The impact of abnormal glucose tolerance and obesity on fetal growth.

OBJECTIVE: Factors linked with insulin resistance were examined for their association with large-for-gestational-age (LGA) infant birth weight and gestational diabetes. STUDY DESIGN: Data came from a longitudinal cohort study of 2,305 subjects without overt diabetes, analyzed using multinomial logistic and linear regression. RESULTS: High maternal BMI (OR = 1.53 (1.11, 2.12)), height (1.98 (1.62, 2.42)), antidepressant use (1.71 (1.20, 2.44)), pregnancy weight-gain exceeding 40 pounds (1.79 (1.25, 2.57)), and high blood sugar (2.68, (1.53, 5.27)) were all positively associated with LGA birth. Strikingly, the difference in risk from diagnosed and treated gestational diabetes compared to women with a single abnormal glucose tolerance test (but no diagnosis of gestational diabetes) was significant (OR = 0.65, p = 0.12 versus OR = 2.84, p < 0.01). When weight/length ratio was used instead, different factors were found to be significant. BMI and pregnancy weight-gain were found to influence the development of gestational diabetes, through an additive interaction. CONCLUSIONS: High prepregnancy BM, height, antidepressant use, pregnancy weight-gain exceeding 40 pounds, and high blood sugar were associated with LGA birth, but not necessarily infant weight/length ratio. An additive interaction between BMI and pregnancy weight-gain influenced gestational diabetes development.

Infant feeding practices and children's weight status.

PURPOSE: Feeding practices for young Canadian children from economically disadvantaged neighbourhoods were examined to determine adherence to infant feeding recommendations and factors associated with children's weight status. METHODS: Data for the study were collected from 1996 to 2003 as part of Better Beginnings, Better Futures, a longitudinal primary prevention initiative in Ontario. Study subjects were 546 children at age three months and 483 children at age 48 months. RESULTS: Mothers who had less than a high school education (odds ratio [OR] = 1.83, confidence interval [CI] = 1.01-3.29) and mothers who did not attend prenatal classes (OR = 2.37, CI = 1.33-4.24) were more likely to use formula. Mothers who were single parents were three times more likely to have an obese child (OR = 3.35, CI = 1.39-8.06) than were mothers who were married or with a partner. CONCLUSIONS: Targeted strategies are needed for families as single-parent households were predictive of obesity in young children. Innovative encouragement to participate in prenatal programming for pregnant women who have less than a high school education may improve breastfeeding rates.

Determinants of diet quality in pregnancy: sociodemographic, pregnancy-specific, and food environment influences.

OBJECTIVE: To advance the knowledge of determinants of diet quality in pregnancy by focusing on both personal characteristics and the food environment. DESIGN: Cross-sectional study in which participants from the Prenatal Health Project were linked to a geographic dataset by home address. Access to fast food, convenience stores, and grocery stores was measured using a geographic information system (ArcGIS9.3). SETTING: Pregnant women (n = 2,282) were recruited between 2002 and 2005 in London, Ontario, Canada. MAIN OUTCOME MEASURE: Dietary quality was measured using a validated food frequency questionnaire and the Canadian Diet Quality Index for Pregnancy. ANALYSIS: Univariate and multivariate linear regressions were calculated with the predictor variables on the Canadian Diet Quality Index for Pregnancy. RESULTS: Pregnant women who were born in Canada, common-law, nulliparous, less physically active, smokers, more anxious, or lacking family support had lower diet quality on average. Presence of fast-food restaurants, convenience stores, and grocery stores within 500 m of participants' homes was not associated with diet quality after controlling for personal variables. CONCLUSIONS AND IMPLICATIONS: The food environment does not seem to have a large influence on diet quality in pregnancy. Further research is needed to determine other potential reasons for low diet quality among pregnant women.

Adolescents' diets do not comply with 2007 Canada's food guide recommendations.

