Research Priorities for Studies Linking Intake of Low-Calorie Sweeteners and Potentially Related Health Outcomes: Research Methodology and Study Design.

Background: In a world of finite research funding, efforts to prioritize future research topics are increasingly necessary. Objective: The aim of this study was to identify and prioritize the direction of future research in the broad area of low-calorie sweetener (LCS) intake and potentially related health outcomes by using a novel method that incorporates evidence mapping in the Agency for Healthcare Research and Quality's Future Research Needs (FRN) process. Methods: A diverse expert stakeholder panel was convened and engaged to identify research gaps and prioritize future research needs. An independent research team hosted a number of interactive webinars and elicited feedback through surveys and individual interviews with the stakeholder panel, which included policymakers, lay audience members, health providers, a research funder, individuals with food industry experience, and researchers of several different specialties. Results: The stakeholder panel generated and ranked a list of 18 FRN questions across 5 broad research areas. Overall, stakeholder panel members unanimously agreed that the research questions that will have the largest public health impact are those that address outcomes related to body weight, appetite, and dietary intake. Although the LCSs included in this FRN project have all been Generally Recognized as Safe by the FDA or approved as food additives, the recurrent concerns and confusions with regard to the "safety" of LCSs by consumers underscore the importance of communicating the science to the general public. Conclusion: Our project provides evidence that engaging a diverse expert stakeholder panel is an effective method of translating gaps in nutrition research into prioritized areas of future research.

Metabolic impact of 100% fruit juice consumption on antioxidant/oxidant status and lipid profiles of adults: An Evidence-Based review.

One hundred percent fruit juice (FJ) contains bioactive compounds with antioxidant activity. As such, this fruit form has the potential to improve antioxidant status and mediate outcomes influenced by redox status. A systematic review of the literature published between 1995 and 2013 was conducted using PubMed database to evaluate associations between intake of 100% FJ and markers of antioxidant/oxidant status and blood lipid levels in healthy, free-living adults ≥18 years. Data extraction and analysis was conducted according to the Academy of Nutrition and Dietetics Evidence Analysis Process. Limited evidence from ten clinical trials meeting inclusion/exclusion criteria suggests potential improvements in a variety of antioxidant or oxidants biomarkers postconsumption of 100% FJ. Weak evidence from five studies suggests that one or more blood lipid measures may be positively influenced by consumption of 100% FJ. Heterogeneity in study methodology including biomarkers, 100% FJ type, dosage, and intervention duration precludes the ability to make evidence-based recommendations regarding a specific dose-duration-juice effect. Key characteristics in study designs were identified which must either be controlled or statistically adjusted for in future investigations in order to obtain a more accurate understanding of the complex relationship between metabolic outcomes and consumption of 100% FJ in context of a healthy dietary pattern.

Impact of 100% Fruit Juice Consumption on Diet and Weight Status of Children: An Evidence-based Review.

Consumption of 100% fruit juice remains controversial for its potential adverse impact on weight and displacement of essential foods in the diets of children. A systematic review of the literature published from 1995-2013 was conducted using the PubMed database to evaluate associations between intake of 100% fruit juice and weight/adiposity and nutrient intake/adequacy among children of 1 to 18 years of age. Weight status outcome measures included body mass index (BMI), BMI z-score, ponderal index, obesity, weight gain, adiposity measures, and body composition. Nutrient outcome measures included intake and adequacy of shortfall nutrients. Data extraction and analysis was conducted according to the Academy of Nutrition and Dietetics Evidence Analysis Process. Twenty-two studies on weight status provided evidence that did not support an association between 100% fruit juice consumption and weight/adiposity in children after controlling for energy intake. Limited evidence from eight studies suggests that children consuming 100% fruit juice have higher intake and adequacy of dietary fiber, vitamin C, magnesium, and potassium. Differences in methodology and study designs preclude causal determination of 100% fruit juice as sole influencer of weight status or nutrient intake/adequacy of shortfall nutrients. In context of a healthy dietary pattern, evidence suggests that consumption of 100% fruit juice may provide beneficial nutrients without contributing to pediatric obesity.

Development and Validation of the Guide for Effective Nutrition Interventions and Education (GENIE): A Tool for Assessing the Quality of Proposed Nutrition Education Programs.

