Advertisement

Development and Evaluation of a Diet Quality Index for Preschool-Aged Children in an Asian population: The Growing Up in Singapore Towards Healthy Outcomes cohort

      Abstract

      Background

      Diet quality indexes are useful tools to measure diet quality because they compare dietary intakes against recommendations. A dietary quality index for Asian preschool-aged children is lacking.

      Objective

      The aims of this study were to develop and evaluate a dietary quality index for preschool-aged children (ie, the DQI-5) based on Singapore dietary recommendations and to examine diet quality in a cohort of 5-year-old children. An additional aim was to assess associations between sociodemographic characteristics and DQI-5 scores.

      Design

      A secondary analysis was conducted using dietary intake of children from the Growing Up in Singapore Towards healthy Outcomes mother–offspring cohort assessed in 2015-2016 using a validated food frequency questionnaire. The sociodemographic data were assessed at recruitment between June 2009 and September 2010. The DQI-5 was evaluated using a construct validity approach, whereby nutrition parameters associated with diet quality were studied.

      Participants and setting

      Participants were 767 Singaporean children aged 5 years of Chinese, Malay, or Indian ethnicity.

      Main outcome measures

      The main outcome measures were the DQI-5 scores and the sociodemographic characteristics associated with diet quality.

      Statistical analyses performed

      Kruskal-Wallis tests were used to evaluate differences in adherence to dietary recommendations across DQI-5 tertiles. Linear multiple regression analysis was performed to identify sociodemographic characteristics that were associated with diet quality in the children.

      Results

      The DQI-5 consists of 12 food and nutrient components, with a minimum score of zero and a maximum score of 110 points. The higher scores indicate a healthier diet, the mean ± SD DQI-5 score for the children was 61.6 ± 13.2. DQI-5 components with low scores included whole grains, vegetables, and fatty acid ratio, whereas total rice and alternatives and milk and dairy products components were overconsumed by 18% and 24.4% of children, respectively. Children with higher scores were more likely to meet dietary recommendations and had higher intake of nutrients such as dietary fiber, iron, vitamin A, and beta carotene. Children whose mothers were of Malay ethnicity and whose mothers had low income, an education below university, and shared primary caregiver responsibilities were more likely to have lower DQI-5 scores.

