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An exploratory trial of parental advice for increasing vegetable acceptance in infancy


Abstract and Figures

Research suggests that repeatedly offering infants a variety of vegetables during weaning increases vegetable intake and liking. The effect may extend to novel foods. The present study aimed to investigate the impact of advising parents to introduce a variety of single vegetables as first foods on infants' subsequent acceptance of a novel vegetable. Mothers of 4- to 6-month-old infants in the UK, Greece and Portugal were randomised to either an intervention group (n 75), who received guidance on introducing five vegetables (one per d) as first foods repeated over 15 d, or a control group (n 71) who received country-specific 'usual care'. Infant's consumption (g) and liking (maternal and researcher rated) of an unfamiliar vegetable were assessed 1 month post-intervention. Primary analyses were conducted for the full sample with secondary analyses conducted separately by country. No significant effect of the intervention was found for vegetable intake in the three countries combined. However, sub-group analyses showed that UK intervention infants consumed significantly more novel vegetable than control infants (32·8 (sd 23·6) v. 16·5 (sd 12·1) g; P =0·003). UK mothers and researchers rated infants' vegetable liking higher in the intervention than in control condition. In Portugal and Greece, there was no significant intervention effect on infants' vegetable intake or liking. The differing outcome between countries possibly reflects cultural variations in existing weaning practices. However, the UK results suggest in countries where vegetables are not common first foods, advice on introducing a variety of vegetables early in weaning may be beneficial for increasing vegetable acceptance.
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An exploratory trial of parental advice for increasing vegetable acceptance in infancy.
Alison Fildes1, Carla Lopes3,4, Pedro Moreira4,5George Moschonis2, Andreia Oliveira3,4,
Christina Mavrogianni2, Yannis Manios2, Rebecca Beeken1, Jane Wardle1, Lucy Cooke1
1Health Behaviour Research Centre, Department of Epidemiology and Public Health,
University College London, Gower Street, London WC1E 6BT, United Kingdom. [AF, RB,
JW and LC]
2Department of Nutrition and Dietetics, Harokopio University, Greece, 70, El. Venizelou,
Kallithea 17671, Athens, Greece [GM, CM, YM]
3Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of
Porto Medical School, Porto, Portugal [CL, AO]
4Institute of Public Health, University of Porto, Portugal [CL, PM AO]
5Faculty of Nutrition and Food Sciences, University of Porto, Portugal [PM]
Corresponding author/requests for reprints:
Lucy Cooke PhD. Health Behaviour Research Centre, Department of Epidemiology and
Public Health, University College London, Gower Street, London WC1E 6BT, UK.
Tel. +44(0)20 7679 1720; fax: +44(0)20 7679 8354; E-mail:
In the UK this trial is registered as ISRCTN85048101
Running title: Trial of vegetable exposure in infancy
Keywords: Vegetables, weaning, infancy, food preferences, children, exposure.
Research suggests repeatedly offering infants a variety of vegetables during weaning2
increases vegetable intake and liking. The effect may extend to novel foods. The present study3
aimed to investigate the impact of advising parents to introduce a variety of single vegetables4
as first foods on infants’ subsequent acceptance of a novel vegetable. Mothers of four-six5
month old infants in the UK, Greece and Portugal were randomised to either an intervention6
group (n=75), who received guidance on introducing five vegetables (one per day) as first7
foods repeated over 15 days, or a control group (n=71) who received country-specific ‘usual8
care’. Infant’s consumption (grams) and liking (maternal and researcher rated) of an9
unfamiliar vegetable were assessed one month post–intervention. Primary analyses were10
conducted for the full sample with secondary analyses conducted separately by country. No11
significant effect of the intervention was found for vegetable intake in the three countries12
combined. However sub-group analyses showed UK intervention infants consumed13
significantly more novel vegetable than control infants (32.8g ± 23.6g vs. 16.5g ± 12.1;14
p=0.003). UK mothers and researchers rated infants’ vegetable liking higher in the15
intervention than control condition. In Portugal and Greece there was no significant16
intervention effect on infants’ vegetable intake or liking. The differing outcome between17
countries possibly reflects cultural variations in existing weaning practices. However, the UK18
results suggest in countries where vegetables are not common first foods, advice on19
introducing a variety of vegetables early in weaning may be beneficial for increasing20
vegetable acceptance.21
An important predictor of children’s fruit and vegetable consumption is their23
enjoyment of these foods(1, 2). Innate preferences for sweet tastes and dislike of sour or bitter24
tastes mean that fruit is readily accepted, but that liking for vegetables may be harder to25
achieve. However, innate preferences can be modified through pre- and post-natal26
experiences(3). Flavours become more acceptable as they grow in familiarity and there is27
unequivocal evidence in young children that intake and liking for unfamiliar foods can be28
increased through repeated exposure, i.e. providing repeated opportunities to taste small29
quantities of the food(4-10).30
Between the ages of 4-7 months, infants are highly receptive to new flavours and31
textures, requiring fewer exposures than older children to increase acceptance(11-14). Exposing32
children to the taste of commonly rejected foods, such as vegetables, may be most effective in33
early infancy before the onset of food neophobia or pickiness (a normal developmental stage34
during the second year of life)(14). Since food preferences develop early and have been shown35
to track through later childhood and into adulthood(15, 16), early intervention is likely to reap36
the greatest benefit.37
While repeated exposure to a single vegetable flavour increases infants’ acceptance,38
the speed with which they acquire preferences means that a lack of sufficient variety might39
result in a ‘monotony’ effect – the infant becoming bored with the taste(17). Daily changes in40
the vegetables offered to infants during the transition to solid foods have been shown to lead41
to immediate increases in preference and intake, and a generalization of the effect to42
acceptance of novel tastes(17-19). In a group of formula-fed infants, the effect of offering a43
variety of different vegetables versus carrots alone, or potatoes alone over a period of nine44
days was evaluated(17). Infants in both the variety and carrot groups significantly increased45
their intake of carrots compared with infants fed potatoes, but only the infants exposed to a46
variety of tastes ate more of a novel food at the end of the exposure period. More recently it47
has been suggested that the variety of vegetables from meal to meal offered to weaning48
infants is more important than the overall number of vegetables offered. For example,49
increased intake of novel foods was observed in weaning-age infants experiencing daily50
changes in the vegetables offered compared to infants fed three vegetables, each for three51
consecutive days(18), suggesting the beneficial effect of variety is maximized by daily52
changes. In addition, a more varied diet during the weaning period has been linked to greater53
dietary diversity in later childhood(20, 21).54
The benefits of repeated and varied exposure early in the complementary feeding55
period have been previously described(18, 19, 22, 23), suggesting promising opportunities for56
increasing children’s vegetable intake. However, no studies to date have tested the procedures57
in the form of an easily disseminable intervention comprising simple, practical guidance to58
parents for introducing a variety of vegetables as first foods. Furthermore, no previous study59
of variety exposure in infants has included a no-treatment control group in which mothers60
receive only the current standard weaning advice offered by their national health service.61
Finally, although current weaning recommendations and practices vary across Europe, no62