OBJECTIVE: To develop and validate the Guide for Effective Nutrition Interventions and Education (GENIE), a checklist of research-based quality indicators for nutrition education programs. DESIGN: A prospective test of criterion validity and inter-rater reliability of a new tool comparing expert assessments and trained reviewer GENIE scores of the same nutrition education proposals. PARTICIPANTS: Ten nutrition education experts; 13 volunteer reviewers. VARIABLES MEASURED: GENIE's face, content, and criterion validity and inter-rater reliability compared using expert assessments and reviewer objective and subjective scores. ANALYSIS: Reviewer scores compared using Spearman correlation. Inter-rater reliability tested using intra-class correlation (ICC), Cronbach alpha, and ANOVA. Criterion validity tested using independent t test and point bi-serial correlation to compare reviewer with expert scores. RESULTS: Correlation found between total objective and total subjective scores. Agreement found between reviewers across proposals and categories considering subjective scores (F = 7.21, P < .001; ICC = 0.76 [confidence interval, 0.53-0.92]) and objective scores (F = 7.88, P < .001; ICC = 0.82 [confidence interval, 0.63-0.94]). Relationship was not significant (r = .564, P = .06) between expert and reviewer proposal scoring groups (high, medium, and low). CONCLUSIONS AND IMPLICATIONS: Results support the validity and reliability of GENIE as a tool for nutrition education practitioners, researchers, and program funding agencies to accurately assess the quality of a variety of nutrition program plans.

Do sugar-sweetened beverages cause adverse health outcomes in adults? A systematic review protocol.

BACKGROUND: Chronic diseases, such as cardiovascular disease and type 2 diabetes, impose significant burden to public health. Most chronic diseases are associated with underlying preventable risk factors, such as elevated blood pressure, blood glucose, and lipids, physical inactivity, excessive sedentary behaviours, overweight and obesity, and tobacco usage. Sugar-sweetened beverages are known to be significant sources of additional caloric intake, and given recent attention to their contribution in the development of chronic diseases, a systematic review is warranted. We will assess whether the consumption of sugar-sweetened beverages in adults is associated with adverse health outcomes and what the potential moderating factors are. METHODS/DESIGN: Of interest are studies addressing sugar-sweetened beverage consumption, taking a broad perspective. Both direct consumption studies as well as those evaluating interventions that influence consumption (e.g. school policy, educational) will be relevant. Non-specific or multi-faceted behavioural, educational, or policy interventions may also be included subject to the level of evidence that exists for the other interventions/exposures. Comparisons of interest and endpoints of interest are pre-specified. We will include randomized controlled trials, controlled clinical trials, interrupted time series studies, controlled before-after studies, prospective and retrospective comparative cohort studies, case-control studies, and nested case-control designs. The MEDLINE, Embase, The Cochrane Library, CINAHL, ERIC, and PsycINFO databases and grey literature sources will be searched. The processes for selecting studies, abstracting data, and resolving conflicts are described. We will assess risk of bias using design-specific tools. To determine sets of confounding variables that should be adjusted for, we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessments. Meta-analysis will be conducted where appropriate; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014009638.

Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol.

BACKGROUND: Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide. Most chronic diseases are associated with underlying preventable risk factors, such as elevated blood pressure, high blood glucose or glucose intolerance, high lipid levels, physical inactivity, excessive sedentary behaviours, and overweight/obesity. The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood. Sugar-sweetened beverages are known to be significant sources of additional caloric intake, and given recent attention to their contribution in the development of chronic diseases, a systematic review is warranted. We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are. METHODS/DESIGN: Of interest are studies addressing sugar-sweetened beverage consumption, taking a broad perspective. Both direct consumption studies as well as those evaluating interventions that influence consumption (e.g. school policy, educational) will be relevant. Non-specific or multi-faceted behavioural, educational, or policy interventions may also be included subject to the level of evidence that exists for the other interventions/exposures. Comparisons of interest and endpoints of interest are pre-specified. We will include randomized controlled trials, controlled clinical trials, interrupted time series studies, controlled before-after studies, prospective and retrospective comparative cohort studies, case-control studies, and nested case-control designs. The MEDLINE®, Embase, The Cochrane Library, CINAHL, ERIC, and PsycINFO® databases and grey literature sources will be searched. The processes for selecting studies, abstracting data, and resolving conflicts are described. We will assess risk of bias using design-specific tools. To determine sets of confounding variables that should be adjusted for, we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessments. Meta-analysis will be conducted where appropriate; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used to determine the quality of evidence for outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014009641.

Bone mineral density in elite adolescent female figure skaters.

