Measuring Dietary Quality Among Toddlers in the Feeding Infants and Toddlers Study, 2016, Using the New Healthy Eating Index-Toddlers-2020.

BACKGROUND: Child diet can influence risk for obesity and other related noncommunicable diseases. Few studies have used the Healthy Eating Index (HEI)-Toddlers-2020 to assess diet quality among toddlers (children aged 12 to 23.9 months). OBJECTIVE: The aim of this study was to examine diet quality among toddlers participating in the Feeding Infants and Toddlers Study, 2016, and determine differences by sociodemographic characteristics. Caregiver perception of how their toddler's diet aligns with HEI-Toddlers-2020 diet quality scores was also assessed. DESIGN: This cross-sectional study used 24-hour dietary records collected in 2016. PARTICIPANTS AND SETTING: Data were collected on toddlers ages 12 to 23.9 months (N = 1133) participating in the Feeding Infants and Toddlers Study, 2016. MAIN OUTCOME MEASURES: Diet quality was assessed using the HEI-Toddlers-2020. STATISTICAL ANALYSES PERFORMED: The population ratio method was used for all analyses using weighted data to estimate HEI-Toddlers-2020 scores overall and within subgroups. To determine significant differences of the HEI-Toddlers-2020 score between subgroups, pairwise t tests were used. Statistical significance at P < .05 was used as a cutoff for all 2-sided P values. RESULTS: Average HEI-Toddlers-2020 score among toddlers ages 12 to 23.9 months participating in the Feeding Infants and Toddlers Study, 2016, was 71.2 out of a possible 100. Total scores (mean, standard error) varied by race and ethnicity with Hispanic toddlers having higher scores compared with non-Hispanic White toddlers (76.4 ± 2.5 vs 69.0 ± 1.2; P = .03) and by federal poverty level with those >200% of the poverty level having higher scores compared with those <100% of the poverty level (74.7 ± 1.5 vs 67.0 ± 2.6; P = .01). CONCLUSIONS: Opportunities for improvement in dietary intake were identified using the new HEI-Toddlers-2020 to assess diet quality among children ages 12 to 23.9 months. Scores were indicative of toddlers consuming excess added sugars and lower-than-recommended amounts of seafood and plant proteins, greens and beans, whole grains, and vegetables. Interventions to improve diet quality in toddlers may benefit from focusing on foods children should eat more of along with foods to consume in moderation.

Breastfed and mixed fed infants who do not consume infant cereal are at risk for inadequate iron intake:data from the feeding infants and toddlers study 2016, a cross-sectional survey.

BACKGROUND: According to the Feeding Infants and Toddlers Study (FITS), the percentage of older infants consuming infant cereal has declined from 72% of 6-11.9 month old infants in 2002 to 52% in 2016. This is especially concerning for breastfed and mixed fed infants because of their increased need for dietary sources of iron. This study explored the association between infant cereal consumption and nutrient intakes among breastfed and mixed fed infants. METHODS: FITS 2016 is the largest cross-sectional survey of food and nutrient intakes among caregivers of children less than 4 years old in the United States. For this analysis, we evaluated 24 h dietary recalls for infants 6-11.9 months who were either breastfed (no infant formula provided, n = 296) or mixed fed (breastmilk and infant formula provided, n = 102). Infants were further categorized as infant cereal consumers or non-consumers. Nutrient intakes were compared with Adequate Intakes or Estimated Average Requirements when available. Differences between cereal consumers and non-consumers were calculated using unpaired T-tests. RESULTS: Significantly fewer breastfed cereal consumers had intakes below the Estimated Average Requirement for iron (19% vs. 96%) and zinc (61% vs. 16%, p < 0.0001). Additionally, significantly more breastfed cereal consumers had intakes above the Adequate Intake level for 12 other nutrients compared to non-consumers. Among mixed fed infants, significantly fewer cereal consumers had intakes below the Estimated Average Requirement for iron compared to non-consumers (5% vs. 70%), but differences in other nutrients were not observed. CONCLUSIONS: Almost all (96%) of the breastfed infants who did not consume infant cereal had inadequate iron intakes. Even among mixed fed infants, significantly fewer infant cereal consumers had inadequate iron intakes compared to non-cereal consumers. Infant cereal is an important source of iron and other key nutrients, especially for infants receiving breastmilk.

Nutrient Intakes among Brazilian Children Need Improvement and Show Differences by Region and Socioeconomic Level.

