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Complementary feeding based on Nordic foods: effects on nutrient intake, growth, biomarkers and eating behavior
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics. (OTIS studien)ORCID iD: 0000-0002-0830-889x
2021 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Tilläggskost med nordisk mat : effekt på näringsintag, tillväxt, biomarkörer och ätbeteende (Swedish)
Abstract [en]

Background: Early nutrition is fundamental to growth and development. Infants develop long lasting food preferences very early in life from food exposures when the brain is impressionable and sensory pathways are receptive. Early food experiences from bitter and sour tastes found in fruits and vegetables can establish longlasting food preferences and healthy eating behavior. Fruits and vegetables can protect against future non-communicable diseases such as cardiovascular diseases, type 2 diabetes, overweight, obesity and cancer. Nordic fruits, berries and vegetables offer high environmental sustainability and favorable taste compositionto establish a variety of food preferences. In this thesis, the focus is on early feeding among healthy, full-term infants and how to establish eating based on Nordic foods.

Methods: The thesis is based on the randomized, controlled trial Optimized complementary feeding study (OTIS), with three papers on the outcomes of the trial and one validation paper. In the trial, the experimental Nordic group (n=125) consumed a diet based on Nordic foods, reduced in protein whereas the control group (n=125) followed the current nutritional recommendations for infants from the Swedish Food Agency. The Nordic group was exposed to a variety of flavors from Nordic, homemade fruit, berry and vegetable purées according to a taste portion schedule with repeated exposures for 24 days during 4-6 months of age. From 6 to 18 months of age the Nordic group experienced a multicomponent intervention of homemade Nordic baby food recipes, family recipes and protein-reduced baby food products together with parental support through social media. The control group followed the Swedish recommendations on how to introduce taste portions and solid foods and were supplied with commercial baby food products with regular content. At baseline, 9, 12 and 18 months of age anthropometry, blood samples, urine samples, questionnaires and dietary data were collected.

Results: Of the 250 infants, 82% (n=206) finished the study until 18 months of age. The attrition rate was higher in the Nordic group (p=0.012). The Nordic group consumed more plant-based foods as fruits, berries, roots and vegetables during the entire study period except at 6 months of age. The protein intake was higher in the control group throughout the study. Plasma urea was higher in the control group as a response to the higher protein intake and plasma folate was higher in the Nordic group as a reflection of the higher fruit and vegetables intake. There were no differences in growth, total energy intake, iron status, breastfeeding durationor any demographic variables between the groups.

Conclusions: A Nordic diet, reduced in protein, increasedthe daily intake of fruit, berries, roots and vegetables, establishing a preferable eating pattern lasting over 12 months. Parental support and systematical flavor learning of Nordic foods may have impacted the infants’ dietary intake in the Nordic group. The Nordic diet is both feasible and safe for infants’ growth, nutritional requirements and development during complementary feeding period between 4-18 months of age. Thus, it may serve as a healthy and environmentally sustainable alternative to future infants and their parents.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2021. , p. 105
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2137
Keywords [en]
Infant feeding, healthy diet, food preference, complementary feeding, eating behavior, repeated exposure, vegetables, fruit, Nordic diet, sustainable diet, nutrition, roots, berries, flavor learning
National Category
Pediatrics
Research subject
Pediatrics; Medicine; Nutrition; Public health
Identifiers
URN: urn:nbn:se:umu:diva-189172ISBN: 978-91-7855-552-9 (print)OAI: oai:DiVA.org:umu-189172DiVA, id: diva2:1609343
Public defence
2021-12-10, Bergasalen, Byggnad 27, Norrlands universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2021-11-19 Created: 2021-11-08 Last updated: 2022-03-07Bibliographically approved
List of papers
1. Protein-Reduced Complementary Foods Based on Nordic Ingredients Combined with Systematic Introduction of Taste Portions Increase Intake of Fruits and Vegetables in 9 Month Old Infants: A Randomised Controlled Trial
Open this publication in new window or tab >>Protein-Reduced Complementary Foods Based on Nordic Ingredients Combined with Systematic Introduction of Taste Portions Increase Intake of Fruits and Vegetables in 9 Month Old Infants: A Randomised Controlled Trial
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2019 (English)In: Nutrients, E-ISSN 2072-6643, Vol. 11, no 6, article id 1255Article in journal (Refereed) Published
Abstract [en]

