During the first year of life, fundamental changes in dietary requirements and in food and feeding patterns take place, more than at any time in life (1,2). It is recommended that infants be exclusively breast-fed for the first 6 months of life (3,4). Afterward, they should be partially breast-fed, be given appropriate complementary food, and become accustomed to the family diet around the end of the first year of life.
Careful and detailed work has been undertaken worldwide to advise mothers on feeding their babies appropriately (5). Regarding breast-feeding, different ways of counseling have proved to be of different effectiveness. Repeated counseling during the first year of life was more effective than postpartum nonrecurring counseling (6–10). Telephone hotlines, although welcomed by mothers, were used only moderately (11,12). Booklets or other written information did not increase the initiation or duration of breast-feeding, not even if combined with other breast-feeding counseling instruments (13,14).
In contrast to breast-feeding promotion, surprisingly little interest has been given to the evaluation of counseling on complementary feeding. One reason may be that it is more difficult to measure the outcome of intervention for the more complex weaning diet. However, the provision of adequate complementary food is not as simple as it seems but is well recognized as a critical factor in preventing child malnutrition and overnutrition. It may also exert long-lasting effects on dietary habits and health later in life (15–17).
As in other industrialized countries, mothers in Germany can receive advice about infant feeding from various sources of information that are easily available. They include booklets or books, telephone hotlines (eg, by baby food companies), online services, or face-to-face counseling by the midwife or the pediatrician. Until now, the effects of these ways of counseling have not been examined as far as we are aware.
Therefore, the objectives of this study were to develop a model for measuring compliance with food-based recommendations for infant feeding with a focus on complementary food and to use this model to investigate the effects of various methods of counseling on total infant diet in a randomized controlled intervention trial.
INFANTS AND METHODS
Mothers were enrolled between May and September 2002 from maternity wards in the city of Dortmund, and from members of a nationwide compulsory health insurance company (NOVITAS Vereinigte BKK, Duisburg, Germany) who reported the birth of a baby. Inclusion criteria for the mothers were that they speak German, be available by telephone, and provide written informed consent of participation. Inclusion criteria for the infants were good health, full-term birth (>37 weeks of pregnancy), and birth weight exceeding >2500 g. The study protocol was approved by the International Scientific Committee of the Research Institute of Child Nutrition, Dortmund.
Dietary counseling in this study was based on the Dietary Schedule for the First Year of Life (Dietary Schedule) recommended by the Nutrition Committee of the German Pediatric Society (Fig. 1) (18). This schedule provides food-based and meal-based advice according to age and almost complies with the German reference nutrient intakes. Mothers are recommended to breast-feed their infants exclusively for 4 to 6 months or otherwise to use infant formula. Afterward, 3 different types of complementary meals are recommended to be introduced one after the other, month by month, accompanied by continued milk feeding (breast or formula) (Fig. 1). Complementary feeding starts with vegetables, usually carrots, that are subsequently completed to a full meal by the addition of potatoes, meat, and plant oil. The second complementary meal consists of milk, whole-grain cereals, and fruit juice. Fruit and whole-grain cereals are the main components, excluding milk, of the third meal. Whole cow's milk may be used in small amounts as part of the complementary milk-cereal meal. Whole cow's milk as a drink should not be given earlier than the introduction of family meals, and the infant should drink the milk from the cup. In general, the infant should become accustomed to family food from the age of around 10 months.
Forms of Intervention
Intervention in this study was nutrition counseling of the mothers. Intervention started when the infant had reached the age of 2 months and lasted until the infant was 12 months old. After giving informed consent to participation, mothers were randomized into 1 of 4 intervention groups (IG0–IG3).
Three different forms of nutrition counseling were used in 3 different combinations or intensities, respectively (Fig. 2). Mothers of the IG1 were offered a telephone hotline (TH) 3 times per week, open for 2 hours each. Mothers of the IG2 received additional written information (WI) on the Dietary Schedule distributed in 3 parts, each dealing with the diet in the coming period. Mothers in the IG3 were offered additional personal telephone counseling (PTC). This meant that at selected age points, when new meals should be introduced (Fig. 1), mothers were called by a counselor (S.K.) from the study center. If they were interested in a conversation, then they were advised on practical dietary matters appropriate for the respective infant age. IG0 was the control group, and those mothers were not counseled at all.