UNLABELLED: Elite adolescent figure skaters must accommodate both the physical demands of competitive training and the accelerated rate of bone growth that is associated with adolescence, in this sport that emphasizes leanness. Although, these athletes apparently have sufficient osteogenic stimuli to mitigate the effects of possible low energy availability on bone health, the extent or magnitude of bone accrual also varies with training effects, which differ among skater disciplines. PURPOSE: We studied differences in total and regional bone mineral density in 36 nationally ranked skaters among 3 skater disciplines: single, pairs, and dancers. METHODS: Bone mineral density (BMD) of the total body and its regions was measured by dual energy x-ray absorptiometry (DXA). Values for total body, spine, pelvis and leg were entered into a statistical mixed regression model to identify the effect of skater discipline on bone mineralization while controlling for energy, vitamin D, and calcium intake. RESULTS: The skaters had a mean body mass index of 19.8 ± 2.1 and % fat mass of 19.2 ± 5.8. After controlling for dietary intakes of energy, calcium, and vitamin D, there was a significant relationship between skater discipline and BMD (p = 0.002), with single skaters having greater BMD in the total body, legs, and pelvis than ice dancers (p < 0.001). Pair skaters had greater pelvic BMD than ice dancers (p = 0.001). CONCLUSIONS: Single and pair skaters have greater BMD than ice dancers. The osteogenic effect of physical training is most apparent in single skaters, particularly in the bone loading sites of the leg and pelvis.

Eating attitudes and food intakes of elite adolescent female figure skaters: a cross sectional study.

BACKGROUND: Elite adolescent female figure skaters compete in an aesthetic-based sport that values thin builds and lithe figures. To conform to the sport's physical requirements, skaters may alter their eating patterns in unhealthful directions. This study assesses the eating attitudes and dietary intakes of elite adolescent female figure skaters to assess the potential nutritional risks among them. METHODS: Thirty-six elite competitive adolescent female figure skaters (mean age 16 ± 2.5 SD years) completed self-administered three-day records of dietary intake and simultaneous physical activity records during training season. Two months later, they attended a national training camp during which they completed the Eating Attitudes Test (EAT-40), provided fasting blood samples, and had heights and weights measured. RESULTS: Participants' mean body mass index (BMI) was 19.8 ± 2.1 SD. Their BMIs were within the normal range, and the majority (70%) did not report a history of recent weight loss. The mean EAT-40 score was normal (19.5 ± 13.5 SD) and below the cut-off score of 30 that indicates clinically significant eating pathology. However, one-quarter of the skaters had EAT-40 scores above 30. The skaters reported a mean energy intake of 1491 ± 471 SD kcal/day (31 ± 10 SD kcal/kg), with 61.6% of calories from carbohydrate, 14.6% from protein, and 23.7% from fat. Their reported dietary intakes were high in carbohydrates but low in total energy, fat, and bone-building nutrients. CONCLUSIONS: Although these highly active young women compete in a sport that prizes leanness, they had appropriate weights. The athletes reported dietary intakes that were far below estimated energy needs and were at moderate risk of disordered eating. Anticipatory guidance is warranted to improve their dietary intakes, particularly of bone-building nutrients.

Feeding Infants and Toddlers Study (FITS): development of the FITS survey in comparison to other dietary survey methods.

OBJECTIVE: This article describes the steps in the planning and development of the 2002 Feeding Infants and Toddlers Study. METHODS: We describe the study's rationale, sampling methodology, survey questionnaire development, dietary methodology, field data collection, and data processing and analysis. A brief review of existing national nutrition surveys and studies of infants and toddlers, and available study designs and dietary methods, is also included. SUBJECTS/SETTING: Most national studies have been cross-sectional and assessed breastfeeding rates, dietary intake, and nutritional status among general and high-risk populations. Other specialized studies have been longitudinal and tracked dietary intake and nutritional status from infancy to the preschool years, or focused on studying a specific research topic, such as the relationship between fluoride intake and dental caries. CONCLUSIONS: The 2002 Feeding Infants and Toddlers Study has advanced the knowledge base on infant and toddler nutrition by using state-of-the-art methodology and by providing researchers with updated information to develop further research questions. Our findings can be used by child health and nutrition organizations to develop dietary recommendations and improved nutrition education materials. Clinicians and practitioners in the fields of public health and wellness can use the information to provide practical advice to parents in a variety of settings to help give children a more healthful start.

Sources of energy and nutrients in the diets of infants and toddlers.

