Ultraprocessed Food Consumption and Cardiometabolic Risk Factors in Children

Importance

High intake of ultraprocessed foods (UPFs) has been associated with higher cardiometabolic risk in adults; however, the evidence in children is limited.

Objective

To investigate the association between UPF consumption and cardiometabolic risk factors in the Childhood Obesity Risk Assessment Longitudinal Study (CORALS).

Design, Setting, and Participants

This baseline cross-sectional analysis was conducted using the data of CORALS participants recruited between March 22, 2019, and June 30, 2022. Preschool children (aged 3-6 years) were recruited from schools and centers in 7 cities in Spain. Inclusion criteria included informed consent signed by parents or caregivers and having a completed a set of questionnaires about the child's prenatal history at home. Exclusion criteria included low command of Spanish or unstable residence.

Exposure

Energy-adjusted UPF consumption (in grams per day) from food frequency questionnaires and based on the NOVA food classification system.

Main Outcomes and Measures

Age- and sex-specific z scores of adiposity parameters (body mass index [BMI], fat mass index, waist-to-height ratio, and waist circumference) and cardiometabolic parameters (diastolic and systolic blood pressure, fasting plasma glucose, homeostasis model assessment for insulin resistance, high-density and low-density lipoprotein cholesterol, and triglycerides) were estimated using linear regression models.

Results

Of 1509 enrolled CORALS participants, 1426 (mean [SD] age, 5.8 [1.1] years; 698 boys [49.0%]) were included in this study. Mothers of children with high UPF consumption were younger, had a higher BMI, were more likely to have overweight or obesity, and had lower education levels and employment rates. Compared with participants in the lowest tertile of energy-adjusted UPF consumption, those in the highest tertile showed higher z scores of BMI (β coefficient, 0.20; 95% CI, 0.05-0.35), waist circumference (β coefficient, 0.20; 95% CI, 0.05-0.35), fat mass index (β coefficient, 0.17; 95% CI, 0.00-0.32), and fasting plasma glucose (β coefficient, 0.22; 95% CI, 0.06-0.37) and lower z scores for HDL cholesterol (β coefficient, -0.19; 95% CI, -0.36 to -0.02). One-SD increments in energy-adjusted UPF consumption were associated with higher z scores for BMI (β coefficient, 0.11; 95% CI, 0.05-0.17), waist circumference (β coefficient, 0.09; 95% CI, 0.02-0.15), fat mass index (β coefficient, 0.11; 95% CI, 0.04-1.18), and fasting plasma glucose (β coefficient, 0.10; 95% CI, 0.03-0.17) and lower HDL cholesterol (β coefficient, -0.07; 95% CI, -0.15 to -0.00). Substituting 100 g of UPFs with 100 g of unprocessed or minimally processed foods was associated with lower z scores of BMI (β coefficient, -0.03; 95% CI, -0.06 to -0.01), fat mass index (β coefficient, -0.03; 95% CI, -0.06 to 0.00), and fasting plasma glucose (β coefficient, -0.04; 95% CI, -0.07 to -0.01).

Conclusions and Relevance

These findings suggest that high UPF consumption in young children is associated with adiposity and other cardiometabolic risk factors, highlighting the need for public health initiatives to promote the replacement of UPFs with unprocessed or minimally processed foods.

Associations Between Eating Speed, Diet Quality, Adiposity, and Cardiometabolic Risk Factors

OBJECTIVE

To assess the associations between eating speed, adiposity, cardiometabolic risk factors, and diet quality in a cohort of Spanish preschool-children.

STUDY DESIGN

A cross-sectional study in 1371 preschool age children (49% girls; mean age, 4.8 ± 1.0 years) from the Childhood Obesity Risk Assessment Longitudinal Study (CORALS) cohort was conducted. After exclusions, 956 participants were included in the analyses. The eating speed was estimated by summing the total minutes used in each of the 3 main meals and then categorized into slow, moderate, or fast. Multiple linear and logistic regression models were fitted to assess the β-coefficient, or OR and 95% CI, between eating speed and body mass index, waist circumference, fat mass index (FMI), blood pressure, fasting plasma glucose, and lipid profile.

RESULTS

Compared with participants in the slow-eating category, those in the fast-eating category had a higher prevalence risk of overweight/obesity (OR, 2.9; 95% CI, 1.8-4.4; P < .01); larger waist circumference (β, 2.6 cm; 95% CI, 1.5-3.8 cm); and greater FMI (β, 0.3 kg/m²; 95% CI, 0.1-0.5 kg/m²), systolic blood pressure (β, 2.8 mmHg; 95% CI, 0.6-4.9 mmHg), and fasting plasma glucose levels (β, 2.7 mg/dL, 95% CI, 1.2-4.2 mg/dL) but lower adherence to the Mediterranean diet (β, -0.5 points; 95% CI, -0.9 to -0.1 points).

