nu ien s
A icle
Role o Young Child Fo mulae and Supplemen s o
Ensu e Nu i ional Adequacy in U.K. Young Child en
Flo en Vieux 1,*, Chloé M. C. B ouzes 2, Ma hieu Maillo 1, And é B iend 3,4, Régis Hanka d 5,
Anne Lluch 2and Nicole Da mon 6
1MS-Nu i ion, Ma seille 13005, F ance; [email p o ec ed]
2Danone Nu icia Resea ch, Cen e Daniel Ca asso, RD128, Palaiseau 91767, F ance;
[email p o ec ed] (C.M.C.B.); [email p o ec ed] (A.L.)
3Cen e o Child Heal h Resea ch, Uni e si y o Tampe e School o Medicine and Tampe e Uni e si y
Hospi al, Uni e si y o Tampe e, Tampe e 33101, Finland; [email p o ec ed]
4Depa men o Nu i ion, Exe cise and Spo s, Facul y o Science, Uni e si y o Copenhagen,
Roligheds ej 30, F ede iksbe g DK-1958, Denma k
5INSERM-U 1069, Uni . F. Rabelais, Tou s F-37000, F ance; [email p o ec ed]
6Aix Ma seille Uni , INSERM, INRA, NORT, Ma seille 13005, F ance; [email p o ec ed]
*Co espondence: lo [email p o ec ed]; Tel.: +33-4-91-32-45-94
Recei ed: 5 July 2016; Accep ed: 26 Augus 2016; Published: 2 Sep embe 2016
Abs ac :
The Eu opean Food Sa e y Au ho i y (EFSA) s a es ha young child o mulae (YCFs)
“canno be conside ed as a necessi y o sa is y he nu i ional equi emen s” o child en aged
12–36 mon h
s. This s udy quan i ies he die a y changes needed o ensu e nu i ional adequacy
in U.K. young child en who consume YCFs and/o supplemen s and in hose who do no . Die a y
da a om 1147 young child en (aged 12–18 mon hs) we e used o iden i y, using linea p og amming
models, he minimum changes needed o ensu e nu i ional adequacy: (i) by changing he quan i ies
o oods ini ially consumed by each child ( epe oi e- oods); and (ii) by in oducing new oods
(non- epe oi e- oods). Mos o he child en consumed nei he YCFs, no supplemen s (61.6%).
Nu i ional adequacy wi h epe oi e- oods alone was ensu ed o only one child in his g oup,
agains 74.4% o he child en consuming YCFs and supplemen . When access o all oods was
allowed, smalle ood changes we e equi ed when YCFs and supplemen s we e ini ially consumed
han when hey we e no . In he o al sample, he main die a y shi s needed o ensu e nu i ional
adequacy we e an inc ease in YCF and a dec ease in cow’s milk (+226 g/day and
−
181 g/day,
espec i ely). Inc easing YCF and supplemen consump ion was he sho es way o co e he EFSA
nu ien equi emen s o U.K. child en.
Keywo ds: young child o mula; supplemen s; indi idual die modeling; die ; EFSA; U.K.
1. In oduc ion
Be ween six and 24 mon hs o age, he ansi ion om an exclusi ely milk-based die o a mo e
di e se and adul -like die has o co e g owing nu ien and ene gy needs [
1
], while allowing
he in oduc ion o new ex u es and as es [
2
,
3
]. Du ing his pe iod, die s may include di e en
milks (e.g., b eas milk, cow’s milks) o comme cial o mulae. Young child o mulae (YCFs) a e
de ined by he Eu opean Food Sa e y Au ho i y Panel on Die e ic P oduc s, Nu i ion and Alle gies
(EFSA NDA Panel) as o mulae in ended o young child en (12–36 mon hs), including o mulae based
on p o ein sou ces o he han cow’s milk [
4
]. Fo i ied wi h nu ien s, such as essen ial a y acids,
i on and i amin D, YCFs a e designed o suppo he nu i ional needs o young child en as pa o a
balanced die [5,6].
