Preliminary validation of the pica, ARFID and rumination disorder interview ARFID questionnaire (PARDI-AR-Q).

BACKGROUND: The Pica, ARFID, and Rumination Disorder Interview (PARDI) is a structured interview that can be used to determine diagnosis, presenting characteristics, and severity across three disorders, including avoidant/restrictive food intake disorder (ARFID). The purpose of this study was to evaluate the psychometric properties of a questionnaire focused specifically on ARFID (PARDI-AR-Q), which has the potential to provide related information with less participant burden. METHODS: Adolescents and adults (n = 71, ages 14-40 years) with ARFID (n = 42) and healthy control participants (HC, n = 29) completed the PARDI-AR-Q and other measures. A subset of the ARFID group (n = 27) also completed the PARDI interview. RESULTS: An exploratory factor analysis of proposed subscale items identified three factors corresponding to the ARFID phenotypes of avoidance based on the sensory characteristics of food, lack of interest in eating or food, and concern about aversive consequences of eating. Further analyses supported the internal consistency and convergent validity of the PARDI-AR-Q subscales, and subscale ratings on the questionnaire showed large and significant correlations (all p-values < 0.001; r's ranging from 0.48 to 0.77) with the corresponding subscales on the interview. The ARFID group scored significantly higher than HC on all subscales. Furthermore, 90% of the ARFID group scored positive on the PARDI-AR-Q diagnostic algorithm while 93% of the HC scored negative. CONCLUSIONS: Though replication in larger and more diverse samples is needed, findings provide early support for the validity of the PARDI-AR-Q as a self-report measure for possible ARFID in clinical or research settings.

The factor structure and validity of a diagnostic interview for avoidant/restrictive food intake disorder in a sample of children, adolescents, and young adults.

OBJECTIVE: There is a paucity of validated diagnostic interviews for avoidant/restrictive food intake disorder (ARFID) to aid identification and classification of cases for both clinical and research purposes. To evaluate the factor structure, construct validity, and criterion validity of the Pica ARFID and Rumination Disorder Interview (PARDI; ARFID module), we administered the PARDI to 129 children and adolescents ages 9-23 years (M = 16.1) with ARFID (n = 84), subclinical ARFID (n = 11), and healthy controls (n = 34). METHOD: We used exploratory factor analysis to examine the factor structure of the PARDI in children, adolescents, and young adults with an ARFID diagnosis, the Kruskal-Wallis analysis of variance and Spearman correlations to test the construct validity of the measure, and non-parametric receiver operating characteristic curves to evaluate the criterion validity of the PARDI. RESULTS: Exploratory factor analysis yielded a 3-factor structure: (1) concern about aversive consequences of eating, (2) low appetite/low interest in food, and (3) sensory sensitivity. Participants with ARFID demonstrated significantly higher levels of sensory sensitivity, low appetite/low-food interest, and concern about aversive consequences of eating symptoms relative to control participants. The construct validity for each PARDI subscale was supported and clinical cutoffs for the low appetite/low interest in food (1.1) and sensory sensitivity subscales (0.6) were established. DISCUSSION: These data present evidence for the factor structure and validity of the PARDI diagnostic interview for diagnosing ARFID in children, adolescents, and young adults, supporting the use of this tool to facilitate ARFID clinical assessment and research. PUBLIC SIGNIFICANCE: Due to the paucity of validated diagnostic interviews for avoidant/restrictive food intake disorder (ARFID), we evaluated the factor structure and validity of the Pica ARFID and Rumination Disorder Interview (ARFID module). Findings suggest that the interview assesses 3 components of ARFID: concern about aversive consequences of eating, low-appetite, and sensory sensitivity, and that clinical threshold scores on the latter two subscales can be used to advance ARFID assessment.

Development of the Pica, ARFID, and Rumination Disorder Interview, a multi-informant, semi-structured interview of feeding disorders across the lifespan: A pilot study for ages 10-22.