This study evaluated the eating behaviours of students in grade six and, three years later when they were in grade nine, relative to the recommendations of Canada's 2007 Food Guide. Students completed a self-administered questionnaire on eating behaviours in 2002 (n=647) and again in 2005 (n=520) as part of Better Beginnings, Better Futures, a primary prevention initiative among economically disadvantaged communities. McNemar analysis and X(2) analysis were used to assess differences in compliance with the recommendations of the Food Guide. Differences in the mean number of servings of the four food groups and the Other Foods group were examined using independent sample t-tests and paired t tests. In grade six, 5% of males and 7% of females met the minimum number of recommended servings for all four food groups. By grade nine this had dropped to 0.4% and 2% respectively. Among males who completed the questionnaire in both grade six and grade nine there was a decline in the mean number of daily servings for all four food groups. For females a similar trend was observed. The likelihood of adolescents meeting all Food Guide recommendations decreased from grade six to grade nine.

Inadequate dietary intakes among pregnant women.

PURPOSE: Eating behaviours were assessed among pregnant women in a mid-sized Canadian city. METHODS: As part of the Prenatal Health Project, we interviewed 2313 pregnant women in London, Ontario. Subjects also completed a food frequency questionnaire. Recruitment took place in ultrasound clinics at 10 to 22 weeks of gestation. The main outcome measures were number of daily servings for each food group, measured against the minimum number recommended by the 2007 Eating Well with Canada's Food Guide (CFG), the proportion of women consuming the recommended number of servings for each and all of the four food groups, and factors associated with adequate consumption. We also determined the number of servings of "other foods." Analysis included descriptive statistics and logistic regression, all at p<0.05. RESULTS: A total of 3.5% of women consumed the recommended number of servings for all four food groups; 15.3% did not consume the minimum number of servings of foods for any of the four food groups. Women for whom this was their first pregnancy were less likely to consume the recommended number of servings from all four food groups (odds ratio=0.41; confidence interval=0.23, 0.74). CONCLUSIONS: Very few pregnant women consumed food group servings consistent with the 2007 recommendations. Strategies to improve dietary behaviours must focus on the establishment of healthy eating behaviours among women of reproductive age.

Higher zinc intake buffers the impact of stress on depressive symptoms in pregnancy.

Prenatal depression is a public health concern. This study's objectives are to model associations involving dietary zinc intake, psychosocial stress, and sociodemographic factors as they interrelate in the development of depressive symptoms in a cohort of pregnant women from London, Ontario (Prenatal Health Project). We hypothesized that (1) psychosocial stress is intermediate in the causal pathway between sociodemographic factors and zinc intake and that (2) zinc intake serves as a partial mediator between sociodemographic factors, psychosocial stress, and the development of depressive symptoms. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). Psychosocial stress was measured by validated scales and summarized into a composite score. Zinc intake was quantified from food frequency questionnaire and nutrient supplement data. Regression methods were used. The Baron and Kenny method was applied to test mediation hypotheses. Stress-zinc interaction terms were added to the regression model predicting CES-D score to test a possible moderating role for zinc. Our analyses showed that social disadvantage, higher stress, and lower zinc intake were associated with higher CES-D score. Every 1-point increase in stress score was associated with a 1-point increase in CES-D score. Being in the lowest quintile of zinc intake was associated with a 1-point increase in CES-D score; although not clinically meaningful, the association was robust. Evidence was not in favor of the mediation hypotheses, but showed instead that zinc intake moderated the association between stress and depressive symptoms; being in the highest zinc quintile appeared to buffer the impact of stress.

A definition, description, and framework for advanced practice in dietetics.

PURPOSE: We explored advanced practice (AP) across the diversity of dietetics to develop a definition, description, and framework for guiding future education, research agendas, and policy development. METHODS: The process began with a literature review and discussion with dietitians exploring AP in other countries. Various concepts were identified, and these informed the phase 1 survey questions. Phase 1 was a 36-item survey created in SurveyMonkey, engaging a purposeful sample of key stakeholders (n=136). A modified Delphi approach, involving seven dietitians from different geographical locations and practice areas, finalized the phase 2 survey. An e-mail link to this 50-item survey was sent to a random sample of dietitians (n=885). The proposed AP framework entailed an iterative approach, integrating survey results with AP literature. RESULTS: Response rates were 40% for phase 1 and 35% for phase 2. In phase 1, 83% of respondents agreed that a depth and breadth definition captured all dietetic job roles, and 95% agreed that it differentiated AP from entry-level practice. Descriptive statistics are presented to provide demographic information and level of agreement with themes relevant to AP. CONCLUSIONS: A framework is presented, and discrepancies with phase 2 results indicate areas for professional development, such as leadership, mentorship, and outcome measurement.