      Conclusions

      The DQI-5 scores revealed diets to be low for several components and excessive for a few. The DQI-5 developed for preschool-aged children in Singapore had adequate construct validity.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • da Costa M.P.
        • Durao C.
        • Lopes C.
        • Vilela S.
        Adherence to a healthy eating index from pre-school to school age and its associations with sociodemographic and early life factors.
        Br J Nutr. 2019; 122: 220-230
        • Ertas Ozturk Y.
        • Bozbulut R.
        • Doger E.
        • Bideci A.
        • Koksal E.
        The relationship between diet quality and insulin resistance in obese children: adaptation of the Healthy Lifestyle-Diet Index in Turkey.
        J Pediatr Endocrinol Metab. 2018; 31: 391-398
        • Manios Y.
        • Kourlaba G.
        • Grammatikaki E.
        • Androutsos O.
        • Moschonis G.
        • Roma-Giannikou E.
        Development of a diet-lifestyle quality index for young children and its relation to obesity: the Preschoolers Diet-Lifestyle Index.
        Public Health Nutr. 2010; 13: 2000-2009
        • Kourlaba G.
        • Panagiotakos D.B.
        Dietary quality indices and human health: a review.
        Maturitas. 2009; 62: 1-8
        • Chamoli R.
        • Jain M.
        • Tyagi G.
        Reliability and validity of the Diet Quality Index for 7-9-year-old Indian children.
        Pediatr Gastroenterol Hepatol Nutr. 2019; 22: 554-564
        • Cheng G.
        • Duan R.
        • Kranz S.
        • Libuda L.
        • Zhang L.
        Development of a dietary index to assess overall diet quality for chinese school-aged children: the Chinese Children Dietary Index.
        J Acad Nutr Diet. 2016; : 608-617
        • Chen L.W.
        • Fung S.M.
        • Fok D.
        • et al.
        The development and evaluation of a Diet Quality Index for Asian toddlers and its perinatal correlates: the GUSTO cohort study.
        Nutrients. 2019; 11: 535
        • Verger E.O.
        • Eussen S.
        • Holmes B.A.
        Evaluation of a nutrient-based diet quality index in UK young children and investigation into the diet quality of consumers of formula and infant foods.
        Public Health Nutr. 2016; 19: 1785-1794
        • Zarrin R.
        • Ibiebele T.I.
        • Marks G.C.
        Development and validity assessment of a diet quality index for Australians.
        Asia Pac J Clin Nutr. 2013; 22: 177-187
        • Soh S.E.
        • Tint M.T.
        • Gluckman P.D.
        • et al.
        Cohort profile: Growing Up in Singapore Towards healthy Outcomes (GUSTO) birth cohort study.
        Int J Epidemiol. 2014; 43: 1401-1409
        • Singapore Health Promotion Board
        Nutrition for pre-schoolers aged 3-4 years (months 37-48).
        • Singapore Health Promotion Board
        Nutrition for pre-schoolers (months 61-72).
        • Singapore Health Promotion Board
        Healthy Meals in Childcare Centres Programme (HMCCP) Toolkit.
        • Singapore Health Promotion Board
        How to eat right to feel right.
        • Krebs-Smith S.M.
        • Pannucci T.E.
        • Subar A.F.
        • et al.
        Update of the Healthy Eating Index: HEI-2015.
        J Acad Nutr Diet. 2018; 118: 1591-1602
        • Han C.
        • Colega M.
        • Quah P.L.
        • et al.
        A healthy eating index to measure diet quality in pregnant women in Singapore: a cross-sectional study.
        BMC Nutr. 2015; 39
        • Golley R.K.
        • Hendrie G.A.
        • McNaughton S.A.
        Scores on the dietary guideline index for children and adolescents are associated with nutrient intake and socio-economic position but not adiposity.
        J Nutr. 2011; 141: 1340-1347
        • Sugianto R.
        • Chan M.J.
        • Wong S.F.
        • et al.
        Evaluation of a quantitative food frequency questionnaire for 5-year-old children in an Asian population.
        J Acad Nutr Diet. 2020; 120: 437-444
        • Singapore Health Promotion Board
        Energy and Nutrient Composition of Food.
        https://focos.hpb.gov.sg/eservices/ENCF/foodsearch.aspx
        Date: 2011
        Date accessed: December 16, 2020
        • World Health Organization
        Assessing and managing children at primary health-care facilities to prevent overweight and obesity in the context of the double burden of malnutrition.
        2017
        • Voortman T.
        • Kiefte-de Jong J.C.
        • Geelen A.
        • et al.
        The development of a diet quality score for preschool children and its validation and determinants in the Generation R Study.
        J Nutr. 2015; 145: 306-314
        • Singapore Health Promotion Board
        Recommended Dietary Allowances for normal healthy persons in Singapore (children & adolescents).
      1. RStudio Software. Version 1.2.5033. PBC;2020.
        • Thomson J.L.
        • Tussing-Humphreys L.M.
        • Goodman M.H.
        • Landry A.S.
        Diet quality in a nationally representative sample of American children by sociodemographic characteristics.
        Am J Clin Nutr. 2019; 109: 127-138
        • US Depts of Agriculture and Health and Human Services
        Dietary Guidelines for Americans, 2020-2025. 2020. 9th Edition.
        https://www.dietaryguidelines.gov/
        Date accessed: March 3, 2021
        • Brownlee I.A.
        • Low J.
        • Duriraju N.
        • et al.
        Evaluation of the proximity of Singaporean children's dietary habits to food-based dietary guidelines.
        Nutrients. 2019; 11: 2615
        • Kranz S.
        • Brauchla M.
        • Slavin J.L.
        • Miller K.B.
        What do we know about dietary fiber intake in children and health? The effects of fiber intake on constipation, obesity, and diabetes in children.
        Adv Nutr. 2012; 3: 47-53
        • Shinozaki K.
        • Okuda M.
        • Sasaki S.
        • Kunitsugu I.
        • Shigeta M.
        Dietary fiber consumption decreases the risks of overweight and hypercholesterolemia in Japanese children.
        Ann Nutr Metab. 2015; 67: 58-64
        • Kim J.
        • Lim H.
        Nutritional management in childhood obesity.
        J Obes Metab Syndr. 2019; 28: 225-235
        • Jarman M.
        • Vashi N.
        • Angus A.
        • et al.
        Development of a diet quality index to assess adherence to Canadian dietary recommendations in 3-year-old children.
        Public Health Nutr. 2020; 23: 385-393
        • Leal K.K.
        • Schneider B.C.
        • Franca G.V.
        • Gigante D.P.
        • dos Santos I.
        • Assuncao M.C.
        [Diet quality of preschool children aged 2 to 5 years living in the urban area of Pelotas, Brazil].
        Rev Paul Pediatr. 2015; 33: 311-318
        • Quah P.L.
        • Kleijweg J.
        • Chang Y.Y.
        • et al.
        Association of sugar-sweetened beverage intake at 18 months and 5 years of age with adiposity outcomes at 6 years of age: the Singapore GUSTO mother-offspring cohort.
        Br J Nutr. 2019; 122: 1303-1312
        • Foo L.H.
        • Lee Y.H.
        • Suhaida C.Y.
        • Hills A.P.
        Correlates of sugar-sweetened beverage consumption of Malaysian preschoolers aged 3 to 6 years.
        BMC Public Health. 2020; 20: 552
        • Zhen-Duan J.
        • Engebretsen B.
        • Laroche H.H.
        Diet and physical activity changes among low-income families: perspectives of mothers and their children.
        Int J Qual Stud Health Well-being. 2019; 141658700
        • Tan B.Q.M.
        • Hee J.M.
        • Yow K.S.
        • Sim X.
        • Asano M.
        • Chong M.F.
        Feeding-related knowledge, attitudes, and practices among grandparents in Singapore.
        Nutrients. 2019; 11: 1696
        • Wong B.W.
        • Toh J.Y.
        • Sugianto R.
        • et al.
        Associations of childcare arrangements with adiposity measures in a multi-ethnic asian cohort: the GUSTO study.
        Int J Environ Res Public Health. 2021; 1812178
        • Chan M.J.
        • Tay G.W.N.
        • Kembhavi G.
        • Lim J.
        • Rebello S.A.
        • Ng H.
        • Lin C.
        • Wang M.C.
        • Muller-Riemenschneider F.
        • Chong M.F.
        Understanding children's perspectives of the influences on their dietary behaviours.
        Public Health Nutr. 2022; : 1-11

