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Pureed Fruit Pouches For Babies – Child Health Under Squeeze

DOI:10.1097/MPG.0000000000002061
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Berthold Koletzko
Berthold Koletzko
Berthold Koletzko
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Nathali Lehmann Hirsch
Nathali Lehmann Hirsch
Jo Martin Jewell
Jo Martin Jewell
Jo Martin Jewell
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Margherita Caroli at Azienda Sanitaria Locale Brindisi
Margherita Caroli
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Copyright © ESPGHAN and NASPGHAN. All rights reserved.
Pureed Fruit Pouches for Babies: Child Health
Under Squeeze
Berthold Koletzko,
y
Nathali Lehmann Hirsch,
y
Jo M. Jewell,
§
Margherita Caroli,
z
Joao Rodrigues Da Silva Breda, and
y
Martin Weber
Breast-feeding is the optimal form of infant feeding, with
numerous benefits for maternal and child health (1 –3). From
an age of about 6 month onwards ‘‘breast milk alone is no longer
sufficient to meet the nutritional requirements of infants’’ (1), and
complementary feeding should be introduced to provide additional
energy and critical nutrients such as iron, zinc, iodine, or long-chain
polyunsaturated fatty acids for supporting continued healthy growth
and development (3,4). In addition to the widely used homemade
complementary foods, many commercial food products for infants
and young children are available. WHO has provided guidance on
ending the inappropriate promotion of such foods for infants and
young children (5).
In recent years, a rapidly increasing number and variety of a
new type of commercial complementary foods has been offered,
that is, pureed, semiliquid foods for infants, and young children
packed in squeezable plastic pouches usually equipped with a spout
and screw cap (Fig. 1). These pureed pouch products promise added
convenience to families: after unscrewing the lid, the contents can
be directly squeezed into an infant’s mouth, or infants can suck out
the contents directly from the spout, thereby enabling fast feeding
on the go. This new method of infant feeding has proved very
popular; even reusable pouches are now sold for feeding infants
with homemade pureed baby food from a squeezable bag.
What might appear as a great idea for adding convenience
and reducing parents’ time spent with infant feeding raises some
serious concerns. The complementary feeding period is not only
about provision of nutrients, but it is also is the period of learning
the transition from exclusive milk feeding to the varied family diet
consumed in early childhood, with rapid advancement of oropha-
ryngeal motor learning and development, and of acquiring feeding
and eating behavior skills (4). If infants are fed predominantly by
sucking from a pouch, this may delay and impair learning to eat
from a spoon; exploring foods with tongue; lips, and hands; and
chewing. Some observations point to a critical time window for the
introduction of lumpy solid foods. Delayed introduction of lumpy
foods after the age of about 9 to 10 months was linked to increased
feeding difficulties and low intakes of eating vegetables and fruits at
later ages (6). Therefore, it is not advisable to provide complemen-
tary feeding mostly by sucking—similar to milk feeding.
Feeding infants a variety of food textures and lumpy foods by
spoon feeding and finger foods provides great opportunities for
intensive reciprocal interaction between parent and infant, for
listening and talking, and for learning to sense each other’s signals
(responsive feeding) (7,8), which may be missed if infants are left
on their own to suck from a pouch.
Major concerns arise also from the typical composition of
baby foods in pouches. Manufacturers tend to stress the natural and
often organic nature of these foods, and the absence of artificial
additions, gluten, lactose, or other components often considered by
the public as less desirable. These products, however, often have a
high energy density, high sugar content, and a very sweet taste. This
adds to the already unbalanced composition of commercial com-
plementary feeds, where two thirds of marketed products were
reported to be sweet foods (9). Many of the pouch products for
infants and young children provide pureed fruit. Although some
pureed foods in pouches are offered with grains and vegetables,
even they tend to have a very sweet taste and to be high in sugar
content, and they also need to be liquid or semiliquid to be delivered
through the spout.
Whole meals provided by fruit only are not usually recom-
mended as part of complementary feeding, because they do not
supply appreciable amounts of those nutrients which need to be
provided in addition to continued breast-feeding, in particular iron,
zinc, iodine, and long-chain polyunsaturated fatty acids . Therefore,
fruits are usually recommended only as an addition to a cereal or as
a small portion to accustom infants to a variety of flavors and
textures, provided after a mixed meal based on vegetables, meat, or
fish (3).
Parents may consider a fruit pouch equivalent to offering a
piece of fresh cut fruit to their baby, which is not the case. The
composition of 10 such products with high sugar contents found in
retail stores in Denmark (Table 1) indicates an energy density of 45
to 95 kcal/100 g, which often is much higher than the typical energy
density of fresh fruit (eg, 54 kcal/100 g apple), presumably due to
removal of water or fiber during the production process, and/or the
preferential use of fruits with high sugar contents. The combination
of a high energy density with an easy consumption by sucking, as
opposed to having to chew and swallow pieces of fruit, can lead to a
high intake of energy and sugar in the form of fructose during a
short time period. Therefore, regular infant feeding with pureed
Received April 27, 2018; accepted June 5, 2018.
From the LMU-Ludwg-Maximilians-Universita¨t Mu
¨nchen, Dr. von
Hauner Children’s Hospital, University of Munich Medical Center,
Mu
¨nchen, Germany, the yWHO Regional Office for Europe, Copenha-
gen, Denmark, the zWHO European Office for Prevention and Control of
Noncommunicable Diseases, Moscow, Russian Federation, and the
§European Childhood Obesity Group, Francavilla Fontana, Italy.
