorphous (foods which take the shape of the container, e.g. pureed foods, porridge) and discrete food items (individual pieces of food e.g. biscuits, rice cakes) between the two methods. The results suggest that the household measures approach to reporting portion size, with the combined use of the graduated utensils, and recording the amount served and the amount left over in the food diaries, may provide a feasible alternative to weighed intakes.

Micronutrient Status and Nutritional Intake in 0- to 2-Year-old Children Consuming a Cows' Milk Exclusion Diet

OBJECTIVES

To study micronutrient status and nutritional intake from complementary feeding in children on a cows' milk exclusion (CME) diet.

METHODS

Fifty-seven children with cows' milk allergy, younger than 2 years, were included in a cross-sectional study. Blood was analyzed for micronutrient status. Complementary feeding was defined as all solids and liquids except of breast milk, and assessed by 3-day food diary. The results were analyzed according to 3 feeding patterns: mainly breast-fed (mBF), partially breast-fed, and no breast milk group (nBM).

RESULTS

The children had a median age of 9 months and micronutrient status was within normal range for total homocysteine (p-tHcy), s-B12, s-folate, b-Hb, s-ferritin, s-zinc, and s-25(OH)D. There were no significant differences between feedings groups, except for B12-biomarkers. The mBF had higher p-tHcy (P < 0.000) and lower s-B12 (P = 0.002) compared nBM. Vitamin B12 deficiency (p-tHcy >6.5 μmol/L combined with s-B12 <250 pmol/L) was found in 12% of participants, most frequently among the mBF (36%) and none in nBM group (P = 0.009). Vitamin B12 intake from complementary feeding was negatively correlated with p-tHcy (r = -0.479, P = 0.001) and positively with s-B12 (r = 0.410, P = 0.003). Iron deficiency anemia was found in 5%. Iron intake correlated positively with b-Hb (r = 0.324, P = 0.02). Zinc deficiency was found in 7% and low 25(OH)D in 9%. Vitamin D intake was positively correlated with the use of supplements (r = 0.456, P = 0.001).

CONCLUSION

The risk of B12 deficiency was high in mBF infants on CME diet, and complementary feeding was associated with better B12 status. Iron, zinc, and vitamin D deficiencies were present in all feeding groups. Complementary feeding should be introduced at 4 to 6 months of age. Vitamin D supplement is recommended to ensure adequate intake.

Development and validation of a food frequency questionnaire for dietary intake assessment among multi-ethnic primary school-aged children

INTRODUCTION

This study aimed to develop and validate a food frequency questionnaire (FFQ) to assess habitual diets of multi-ethnic Malaysian children aged 7-12 years.

METHODS

A total of 236 primary school children participated in the development of the FFQ and 209 subjects participated in the validation study, with a subsample of 30 subjects participating in the reproducibility study. The FFQ, consisting of 94 food items from 12 food groups, was compared with a three-day dietary record (3DR) as the reference method. The reproducibility of the FFQ was assessed through repeat administration (FFQ2), seven days after the first administration (FFQ1).

RESULTS

The results of the validation study demonstrated good acceptance of the FFQ. Mean intake of macronutrients in FFQ1 and 3DR correlated well, although the FFQ intake data tended to be higher. Cross-classification of nutrient intake between the two methods showed that < 7% of subjects were grossly misclassified. Moderate correlations noted between the two methods ranged from r = 0.310 (p < 0.001) for fat to r = 0.497 (p < 0.001) for energy. The reproducibility of the FFQ, as assessed by Cronbach's alpha, ranged from 0.61 (protein) to 0.70 (energy, carbohydrates and fat). Spearman's correlations between FFQ1 and FFQ2 ranged from rho = 0.333 (p = 0.072) for protein to rho = 0.479 (p < 0.01) for fat.

CONCLUSION

These findings indicate that the FFQ is valid and reliable for measuring the average intake of energy and macronutrients in a population of multi-ethnic children aged 7-12 years in Malaysia.

Development and Application of the Remote Food Photography Method to Measure Food Intake in Exclusively Milk Fed Infants: A Laboratory-Based Study

Background

Accurate methods of assessing food intake in infants are needed to assess the relationship between infant feeding practices and risk of childhood obesity. Current methods are either subjective or have limited ability for use beyond clinical research settings.

Objective

To assess the accuracy of the RFPM to evaluate simulated milk intake including energy, macronutrient, and micronutrient intake compared to direct weighing within a controlled study.

Methods

Individuals were recruited to prepare three 2 fl oz, 4 fl oz, 6 fl oz, and 8 fl oz servings of infant formula and to capture photographs at different stages of preparation (dry powdered formula, prepared formula, and liquid waste) using the SmartIntake^® application. Gram weights of the bottles were obtained by the RFPM and direct weighing. Using the United States Department of Agriculture National Nutrient Database for Standard Reference, energy, macronutrient, and micronutrient values were generated from gram weights.

Results

Intake of formula prepared from powder measured by the RFPM was equivalent to weighed intake within 7.5% equivalence bounds among all servings and each serving size. The mean difference between methods varied among servings sizes with the RFPM underestimating intake by 1.6 ± 0.4 kcals in 2 fl oz servings, 4.8 ± 0.6 kcals in 4 fl oz servings, and 6.2 ± 1.0 kcals in 6 fl oz servings, and overestimating intake by 0.1 ± 1.2 kcals in 8 fl oz servings. Bland-Altman analysis showed that the RFPM overestimated intake at lower levels food intake and underestimated intake at higher levels. Considering photographs of only the prepared formula bottle and the bottle with formula waste to simulate ready-to-feed formula and human breast milk, intake estimated by the RFPM was equivalent to the directly weighed intake within 7.5% for all servings.

