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Background Diet quality indexes are useful tools to measure diet quality because they compare dietary intakes against recommendations. A dietary quality index for Asian preschool-aged children is lacking. Objective The aims of this study were to develop and evaluate a dietary quality index for preschool-aged children (ie, the DQI-5) based on Singapore dietary recommendations and to examine diet quality in a cohort of 5-year-old children. An additional aim was to assess associations between sociodemographic characteristics and DQI-5 scores. Design A secondary analysis was conducted using dietary intake of children from the Growing Up in Singapore Towards healthy Outcomes mother–offspring cohort assessed in 2015-2016 using a validated food frequency questionnaire. The sociodemographic data were assessed at recruitment between June 2009 and September 2010. The DQI-5 was evaluated using a construct validity approach, whereby nutrition parameters associated with diet quality were studied. Participants and setting Participants were 767 Singaporean children aged 5 years of Chinese, Malay, or Indian ethnicity. Main outcome measures The main outcome measures were the DQI-5 scores and the sociodemographic characteristics associated with diet quality. Statistical analyses performed Kruskal-Wallis tests were used to evaluate differences in adherence to dietary recommendations across DQI-5 tertiles. Linear multiple regression analysis was performed to identify sociodemographic characteristics that were associated with diet quality in the children. Results The DQI-5 consists of 12 food and nutrient components, with a minimum score of zero and a maximum score of 110 points. The higher scores indicate a healthier diet, the mean ± SD DQI-5 score for the children was 61.6 ± 13.2. DQI-5 components with low scores included whole grains, vegetables, and fatty acid ratio, whereas total rice and alternatives and milk and dairy products components were overconsumed by 18% and 24.4% of children, respectively. Children with higher scores were more likely to meet dietary recommendations and had higher intake of nutrients such as dietary fiber, iron, vitamin A, and beta carotene. Children whose mothers were of Malay ethnicity and whose mothers had low income, an education below university, and shared primary caregiver responsibilities were more likely to have lower DQI-5 scores. Conclusions The DQI-5 scores revealed diets to be low for several components and excessive for a few. The DQI-5 developed for preschool-aged children in Singapore had adequate construct validity.

Advances in technology enabled the development of a web-based, pictorial FFQ to collect parent-report dietary intakes of 7-year-old children in the Growing Up in Singapore Towards healthy Outcomes study. This study aimed to compare intakes estimated from a paper-FFQ and a web-FFQ and examine the relative validity of both FFQ against 3-d diet records (3DDR). Ninety-two mothers reported food intakes of their 7-year-old child on a paper-FFQ, a web-FFQ and a 3DDR. A usability questionnaire collected participants’ feedback on the web-FFQ. Correlations and agreement in energy, nutrients and food groups intakes between the dietary assessments were evaluated using Pearson’s correlation, Lin’s concordance, Bland–Altman plots, Cohen’s κ and tertile classification. The paper- and web-FFQ had good correlations (≥ 0·50) and acceptable-good agreement (Lin’s concordance ≥ 0·30; Cohen’s κ ≥ 0·41; ≥ 50 % correct and ≤ 10 % misclassification into same or extreme tertiles). Compared with 3DDR, both FFQ showed poor agreement (< 0·30) in assessing absolute intakes except micronutrients (web-FFQ had acceptable-good agreement), but showed acceptable-good ability to classify children into tertiles (κ ≥ 0·21; ≥ 40 % and ≤ 15 % correct or misclassification). Bland–Altman plots suggest good agreement between web-FFQ and 3DDR in assessing micronutrients and several food groups. The web-FFQ was well-received, and majority (81 %) preferred the web-FFQ over the paper-FFQ. The newly developed web-FFQ produced intake estimates comparable to the paper-FFQ, has acceptable-good agreement with 3DDR in assessing absolute micronutrients intakes and has acceptable-good ability to classify children according to categories of intakes. The positive acceptance of the web-FFQ makes it a feasible tool for future dietary data collection.