Address correspondence and reprint requests to Berthold Koletzko, MD,
PhD, Dres hc, LMU-Ludwig-Maximilians-Universita¨t Mu
¨nchen, Dr.
von Hauner Children’s Hospital, Lindwurmstr 4, 80337 Mu
¨nchen,
Germany (e-mail: office.koletzko@med.lmu.de).
The work of B.K. is financially supported in part by the Commission of the
European Communities, Projects Early Nutrition (FP7-289346), DYNA-
HEALTH (H2020-633595), and LIFECYCLE (H2020-SC1-2016-RTD),
the European Research Council Advanced Grant META-GROWTH
(ERC-2012-AdG 322605), the Erasmus Plus programme ‘‘Early Nutri-
tion eAcademy Southeast Asia—573651-EPP-1-2016-1-DE-EPPKA2-
CBHE-JP,’’ and the EU Interreg Programme ‘‘Focus in CD-CE111.’’
Travel support to attend meetings at the WHO regional Office for Europe
was provided by the European Society for Paediatric Gastroenterology,
Hepatology and Nutrition (www.espghan.org). J.R.B., J.M.J., and
M.W are WHO staff members. The opinions expressed are theirs and
do not necessarily reflect the views and policies of the World Health
Organization.
The authors report no conflicts of interest.
Copyright #2018 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000002061
EDITORIAL
JPGN Volume 67, Number 5, November 2018 561
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
fruit from pouches may bear the risk to induce overfeeding and an
excessive infant weight gain, which has been associated with a
markedly increased risk of later obesity (10,11). Many such pro-
ducts have extremely high sugar contents ranging from 84% to 98%
of total energy content (Table 1), which seems inadequate for a meal
provided to babies. Apparently most if not all of the sugar content is
composed of sugars found naturally in fruits, and not of ‘‘added
sugars’’ supplemented during processing of the foods. Although the
term ‘‘added sugar’’ is useful for regulatory and policy purposes,
we do not consider it to describe the quality and suitability of
complementary foods because any content of sugars, be it
from prepared fruits and other ingredients or from added isolated
sugars, has similar untoward metabolic, dental, and other health
effects (12).
A pureed food with high sugar content is more likely to stick
on dental surfaces than chewed foods with abrasive qualities, and
thereby may pose an increased risk for the development of dental
caries. Also, the repeated exposure to the very sweet taste of such
products may induce potential programming effects on later taste
and food choices. Early dietary experience of sweet tasting foods
and drinks was linked to a stronger preference of sweet foods later
(13), which is undesirable because of the associated risk increase for
dental caries, obesity, and associated diseases (14).
The very high sugar intake with feeding a whole comple-
mentary feeding meal based on pureed fruits must be expected to
increase blood glucose and insulin levels to an even greater extent
than occurring with eating an equal amount of intact fruit, because
the preserved matrix of natural fruits tends to slow down absorption,
as compared to absorption from mushed foods. For example the
glycemic index of mashed potatoes is 83 and thus far higher than the
glycemic index of boiled potatoes with only 49 (5). A high glycemic
load stimulates high infant insulin secretion that can induce an
undesirable high infant weight gain velocity and increased later
obesity risk (15). High habitual dietary sugar intake over lifetime
has also been associated with an increased adiposity-related cancer
risk (16). In the project VIVA birth cohort study, maternal sugar
intake in pregnancy and offspring sugar intake in early childhood
were inversely associated with child cognition (17). Different fruits
vary in the composition of sugars, but fruits are generally rich in
fructose, along with variable contents of glucose and sucrose (18). It
appears likely that the high fructose intake with pureed fruit
pouches has greater adverse metabolic effects than similar intakes
of other carbohydrates, because fructose appears to promote de
novo lipogenesis, hepatic steatosis, and nonalcoholic fatty liver
disease (19–21), and also a fructose-induced increase in asthma risk
has been reported (22). Although further work is needed to define
and fully understand the health impact of dietary sugars (23), based
on the currently available data a limited dietary sugar intake is
strongly recommended (14).
We conclude that infants and young children should not
regularly suck pureed foods from a plastic pouch, but rather be
given the opportunity to explore a variety of foods given by
spoon feeding or as finger foods, supported by a reciprocal,
responsive relationship between parent and infant. We recom-
mend the use of well-prepared home-made complementary foods
with limited amounts of sugar but high contents of nutrients that
are of critical importance for the age, and that offer diverse
flavor and texture experiences. If commercial complementary
foods are used, they should be selected based on the same
TABLE 1. Energy density (kcal/100 g) and sugar contents (percentage of energy) in 10 fruit puree pouch products with high natural sugar contents
sold in retail stores in Denmark in May 2017
Declared Main Ingredients Promoted From Age, mo Energy, kcal/100 g Sugar, g/100 g Sugar (percentage of kcal)
Banana 4 95 23.2 98
Apple, banana, and mango smoothie 6 64 14.0 88
Strawberry and apple 4 45 9.8 87
Apple and plums 4 58 12.6 87
Apple and banana smoothie 6 65 14.0 86
Banana and apple 4 76 16.3 86
Prunes 4 45 9.6 85
Banana, mango, apricot, apple 6 72 15.2 84
Apple and mango smoothie 6 57 12.0 84
Apple and strawberry 6 57 12.0 84
Data represent the declarations on the package.
FIGURE 1. Example of a pureed fruit pouch offered for infants and
young children.