CONCLUSIONS

Eating fast is associated with higher adiposity, certain cardiometabolic risk factors, and lower adherence to a Mediterranean diet. Further long-term and interventional studies are warranted to confirm these associations.

An ESPGHAN Position Paper on the Use of Low-FODMAP Diet in Pediatric Gastroenterology

Excluding oligo-, di-, monosaccharides and polyols (FODMAPs) from the diet is increasingly being used to treat children with gastrointestinal complaints. The aim of this position paper is to review the available evidence on the safety and efficacy of its use in children and provide expert guidance regarding practical aspects in case its use is considered . Members of the Gastroenterology Committee, the Nutrition Committee and the Allied Health Professionals Committee of the European Society for Pediatric Gastroenterology Hepatology and Nutrition contributed to this position paper. Clinical questions regarding initiation, introduction, duration, weaning, monitoring, professional guidance, safety and risks of the diet are addressed. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. The systematic literature search revealed that the low-FODMAP diet has not been comprehensively studied in children. Indications and contraindications of the use of the diet in different pediatric gastroenterological conditions are discussed and practical recommendations are formulated. There is scarce evidence to support the use of a low-FODMAP diet in children with Irritable Bowel Syndrome and no evidence to recommend its use in other gastrointestinal diseases and complaints in children. Awareness of how and when to use the diet is crucial, as a restrictive diet may impact nutritional adequacy and/or promote distorted eating in vulnerable subjects. The present article provides practical safety tips to be applied when the low-FODMAP diet is considered in children.

Energy and Macronutrient Intakes With Eating Occasions Consumed by European Children From Ages 3 to 8 Years: The EU Childhood Obesity Project Study

Objectives

We characterized the distribution of energy and macronutrient intakes across eating occasions (EO) in a longitudinal study in children from 3 to 8 yrs in 5 European countries.

Methods

In the Childhood Obesity Project Study, 3-day weighed food records were collected at 3, 4, 5, 6 and 8 yrs of age for children from Belgium, Germany, Italy, Poland and Spain. Food intakes were assigned to EO based on country-specific times of the day and EO size. A consistent pattern with 3 meals (breakfast, lunch, supper) and 2 snacks (morning, afternoon) was identified. We analyzed longitudinal changes in diurnal energy and nutrient intake with age and estimated mixed effects models with child-specific intercept and slope for age. Age was analysed as quadratic term.

Results

The analyzed food intakes of 740 children showed the proportion of energy consumed within the day as follows: lunch (30.3%±8.3, M ± SD), supper (25.3%±8.0), breakfast (18.6%±6.6) and snacks (afternoon (16.3%±7.2); morning (10.1%±6.7)). Italian children had the lowest intake during morning (5.4%± 3.8) and the highest proportion of skipping morning snack (49%). The portion of fat and protein (as % total energy intake per EO) was high at lunch (fat 36.3%±9.1; protein 18.1%±5.2) and supper (fat 39.1%±10.9; protein 17.7%±5.6) and for carbohydrates at snacks (61.6%±11.6) and breakfast (53.7%±11.7), respectively. In Spain, fat and protein intakes were above study average at all EO. Energy intakes at snacks varied significantly with age (morning βage = -36.22kcal, βage2 = 3.29kcal; afternoon βage = 28.37 kcal, βage2 = −3.21kcal; P &gt;0.001). There were no diurnal energy and nutrient differences between sexes.

Conclusions

The studied children consumed the major portions of dietary energy, protein and fat at lunch and supper, while most carbohydrates were provided with snacks and breakfast. With increasing age, energy intakes varied with morning and afternoon snacks. Further studies should explore whether diurnal variation of dietary intakes is associated with health outcomes.

Funding Sources

Partial financial support was received from the Commission of the European Community, the EU Seventh Framework Programme, project EarlyNutrition, the EU H2020 project PHC-2014-DynaHealth and the European Research Council Advanced Grant META-GROWTH.

Association of Protein Intake during the Second Year of Life with Weight Gain-Related Outcomes in Childhood: A Systematic Review

There is accumulating evidence that early protein intake is related with weight gain in childhood. However, the evidence is mostly limited to the first year of life, whereas the high-weight-gain-velocity period extends up to about 2 years of age. We aimed to investigate whether protein intake during the second year of life is associated with higher weight gain and obesity risk later in childhood. We conducted a systematic review with searches in both PubMed®/MEDLINE® and the Cochrane Central Register of Controlled Trials. Ten studies that assessed a total of 46,170 children were identified. We found moderate-quality evidence of an association of protein intake during the second year of life with fat mass at 2 years and at 7 years. Effects on other outcomes such as body mass index (BMI), obesity risk, or adiposity rebound onset were inconclusive due to both heterogeneity and low evidence. We conclude that higher protein intakes during the second year of life are likely to increase fatness in childhood, but there is limited evidence regarding the association with other outcomes such as body mass index or change in adiposity rebound onset. Further well-designed and adequately powered clinical trials are needed since this issue has considerable public health relevance.