OBJECTIVE: Avoidant/restrictive food intake disorder (ARFID), pica, and rumination disorder (RD) were added to the revised DSM-5 Feeding and Eating Disorders chapter in 2013. We developed a structured interview-the Pica, ARFID, and Rumination Disorder Interview (PARDI)-to assess the presence and severity of these diagnoses for evaluation and treatment planning in clinical and research settings. Here, we describe the development of the PARDI and provide a preliminary report on feasibility, acceptability, reliability, and validity in relation to ARFID. METHOD: We created an initial item pool from existing measures of similar constructs and clinical experience. The PARDI includes items assessing the level of endorsement and overall severity of common ARFID features organized into profiles (i.e., sensory sensitivity, lack of interest in eating, and fear of aversive consequences) and algorithms for diagnosing ARFID, pica, and RD. We collected initial psychometric data from participants (10-22 years) with ARFID (n = 39), clinically significant avoidant/restrictive eating (n = 8), and healthy controls (n = 10). RESULTS: On average, the PARDI took 39 min to complete and was acceptable to participants. All subscales achieved internal consistency greater ≥0.77, and inter-rater reliability for the ARFID diagnosis was moderate (κ = 0.75). Individuals with ARFID scored significantly higher than healthy controls on ARFID severity and ARFID profiles. DISCUSSION: The PARDI appears acceptable to respondents and preliminary evidence of reliability and validity has been demonstrated in an initial sample. Larger-scale validation studies are currently underway. The PARDI is freely available to clinicians and researchers.

The individual environment, not the family is the most important influence on preferences for common non-alcoholic beverages in adolescence.

Beverage preferences are an important driver of consumption, and strong liking for beverages high in energy (e.g. sugar-sweetened beverages [SSBs]) and dislike for beverages low in energy (e.g. non-nutritive sweetened beverages [NNSBs]) are potentially modifiable risk factors contributing to variation in intake. Twin studies have established that both genes and environment play important roles in shaping food preferences; but the aetiology of variation in non-alcoholic beverage preferences is unknown. 2865 adolescent twins (18-19-years old) from the Twins Early Development Study were used to quantify genetic and environmental influence on variation in liking for seven non-alcoholic beverages: SSBs; NNSBs; fruit cordials, orange juice, milk, coffee, and tea. Maximum Likelihood Structural Equation Modelling established that beverage preferences have a moderate to low genetic basis; from 18% (95% CI: 10%, 25%) for orange juice to 42% (36%, 43%) for fruit cordials. Aspects of the environment that are not shared by twin pairs explained all remaining variance in drink preferences. The sizeable unique environmental influence on beverage preferences highlights the potential for environmental modification. Policies and guidelines to change preferences for unhealthy beverages may therefore be best directed at the wider environment.

Prevention of neonatal late-onset sepsis: a randomised controlled trial.

BACKGROUND: Late-onset sepsis (LOS), defined as sepsis occurring after 48 h of age causes substantial mortality and morbidity in very low birth weight infants. Risk factors for LOS include immaturity, intravascular catheters, mechanical ventilation, and prolonged parenteral nutrition (PN). Little attention has been paid to studying the effects of PN administration methods. The aim of the study was to compare a bundle of measures for PN line management incorporating a strict aseptic technique with standard line management on LOS in very low birth weight infants. METHODS: Infants <1500 g birth weight who required PN were randomised to either a bundle of a strict aseptic technique for line management together with single use intravascular catheter for PN or a standard technique. The primary outcome was the incidence of LOS in the first 28 days of life. Secondary outcomes were mortality, neonatal morbidities and developmental outcome at 12 months of age. RESULTS: There were 126 infants in the aseptic technique group and 123 in the standard technique group. Forty (31.8%) infants in the aseptic technique group and 36 (29.3%) in the standard technique group had an episode of sepsis (p = 0.77). This corresponds to incidences of 15.8 and 14.2 episodes of sepsis per 1000 patient days respectively. Subgroup analyses for infants <1000 g also revealed no difference in the rate of sepsis between the intervention and control groups. (p = 0.43). There were no significant differences in secondary outcomes and development between the groups. CONCLUSION: A bundle of measures including strict aseptic technique for parenteral nutrition line management did not result in a reduction in LOS when compared to a standard technique. There is no evidence to recommend this as routine practice. TRIAL REGISTRATION: Interdisciplinary Maternal Perinatal Australasian Collaborative Trials (IMPACT) Network, TRN registration number: PT0363. Date: 06/03/2001; Australian New Zealand Clinical Trials Registry (ANZCTR), TRN registration number: ACTRN12617000455369 . Date: 28/03/2017 (retrospectively registered).