Conclusions

The RFPM has higher accuracy than subjective methods and similar accuracy as compared to the objective methods in estimating simulated intake of milk and formula with lower burden to caregivers. The RFPM is a viable method for measuring intake in exclusively milk fed infants by caregivers in a controlled environment with potential for widespread use in research and clinical practice.

The impact of the elimination diet on growth and nutrient intake in children with food protein induced gastrointestinal allergies

Background

Non immunoglobulin E (IgE) mediated allergies affecting the gastrointestinal tract require an elimination diet to aid diagnosis. The elimination diet may entail multiple food eliminations that contribute significantly to macro- and micro-nutrient intake which are essential for normal growth and development. Previous studies have indicated growth faltering in children with IgE-mediated allergy, but limited data is available on those with delayed type allergies. We therefore performed a study to establish the impact on growth before and after commencing an elimination diets in children with food protein induced non-IgE mediated gastrointestinal allergies.

Methods

A prospective, observational study was performed at the tertiary gastroenterology department. Children aged 4 weeks–16 years without non-allergic co-morbidities who were required to follow an elimination diet for suspected food protein induced gastrointestinal allergies were included. Growth parameters pre-elimination were taken from clinical notes and post-elimination measurements (weight and height) were taken a minimum of 4 weeks after the elimination diet. A 3-day estimated food diary was recorded a minimum of 4 weeks after initiating the elimination diet, including also any hypoallergenic formulas or over the counter milk alternatives that were consumed.

Results

We recruited 130 children: 89 (68.5 %) boys and a median age of 23.3 months [IQR 9.4–69.2]. Almost all children (94.8 %) in this study eliminated CM from their diet and average contribution of energy in the form of protein was 13.8 % (SD 3.9), 51.2 % (SD 7.5) from carbohydrates and 35 % (SD 7.5) from fat. In our cohort 9 and 2.8 % were stunted and wasted respectively. There was a statistically significant improvement in weight-for-age (Wtage) after the 4 week elimination diet. The elimination diet itself did not improve any of the growth parameters, but achieving energy and protein intake improved Wtage and WtHt respectively, vitamin and/or mineral supplements and hypoallergenic formulas were positively associated with WtHt and Wtage.

Conclusion

With appropriate dietary advice, including optimal energy and protein intake, hypoallergenic formulas and vitamins and mineral supplementation, growth parameters increased from before to after dietary elimination. These factors were positively associated with growth, irrespective of the type of elimination diet and the numbers of foods eliminated.

Measurement of obesity prevention in childcare settings: A systematic review of current instruments

OBJECTIVE

The incidence of childhood obesity is highest among children entering kindergarten. Overweight and obesity in early childhood track through adulthood. Programs increasingly target children in early life for obesity prevention. However, the published literature lacks a review on tools available for measuring behaviour and environmental level change in child care. The objective is to describe measurement tools currently in use in evaluating obesity-prevention in preschool-aged children.

METHODS

Literature searches were conducted in PubMed using the keywords "early childhood obesity," "early childhood measurement," "early childhood nutrition" and "early childhood physical activity." Inclusion criteria included a discussion of: (1) obesity prevention, risk assessment or treatment in children ages 1-5 years; and (2) measurement of nutrition or physical activity.

RESULTS

One hundred thirty-four publications were selected for analysis. Data on measurement tools, population and outcomes were abstracted into tables. Tables are divided by individual and environmental level measures and further divided into physical activity, diet and physical health outcomes. Recommendations are made for weighing advantages and disadvantages of tools.

CONCLUSION

Despite rising numbers of interventions targeting obesity-prevention and treatment in preschool-aged children, there is no consensus for which tools represent a gold standard or threshold of accuracy.

Energy and nutrient intakes of young children in the UK: findings from the Gemini twin cohort

Data on the diets of young children in the UK are limited, despite growing evidence of the importance of early diet for long-term health. We used the largest contemporary dietary data set to describe the intake of 21-month-old children in the UK. Parents of 2336 children aged 21 months from the UK Gemini twin cohort completed 3-d diet diaries in 2008/2009. Family background information was obtained from questionnaires completed 8 months after birth. Mean total daily intakes of energy, macronutrients (g and %E) and micronutrients from food and beverages, including and excluding supplements, were derived. Comparisons with UK dietary reference values (DRV) were made using t tests and general linear regression models, respectively. Daily energy intake (kJ), protein (g) and most micronutrients exceeded DRV, except for vitamin D and Fe, where 96 or 84 % and 70 or 6 % of children did not achieve the reference nutrient intake or lower reference nutrient intake (LRNI), respectively, even with supplementation. These findings reflect similar observations in the smaller sample of children aged 18-36 months in the National Diet and Nutrition Survey. At a population level, young children in the UK are exceeding recommended daily intakes of energy and protein, potentially increasing their risk of obesity. The majority of children are not meeting the LRNI for vitamin D, largely reflecting inadequate use of the supplements recommended at this age. Parents may need more guidance on how to achieve healthy energy and nutrient intakes for young children.

The Remote Food Photography Method Accurately Estimates Dry Powdered Foods-The Source of Calories for Many Infants

BACKGROUND

Infant formula is a major source of nutrition for infants, with more than half of all infants in the United States consuming infant formula exclusively or in combination with breast milk. The energy in infant powdered formula is derived from the powder and not the water, making it necessary to develop methods that can accurately estimate the amount of powder used before reconstitution.