study to date has examined cross-cultural differences in the effectiveness of such an63
The present study is an exploratory trial of an intervention comprising guidance to65
parents on the introduction of a variety of vegetables at the first stages of weaning. The66
primary outcome was infants’ consumption of a novel vegetable, offered one month after the67
start of complementary feeding. The secondary outcome was infant’s ‘liking’ for the novel68
vegetable, rated by both researchers and mothers. The same procedure was followed by69
researchers in the United Kingdom, Greece and Portugal in order to examine the effect of the70
intervention compared with usual care in the different countries.71
Subjects and Methods73
Trial design74
A multicentre, individually randomized (ratio; 1:1), parallel-group study design was75
adopted for this exploratory trial conducted in the UK, Greece and Portugal between February76
2011 and July 2012.77
Sample size78
Estimating effect size was difficult because few comparable studies have been79
published. The closest study in the literature(17) achieved an extremely large effect on vegetable80
intake (d = 4.0) from a brief but intensive exposure-based intervention, with outcomes measured81
in the laboratory. A second parent-led, exposure-based intervention with 2-6 year olds showed82
a significant, but smaller effect (d = 0.2) on children’s vegetable consumption(4). Outcomes in83
previous studies have therefore ranged from small to very large, with larger effects in a younger84
age-group which is most comparable to the present study. The sample size for the current trial85
(n=120) was therefore designed to provide 80% power to detect a medium effect size (d = 0.5)86
at p = .05 (24) on intake of a novel vegetable in a taste test.87
Recruitment of participants88
Women in the final trimester of their pregnancy and mothers of infants less than 689
months old were recruited from antenatal clinics (n=327), primary care, paediatricians, and90
hospitals in London (UK), Athens (Greece), and Porto (Portugal) to a larger study exploring91
children’s fruit and vegetable acceptance during weaning. Mothers were eligible to participate92
if they were over 18 years old at recruitment, they were sufficiently proficient in each93
country’s respective native language to understand the study materials and their infant was94
born after 37 weeks gestation, without diagnosed feeding problems. Mothers who volunteered95
to participate were asked to complete a consent form and baseline questionnaire following96
recruitment. A sub-sample of these participants was randomly selected to take part in the97
current trial and invited to meet with a researcher or health professional immediately prior to98
the initiation of complementary feeding. All participants were advised that they were free to99
withdraw from the study at any point. The flow of participants through the trial in each of the100
three countries is illustrated in Figure 1.101
An independent statistician at University College London generated a block103
randomization matrix that was used in all three countries. Individual participants were104
randomly assigned to an intervention or control (‘usual care’) condition following an initial105
interview to establish feeding method. As research has shown that breast-fed infants accept106
new foods more readily than their formula-fed counterparts(25, 26), equal representation of107
breast-fed and formula-fed infants were ensured across the groups, and within each Country,108
using block randomization. Allocation was revealed to the researcher. Because of the nature109
of the intervention, parents in the intervention arm and researchers delivering the intervention110
were not blind. However parents were unaware of the randomized controlled design and111
therefore neither the control nor the intervention group knew of the existence of the other.112
Ethical approval113
This study was conducted according to the guidelines laid down in the Declaration of114
Helsinki and all procedures involving human subjects/patients were approved by the relevant115
ethical committees in each participating country. In the UK, ethical approval was granted by116
the NHS Central London Research Ethics Committee (10/H0718/54), research and117
development approval by NHS University College Hospital and NHS North Central London118
Research Consortium. In Greece, ethical approval was granted by the Ethical Committee of119
Harokopio University of Athens (session no. 27/14-07-2010). In Portugal, ethical approval120
was granted by the local ethical committee (Ethical committee for Health of the São João121
Hospital/ University of Porto Medical School – 29.JUL10-12951). Written informed consent122
was obtained from the subjects.123
All participants met with a researcher or health professional immediately prior to the126
initiation of complementary feeding (i.e. introducing solid foods). Visits took place either at127
the participants’ home or a paediatrician’s office and the mothers determined the precise128
timing of these visits (which in some instances was up to 4 weeks prior to the initiation of129
complementary feeding).130
In the intervention group, a researcher or health professional explained to the131
participant ; (i) the importance of introducing vegetables early in the weaning process, (ii) the 132
beneficial effects of offering different single vegetables each day, (iii) the techniques of133
exposure feeding, (iv) interpreting infants’ facial reactions to food, and (v) the need for134
persistence when an infant initially rejects a food. A leaflet reinforcing these messages135
(standardised across countries) was given to participants, who were then asked to complete a136
short questionnaire about their infant’s early milk-feeding experiences.137
In consultation with mothers (and paediatricians in the Portuguese sample), five138
vegetables were selected as the first foods to be introduced. Mothers were provided with a139
small number of commercially available vegetable purees to use, but were told that they could140
prepare their own foods if they preferred. They were asked to offer the five vegetables in a141
sequence over 15 days as follows: A,B,C,D,E, A,B,C,D,E, A,B,C,D,E and to record progress142
on a chart provided. For a further five days, participants were told to continue to offer143
vegetables, but in addition, to start to introduce additional age-appropriate foods.144
Participants in the control group completed the same questionnaire as intervention145
mothers. However control mothers were not offered any specific guidance, instructions or146
information on weaning with vegetables. Instead the control group received ‘usual care’147
which varies between European countries.148
In the UK, the recommendations are to introduce fruits, vegetables and baby rice or149
cereal as first foods, but the information provided to mothers is inconsistent and the advice150
available may vary by local health authority. In Greece, paediatricians provide parents with151
guidance on appropriate first foods, commonly baby rice, cereals or fruits. In Portugal, the152
guidelines for weaning are not prescriptive and health professionals are advised to adapt153
international and national recommendations (e.g.. from WHO, ESPGHAN and Portuguese154
Paediatric Society), to the needs and circumstances of individual infants(27). Recently there155
has been a move towards advice to introduce vegetable soups or purees as first foods.156
Outcome Measures157
Mothers in both control and intervention groups completed questionnaires about158
themselves and their infant prior to the intervention and at follow-up (one month after the159
introduction of solid foods), which included items on demographics and feeding practices.160
Mothers reported their date of birth, parity, marital status and educational qualifications.161
Mothers reported separately on the frequency of fruit and vegetable servings they had162
consumed in the past week and the data was recoded to provide an estimation of the total163
number each of fruit and vegetable portions consumed daily. Self-reported height and weight164
was used to calculate maternal BMI (kg/m2) and maternal age was calculated at the time of165
child’s birth. Maternal age and BMI were treated as continuous variables, while education166
was dichotomized as ‘university level’ vs. ‘below university level’. Mothers were also asked167