Editorial JPGN Volume 67, Number 5, November 2018
562 www.jpgn.org
Copyright © ESPGHAN and NASPGHAN. All rights reserved.
guiding principles. Readymade pureed fruits should usually not
substitute for a whole meal, but only be used as an addition to a
meal, for example, as an addition to a cereal, and they should be
fed by a spoon and not by sucking out of a pouch. Implementa-
tion of regulatory standards for these types of products may be
required to protect child health.
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JPGN Volume 67, Number 5, November 2018 Editorial
www.jpgn.org 563
... The current study found that food in pouches had a similar energy content to other forms of commercial infant foods. This suggests that concerns about the risk of excess energy consumption [12,13,28], if supported by future research, would not be from the energy content of pouch foods, but rather would be from the influence of pouches on eating behaviour. For example, this could be due to the ease with which pouch foods can be delivered and consumed, as the texture of the food in pouches must be smooth enough to fit through the nozzle. ...
... This is the first study to report the "free sugars" and "added sugars" content of commercial infant foods. The finding that pouches, on average, did not contain any free or added sugars was surprising, particularly given the widespread concern about high sugars content in pouches, and the emphasis being placed on the sugars content of commercial infant foods in the literature [8,28,43]. The WHO Regional Office for Europe made a call in 2019 to ban added sugars and "sweetening agents" (including fruit juices and fruit juice concentrates) in commercially available complementary foods [27]. ...
... However, it is important to note a number of caveats. First, some commentators have expressed concerns about the "high sugars content" of pouches (relying on the total sugars amount reported on the label) and pointed to the use of fruit as a particular concern [11,28]. Although fruits do contain sugars, unlike table sugars, they also provide beneficial nutrients including phytochemicals, antioxidants, and dietary fibre [50]. ...
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... An increasing number of these products come in tetra packs with a spout and screw cap that the child can open to squeeze to suck/drink the liquid. This formulation does not help the development of chewing, encourages the consumption of sweet drinks instead of water, the formation of tooth decay due to the high intake of sugars, and finally, leaves the child alone at the time of intake, missing an opportunity for young children and parents to interact with each other during feeding [28]. ...
... The EU legislation and Codex standards recommend different upper limits for lipid content according to the type of food [27,28]. Briefly, as summarized by the WHO document, total fat should not exceed 4.5 g/100 kcal except for in some meat-fish-or cheese-based meals as they are naturally richer in fat content and with a fat content that can be <6 g per 100 kcal [12]. ...
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... The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommends that the energy intake from free sugars for children should be less than 5% of total energy intake [11]. Contrary to these recommendations, baby food pouches are more likely to contain higher levels of sugar than other package types [10,[12][13][14]. Particular concern has been raised that fruit pouches are too energy dense, contain too much sugar and induce a preference for sweet taste. ...
... Particular concern has been raised that fruit pouches are too energy dense, contain too much sugar and induce a preference for sweet taste. In turn, these features are suggested to result in overfeeding and excessive weight gain in toddlers [14,15]. Yet, health outcomes in relation to consumption of fruit pouches have been insufficiently studied [16]. ...
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Concerns have been raised that an overconsumption of baby food fruit pouches among toddlers might increase the risk of childhood obesity. This study aimed to quantify the consumption of fruit pouches and other fruit containing food products and to explore potential correlations between the consumption of these products and body-mass index z-score (BMIz) at 18 months, taking other predictive factors into consideration. The study was based on 1499 children and one-month-recall food frequency questionnaires from the Swedish population-based birth cohort NorthPop. Anthropometric outcome data were retrieved from child health care records. BMIz at 18 months of age was correlated to maternal BMI and gestational weight gain and inversely correlated to fruit juice consumption and breastfeeding. BMIz at 18 months of age was not correlated to consumption of fruit pouches, sugar-sweetened beverages, whole fruit or milk cereal drink. Overweight at 18 months of age was correlated to maternal BMI and inversely correlated to breastfeeding duration. To our knowledge, this is the first study that investigates possible associations between baby food fruit pouch consumption and overweight in toddlers. We found that moderate fruit pouch consumption is not associated with excess weight at 18 months of age.
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... Concern has been raised as those fruity pouches contain much fructose (carbohydrate), which has not always been declared as 'added sugar' [14]. Several studies [15][16][17] were published showing that the median total sugar content of kids' pouches was more than three times that of cans and jars. Concerns are not only a high energy density, but it may also induce a preference for sweet taste and lead to obesity later in life. ...
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Introduction: Our diet is the sum of many different influences and has visibly changed over the past decades. Since children also imitate their parents when it comes to eating habits, the aim of the study was to assess the current dietary habits in Swiss children. Method: Cross-sectional study of children between 0 and 18 years of age in Switzerland. Results: A total of 1964 children participated, with an average age of 7.4 years. A total of 57.9% of participants stated to buy supplements to promote health, while fruit juices/smoothies were the most popular product (42.5%), followed by protein-enriched products (40%) and vitamins/minerals (29%). A statistically significant correlation between longer screen time, a higher socioeconomic background, and the intake of supplements was found. Over 20% of all families regularly consume plant-based drinks. Discussion: This Swiss cross-sectional study of over 1900 participants reveals that 58% of all participants buy supplements or special kid's food to promote the child's health. There is a correlation between higher screen time, higher parental income, and the usage of supplements. A total of 23% of participating families consume at least one plant-based drink on a regular basis. As more and more families use supplements, the pediatrician should not only focus on weight, which reflects the intake of macronutrients but should also take a history of whether children omit certain foods or take supplements to ensure the child does not have a deficiency of micronutrients.