In 2013, he EFSA NDA Panel de i ed le els o nu ien s conside ed adequa e o mos in an s
and young child en by e iewing e e ence alues se by he Scien i ic Commi ee o Foods in 1993 [
7
]
Nu ien s 2016,8, 539; doi:10.3390/nu8090539 www.mdpi.com/jou nal/nu ien s
Nu ien s 2016,8, 539 2 o 17
in ligh o mo e ecen ecommenda ions [
8
]. The same epo indica ed ha YCFs we e “one o se e al
means o inc ease n-3 PUFA, i on, i amin D and iodine in akes in in an s and young child en li ing in
Eu ope wi h inadequa e o a isk o inadequa e s a us o hese nu ien s”. The epo also s a es ha
he e is “no unique ole o young-child o mulae in sa is ying he nu i ional equi emen s o young
child en” [
8
]. The po en ial con ibu ion o YCFs o he die s o young child en in Eu ope hus needs
o be cla i ied. The e a e se e al ways in which nu ien gaps in he child’s ood di e si ica ion phase
can be illed. These include changing die a y habi s, consuming o i ied oods and d inks (such as
YCFs) and/o aking supplemen s. The choice will depend on local habi s, indi idual accep abili y,
he cos and accessibili y o p oduc s and he quali y and quan i y o he oods and d inks al eady
being consumed.
Linea p og amming can be used o suppo app op ia e complemen a y eeding ad ice based
on locally-a ailable oods [
3
,
9
–
11
]. Taking in o accoun indi idual ood pa e ns and p e e ences,
linea p og amming can ansla e speci ic nu ien ecommenda ions in o ealis ic indi idual ood
choices [
12
]. In he p esen s udy, indi idual die modeling was used o de e mine he die a y changes
needed o a ain nu i ional adequacy in U.K. young child en who consume YCFs and/o supplemen s
and in hose who do no . A nu i ionally-adequa e die is de ined as a die co e ing a se o nu ien
ecommenda ions, he e he EFSA nu ien equi emen s o 12–18 mon hs. The hypo hesis was ha he
consump ion o YCFs and/o supplemen s was no s ic ly necessa y o ensu e nu i ional adequacy,
al hough i migh acili a e i .
2. Ma e ials and Me hods
2.1. Die a y Su ey and S udy Sample
Die a y da a we e aken om he Die and Nu i ion Su ey o In an s and Young Child en
(DNSIYC). This desc ip i e, c oss-sec ional, na ional su ey conduc ed in 2011 p o ides de ailed
in o ma ion on ood and d ink consump ion on 4 consecu i e days in a ep esen a i e sample
o 2683 in an s and young child en aged 4–18 mon hs li ing in he U.K. The design, me hodology and
esul s o DNSIYC ha e been desc ibed elsewhe e [
13
]. Full e hical app o al o he ini ial su ey was
ecei ed om he Camb idgeshi e 4 Resea ch E hics Commi ee on 18 Janua y 2010.
To a ge he age g oup o which YCFs a e designed, only child en olde han 12 mon hs
(n= 1275) we e selec ed o his s udy. Da a om child en wi h less han 4 ood-dia y days comple ed
(n= 35), o wi h an ene gy in ake abo e o below 3 s anda d de ia ions (SD) om he mean
(gende sepa a ed; n= 9) [
14
], o who consumed specialized o mulae o alle gy o lac ose in ole ance
(n= 61) we e igno ed. Gi en ha changes in YCF powde consump ion canno be conside ed alone
(as i has o be associa ed wi h wa e ), eco ds only men ioning powde YCFs (n= 23) we e also
excluded, yielding a inal sample size o 1147 child en.
The sample was di ided in o ou g oups depending on he consump ion o YCFs and/o
supplemen use: “no YCF, no Suppl”, “no YCF, Suppl”, “YCF, no Suppl” and “YCF & Suppl”.
2.2. Food Da abase
Ene gy and nu ien con en s o oods we e aken om he Depa men o Heal h’s Nu ien
Da abase [
15
] and om in o ma ion p o ided by manu ac u e s. Following he classi ica ion o oods
p o ided by he DNSIYC s udy epo , indi idual ood i ems consumed (n= 2215 ood i ems) we e
di ided in o 11 ood ca ego ies and 26 ood subca ego ies (Table S1). Supplemen s had hei own
ca ego y and we e mos ly mul i- i amins, wi h 61% o hem including i amins A, C and D. YCFs
we e included in he dai y p oduc s ca ego y. Compa ed wi h he a e age consumed cow’s milk, he
a e age consumed YCFs con ained lowe le els o p o eins, iodine, i amin B12, ibo la in and SFA
and highe le els o i amin E, i amin C, n-3 and n-6 a y acids, i on and i amin D.