to record their child's date of birth, sex, birth weight (in kg), and the number of weeks’168
gestation at birth, to provide an estimate of gestational age. Feeding method was assessed169
with the question ‘Which feeding methods did you use in the first three months’, with170
response options: ‘entirely breastfeeding’; ‘mostly breastfeeding with some bottle-feeding’;171
‘equally breastfeeding and bottle-feeding’; ‘mostly bottle-feeding and some breastfeeding’;172
‘almost entirely bottle-feeding (only tried breastfeeding a few times)’; ‘entirely bottle-feeding173
(never tried breastfeeding)’; and ‘other’. Infant age at the time of introduction to solids was174
calculated in weeks by using the child’s date of birth and the date on which mother’s reported175
that they had offered solid food for the first time.176
At follow-up, taste tests were administered in which an unfamiliar vegetable177
(artichoke puree) was offered to participating infants. The primary outcome was intake (g) of178
the novel vegetable. Infant liking for the vegetable (independently rated by mothers and179
researchers) was also recorded. The procedure was then repeated with a novel fruit (peach180
puree), which acted as a control food and to provide an indication of whether the intervention181
had the unintended side effect of reducing acceptance of foods other than vegetables.182
Taste tests took place in the infant’s home or paediatrician’s office and test foods were183
fed to infants by mothers in the presence of the researcher. The researcher present at the taste184
test was the same individual who delivered the intervention and was not therefore able to be185
blinded to condition. Taste tests were conducted at the child’s mealtime in order to ensure that186
they were hungry. Mothers were provided with two 130g jars of artichoke puree, the contents187
of which were weighed prior to the start of the taste test. Artichoke puree was selected on the188
basis that it is an unfamiliar and rarely consumed vegetable among young children across189
Europe(8, 28) and not available as a commercial baby food in any of the three participating190
countries. Mothers were instructed to feed their infant as normal and at their usual pace until191
the infant refused the food on three or more occasions, or had finished two full jars. Refusal192
was defined as keeping the mouth closed, turning the head away, pushing the spoon away,193
crying, or playing(19). Conditions were kept as naturalistic as possible; with mothers using194
any techniques (i.e. facial expressions, verbal encouragements, etc.) they would normally195
employ to encourage their infant to eat in a mealtime situation. On completion of the test, all196
spilled food was returned to the bowl/jar which was weighed again to calculate the weight of197
food consumed(19). Immediately after each feeding session, the mother and researcher198
separately and independently rated the infant’s apparent liking for the food on a 9-point scale,199
ranging from 1 = ’dislikes very much‘, to 9 = ’likes very much‘ with a central point of200
5 = ’neither likes nor dislikes‘(22, 29). The entire process was then repeated with the unfamiliar201
test fruit (peach puree). The vegetable was always offered first followed by the fruit202
approximately ten minutes later.203
Statistical analyses204
Participants with complete data on the primary outcome (intake at the taste test) were205
included in the analyses. ANCOVAs were conducted to compare intervention and control206
groups by weight of vegetable consumed, and researcher’s and mother’s rating of vegetable207
liking at the taste test while controlling for country. These analyses were repeated for fruit208
intake and the researcher’s and mother’s rating of fruit liking at the taste test. As typical209
weaning practices in the three participating nations varied secondary analyses were then210
performed comparing intake and liking ratings between intervention and control groups for211
each country separately.212
The flow of participants through the trial is illustrated in Figure 1. In total, 139214
families completed the trial including the taste tests 1 month post-intervention (53, 31 and 55215
families in the UK, Greece and Portugal respectively). Sample demographics are presented in216
Table 1. The first solid foods consumed by the infants in the three countries, provided by217
experimental condition, are shown in Table 2.218
Completed intervention charts were returned by 86% of intervention families (UK;219
100% [28/28], Greece; 100% [16/16], Portugal; 63% [17/27]). Completed charts revealed that220
over the 15 day intervention period parents recorded their infants consuming vegetables on221
89% (mean=13.3, SD=3.0) of the 15 possible eating occasions (UK; [86%] mean=12.8,222
SD=3.4, Greece; [95%], mean=14.2, SD=1.8, Portugal [88%], mean=13.1, SD=3.0). Infants223
were recorded as eating nothing on 7% (mean=1.0, SD=1.8) of the 15 intervention days (UK;224
[6%] mean=1.1, SD=2.4, Greece; [5%], mean=0.8, SD=1.8, Portugal; [8%], mean=1.2,225
SD=1.7). Data on infants’ willingness to eat during the intervention period was missing for226
5% of the total eating occasions (UK; 8%, Greece; 0%, Portugal; 5%).227
The results of the taste tests by experimental condition are shown in Table 3. The228
mean intake of the unfamiliar vegetable puree was almost 10g higher among intervention229
group infants (38.91g) compared to the control group (29.84g). However the primary analyses230
examining the effect of the intervention in the three countries combined (n = 139) revealed no231
significant main effect of the intervention on vegetable intake, controlling for the effect of232
country (F (1, 135) = 3.49, p = 0.064). Infants in the intervention group were rated by233
researchers as liking the unfamiliar vegetable significantly more than control infants (F234
(1,135) = 4.70, p < 0.032) but a similar trend observed for maternal ratings of infants'235
vegetable liking did not reach significance (F (1,135) = 3.84, p = 0.052), while controlling for236
the effect of country in the pooled sample. No main effect of the intervention was found for237
either intake or liking ratings for fruit.238
Separate analyses by country revealed a significant effect of the intervention on intake239
of the novel vegetable in the UK, with intervention infants eating on average 16g more240
artichoke puree than control infants (32.8g vs. 16. 5g; t(51) = 3.10; p = 0.003) (see Table 4).241
This group difference in vegetable intake represented a large effect size (Cohen’s d = 0.8) (13).242
UK intervention infants were also rated as liking the puree significantly more than control243
infants by mothers (6.7 vs. 4.3; t(51) = 4.51; p < 0.001) and researchers (6.7 vs. 4.6; t(51) =244
4.37; p < 0.001) separately (see Table 4). A large intervention effect size was observed for245
both maternal and researcher ratings of liking (Cohen’s d = 1.2 for both). No group246
differences were found between UK intervention and control infants for intake (27.9g vs.247
40.7g) or liking ratings of the unfamiliar fruit.248
In the Greek sample, mean intake in the intervention group was on average 13g higher249
than in the control group (36.3g versus 23.6g) although this difference was not statistically250
significant. Intervention infants were also given slightly higher vegetable liking ratings in the251
taste test by both mothers (4.3 vs. 3.3) and researchers (4.6 vs. 3.4) in Greece but again these252
differences were not significant.253
In Portugal, no significant intervention effect on infants’ intake of the artichoke puree254
was observed at follow-up with intervention infants consuming only an average of 2g more255
than control infants (46.9g vs. 45.1g). Similarly there was no effect of the intervention on256
mothers’ or researchers’ vegetable liking ratings for the Portuguese infants (4.6 vs. 5.2 and257
4.5 v. 5.0 respectively).258
There were no significant group differences in intake or either mother’s or researcher’s259
ratings of the infants liking of the unfamiliar fruit puree in any of the three countries (see260
Table 4).261
No significant main effect of the intervention on children’s intake of a novel vegetable263
was found in the full sample. Children in the intervention group were rated by researchers as264
liking the unfamiliar vegetable more than the control group but this was not the case for265