Understanding Food Fussiness and Its Implications for Food Choice, Health, Weight and Interventions in Young Children: The Impact of Professor Jane Wardle.

PURPOSE OF REVIEW: This review examines the concepts of fussy eating and food neophobia in the context of key determinants of the development of children's food preferences. We discuss the evidence for genetic versus parental and other environmental influences on the ontogeny of these behavioural traits and the implications of current knowledge for interventions that attempt to lessen the impact of these traits on children's diets. Finally, we consider whether these traits increase the risk of a child becoming obese, or alternatively, underweight and malnourished. RECENT FINDINGS: Fussy eating and neophobia are related concepts with both genetic and environmental aetiologies. Parent-child correlations and heritability estimates are moderate to high for both traits, but aspects of the family environment remain influential in young children, although no longer in young adults. Parental strategies based around repeat tasting opportunities can improve acceptance of disliked foods in even the fussiest children. Fussy eating and neophobia are not risk factors for obesity but could limit growth in severe cases. Fussy eating and food neophobia are common concerns for parents, though health risks are low. Dissemination of evidence-based strategies to parents that can encourage a more varied diet in young children would be helpful.

Food fussiness and food neophobia share a common etiology in early childhood.

BACKGROUND: 'Food fussiness' (FF) is the tendency to be highly selective about which foods one is willing to eat, and emerges in early childhood; 'food neophobia' (FN) is a closely related characteristic but specifically refers to rejection of unfamiliar food. These behaviors are associated, but the extent to which their etiological architecture overlaps is unknown. The objective of this study was to quantify the relative contribution of genetic and environmental influences to variation in FF and FN in early childhood; and to establish the extent to which they share common genetic and environmental influences. METHOD: Participants were 1,921 families with 16-month-old twins from the Gemini birth cohort. Parents completed the Child Eating Behaviour Questionnaire which included three FF items and four FN items. Bivariate quantitative genetic modeling was used to quantify: (a) genetic and environmental contributions to variation in FF and FN; and (b) the extent to which genetic or environmental influences on FF and FN are shared across the traits. RESULTS: Food fussiness and FN were strongly correlated (r = .72, p < .001). Proportions of variation in FF were equally explained by genetic (.46; 95% CI: 0.41-0.52) and shared environmental influences (.46; 95% CI: 0.41-0.51). Shared environmental effects accounted for a significantly lower proportion of variation in FN (.22; 95% CI: 0.14-0.30), but genetic influences were not significantly different from those on FF (.58, 95% CI: 0.50-0.67). FF and FN largely shared a common etiology, indicated by high genetic (.73; 95% CI: 0.67-0.78) and shared environmental correlations (.78; 95% CI: 0.69-0.86) across the two traits. CONCLUSIONS: Food fussiness and FN both show considerable heritability at 16 months but shared environmental factors, for example the home environment, influenced more interindividual differences in the expression of FF than in FN. FF and FN largely share a common etiology.

Genetic and environmental influences on food preferences in adolescence.

