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J Pediatr. Author manuscript; available in PMC 2017 June 23. Published in final edited form as: J Pediatr. 2015 November ; 167(5): 952–953. doi:10.1016/j.jpeds.2015.08.024.
Infants’ Dietary Diversity Scores: United States Breastfed Infants Fall Short Bridget E. Young, PhD and Nancy F. Krebs, MD Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado
Author Manuscript
The World Health Organization (WHO) has devised and disseminated complementary feeding guidelines to meet the nutritional needs of older infants.1 This emphasis is warranted because the period of complementary feeding represents the largest proportion of the “first 1000 days,” and the experiences in this period lay the foundation for a child’s later eating preferences and patterns. The WHO guidelines, which particularly target breastfed infants in low resource settings, highlight the importance of dietary diversity, defined as the number of food groups consumed over a brief observation period. This focus on diversity is designed to assure adequacy of macro- and micro-nutrient intakes during a period when nutrient requirements are relatively high and breast milk alone no longer suffices. Better dietary diversity scores have been shown to predict better diet quality.2
Author Manuscript Author Manuscript
In contrast to international settings, in westernized populations, much of the emphasis over the last 3 decades on feeding children under 2 years has related to the timing of introduction of complementary foods, obtaining sufficient iron, limiting use of salt and sugar, and avoiding allergenic foods to prevent atopic disease.3 In recent years, timing and quality of food choices also have been examined in relation to obesity prevention, often with encouragement for more fruit and vegetable consumption, which has been reported to be low for many older infants and toddlers.4–6 Some research has highlighted the need to target select micronutrients, especially iron, during the complementary feeding period.4,7 However, in the US, the dominance of formula feeding in later infancy has contributed to a presumption of the adequacy (or even surplus) of nutrient intakes and to less explicit emphasis on dietary diversity. Ironically, for those infants who are fed according to universal recommendations (ie, to breastfeed through at least the first year of life), little acknowledgement has been made in feeding guidance that the quality of complementary foods is especially critical to avoid nutritional gaps and imbalances in these older breastfed infants.5 In this issue of The Journal, Woo et al compare the dietary diversity of older infants (6–12 months) across 3 international sites in the US, Mexico, and China.8 This study makes a significant contribution to the limited literature base on the quality of complementary feeding, and is unique in its comparison of 3 different urbanized cultural settings. An
Reprint requests: Nancy F. Krebs, MD, University of Colorado School of Medicine, Anschutz Medical Campus, 12700 E 19th Ave, Box C225, Aurora, CO, 80045. [email protected]. The authors declare no conflicts of interest.
Young and Krebs
Page 2
Author Manuscript
additional considerable strength of this study is the focus on primarily breastfed infants; the breastfeeding intensity in the population as a whole at 6 months was over 50%. As noted above, studies of complementary feeding often fail to distinguish between infants who are breastfed vs formula fed, even though their nutrient needs differ markedly. The focus of Woo et al on breastfed infants diminishes this large confounder. The large sample size and extensive follow-up allow for both quality insights into each population’s dietary patterns as well as valid comparisons between sites.
Author Manuscript
The striking differences in achievement of minimum dietary diversity (MDD) among the groups is clearly depicted in Figure 1 of the article,8 with the US site falling far (and significantly) below the diversity achieved by the Shanghai site. This difference was held in the cohort as a whole, regardless of whether the infants were grouped according to their consumption of less than or more than 50% of their foods as human milk. One of the likely contributing differences in the MDD scores among sites was the lack of eggs and dairy products in the US infants’ diets.
Author Manuscript
Complementary feeding recommendations from the American Academy of Pediatrics (AAP) to prevent atopic disease have changed dramatically over the last decade. In 2008, and reaffirmed in 2014, the AAP rescinded the recommendations to delay the introduction of eggs, nuts, peanuts, and fish until up to 3 years of age for prevention of allergy. Both the AAP and the American Academy of Allergy, Asthma, and Immunology have recently endorsed introduction of these allergenic foods along with other complementary foods between ages 4 and 6 months.4,9,10 Emerging evidence suggests that delayed introduction of the allergenic foods may increase risk of sensitization.10 Eggs and dairy products represent 2 of the 7 independent food groups that comprise the WHO MDD score indicator utilized by Woo et al. Because the change in the AAP’s longstanding recommendation to avoid eggs through the first year of life occurred mid-way through recruitment for this study, the new recommendation was likely not translated to participating mothers. The history of wavering recommendations on introduction of these foods in the US may have delayed the timing of dissemination of the new recommendations to parents in the primary care setting.