OBJECTIVE

Our aim was to assess the use of the Remote Food Photography Method to accurately estimate the weight of infant powdered formula before reconstitution among the standard serving sizes.

METHODS

For each serving size (1 scoop, 2 scoops, 3 scoops, and 4 scoops), a set of seven test bottles and photographs were prepared as follow: recommended gram weight of powdered formula of the respective serving size by the manufacturer; three bottles and photographs containing 15%, 10%, and 5% less powdered formula than recommended; and three bottles and photographs containing 5%, 10%, and 15% more powdered formula than recommended (n=28). Ratio estimates of the test photographs as compared to standard photographs were obtained using standard Remote Food Photography Method analysis procedures. The ratio estimates and the US Department of Agriculture data tables were used to generate food and nutrient information to provide the Remote Food Photography Method estimates.

STATISTICAL ANALYSES PERFORMED

Equivalence testing using the two one-sided t tests approach was used to determine equivalence between the actual gram weights and the Remote Food Photography Method estimated weights for all samples, within each serving size, and within underprepared and overprepared bottles.

RESULTS

For all bottles, the gram weights estimated by the Remote Food Photography Method were within 5% equivalence bounds with a slight underestimation of 0.05 g (90% CI -0.49 to 0.40; P<0.001) and mean percent error ranging between 0.32% and 1.58% among the four serving sizes.

CONCLUSIONS

The maximum observed mean error was an overestimation of 1.58% of powdered formula by the Remote Food Photography Method under controlled laboratory conditions, indicating that the Remote Food Photography Method accurately estimated infant powdered formula.

Dietary protein intake is associated with body mass index and weight up to 5 y of age in a prospective cohort of twins

BACKGROUND

Few large epidemiologic studies have investigated the role of postweaning protein intake in excess weight and adiposity of young children, despite children in the United Kingdom consistently consuming protein in excess of their physiologic requirements.

OBJECTIVE

We investigated whether a higher proportion of protein intake from energy beyond weaning is associated with greater weight gain, higher body mass index (BMI), and risk of overweight or obesity in children up to 5 y of age.

DESIGN

Participants were 2154 twins from the Gemini cohort. Dietary intake was collected by using a 3-d diet diary when the children had a mean age of 21 mo. Weight and height were collected every 3 mo, from birth to 5 y. Longitudinal models investigated associations of protein intake with BMI, weight, and height, with adjustment for age at diet diary, sex, total energy intake, birth weight/length, and rate of prior growth and clustering within families. Logistic regression investigated protein intake in relation to the odds of overweight or obesity at 3 and 5 y of age.

RESULTS

A total of 2154 children had a mean ± SD of 5.7 ± 3.2 weight and height measurements up to 5 y. Total energy from protein was associated with higher BMI (β = 0.043; 95% CI: 0.011, 0.075) and weight (β = 0.052; 95% CI: 0.031, 0.074) but not height (β = 0.088; 95% CI: -0.038, 0.213) between 21 mo and 5 y. Substituting percentage energy from fat or carbohydrate for percentage energy from protein was associated with decreases in BMI and weight. Protein intake was associated with a trend in increased odds of overweight or obesity at 3 y (OR = 1.10; 95% CI 0.99, 1.22, P = 0.075), but the effect was not statistically significant at 5 y.

CONCLUSION

A higher proportion of energy from protein during the complementary feeding stage is associated with greater increases in weight and BMI in early childhood in this large cohort of United Kingdom children.

Appetitive traits and food intake patterns in early life

BACKGROUND

High food responsiveness (FR) and low satiety responsiveness (SR) are 2 appetitive traits that have been associated longitudinally with risk of excessive weight gain; however, to our knowledge, no studies have examined the associations between these traits and eating patterns in daily life in young children.

OBJECTIVE

We tested the hypothesis that higher FR is independently associated with a higher meal frequency and that lower SR is associated with a larger meal size.

DESIGN

Data were from 1102 families (2203 children) from the Gemini twin birth cohort. Appetite was assessed with the use of the Child Eating Behavior Questionnaire when the children were 16 mo old (mean ± SD: 15.73 ± 1.08 mo old), and meal frequency (eating occasions per day) and meal size (kilojoules per eating occasion) were determined from 3-d diet diaries completed by parents when the children were 21 mo old (mean ± SD: 20.65 ± 1.10 mo old). Complex samples general linear models were used to explore cross-sectional associations between appetitive traits and meal variables.

RESULTS

After adjustment for the covariates gestational age, birth weight, sex, difference in age at diet-diary completion, and appetite measurement, higher FR was associated with more-frequent meals (B ± SE: 0.13 ± 0.04; P = 0.001) but not with meal size (P = 0.41), and lower SR was associated with a larger meal size (B ± SE: -47.61 ± 8.79; P < 0.001) but not with meal frequency (P = 0.15).

CONCLUSIONS

FR and SR predict different eating variables with more food-responsive children eating more frequently, whereas less-satiety-responsive children eat more food on each eating occasion. Different strategies may be required to reduce the potential effects of FR and SR on weight gain.

Sleep and nighttime energy consumption in early childhood: a population-based cohort study

BACKGROUND

Shorter sleep is a risk factor for weight gain in young children. Experimental studies show that sleep deprivation is associated with higher nighttime energy intake, but no studies have examined the patterning of energy intake in relation to nighttime sleep duration in young children.

