HDL High-density lipoprotein HEI Healthy Eating Index LDL Low-density lipoprotein
Introduction
The early years of childhood are characterized by accelerated growth and huge acquisitions in the development process, including the ability to
M. R. Vitolo (*)
Department of Nutrition , Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Sarmento Leite 245 , 90050170
Porto Alegre , RS , Brazil e-mail: [email protected] M. L. da Costa Louzada • F. Rauber Graduate Program of Health Sciences ,
Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) , Porto Alegre , RS , Brazil
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Keywords
Diet • Counselling • Food habits • Infant • Child • Health
Maternal Dietary Counselling and Children’s Diet Quality
Márcia Regina Vitolo, Maria Laura da Costa Louzada, and Fernanda Rauber
Key Points
• The fi rst 2–3 years of life play an important role in the future food habits.
• Maternal attitudes and beliefs most directly affect children’s food intake.
• Maternal dietary counselling is effective to improve children diet quality even in low income population.
• In childhood, diet quality infl uences health condition since it is a critical period for the prevention of both defi ciency-related and excess-related nutritional disorders.
• Interventions to promote healthy feeding practices at the beginning of life have the potential to infl uence health conditions throughout the course of life.
receive, chew and digest foods besides breast milk as well as ingestive self-control. There is evidence that the foods that children receive in the fi rst 2 years of life will determine their prefer- ences and that these preferences can last until adulthood [ 1 – 3 ]. Consequently, inadequate feed- ing practices during childhood constitute a public health problem, being associated with the occur- rence of micronutrient defi ciencies [ 4 ], over- weight [ 5 ] and later cardiovascular disease risk factors [ 6 ]. Thus, this chapter will discuss the formation of feeding habits in early childhood, the importance and infl uence of nutritional pro- grams and guidance for mothers and the impact of diet quality on children’s health.
The Development of Children’s Eating Habits
Food habits are a result of genetic factors; envi- ronmental and family infl uences; psychosocial and cultural factors; and especially individual preferences [ 2 , 7 ]. Children are genetically pre- disposed to accept sweet-tasting substances, reject acidic and bitter ones and associate food intake with its psychophysiological conse- quences [ 7 – 9 ]. Beginning at age two in particu- lar, children are also predisposed to food neophobia—a phase in which the rejection of new foods is manifested [ 9 ]. A survey of approximately 600 children between the ages of 2 and 6 years demonstrated that neophobia was associated with lower consumption of fruits, vegetables and meats but did not infl uence the intake of dairy products, cakes, cookies and other fl our products [ 10 ].
Surveys conducted with children aged 2–14 in different countries have demonstrated a transcul- tural pattern regarding food preferences: foods with a high concentration of sugar and fat such as ice cream, pizza, cake and French fries were indi- cated as favourites while vegetables were named as the least-preferred food group [ 11 – 13 ].
Despite the genetic and biological basis in determining food preferences, studies indicate that they are strongly modifi ed by the intensity of children’s experiences with food [ 9 – 14 ]. Food exposure frequency, the physiological conse-
quences caused by the intake of different food types and the social context of eating are factors that can affect food acceptance patterns in the fi rst years of life [ 14 ].
In the fi rst years of life, parents also play an important role throughout the development of eating habits since they infl uence food familiarity by controlling a child’s food environment, expo- sure and availability [ 15 , 16 ]. Although there are innumerable external factors that infl uence eating habits—such as family income, food prices and advertising [ 17 , 18 ]—evidence indicates that maternal attitudes and beliefs most directly affect children’s food intake [ 15 ].
Inappropriate feeding practices in the fi rst years of life are associated with parents’ or care- givers’ lack of knowledge and information as well as restrictions imposed by traditions, beliefs and myths [ 19 ]. Thus interventions to dissemi- nate appropriate knowledge and information to mothers are essential for behavioural changes and improved infant feeding [ 20 ].
Maternal Education Programs to Improve Infant Feeding Practices There are many limiting factors that can interfere with an educational program’s success—such as intervention intensity, the complexity of behav- iour to be changed and the existence of external constraints such as a lack of access to food [ 21 ].
The ideal design for each intervention depends on local culture, resources, infrastructure and communication channels as well as the potential to modify them [ 22 ]. The most effective educa- tional interventions use a limited number of mes- sages aimed at feasible practices to be adopted by the target population, besides being based on local health problem data related to feeding prac- tices that can plausibly be modifi ed [ 22 ].