Brazil is the most populous country in South America. Using 24 h dietary data, we compared the nutrient intakes of 4-13-year-olds to reference values and tested for regional and socioeconomic (SES) differences. A considerable proportion reported intakes below the Estimated Average Requirements (EAR) for vitamins E (78.1%, 96.5%), D (100% for both), and calcium (80.5%, 97.7%) for 4-8 and 9-13-year-olds, respectively. Few exceeded Adequate Intakes (AI) for potassium or fiber. Older children reported greater inadequacies and, while there was regional variability, patterns of inadequacy and excess tended to be similar. For vitamin C, the percent of children below EAR in the Northeast and Southeast was lower than in the South. Most children, regardless of SES, had energy intakes within the Acceptable Macronutrient Distribution Ranges (AMDRs) for carbohydrates and protein. Over a quarter reported total energy from fat less than the AMDR, and inversely associated with SES (low 50.9%, moderate 26.0%, and high 15.0%), but also exceeding the percentage of energy recommendation for saturated fat, increasing with SES (low 18.1%, moderate 38.9%, and high 48.8%). The contrast observed between the diets of young Brazilians and recommendations underscores the need for individual and regional environmental interventions to promote healthier dietary patterns.

Development and Application of a Total Diet Quality Index for Toddlers.

For the first time, the 2020-2025 Dietary Guidelines for Americans include recommendations for infants and toddlers under 2 years old. We aimed to create a diet quality index based on a scoring system for ages 12 to 23.9 months, the Toddler Diet Quality Index (DQI), and evaluate its construct validity using 24 h dietary recall data collected from a national sample of children from the Feeding Infants and Toddlers Study (FITS) 2016. The mean (standard error) Toddler DQI was 49 (0.6) out of 100 possible points, indicating room for improvement. Toddlers under-consumed seafood, greens and beans, and plant proteins and over-consumed refined grains and added sugars. Toddler DQI scores were higher among children who were ever breastfed, lived in households with higher incomes, and who were Hispanic. The Toddler DQI performed as expected and offers a measurement tool to assess the dietary quality of young children in accordance with federal nutrition guidelines. This is important for providing guidance that can be used to inform public health nutrition policies, programs, and practices to improve diets of young children.

Evaluation of the introduction of allergen-containing foods: Feeding Infants and Toddlers Study 2016.

BACKGROUND: Guidelines on the early introduction of allergen-containing foods are evolving; however, little national data exist defining current allergen-feeding practices. OBJECTIVE: To investigate the consumption rates of foods containing egg and peanut among infants and toddlers before the guideline changes in 2017. METHODS: The Feeding Infants and Toddlers Study 2016 was conducted nationally among 3235 caregivers with a child under 4 years of age. The 24-hour dietary recalls were reviewed for peanut or egg ingredients. Participants were categorized as "consuming peanut or egg-containing foods" or "not consuming peanut or egg-containing foods." Data on physician-diagnosed food allergies and avoidance were collected. RESULTS: The consumption rates of peanut- and egg-containing foods were low. For the age group of 4 to 5.9 months, 0.3% reported peanut consumption and 2.4% reported egg consumption. For the age group of 6 to 8.9 months, 0.9% reported eating peanut-containing foods and 13.0% egg, and for the age group of 9 to 11.9 months, 5.5% were consuming peanut-containing foods and 33.2% egg-containing foods. Peanut or egg ingredients were identified in the diet of children whose caregivers reported avoidance. CONCLUSION: Before the publication of the 2017 Addendum Guidelines for the Prevention of Peanut Allergy, there were low rates of reported peanut consumption across the study population with less than 1% of any age group before 9 months of age and less than 6% in any age group before 12 months of age consuming peanut on the 24-hour recall day. In addition, reported egg consumption was low and increased with age. These results serve as an important baseline comparison for future studies evaluating the implementation and impact of early peanut and egg introduction.

A Substantial Proportion of 6- to 12-Month-Old Infants Have Calculated Daily Absorbed Iron below Recommendations, Especially Those Who Are Breastfed.

