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Food and beverage intake in Australian children aged 12–16 months participating in the NOURISH and SAIDI studies

Food and beverage intake in Australian children aged 12–16 months participating in the NOURISH... considerable physical and emotional Objective: To describe the quantity and diversity of food and beverage intake in Australian Tdevelopment and represent a key time children aged 12–16 months and to determine if the amount and type of milk intake is in the child’s transition from infant feeding associated with dietary diversity. to family food. During the second year of life, the speed of growth slows in comparison Methods: Mothers participating in the NOURISH and South Australian Infant Dietary Intake to infancy while nutrient needs remain (SAIDI) studies completed a single 24-hour recall of their child’s food intake, when children high. Children aged 1–2 years require more (n=551) were aged 12–16 months. The relationship between dietary diversity and intake of nutrients and energy per kilogram of body cow’s milk, formula or breastmilk was examined using one-way ANOVA. weight than adults, which means toddlers Results: Dairy and cereal were the most commonly consumed food groups and the greatest must consume an energy- and nutrient-dense contributors to daily energy intake. Most children ate fruit (87%) and vegetables (77%) on diet. This age coincides with the development the day of the 24-hour recall while 91% ate discretionary items. Half the sample ate less than of autonomy and independence, food 30 g of meat/alternatives. A quarter of the children were breastfeeding while formula was fussiness and neophobia – the refusal of consumed by 32% of the sample, providing 29% of daily energy intake. Lower dietary diversity new foods. Repeated exposure to fruit and was associated with increased formula intake. vegetables may overcome a toddler’s natural Conclusions: The quality of dietary intake in this group of young children is highly variable. tendency for food refusal, thereby increasing Most toddlers were consuming a diverse diet, though almost all ate discretionary items. The a child’s liking for these foods and subsequent amount and type of meat/alternatives consumed was poor. intake. Liking a nutrient-dense diet that Implications: Health professionals should advise parents to offer iron-rich foods, while limiting incorporates all five core food groups is discretionary choices and use of formula at an age critical in the development of long-term important, as evidence suggests that food food preferences. preferences develop during early childhood and persist into adulthood. Dietary diversity, Key words: toddler, intake, diversity, breastfeeding, formula represented by the number of foods or food groups eaten during a given time-period, is to prevent childhood obesity and the preferences and support appropriate growth. an indicator of dietary quality and nutrient 7 onset of chronic disease. In contrast, iron Unfortunately, health professionals know little adequacy in developed countries. deficiency anaemia remains an issue for about which foods parents are offering and Normal child development now occurs in a toddlers in both developed and developing what children are actually eating at the critical world where paediatric obesity is a global countries. High intake of cow’s milk and 1–2 years of age. Several surveys examine health concern. Since 1986, prevalence of low meat consumption contribute to iron breastfeeding duration and introduction 8,9 overweight and obesity in Australia has deficiency. Excessive intake of formula or of solid foods during the period from birth 11-13 doubled, with about 18–21% of children cow’s milk may limit intake and diversity of to age 12 months, while the National aged 2-3 years now classified as overweight foods in the child’s diet, which in turn limits Children’s Nutrition and Physical Activity 6 10 or obese. Dietary intervention in infancy – their exposure to new tastes and textures. Survey (referred to here as the 2007 Children’s promoting fruit and vegetable consumption, In the face of such challenges, parents Survey) reported on the diets of Australian while reducing intake of foods that are are required to provide their child with a children from age 2–16 years. energy dense but nutrient poor – is important nutritious and varied diet, foster healthy food 1. School of Exercise and Nutrition Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology 2. Nutrition and Dietetics, Flinders Clinical and Molecular Medicine, School of Medicine, Flinders University, South Australia Correspondence to: Ms Rebecca Byrne, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Queensland 4059; e-mail: rebecca.byrne@student.qut.edu.au Submitted: September 2013; Revision requested: December 2013; Accepted: March 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38;326-31; doi: 10.1111/1753-6405.12249 326 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Food and beverage intake in children aged 12–16 months The few existing surveys reveal poor quality using consecutive sampling and asked to All items from the 24-hour dietary recall intakes in very young children. The Perth provide consent to be contacted when were entered into FoodWorks Professional Infant Feeding Study II (PIFS II) conducted infants were four to seven months of age version 9 using the AUSNUT 2007 database in 2002–2003 (n=453) reported that by 52 for full enrolment in the studies. Inclusion from the 2007 Children’s Survey. Since this weeks of age, 92% of infants had consumed criteria: mothers 18 years or older, with the database included a limited number of biscuits and cakes, 79% hot chips/French facility for written and spoken English, who commercial infant products, an additional fries and 68% had eaten ice-cream. had delivered a healthy infant (≥37 weeks, database containing information on these A longitudinal analysis of 177 children ≥2500 g), able and willing to attend sessions products was created by study staff. Nutrient participating in the Melbourne Infant Feeding at designated clinics and – for NOURISH information was sourced from websites, Activity and Nutrition Trial reported that gram only – who were first-time mothers. Exclusion manufacturers or nutrient information panels. intake of vegetables decreased between nine criteria: mothers with a documented history Mixed dishes prepared at home were added and 18 months of age, while intake of energy- of domestic violence, intravenous substance to FoodWorks as a recipe, or if there were dense snacks increased. In the United States, use, self-reported eating or psychiatric fewer than three ingredients the foods were the Feeding Infants and Toddlers Study disorders, or other mental health problems; entered directly as separate items. (FITS) is a nationally representative survey of and/or infants diagnosed with congenital Breastfeeds were quantified as minutes children aged between four and 24 months. abnormalities or a chronic condition likely in which the child was actively feeding to The most recent survey in 2008, using a to affect normal development. Approval a maximum of 10 minutes per feed. Milk single 24-hour recall revealed that among was gained from 11 human research ethics transfer from the breast after this duration children aged 12–14.9 months (n=243), only committees including Queensland University is considered too slow to contribute three-quarters consumed fruit and the same of Technology and Flinders University. significantly to nutrient intake in this age proportion consumed vegetables. The most 18 This analysis uses data from the assessment group. If a second breastfeed started commonly consumed vegetable was fried that occurred when children were 12–16 within 30 minutes of the start of the previous potato. months of age, collected between June 2009 feed, it was not considered a new feed, and The aims of this analysis were to describe the and June 2010. Participants in metropolitan