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New Findings from the Feeding Infants and Toddlers Study: Data to Inform Action

      This supplement to the Journal of The American Dietetic Association provides the first release of descriptive information on the diets of American infants, toddlers, and preschoolers from the 2008 Feeding Infants and Toddlers Study (FITS 2008). There are few large-scale population studies devoted to investigating the diets of very young children, and there are gaps in reports from the National Health and Nutrition Examination Survey (NHANES) What We Eat in America study for infants and toddlers younger than age 2 years. FITS, a cross-sectional study, strives to fill this gap by collecting information on infant feeding practices, diet and health behaviors, and 24-hour dietary recalls in a national sample of children from birth to age 47 months.

      Importance of FITS

      Data from FITS 2008 can make major contributions to the field of childhood nutrition and help improve the diets of young children. FITS 2008 provides population-level data that can be used to monitor the diets of infants, toddlers, and preschoolers and feeding transitions in the early years of life. This supplement includes data on the prevalence of breastfeeding that can be used to assess Healthy People 2010 targets, infant feeding practices that can be compared to recommendations by the American Academy of Pediatrics, and food and nutrient intakes assessed using the Dietary Guidelines for Americans and Dietary Reference Intakes (
      Healthy People 2010: Conference Edition in Two Volumes.
      ,
      American Academy of Pediatrics Pediatric Nutrition Handbook.
      ,
      Nutrition and Your Health: Dietary Guidelines for Americans, 2005.
      ,
      Institute of Medicine, Food and Nutrition Board
      Dietary Reference Intakes: Applications in Dietary Assessment.
      ).
      Two previous supplements to the Journal—in January 2004 and January 2006—provided a set of research findings from the first FITS, FITS 2002. Findings from FITS 2002 have been widely used for monitoring dietary intakes, policymaking, identifying research needs, food marketing, and consumer education. FITS 2002 data have been used by policymakers and researchers to assess progress in meeting public health goals, dietary guidelines, and recommendations from authoritative health groups such as the American Academy of Pediatrics and the American Heart Association (
      American Academy of Pediatrics Pediatric Nutrition Handbook.
      ,
      • Gidding S.S.
      • Dennison B.A.
      • Birch L.L.
      • Daniels S.R.
      • Gilman M.W.
      • Lichtenstein A.H.
      • Rattay K.T.
      • Steinberger J.
      • Stettler N.
      • Van Horn L.
      American Heart Association
      Dietary recommendations for children and adolescents A guide for practitioners: Consensus statement from the American Heart Association. Scientific statement endorsed by AAP.
      ). The Institute of Medicine cited FITS 2002 data in its reports on the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages, strategies to reduce sodium intakes, and prevention of childhood obesity (
      Institute of Medicine Committee to Review the WIC Food Packages
      WIC Food Packages: Time for a Change.
      ,
      ,
      Institute of Medicine
      Strategies to Reduce Sodium Intake in the United States.
      ). FITS 2002 findings called attention to areas where improvements were needed in infant and toddler feeding practices (for example, more fruits and vegetables and fewer sweets and french fries/fried potatoes) and to methodological considerations in interpreting dietary intakes of very young children (
      • Briefel R.
      • Reidy K.
      • Karwe V.
      • Devaney B.
      Feeding Infants and Toddlers: Study improvements needed in meeting infant feeding recommendations.
      ,
      • Devaney B.L.
      • Ziegler P.J.
      • Pac S.
      • Karwe V.
      • Barr S.I.
      Nutrient intakes of infants and toddlers.
      ,
      • Devaney B.
      • Fox M.K.
      Dietary intakes of infants and toddlers: Problems start early.
      ,
      • Fisher J.O.
      • Butte N.F.
      • Mendoza P.M.
      • Wilson T.A.
      • Hodges E.A.
      • Reidy K.C.
      • Deming D.
      Overestimation of infant and toddler energy intake by 24-h recall compared with weighed food records.
      ). Data from FITS 2002 were also used to develop Start Healthy feeding recommendations and consumer messages for parents and other caretakers (
      • Butte N.
      • Cobb K.
      • Dwyer J.
      • Graney L.
      • Heird W.
      • Rickard K.
      The Start Healthy Feeding Guidelines for infants and toddlers.
      ,
      • Pac S.
      • McMahon K.
      • Ripple M.
      • Reidy K.
      • Ziegler P.
      • Myers E.
      Development of the Start Healthy feeding guidelines for infants and toddlers.
      ).
      Since the time when the first FITS was being planned nearly a decade ago, childhood obesity has emerged as a major public health concern (
      ,
      • Ogden C.L.
      • Carroll M.D.
      • Curtin L.R.
      • Lamb M.
      • Flegal K.M.
      Prevalence of high body mass index in U.S. children and adolescents, 2007-2008.
      ). Government and private campaigns have been initiated in an effort to curb obesity by 2015 and attention has focused on diet quality and the food environments of the preschool population (
      • Dietz W.
      Eating behaviors of the young child Practices and Interventions.
      ,
      National Collaborative on Childhood Obesity Research Homepage
      ,
      • McKinnon R.A.
      • Reedy J.
      • Morrissette M.A.
      • Lytle L.A.
      • Yaroch A.
      Measures of the food environment A compilation of the literature, 1990–2007.
      ,
      • Cooke L.
      The importance of exposure for healthy eating in childhood: A review.
      ). For FITS 2008, the decision was made to extend the upper age range of the sample from 23 months in the 2002 FITS to 4 years. This decision stemmed, in part, from the observation that the quality of food consumption declines from infancy through the preschool years, a critical time when dietary and physical activity patterns are forming and when childhood obesity may occur (
      ,
      • Dietz W.
      Eating behaviors of the young child Practices and Interventions.
      ,
      • Cooke L.
      The importance of exposure for healthy eating in childhood: A review.
      ,
      • Fox M.K.
      • Pac S.
      • Devaney B.
      • Jankowski L.
      Feeding Infants and Toddlers Study: What foods are infants and toddlers eating?.
      ).
      There are few large-scale population studies devoted to investigating the diets of very young children and the utility of the data varies. The gold standard for national dietary data in the United States, NHANES, does not estimate the volume of breast milk and, therefore, does not calculate or report food and nutrient intakes for infants and children who are breastfeeding. In addition, national dietary data reports from the NHANES What We Eat in America study (
      What We Eat in America data tables 1-36, NHANES 2007-2008 US Department of Agriculture, Agricultural Research Service Web site.
      ) are typically produced for ages 2 years and older, although younger children are included in the sample and intakes for non-breastfeeding infants and toddlers can be estimated using public use data files. The result is that the national dietary intake estimates from NHANES exclude an important subgroup of the population—those who are breastfeeding—and do not provide data to fully assess infant feeding transitions from breast milk to table foods. The national Infant Feeding and Practices Study uses mailed questionnaires for mothers to record foods fed to infants, but these do not allow for quantitative estimation of food and nutrient intake (
      • Fein S.B.
      • Labiner-Wolfe J.
      • Shealy K.R.
      • Li R.
      • Chen J.
      • Grummer-Strawn L.M.
      Infant Feeding Practices Study II: Study methods.
      ).