OBJECTIVE: To identify major sources of energy and 24 nutrients and dietary constituents in the diets of US infants and toddlers and to describe shifts in major nutrient sources as children age. DESIGN: Data from 24-hour recalls collected in the 2002 Feeding Infants and Toddlers Study were analyzed to determine the percentage contribution of foods and supplements to total intakes of energy, nutrients, and other dietary constituents. A total of 3,586 unique foods and dietary supplements were reported. Reported foods and supplements were classified into 71 groups based on similarities in nutrient content and use. Nine-hundred seventy-nine food mixtures were disaggregated into their ingredients and ingredients were classified into one of the 71 groups using the same decision rules that guided classification of foods analyzed at the whole food level. SUBJECTS/SETTING: A national random sample of 3,022 US infants and toddlers 4 to 24 months of age. STATISTICAL ANALYSES PERFORMED: The population proportion formula was used to determine the percentage contribution of each of the 71 groups to total intakes. This was done by summing the weighted amount of a given nutrient provided by a given group for all individuals in the sample and dividing by the total weighted amount of that nutrient consumed by all individuals from all foods and supplements. Groups that provided at least 1% of the nutrient in question were rank-ordered. Separate tabulations were prepared for three age groups (4-5 months, 6-11 months, and 12-24 months). RESULTS: Infant formula, breast milk, and milk are major contributors of energy and most nutrients in the diets of infants and toddlers. Among toddlers, juices and fruit-flavored drinks are the second and third most important sources of energy. Fortified foods make substantial contributions to intakes of many essential nutrients, and these contributions increase as children age. For example, among toddlers, fortified grain-based foods make substantial contributions to intakes of vitamin A, iron, and folate, relative to foods that are naturally rich in these nutrients. Supplements also make substantial contributions to intakes of vitamins and selected minerals, particularly among toddlers. CONCLUSIONS: In assessing dietary intakes of infants and toddlers, dietetics professionals need to carefully consider contributions of fortified foods and supplements. Dietetics professionals should educate caregivers of infants and toddlers about the importance of foods (rather than just nutrients) in promoting health and about the importance of early feeding practices in the development of lifelong eating habits. Caregivers should be encouraged to avoid relying on fortified foods and supplements to meet nutrient needs and educated about the potential risk of excessive intakes. Caregivers of toddlers and infants over 4 to 6 months of age who are consuming solid foods should be encouraged to feed a wide variety of fruits, vegetables, and whole grains, as well as foods naturally rich in iron.

Current electrolyte intakes of infants and toddlers.

OBJECTIVE: To determine how sodium, chloride, and potassium intakes of today's infants and toddlers compare with the Dietary Reference Intakes (DRIs) of these nutrients established recently by the Food and Nutrition Board of the Institute of Medicine. STUDY DESIGN: Population estimates of usual intake distributions of sodium, chloride (assumed to be equamolar to sodium), and potassium of 4- to 5-, 6- to 11-, and 12- to 24-month-old infants and toddlers were calculated and compared with DRIs of these nutrients by 0- to 6-month-old, 7- to 12-month-old, and 1- to 3-year-old children. SUBJECTS: Infants and toddlers (n=3,022) who participated in the 2002 Feeding Infants and Toddlers Study. STATISTICAL ANALYSES: Means and distributions (percentiles) of the usual intakes of sodium, chloride, and potassium were calculated using Institute of Medicine-recommended procedures and compared with the DRIs (ie, Adequate Intake [AI] and tolerable upper intake level [UL]). RESULTS: Mean sodium and chloride intakes of 4- to 5-month-old infants (188 mg/day and 290 mg/day, respectively) were 57% greater than the AIs (120 mg/day and 180 mg/day) and mean potassium intake (730 mg/day) was 83% higher than the AI (400 mg/day). Mean sodium, chloride, and potassium intakes of 6- to 11-month-old infants were 493 mg/day, 761 mg/day, and 1,225 mg/day, respectively-33%, 33%, and 75% higher than the AIs of these nutrients for this age group (sodium, 370 mg/day; chloride, 570 mg/day; potassium, 700 mg/day). Even the 10th percentile of potassium intake of this age group was greater than the AI. The usual mean sodium and chloride intakes of 12- to 24-month-old toddlers (1,638 mg/day and 2,528 mg/day, respectively) were 64% higher than the AIs (1,000 mg/day and 1,540 mg/day, respectively) and the usual mean sodium and chloride intakes of 58% of this age group were above the ULs. In contrast, mean potassium intake of 12- to 24-month-old toddlers (1,971 mg/day) was only 66% of the AI (3,000 mg/day). At all ages, sources of sodium, chloride, and potassium intakes reflected current feeding guidelines, primarily human milk and formula prior to 6 months of age and primarily cow's milk and table foods after 1 year of age. CONCLUSIONS: Mean sodium and chloride intakes of infants and toddlers who participated in the 2002 Feeding Infants and Toddlers Study exceeded the recently established AIs of these nutrients and the mean intake of 58% of toddlers exceeded the ULs. Mean potassium intake of infants also exceeded the AI of potassium, but the mean potassium intake of toddlers was only 66% of the AI. Whether current intakes of sodium, chloride, and potassium by infants and toddlers are problematical is not clear. Nonetheless, it seems desirable to bring these intakes closer to AIs. This can be accomplished by continuing breast- or formula-feeding and delaying the introduction of cow's milk; limiting the amount of salt added to home-prepared foods; limiting the intake of high-sodium foods, such as processed meats and salty snacks; and increasing the intake of fruits (high potassium and low sodium content) and vegetables (moderate potassium and sodium content).

Feeding Infants and Toddlers Study: do vitamin and mineral supplements contribute to nutrient adequacy or excess among US infants and toddlers?