Compliance with the recommendations from the Dietary Schedule was examined by dietary assessments at significant age points in the intervention period (Fig. 1). By use of standardized telephone interviews (TI), mothers were asked to report the actual food and meal consumption of the infant. TI were timed within 2 weeks of the end of the 2nd month of age (start of intervention), the end of the 4th and 6th months of age (earliest and latest time points for introduction of complementary foods), the end of the 9th month (earliest introduction of family foods), and the end of the 12th month (end of intervention) (Fig. 1).
Mothers also gave the data for measured body weight and length of the infant from the latest pediatric checkup. They were also asked if they had used other dietary counseling in addition to the offers in the study.
To avoid having the personal contacts during the repeated PTC influence the answers in the TI, TIs were always conducted before the PTC of the respective age. Furthermore, control questions were included in the TI (ie, the age of introduction of a specific type of complementary food was repeatedly asked).
The dietary data were evaluated by comparison with the recommendations from the Dietary Schedule. A total of 48 food-based recommendations were specified; in detail these were 5 (8,15,12) recommendations for the age of 2 (4,6,9,12) months. Compliance with an individual food-based recommendation was valued with 1 point, noncompliance with 0 points. Table 1 shows an example of the valuations at the end of age 9 months (Table 1).
The points for the food-based recommendations for each age were summed up stepwise into scores representing increasingly more complex aspects of dietary quality. As a first step, 4 meal scores were constructed: breast milk/formula, complementary food, beverages, and snacks. To adjust for different numbers of food-based recommendations, meal scores were standardized and could range between 0 (compliant with none of the recommendations) and 1 (compliant with all of the recommendations).
As a second step, standardized meal scores were summed up to standardized daily nutrition scores, representing the total diet at the respective age. As a third and final step, the 5 daily nutrition scores for each infant were summed up to a total diet score that represented compliance with the total of food-based recommendations between the ages of 2 and 12 months.
Data analysis was performed by use of SAS procedures (Statistical Analysis System version 8e, SAS Institute, Cary, NC). Infants were randomly assigned to the study groups by random numbers generated with the RANUNI function. To test for differences between the scores for the IGs, the χ2 test was used for food-based recommendations and meal scores, and the Kruskal-Wallis test (NPAR1WAY) for the standardized daily nutrition scores and total diet scores. P ≤ 0.05 was valued as significant.
The main outcome variable was the standardized total diet score. Post hoc calculation showed that the given group size enabled the detection of a difference of 0.1 score points with a power of β ≥ 0.8 at an α = 0.05 (19).
From the total of 727 mothers eligible for participation, 235 gave their written consent for study participation. Baseline randomization (2 months) is depicted in Fig. 2. Baseline characteristics of the study sample were not different between the IGs (Table 2).
Offers of nutritional counseling were used moderately throughout the intervention period. TH was used by 52 mothers (37% of potential users) for a total of 107 calls, most frequently when infants were between 4 and 9 months old. Most often, TH questions concerned complementary feeding (64%). PTC was used on average by 54% of the mothers, most often (64%) at the age of 6 months. Mean (SD) duration was 14 (9) minutes. Nonparticipation in the PTC was most often caused by nonavailability at the fixed date or lack of interest because mothers already felt self-confident because of their dietary experience with an older child. Long-term compliance with the TI for evaluation was 99%.
Increasing intensity of counseling improved compliance with the food-based recommendations for choice of milk (breast milk, formula) significantly at each age and with other food-based recommendations sporadically (Fig. 3). From the age of 6 months onward, increasing intensity of counseling also significantly improved 2 of the 4 meal scores (milk, beverages) (data not shown) and the daily nutrition scores (Fig. 4).
The standardized total diet score of the control group (IG0) of 0.57 indicates that more than half of the food-based recommendations were fulfilled without any counseling. Nevertheless, the total diet score improved with increasing counseling intensity (Fig. 5) as a result of personal counseling by the TH and the PTC. Counseling by WI did not increase compliance with the recommendations.
To our knowledge, this is the first randomized controlled intervention trial to examine maternal compliance with a program for dietary counseling focused on complementary feeding and total diet in the second half of the first year of life.
The results show that the effects of counseling on compliance with food-based recommendations could be measured by using specific nutritional scores, and personal counseling by telephone (TH and PTC) improved compliance with the recommendations, whereas counseling by written material (WI) was almost ineffective.
Describing the consumption of food or food groups is one of the major approaches to the assessment of overall diet quality. Several indices have been developed to measure dietary quality in adults and children (20–23). We are unaware of any index to measure the quality of infant nutrition.