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... It has been proposed that parents or caregivers may choose to offer these squeeze pouches for convenience, ease of use, and to allow children to self-feed [2]. On the other hand, it has been suggested that feeding with squeeze pouches is an expensive alternative to making purées at home, and that food in pouches is less likely to provide the sensory experience of seeing, smelling, and touching new foods which may result in increased feeding difficulties [3,4]. To date, these questions have not been investigated in research studies, yet these opposing perspectives can make the use of pouches polarizing. ...
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Globally, a recent phenomenon in complementary feeding is the use of squeezable baby food pouches. However, some health agencies have raised concerns about their possible long-term health effects. The aim of this study was to describe parental perceptions of the use of baby food pouches during complementary feeding (i.e., the transition from an entirely milk-based diet to solid foods) using a netnographic analysis of discussions on publicly available forums. In this study, the community was parents of young children. Six parenting forums were identified through a Google search using defined selection criteria. Discussion threads relating to baby food pouches were collected and imported into NVivo12 for thematic analysis via inductive reasoning. Perceptions of baby food pouches fell within two broad categories-benefits and concerns. The most commonly reported themes related to benefits were: convenience, health, baby enjoys, variety, and cost; whereas the most common concerns reported were: health, cost, lack of dietary exposure, dependence, and waste. Many parents reported both benefits and concerns. Once research has determined the long-term effect of using pouches on infants' health regarding eating habits, nutritional status, growth, and development, the findings of this study can inform educational strategies to either encourage or discourage their use.
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... Despite their market success and competitive advantages compared to other types of packaging (e.g., convenience, mess-free, shelf stability), several consumer groups, public health authorities and scholars have argued that baby food pouches (particularly those based on fruits) contain too much sugar and induce a preference for sweet taste in children, which in turn is likely to result in excessive weight gain (Beauregard et al., 2019;Hutchinson et al., 2021;Katiforis et al., 2021;Koletzko et al., 2018Koletzko et al., , 2019Moding et al., 2019;The New York Times, 2018;Theurich, 2018Theurich, , 2019Westland & Crawley, 2018). For example, Moding et al. (2019) evidenced that infant and toddler pouches contained more sugars per serving compared to infant and toddler foods in other packaging types. ...
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Consumer demand of commercial baby food packaged in squeezable pouches has increased in the last few years. However, pouches have been criticized for having excessive levels of sugar and too many processed ingredients. This study examined how reformulations towards healthier (lower sugar levels) and more natural (fewer processed ingredients) products influenced toddlers’ and parents’ sensory acceptability. Three pairs of baby yogurt pouches (old versus reformulated recipes) were tested. In the reformulated recipes, fruit concentrates were replaced by fruit purees, and added sugar was eliminated. 150 parent-toddler (1-4 years) dyads were included in a 4-day double-blind randomized cross-over study in Spain. Each parent-toddler dyad tested one of the three yogurt pairs (A-B, C-D, E-F). Toddler’s acceptability was measured by the toddler’s reaction and by the estimated and relative intake. Parent’s overall liking and sensory evaluation was measured on a 7-point hedonic scale. Although the reformulated recipes of two yogurt pairs scored significantly lower on acceptability in toddlers (pair A-B: 3.39 ± 0.49 and 3.12 ± 0.70; pair C-D: 3.54 ± 0.61 and 3.30 ± 0.65, P < 0.05) and their parents (pair A-B: 5.73 ± 0.97 and 5.04 ± 1.43; pair C-D: 5.84 ± 1.27 and 5.04 ± 1.51, P < 0.05), all reformulated recipes were highly accepted. The reformulation of food products represents a huge challenge for food manufacturers. Our findings suggest that a reduction of sugar content up to 30% along with a reduction in the number of processed ingredients is acceptable by toddlers and their parents.
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... The protective role of breastfeeding (BF) against overweight and obesity has been reported in many studies, showing a greater effect with longer duration of breastfeeding [9][10][11]. However, the association of timing of CF introduction and the quantity and quality of CF with childhood obesity is controversial [12][13][14][15][16][17][18]. Some studies reported an association of very early CF introduction before four months of age with later obesity in formula-fed infants whereas there was little effect in breastfed infants [19]; overweight and obesity at 2-12 years; obesity at three years [20,21]. ...
Complementary Feeding and Overweight in European Preschoolers: The ToyBox-Study Yannis Manios 10 and on behalf of the ToyBox-study Group †
Article
  • Apr 2021
Citation: Usheva, N.; Galcheva, S.; Cardon, G.; De Craemer, M.; Androutsos, O.; Kotowska, A.; Socha, P.; Koletzko, B.V.; Moreno, L.A.; Iotova, V.; et al. Complementary Feeding and Overweight in European Preschoolers: The ToyBox-Study. Nutrients 2021, 13, 1199. https://
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... The protective role of breastfeeding (BF) against overweight and obesity has been reported in many studies, showing a greater effect with longer duration of breastfeeding [9][10][11]. However, the association of timing of CF introduction and the quantity and quality of CF with childhood obesity is controversial [12][13][14][15][16][17][18]. Some studies reported an association of very early CF introduction before four months of age with later obesity in formula-fed infants whereas there was little effect in breastfed infants [19]; overweight and obesity at 2-12 years; obesity at three years [20,21]. ...
