Increasing Children's Vegetable Consumption: Translating a Review of the Evidence Base to Develop Best Practice Guidelines.

Introduction: Dietary guidelines worldwide emphasize the importance of consuming vegetables as part of a healthy diet. Despite this, translating this information into messages for consumers that change behavior has been difficult. There have been population-level social marketing campaigns as well as several smaller campaigns directed specifically toward children, which have demonstrated small increases in consumption. However, achieving meaningful and sustained increases in children's vegetable consumption remains a challenge. This article describes the process of synthesizing the published literature and translating these findings to inform the development of 7 best practice guidelines to increase children's vegetable intake. Methods: The first step in this process was a systematic review of scientific literature to identify the components of interventions that were associated with successfully increasing vegetable intake. The synthesis of effective intervention components was guided by the Behavior Change Wheel. These scientific findings were translated to guidelines for best practice. This process involved a team of nutrition and behavioral researchers and nutrition practitioners translating the science into actionable advice that could be adopted by a range of stakeholders. The 6 selected stakeholders included long daycare centers, after-hours school care providers, primary schools, industry groups and growers, researchers, and government policy makers. Stakeholders were involved in the development process through surveys and interviews to understand their requirements for resources to support adoption of the best practice guidelines within each setting and within the context of existing practice. Results: The guidelines center on coordination of effort, with a focus on components such as planning, environmental restructuring, barrier reduction, feedback, and monitoring. In consultation with key stakeholders, a range of resources were developed for each setting to support the implementation of best practice, with the aim of achieving meaningful increases in intake. The resources and tools have been made available at http://www.vegkit.com.au. Conclusions: The translation of knowledge into practice is not traditionally included as part of the research process. Therefore, combining the process of reviewing the science and translating the evidence to stakeholder resources to influence practice in 1 research study is novel, and the study could be used to guide future research translation activities within and beyond the field of public health nutrition.

Evaluation of a long day care intervention targeting the mealtime environment and curriculum to increase children's vegetable intake: a cluster randomised controlled trial using the multiphase optimisation strategy framework.

OBJECTIVE: To determine the reach, adoption, implementation and effectiveness of an intervention to increase children's vegetable intake in long day care (LDC). DESIGN: A 12-week pragmatic cluster randomised controlled trial, informed by the multiphase optimisation strategy (MOST), targeting the mealtime environment and curriculum. Children's vegetable intake and variety was measured at follow-up using a modified Short Food Survey for early childhood education and care and analysed using a two-part mixed model for non-vegetable and vegetable consumers. Outcome measures were based on the RE-AIM framework. SETTING: Australian LDC centres. PARTICIPANTS: Thirty-nine centres, 120 educators and 719 children at follow-up. RESULTS: There was no difference between intervention and waitlist control groups in the likelihood of consuming any vegetables when compared with non-vegetable consumers for intake (OR = 0·70, (95 % CI 0·34-1·43), P = 0·32) or variety (OR = 0·73 (95 % CI 0·40-1·32), P = 0·29). Among vegetable consumers (n 652), there was no difference between groups in vegetable variety (exp(b): 1·07 (95 % CI:0·88-1·32, P = 0·49) or vegetable intake (exp(b): 1·06 (95 % CI: 0·78, 1·43)), P = 0·71) with an average of 1·51 (95 % CI 1·20-1·82) and 1·40 (95 % CI 1·08-1·72) serves of vegetables per day in the intervention and control group, respectively. Intervention educators reported higher skills for promoting vegetables at mealtimes, and knowledge and skills for teaching the curriculum, than control (all P < 0·001). Intervention fidelity was moderate (n 16/20 and n 15/16 centres used the Mealtime environment and Curriculum, respectively) with good acceptability among educators. The intervention reached 307/8556 centres nationally and was adopted by 22 % eligible centres. CONCLUSIONS: The pragmatic self-delivered online intervention positively impacted educator's knowledge and skills and was considered acceptable and feasible. Intervention adaptations, using the MOST cyclic approach, could improve intervention impact on children' vegetable intake.