Although increasing the duration of exclusive breastfeeding is still a global challenge—including in countries with high breastfeeding rates—studies conducted in countries with different cultures and socioeconomic conditions demonstrate the effec- tiveness of maternal counselling on the promo- tion of this practice [ 23 ]. Considering the fact that the main reasons for the low prevalence of
95
exclusive breastfeeding are the absence of social group and health professional support; the moth- er’s stress; maternal perception that breast milk does not adequately meet the baby’s needs; and family pressure to introduce new foods [ 24 ], programs that provide mothers with information, counselling and support appear essential in reversing this situation. Ibanez et al. [ 25 ] evalu- ated ten studies conducted with 1,445 women of low socioeconomic status and concluded that educational programs conducted with mothers were effective in stimulating breastfeeding initi- ation and continuing breastfeeding until 3 months after birth. The studies assessed had various forms of intervention, but the most effec- tive ones conducted multiple yet short orienta- tion sessions (~30 min).
Shi and Zang [ 20 ] performed a systematic review of studies published since 1998 that assess the effectiveness of dietary interventions with educational components related to complemen- tary feeding in developing countries. The authors described 15 studies in different countries (including nine randomized clinical trials) and concluded that the evidence supports the hypoth- esis that educational interventions are effective in improving the quality of complementary feeding but that the analysis and comparison of the stud- ies’ results must take into consideration the dif- ferent local profi les relating to socioeconomic conditions, disease prevalence and children’s nutritional status (Table 8.1 ). In a meta-analysis, Imdad et al. [ 26 ] assessed the impact of experi- mental and quasi-experimental studies that use educational strategies with mothers (with or without the provision of fortifi ed foods) on chil- dren’s growth in developing countries. Likewise, the authors reported that maternal nutritional counselling (with or without the concurrent pro- vision of fortifi ed foods) resulted in greater height and weight gain between 6 and 24 months of age. Most of the studies described were con- ducted in communities with a moderate or high prevalence of child malnutrition and limited food availability and demonstrated that maternal dietary counselling can be effective in increasing energy intake, food consumption frequency and diet quality as well as accelerating height and weight gain in the fi rst 2 years of life.
However, the current epidemiological situation in the majority of developed and developing coun- tries (characterized by high childhood obesity rates and early onset of cardiovascular risk factors) highlights the need for action strategies to also be focused on problems related to excessive weight gain and associated risk factors. The few studies that have been published in the scientifi c literature have assessed the effectiveness of infant interven- tions with this objective.
In a recent systematic review, Ciampa et al.
[ 27 ] described only 12 articles (representing the results of ten studies) that aimed to test educa- tional interventions conducted with the parents of children under 2 years old for obesity prevention.
Among the studies described, only three were randomized clinical trials and seven were evalu- ated as being “of low quality” due to method- ological limitations. No intervention caused any signifi cant impact on the children’s weight.
In a short-term assessment, Kavanagh et al.
[ 28 ] conducted a randomized clinical trial with children aged between 3 and 10 months who were artifi cially breastfed in the city of Sacramento, CA, USA with the objective of pre- venting excessive weight gain. The parents of children belonging to the intervention group par- ticipated in a single orientation session about infant feeding in which they were advised on how to recognize signs of satiety and limit the volume of bottle milk per meal. The results showed no change in bottle-feeding practices among the groups, stressing the diffi culty of modifying this behaviour among children.
The Strip Study is a randomized clinical trial that begun in Finland in 1990 in which families with 5-month-old children were recruited and randomized to receive home-based dietary coun- selling at an interval of 1–3 months when the chil- dren were between 8 and 24 months of age and twice a year from the age of 2 years. The interven- tion was carried out individually and was based on families’ experiences during the well- child care visits and aimed mainly to ensure the quantity and quality of fat intake. The results showed that, between 8 months and 2 years of age, the inter- vention group had a lower intake of total fat (a 2 % reduction in relation to total energy con- sumed) and saturated fat (a 3 % reduction in
8 Maternal Dietary Counselling and Children’s Diet Quality
Table 8.1 Nutrition education intervention programs to improve infant complementary feeding in developing coun- tries [ 20 ]
Site Subjects Intervention strategies Main fi ndings
Bhandari
et al. (2004), India
Five hundred and fi fty-two in the interven- tion (four communities) and 473 in the control (four communities).