Complementary Feeding and Overweight in European Preschoolers: The ToyBox-Study
Article
Full-text available
  • Apr 2021
Complementary feeding (CF) should start between 4–6 months of age to ensure infants’ growth but is also linked to childhood obesity. This study aimed to investigate the association of the timing of CF, breastfeeding and overweight in preschool children. Infant-feeding practices were self-reported in 2012 via a validated questionnaire by >7500 parents from six European countries participating in the ToyBox-study. The proportion of children who received breast milk and CF at 4–6 months was 51.2%. There was a positive association between timing of solid food (SF) introduction and duration of breastfeeding, as well as socioeconomic status and a negative association with smoking throughout pregnancy (p < 0.005). No significant risk to become overweight was observed among preschoolers who were introduced to SF at 1–3 months of age compared to those introduced at 4–6 months regardless of the type of milk feeding. Similarly, no significant association was observed between the early introduction of SF and risk for overweight in preschoolers who were breastfed for ≥4 months or were formula-fed. The study did not identify any significant association between the timing of introducing SF and obesity in childhood. It is likely that other factors than timing of SF introduction may have impact on childhood obesity.
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Documnento Intersocietario ALIMENTAZIONE COMPLEMENTARE
Article
Full-text available
  • Oct 2021
In 2021 a multidisciplinary expert panel of four Italian scientific Pediatric Societies produced a Document on Complementary feeding (CF). The aim was to provide useful clinical advice for pediatricians working in Pediatric Divisions, the Primary Care Services, residents or Ph.D. students, pediatric nurses, and specialists. The nutrition committees of the Italian Society for Preventive and Social Pediatrics (SIPPS), the Italian Society for Developmental Origins of Health and Disease (SIDOHaD), the Italian Federation of Pediatricians (FIMP), and the Italian Society of Pediatric Nutrition (SINUPE) provided an update of the available clinical literature. The complementary feeding phase is characterized by rapid growth and development, exposing infants at an increased risk of nutrient excesses or deficiencies. Consequently, complementary foods (semisolid, solid foods and liquids other than breast milk, infant formula, follow-on formula, and young-child formula ) and correct feeding practices can prevent malnutrition.
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Nutritional Implications of Baby-Led Weaning and Baby Food Pouches as Novel Methods of Infant Feeding: Protocol for an Observational Study (Preprint)
Article
  • Mar 2021
Background The complementary feeding period is a time of unparalleled dietary change for every human, during which the diet changes from one that is 100% milk to one that resembles the usual diet of the wider family in less than a year. Despite this major dietary shift, we know relatively little about food and nutrient intake in infants worldwide and virtually nothing about the impact of baby food “pouches” and “baby-led weaning” (BLW), which are infant feeding approaches that are becoming increasingly popular. Pouches are squeezable containers with a plastic spout that have great appeal for parents, as evidenced by their extraordinary market share worldwide. BLW is an alternative approach to introducing solids that promotes infant self-feeding of whole foods rather than being fed purées, and is popular and widely advocated on social media. The nutritional and health impacts of these novel methods of infant feeding have not yet been determined. Objective The aim of the First Foods New Zealand study is to determine the iron status, growth, food and nutrient intakes, breast milk intake, eating and feeding behaviors, dental health, oral motor skills, and choking risk of New Zealand infants in general and those who are using pouches or BLW compared with those who are not. Methods Dietary intake (two 24-hour recalls supplemented with food photographs), iron status (hemoglobin, plasma ferritin, and soluble transferrin receptor), weight status (BMI), food pouch use and extent of BLW (questionnaire), breast milk intake (deuterium oxide “dose-to-mother” technique), eating and feeding behaviors (questionnaires and video recording of an evening meal), dental health (photographs of upper and lower teeth for counting of caries and developmental defects of enamel), oral motor skills (questionnaires), and choking risk (questionnaire) will be assessed in 625 infants aged 7.0 to 9.9 months. Propensity score matching will be used to address bias caused by differences in demographics between groups so that the results more closely represent a potential causal effect. Results This observational study has full ethical approval from the Health and Disability Ethics Committees New Zealand (19/STH/151) and was funded in May 2019 by the Health Research Council (HRC) of New Zealand (grant 19/172). Data collection commenced in July 2020, and the first results are expected to be submitted for publication in 2022. Conclusions This large study will provide much needed data on the implications for nutritional intake and health with the use of baby food pouches and BLW in infancy. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12620000459921; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379436. International Registered Report Identifier (IRRID) DERR1-10.2196/29048
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Excess free fructose, high-fructose corn syrup and adult asthma: the Framingham Offspring Cohort
Article
Full-text available
  • Mar 2018
There is growing evidence that intakes of high-fructose corn syrup (HFCS), HFCS-sweetened soda, fruit drinks and apple juice – a high-fructose 100 % juice – are associated with asthma, possibly because of the high fructose:glucose ratios and underlying fructose malabsorption, which may contribute to enteral formation of pro-inflammatory advanced glycation end products, which bind receptors that are mediators of asthma. Cox proportional hazards models were used to assess associations between intakes of these beverages and asthma risk, with data from the Framingham Offspring Cohort. Diet soda and orange juice – a 100 % juice with a 1:1 fructose:glucose ratio – were included for comparison. Increasing intake of any combination of HFCS-sweetened soda, fruit drinks and apple juice was significantly associated with progressively higher asthma risk, plateauing at 5–7 times/week v. never/seldom, independent of potential confounders (hazard ratio 1·91, P<0·001). About once a day consumers of HFCS-sweetened soda had a 49 % higher risk (P<0·011), moderate apple juice consumers (2–4 times/week) had a 61 % higher risk (P<0·007) and moderate fruit drink consumers had a 58 % higher risk (P<0·009), as compared with never/seldom consumers. There were no associations with diet soda/orange juice. These associations are possibly because of the high fructose:glucose ratios, and fructose malabsorption. Recommendations to reduce consumption may be inadequate to address asthma risk, as associations are evident even with moderate intake of these beverages, including apple juice – a 100 % juice. The juice reductions in the US Special Supplemental Nutrition Program for Women, Infants, and Children in 2009, and the plateauing/decreasing asthma prevalence (2010–2013), particularly among non-Hispanic black children, may be related. Further research regarding the consequences of fructose malabsorption is needed.