BACKGROUND: Food preferences vary substantially among adults and children. Twin studies have established that genes and aspects of the shared family environment both play important roles in shaping children's food preferences. The transition from childhood to adulthood is characterized by large gains in independence, but the relative influences of genes and the environment on food preferences in late adolescence are unknown. OBJECTIVE: The aim of this study was to quantify the contribution of genetic and environmental influences on food preferences in older adolescents. DESIGN: Participants were 2865 twins aged 18-19 y from the TEDS (Twins Early Development Study), a large population-based cohort of British twins born during 1994-1996. Food preferences were measured by using a self-report questionnaire of 62 individual foods. Food items were categorized into 6 food groups (fruit, vegetables, meat or fish, dairy, starch foods, and snacks) by using factor analysis. Maximum likelihood structural equation modeling established genetic and environmental contributions to variations in preferences for each food group. RESULTS: Genetic factors influenced a significant and substantial proportion of the variation in preference scores of all 6 food groups: vegetables (0.54; 95% CI: 0.47, 0.59), fruit (0.49; 95% CI: 0.43, 0.55), starchy foods (0.32; 95% CI: 0.24, 0.39), meat or fish (0.44; 95% CI: 0.38, 0.51), dairy (0.44; 95% CI: 0.37, 0.50), and snacks (0.43; 95% CI: 0.36, 0.49). Aspects of the environment that are not shared by 2 twins in a family explained all of the remaining variance in food preferences. CONCLUSIONS: Food preferences had a moderate genetic basis in late adolescence, in keeping with findings in children. However, by this older age, the influence of the shared family environment had disappeared, and only aspects of the environment unique to each individual twin influenced food preferences. This finding suggests that shared environmental experiences that influence food preferences in childhood may not have effects that persist into adulthood.

Nature and Nurture in Early Feeding Behavior.

Obesity has reached epidemic proportions and research into its prevention is increasingly focusing on the earliest stages of life. Avidity of appetite has been linked to a higher risk of obesity, but studies in infancy were scarce. The Gemini twin cohort was established to investigate genetic and environmental determinants of weight trajectories in early childhood with a focus on appetite and the home environment. Gemini families have been supplying questionnaire data at regular intervals, starting when the twins were 8 months old. Analyses of data on infant appetite and weight have provided a number of important findings. Firstly, a prospective study found that appetite in infancy drives weight gain more strongly than weight drives appetite, although the two processes do coexist. A further study using a subsample of twins discordant for appetite ruled out the possibility of familial confounding, suggesting a causal role for appetite in weight. Heritability estimates for appetitive traits were moderate to high (53-84%). Finally, multivariate analyses indicated that roughly one third of the genes related to weight are also related to appetite and vice versa. Environmental factors affecting appetite in infancy are understudied, but some potential strategies for minimizing over- or underconsumption by at-risk individuals are suggested.

Repair of congenital diaphragmatic hernia during extracorporeal life support: experience with six neonates.

BACKGROUND: The management of congenital diaphragmatic hernia (CDH) in neonates has evolved considerably over the last three decades. Initial stabilization followed by surgical repair is the current standard of care. A subset fails to achieve adequate oxygenation with medical management, including the use of high frequency oscillation and inhaled nitric oxide. The mortality in this group exceeds 80% without additional management strategies. Extracorporeal life support (ECLS) is a well-established modality for managing these neonates with CDH and has been shown to improve early survival in selected cases. METHODS: This is a retrospective analysis of six neonates with CDH who underwent repair during ECLS between September 2011 and November 2014. RESULTS: Of 24 admissions with CDH, there were six neonates (25%) who required ECLS. All the six had CDH repair during ECLS. There were no intra-operative bleeding complications. There were no clotting complications related to stopping heparin during CDH repair. There was one hospital death. Five neonates were weaned from ECLS and discharged home. CONCLUSIONS: Data from our small cohort of patients illustrate that early survival is possible in extremely compromised neonates who otherwise would have died without ECLS. Our experience demonstrates that CDH repair can safely be performed during ECLS. Use of ECLS, early repair during ECLS, lung protective ventilation strategies and aggressive management of pulmonary hypertension were associated with good early survival. ECLS should be considered as an integral part of therapeutic armamentarium for CDH in neonates.

Common genetic architecture underlying young children's food fussiness and liking for vegetables and fruit.