OBJECTIVES

The objectives of the study were to test the hypothesis that shorter-sleeping children would show higher nighttime energy intake and to examine whether the additional calories were from drinks, snacks or meals.

METHODS

Participants were 1278 families from the Gemini twin cohort, using data from one child per family selected at random to avoid clustering effects. Nighttime sleep duration was measured at 16 months of age using the Brief Infant Sleep Questionnaire. Energy intake by time of day and eating episode (meal, snack, drink) were derived from 3-day diet diaries completed when children were 21 months.

RESULTS

Consistent with our hypothesis, shorter-sleeping children consumed more calories at night only (linear trend P < 0.001), with those sleeping <10 h consuming on average 120 calories (15.2% of daily intake) more at night than those sleeping ≥13 h. The majority of nighttime intake was from milk drinks. Associations remained after adjusting for age, sex, birth weight, gestational age, maternal education, weight and daytime sleep.

CONCLUSIONS

Shorter-sleeping, young children consume more calories, predominantly at night, and from milk drinks. Parents should be aware that providing milk drinks at night may contribute to excess intake. This provides a clear target for intervention that may help address associations between sleep and weight observed in later childhood.

A practical approach to vitamin and mineral supplementation in food allergic children

Background

The management of food allergy in children requires elimination of the offending allergens, which significantly contribute to micronutrient intake. Vitamin and mineral supplementation are commonly suggested as part of dietary management. However a targeted supplementation regime requires a complete nutritional assessment, which includes food diaries. Ideally these should be analysed using a computerised program, but are very time consuming. We therefore set out to evaluate current practice of vitamin and mineral supplementation in a cohort of children with non-Immunoglobulin E (IgE) mediated food allergies.

Methods

This prospective, observational study recruited children aged 4 weeks – 16 years, who required to follow an elimination diet for non-IgE mediated allergies. Only children that improved according to a symptom score and were on a vitamin and/or mineral supplement were included. A 3-day food diary including vitamin and mineral supplementation was recorded and analysed using Dietplan computer program. We assessed dietary adequacy with/without the supplement using the Dietary Reference Values.

Results

One hundred-and-ten children had completed food diaries and of these 29% (32/110) were taking vitamin and/or mineral supplements. Children on hypoallergenic formulas were significantly (p = 0.007) less likely to be on supplements than those on alternative over-the-counter milks. Seventy-one percent had prescribable supplements, suggested by a dietitian/physician. Sixty percent of those without a vitamin supplement had a low vitamin D intake, but low zinc, calcium and selenium was also common. Of the supplemented cohort many continued to be either under or over-supplemented.

Conclusion

This study has raised the question for the first time, whether clinicians dealing with paediatric food allergies should consider routine vitamin and/or mineral supplements in the light of deficient intake being so common in addition to being so difficult to predict.

DINO (Diet In Nutrients Out) - an integrated dietary assessment system

OBJECTIVE

The current paper describes Diet In Nutrients Out (DINO), an integrated dietary assessment system incorporating dietary data entry and nutritional analysis within one platform for use in dietary assessment in small-scale intervention studies to national surveys.

DESIGN

DINO contains >6000 food items, mostly aggregated composites of branded foods, across thirty-one main food groups divided into 151 subsidiary groups for detailed reporting requirements, with fifty-three core nutrient fields.

SETTING

MRC Human Nutrition Research (HNR), Cambridge, UK and MRC Keneba, Gambia.

SUBJECTS

DINO is used across dietary assessment projects at HNR and MRC Keneba.

RESULTS

DINO contains macro- and micronutrients as well as additional variables of current research and policy interest, such as caffeine, whole grains, vitamin K and added sugars. Disaggregated data are available for fruit, vegetables, meat, fish and cheese in composite foods, enabling greater accuracy when reporting food consumption or assessing adherence to dietary recommendations. Portion sizes are categorised in metric and imperial weights, with standardised portion sizes for each age group. Regular reviews are undertaken for portion sizes and food composition to ensure contemporary relevance. A training programme and a checking schedule are adhered to for quality assurance purposes, covering users and data. Eating context questions are integrated to record where and with whom the respondent is eating, allowing examination between these factors and the foods consumed.

CONCLUSIONS

An up-to-date quality-assured system for dietary assessment is crucial for nutritional surveillance and research, but needs to have the flexibility to be tailored to address specific research questions.

Dietary intake of young twins: nature or nurture?

BACKGROUND

The early years in life are increasingly recognized as a critical period for the development of diet-related behavioral traits. However, discussions continue on the relative role of genes and the environment in determining dietary intake, particularly in young children for whom detailed dietary information is limited.

OBJECTIVES

This study tested the hypothesis that diet in early childhood is primarily determined by the environment rather than by genes. A secondary aim was to characterize the early childhood diet.

DESIGN

A classic twin design used 3-d dietary data collected at age 21 mo from the Gemini cohort. From the full sample of 2402 families with twins, dietary diaries were available for 1216 twin pairs (384 monozygotic and 832 dizygotic pairs) after exclusions. Intakes of macronutrients, food, and beverages were estimated. Twin analyses quantified the contributions of genetic and environmental factors to population variation in intake.

RESULTS

At age 21 mo, children consumed small portions of a wide range of family foods. The shared environment was the predominant determinant, contributing between 66% (95% CI: 52%, 77%; milk-based desserts) and 97% (95% CI: 95%, 98%; juice) of the variation in intake. Genetic factors were estimated to account for between 4% (95% CI: 0%, 10%; savory snacks) and 18% (95% CI: 14%, 23%; bread) of dietary intake variation.

