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Advances in technology enabled the development of a web-based, pictorial FFQ to collect parent-report dietary intakes of 7-year-old children in the Growing Up in Singapore Towards healthy Outcomes study. This study aimed to compare intakes estimated from a paper-FFQ and a web-FFQ and examine the relative validity of both FFQ against 3-d diet records (3DDR). Ninety-two mothers reported food intakes of their 7-year-old child on a paper-FFQ, a web-FFQ and a 3DDR. A usability questionnaire collected participants’ feedback on the web-FFQ. Correlations and agreement in energy, nutrients and food groups intakes between the dietary assessments were evaluated using Pearson’s correlation, Lin’s concordance, Bland–Altman plots, Cohen’s κ and tertile classification. The paper- and web-FFQ had good correlations (≥ 0·50) and acceptable-good agreement (Lin’s concordance ≥ 0·30; Cohen’s κ ≥ 0·41; ≥ 50 % correct and ≤ 10 % misclassification into same or extreme tertiles). Compared with 3DDR, both FFQ showed poor agreement (< 0·30) in assessing absolute intakes except micronutrients (web-FFQ had acceptable-good agreement), but showed acceptable-good ability to classify children into tertiles (κ ≥ 0·21; ≥ 40 % and ≤ 15 % correct or misclassification). Bland–Altman plots suggest good agreement between web-FFQ and 3DDR in assessing micronutrients and several food groups. The web-FFQ was well-received, and majority (81 %) preferred the web-FFQ over the paper-FFQ. The newly developed web-FFQ produced intake estimates comparable to the paper-FFQ, has acceptable-good agreement with 3DDR in assessing absolute micronutrients intakes and has acceptable-good ability to classify children according to categories of intakes. The positive acceptance of the web-FFQ makes it a feasible tool for future dietary data collection.
There is limited data on the dietary patterns of 5-year-old children in Asia. The study examined childhood dietary patterns and their maternal and child correlates in a multi-ethnic Asian cohort. Based on caregiver-reported 1-month quantitative FFQ of 777 children from the Growing Up in Singapore Towards healthy Outcomes cohort, cluster analysis identified two mutually exclusive clusters. Children in the ‘Unhealthy’ cluster (43·9 %) consumed more fries, processed meat, biscuits and ice cream, and less fish, fruits and vegetables compared with those in the ‘Healthy’ cluster (56·1 %). Children with mothers of lower educational attainment had twice the odds of being assigned to the ‘Unhealthy’ cluster (adjusted OR (95 % CI) = 2·19 (95 % CI 1·49–3·24)). Children of Malay and Indian ethnicities had higher odds of being assigned to the ‘Unhealthy’ cluster (adjusted OR = 25·46 (95 % CI 15·40, 42·10) and 4·03 (95 % CI 2·68–6·06), respectively), relative to Chinese ethnicity. In conclusion, this study identified two dietary patterns in children, labelled as the ‘Unhealthy’ and ‘Healthy’ clusters. Mothers’ educational attainment and ethnicity were two correlates that were associated with the children’s assignments to the clusters. These findings can assist in informing health promotion programmes targeted at Asian children.
To identify a posteriori dietary patterns among women planning pregnancy and assess the reproducibility of these patterns in a subsample using two dietary assessment methods.
A semi-quantitative FFQ was administered to women enrolled in the Singapore PREconception Study of long-Term maternal and child Outcomes study. Dietary patterns from the FFQ were identified using exploratory factor analysis (EFA). In a subsample of women (n 289), 3-d food diaries (3DFD) were also completed and analysed. Reproducibility of the identified patterns was assessed using confirmatory factor analysis (CFA) in the subsample, and goodness of fit of the CFA models was examined using several fit indices. Subsequently, EFA was conducted in the subsample and dietary patterns of the FFQ and the 3DFD were compared.
1007 women planning pregnancy (18–45 years).