maternal ratings. However, UK intervention infants ate significantly more of an unfamiliar266
vegetable and were rated by both mothers and researchers as liking the vegetable more than267
infants in the control group one month after the introduction of solid foods. In the Greek and268
Portuguese samples, there was no significant effect of the intervention on either intake or269
liking of an unfamiliar vegetable. However, observations of the raw data in Greece did270
suggest a positive trend towards higher consumption among the intervention infants.271
The UK findings provide support for previous research showing repeated exposure to272
vegetables during complementary feeding can impact positively on infants’ vegetable273
acceptance(22, 30, 31) and daily changes in the variety of vegetables consumed increase274
acceptance of a novel food(17, 18). The differences in the outcomes observed across the three275
study sites may be partly explained by cultural variations in typical weaning practices in these276
countries. Recent research has revealed that Portuguese school-children have among the277
highest levels of vegetable intake in Europe(32). In addition, the Euro-Growth study,278
examining infant feeding practices and the introduction of complementary foods across279
Europe, found that fruit was the most common first food offered to infants in both Greece and280
the UK, while in Portugal it was cereal or vegetables(33). This suggests that normal weaning281
practices in Portugal more closely resemble those advocated in the present study, potentially282
minimizing differences between intervention and control groups. The observation that over283
70% of the Portuguese control infants in the present study were given vegetable-based soups284
as their first food supports this assertion. In contrast, only 32% of the UK control infants and285
just 7% of the Greek control infants received vegetables as their first foods. Instead, baby rice286
or cereals were the most common first foods consumed by control infants in the UK (56%)287
and Greece (73%). This is also reflected in the raw intake data from the taste test in which288
Portuguese control infants ate more of the unfamiliar vegetable puree than UK and Greek289
Intervention infants.290
No group differences in fruit intake or liking were observed in the taste test in any of291
the 3 countries. This suggests that introducing single vegetables as first foods, and not292
offering fruit for the first 15 days does not reduce fruit preference in young infants. This is293
reassuring but unsurprising given infants’ innate preferences for sweet tastes(34, 35). The294
finding that vegetable exposure does not affect fruit acceptance also supports a recent study295
that found infants who had been exposed to 5 days of rice flour porridge, followed by 19 days296
of vegetables, ate on average the same amount of a novel fruit immediately post-intervention297
as infants who had no exposure yet to either fruits or vegetables and had only received 5 days298
of rice flour porridge(30).299
Alternative explanations for the group differences in novel vegetable acceptance300
observed for UK infants should be acknowledged. It is possible that the intervention infants301
received less energy as a result of consuming vegetables only for the first 15 days of weaning302
and were therefore hungrier than control infants during this period. However there is no clear303
reason why this phenomenon should be unique to UK infants. Additionally, first solid foods304
are ‘complementary’ to the continuation of milk feeding and most infants continue to305
consume a large proportion of their energy via breast or formula milk during this early306
weaning period, particularly if solids are introduced prior to 6 months as was common in the307
present study. As the intervention feeding plan lasted 15 days and the taste tests were308
conducted one month after the introduction of solids it is particularly unlikely that309
intervention infants were systematically hungrier than control infants at the time of the taste310
Necessary variations in the study procedures of the participating countries are likely to312
have impacted on results. In Portugal researchers had to acquire permission from the infants’313
paediatricians/GP in order to conduct the study and in a proportion of cases the advice was314
delivered by health professionals rather than researchers. Although acceptance was generally315
high, health professionals did not comply fully with the intervention even after agreeing to316
participate. Consequently, fidelity of, and adherence to the intervention may have been317
undermined. There is some evidence of lower compliance among Portuguese participants -318
only 67% of the intervention mothers gave their infants an isolated vegetable as their first319
food as requested, compared to 93% in the UK and 100% in Greece. Additionally fewer320
Portuguese intervention parents (63%, compared to 100% in the UK and Greece) returned321
completed study charts, suggesting lower compliance with the intervention procedure. There322
is need to repeat this study in a larger sample within countries where vegetables are not323
already common first foods and future research would benefit from exploring differences in324
outcome when advice is delivered by health professionals compared to researchers. A further325
limitation of this study is that while mothers were unaware of the study hypotheses, neither326
they nor researchers could be “blinded” to treatment which may have influenced preference327
ratings in the taste tests. However, the ecological validity of the experiment; the fact it was328
implemented by mothers themselves in the home is a strength, as is the randomized study329
design and inclusion of a no-treatment control.330
The intervention was received positively by parents who particularly welcomed the331
simple, prescriptive, and unambiguous nature of the instructions at an often anxiety-332
provoking stage of infant development. UK intervention infants showed increased intake and333
liking of an unfamiliar vegetable in the short term but this was not true in Portugal where334
vegetables are commonly given as first foods. It appears that repeated exposure to a variety335
of vegetables at weaning may work to increase vegetable acceptance in the short-term in336
countries where vegetables are not typically provided as first foods. However, the longer337
term impact of the intervention remains to be explored. This intervention is straightforward338
and would be easy to disseminate to mothers during an infants’ first months when parents are339
in frequent contact with health professionals and actively seeking advice about weaning.340
The authors would like to thank the families who participated in the study and the healthcare342
providers and staff who assisted with their recruitment.343
Financial Support345
This research is supported By: European Community’s Seventh Framework Programme346
(FP7/2007-2013) under the grant agreement n°245012-HabEat. The purees offered to347
participants in this study and the artichoke and peach purees used as a test food were donated348
by Danone Nutricia Research. The funders had no role in the design, analysis or writing of349
this article.350
Conflict of Interest352
None of the authors reported a conflict of interest.353
The authors’ responsibilities were as follows - LC, CL, PM, YM and JW: designed the356
research; AF, GM, CL, AO and CM: conducted the research; AF, AO, CM and RB analysed357
data; AF, LC, GM, CL, RB, AO, CM, GM and JW: wrote the manuscript; AF: had primary358
responsibility for the final content of the manuscript; and all authors: read and approved the359
final manuscript.360
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Figure 1: Flow of participants through the study
1Reasons for lost to follow up following randomization: In the UK intervention group family non-contactable (n=1); In Portugal intervention group family withdrew from
study (n=1); In Portugal control group family unavailable for visit (n=1).
2Reasons for lost to follow up following first visit: In the UK intervention group baby was unwell so unable to complete taste test (n=1) and family unavailable for visit
(n=1); in the UK control group family unavailable for visit (n=1), family withdrew from study (n=1).
3Families that completed the taste test (the primary outcome).