CONCLUSION

Shared environmental influences are the predominant drivers of dietary intake in very young children, indicating the importance of factors such as the home food environment and parental behaviors.

Comparison of energy intake in toddlers assessed by food frequency questionnaire and total energy expenditure measured by the doubly labeled water method

The ability of parents to accurately report energy intake in toddlers has rarely been validated using the gold-standard doubly labeled water (DLW) method to assess total energy expenditure (TEE). The aim of the study was to evaluate the accuracy of toddler energy intake (EI), estimated using the Australian Child and Adolescent Eating Survey (ACAES) food frequency questionnaire (FFQ) by parent report compared with a weighed food record (WFR) and TEE measured by DLW. Twelve toddlers had TEE assessed over 10 days using DLW. Usual energy intake was estimated by the primary caregiver, using standard toddler portions in ACAES-FFQ and a 4-day WFR and daily EI (in kilocalories) derived using national nutrient databases. Accuracy of reporting was calculated from absolute (EI-TEE) and percentage (EI/TEE×100) differences between EI and TEE and Pearson correlations and limits of agreement from Bland-Altman plots. Toddlers (n=12, 7 boys) had a mean age of 3.2±0.5 years, body mass index 16.2±0.9 kg, body mass index z score 0.1±0.8, EI from ACAES-FFQ 1,183±281kcal/day, and WFR 1,179±278 kcal/day and DLW TEE 1,251±149 kcal/day. The mean difference and limits of agreement (±2 standard deviations) compared with DLW was -68 (-623, 488) kcal/day for the FFQ and for the WFR -72 (-499, 354) kcal/day. Although both a semiquantitative FFQ and WFR can adequately estimate toddler energy intake at the group level in this population, toddler-specific portion size estimates should be assigned to foods listed in the FFQ. Choice of method is likely to depend on practical issues, including cost and burden.

A review of energy intake measures used in young children with cerebral palsy

The aim of this review was to evaluate the psychometric properties and clinical utility of energy intake measures used in young children with cerebral palsy (CP). Five databases were searched for relevant literature, and measures were included if they (1) directly measured energy intake in kilojoules/kilocalories per day; (2) had published data in kilojoules/kilocalories per day for children with CP from birth to 5 years; and (3) at least 40% of participants had a diagnosis of CP. Three measures met criteria: a 3-day weighed food record, a 3-day estimated food record, and a 7-day estimated food record. Included measures were evaluated on their characteristics, intended outcome, and validity. Reliability and responsiveness were not reported for any measure. Currently there is no dietary methodology that has proven reliability or repeated validity in young children with CP. Clinicians and researchers should not rely on current methodologies until further evaluation.

Infants perceived as "fussy" are more likely to receive complementary foods before 4 months

OBJECTIVE

Our purpose was to assess early infant-feeding patterns in a cohort of low-income black mothers and to examine associations between maternal perception of infant temperament and complementary feeding (CF) before 4 months.

METHODS

We used cross-sectional data from the 3-month visit (n = 217) of the Infant Care, Feeding and Risk of Obesity Study to assess relationships between early feeding of solids or juice and 6 dimensions of perceived infant temperament. Descriptive statistics were used to assess infant-feeding patterns, and logistic regression models were fit for each diet-temperament relationship found significant in the bivariate analyses.

RESULTS

Seventy-seven percent of the infants were fed solid foods at 3 months, 25% were fed juice, and 6% were exclusively breastfed. In multivariable analyses, 2 dimensions of perceived infant temperament were associated with early feeding of solid foods (distress-to-limitations odds ratio [OR]: 1.97 [95% confidence interval (CI): 1.12-3.44]; activity-level OR: 1.75 [95% CI: 1.07-2.85]), whereas 1 dimension, low-intensity pleasure, was associated with early feeding of juice (OR: 0.51 [95% CI: 0.34-0.78]). Maternal characteristics significantly associated with early CF included breastfeeding, obesity, and depressive symptoms.

CONCLUSIONS

Low-income black mothers may represent a priority population for interventions aimed at improving adherence to optimal infant feeding recommendations. That maternal perceptions of several domains of perceived infant temperament are related to early CF suggests that this is an important factor to include in future observational research and in the design of interventions.

Methodology for longitudinal assessment of nutrient intake and dietary habits in early childhood in a transnational multicenter study

OBJECTIVES

The aim of this study was to describe developed methods for repeated longitudinal assessment of feeding habits and nutrient intakes of children in a multicenter trial in different European countries and to assess feasibility.

PATIENTS AND METHODS

Nutrient intake and dietary habits of formula-fed and breast-fed infants were assessed in 5 European countries (Belgium, Germany, Italy, Poland, and Spain). Prospective age-adapted 3-day weighed food records were used from birth to 2 years of age (1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 18, and 24 months). Standard operating procedures were developed to check each day's food record for quality. Dietitians were trained by using standardized food records. Data entry and nutrient analyses were performed with a dedicated software developed for this project.

RESULTS

Of 1368 study participants, at least one 3-day food record was available; of 25,367 1-day food records, data on quality could be evaluated. Overall, between 81% and 97% (depending on the country) of the food records had been completed with high accuracy. The implementation of solid foods and regular family foods decreased the recording quality significantly during the 2-year time course (P < 0.001). The standardized training shows coefficients of variation up to a maximum of about 41%, indicating differences in data entry.

CONCLUSIONS

The experiences gathered indicate that collecting dietary and behavioral data in a large number of infants from different cultures is a challenging but feasible task in which permanent supervision and training is vital. However, we conclude that the established methodology is suitable to obtain valuable results on current infant nutrition practice in Europe.