Three dietary patterns were identified from the FFQ: the ‘Fish, Poultry/Meat and Noodles’ pattern was characterised by higher intakes of fish, poultry/meat and noodles in soup; ‘Fast Food and Sweetened Beverages’ pattern was characterised by higher intakes of fast food, sweetened beverages and fried snacks; ‘Bread, Legumes and Dairy’ pattern was characterised by higher intakes of buns/ethnic breads, nuts/legumes and dairy products. The comparative fit indices from the CFA models were 0·79 and 0·34 for the FFQ and 3DFD of the subsample, respectively. In the subsample, three similar patterns were identified in the FFQ while only two for the 3DFD.
Dietary patterns from the FFQ are reproducible within this cohort, providing a basis for future investigations on diet and health outcomes.
Pro-vitamin A carotenoids namely α-, β-carotene and β-cryptoxanthin have potential roles in neurocognitive development, but current literature on these carotenoids mainly focused on preventing cognitive decline in the elderly. This study examined the associations of maternal plasma pro-vitamin A carotenoids concentrations with offspring cognitive development up to 54 months in the GUSTO mother-offspring cohort study.
Materials and Methods
Maternal plasma pro-vitamin A carotenoids concentrations at delivery were determined by ultra-performance liquid chromatography. At age 24 months, the Bayley Scales of Infant and Toddler Development (BSID-III) was used to assess children's development for the following domains: cognitive, receptive and expressive language, and fine and gross motor. At age 54 months, the Kaufman Brief Intelligence Test (KBIT-2) was used to assess children's verbal and non-verbal intelligence. Associations of maternal pro-vitamin A carotenoids with offspring cognitive development at each time point were examined in 419 mother-offspring pairs using linear regressions adjusted for confounders (e.g. maternal demographics, antenatal mental health and breastfeeding duration).
Median (IQR) maternal plasma concentrations (mg/L) were: α-carotene 0.052 (0.032–0.081), β-carotene 0.189 (0.134–0.286), and β-cryptoxanthin 0.199 (0.123–0.304). In 24 months old infants, higher maternal β-cryptoxanthin (per SD increment) were associated with higher scores in most of BSID-III domains: cognitive [β 0.18, (0.08, 0.28) SD], receptive language [β 0.17 (0.07, 0.27) SD], fine motor [β 0.16 (0.06, 0.27) SD], and gross motor [β 0.16 (0.06, 0.27) SD]. Additionally, a 1-SD increment in maternal β-carotene concentrations were associated with 0.16 SD higher scores in BSID-III cognitive domain (95%: 0.04, 0.28), which was attenuated after adjusting for breastfeeding duration. No significant associations were observed between maternal α-carotene concentrations and BSID-III in children at 24 months of age, or between maternal pro-vitamin A carotenoids and KBIT-2 in children at 54 months of age.
Our study provides novel data suggesting a role of maternal pro-vitamin A carotenoids, especially β-cryptoxanthin, in offspring early cognitive development. This adds support to the importance of consuming sufficient amounts of red- and orange-coloured fruit and vegetables (rich sources of β-cryptoxanthin and β-carotene) during pregnancy. Further studies are required in other mother-offspring cohort with larger sample sizes, and intervention trials to confirm an effect of pro-vitamin A carotenoids on neurocognitive development.