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

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

Development and validation of a short dietary questionnaire for assessing obesity-related dietary behaviours in young children.

There are few short, validated tools to assess young children's obesity-related dietary behaviours, limiting the rapid screening of dietary behaviours in research and practice-based early obesity prevention. This study aimed to develop and assess the reliability and validity of a caregiver-reported short dietary questionnaire to rapidly assess obesity-related dietary behaviours in children aged 6 months to 5 years. The Early Prevention of Obesity in Childhood Dietary Questionnaire (EPOCH-DQ) was developed using a rigorous process to determine content and structural validity. Three age-appropriate versions were developed for (1) infants, aged 6-12 months, (2) toddlers, aged 1-2.9 years and (3) pre-schoolers, aged 3-5 years. The questionnaire (7-15 items) measures dietary behaviours, including diet risk from non-core food and beverage intake, diet quality from vegetable frequency, bread type and infant feeding practices. Test-retest reliability was assessed from repeated administrations 1 week apart (n = 126). Internal consistency, concurrent validity (against a comparison questionnaire, the InFANT Food Frequency Questionnaire), construct validity and interpretability were assessed (n = 209). Most scores were highly correlated and significantly associated (p < 0.05) for validity (rs: 0.45-0.89, percentage agreement 68%-100%) and reliability (intraclass correlation coefficient: 0.61-0.99) for diet risk, diet quality and feeding practice items. The EPOCH-DQ shows acceptable validity and reliability for screening of obesity-related behaviours of children under 5 years of age. The short length and, thus, low participant burden of the EPOCH-DQ allows for potential applications in various settings. Future testing of the EPOCH-DQ should evaluate culturally and socio-economically diverse populations and establish the predictive validity and sensitivity to detect change.

Screening tools used in primary health care settings to identify health behaviours in children (birth-16 years); A systematic review of their effectiveness, feasibility and acceptability.

BACKGROUND: Child health behaviour screening tools have potential to enhance the effectiveness of health promotion and early intervention. This systematic review aimed to examine the effectiveness, acceptability and feasibility of child health behaviour screening tools used in primary health care settings. METHODS: A systematic review of studies published in English in five databases (CINAHL, Medline, Scopus, PsycINFO and Web of Science) prior to July 2022 was undertaken. Eligible studies described: 1) screening tools for health behaviours (dietary, physical activity, sedentary or sleep-related behaviours) used in primary health care settings in children birth to 16 years; 2) tool effectiveness for identifying child health behaviours and changing practitioner behaviour; 3) tool acceptability or feasibility from child, caregiver or practitioner perspective and/or 4) implementation of the screening tool. RESULTS: Of the 7145 papers identified, 22 studies describing 14 screening tools were included. Only four screening tools measured all four behaviour domains. Fourteen studies reported changes in practitioner self-reported behaviour, knowledge and practice. Practitioners and caregivers identified numerous benefits and challenges to screening. CONCLUSIONS: Health behaviour screening can be an acceptable and feasible strategy to assess children's health behaviours in primary health care. Further evaluation is needed to determine effectiveness on child health outcomes.

Evaluation of a menu box delivery service for Australian long-day care services to improve food provision and child intake: a cluster randomised controlled trial.