Followed from birth to 18 months of age
Nutrition counselling, monthly home visits, group training, feeding demon- stration, community mobilization
Children in the intervention group got greater length gain (0.32 cm, 95 % CI: 0.03–0.61) than did controls. But there was no difference in weight. The intervention group had higher energy intakes (531 kJ/day at 9 months and 1,230 kJ/day at 18 months)
Kilaru et al. (2005), India
Sixty-nine infants aged 5–11 months each from the intervention and control were followed till 24 months
Monthly nutrition education, growth chart
Girls in the intervention group had a weight velocity 77 g per month greater than controls.
The intervention increased feeding frequency, dietary diversity and consumption of bananas
Roy et al. (2005), Bangladesh
Two hundred and eighty-two moderately malnourished children aged 6–24 months from 15 communities were randomized to two intervention groups and one comparison group
INE group received nutrition education (group training and demonstration of preparing khichuri), the INE + SF group received nutrition education and food supplementation
The WAZ score was 0.28 higher in the INE group and 0.43 higher in the INE + SF group compared to the comparison group. No signifi cant difference in nutritional status between the INE and INE + SF groups Penny
et al. (2005), Peru
One hundred and eighty-seven children from six communities in intervention and 190 from six communities in control. Followed from birth to 18 months of age
Nutrition counselling, group training, demonstra- tion of recipe preparation, recommended recipes:
thick puree, adding liver, egg, fi sh to infant diet
The intervention group was 1.07 cm (95 % CI: 0.49–1.65) taller and 0.30 kg (95 % CI:
0.06, 0.53) heavier than the controls. The increment in WAZ score of the intervention group was 0.29 (95 % CI:
0.1–0.47) higher, and increment in HAZ was 0.39 (95 % CI:
0.21–0.56) higher Santos et al. [ 21 ],
Brazil
Twenty-eight health centres were paired and randomized to treatment.
Two hundred and eighteen children <18 months in intervention and 206 controls were visited 8, 45 and 180 days after initial consultation
Nutrition education on IMCI feeding guidelines (feeding frequency, increase energy and nutrient density, add animal protein and micronutrients)
The intervention group had higher daily fat, energy and nutrient intake and better knowledge. Among those children entered the interven- tion after 1 year of age, weight gain was higher in intervention group (1.48 vs. 1.14 kg); WAZ and WHZ score gain was higher in intervention group (0.3 vs. 0.1; and 0.4 vs. 0.1) Salehi et al. (2004),
Iran
Four hundred and six children aged 0–59 months from intervention group and 405 controls.
Intervention lasted for 12 months
Training infl uential people, girls and tribal teachers to disseminate use of eggs, vegetables and legumes
The intervention group achieved 0.42 kg heavier in weight, 1.6 cm longer in length, 0.5 cm longer MAC, 0.45 greater WAZ, 0.41 greater HAZ and 0.266 greater WHZ than controls ( p < 0.05)
(continued)
97
Site Subjects Intervention strategies Main fi ndings
Mackintosh et al.
(2002) Viet Nam
Forty-six households were selected from four PANP communities and 25 from comparisons.
Two children from each household, one in PANP program, another not
Nutrition counselling, group training, community mobilization
The WAZ was 0.63 higher and the WHZ was 0.74 higher in the intervention group than the comparison. The intervention group performed better in feeding frequency and hand-washing practices Pacho et al. (2002),
Viet Nam
Twelve communities were randomized to treatment.
One hundred and nineteen children 5–25 months each in intervention and comparison. Followed for 6 months
Nutrition education, growth monitoring
The intervention group had higher consumption of all food groups and higher nutrient and energy intakes
Gardener et al.
(2007), West Africa
Two cross-sectional surveys (before/after intervention): 1,807 children 6–35 months at baseline and 1,676 at the second survey
Nutritional education, growth monitoring and food supplementation
The wasting rate of the intervention group decreased from 13.7 to 8.6 %, compared to from 11.3 to 10.8 % in the control group
Hotz and Gilson (2005), Malawi
Eighty-seven and 42 breastfed children aged 9–23 months from three intervention villages and one control village
Four nutrition education sessions, individual counselling, use of soaked pounded maize fl our, enriching maize porridge with egg, banana, oil, etc.