The Better Beginnings, Better Futures project: findings from grade 3 to grade 9.

Although comprehensive and ecological approaches to early childhood prevention are commonly advocated, there are few examples of long-term follow-up of such programs. In this monograph, we investigate the medium- and long-term effects of an ecological, community-based prevention project for primary school children and families living in three economically disadvantaged neighborhoods in Ontario, Canada. The Better Beginnings, Better Futures (BBBF) project is one of the most ambitious Canadian research projects on the long-term impacts of early childhood prevention programming to date. Bronfenbrenner's ecological model of human development informed program planning, implementation, and evaluation. Using a quasi-experimental design, the BBBF longitudinal research study involved 601 children and their families who participated in BBBF programs when children were between 4 and 8 years old and 358 children and their families from sociodemographically matched comparison communities. We collected extensive child, parent, family, and community outcome data when children were in Grade 3 (age 8­9), Grade 6 (age 11­12), and Grade 9 (age 14­15). The BBBF mandate was to develop programs that would positively impact all areas of child's development; our findings reflect this ecological approach. We found marked positive effects in social and school functioning domains in Grades 6 and 9 and evidence of fewer emotional and behavioral problems in school across the three grades. Parents from BBBF sites reported greater feelings of social support and more positive ratings of marital satisfaction and general family functioning, especially at the Grade 9 follow-up. Positive neighborhood-level effects were also evident. Economic analyses at Grade 9 showed BBBF participation was associated with government savings of $912 per child. These findings provide evidence that an affordable, ecological, community-based prevention program can promote long-term development of children living in disadvantaged neighborhoods and produce monetary benefits to government as soon as 7 years after program completion.

Depressive symptoms during pregnancy in relation to fish consumption and intake of n-3 polyunsaturated fatty acids.

An inverse association between depression and the n-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), primarily obtained from fish consumption, is observed in both observational and experimental research and is biologically plausible. Study objectives were to examine whether prenatal depressive symptoms were associated with lower intakes of fish or EPA+DHA. Pregnant women (n = 2394) completed a telephone interview between 10 and 22 weeks' gestation in London, Ontario, 2002-05. Depressive symptoms were measured using the Center for Epidemiologic Studies - Depression Scale (CES-D). Intakes of fish and EPA+DHA were measured using a validated food-frequency questionnaire. Sequential multiple regression was used to examine associations of depressive symptoms with intake of fish and EPA+DHA, respectively, while controlling for sociodemographic, health and lifestyle variables. The mean CES-D score was 9.9 (SD 8.0). Intake of EPA+DHA was dichotomised at the median value of 85 mg/day. Fish consumption and intake of EPA+DHA were not associated with prenatal depressive symptoms after adjustment for confounders; however, depressive symptoms were significantly higher for lower intakes of EPA+DHA among current smokers and women of single/separated/divorced marital status. The adjusted difference in CES-D scores between intake categories of EPA+DHA was -2.4 [95% CI -4.2, -0.4] for current smokers and -2.8 [95% CI -5.2, -0.4] for women of single marital status. Although pregnant women may be at risk for low concentrations of EPA and DHA, an association between low intakes of EPA+DHA and increased depressive symptoms was only observed among current smokers and women of single marital status.

Dietary change: what are the responses and roles of significant others?