There is limited data on the dietary patterns of 5-year-old children in Asia. The study examined childhood dietary patterns and their maternal and child correlates in a multi-ethnic Asian cohort. Based on caregiver-reported 1-month quantitative FFQ of 777 children from the Growing Up in Singapore Towards healthy Outcomes cohort, cluster analysis identified two mutually exclusive clusters. Children in the ‘Unhealthy’ cluster (43·9 %) consumed more fries, processed meat, biscuits and ice cream, and less fish, fruits and vegetables compared with those in the ‘Healthy’ cluster (56·1 %). Children with mothers of lower educational attainment had twice the odds of being assigned to the ‘Unhealthy’ cluster (adjusted OR (95 % CI) = 2·19 (95 % CI 1·49–3·24)). Children of Malay and Indian ethnicities had higher odds of being assigned to the ‘Unhealthy’ cluster (adjusted OR = 25·46 (95 % CI 15·40, 42·10) and 4·03 (95 % CI 2·68–6·06), respectively), relative to Chinese ethnicity. In conclusion, this study identified two dietary patterns in children, labelled as the ‘Unhealthy’ and ‘Healthy’ clusters. Mothers’ educational attainment and ethnicity were two correlates that were associated with the children’s assignments to the clusters. These findings can assist in informing health promotion programmes targeted at Asian children.

Childcare arrangements shape behavioural patterns that influence the risk of childhood obesity. However, little is known of its influence on childhood obesity in Singapore. We aim to examine the associations between childcare arrangements at the age of 5 years and childhood adiposity at age 6 years. Children from the GUSTO study were grouped into three childcare arrangements at age 5: full-time centre-based childcare (FC), partial centre-based with parental care (PCP), and partial centre-based with non-parents (grandparents and domestic helpers) as caregivers (PCN). Diet, physical activity and sedentary behaviour information were collected at age 5, while anthropometric measurements were collected at age 6. Associations were analysed using multivariable regression models. Among 540 children, those in PCN had higher BMI z-scores (β: 0.34; 95% CI: 0.01, 0.66), greater sum of skinfold thicknesses (mm) (β: 3.75; 95% CI: 0.53, 6.97) and were 3.55 times (95% CI: 1.78, 7.05) more likely to be overweight/obese than those in FC. Adiposity measures in PCP children did not differ from those in FC. PCN children were reported to have more screen time and greater fast-food intake. Children in PCN tended to have higher adiposity measures. Greater engagement of non-parental caregivers should be considered in interventions targeting child obesity. Agency for Science, Technology and Research (A*STAR) Ministry of Health (MOH) National Medical Research Council (NMRC) Published version The GUSTO cohort study was funded by the Singapore National Research Foundation’s Translational and Clinical Research (TCR) Flagship Programme and was administered by the Singapore Ministry of Health’s National Medical Research Council (NMRC), Singapore—NMRC/TCR/004- NUS/2008; NMRC/TCR/012-NUHS/2014. Additional funding was given by the Singapore Institute for Clinical Sciences, Agency for Science Technology and Research (A*STAR), Singapore. KMG is supported by the UK Medical Research Council (MC_UU_12011/4), the National Institute for Health Research (NIHR Senior Investigator NF-SI-0515-10042), NIHR Southampton 1000DaysPlus Global Nutrition Research Group (17/63/154) and NIHR Southampton Biomedical Research Centre (IS-BRC1215-20004), the British Heart Foundation (RG/15/17/3174) and by the European Union (Erasmus+ Programme Early Nutrition eAcademy Southeast Asia-573651-EPP-1-2016-1-DE-EPPKA2-CBHE-JP and ImpENSA.