Recent evidence suggests that synchronizing eating-fasting schedules with body's circadian rhythms or day-night cycles is important for metabolic health. Besides food quantity and quality, food timing may contribute to weight regulation. However, it is unclear if this factor during pregnancy can influence maternal weight retention after childbirth. Using data from a prospective cohort, the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study, we examined the associations of maternal circadian eating pattern and diet quality in pregnancy with substantial postpartum weight retention (PPWR) at 18 months. We assessed 687 pregnant women for their circadian eating pattern (night-eating, night-fasting and eating episodes) and diet quality (Healthy Eating Index) based on information derived from 24-h dietary recall at 26–28 weeks’ gestation. Night-eating was defined as > 50% of total energy intake during 1900–0659 h; night-fasting duration was determined based on the longest fasting interval between consumption of a calorie-containing food or beverage during 1900–0659 h; eating episodes were defined as events that provided ≥ 210 kJ with time intervals between eating episodes of ≥ 15 min; diet quality was ascertained using the Healthy Eating Index which measures adherence to the Singapore dietary guidelines for pregnant women. PPWR was calculated by subtracting the weight at the first antenatal clinic visit from weight at 18-month postpartum. Substantial PPWR was defined as weight retention of 5 kg or more. Adjusting for maternal age, ethnicity, education, parity, night shift, mood, body mass index and total energy intake, multivariable binary logistic regression analysis was performed to estimate odds ratio (OR) of substantial PPWR in relation to circadian eating pattern and diet quality. Of 687 women, 110 (16%) had substantial PPWR. After confounders adjustment, night-eating (OR 1.95; 95% confidence interval 1.05, 3.62) and lower diet quality (1.91; 1.17, 3.10) were independently associated with higher odds of substantial PPWR. No associations with substantial PPWR were observed for night-fasting duration and number of eating episodes. During pregnancy, women with higher caloric consumption at night and lower diet quality had a greater likelihood of substantial PPWR. These findings suggest that aligning eating time with day-night cycles and adherence to dietary guidelines during pregnancy may help to alleviate overweight and obesity risk in postpartum life. There is a possibility that these eating patterns persist beyond pregnancy and pose implications for long-term obesity development. Further investigation on this area is required.
Maternal and child health are intrinsically linked. With accumulating evidence over the past two decades supporting the developmental origins of health and diseases hypothesis, it is now widely recognised that nutrition in the first 1000 d sets the foundation for long-term health. Maternal diet before, during and after pregnancy can influence the developmental pathways of the fetus and lead to health consequences later in life. While maternal and infant mortality rates have declined significantly in the past two decades, the growing burden of obesity and chronic non-communicable diseases in women of reproductive age and children is on a rapid rise worldwide, in developed and developing countries. A key contributory factor is malnutrition, which is a consequence of consuming poor quality diets. Suboptimal macronutrient balance and micronutrient inadequacies can lead to undesirable maternal body composition and metabolism, in turn influencing the health of the mother and leading to longer-term metabolic and cognitive health consequences in the infant. The GUSTO (Growing Up in Singapore Towards healthy Outcomes) study, a mother–offspring multi-ethnic cohort study in Singapore, has contributed to this body of evidence over the past 10 years. This review will illustrate how nutritional epidemiological research through a birth cohort has illuminated the importance and urgency of maternal and child nutrition and health in a modern, industrialised setting. It underscores the importance of a number of critical nutrients during pregnancy, in combination with healthy dietary patterns and appropriate meal timing, for optimal maternal and child health.
Consumption of sugar-sweetened beverages (SSB) by infants and young children are less explored in Asian populations. The Growing Up in Singapore Towards healthy Outcomes cohort study examined associations between SSB intake at 18 months and 5 years of age, with adiposity measures at 6 years of age. We studied Singaporean infants/children with SSB intake assessed by FFQ at 18 months of age (n 555) and 5 years of age (n 767). The median for SSB intakes is 28 (interquartile range 5·5–98) ml at 18 months of age and 111 (interquartile range 57–198) ml at 5 years of age. Association between SSB intake (100 ml/d increments and tertile categories) and adiposity measures (BMI standard deviation scores (sd units), sum of skinfolds (SSF)) and overweight/obesity status were examined using multivariable linear and Poisson regression models, respectively. After adjusting for confounders and additionally for energy intake, SSB intake at age 18 months were not significantly associated with later adiposity measures and overweight/obesity outcomes. In contrast, at age 5 years, SSB intake when modelled as 100 ml/d increments were associated with higher BMI by 0·09 (95 % CI 0·02, 0·16) sd units, higher SSF thickness by 0·68 (95 % CI 0·06, 1·44) mm and increased risk of overweight/obesity by 1·2 (95 % CI 1·07, 1·23) times at age 6 years. Trends were consistent with SSB intake modelled as categorical tertiles. In summary, SSB intake in young childhood is associated with higher risks of adiposity and overweight/obesity. Public health policies working to reduce SSB consumption need to focus on prevention programmes targeted at young children.