the time was added to the previous feed quantity and diversity of food and beverage areas attended study-specific assessment up to a maximum of 10 minutes. Similarly, intake in a group of Australian children clinics where anthropometric measures were breastfeeds of less than two minutes were aged 12–16 months and to determine if taken by trained study staff using a standard not considered long enough to contribute amount and type of milk intake is associated protocol. In regional areas, participants to nutrient intake and were not entered as with dietary diversity as children make the were measured at their local child health intake in FoodWorks. The child was assumed transition from a milk-based diet in infancy to or medical clinic. Demographic data were to take 10 g of milk per minute from the a mixed diet of family meals. collected via self-administered questionnaire. breast with breastmilk providing 2.77 kJ/g. Weight-for-age z-scores were calculated for Each FoodWorks file was checked to ensure children using WHO Anthro (2008). the correct subject ID, date of recall and meal Methods Within two weeks of measurement, a dietitian times, and that the quantities of food and This is a cross-sectional data analysis of contacted each mother by telephone, to drink consumed, as well as total energy and mother-toddler dyads participating in: conduct a three-pass 24-hour dietary recall. macronutrient intakes, appeared reasonable. Participants were not aware the caller was Any assumptions made in the absence of 1. The control group of NOURISH, a a dietitian and, while they knew that they sufficient detail were also checked to ensure randomised controlled trial (RCT) would be contacted, the exact date was they were consistent with protocol and any evaluating the effect of an intervention to unknown. Each mother was asked to recall suspicious entries were checked against the promote positive feeding practices in very everything her child ate or drank in the hardcopy recall. young children. previous 24 hours, starting from midnight on The food recall data were exported from 2. An additional sample of mothers recruited the previous day, with quantities estimated FoodWorks into an Access database and for the South Australian Infants Dietary using household measures (metric cup, merged with an eight-digit food group code Intake (SAIDI) Study. tablespoon and teaspoon). A visual aid, that allows identification of each unique food. SAIDI participants were recruited showing images of metric cup sizes and These eight-digit codes are available from simultaneously and using the same actual size illustrations of tablespoon and Food Standards Australia New Zealand for all protocol as NOURISH. The active group of teaspoon measures, had been provided at items in the AUSNUT 2007 database. Study the NOURISH RCT was not included in this assessment. For dishes prepared at home, staff allocated additional eight-digit codes analysis. It was anticipated these mothers the mother was asked to provide the recipe to infant foods and mixed dishes. Codes would report higher intakes of core foods with ingredient quantities and the amount were allocated based on the predominant and fewer discretionary items following her child consumed. The time of each eating ingredient, for example, a casserole with their exposure to the NOURISH intervention, occasion was also recorded. Each mother was 30% beef, 60% vegetable and 10% water compared to the control group (and SAIDI). given a specially designed booklet, so that if was allocated a code within the vegetable Mothers at maternity hospitals in Brisbane, the child was in the care of another person, group. This database was imported into PASW Queensland (n=3) and metropolitan and the carer could record the child’s intake and Statistics 18.0.1 (2009) for analysis. regional South Australia (n=11) were the mother could accurately report it, if a approached within 72 hours post-partum recall was collected the following day. 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 327 © 2014 Public Health Association of Australia Byrne, Magarey and Daniels Article Food and beverages were classified into 10 such as biscuits, cakes, sweet/savoury pastry calculated (for consumers and the entire groups. These consisted of five core groups: items, spreads and sauces, butter and dairy sample) and expressed as a percentage. A fruit, vegetables (including legumes), cereals, blends, cream, ice-cream, chocolate, lollies, diversity score was calculated for each child as meat/alternatives (including fish, poultry, and crisps and ‘fast-food’ . Juice, fruit drinks, the number of core food groups (as defined eggs) and dairy; and five additional groups: cordial, soft drinks and flavoured milks were above) consumed on the day of the 24-hour unsaturated fats and oils, discretionary classified as sweet beverages. For each group, recall, giving a potential score between zero choices, sweet beverages, breastmilk and the proportion of children consuming any and five. Results are presented as mean formula. The dairy group included all milks, of that food or beverage on the day of the and standard deviation (SD) or median and yoghurt and cheese and dairy alternatives 24-hour recall is reported. Intake (g/day) of interquartile ranges (IQR) as appropriate. (soy/rice/oat). Intake of cow’s milk alone each group is reported for consumers only. ANCOVA was used to compare intake of is also reported separately. Discretionary The contribution of each food and beverage milks across each category of diversity items included foods high in fat or sugar, group to the total daily energy intake was score adjusting for child age (to account for the transition from a milk-based diet to family foods). Milks were divided into three Table 1: Characteristics of participating mothers and children (n=551). groups – formula, breastmilk and cow’s milk/ Characteristic Mean (SD) % (n) alternatives (included beverages that mothers Child age (months) 13.7 (1.1) might use instead of cow’s milk in a child’s Birthweight (kg) 3.5 (0.5) diet, such as goat’s milk and soy beverages). a b Weight-for-age z-score at 12-16 months of age (n=499 ) 0.53(.90) Intake of formula was compared across each Male gender 46 (254) category of diversity score, defined as gram intake of formula on the day of 24-hour recall First-born 66 (365) b and also as percentage of estimated energy Maternal age at birth of child (years) (n=549 ) 31.2 (5.2) requirement (EER) provided by formula. This Maternal education was repeated with intake of breastmilk and Year 12 or less 23 (126) with cow’s milk/alternatives. The calculation Trade/TAFE 28 (153) of EER involves adding an age-specific value University 49 (272) for growth (85 kJ for infants aged 1–2 years) c b Family income (n= 470 ) to the total energy expenditure (TEE). TEE $0 – $50,000 20 (94) for each individual was calculated using an $50,001 – $70,000 21 (98) equation that reliably predicts total energy More than $70,001 59 (278) expenditure (kJ/day) during the first two a Derived using WHO Anthro (2008) years of life – TEE = [-0.416 + (0.371 x Weight)] b n values <551 due to missing data 21 x 1000. c Median gross income in Australia in 2008 – all household types = $67,000 Results Table 2: Percentage of children aged 12-16 months (n=551) consuming each food and beverage group on the day of 24hour recall, median intake (g/day) of consumers, and contribution to total energy intake for consumers and Twenty-four hour recall data were available the whole sample. for 551 mother-toddler dyads. Child and % total energy intake % total energy intake Food or beverage group Proportion Intake g/day of maternal characteristics are shown in Table 1. consuming any consumers derived from group – derived from group – Eighty per cent (n=443) of 24-hour recalls Median (IQR) consumers only whole sample % (n) were completed on a weekday; 149 were Median (IQR) Median (IQR) completed during summer, 19 in autumn, 183 Fruit 87 (481) 131 (76-199) 9 (6-13) 8 (4-13) in winter and 29 in spring. Vegetables 77 (424) 89 (43-164) 5 (2-10) 3(0.2-9) Table 2 shows the proportion of children Cereals 97 (537) 72 (37-121) 18 (11-25) 17 (11-25) consuming any fruit, vegetables, cereal, meat/ Meat & alternatives 78 (430) 56 (28-105) 8 (5-14) 6 (1-12) alternatives, dairy, unsaturated fats and oils, Dairy 96 (529) 373 (146-628) 29 (17-46) 28 (15-46) discretionary items, sweet beverages, formula Cow’s milk 78 (431) 370 (129-577) 22 (9-38) 14 (6-28) or breastmilk. Twenty children ate neither fruit nor vegetables on the day of the 24-hour Unsaturated fats /oils 30 (166) 3 (2-5) 2 (1-3) 0 (0-1) recall. Only 86% (n=476) of children were Discretionary items 91 (502) 23 (10-51) 9 (4-14) 8 (3-14) reported to consume water as a drink. Table Sweet beverages 19 (102) 65 (23-131) 2 (0.8-4) 0 (0-0) 2 also shows the median daily intake (grams/ Formula 32 (179) 441 (258-618) 29 (18-43) 0 (0-17) day) of consumers and the contribution of Breast milk 23 (124) 200 (133-350) 15 (9-26) 0 (0-0) each food group to daily energy intake for a including legumes consumers and the whole sample. Mean b regular fat, reduced fat and skim milk, cheese, yoghurt, goat’s milk and soy/rice/oat beverages energy intake on the day of the recall was c including 100% fruit juice 4,194 kJ (SD=1092). The most commonly d Infant formula, follow-on formula and toddler milk 328 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Food and beverage intake in children aged 12–16 months consumed items within each food group are Figure 1: Mean formula intake (grams) and mean percentage of estimated energy requirement derived from shown in Table 3. formula, on day of 24-hour recall, across categories of diversity score (N=551). Of the 179 children consuming formula, 30 were having an infant formula, 60 a follow-on formula, and 91 children were drinking ‘toddler milk’ (one child consumed both infant and follow-on formula; another child both infant formula and toddler milk) on the day of the 24-hour recall. For consumers, formula intake made the greatest contribution to daily energy intake, providing a median of 29%. Median diversity score was 5 (IQR=4-5). Fifty- six per cent of children (n=307) had a diversity score of five; 31% (n=170) a score of four; 11% (n=61) a score of three; and 2% (n=11) a score of two. No child had a score of one or zero. Diversity Score Diversity score increased with decreasing formula intake (Figure 1). As child age was inversely related to formula intake, F(1, 546)= Dairy and cereal were the most commonly dietary energy for children aged 2–3 years 7.66, p=0.006, r =0.12, age was controlled for consumed food groups, eaten by 96% and (n=1,000). when investigating the relationship between 97% of children respectively. Of the five Median intake of meat/alternatives was diversity score and formula intake. There core food groups, these were the greatest 56 g per day for consumers of this food was significant inverse relationship between contributors to daily energy intake, with group with the lower limit of the IQR being diversity score and gram intake of formula, dairy contributing 28% and cereal 17%. This 28 g, while 22% of children in the sample F(3, 546)= 6.79, p<0.001, partial η =0.04., and is similar to the 2007 Children’s Survey where consumed no items from this food group. percentage of EER derived from formula, F(3, dairy and cereals provided 45% of total 494)= 5.51, p=0.001, partial η =0.03. Similar analysis with cow’s milk and breastmilk Table 3: Three most commonly consumed items in each food group on the day of 24-hour recall by children aged showed no so such relationship. 12-16 months (N=551). Food group % (n) consuming at least once on day of recall Discussion Fruit Banana 49 (272) This study provides insight into the dietary Sultana, dried 15 (81) habits of Australian toddlers – both the Strawberry, fresh 10 (55) quantity and diversity of foods consumed. It Seedless green grapes 10 (55) includes some of the first detailed intake data Vegetables Carrot, baked/boiled/steamed without added fat 33 (182) on a cohort of healthy children less than two Potato, peeled, baked/boiled/steamed, no added fat 26 (142) years of age. Broccoli, boiled/steamed 19 (103) The quality of dietary intake across this group Cereals Breakfast cereal, whole wheat biscuit 48 (263) is highly variable. Only 56% of children had White bread 24 (134) the maximum diversity score of five, which Wholemeal bread 22 (122) meant they consumed fruit, vegetables, Meat/alternatives Egg, chicken, baked 13 (73) cereal, meat/alternatives and dairy on the Chicken breast, lean, cooked without fat 12 (67) day of the 24-hour recall. Thirteen per cent of Leg ham, lean 9 (47) children ate foods from three or fewer core Dairy Cow’s milk, regular fat 75 (414) food groups. The majority of children ate fruit Cheddar cheese, regular fat 31 (172) (87%) and vegetables (77%) on the day of Cheddar cheese, regular fat, processed 16 (90) the 24-hour recall – higher than that found Unsaturated Fats and oils Polyunsaturated margarine 13 (72) in FITS 2008 (74% and 72%), but lower than Monounsaturated margarine 8 (45) a study of 374 children aged 12–36 months, Olive oil 7 (39) also conducted in Adelaide, where 89% of Discretionary items Vegemite 32 (179) children consumed fruit and 85% vegetables Plain sweet biscuit 21 (116) in the previous 24 hours. Only 4% (n=20) of Butter 19 (106) children in the current sample ate neither fruit Sweet beverages 100% Apple juice 4 (22) nor vegetables. 100% Orange juice 2 (12) Apple & Blackcurrant juice 2 (12) 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 329 © 2014 Public Health Association of Australia Formula Intake (g) Percentage of EER Byrne, Magarey and Daniels Article This means almost 50% of children ate less Water and cow’s milk were the most figures are similar to the nationally than 30 g meat/alternatives on the day of commonly consumed beverages. Only 19% representative Longitudinal Study of the recall. In addition, the most commonly of children consumed any sweet beverages, Australian Children. At 12 months of age, consumed items – egg, chicken and ham – with a median intake of 65 g/d (about 62 mL) 28% of children in the LSAC cohort (N=5,000) are poorer sources of iron compared with and 100% juice being the most frequently were continuing to breastfeed, decreasing to red meats. Choosing these foods often may consumed sweet beverage. This is consistent 9% of children at 18 months. Within the 2010 have implications for the iron status of young with feeding guidelines advising that children Australian National Infant Feeding Survey, children. over the age of 12 months be offered water or 18% of children were receiving breastmilk at milk as drinks in preference to juice, and juice 13–18 months of age. A food group with a surprising low being limited to 120–180 mL per day. Juice proportion of consumers – 30% of children The inherent limitations of this study are was classified within the ‘sweet beverage’ – was unsaturated fats and oils. It appears those associated with any collection of category rather than ‘fruit’ in this analysis, that children are being offered butter as dietary data. The results are based on a single given the link between intake of fruit juice a spread rather than unsaturated choices, 24-hour recall. While one day of intake per and poor health in young children including with butter consumed by 19% of the sample person is valid for group-level estimates dental caries, diarrhoea and the development 28 versus 13% having polyunsaturated and of food intake, there is the potential for a of obesity. This approach has been used 8% monounsaturated margarines. Butter single day to under-estimate the proportion 13,14 in other Australian studies. While milk is was the third most commonly eaten item that usually consume all five core food recommended, guidelines also advise daily within the food group labelled ‘discretionary groups, given these foods form the basis consumption of cow’s milk be less