Silvia Scaglioni

Lower protein in infant formula is associated with lower weight up to age 2 y: a randomized clinical trial

BACKGROUND Protein intake during infancy was associated with rapid early weight gain and later obesity in observational studies. OBJECTIVE The objective was to test the hypothesis that higher protein intake in infancy leads to more rapid length and weight gain in the first 2 y of life. DESIGN In a multicenter European study, 1138 healthy, formula-fed infants were randomly assigned to receive cow milk-based infant and follow-on formula with lower (1.77 and 2.2 g protein/100 kcal, respectively) or higher (2.9 and 4.4 g protein/100 kcal, respectively) protein contents for the first year. For comparison, 619 exclusively breastfed children were also followed. Weight, length, weight-for-length, and BMI were determined at inclusion and at 3, 6, 12, and 24 mo of age. The primary endpoints were length and weight at 24 mo of age, expressed as length and weight-for-length z scores based on the 2006 World Health Organization growth standards. RESULTS Six hundred thirty-six children in the lower (n = 313) and higher (n = 323) protein formula groups and 298 children in the breastfed group were followed until 24 mo. Length was not different between randomized groups at any time. At 24 mo, the weight-for-length z score of infants in the lower protein formula group was 0.20 (0.06, 0.34) lower than that of the higher protein group and did not differ from that of the breastfed reference group. CONCLUSIONS A higher protein content of infant formula is associated with higher weight in the first 2 y of life but has no effect on length. Lower protein intake in infancy might diminish the later risk of overweight and obesity. This trial was registered at clinicaltrials.gov as NCT00338689.

Influence of parental attitudes in the development of children eating behaviour.

The present paper is a review of available data on effects of parental feeding attitudes and styles on child nutritional behaviour. Food preferences develop from genetically determined predispositions to like sweet and salty flavours and to dislike bitter and sour tastes. There is evidence for existence of some innate, automatic mechanism that regulate appetite. However, from birth genetic predispositions are modified by experience. There are mechanisms of taste development: mere exposure, medicine effect, flavour learning, flavour nutrient learning. Parents play a pivotal role in the development of their childs food preferences and energy intake, with research indicating that certain child feeding practices, such as exerting excessive control over what and how much children eat, may contribute to childhood overweight. Mothers are of particular interest on childrens eating behaviour, as they have been shown to spend significantly more time than fathers in direct interactions with their children across several familial situations.A recent paper describes two primary aspects of control: restriction, which involves restricting childrens access to junk foods and restricting the total amount of food, and pressure, which involves pressuring children to eat healthy foods (usually fruits and vegetables) and pressuring to eat more in general. The results showed significant correlations between parent and child for reported nutritional behaviour like food intake, eating motivations, and body dis- and satisfaction. Parents create environments for children that may foster the development of healthy eating behaviours and weight, or that may promote overweight and aspects of disordered eating. In conclusion positive parental role model may be a better method for improving a childs diet than attempts at dietary control.

Can infant feeding choices modulate later obesity risk

Since the concept of lasting programming effects on disease risk in human adults by the action of hormones, metabolites, and neurotransmitters during sensitive periods of early development was proposed >3 decades ago, ample supporting evidence has evolved from epidemiologic and experimental studies and clinical trials. For example, numerous studies have reported programming effects of infant feeding choices on later obesity. Three meta-analyses of observational studies found that obesity risk at school age was reduced by 15-25% with early breastfeeding compared with formula feeding. We proposed that breastfeeding protects against later obesity by reducing the occurrence of high weight gain in infancy and that one causative factor is the lower protein content of human milk compared with most infant formula (the early protein hypothesis). We are testing this hypothesis in the European Childhood Obesity Project, a double-blind, randomized clinical trial that includes >1000 infants in 5 countries (Belgium, Germany, Italy, Poland, and Spain). We randomly assigned healthy infants who were born at term to receive for the first year infant formula and follow-on formula with higher or lower protein contents, respectively. The follow-up data obtained at age 2 y indicate that feeding formula with reduced protein content normalizes early growth relative to a breastfed reference group and the new World Health Organization growth standard, which may furnish a significant long-term protection against later obesity. We conclude that infant feeding practice has a high potential for long-term health effects, and the results obtained should stimulate the review of recommendations and policies for infant formula composition.

Early macronutrient intake and overweight at five years of age.