BACKGROUND: Food fussiness (FF) is common in early childhood and is often associated with the rejection of nutrient-dense foods such as vegetables and fruit. FF and liking for vegetables and fruit are likely all heritable phenotypes; the genetic influence underlying FF may explain the observed genetic influence on liking for vegetables and fruit. Twin analyses make it possible to get a broad-based estimate of the extent of the shared genetic influence that underlies these traits. OBJECTIVE: We quantified the extent of the shared genetic influence that underlies FF and liking for vegetables and fruit in early childhood with the use of a twin design. DESIGN: Data were from the Gemini cohort, which is a population-based sample of twins born in England and Wales in 2007. Parents of 3-y-old twins (n= 1330 pairs) completed questionnaire measures of their children's food preferences (liking for vegetables and fruit) and the FF scale from the Children's Eating Behavior Questionnaire. Multivariate quantitative genetic modeling was used to estimate common genetic influences that underlie FF and liking for vegetables and fruit. RESULTS: Genetic correlations were significant and moderate to large in size between FF and liking for both vegetables (-0.65) and fruit (-0.43), which indicated that a substantial proportion of the genes that influence FF also influence liking. Common genes that underlie FF and liking for vegetables and fruit largely explained the observed phenotypic correlations between them (68-70%). CONCLUSIONS: FF and liking for fruit and vegetables in young children share a large proportion of common genetic factors. The genetic influence on FF may determine why fussy children typically reject fruit and vegetables.

The relationship between appetite and food preferences in British and Australian children.

BACKGROUND: Appetitive traits and food preferences are key determinants of children's eating patterns but it is unclear how these behaviours relate to one another. This study explores relationships between appetitive traits and preferences for fruits and vegetables, and energy dense, nutrient poor (noncore) foods in two distinct samples of Australian and British preschool children. METHODS: This study reports secondary analyses of data from families participating in the British GEMINI cohort study (n = 1044) and the control arm of the Australian NOURISH RCT (n = 167). Food preferences were assessed by parent-completed questionnaire when children were aged 3-4 years and grouped into three categories; vegetables, fruits and noncore foods. Appetitive traits; enjoyment of food, food responsiveness, satiety responsiveness, slowness in eating, and food fussiness were measured using the Children's Eating Behaviour Questionnaire when children were 16 months (GEMINI) or 3-4 years (NOURISH). Relationships between appetitive traits and food preferences were explored using adjusted linear regression analyses that controlled for demographic and anthropometric covariates. RESULTS: Vegetable liking was positively associated with enjoyment of food (GEMINI; ß = 0.20 ± 0.03, p < 0.001, NOURISH; ß = 0.43 ± 0.07, p < 0.001) and negatively related to satiety responsiveness (GEMINI; ß = -0.19 ± 0.03, p < 0.001, NOURISH; ß = -0.34 ± 0.08, p < 0.001), slowness in eating (GEMINI; ß = -0.10 ± 0.03, p = 0.002, NOURISH; ß = -0.30 ± 0.08, p < 0.001) and food fussiness (GEMINI; ß = -0.30 ± 0.03, p < 0.001, NOURISH; ß = -0.60 ± 0.06, p < 0.001). Fruit liking was positively associated with enjoyment of food (GEMINI; ß = 0.18 ± 0.03, p < 0.001, NOURISH; ß = 0.36 ± 0.08, p < 0.001), and negatively associated with satiety responsiveness (GEMINI; ß = -0.13 ± 0.03, p < 0.001, NOURISH; ß = -0.24 ± 0.08, p = 0.003), food fussiness (GEMINI; ß = -0.26 ± 0.03, p < 0.001, NOURISH; ß = -0.51 ± 0.07, p < 0.001) and slowness in eating (GEMINI only; ß = -0.09 ± 0.03, p = 0.005). Food responsiveness was unrelated to liking for fruits or vegetables in either sample but was positively associated with noncore food preference (GEMINI; ß = 0.10 ± 0.03, p = 0.001, NOURISH; ß = 0.21 ± 0.08, p = 0.010). CONCLUSION: Appetitive traits linked with lower obesity risk were related to lower liking for fruits and vegetables, while food responsiveness, a trait linked with greater risk of overweight, was uniquely associated with higher liking for noncore foods.

An exploratory trial of parental advice for increasing vegetable acceptance in infancy.