Allocated to control:
UK: n= 27
Portugal: n=29
Greece: n=15
Total: n=71
Allocated to intervention;
UK: n= 31
Portugal: n=28
Greece: n=16
Total: n=75
Did not complete first visit
UK: n=1
Portugal: n=1
Greece: n=0
Total: n=2
Did not complete first visit
UK: n= 0
Portugal: n=1
Greece: n=0
Total: n=1
Completed first visit;
UK: n=27
Portugal: n=28
Greece: n =15
Total: n=70
Completed first visit;
UK: n=30
Portugal: n=27
Greece: n=16
Total: n=73
Completed Follow-up
UK: n= 28
Portugal: n=27
Greece: n=16
Total: n=71
Mothers and infants selected to current
trial and randomized to group;
UK: n= 58
Portugal: n=57
Greece: n=31
Total: n= 146
Did not complete Follow-up
UK: n= 2
Portugal: n=0
Greece: n=0
Total: n=2
Did not complete Follow-up
UK: n=2
Portugal: n=0
Greece: n=0
Total: n=2
Completed Follow-up
UK: n=25
Portugal: n =28
Greece: n =15
Total: n=68
Table 1: Characteristics of mothers and infants by condition and country
Control Intervention
(n =68)
(n =71)
Age (at child’s birth, years), mean (SD) 34.2 (5.1) 31.5 (4. 7) 32.0 (4.5) 32.7 (4.8) 34.8 (2.9) 33.6 (4.0) 31.3 (5.5) 33.2 (4.5) 33.0 (4.7)
BMI (kg/m
), mean (SD) 23.4 (4.3) 22.4 (3.6) 24.1 (6.8) 23.5 (5.4) 21.9 (2.2) 23.3 (4.5) 22.9 (3.4) 22.6 (3.3) 23.0 (2.4)
Primapara, n (%) 16 (64.0) 8 (53.3) 14 (50.0) 38 (55.9) 14 (50.0) 8 (50.0) 17 (62.9) 39 (54.9) 77 (55.4)
Education, n (%)
Below University
Undergraduate or above
2 (8.7)
23 (91.3)
6 (40.0)
9 (60.0)
12 (42.9)
16 (57.1)
20 (29.4)
48 (70.6)
2 (7.1)
26 (92.9)
4 (25.0)
12 (75.0)
11 (40.7)
16 (59.3)
17 (23.9)
54 (76.1)
37 (26.6)
102 (73.4)
Marital status, n (%)
24 (96.0)
1 (4.0)
14 (93.3)
1 (6.7)
25 (89.3)
3 (10.7)
63 (92.6)
5 (7.4)
27 (96.4)
1 (3.6)
16 (100.0)
0 (0.0)
24 (88. 9)
3 (11.1)
67 (94.4)
4 (5.6)
130 (93.5)
9 (6.5)
Vegetable intake (serves/day), mean (SD) 2.6 (1.1) 1.0 (0.5) 2.1 (1.5) 2.1 (1.3) 2.6 (1.1) 1.2 (0.6) 1.7 (1.1) 1.9 (1.2) 2.0 (1.2)
Fruit intake (serves/day), mean (SD) 2.6 (1.2) 1.7 (0.9) 2.3 (1.2) 2.3 (1.2) 2.6 (1.1) 1.4 (1.0) 2.1 (1.2) 2.1 (1.2) 2.2 (1.2)
Sex (male), n (%) 12 (48.0) 10 (66.7) 11 (39.3) 33 (48.5) 16 (57.1) 11 (68.8) 13 (48.2) 40 (56.3) 73 (52.5)
Milk feeding method, n (%)
Entirely breastfed
Entirely bottle fed
17 (68.0)
5 (20.0)
3 (12.0)
5 (33.3)
10 (66.7)
0 (0.0)
15 (53.6)
10 (35.7)
3 (10.7)
37 (54.4)
25 (36.8)
6 (8.8)
15 (53.6)
11 (39.3)
2 (7.1)
6 (37.5)
10 (62.5)
0 (0.0)
14 (51.9)
10 (37.0)
3 (11.1)
35 (49.3)
31 (43.7)
5 (7.0)
72 (51.8)
56 (40.3)
11 (7.9)
Gestational age (weeks), mean (SD) 39.2 (1.5) 37.9 (2.6) 39.0 (1.7) 38.9 (1.9) 39.7 (1.3) 39.0 (1.9) 38.5 (2.0) 39.1 (1. 8) 39.0 (1.8)
Birth weight (kg), mean (SD) 3.6 (0.6) 3.1 (0.5) 3.1 (0.5) 3.3 (0.6) 3.6 (0.5) 3.2 (0.4) 3.1 (0.4) 3.3 (0.5) 3.3 (0.5)
Age at introduction of solid foods, mean (SD) 5.3 (0.5) 5.1 (0.6) 5.0 (0.7) 5.2 (0.6) 5.4 (0.5) 5.8 (0.3) 5.0 (0.6) 5.3 (0.6) 5.2 (0.6)
1The variables were categorized as follows:
Below university: No qualifications, secondary school certificate, technical school, high school certificate, private faculty diploma
Undergraduate +: Undergraduate Degree, Postgraduate Qualification
2The variables were categorized as follows:
Entirely breastfed: Breastfeeding exclusively
Mixed: Mostly breastfeeding with some bottle-feeding, equally breastfeeding and bottle-feeding, mostly bottle-feeding and some breastfeeding
Entirely bottle fed: Almost all bottle-feeding (only tried breastfeeding a few times), Bottle-feeding only (never tried breastfeeding)
Table 2: First foods offered to infants by country and experimental condition
Food Categories Countries combined UK Greece Portugal
n ( %) n ( %) n ( %) n ( %) n ( %) n ( %) n ( %) n ( %)
Isolated vegetable 10 (14.7) 60 (84.5) 8 (32.0) 26 (92.9) 1 (6.7) 16 (100.0) 1 (3.6) 18 (66.7)
Isolated fruit 7 (10.3) - - 3 (12.0) - - 3 (20.0) - - 1 (3.6) - -
Baby rice or cereal 31 (45.6) 7 (9.9) 14 (56.0) 2 (7.1) 11 (73.3) - - 6 (21.4) 5 (18.5)
Vegetable soup
20 (29.4) 4 (5.6) - - - - - - - - 20 (71.4) 4 (14.8)
1Vegetable soups are common weaning foods in Portugal and typically include potato, olive oil and at least two different vegetables (e.g. carrot, pumpkin, onion, garlic, and
Table 3: Taste Test: Vegetable and Fruit intake and liking rating by experimental condition
(n = 68)
Mean (SD) Mean (SD) p-value
Vegetable (artichoke)
Intake (g) 29.84 (30.12) 38.91 (33.65) 0.064
Maternal rated liking 4.50 (2.63) 5.34 (2.47) 0.052
Researcher rated liking 4.51 (2.37) 5.38 (2.36) 0.032*
Fruit (peach)
Intake (g) 64.23 (65.56) 51.18 (51.76) 0.211
Maternal rated liking 6.57 (2.66) 6.20 (51.76) 0.371
Researcher rated liking 6.46 (2.71) 6.07 (2.45) 0.327
1Effect of condition controlling for Country
* P-values representing significant group differences (< 0.05)
Table 4: Taste Test: Vegetable and Fruit intake and liking rating by country and experimental condition
* P-values representing significant group differences (< 0.05)
(n = 25)
(n = 15)
(n = 28)
Mean (SD) Mean (SD) p-value
Mean (SD) Mean (SD) p-value
Mean (SD) Mean (SD) p-value
Vegetable (artichoke)
Intake (g) 16.47 (12.09) 32.75 (23.64) 0.003* 23.60 (22.81) 36.25 (28.74) 0.187 45.11 (37.73) 46.89 (43.36) 0.871
Maternal rated liking 4.29 (2.03) 6.69 (1.83) <0.001* 3.33 (2.35) 4.25 (2.44) 0.296 5.21 (3.05) 4.59 (2.49) 0.412
Researcher rated liking 4.58 (1.82) 6.66 (1.63) <0.001* 3.40 (2.20) 4.63 (2.10) 0.123 4.96 (2.74) 4.52 (2.61) 0.540
Fruit (peach)
Intake (g) 40.70 (32.60) 27.93 (30.09) 0.144 58.40 (49.57) 82.50 (68.04) 0.272 88.36 (85.50) 56.74 (48.82) 0.098
Maternal rated liking 7.25 (2.35) 6.69 (2.00) 0.352 5.20 (2.65) 6.00 (2.88) 0.428 6.68 (2.78) 5.85 (2.82) 0.273
Researcher rated liking 7.29 (2.26) 6.97 (1.68) 0.549 5.13 (2.17) 5.88 (2.63) 0.400 6.39 (3.12) 5.30 (2.79) 0.095
... The evidence base was considered sufficient to start recommending the approach as a strategy to improve vegetable acceptance throughout childhood, which some authorities such as the National Health Service, UK (NHS) (20) and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (21) now reflect in their current messaging. However, further longitudinal randomized controlled trials (RCTs) are needed to improve international consensus (19,(22)(23)(24) as the few studies examining a vegetables-first approach, although compelling, are limited by factors including short follow-up periods, small samples, and the use of control groups that do not necessarily reflect common practices (25)(26)(27)(28). In addition, none of these intervention studies have reported infants' iron status (25)(26)(27)(28), which is problematic given the high risk of iron deficiency at this age (19). ...