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Infant feeding and growth trajectory patterns in childhood and body composition in young adulthood
Article
Full-text available
  • Aug 2017
Background: Growth patterns of breastfed and formula-fed infants may differ, with formula-fed infants growing more rapidly than breastfed infants into childhood and adulthood. Objective: Our objectives were to identify growth patterns and investigate early nutritional programming potential on growth patterns at 6 y and on body composition at 20 y. Design: TheWest Australian Pregnancy Cohort (Raine) Study and 3 European cohort studies (European Childhood Obesity Trial, Norwegian Human Milk Study, and Prevention of Coeliac Disease) that collaborate in the European Union-funded Early Nutrition project combined, harmonized, and pooled data on full breastfeeding, anthropometry, and body composition. Latent growth mixture modeling was applied to identify growth patterns among the 6708 individual growth trajectories. The association of full breastfeeding for <3 mo compared with ≥3 mo with the identified trajectory classes was assessed by logistic regression. Differences in body composition at 20 y among the identified trajectory classes were tested by analysis of variance. Results: Three body mass index (BMI; in kg/m²) trajectory patterns were identified and labeled as follows-class 1: Persistent, accelerating, rapid growth (5%); class 2: Early, nonpersistent, rapid growth (40%); and class 3: normative growth (55%). A shorter duration of full breastfeeding for <3 mo was associated with being in rapidgrowth class 1 (OR: 2.66; 95% CI: 1.48, 4.79) and class 2 (OR: 1.96; 95% CI: 1.51, 2.55) rather than the normative-growth class 3 after adjustment for covariates. Both rapid-growth classes showed significant associations with body composition at 20 y (P <0.0001). Conclusions: Full breastfeeding for <3 mo compared with ≥3 mo may be associated with rapid growth in early childhood and body composition in young adulthood. Rapid-growth patterns in early childhood could be a mediating link between infant feeding and long-term obesity risk.
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Effects of Dietary Fructose Restriction on Liver Fat, De Novo Lipogenesis, and Insulin Kinetics in Children With Obesity
Article
Full-text available
Background & Aims Consumption of sugar is associated with obesity, type 2 diabetes mellitus, non-alcoholic fatty liver disease, and cardiovascular disease. The conversion of fructose to fat in liver (de novo lipogenesis, DNL) may be a modifiable pathogenetic pathway. We determined the effect of 9 days of isocaloric fructose restriction on DNL, liver fat, visceral fat (VAT), subcutaneous fat, and insulin kinetics in obese Latino and African American children with habitual high sugar consumption (fructose intake more than 50 g/day). Methods Children (9–18 years old; n = 41) had all meals provided for 9 days with the same energy and macronutrient composition as their standard diet, but with starch substituted for sugar, yielding a final fructose content of 4% of total kcal. Metabolic assessments were performed before and after fructose restriction. Liver fat, VAT, and subcutaneous fat were determined by magnetic resonance spectroscopy and imaging. The fractional DNL area under the curve value was measured using stable isotope tracers and gas chromatography/mass spectrometry. Insulin kinetics were calculated from oral glucose tolerance tests. Paired analyses compared change from day 0 to day 10 within each child. Results Compared with baseline, on day 10, liver fat decreased from a median of 7.2% (inter-quartile range, 2.5%–14.8%) to 3.8% (inter-quartile range, 1.7%–15.5%)(P<.001) and VAT decreased from 123 cm³ (inter-quartile range, 85–145 cm³) to 110 cm³ (inter-quartile range, 84–134 cm³) (P<.001). The DNL area under the curve decreased from 68% (inter-quartile range, 46%–83%) to 26% (inter-quartile range, 16%– 37%) (P<0.001). Insulin kinetics improved (P<.001). These changes occurred irrespective of baseline liver fat. Conclusions Short-term (9 day) isocaloric fructose restriction decreased liver fat, VAT, and DNL, and improved insulin kinetics in children with obesity. These findings support efforts to reduce sugar consumption. ClinicalTrials.gov no: NCT01200043
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Palm Oil and Beta-palmitate in Infant Formula: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition
Article
  • May 2019
Background: Palm oil (PO) is used in infant formulas in order to achieve palmitic acid (PA) levels similar to those in human milk. PA in PO is esterified predominantly at the SN-1,3 position of triacylglycerol (TAG), and infant formulas are now available in which a greater proportion of PA is in the SN-2 position (typical configuration in human milk). As there are some concerns about the use of PO, we aimed to review literature on health effects of PO and SN-2-palmitate in infant formulas. / Methods: PubMed and Cochrane Database of Systematic Reviews were systematically searched for relevant studies on possible beneficial effects or harms of either PO or SN-2-palmitate in infant formula on various health outcomes. / Results: We identified 12 relevant studies using PO and 21 studies using SN-2-palmitate. Published studies have variable methodology, subject characteristics, and some are underpowered for the key outcomes. PO is associated with harder stools and SN-2-palmitate use may lead to softer stool consistency. Bone effects seem to be short-lasting. For some outcomes (infant colic, faecal microbiota, lipid metabolism), the number of studies is very limited and summary evidence inconclusive. Growth of infants is not influenced. There are no studies published on the effect on markers of later diseases. / Conclusions: There is insufficient evidence to suggest that PO should be avoided as a source of fat in infant formulas for health reasons. Inclusion of high SN-2-palmitate fat blend in infant formulas may have short-term effects on stool consistency but cannot be considered essential.