My E-Diary for Activities and Lifestyle (MEDAL), a web-based application, was developed to assess the diets of children. This study examined the validity of school recess meals reported by children on MEDAL, using meal photography as the reference. Recess meals were photographed by trained researchers, and food items and portion sizes of recess meals reported on MEDAL were compared to recess meal photos. Validity was assessed by percentages of match, omission and intrusion for food items and percentages of the match, underestimation and overestimation for portion sizes. The Mann–Whitney test and the Wilcoxon matched-pairs signed-rank test examined if sex, school and day of recording influenced the validity of food item reporting. We found that participants (n = 33, aged 10–11 years) recalled 60.2% of food items consumed at recess accurately (matches), omissions (24.6%) were more common than intrusions (15.2%). Omissions tended to be side dishes, and intrusions tended to be high-calorie items. Sex, school and day of recording did not influence validity. For food portion sizes, 58.3% of items were accurately reported. Overestimations (33.3%) were more common than underestimations (8.3%). In conclusion, these children were able to report food items consumed during school recess meals using MEDAL, albeit with limitations on the degree of accuracy.

PURPOSE: Few studies have described adherence to dietary patterns over time in women of childbearing age. This study aims to describe, examine the stability and changes in dietary patterns between pregnancy and 6 years post-pregnancy and the sociodemographic and lifestyle factors influencing the adherence over time. METHODS: During pregnancy and at 6 years post-pregnancy, 24-hour recalls and food frequency questionnaires were collected, respectively, from 709 women. Data on sociodemographic and lifestyle factors were collected via questionnaires. Dietary patterns were identified using principal component analysis and stability assessed using Pearson’s correlation coefficients (r) and Cohen’s weighted kappa (k). Associations with sociodemographic characteristics were assessed by multiple logistic regression. RESULTS: The ‘Fruits, Vegetables and Legumes’ (FVL) and ‘Seafood, Noodle, Soup’ (SNS) patterns were identified at both time points, with low correlation for the dietary pattern z-scores (r: 0.2 and 0.3, respectively) and modest agreement in tertile assignment, suggesting poor stability. An ‘unhealthy’ pattern was only observed at 6 years post-pregnancy. Women who showed increased adherence to FVL pattern had higher educational attainment and exhibited healthy lifestyle behaviours. Women who had gestational diabetes during pregnancy were less likely to decrease adherence to FVL pattern over time. Women who adhered more closely to the ‘unhealthy’ pattern at 6 years post-pregnancy tended to be younger, of Malay ethnicity, had lower socioeconomic status, were less physically active and had additional pregnancies. CONCLUSIONS: Dietary habits of women became less healthy during the transition from pregnancy to 6 years post-pregnancy. However, results should be interpreted with caution due to the different dietary assessment tools used at the two time points.

Consumption of sugar-sweetened beverages (SSB) by infants and young children are less explored in Asian populations. The Growing Up in Singapore Towards healthy Outcomes cohort study examined associations between SSB intake at 18 months and 5 years of age, with adiposity measures at 6 years of age. We studied Singaporean infants/children with SSB intake assessed by FFQ at 18 months of age (n 555) and 5 years of age (n 767). The median for SSB intakes is 28 (interquartile range 5·5–98) ml at 18 months of age and 111 (interquartile range 57–198) ml at 5 years of age. Association between SSB intake (100 ml/d increments and tertile categories) and adiposity measures (BMI standard deviation scores (sd units), sum of skinfolds (SSF)) and overweight/obesity status were examined using multivariable linear and Poisson regression models, respectively. After adjusting for confounders and additionally for energy intake, SSB intake at age 18 months were not significantly associated with later adiposity measures and overweight/obesity outcomes. In contrast, at age 5 years, SSB intake when modelled as 100 ml/d increments were associated with higher BMI by 0·09 (95 % CI 0·02, 0·16) sd units, higher SSF thickness by 0·68 (95 % CI 0·06, 1·44) mm and increased risk of overweight/obesity by 1·2 (95 % CI 1·07, 1·23) times at age 6 years. Trends were consistent with SSB intake modelled as categorical tertiles. In summary, SSB intake in young childhood is associated with higher risks of adiposity and overweight/obesity. Public health policies working to reduce SSB consumption need to focus on prevention programmes targeted at young children.

