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Influence of early weaning practices on acceptance of new vegetables / foods in
3-4 and 6-7 year-old children in 2 European countries
Dr. Andrea Maier
2
Background
Breast- or formula-feeding influence later food acceptance – Short-term: Breastfeeding facilitates acceptance of new foods early in weaning
(Sullivan & Birch, 1994; Maier et al., 2008).
– Longer-term: Infants fed hydrolysed protein formula prefer acidic drinks at 4-5 yrs
(Mennella & Beauchamp, 2002).
Early sensory experiences influence acceptance of new foods – Short-term: High variety of vegetables at the start of weaning increases acceptance
of new foods over the next few days (Gerrish & Mennella, 2001) and over the next
few months (Maier et al., 2008)
– Longer-term: Variety for fruits in the first two years is linked to liking a variety of
fruits at school age (Skinner et al., 2002)
Repeated Exposure – At weaning, intake of a new food increases rapidly on repeated exposure (Birch et al.,
1998)
– In 7-month old infants, an initially disliked vegetable will be accepted if offered 7-8
times (Maier et al., 2007)
How long does this increased acceptance last ?
3 Andrea Maier NRC/FCI
Breast /
formula-
feeding
Breast /
formula-
feeding
Weaning
5 mo
Infants
7 mo
Variety
France Germany
Intervention study
Early Sensory Experience
Age
Experimental Design and Subjects
Birth
4 Andrea Maier NRC/FCI
Carrot 1st NF 2nd NF 3rd NF 4th NF
D1 D12 D23 1mo 2mo
No
Low
High
Breast /
formula-
feeding
Breast /
formula-
feeding
Infants
7 mo Birth
Variety
France Germany
Weaning
5 mo
Variety
75 72
= 147 infants
Intervention study
Early Sensory Experience
Age
Experimental Design and Subjects
5 Andrea Maier NRC/FCI
Breast /
formula-
feeding
Weaning
5 mo
Infants
7 mo Birth
Variety
France Germany
7 mo
Repeated Exposure
liked = carrot
Day 1 8 16
disliked
75 72
= 147 infants
Intervention study
Early Sensory Experience
Age
Experimental Design and Subjects
6 Andrea Maier NRC/FCI
Data Food frequency questionnaire
7-day intake diary (toddler)
Observation study
Follow-up 1
Breast /
formula-
feeding
Weaning
5 mo Weaning + 9 mo
15 mo
Infants Toddlers
7 mo Birth
Variety Repeated
exposure
France Germany
Birth
Follow up study 1
Children feeding
style
Follow-up study 1
Children’s
feeding style
Weaning + 9 mo
15 mo
61 44
= 105 children 75 72
= 147 infants
Intervention study
Early Sensory Experience
Experimental Design and Subjects
Key factors Breastfeeding
Variety
Age/weight
7 Andrea Maier NRC/FCI
Key factors Breastfeeding
Variety
Age/BMI
Mothers’/children’s characteristics: - Children pickiness
Observation study
Follow-up 1
Breast /
formula-
feeding
Weaning
5 mo Weaning + 9 mo
15 mo
Infants Toddlers
7 mo Birth
Variety Repeated
exposure
France Germany
Observation study
Follow-up 2
Follow up study 1
Children feeding
style
Follow-up study 2
Children + mother’s
feeding style
3-4 ys
61 44
= 105 children
59 38
= 97 children 75 72
= 147 infants
Intervention study
Early Sensory Experience
Age
Children
Experimental Design and Subjects
Data Food frequency questionnaire
7-day intake diary (child and mother)
8 Andrea Maier NRC/FCI
Intervention Study to measure: Variety Effect
Repeated Exposure Effect
Observation study
Follow-up 1
Breast /
formula-
feeding
Weaning
5 mo
Weaning + 9 mo
15 mo
Infants Toddlers
7 mo Birth
Variety Repeated
exposure
France Germany
Observation study
Follow-up 2
Follow-up study 3
Children + mother’s
feeding style
3-4 ys
47
= 79 children
75 72
= 147 infants
Intervention study
Early Sensory Experience
Experimental Design and Subjects
Children
Intervention Study
Follow-up 3
6-7 ys
Children
2011-2012
32
The study on experience with variety at weaning showed….