Protein intakes and their nutritional sources during the first 2 years of life: secondary data evaluation from the European Childhood Obesity Project

BACKGROUND/OBJECTIVES

High protein intake in infancy affects future obesity risk and other health outcomes. We aim to describe total protein intake and its sources in a birth cohort in five European countries over the first 2 years of life.

SUBJECTS/METHODS

A total of 746 formula-fed infants were included. Three-day weighed dietary records at 6, 7, 8, 9, 12, 18 and 24 months of age were used. Kruskal-Wallis, ANOVA and Friedman's tests were used to assess possible differences in nutritional intake among countries and over time.

RESULTS

Dairy products were the main components of the infants' diets. Cow's milk was rarely introduced before 12 months of age, whereas infants' formula was the main contributor of protein intake. Food choices and protein intake differed among countries (P<0.001). Protein intake often exceeded European recommendations from 9 months onwards, partly because of the substitution of dairy protein (mainly infant formula) by meat protein. Two nutritional patterns were identified that were characterised by differences in energy, fat, protein and animal protein intake. Finally, food consumption was not always in line with protein intakes, and thus infants from some countries showed high consumption of specific food groups but relatively low protein intakes.

CONCLUSIONS

During weaning, over-limited substitution of dairy products with other sources (especially meat) resulted in relatively high protein intakes in formula-fed infants. Differences in preferences of specific protein sources from complementary foods existed among European countries. Great opportunities in improving early nutrition were revealed, although cultural and geographical differences should always be considered.

Validation of the Child Feeding Questionnaire in Spanish Parents of Schoolchildren

OBJECTIVE

To test the reliability and factorial validity of the Child Feeding Questionnaire (CFQ) within a Spanish sample.

DESIGN

Cross-sectional study.

SETTING

All schools in a Spanish Mediterranean city of about 100,000 inhabitants.

PARTICIPANTS

From a potential population of 1,623 children (mean age, 8.5 years), 960 parents (459 fathers and 501 mothers) of 515 children participated (32% response).

MAIN OUTCOME MEASURE(S)

The Spanish version of the CFQ was completed by both parents. Body mass index of the children was obtained from measured heights and weights. Parents reported their anthropometric and employment data.

ANALYSIS

Reliability was assessed using Cronbach α. Factorial validity was examined by Procrustes semi-confirmatory factor and confirmatory factor analyses.

RESULTS

Seven major factors with loadings similar to those in the original questionnaire were found: perceived responsibility, perceived parent weight, perceived child weight, concern about child weight (CN), pressure to eat (PE), monitoring, and restriction. Reliability was adequate for each factor and overall CFQ (α = .86). Goodness of fit indexes for confirmatory factor analysis solutions was acceptable. Item loadings ranged from 0.30 to 0.92. The factor of CN was associated with restriction [multivariate coefficient (R(2)) = 0.14; P < .001] and PE (R(2) = 0.36; P< .001). Child's body mass index showed a negative association with PE (R(2) = 0.11; P < .001) and a positive association with CN (R(2) = 0.25; P < .001) and factors related to feeding control (monitoring and restriction, R(2) = 0.04 and R(2) = 0.09, respectively; P < .001).

CONCLUSIONS AND IMPLICATIONS

Results support the reliability and validity of the CFQ for a Spanish population, allowing for comparisons across cultures. The CFQ may be useful to identify parental feeding attitudes that can contribute to preventing risky eating behaviors in their children.

Being overweight or obese is associated with inhibition control in children from six to ten years of age

AIM

This study investigated the relationship between being overweight or obese and executive function in six- to ten-year-olds.

METHODS

The participants were 515 children (250 boys) from schools in Reus, Spain. The initial sample was measured and weighed and assessed with the Children's Color Trail Test. Children classified as overweight, including obese, and their age- and gender-matched controls (n = 221), were assessed in a second phase with the Five Digit Test (FDT) and the Symbol Digit Modalities Test. Logistic regression models were applied to analyse the effect of executive functions on being overweight, including obese.

RESULTS

We found that 28.9% of the children were overweight and 7.2% were obese. The FDT showed that inhibition (odds risk of 1.04, range 1.00-1.08, p = 0.04) and flexibility (odds risk of 1.04, range 1.00-1.07, p = 0.02) were significantly associated with overweight, including obesity, regardless of sociodemographic and psychopathological variables.

