Role of Young Child Formulae and Supplements to Ensure Nutritional Adequacy in U.K. Young Children

nutrients Article Role of Young Child Formulae and Supplements to Ensure Nutritional Adequacy in U.K. Young Children Florent Vieux 1,*, Chloé M. C. Brouzes 2, Matthieu Maillot 1, André Briend 3,4, Régis Hankard 5, Anne Lluch 2and Nicole Darmon 6 1MS-Nutrition, Marseille 13005, France; [email protected] 2Danone Nutricia Research, Centre Daniel Carasso, RD128, Palaiseau 91767, France; [email protected] (C.M.C.B.); [email protected] (A.L.) 3Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, University of Tampere, Tampere 33101, Finland; [email protected] 4Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 30, Frederiksberg DK-1958, Denmark 5INSERM-U 1069, Univ. F. Rabelais, Tours F-37000, France; r[email protected] 6Aix Marseille Univ, INSERM, INRA, NORT, Marseille 13005, France; [email protected] *Correspondence: flor[email protected]; Tel.: +33-4-91-32-45-94 Received: 5 July 2016; Accepted: 26 August 2016; Published: 2 September 2016 Abstract: The European Food Safety Authority (EFSA) states that young child formulae (YCFs) “cannot be considered as a necessity to satisfy the nutritional requirements” of children aged 12–36 month s. This study quantifies the dietary changes needed to ensure nutritional adequacy in U.K. young children who consume YCFs and/or supplements and in those who do not. Dietary data from 1147 young children (aged 12–18 months) were used to identify, using linear programming models, the minimum changes needed to ensure nutritional adequacy: (i) by changing the quantities of foods initially consumed by each child (repertoire-foods); and (ii) by introducing new foods (non-repertoire-foods). Most of the children consumed neither YCFs, nor supplements (61.6%). Nutritional adequacy with repertoire-foods alone was ensured for only one child in this group, against 74.4% of the children consuming YCFs and supplement. When access to all foods was allowed, smaller food changes were required when YCFs and supplements were initially consumed than when they were not. In the total sample, the main dietary shifts needed to ensure nutritional adequacy were an increase in YCF and a decrease in cow’s milk (+226 g/day and − 181 g/day, respectively). Increasing YCF and supplement consumption was the shortest way to cover the EFSA nutrient requirements of U.K. children. Keywords: young child formula; supplements; individual diet modeling; diet; EFSA; U.K. 1. Introduction Between six and 24 months of age, the transition from an exclusively milk-based diet to a more diverse and adult-like diet has to cover growing nutrient and energy needs [ 1 ], while allowing the introduction of new textures and tastes [ 2 , 3 ]. During this period, diets may include different milks (e.g., breast milk, cow’s milks) or commercial formulae. Young child formulae (YCFs) are defined by the European Food Safety Authority Panel on Dietetic Products, Nutrition and Allergies (EFSA NDA Panel) as formulae intended for young children (12–36 months), including formulae based on protein sources other than cow’s milk [ 4 ]. Fortified with nutrients, such as essential fatty acids, iron and vitamin D, YCFs are designed to support the nutritional needs of young children as part of a balanced diet [5,6]. In 2013, the EFSA NDA Panel derived levels of nutrients considered adequate for most infants and young children by reviewing reference values set by the Scientific Committee for Foods in 1993 [ 7 ] Nutrients 2016,8, 539; doi:10.3390/nu8090539 www.mdpi.com/journal/nutrients Nutrients 2016,8, 539 2 of 17 in light of more recent recommendations [ 8 ]. The same report indicated that YCFs were “one of several means to increase n-3 PUFA, iron, vitamin D and iodine intakes in infants and young children living in Europe with inadequate or at risk of inadequate status of these nutrients”. The report also states that there is “no unique role of young-child formulae in satisfying the nutritional requirements of young children” [ 