November Blog Post!
I bet everyone is excited for their breaks! I know I am! One more blog spot before we have December off.
Article Link: http://jandonline.org/article/S2212-2672(17)31089-4/pdf
ABSTRACT
Background Food
reluctance can present as fussiness, picky eating, slowness in eating, and high
satiety responsiveness. It can be associated with inadequate weight gain during
early childhood. Although a majority of preschoolers attend daycare centers,
associations between their eating behaviors at daycare and their body
composition have not been studied.
Objective Our aim
was to develop an estimate of food reluctance and to assess the relationship
between food reluctance at daycare and body mass index (BMI) and waist
circumference of preschoolers.
Design We
conducted a cross-sectional secondary analyses. Food reluctance was estimated
using weighted digital plate waste analysis. Intra-rater, inter-rater, and
testretest reliability and convergent validity of the food reluctance score
were tested. The food reluctance score was then compared to preschool
children’s BMI and waist circumference.
Participants/setting
Participants included 309 children aged 3 to 5 years in 24 daycare centers
across the Canadian province of New Brunswick.
Main outcome measures
Preschool children’s waist circumference and age-adjusted BMI derived from
objectively measured height and weight were analyzed.
Statistical analyses
performed Intraclass correlations were used to determine the reliability of the
new estimate. Spearman correlation was used to compare the estimate with
parental report of food reluctance. Multivariate linear regressions were used
to examine the relationship between food reluctance and waist circumference and
age-adjusted BMI.
Results The
estimated food reluctance score demonstrated excellent inter- and intra-rater
reliability (intraclass correlation>0.97; P<0.0001) and good test-retest
reliability (intraclass correlation=0.72; P<0.0001). It also provided
evidence of convergent validity through correlation with reluctance-related
subscales of the Child Eating Behavior Questionnaire (r=.53, P<0.0001).
Greater demonstration of food reluctance at the daycare center was associated
with a lower age-adjusted BMI (adjusted β -1.41; 95% CI -.15 to -2.67), but was
not associated with children’s waist circumference (adjusted β
-.60; 95% CI -2.06 to .86).
Conclusions Signs
of food reluctance can be observed in daycare and relate to lower BMI among
preschoolers.
Blog Discussion
Feel free to take this article in directions that I have not
coaxed you toward! Here are some questions to get us started!
The article defines food reluctance as fussiness, picky
eating, slowness in eating, and high satiety responsiveness. In your own words,
how do you define food reluctance?
The researchers used a cross-sectional secondary analysis as their study design, do you see this as a flaw or using resources to their advantage?
Within the introduction and results of this study, the
researchers focus much of their attention towards eating behaviors of preschool
children and state that day care centers are a good setting to intervene on the
eating behaviors of children. Do you think this study would have had a greater
impact if the researchers did their own study to test waste circumference and BMI against an
experimental group that received basic nutrition education? How do you think
eating behaviors would have been impacted and would these eating behaviors significantly impact BMI and waist circumference?
posted by Unknown @ 4:55 PM
22 comments
22 Comments:
It is always interesting to me to see studies relating to poor intake as well as the many other studies we’ve seen previously talking about excess intake in the pediatric population. We walk such a fine line between over and under feeding, but what is truly the most successful recommendation to get appropriate intake? Unfortunately, this study did not speak much as to how we can improve or adapt food reluctance, but it does introduce the concept and spark some conversation.
I have a few concerns with this study in regards to the “Body Composition Measurements”. Utilizing BMI in any population can be somewhat concerning to me as it only considers a few minor measurements and tries to predict large outcomes in terms of health. BMI does not take into account whether a child was SGA, AGA or LGA at birth, or with irregular growth patterns of sprouting taller before putting on weight, or many other pieces of information that may be important factors in a child’s body composition.