Nu ien s 2016,8, 539 3 o 17
2.3. Die Quali y Indica o s
The nu i ional quali y o each die was assessed wi h he mean adequacy a io [
16
–
18
],
using 22 bene icial nu ien s in he calcula ion and es ima ed as ollows (1):
Mean Adequacy Ra io =1
22 ×
22
∑
bn=1
in akebn
RVbn
×100 (1)
whe e in ake
bn
is he daily in ake o each bene icial nu ien bn and RV
bn
is he e e ence alue (RV)
o ha nu ien . As p e iously p oposed [
19
,
20
], each a io (100
×
in ake
bn
/RV
bn
) was unca ed
a 100, so ha a high in ake o one nu ien could no compensa e o a low in ake o ano he .
The po en ial enal solu e load (PRSL) e e s o he solu es o die a y o igin ha mus be exc e ed
by he kidneys when no used o g owing new issues o los h ough non- enal ou es [
21
–
23
]. In his
s udy, PRSL was es ima ed as desc ibed by Bonne e al. [24], as ollows (2):
PRSL (mmol)=5.7 ×p o ein (g)+sodium (mg)
23 +po assium (mg)
39 +0.55 ×phospho us (mg)
31 (2)
A die oo high in p o eins, sodium, chlo ide, po assium and phospho us, wi h limi ed wa e
in ake, leads o a high PRSL.
2.4. Indi idual Die Modeling wi h Linea P og amming
The p inciple o die modeling and he pa ame e s used o his s udy a e desc ibed in de ail
in Appendix A. B ie ly, he p esen modeling app oach was used o design die s mee ing a se o
nu i ional ecommenda ions, while keeping as close as possible o he obse ed die . Two linea
p og amming models we e un o each child. Bo h we e in ended o make nu i ionally-adequa e
die s, bu di e ed in he lis o oods allowed. “Repe oi e-only models” allowed he inclusion o
only epe oi e- oods, i.e., oods eco ded in an indi idual child’s ou -day ood dia y. “All- oods
models” allowed bo h epe oi e- oods and non- epe oi e- oods, i.e., all oods eco ded in a leas one
ood dia y o he su ey. “Repe oi e-only models” we e used o assess he easibili y o designing
nu i ionally-adequa e die s wi h epe oi e- oods only [
25
], while “all- oods models” we e used o
iden i y he ood changes needed o a ain nu i ional adequacy wi h minimum changes o he exis ing
die [
12
]. Nu i ional adequacy was de ined as p o iding all le els o nu ien s conside ed adequa e
o mos young child en by he EFSA [8], e e ed o below as e e ence alues (RVs).
2.5. S a is ical Analysis
2.5.1. Compa ison o Cha ac e is ics and Obse ed Die s in he 4 G oups o Child en
Di e ences be ween he ou g oups o child en we e es ed using he chi-squa ed es o logis ic
eg ession o ca ego ical a iables and gene al linea models o con inuous a iables.
2.5.2. Die s Modeled wi h “Repe oi e-Only Foods”
The pe cen age o child en o whom i was possible o model a nu i ionally-adequa e die om
hei epe oi e- oods only was calcula ed and compa ed ac oss he ou g oups using he chi-squa ed
es o logis ic eg ession. A sensi i i y analysis was pe o med o assess whe he o no he easibili y
o modeling adequa e die s was impac ed by emo ing he nu ien cons ain s co esponding o he
leas equen ly a ained RVs.
2.5.3. Die s Modeled wi h “All-Foods”
Fo “all- oods models”, a ia ions o ood weigh s be ween obse ed and modeled die s
(mean weigh s o oods o inc ease, mean weigh s o oods o dec ease and mean weigh s o
non- epe oi e- oods added, in g ams) we e also compa ed be ween g oups o child en. To
Nu ien s 2016,8, 539 4 o 17
examine whe he o no a ia ions in ood quan i ies we e signi ican ly di e en om 0, pai ed
S uden - es s we e un o he whole sample and wi hin each g oup o child en. To de e mine
whe he hese a ia ions we e simila ac oss g oups, a gene al linea model analysis was pe o med.