8 ]. The potential contribution of YCFs to the diets of young children in Europe thus needs to be clarified. There are several ways in which nutrient gaps in the child’s food diversification phase can be filled. These include changing dietary habits, consuming fortified foods and drinks (such as YCFs) and/or taking supplements. The choice will depend on local habits, individual acceptability, the cost and accessibility of products and the quality and quantity of the foods and drinks already being consumed. Linear programming can be used to support appropriate complementary feeding advice based on locally-available foods [ 3 , 9 – 11 ]. Taking into account individual food patterns and preferences, linear programming can translate specific nutrient recommendations into realistic individual food choices [ 12 ]. In the present study, individual diet modeling was used to determine the dietary changes needed to attain nutritional adequacy in U.K. young children who consume YCFs and/or supplements and in those who do not. A nutritionally-adequate diet is defined as a diet covering a set of nutrient recommendations, here the EFSA nutrient requirements for 12–18 months. The hypothesis was that the consumption of YCFs and/or supplements was not strictly necessary to ensure nutritional adequacy, although it might facilitate it. 2. Materials and Methods 2.1. Dietary Survey and Study Sample Dietary data were taken from the Diet and Nutrition Survey of Infants and Young Children (DNSIYC). This descriptive, cross-sectional, national survey conducted in 2011 provides detailed information on food and drink consumption on 4 consecutive days in a representative sample of 2683 infants and young children aged 4–18 months living in the U.K. The design, methodology and results of DNSIYC have been described elsewhere [ 13 ]. Full ethical approval for the initial survey was received from the Cambridgeshire 4 Research Ethics Committee on 18 January 2010. To target the age group for which YCFs are designed, only children older than 12 months (n= 1275) were selected for this study. Data from children with less than 4 food-diary days completed (n= 35), or with an energy intake above or below 3 standard deviations (SD) from the mean (gender separated; n= 9) [ 14 ], or who consumed specialized formulae for allergy or lactose intolerance (n= 61) were ignored. Given that changes in YCF powder consumption cannot be considered alone (as it has to be associated with water), records only mentioning powder YCFs (n= 23) were also excluded, yielding a final sample size of 1147 children. The sample was divided into four groups depending on the consumption of YCFs and/or supplement use: “no YCF, no Suppl”, “no YCF, Suppl”, “YCF, no Suppl” and “YCF & Suppl”. 2.2. Food Database Energy and nutrient contents of foods were taken from the Department of Health’s Nutrient Database [ 15 ] and from information provided by manufacturers. Following the classification of foods provided by the DNSIYC study report, individual food items consumed (n= 2215 food items) were divided into 11 food categories and 26 food subcategories (Table S1). Supplements had their own category and were mostly multi-vitamins, with 61% of them including vitamins A, C and D. YCFs were included in the dairy products category. Compared with the average consumed cow’s milk, the average consumed YCFs contained lower levels of proteins, iodine, vitamin B12, riboflavin and SFA and higher levels of vitamin E, vitamin C, n-3 and n-6 fatty acids, iron and vitamin D. Nutrients 2016,8, 539 3 of 17 2.3. Diet Quality Indicators The nutritional quality of each diet was assessed with the mean adequacy ratio [ 16 – 18 ], using 22 beneficial nutrients in the calculation and estimated as follows (1): Mean Adequacy Ratio =1 22 × 22 ∑ bn=1 intakebn RVbn ×100 (1) where intake bn is the daily intake of each beneficial nutrient bn and RV bn is the reference value (RV) for that nutrient. As previously proposed [ 19 , 20 ], each ratio (100 × intake bn /RV bn ) was truncated at 100, so