OBJECTIVE: To evaluate the impact of a menu box delivery service tailored to the long-day care (LDC) setting on improving menu compliance with recommendations, children's diet quality and dietary intake while in care. DESIGN: A cluster randomised controlled trial in LDC centres randomly assigned to an intervention (menu box delivery) or comparison (menu planning training) group. The primary outcome was child food provision and dietary intake. Secondary outcomes include menu compliance and process evaluation, including acceptability, fidelity and menu cost (per child, per day). SETTING: South Australian LDC centres. PARTICIPANTS: Eight LDC centres (n 224 children) provided data. RESULTS: No differences were observed in serves/d between intervention and comparison centres, for provision (intervention, 0·9 inter-quartile range (IQR) 0·7-1·2; comparison, 0·8 IQR 0·5-1·3) or consumption (intervention, 0·5 IQR 0·2-0·8; comparison, 0·5 IQR 0·3-0·9) of vegetables. Child food provision and dietary intake were similar across both groups for all food groups (P < 0·05). At follow-up, all intervention centres met menu planning guidelines for vegetables, whereas only one comparison centre met guidelines. Intervention centre directors found the menu box delivery more acceptable than cooks. Cost of the intervention was AUD$2·34 greater than comparison centres (intervention, AUD$4·62 (95 % CI ($4·58, $4·67)); comparison, AUD$2·28 (95 % CI ($2·27, $2·30)) per child, per day). CONCLUSIONS: Menu compliance can be improved via a menu delivery service, delivering equivalent impacts on child food provision and dietary intake compared with an online training programme. Further exploration of cooks acceptability and cost is essential before scaling up to implementation.

Development and internal validation of the SMILE-FSS: a Free Sugars Screener for Australian children aged 2 and 5 years.

OBJECTIVE: To develop and internally validate a Free Sugars Screener (FSS) for Australian children aged 2 and 5 years. DESIGN: Using data collected from a ninety-nine-item (2-year-olds) and ninety-eight-item (5-year-olds) FFQ in the Study of Mothers' and Infants' Life Events affecting oral health (SMILE-FFQ), a regression-based prediction modelling approach was employed to identify a subset of items that accurately estimate total free sugars intake (FSI). The predictors were grams of free sugars (FSg) for individual items in the SMILE-FFQ and child's age and sex. The outcome variable was total FSI per person. To internally validate the SMILE-FSS items, the estimated FSg was converted to percent energy from free sugars (%EFS) for comparison to the WHO free sugars guideline categories (< 5 %, 5-< 10 % and ≥ 10 %EFS) using cross-classification analysis. SETTING: Australia. PARTICIPANTS: 858 and 652 2- and 5-year-old children, respectively, with complete dietary (< 5 % missing) and sociodemographic data. RESULTS: Twenty-two and twenty-six items were important in predicting FSI at 2 and 5 years, respectively. Items were similar between ages with more discretionary beverage items (e.g. sugar-sweetened beverages) at 5 years. %EFS was overestimated by 4·4 % and 2·6 %. Most children (75 % and 82 %) were categorised into the same WHO free sugars category with most (87 % and 95 %) correctly identified as having < 10 %EFS in line with the WHO recommendation. CONCLUSIONS: The SMILE-FSS has good internal validity and can be used in research and practice to estimate young Australian children's FSI and compare to the WHO free sugars guidelines to identify those 'at risk'.

Development of an initiatives package to increase children's vegetable intake in long day care centres using the Multiphase Optimisation Strategy (MOST) randomised factorial experiment.

OBJECTIVE: To inform a package of initiatives to increase children's vegetable intake while in long day care (LDC) by evaluating the independent and combined effects of three initiatives targeting food provision, the mealtime environment and the curriculum. DESIGN: Using the Multiphase Optimisation Strategy (MOST) framework, a 12-week, eight-condition (n 7 intervention, n 1 control) randomised factorial experiment was conducted. Children's dietary intake data were measured pre- and post-initiative implementation using the weighed plate waste method (1× meal and 2× between-meal snacks). Vegetable intake (g/d) was calculated from vegetable provision and waste. The optimal combination of initiatives was determined using a linear mixed-effects model comparing between-group vegetable intake at follow-up, while considering initiative fidelity and acceptability. SETTING: LDC centres in metropolitan Adelaide, South Australia. PARTICIPANTS: 32 centres, 276 staff and 1039 children aged 2-5 years. RESULTS: There were no statistically significant differences between any of the intervention groups and the control group for vegetable intake (all P > 0·05). The curriculum with mealtime environment group consumed 26·7 g more vegetables/child/day than control (ratio of geometric mean 3·29 (95 % CI 0·96, 11·27), P = 0·06). Completion rates for the curriculum (> 93 %) and mealtime environment (61 %) initiatives were high, and acceptability was good (4/5 would recommend), compared with the food provision initiative (0-50 % completed the menu assessment, 3/5 would recommend). CONCLUSION: A programme targeting the curriculum and mealtime environment in LDC may be useful to increase children's vegetable intake. Determining the effectiveness of this optimised package in a randomised controlled trial is required, as per the evaluation phase of the MOST framework.