Author Manuscript
The fact that the US population had the lowest adherence to WHO recommendations for dietary diversity by age 12 months is both notable and disturbing, particularly in view of the US government’s 40-year history of dietary guidance for health promotion and disease prevention for the population over 2 years of age.3 The US cohort was especially limited in the meat/high protein food groups with only 7% of calories coming from high protein, animal source foods by 12 months of age, compared with 17% in the Shanghai cohort. This discrepancy is particularly concerning given that the US cohort actually had the highest rate of breastfeeding intensity by 12 months of age. These US infants likely would have had the highest dietary “dependence” on such nutrient dense foods as meats, to reach protein, iron, zinc, and other micronutrient intake recommendations. This difference is particularly evident in Figure 1, C in the article by Woo et al.8 In the US cohort, fewer than 30% of infants with high breastfeeding intensity achieved MDD by age 12 months. This observation may reflect both a cultural phenomenon and lack of provider awareness or communication of the biologically-driven dependence of breastfed infants on high-quality, nutrient-dense complementary foods. Although undoubtedly “breast is best,” if this principle is taken to
J Pediatr. Author manuscript; available in PMC 2017 June 23.
Young and Krebs
Page 3
Author Manuscript
extreme and introduction of nutrient dense complementary foods is delayed well past 6 months of age, the extensively breastfed older infant is at risk for suboptimal intakes of multiple micronutrients, anemia, growth faltering, and other poor health outcomes. This concern is corroborated by data from the Feeding Infants and Toddlers Study (FITS), which tracks the dietary intakes of US infants aged 4.5–24 months. This data has shown that approximately 12% and 6% of US infants 6–11 months of age do not meet estimated requirements for iron and zinc, respectively.11
Author Manuscript
Additional data from the FITS suggests that US infants are doing relatively well meeting requirements for energy, protein, and the majority of micronutrients.11 From 2002 to 2008, US infants showed improvement in dietary intake patterns by consuming more human milk, less infant cereal, and decreased salty snacks and desserts.6,12 Although data from FITS indicated the fruit and vegetable consumption remained lower than desired, the data presented by Woo et al indicate that predominantly breastfed infants from the US had similar or even higher fruit and vegetable intake compared with Mexican and Chinese counterparts. This discrepancy is likely driven by the fact that the FITS database includes a preponderance of formula fed infants, whereas the analysis by Woo et al focuses on breastfed infants.6,8
Author Manuscript
In conclusion, the analysis of dietary diversity presented in this issue of The Journal highlights that the cohort of US breastfed infants fell well behind other countries in ensuring that infants are introduced to and consuming a large variety of foods by 12 months. Because of the higher breastfeeding intensity among the US population at 12 months, this limited dietary diversity places a proportion of US children (especially the exclusively and extensively breastfed infant) at risk for nutrient deficiencies and suboptimal feeding behaviors during a formative period. The study supports the need for evidence-based dietary guidelines for infants from birth to 24 months, an initiative that is now underway to be part of the 2020 Dietary Guidelines for Americans.3 These findings also highlight the importance of tailored recommendations for breastfed vs formula fed infants to assure that dietary diversity and nutrient adequacy are achieved during the critical first postnatal year. Such early investments in promotion of healthy eating patterns will yield benefits for health well beyond the “1000-day” window.
Glossary
Author Manuscript
AAP
American Academy of Pediatrics
FITS
Feeding Infants and Toddlers Study
MDD
Minimum dietary diversity
WHO
World Health Organization
References 1. PAHO/WHO. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC: PAHO, WHO; 2003. 2. Moursi MM, Arimond M, Dewey KG, Treche S, Ruel MT, Delpeuch F. Dietary diversity is a good predictor of the micronutrient density of the diet of 6- to 23-month-old children in Madagascar. J Nutr. 2008; 138:2448–53. [PubMed: 19022971] J Pediatr. Author manuscript; available in PMC 2017 June 23.
