Maternal diet during early childhood, but not pregnancy, predicts diet quality and fruit and vegetable acceptance in offspring

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<ul><li><p>Maternal diet during early childhood, but notpregnancy, predicts diet quality and fruit and vegetableacceptance in offspring</p><p>Amy M. Ashman*, Clare E. Collins, Alexis J. Hure, Megan Jensen andChristopher Oldmeadow**,*School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, 2308, Australia, Gomeroi gaaynggal centre, The University ofNewcastle, Tamworth, New South Wales 2340, Australia, Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle,Callaghan, New South Wales 2308, Australia, School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales 2308,Australia, CHU Sainte-Justine, Montral, Quebec H3T 1C5, Canada, **Clinical Research Design, IT and Statistical Services, Hunter Medical ResearchInstitute, Rankin Park, New South Wales 2305, Australia, and School of Medicine and Public Health, Faculty of Health and Medicine, The University ofNewcastle, Callaghan, New South Wales 2308, Australia</p><p>Abstract</p><p>Studies have identified prenatal flavour exposure as a determinant of taste preferences in infants; however, thesestudies have focused on relatively small samples and limited flavours. As many parents struggle with gettingchildren to accept a variety of nutritious foods, a study of the factors influencing food acceptance is warranted.The objective of this study was to determine whether exposure to a wider variety of fruit and vegetables andoverall higher diet quality in utero results in acceptance of a greater variety of these foods and better diet qualityfor offspring during childhood. This study is a secondary data analysis of pregnant women (n = 52) and theirresulting offspring recruited for the Women and Their Childrens Health study in NSW, Australia. Dietaryintake of mothers and children was measured using food frequency questionnaires. Diet quality and vegetableand fruit variety were calculated using the Australian Recommended Food Score and the Australian Child andAdolescent Recommended Food Score. Associations between maternal and child diet quality and variety wereassessed using Pearsons correlations and the total effect of in utero maternal pregnancy diet on childhood dietwas decomposed into direct and indirect effect using mediation analysis. Maternal pregnancy and post-natal dietwere both correlated with child diet for overall diet quality and fruit and vegetable variety (P &lt; 0.001). Mediationanalyses showed that the indirect effect of maternal pregnancy diet on child diet was mediated through maternalpost-natal diet, particularly for fruit (P = 0.045) and vegetables (P = 0.055). Nutrition intervention should there-fore be aimed at improving diet quality and variety in mothers with young children, in order to subsequentlyimprove eating habits of offspring.</p><p>Keywords: pregnancy, child, diet quality, variety, fruit, vegetable.</p><p>Correspondence: Professor Clare E. Collins, Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle,Callaghan, NSW 2308, Australia. E-mail: Clare.Collins@newcastle.edu.au</p><p>Introduction</p><p>Vegetables and fruit are cornerstones of a healthfuldiet, and their consumption has long been linked withchronic disease prevention and positive health out-comes (National Health and Medical ResearchCouncil, Department of Health and Ageing 2013).However, the 2007 Childrens Nutrition and PhysicalActivity Survey showed that three quarters of Aus-</p><p>tralian children aged 2 to 8 years did not meet veg-etable recommendations for a healthy, nutrient-densevaried diet, with inadequate fruit and vegetableintake, and high saturated fat and sugar intakehighlighted (Department of Health and Ageing,Department of Agriculture, Fisheries and Forestry2008). Poor eating habits in childhood have beenshown to track into adulthood and can contribute tothe development of chronic disease later in life</p><p>bs_bs_banner</p><p>DOI: 10.1111/mcn.12151</p><p>Original Article</p><p>1 2014 John Wiley &amp; Sons Ltd Maternal and Child Nutrition (2014), , pp. </p><p>mailto:Clare.Collins@newcastle.edu.au</p></li><li><p>(Berenson et al. 1992; Mikkil et al. 2005; Northstone&amp; Emmett 2008). It is therefore imperative to estab-lish healthy eating habits in early childhood.</p><p>In westernized countries, most of the diseaseburden from poor nutrition is due to excess intake ofenergy-dense, nutrient-poor foods, which are foodshigh in energy, saturated fat and added or refinedsugars and/or salt (National Health and MedicalResearch Council, Department of Health and Ageing2013). These energy-dense, nutrient-poor foods arereadily available and affordable (Beauchamp &amp;Mennella 2009). Many parents report difficulties withfeeding children a wide variety of nutrient-densefoods from the core food groups (vegetables andlegumes, fruit, whole grains, lean meat and vegetarianalternatives and dairy foods), particularly for vegeta-bles (National Health and Medical Research Council,Department of Health and Ageing 2013). Encourag-ing vegetable intake from an early age remains achallenging area for both parents and dietetic profes-sionals (Carruth et al. 2004; Maier et al. 2007).If children enjoy the flavour of a food, they are morelikely to consume it (Benton 2004; Beauchamp &amp;Mennella 2009). Young children are also more likelyto accept a food if its flavour is familiar to them(Beauchamp &amp; Mennella 2009). An exploration intofood acceptance in young children can therefore leadto valuable insight upon which to base nutritionintervention.