I am Benoist I am 4 month old
I am starting to eat my first vegetable
No
Low
High
I am Emma I am 5 month old
I am starting to eat my first vegetable
10
0
60
120
180
zuc-tom (day 12) peas (day 23) meat (day 43) fish (day 56)
Quanti
ty c
onsu
med (
g) Breastfed
Formula-fed
***
***
Vegetable Meat & Fish
*
Breastfeeding facilitated acceptance of new foods at weaning (Dijon and Aalen)
Breastfeeding effects on acceptance of new foods attenuate with time
Maier et al., 2008
***p<0.001
*p<0.05
11
0
60
120
180
zuc-tom (day 12) peas (day 23) meat (day 43) fish (day 56)
Quanti
ty c
onsu
med (
g) No
Low High
*** *** **
** Vegetable Meat & Fish
Experience with variety increased acceptance for the new foods for nearly 2 months
11
Frequency of changes (but not the number of foods offered) increased acceptance
Maier et al., 2008
***p<0.001
*p<0.05
12 Andrea Maier NRC/FCI
13
Initially refused vegetable is almost always accepted if offered 7-8 times
Days
Effects of repeated exposure on acceptance of an initially disliked vegetable – mean intake
Mean age: 7 month
Maier et al., 2007
Day 1 8 16
100
50
150
200
250
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Inta
ke
(g
m)
Initially rejected vegetable
Familiar (liked) vegetable
Disliked
Veg
Liked Veg = Carrot
Science Push to Communication
RESULTS of follow-up study at
3-4 years
I am Emma I am now 3 yrs old
I love potatoes
I am Benoist
I am now 4 yrs old I like loads of
different foods
Recall: Methods and Questionnaire
Food Frequency Questionnaire: – Content
• Food categories: Beverage, fruits, vegetables, cereals, starchy foods, protein-rich foods (meat, fish), mixed meal, dairy products, cheese, sweets
• For offered foods: Like (accepted) or Dislike (refused)?
• Child’s pickiness: Questionnaire asked to mothers with 9 items describing child’s pickiness (Carruth et al., 1998) measured using a 7-point Likert-type scale
– Output: at 15 months and at 3-4 years: • Liking: Number of vegetables (or foods) accepted by child
• Ratio: Number of vegetables (or foods) accepted by child / number offered by mother
Intake Diary
– Content: 7-day diary of child’s and mother’s food intake
– Output: Number of foods (and particularly of vegetables) eaten
ANOVA used to identify sources of variation
– Factors in the model:
• Main effects: breastfeeding, early variety experience, country
• Interactions: variety*breastfeeding, country* breastfeeding, country*variety
• Others: age, BMI/weight
17
Acceptance of Vegetables
Breastfeeding / Early Variety Effects
3-4 years
Variety Breast/
Formula
34 No 38 Fo
28 Low
59 Br 35 High
3-4yr
Error bars
represent
Standard Error of
the Mean (SEM)
Hypothesis 1: Infants who were breastfed or experienced “high variety” at weaning should accept more vegetables at 3-4 years.
Result 1: (Vegetables): Variety experience effect is significant but breastfeeding effect is only significant for relative acceptance (Ratio)
*p<0.05
Acceptance of ALL FOODS
Breastfeeding / Early Variety Effects
18 Andrea Maier NRC/FCI
3-4yr
Hypothesis 2: Infants who were breastfed and/or experienced “high variety” should accept more foods at 3-4 years.
19 Andrea Maier NRC/FCI
20 Andrea Maier NRC/FCI
21 Andrea Maier NRC/FCI
22
Fruit & Vegetable Intake
Was the recommended “5 fruit & veg a day” achieved by children in the
study ?
Result 3:
– Mean daily fruit & veg. intake is ~3 portions (including 100% fruit juices but not
potatoes)
– 7% of the children consumed at least 5 portions of fruit&veg
– Including potatoes increased average by 0.25
3-4yr
nb fruit+veg+juice /day
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7
% c
hild
ren
nb fruit+veg+juice /day
0
5
10
15
20
25
30
35
40
0 1 2 3 4 5 6 7
% c
hildre
nnb fruit+veg+juice /day
0
10
20
30
40
50
60
0 1 2 3 4 5 6 7
% c
hildre
n
GERMANY FRANCE
Average =
~3
Average =
~3
Average =
~3
% of veg eaten during the week:
potato (22), cucumber (21), tomato (20),
pepper (14), green salad (11), cauliflower
(5), mix veg (7)
% of veg eaten during the week:
potato (25), tomato (23), beans (13),
cucumber (8), zucchini (8),
peas (6), mix veg (17)
From 7 day
intake diary
23
Pickiness is not related to mother’s neophobia (r = 0.16)
– Correlation between mother’s neophobia and infant pickiness is not
significant
neophobia = f (pickiness)
-40
-30
-20
-10
0
10
20
30
-30 -20 -10 0 10 20Pickiness
Ne
op
ho
bia
r = 0.16
This hypothesis was not confirmed
Child’s Pickiness 3-4yr
Hypothesis 5: Maternal neophobia should influence the child’s pickiness.