Also, the use of waist circumference is an interesting choice due to the lack of age-adjusted international standards for that measure, leading to limited data outcomes. Additionally, the article itself even noted that age likely confounded this data. Although there have to be some aspects that go into body composition measures of children, I don’t believe the selected measures were sufficient in gaining adequate information to accurately predict the child’s overall health outcome trajectory. I think this study considers itself very preliminary in terms of plate waste as a measure of food reluctance, but I would be interested to see more data on a longitudinal scale that could progress to actual health outcomes to measure rather than attempting to predict them through equations.
Hi Austin,
In my own words, I would define food reluctance as a physical action or verbalized intent which demonstrates unwillingness to consume food.
In regards to the study design, I agree that a cross section analysis is probably the best way to analyze this population. However, conducting a secondary analysis of data previously collected for a different purpose/study could be problematic. If the researchers had collected data themselves specifically for the current study, perhaps they would have approached data collection a little differently or attempted to collect different data points that relate more to the current study.
In terms of tweaking the study to measure a control group against an experimental group that has had nutrition education, I am not sure this would be very effective with such young children. At this age, I think modeling good eating behavior would be more effective than telling the children they need to eat what is on their plate. That being said, if there was an experimental group of day care children which observed adults modeling good eating behavior, I think that might be more effective than general nutrition education and I do think that experimental group would potentially have higher BMIs and waist circumferences.
Lauren,
I agree with you that BMI and waist circumference are interesting choices for measuring physical results of food reluctance in children. Children are so variable in size anyway, and some grow a bit faster than others and/or lose their “baby fat” at different times. I would posit this issue is a result of conducting a secondary analysis for this study instead of collecting data specifically for the current study and conducting a primary analysis on the collected data.
How timely that Austin selected this article for November, as I just observed lunchtime at ISU Childcare this past week.
I think that this article, like Lauren mentioned, is very preliminary and serves to “get the ball rolling” and to get us thinking about eating patterns and behaviors outside of the home, away from parents, how these may relate to health outcomes, and how we can measure and assess them. Because of that, it certainly has some shortcomings in my opinion. I agree that BMI and WC may not be the best measurements to assess body composition for the same reasons that Lauren and Erin discussed. I am not exactly sure what “measurements” I would recommend or those that would be most appropriate, just children’s bodies are so variable and there are many factors that come into play regarding body composition (weight at birth, height, activity level, etc.). Does anyone have ideas?? I also think, in terms of health outcomes, it would be important to assess their nutrient intake in relation to their needs, especially as the article mentions concern over specific nutrient deficiencies in addition to inadequate weight gain. I also find concern in the fact that data from only two days were used. Does this give an accurate representation of children’s behaviors or habits? Also, appetite levels were not considered or mentioned, nor were the presence of other meals/snacks that may have been served during daycare hours. Also, I was curious as to the schedule at the day cares. What did the children right before lunch or right after? Did they have playtime or naptime after lunch as that may play a role in food reluctance.
From my experience at ISU childcare, I was able to observe a few strategies used at mealtime that I thought were effective in promoting adequate consumption:
• Children sat at small tables (2-3 children) with 1 teacher
• Teacher ate lunch with children, eating the same foods
• Meal was served family-style, each child independently served themselves from a larger serving vessel. This allowed children to take as much or as little of a food as they desired and decide if they would like more.
• All children were required to take a portion of every item offered and taste it.
• Children had 45 minutes to work their way through lunch
I think the approach that ISU Childcare currently uses is appropriate and encourages and promotes desired eating behaviors. It is very supportive of intuitive eating which I appreciate. Children are naturally very intuitive eaters, but with so many societal pressures, norms, and expectations and media messages, this is something that is slowly being stripped from them, in my opinion. Like Erin, I think behavioral/modeling approaches to “nutrition education” would be most effective among this population - children are always (always!) watching and often mimic or copy the behavior of others. Daycare centers are an opportune environment to practice that modeling, as the article pointed out that children spend nearly 30 hours a week in such centers.