than 500 choices’ and 91% of children in the sample of daily intake. The potential for over- mL because of the high protein and low iron consumed discretionary foods. Median estimation of energy intake has also been content and risk of reducing diversity in the 29 intake of discretionary choices was not documented in this age group. This may diet. Median intake of consumers (n=431) excessive at 23 g; however, the upper level be due to errors by caregivers in estimating was 370 g per day (about 360 mL) – well of the IQR was 14% of daily energy intake. the portion size consumed. Toddlers can be below the suggested limit – and there was This indicates a disproportionate intake of independent eaters and food spillage may no association between intake of cow’s milk/ these foods compared with core foods in not be taken into account. Over-reporting alternatives and diversity score. some children. Toddlers need energy dense of intake by caregivers may be motivated by foods to ensure sufficient energy for growth, An important finding was that a lower the desire to portray their child as eating well but it is important to consider the quality diversity score was associated with greater at an age characterised by fussy eating and of food offered. Plain sweet biscuits were intake of formula, measured as grams or as a neophobia. popular, eaten by 21% of children. In Perth percentage of EER. Despite feeding guidelines Most recalls were completed on a weekday. (PIFS II), 92% of children had tried biscuits/ advising that cow’s milk can be used as a While the eating patterns of older children cakes by 12 months of age (n=587). drink and toddler milks are unnecessary in the and adults vary depending on the day of the Toddlers are very active but have variable second year of life, one-third of children in week, due to school and work commitments, appetites. As a result, they tend to consume the sample were having some type of formula this variability may be less of an issue in small frequent meals over the day to meet during the 24-hour recall. Formula provided infants with a predominately milk-based diet their energy and nutrient needs. Biscuits a substantial proportion of energy intake to and toddlers while in the ‘transition’ to family may become one of these ‘meals’. Biscuits those children (29%). Intake did decrease food. do not need cold storage or preparation, so with increasing child age, supporting the idea Participants were from high-income families, are an easy option for parents, particularly of a dietary transition during toddlerhood; a factor known to be predictive of healthy when away from home. Oer ff ing butter and however, the inverse relationship between eating patterns. Mothers agreeing to biscuits is inconsistent with the Australian diversity score and formula intake remained participate in research may also be better Dietary Guidelines that recommend limiting after controlling for child age. informed regarding the importance of intake of foods containing saturated fat, Why parents continue providing formula in infant nutrition than the general population. and replacing these foods with choices that the second year of life requires further study. However, demographic diversity remains a contain predominantly polyunsaturated Food refusal and neophobia are common strength of this study. The sample included and monounsaturated fats. Parents in toddlers and parents may give their child participants from urban and rural areas, need suggestions for better alternatives, formula to supplement what they consider mothers with varying numbers of children while considering cost, preparation and to be an inadequate food intake. But the and mothers with varying education levels. practicalities of life with a toddler. higher protein content and slower rate of About a quarter of mothers had an education Vegemite, a quintessential Australian gastric emptying of formula (compared to level of Year 12 or less, another quarter with 24,25 food, was the most commonly consumed breastmilk) has the potential to decrease a TAFE qualification and the remaining 50% discretionary item, eaten by a third of the appetite, intake and diversity at an age with a university education. The Australian toddlers. While is it mostly eaten in small crucial to the development of lifelong food Bureau of Statistics reports that about 40% amounts and in conjunction with core-food, preferences. of women aged 25–29 years hold a bachelor the flavour may perpetuate a young child’s 32 Within this group, with a mean age of 13.7 degree or higher. innate preference for salt. Parents may be months, 23% of the children consumed advised to use this spread sparingly and not breastmilk on the day of the recall. These offer it to children every day. 330 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Food and beverage intake in children aged 12–16 months 6. Department of Health and Ageing, the Department of 20. National Health and Medical Research Council. Conclusions and implications Agriculture, Fisheries and Forestry, and the Australian Australian Dietary Guidelines. Canberra (AUST): NHMRC; Food and Grocery. 2007 Australian National Children’s 2013. This study provides insight into the dietary Nutrition and Physical Activity Survey – Main Findings. 21. Butte NF. Energy Requirements of Infants. Background Canberra (AUST): Commonwealth Department of Paper Prepared for the Joint FAO:WHO:UNU Expert habits of Australian children aged 12–16 Health and Ageing; 2008. 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Canberra (AUST): AIHW; 2011. preferences. 2007. 28. Briefel RR, Kalb LM, Condon E, Deming DM, Clusen NA, 13. Koh GA, Scott JA, Oddy WH, Graham KI, Binns CW. Fox MK, et al. The Feeding Infants and Toddlers Study Exposure to non-core foods and beverages in the 2008: Study design and methods. J Am Diet Assoc. first year of life: results from a cohort study. Nutr Diet. 2010;110 Suppl 12:16-26. Acknowledgements 2010;67:137-42. 29. Fisher JO, Butte N, Mendoza PM, Wilson TA, Hodges EA, 14. Lioret S, McNaughton SA, Spence AC, Crawford D, Reidy KC, et al. Overestimation of infant and toddler The authors thank the families participating Campbell KJ. Tracking of dietary intakes in early energy intake by 24-h recall compared with weighed childhood: The Melbourne InFANT program. Eur J Clin food records. Am J Clin Nutr. 2008;88:470-15. in NOURISH and SAIDI and our research Nutr. 2013;67(3):275-81. 30. Devaney B, Ziegler P, Pac S, Karwe V, Barr S. Nutrient team in Brisbane and Adelaide, particularly 15. Siega-Riz AM, Deming DM, Reidy KC, Fox MK, Condon intakes of infants and toddlers. J Am Diet Assoc. Kylie Markow and Jo Meedeniya. NOURISH is E, Briefel RR. Food consumption patterns of infants and 2004;104 (1 Suppl 1):14-21. toddlers: Where are we now? J Am Diet Assoc. 2010;110 31. Smithers LG, Brazionis L, Golley RK, Mittinty funded by the National Health and Medical Suppl 12:38-51. MN, Northstone K, Emmett P, et al. Associations Research Council (No. 426704) and SAIDI by 16. Daniels L, Magarey AM, Battistutta D, Nicholson JM, between dietary patterns at 6 and 15 months of Farrell A, Davidson G, et al. The NOURISH randomised age and sociodemographic factors. Eur J Clin Nutr. the South Australian Government. The first controlled trial: Positive feeding practices and food 2012;66(6):658-66. author is funded by a PhD scholarship at QUT. preferences in early childhood – a primary prevention 32. Australian Bureau of Statistics. 4125.0 – Gender program for childhood obesity. BMC Public Health. Indicators, Australia, January 2013. Canberra (AUST): 2009;9:387-96. ABS; 2013. 17. Jonnalagadda SS, Mitchell DC, Smiciklas-Wright H, 33. Australian Bureau of Statistics. 6523.0 – Household References Meaker KB, Heel NV, Karmally W, et al. Accuracy of Income and Income Distribution, Australia, 2007-08. 1. National Health and Medical Research Council. Infant energy intake data estimated by a multiplepass, Canberra (AUST): ABS; 2009. Feeding Guidelines. Canberra (AUST): NHMRC; 2012. 