CONCLUSION

These results suggest that children who were overweight or obese had a reduced ability to mobilise the cognitive effort required to inhibit involuntary responses and to switch between different mental operations. A developmental trajectory would provide important insights into the relationship between executive functioning pattern and the risk of being overweight or obese.

Nutrition and neurodevelopment in children: focus on NUTRIMENTHE project

There is growing evidence that early nutrition affects later cognitive performance. The idea that the diet of mothers, infants, and children could affect later mental performance has major implications for public health practice and policy development and for our understanding of human biology as well as for food product development, economic progress, and future wealth creation. To date, however, much of the evidence is from animal, retrospective studies and short-term nutritional intervention studies in humans. The positive effect of micronutrients on health, especially of pregnant women eating well to maximise their child's cognitive and behavioural outcomes, is commonly acknowledged. The current evidence of an association between gestational nutrition and brain development in healthy children is more credible for folate, n-3 fatty acids, and iron. Recent findings highlight the fact that single-nutrient supplementation is less adequate than supplementation with more complex formulae. However, the optimal content of micronutrient supplementation and whether there is a long-term impact on child's neurodevelopment needs to be investigated further. Moreover, it is also evident that future studies should take into account genetic heterogeneity when evaluating nutritional effects and also nutritional recommendations. The objective of the present review is to provide a background and update on the current knowledge linking nutrition to cognition and behaviour in children, and to show how the large collaborative European Project NUTRIMENTHE is working towards this aim.

Sex differences in the endocrine system in response to protein intake early in life

BACKGROUND

Nutritional factors during a sensitive period can influence child development in a sex-related manner.

OBJECTIVE

Our aim was to investigate whether sex modulates the responses of relevant biochemical parameters and growth to different protein intakes early in life.

DESIGN

In a randomized controlled trial, formula-fed infants were assigned to receive formula with higher protein (HP) or lower protein (LP) content. The main outcome measures were insulin-like growth factor (IGF)-1 axis parameters, weight, length, BMI, leptin, and C-peptide/creatinine ratio at 6 mo of age. Dietary intake during the first 6 mo of life was also assessed.

RESULTS

The IGF-1 axis response to HP feeding was modulated by sex. Total and free IGF-1 and IGF binding protein 3 concentrations were higher in girls than in boys. Compared with the LP diet, the HP diet was associated with higher IGF-1 and lower IGF binding protein 2 secretion. The response to this HP content formula tended to be stronger in girls than in boys. The HP diet was associated with a higher C-peptide/creatinine ratio. The leptin concentration was higher in girls than in boys and was correlated to the IGF-1 axis parameters. No interaction between sex and nutritional intervention was shown on growth.

CONCLUSIONS

Our findings show that the endocrine response to a high protein diet early in life may be modulated by sex. The IGF-1 axis of female infants shows a stronger response to the nutritional intervention than does that of male infants, but there is no enhanced effect on growth. This trial was registered at clinicaltrials.gov as NCT00338689.

[Food intake, dietary habits and nutritional status of the population of Reus (X): Evolution of the diet and the contribution of macronutrients to energy intake (1983-1999) by age and sex]

BACKGROUND

To study the evolution of the diet and the nutritional intake between 1983 and 1999, by age and sex.

SUBJECTS AND METHODS

We performed a series of analysis of the food intake on a representative sample of the population of Reus (aged 10-69 years). Dietary intake was estimated using the 24-hours recall method. In 1999 the sample size was 839 individuals, 41% of them having taken part in the studies since 1983. Results are shown as mean (standard deviation).

RESULTS

In 1999, the energy intake was 2524 (582) kcal in men aged 35-44 years (n = 57), and 1827 (490) kcal in women (n = 95) (p < 0.001 between sexes). The energy intake decreases with age (significant trend [p < 0.001] between 15-69 years) and it is higher in men than in women in all the age groups studied. When comparing similar age groups, we observe that this energy intake has not changed significantly since 1983. Between 1983 and 1999 the contribution of the macronutrients to the total energy intake has become more similar between ages and sexes. In 1999, in men aged 35-44 years a 15.6% of the energy came from proteins, 42% from fat and 42.5% from carbohydrates; in women of the same age: a 17.3% of the energy came from proteins, 42.4% from fat and 40.3% from carbohydrates). During this period we observed, however, remarkable changes in the diet which imply the increasing participation of the dairy products, vegetables and meat in the energy intake, or the significant decrease of the role of tubers, eggs and visible fat.

CONCLUSIONS

Our population maintains an energy intake without significant changes, and it presents a trend towards a progressive uniformity of the nutritional balance between the different ages and sexes, although there are significant changes in some components of the diet.