What is the relationship between types and amounts of complementary foods and beverages and growth, size, and body composition?

Conclusion Statement

• Moderate evidence indicates that higher versus lower meat intake or meat versus iron-fortified cereal intake over a short duration (~3mo) during the complementary feeding period does not favorably or unfavorably influence growth, size, and/or body composition. There is insufficient evidence to determine a relationship between meat intake and prevalence/incidence of overweight or obesity.
• Limited evidence suggests that type or amount of cereal given does not favorably or unfavorably influence growth, size, body composition, and/or prevalence/incidence of overweight or obesity.
• Moderate evidence suggests that consumption of complementary foods with different fats and/or fatty acid composition does not favorably or unfavorably influence growth, size, or body composition. There is not enough evidence to determine a relationship between consumption of complementary foods with different fats and/or fatty acid composition and/or prevalence/incidence of overweight or obesity.
• Limited evidence suggests that sugar sweetened beverage consumption during the complementary feeding period is associated with increased risk of obesity in childhood, but is not associated with other measures of growth, size, and body composition.
• Limited evidence showed a positive association between juice intake and infant weight-for-length and child BMI z-scores.
• No conclusion could be made about the relationship between other complementary foods (vegetables, fruit, dairy products and/or cow’s milk, cereal-based products, milk-cereal drink, and/or categories such as “ready-made foods“) and growth, size, body composition, and/or prevalence/incidence of overweight or obesity.
• No conclusion could be made about the relationship between distinct dietary patterns during the complementary feeding period and growth, size, body composition, and/or prevalence/incidence of malnutrition, overweight or obesity. 

Grades: Moderate - Meat; Different Fats and/or Fatty Acid Composition; Limited - Juice; Sugar-Sweetened Beverages; Grade Not Assignable - Cereal; Other CFB; Dietary Patterns

Plain Language Summary

What is the question?

• The question is: What is the relationship between types and amounts of complementary foods and beverages consumed and growth, size, and body composition?

What is the answer to the question?

• Moderate evidence indicates that higher versus lower meat intake or meat versus iron-fortified cereal intake over a short duration (~3mo) during the complementary feeding period does not favorably or unfavorably influence growth, size, and/or body composition. There is insufficient evidence to determine a relationship between meat intake and prevalence/incidence of overweight or obesity.
• Limited evidence suggests that type or amount of cereal given does not favorably or unfavorably influence growth, size, body composition, and/or prevalence/incidence of overweight or obesity.
• Moderate evidence suggests that consumption of complementary foods with different fats and/or fatty acid composition does not favorably or unfavorably influence growth, size, or body composition. There is not enough evidence to determine a relationship between consumption of complementary foods with different fats and/or fatty acid composition and/or prevalence/incidence of overweight or obesity.
• Limited evidence suggests that sugar sweetened beverage consumption during the complementary feeding period is associated with increased risk of obesity in childhood, but is not associated with other measures of growth, size, and body composition.
• Limited evidence showed a positive association between juice intake and infant weight-for-length and child BMI z-scores.
• No conclusion could be made about the relationship between other complementary foods (vegetables, fruit, dairy products and/or cow’s milk, cereal-based products, milk-cereal drink, and/or categories such as “ready-made foods“) and growth, size, body composition, and/or prevalence/incidence of overweight or obesity.
• No conclusion could be made about the relationship between distinct dietary patterns during the complementary feeding period and growth, size, body composition, and/or prevalence/incidence of malnutrition, overweight or obesity.

Why was this question asked? 

• This important public health question was identified and prioritized as part of the U.S. Department of Agriculture and Department of Health and Human Services Pregnancy and Birth to 24 Months Project.

How was this question answered? 

• A team of Nutrition Evidence Systematic Review staff conducted a systematic review in collaboration with a group of experts called a Technical Expert Collaborative

What is the population of interest? 

• Generally healthy infants and toddlers who were fed complementary foods and beverages from ages 0-24 months and had growth, size, and/or body composition outcomes measured across the lifespan

What evidence was found? 

• Forty-nine articles were included that addressed type and/or amount of complementary foods and beverages consumed, including the introduction of specific complementary foods and beverages and dietary patterns during the complementary feeding period.
• The study designs included 18 randomized controlled trials, 1 non-randomized controlled trial, and 30 prospective cohort studies
• The studies varied in terms of the types and/or amounts of CFB examined, which included dietary patterns consumed during the complementary feeding period, meat, cereal, foods with different fatty acid composition, SSB, juice or 100% juice, and other CFB
• The gaps and limitations in the evidence may include the following:
  • Randomized controlled trials and studies that examine a wider range of specific types and amounts complementary foods and beverages,
  • Research that accounts for the rationale for type/amount of complementary foods and beverages given (e.g., reverse causality), and adjusts for potential confounders (e.g., human milk and/or formula-feeding and baseline growth status).