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Carbohydrates and diet patterns in nonalcoholic fatty liver disease in children and adolescents
Article
  • May 2018
Purpose of review: The primary treatment for nonalcoholic fatty liver disease (NAFLD) in children is lifestyle change, including a healthier diet. However, there are no agreed upon expert recommendations for a specific diet in the prevention or treatment of NAFLD. In this study, we review studies published between 2015 and 2017 contributing to further understanding of the role of diet in the development and progression of NAFLD, particularly those addressing sugars and dietary patterns. Recent findings: Multiple recent studies have expanded on earlier evidence that suggests that high intake of sugars plays a causal role in the development of NAFLD, including several recent experimental studies in adults and children that support a unique effect of fructose consumption on liver fat accumulation. Evidence also points to protective effects of dietary patterns that include but are not limited to minimizing sugar intake, Dietary Approaches to Stop Hypertension (DASH), high protein and the Mediterranean diet. The effect of diet may act through its impact on the microbiome, and may be modified by presence or absence of genetic polymorphisms (nutrigenomics) and several new studies demonstrate this. Summary: Diet appears to be a powerful tool in the prevention and treatment of NAFLD. It is imperative that researchers and clinicians continue to hone in on the mechanistic pathways and specific diets to reverse the growing morbidity and mortality of NAFLD.
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Associations of Prenatal and Child Sugar Intake With Child Cognition
Article
  • Apr 2018
Introduction Sugar consumption among Americans is above recommended limits, and excess sugar intake may influence cognition. The aim of this study was to examine associations of pregnancy and offspring sugar consumption (sucrose, fructose) with child cognition. Additionally, associations of maternal and child consumption of sugar-sweetened beverages (SSBs), other beverages (diet soda, juice), and fruit with child cognition were examined. Methods Among 1,234 mother–child pairs enrolled 1999–2002 in Project Viva, a pre-birth cohort, in 2017 diet was assessed during pregnancy and early childhood, and cognitive outcomes in early and mid-childhood (median ages 3.3 and 7.7 years). Analyses used linear regression models adjusted for maternal and child characteristics. Results Maternal sucrose consumption (mean 49.8 grams/day [SD=12.9]) was inversely associated with mid-childhood Kaufman Brief Intelligence Test (KBIT-II) non-verbal scores (–1.5 points per 15 grams/day, 95% CI= –2.8, –0.2). Additionally, maternal SSB consumption was inversely associated with mid-childhood cognition, and diet soda was inversely associated with early and mid-childhood cognition scores. Early childhood consumption of SSBs was inversely associated with mid-childhood KBIT-II verbal scores (–2.4 points per serving/day, 95% CI= –4.3, –0.5) while fruit consumption was associated with higher cognitive scores in early and mid-childhood. Maternal and child fructose and juice consumption were not associated with cognition. After adjusting for multiple comparisons, the association between maternal diet soda consumption and mid-childhood KBIT-II verbal scores remained significant. Conclusions Sugar consumption, especially from SSBs, during pregnancy and childhood, and maternal diet soda consumption may adversely impact child cognition, while child fruit consumption may lead to improvements. Interventions and policies that promote healthier diets may prevent adverse effects on childhood cognition.
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Consumption of Sugars, Sugary Foods and Sugary Beverages in Relation to Adiposity-Related Cancer Risk in the Framingham Offspring Cohort (1991-2013)
Article
  • Apr 2018
Background: Higher sugar consumption may increase cancer risk by promoting insulin-glucose dysregulation, oxidative stress, hormonal imbalances, and excess adiposity. This prospective study investigates the association between dietary sugars(fructose and sucrose) and sugary foods and beverages in relation to combined and site-specific (breast, prostate, colorectal) adiposity-associated cancers. Methods: The analytic sample consisted of 3,184 adults, aged 26-84y, from the Framingham Offspring cohort. Diet data was first collected between 1991-1995 using a food frequency questionnaire. Intakes of fructose, sucrose, sugary foods and sugary beverages (fruit juice and sugar-sweetened beverages) were derived. Participants were followed up until 2013 to ascertain cancer incidence; 565 doctor-diagnosed adiposity-related cancers, including 124 breast, 157 prostate and 68 colorectal cancers occurred. Multivariable-adjusted Cox proportional hazards models were used to evaluate associations. Tests for interaction with BMI and waist circumference were conducted. Results: No associations were observed between fructose, sucrose, sugary food consumption and combined incidence of adiposity-related cancers or the examined site-specific cancers. While total consumption of sugary beverages was not associated with site-specific cancer risk, higher intakes of fruit juice were associated with 58% increased prostate cancer risk(HR:1.58;95%CI:1.04-2.41) in multivariable-adjusted models. In exploratory stratified analyses, higher sugary beverage intakes increased overall adiposity-related cancer risk by 59% in participants with excessive central adiposity(HR:1.59;95%CI:1.01-2.50)(p-trend=0.057). Conclusions: In this cohort of American adults, higher sugary beverage consumption was associated with increased cancer risk among participants with central adiposity. Impact: These analyses suggest that avoiding sugary beverages represents a simple dietary modification that may be used as an effective cancer control strategy.
