Dr Kerith Duncanson

Introduction: Functional dyspepsia (FD), characterised by symptoms of epigastric pain or early satiety and post prandial distress, has been associated with duodenal eosinophilia, raising the possibility that it is driven by an environmental allergen. Non-coeliac gluten or wheat sensitivity (NCG/WS) has also been associated with both dyspeptic symptoms and duodenal eosinophilia, suggesting an overlap between these two conditions. The aim of this study was to evaluate the role of wheat (specifically gluten and fructans) in symptom reduction in participants with FD in a pilot randomized double-blind, placebo controlled, dietary crossover trial. Methods: Patients with Rome III criteria FD were recruited from a single tertiary centre in Newcastle, Australia. All were individually counselled on a diet low in both gluten and fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) by a clinical dietitian, which was followed for four weeks (elimination diet phase). Those who had a >30% response to the run-in diet, as measured by the Nepean Dyspepsia Index, were then re-challenged with ¿muesli¿ bars containing either gluten, fructan, or placebo in randomised order. Those with symptoms which significantly reduced during the elimination diet, but reliably reappeared (a mean change in overall dyspeptic symptoms of >30%) with gluten or fructan re-challenge were deemed to have wheat induced FD. Results: Eleven participants were enrolled in the study (75% female, mean age 43 years). Of the initial cohort, nine participants completed the elimination diet phase of whom four qualified for the rechallenge phase. The gluten-free, low FODMAP diet led to an overall (albeit non-significant) improvement in symptoms of functional dyspepsia in the diet elimination phase (mean NDI symptom score 71.2 vs. 47.1, p = 0.087). A specific food trigger could not be reliably demonstrated. Conclusions: Although a gluten-free, low-FODMAP diet led to a modest overall reduction in symptoms in this cohort of FD patients, a specific trigger could not be identified. The modified Salerno criteria for NCG/WS identification trialled in this dietary rechallenge protocol was fit-for-purpose. However, larger trials are required to determine whether particular components of wheat induce symptoms in functional dyspepsia.

Food ingestion is heavily implicated in inducing symptoms of irritable bowel syndrome (IBS) and functional dyspepsia (FD), which affect over one-third of adults in developed countries. The primary aim of this paper was to assess the alignment of dietary assessment and symptom-reporting capture periods in diet-related studies on IBS or FD in adults. Secondary aims were to compare the degree of alignment, validity of symptom-reporting tools and reported significant associations between food ingestion and symptoms. A five-database systematic literature search resulted in 40 included studies, from which data were extracted and collated. The food/diet and symptom capture periods matched exactly in 60% (n = 24/40) of studies, overlapped in 30% (n = 12/40) of studies and were not aligned in 10% (n = 4/40) of studies. Only 30% (n = 12/40) of studies that reported a significant association between food and global gastrointestinal symptoms used a validated symptom-reporting tool. Of the thirty (75%) studies that reported at least one significant association between individual gastrointestinal symptoms and dietary intake, only four (13%) used a validated symptom tool. Guidelines to ensure that validated symptom-reporting tools are matched with fit-for-purpose dietary assessment methods are needed to minimise discrepancies in the alignment of food and symptom tools, in order to progress functional gastrointestinal disorder research.

Guidance for food consumption and portion control plays an important role in the global management of overweight and obesity. Carefully conceptualised serving size labelling can contribute to this guidance. However, little is known about the relationship between the information that is provided regarding serving sizes on food packages and levels of actual food consumption. The aim of this systematic review was to investigate how serving size information on food packages influences food consumption. We conducted a systematic review of the evidence published between 1980 and March 2018. Two reviewers screened titles and abstracts for relevance and assessed relevant articles for eligibility in full-text. Five studies were considered eligible for the systematic review. In three of the included studies, changes in serving size labelling resulted in positive health implications for consumers, whereby less discretionary foods were consumed, if serving sizes were smaller or if serving size information was provided alongside contextual information referring to the entire package. One study did not find significant differences between the conditions they tested and one study suggested a potentially negative impact, if the serving size was reduced. The influence of labelled serving size on consumption of non-discretionary foods remains unclear, which is partially due to the absence of studies specifically focusing on non-discretionary food groups. Studies that investigate the impact of serving size labels within the home environment and across a broad demographic cross-section are required.