OBJECTIVE: To examine the influence of the macronutrient intake in early life on the development of overweight in children.DESIGN AND SUBJECTS: An ongoing longitudinal study including 147 randomized healthy children followed up from birth.MEASUREMENTS: Anthropometric parameters were measured at birth, 1 and 5 y of age. Dietary habits at the age of 1 and 5  were assessed by age-adjusted food-frequency questionnaires and 24 h recalls. Parents’ body mass index (BMI) was also recorded.RESULTS: Parental overweight was observed for 51% children. The prevalence of overweight at the age of 5 y was higher in children with than without parental overweight (37.3% vs 8.3%, P<0.0001). Five-year old overweight children had a higher percentage intake of proteins at the age of 1 y than non overweight children (22% vs 20%, P=0.024) and lower intake of carbohydrates (44% vs 47%, P=0.031). Multiple logistic analysis confirmed that protein intake at 1 y of age was associated with overweight at 5 y (P=0.05). In children born from overweight mothers, prevalence of overweight at the age of 5 y tended to be higher in bottle-fed than in breast-fed ones (62.5% vs 23.3%, P=0.08).CONCLUSION: Parental overweight is a major risk factor for childhood overweight in the first years of life, but an early high protein intake may also influence the development of adiposity.

Milk protein intake, the metabolic-endocrine response, and growth in infancy: data from a randomized clinical trial

BACKGROUND Protein intake in early infancy has been suggested to be an important risk factor for later obesity, but information on potential mechanisms is very limited. OBJECTIVE This study examined the influence of protein intake in infancy on serum amino acids, insulin, and the insulin-like growth factor I (IGF-I) axis and its possible relation to growth in the first 2 y of life. DESIGN In a multicenter European study, 1138 healthy, formula-fed infants were randomly assigned to receive cow-milk-based infant and follow-on formulas with lower protein (LP; 1.77 and 2.2 g protein/100 kcal) or higher protein (HP; 2.9 and 4.4 g protein/100 kcal) contents for the first year. Biochemical variables were measured at age 6 mo in 339 infants receiving LP formula and 333 infants receiving HP formula and in 237 breastfed infants. RESULTS Essential amino acids, especially branched-chain amino acids, IGF-I, and urinary C-peptide:creatinine ratio, were significantly (P < 0.001) higher in the HP group than in the LP group, whereas IGF-binding protein (IGF-BP) 2 was lower and IGF-BP3 did not differ significantly. The median IGF-I total serum concentration was 48.4 ng/mL (25th, 75th percentile: 27.2, 81.8 ng/mL) in the HP group and 34.7 ng/mL (17.7, 57.5 ng/mL) in the LP group; the urine C-peptide:creatinine ratios were 140.6 ng/mg (80.0, 203.8 ng/mg) and 107.3 ng/mg (65.2, 194.7 ng/mg), respectively. Most essential amino acids, IGF-I, C-peptide, and urea increased significantly in both the LP and HP groups compared with the breastfed group. Total IGF-I was significantly associated with growth until 6 mo but not thereafter. CONCLUSIONS HP intake stimulates the IGF-I axis and insulin release in infancy. IGF-I enhances growth during the first 6 mo of life. This trial was registered at clinicaltrials.gov as NCT00338689.

Feeding practices of infants through the first year of life in Italy

Aim: To investigate infant feeding practices through the first year of life in Italy, and to identify factors associated with the duration of breastfeeding and early introduction of solid foods. Methods: Structured phone interviews on feeding practices were conducted with 2450 Italian‐speaking mothers randomly selected among women who delivered a healthy‐term singleton infant in November 1999 in Italy. Interviews were performed 30 d after delivery and when the infants were aged 3, 6, 9 and 12 mo. Type of breastfeeding was classified according to the WHO criteria. Results: Breastfeeding started in 91.1% of infants. At the age of 6 and 12mo, respectively, 46.8% and 11.8% of the infants was still breastfed, 68.4% and 27.7% received formula, and 18.3% and 65.2% were given cows milk. Solids were introduced at the mean age of 4.3 mo (range 1.6–6.5 mo). Introduction of solids occurred before age 3 and 4 mo in 5.6% and 34.2% of infants, respectively. The first solids introduced were fruit (73.1%) and cereals (63.9%). The main factors (negatively) associated with the duration of breastfeeding were pacifier use (p > 0.0001), early introduction of formula (p > 0.0001), lower mothers age (p > 0.01) and early introduction of solids (p= 0.05). Factors (negatively) associated with the introduction of solids foods before the age of 3 mo were mother not having breastfed (p > 0.01), early introduction of formula (p > 0.01), lower infant bodyweight at the age of 1 mo (p= 0.05) and mother smoking (p= 0.05).

