The baby's first bites RCT: evaluating a vegetable-exposure and a sensitive-feeding intervention in terms of child health outcomes and maternal feeding behavior during toddlerhood

Education and Child Studie

Children and vegetables: strategies to increase children’s liking and intake of vegetables

Background and aim Children’s vegetable intake is far below that recommended. Despite increased awareness of the importance of vegetable consumption for health, it remains challenging to improve children’s vegetable intake. Since food preferences are central to food intake, it is important to understand how they are shaped and which factors play a role in this. So far, research on the formation of vegetable preferences has focused mainly on infants and school age children but is not elaborately investigated in toddlers/pre-schoolers. Therefore the aim of this thesis was to investigate the underlying mechanisms and modifying factors that play a role in developing 2–5-year-old children’s acceptance of vegetables. Effects of different learning mechanisms, strategies, and modifying factors were explored by diverse studies, including four intervention studies in ecological settings (day-care centres and at home). In another study, we compared 10 intervention studies across Europe. Methods We conducted a series of day-care and in-home interventions. Healthy toddlers and pre-school children participated in the studies. Vegetable liking was measured by relative preference, and consumption was measured by (ad libitum) intake. First, we studied the underlying mechanisms – flavour–nutrient learning, flavour–flavour learning, and repeated exposure – involved in the development toddlers’ food preferences in the short and long term. Novel products like green vegetable soups and vegetable crisps were used as test products, using within-subject designs. The soups differed in energy density to test flavour–nutrient learning (n=28), and the crisps were offered with different dips to test flavour–flavour learning (n=39). Next, we investigated the efficacy of other strategies like taste modification (n=103) and choice-offering (n=70) on 2–5-year-old children’s vegetable liking and intake, using between-subjects designs. Children consumed different vegetable products at home at dinnertime and therefore we used more familiar vegetables as test products. Finally, we combined the results of 10 intervention studies across Europe to explore the influence of individual child characteristics such as breastfeeding history and breastfeeding duration, age, gender, and food neophobia on 2– 6-year-old children’s (n=750) actual vegetable intake. Results We found a clear and persistent effect of repeatedly offering novel and/or disliked vegetables on 2–5-year-old children’s intake. Results for preferences were inconsistent across the studies. We found no strong evidence that strategies such as flavour–flavour learning, flavour–nutrient learning, diluting/hiding a vegetable were more effective in changing vegetable preference than repeated exposure alone. We observed a small positive effect of choice-offering; this strategy could possibly be effective in somewhat older children who already like vegetables, to increase their consumption volume. Factors like breastfeeding duration, vegetable liking, and food neophobia were important for children’s vegetable intake. Children who were more reluctant to try novel food had lower vegetable intake and were not responsive to strategies like repeated exposure, blending, mixing, or hiding vegetables. Longer breastfeeding duration was positively associated with a higher vegetable intake by 2–6-year-old children across three European countries. Gender and age had no influence. Conclusions This thesis demonstrates that repeatedly offering a novel or disliked vegetable in a trusted positive environment is highly effective in promoting toddlers’ and pre-school children’s vegetable intake. Repeated exposure seems to be the way to teach young children to accept novel or disliked foods. Other strategies such as flavouring, adding energy, or taste modification may be helpful in promoting young children’s willingness to try and taste vegetables. Additional strategies such as choice-offering are needed to promote intake of already liked/familiar vegetables when children get older. Individual differences in child characteristics such as food neophobia, breastfeeding duration, and age play a role in shaping food preferences and therefore should get more attention in strategies to promote children’s vegetable acceptance. These results can be used by parents, caregivers, and public health organizations to stimulate children’s vegetable consumption to maintain a more balanced diet.</p

Efficacy of repeated exposure and flavour-flavour learning as mechanisms to increase preschooler's vegetable intake and acceptance