      FITS 2008 Methods and Research Findings: Opportunities for Action

      This third Journal supplement devoted to FITS provides details on the FITS 2008 study design and methods and the results of food and nutrient intake analyses for the full sample of children from birth to age 47 months by age group. In planning any large-scale study, especially one that requires considerable effort and resources to sample and recruit respondents for age-eligible children and collect 24-hour dietary recalls by telephone, tradeoffs in sample design and sample sizes are inevitable. A study decision was made to expand the age range of the sample up to age 4 years in FITS 2008, but also maintain sufficient sample sizes to compare dietary intakes between FITS 2002 and FITS 2008 for the 4- to 23-month-olds (
      • Briefel R.B.
      • Kalb L.M.
      • Condon E.
      • Deming D.M.
      • Clusen N.A.
      • Fox M.K.
      • Harnack L.
      • Gemmill E.
      • Stevens M.
      • Reidy K.C.
      The Feeding Infants and Toddlers Study 2008: Study design and methods.
      ). FITS 2008 methods were consistent with FITS 2002 to allow for such comparisons and to meet other research objectives: 2 days of dietary intake data were collected from a subsample of respondents for the estimation of usual nutrient intakes, and food consumption analyses are based on 1-day mean intakes in the population (
      • Devaney B.
      • Kalb L.
      • Briefel R.
      • Zavitsky-Novak T.
      • Clusen N.
      • Ziegler P.
      Feeding Infants and Toddlers Study: Overview of the study design.
      ,
      • Ziegler P.
      • Briefel R.R.
      • Clusen N.
      • Devaney B.
      Feeding Infants and Toddlers Study (FITS): Development of the FITS survey in comparison to other dietary survey methods.
      ). Sharing study methods can benefit other researchers who may wish to adopt or adapt the methods to meet their study's objectives. Detailing survey methods can also be instrumental in being open about the challenges of conducting large dietary studies; self-reported diet data and response issues are important considerations in interpreting any study findings (
      • Curtin R.
      • Presser S.
      • Singer E.
      Changes in telephone survey nonresponse over the past quarter century.
      ).
      Butte and colleagues (
      • Butte N.F.
      • Fox M.K.
      • Briefel R.R.
      • Siega-Riz A.M.
      • Dwyer J.T.
      • Deming D.M.
      • Reidy K.C.
      Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed Dietary Reference Intakes.
      ) assess usual nutrient intakes from foods and supplements and discuss the contribution of dietary supplements to total intakes. Overall, usual nutrient intakes in 2008 are adequate and similar to those in 2002, but there is plenty of room for improvement. Toddlers' and preschoolers' intakes of some nutrients are excessive (eg, sodium, folate, vitamin A, and zinc) or higher than recommended (eg, saturated fat as a percentage of total energy), and below recommended levels for fiber and potassium. The 2008 FITS nutrient assessments indicate the need to monitor iron intakes of older infants, and increase fiber, potassium, and healthier fats in toddlers' and preschoolers' diets. Further, the findings suggest caution in food fortification and nutrient supplementation of young children.
      Siega-Riz and colleagues (
      • Siega-Riz A.M.
      • Deming D.M.
      • Reidy K.C.
      • Fox M.K.
      • Condon E.
      • Briefel R.R.
      Food consumption patterns of infants and toddlers: Where are we now?.
      ) describe infant feeding practices, including breastfeeding, and the proportions of each age group consuming specific foods and food groups. Their article also compares FITS 2002 and 2008 data for children aged 4 to 23 months and finds some improvements, including lower percentages of older infants and toddlers consuming desserts, sweets, sugar-sweetened beverages, and french fries and similar potato products. Breastfeeding initiation rates remain high and continued breastfeeding at 6 months is close to recommended goals. The 2008 FITS data suggest that many mothers are breastfeeding longer, a finding that has also been reported in other national studies (