24-hour dietary recall technique. J Am Diet Assoc. 2. Dovey TM, Staples PA, Gibson EL, Halford JCG. Food 2000;100(3):303-11. neophobia and ‘picky/fussy’ eating in children: A review. 18. Kent JC, Mitoulas L, Cox DB, Owens RA, Hartmann PE. Appetite. 2008;50:181-93. Breast volume and milk production during extended 3. Savage JS, Fisher JO, Birch LL. Parental influence on lactation in women. Exp Physiol. 1999;84:435-47. eating behaviour: Conception to adolescence. J Law 19. Department of Health and Ageing, National Health and Med Ethics. 2007;35(1):22-34. Medical Research Council, Ministry of Health. Nutrient 4. Skinner JD, Carruth BR, Bounds W, Ziegler PJ. Children’s Reference Values for Australia and New Zealand Including food preferences: a longitundinal analysis. J Am Diet Recommended Dietary Intakes. Canberra (AUST): Assoc. 2002;102:1638-47. Commonwealth of Australia; 2006. 5. Ruel MT. Operationalising dietary diversity: A review of measurement issues and research priorities. J Nutr. 2003;133:3911S-26S. 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 331 © 2014 Public Health Association of Australia http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Food and beverage intake in Australian children aged 12–16 months participating in the NOURISH and SAIDI studies

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Wiley
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© 2014 Public Health Association of Australia
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1326-0200
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10.1111/1753-6405.12249
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Abstract

considerable physical and emotional Objective: To describe the quantity and diversity of food and beverage intake in Australian Tdevelopment and represent a key time children aged 12–16 months and to determine if the amount and type of milk intake is in the child’s transition from infant feeding associated with dietary diversity. to family food. During the second year of life, the speed of growth slows in comparison Methods: Mothers participating in the NOURISH and South Australian Infant Dietary Intake to infancy while nutrient needs remain (SAIDI) studies completed a single 24-hour recall of their child’s food intake, when children high. Children aged 1–2 years require more (n=551) were aged 12–16 months. The relationship between dietary diversity and intake of nutrients and energy per kilogram of body cow’s milk, formula or breastmilk was examined using one-way ANOVA. weight than adults, which means toddlers Results: Dairy and cereal were the most commonly consumed food groups and the greatest must consume an energy- and nutrient-dense contributors to daily energy intake. Most children ate fruit (87%) and vegetables (77%) on diet. This age coincides with the development the day of the 24-hour recall while 91% ate discretionary items. Half the sample ate less than of autonomy and independence, food 30 g of meat/alternatives. A quarter of the children were breastfeeding while formula was fussiness and neophobia – the refusal of consumed by 32% of the sample, providing 29% of daily energy intake. Lower dietary diversity new foods. Repeated exposure to fruit and was associated with increased formula intake. vegetables may overcome a toddler’s natural Conclusions: The quality of dietary intake in this group of young children is highly variable. tendency for food refusal, thereby increasing Most toddlers were consuming a diverse diet, though almost all ate discretionary items. The a child’s liking for these foods and subsequent amount and type of meat/alternatives consumed was poor. intake. Liking a nutrient-dense diet that Implications: Health professionals should advise parents to offer iron-rich foods, while limiting incorporates all five core food groups is discretionary choices and use of formula at an age critical in the development of long-term important, as evidence suggests that food food preferences. preferences develop during early childhood and persist into adulthood. Dietary diversity, Key words: toddler, intake, diversity, breastfeeding, formula represented by the number of foods or food groups eaten during a given time-period, is to prevent childhood obesity and the preferences and support appropriate growth. an indicator of dietary quality and nutrient 7 onset of chronic disease. In contrast, iron Unfortunately, health professionals know little adequacy in developed countries. deficiency anaemia remains an issue for about which foods parents are offering and Normal child development now occurs in a toddlers in both developed and developing what children are actually eating at the critical world where paediatric obesity is a global countries. High intake of cow’s milk and 1–2 years of age. Several surveys examine health concern. Since 1986, prevalence of low meat consumption contribute to iron breastfeeding duration and introduction 8,9 overweight and obesity in Australia has deficiency. Excessive intake of formula or of solid foods during the period from birth 11-13 doubled, with about 18–21% of children cow’s milk may limit intake and diversity of to age 12 months, while the National aged 2-3 years now classified as overweight foods in the child’s diet, which in turn limits Children’s Nutrition and Physical Activity 6 10 or obese. Dietary intervention in infancy – their exposure to new tastes and textures. Survey (referred to here as the 2007 Children’s promoting fruit and vegetable consumption, In the face of such challenges, parents Survey) reported on the diets of Australian while reducing intake of foods that are are required to provide their child with a children from age 2–16 years. energy dense but nutrient poor – is important nutritious and varied diet, foster healthy food 1. School of Exercise and Nutrition Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology 2. Nutrition and Dietetics, Flinders Clinical and Molecular Medicine, School of Medicine, Flinders University, South Australia Correspondence to: Ms Rebecca Byrne, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Queensland 4059; e-mail: rebecca.byrne@student.qut.edu.au Submitted: September 2013; Revision requested: December 2013; Accepted: March 2014 The authors have stated they have no conflict of interest. Aust NZ J Public Health. 2014; 38;326-31; doi: 10.1111/1753-6405.12249 326 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Food and beverage intake in children aged 12–16 months The few existing surveys reveal poor quality using consecutive sampling and asked to All items from the 24-hour dietary recall intakes in very young children. The Perth provide consent to be contacted when were entered into FoodWorks Professional Infant Feeding Study II (PIFS II) conducted infants were four to seven months of age version 9 using the AUSNUT 2007 database in 2002–2003 (n=453) reported that by 52 for full enrolment in the studies. Inclusion from the 2007 Children’s Survey. Since this weeks of age, 92% of infants had consumed criteria: mothers 18 years or older, with the database included a limited number of biscuits and cakes, 79% hot chips/French facility for written and spoken English, who commercial infant products, an additional fries and 68% had eaten ice-cream. had delivered a healthy infant (≥37 weeks, database containing information on these A longitudinal analysis of 177 children ≥2500 g), able and willing to attend sessions products was created by study staff. Nutrient participating in the Melbourne Infant Feeding at designated clinics and – for NOURISH information was sourced from websites, Activity and Nutrition Trial reported that gram only – who were first-time mothers. Exclusion manufacturers or nutrient information panels. intake of vegetables decreased between nine criteria: mothers with a documented history Mixed dishes prepared at home were added and 18 months of age, while intake of energy- of domestic violence, intravenous substance to FoodWorks as a recipe, or if there