Young and Krebs
Page 4
Author Manuscript Author Manuscript
3. Raiten DJ, Raghavan R, Porter A, Obbagy JE, Spahn JM. Executive summary: evaluating the evidence base to support the inclusion of infants and children from birth to 24 months of age in the Dietary Guidelines for Americans–“the B-24 Project”. Am J Clin Nutr. 2014; 99:663S–91S. [PubMed: 24500158] 4. American Academy of Pediatrics. Pediatric Nutrition Handbook. 7. Elk Grove Village, IL: American Academy of Pediatrics; 2014. 5. Young BE, Krebs NF. Complementary feeding: critical considerations to optimize growth, nutrition, and feeding behavior. Curr Pediatr Rep. 2013; 1:247–56. [PubMed: 25105082] 6. Siega-Riz AM, Deming DM, Reidy KC, Fox MK, Condon E, Briefel RR. Food consumption patterns of infants and toddlers: where are we now? J Am Diet Assoc. 2010; 110(12 Suppl):S38–51. [PubMed: 21092767] 7. Krebs NF, Sherlock LG, Westcott J, Culbertson D, Hambidge KM, Feazel LM, et al. Effects of different complementary feeding regimens on iron status and enteric microbiota in breastfed infants. J Pediatr. 2013; 163:416–23. [PubMed: 23452586] 8. Woo JG, Herbers PM, McMahon RJ, Davidson BS, Ruiz-Palacios GM, Peng YM, et al. Longitudinal development of infant complementary diet diversity in three international cohorts. J Pediatr. 2015; 167:969–74. [PubMed: 26227436] 9. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008; 121:183–91. [PubMed: 18166574] 10. Fleischer DM, Spergel JM, Assa’ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allerg Clin Immunol Pract. 2013; 1:29–36. 11. Butte NF, Fox MK, Briefel RR, Siega-Riz AM, Dwyer JT, Deming DM, et al. Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed dietary reference intakes. J Am Diet Assoc. 2010; 110(12 Suppl):S27–37. [PubMed: 21092766] 12. Siega-Riz AM, Kinlaw A, Deming DM, Reidy KC. New findings from the Feeding Infants and Toddlers Study 2008. Nestle Nutr Workshop Ser Pediatr Program. 2011; 68:83–100.
Author Manuscript Author Manuscript J Pediatr. Author manuscript; available in PMC 2017 June 23.
J Pediatr. Author manuscript; available in PMC 2017 June 23. Published in final edited form as: J Pediatr. 2015 November ; 167(5): 952–953. doi:10.1016/j.jpeds.2015.08.024.
Infants’ Dietary Diversity Scores: United States Breastfed Infants Fall Short Bridget E. Young, PhD and Nancy F. Krebs, MD Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, Colorado
Author Manuscript
The World Health Organization (WHO) has devised and disseminated complementary feeding guidelines to meet the nutritional needs of older infants.1 This emphasis is warranted because the period of complementary feeding represents the largest proportion of the “first 1000 days,” and the experiences in this period lay the foundation for a child’s later eating preferences and patterns. The WHO guidelines, which particularly target breastfed infants in low resource settings, highlight the importance of dietary diversity, defined as the number of food groups consumed over a brief observation period. This focus on diversity is designed to assure adequacy of macro- and micro-nutrient intakes during a period when nutrient requirements are relatively high and breast milk alone no longer suffices. Better dietary diversity scores have been shown to predict better diet quality.2
Author Manuscript Author Manuscript
In contrast to international settings, in westernized populations, much of the emphasis over the last 3 decades on feeding children under 2 years has related to the timing of introduction of complementary foods, obtaining sufficient iron, limiting use of salt and sugar, and avoiding allergenic foods to prevent atopic disease.3 In recent years, timing and quality of food choices also have been examined in relation to obesity prevention, often with encouragement for more fruit and vegetable consumption, which has been reported to be low for many older infants and toddlers.4–6 Some research has highlighted the need to target select micronutrients, especially iron, during the complementary feeding period.4,7 However, in the US, the dominance of formula feeding in later infancy has contributed to a presumption of the adequacy (or even surplus) of nutrient intakes and to less explicit emphasis on dietary diversity. Ironically, for those infants who are fed according to universal recommendations (ie, to breastfeed through at least the first year of life), little acknowledgement has been made in feeding guidance that the quality of complementary foods is especially critical to avoid nutritional gaps and imbalances in these older breastfed infants.5 In this issue of The Journal, Woo et al compare the dietary diversity of older infants (6–12 months) across 3 international sites in the US, Mexico, and China.8 This study makes a significant contribution to the limited literature base on the quality of complementary feeding, and is unique in its comparison of 3 different urbanized cultural settings. An
Reprint requests: Nancy F. Krebs, MD, University of Colorado School of Medicine, Anschutz Medical Campus, 12700 E 19th Ave, Box C225, Aurora, CO, 80045. [email protected]. The authors declare no conflicts of interest.