OBJECTIVE: To report the prevalence of dietary supplement use in a random sample of US infants 4 to 24 months of age, and to compare demographic characteristics, usual nutrient intakes, and food patterns of supplement users and nonusers. DESIGN: Data from 24-hour recalls collected for the 2002 Feeding Infants and Toddlers Study were analyzed. Recalls included nutrient contributions from dietary supplements as well as all foods and beverages. We estimated usual energy and nutrient intakes of supplement users and nonusers, as well as the prevalence of nutrient adequacy and excess in the two groups. We also compared demographic characteristics and food patterns of supplement users and nonusers and, for supplement users, estimated the proportion of total intake provided by foods and the proportion provided by supplements. SUBJECTS: A national random sample of 3,022 infants and toddlers age 4 to 24 months, including 430 vitamin and/or mineral supplement users and 2,592 nonusers. STATISTICAL ANALYSIS: We compared means, percentile distributions, and proportions by age and supplement subgroup, and applied the Dietary Reference Intakes to assess usual nutrient intakes. We conducted regression analysis to determine which population characteristics predict the use of dietary supplements in this population. RESULTS: Overall, 8% of infants age 4 to 5 months received some type of dietary supplement. The prevalence of supplement use increased with age, to 19% among infants 6 to 11 months and 31% among toddlers 12 to 24 months. The vast majority of supplement users (97%) received only one type of supplement, most commonly a multivitamin and/or mineral supplement. Vitamin/mineral supplement use among infants and toddlers was associated with being a first-born child and being reported by the primary caretaker as being a picky eater. Characteristics that were independent predictors of supplement use were living in the Northeast, being male, and living in a household with fewer children. We found no significant differences between supplement users and nonusers in mean daily intakes of nutrients or nutrient density from foods alone, and few differences in food consumption. Overall, the prevalence of inadequate intakes was low (<1% to 2%). However, 65% of supplement nonusers and 9% of supplement users had vitamin E intakes less than the Estimated Average Requirement. Excessive intakes (ie, intakes above the Tolerable Upper Intake Level) were noted for both supplement users and nonusers for vitamin A (97% and 15% of toddlers) and zinc (60% and 59% of older infants and 68% and 38% of toddlers) as well as for folate among supplement users (18% of toddlers). CONCLUSIONS: Generally, healthy infants and toddlers can achieve recommended levels of intake from food alone. Dietetics professionals should encourage caregivers to use foods rather than supplements as the primary source of nutrients in children's diets. Vitamin and mineral supplements can help infants and toddlers with special nutrient needs or marginal intakes achieve adequate intakes, but care must be taken to ensure that supplements do not lead to excessive intakes. This is especially important for nutrients that are widely used as food fortificants, including vitamin A, zinc, and folate.

Average portions of foods commonly eaten by infants and toddlers in the United States.

OBJECTIVES: To examine average portion sizes consumed per eating occasion by infants and toddlers. Average portions reported for toddlers were compared to average portions for comparably aged children reported in the 1994 to 1996 and 1998 Continuing Survey of Food Intakes by Individuals. In addition, reported average portions were compared with minimum required portion sizes for meals served to infants and toddlers in the Child and Adult Care Food Program (CACFP). DESIGN: Data from 24-hour recalls collected in the 2002 Feeding Infants and Toddlers Study (FITS) were analyzed. Average portion sizes were determined for major food groups and individual foods that were reported by at least 5% of the population. Most foods were reported separately; however, sandwiches were disaggregated into their components. Gram weights of portions consumed were converted, on a food-by-food basis, to household units so that foods with different volume-to-weight ratios could be analyzed together. SUBJECTS/SETTING: A national random sample of 3,022 US infants and toddlers 4 to 24 months of age. STATISTICAL ANALYSES PERFORMED: For each food and food group, average portion sizes per eating occasion were computed for up to six age groups. An average per-eating occasion portion was determined for each child who consumed a given food by summing the total amount of food consumed over the day and dividing by the number of eating occasions. These estimates were then summed across all children who consumed the food and divided by the total number of consumers. The number of eating occasions was defined as the total number of times a child had anything to eat or drink during the day, excluding eating occasions that included only water and/or supplements. RESULTS: For most foods, there was a gradual increase in the average portion as age increased. Average portions reported for FITS toddlers were consistent with those reported for comparably aged children in the most recent Continuing Survey of Food Intakes by Individuals. The average portions reported for FITS infants and toddlers were consistent with CACFP-recommended portion sizes for formula, juice, meats, and cheese. For milk (toddlers only), cereal, breads, fruits, and vegetables, average portions reported in FITS were consistently larger than CACFP portion sizes. Distributions showed that, in many cases, the per-eating occasion portion sizes of 50% to 90% of FITS infants and toddlers exceeded the CACFP portion sizes. CONCLUSIONS: Dietitians, pediatricians, and health educators can use the data presented in this article to provide guidance to parents and caregivers about reasonable portion sizes for infants and toddlers. The data should also be useful to those who plan meals for infants and toddlers in child care settings and to researchers studying dietary intakes of infants and toddlers. Advice about reasonable portion sizes should always be tempered with appropriate cautions about avoiding coercive "clean your plate" feeding practices. Parents and caregivers should be encouraged to offer infants and toddlers appropriate portions of healthful foods from the basic food groups, with a special emphasis on fruits, vegetables, and whole grains, and allow them to eat until they are satiated.