Background - Dutch children's diets, like the diets of many children in Europe and the US are not balanced, do not contain enough vegetables and have been associated with a high prevalence of childhood obesity. Promoting children's vegetable intake is challenging. Objective - We investigated the relative effectiveness of repeated exposure and flavour–flavour learning in increasing vegetable intake and acceptance in preschoolers. Methods - During an intervention period of 7 weeks, 39 toddlers (aged 1.5 to 4¿years) consumed red beet and parsnip crisps at day-care centres in Wageningen, the Netherlands. Half of the group received red beet crisps with a dip of tomato ketchup (Conditioned [C]) and parsnip with a neutral white sauce (Unconditioned, [UC]), whereas for the other half the order was reversed (red beet [UC], parsnip [C]). Preference and ad libitum consumption of vegetable crisps were measured once before and three times after the intervention over the course of a 6-month follow-up period to assess longer-term effects. Results - Intake increased significantly after the intervention for both vegetables (on average with 8¿g; an increase of approximately 300%), and this effect was persistent even 6 months afterwards. The increase was irrespective of crisps being offered with C or UC dip sauce. Conclusions These results suggest a robust and persistent effect of repeated exposure but no effect of flavour–flavour learning. Offering pure vegetable tastes repeatedly is sufficient to increase intake

Effectiveness of flavour nutrient learning and mere exposure as mechanisms to increase toddler's intake and preference for green vegetables

Children’s consumption of vegetables is still below recommendations. Since preference is the most important predictor of children’s intake and most children dislike vegetables, new strategies are needed to increase their preferences for vegetables. Flavour nutrient learning (FNL) could be an effective mechanism to change preferences. Forty healthy toddlers were included in a randomized intervention study. During an intervention period of 7 weeks, they consumed vegetable soups (endive and spinach) twice per week. Half of the group received a high-energy variant of one soup (e.g. HE spinach) and a low energy variant of the other (LE endive), whereas for the other half the order was reversed (HE endive, LE spinach). Primary outcome measures were preference and ad libitum consumption (with a maximum of 200 g) of both vegetable products (LE), measured before, shortly after the intervention period, and 2 and 6 months following conditioning to assess longer-term effects. After completion of the intervention period, 28 children (14 girls and 14 boys, age 35 months; SD ± 8.3) met criteria for FNL to occur, and were included in further data analysis. Results showed a significant increase (~58 g) in ad libitum intake for both vegetable soups (stable over time), but irrespective of the energy content. This indicates a robust effect of mere exposure on intake, but no FNL. For preference, however, results showed a significant shift in liking for the vegetable soup consistently paired with high energy, supporting FNL

Efficacy of repeated exposure and flavour-flavour learning as mechanisms to increase preschooler's vegetable intake and acceptance

Background - Dutch children's diets, like the diets of many children in Europe and the US are not balanced, do not contain enough vegetables and have been associated with a high prevalence of childhood obesity. Promoting children's vegetable intake is challenging. Objective - We investigated the relative effectiveness of repeated exposure and flavour–flavour learning in increasing vegetable intake and acceptance in preschoolers. Methods - During an intervention period of 7 weeks, 39 toddlers (aged 1.5 to 4¿years) consumed red beet and parsnip crisps at day-care centres in Wageningen, the Netherlands. Half of the group received red beet crisps with a dip of tomato ketchup (Conditioned [C]) and parsnip with a neutral white sauce (Unconditioned, [UC]), whereas for the other half the order was reversed (red beet [UC], parsnip [C]). Preference and ad libitum consumption of vegetable crisps were measured once before and three times after the intervention over the course of a 6-month follow-up period to assess longer-term effects. Results - Intake increased significantly after the intervention for both vegetables (on average with 8¿g; an increase of approximately 300%), and this effect was persistent even 6 months afterwards. The increase was irrespective of crisps being offered with C or UC dip sauce. Conclusions These results suggest a robust and persistent effect of repeated exposure but no effect of flavour–flavour learning. Offering pure vegetable tastes repeatedly is sufficient to increase intake

Influence of choice on vegetable intake in children: an in-home study

Children's vegetable consumption is still far below that recommended, and stimulating their intake is a challenge for caregivers. The objective of this study was to investigate whether choice-offering is an effective strategy to increase children's vegetable intake in an in-home situation. Seventy children (mean age 3.7; SD 1) randomly assigned to a choice or a no-choice condition, were exposed 12 times to six familiar target vegetables at home during dinner. In the choice group, two selected vegetables were offered each time, whereas the no-choice group only received one vegetable. Vegetable intake was measured by weighing children's plates before and after dinner. A mixed linear model with age, gender, and baseline vegetable liking as covariates was used to compare intake between the choice and the no-choice group. Mixed linear model analysis yielded estimated means for vegetable intake of 48.5¿g +/- 30 in the no-choice group and 57.7¿g¿+/- 31 for the choice group (P¿=¿0.09). In addition, baseline vegetable liking (P