Evidence on long-term influences of maternal vitamin B12 deficiency or concentrations on infant cognition is limited. We examined associations between maternal plasma vitamin B12 and cognitive development in 24-month-old infants. Maternal plasma vitamin B12 concentrations were measured at 26–28 weeks’ gestation; infant cognitive development was assessed with the Bayley Scales of Infant and Toddler Development-III at 24 months, for 443 mother–infant pairs from the Growing Up in Singapore Towards Healthy Outcomes cohort. Linear regressions adjusted for key confounders examined associations of maternal vitamin B12 with cognitive, receptive and expressive language, fine and gross motor subscales. Co-occurrence of maternal vitamin B12 with folate or vitamin B6 insufficiencies on child’s cognition was explored. Average maternal plasma vitamin B12 concentrations was 220·5 ± 80·5 pmol/l; 15 % and 41 % of mothers were vitamin B12 deficient (<148 pmol/l) and insufficient (148–220·9 pmol/l), respectively. Infants of mothers with vitamin B12 deficiency had 0·42 (95 % CI −0·70, −0·14) sd lower cognitive scores, compared with infants of mothers with sufficient vitamin B12. Co-occurrence of maternal vitamins B12 and B6 insufficiencies was associated with 0·37 (95 % CI −0·69, −0·06) sd lower cognitive scores in infants compared with infants of mothers sufficient in both vitamins. No significant associations were observed with other subscales. Study findings suggest the possible need to ensure adequate vitamin B12 during pregnancy. The impact of co-occurrence of maternal B-vitamins insufficiencies on early cognitive development warrants further investigation.
Dietary intake of toddlers has been of growing interest due to its long-term consequences on health. However, previous works have focused largely on Caucasian populations and less is known about Asian toddlers. We aimed to validate a semi-quantitative FFQ designed to assess dietary intakes of 18-month-old toddlers in a multi-ethnic Asian cohort.
An FFQ of ninety-four food items, identified based on food records of 12-month-old GUSTO children, the Southampton Women’s Survey 12 Month Infancy Questionnaire and inputs from paediatric dietitians, was filled out two weeks before the 18th-month clinic visit. As the reference method, two non-consecutive 24 h recalls (24HR) were administered during and two weeks after the clinic visit. FFQ nutrient intakes were validated against averaged 24HR nutrient intakes, using the Wilcoxon signed-rank test, Spearman’s rank-order correlation, cross-classification and the Bland–Altman method.
Data from the Singapore Growing Up in Singapore Towards Healthy Outcomes (GUSTO) mother–offspring birth cohort.
Toddlers (n 188) aged 18 months.
Absolute nutrient intakes from the FFQ were significantly higher than from the 24HR, except for vitamin A. After energy adjustments, r range was 0·56–0·78 (macronutrients) and 0·40–0·54 (micronutrients). De-attenuation increased r to 0·58–0·96 and 0·45–0·65 for macro- and micronutrients, respectively. Of participants, ≥82·4 % (macronutrients) and ≥77·7 % (micronutrients) were classified in the same and adjacent quartiles. No clear systematic increase in intake differences with increasing mean intake was observed in Bland–Altman plots.
This FFQ can provide a satisfactory assessment of toddlers’ energy-adjusted nutrient intakes, as well as accurately rank them in a group.
Early life nutrition and feeding practices are important modifiable determinants of subsequent obesity, yet little is known about the circadian feeding pattern of 12-month-old infants. We aimed to describe the 24-h feeding patterns of 12-month-old infants and examine their associations with maternal and infant characteristics. Mothers from a prospective birth cohort study (n 431) reported dietary intakes of their 12-month-old infants and respective feeding times using 24-h dietary recall. Based on their feeding times, infants were classified into post-midnight (00.00–05.59 hours) and pre-midnight (06.00–23.59 hours) feeders. Mean daily energy intake was 3234 (sd 950) kJ (773 (sd 227) kcal), comprising 51·8 (sd 7·8) % carbohydrate, 33·9 (sd 7·2) % fat and 14·4 (sd 3·2) % protein. Mean hourly energy intake and proportion of infants fed were lower during post-midnight than pre-midnight hours. There were 251 (58·2 %) pre-midnight and 180 (41·8 %) post-midnight feeders. Post-midnight feeders consumed higher daily energy, carbohydrate, fat and protein intakes than pre-midnight feeders (all P<0·001). The difference in energy intake originated from energy content consumed during the post-midnight period. Majority (n 173) of post-midnight feeders consumed formula milk during the post-midnight period. Using multivariate logistic regression with confounder adjustment, exclusively breast-feeding during the first 6 months of life was negatively associated with post-midnight feeding at 12 months (adjusted OR 0·31; 95 % CI 0·11, 0·82). This study provides new insights into the circadian pattern of energy intake during infancy. Our findings indicated that the timing of feeding at 12 months was associated with daily energy and macronutrient intakes, and feeding mode during early infancy.