Aim: Grandparents are assuming increased child-caregiving responsibilities, which potentially influences the dietary intake of grandchildren. The aim of this systematic review is to determine the influence of grandparental care on the dietary intake, food-related behaviours, food choices and weight status of their preschool and school-aged grandchildren. Methods: Six electronic health databases were searched in January 2017. Inclusion criteria were publication in English language, peer-reviewed journal between 2000 and 2017; children aged 2¿12 years; study outcomes included child dietary intake/weight status, grandparent nutrition knowledge/beliefs or grandparent/parent feeding practices. Included studies were appraised for quality and bias. The review was registered with PROSPERO, number CRD42016047518. Results: Sixteen studies were identified in the review, published between 2007 and 2016, with 15 assessed as moderate or high quality. Nine studies reported grandparental child feeding attitudes and behaviours that are considered to negatively influence child dietary intake, while three studies identified positive influences. Seven studies identified that differences in child feeding attitudes and behaviours between parents and grandparents created conflict and tensions between caregivers, often resulting in poor feeding practices. Statistically significant positive associations (odds ratio 1.47¿1.72) between grandparent cohabitation and increased rates of child overweight and obesity were found in four studies. Conclusions: Grandparents in caregiving roles may negatively influence the dietary intake and weight status of their grandchildren. More rigorous, targeted studies are required to further define the mechanisms by which grandparents' knowledge, attitudes and feeding behaviours may influence child dietary intake. This review suggests that grandparents may be an important audience to target in future child nutrition interventions.

Aim: The aim was to evaluate the utility of a brief dietary intake assessment tool in measuring nutritional adequacy of preschoolers and differences in food and nutrient intake between quartiles stratified by overall diet quality. Methods: Dietary intakes of preschoolers (n = 146) from the Feeding Healthy Food to Kids trial were reported by parents/caregivers using a 120-item food frequency questionnaire (FFQ). Diet quality was assessed using the Australian Recommended Food Score for Preschoolers. Analyses were performed using Kruskal¿Wallis one-way analysis of variance, adjusted for Type 1 error. Participants were grouped into quartiles by total food score for comparison of subscale scores, food groups and nutrient intakes from the FFQ. Results: Participants who scored less than the median total food score of 36 were more likely to have suboptimal micronutrient intakes. Median fruit (9 vs 5, P < 0.0001) and vegetable (14 vs 7, P < 0.0001) subscale scores for preschoolers in the highest quartile were significantly higher than the lowest quartile, indicating much greater fruit and vegetable variety. Statistically significant differences in diet quality score by quartiles (P < 0.05) were found for total energy and percentage energy from core foods, protein, fibre and 11 micronutrients. Conclusions: The Australian Recommended Food Score for Preschoolers is a practical brief diet quality assessment tool to measure food variety and nutritional adequacy in Australian preschoolers. Stratifying children by baseline diet quality in future nutrition interventions is recommended in order to identify those who are likely to benefit or require more targeted approaches to address specific nutritional needs in order to optimise food and nutrient intakes.

Issues addressed It is not known whether individuals can accurately estimate the portion size of foods usually consumed relative to standard serving sizes in national food selection guides. The aim of the present cross-sectional pilot study was to quantify what adults and children deem a typical portion for a variety of foods and compare these with the serving sizes specified in the Australian Guide to Healthy Eating (AGHE). Methods Adults and children were independently asked to serve out their typical portion of 10 common foods (rice, pasta, breakfast cereal, chocolate, confectionary, ice cream, meat, vegetables, soft drink and milk). They were also asked to serve what they perceived a small, medium and large portion of each food to be. Each portion was weighed and recorded by an assessor and compared with the standard AGHE serving sizes. Results Twenty-one individuals (nine mothers, one father, 11 children) participated in the study. There was a large degree of variability in portion sizes measured out by both parents and children, with means exceeding the standard AGHE serving size for all items, except for soft drink and milk, where mean portion sizes were less than the AGHE serving size. The greatest mean overestimations were for pasta (155%; mean 116 g; range 94-139g) and chocolate (151%; mean 38 g; range 25-50g), each of which represented approximately 1.5 standard AGHE servings. Conclusion The findings of the present study indicate that there is variability between parents' and children's estimation of typical portion sizes compared with national recommendations. So what? Dietary interventions to improve individuals' dietary patterns should target education regarding portion size.

Background: Diet quality tools provide researchers with brief methods to assess the nutrient adequacy of usual dietary intake. This study describes the development and validation of a pediatric diet quality index, the Australian Recommended Food Scores for Pre-schoolers (ARFS-P), for use with children aged two to five years. Methods. The ARFS-P was derived from a 120-item food frequency questionnaire, with eight sub-scales, and was scored from zero to 73. Linear regressions were used to estimate the relationship between diet quality score and nutrient intakes, in 142 children (mean age 4 years) in rural localities in New South Wales, Australia. Results: Total ARFS-P and component scores were highly related to dietary intake of the majority of macronutrients and micronutrients including protein, ß-carotene, vitamin C, vitamin A. Total ARFS-P was also positively related to total consumption of nutrient dense foods, such as fruits and vegetables, and negatively related to total consumption of discretionary choices, such as sugar sweetened drinks and packaged snacks. Conclusion: ARFS-P is a valid measure that can be used to characterise nutrient intakes for children aged two to five years. Further research could assess the utility of the ARFS-P for monitoring of usual dietary intake over time or as part of clinical management.