Trajectories of child free sugars intake and dental caries - a population-based birth cohort study.

OBJECTIVES: To investigate the association between trajectories of free sugars intake during the first five years of life and dental caries experience at five years. METHODS: Data from the SMILE population-based prospective birth cohort study, collected at one, two and five years old, were used. A 3-days dietary diary and food frequency questionnaire were used to estimate free sugars intake (FSI) in grams. The primary outcomes were dental caries prevalence and experience (dmfs). The Group-Based Trajectory Modelling method was used to characterize three FSI trajectories ('Low and increasing'; 'Moderate and increasing'; and 'High and increasing'), which were the main exposures. Multivariable regression models were generated to compute adjusted prevalence ratios (APR) and rate ratios (ARR) for the exposure, controlling for socioeconomic factors. RESULTS: The prevalence of caries was 23.3%, with a mean dmfs of 1.4, and a median of 3.0 among those who had caries. There were clear gradients of caries prevalence and experience by the FSI trajectories. The 'High and increasing' had an APR of 2.13 (95%CI 1.23-3.70) and ARR of 2.77 (95%CI 1.45-5.32) against the 'Low and increasing'. The 'Moderate and increasing' group had intermediate estimates. A quarter of the caries cases could have been prevented if the whole study sample had been in the 'Low and increasing' FSI trajectory. CONCLUSION: A sustained, high trajectory of FSI from a young age was positively associated with child dental caries. Measures to minimise consumption of free sugars must commence early in life. CLINICAL SIGNIFICANCE: The study has provided high level evidence to inform clinicians' decisions in promoting a healthy dietary pattern for young children.

Pairwise approach for analysis and reporting of child's free sugars intake from a birth cohort study.

OBJECTIVES: The prospective cohort design is an important research design, but a common challenge is missing data. The purpose of this study is to compare three approaches to managing missing data, the pairwise (n = 1386 children), the partial or modified pairwise (n = 1019) and the listwise (n = 546), to characterize the trajectories of children's free sugars intake (FSI) across early childhood. METHODS: By applying the Group-based Trajectory Model Technique to three waves of data collected from a prospective cohort study of South Australian children, this study examined the three approaches in managing missing data to validate and discuss children's FSI trajectories. RESULTS: Each approach identified three distinct trajectories of child's FSI from 1 to 5 years of age: (1) 'low and fast increasing', (2) 'moderate and increasing' and (3) 'high and increasing'. The trajectory memberships were consistent across the three approaches, and were for the pairwise scenario (1) 15.1%, (2) 68.3% and (3) 16.6%; the partial or modified pairwise (1) 15.9%, (2) 64.1% and (3) 20.0%; and the listwise (1) 14.9%, (2) 64.9% and (3) 20.2% of children. CONCLUSIONS: Given the comparability of the findings across the analytical approaches and the samples' characteristics between baseline and across different data collection waves, it is recommended that the pairwise approach be used in future analyses to optimize the sample size and statistical power when examining the relationship between FSI in the first years of life and health outcome such as dental caries.