Fruits and vegetables are healthy foods but under-consumed among infants and children. Approaches to increase their intake are urgently needed. This study investigated the effects of a systematic introduction of taste portions and a novel protein-reduced complementary diet based on Nordic foods on fruit and vegetable intake, growth and iron status to 9 months of age. Healthy, term infants (n = 250) were recruited and randomly allocated to either a Nordic diet group (NG) or a conventional diet group (CG). Infants were solely breast- or formula-fed at study start. From 4 to 6 months of age, the NG followed a systematic taste portions schedule consisting of home-made purées of Nordic produce for 24 days. Subsequently, the NG was supplied with baby food products and recipes of homemade baby foods based on Nordic ingredients but with reduced protein content compared to the CG. The CG was advised to follow current Swedish recommendations on complementary foods. A total of 232 participants (93%) completed the study. The NG had significantly higher intake of fruits and vegetables than the CG at 9 months of age; 225 ± 109 g/day vs. 156 ± 77 g/day (p < 0.001), respectively. Energy intake was similar, but protein intake was significantly lower in the NG (−26%, p < 0.001) compared to the CG. This lower protein intake was compensated for by higher intake of carbohydrate from fruits and vegetables. No significant group differences in growth or iron status were observed. The intervention resulted in significantly higher consumption of fruits and vegetables in infants introduced to complementary foods based on Nordic ingredients.

Place, publisher, year, edition, pages
MDPI, 2019
Keywords
infant feeding, Nordic diet, eating behaviour, repeated exposure
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:umu:diva-161926 (URN)10.3390/nu11061255 (DOI)000474936700061 ()31159495 (PubMedID)2-s2.0-85067185540 (Scopus ID)
Available from: 2019-08-06 Created: 2019-08-06 Last updated: 2023-08-28Bibliographically approved
2. A randomized, controlled trial of a Nordic, protein-reduced complementary diet: effects on dietary intake, biomarkers and growth until 18 months of age
Open this publication in new window or tab >>A randomized, controlled trial of a Nordic, protein-reduced complementary diet: effects on dietary intake, biomarkers and growth until 18 months of age
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Plant-based foods introduced during complementary feeding (CF) can contribute to long-term health andclimate friendly diet, but longitudinal multicomponent approaches are lacking.

Objectives: To investigate the effects of a protein-reduced, Nordic complementary diet on dietary intake, biomarkers andgrowth and compared to the current Swedish dietary recommendations for infants until 18 mo of age.

Design: Healthy, term infants (n=250) were recruited and randomly allocated to either a Nordic diet group (NG) or aconventional diet group (CG). From 4-6 mo of age, the NG followed a taste portions schedule with Nordic fruitand vegetables. From 6 mo up to 18 mo of age, the NG was supplied with Nordic homemade baby food recipes,protein-reduced baby food products and parental support. The CG followed the current Swedish dietaryrecommendations for infants. Dietary intake data, biomarkers and anthropometry were collected frombaseline up to 18 mo of age.

Results: Of the 250 infants, 82% (n=206) completed the study. The NG consumed daily 42-45% more fruit andvegetables compared to the CG at 12 and 18 mo of age (p<0.001). Plasma folate was higher in the NGcompared to the CG at 12 mo (p<0.001) and 18 mo of age (p=0.003) and protein intake and blood ureanitrogen (BUN) were lower at both 12 and 18 mo of age (p<0.001). There were no group differences in energyintake (EI), growth, iron status or other biomarkers.

Conclusions: The NG consumed significantly more plant-based Nordic foods compared to CG, a difference that lasted at leastuntil 18 mo of age. The lower protein intake in the NG had no effect on growth or iron status. The introductionof a protein-reduced, Nordic diet during CF is safe and feasible, and benefits a sustainable environment andhealth already during infancy and early childhood. 

Keywords
infant feeding, early nutrition, infancy, repeated exposure, fruit, vegetables, sustainable eating, environment, plant-based food, healthy diet.
National Category
Pediatrics
Research subject
Medicine; Medicine; Pediatrics
Identifiers
urn:nbn:se:umu:diva-189171 (URN)
Available from: 2021-11-08 Created: 2021-11-08 Last updated: 2021-11-11
3. Acceptance of a Nordic, Protein-Reduced Diet for Young Children during Complementary Feeding: A Randomized Controlled Trial
Open this publication in new window or tab >>Acceptance of a Nordic, Protein-Reduced Diet for Young Children during Complementary Feeding: A Randomized Controlled Trial
Show others...
2021 (English)In: Foods, E-ISSN 2304-8158, Vol. 10, article id 275Article in journal (Refereed) Published
Abstract [en]