Relationship between portion size and energy intake among infants and toddlers: evidence of self-regulation.

OBJECTIVES: To assess whether dietary intakes of infants and young toddlers show evidence of energy self-regulation. DESIGN: Data from 24-hour recalls collected in the 2002 Feeding Infants and Toddlers Study were analyzed. Multivariate regressions were used to explore the relationship between portion size and usual energy intake as well as the relationship between portion size, number of eating occasions, number of unique foods, and energy density. SUBJECTS/SETTING: A national random sample of 3,022 US infants and toddlers 4 to 24 months of age. STATISTICAL ANALYSES PERFORMED: To measure variability in portion size, an average portion size z score was computed for each child in the sample, across 45 different food groups. The number of eating occasions was defined as the total number of times a child had anything to eat or drink during the day, excluding eating occasions that included only water and/or supplements. The total number of unique foods in a day was defined as the number of unique food codes included in the 24-hour recall, and energy density was computed as kilocalories/gram, including all foods, beverages, and water. Linear regression models were used to assess the effect of portion size and other self-regulation mechanisms on energy intake and to assess the effect of these self-regulation mechanisms on portion size. Separate analyses were performed for three age groups: 4 to 5 months, 6 to 11 months, and 12 to 24 months. RESULTS: A significant negative association was found for all age groups between the number of eating occasions and average portion size z scores, indicating that children who eat less often during the day consume larger-than-average-portion sizes and children who eat more often during the day consume smaller-than-average portions. For infants (11 months and younger), a significant negative association was noted between energy density and average portion size z scores, indicating that, as the energy density of the diet goes down, infants consume larger-than-average portions and, as the energy density of the diet goes up, they consume smaller-than-average portions. Among infants 6 to 11 months, there was a significant positive relationship between portion size and the number of unique foods consumed. For toddlers, there was no association between average portion size z scores and energy density, suggesting that energy self-regulation mechanisms are diminished in this age group. CONCLUSIONS: Our findings confirm the presence of energy self-regulation among infants and young toddlers. These findings can be used to assure parents and caregivers that infants have an innate ability to regulate energy intake. At the same time, it is important to educate parents and caregivers about the potential for environmental cues to diminish natural hunger-driven eating behaviors, even among young toddlers. Dietetics professionals should emphasize the potential adverse effects that coercive feeding behaviors can have on children's innate ability to regulate energy intake. This includes not only admonitions to "clean your plate," but overrestriction of intake that may be motivated by concerns that children are overeating.

Feeding Infants and Toddlers Study: characteristics and usual nutrient intake of Hispanic and non-Hispanic infants and toddlers.

