Nutrition Assessment Project: Sugar Intake Affects Social and Emotional Development in Infants and Toddlers

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Introduction

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Children’s brains are rapidly growing from birth to two years old and these new connections form patterns of food preferences and eating behaviors1.  Particularly the first 24 months after birth is when eating behaviors develop dramatically; children transition from consuming breast milk, or formula, exclusively for the first six months, to the introduction of “table foods” in infancy and toddlerhood1.  Table foods are fruits, vegetables, grains, meats, and eggs that are not pureed, rather they resemble adult consumed foods1.  Infancy and early toddlerhood is an important time for caregivers to introduce foods into the child’s diet that compose a healthy diet; doing so will increase the acceptance of such foods with various textures and flavors, including fruits and vegetables1.

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It is extremely important for the introduction of vegetables that are bitter tasting since humans are born with a preference for eating sweet foods2.  Sweet foods are seen as being “safe”, while bitter foods evolutionary signifies foods are rancid or toxic to the body; therefore it makes sense that humans have evolved to prefer sweet foods2.  This innate preference starts when the child is born and the first substance ingested is filled with sugar–milk; milk contains sugar lactose as the primary carbohydrate2,3.  Mature human milk contains over 7 grams of carbohydrates per 100 grams of breast milk4.  The first six months of life the infant should be exclusively fed human milk, or formula, and after that the recommended first foods to feed an infant is iron-fortified cereal; additionally, some caregivers choose to introduce juice at this time4,5.  Gerber recommends 100% juice as the choice of juice given to infants5, however they fail to address the sugar component of such substances.  Welch’s 100% Grape Fruit Juice contains 36 grams of sugar per 8 fluid ounces6; for reference, infants should be eating 95 grams of carbohydrates a day between seven and twelve months7.  If an infant is given a small glass of juice, they are consuming about one-third of the amount of carbohydrates they require for that day in one single drink.  It should be noted that Welch’s Regular Grape Juice had roughly the same sugar content as their 100% juice; therefore in both cases when sugar is added, and when it is not, infants are ingesting the same amount of sugar8. 

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It has been shown that infants who consume sugary beverages greater than or equal to three times a week have a two-fold times higher risk of being obese at age six9.  The American Academy of Pediatrics recommends no more than four to six ounces of fruit juice per day for a child ranging from one to six years old, yet by nineteen to twenty-four months the mean intake of children consuming 100% fruit juice is 9.5 ounces per day, with ten percent of toddlers consuming more than fourteen ounces a day10.  This high consumption of juice also means a high ingestion of sugar.

As children develop they are increasingly fed solid foods that are tailored to their specific developmental age.  In a study looking at foods given to infants and toddlers, it was found that 52% of infant ready-to-serve mixed grains and fruits contained more than one added sugar, and 44% of them contained more than 35% of its calories from sugar; on average these foods consisted of 9 grams of sugar per 100 grams of product11.  More concerning is that 88% of fruit-based snacks geared towards infants consisted of 60 grams of sugar per 100 grams of food11.  A substantial portion of infant- and toddler-foods contains sugar in the following primary forms: fruit juice concentrate, sugar, cane, syrup, and malt11. 

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High sugar consumption has been correlated with depression, anxiety, and cognitive decline43.  Consuming substances high in sugar can result in a “sugar crash” when blood sugar levels drop after a sudden peak shortly after consuming such foods43.  This has been linked to irritability, brain fog, fatigue, and mood swings43.  These substances can also influence neurotransmitters that help stabilize and regulate emotions43.  Sugar stimulates the release of neurotransmitter serotonin, which makes people feel happy43.  However, constant stimulation of this neurotransmitter can deplete the body’s small pool of serotonin and contribute to depression43.  Sugar-laden foods also cause inflammation in the body, further contributing to depressive symptoms43.  Animal research has demonstrated that consumption of a diet high in sugar can worsen depression and anxiety in adolescence by affecting neuronal pathways of stress44.

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Little to no research has been performed looking at the relationship between increased sugar consumption in infants and toddlers and how that affects their social and emotional development.  Given the research above, it is important to assess the sugar intake of infants and toddlers since it is often overlooked in infant and toddle-geared foods, and sugar can derail emotional regulation.  According to the Center for Disease, Control, and Prevention infants range from birth to one year old, and toddlers are one to three years old12.  Furthermore, the target population of this assessment project is infants and early toddlerhood in a low-income population; specifically looking at 1-2 years of age since research has shown a correlation of infant/toddler diets and obesity later in life9.  When looking at infant and toddler foods sold in low-income populations, 60% of such products have sucrose and/or high fructose corn syrup listed among the first five ingredients13, which is why a low-income sample would be assessed. 