Background/Aims: Insufficient vitamin D status has been associated with adverse pregnancy outcomes; thus, it has been recognized as a public health concern. There have been no published data on vitamin D status in Bangladeshi pregnant women. The objective of this study was to determine the prevalence and risk factors of vitamin D deficiency among pregnant women in rural Bangladesh. Methods: A cross-sectional study was conducted with 522 pregnant women, with a gestational age of

BackgroundFood frequency questionnaires (FFQs) are often used to assess dietary intakes due to their ability to assess intake over extended periods, their low respondent burden, and their cost-effectiveness. A quantitative FFQ that includes locally appropriate food items for 5-year-old children in a multiethnic Asian population was developed, but its validity has not previously been evaluated.ObjectiveTo evaluate the relative validity of a newly developed FFQ as a dietary assessment tool for 5-year-old children in a multiethnic Asian population.DesignThe 112 –food item FFQ was administered by trained interviewers to caregivers of children. Frequency of food items consumed in the previous month and portion size information were collected. The FFQs were evaluated against 3-day nonweighed diet records (DRs) completed by caregivers.Participants/settingThe dietary data of 361 children aged 5 years from the Growing Up in Singapore Towards Healthy Outcomes mother-offspring cohort were collected in 2015-2016.Main outcome measuresNutrients of interest included energy, macronutrients, fiber, cholesterol, vitamin A, beta carotene, calcium, and iron, calculated from the FFQs and DRs.Statistical analyses performedNutrient intakes according to FFQs in relation to DRs were assessed using Pearson’s correlation, Lin’s concordance, Bland-Altman plots, quintile joint classification, and Cohen’s κ statistics.ResultsThe highest energy-adjusted correlation (Pearson’s r=0.71) and concordance (Lin’s concordance=0.69) were observed for calcium. Fiber, saturated fat, polyunsaturated fatty acids (PUFA), cholesterol, and iron also showed correlation coefficients and concordance of at least 0.40. Bland-Altman plots suggested no substantial bias across ranges of intakes for the nutrients with correlations and concordance of 0.40 or above. Quintiles joint classification showed substantial agreement for calcium (κ=0.66), and moderate agreement for iron, fiber, saturated fat, polyunsaturated fat, and beta carotene (κ=0.59, 0.54, 0.49, 0.44, 0.43, respectively).ConclusionsThe newly developed FFQ is in reasonable agreement with DR for estimating intakes of calcium, fiber, saturated fat, PUFA, cholesterol, and iron. In addition, the FFQ is able to classify children according to quintiles of nutrient intakes, with moderate to substantial quintile agreements between FFQ and DR for calcium, iron, fiber, saturated fat, PUFA, and beta carotene. To assess the remaining nutrients, DR method is recommended instead of the FFQ.