A speci ic analysis ocused on he a ia ion in YCF and cow’s milk quan i ies be ween modeled and
obse ed die s. Two-by- wo compa ison es s wi h Bon e oni co ec ions assessed, when ele an ,
s a is ically-signi ican di e ences be ween wo g oups.
The SAS sys em Ve sion 9.4 (SAS Ins i u e, Ca y, NC, USA) was used o all analyses.
When speci ied, analyses we e adjus ed o age and ene gy in ake. A p- alue < 0.01 was se as
signi ican o he s a is ical es s.
3. Resul s
3.1. Desc ip ion o he Sample
Child en’s cha ac e is ics o he whole sample and o each o he ou g oups a e p esen ed in
Table 1. The la ges g oup was “no YCF, no Suppl” (61.6%), ollowed by “YCF, no Suppl” (29.7%),
“no YCF, Suppl” (4.9%) and “YCF & Suppl” (3.7%). Gende , heigh , weigh and BMI did no di e
signi ican ly ac oss he ou g oups. Only 7.4% o child en we e s ill being b eas ed a he ime o he
su ey. Child en in he “no YCF, no Suppl” g oup we e sligh ly olde (14.6 mon hs) and had a highe
ene gy in ake (983 kcal/day) han hose in he “YCF, no Suppl” g oup (13.8 mon hs and 938 kcal/day).
Die quali y indica o s signi ican ly di e ed be ween g oups, wi h he lowes mean adequacy a io
and he highes PRSL obse ed in he “no YCF, no Suppl” g oup. The mean adequacy a io was highe
o child en consuming supplemen s (92.5%), YCFs (94.8%) o bo h (97.5%) han o child en in he
“no YCF, no Suppl” g oup (88.6%).
Table 1.
Gende , age, heigh , weigh , BMI and die cha ac e is ics ( epo ed b eas eeding, ene gy
in ake and nu i ional quali y indica o s) in he ou g oups o child en *.
All No YCF,
No Suppl a
No YCF,
Suppl a
YCF,
No Suppl a
YCF &
Suppl ap*
Numbe o child en (n)1147 707 56 341 43
Gende (%)
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 mon hs) <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
An h opome ic da a
In an heigh (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
In an weigh (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
Numbe o missing alues 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
Numbe o missing alues 158 96 7 49 6
Repo ed b eas eeding (%)
S ill b eas eeding 7.41 8.49 14.3 4.40 4.65 0.02
No longe b eas eeding 68.3 64.6 67.9 74.8 79.1 0.004 1
Ne e b eas ed 24.1 26.7 17.9 20.8 16.3 0.06
Nu ien s 2016,8, 539 5 o 17
Table 1. Con .
All No YCF,
No Suppl a
No YCF,
Suppl a
YCF,
No Suppl a
YCF &
Suppl ap*
Numbe o missing alues 1 1 0 0 0
Ene gy (kcal/day)
Mean 968 983 972 938 950 0.005 1
SD 196 199 228 183 166
Die quali y indica o s
Mean adequacy a io (%)
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” e e s o child en who did no consume ei he young child o mulae (YCFs) o
supplemen s du ing he ou days o die a y eco d; “no YCF, Suppl” e e s o hose who did no consume YCFs,
bu who consumed supplemen s; “YCF, no Suppl” e e s o hose who consumed YCFs, bu no supplemen s;
“YCF & Suppl” e e s o hose who consumed bo h YCFs and supplemen s. * S a is ical signi icance o he
di e ences ac oss he ou g oups o child en. Gene al linea model es s we e un o all es s excep “ epo ed
b eas eeding”, which was es ed using he chi-squa ed es .