The intervention group had larger quantity of complemen- tary foods and higher diet intake of energy, animal protein and micronutrient. Did not report growth data Guldan et al. [ 19 ],
China
Two hundred and fi fty infants from two intervention townships and 245 from two control townships, recruited at birth and evaluated at 4–12 months
Monthly growth monitor- ing, nutrition counselling to pregnant women, complementary food recipes
The intervention group had higher WAZ (−1.17 vs. −1.93) and HAZ (−1.32 vs. 1.96), lower anaemia rate (22 % vs.
32 %) and higher breast-feed- ing rate (83 % vs. 75 %) at 12 months
Li et al. (2007), China
Three hundred and fi fty-two newborns of Dai minority in Yunnan Province
Nutrition education, growth monitoring, demonstration of preparing weaning food, integrated management of childhood diseases
Weight was increased by 0.83 kg among male infants aged 4–5 months, 0.64 and 0.42 kg between 12–13 and 15–16 months. Prevalence of underweight decreased from 20.5 to 13.7 % between 6 and 11 months, from 39.0 to 26.4 % at 12–17 months
Bhandari et al.
(2001), India
Four hundred and eighteen infants 4 months of age were randomized to intervention or comparison groups and followed until 12 months
Two intervention groups:
food supplementation (milk cereal supplement packet) and nutritional counselling
Food supplementation increased energy intakes (1,212–2,257 kJ) and weight increment (250 g, 95 % CI:
20–480 g); no effects on length;
nutritional counselling alone had no impacts on weight and length, but increased energy intakes (280–752 kJ) Table 8.1 (continued)
(continued) 8 Maternal Dietary Counselling and Children’s Diet Quality
relation to total energy consumed) and greater intake of polyunsaturated fat (a 1 % increase in relation to total energy consumed)—without differ- ences in total energy, vitamins and minerals con- sumed between the groups [ 29 ]. Monitoring of the children showed that the intervention continued to positively infl uence the children’s diets between 4 and 10 years of age, with the intervention group having 2–3 % lower intake of total and saturated fat and 0.5–1 % higher intake of polyunsaturated fat in relation to total energetic intake [ 30 ]. In regard to nutritional status, the intervention demonstrated a protective role against the development of over- weight from 2 to 10 years of age, but only among girls [ 31 ]. Total and LDL serum cholesterol levels were lower in the intervention group compared to the control group during all years of the follow-up, while HDL levels showed no signifi cant differ- ences [ 32 ]. At 9 years of age, the intervention group demonstrated better insulin sensitivity com- pared to the control group [ 33 ].
The Brazilian Health Ministry and the Pan- American Health Organization published the fi rst
edition of the “Feeding Guide for Children Under Two” in Brazil in 2002 [ 34 ]. The publication was based on feeding guidelines proposed by the World Health Organization for this life cycle and was prepared according to local socioeconomic and cultural contexts and health problems related to feeding—after extensive data collection in the country. Using this study, recommendations were prepared and published in the technical manual
“Ten Steps for Healthy Feeding for Brazilian Children from Birth to Two Years of Age”, aim- ing to guide the content of messages to be passed on to the target population. Its main objectives are the promotion of exclusive breastfeeding until the child’s sixth month of age, complemen- tary feeding until 2 years of age and appropriate introduction of complementary foods [ 35 ].
The “Ten Steps for Healthy Feeding for Brazilian Children From Birth to Two Years of Age” are: (1) Exclusive breastfeeding up to 6 months; (2) After 6 months, mothers should continue breastfeeding up to 2 years and gradually introduce complementary foods; (3)
Site Subjects Intervention strategies Main fi ndings
Aboud et al. (2008), Bangladesh
One hundred children 12–24 months of age were in the intervention group and 102 compa- rable children were enrolled in control group.
They were followed until 5 months
post-intervention
Weekly education sessions on child nutrition, child self-feeding and parent’s responsive feeding
Children in intervention group gained 0.34 kg more weight than controls. Child self-feed- ing behaviour, diet variety and mother’s knowledge were better in the intervention than control group
Campbell et al.
(1998), Pakistan
Three hundred and seventy-fi ve children aged 6–24 months were recruited from 36 health centres and assigned to intervention or control.
They were followed for 180 days
post-intervention
Health care providers received training on feeding counselling using the Integrated Management of Childhood Illness (IMCI) module, then they discussed with mothers regarding the recom- mended foods and frequency of feeding
The intervention group had signifi cantly higher weight-for- age score than the control group (−1.14 vs. −1.65).