that a high intake of one nutrient could not compensate for a low intake of another. The potential renal solute load (PRSL) refers to the solutes of dietary origin that must be excreted by the kidneys when not used for growing new tissues or lost through non-renal routes [ 21 – 23 ]. In this study, PRSL was estimated as described by Bonnet et al. [24], as follows (2): PRSL (mmol)=5.7 ×protein (g)+sodium (mg) 23 +potassium (mg) 39 +0.55 ×phosphorus (mg) 31 (2) A diet too high in proteins, sodium, chloride, potassium and phosphorus, with limited water intake, leads to a high PRSL. 2.4. Individual Diet Modeling with Linear Programming The principle of diet modeling and the parameters used for this study are described in detail in Appendix A. Briefly, the present modeling approach was used to design diets meeting a set of nutritional recommendations, while keeping as close as possible to the observed diet. Two linear programming models were run for each child. Both were intended to make nutritionally-adequate diets, but differed in the list of foods allowed. “Repertoire-only models” allowed the inclusion of only repertoire-foods, i.e., foods recorded in an individual child’s four-day food diary. “All-foods models” allowed both repertoire-foods and non-repertoire-foods, i.e., all foods recorded in at least one food diary of the survey. “Repertoire-only models” were used to assess the feasibility of designing nutritionally-adequate diets with repertoire-foods only [ 25 ], while “all-foods models” were used to identify the food changes needed to attain nutritional adequacy with minimum changes to the existing diet [ 12 ]. Nutritional adequacy was defined as providing all levels of nutrients considered adequate for most young children by the EFSA [8], referred to below as reference values (RVs). 2.5. Statistical Analysis 2.5.1. Comparison of Characteristics and Observed Diets in the 4 Groups of Children Differences between the four groups of children were tested using the chi-squared test or logistic regression for categorical variables and general linear models for continuous variables. 2.5.2. Diets Modeled with “Repertoire-Only Foods” The percentage of children for whom it was possible to model a nutritionally-adequate diet from their repertoire-foods only was calculated and compared across the four groups using the chi-squared test or logistic regression. A sensitivity analysis was performed to assess whether or not the feasibility of modeling adequate diets was impacted by removing the nutrient constraints corresponding to the least frequently attained RVs. 2.5.3. Diets Modeled with “All-Foods” For “all-foods models”, variations of food weights between observed and modeled diets (mean weights of foods to increase, mean weights of foods to decrease and mean weights of non-repertoire-foods added, in grams) were also compared between groups of children. To Nutrients 2016,8, 539 4 of 17 examine whether or not variations in food quantities were significantly different from 0, paired Student t-tests were run for the whole sample and within each group of children. To determine whether these variations were similar across groups, a general linear model analysis was performed. A specific analysis focused on the variation in YCF and cow’s milk quantities between modeled and observed diets. Two-by-two comparison tests with Bonferroni corrections assessed, when relevant, statistically-significant differences between two groups. The SAS system Version 9.4 (SAS Institute, Cary, NC, USA) was used for all analyses. When specified, analyses were adjusted for age and energy intake. A p-value < 0.01 was set as significant for the statistical tests. 