      • Scanlon K.S.
      • Grummer-Strawn L.
      • Li R.
      • Chen J.
      Racial and ethnic differences in breastfeeding initiation and duration by State-National Immunization Survey, US 2004-2008.
      ,
      Breastfeeding Report Card-United States, 2010 Centers for Disease Control and Prevention Web site.
      ).
      Fox and colleagues (
      • Fox M.K.
      • Condon E.
      • Briefel R.R.
      • Reidy K.C.
      • Deming D.M.
      Food consumption patterns of young preschoolers: Are they starting off on the right path?.
      ) report food and food group consumption among preschoolers, and set the stage for more in-depth analyses on portion sizes and MyPyramid () equivalents in the future. Preschoolers' diets were low in fruits and vegetables, and discretionary calories was commonly consumed. Among preschoolers, french fries were the most common vegetable consumed, and 40% to 60% consumed sugar-sweetened beverages. The FITS 2008 data on food consumption show a clear decline in overall diet quality from infancy and toddlerhood to the preschool period. Fruit and vegetable consumption is below recommended levels in all age groups studied (
      Nutrition and Your Health: Dietary Guidelines for Americans, 2005.
      ,
      • Siega-Riz A.M.
      • Deming D.M.
      • Reidy K.C.
      • Fox M.K.
      • Condon E.
      • Briefel R.R.
      Food consumption patterns of infants and toddlers: Where are we now?.
      ,
      • Fox M.K.
      • Condon E.
      • Briefel R.R.
      • Reidy K.C.
      • Deming D.M.
      Food consumption patterns of young preschoolers: Are they starting off on the right path?.
      ).
      Dwyer and colleagues (
      • Dwyer J.T.
      • Butte N.F.
      • Deming D.M.
      • Siega-Riz A.M.
      • Reidy K.C.
      Feeding Infants and Toddlers Study 2008: Progress, continuing concerns, and implications.
      ) summarize the overall food and nutrient findings of FITS 2008, describe progress in meeting public health and pediatric recommendations, and provide suggestions for dietetics practitioners, health care practitioners, and families to improve feeding practices. Their article highlights the need for educating families about feeding transitions. Straightforward toddler feeding guidelines (for 12- to 23-month-olds) would bridge the gap between the American Academy of Pediatrics recommendations for infants and the Dietary Guidelines for Americans for children aged 24 months and older (
      American Academy of Pediatrics Pediatric Nutrition Handbook.
      ,
      Nutrition and Your Health: Dietary Guidelines for Americans, 2005.
      ).
      The FITS research articles are complemented by two commentaries. Suzanne Murphy, PhD, RD, an expert in national nutrition monitoring and nutrient assessment using the Dietary Reference Intakes, comments on the FITS 2008 methods and nutrient assessment and provides recommendations for NHANES to consider imputing breast milk volumes as FITS does (
      • Murphy S.P.
      The fitness of FITS.
      ). NHANES may want to consider adopting a similar evidence-based methodology to impute breast milk volumes since this would provide a means to monitor and report the dietary intake and nutritional status of all infants and young children in the United States, breastfeeding and non-breastfeeding. Researchers or data users could opt to include or exclude 24-hour dietary recalls with imputed breast milk volumes based on their research objectives. The second commentary, by May and Dietz of the Centers for Disease Control and Prevention (
      • May A.L.
      • Dietz W.H.
      The Feeding Infants and Toddlers Study 2008: Opportunities to assess parental, cultural, and environmental influences on dietary behaviors and obesity prevention among young children.
      ), addresses the FITS 2008 findings on food consumption in light of the food environment and the role that parents can play in improving their children's diet. They also discuss the role of medical providers and cultural and environmental influences on parental feeding strategies.