OBJECTIVE: This study examined the impact of one person's dietary change on the experiences of a significant other with whom they regularly shared meals. DESIGN: Qualitative constant comparison approach using semistructured interviews. SETTING: Community-based. PARTICIPANTS: Forty-two participants were recruited using a stratified purposive sampling strategy. ANALYSIS: Verbatim transcripts were analyzed using NUD*IST, version 4.0 software (Qualitative Solutions and Research, Melbourne, Australia, 1997) and manual coding. RESULTS: Most dietary changers had modified their diets in response to a disease diagnosis (eg, cardiovascular disease, diabetes, cancer, hypoglycemia, acquired immunodeficiency syndrome (AIDS), ulcer, allergies). Others had changed their diets for personal reasons (eg, weight loss, vegetarian diets). The dietary changes included dietary fat reduction, conversion to vegetarian or vegan diets, restriction of total kilocalorie intake, and elimination or reduction of specific food items. Significant others described a range of emotional responses to the dietary change, including cooperation, encouragement, skepticism, and anger. Significant others' descriptions of the roles that they played in the dietary change were positive (enabling), neutral (neither enabling nor inhibiting), or negative (inhibiting). Most significant others played positive roles; few played neutral or negative roles. CONCLUSIONS AND IMPLICATIONS: Understanding dietary change from the perspective of significant others can enable nutrition professionals to develop strategies to promote dietary modifications as a shared activity.

Fish consumption among pregnant women in London, Ontario: associations with socio-demographic and health and lifestyle factors.

BACKGROUND: Intake of fish and omega-3 fatty acids is inversely related to adverse health outcomes; however, these relationships may be confounded by socio-economic status and health behaviours. This study's purpose was to describe the socio-demographic, health and lifestyle correlates of fish consumption among pregnant women. METHODS: Pregnant women (n=2394) completed a telephone interview between 10-22 weeks' gestation (London, Ontario, 2002-5) containing questions on socio-demographic, health and lifestyle variables; dietary intake was measured using a 106-item validated food-frequency questionnaire. Unadjusted and adjusted risk ratios were obtained using a modified Poisson regression model. RESULTS: Infrequent fish consumption, <1/week, was reported by 32% of women. After adjusting for age and education, infrequent fish consumption was associated with education

Persistence of overweight among young children living in low income communities in Ontario.

OBJECTIVE: The rise in the prevalence of overweight in pediatric populations is a major health concern. Little is known however, about the prevalence of overweight in younger children. Our objectives were to determine the annual prevalence of overweight in children from junior kindergarten (JK) to grade 3; to assess the persistence of overweight over this time period; and, to identify factors associated with overweight in this group. METHODS: Annual interviews were completed with parents (primarily the mother) living in economically disadvantaged communities in Ontario who are participating in the Better Beginnings, Better Futures project. Weight and height were measured annually for the children (n=760) beginning in JK. Risk of overweight was defined as body mass index (BMI) >or= 85th to < 95th percentile; overweight was BMI >or= 95th percentile. Parents' height and weight were self-reported; BMI >or= 25 was considered overweight. RESULTS: The risk of overweight among children ranged from 14.1% to 17.5%; the prevalence of overweight increased from 9.9% to 15.2%; 68.2% (15/22) of the children who were overweight in JK were >95th percentile in grade 3. BMI >or= 85th to < 95th percentile or >or= 95th percentile in JK were strongly predictive of overweight in grade 3. Almost 50% of the mothers were overweight. CONCLUSIONS: A high prevalence of overweight was found in young children; and, for a large proportion, their early weight status persisted. Strategies promoting healthy eating and physical activity for both children and parents are essential.

Eat smart! Workplace Cafeteria Program evaluation of the nutrition component.

PURPOSE: The nutrition component of the Eat Smart! Workplace Cafeteria Program (ESWCP) in a hospital was evaluated. We assessed staff's frequency of visits to and purchases in the hospital cafeteria, attitudes about the program, short-term eating behaviour change, and suggestions to improve the ESWCP. METHODS: Questionnaires were sent to hospital staff members who were not on leave (n=504). Dillman's Tailored Design Method was used to design and implement the survey. Four mail-outs were used and yielded a 51% response rate. RESULTS: Eighty-seven percent of respondents visited the hospital cafeteria at least once a week in an average seven-day week, and 69% purchased one to five meals or snacks there each week. Eighty-six percent of respondents said that they were aware of the hospital's program. Notices on cafeteria tables were the primary method of learning about the program (67%). Reported program benefits included increased knowledge about healthy eating, convenience of having healthy foods in the cafeteria, and increased energy. CONCLUSION: Many respondents were aware of the program, provided positive comments about it, and reported positive changes in eating habits. However, future observational research is warranted to note foods served and sold before and after program implementation, as well as to examine whether results can be generalized to other settings.