A systematic review of the validity of dietary assessment methods in children when compared with the method of doubly labeled water

Measuring dietary intake in children enables the assessment of nutritional adequacy of individuals and groups and can provide information about nutrients, including energy, food, and eating habits. The aim of this review was to determine which dietary assessment method(s) provide a valid and accurate estimate of energy intake by comparison with the gold standard measure, doubly labeled water (DLW). English-language articles published between 1973 and 2009 and available from common nutrition databases were retrieved. Studies were included if the subjects were children birth to age 18 years and used the DLW technique to validate reported energy intake by any other dietary assessment method. The review identified 15 cross-sectional studies, with a variety of comparative dietary assessment methods. These included a total of 664 children, with the majority having <30 participants. The majority of dietary assessment method validation studies indicated a degree of misreporting, with only eight studies identifying this to a significant level (P<0.05) compared to DLW estimated energy intake. Under-reporting by food records varied from 19% to 41% (n=5 studies) with over-reporting most often associated with 24-hour recalls (7% to 11%, n=4), diet history (9% to 14%, n=3), and food frequency questionnaires (2% to 59%, n=2). This review suggested that the 24-hour multiple pass recall conducted over at least a 3-day period that includes weekdays and weekend days and uses parents as proxy reporters is the most accurate method to estimate total energy intake in children aged 4 to 11 years, compared to total energy expenditure measured by DLW. Weighed food records provided the best estimate for younger children aged 0.5 to 4 years, whereas the diet history provided better estimates for adolescents aged≥16 years. Further research is needed in this area to substantiate findings and improve estimates of total energy expenditure in children and adolescents.

Assessing the intake of obesity-related foods and beverages in young children: comparison of a simple population survey with 24 hr-recall

Background

With an increasing focus on obesity prevention there is a need for simple, valid tools to assess dietary indicators that may be the targets of intervention programs. The objective of this study was to determine the relative validity of previous day dietary intake using a newly developed parent-proxy questionnaire (EPAQ) for two to five year old children.

Methods

A convenience sample of participants (n = 90) recruited through preschools and the community in Geelong, Australia provided dietary data for their child via EPAQ and interviewer-administered 24-hour dietary recall (24 hr-recall). Comparison of mean food and beverage group servings between the EPAQ and 24 hr-recall was conducted and Spearman rank correlations were computed to examine the association between the two methods.

Results

Mean servings of food/beverage groups were comparable between methods for all groups except water, and significant correlations were found between the servings of food and beverages using the EPAQ and 24-hr recall methods (ranging from 0.57 to 0.88).

Conclusion

The EPAQ is a simple and useful population-level tool for estimating the intake of obesity-related foods and beverages in children aged two to five years. When compared with 24-hour recall data, the EPAQ produced an acceptable level of relative validity and this short survey has application for population monitoring and the evaluation of population-based obesity prevention interventions for young children.

Relative validity and reproducibility of a food-frequency questionnaire for estimating food intakes among Flemish preschoolers

The aims of this study were to assess the relative validity and reproducibility of a semi-quantitative food-frequency questionnaire (FFQ) applied in a large region-wide survey among 2.5–6.5 year-old children for estimating food group intakes. Parents/guardians were used as a proxy. Estimated diet records (3d) were used as reference method and reproducibility was measured by repeated FFQ administrations five weeks apart. In total 650 children were included in the validity analyses and 124 in the reproducibility analyses. Comparing median FFQ1 to FFQ2 intakes, almost all evaluated food groups showed median differences within a range of ± 15%. However, for median vegetables, fruit and cheese intake, FFQ1 was > 20% higher than FFQ2. For most foods a moderate correlation (0.5–0.7) was obtained between FFQ1 and FFQ2. For cheese, sugared drinks and fruit juice intakes correlations were even > 0.7. For median differences between the 3d EDR and the FFQ, six food groups (potatoes & grains; vegetables Fruit; cheese; meat, game, poultry and fish; and sugared drinks) gave a difference > 20%. The largest corrected correlations (>0.6) were found for the intake of potatoes and grains, fruit, milk products, cheese, sugared drinks, and fruit juice, while the lowest correlations (<0.4) for bread and meat products. The proportion of subjects classified within one quartile (in the same/adjacent category) by FFQ and EDR ranged from 67% (for meat products) to 88% (for fruit juice). Extreme misclassification into the opposite quartiles was for all food groups < 10%. The results indicate that our newly developed FFQ gives reproducible estimates of food group intake. Overall, moderate levels of relative validity were observed for estimates of food group intake.

What do babies eat? Evaluation of a food frequency questionnaire to assess the diets of infants aged 12 months

OBJECTIVE

To evaluate the relative validity of an FFQ for assessing nutrient intakes in 12-month-old infants.

DESIGN AND SETTING

The FFQ was developed to assess the diets of infants born to women in the Southampton Women's Survey (SWS), a population-based survey of young women and their offspring. The energy and nutrient intakes obtained from an interviewer-administered FFQ were compared with those obtained from 4 d weighed diaries (WD).

SUBJECTS AND METHODS

A sub-sample of fifty infants (aged 1 year) from the SWS had their diets assessed by both methods. The FFQ recorded the frequencies and amounts of foods and drinks consumed by the infants over the previous 28 d; milk consumption was recorded separately. The WD recorded the weights of all foods and drinks consumed by the infants on 4 d following the FFQ completion.

