Published: 2022
Total Pages: 0
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The prevalence of overweight and related health problems is increasing globally. Low vegetable intake and failing to self-regulate energy intake (i.e., eat in the absence of hunger) increase the risk of developing overweight. Interventions promoting healthy eating behaviors from an early age are needed as food preferences and related dietary habits are shaped in the first two years of life, and track into adulthood. The aim of this thesis was to investigate whether vegetable intake and liking of babies and toddlers can be improved, and whether self-regulation of energy intake is present. To this end, the effect of repeated exposure to vegetables on children’s vegetable intake and liking from the first bites of solid food (age 4-6 months), until the age of 24 months was investigated. Eating in the absence of hunger was studied in the same children at the age of 18- and 24 months. The components studied in this thesis were part of an overarching randomized controlled trial, Baby’s First Bites, which tested interventions on the what and how in complementary feeding. Chapter 2 described in detail the rationale and the design of this trial including a repeated vegetable-exposure (what) and sensitive-feeding (how) intervention. In Chapter 3 we evaluated the effects of the vegetable-exposure and sensitive-feeding intervention in terms of child health outcomes and maternal feeding behavior (outside of the scope of this thesis) at child ages 18 and 24 months. Chapter 4 described the intervention in more detail and evaluated the effects of the intervention on infant’s vegetable intake, liking and variety of vegetables consumed during the first weeks of complementary feeding and at the age of 12 months. We found no added effects of repeated exposure to vegetables (combined with consultation sessions to promote repeated exposure until the age of 16 months), as compared to exposure to fruits and a sweet vegetable (carrot) (combined with the sensitive feeding intervention or general contact in the control condition) on infants vegetable intake. This was neither the case directly after the feeding schedule, nor at the ages of 12, 18 and 24 months. It is noteworthy, however, that vegetable intake was on average high at these ages in the full sample: approx. 86 grams, 87 grams and 77 grams respectively. At the age of 12 months a higher variety in vegetable intake was associated with higher absolute vegetable intake (chapter 4), suggesting that consuming a higher variety of different types of vegetables contribute to increasing absolute vegetable intake. In addition, children who ate a higher variety of vegetables also had parents (or at least mothers) eating a larger variety of vegetables (chapter 4). This suggests an effect of parent modelling which has been proven to be an effective method to increase vegetable intake in children. Of the other modifying factors we assessed, only food neophobia was associated with absolute vegetable intake. Food neophobic children ate less vegetables (chapter 4). We did not find differences in child self-regulation of energy intake and BMI-z between conditions (chapter 3). Chapter 5 described an eating in the absence of hunger (EAH) experiment that was designed and conducted within the BFB RCT. We found that children as young as 18 months displayed this behavior. The majority (90%) of children consumed palatable finger foods despite just having eaten a meal. Secondly, we found that EAH at 18 months predicted EAH at 24 months. Furthermore, unexpectedly, a positive association was found between satiety of the child (as estimated by the mother) and the energy intake of finger foods (i.e. higher satiety scores were associated with increased intake of finger foods). Finally, a child’s enjoyment of food was positively associated with the intake of finger foods. This thesis demonstrates that repeated exposure does have an added benefit in infants and toddlers who already have sufficient vegetable intake, as intake was relatively high in the full sample. The control condition in the trial may have been a positive control as no guidelines or restrictions were given on vegetable exposure after the feeding schedule, which could have led to (a high) vegetable exposure in the period thereafter. We did demonstrate that repeated exposure is effective in increasing liking of vegetables. If increased vegetable liking persists over time, perhaps this will also translate to increased intake in the long run. Moreover, we found that food neophobia and variety in vegetable intake play a role in determining vegetable intake. These factors may be taken into account in future studies by targeting groups who may still benefit from early repeated exposure to vegetables (e.g., children with a one-sided diet or food neophobia). Moreover, we showed that eating in the absence of hunger occurs within the first two years of life. Our findings suggest the importance of the eating environment in which parents and caregivers can play an important part in the prevention of overeating. The contemporary living environment seems to revolve around easy access and convenient foods, it is therefore important to create awareness that toddlers are sensitive to the eating environment and to stimulate healthy eating behavior at a young age. Factors that play a key role in this are 1) targeting vegetable intake, 2) self-regulation of energy intake, 3) the context in which food is offered and 4) the type of food that is offered. To further enhance diet quality and consequently health of toddlers it is important to stimulate a multidisciplinary approach in which researchers, parents and caregivers, daycare centers, community and the government collaborate in finding ways to enhance healthy eating behavior of young children to prevent overweight and obesity and to promote health.