I was excited to read about this topic and population. As you know, I have a lot of experience in daycare and those kiddos have my heart! I was a little concerned when I started reading the article that all they based the children’s food reluctance score on was weighted plate waste analysis…but then saw that they did quite a few tests for accuracy of the measure as well as compared the score to what the children’s parents reported via the Child Eating Behavior Questionnaire. This helped me view this measure in a better light.
My first thoughts regarding the results were that it was kind of obvious. Of course the children who are not eating much at daycare will likely have a lower BMI, and since that is a weight to height calculation their body build is sort of taken out of the picture (so waist circumference does not have as much of a significant relationship). Lauren makes a good point about the oddity in choosing solely these measures for the study.
I saw a lot of food reluctance at my daycare job in high school/college. As the article mentioned, there are many different causes. In my experience, some kids are small and don’t eat much ever, some mess around at the table, others are scared to try new things or may be rushed by the daycare staff, and I’ve noticed that peer pressure (looking cool and eating what your friends are eating) is a huge thing, even at a young age!
Erin’s definition of food reluctance was spot on. Kids definitely portray a dislike or uninterest of food in a large number of ways! However, I do not really consider the cross-sectional secondary analysis study design as an issue. If the data was already there and had just not yet been utilized in the way they aimed, I do not see a problem in taking that information (plate waste, BMI, waist circumference). They were able to use the information and not interrupt the daycares again. However, if they had different goals for the study, this design would not be a proper choice.
I agree that daycare centers prove to be an ideal place to focus nutrition interventions/efforts. After all, kids in daycare do spend a large amount of time there, and consumer up to two meals and two snacks at daycare! Daycare shapes a lot of children in how they approach social situations, how they act, and what they believe is true about themselves and others. Eating behaviors can be observed/developed there as well. To address Austin’s question, I know that these interventions need to start with the daycare workers. The food behaviors I mentioned in my primary post have a lot to do with the environment created by the daycare director and workers. I think to address food reluctance, the daycare needs to provide the children with frequent and consistent exposure to vegetables and fruits, and other foods that they are trying to promote. Obviously, they do not want to waste the food that they are serving- that is money out of their pockets. Next, adequate time to eat is a must for this population. Preschoolers take a long time to eat. Socializing at the table can be a good thing for them, as long as they are not messing around and the conversations/activity is positive. Finally, and also aimed at the childcare workers, it is up to the staff to provide the kiddos with positive food messages and proper modeling! Kids are always watching the adults, so sitting down to eat with them (with a healthy, balanced plate) can show them that brussels sprouts and quinoa are yummy and healthy. Quite often at my work, the gals would eat other things and try to keep them away from the kids, but of course the children noticed the pizza rolls, pop, candy, etc! All that to say that the basic nutrition education would need to be tailored to the daycare workers- though a little lesson with the kids would be awesome as well. :) Thank you Jenni for providing insight into what ISU Childcare does. It sounds like they do a phenomenal job!! But as Lauren noted, what is the line? We don’t want to force-feed kids (Rachel has talked about the “clean-plate club” before), see an unhealthy increase in weight status, or anything of that sort!
Jenni,
I am so glad you got the opportunity to visit ISU’s childcare center! I felt as though their methods for eating with the children and modeling healthy behaviors was such an easy way to promote appropriate habits. You make a great observation that the meals are at least 45 minutes, allowing the children to really appreciate the taste, smell and other features of the food. What a cool way to start promoting mindful eating at an appropriate pace! I wonder if there are any schools that look into more of this mindful approach at a K-5 level or at higher levels? Even without the continued modeling of teachers at the table, promoting this pattern of eating throughout all levels of education could be beneficial for endorsing healthy habits.
Erin's definition of food reluctance is spot on. This definition includes the parameters the authors use as their own definition: fussiness, picky eating, slowness in eating, and high satiety responsiveness. In my own experience with child eating behaviors, I noticed that a lack of interest and wandering away from the table during mealtimes. This was an unspoken way of the child showing reluctance to the food they were presented with. Preschools are an excellent setting to instill proper eating behaviors and provide early intervention as many of us have discussed already.