      Biography

      M. R. Rolands is a master’s degree student, research in nutrition and dietetics, Department Nutrition and Dietetics, Faculty of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.

      Biography

      K. Van der Horst is head, research in nutrition and dietetics, Department Nutrition and Dietetics, Faculty of Health Professions, Bern University of Applied Sciences, Bern, Switzerland.

      Biography

      J. Y. Toh is a senior research officer, Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research, Singapore.

      Biography

      R. Sugitano is a doctoral degree student, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.

      Biography

      W. L. Yuan is a postdoctoral researcher, Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research, and a postdoctoral researcher, Université de Paris, CRESS, Inserm, Paris, France.

      Biography

      Y. S. Lee is a principal investigator, Singapore Institute for Clincial Sciences, Agency for Science, Technology, and Research; professor, Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; and a senior consultant, Division of Paediatric Endocrinology, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore.

      Biography

      K. H. Tan is a professor, Duke-National University of Singapore Graduate Medical School, Singapore; and a senior consultant, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore.

      Biography

      F. Yap is a clinical professor, Duke-National University of Singapore Graduate Medical School, Singapore; a senior consultant, Department of Pediatric Endocrinology, KK Women's and Children's Hospital, Singapore; and an associate professor, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.

      Biography

      K. M. Godfrey is a professor, Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom; and an honorary consultant, National Institute for Health Research Southampton Biomedical Research Centre, University Hospital Southampton, NHS Foundation Trust, Southampton, United Kingdom.

      Biography

      J. G. Eriksson is executive director and programme director, Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore; a professor, Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; program director, Folkhälsan Research Center, Helsinki, Finland; and chief physician, Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

      Biography

      Y.-S. Chong is chief clinical officer, Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research, Singapore; and a professor, Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

      Biography

      M. F.-F. Chong is principal investigator, Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore; and an assistant professor, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.