OBJECTIVE: To compare demographic and maternal characteristics and usual nutrient intakes of Hispanic and non-Hispanic infants and toddlers 4 to 24 months of age in the United States. DESIGN: We conducted three interviews by telephone to collect information on sociodemographic and maternal characteristics, feeding practices, and dietary intake in the 2002 Feeding Infants and Toddlers Study. We collected 24-hour dietary recalls, including a second day's intake on a subsample, using the Nutrition Data System for Research. We used the Personal Computer version of the Software for Intake Distribution Estimation to estimate usual nutrient intake and nutrient adequacy and excess for three age subgroups-infants 4-5 months, infants 6-11 months, and toddlers 12-24 months-and Hispanic or non-Hispanic ethnicity. SUBJECTS: A national sample of 3,022 infants and toddlers age 4-24 months, including 371 Hispanic and 2,637 non-Hispanic subjects. STATISTICAL ANALYSIS: We compared means, percentile distributions, and percentages by age/Hispanic ethnicity subgroup, and applied the Dietary Reference Intakes to assess nutrient intakes. RESULTS: Mothers of Hispanic infants and toddlers were younger, less likely to be married, and had lower education levels than mothers of non-Hispanic infants and toddlers (P<.01). Hispanic infants and toddlers had significantly higher rates of participation in the Special Supplemental Nutrition Program for Women, Infants, and Children than non-Hispanic infants and toddlers (42% to 23%) and were more likely to reside in urban areas and have lower annual household income levels (P<.01). There were no significant differences in usual energy intake between Hispanic and non-Hispanic infants and toddlers, and mean usual energy intake exceeded the mean estimated energy requirement for all age/ethnicity subgroups. Hispanic toddlers consumed a significantly higher proportion of energy from carbohydrate (56% to 53%, P<.01) and a significantly lower percentage of energy from fat (31% to 33%, P<.01) than non-Hispanics. Comparing usual mean intakes, Hispanic infants age 6 to 11 months had a significantly lower intake of calcium than non-Hispanics (means of 574 mg and 626 mg per day, respectively, P<.05) and a significantly higher intake of sodium compared with non-Hispanics of the same age (means of 647 mg to 476 mg per day, P<.01). For infants, mean usual intakes were adequate for all nutrients. For toddlers, the prevalence of nutrient inadequacy was low (<1%) with the exception of vitamin E, which was inadequate for 39% of Hispanic toddlers and 50% of non-Hispanic toddlers. For nutrients with defined Tolerable Upper Intake Levels, more than one third to almost half of toddlers exceeded the Tolerable Upper Intake Levels for vitamin A and zinc, and more than half (53% and 58% for Hispanics and non-Hispanic toddlers, respectively) exceeded the Tolerable Upper Intake Level for sodium. Usual mean intakes of vitamins A, C, and E and folate, potassium, and fiber were significantly higher among Hispanic toddlers compared with non-Hispanic toddlers. CONCLUSIONS: The Feeding Infants and Toddlers Study data provide information that is useful to practitioners, Special Supplemental Nutrition Program for Women, Infants, and Children program staff, and parents for delivering nutrition education messages that are consistent with dietary guidance for infants and toddlers as well as compatible with cultural preferences.

Feeding Infants and Toddlers Study: the types of foods fed to Hispanic infants and toddlers.

OBJECTIVE: To assess the prevalence of breastfeeding and formula feeding, the age of introduction to specific foods, and the types of foods and beverages consumed by Hispanic infants and toddlers compared with similarly aged non-Hispanic infants and toddlers living in the United States. DESIGN: Descriptive and comparative analysis of dietary recall data and responses to specific interview questions, which were collected in the 2002 Feeding Infants and Toddlers Study. Breastfeeding status, timing of introduction of complementary foods, percentage consuming foods from specific food groups, and the most frequently consumed fruits and vegetables by Hispanic and non-Hispanic children by age group (4-5 months, 6-11 months, 12-24 months). SUBJECTS: A national random sample of 371 Hispanic and 2,637 non-Hispanic infants and toddlers between the ages of 4 and 24 months. STATISTICAL ANALYSIS: To test for differences between Hispanic and non-Hispanic children in the percentage who consumed a particular food item, we calculated percentages and standard errors in SUDAAN and 95% and 99% confidence intervals. The most frequently consumed fruits and vegetables were determined by tallying the percentage of infants and toddlers who consumed each specific fruit or vegetable on a given day. RESULTS: Although there were some similarities, the early flavor and food experiences of Hispanic infants were different from similarly aged non-Hispanic infants in several ways. Hispanic infants younger than 1 year of age were more likely to have ever been breastfed and those who were 4 to 5 months were more likely than non-Hispanics to be eating pureed baby foods on a daily basis. Although less likely to be eating non-infant cereals and baby food vegetables, 6- to 11-month-old Hispanics were more likely to be eating fresh fruits, fruit-flavored drinks, baby cookies, and foods such as soups, rice, and beans that are common in many Hispanic cultures. When fruits were introduced into the Hispanic child's diet, they were most commonly consumed fresh. This higher prevalence of being fed soups, rice, beans, and sweetened fruit-flavored drinks as well as tortillas was also observed among the 12- to 24-month-old toddlers. CONCLUSIONS: Dietetics professionals should be aware of the cultural differences in the foods fed to infants and toddlers that may contribute to the development of long-term food preferences and impact on nutrition. Understanding the factors that underlie food preferences is important if we are to develop evidence-based strategies to improve children's eating habits and lower their risks factors associated with obesity and other chronic diseases.

Feeding Infants and Toddlers Study: meal and snack intakes of Hispanic and non-Hispanic infants and toddlers.