Background: Food frequency questionnaires (FFQ) are used in epidemiological studies to investigate the relationship between diet and disease. There is a need for a valid and reliable adult FFQ with a contemporary food list in Australia. Aims: To evaluate the reproducibility and comparative validity of the Australian Eating Survey (AES) FFQ in adults compared to weighed food records (WFRs). Methods: Two rounds of AES and three-day WFRs were conducted in 97 adults (31 males, median age and BMI for males of 44.9 years, 26.2 kg/m , females 41.3 years, 24.0 kg/m . Reproducibility was assessed over six months using Wilcoxon signed-rank tests and comparative validity was assessed by intraclass correlation coefficients (ICC) estimated by fitting a mixed effects model for each nutrient to account for age, sex and BMI to allow estimation of between and within person variance. Results: Reproducibility was found to be good for both WFR and FFQ since there were no significant differences between round 1 and 2 administrations. For comparative validity, FFQ ICCs were at least as large as those for WFR. The ICC of the WFR-FFQ difference for total energy intake was 0.6 (95% CI 0.43, 0.77) and the median ICC for all nutrients was 0.47, with all ICCs between 0.15 (%E from saturated fat) and 0.7 (g/day sugars). Conclusions: Compared to WFR the AES FFQ is suitable for reliably estimating the dietary intakes of Australian adults across a wide range of nutrients. © 2013 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. 2 2

Background: A direct association between parenting style and child feeding behaviours has not been established. This review explores whether an authoritative, authoritarian or permissive parenting style is associated with parental pressure to eat, responsibility, monitoring or restriction of child dietary intake. Methods: A search of eight electronic health databases was conducted. Inclusion criteria were children aged <12 years, published between 1975 and 2012, measured and reported associations between parenting style and child feeding behaviours. Results: Seven studies (n = 1845) were identified in the review. An authoritarian parenting style was associated with pressuring a child to eat and having restrictive parental food behaviours. Authoritative parenting was associated with parental monitoring of child food intake. A permissive parenting style was inversely related to monitoring of child dietary intake. Conclusions: Parenting styles showed only weak to moderate associations with individual domains of child feeding. The most consistent relationship found was a negative association between permissive parenting and monitoring for both mothers and fathers in two studies. Progress in this field could be achieved by conducting studies targeting fathers and culturally diverse populations, and development of a tool which could reflect overall child feeding behaviour rather than individual domains.

OBJECTIVES:: Community-based nutrition interventions aimed at influencing child dietary intake are rarely evaluated. We hypothesised that providing self-directed nutrition and parenting resources to parents living in rural northern New South Wales, Australia, would positively affect the dietary patterns of children ages 2 to 5 years. METHODS:: A total of 146 parent-child dyads (76 boys, ages 2.0-5.9 years) were randomly assigned to either a 12-month parent-centred intervention involving self-directed education provided in CD and DVD formats, or a participant-blinded control group who received generic nutrition and physical activity information. Data were collected at baseline, 3, and 12 months. RESULTS:: Total reported energy from nutrient-dense food groups and percentage energy from energy-dense, nutrient-poor foods were high at baseline relative to estimated total energy expenditure for child age. Using random effects modelling, there were significant group-by-time effects for a reduction in mean (standard deviation) total energy intake (EI) at 12 months (-461 kJ/day (196); Pâ¿¿=â¿¿0.04). An intervention group-by-time effect on carbohydrate intake (-17.4 g/day (10.6); Pâ¿¿<â¿¿0.05) was largely attributable to decreased consumption of breads and cereals (-180 g/day (80); Pâ¿¿=â¿¿0.007). Decreases in energy-dense, nutrient-poor foods were not statistically significant. CONCLUSIONS:: The proportion of total EI from noncore foods in children in rural New South Wales is high and did not improve in response to a low-intensity nutrition intervention. Parents reported small changes in consumption frequency for core and noncore food intakes, leading to a reduction in total EI. Strategies to increase resource use such as prompting via e-mail are required to further explore the effectiveness of nutrition resource dissemination at a population level. Copyright © 2013 by European Society for Pediatric Gastroenterology.