OBJECTIVES: We assessed the stability of maternal dietary patterns from pregnancy to 6 years post-pregnancy and their associated-sociodemographic and lifestyle factors. METHODS: At 26–28 weeks’ gestation and 6 years post-pregnancy, 24-hour recalls and food frequency questionnaires were collected, respectively, from women in the GUSTO mother-offspring cohort (n = 709). Data on maternal sociodemographic and lifestyle factors were collected at recruitment and again during the 4 to 6-year follow-up visits. Dietary patterns were identified using principal component analysis and stability assessed using Pearson's correlation coefficients and Cohen's weighted kappa. Associations were assessed by multivariable logistic regression, with adjustment for covariates. RESULTS: The ‘Fruits, Vegetables and Legumes’ (FVL) and ‘Seafood, Noodle, Soup’ (SNS) patterns were identified at both time points, with poor correlation for the dietary pattern z-scores (correlation coefficients: 0.2 and 0.3, respectively) and modest agreement in tertile assignment (weighted κ: 0.11 and 0.15, respectively), suggesting poor stability. An ‘unhealthy’ pattern was only observed at 6 years post-pregnancy. Women with only primary/secondary level education tended to decrease adherence to FVL pattern over time. Women who had gestational diabetes during pregnancy tended to maintain high adherence to FVL pattern over time. Other health conditions such as hypertension during pregnancy and post-delivery development of type 2 diabetes and hypertension did not appear to influence change in women's diet. Women who showed increased adherence to FVL pattern also exhibited healthy lifestyle behaviours, such as being more physically active, post-pregnancy. Women who adhered more closely to the ‘unhealthy’ pattern at 6 years post-pregnancy tended to be younger, of Malay ethnicity, had lower education, had lower household income at 5 years post-pregnancy, were less physically active and had additional pregnancies. CONCLUSIONS: Study findings may be used to inform the design of public health interventions for certain subgroups of women during pregnancy and at post-pregnancy that target key dietary and lifestyle risk behaviours. FUNDING SOURCES: Singapore Ministry of Health's NMRC, Singapore—NMRC/TCR/004-NUS/2008; NMRC/TCR/012-NUHS/2014, SICS, A*STAR, and MOE Academic Research Fund.

Background: In Asia, little is known about how maternal feeding practices are associated with dietary intakes and body mass index (BMI) in preschoolers. Objective: To assess the relationships between maternal feeding practices with dietary intakes and BMI in preschoolers in Asia using cross-sectional analysis in the GUSTO (Growing Up in Singapore Towards healthy Outcomes) cohort. Participant settings: Mothers (n = 511) who completed the Comprehensive Feeding Practices Questionnaire (CFPQ) and a semi-quantitative Food Frequency Questionnaire (FFQ) when children were 5 years old. Statistical analysis: Associations between 12 maternal feeding practices (mean scores divided into tertiles) and children’s dietary intakes of seven food groups and BMI z-scores were examined using the general linear regression model. Weight and height of the child were measured, and dietary intakes derived from the FFQ. Results: Compared to those in the low tertile, mothers in the high tertile of modelling healthy food intakes had children with higher intakes of vegetables[+20.0g/day (95%CI:11.6,29.5)] and wholegrains[+ 20.9g/day (9.67,31.1)] but lower intakes of sweet snacks[-10.1g/day (-16.3,-4.94)] and fast-foods[-5.84g/day (-10.2,-1.48)]. Conversely, children of mothers in the high tertile for allowing child control (lack of parental control) had lower intake of vegetables[-15.2g/day (-26.6,-5.21)] and wholegrains[-13.6g/day (-22.9,-5.27)], but higher intakes of sweet snacks[+13.7g/day (7.7, 19.8)] and fast-foods[+6.63g/day (3.55,9.72)]. In relation to BMI at 5 years, food restrictions for weight was associated with higher BMI z-scores [0.86SD (0.61,1.21)], while use of pressure was associated with lower BMI z-scores[-0.49SD(-0.78,-0.21)]. Conclusions and implications: Modelling healthy food intakes by mothers was the key feeding practice associated with higher intakes of healthy foods and lower intakes of discretionary foods. The converse was true for allowing child control. Only food restrictions for weight and use of pressure were associated with BMI z-scores. NRF (Natl Research Foundation, S’pore) ASTAR (Agency for Sci., Tech. and Research, S’pore) NMRC (Natl Medical Research Council, S’pore) MOH (Min. of Health, S’pore) Published version

Background: Osteoporosis occurred in 64% of Indonesian women aged 60-64 years. The risk of osteoporosis can be reduced by achieving optimal peak bone mass in ages 25-32 years. However, 33.4% women had low peak bone mass (LPBM).Objective: We aimed to develop a tool to identify women at risk of developing LPBM in order to ameliorate this situation. Some risk/protective factors were explored in a case-control study.Method: We recruited 25 cases, those with LPBM (T-score