Feeding patterns and weight among First Nations children.

PURPOSE: Little information is available on the growth and feeding patterns of First Nations children. Our goal was to assess the anthropometric status, feeding practices, and dietary intake of children born in 1994 or 1995 (n=102) and living in Walpole Island First Nation. METHODS: Information on demographic characteristics and infant feeding practices was obtained through parent interviews conducted between 1994 and 1999. Parents also completed a 24-hour dietary recall for their children when they were 48 months old. Head circumference was measured at three and 18 months, and weight and length/height at three, 18, 33, and 48 months. RESULTS: Most infants (75%) were breastfed at birth; however, by the time infants were three months old, 39.7% of the mothers had stopped breastfeeding. Over half (57.1%) of the infants were fed solids before age three months, 11.6% were given whole milk before age nine months, and 59.4% had low fat milk before age two years. Body mass index (kg/m2) (BMI) was above the 85th percentile for 27.8% at the 48-month interview, and was associated with a maternal BMI above 25 (OR=7.8, CI=1.1-41.9). CONCLUSIONS: Mothers need to be encouraged to follow current infant feeding recommendations. Strategies should be developed to reduce the prevalence of overweight among adults and children in First Nations communities.

Adolescents' low-carbohydrate-density diets are related to poorer dietary intakes.

This study was undertaken to assess how low-carbohydrate-density diets below the acceptable macronutrient distribution range relate to food and micronutrient intake and sociodemographic and health-related characteristics. The multistage stratified cluster design in the 1990 Ontario Health Survey was used. There were 5,194 subjects, 12 to 18 years of age, in sampled households. Dietary data were collected via a food frequency questionnaire. Low-carbohydrate-density diets were consumed by 27.6% of males and 24.1% of females. Low-carbohydrate-density diets were related (P < .05) to reduced sufficiency of vegetables and fruit and higher consumption of meat and alternatives and added fats. The low-carbohydrate-density diet resulted in intakes lower in vitamin C and fiber and higher in cholesterol and total fat. The low-carbohydrate-density diet was directly associated with being Canadian-born (odds ratio [OR] = 1.78, 95% confidence interval [CI] = 1.27 to 2.50), overweight status (OR = 1.27, 95% CI = 1.02 to 1.57), smoking (OR = 1.53, 95% CI = 1.23 to 1.90), alcohol use (OR = 1.46, 95% CI = 1.21 to 1.75), and poorer self-rated health (OR = 1.47, 95% CI = 1.01 to 2.14). Use of the acceptable macronutrient distribution range identified adolescents with low-carbohydrate-density diets whose food choices and nutrient intake may impact negatively on short- and long-term health.

Determinants of healthy eating in children and youth.

This review outlines the state of knowledge and research gaps in the area of determinants of healthy eating among children and youth. The article is structured around individual and collective determinants that affect healthy eating in children and youth. We defined healthy eating as "eating practices and behaviours that are consistent with improving, maintaining and/or enhancing health." Relevant databases were searched for papers published between January 1992 and March 2003 that focussed on children or youth and reported at least one factor relevant to healthy eating. Among collective factors, familial factors and the nature of foods available in the physical environment, including at home, schools and in fast-food establishments, stand out as significant influences on healthy eating in children and youth. The media, particularly television, also have an enormous potential influence and can overshadow familial influences. Individual factors identified include knowledge, attitudes and food preferences; only the latter have been identified as a strong determinant of healthy eating in both children and adolescents. The results of the review identified a significant body of literature in the area of determinants of healthy eating in children and youth; however, very little of this research has taken place in Canada. Only a few determinants, such as economic factors and food security, the content of media nutritional messages, and the issue of flavours, neophobia and food preferences, have undergone some examination by Canadian researchers. Research priorities for Canada in the area of determinants of healthy eating and surveillance of eating behaviours are identified.