... However, further longitudinal randomized controlled trials (RCTs) are needed to improve international consensus (19,(22)(23)(24) as the few studies examining a vegetables-first approach, although compelling, are limited by factors including short follow-up periods, small samples, and the use of control groups that do not necessarily reflect common practices (25)(26)(27)(28). In addition, none of these intervention studies have reported infants' iron status (25)(26)(27)(28), which is problematic given the high risk of iron deficiency at this age (19). ...
... only fruit purées. Fildes et al. (28) found UK infants who received a variety of single vegetables as first foods during the first 15 d of CF ate twice as much of a new vegetable (artichoke purée) 1 mo postintervention as infants who started with fruit, vegetables, and infant rice/cereal. In the 2-arm RCT by Hetherington et al. (25), infants who were introduced to vegetable tastes early and gradually (first to milk, then rice cereal) during the first 24 d of CF showed greater intake, pace of eating, duration, and liking of vegetable purées compared with those introduced to plain milk/rice cereal before vegetables. ...
Full-text available
Background: Starting complementary feeding (CF) with vegetables only may improve vegetable acceptance throughout childhood. Objectives: We aimed to test whether exposure to vegetables only during the first 4 wk of CF increases later vegetable acceptance compared with a control group receiving fruit and vegetables. Methods: In this randomized, controlled, parallel-group study, 117 Auckland infants received either vegetables only (veg-only, n = 61) or a combination of fruit and vegetables (control, n = 56) for a duration of 4 wk, starting from the first day of CF at ∼4-6 mo of age. The primary outcome measure was intake of target vegetables (broccoli, spinach) provided by the study at 9 mo of age. Daily intake of vegetables (FFQs) at 9 mo was a supporting measure. Infants' iron status (serum ferritin, hemoglobin) was examined at all time points. Results: The veg-only infants consumed more broccoli and spinach than controls [mean difference (95% CI): 11.83 (0.82, 22.84) g, P = 0.036 and 10.19 (0.50, 19.87) g, P = 0.039, respectively]. Intake of pear was comparable among intervention groups (P = 0.35). At 9 mo, veg-only infants consumed target vegetables at a faster rate [mean difference (95% CI): broccoli, 3.37 (1.26, 5.47), P = 0.002; spinach, 4.12 (0.80, 7.45), P = 0.016] and showed greater acceptance for target vegetables [mean difference (95% CI): broccoli, 0.38 (0.07, 0.70), P = 0.019; spinach, 032 (0.04, 0.60), P = 0.024] than controls. The rate of eating and acceptance of pear was comparable among intervention groups (P = 0.42 and P = 0.98, respectively). Also, veg-only infants consumed more vegetables than controls [86.3 (52.5, 146.3) compared with 67.5 (37.5, 101.3) g, respectively, P = 0.042]. Introducing vegetables as the first food was not associated with 9-mo iron status. Conclusions: Providing vegetables as first foods increased vegetable intake at 9 mo of age and may be an effective strategy for improving child vegetable consumption and developing preferences for vegetables in infancy.
... The prioritisation of vegetables only from the start of complementary feeding is known as a "vegetables first" approach to complementary feeding. Only a handful of studies investigating the effects of this approach have been published, with none in New Zealand [33][34][35][36][37]. Barends et al. compared the effects of repeated exposure and starting complementary feeding with vegetables only across four different treatment groups over 18 days. ...
... Their follow-up study [35] suggested that starting complementary feeding with vegetables only results in higher daily vegetable consumption until at least 12 months of age; however, further investigation was needed on how to maintain this effect until 24 months of age. Three other studies suggest vegetables as first foods may improve vegetable acceptance later, at least in the short term [33,[36][37][38][39]. However, comparability of findings remains limited due to considerable variability in study designs, small sample sizes, and/or poor ecological validity (e.g. ...
... Mothers will complete a 4-day weighed food diary during the first and last 4 days of the 4-week intervention to primarily measure infant food intake (grammes). In alignment with other studies [33][34][35][36][37][38][39][55][56][57], this will involve weighing the food before and after consumption . Foods will be labelled by colour and none list the ingredients but mothers are reassured that the foods align with New Zealand infant feeding guidelines. ...
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Background Vegetables as first complementary foods for infants may programme taste preferences that lead to improved vegetable intake in children. Yet few studies have investigated the impact of a ”vegetables first” approach to complementary feeding, especially in New Zealand. The purpose of this randomised control trial is to investigate the effect of starting complementary feeding with vegetables only on infants’ later intake and liking of vegetables, compared to those starting with fruit and vegetables. Methods/design One-hundred and twenty mother-infant pairs living in Auckland, New Zealand, will be randomised to receive either vegetables only (intervention) or fruit and vegetables (control) for 28 days, starting from the first day of complementary feeding at around 4–6 months of age. Infants will be presented with a brassica (broccoli), followed by a green leafy vegetable (spinach) and sweet fruit (pear) at 9 months of age. The primary outcome measures of intake of each food will be assessed using a weighed food diary. Secondary outcome measures of overall intake, liking and wanting of vegetables will be assessed using a food frequency questionnaire, liking tool and video coding tool, respectively, at 9, 12, and 24 months of age. Infant growth and iron status will be assessed as part of health screening and monitoring at baseline, post intervention and 9 months of age. Other biological samples to be collected include infant stool samples, vitamin D (mother and infant), iron status (mother), and mothers’ diet. Discussion This randomised, controlled trial will be the first to our knowledge to investigate a “vegetables first” approach to complementary feeding on infants’ liking and intake of vegetables in New Zealand. Comparison against standard practice (fruit and vegetables as first foods) should complement other trials underway, such as the Baby’s First Bites and Nordic OTIS trial. Results may contribute to the evidence supporting complementary feeding guidelines in New Zealand and worldwide. Trial registration Australian New Zealand Clinical Trial Registry ACTRN12619000737134 . Registered on 16 May 2019.