Faster eating rates are associated with increased energy intake, but little is known about the relationship between children’s eating rate, food intake and adiposity. We examined whether children who eat faster consume more energy and whether this is associated with higher weight status and adiposity. We hypothesised that eating rate mediates the relationship between child weight and ad libitum energy intake. Children (n 386) from the Growing Up in Singapore Towards Healthy Outcomes cohort participated in a video-recorded ad libitum lunch at 4·5 years to measure acute energy intake. Videos were coded for three eating-behaviours (bites, chews and swallows) to derive a measure of eating rate (g/min). BMI and anthropometric indices of adiposity were measured. A subset of children underwent MRI scanning (n 153) to measure abdominal subcutaneous and visceral adiposity. Children above/below the median eating rate were categorised as slower and faster eaters, and compared across body composition measures. There was a strong positive relationship between eating rate and energy intake (r 0·61, P<0·001) and a positive linear relationship between eating rate and children’s BMI status. Faster eaters consumed 75 % more energy content than slower eating children (Δ548 kJ (Δ131 kcal); 95 % CI 107·6, 154·4, P<0·001), and had higher whole-body (P<0·05) and subcutaneous abdominal adiposity (Δ118·3 cc; 95 % CI 24·0, 212·7, P=0·014). Mediation analysis showed that eating rate mediates the link between child weight and energy intake during a meal (b 13·59; 95 % CI 7·48, 21·83). Children who ate faster had higher energy intake, and this was associated with increased BMI z-score and adiposity.
Maternal vitamin D status during pregnancy has been associated with infant birth and postnatal growth outcomes, but reported findings have been inconsistent, especially in relation to postnatal growth and adiposity outcomes. In a mother–offspring cohort in Singapore, maternal plasma vitamin D was measured between 26 and 28 weeks of gestation, and anthropometric measurements were obtained from singleton offspring during the first 2 years of life with 3-month follow-up intervals to examine birth, growth and adiposity outcomes. Associations were analysed using multivariable linear regression. Of a total of 910 mothers, 13·2 % were vitamin D deficient (<50 nmol/l) and 26·5 % were insufficient (50–75 nmol/l). After adjustment for potential confounders and multiple testing, no statistically significant associations were observed between maternal vitamin D status and any of the birth outcomes – small for gestational age (OR 1·00; 95 % CI 0·56, 1·79) and pre-term birth (OR 1·16; 95 % CI 0·64, 2·11) – growth outcomes – weight-for-age z-scores, length-for-age z-scores, circumferences of the head, abdomen and mid-arm at birth or postnatally – and adiposity outcomes – BMI, and skinfold thickness (triceps, biceps and subscapular) at birth or postnatally. Maternal vitamin D status in pregnancy did not influence infant birth outcomes, postnatal growth and adiposity outcomes in this cohort, perhaps due to the low prevalence (1·6 % of the cohort) of severe maternal vitamin D deficiency (defined as of <30·0 nmol/l) in our population.
Little is known about the influences of maternal and infant correlates on maternal feeding beliefs and practices in the first 2 years of life, despite its important role in early obesogenic eating behaviours and weight gain.