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Fructose metabolism and noncommunicable diseases: Recent findings and new research perspectives
Article
  • Feb 2018
Purpose of review: There is increasing concern that dietary fructose may contribute to the development of noncommunicable diseases. This review identifies major new findings related to fructose's physiological or adverse effects. Recent findings: Fructose is mainly processed in splanchnic organs (gut, liver, kidneys) to glucose, lactate, and fatty acids, which can then be oxidized in extrasplanchnic organs and tissues. There is growing evidence that splanchnic lactate production, linked to extrasplanchnic lactate metabolism, represents a major fructose disposal pathway during and after exercise. Chronic excess fructose intake can be directly responsible for an increase in intrahepatic fat concentration and for the development of hepatic, but not muscle insulin resistance. Although it has long been thought that fructose was exclusively metabolized in splanchnic organs, several recent reports provide indirect that some fructose may also be metabolized in extrasplanchnic cells, such as adipocytes, muscle, or brain cells; the quantity of fructose directly metabolized in extrasplanchnic cells, and its physiological consequences, remain however unknown. There is also growing evidence that endogenous fructose production from glucose occurs in humans and may have important physiological functions, but may also be associated with adverse health effects. Summary: Fructose is a physiological nutrient which, when consumed in excess, may have adverse metabolic effects, mainly in the liver (hepatic insulin resistance and fat storage). There is also concern that exogenous or endogenously produced fructose may be directly metabolized in extrasplanchnic cells in which it may exert adverse metabolic effects.
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Sugar in Infants, Children and Adolescents: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition
Article
The consumption of sugars, particularly sugar-sweetened beverages (SSBs; beverages or drinks that contain added caloric sweeteners (i.e. sucrose, high-fructose corn syrup, fruit-juice concentrates), in European children and adolescents exceeds current recommendations. This is of concern because there is no nutritional requirement for free sugars, and infants have an innate preference for sweet taste, which may be modified and reinforced by pre- and postnatal exposures. Sugar containing beverages/free sugars increase the risk for overweight/obesity and dental caries, can result in poor nutrient supply and reduced dietary diversity and may be associated with increased risk of type 2 diabetes mellitus, cardiovascular risk, and other health effects. The term 'free sugars', includes all monosaccharides/disaccharides added to foods/beverages by the manufacturer/cook/consumer, plus sugars naturally present in honey/syrups/unsweetened fruit juices and fruit juice concentrates. Sugar naturally present in intact fruits and lactose in amounts naturally present in human milk or infant formula, cow/goat milk and unsweetened milk products is not free sugar. Intakes of free sugars should be reduced and minimised with a desirable goal of <5% energy intake in children and adolescents aged ≥ 2-18 years. Intakes should probably be even lower in infants and toddlers <2 years. Healthy approaches to beverage and dietary consumption should be established in infancy, with the aim of preventing negative health effects in later childhood and adulthood. Sugar should preferably be consumed as part of a main meal and in a natural form as human milk, milk, unsweetened dairy products and fresh fruits, rather than as SSBs, fruit juices, smoothies and/or sweetened milk products. Free sugars in liquid form should be replaced by water or unsweetened milk drinks. National Authorities should adopt policies aimed at reducing the intake of free sugars in infants, children and adolescents. This may include education, improved labelling, restriction of advertising, introducing standards for kindergarten and school meals, and fiscal measures, depending on local circumstances.
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Infant feeding and growth trajectory patterns in childhood and body composition in young adulthood
Article
  • Jun 2017
Background: Growth patterns of breastfed and formula-fed infants may differ, with formula-fed infants growing more rapidly than breastfed infants into childhood and adulthood. Objective: Our objectives were to identify growth patterns and investigate early nutritional programming potential on growth patterns at 6 y and on body composition at 20 y. Design: The West Australian Pregnancy Cohort (Raine) Study and 3 European cohort studies (European Childhood Obesity Trial, Norwegian Human Milk Study, and Prevention of Coeliac Disease) that collaborate in the European Union–funded Early Nutrition project combined, harmonized, and pooled data on full breastfeeding, anthropometry, and body composition. Latent growth mixture modeling was applied to identify growth patterns among the 6708 individual growth trajectories. The association of full breastfeeding for <3 mo compared with ≥3 mo with the identified trajectory classes was assessed by logistic regression. Differences in body composition at 20 y among the identified trajectory classes were tested by analysis of variance. Results: Three body mass index (BMI; in kg/m²) trajectory patterns were identified and labeled as follows—class 1: persistent, accelerating, rapid growth (5%); class 2: early, nonpersistent, rapid growth (40%); and class 3: normative growth (55%). A shorter duration of full breastfeeding for <3 mo was associated with being in rapid-growth class 1 (OR: 2.66; 95% CI: 1.48, 4.79) and class 2 (OR: 1.96; 95% CI: 1.51, 2.55) rather than the normative-growth class 3 after adjustment for covariates. Both rapid-growth classes showed significant associations with body composition at 20 y (P < 0.0001). Conclusions: Full breastfeeding for <3 mo compared with ≥3 mo may be associated with rapid growth in early childhood and body composition in young adulthood. Rapid-growth patterns in early childhood could be a mediating link between infant feeding and long-term obesity risk.
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