... Within the HabEat study across Europe, a 'vegetables first' approach was trialled in three different nations -Greece, Portugal and the UK. The intervention groups received guidance to introduce a variety of vegetables as first foods during the first 15 days of the complementary feeding period and the control group received the standard complementary feeding guidance from that country [71]. Mothers were provided some commercially available vegetable purées but could prepare their own if preferred. ...
... Infants in the intervention groups ate significantly more of the unfamiliar vegetable than those in the control group, and infants from the UK consumed almost double the amount of the new vegetable compared to control group. This effect was not observed in infants from Greece or Portugal, perhaps because vegetables (and vegetable soup in Portugal) are already a common first food [71]. In a country like the UK, a vegetables first approach increased liking and intake of a novel vegetable compared to usual practice, which at the time was baby rice. ...
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Purpose of Review To provide a rationale for promoting a vegetables first approach to complementary feeding (CF), building on prior exposure to vegetable flavours experienced in utero and via breastfeeding (chemosensory continuity). Recent Findings Vegetables confer selective health benefits but population intakes are below recommendations globally; maternal intake of vegetables during both pregnancy and lactation promotes familiarity with some vegetable flavours. Building on this exposure, vegetables as a first food during CF further promote acceptance. However, experiments testing efficacy of a vegetables first approach to CF demonstrate increased liking and intake, some evidence of generalisability but little evidence of sustained effects beyond infancy. Summary The aim to increase the quantity and variety of vegetables eaten by children is both desirable, to improve nutrient quality of the diet, and achievable. However, longer, larger, randomised control trials are needed to evidence any longer term, sustainable benefits to liking and intake of vegetables.
... A randomized controlled trial conducted in UK, Greece, and Portugal specifically investigated whether exposure to a variety of vegetables early in the complementary feeding process would prevent the observed decline in liking and intake of vegetables at a later age (Fildes et al., 2015). Parents of 4e6-month-old infants were randomized to receive shortly before the start of complementary feeding either (i) guidance on introducing a variety of culturally appropriate vegetables as first complementary foods or (ii) usual care. ...
In the first section of this chapter, an overview of what is known about early flavor exposure, distinguishing between taste and flavor (aroma), and texture exposure is provided. In the second section, we describe what has been researched regarding the influence of early flavor exposure on the development of food preference, looking at prenatal exposure, exposure received in the context of milk feeding and exposure received in the context of complementary feeding. The role of texture exposure is looked from the development of oral feedings skills perspective and parental feeding practices with respect to introduction of solids. The third section is a description of what has been shown regarding the relationships between early exposure and food neophobia. The chapter ends with a comment on likely future trends, and by a description of sources of further information.
Perceiving and responding to the sensory world is a crucial part of development. Sensory perception of taste, smell, and touch starts in utero, and these senses are a gateway through which infants learn about the flavor of food. Traditionally, theories about sensory development focused upon the dichotomy of whether preferences were innate or learned; however, recent researchers have adopted process‐oriented models. In early infancy there is a preference for the familiar, and infants quickly learn to like familiar sensations. However infants who are exposed to a varied world of tastes, smells, and tactile sensations tend to respond more favorably to new stimuli. Research into sensory development is constrained by both the challenges of working with infants and the complex and varied sensory world that each individual child experiences. It is increasingly recognized that sensory processing is an important, but overlooked, factor in the acceptance and rejection of foods throughout the lifespan.
Full-text available
Purpose of Review The purpose of this review is to (1) present a conceptual definition of infant food acceptance, (2) explore methodological challenges to measuring different components of food acceptance, and (3) provide recommendations for future research on food acceptance during infancy. Recent Findings Infant food acceptance includes separate but overlapping components: wanting, liking, and consumption. Recent evidence suggests that although these components are often correlated, there is variability in the sensitivity of these measures to detect differences in infants’ responses to target foods. Summary To date, consumption and caregiver perceptions of liking have been the primary outcome measures of interest in studies of infant food acceptance. More diverse and precise measures across the three components of infant food acceptance are needed to address a wider scope of research questions, which would in turn strengthen the interpretability and translational potential of research in this area.
Lifestyle interventions are effective from the earliest years of childhood. To best promote health, lifestyle factors should be implemented for children and their families from birth. This includes introducing families to the benefits of a whole-food plant-based (WFPB) or plant-predominant diet, daily physical activity, positive family and peer social connections, avoidance of risky substances for caregivers, optimal sleep habits, and stress management and mindfulness for all family members. Through attention to these six pillars of lifestyle medicine, children and their families can succeed in initiating and maintaining optimal lifelong physical and mental health.
Pediatric nutrition is important for ensuring adequate growth and health but also in creating a foundation for healthy behaviors throughout the life span. Caregiver support is vital to model and encourage these healthful behaviors and beneficial for the whole family. Children should be encouraged to eat a variety of foods including whole grains, fruits/vegetables, lean proteins, and dairy and aim to be physically active each day. Balanced nutrition can help decrease the risk of obesity and various illnesses.
Early feeding practices have been related to child's body mass index (BMI), however, their role in establishing dietary patterns is less well understood. The aim of this study was to examine the association of parent-reported early feeding practices (breastfeeding duration, type of foods and timing of complementary feeding) and dietary patterns identified at age 7 to explain BMI z-scores at 10 years of age. Participants were children from the Generation XXI cohort, evaluated at 4, 7 and 10 years of age (n = 3673). At 7 years-old, dietary intake was assessed with a validated food-frequency questionnaire. Two dietary patterns were previously derived: “Energy-dense foods” (high in energy-dense foods, and low in vegetable soup, significantly associated with BMI z-score at 10 years-old, and the “Fish-based” dietary pattern (high in fish consumption and low in energy-dense foods). Adjusted sex-stratified associations were estimated by generalized linear models. Boys and girls who were never breastfed or were breastfed for a very short duration had lower scores in the “Fish-based” dietary pattern, compared to those with longer breastfeeding durations (Boys: β = −0.219; 95%CI: 0.361; −0.077; Girls: β = −0.223; 95%CI: 0.358; −0.088). No significant associations between breastfeeding and the “Energy-dense foods” dietary pattern were found. Boys and girls who were offered cereals as a first food during complementary feeding, in comparison with soup, presented lower scores in the “Energy-dense foods” dietary pattern (Boys: β = −0.183; 95%CI: 0.292; −0.074; Girls: β = −0.155; 95%CI: 0.259; −0.050), but only girls presented higher scores in the ‘Fish-based’ dietary pattern (β = 0.137; 95%CI: 0.006; 0.267). The age of introduction of complementary feeding was not significantly associated with the dietary patterns. Parents should be supported in their infant feeding decisions, given the potential effects of breastfeeding duration and first foods at complementary feeding on shaping longer term dietary patterns of young children.