3. Results 3.1. Description of the Sample Children’s characteristics for the whole sample and for each of the four groups are presented in Table 1. The largest group was “no YCF, no Suppl” (61.6%), followed by “YCF, no Suppl” (29.7%), “no YCF, Suppl” (4.9%) and “YCF & Suppl” (3.7%). Gender, height, weight and BMI did not differ significantly across the four groups. Only 7.4% of children were still being breastfed at the time of the survey. Children in the “no YCF, no Suppl” group were slightly older (14.6 months) and had a higher energy intake (983 kcal/day) than those in the “YCF, no Suppl” group (13.8 months and 938 kcal/day). Diet quality indicators significantly differed between groups, with the lowest mean adequacy ratio and the highest PRSL observed in the “no YCF, no Suppl” group. The mean adequacy ratio was higher for children consuming supplements (92.5%), YCFs (94.8%) or both (97.5%) than for children in the “no YCF, no Suppl” group (88.6%). Table 1. Gender, age, height, weight, BMI and diet characteristics (reported breastfeeding, energy intake and nutritional quality indicators) in the four groups of children *. All No YCF, No Suppl a No YCF, Suppl a YCF, No Suppl a YCF & Suppl ap* Number of children (n)1147 707 56 341 43 Gender (%) Male 50.9 51.6 53.6 49.6 46.5 0.83 Female 49.1 48.4 46.4 50.4 53.5 Child's age (in months) <0.001 1 Mean 14.3 14.6 14.5 13.8 14.4 SD 1.62 1.58 1.56 1.61 1.60 Anthropometric data Infant height (cm) Mean 79.7 79.8 79.8 79.5 79.2 0.31 SD 3.46 3.50 3.35 3.24 4.52 nmissing 145 89 6 45 5 Infant weight (kg) Mean 10.9 11.0 10.7 10.9 10.6 0.12 SD 1.31 1.33 1.22 1.29 1.31 Number of missing values 42 27 2 10 3 BMI (kg/m2) Mean 17.1 17.2 16.7 17.1 16.8 0.16 SD 1.56 1.54 1.54 1.62 1.52 Number of missing values 158 96 7 49 6 Reported breastfeeding (%) Still breastfeeding 7.41 8.49 14.3 4.40 4.65 0.02 No longer breastfeeding 68.3 64.6 67.9 74.8 79.1 0.004 1 Never breastfed 24.1 26.7 17.9 20.8 16.3 0.06 Nutrients 2016,8, 539 5 of 17 Table 1. Cont. All No YCF, No Suppl a No YCF, Suppl a YCF, No Suppl a YCF & Suppl ap* Number of missing values 1 1 0 0 0 Energy (kcal/day) Mean 968 983 972 938 950 0.005 1 SD 196 199 228 183 166 Diet quality indicators Mean adequacy ratio (%) Mean 90.9 88.6 92.5 94.8 97.5 <0.001 1,2,3,4,5 SD 6.05 5.34 4.73 5.28 2.16 PRSL (mmol) Mean 312 332 328 272 277 <0.001 1,3,5,6 SD 78.8 76.2 87.3 66.6 66.9 a “no YCF, no Suppl” refers to children who did not consume either young child formulae (YCFs) or supplements during the four days of dietary record; “no YCF, Suppl” refers to those who did not consume YCFs, but who consumed supplements; “YCF, no Suppl” refers to those who consumed YCFs, but not supplements; “YCF & Suppl” refers to those who consumed both YCFs and supplements. * Statistical significance of the differences across the four groups of children. General linear model tests were run for all tests except “reported breastfeeding”, which was tested using the chi-squared test. 1 Indicates a significant difference between “no YCF, no Suppl” and “YCF, no Suppl”; 2 indicates a significant difference between “no YCF, no Suppl” and “no YCF, Suppl”; 3 indicates a significant difference between “no YCF, no Suppl” and “YCF & Suppl”; 4 indicates a significant difference between “YCF & Suppl” and “YCF, no Suppl”; 5 indicates a significant difference between “YCF & Suppl” and “No YCF, Suppl”; 6 indicates a significant difference between “YCF, no Suppl” and “no YCF, Suppl”. 3.2. Nutrients in Observed Diets The RVs and the percentage of observed diets attaining each nutrient RV for the whole sample and across the four groups of children are presented in Table 2. Observed diets rarely reached the RV level for vitamin D (7.9%), fiber (20.6%), iron (28.2%), water (28.2%) and vitamin E (29.2%). For these nutrients and for most other nutrients, the percentage ranged significantly across groups. It was generally higher for children consuming YCFs and/or supplements. Almost all children’s diets (99.9%) supplied protein in sufficient amounts. Fewer than half of the children had fat intakes within the recommended range. The fat intakes of those not meeting the recommendation were mainly below the minimal recommended level. This was critical in the “YCF & Suppl” group, in which 74% (i.e., 100–26) of the children consumed less than 35% of their energy from fats. 3.3. Feasibility of Repertoire-Only Models When only