OBJECTIVE: To describe meal and snack patterns of Hispanic and non-Hispanic infants and toddlers. DESIGN: A cross-sectional telephone survey in which mothers or other primary caregivers reported their infants' and toddlers' food and beverage intake for a 24-hour period. SUBJECTS/SETTING: Subjects were a subset of the national random sample of children aged 4-24 months who participated in the 2002 Feeding Infants and Toddlers Study. The Feeding Infants and Toddlers Study includes a stratified random sample of 3,022 infants and toddlers aged 4-24 months. Three hundred seventy-one Hispanic and 2,637 non-Hispanic children who had 24-hour dietary recalls are included in the subset. ANALYSES: Means+/-standard errors of daily intakes of energy, nutrients, and nutrient densities were calculated, as were percentages of children consuming foods at each eating occasion. RESULTS: Hispanic and non-Hispanic infants and toddlers, on average, were fed seven times per day. Overall, the percentages of children who ate snacks increased with age, and more than 80% of toddlers aged 12-24 months consumed afternoon snacks, with more than 90% of Hispanic children consuming an afternoon snack. In each age group, there were significant differences between ethnic groups in nutrient intakes by eating occasion. No significant difference was seen for energy across all meal occasions. At age 6-11 months, Hispanic children had a significantly lower intake of carbohydrate at dinner and lower intake of saturated fat at afternoon snacks compared with non-Hispanic children (P<.05). The main difference between Hispanic children's and non-Hispanic children's intakes by eating occasion is at age 12-24 months. Hispanics aged 12-24 months had significantly (P<.05) lower percentages of energy from fat and saturated fat and a significantly (P<.05) higher percentage of carbohydrate at lunch compared with non-Hispanic children. For dinner, Hispanic toddlers had significantly (P<.05) lower intakes of total fat and saturated fat compared with non-Hispanic toddlers at age 12-24 months. Overall fiber intake contributed 2 g/meal for both ethnic groups. Snacks contributed, on average, less than 1 g fiber, except Hispanic toddlers had significantly higher fiber intake at afternoon snacks (1.5 g) than non-Hispanic toddlers. Foods frequently consumed at meals and snacks were lacking in whole grains, vegetables, and fruits. Most nutrients were not significantly different between Hispanics and non-Hispanics for meals and snacks. CONCLUSIONS: Considering the sizeable contribution that snacks make toward overall energy, parents and caregivers should plan toddlers' snacks to complement meals by including additional fruits, vegetables, and whole grains that are culturally appropriate rather than fruit drinks, cookies, and crackers. This will increase fiber intake and limit fat and sugar intakes. To develop healthful eating patterns, introduce toddlers to foods eight to 10 times to increase food acceptance and the likelihood of establishing healthful eating patterns. Dietetics professionals need to consider cultural differences when developing meal and snack patterns for Hispanic and non-Hispanic infants and toddlers.

Nutrient intakes and food patterns of toddlers' lunches and snacks: influence of location.

OBJECTIVE: To describe nutrient intake and food patterns of lunches and snacks eaten at various locations by US toddlers. DESIGN: A national, cross-sectional telephone survey in which mothers and primary caretakers reported toddlers' food and beverage intake for a 24-hour period. SUBJECTS: Toddlers (n=632), aged 15 to 24 months, a subset in the 2002 Feeding Infants and Toddlers Study. ANALYSES: Means+/-standard errors of the mean, percentages, t tests of mean differences, mean energy and nutrient intake, and nutrient density of toddlers' lunches and snacks. RESULTS: Overall, on any given day, 42.6% of toddlers consumed all meals and snacks at home, 8.1% consumed any meal or snack at day care (and others at home), and 49.3% consumed any meal or snack away from home (all other locations excluding day care). Mean energy intake at lunch ranged from 281 kcal at home to 308 kcal away from home to 332 kcal at day care. There were no significant differences in mean macronutrient intake or fiber intake across locations, but lunches eaten at day care were significantly higher in calcium, phosphorus, magnesium, vitamin D, potassium, and riboflavin compared with those eaten at home or away (P<.05). Mean trans fat intake was significantly (P<.01) lower for lunches consumed at home compared with away from home. For lunches consumed at away locations, the most frequently consumed item, by 35% of toddlers, was french fries. Carbonated beverages were consumed at away lunches by 16% of toddlers, compared with 3% at home and none at day care. Morning snacks provided 124 to 156 kcal and afternoon snacks provided from 139 to 170 kcal, depending on the location. Foods typically eaten at morning snacks for all locations were water, cow's milk, crackers, and 100% juice. Beverages frequently consumed at afternoon snacks were water, whole cow's milk, fruit-flavored drinks, and 100% apple juice. The most frequently consumed foods for an afternoon snack at home or day care were crackers or non-baby food cookies. CONCLUSIONS: Nutritious choices such as milk, fruits, vegetables, and whole grains need to be encouraged in a variety of forms to give toddlers an opportunity to build broader food preferences for life. The consumption of milk at home and other locations, such as restaurants and friends' homes, needs to be encouraged in place of fruit-flavored drinks or other sweetened beverages. For lunches at home, parents may be especially receptive to suggestions about appropriate and easy-to-serve foods, homemade or commercial, for a toddler's lunches and snacks. Day-care providers should be encouraged to use menu planning aids, such as those available from the US Department of Agriculture, even if they are not regulated by a government program.