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The assessments to be used are 24-hour dietary recalls and the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) completed with the primary caregiver.  Dietary recalls with the child’s primary caregiver will consist of asking the primary caregiver about all foods, beverages, substances, and supplements that infant or toddler consumed on the previous day14.  Ideally the dietary recalls would be performed numerous times, around 4-7 times, to accurately reflect diet variation.  These food records will be entered into a food composition database and analyzed for sugar consumption14.  This data will show the individual consumption of sugar amongst the participating infants and toddlers.  The other assessment that will be used is the BITSEA15, which is a parent report questionnaire of 42 items with a 5-10 minute completion rate that will screen the twelve to twenty-four month old for social-emotional and behavioral problems, as well as developmental delays15.  Developmental delays are incorporated in the BITSEA since these can aid in the regulation of social and emotional development.15 

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The data gathered from the dietary recalls and the BITSEA will allow researchers to establish a relationship between infant/toddler dietary intake of sugar and the child’s social-emotional behavior.  Previous studies have correlated sugar consumption in children with attention deficit disorder with hyperactivity, and altered behavior with children who do not have the disorder33.  Few, if any studies, have examined a similar phenomenon with sugar consumption for infants’ and toddlers’ social-emotional development.

 

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Assessment Methods

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            Twenty-four hour dietary recalls are commonly used to assess one’s diet and have proven valuable in capturing the variety amongst individual’s diets when multiple are completed16.  This type of assessment can be used across cultures, which is important since different cultures introduce various foods at infancy17.  For example, Mexican cultures introduce spicy foods in early childhood and gradually increase the spice strength with chili peppers17.  Jamaican caregivers often feed the infant fruit, such as banana, papaya, or apple with honey, before being served milk in the morning18.  Children are shown to adapt to cultural eating practices, and the variety of foods used in different cultures is important to observe when assessing infant and toddler diets17; different foods introduced may have more sugar than others.  Moreover, dietary recalls allows the interviewee, in this case the caregiver, to discuss what was consumed by him/herself or by others, and allows the inclusion of such cultural foods. 

Different ethnicities may reflect cultural differences in food consumption.  The National Center for Children in Poverty has looked at the different ethnicities among low-income children in the United States.  In 2015, 63% of Hispanic children lived in low-income families, as well as 63% Black children, 30% White children, and 29% Asian children19.  Different ethnicities often reflect varying cultures, and cultures can have diet implication as discussed above40,17,18.  Therefore using a dietary recalls would allow for culturally appropriate foods given to infants and toddlers among low-income families to be assessed for sugar consumption.

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Sugar is in a variety of different foods.  Naturally occurring sugars can be found in dairy products, vegetables, and fruits, whether they are fresh, dried or canned, and 100% fruit and/or vegetable juices20.  There are also foods that contain added sugars, including grain-based desserts, sugar-sweetened beverages, and, of course, sweets20.  This project intends to capture all of the sugar consumed by infants and toddlers in a variety of foods.  Conducting a 24-hour dietary recall allows for the inclusion of all foods consumed by the research participant to be specifically analyzed for their sugar component.

           

Children do not regulate what they eat until pre-school aged, consuming what the caregiver provides to them, which is usually the mother21.  Additionally, children cannot communicate clearly at infancy and toddler-aged22.  Babbling and select words are the average extent of a child at this age’s communication abilities22.  Therefore, interviewing the primary caregiver is the most plausible way to assess the consumption of the infant or toddler.

The National Cancer Institute (NCI) describes salient features of the dietary recall as being not affected by reactivity, since recalls are generally unannounced, and typically interviewer-administered, which prompts a more detailed review of the consumption data28.  The NCI further describes the use of a proxy, in this case the caregiver, to better communicate and conduct the dietary recall interview about the targeted subject(s)28.  The NCI assumes the dietary recall method is an unbiased instrument for measuring usual intake and a good way to model usual intake30.  Gerber, a company who is committed to producing high-quality baby food products based on scientific research, uses dietary recalls as a way to learn about the nutrient intakes among infants and toddlers by interviewing parents or caregivers29,41.   Furthermore, parents are often used as a proxy reporter of young children’s consumption due to children having low literacy levels, limited cognitive abilities, and their lack of ability to accurately estimate portion sizes38.