Research suggests that repeatedly offering infants a variety of vegetables during weaning increases vegetable intake and liking. The effect may extend to novel foods. The present study aimed to investigate the impact of advising parents to introduce a variety of single vegetables as first foods on infants' subsequent acceptance of a novel vegetable. Mothers of 4- to 6-month-old infants in the UK, Greece and Portugal were randomised to either an intervention group (n 75), who received guidance on introducing five vegetables (one per d) as first foods repeated over 15 d, or a control group (n 71) who received country-specific 'usual care'. Infant's consumption (g) and liking (maternal and researcher rated) of an unfamiliar vegetable were assessed 1 month post-intervention. Primary analyses were conducted for the full sample with secondary analyses conducted separately by country. No significant effect of the intervention was found for vegetable intake in the three countries combined. However, sub-group analyses showed that UK intervention infants consumed significantly more novel vegetable than control infants (32.8 (SD 23.6) v. 16.5 (sd 12.1) g; P =0.003). UK mothers and researchers rated infants' vegetable liking higher in the intervention than in control condition. In Portugal and Greece, there was no significant intervention effect on infants' vegetable intake or liking. The differing outcome between countries possibly reflects cultural variations in existing weaning practices. However, the UK results suggest in countries where vegetables are not common first foods, advice on introducing a variety of vegetables early in weaning may be beneficial for increasing vegetable acceptance.

Could the Food Neophobia Scale be adapted to pregnant women? A confirmatory factor analysis in a Portuguese sample.

BACKGROUND: The Food Neophobia Scale (FNS) is widely used in different countries, however appropriate psychometric analyses are required to allow cross-cultural comparisons. To our knowledge, most studies have been conducted among children and adult populations, with no reference to pregnant women. The objective of this study was to translate and test the psychometric properties of a Portuguese version of the FNS, and to identify clusters of food neophobia during pregnancy. METHODS: The FNS was translated into Portuguese by three health researchers, and back-translated into English by an independent native English speaker and professional translator. The scale was self-administered in a sample of 219 women from the baseline evaluation of the Taste intervention study (HabEat project: http://www.habeat.eu/), who attended medical visits in two hospitals from Porto, Portugal, reporting food neophobia during the last trimester of pregnancy. The FNS consists of 10 items with a 7-point rating scale. An exploratory analysis was performed to evaluate the scale's dimensionality, followed by a confirmatory factor analysis to test the fit of the previous model by using different indexes. Cronbach's alpha coefficient was calculated to evaluate the internal reliability of the scale. The construct validity was assessed by comparing the FNS scores by categories of education, age and fruit and vegetables intake by ANOVA. A Model-based clustering was used to identify patterns of food neophobia; the number of latent classes was defined according to the Bayesian information criterion. RESULTS: A two-factor model solution was obtained (after excluding item 8 with a factor loading <0.4), explaining 51% of the total variance. Cronbach's alpha was 0.75 for factor 1 (5 items) and 0.71 for factor 2 (4 items). Items 1, 4, 6, 9 and 10 loaded into the first factor (i.e. more willingness to try new foods; less neophobic traits) and items 2, 3, 5 and 7 loaded into a second factor (i.e. more neophobic traits). A good global of fitness of the model was confirmed by fit indexes: TLI=0.876, CFI=0.911, RMSEA=0.088 and SRMR=0.051. The higher the education, age, and fruit and vegetables intake the lower the neophobic tendency, measured by the Portuguese FNS. Three patterns (i.e. clusters) of food neophobia, characterizing neophobia traits of pregnant women were identified: Moderate Neophilic, Moderate Neophobic, and Extreme Neophilic (cut-off points were provided). CONCLUSION: The Portuguese version of the FNS has the basic requirements of a valid and reliable measure of food neophobia and permits the identification of clusters of neophobic traits during pregnancy.

Nature and nurture in children's food preferences.