repertoire-foods were allowed, achieving EFSA nutritional adequacy was almost impossible for children in the “no YCF, no Suppl” group (Figure 1). The percentage of feasibility in this group was 0.1% (only one child out of 707). By contrast, feasibility reached 74.4% in the “YCF & Suppl” group. As vitamin D was the least frequently attained RVs in the observed diets, it was removed from the sensitivity analysis. The percentage of feasibility consequently increased for each group of children. Nutrients 2016,8, 539 6 of 17 Table 2. Reference values for each nutrient, percentage of observed diets attaining each reference value (RV) for the whole sample and across the four groups of children a. Nutrients Reference Value All (n= 1147) No YCF, No Suppl a No YCF, Suppl a YCF, No Suppl aYCF & Suppl ap-Unadjusted Analysis * p-Adjusted Analysis ** (n= 707) (n= 56) (n= 341) (n= 43) Macronutrients Water (H2O) ≥1100 mL/day b28.2 29.3 26.8 25.2 37.2 0.30 0.18 Proteins ≥1.14 g/kg body weight c99.9 100 100 99.7 100 0.50 *** 0.99 *** Carbohydrates 45%–60% energy d82.0 80.9 83.9 85.6 69.8 0.04 0.03 Carbohydrates min ≥45% of energy d90.0 86.3 87.5 97.1 97.7 <0.001 <0.0001 Carbohydrates max ≤60% of energy d92.0 94.6 96.4 88.6 72.1 <0.001 <0.0001 Fiber >10 g/day b20.6 15.3 10.7 30.8 39.5 <0.001 <0.001 Total fats 35%–40% energy d43.7 45.0 51.8 41.9 25.6 0.04 0.08 Total fats min ≥35% of energy d59.0 62.9 66.1 54.0 25.6 <0.001 <0.001 Total fats max ≤40% of energy d84.7 82.0 85.7 88.0 100 0.002 0.009 n-6 FA ≥3% energy f86.7 81.2 80.4 97.6 100.0 <0.001 <0.001 *** n-3 FA ≥0.5% energy f77.0 68.3 69.6 93.5 97.7 <0.001 <0.001 Vitamins Thiamin ≥0.5 mg/day c95.1 94.1 98.2 96.2 100.0 0.12 *** 0.03 *** Riboflavin ≥0.8 mg/day b93.1 93.5 96.4 90.9 100.0 0.08 *** 0.37 *** Niacin ≥ 9 mg nicotinic acid eq/day c97.3 98.6 98.2 94.4 97.7 0.001 *** 0.007 Pantothenic acid ≥4 mg/day b77.3 83.0 89.3 63.3 79.1 <0.001 <0.001 Vitamin B6 min ≥0.7 mg/day c86.9 93.5 96.4 71.5 88.4 <0.001 <0.001 Vitamin B6 max ≤5 mg/day e100.0 100.0 100.0 100.0 100.0 N.A. N.A. Biotin ≥20 µg/day b60.1 66.0 67.9 48.4 44.2 <0.001 <0.001 Folates ≥100 µg/day c88.7 87.1 92.9 90.0 100.0 0.03 0.02 *** Vitamin B12 ≥0.9 µg/day c99.6 99.6 100.0 99.7 100.0 0.92 *** 0.91 *** Vitamin C ≥20 mg/day c95.9 93.3 100.0 100.0 100.0 <0.001 *** 0.99 *** Vitamin D min ≥10 µg/day b7.9 0 16.1 15.5 67.4 <0.001 *** <0.001 *** Vitamin D max ≤50 µg/day e100.0 100.0 100.0 100.0 100.0 N.A. N.A. Vitamin E ≥6 mg tocopherol eq/d b29.2 5.7 33.9 70.4 83.7 <0.001 <0.001 Retinol equivalent ≥400 µg /day b79.2 70.9 94.6 92.1 95.3 <0.001 <0.001 Retinol ≤800 µg/day e98.5 99.6 89.3 99.4 86.0 <0.001 *** <0.001 *** Minerals Sodium ≥170 mg/day b99.8 100.0 100.0 99.4 100.0 0.19 *** 0.97 *** Potassium ≥800 mg/day c97.4 98.2 98.2 95.3 100.0 0.03 *** 0.05 *** Magnesium ≥85 mg/day c93.3 95.3 94.6 89.1 90.7 0.002 *** 0.001 *** Chloride ≥270 mg/day b100.0 100.0 100.0 100.0 100.0 N.A. N.A. Calcium ≥600 mg/day c78.2 82.6 76.8 69.2 79.1 <0.001 <0.001 Phosphorus ≥460 mg/day c94.2 96.0 96.4 90.0 93.0 0.001 *** 0.002 *** Nutrients 2016,8, 539 7 of 17 Table 2. Cont. Nutrients Reference Value All (n= 1147) No YCF, No Suppl a No YCF, Suppl a YCF, No Suppl aYCF & Suppl ap-Unadjusted Analysis * p-Adjusted Analysis ** (n= 707) (n= 56) (n= 341) (n= 43) Iodine min ≥90 µg/day b,c 88.1 91.65 91.1 81.2 79.1 <0.001 <0.001 Iodine max ≤200 µg/day e62.1 49.1 50.0 87.7 88.4 <0.001 <0.001 Iron ≥8 mg/day b,c 28.2 9.9 19.6 61.0 79.1 <0.001 <0.001 Copper min ≥0.4 mg/day c71.9 64.9 69.6 84.2 93.0 <0.001 <0.001 Copper max ≤1 mg/day e99.5 99.9 98.2 98.8 100.0 0.08 *** 0.13 *** Zinc min ≥4 mg/day c91.6 89.1 89.3 96.2 100.0 <0.001 *** <0.001 *** Zinc max ≤7 mg/day e91.2 97.2 91.1 81.8 67.4 <0.001 *** <0.001 *** Selenium min ≥20 µg/day c59.4 55.3 60.7 66.3 69.8 0.004 <0.001 Selenium max ≤60 µg/day e100.0 100.0 100.0 100.0 100.0 N.A. N.A. Manganese ≥0.5 mg/day b96.4 97.0 100.0 94.4 97. 