It should be noted that infants and toddlers are not the only people with low literacy levels.  There are between 40-44 million adults who are below basic literacy levels23.  People considered to be in Level 1 of literacy cannot identify a piece of information in a short news article, nor can they locate a time or place of a meeting on a form or respond to a survey23.  Many adults with low literacy proficiency live in poverty; in fact, 43% live in poverty24.  An advantage of using dietary recalls is that they do not require participants to have a high level of literacy given that they are administered verbally; moreover, these assessments are appropriate for low-literacy people25. However, due to dietary recalls involving verbal discussion between the caregiver and interviewee in this situation, interpreters will need to be present when interviewing caregivers that do not speak English.  Over 21% of households do not speak English as their native language in the United States26, and many low-income families speak Spanish27.  Therefore, an interpreter would be on site to facilitate dietary recall interviews with caregivers who cannot speak English.

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These dietary recalls will be entered into a nutrient database in order to quantify the subject’s sugar intake.  The data collected via this method is detailed, including the cooking practices, meal label and eating frequency, in addition to including all foods; this occurs due to dietary recalls being an open-ended process30.  Recalls use the Food and Nutrient Database for Dietary Studies (FNDDS) to evaluate nutrient intake data35.  The FNDDS provides nutrient values for food and beverage products that have been reported in the “What we Eat in America” study, which is the dietary component of the National Health and Nutrition Examination Survey35.  Therefore foods reported during interviews will most likely be included in the FNDDS.  FNDDS also allows for analysis of specific nutrient profiles of food35; the sugar component of foods consumed will be observed via coding dietary recalls and running sugar-nutrient analyses on the infants’ and toddlers’ diets.

 

The Brief Infant-Toddler Social and Emotional Assessment (BITSEA) is a standardized tool designed to assess the social and emotional difficulties in children aged 12 to about 35 months31.  It is a brief screening tool that looks at externalizing and internalizing problems, maladaptive behaviors, dysregulation, competencies and atypical behaviors31. It can be used in a variety of different settings, such as visits with at-risk children and families, pediatric primary care, and early intervention sites31.  Ultimately this evaluates a parent’s perception of a child’s behavior to guide further discussion, and it identifies where the child may need further assessment regarding his/her social or emotional issues31.

There are two scores that will be obtained and analyzed with the BITSEA: the Problem Total score and the Competence Total score31.  The Problem scale covers 32 items in the following areas: externalizing and internalizing problems, problems with emotional dysregulation, atypical behaviors, and maladaptive behaviors; externalizing problems include over-activity, aggression, and defiance, while internalizing problems refer to anxiety and depression of the infant31.  On the Competence scale there are 11 items that measure social-emotional capabilities like sustained attention, mastery motivation, pro-social peer relations, compliance, empathy, social relatedness, and imitation and play skills31.  The BITSEA score can be obtained by hand after obtaining both the Problem and Competence Total scores by adding up response ratings31.  For the Problem scale a score in the 25th percentile or higher is deemed as “possible problems” with the child’s behavior and development, and a child with a percentile rank of 15 or lower on the Competence scale are determined to have a “possible deficit/delay range”31.

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There are several reasons why identifying social and emotional issues are critical in young children32.  Diagnosis of common psychological disorders resulting in altered behavioral and emotional events occur early in life with children32.  These behavioral and emotional problems have been shown to persist into late toddlerhood and adolescence if not addressed32.  Also, young children with persistent externalizing and internalizing problems have greatest impairment, much problem with stability, and more use of mental health services as they grow and develop32.  Early identification and intervention of emotional and behavioral problems in infancy and toddlerhood have proven successful32.

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The BITSEA kit is inexpensive being $110.25 which includes the manual for assessment, 25 parent record forms, and 25 childcare provider record forms; more forms can be purchased separately as needed by the publisher.  The scoring assistant software is available for purchase for an addition one-time fee of $92.5031.  This screening tool is available in both English and Spanish, not requiring the expense of an interpreter to administer; additionally this is usually a self-administered test, not requiring the expense of training or employing the assistance of health care personnel to administer31.  A systematic review of existing assessment procedures for infant’s social and emotional development demonstrate assessment most likely are in the form of parent- or caregiver-report questionnaires32, like the BITSEA, which is another reason to assess the development of infants and toddlers with this assessment.