Mothers in the intervention group achieved better knowledge
Cited with permission obtained: Shi L, Zhang J. Recent evidence of the effectiveness of educational interventions for improving complementary feeding practices in developing countries. J Trop Pediatr. April 2010;57(2):91–98
PANP poverty alleviation and nutrition program, WAZ weight-for-age z score, WHZ weight for height z score, HAZ height for age z score, INE group intensive nutrition education, INE+SF group intensive nutrition education and additional supplementary feeding, MAC mean arm circumference
Table 8.1 (continued)
99
Complementary food should be given 3 times a day (two fruits and a meal at lunch) if the child was being breastfed; 5 times, if not and the moth- ers were advised not to use bottles or breastfeed- ing as pacifi ers; (4) Mealtimes should be adjusted to the child’s internal hunger and satiety cues; (5) New foods should gradually get thicker up to the time the child is able to eat a family meal and complementary foods should not be liquefi ed as a soup; (6) A wide variety of healthy foods should be given every day to ensure intake of different nutrients; (7) Daily intake of different fruits and vegetables; (8) Avoid offering sugar, sweets, soft
drinks, salty snacks, cookies, processed and fried foods; (9) Good hygienic practices in preparing and handling food; (10) Adequate feeding pat- terns during child illness [ 35 ].
The impact of these Brazilian feeding guide- lines through maternal counselling during home visits in the fi rst year of life showed that the inter- vention was associated with a higher occurrence of exclusive breastfeeding and breastfeeding in general (Table 8.2 ) [ 36 ] and lower intake of high- energy foods in the fi rst year of life (Table 8.3 ) [ 37 ]. In the same group of children, a longitudi- nal study showed that at preschool age (3–4 years),
Table 8.2 Effectiveness of a home-based maternal dietary counselling on breastfeeding practices [ 36 ] Intervention Control
RR 95 % CI
n % n %
Feeding practices Exclusive breastfeeding
<1 month 54 33.3 111 48.0 0.69 0.54–0.90
>=4 months 73 45.1 66 28.6 1.58 1.21–2.06
=6 months 31 19.1 19 8.2 2.34 1.37–3.99
Breastfeeding At 6 months 114 66.3 134 55.6 1.19 1.02–1.39
At 12 months 86 52.8 98 41.9 1.26 1.02–1.55
Adapted from Vitolo MR, Bortolini GA, Feldens CA, Drachler ML. [Impacts of the 10 Steps to Healthy Feeding in Infants: a randomized fi eld trial]. Cad Saúde Pública. September-October 2005;21(5):1448–1457. Article in Portuguese
Table 8.3 Effectiveness of a home-based maternal dietary counselling on energy-dense foods consumption Intervention n = 161 Control n = 229
RR (95 % CI)
n (%) n (%)
Consumption in the prior month
Candies 102 (63.4) 171 (74.7) 0.85 (0.74–0.98)*
Soft drink 118 (73.3) 190 (83.0) 0.88 (0.79–0.99)*
Table sugar 151 (93.8) 219 (95.6) 0.98 (0.93–1.03)
Honey 52 (32.3) 114 (49.8) 0.65 (0.50–0.84)*
Cookies 112 (69.6) 201 (87.8) 0.79 (0.71–0.89)*
Chocolate 81 (50.3) 160 (69.9) 0.72 (0.60–0.86)*
Salty snacks 113 (70.2) 187 (81.7) 0.86 (0.76–0.97)*
LD foods group 57 (35.4) 129 (56.3) 0.62 (0.49–0.80)*
SD foods group 27 (16.8) 83 (36.2) 0.46 (0.31–0.68)*
Early introduction
Honey (<6 months) 32 (19.9) 98 (42.6) 0.47 (0.33–0.66)*
Table sugar (<6 months) 97 (60.2) 167 (72.0) 0.84 (0.72–0.97)*
Soft drink (<10 months) 74 (45.7) 138 (60.0) 0.76 (0.62–0.93)*
Adapted from Vitolo MR, Campagnolo PD, Hoffman DJ. Maternal dietary counseling reduces consumption of energy- dense foods among infants: a randomized controlled trial J Nutr Educ Behav. Mar 2012, 44(2):140–147
SD group: children who had eaten all the following foods, candies, soft drinks, table sugar and honey during the last month. LD group: Children who had eaten all the following foods, salty snacks, cookies and chocolate during the last month
* p < 0.05
8 Maternal Dietary Counselling and Children’s Diet Quality