RESULTS

The Spearman rank correlation coefficients for intakes of energy, macronutrients and eighteen micronutrients, determined by the two methods, ranged from r = 0.25 to 0.66. Bland-Altman statistics showed that mean differences between methods were in the range +5% to +60% except for vitamin D (+106%). Differences in micronutrient intake were partly explained by changes in patterns of milk consumption between the two assessments.

CONCLUSION

Although there were differences in absolute energy and nutrient intakes between methods, there was reasonable agreement in the ranking of intakes. The FFQ is a useful tool for assessing energy and nutrient intakes of healthy infants aged around 12 months.

Overestimation of infant and toddler energy intake by 24-h recall compared with weighed food records

BACKGROUND

Twenty-four-hour dietary recalls have been used in large surveys of infant and toddler energy intake, but the accuracy of the method for young children is not well documented.

OBJECTIVE

We aimed to determine the accuracy of infant and toddler energy intakes by a single, telephone-administered, multiple-pass 24-h recall as compared with 3-d weighed food records.

DESIGN

A within-subjects design was used in which a 24-h recall and 3-d weighed food records were completed within 2 wk by 157 mothers (56 non-Hispanic white, 51 non-Hispanic black, and 50 Hispanic) of 7-11-mo-old infants or 12-24-mo-old toddlers. Child and caregiver anthropometrics, child eating patterns, and caregiver demographics and social desirability were evaluated as correlates of reporting bias.

RESULTS

Intakes based on 3-d weighed food records were within 5% of estimated energy requirements. Compared with the 3-d weighed food records, the 24-h recall overestimated energy intake by 13% among infants (740 +/- 154 and 833 +/- 255 kcal, respectively) and by 29% among toddlers (885 +/- 197 and 1140 +/- 299 kcal, respectively). Eating patterns (ie, frequency and location) did not differ appreciably between methods. Macronutrient and micronutrient intakes were higher by 24-h recall than by 3-d weighed food record. Dairy and grains contributed the most energy to the diet and accounted for 74% and 54% of the overestimation seen in infants and toddlers, respectively. Greater overestimation was associated with a greater number of food items reported by the caregiver and lower child weight-for-length z scores.

CONCLUSIONS

The use of a single, telephone-administered, multiple-pass 24-h recall may significantly overestimate infant or toddler energy and nutrient intakes because of portion size estimation errors.

What do babies eat? Evaluation of a food frequency questionnaire to assess the diets of infants aged 6 months

OBJECTIVE

To evaluate the relative validity of a food frequency questionnaire (FFQ) for assessing nutrient intakes in 6-month-old infants.

DESIGN AND SETTING

The FFQ was developed to assess the diets of infants born to women in the Southampton Women's Survey (SWS), a population-based survey of young women and their offspring. The energy and nutrient intakes obtained from an interviewer-administered FFQ were compared with those obtained from a 4-day weighed diary.

SUBJECTS AND METHODS

A sub-sample of 50 infants aged 6 months from the SWS had their diets assessed by both methods. The FFQ recorded the frequencies and amounts of milks, baby foods, regular foods and drinks consumed by the infants over the previous seven days. The diaries recorded the weights of all foods and drinks consumed by the infants on four separate days within 15 days following FFQ completion.

RESULTS

Spearman rank correlation coefficients for intakes of energy, macronutrients and 18 micronutrients, determined by the two methods, ranged from r = 0.39 to 0.86; adjustment for energy intake tended to increase the correlation coefficients, range r(a) = 0.55 to 0.89. Bland-Altman statistics showed that mean differences between methods were in the range of -12.5% to +12.5% except for vitamin B12 (-18.9%).

CONCLUSION

Although there were differences in absolute energy and nutrient intakes between methods, Spearman rank correlation coefficients indicated reasonable agreement in the ranking of intakes. The interviewer-administered FFQ is a useful tool for assessing energy and nutrient intakes of healthy infants aged about 6 months.

Validity and reproducibility of a semi-quantitative food-frequency questionnaire for estimating calcium intake in Belgian preschool children

Relative validity and reproducibility of a semi-quantitative food-frequency questionnaire (FFQ) for measuring preschool children's usual Ca intake were assessed using parents or guardians as a proxy. Estimated diet records (EDR; 3d) were used as the reference method and reproducibility was measured by repeated FFQ administrations 5 weeks apart. From 2095 preschool children (2·5–6·5 years) randomly selected in Flanders (Flemish region of Belgium), 1052 returned a FFQ and EDR. Stringent exclusion procedures reduced the sample for validity analyses to 509 children. From a separate sample of 244 preschool children, 124 returned two FFQ, of whom sixty were included in the reproducibility analysis. Mean Ca intakes were 838 (sd 305) and 777 (sd 296) mg/d for EDR and FFQ respectively, indicating a mean difference of 60·9 (sd 294·4) mg/d (p<0·001). Pearson's correlation was 0·52. Cross-classification analysis of the FFQ and EDR classified 83%of the subjects in the same or adjacent category and 2·4% in extreme quartiles. Actual values for surrogate FFQ quartiles showed a progressive increase in Ca intake (p<0·001). The FFQ correctly identified 77% of the children consuming less Ca than the age-specific RDA (800mg/d). Correlation between repeated administrations was 0·79. No significant difference between mean Ca intakes was established by two administrations (23·8 (sd 161·2) mg/d). Cross-classification of repeated administrations classified 93·4% of the subjects in the same or adjacent category and no subjects in extreme categories. This FFQ tended to underestimate preschool children's Ca intake when administered by a proxy. However, it demonstrated good repeatability and fairly good ability to classify subjects into extremes of Ca intake.