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

OBJECTIVE: This study examined parental work hours and household income as determinants of discretionary (energy dense, nutrient poor) food and beverage intake in young children, including differences by eating occasion. DESIGN: Secondary analysis of cross-sectional data. Three hierarchical regression models were conducted with percent energy from discretionary food and beverages across the day, at main meals, and at snack times being the outcomes. Dietary intake was assessed by 1x24-hour recall and 1-2x24-hour food record(s). Both maternal/paternal work hours were included, and total household income. Covariates included household, parent and child factors. SETTING: Data from the NOURISH/SAIDI studies were collected between 2008-13. PARTICIPANTS: Participants included 526 mother-child dyads (median(IQR) child age 1.99(1.96,2.03) years). Forty-one percent of mothers did not work while 57% of fathers worked 35-40 hours/week. Most (85%) households had an income of ≥$50k AUD/year. RESULTS: Household income was consistently inversely associated with discretionary energy intake (ß= -0.12 to -0.15). Maternal part-time employment (21-35 hours/week) predicted child consumption of discretionary energy at main meals (ß=0.10, p=0.04). Paternal unemployment predicted a lower proportion of discretionary energy at snacks (ß= -0.09, p=0.047). CONCLUSIONS: This work suggests that household income should be addressed as a key opportunity-related barrier to healthy food provision in families of young children. Strategies to reduce the time burden of healthy main meal provision may be required in families where mothers juggle longer part-time working hours with caregiving and domestic duties. The need to consider the role of fathers and other parents/caregivers in shaping children's intake was also highlighted.

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

OBJECTIVE: To prioritise and refine a set of evidence-informed statements into advice messages to promote vegetable liking in early childhood, and to determine applicability for dissemination of advice to relevant audiences. DESIGN: A nominal group technique (NGT) workshop and a Delphi survey were conducted to prioritise and achieve consensus (≥70 % agreement) on thirty evidence-informed maternal (perinatal and lactation stage), infant (complementary feeding stage) and early years (family diet stage) vegetable-related advice messages. Messages were validated via triangulation analysis against the strength of evidence from an Umbrella review of strategies to increase children's vegetable liking, and gaps in advice from a Desktop review of vegetable feeding advice. SETTING: Australia. PARTICIPANTS: A purposeful sample of key stakeholders (NGT workshop, n 8 experts; Delphi survey, n 23 end users). RESULTS: Participant consensus identified the most highly ranked priority messages associated with the strategies of: 'in-utero exposure' (perinatal and lactation, n 56 points) and 'vegetable variety' (complementary feeding, n 97 points; family diet, n 139 points). Triangulation revealed two strategies ('repeated exposure' and 'variety') and their associated advice messages suitable for policy and practice, twelve for research and four for food industry. CONCLUSIONS: Supported by national and state feeding guideline documents and resources, the advice messages relating to 'repeated exposure' and 'variety' to increase vegetable liking can be communicated to families and caregivers by healthcare practitioners. The food industry provides a vehicle for advice promotion and product development. Further research, where stronger evidence is needed, could further inform strategies for policy and practice, and food industry application.

Supporting strategies for enhancing vegetable liking in the early years of life: an umbrella review of systematic reviews.

BACKGROUND: Many children worldwide do not eat recommended amounts of vegetables. Disliking vegetables is a key factor associated with low intake. OBJECTIVE: This umbrella review synthesized systematic reviews to determine the effectiveness of sensory and behavioral strategies to facilitate liking of vegetables (primary outcome) in young children up to 5 y of age, as key predictors of vegetable intake (secondary outcome). METHODS: Nine databases were searched up to May 2019 (updated in September 2020). Two reviewers independently conducted study screening and selection, data extraction, and assessment of methodological quality using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Eleven reviews (n = 1 rated strong quality, n = 4 moderate quality, n = 6 low/critically low quality) examining 85 primary studies met the review criteria: systematic reviews and meta-analyses of primary studies (any quantitative design) that examined sensory or behavioral strategies on vegetable liking or intake (outcomes reported separately for children ≤5 y). Strategy effectiveness was synthesized into 3 categories based on evidence strength: 1) promising (large and consistent body of moderate quality evidence), 2) emerging (small to moderate body of mixed consistency and quality evidence), and 3) limited (small body of limited consistency and quality evidence). RESULTS: Promising evidence was identified for repeated exposure to a single or a variety of vegetables. Emerging evidence was identified for several strategies that increase familiarity with vegetable flavors (e.g., via exposure in utero and through breast milk, and a "vegetable first" approach to complementary feeding) and/or willingness to try vegetables (e.g., via parental role modeling, nonfood rewards, and vegetable-based story books). CONCLUSIONS: Current evidence supports incorporation of tailored advice into guideline documents for parents and carers to repeatedly expose their children to a variety of vegetables to increase vegetable intake. Ongoing robust research on strategies to facilitate children's liking of vegetables is warranted to strengthen the evidence base underpinning advice for parents and health professionals.