Like Kaitlin said, I thought the outcomes of this study were a bit obvious. However, researching these topics and finding significant results strengthens the literature and provides insight as to why this is important.
I don't think the outcomes of this study would have been greatly impacted if the researchers performed their own primary research to collect data. As many have mentioned, I do think that waist circumference is not the greatest variable to research. In my own research regarding eating preferences of preschool-aged children with Dr. Vollmer, we used the Preschool Adapted Food Liking Survey (PALS) to measure child food preferences (the parents' perception since they filled it out on behalf of their child). I loved this because we were able to see the child's preference of different foods and beverages that were then categorized into fruit, vegetables, high fat and/or sugar foods. Although we didn't report the relationship in our final manuscript, we calculated Z-scores of each child, which I find would make more sense than to use waist circumference. Height and weight play a more vital role to evaluate children's nutrition and developmental status than solely waist circumference.
Jenni, thanks for your insight of ISU's Childcare Center. The eating environment they provide sounds as if it is exactly what children need in order to develop healthy eating behaviors and preferences.
Lauren, there are schools who practice and encourage mindful eating. I think the literature is strong enough at this point for school districts to realize they harness the most power in teaching children of all ages proper eating behaviors. I also believe that having RDNs working as food service directors has pushed the initiation of mindful eating programs and settings in K-12 schools.
Wow Jamey, that is awesome that there are school districts that support and encourage mindful eating in their foodservice programs - I am going to have to research and dig into this more!
Kaitlyn, I think you hit it on the head when you discussed the importance of the day care workers and their attitudes and behaviors - thanks for sharing your experiences too. I am curious as to how/if you addressed or responded to the actions of your fellow co-workers? I am sure you modeled idea eating behaviors and were a fantastic role model for the children and I am sure it would be frustrating to be around others who may have not been supporting, and instead combating, you efforts. When I was at FNCE, I attended a session about a K-12 food service program/organization. They worked with districts to provide training to food service staff and district administrators in order to cultivate a food service department and program in which everyone was on the same page and had the same tools to promote a healthy, high-quality, safe and mindful eating environment and meal service for the students. Based on the outcomes reported by the speakers (one was a district food service director and RDN and the other was a chef-RDN), it seemed to be a very effective program and may be appropriate to modify and apply in the childcare field. Although, I am not sure all districts or childcare programs would have the time and money to devote to a training program like that...time and money, the ever-present challenges to work around.
Austin, you pose some good questions.
1. My definition of food reluctance would be any food that a person is unwilling to eat (pickiness), one that a person refuses to eat for personal reasons (ex. Vegan), or any food that a person does not want to try due to previous bad experiences (ex. Getting sick from a certain food). I do not really agree with the authors definition of eating slow. Rate of eating does not really reflect food reluctance, especially in the age group under study. Kids are chatting more than they are eating most of the time. Some children are just slow eaters, which is something that should be encouraged. Adults eat way to fast and do not take the time to enjoy our food. Preschools have not learned/been forced to do this yet so their rate of eating should look much different than older children and adults.
2/3. I read your questions before reading the article. To be honest, I had to look up what a cross-sectional secondary analysis was. This made it easier to understand the methodology while reading the article. While I do not think that this type of research produces the best results, some preliminary information about this topic was needed. I do think the authors need to take the next step and conduct their own study and gather their own data to provide more evidence and greater reliability. I think the data they used could be easier to manipulate in the direction the researchers wanted. I like the idea of provided a group of children nutritional education and determining if that had any impact on their level of food reluctance and thus their BMI.
Jenni, You had a lot of the same questions I had about the article. I think there were a lot of gaps in the research and thus the data that was collected. Many thinks could have affected how much the children ate, like you pointed out. The fact that they only used two day’s worth of data was a huge weakness in my opinion. I am glad you were able to see how meal times worked at ISU.