OBJECTIVE: To calculate the amount of bioavailable iron consumed among 6- to 12- month-old infants considering differences in iron bioavailability among dietary iron sources and to compare this with current recommended intakes. STUDY DESIGN: We used the Feeding Infants and Toddlers Study database of dietary intakes from 2016 and the estimated bioavailability of dietary iron sources to evaluate the proportion of infants whose calculated total daily absorbed iron fell below physiologic requirements, that is, the recommended amount needed to fully support growth and erythropoiesis. RESULTS: The calculated daily iron absorption was below the recommended amount in 54.3% of infants evaluated ranging from 19.5% of 448 exclusively formula-fed infants, to 95.8% of 296 exclusively breastfed infants and 72.2% of 102 mixed fed infants. The calculated mean iron absorption of 6- to 9- month-old breastfed infants was 0.27 mg/day, far less than the estimated physiologic requirement of 0.69 mg/day. The most highly bioavailable iron, heme iron, was <12% of the contributor to total iron absorbed in breastfed infants. CONCLUSIONS: These data indicate a need for further education and public health policies to support increased iron intake in 6- to 12- month-old infants, emphasizing those receiving any breast milk. Exclusively formula-fed infants are at lower risk, but rates of low absorbed iron indicate that all infants may need monitoring for clinical evidence of low iron status. Consideration should be given to increasing the proportion of heme iron obtained from animal products in the diet where feasible.

The Special Supplemental Nutrition Program for Women, Infants, and Children is Associated with Several Changes in Nutrient Intakes and Food Consumption Patterns of Participating Infants and Young Children, 2008 Compared with 2016.

BACKGROUND: In 2009 the USDA's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) updated the food packages provided to participants. OBJECTIVES: This study investigates associations between WIC participation and nutrients and food groups consumed using data from the Feeding Infants and Toddlers Study's 2008 and 2016 nationwide, cross-sectional surveys of children <4 y, weighted to be representative of the US population. METHODS: The study data included 2892 children aged 6-47.9 mo in 2008 and 2635 in 2016. Differences were analyzed by WIC participation, survey year, and child age (infants 6-11.9 mo old, toddlers 12-23.9 mo old, preschoolers 24-47.9 mo old). Usual nutrient intake distributions were estimated using National Cancer Institute methodology. Daily food group consumption differences were tested via multivariate regression. All analyses controlled for income. RESULTS: In 2016 18.6% of infants had iron intakes below the estimated average requirement (EAR), compared to 7.6% in 2008; 87% of WIC infants met the EAR, compared with 69% of non-WIC infants. In 2016 37% of WIC preschoolers met saturated fat guidelines, compared with 25% in 2008; in both years, fewer than one-third of non-WIC preschoolers met the guidelines. More WIC infants than non-WIC infants consumed infant cereals in 2016 (58% compared with 45%, respectively). More WIC infants ate vegetables daily in 2016 than in 2008 (74% compared with 59%, respectively).  In 2016, as compared with 2008, more WIC infants consumed baby-food vegetables (55% compared with 29%, respectively) and fruits (56% compared with 41%, respectively). In 2016 47% of WIC preschoolers drank low-fat milk, compared with 19% of non-WIC preschoolers. CONCLUSIONS: Infant iron intakes are concerning, although more WIC infants meet the EAR. WIC infants' vegetable intakes have improved; baby-food vegetables have become important contributors to their intakes. In 2016 WIC children were more likely than non-WIC children to shift to lower-fat milks at 2 y of age, likely contributing to lower saturated fat intakes.

Rams Have Heart, a Mobile App Tracking Activity and Fruit and Vegetable Consumption to Support the Cardiovascular Health of College Students: Development and Usability Study.

BACKGROUND: With the increasing use of mobile devices to access the internet and as the main computing system of apps, there is a growing market for mobile health apps to provide self-care advice. Their effectiveness with regard to diet and fitness tracking, for example, needs to be examined. The majority of American adults fail to meet daily recommendations for healthy behavior. Testing user engagement with an app in a controlled environment can provide insight into what is effective and not effective in an app focused on improving diet and exercise. OBJECTIVE: We developed Rams Have Heart, a mobile app, to support a cardiovascular disease (CVD) intervention course. The app tracks healthy behaviors, including fruit and vegetable consumption and physical activity, throughout the day. This paper aimed to present its functionality and evaluated adherence among the African American college student population. METHODS: We developed the app using the Personal Health Informatics and Intervention Toolkit, a software framework. Rams Have Heart integrates self-reported health screening with health education, diary tracking, and user feedback modules to acquire data and assess progress. The parent study, conducted at a historically black college and university-designated institution in southeastern United States, consisted of a semester-long intervention administered as an academic course in the fall, for 3 consecutive years. Changes were made after the cohort 1 pilot study, so results only include cohorts 2 and 3, comprising a total of 115 students (n=55 intervention participants and n=54 control participants) aged from 17 to 24 years. Data collected over the study period were transferred using the secure Hypertext Transfer Protocol Secure protocol and stored in a secure Structured Query Language server database accessible only to authorized persons. SAS software was used to analyze the overall app usage and the specific results collected. RESULTS: Of the 55 students in the intervention group, 27 (49%) students in cohort 2 and 25 (45%) in cohort 3 used the Rams Have Heart app at least once. Over the course of the fall semester, app participation dropped off gradually until exam week when most students no longer participated. The average fruit and vegetable intake increased slightly, and activity levels decreased over the study period. CONCLUSIONS: Rams Have Heart was developed to allow daily tracking of fruit and vegetable intake and physical activity to support a CVD risk intervention for a student demographic susceptible to obesity, heart disease, and type 2 diabetes. We conducted an analysis of app usage, function, and user results. Although a mobile app provides privacy and flexibility for user participation in a research study, Rams Have Heart did not improve compliance or user outcomes. Health-oriented research studies relying on apps in support of user goals need further evaluation.