were dense snacks increased. In the United States, use, self-reported eating or psychiatric fewer than three ingredients the foods were the Feeding Infants and Toddlers Study disorders, or other mental health problems; entered directly as separate items. (FITS) is a nationally representative survey of and/or infants diagnosed with congenital Breastfeeds were quantified as minutes children aged between four and 24 months. abnormalities or a chronic condition likely in which the child was actively feeding to The most recent survey in 2008, using a to affect normal development. Approval a maximum of 10 minutes per feed. Milk single 24-hour recall revealed that among was gained from 11 human research ethics transfer from the breast after this duration children aged 12–14.9 months (n=243), only committees including Queensland University is considered too slow to contribute three-quarters consumed fruit and the same of Technology and Flinders University. significantly to nutrient intake in this age proportion consumed vegetables. The most 18 This analysis uses data from the assessment group. If a second breastfeed started commonly consumed vegetable was fried that occurred when children were 12–16 within 30 minutes of the start of the previous potato. months of age, collected between June 2009 feed, it was not considered a new feed, and The aims of this analysis were to describe the and June 2010. Participants in metropolitan the time was added to the previous feed quantity and diversity of food and beverage areas attended study-specific assessment up to a maximum of 10 minutes. Similarly, intake in a group of Australian children clinics where anthropometric measures were breastfeeds of less than two minutes were aged 12–16 months and to determine if taken by trained study staff using a standard not considered long enough to contribute amount and type of milk intake is associated protocol. In regional areas, participants to nutrient intake and were not entered as with dietary diversity as children make the were measured at their local child health intake in FoodWorks. The child was assumed transition from a milk-based diet in infancy to or medical clinic. Demographic data were to take 10 g of milk per minute from the a mixed diet of family meals. collected via self-administered questionnaire. breast with breastmilk providing 2.77 kJ/g. Weight-for-age z-scores were calculated for Each FoodWorks file was checked to ensure children using WHO Anthro (2008). the correct subject ID, date of recall and meal Methods Within two weeks of measurement, a dietitian times, and that the quantities of food and This is a cross-sectional data analysis of contacted each mother by telephone, to drink consumed, as well as total energy and mother-toddler dyads participating in: conduct a three-pass 24-hour dietary recall. macronutrient intakes, appeared reasonable. Participants were not aware the caller was Any assumptions made in the absence of 1. The control group of NOURISH, a a dietitian and, while they knew that they sufficient detail were also checked to ensure randomised controlled trial (RCT) would be contacted, the exact date was they were consistent with protocol and any evaluating the effect of an intervention to unknown. Each mother was asked to recall suspicious entries were checked against the promote positive feeding practices in very everything her child ate or drank in the hardcopy recall. young children. previous 24 hours, starting from midnight on The food recall data were exported from 2. An additional sample of mothers recruited the previous day, with quantities estimated FoodWorks into an Access database and for the South Australian Infants Dietary using household measures (metric cup, merged with an eight-digit food group code Intake (SAIDI) Study. tablespoon and teaspoon). A visual aid, that allows identification of each unique food. SAIDI participants were recruited showing images of metric cup sizes and These eight-digit codes are available from simultaneously and using the same actual size illustrations of tablespoon and Food Standards Australia New Zealand for all protocol as NOURISH. The active group of teaspoon measures, had been provided at items in the AUSNUT 2007 database. Study the NOURISH RCT was not included in this assessment. For dishes prepared at home, staff allocated additional eight-digit codes analysis. It was anticipated these mothers the mother was asked to provide the recipe to infant foods and mixed dishes. Codes would report higher intakes of core foods with ingredient quantities and the amount were allocated based on the predominant and fewer discretionary items following her child consumed. The time of each eating ingredient, for example, a casserole with their exposure to the NOURISH intervention, occasion was also recorded. Each mother was 30% beef, 60% vegetable and 10% water compared to the control group (and SAIDI). given a specially designed booklet, so that if was allocated a code within the vegetable Mothers at maternity hospitals in Brisbane, the child was in the care of another person, group. This database was imported into PASW Queensland (n=3) and metropolitan and the carer could record the child’s intake and Statistics 18.0.1 (2009) for analysis. regional South Australia (n=11) were the mother could accurately report it, if a approached within 72 hours post-partum recall was collected the following day. 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 327 © 2014 Public Health Association of Australia Byrne, Magarey and Daniels Article Food and beverages were classified into 10 such as biscuits, cakes, sweet/savoury pastry calculated (for consumers and the entire groups. These consisted of five core groups: items, spreads and sauces, butter and dairy sample) and expressed as a percentage. A fruit, vegetables (including legumes), cereals, blends, cream, ice-cream, chocolate, lollies, diversity score was calculated for each child as meat/alternatives (including fish, poultry, and crisps and ‘fast-food’ . Juice, fruit drinks, the number of core food groups (as defined eggs) and dairy; and five additional groups: cordial, soft drinks and flavoured milks were above) consumed on the day of the 24-hour unsaturated fats and oils, discretionary classified as sweet beverages. For each group, recall, giving a potential score between zero choices, sweet beverages, breastmilk and the proportion of children consuming any and five. Results are presented as mean formula. The dairy group included all milks, of that food or beverage on the day of the and standard deviation (SD) or median and yoghurt and cheese and dairy alternatives 24-hour recall is reported. Intake (g/day) of interquartile ranges (IQR) as appropriate. (soy/rice/oat). Intake of cow’s milk alone each group is reported for consumers only. ANCOVA was used to compare intake of is also reported separately. Discretionary The contribution of each food and beverage milks across each category of diversity items included foods high in fat or sugar, group to the total daily energy intake was score adjusting for child age (to account for the transition from a milk-based diet to family foods). Milks were divided into three Table 1: Characteristics of participating mothers and children (n=551). groups – formula, breastmilk and cow’s milk/ Characteristic Mean (SD) % (n) alternatives (included beverages that mothers Child age (months) 13.7 (1.1) might use instead of cow’s milk in a child’s Birthweight (kg) 3.5 (0.5) diet, such as goat’s milk and soy beverages). a b Weight-for-age z-score at 12-16 months of age (n=499 ) 0.53(.90) Intake of formula was compared across each Male gender 46 (254) category of diversity score, defined as gram intake of formula on the day of 24-hour recall First-born 66 (365) b and also as percentage of estimated energy Maternal age at birth of child (years) (n=549 ) 31.2 (5.2) requirement (EER) provided by formula. This Maternal education was repeated with intake of breastmilk and Year 12 or less 23 (126) with cow’s milk/alternatives. The calculation Trade/TAFE 28 (153) of EER involves adding an age-specific value University 49 (272) for growth (85 kJ for infants aged 1–2 years) c b Family income (n= 470 ) to the total energy expenditure (TEE). TEE $0 – $50,000 20 (94) for each individual was calculated using an $50,001 – $70,000 21 (98) equation that reliably predicts total energy More than $70,001 59 (278) expenditure (kJ/day) during the first two a Derived using WHO Anthro (2008) years of life – TEE = [-0.416 + (0.371 x Weight)] b n values <551 due to missing data 21 x 1000. c Median gross income in Australia in 2008 – all household types = $67,000 Results Table 2: Percentage of children aged 12-16 months (n=551) consuming each food and beverage group on the day of 24hour recall, median intake (g/day) of consumers, and contribution to total energy intake for consumers and Twenty-four hour recall data were available the whole sample. for 551 mother-toddler dyads. Child and % total energy intake % total energy intake Food or beverage group Proportion Intake g/day of maternal characteristics are shown in Table 1. consuming any consumers derived from group – derived from group – Eighty per cent (n=443) of 24-hour recalls Median (IQR) consumers only whole sample % (n) were completed on a weekday; 149 were Median (IQR) Median (IQR) completed during summer, 19 in autumn, 183 Fruit 87 (481) 131 (76-199) 9 (6-13) 8 (4-13) in winter and 29 in spring. Vegetables 77 (424) 89 (43-164) 5 (2-10) 3(0.2-9) Table 2 shows the proportion of children Cereals 97 (537) 72 (37-121) 18 (11-25) 17 (11-25) consuming any fruit, vegetables, cereal, meat/ Meat & alternatives 78 (430) 56 (28-105) 8 (5-14) 6 (1-12) alternatives, dairy, unsaturated fats and oils, Dairy 96 (529) 373 (146-628) 29 (17-46) 28 (15-46) discretionary items, sweet beverages, formula Cow’s milk 78 (431) 370 (129-577) 22 (9-38) 14 (6-28) or breastmilk. Twenty children ate neither fruit nor vegetables on the day of the 24-hour Unsaturated fats /oils 30 (166) 3 (2-5) 2 (1-3) 0 (0-1) recall. Only 86% (n=476) of children were Discretionary items 91 (502) 23 (10-51) 9 (4-14) 8 (3-14) reported to consume water as a drink. Table Sweet beverages 19 (102) 65 (23-131) 2 (0.8-4) 0 (0-0) 2 also shows the median daily intake (grams/ Formula 32 (179) 441 (258-618) 29 (18-43) 0 (0-17) day) of consumers and the contribution of Breast milk 23 (124) 200 (133-350) 15 (9-26) 0 (0-0) each food group to daily energy intake for a including legumes consumers and the whole sample. Mean b regular fat, reduced fat and skim milk, cheese, yoghurt, goat’s milk and soy/rice/oat beverages energy intake on the day of the recall was c including 100% fruit juice 4,194 kJ (SD=1092). The most commonly d Infant formula, follow-on formula and toddler milk 328 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Food and beverage intake in children aged 12–16 months consumed items within each food group are Figure 1: Mean formula intake (grams) and mean percentage of estimated energy requirement derived from shown in Table 3. formula, on day of 24-hour recall, across categories of diversity score (N=551). Of the 179 children consuming formula, 30 were having an infant formula, 60 a follow-on formula, and 91 children were drinking ‘toddler milk’ (one child consumed both infant and follow-on formula; another child both infant formula and toddler milk) on the day of the 24-hour recall. For consumers, formula intake made the greatest contribution to daily energy intake, providing a median of 29%. Median diversity score was 5 (IQR=4-5). Fifty- six per cent of children (n=307) had a diversity score of five; 31% (n=170) a score of four; 11% (n=61) a score of three; and 2% (n=11) a score of two. No child had a score of one or zero. Diversity Score Diversity score increased with decreasing formula intake (Figure 1). As child age was inversely related to formula intake, F(1, 546)= Dairy and cereal were the most commonly dietary energy for children aged 2–3 years 7.66, p=0.006, r =0.12, age was controlled for consumed food groups, eaten by 96% and (n=1,000). when investigating the relationship between 97% of children respectively. Of the five Median intake of meat/alternatives was diversity score and formula intake. There core food groups, these were the greatest 56 g per day for consumers of this food was significant inverse relationship between contributors to daily energy intake, with group with the lower limit of the IQR being diversity score and gram intake of formula, dairy contributing 28% and cereal 17%. This 28 g, while 22% of children in the sample F(3, 546)= 6.79, p<0.001, partial η =0.04., and is similar to the 2007 Children’s Survey where consumed no items from this food group. percentage of EER derived from formula, F(3, dairy and cereals provided 45% of total 494)= 5.51, p=0.001, partial η =0.03. Similar analysis with cow’s milk and breastmilk Table 3: Three most commonly consumed items in each food group on the day of 24-hour recall by children aged showed no so such relationship. 12-16 months (N=551). Food group % (n) consuming at least once on day of recall Discussion Fruit Banana 49 (272) This study provides insight into the dietary Sultana, dried 15 (81) habits of Australian toddlers – both the Strawberry, fresh 10 (55) quantity and diversity of foods consumed. It Seedless green grapes 10 (55) includes some of the first detailed intake data Vegetables Carrot, baked/boiled/steamed without added fat 33 (182) on a cohort of healthy children less than two Potato, peeled, baked/boiled/steamed, no added fat 26 (142) years of age. Broccoli, boiled/steamed 19 (103) The quality of dietary intake across this group Cereals Breakfast cereal, whole wheat biscuit 48 (263) is highly variable. Only 56% of children had White bread 24 (134) the maximum diversity score of five, which Wholemeal bread 22 (122) meant they consumed fruit, vegetables, Meat/alternatives Egg, chicken, baked 13 (73) cereal, meat/alternatives and dairy on the Chicken breast, lean, cooked without fat 12 (67) day of the 24-hour recall. Thirteen per cent of Leg ham, lean 9 (47) children ate foods from three or fewer core Dairy Cow’s milk, regular fat 75 (414) food groups. The majority of children ate fruit Cheddar cheese, regular fat 31 (172) (87%) and vegetables (77%) on the day of Cheddar cheese, regular fat, processed 16 (90) the 24-hour recall – higher than that found Unsaturated Fats and oils Polyunsaturated margarine 13 (72) in FITS 2008 (74% and 72%), but lower than Monounsaturated margarine 8 (45) a study of 374 children aged 12–36 months, Olive oil 7 (39) also conducted in Adelaide, where 89% of Discretionary items Vegemite 32 (179) children consumed fruit and 85% vegetables Plain sweet biscuit 21 (116) in the previous 24 hours. Only 4% (n=20) of Butter 19 (106) children in the current sample ate neither fruit Sweet beverages 100% Apple juice 4 (22) nor vegetables. 100% Orange juice 2 (12) Apple & Blackcurrant juice 2 (12) 2014 vol . 38 no . 