Cross-sectional study using demographic data of mothers and infants obtained at 26–28 weeks of gestation, and postnatally from birth to 15 months, respectively. The Infant Feeding Questionnaire was administered at 15 months postpartum. The associations between maternal and infant characteristics with seven maternal feeding beliefs and practices subscales were evaluated using multivariate linear regression analysis.
Data obtained from the Singapore GUSTO (Growing Up in Singapore Towards healthy Outcomes) mother–offspring birth cohort.
Mothers and infants (n 1237).
Among other maternal correlates such as age, education, BMI, income and milk feeding practices, ethnicity was a consistent factor associated with six subscales, including concern about infant overeating/undereating and weight status, concern and awareness about infants’ hunger and satiety cues, social interaction during feeding and feeding an infant on schedule. Similarly, among infant correlates such as gender and birth order, infant body size gain (reflected by BMI Z-score change from 0 to 15 months) was significantly associated with all subscales except feeding an infant on schedule. Overall, maternal correlates had greater influence on all subscales compared with infant correlates except for the maternal concern about infant undereating or becoming underweight subscale.
The present study highlights that maternal feeding beliefs and practices can be influenced by both maternal correlates and infant correlates at 15 months of age.
Little is known about the influence of meal timing and energy consumption patterns throughout the day on glucose regulation during pregnancy. We examined the association of maternal feeding patterns with glycaemic levels among lean and overweight pregnant women. In a prospective cohort study in Singapore, maternal 24-h dietary recalls, fasting glucose (FG) and 2-h postprandial glucose (2HPPG) concentrations were measured at 26–28 weeks of gestation. Women (n 985) were classified into lean (BMI<23 kg/m2) or overweight (BMI≥23 kg/m2) groups. They were further categorised as predominantly daytime (pDT) or predominantly night-time (pNT) feeders according to consumption of greater proportion of energy content from 07.00 to 18.59 hours or from 19.00 to 06.59 hours, respectively. On stratification by weight status, lean pNT feeders were found to have higher FG than lean pDT feeders (4·36 (sd 0·38) v. 4·22 (sd 0·35) mmol/l; P=0·002); however, such differences were not observed between overweight pDT and pNT feeders (4·49 (sd 0·60) v. 4·46 (sd 0·45) mmol/l; P=0·717). Using multiple linear regression with confounder adjustment, pNT feeding was associated with higher FG in the lean group (β=0·16 mmol/l; 95 % CI 0·05, 0·26; P=0·003) but not in the overweight group (β=0·02 mmol/l; 95 % CI −0·17, 0·20; P=0·879). No significant association was found between maternal feeding pattern and 2HPPG in both the lean and the overweight groups. In conclusion, pNT feeding was associated with higher FG concentration in lean but not in overweight pregnant women, suggesting that there may be an adiposity-dependent effect of maternal feeding patterns on glucose tolerance during pregnancy.
The aims of this study were to develop and validate a prediction equation of fat-free mass (FFM) based on bioelectrical impedance analysis (BIA) and anthropometry using air-displacement plethysmography (ADP) as a reference in Asian neonates and to test the applicability of the prediction equations in an independent Western cohort. A total of 173 neonates at birth and 140 at two weeks of age were included. Multiple linear regression analysis was performed to develop the prediction equations in a two-third randomly selected subset and validated on the remaining one-third subset at each time point and in an independent Queensland cohort. FFM measured by ADP was the dependent variable, and anthropometric measures, sex and impedance quotient (L2/R50) were independent variables in the model. Accuracy of prediction equations was assessed using intra-class correlation and Bland–Altman analyses. L2/R50 was the significant predictor of FFM at week two but not at birth. Compared with the model using weight, sex and length, including L2/R50 slightly improved the prediction with a bias of 0·01 kg with 2 sd limits of agreement (LOA) (0·18, −0·20). Prediction explained 88·9 % of variation but not beyond that of anthropometry. Applying these equations to the Queensland cohort provided similar performance at the appropriate age. However, when the Queensland equations were applied to our cohort, the bias increased slightly but with similar LOA. BIA appears to have limited use in predicting FFM in the first few weeks of life compared with simple anthropometry in Asian populations. There is a need for population- and age-appropriate FFM prediction equations.
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