      Conclusions

      The FITS findings included in this supplement provide updated information on the food and nutrient intakes of infants, toddlers, and preschoolers. Future FITS dietary analysis stratified by other population characteristics, such as race/ethnicity, breastfeeding status, and participation in WIC, would provide information on population subgroups at nutritional risk. Evaluation of young children's meal and snack patterns and physical activity and diet behaviors relative to obesity risk are also needed. The findings also suggest that additional research is needed on the Dietary Reference Intakes' upper limit levels for selected nutrients and on methods to improve portion size estimation by parents to reduce over-reporting tendencies.
      As in the previous FITS, the 2008 FITS is a collaboration among researchers trained in nutrition, dietetics, epidemiology, statistics, public health, and public policy. The study was funded by food industry, carried out by an independent research organization, and reviewed by an external advisory panel. Data from FITS provide an opportunity for policymakers and researchers to monitor the population's food and nutrient intake, to track the prevalence of breastfeeding and dietary supplement use, to estimate the contribution of supplements to total nutrient intake, and to investigate dietary behaviors that may be associated with childhood obesity. Dietetics practitioners and other health care providers can use the FITS findings to identify areas for parents and clients to improve their young children's diet quality.
      STATEMENT OF POTENTIAL CONFLICT OF INTEREST: The author was the project director/principal investigator for the Feeding Infants and Toddlers Study (FITS) 2008 under a contract funded by Nestlé (Florham Park, NJ) with Mathematica Policy Research, Inc (Princeton, NJ). The opinions expressed in this editorial are those of the author and do not necessarily represent the views or recommendations of Mathematica Policy Research.
      FUNDING/SUPPORT: The FITS research was funded by Nestlé (Florham Park, NJ) through a contract with Mathematica Policy Research, Inc (Princeton, NJ) and its subcontractor, the University of Minnesota (Minneapolis, MN). There was no funding support for writing this editorial.
      ACKNOWLEDGEMENTS: It has been educational to serve as guest editor for this supplement and I have a new appreciation for the behind-the-scenes effort required to produce a high-quality, objective, scientific journal supplement. I want to offer special thanks to my colleague, Elizabeth Condon, MS, RD, who assisted with all editorial duties, and to Linda Van Horn, PhD, RD, for the opportunity to serve as guest editor. I would also like to thank the authors; the editorial staff, especially Claire Zulkey, Jennifer Herendeen, and Ryan Lipscomb; as well as Cathy Desko at Elsevier, for their assistance and ongoing help throughout the preparation of the supplement. Finally, I thank the reviewers who gave their time and expertise to reviewing manuscripts and providing useful suggestions, and Mary Kay Crepinsek, MS, RD, and Elizabeth Condon, MS, RD, for their review and insightful comments on an earlier version of this editorial.

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      Biography

      R. R. Briefel is a senior fellow, Mathematica Policy Research, Washington, DC.