While I was at DCR, I saw several meal times, both at home day cares and at centers. I was amazed at how differently each place conducted meal times. One home ate outside under a tree picnic style, one made all the children sit at a table and be quite while eating, the centers did not really measure how much of anything they were giving. It was crazy that something that seems as simple as eating a meal can be done in so many different ways.
I agree with Kaitlyn that day cares are an excellent place for nutritional interventions. Most of my time at DCR was developing materials that day care providers could use to promote healthy eating and a variety of food. The attitude of the day care providers seemed to make a huge difference on the food offered to the children. Some strived to offer a variety every week while others served the same orange/tan processed foods over and over. We cannot expect kids to eat different foods if they don’t ever get them offered.
Everyone has a lot of great insight!
To kind of work backwards. Reilly, when you stated that eating slowly does not strike you as a form of food reluctance and then tied in the fact that we are having to teach adults to eat slowly, this was the exact thought that popped into my mind as well. When kids have shortened eating periods, I think it creates a sense of urgency that can translate to eating behaviors at home. This made me really appreciate the shared experiences by you, Jennie, and Kaitlyn. It was very interesting to read about how different each meal time was! I really liked that fact that meals were served family style
-How can we better implement healthy eating periods like the ones mentioned so that more daycare centers and school are able to adopt these practices?
I also agree with the many comments about how the outcome of this study was a bit obvious but makes for good preliminary evidence to build off of. This was one reason that I chose this article, because, to be honest, I thought it was a bit basic and monotonous to be placed in the AND journal and wanted to see what others thought. I’m interested in Lauren’s thoughts on observing data on a longitudinal scale instead of just predicting health outcomes.
-How can future research utilize the outcomes of this study to expand our knowledge on food reluctance and health measures?
Oops! Forgot to finish my thought.
I really liked that fact that meals were served family style to preserve intuitive eating. I also think that having an authority figure to be present and eat with the children is a great way to promote healthy eating behaviors, as long as they aren’t eating pizza and junk every day, like Kaitlyn mentioned.
I agree with the above criticisms of the use of BMI and waist circumference; with that said, I think it is acceptable to give the researches some leeway in their use of these measurements. This study was the first of its kind; future studies can utilize measures that more accurately reflect a child's development.
The above criticism stirs me to reflect on the nature of BMI as a whole. My conception of BMI is that of a screening tool used to quickly assess one's risk for diet/lifestyle related co-morbidities. Speaking from recent experience, everyday at Proctor, we would assess any new patients with a BMI less than 18. Sometimes these patients were nutritionally adequate, and often times they were not. Being a screening tool, I think that BMI is a more useful tool in analyzing large groups of people (several thousand) as opposed to smaller groups (hundreds). BMI does not account for individual variation, and thus for smaller samples, some important info is lost. In very large samples however, I suspect that the sheer number of participants would better account for individual variation. To tie this line of thinking back to the study in question, I think that BMI is a less ideal measure for this study due to its sample size (~300) rather than it being an intrinsically flawed measure. "Quantity has a quality all of its own" as the old saying goes.
To me, food reluctance would be hesitancy or unwillingness to try new foods, but I also agree with the article's definition of the term. I thought this was a very interesting article. Preschool age is where that majority of food fussiness and pickiness begins. After reading about Ellyn Satter’s Division of Responsibility, this subject peaked my interest.
Plate waste analysis was used in this study to measure food reluctance. Although I have had some challenges with plate waste analysis in my rotations due to accuracy and accountability, it seems as though the researchers in this study took a lot into consideration when analyzing waste. It mentions that there were trained research assistants taking pictures, weighing of food items, and calculating grams of each food group. Even the distance of the photographs were measured, which I think shows credibility. I was impressed with this method of analysis, and believe it could be an accurate measurement.
Overall, similar to what the researchers stated, I believe that daycare centers provide an ideal atmosphere to intervene on nutrition habits and practices. As the article mentions, children attend daycare for about 29 hours a week. Some children may not have a chance to learn positive eating behaviors at home or even be able to try new foods, so providing a positive mealtime atmosphere with different options at daycare is important. Also, I agree with the results of this study as I would assume that if a child is portraying signs of food reluctance, then their BMI and waist circumference would be negatively impacted. Children who are not consuming adequate nutrition due to picking eating, fussiness etc….are going to show lower/smaller growth curves.