How up-to-date is this systematic review? 

• This review includes literature from 01/1980 to 07/2016.

Technical Abstract

Background

• The goal of this systematic review was to examine the following question: What is the relationship between types and amounts of complementary foods and beverages (CFB) consumed and growth, size, and body composition?
• Systematic reviews were conducted as part of the U.S. Department of Agriculture and Department of Health and Human Services Pregnancy and Birth to 24 Months Project.
• Complementary feeding is the process that starts when human milk or infant formula is complemented by other foods and beverages, beginning during infancy and typically continuing to 24 months of age. 

Conclusion Statement and Grade

• Moderate evidence indicates that higher versus lower meat intake or meat versus iron-fortified cereal intake over a short duration (~3mo) during the complementary feeding period does not favorably or unfavorably influence growth, size, and/or body composition. There is insufficient evidence to determine a relationship between meat intake and prevalence/incidence of overweight or obesity.
• Limited evidence suggests that type or amount of cereal given does not favorably or unfavorably influence growth, size, body composition, and/or prevalence/incidence of overweight or obesity.
• Moderate evidence suggests that consumption of complementary foods with different fats and/or fatty acid composition does not favorably or unfavorably influence growth, size, or body composition. There is not enough evidence to determine a relationship between consumption of complementary foods with different fats and/or fatty acid composition and/or prevalence/incidence of overweight or obesity.
• Limited evidence suggests that sugar sweetened beverage consumption during the complementary feeding period is associated with increased risk of obesity in childhood, but is not associated with other measures of growth, size, and body composition.
• Limited evidence showed a positive association between juice intake and infant weight-for-length and child BMI z-scores.
• No conclusion could be made about the relationship between other complementary foods (vegetables, fruit, dairy products and/or cow’s milk, cereal-based products, milk-cereal drink, and/or categories such as “ready-made foods“) and growth, size, body composition, and/or prevalence/incidence of overweight or obesity.
• No conclusion could be made about the relationship between distinct dietary patterns during the complementary feeding period and growth, size, body composition, and/or prevalence/incidence of malnutrition, overweight or obesity.
  
  Grades: Moderate- Meat; Different Fats and/or Fatty Acid Composition;
  Limited- Juice; Sugar-Sweetened Beverages;
  Grade Not Assignable- Cereal; Other CFB; Dietary Patterns

Methods 

• This systematic review was conducted by a team of staff from the Nutrition Evidence Systematic Review in collaboration with a Technical Expert Collaborative.
• A literature search was conducted using 4 databases (PubMed, Cochrane, Embase, and CINAHL) to identify articles that evaluated the intervention or exposure of types and amounts of CFB consumed and the outcomes of growth, size, and/or body composition. A manual search was conducted to identify articles that may not have been included in the electronic databases searched. Articles were screened by two authors independently for inclusion based on pre-determined criteria.
• Data extraction and risk of bias assessment were conducted for each included study, and both were checked for accuracy. The body of evidence was qualitatively synthesized to inform development of a conclusion statement(s), and the strength of evidence was graded using pre-established criteria evaluating the body of evidence on internal validity/risk of bias, adequacy, consistency, impact, and generalizability.

Summary of Findings 

• This review includes 49 articles from 18 randomized controlled trials, 1 non-randomized controlled trial, and 30 prospective cohort studies
• The studies varied in terms of the types and/or amounts of CFB examined, which included dietary patterns consumed during the complementary feeding period, meat, cereal, foods with different fatty acid composition, sugar-sweetened beverages, juice or 100% juice, and other CFB
• Gaps and limitations in the evidence include the need for randomized controlled trials and studies that examine a wider range of specific types and amounts complementary foods and beverages, account for the rationale for type/amount of complementary foods and beverages given (e.g., reverse causality), and adjust for potential confounders (e.g., human milk and/or formula-feeding and baseline growth status).

Suggested Citation

Suggested Citation: English LK, Obbagy JE, Wong YP, Psota TL, Nadaud P, Johns K, Terry N, Butte NF, Dewey KG, Fleischer DM, Fox MK, Greer FR, Krebs NF, Scanlon KS, Casavale KO, Spahn JM, Stoody E. Types and Amounts of Complementary Foods and Beverages and Growth, Size, and Body Composition: A Systematic Review. April 2019. U.S. Department of Agriculture, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Nutrition Evidence Systematic Review. Available at: https://doi.org/10.52570/NESR.PB242018.SR0306