Reliability and Validity of a Carbohydrate-Counting Knowledge Questionnaire for Young Australians With Type 1 Diabetes.

OBJECTIVE: To test the reliability and validity of a carbohydrate-counting knowledge questionnaire in young Australians with type 1 diabetes mellitus (T1DM). METHODS: Children or young adults (<20 years) with T1DM, or their parents, completed the 72-item Australian PedCarbQuiz (AusPCQ), adapted from the American PedCarbQuiz, and an expert assessment of carbohydrate-counting knowledge. Responses were scored and summed (0-72, higher scores = greater knowledge). Internal reliability was assessed using Cronbach α, and relative validity using Spearman correlations (with HbA1c) and Bland-Altman analysis (with the expert assessment). RESULTS: Australian PedCarbQuiz reliability (n = 44, mean score = 59.7 ± 5.6) was acceptable (α = 0.83). There was a lack of agreement (mean bias = 10.7, P = 0.008) and significant proportional bias between AusPCQ scores and expert assessments (ß = -0.73 [95% confidence interval, -1.82 to -0.79]; P < 0.001). CONCLUSIONS AND IMPLICATIONS: The AusPCQ was shown to be reliable but not valid in a small sample. Testing in a larger sample is warranted.

Are meal kits health promoting? Nutritional analysis of meals from an Australian meal kit service.

SUMMARY: Meal kits are popular for consumers seeking greater convenience in preparing meals at home. The market share for meal kit subscription services (MKSSs) is growing in developed nations including Australia, however, literature about their health promoting qualities, e.g. nutritional composition, is scarce. This study aimed to assess the characteristics and nutritional composition of meals offered from an MKSS over 12 months. Nutritional data were extracted from recipes available to order from HelloFresh in Australia from 1 July 2017 to 30 June 2018. In total, 346 (251 unique) recipes were retrieved. Per serve (median size 580 g), meals contained a median of 2840 kJ (678 kcal) of energy, 58 g carbohydrate (14 g sugar), 44 g protein, 28 g total fat (8 g saturated fat) and 839 mg sodium. Median energy from macronutrients was total fat (38%), carbohydrates (34%), protein (25%) and saturated fat (11%). This paper is the first to describe characteristics of recipes available from an MKSS over a 12-month period of time. With their growing popularity, meal kit delivery services have the capacity to influence consumer food behaviours, diets and subsequently population health. MKSSs may function to promote health though education, training, and enabling home cooking behaviours, and may be a powerful commitment device for home cooking behaviour change. However, it is important for health professionals, including dietitians and nutritionists, to understand the nutritional risks, benefits and suitability of this contemporary mealtime option before recommending them to clients and members of the public as part of health promotion. LAY SUMMARY: Meal kit delivery services are growing in popularity in developed countries, complementing busy lifestyles with pre-measured ingredients and recipe instructions delivered to the home. These meal kits have the ability to influence consumer diets and population health, and may support health promoting diet behaviours, e.g. eating vegetables, and enable home cooking. In this study, we reviewed a years' worth of recipes from a popular meal kit service. We report that a typical recipe contained approximately nine different ingredients, comprising three vegetables and required three ingredients from the home pantry. Meals took ∼35 min to prepare and were found to be relatively high in energy from fat and protein, and relatively low in energy from carbohydrates. The level of sodium varied widely and some meals exceeded the Australian Suggested Dietary Target for sodium (<2000 mg). Meal kit recipes were found to have health promoting qualities, frequently including vegetable ingredients, however, improvements to recipes would make these meal kits more health promoting. Current diet intakes and the nutritional composition of meal kits recipes should be reviewed before being recommended by health professionals.