Trends in Food Consumption Patterns of US Infants and Toddlers from Feeding Infants and Toddlers Studies (FITS) in 2002, 2008, 2016.

The Feeding Infants and Toddlers Study (FITS) is the largest survey of dietary intake among infants and young children in the United States. Dietary patterns in early childhood are a key component of prevention of diet-related chronic diseases, yet little is known about how food consumption patterns of infants and young children have changed over time. The objective of this study is to examine trends in food and beverage consumption among children ages 6-23.9 months using data from the FITS conducted in 2002, 2008, and 2016. A total of 5963 infants and young children ages 6-23.9 months were included in these analyses. Food consumption data were collected using a multiple-pass 24-h recall by telephone using the Nutrition Data System for Research. Linear trends were assessed using the Wald's test in a multivariable linear regression model. Positive significant findings include increases in breast milk consumption and decreases in the consumption of sweets, sugar-sweetened beverages, and 100% fruit juice. More troubling findings include decreasing infant cereal consumption, stagnant or decreasing whole grain consumption, and stagnant consumption of vegetables. Our findings suggest some promising improvements in dietary intake among infants and toddlers in the United States over the past 15 years, but further policy, programmatic, and industry efforts are still needed.

Trends in Mean Nutrient Intakes of US Infants, Toddlers, and Young Children from 3 Feeding Infants and Toddlers Studies (FITS).

BACKGROUND: Many updates to young child feeding recommendations have been published over the past decade, but concurrent intake trends have not been assessed. OBJECTIVE: The aim of this study was to evaluate adequacy and trends in energy and nutrient intakes of US infants and children aged 0-47.9 mo through use of Feeding Infants and Toddlers Study (FITS) data from 2002, 2008, and 2016. METHODS: FITS are cross-sectional surveys of parents/caregivers of infants and young children (FITS 2002, n = 2962; FITS 2008, n = 3276; FITS 2016, n = 3235). Dietary intakes were assessed by telephone with trained interviewers using the Nutrition Data System for Research. Mean ± SE nutrient intakes were calculated. Diet adequacy was assessed with the nutrient adequacy ratio (NAR) for 17 nutrients and the corresponding mean adequacy ratio. RESULTS: Energy and macronutrient intakes were generally stable across surveys, but significant decreases for saturated fat and total sugars and an increase in fiber were observed among 6-11.9-mo-olds and 12-23.9-mo-olds (P-trend < 0.0001). Mean sodium intakes exceeded Adequate Intakes (AI) for all ages, whereas fiber intakes were universally below the AI. Nutrients with the lowest NAR values were vitamin D (range 0.41-0.67/1.00) and vitamin E (range 0.60-0.79/1.00 for 2008 and 2016). For iron, infants aged 6-11.9 mo had the lowest NAR values at 0.77-0.88/1.00, compared to 0.85-0.89/1.00 for 12-47.9-mo-olds. Potassium was low from 12 to 47.9 mo (NAR range 0.55-0.63/1.00 across survey years). The nutrients with the greatest decline in mean intakes were iron and vitamins D and E among 6-11.9-mo-olds, and vitamin D and potassium among 12-23.9-mo-olds in 2016 compared to 2002. CONCLUSIONS: The diets of US infants and young children were generally adequate for most micronutrients and stable over time, but sodium intakes were too high, and nutrient gaps still existed, especially for vitamins D, E, and fiber across ages and for iron among infants.