Young and Krebs
Page 2
Author Manuscript
additional considerable strength of this study is the focus on primarily breastfed infants; the breastfeeding intensity in the population as a whole at 6 months was over 50%. As noted above, studies of complementary feeding often fail to distinguish between infants who are breastfed vs formula fed, even though their nutrient needs differ markedly. The focus of Woo et al on breastfed infants diminishes this large confounder. The large sample size and extensive follow-up allow for both quality insights into each population’s dietary patterns as well as valid comparisons between sites.
Author Manuscript
The striking differences in achievement of minimum dietary diversity (MDD) among the groups is clearly depicted in Figure 1 of the article,8 with the US site falling far (and significantly) below the diversity achieved by the Shanghai site. This difference was held in the cohort as a whole, regardless of whether the infants were grouped according to their consumption of less than or more than 50% of their foods as human milk. One of the likely contributing differences in the MDD scores among sites was the lack of eggs and dairy products in the US infants’ diets.
Author Manuscript
Complementary feeding recommendations from the American Academy of Pediatrics (AAP) to prevent atopic disease have changed dramatically over the last decade. In 2008, and reaffirmed in 2014, the AAP rescinded the recommendations to delay the introduction of eggs, nuts, peanuts, and fish until up to 3 years of age for prevention of allergy. Both the AAP and the American Academy of Allergy, Asthma, and Immunology have recently endorsed introduction of these allergenic foods along with other complementary foods between ages 4 and 6 months.4,9,10 Emerging evidence suggests that delayed introduction of the allergenic foods may increase risk of sensitization.10 Eggs and dairy products represent 2 of the 7 independent food groups that comprise the WHO MDD score indicator utilized by Woo et al. Because the change in the AAP’s longstanding recommendation to avoid eggs through the first year of life occurred mid-way through recruitment for this study, the new recommendation was likely not translated to participating mothers. The history of wavering recommendations on introduction of these foods in the US may have delayed the timing of dissemination of the new recommendations to parents in the primary care setting.
Author Manuscript
The fact that the US population had the lowest adherence to WHO recommendations for dietary diversity by age 12 months is both notable and disturbing, particularly in view of the US government’s 40-year history of dietary guidance for health promotion and disease prevention for the population over 2 years of age.3 The US cohort was especially limited in the meat/high protein food groups with only 7% of calories coming from high protein, animal source foods by 12 months of age, compared with 17% in the Shanghai cohort. This discrepancy is particularly concerning given that the US cohort actually had the highest rate of breastfeeding intensity by 12 months of age. These US infants likely would have had the highest dietary “dependence” on such nutrient dense foods as meats, to reach protein, iron, zinc, and other micronutrient intake recommendations. This difference is particularly evident in Figure 1, C in the article by Woo et al.8 In the US cohort, fewer than 30% of infants with high breastfeeding intensity achieved MDD by age 12 months. This observation may reflect both a cultural phenomenon and lack of provider awareness or communication of the biologically-driven dependence of breastfed infants on high-quality, nutrient-dense complementary foods. Although undoubtedly “breast is best,” if this principle is taken to
J Pediatr. Author manuscript; available in PMC 2017 June 23.