Influence of choice on vegetable intake in children: an in-home study

Children's vegetable consumption is still far below that recommended, and stimulating their intake is a challenge for caregivers. The objective of this study was to investigate whether choice-offering is an effective strategy to increase children's vegetable intake in an in-home situation. Seventy children (mean age 3.7; SD 1) randomly assigned to a choice or a no-choice condition, were exposed 12 times to six familiar target vegetables at home during dinner. In the choice group, two selected vegetables were offered each time, whereas the no-choice group only received one vegetable. Vegetable intake was measured by weighing children's plates before and after dinner. A mixed linear model with age, gender, and baseline vegetable liking as covariates was used to compare intake between the choice and the no-choice group. Mixed linear model analysis yielded estimated means for vegetable intake of 48.5¿g +/- 30 in the no-choice group and 57.7¿g¿+/- 31 for the choice group (P¿=¿0.09). In addition, baseline vegetable liking (P

Eating in the absence of hunger in 18-month-old children in a home setting

BACKGROUND\nOBJECTIVES\nMETHODS\nRESULTS\nCONCLUSION\nEating in the absence of hunger (EAH), the susceptibility to eat despite satiety, may increase overweight. While EAH has been established in school-aged children, less is known about it during toddlerhood.\nThis study assessed to what extent 18-month-old children eat in the absence of hunger, the stability of this behaviour at 24 months and the association of child eating behaviours with EAH.\nChildren were presented with four palatable finger foods (total 275 kcal) after dinner. Univariate GLM's assessed the association between EAH, child satiety and eating behaviours and energy intake of dinner at 18 and 24 months (n = 206 and 103, respectively). Another GLM was run to assess the association between EAH at both time points.\nMean (±SD) energy intakes from dinner and finger foods were 240 kcal (±117) and 40 kcal (±37), respectively. No association was found between energy intake of dinner and finger foods. Enjoyment of food was significantly related to intake of finger foods (P = .005). EAH at 18 months predicted EAH at 24 months.\nEighteen-month-old children ate in the absence of hunger, irrespective of satiety. Thus, preceding energy intake was not compensated for. Other factors, for example, enjoyment of food seem to determine finger food intake.NWO057-14-002Education and Child Studie

The baby’s first bites RCT: evaluating a vegetable-exposure and a sensitive-feeding intervention in terms of child health outcomes and maternal feeding behavior during toddlerhood

Education and Child Studie

Baby's first bites: a randomized controlled trial to assess the effects of vegetable-exposure and sensitive feeding on vegetable acceptance, eating behavior and weight gain in infants and toddlers

BACKGROUND: The start of complementary feeding in infancy plays an essential role in promoting healthy eating habits. Evidence shows that it is important what infants are offered during this first introduction of solid foods: e.g. starting exclusively with vegetables is more successful for vegetable acceptance than starting with fruits. How infants are introduced to solid foods also matters: if parents are sensitive and responsive to infant cues during feeding, this may promote self-regulation of energy intake and a healthy weight. However, the effectiveness of the what and the how of complementary feeding has never been experimentally tested in the same study. In the current project the what and how (and their combination) are tested in one study to determine their relative importance for fostering vegetable acceptance and self-regulation of energy intake in infants. METHODS: A four-arm randomized controlled trial (Baby's First Bites (BFB)) was designed for 240 first-time Dutch mothers and their infants, 60 per arm. In this trial, we compare the effectiveness of (a) a vegetable-exposure intervention focusing on the what in complementary feeding; (b) a sensitive feeding intervention focusing on the how in complementary feeding, (c) a combined intervention focusing on the what and how in complementary feeding; (d) an attention-control group. All mothers participate in five sessions spread over the first year of eating solid foods (child age 4-16 months). Primary outcomes are vegetable consumption, vegetable liking and self-regulation of energy intake. Secondary outcomes are child eating behaviors, child anthropometrics and maternal feeding behavior. Outcomes are assessed before, during and directly after the interventions (child age 18 months), and when children are 24 and 36 months old. DISCUSSION: The outcomes are expected to assess the impact of the interventions and provide new insights into the mechanisms underlying the development of vegetable acceptance, self-regulation and healthy eating patterns in infants and toddlers, as well as the prevention of overweight. The results may be used to improve current dietary advice given to parents of their young children on complementary feeding. TRIAL REGISTRATION: The trial was retrospectively registered during inclusion of participants at the Netherlands National Trial Register (identifier NTR6572 ) and at ClinicalTrials.gov ( NCT03348176 ). Protocol issue date: 1 April 2018; version number 1.</p