The Centers for Disease Control and Prevention: Findings From The National Healthy Worksite Program.

OBJECTIVE: To evaluate employers' implementation of evidence-based interventions, and changes in employees' behaviors associated with participating in the national healthy worksite program (NHWP). METHODS: NHWP recruited 100 small and mid-sized employers and provided training and support for 18 months. Outcome measures were collected with an employer questionnaire, an employee survey, and biometric data at baseline and 18 months later. RESULTS: The 41 employers who completed the NHWP implemented significantly more evidence-based interventions and had more comprehensive worksite health promotion programs after participating. Employees made significant improvements in physical activity and nutritional behaviors, but did not significantly improve employee weight. CONCLUSIONS: Training and technical support can help small and mid-sized employers implement evidence-based health interventions to promote positive employee behavior changes. A longer follow up period may be needed to assess whether NHWP led to improvements in clinical outcomes.

Adolescents' Assessments of the Helpfulness of Treatment for Major Depression: Results From a National Survey.

OBJECTIVE: The study investigated perceived helpfulness of counseling or medication in a national sample of adolescents with a major depressive episode. METHODS: Secondary data analysis of the National Survey on Drug Use and Health was conducted. The sample comprised adolescents (ages 12-17) with a past-year major depressive episode who reported receiving either counseling and no medication (N=2,000) or medication and counseling (N=1,300) for depression in the past year. Adolescents who received counseling only evaluated the helpfulness of counseling, and adolescents who received medication and counseling evaluated the helpfulness of medication. Responses were analyzed by using descriptive statistics and ordered logistic regression models. RESULTS: Among adolescents who received counseling only, 10% reported that counseling was extremely helpful, 22% that it helped a lot, 25% that it helped some, 24% that it helped a little, and 20% that it was not at all helpful. Among adolescents who received medication and counseling, 17% reported that medication was extremely helpful, 30% that it helped a lot, 22% that it helped somewhat, 16% that it helped a little, and 15% that it was not at all helpful. In adjusted models, adolescents with greater parental support and fewer than two delinquent behaviors in the past year were more likely to endorse treatment as helpful. CONCLUSIONS: About 32% to 47% of adolescents in the general population reported that depression treatment was extremely helpful or helped a lot. This is substantially lower than response rates in clinical trials. The reasons for these divergent findings merit further investigation.

Individual patterns of alcohol use.

AIMS: We present methodology to identify statistically distinct patterns of daily alcohol use and classify them into categories that could be further used in monitoring of transitions between patterns such as transitions from regular to problem use. DATA: The study analyzed individual patterns of adult alcohol consumption from two datasets containing short (<6 month) and long (up to 2years) daily records of drinking. These data were collected over the period between 1999 and 2003. RESULTS: By using a non-parametric (Kolmogorov-Smirnov) test we have identified distinct drinking patterns and classified them into 8 types according to their means, percentages of non-drinking days and variances of consumed amount during drinking days. For each studied individual we calculated a transition chart that characterizes transitions between the types. CONCLUSIONS: Individual daily consumption patterns can be identified, and classified into distinct patterns. Changes between the patterns could be related to life events or environmental trends, and thus provide insights into pathways towards either heavier use or recovery.

The adolescent family life program: a multisite evaluation of federally funded projects serving pregnant and parenting adolescents.

OBJECTIVES: We evaluated the effectiveness of care demonstration projects supported by the Title XX Adolescent Family Life (AFL) program, which serves pregnant and parenting adolescents in an effort to mitigate the risks associated with adolescent childbearing. METHODS: This cross-site evaluation involved 12 projects and 1038 adolescents who received either enhanced services funded by the AFL program or usual care. We examined the effects of enhanced services on health, educational, and child care outcomes approximately 6 months to 2 years after intake and explored moderation of program effects by time since intake and project characteristics associated with outcomes. RESULTS: The odds of using long-acting reversible contraception (odds ratio [OR] = 1.58) and receiving regular child care (OR = 1.50) in the past month were higher in the intervention group than in the comparison group. Odds of a repeat pregnancy were lower (OR = 0.39) among intervention group adolescents than among comparison group adolescents within 12 months of intake. Several project characteristics were associated with adolescent health outcomes. CONCLUSIONS: These projects show promise in improving effective contraceptive use, increasing routine child care, and yielding short-term decreases in repeat pregnancy.