2H2O turnover method as a means to detect bias in estimations of intake of nonbreast milk liquids in breast-fed infants

OBJECTIVE

Firstly, to compare food, and macronutrient intake as obtained from a single 24-h recall and a frequency questionnaire (FQ) covering a 14-day period in breast-fed infants aged 4 months of age. Secondly, nonbreast milk water intake (NB-WI, ml/day) was used as an estimation of energy and macronutrient intake, and NB-WI as calculated from FQ (NB-WIFQ) was compared with NB-WI as measured using the dose-to-the-mother 2H2O turnover method (NB-WIDO) covering the same 14-day period.

DESIGN

Cross-sectional.

SETTING

Community-based study in urban Pelotas, Southern Brazil.

SUBJECTS

In all, 67 breast-fed infants aged 4 months of age recruited at birth.

MAIN OUTCOME MEASURES

(1) Bias in estimations of food and macronutrient intake of the 24-h recall relative to FQ; (2) Bias in NB-WIFQ relative to NB-WIDO.

RESULTS

In infants with an energy intakeFQ from complementary foods above the 50th percentile (1.03 kcal/day), estimations of water, tea, juice, and milk intake were not different between 24-h recall and FQ (n=34). Nor were estimations of energy and macronutrient intake (protein, fat, and carbohydrates) different between the two methods, and bias was nonsignificant. NB-WIDO was divided into quintiles and compared with NB-WI(FQ). The first two quintiles included negative values for NB-WIDO as a result of random errors of the 2H2O turnover method. Subsequently, bias of NB-WIFQ relative to NB-WIDO was positive in the 1st (P=0.001) and 2nd quintile (P=0.638), respectively. Bias was negative for the three highest quintiles, and within this group, underestimation by FQ was significant for the 3rd and 4th quintile (-57.4%, P=0.019; -43.7%, P=0.019).

CONCLUSIONS

Firstly, at the age of 4 months FQ covering a 14-day period provides similar results on food and macronutrient intake as compared to a single 24-h recall for estimations of complementary liquid foods. Secondly, NB-WIFQ appeared to be a good proxy for macronutrient and energy intake in breast-fed infants receiving other liquids. In infants with NB-WIDO>0, the method provides a useful tool for the detection of bias from FQ, and results indicate an underestimation from FQ relative to the 2H2O turnover method. This exercise could be applied wherever the 2H2O turnover method is used in combination with conventional food consumption techniques for measuring intake of nonbreast milk liquids of breast-fed infants in whom solid foods have not yet been introduced. It would help interpreting estimations of macronutrient intake, and could be relevant to studies of dietary intake of infants and its relationship with growth and health.

Number of days needed to assess energy and nutrient intake in infants and young children between 6 months and 2 years of age

OBJECTIVE

To estimate the minimum number of days of recorded dietary intake needed to place infants and young children into thirds of a population distribution with an acceptable degree of accuracy.

DESIGN

Dietary intake data collected from 5-day weighed food records for 72 infants and young children up to 2 y of age, collected during a cross-sectional study, were analysed to estimate the number of recording days necessary to assess intake of energy and 10 nutrients.

SETTING

Community study among healthy infants and children.

SUBJECTS

Parents attended recruitment sessions in local community areas. In total, 72 subjects were entered into the study and all completed the 5-day dietary assessment period.

INTERVENTIONS

A 5-day weighed record of children's dietary intake was made by the parents or regular carer.

RESULTS

Mean within subject standard deviations were smaller than mean between subject standard deviations with respect to energy (778 vs 824 kJ/day), macronutrient subclasses: protein (8 vs 9.4 g/day); fat (9 vs 10 g/day); and carbohydrate (26 vs 29 g/day) and for specific micronutrients: calcium (163 vs 236 mg/day); phosphorus (143 vs 270 mg/day); magnesium (25 vs 43 mg/day); iron (2 vs 3 mg/day); zinc (1 vs 1.3 mg/day); ascorbic acid (27 vs 64 mg/day) and retinol equivalents (281 vs 424 microg/day). Estimated number of days of food records necessary to assess intake of energy, protein, fat and carbohydrate with acceptable degree of accuracy were 5,4,4 and 3, respectively. For all the micronutrients included in this analysis 2 days of recording were necessary.

CONCLUSION

Compared with adults and older children, fewer days are needed to classify this age group into thirds of the distribution with an acceptable degree of accuracy according to intake of energy and specific nutrients.

SPONSORSHIP

The data collection phase of this study was supported by a grant from the Procter and Gamble Company, Cincinnati, OH, USA.

Validity of the assessment of dietary intake: problems of misreporting

PURPOSE OF REVIEW

This is a review of recent studies on the analysis of misreporting of food intake and on the consequences of misreporting for the interpretation of dietary surveys. Bias in the assessment of dietary intake was analysed from studies comparing reported intake with doubly labelled water assessed energy expenditure.

RECENT FINDINGS

There is not yet a method for the accurate determination of dietary intake. Physical and psychological characteristics of study participants play an important role in the observed reporting bias. The degree of misreporting might increase with repeated dietary assessment in the same subjects, confounding the results of intervention studies.

SUMMARY

Campaigns aimed at changing food intake might not be as successful as concluded from the results of national food consumption measurements. Subjects might be reporting according to expected instead of real intake. In a clinical setting, the increased awareness of the nursing staff has been observed to result in overreporting of intake.