The BITSEA is a very reliable test.  Inter-rater reliability was examined looking between parents among 94 couples of parents of the same child31.  The inter-rater reliability fell in the “good” to “excellent” range according to the Intraclass Correlations Coefficients for both boys and girls31.  There is also good test re-test reliability according to the BITSEA manual31.  Administration of the BITSEA was conducted with 84 parents and a Pearson correlation f 0.92 for the Problem Total score and 0.82 for the Competence Total score was received between both parents31.  This assessment proves itself worthy to be used in this study examining the social and emotional development of infants and toddlers consuming varying sugar levels31.

 

The data analysis from the two assessments will be able to show a possible correlation between high sugar consumption and an increased risk of social and emotional dysregulation among infants and toddlers participating in the study.

 

 

Validation

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Dietary recalls can be validated using recovery biomarkers, such as doubly labeled water, as well as less obtrusive methods, like observing eating behaviors or using a weighed food record36.  Doubly labeled water (DLW) is the preferred validation method for dietary recalls if the study budget allows for this validation method; it is often considered the “gold standard” reference method for validating energy intake measurements and DLW has proven to be a more accurate estimate of consumption in younger age-groups 37,38.  The DLW technique consists of dosing the participant with an accurately measured quantity of DLW.  Urine samples are then collected over a predetermined period of time and these samples are analyzed to calculate total energy expenditure38.

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A systematic review compared various dietary assessments methods, including dietary recalls, to DLW38.  This study aimed to determine which dietary assessment method was an accurate method of consumption in children ranging in ages from birth to 18 years old38.  Fifteen cross-sectional studies were analyzed38.  The review concluded that dietary recalls were the most accurate measurement of intake in children four to eleven years old when compared to DLW38.  For younger children within the age ranges of six months to four years old using a caregiver as a proxy of recalling intake, weighed food records were the best estimate of energy intake38.  It should be noted that each study had less than 30 participants, which decreases the external validity of these conclusions38.  For the purposes of the current study, using the DLW assessment technique to validate sugar consumption will not tease apart the energy from sugar; therefore this validation method would not be the useful when observing the accuracy of the dietary recalls in search for sugar consumption intake.

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A less obtrusive method for validating dietary recalls if by using a weighed food record39.  Research has demonstrated caretakers provide information for dietary recalls that correlates highly with the child’s weighed food intake39.  A study was conducted with preschool aged children, and 96% of foods identified by parents via dietary recalls were correctly identified when compared to a weighed food record39.  Conclusions drawn from the study included that parents of children, especially of younger ages, are reliable reporters of the child’s in-home dietary intake39.  Although this population is slightly older than the population of interest for this assessment project, the findings show significant rationale for using parents as a proxy for dietary recalls in young children.  I propose using the same method with a younger population being this validation method is inexpensive, non-invasive, and the record will show exactly what foods were consumed, allowing the researcher to see the amount of sugar consumption of the child.  Training of parents or caregivers and the distribution of study-appropriate scales would occur before validation begins.  Due to weighed food records being tedious, incentives for the parent would be considered to increase study participation.

 

            The BITSEA has been validated using the Infant-Toddler Social and Emotional Assessment (ITSEA), which is a similar test to the BITSEA only longer.  There was high correlation when comparing the two methods Problem Total scores (r=0.57 to 0.77) and Competence Total scores for both boys and girls, r=0.77 and r=0.69, respectively31.  The BITSEA has also been validated with a number of other social and emotional assessment methods31.  The Ages and Stages Questionnaire: Social Emotional assessment had a 0.55 correlation to the BITSEA Problem total score and Competence score31.  Because the highest correlation was seen amongst the BITSEA and ITSEA, I would validate with the ITSEA.  This validation method is longer than the BITSEA, but it is still used for the same population of interest and has a similar format of conducting, just requires more time for its increased length.  Due to the increased time for this validation method of the BITSEA, incentives for the participants would be considered, if assessment project’s budget allows.

 

The assessments used, including validation methods, would not require blood drawn from the infant, which can often cause much distress for both child and caregiver42. 

 

Conducting dietary recalls and the BITSEA with caregivers will allow assessment of sugar consumption of their infant or child to see if there is a correlation between sugar consumption and social and emotional development.

 

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2. Birch, L., Savage, J. S., & Ventura, A. (2007). Influences on the Development of Children’s Eating Behaviours: From Infancy to Adolescence. Canadian Journal of Dietetic Practice and Research : A Publication of Dietitians of Canada = Revue Canadienne de La Pratique et de La Recherche En Dietetique : Une Publication Des Dietetistes Du Canada, 68(1), s1–s56.

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