24 Andrea Maier NRC/FCI
Aalen Dijon Test diff
N % N %
All mothers 40 100 22 100
Mothers still offering the initially disliked vegetable 27 68 21 95 p < 0.01
Children still eating the initially disliked vegetable:
-Out of all mothers
-Out of the mothers still offering
21
21
53
78
19
19
86
90
p < 0.01
3-4yr Impact on initially disliked vegetable
Repeated exposure
Hypothesis 5: Most children who were repeatedly offered an initially disliked vegetable and accepted it more readily should still consume and like it at 3-4 years
Result 5: Most children still liked the initially disliked vegetable at 3-4 yr.
Liking persisted better in Dijon than in Aalen
25
Breastfeeding / Early Variety Effects
Breastfed infants and infants experienced high variety liked more vegetables at 15 months and 3-4 years, suggesting that providing a wide range of vegetables early in weaning increases subsequent vegetable acceptance
Effects were stronger for vegetables than for all foods and attenuated over time
Variety offered in Dijon (France) is globally higher than in Aalen (Germany)
High variety group in Dijon, France liked significantly more foods than any of the other groups
Breastfeeding + Early Variety Effects Impact on BMI?
There was no evidence that liking more vegetables/foods increases the likelihood of over eating and hence of children being overweight.
Repeated Exposure
Acceptance following repeated exposure early in weaning to an initially disliked food seems to persist into early childhood
Key Findings from earlier follow-up
study 2 (3-4 years)
NOW: Follow-up study 3 -Intervention Study in 6-7 year old children
27
Recall Key Objectives of the study
Long term effects of breastfeeding and early variety experience (i.e., daily changes) during weaning practices on acceptance of new foods
Acceptance of a new vegetable (NEW)
Acceptance of an initially disliked vegetable (ID)
28
Experimental Protocol and
Session Procedure in LAB Enviroment
Experimental sessions at INRA, Dijon, France
and hospital at Aalen in Germany
Study run at the observation room (specific to run test with children)
Same conditions for each child
Meals were filmed
Children at similar hunger stage (didn’t eat for 2 hours before the test)
Test at lunch time (better than dinner because children were less tired)
29
4 parts for each experimental session
Part 1 : Acclimatizing of the child to the room, study
environment and the observer
Part 2 : Game played by the child and the observer:
Training to use the hedonic scale
Part 3 : Tasting Phase
Part 4 : Meal (Lunch) Phase
30
Part 2 : Game: Training the child
to the hedonic scale
7-point scale from “super bad” to “super good” (developed by Kroll, 1990)
– Translated into French and German and validated
– Close to the vocabulary of the child
– Experimenter names each label after the child tastes each vegetable (some children cannot read)
Explanation of each point of the scale (examples for food items)
Pre-test understanding of the scale with different foods (fish, fruits… but not vegetables)
31
Part 3 : Tasting Phase
A lunch tray composed of 6 vegetables (15 g/vegetable) is offered to
the child (randomized for each child)
– 4 vegetables (the same to all children)
– the ID (initially disliked vegetable or for children without an identified
initially dislike vegetable, one chosen on the basis of the consumption
questionnaire)
– a NEW (new vegetable) identified by the consumption questionnaire
Round lunch tray for the 6 vegetables
Acceptance (Liking) Measured for all 6 vegetables (NEW, Initially
disliked, V1, V2, V3, V4)
– By the mother
– By the child
– By the observer (after the meal on the basis of the film)
32
Part 3 : Appetizer (“Tasting”) Phase
Hedonic (Liking) Scale by the Child - Procedure
The child tastes each vegetable
The mother rates the liking of each vegetable by her child (before the
child’s response) on a 9 point hedonic scale.
The child rates each vegetable on the 7-point scale (taste 1 veg -
rate 1 veg, taste 2 veg – rate 2 veg, etc…) with the help of the
experimenter who will repeat for each vegetable the 7 points of the
hedonic scale
The experimenter then ranks the 6 vegetables from most to least
liked (as rated by the child)
The rank-order is then checked with the child
33
Part 4: Meal (Lunch) time
Free Choice between: – The child chooses what he wants to eat, the quantity, the order
– The same 6 vegetables (50 g for each vegetable) in small white plates
– Water
Questionnaires used – Child Eating Behaviour Questionnaire (CEBQ) (Wardle et al, 2001) .