I wouldn’t define slowness in eating as fussy. I have always been a slow eater and although I was a slightly picky eater when I was younger, it had nothing to do with how slow I ate. I would define food reluctance and a clear attitude or expression towards foods served and fight to not have to eat them. I remember my brother clearly throwing up on purpose just so he would never have to eat carrots again.
I think the biggest flaw in the design of the study was that they only observed 2 days! What if the child wasn’t feeling well or some other extraneous factor. I believe that a longer observation period would have a more accurate representation of food reluctance.
I agree that a control group would have been another great way to test their hypothesis. I would like to have seen test groups that observed meals with their family present. I also think the experimental group with the nutrition education would should greater interest in certain foods such as vegetables. Providing the children an opportunity to get excited about these food groups may help encourage them to eat more. This also goes back to research that discusses having children help cooking the meals encourages better eating behaviors and interest in the food being served.
Micheal, I would have to agree with you the BMI does not always represent the nutrition status of an individual accurately. As you mentioned, it is a good screening tool and a great place to start, though. Also, with the age of the participants, it is difficult to obtain an accurate BMI due to many different body types of younger children due to their growth patterns. Is there another route you would have taken in obtaining nutritional status?
Elyse, I would agree that 2 days is an insufficient time period for representing eating habits of a population. If you were to do this research, what time frame would choose to collect data in order to get an accurate representation?
I agree with Elye's comment that 2 days is not adequate for obtaining an accurate picture of one's dietary habits. In adult studies, a cross-validation measure such as a 24 hour recall is typically used to verify the patterns/trends shown in the initial data. I wonder if there is any way the researchers could have modified it or another measure to cross-validate the plate waste measure they created.
Austin,
I would use at a minimum 1 week, but preferably 2 or more. Taste preferences and food aversions could easily skew the data. For instance, lets say a kid got the flu the night they ate a rice dish and that was one of the dishes served within the 2 days of data collection. I'm sure there were other students that had similar instances. Realistically, collecting data much longer would take a lot of time and money and an increased rate of participant drop out. There is a fine balance.
Many comments made earlier mentioned the atmosphere that kids had during meal time. (see Reilly, Jenni, and Kaitlyn's posts)
Imagine you were going to extend the data collection time period and include an intervention. Do you think meal time atmosphere would have a larger impact on plate waste when compared to nutrition interventions?
Michael, I agreed with your analysis of BMI and definitely see it being a more useful measurement when dealing with a larger population.
Elyse, you mentioned that 2 days was an insufficient amount of time to observe the children. You then suggested observing them for a week or more. I also agree with this statement as you mentioned many other variables could be taken into consideration for reasons as to why the children were showing "food reluctant" behaviors. These behaviors would have been better analyzed if the study allowed more time.
Along with that, I wonder if it would have been beneficial for there to be several more research assistants, that way there could be one researcher observing the same child for a weeks time. If the same researcher was observing the same child they would be able to pick up on different behavioral and social factors that could influence their eating habits.
Austin, I am not sure if I am understanding your last question correctly, but when I think of nutrition interventions for children I think of educating them on how important food is for growth, in a very simplistic fashion, and not necessarily focusing on "good" and "bad" foods. I feel that if you tell a child that something is "bad for them" then that item might show a greater waste. With a positive mealtime atmosphere and interventions about how food is crucial for growth and development then I could suspect some decreases in plate waste. It is challenging because it would be a well thought out intervention to ensure all food is receiving a positive connotation. For example, at home if a parent or sibling does not like green beans and makes comments about how they are "gross" at the dinner table, then that child will also think that green beans are gross and when presented them during mealtime at daycare they will not be touched. An intervention to motivate children to try new things would be most beneficial. If that makes sense....
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