</p><p>The majority of observational studies of fruit andvegetable intake in children have focused on post-natal influences on food choices (Benton 2004; Savageet al. 2007; Fisk et al. 2011). Experimental studiesaiming to increase fruit and vegetable intake in youngchildren have also focused primarily on post-natalexposure (Birch et al. 1998; Forestell &amp; Mennella2007; Maier et al. 2007; Mennella et al. 2008). Thesestudies have shown that exposure to a food throughbreast milk or formula or exposure to a solid food</p><p>during infancy promotes long-lasting effects, namelyfamiliarity of and preference for this food (Schaalet al. 2000; Forestell &amp; Mennella 2007; Mennella et al.2008).</p><p>While extensive studies examining post-natal influ-ences on child taste preferences are available, limiteddata are available on the prenatal influence on tastedevelopment. It has been suggested that infants areborn with innate preferences for sweet, salty andumami foods over bitter or sour foods (Beauchamp &amp;Mennella 2009). However, humans can override theseinnate preferences and develop preferences for bitteror sour foods, including certain vegetables and fruit(Maier et al. 2007; Mennella et al. 2008; Beauchamp &amp;Mennella 2009). Classic studies by Mennella and col-leagues have increased our understanding of theinfluence of maternal diet and in utero flavour expo-sure on the future taste preferences of offspring(Mennella et al. 2001). By 1315 weeks gestation, thefetus can perceive tastes and smells while still in thewomb via amniotic fluid (Mennella et al. 1995, 2001),suggesting the earliest taste and smell experiencesbegin during gestation (Mennella et al. 2001). Indeed,Mennella has shown that prenatal exposure to certainflavours is associated with a greater acceptance ofthese foods in infancy (Mennella et al. 2001). In arandomised controlled trial, mothers in the experi-mental group drank 300 mL carrot juice 4 days perweek for three consecutive weeks during the last tri-mester of pregnancy. At 56 months old, the infantswho had been exposed to the carrot flavour prenatallyexhibited less negative facial responses while beingfed carrot-flavoured cereal, relative to plain cereal(P = 0.01). The control group exhibited the oppositetendency, although this was not significant. (Mennellaet al. 2001). Multiple animal studies on rat, pig, sheepand rabbit young support the finding that prenatalflavour learning influences feeding preferences(Bilk et al. 1994; Bayol et al. 2007; Simitzis et al. 2008;</p><p>Key messages</p><p> Maternal post-natal diet, not pregnancy diet, is associated with child diet. Maternal post-natal diet, not maternal pregnancy diet, predicted child diet quality, and vegetable and fruit</p><p>variety. Nutrition interventions should aim to improve diet quality and variety in mothers with young children.</p><p>A.M. Ashman et al.2</p><p> 2014 John Wiley &amp; Sons Ltd Maternal and Child Nutrition (2014), , pp. </p></li><li><p>Oostindjer et al. 2009). Although studies in humanshave been of relatively small sample sizes and usedonly one or two foods, these early studies and animalmodels support the hypothesis for in utero flavourlearning (Schaal et al. 2000; Mennella et al. 2001).</p><p>Whole foods contain not only macro- andmicronutrients but a range of other non-nutrientcomponents, including phytochemicals that offerprotective effects against disease (National Healthand Medical Research Council, Department ofHealth and Ageing 2013). Therefore, exposure to abroader variety of flavours is associated with greatervariety of food and therefore a broader range ofmacronutrients, micronutrients and non-nutrientcompounds consumed (National Health and MedicalResearch Council, Department of Health and Ageing2013). Diet quality refers to both diet variety andnutritional adequacy, and high-quality diet is associ-ated with improved health outcomes and reducedrisk of chronic disease (National Health and MedicalResearch Council, Department of Health and Ageing2013). Therefore, willingness to accept a wide rangeof flavours will likely increase both diet variety anddiet quality (Mennella et al. 2008). While food prefer-ence refers to foods that are found to be enjoyableand pleasant, food acceptance is also used in thisstudy to refer to those foods which are willinglyconsumed.</p><p>There is a need to explore the relationship betweenmaternal diet quality during pregnancy and the dietquality of their offspring. The primary aim of thisstudy was to test whether maternal diet during preg-nancy was associated with childhood diet quality atage 23 years. The secondary aim was to test whethermaternal fruit and vegetable intake during pregnancywas associated with child fruit and vegetable con-sumption at 23 years. Maternal post-natal diet wasalso considered as a potential predictor of the childsdiet.