Study of Mothers' and Infants' Life Events Affecting Oral Health (SMILE) birth cohort study: cohort profile.

PURPOSE: The long-term goal of the Study of Mothers' and Infants' Life Events Affecting Oral Health (SMILE) birth cohort study is to identify and evaluate the relative importance and timing of critical factors that shape the oral health of young children. It will then evaluate those factors in their inter-relationship with socioeconomic influences. PARTICIPANTS: SMILE is a single-centre study conducted in Adelaide, Australia. All newborns at the main three public hospitals between July 2013 and August 2014 were eligible for inclusion. The final recruited sample at birth was 2181 mother/infant dyads. Participants were followed up with questionnaires when the child was 3 and 6 months of age, and 1, 2 and 5 years of age. Oral epidemiological examinations and anthropometric assessments were conducted at age 2 and 5 years. FINDINGS TO DATE: SMILE has contributed comprehensive data on dietary patterns of young children. Intakes of free sugars, core and discretionary foods and drinks have been detailed. There was a sharp increase in free sugars intake with age. Determinants of dietary patterns, oral health status and body weight during the first 5 years of life have been evaluated. Socioeconomic characteristics such as maternal education and household income and area-level socioeconomic profile influenced dietary patterns and oral health behaviours and status. FUTURE PLAN: Funding has been obtained to conduct oral epidemiological examinations and anthropometric assessments at age 7-8 years. Plans are being developed to follow the cohort into adolescent years.

Improving the Reporting of Young Children's Food Intake: Insights from a Cognitive Interviewing Study with Mothers of 3-7-Year Old Children.

Short food questions (SFQ) allow for rapid reporting of food intake across a variety of settings but are limited by poor validity and reliability. Understanding the recall process used by parents to report children's food intake can improve question design and psychometric performance. This study aimed to improve understanding of how parents report children's dietary intake using SFQ. Semi-structured, cognitive interviews were conducted with 21 mothers of 3-7-year-old children. Mothers were asked to 'think-aloud' while answering SFQ about their child's food intake. Thematic analysis identified themes relating to parent's question and answer process and barriers to recall. Information retrieval strategies focused on 'use-of-time' and 'sphere of food provision' and differed for core versus unhealthy foods. Recall of routine and home food provision were used to report core food intake, whereas recall of special occasions and food provision outside the home guided recall of discretionary foods. Mothers utilize different recall strategies for core and discretionary foods based on use of time and the sphere of food provision. The ease of reporting children's dietary intake may be improved by utilizing a shorter recall time frame, clear and direct question wording, and use of food examples and recall prompts.

Weight status and diets of children aged 1-12 years attending a tertiary public paediatric outpatient clinic.

AIM: To assess the weight status and diets of a sample of paediatric outpatients, explore the relationship between the two and compare child weight status with parental perception of child weight and parents' self-reported weight. METHODS: Parents/carers of 1-12-year-olds attending paediatric outpatients at Flinders Medical Centre, South Australia, between October 2015 and May 2016 completed a demographic and validated age-based dietary questionnaire (toddlers (1-3 years), pre-schoolers (>3 to <5 years) or children (5-12 years)). Dietary risk scores (low/moderate/high/very high) were calculated for toddlers and pre-schoolers and diet quality and food behaviours scores for children. Body mass index (BMI) z-score and weight status were determined from measured height and weight. RESULTS: Of 114 toddlers, 115 pre-schoolers and 250 children, 65% were of a healthy weight, 10% underweight and 25% overweight or obese. Most (~80%) toddlers and pre-schoolers had diets classified as 'moderate' risk, and the diets (35-90%) and behaviours (90%) of most 5-12-year-olds fell short of the guidelines. There was no significant relationship between overall diet risk or quality and BMI z-score. Healthier food behaviours scores were inversely correlated with BMI z-scores (ß -0.061, 95% confidence interval (CI) -0.089, -0.033, P < 0.005). Parents' perception of child weight status was inaccurate. Parent's self-reported weight status was significantly associated with the BMI z-scores of toddlers (ß 0.301, 95% CI 0.189-1.174, P = 0.007) and pre-schoolers (ß 0.220, 95% CI 0.032-0.859, P = 0.035). CONCLUSIONS: Poor diets and high rates of overweight/obesity highlight the need for screening within the paediatric outpatient setting. Parents' own weight status, and their inaccurate perception of their child's, should be considered future intervention targets for improving child and parent health.