BACKGROUND: Health professionals identify food provision in the home as a key influence on children's food preferences. In contrast, parents often perceive children's food preferences to be inborn. One explanation for this discrepancy could be that environmental and genetic influences vary by food type. OBJECTIVE: We assessed genetic and environmental contributions to preferences for a wide variety of foods in a large pediatric twin sample. DESIGN: Data were from Gemini, which is a cohort of UK twins born in 2007. Preferences for 114 foods were assessed by parent-completed questionnaire when children were aged 3 y (n = 2686). Foods tried by >75% of respondents were grouped into protein, vegetables, fruit, dairy, starches, and snacks. Quantitative model-fitting analyses were used to assess genetic and environmental influences for each food group. RESULTS: The genetic influence was higher for vegetables (54%; 95% CI: 47%, 63%), fruit (53%; 95% CI: 45%, 61%), and protein (48%; 95% CI: 40%, 57%) but lower for starches (32%; 95% CI: 26%, 38%), snacks (29%; 95% CI: 24%, 35%), and dairy (27%; 95% CI: 20%, 35%). In contrast, shared-environment effects were higher for snacks (60%; 95% CI: 54%, 65%), starches (57%; 95% CI: 51%, 62%), and dairy (54%; 95% CI: 47%, 60%) and lower for vegetables (35%; 95% CI: 27%, 42%), fruit (35%; 95% CI: 26%, 43%), and protein (37%; 95% CI: 27%, 45%). Nonshared environment effects were small for all foods (11-19%). CONCLUSIONS: Both genetic and environmental effects were significant for all food groups, but genetic effects dominated for more nutrient-dense foods (vegetables, fruit, and protein), whereas shared environmental effects dominated for snacks, dairy, and starches. These findings endorse the view of health professionals that the home environment is the main determinant of children's liking for energy-dense foods implicated in excessive weight gain but suggest that parents are also correct by identifying innate differences in liking, particularly for nutrient-dense foods that parents and health educators try to encourage.

Parent-administered exposure to increase children's vegetable acceptance: a randomized controlled trial.

BACKGROUND: Repeated taste exposure, in combination with small rewards, has been shown to increase children's acceptance of disliked foods. However, previous studies have used direct contact with researchers or professionals for the implementation of the repeated exposure procedure. If mailed taste exposure instructions to parents produced comparable outcomes, this could be a cost-effective and easily disseminable strategy to promote healthier diets in children. OBJECTIVE: Our randomized controlled study aimed to test the efficacy and acceptability of mailed materials giving instructions on taste exposure as a means of increasing acceptance of vegetables in preschool-aged children. DESIGN: Participants were families of 3-year-old twins from the Gemini cohort who took part between March 2011 and April 2012. Families were randomized to a mailed intervention or a no treatment control condition. The intervention involved offering each child 14 daily tastes of a disliked (target) vegetable with a small reward (a sticker) if the child complied. MAIN OUTCOME MEASURES: Outcomes were the child's intake of the target vegetable (number of pieces) and parent reports of the child's liking at two baseline (T1 and T2) and one postintervention (T3) behavior assessment. RESULTS: Record sheets with intake and liking data from T1, T2, and T3 were returned for 472 children, of which 442 were complete (94%). Over the intervention period (T2 to T3) intake and liking of the target vegetable increased significantly more in the intervention group than in the control group (intake: odds ratio 12.05, 95% CI 8.05 to 18.03, P<0.001; liking: odds ratio 12.34, CI 7.97 to 19.12, P<0.001). Acceptability of the procedure was very high among parents who completed the protocol. CONCLUSIONS: Mailed instructions for taste exposure were effective in increasing children's acceptance of an initially disliked vegetable. These results support the value of parent-administered exposure to increase children's vegetable acceptance, and suggest that it can be carried out without direct health professional contact.

Methodological development of an exploratory randomised controlled trial of an early years' nutrition intervention: the CHERRY programme (Choosing Healthy Eating when Really Young).