Responsiveness to foods, enjoyment of food, satiety responsiveness, slowness in eating, fussiness, emotional overeating, emotional under-eating, and desire for drinks.
– General food frequency questionnaire for all food categories
– Food frequency questionnaire for all vegetables
– Intake Diary
RESULTS of follow-up study 3 at
6-7 years
I am Sandrine I am 6 yrs old
I love a variety of veggies
I am Raphael I am now 6 yrs old
And I like only
carrots
35
Acceptance of Vegetables - INTAKE
Breastfeeding / Early Variety Effects 6-7yr
Hypothesis 1: Children who were breastfed and/or experienced “high variety” (i.e., daily changes) early in weaning should accept more easily a new vegetable at 6-7 years.
Result 1: Both Breastfeeding & Variety experience effects were significant
Variety: p<0.001
Typemilk: p=0.01
6yrs years
Variety Breast/
Formula
24 No 28 Fo
25 Low
51 Br 30 High
36
Liking and Disliking of vegetables
French child eating all vegetables
offered – high variety group
37
German child eating all
vegetables offered – high variety group
38 Andrea Maier NRC/FCI
German child eating hardly any
vegetables offered – no variety group
39
40 Andrea Maier NRC/FCI
Acceptance of Vegetables – LIKING Mother
Breastfeeding / Early Variety Effects
Hypothesis 2: Children who were breastfed and/or experienced “high variety” (i.e.,daily changes) early in weaning should like the new vegetable more at 6 years.
Result 2: Variety experience effects were significant; Breastfeeding showed tendency but NS
Variety Effect Milk Feeding Effect
Variety: p=0.009; Typemilk: p=0.058
6-7yr
There was a
significant difference
between childrens’
liking scores for the
new vegetable
Children who
experienced High
variety liked the new
vegetable more than
did those who had
Low (p<0.001) or No
variety (p<0.001)
Acceptance of Vegetables – LIKING CHILD
Early Variety Effects
0
1
2
3
4
5
6
7
8
9
high low no
Group
Me
an
Lik
ing S
co
re fo
r N
ew
Ve
g (
Ch
ild)
country DE FR total
Hypothesis 3: Children who experienced “high variety” (i.e.,daily changes) early in weaning should like the new vegetable more at 6 years.
Result 3: Variety in weaning increases acceptance as compared to no/low variety
6-7yr
42
Impact on initially disliked vegetable
Repeated exposure
Hypothesis 4: Most children who were repeatedly offered an initially disliked vegetable and accepted it more readily should still consume and like it at 6-7 years Liking rating from child (liking score) and liking rating from mother (questionnaire)
Result 4: 54% of children still liked the initially disliked vegetable at 6-7 yrs .
65% of mothers rated that their child as still liking the initially disliked
vegetable at 6 yrs. Liking persisted better in Dijon than in Aalen.
Aalen Dijon
N % N %
Mothers Liking ratings (9 point scale) 29 56 19 79
Children still eating and liking the initially disliked
vegetable
29 52 19 58
6-7yr
43
Overall Results / Conclusions
Infants experienced high variety at weaning consumed and liked the new vegetables significantly in both countries, suggesting that providing a wide range of vegetables early in weaning can increase subsequent vegetable acceptance later in childhood
Breastfeeding facilitated acceptance of new vegetables later in childhood.
Acceptance following repeated exposure early in weaning to an initially disliked food seems to persist into later childhood (6-7 yrs)
These results suggest that early sensory experiences can influence food acceptance for several years
Results provide some eminently practical input for mothers concerning how they can improve vegetable acceptance by their children
44
Variety Effect
5 months
Possible influences on food preference
considered up to childhood
15 months 3 years 5 years
Intensity of Effect
Repeated
Exposure
Child/mother
interaction
Culture, family,
peers, and
personal
experience
10 years
Breastfeeding
Important period of learning!
But what exactly seems to be retained ?
abcdef What mothers & paediatricians say….
“It helped me a lot that we have started earlier introduction of many different vegetable and going
beyond carrot and potato. My child really likes many
vegetables although I do not eat a lot of healthy . “
foods. A German Mother
“I was pleased to be in the study and get to know more about good weaning practices and healthy
eating patterns in children. I would have not known otherwise. “
A French Mother
“This study is very important to show that early variety is key in infant feeding style and does not contradict with allergy guidelines – needs to be a
change in feeding recommendation.” FKE, German Institute of Child Paediatrician
“Seeing that Nestle supports and drives such a study is great . “
Paediatricians France
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Questions ??