7 0.07 *** 0.94 *** a “no YCF, no Suppl” refers to children who did not consume either YCFs or supplements during the four days of dietary record; “no YCF, Suppl” refers to those who did not consume YCFs, but who consumed supplements; “YCF, no Suppl” refers to those who consumed YCFs, but not supplements; “YCF & Suppl” refers to those who consumed both YCFs and supplements. b Requirement derived by the EFSA from an adequate intake. c Requirement derived by the EFSA from a Population Reference Intake. d Requirement derived by the EFSA from a reference intake range. e Requirement derived by the EFSA from a tolerable upper intake level. f Based on Nordic recommendations [ 26 ]. * Unadjusted analysis, using a chi-squared test for the percentage of observed diets attaining each RV; ** analysis adjusted for age and energy intake, using logistic regression for the percentage of observed diets attaining each RV; *** p-value to be interpreted with caution due to the presence of 100% or 0% in one group. Nutrients 2016,8, 539 8 of 17 Nutrients 2016,8,5398of17   Figure1.Percentageofchildrenforwhomitwasfeasibletomodelanutritionally‐adequatedietwith theirrepertoire‐foodsonlyforthewholesampleandacrossthefourgroupsofchildrenwithand withoutvitaminDconstraint a,b . a Significant(p<0.01)associationswereobservedbetweenthe percentageoffeasibilityandgroupsofchildrenwhateverthemodel(i.e.,withandwithoutthe vitaminDconstraint),withandwithoutadjustmentsforageandenergy(usinglogisticregression andchi‐squaredtests,respectively); b “noYCF,noSuppl”referstochildrenwhodidnotconsume eitherYCFsorsupplementsduringthefourdaysofdietaryrecord;“noYCF,Suppl”referstothose whodidnotconsumeYCFs,butwhoconsumedsupplements;“YCF,noSuppl”referstothosewho consumedYCFs,butnotsupplements;“YCF&Suppl”referstothosewhoconsumedbothYCFs andsupplements. 3.4.DietaryChangesInducedbytheAll‐FoodsModels Whenaccesstoallfoods(i.e.,bothrepertoire‐andnon‐repertoire‐foods)wasallowed,itwas possibletomodelanutritionally‐adequatedietforeachchild(i.e.,feasibilityreached100%).On average,thisinducedanetincreaseintotaldietweight(onaverage+185g/day),asaresultofboth theincreaseanddecreaseinrepertoire‐foodsandtheadditionofnon‐repertoire‐foods.Thelargest variationsinfoodquantitieswererequiredforchildrenofthe“noYCF,noSuppl”group(Figure2). Bycontrast,inthe“YCF&Suppl”group,theadditionofnon‐repertoire‐foodsandthedecreasein repertoire‐foodsweresignificantlysmallerthaninalloftheothergroups(two‐by‐twotests, datanotshown). Quantitiesoffoodcategoriesandsubcategoriesforobservedandmodeleddiets(all‐foods models)arepresentedinTable3.Thereweresignificantchangesacrossgroupsbetweentheobserved andmodeleddietforsupplements,YCFs,cow’smilk,meat,eggsandanimalfats.Supplementsand YCFsincreasedsignificantlyforallgroups,exceptfor“YCF&Suppl”,withthelargestvariationfor the“noYCF,noSuppl”.Inthisgroup,almostallofthenon‐repertoire‐foodadded(i.e.,332g/day; Figure2)wascomposedofYCF(+312g/day).Cow’smilksignificantlydecreasedinallofthegroups exceptfor“YCF&Suppl”,withthelargestdecreaseincow’smilk(−266g/day)forthe“noYCF,no Suppl”group.Inthewholesample,besidestheincreaseinYCFandthedecreaseincow’smilk,the otherimportantdietaryshiftswereincreasesinwater(+110g/day)andfruitandvegetables(+65 g/day).Starchyfoodsweredecreasedforallofthegroupsofchildren,exceptin“noYCF,Suppl”, whileaddedfatswereincreasedinallofthegroups. Figure 1. Percentage of children for whom it was feasible to model a nutritionally-adequate diet with their repertoire-foods only for the whole sample and across the four groups of children with and without vitamin D constraint a,b . a Significant (p< 0.01) associations were observed between the percentage of feasibility and groups of children whatever the model (i.e., with and without the vitamin D constraint), with and without adjustments for age and energy (using logistic regression and chi-squared tests, respectively); b “no YCF, no Suppl” refers to children who did not consume either YCFs or supplements during the four days of dietary record; “no YCF, Suppl” refers to those who did not consume YCFs, but who consumed supplements; “YCF, no Suppl” refers to those who consumed YCFs, but not supplements; “YCF & Suppl” refers to those who consumed both YCFs and supplements. 