</p><p>Materials and methods</p><p>Study design</p><p>This study is a secondary data analysis of the Womenand Their Childrens Health (WATCH) prospective</p><p>cohort study, which followed pregnant women andtheir offspring up to 4 years of age (Hure et al. 2012).All pregnant women less than 18 weeks gestationwere eligible to participate in the WATCH study onthe provision that they lived in the local or neighbour-ing areas and were able to commute to John HunterHospital (JHH) in Newcastle, New South Wales, Aus-tralia, for data collection. Participants were recruitedthrough midwives at the JHH antenatal clinic, localmedia coverage and word of mouth. Pregnant womenattended JHH for data collection at 19, 24, 30 and 36weeks gestation.Additionally, data collection for bothmothers and their offspring occurred at post-natalquarterly intervals for the first 12 months, and thenannually until 23 years of age (Hure et al. 2012).Between June 2006 and December 2007, 180 womenwere deemed eligible to participate. Of this sample74% remained 2 years after study commencement(Hure et al. 2012). Detailed methods of the WATCHstudy are published elsewhere (Hure et al. 2012). Thiscurrent study uses the dietary intake data frommothers and their offspring up to 3 years of age.</p><p>Ethics approval</p><p>The WATCH study was approved by the Hunter NewEngland Human Research Ethics Committee in 2006and was also registered with the University of New-castle Human Research Ethics Committee (Hureet al. 2012).All participants in the WATCH study gaveinformed, written consent to participate. Participantsdid not receive any financial incentives to participate.Data were de-identified before commencement ofthis study (Hure et al. 2012).</p><p>Data collection</p><p>Data were obtained on a number of health,anthropometric, socio-economic and lifestyle vari-ables (Hure et al. 2012). Anthropometric datawere collected by an Accredited Practicing Dietitianand Level 1 Anthropometrist accredited by theInternational Society for the Advancement ofKinanthropometry. Data collection included height/length, weight, circumferences and skinfold thick-nesses of both mothers and their children.</p><p>Maternal diet and diet quality in offspring 3</p><p> 2014 John Wiley &amp; Sons Ltd Maternal and Child Nutrition (2014), , pp. </p></li><li><p>Standardized methods of data collection were used,and are described in detail elsewhere (Hure et al.2012).The following variables were selected for use inthe current analysis.</p><p>Data on education, income and marital statuswere self-reported and the questions were modelledon Womens Health Australia surveys (Brown &amp;Dobson 2000). Further information relating tomedical and socio-economic data were obtainedfrom the Obstetrix database, the major record ofantenatal information, birth outcomes and patientand family history in New South Wales, Australia(LeMay 2005).</p><p>Dietary intake</p><p>Maternal dietary intake was assessed using thevalidated Dietary Questionnaire for EpidemiologyStudies (DQES) food frequency questionnaire(FFQ; Cancer Council Victoria 2005) developedby the Cancer Council of Victoria (Hodge et al.2002). The DQES asks about intake of 74 foods;participants were asked to report intake frequencyover the last 312 months, on a 10-point scale ofnever to three or more times per day (Hure et al.2009). Questions regarding total intake of fruit andvegetables were used to adjust for potential over-reporting of intakes of individual fruit and vegeta-bles (Hure et al. 2009). Nutrient intakes werecomputed from NUTTAB 1995 (Cancer CouncilVictoria 2005).</p><p>Child dietary intake was assessed from 2 years ofage using the toddler version of the Australian Childand Adolescent Eating Survey (ACAES; Watson et al.2009; Collins et al. 2013). Mothers completed theACAES for their child, reporting the consumptionfrequency (ranging from never to four times perday) for a range of foods over the preceding 6months. The ACAES is a validated FFQ, which dem-onstrates acceptable reliability for ranking nutrientintakes in Australian toddlers 24 years old (Collinset al. 2013). Nineteen questions relate to the intake ofvegetables and 11 items to fruit, with a separatesection to adjust for seasonal fruit intake (Watsonet al. 2009).</p><p>Australian Recommended Food Score</p><p>The Australian Recommended Food Score (ARFS)and the Australian Child and Adolescent Recom-mended Food Score (ACARFS) were used to calcu-late a diet variety score for mothers and theiroffspring (Collins et al. 2008; Marshall et al. 2012).TheARFS is a numerical value of diet quality and variety(Collins et al. 2008). It is calculated based on the levelof alignment between reported consumption fre-quency of foods featured in the DQES/ACAES andDietary Guidelines for Australian Adults and Austral-ian Guide to Healthy Eating recommendations(Kant &amp; Thompson 1992; The Childrens Hea...</p></li></ul>

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