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Children are not consuming sufficient amounts of fruits and vegetables in their habitual diet. Methods derived from associative learning theories could be effective at promoting vegetable intake in pre-school children. The objective of the present study was to compare the effectiveness of different learning strategies in promoting the intake of a novel vegetable. Children aged between 9 and 38 months were recruited from UK nurseries. The children (n 72) were randomly assigned to one of three conditions (repeated exposure, flavour-flavour learning or flavour-nutrient learning). Each child was offered ten exposures to their respective version of a novel vegetable (artichoke). Pre- and post-intervention measures of artichoke purée and carrot purée (control vegetable) intake were taken. At pre-intervention, carrot intake was significantly higher than artichoke intake (P < 0·05). Intake of both vegetables increased over time (P < 0·001); however, when changes in intake were investigated, artichoke intake increased significantly more than carrot intake (P < 0·001). Artichoke intake increased to the same extent in all three conditions, and this effect was persistent up to 5 weeks post-intervention. Five exposures were sufficient to increase intake compared to the first exposure (P < 0·001). Repeated exposure to three variants of a novel vegetable was sufficient to increase intake of this vegetable, regardless of the addition of a familiar taste or energy. Repetition is therefore a critical factor for promoting novel vegetable intake in pre-school children.
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Increased fruit and vegetable consumption early in life may lead to life-long intake of fruits and vegetables, which in turn may be beneficial for weight control and other health outcomes in later life. Although health officials worldwide recommend delaying solid foods until 6 months of age, younger infants often receive solid food, which may affect later obesity rates. The timing of introduction to solid foods is important both nutritionally and developmentally and may affect acceptance of foods both in infancy and later in life. Infants can clearly discriminate the flavors of different fruits and vegetables. Repeated flavor experiences promote the willingness to eat a variety of foods: infants will consume more of foods that have a familiar flavor and are more accepting of novel flavors if they have experience with flavor variety. Many flavors that the mother either ingests or inhales are transmitted to her milk and/or amniotic fluid. Mothers can help the transition from a diet exclusively of milk or formula to a mixed diet by providing the infant familiar flavors in both milk or formula and solid foods. Exposure to a variety of flavors during and between meals appears to facilitate acceptance of novel foods. Providing novelty in the context of a familiar food might prove to be an optimal combination to progressively accustom infants to a diversity of novel foods. When repeatedly exposing infants to flavors of some vegetables that have bitter tastes, mothers should focus not on infants' facial expressions but on their willingness to eat the food and should continue to provide repeated opportunities to taste the food. Introducing children repeatedly to individual as well as a variety of fruits and vegetables, both within and between meals, might help them be more accepting of fruits and vegetables, which is difficult to enhance beyond toddlerhood.
How children acquire preferences for added sugar and salt was examined by investigating the effects of repeated exposure to 1 of 3 versions of a novel food (sweetened, salty, or plain tofu) on children's preference for those and other similar foods. Participants were 39 4- and 5-yr-olds assigned to taste only 1 of 3 flavored versions 15 times over several weeks. Preferences for all versions were obtained before, during, and after the exposure series. Preference increased for the exposed version only. Experience with 1 flavored version did not produce generalized liking for all 3 versions of the food. Experience with 1 version (flavored or plain) actually produced a decline in preference for the other version. This was true whether children had experience with plain or flavored versions of the food. The acquired preference was restricted to the particular food/flavor complex; through exposure, children seemed to learn whether it was appropriate to add salt or sugar to a particular food. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Social-cognitive theory (SCT) was used to explain the fruit and vegetable intake of 1,398 3rd graders. SCT variables assessed included self-efficacy, outcome expectations, preferences, social norms, asking skills, and knowledge. Fruit and vegetable intake was assessed with 7-day records. Bivariate correlations with fruit and vegetable intake ranged from .17 for asking skills to .29 for fruit and vegetable preferences. In analyses controlling for school-level clustering, only preferences and positive outcome expectations remained significantly associated with fruit and vegetable intake, accounting for approximately 10%–11% of the variance. Limitations in the conceptualization, scope, and measurement of the variables assessed may have contributed to the weak associations observed. Models incorporating factors other than individual-level social-cognitive variables may be required to more fully explain children's dietary behavior. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Twelve infants, aged 16–25 weeks and formerly breast-fed, were tested for their preference for the taste of salt in the first food fed to them. Preference was found to decline with infant age. Because preference for salted food is known to relate to dietary experience of salt in 6-month-old infants, this decline suggests that an initial salt preference is modified by exposure to a low-sodium diet, that is, breast milk. Infant feeding behaviors were found to be a reliable indicator of satiety, and they were also found to differ according to taste preference. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In the weeks following the start of weaning, 70 mothers were asked to identify a vegetable purée that their infant disliked and that they normally would not offer again. The 49 who did so were then asked to offer that vegetable on alternate days for 16 days, and to offer a well-liked one (carrot purée) on the other days. Amount eaten and acceptance were measured at each meal. On the first day of exposure, mean intake of the initially disliked vegetable was 39 ± 29 g and of the liked one, 164 ± 73 g (mean ± SD). Over the following days, intake of the initially disliked vegetable increased rapidly and by the eighth exposure was 174 ± 54 g, similar to that of the liked vegetable (186 ± 68 g). A similar pattern of results was found for mother-reported liking ratings. These effects of repeated exposure appear to be long lasting because nine months later, 63% of the infants were still eating and liking the initially disliked vegetable. The present study shows that when a vegetable is initially disliked it is worth persisting in feeding it for at least eight subsequent meals.
In nature, carbohydrates are a source of energy often equated with sweetness, the detection of which is associated with powerful hedonic appeal. Intakes of processed carbohydrates in the form of added sugars and sugar-sweetened beverages have risen consistently among all age groups over the last two decades. In this review, we describe the biological underpinnings that drive the consumption of sweet-tasting foods among pediatric populations. Scientific literature suggests that children's liking for all that is sweet is not solely a product of modern-day technology and advertising but reflects their basic biology. In fact, heightened preference for sweet-tasting foods and beverages during childhood is universal and evident among infants and children around the world. The liking for sweet tastes during development may have ensured the acceptance of sweet-tasting foods, such as mother's milk and fruits. Moreover, recent research suggests that liking for sweets may be further promoted by the pain-reducing properties of sugars. An examination of the basic biology of sweet taste during childhood provides insight, as well as new perspectives, for how to modify children's preferences for and intakes of sweet foods to improve their diet quality.