3.4. Dietary Changes Induced by the All-Foods Models When access to all foods (i.e., both repertoireand non-repertoire-foods) was allowed, it was possible to model a nutritionally-adequate diet for each child (i.e., feasibility reached 100%). On average, this induced a net increase in total diet weight (on average +185 g/day), as a result of both the increase and decrease in repertoire-foods and the addition of non-repertoire-foods. The largest variations in food quantities were required for children of the “no YCF, no Suppl” group (Figure 2). By contrast, in the “YCF & Suppl” group, the addition of non-repertoire-foods and the decrease in repertoire-foods were significantly smaller than in all of the other groups (two-by-two tests, data not shown). Quantities of food categories and subcategories for observed and modeled diets (all-foods models) are presented in Table 3. There were significant changes across groups between the observed and modeled diet for supplements, YCFs, cow’s milk, meat, eggs and animal fats. Supplements and YCFs increased significantly for all groups, except for “YCF & Suppl”, with the largest variation for the “no YCF, no Suppl”. In this group, almost all of the non-repertoire-food added (i.e., 332 g/day; Figure 2) was composed of YCF (+312 g/day). Cow’s milk significantly decreased in all of the groups except for “YCF & Suppl”, with the largest decrease in cow’s milk ( − 266 g/day) for the “no YCF, no Suppl” group. In the whole sample, besides the increase in YCF and the decrease in cow’s milk, the other important dietary shifts were increases in water (+110 g/day) and fruit and vegetables (+65 g/day). Starchy foods were decreased for all of the groups of children, except in “no YCF, Suppl”, while added fats were increased in all of the groups. Nutrients 2016,8, 539 9 of 17 Table 3. Food categories and subcategories quantities (g/day) in observed diets and diets modeled with the all-foods models a, for the four groups of children. All 1(n= 1147) No YCF, No Suppl b2 (n= 707) No YCF, Suppl b3 (n= 56) YCF, No Suppl b4 (n= 341) YCF & Suppl b5 (n= 43) Test of Modeled vs. Observed Variation Across Groups Observed Modeled Observed Modeled Observed Modeled Observed Modeled Observed Modeled Unadjusted pAdjusted p** Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Supplements 1,2,3,4 0.11 0.54 0.74 1.03 0.00 0.00 0.81 1.03 1.30 1.34 1.82 1.55 0.00 0.00 0.36 0.59 1.29 1.37 1.35 1.36 <0.001 <0.001 Dairy products 1,2,3,4 503 185 529 134 484 185 512 128 519 207 441 157 536 178 577 126 539 177 551 124 0.001 <0.001 YCF 1,2,3,4 119 200 345 154 0.00 0.00 312 132 0.00 0.00 157 135 353 186 439 143 383 190 399 155 <0.001 <0.001 Cow’s milk 1,2,3,4 303 228 122 87.9 399 200 133 86.9 413 203 192 125 113 142 88.2 69.3 88.8 117 106 76.9 <0.001 <0.001 Breast milk 20.7 89.0 20.7 89.0 24.1 94.5 24.1 94.5 46.2 155 46.2 155 11.6 63.1 11.6 63.1 4.65 21.3 4.65 21.3 Fresh dairy products 1,2,3,4,5 51.5 40.0 33.9 33.1 52.0 40.3 34.7 33.6 51.6 39.1 38.2 34.0 50.5 39.3 31.8 32.1 51.7 43.1 32.7 31.8 0.73 0.79 Cheese and cream 1,2,4 8.49 9.71 7.49 8.66 8.47 9.69 7.75 8.81 8.22 9.87 7.19 8.46 8.23 9.44 6.76 7.97 11.1 11.6 9.43 11.1 0.22 0.32 Fruit and vegetable 1,2,3,4,5 156 99.0 222 91.1 161 97.2 223 90.3 185 115 268 94.2 139 96.0 211 88.9 167 112 228 98.4 0.03 0.10 Fruits 1,2,3,4 78.5 63.0 94.7 65.6 81.3 62.3 94.6 64.5 95.2 73.7 116 67.1 69.5 60.2 91.8 66.5 81.1 73.1 92. 6 69.8 0.02 0.02 Vegetables 1,2,3,4,5 56.1 44.9 106 52.5 56.7 45.1 105 51.9 69.3 51.3 132 53.3 51.9 43.0 103 53.4 62.3 44.5 115.3 46.6 0.09 0.04 Fruit juice 13.0 38.7 12.4 33.1 13.2 37.7 13.2 33.8 13.3 33.3 12.4 30.5 11.4 39.6 10.1 31.1 22.1 52.4 17.8 39.0 0.77 0.90 Soups 8.63 25.3 8.37 23.9 10.3 28.8 10.2 27.9 7.45 12.6 7.29 12.4 6.20 19.6 5.48 16.3 1.36 5.63 2.36 9.16 0.48 0.39 Starchy foods 1,2,4,5 119 60.8 105 60.0 128 60.4 113 60.7 118 56.4 115 63.7 101 57.9 88. 