1
Indica es a signi ican di e ence be ween
“no YCF, no Suppl” and “YCF, no Suppl”;
2
indica es a signi ican di e ence be ween “no YCF, no Suppl”
and “no YCF, Suppl”;
3
indica es a signi ican di e ence be ween “no YCF, no Suppl” and “YCF & Suppl”;
4
indica es a signi ican di e ence be ween “YCF & Suppl” and “YCF, no Suppl”;
5
indica es a signi ican
di e ence be ween “YCF & Suppl” and “No YCF, Suppl”;
6
indica es a signi ican di e ence be ween
“YCF, no Suppl” and “no YCF, Suppl”.
3.2. Nu ien s in Obse ed Die s
The RVs and he pe cen age o obse ed die s a aining each nu ien RV o he whole sample
and ac oss he ou g oups o child en a e p esen ed in Table 2. Obse ed die s a ely eached
he RV le el o i amin D (7.9%), ibe (20.6%), i on (28.2%), wa e (28.2%) and i amin E (29.2%).
Fo hese nu ien s and o mos o he nu ien s, he pe cen age anged signi ican ly ac oss g oups.
I was gene ally highe o child en consuming YCFs and/o supplemen s. Almos all child en’s
die s (99.9%) supplied p o ein in su icien amoun s. Fewe han hal o he child en had a in akes
wi hin he ecommended ange. The a in akes o hose no mee ing he ecommenda ion we e mainly
below he minimal ecommended le el. This was c i ical in he “YCF & Suppl” g oup, in which 74%
(i.e., 100–26) o he child en consumed less han 35% o hei ene gy om a s.
3.3. Feasibili y o Repe oi e-Only Models
When only epe oi e- oods we e allowed, achie ing EFSA nu i ional adequacy was almos
impossible o child en in he “no YCF, no Suppl” g oup (Figu e 1). The pe cen age o easibili y
in his g oup was 0.1% (only one child ou o 707). By con as , easibili y eached 74.4% in he
“YCF & Suppl” g oup. As i amin D was he leas equen ly a ained RVs in he obse ed die s, i was
emo ed om he sensi i i y analysis. The pe cen age o easibili y consequen ly inc eased o each
g oup o child en.

Nu ien s 2016,8, 539 6 o 17
Table 2.
Re e ence alues o each nu ien , pe cen age o obse ed die s a aining each e e ence alue (RV) o he whole sample and ac oss he ou g oups
o child en a.
Nu ien s Re e ence Value All
(n= 1147)
No YCF,
No Suppl a
No YCF,
Suppl a
YCF,
No Suppl aYCF & Suppl ap-Unadjus ed
Analysis *
p-Adjus ed
Analysis **
(n= 707) (n= 56) (n= 341) (n= 43)
Mac onu ien s
Wa e (H2O) ≥1100 mL/day b28.2 29.3 26.8 25.2 37.2 0.30 0.18
P o eins ≥1.14 g/kg body weigh c99.9 100 100 99.7 100 0.50 *** 0.99 ***
Ca bohyd a es 45%–60% ene gy d82.0 80.9 83.9 85.6 69.8 0.04 0.03
Ca bohyd a es min ≥45% o ene gy d90.0 86.3 87.5 97.1 97.7 <0.001 <0.0001
Ca bohyd a es max ≤60% o ene gy d92.0 94.6 96.4 88.6 72.1 <0.001 <0.0001
Fibe >10 g/day b20.6 15.3 10.7 30.8 39.5 <0.001 <0.001
To al a s 35%–40% ene gy d43.7 45.0 51.8 41.9 25.6 0.04 0.08
To al a s min ≥35% o ene gy d59.0 62.9 66.1 54.0 25.6 <0.001 <0.001
To al a s max ≤40% o ene gy d84.7 82.0 85.7 88.0 100 0.002 0.009
n-6 FA ≥3% ene gy 86.7 81.2 80.4 97.6 100.0 <0.001 <0.001 ***
n-3 FA ≥0.5% ene gy 77.0 68.3 69.6 93.5 97.7 <0.001 <0.001
Vi amins
Thiamin ≥0.5 mg/day c95.1 94.1 98.2 96.2 100.0 0.12 *** 0.03 ***
Ribo la in ≥0.8 mg/day b93.1 93.5 96.4 90.9 100.0 0.08 *** 0.37 ***
Niacin ≥
9 mg nico inic acid eq/day
c97.3 98.6 98.2 94.4 97.7 0.001 *** 0.007
Pan o henic acid ≥4 mg/day b77.3 83.0 89.3 63.3 79.1 <0.001 <0.001
Vi amin B6 min ≥0.7 mg/day c86.9 93.5 96.4 71.5 88.4 <0.001 <0.001
Vi amin B6 max ≤5 mg/day e100.0 100.0 100.0 100.0 100.0 N.A. N.A.