In this study, food-based and meal-based scores were developed to characterize the quality of infant nutrition. According to the concept of the food-based dietary guidelines (24), the German Dietary Schedule for infant nutrition translates existing nutrient-based recommendations into a food-based total diet concept that is meaningful to mothers. Here, food consumption was used as a proxy for nutrient intake. We assumed that nutrient intake would be closer to the references the closer the food intake complied with the Dietary Schedule. In this way, as many as 15 dietary criteria could be evaluated at an individual age.
Although details for complementary feeding are not common for different countries, the principles all focus on the same main issues. Hence, the scores developed here may be adapted to other countries as well.
Overall, infants in this study were well nourished, similarly to the findings from a Germany-wide breast-feeding survey and the local DONALD study (Dortmund Nutritional and Anthropometric Longitudinally Designed Study) (25,26). Nevertheless, compliance with recommendations was enhanced significantly by counseling, although the offers were accepted by mothers only moderately.
In accordance with the recommendations, approximately 90% of mothers in this study and other surveys in Germany (25,26) began by breast-feeding their infants. Although breast-feeding duration has been on the rise in recent decades in Germany (26), the recommendations for the duration of exclusive breast-feeding and for partial breast-feeding have not yet been achieved. Whereas the timing and composition of complementary meals were in general in line with the dietary schedule (Fig. 1), fluids in terms of juices or tea were usually introduced too early. Similarly, from a large study of feeding infants and toddlers in the United States, it was concluded that parents in particular should be advised to breast-feed throughout the first year of life, to choose beverages wisely for their infants, and to select nutrient-dense foods for complementary meals (27).
In this study, we tested PTC as an innovative method in addition to classic methods of nutrition counseling such as booklets or telephone hotlines. In accordance with experiences from breast-feeding counseling, we found that the counseling effects of booklets were slight (11,13) compared with personal counseling (6,8,28). The measurable success of counseling in this study could be explained by the fact that counseling was closely meshed with the time of introduction of new complementary meals, when mothers may feel the need for advice.
Experiences from breast-feeding counseling showed that compliance with recommendations decreased with increasing age of the infants and was much higher with regard to milk nutrition than to complementary foods (29–31). Possible causes discussed by Schoetzau et al (30) may also be relevant for our study. Nutritional recommendations would be followed better if they were given for shorter time periods. In this study, intervals of counseling were longer in the second half of the first year than in the first half, and advice had to be remembered for a longer time. Therefore, such nutritional counseling should be more comprehensive. Furthermore, counseling regarding complementary feeding needs to be much more complex than for milk feeding, thus perhaps limiting the acceptance and practicability.
These facts are well in accordance with the feeding infants and toddlers study done in the United States, which suggests that developing comprehensive interventions that provide guidance not just on breast-feeding but also on the entire infant-feeding and child-feeding continuum will be one of the significant challenges for improving infant and child nutrition in the future (27).
Owing to the elaborate study protocol, a conveniently small sample was recruited. However, the group size was adequate for estimating the total nutrition score as a primary outcome variable. For less aggregated scores, differences between the groups were often not significant. However, all of the links between the intensity of counseling and compliance with recommendations were plausible and point to the fact that even slight effects of specific counseling combined to produce more favorable nutrition. Thus, for total nutrition, significant differences between the groups could be shown.
From a public health point of view, it would be desirable to verify the outcome of this study with a larger sample size. This may show more often the effects for single food-based or meal-based scores as well. Then it would be possible to develop counseling messages that are better tailored for mothers of infants.
In accordance with other studies, the mothers in all of the IGs in our study named the pediatrician and magazines as their most used sources of dietary information (32,33). Approximately 50% of the mothers throughout the IGs used these sources outside study treatment (Table 2). We do not know whether this external information was concordant with our study counseling or whether the counseling effects of the study were thereby biased.
Another weakness of the study is that we cannot exclude that mothers with a particular interest in infant nutrition were overrepresented. Moreover, a study should be conducted to determine whether the effects shown here for mothers with above-average levels of education are also valid for groups of mothers with lower educational levels and for non–German-speaking mothers.
It must also be stated that in the dietary assessment the mothers gave their own accounts of the feeding. To overcome the problem of receiving socially desirable answers, TIs were always done before counseling. Additionally, TIs were made by uncommitted interviewers.
In conclusion, the measured effects of our innovative approach of personal telephone counseling point to the advantages of personal contact for dietary counseling of parents concerning their infants' diet. Over and above our telephone-based approach, face-to-face contact—for instance between mothers and experts—may positively influence infant feeding practices even more favorably.
The authors thank all of the mothers who participated in this study and made it possible through their invaluable contributions.
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