9 54.3 111 66.7 94.9 60.5 0.13 0.08 Bread 1,2,4,5 27.9 19.8 20.6 17.4 30.9 21.0 23.2 18.6 21.4 13.9 19.1 14.1 24.0 17.6 16.6 14.5 18.2 13.0 13.1 12.5 0.03 0.02 Other starchy foods 1,2 91.0 57.1 84.7 54.8 97.0 56.2 89.9 55.0 96.6 55.5 95.8 59.1 77.5 55.9 72.3 51.46 92.7 67.2 81.7 58.4 0.40 0.34 Meat fish eggs 1,2,3,4,5 51.5 34.8 60.5 34.7 54.9 35.3 64.9 34.9 49.2 30.4 64.5 32.6 45.5 32.1 51.4 31.6 47.3 44.9 55.5 44.2 <0.001 0.001 Meat 334.6 28.6 35.1 27.9 38.1 30.1 38.3 29.0 27.5 21.1 33.4 25.3 28.9 24.6 29.4 24.2 30.1 31.9 30.7 31.8 <0.001 <0.001 Fish 1,2 9.77 14.1 10.9 14.5 9.91 14.3 11.2 14.5 11.3 16.1 11.3 17.4 9.33 13.4 10.2 14.1 9.07 13.4 10.4 14.6 0.65 0.77 Eggs 1,2,3,4,5 7.20 11.5 14.5 17.8 6.87 11.3 15.4 19.0 10.5 14.3 19.7 19.2 7.23 11.7 11.8 14.8 8.18 9.42 14.4 15.3 <0.001 <0.001 Sweets & salted foods and drinks 1,2,4 74.5 128 65.0 120 88.6 146 77.6 138 70.1 112 67.8 110 48.5 79.4 41.1 76.3 52.8 83.5 44.9 72.2 0.06 0.05 Savory foods 12.16 3.78 2.00 3.62 2.51 3.99 2.35 3.84 1.76 3.91 1.81 3.99 1.57 3.21 1.38 2.93 1.60 3.65 1.51 3.64 0.86 0.75 Soft drinks 1,2 42.0 120 39.3 115 52.9 140 48.9 133 42.2 107 41.7 107 21.4 70.0 20.9 69.4 25.8 64.9 24.0 64.1 0.09 0.16 Sweet foods 1,2,4 30.3 31.4 23.7 25.7 33.2 30.6 26.3 26.7 26.1 26.1 24.2 25.4 25.5 30.3 18.8 22.8 25.5 48.7 19.4 25.7 0.29 0.24 Toddlers foods and drink 1,2,4 62.9 108 57.0 91.9 41.9 83.1 37.9 69.4 78.4 118 74.8 103 94.4 129 85.5 110 138 170 123 144 0.18 0.36 Toddlers foods 52.7 85.1 50.9 81.9 35.6 65.8 34.5 63.0 67.7 90.6 68.2 92.9 81.4 107 77.8 103 86.2 92.5 83.5 89.1 0.49 0.78 Toddlers drinks 1,2 10.2 51.4 6.15 34.6 6.32 41.6 3.31 27.9 10.8 47.4 6.55 25.2 13.0 56.1 7.72 36.0 52.3 111 39.9 83.8 0.28 0.34 Added fats 1,2,3,4,5 4.80 4.17 6.34 5.01 5.14 4.31 6.75 5.10 4.55 3.39 7.04 4.70 4.34 4.04 5.39 4.71 3.30 2.83 6.14 5.12 0.01 0.03 Animal fats 1,5 1.70 3.37 1.92 3.62 1.67 3.43 1.85 3.60 1.64 2.47 1.86 2.88 1.83 3.49 1.94 3.62 1.35 2.25 2.92 4.72 0.005 0.003 Vegetable fats 1,2,3,4,5 3.10 3.46 4.42 4.38 3.47 3.65 4.90 4.53 2.91 3.13 5.18 4.57 2.51 3.12 3.46 3.94 1.96 2.22 3.23 3.28 0.03 0.16 Water 1,2,3,4,5 121 129 231 154 119 134 223 162 158 125 301 152 116 120 235 137 141 124 238 118 0.04 0.09 Low calorie drinks, tea and coffee 97.8 174 97.3 173 122 197 121 196 32.7 70.9 32.7 70.9 67.4 130 67.4 130 23.2 51.7 23.2 51.7 0.67 0.73 Low calorie drinks 93.9 172 93.4 171 118 195 117 193 29.3 68.3 29.3 68.3 64.0 128 64.0 128 19.6 51.6 19.6 51.6 0.67 0.73 Tea coffee 3.89 20.4 3.89 20.4 4.20 22.1 4.20 22.1 3.44 13.4 3.44 13.4 3.37 18.4 3.37 18.4 3.58 12.3 3.58 12.3 0.89 0.89 Others c,1,2,3,4 7.27 11.1 8.95 12.5 7.95 10.7 10.1 12.6 5.71 8.83 7.64 9.91 6.48 12.4 7.35 12.9 4.27 8.70 5.06 9.11 0.001 0.01 a “All-foods models” refers to the linear programming models where all of the foods reported as consumed by the sample were taken as variables; b “no YCF, no Suppl” refers to children who did not consume either YCFs or supplements during the four days of dietary record; “no YCF, Suppl” refers to those who did not consume YCFs, but who consumed supplements; “YCF, no Suppl” refers to those who consumed YCFs, but not supplements; “YCF & Suppl” refers to those who consumed both YCFs and supplements; c others include savory sauces, pickles, gravies, condiments, powders for drinks and wine; 1 indicates a significant difference (p< 0.01) between food quantities from observed and modeled diets in the overall sample; 2 indicates significant difference (p< 0.01) between food quantities from observed and modeled diets in the “no YCF no Suppl” group of children; 3 indicates significant difference (p< 0.01) between food quantities from observed and modeled diets in the “no YCF Suppl” group of children; 4 indicates significant difference (p< 0.01) between food quantities from observed and modeled diets in the “YCF no Suppl” group of children; 5 indicates significant difference (p< 0.01) between food quantities from observed and modeled diets in the “YCF & Suppl” group of children; ** analysis adjusted for age and energy intake, using the general linear model for variation between modeled and observed quantities across groups. 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