Bio in ≥20 µg/day b60.1 66.0 67.9 48.4 44.2 <0.001 <0.001
Fola es ≥100 µg/day c88.7 87.1 92.9 90.0 100.0 0.03 0.02 ***
Vi amin B12 ≥0.9 µg/day c99.6 99.6 100.0 99.7 100.0 0.92 *** 0.91 ***
Vi amin C ≥20 mg/day c95.9 93.3 100.0 100.0 100.0 <0.001 *** 0.99 ***
Vi amin D min ≥10 µg/day b7.9 0 16.1 15.5 67.4 <0.001 *** <0.001 ***
Vi amin D max ≤50 µg/day e100.0 100.0 100.0 100.0 100.0 N.A. N.A.
Vi amin E ≥6 mg ocophe ol eq/d b29.2 5.7 33.9 70.4 83.7 <0.001 <0.001
Re inol equi alen ≥400 µg /day b79.2 70.9 94.6 92.1 95.3 <0.001 <0.001
Re inol ≤800 µg/day e98.5 99.6 89.3 99.4 86.0 <0.001 *** <0.001 ***
Mine als
Sodium ≥170 mg/day b99.8 100.0 100.0 99.4 100.0 0.19 *** 0.97 ***
Po assium ≥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 ***
Chlo ide ≥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
Phospho us ≥460 mg/day c94.2 96.0 96.4 90.0 93.0 0.001 *** 0.002 ***
Nu ien s 2016,8, 539 7 o 17
Table 2. Con .
Nu ien s Re e ence Value All
(n= 1147)
No YCF,
No Suppl a
No YCF,
Suppl a
YCF,
No Suppl aYCF & Suppl ap-Unadjus ed
Analysis *
p-Adjus ed
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
I on ≥8 mg/day b,c 28.2 9.9 19.6 61.0 79.1 <0.001 <0.001
Coppe min ≥0.4 mg/day c71.9 64.9 69.6 84.2 93.0 <0.001 <0.001
Coppe 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” e e s o child en who did no consume ei he YCFs o supplemen s du ing he ou days o die a y eco d; “no YCF, Suppl” e e s o hose who did no consume
YCFs, bu who consumed supplemen s; “YCF, no Suppl” e e s o hose who consumed YCFs, bu no supplemen s; “YCF & Suppl” e e s o hose who consumed bo h YCFs and
supplemen s.
b
Requi emen de i ed by he EFSA om an adequa e in ake.
c
Requi emen de i ed by he EFSA om a Popula ion Re e ence In ake.
d
Requi emen de i ed by he
EFSA om a e e ence in ake ange.
e
Requi emen de i ed by he EFSA om a ole able uppe in ake le el.
Based on No dic ecommenda ions [
26
]. * Unadjus ed analysis, using a
chi-squa ed es o he pe cen age o obse ed die s a aining each RV; ** analysis adjus ed o age and ene gy in ake, using logis ic eg ession o he pe cen age o obse ed die s
a aining each RV; *** p- alue o be in e p e ed wi h cau ion due o he p esence o 100% o 0% in one g oup.
Nu ien s 2016,8, 539 8 o 17
Nu ien s 2016,8,5398o 17


Figu e1.Pe cen ageo child en o whomi was easible omodelanu i ionally‐adequa edie wi h
hei  epe oi e‐ oodsonly o  hewholesampleandac oss he ou g oupso child enwi hand
wi hou  i aminDcons ain 
a,b
.
a
Signi ican (p<0.01)associa ionswe eobse edbe ween he
pe cen ageo  easibili yandg oupso child enwha e e  hemodel(i.e.,wi handwi hou  he
i aminDcons ain ),wi handwi hou adjus men s o ageandene gy(usinglogis ic eg ession
andchi‐squa ed es s, espec i ely);
b
“noYCF,noSuppl” e e s ochild enwhodidno consume
ei he YCFso supplemen sdu ing he ou dayso die a y eco d;“noYCF,Suppl” e e s o hose
whodidno consumeYCFs,bu whoconsumedsupplemen s;“YCF,noSuppl” e e s o hosewho
consumedYCFs,bu no supplemen s;“YCF&Suppl” e e s o hosewhoconsumedbo hYCFs
andsupplemen s.