Introduction of Complementary Feeding in 5 European Countries

Objectives: Little is known about the practice of introducing complementary feeding across Europe. We aim at describing times of solid introduction in healthy infants in 5 European countries. Materials and Methods: Between October 2002 and June 2004, 1678 healthy term infants were either breast-fed (BF) for at least 4 months (n = 588) or study formula–fed (FF) (n = 1090) with different protein contents. Three-day-weighed food protocols were obtained at ages 1, 2, 3, 4, 5, 6, 7, 8, 9, and 12 completed months. Results: Solids were introduced earlier in FF infants (median 19 weeks, interquartile range 17–21) than BF infants (median 21 weeks, interquartile range 19–24). Some 37.2% of FF infants and 17.2% of BF infants received solid foods at 4 completed months, which is earlier than recommended in Europe. Solids had been introduced at 7 completed months in 99.3% of FF infants and 97.7% of BF infants, respectively. Belgium had the highest percentage of solids feeding in FF infants at 3 (15.8%) and 4 (55.6%) completed months, and in BF infants at 4 (43%) and 5 (84.8%) completed months. Multiple regression showed low maternal age, low education level, and maternal smoking to predictors an early introduction of solids at 3 and 4 completed months. Conclusions: Complementary feeding is introduced earlier than recommended in a sizeable number of infants, particularly among FF infants. Country- and population-specific approaches to adequately inform parents should be explored.

Breakfast: A Good Habit, not a Repetitive Custom

In developed countries, obesity is the most frequent nutritional disorder, and overweight and obesity prevalences have increased whilst physical activity and breakfast consumption have declined. There is growing scientific interest in the possible role of breakfast in weight control and in factors such as appetite control, dietary quality and reduced risk for chronic diseases. The current article reviews the literature and discusses how the breakfast ‘environment’ and the composition of breakfast meals might be improved, particularly in children, so as to maintain the breakfast eating habit throughout life. Recommendations are proposed to encourage children to keep eating breakfast and the nutritional composition of the ‘American breakfast’ and two types of Mediterranean ‘cereal breakfasts’ are compared. We also propose a new breakfast type for children and adolescents that is based on chocolate hazelnut spread within a mixed breakfast type in order to reinforce positive experiences.

How much protein is safe

BACKGROUND:Since breastfeeding and human milk seem to prevent, while high dietary proteins in the first 2 y of life seem to promote, later overweight, questions have been raised on the safe levels of proteins in the early years. How much protein (as a percentage of total calorie intake) is safe?METHODS:Revision of available data on the protein content of human milk, protein intake in the first 2 y of life and their association with body mass development.RESULTS:We should move from the figure of 7–8% in the 4-month exclusively breastfed infants up to the maximum acceptable levels of 14% in 12–24-month-old infants. When protein supply represents less than 6% and energy is limited, fully breastfed infants are likely to enter a status of negative nutrient balance. Over the limit of 14% energy from proteins in the 6–24 months period, some mechanisms may begin to operate, leading young children towards an early adiposity rebound and overweight development, beyond any genetic predisposition. Preliminary data seem to indicate a causal role for whole cows milk proteins.CONCLUSION:We suggest maintaining breastfeeding as long as possible, and, in case human milk is insufficient, to introduce infant formulas, appropriate for age, up to 18–24 months, in order to keep protein intakes in the safe range of 8–12% within a diet adequate in energy and balanced as far as macronutrients.

Dietary macronutrient intake during the first 10 years of life in a cohort of Italian children

Objective: To describe the longitudinal pattern of dietary energy and macronutrient intakes during the first 10 years of life in a sample of healthy Italian children. Patients and Methods: Sixty-one healthy children were followed from birth to 10 years of age. At 1, 5, 8, and 10 years of age, anthropometric measurements were taken and nutritional habits evaluated using a standardized food frequency questionnaire. Results: Compared to the Italian recommended dietary allowances, the childrens diet was high in protein at any age, high in lipids from age 5 onward, and high in calories at 5 years of age. At 1 year, mean (SD) protein, carbohydrate, and lipid intake, expressed as percentage of total energy, was 20% (3%), 48% (7%), and 34% (5%), respectively. Afterward, the corresponding mean value ranged around 14% to 15%, 57% to 60%, and 29% to 32%. The mean glycemic load and overall glycemic index ranged around 143 to 150 and 58 to 59, respectively. A difference between boys and girls was found in the longitudinal pattern for the intake of energy (P < 0.0001) and glycemic load (P < 0.0001). The individual longitudinal dietary pattern varied over time for the intake of total energy (P < 0.0001), any macronutrient (P < 0.0001), and overall glycemic index (P = 0.05). Conclusions: Although the amount of energy intake was in accordance with the Italian recommended dietary allowances, children consumed a high-protein and high-lipid diet. Early and continuous dietary education of children and parents may provide support for adequate nutritional habits throughout their childhood.