4 Australian and New Zealand Journal of Public Health 329 © 2014 Public Health Association of Australia Formula Intake (g) Percentage of EER Byrne, Magarey and Daniels Article This means almost 50% of children ate less Water and cow’s milk were the most figures are similar to the nationally than 30 g meat/alternatives on the day of commonly consumed beverages. Only 19% representative Longitudinal Study of the recall. In addition, the most commonly of children consumed any sweet beverages, Australian Children. At 12 months of age, consumed items – egg, chicken and ham – with a median intake of 65 g/d (about 62 mL) 28% of children in the LSAC cohort (N=5,000) are poorer sources of iron compared with and 100% juice being the most frequently were continuing to breastfeed, decreasing to red meats. Choosing these foods often may consumed sweet beverage. This is consistent 9% of children at 18 months. Within the 2010 have implications for the iron status of young with feeding guidelines advising that children Australian National Infant Feeding Survey, children. over the age of 12 months be offered water or 18% of children were receiving breastmilk at milk as drinks in preference to juice, and juice 13–18 months of age. A food group with a surprising low being limited to 120–180 mL per day. Juice proportion of consumers – 30% of children The inherent limitations of this study are was classified within the ‘sweet beverage’ – was unsaturated fats and oils. It appears those associated with any collection of category rather than ‘fruit’ in this analysis, that children are being offered butter as dietary data. The results are based on a single given the link between intake of fruit juice a spread rather than unsaturated choices, 24-hour recall. While one day of intake per and poor health in young children including with butter consumed by 19% of the sample person is valid for group-level estimates dental caries, diarrhoea and the development 28 versus 13% having polyunsaturated and of food intake, there is the potential for a of obesity. This approach has been used 8% monounsaturated margarines. Butter single day to under-estimate the proportion 13,14 in other Australian studies. While milk is was the third most commonly eaten item that usually consume all five core food recommended, guidelines also advise daily within the food group labelled ‘discretionary groups, given these foods form the basis consumption of cow’s milk be less than 500 choices’ and 91% of children in the sample of daily intake. The potential for over- mL because of the high protein and low iron consumed discretionary foods. Median estimation of energy intake has also been content and risk of reducing diversity in the 29 intake of discretionary choices was not documented in this age group. This may diet. Median intake of consumers (n=431) excessive at 23 g; however, the upper level be due to errors by caregivers in estimating was 370 g per day (about 360 mL) – well of the IQR was 14% of daily energy intake. the portion size consumed. Toddlers can be below the suggested limit – and there was This indicates a disproportionate intake of independent eaters and food spillage may no association between intake of cow’s milk/ these foods compared with core foods in not be taken into account. Over-reporting alternatives and diversity score. some children. Toddlers need energy dense of intake by caregivers may be motivated by foods to ensure sufficient energy for growth, An important finding was that a lower the desire to portray their child as eating well but it is important to consider the quality diversity score was associated with greater at an age characterised by fussy eating and of food offered. Plain sweet biscuits were intake of formula, measured as grams or as a neophobia. popular, eaten by 21% of children. In Perth percentage of EER. Despite feeding guidelines Most recalls were completed on a weekday. (PIFS II), 92% of children had tried biscuits/ advising that cow’s milk can be used as a While the eating patterns of older children cakes by 12 months of age (n=587). drink and toddler milks are unnecessary in the and adults vary depending on the day of the Toddlers are very active but have variable second year of life, one-third of children in week, due to school and work commitments, appetites. As a result, they tend to consume the sample were having some type of formula this variability may be less of an issue in small frequent meals over the day to meet during the 24-hour recall. Formula provided infants with a predominately milk-based diet their energy and nutrient needs. Biscuits a substantial proportion of energy intake to and toddlers while in the ‘transition’ to family may become one of these ‘meals’. Biscuits those children (29%). Intake did decrease food. do not need cold storage or preparation, so with increasing child age, supporting the idea Participants were from high-income families, are an easy option for parents, particularly of a dietary transition during toddlerhood; a factor known to be predictive of healthy when away from home. Oer ff ing butter and however, the inverse relationship between eating patterns. Mothers agreeing to biscuits is inconsistent with the Australian diversity score and formula intake remained participate in research may also be better Dietary Guidelines that recommend limiting after controlling for child age. informed regarding the importance of intake of foods containing saturated fat, Why parents continue providing formula in infant nutrition than the general population. and replacing these foods with choices that the second year of life requires further study. However, demographic diversity remains a contain predominantly polyunsaturated Food refusal and neophobia are common strength of this study. The sample included and monounsaturated fats. Parents in toddlers and parents may give their child participants from urban and rural areas, need suggestions for better alternatives, formula to supplement what they consider mothers with varying numbers of children while considering cost, preparation and to be an inadequate food intake. But the and mothers with varying education levels. practicalities of life with a toddler. higher protein content and slower rate of About a quarter of mothers had an education Vegemite, a quintessential Australian gastric emptying of formula (compared to level of Year 12 or less, another quarter with 24,25 food, was the most commonly consumed breastmilk) has the potential to decrease a TAFE qualification and the remaining 50% discretionary item, eaten by a third of the appetite, intake and diversity at an age with a university education. The Australian toddlers. While is it mostly eaten in small crucial to the development of lifelong food Bureau of Statistics reports that about 40% amounts and in conjunction with core-food, preferences. of women aged 25–29 years hold a bachelor the flavour may perpetuate a young child’s 32 Within this group, with a mean age of 13.7 degree or higher. innate preference for salt. Parents may be months, 23% of the children consumed advised to use this spread sparingly and not breastmilk on the day of the recall. These offer it to children every day. 330 Australian and New Zealand Journal of Public Health 2014 vol . 38 no . 4 © 2014 Public Health Association of Australia Lifestyle Food and beverage intake in children aged 12–16 months 6. Department of Health and Ageing, the Department of 20. National Health and Medical Research Council. Conclusions and implications Agriculture, Fisheries and Forestry, and the Australian Australian Dietary Guidelines. Canberra (AUST): NHMRC; Food and Grocery. 2007 Australian National Children’s 2013. This study provides insight into the dietary Nutrition and Physical Activity Survey – Main Findings. 21. Butte NF. Energy Requirements of Infants. Background Canberra (AUST): Commonwealth Department of Paper Prepared for the Joint FAO:WHO:UNU Expert habits of Australian children aged 12–16 Health and Ageing; 2008. Consultation on Energy in Human Nutrition. Rome (ITA): months. Nationally representative dietary 7. Waters E, de Silva-Sanigorski A, Hall BJ, Brown T, United Nations University World Health Organization Campbell KJ, Gao Y, et al. Interventions for preventing Food and Agriculture Organization of the United data in this age group is not available. obesity in children (Cochrane Review). In: The Cochrane Nations; 2001. Most children were consuming a diverse Database Of Systematic Reviews; Issue 12; 2011. 22. Chan L, Magarey AM, Daniels L. Maternal feeding range of food groups, including fruits and Chichester (UK): John Wiley & Sons; 2011. practices and feeding behaviours of Australian 8. Borgna-Pignatti C, Marsella M. Iron dec fi iency in infancy children aged 12-36 months. Matern Child Health J. vegetables, while a quarter were continuing and childhood. Pediatr Ann. 2008;37(5):329-37. 2011;15:1363-71. to breastfeed. A third of the sample was 9. 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