Early life is critical for developing healthy eating patterns. This study aimed to investigate the effects of a Nordic, protein-reduced complementary diet (ND) compared to a diet following the current Swedish dietary guidelines on eating patterns and food acceptance. At 4–6 months (mo) of age infants were randomized to a Nordic group (NG, n = 41) or a Conventional group (CG, n = 40), and followed until 18 mo of age. Daily intake of fruits and vegetables (mean ± sd) at 12 mo was significantly higher in the NG compared to the CG: 341 ± 108 g/day vs. 220 ± 76 g/day (p < 0.001), respectively. From 12 to 18 mo, fruit and vegetable intake decreased, but the NG still consumed 32% more compared to the CG: 254 ± 99 g/day vs. 193 ± 67 g/day (p = 0.004). To assess food acceptance, both groups were tested with home exposure meals at 12 and 18 mo. No group differences in acceptance were found. We find that a ND with parental education initiates healthy eating patterns during infancy, but that the exposure meal used in the present study was insufficient to detect major differences in food acceptance. This is most likely explained by the preparation of the meal. Nordic produce offers high environmental sustainability and favorable taste composition to establish healthy food preferences during this sensitive period of early life.

Place, publisher, year, edition, pages
Basel: MDPI, 2021
Keywords
infant feeding, healthy eating, food preference, eating behavior, repeated exposure, vegetables, fruits, sustainable eating, environment
National Category
Pediatrics
Research subject
Pediatrics
Identifiers
urn:nbn:se:umu:diva-181856 (URN)10.3390/foods10020275 (DOI)000622535800001 ()2-s2.0-85102421382 (Scopus ID)
Funder
Region Västerbotten, VLL-644531Region Västerbotten, VLL-488901Region Västerbotten, VLL- 677921Region Västerbotten, VLL-761381
Available from: 2021-03-29 Created: 2021-03-29 Last updated: 2023-09-05Bibliographically approved
4. Active Image-Assisted Food Records in Comparison to Regular Food Records: A Validation Study against Doubly Labeled Water in 12-Month-Old Infants
Open this publication in new window or tab >>Active Image-Assisted Food Records in Comparison to Regular Food Records: A Validation Study against Doubly Labeled Water in 12-Month-Old Infants
2018 (English)In: Nutrients, E-ISSN 2072-6643, Vol. 10, no 12, article id 1904Article in journal (Refereed) Published
Abstract [en]

Overreporting of dietary intake in infants is a problem when using food records (FR), distorting possible relationships between diet and health outcomes. Image-assisted dietary assessment may improve the accuracy, but to date, evaluation in the pediatric setting is limited. The aim of the study was to compare macronutrient and energy intake by using an active image-assisted five-day FR against a regular five-day FR, and to validate image-assistance with total energy expenditure (TEE), was measured using doubly labeled water. Participants in this validation study were 22 healthy infants randomly selected from the control group of a larger, randomized intervention trial. The parents reported the infants’ dietary intake, and supplied images of main course meals taken from standardized flat-surfaced plates before and after eating episodes. Energy and nutrient intakes were calculated separately using regular FR and image-assisted FRs. The mean (± standard deviations) energy intake (EI) was 3902 ± 476 kJ/day from the regular FR, and 3905 ± 476 kJ/day from the FR using active image-assistance. The mean EI from main-course meals when image-assistance was used did not differ (1.7 ± 55 kJ, p = 0.89) compared to regular FRs nor did the intake of macronutrients. Compared to TEE, image-assisted FR overestimated EI by 10%. Without validation, commercially available software to aid in the volume estimations, food item identification, and automation of the image processing, image-assisted methods remain a more costly and burdensome alternative to regular FRs in infants. The image-assisted method did, however, identify leftovers better than did regular FR, where such information is usually not readily available. View Full-Text

Place, publisher, year, edition, pages
MDPI, 2018
Keywords
energy intake, dietary assessment, image-assisted method, infant, food record, doubly labeled water
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:umu:diva-155779 (URN)10.3390/nu10121904 (DOI)000455073200085 ()30518042 (PubMedID)2-s2.0-85057968132 (Scopus ID)
Available from: 2019-01-28 Created: 2019-01-28 Last updated: 2023-08-28Bibliographically approved

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