Dietary Patterns and Risk of Obesity and Early Childhood Caries in Australian Toddlers: Findings from an Australian Cohort Study.

We examined associations between dietary patterns at 12 months, characterised using multiple methodologies, and risk of obesity and early childhood caries (ECC) at 24-36 months. Participants were Australian toddlers (n = 1170) from the Study of Mothers' and Infants' Life Events affecting oral health (SMILE) birth cohort. Principal Components Analysis (PCA) and the Dietary Guideline Index for Children and Adolescents (DGI-CA) were applied to dietary intake data (1, 2 or 3-days) at 12 months, and regression analysis used to examine associations of dietary patterns with body mass index Z-score and presence of ECC at 24-36 months. Two dietary patterns were extracted using PCA: family diet and cow's milk and discretionary combination. The mean DGI-CA score was 56 ± 13 (out of a possible 100). No statistically significant or clinically meaningful associations were found between dietary pattern or DGI-CA scores, and BMI Z-scores or ECC (n = 680). Higher cow's milk and discretionary combination pattern scores were associated with higher energy and free sugars intakes, and higher family diet pattern scores and DGI-CA scores with lower free sugars intakes. The association between dietary patterns and intermediate outcomes of free sugars and energy intakes suggests that obesity and/or ECC may not yet have manifested, and thus longitudinal investigation beyond two years of age is warranted.

A Digital Intervention for Australian Adolescents Above a Healthy Weight (Health Online for Teens): Protocol for an Implementation and User Experience Study.

BACKGROUND: More than one-fourth of Australian adolescents are overweight or obese, with obesity in adolescents strongly persisting into adulthood. Recent evidence suggests that the mid-teen years present a final window of opportunity to prevent irreversible damage to the cardiovascular system. As lifestyle behaviors may change with increased autonomy during adolescence, this life stage is an ideal time to intervene and promote healthy eating and physical activity behaviors, well-being, and self-esteem. As teenagers are prolific users and innate adopters of new technologies, app-based programs may be suitable for the promotion of healthy lifestyle behaviors and goal setting training. OBJECTIVE: This study aims to explore the reach, engagement, user experience, and satisfaction of the new app-based and Web-based Health Online for Teens (HOT) program in a sample of Australian adolescents above a healthy weight (ie, overweight or obese) and their parents. METHODS: HOT is a 14-week program for adolescents and their parents. The program is delivered online through the Moodle app-based and website-based learning environment and aims to promote adolescents' lifestyle behavior change in line with Australian Dietary Guidelines and Australia's Physical Activity and Sedentary Behaviour Guidelines for Young People (aged 13-17 years). HOT aims to build parental and peer support during the program to support adolescents with healthy lifestyle behavior change. RESULTS: Data collection for this study is ongoing. To date, 35 adolescents and their parents have participated in one of 3 groups. CONCLUSIONS: HOT is a new online-only program for Australian adolescents and their parents that aims to reduce cardiovascular disease risk factors. This protocol paper describes the HOT program in detail, along with the methods to measure reach, outcomes, engagement, user experiences, and program satisfaction. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000465257; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374771. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13340.