Young and Krebs
Page 3
Author Manuscript
extreme and introduction of nutrient dense complementary foods is delayed well past 6 months of age, the extensively breastfed older infant is at risk for suboptimal intakes of multiple micronutrients, anemia, growth faltering, and other poor health outcomes. This concern is corroborated by data from the Feeding Infants and Toddlers Study (FITS), which tracks the dietary intakes of US infants aged 4.5–24 months. This data has shown that approximately 12% and 6% of US infants 6–11 months of age do not meet estimated requirements for iron and zinc, respectively.11
Author Manuscript
Additional data from the FITS suggests that US infants are doing relatively well meeting requirements for energy, protein, and the majority of micronutrients.11 From 2002 to 2008, US infants showed improvement in dietary intake patterns by consuming more human milk, less infant cereal, and decreased salty snacks and desserts.6,12 Although data from FITS indicated the fruit and vegetable consumption remained lower than desired, the data presented by Woo et al indicate that predominantly breastfed infants from the US had similar or even higher fruit and vegetable intake compared with Mexican and Chinese counterparts. This discrepancy is likely driven by the fact that the FITS database includes a preponderance of formula fed infants, whereas the analysis by Woo et al focuses on breastfed infants.6,8
Author Manuscript
In conclusion, the analysis of dietary diversity presented in this issue of The Journal highlights that the cohort of US breastfed infants fell well behind other countries in ensuring that infants are introduced to and consuming a large variety of foods by 12 months. Because of the higher breastfeeding intensity among the US population at 12 months, this limited dietary diversity places a proportion of US children (especially the exclusively and extensively breastfed infant) at risk for nutrient deficiencies and suboptimal feeding behaviors during a formative period. The study supports the need for evidence-based dietary guidelines for infants from birth to 24 months, an initiative that is now underway to be part of the 2020 Dietary Guidelines for Americans.3 These findings also highlight the importance of tailored recommendations for breastfed vs formula fed infants to assure that dietary diversity and nutrient adequacy are achieved during the critical first postnatal year. Such early investments in promotion of healthy eating patterns will yield benefits for health well beyond the “1000-day” window.
Glossary
Author Manuscript
AAP
American Academy of Pediatrics
FITS
Feeding Infants and Toddlers Study
MDD
Minimum dietary diversity
WHO
World Health Organization
References 1. PAHO/WHO. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC: PAHO, WHO; 2003. 2. Moursi MM, Arimond M, Dewey KG, Treche S, Ruel MT, Delpeuch F. Dietary diversity is a good predictor of the micronutrient density of the diet of 6- to 23-month-old children in Madagascar. J Nutr. 2008; 138:2448–53. [PubMed: 19022971] J Pediatr. Author manuscript; available in PMC 2017 June 23.
Young and Krebs
Page 4
Author Manuscript Author Manuscript
3. Raiten DJ, Raghavan R, Porter A, Obbagy JE, Spahn JM. Executive summary: evaluating the evidence base to support the inclusion of infants and children from birth to 24 months of age in the Dietary Guidelines for Americans–“the B-24 Project”. Am J Clin Nutr. 2014; 99:663S–91S. [PubMed: 24500158] 4. American Academy of Pediatrics. Pediatric Nutrition Handbook. 7. Elk Grove Village, IL: American Academy of Pediatrics; 2014. 5. Young BE, Krebs NF. Complementary feeding: critical considerations to optimize growth, nutrition, and feeding behavior. Curr Pediatr Rep. 2013; 1:247–56. [PubMed: 25105082] 6. Siega-Riz AM, Deming DM, Reidy KC, Fox MK, Condon E, Briefel RR. Food consumption patterns of infants and toddlers: where are we now? J Am Diet Assoc. 2010; 110(12 Suppl):S38–51. [PubMed: 21092767] 7. Krebs NF, Sherlock LG, Westcott J, Culbertson D, Hambidge KM, Feazel LM, et al. Effects of different complementary feeding regimens on iron status and enteric microbiota in breastfed infants. J Pediatr. 2013; 163:416–23. [PubMed: 23452586] 8. Woo JG, Herbers PM, McMahon RJ, Davidson BS, Ruiz-Palacios GM, Peng YM, et al. Longitudinal development of infant complementary diet diversity in three international cohorts. J Pediatr. 2015; 167:969–74. [PubMed: 26227436] 9. Greer FR, Sicherer SH, Burks AW. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008; 121:183–91. [PubMed: 18166574] 10. Fleischer DM, Spergel JM, Assa’ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allerg Clin Immunol Pract. 2013; 1:29–36. 11. Butte NF, Fox MK, Briefel RR, Siega-Riz AM, Dwyer JT, Deming DM, et al. Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed dietary reference intakes. J Am Diet Assoc. 2010; 110(12 Suppl):S27–37. [PubMed: 21092766] 12. Siega-Riz AM, Kinlaw A, Deming DM, Reidy KC. New findings from the Feeding Infants and Toddlers Study 2008. Nestle Nutr Workshop Ser Pediatr Program. 2011; 68:83–100.
Author Manuscript Author Manuscript J Pediatr. Author manuscript; available in PMC 2017 June 23.