Good nutrition in the early years of life is vitally important for a child's development, growth and health. Children's diets in the United Kingdom are known to be poor, particularly among socially disadvantaged groups, and there is a need for timely and appropriate interventions that support parents to improve the diets of young children. The Medical Research Council has highlighted the importance of conducting developmental and exploratory research prior to undertaking full-scale trials to evaluate complex interventions, but have provided very limited detailed guidance on the conduct of these initial phases of research. This paper describes the initial developmental stage and the conduct of an exploratory randomised controlled trial undertaken to determine the feasibility and acceptability of a family-centred early years' nutrition intervention. Choosing Healthy Eating when Really Young (CHERRY) is a programme for families with children aged 18 months to 5 years, delivered in children's centres in one urban (Islington) and one rural (Cornwall) location in the United Kingdom. In the development stage, a mixed-methods approach was used to investigate the nature of the problem and options for support. A detailed review of the evidence informed the theoretical basis of the study and the creation of a logic model. In the feasibility and pilot testing stage of the exploratory trial, 16 children's centres, with a sample of 394 families were recruited onto the study. We hope that the methodology, which we present in this paper, will inform and assist other researchers in conducting community-based, exploratory nutrition research in early years settings.

Healthy feeding habits: efficacy results from a cluster-randomized, controlled exploratory trial of a novel, habit-based intervention with parents.

BACKGROUND: As dietary gatekeepers for young children, parents are often the proximal target of family-based dietary interventions. Habit theory offers a novel approach to modifying parental feeding, based on "context-dependent repetition" to promote automatic responding and to reduce decisional conflict. OBJECTIVE: This exploratory trial evaluated an intervention promoting habit formation for 3 parental feeding behaviors: serving fruit/vegetables, serving healthy snacks, and serving nonsweetened drinks. The primary outcome was parental habit strength for each behavior. The secondary outcome was children's food intake. DESIGN: Parents of children aged 2-6 y (n = 126) were recruited from 6 children's centers in London and cluster-randomized to intervention (n = 3) or no-treatment control (n = 3) conditions. Parents in the intervention group (n = 58) received training on habit formation for 3 feeding behaviors; control participants (n = 68) were asked only to complete the measures. At baseline and after treatment, parents completed validated measures of subjective "automaticity" for feeding behaviors and a brief child food-frequency measure. Parents in the intervention group were interviewed about the program. The change between groups, after clustering was controlled for, was analyzed. RESULTS: For all parental feeding behaviors, automaticity increased more in the intervention group than in the control group (P < 0.01 for all). Significant intervention effects on children's intake of vegetables (P = 0.003), healthy snacks (P = 0.009), and water (P = 0.032) were observed. Changes in children's food intake correlated with changes in parental automaticity of feeding behaviors, and program acceptability was high. CONCLUSIONS: A habit-based intervention successfully modified parental feeding behaviors, affected children's diets positively, and was well received by parents. Habit theory provides a promising new tool to support family-based obesity prevention. This trial was registered as ISRCTN09910187.

Rewards can be used effectively with repeated exposure to increase liking of vegetables in 4-6-year-old children.

OBJECTIVE: To examine whether parents offering a sticker reward to their child to taste a vegetable the child does not currently consume is associated with improvements in children's liking and consumption of the vegetable. DESIGN: A randomized controlled trial evaluated the effectiveness of exposure only (EO) and exposure plus reward (E + R), relative to a control group, on children's liking and consumption of a target vegetable. Assessments were conducted at baseline and 2 weeks from baseline (post-intervention). Follow-up assessments were conducted at 4 weeks and 3 months from baseline. SETTING: The study took place in Adelaide, South Australia. Participants were self-selected in response to local media advertisements seeking to recruit parents finding it difficult to get their children to eat vegetables. SUBJECTS: Participants were 185 children (110 boys, seventy-five girls) aged 4-6 years and their primary caregiver/parent (172 mothers, thirteen fathers). RESULTS: The E + R group was able to achieve more days of taste exposure. Both EO and E + R increased liking at post-intervention compared with control and no further change occurred over the follow-up period. All groups increased their intake of the target vegetable at post-intervention. Target vegetable consumption continued to increase significantly over the follow-up period for E + R and control but not for EO. CONCLUSIONS: The findings provide support for the effectiveness of using a sticker reward with a repeated exposure strategy. In particular, such rewards can facilitate the actual tastings necessary to change liking.