Dietary intake among young adolescents in Ontario: associations with vegetarian status and attitude toward health.

BACKGROUND: This study aimed to describe the dietary intakes of adolescent vegetarians and omnivores and determine if, and how, attitude toward personal health related to food consumption. METHODS: Among grade 9 students in Ontario, Canada (n = 630), vegetarian status and estimated consumption of foods and food groups were determined by food frequency questionnaire. Personal health was self-categorized as very important (the "health conscious") or somewhat/not important (the "non-health conscious"). RESULTS: The prevalence of vegetarianism was 6.5% (CI = 4.6-8.4%) among females and 1.0% (CI = 0.2-1.8%) among males. Health-conscious omnivores consumed more grain, vegetables and fruit, and milk product than non-health-conscious omnivores (P < 0.05). Health-conscious vegetarians ingested more grain products, vegetables and fruit, and meat and alternatives than non-health-conscious vegetarians (P < 0.05). Among non-health-conscious vegetarians, none consumed two daily servings of meat and alternatives compared to 60.5% of non-health-conscious omnivores (P < 0.001). Among health-conscious vegetarians, milk product consumption was lower than that of health-conscious omnivores (P = 0.015). CONCLUSIONS: Large proportions of both vegetarian and omnivore adolescents consumed suboptimal diets. Health consciousness had value as an indicator of dietary adequacy and may be useful as a rudimentary screen for problematic dietary consumption patterns.

What do Ontario children eat for breakfast? Food group, Energy and macronutrient intake.

This study included 305 children living in Ontario in 1993. Our objective was to determine the proportion of daily energy and macronutrient intake consumed at breakfast, and the major food groups contributing to this meal. Demographic data were obtained in a parent interview that was part of the prevention project Better Beginnings, Better Futures. A single 24-hour recall among parents indicated that breakfast provided a mean of 1,230 (+/- 607) kJ. Although only 4.9% (n= 15) of children ate nothing at breakfast, 26.9% had <837 kJ. Many (59.7%) had amid-morning snack; however, children who consumed <837 kJ at breakfast were not more likely to have a snack than were those who had a greater energy intake. The major sources of energy were foods from the milk (27.4%), cereals (22.1%), and breads (14.1%)groups. Energy intake at breakfast was no different in children whose household income was at or above the low-income cutoff than in children whose household income was below the cutoff. While few children missed breakfast, many needed more energy at this meal, and non-economic as well as economic influences on breakfast consumption need to be identified.

Smoking, physical activity and breakfast consumption among secondary school students in a southwestern Ontario community.

OBJECTIVES: To determine the prevalence of smoking, low levels of physical activity, and missing breakfast among students (n=318) in grades 9 through 12 in three schools in southwestern Ontario; to see if these behaviours were associated; and, whether there were gender differences. METHODS: A self-administered survey was conducted in grade 10 English classes. RESULTS: The response rate was 87.1%. The prevalence of smoking was 36.2%; there was no gender difference. Only 42.8% of students ate breakfast daily; 48.8% of boys and 36.1% of girls (chi2 = 5.2; p<0.05). A higher proportion of boys (77.1%) were active for at least 30 minutes > or = 3 times/week compared to girls (66.0%) (chi2 = 4.8; p<0.05). Students who were active > or = 3 times/week were more likely to eat breakfast daily and, among boys, 60.4% of non-smokers ate breakfast daily compared to 31.9% of those currently smoking (chi2 = 13.3; p<0.001). There were no differences among girls. More girls (63.9%) were concerned about gaining weight compared to boys (36.1%) (chi2 = 37.7; p<0.001). Among girls, a higher proportion of those who were concerned about gaining weight were less likely to engage in physical activity or smoke, and more likely to skip breakfast compared to those who were not concerned. DISCUSSION: Weight concern was not associated with frequency of physical activity, smoking, or breakfast consumption among boys. The high prevalence rates for these behaviours suggests that interventions in high schools should include daily physical activity, promotion of breakfast eating (either at home or in the school), and encouragement to quit smoking.