3.4.Die a yChangesInducedby heAll‐FoodsModels
Whenaccess oall oods(i.e.,bo h epe oi e‐andnon‐ epe oi e‐ oods)wasallowed,i was
possible omodelanu i ionally‐adequa edie  o eachchild(i.e., easibili y eached100%).On
a e age, hisinducedane inc easein o aldie weigh (ona e age+185g/day),asa esul o bo h
heinc easeanddec easein epe oi e‐ oodsand headdi iono non‐ epe oi e‐ oods.Thela ges 
a ia ionsin oodquan i ieswe e equi ed o child eno  he“noYCF,noSuppl”g oup(Figu e2).
Bycon as ,in he“YCF&Suppl”g oup, headdi iono non‐ epe oi e‐ oodsand hedec easein
epe oi e‐ oodswe esigni ican lysmalle  haninallo  heo he g oups( wo‐by‐ wo es s,
da ano shown).
Quan i ieso  oodca ego iesandsubca ego ies o obse edandmodeleddie s(all‐ oods
models)a ep esen edinTable3.The ewe esigni ican changesac ossg oupsbe ween heobse ed
andmodeleddie  o supplemen s,YCFs,cow’smilk,mea ,eggsandanimal a s.Supplemen sand
YCFsinc easedsigni ican ly o allg oups,excep  o “YCF&Suppl”,wi h hela ges  a ia ion o 
he“noYCF,noSuppl”.In hisg oup,almos allo  henon‐ epe oi e‐ oodadded(i.e.,332g/day;
Figu e2)wascomposedo YCF(+312g/day).Cow’smilksigni ican lydec easedinallo  heg oups
excep  o “YCF&Suppl”,wi h hela ges dec easeincow’smilk(−266g/day) o  he“noYCF,no
Suppl”g oup.In hewholesample,besides heinc easeinYCFand hedec easeincow’smilk, he
o he impo an die a yshi swe einc easesinwa e (+110g/day)and ui and ege ables(+65
g/day).S a chy oodswe edec eased o allo  heg oupso child en,excep in“noYCF,Suppl”,
whileadded a swe einc easedinallo  heg oups.
Figu e 1.
Pe cen age o child en o whom i was easible o model a nu i ionally-adequa e die
wi h hei epe oi e- oods only o he whole sample and ac oss he ou g oups o child en wi h
and wi hou i amin D cons ain
a,b
.
a
Signi ican (p< 0.01) associa ions we e obse ed be ween
he pe cen age o easibili y and g oups o child en wha e e he model (i.e., wi h and wi hou he
i amin D cons ain ), wi h and wi hou adjus men s o age and ene gy (using logis ic eg ession and
chi-squa ed es s, espec i ely);
b
“no YCF, no Suppl” e e s o child en who did no consume ei he
YCFs o supplemen s du ing he ou days o die a y eco d; “no YCF, Suppl” e e s o hose who did
no consume YCFs, bu who consumed supplemen s; “YCF, no Suppl” e e s o hose who consumed
YCFs, bu no supplemen s; “YCF & Suppl” e e s o hose who consumed bo h YCFs and supplemen s.
3.4. Die a y Changes Induced by he All-Foods Models
When access o all oods (i.e., bo h epe oi e- and non- epe oi e- oods) was allowed,
i was possible o model a nu i ionally-adequa e die o each child (i.e., easibili y eached 100%).
On a e age, his induced a ne inc ease in o al die weigh (on a e age +185 g/day), as a esul
o bo h he inc ease and dec ease in epe oi e- oods and he addi ion o non- epe oi e- oods.
The la ges a ia ions in ood quan i ies we e equi ed o child en o he “no YCF, no Suppl” g oup
(Figu e 2). By con as , in he “YCF & Suppl” g oup, he addi ion o non- epe oi e- oods and he
dec ease in epe oi e- oods we e signi ican ly smalle han in all o he o he g oups ( wo-by- wo es s,
da a no shown).
Quan i ies o ood ca ego ies and subca ego ies o obse ed and modeled die s (all- oods models)
a e p esen ed in Table 3. The e we e signi ican changes ac oss g oups be ween he obse ed and
modeled die o supplemen s, YCFs, cow’s milk, mea , eggs and animal a s. Supplemen s and YCFs
inc eased signi ican ly o all g oups, excep o “YCF & Suppl”, wi h he la ges a ia ion o he “no
YCF, no Suppl”. In his g oup, almos all o he non- epe oi e- ood added (i.e., 332 g/day; Figu e 2)
was composed o YCF (+312 g/day). Cow’s milk signi ican ly dec eased in all o he g oups excep
o “YCF & Suppl”, wi h he la ges dec ease in cow’s milk (
−
266 g/day) o he “no YCF, no Suppl”
g oup. In he whole sample, besides he inc ease in YCF and he dec ease in cow’s milk, he o he
impo an die a y shi s we e inc eases in wa e (+110 g/day) and ui and ege ables (+65 g/day).
S a chy oods we e dec eased o all o he g oups o child en, excep in “no YCF, Suppl”, while added
a s we e inc eased in all o he g oups.
Nu ien s 2016,8, 539 9 o 17
Table 3. Food ca ego ies and subca ego ies quan i ies (g/day) in obse ed die s and die s modeled wi h he all- oods models a, o he ou g oups o child en.
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) Tes o Modeled s. Obse ed
Va ia ion Ac oss G oups
Obse ed Modeled Obse ed Modeled Obse ed Modeled Obse ed Modeled Obse ed Modeled Unadjus ed pAdjus ed p**
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Supplemen s 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
Dai y p oduc s 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
B eas 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
F esh dai y p oduc s 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 c eam 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
F ui and ege able 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
F ui s 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
Vege ables 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
F ui 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
S a chy oods 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
B ead 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
O he s a chy oods 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
Mea ish 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
Mea 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
Swee s & sal ed oods
and d inks 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
Sa o y oods 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
So d inks 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
Swee oods 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
Toddle s oods and
d ink 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
Toddle s oods 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
Toddle s d inks 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 a s 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 a s 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
Vege able a s 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
Wa e 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 calo ie d inks,
ea and co ee 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 calo ie d inks 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 co ee 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
O he s 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- oods models” e e s o he linea p og amming models whe e all o he oods epo ed as consumed by he sample we e aken as a iables;
b
“no YCF, no Suppl” e e s o
child en who did no consume ei he YCFs o supplemen s du ing he ou days o die a y eco d; “no YCF, Suppl” e e s o hose who did no consume YCFs, bu who consumed
supplemen s; “YCF, no Suppl” e e s o hose who consumed YCFs, bu no supplemen s; “YCF & Suppl” e e s o hose who consumed bo h YCFs and supplemen s;
c
o he s include
sa o y sauces, pickles, g a ies, condimen s, powde s o d inks and wine;
1
indica es a signi ican di e ence (p< 0.01) be ween ood quan i ies om obse ed and modeled die s in he
o e all sample;
2
indica es signi ican di e ence (p< 0.01) be ween ood quan i ies om obse ed and modeled die s in he “no YCF no Suppl” g oup o child en;
3
indica es signi ican
di e ence (p< 0.01) be ween ood quan i ies om obse ed and modeled die s in he “no YCF Suppl” g oup o child en;
4
indica es signi ican di e ence (p< 0.01) be ween ood
quan i ies om obse ed and modeled die s in he “YCF no Suppl” g oup o child en;
5
indica es signi ican di e ence (p< 0.01) be ween ood quan i ies om obse ed and modeled
die s in he “YCF & Suppl” g oup o child en; ** analysis adjus ed o age and ene gy in ake, using he gene al linea model o a ia ion be ween modeled and obse ed quan i ies
ac oss g oups.
Nu ien s 2016,8, 539 16 o 17
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