Associations between early introduction to complementary foods, subsequent cereal-added bottle feeding and daily macronutrient intake among infants

Abstract

Introducing complementary foods early during infancy has been associated with an increased risk of overweight later in life, but the pathway is an understudied topic. Hence the study was conducted with low-income and primarily minority mother-infant dyads to: 1) understand how the introduction of complementary foods prior to 4 months was associated with socio-demographic characteristics and food security status; 2) determine the association between early introduction to complementary foods and breastfeeding and adding cereal into the bottle in later infancy (i.e., at 6 and 9 months), and; 3) examine how adding infant cereal into the bottle was related to daily calorie and macronutrient intake in infancy. We conducted interviews with mothers (n = 201) at 4 months of age and 24-hour feeding recalls at age 6 and 9 months. Results indicated that 29% of the infants were fed complementary foods before 4 months of age. Introducing complementary foods early was negatively associated with breastfeeding and positively associated with adding cereal into the bottle at 6-months. This practice was more common among those who experienced marginal to very low levels of food security. Comparing by race/ethnicity, Latinx mothers were significantly less likely to introduce solids early. After controlling for sex, infants fed cereal in the bottle were consuming significantly more calories compared to their counterparts. Specifically, adding cereal into the bottle resulted in approximately 10% additional daily calorie intake among infants. Understanding how these feeding practices affect appetite development and weight status during infancy is warranted.

INTRODUCTION

Infancy is a critical stage for establishing healthy dietary patterns. The 2020–2025 U.S Department of Agriculture Dietary Guidelines for Americans (DGA) provides feeding recommendations for infants and toddlers (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). The DGA recommends exclusive feeding of human milk for the first six months. When feeding human milk exclusively or partially is not possible, iron-fortified infant formula is recommended. (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2020). Further, introduction to complementary foods prior to four months is not recommended because gastrointestinal, immunological, and renal systems are not yet fully matured, and infants’ oral motor skills may not be developmentally ready to swallow food (Naylor & Morrow, 2001). In addition, early introduction to complementary foods and beverages has been associated with discontinued breastfeeding, early transition to formula feeding, and non-responsive feeding styles, which in turn have been shown to increase the risk for poor dietary habits and childhood obesity (Pérez-Escamilla et al., 2017; Baidal et al., 2016).

Infant cereal is a common initial complementary food. About half of the infants in the U.S. receive cereal daily, commonly through a bottle with formula or breastmilk (Roess et al., 2018; Smith et al., 2019). For instance, a study conducted among a low-income and predominantly African American population found that 78% of the infants were given infant cereal at 3 months of age, with 85% receiving it through a formula bottle (Thompson & Bentley, 2013). In addition to the misconception about cereal in the bottle increasing infants’ sleep, feeding cereal-added formula bottle is also common when infant fussiness is interpreted as a sign of hunger (Lucas et al., 2017; Savage and Birch, 2017).

In formula feeding guidelines, the American Academy of Pediatrics advises against adding infant cereal to a bottle to avoid overfeeding and dysregulation of infants’ hunger and satiety cues (Jana and Shu, 2015). However, there is a lack of understanding on how this practice contributes to daily calorie and macronutrient intake. This is a critical gap, since formula feeding, also referred to as bottle feeding, is very common among low-income, single-parent, and racial/ethnic minority households (Orozco et al., 2020; Barrera et al., 2018; Perez-Escamilla et al., 2017). A recent review designed to understand the association between formula feeding and rapid weight gain found that behaviors associated with formula feeding played a larger role in increasing the risk for rapid weight gain than the nutrient composition of the formula (Appleton et al., 2018). Practices such as adding cereal to the formula and pressuring infants to finish the bottle were associated with overfeeding and rapid weight gain among formula fed infants.

This study aimed to understand how the introduction of complementary foods prior to 4 months was associated with socio-demographic characteristics and food security status among low-income and primarily racial/ethnic minority mother-infant dyads. Additional study aims were to determine the association between early introduction to complementary foods and breastfeeding and adding cereal into the bottle in later infancy (i.e., at 6 and 9 months), and examine how adding infant cereal into the bottle was related to daily calorie and macronutrient intake in infancy.

METHODS

This longitudinal study involving mother-infant dyads was approved by the Office of Research Integrity at University of North Carolina at Greensboro and a partnering pediatric clinic. The study was conducted from March 2019 to March 2022. The partnering pediatric clinic mainly served minority and low-income families, with approximately 85% of patients received Medicaid, representing a household income of < 210% below the federal poverty line (NC Medicaid and Health Choice Outreach and Public Health, Health and Human Services, n.d). Participant selection criteria included: biological mother, at least 18 years of age, fluent in English or Spanish, Medicaid recipient, singleton infant born at full- term defined as 37 weeks or longer gestation. Having an infant younger than 2 months of age at the time of recruitment was also one of the selection criteria.

We carried out in-person recruitment by approaching potential participants in the clinic’s waiting area. Using the appointment schedule, mothers visiting for well-child appointments were approached by the study staff to explain and assess their interest in study participation. Upon indication of interest and confirmation of eligibility, mothers were given the opportunity to review the documents and ask questions before signing and providing informed consent. Participants were asked to provide contact information to schedule and conduct in-person or phone interviews at regular intervals. Of the mothers who consented and provided contact information, approximately 90% participated in the study. Reasons for not continuing in the study included: move out of the state, change of mind or too busy to participate. Interviews were conducted during a 10-day window before or after infant’s age of 4, 6, and 9 months. Specifically, for the interviews conducted before the 4-month date, it was on average 5 days prior to the date ensuring there was no underreporting of complementary food introduction due to early interview.

Prior to COVID-19 restrictions in March 2020, the interviews were conducted in person or over the phone based on participants’ preferences. In response to the pandemic, all interviews were conducted over the phone from March 2020 onwards. To examine the study objectives, the recruitment sample of 247 infants was restricted to infants who were given formula at 4 months (n=201, 81%). Infants received formula either exclusively (n=86, 43%) or partially with breastmilk (n=115, 57%). Participants received e-gift cards or physical grocery store gift cards at each interview.

INTERVIEWS AND MEASURES

The interviews were conducted by well-trained bilingual research assistants fluent in English and Spanish. The research assistants received training in interview techniques and cultural competency and conducted 5 mock interviews prior to joining the data collection team. Each interview lasted approximately 30 minutes using the secure electronic data capture tool REDCap hosted at University of North Carolina at Greensboro.

At the 4-month interview, we collected information on socio-demographics, including maternal education, marital status, household size, and race/ethnicity. We also collected information on food security, breastfeeding status, and the introduction of complementary foods. We used the 6-item Short Form Food Security Survey Module and guidelines to assess food security status.

Questions from the Infant Feeding Practices Study II, conducted by the Food and Drug Administration and Centers for Disease Control and Prevention (CDC), were used to collect information on feeding practices (Fein et al., 2008). For breastfeeding, the following question was asked, “are you currently breastfeeding or feeding your baby pumped milk?”, yielding a ‘yes’ or ‘no’ response. To determine early introduction to complementary foods, we asked, “Is your baby fed any solid foods (like baby cereal, rice puffs, crackers, mashed potato, etc.) through formula or directly?”, yielding a ‘yes’ or ‘no’ response. Additionally, the frequency of feeding different foods was also used to assess complementary feeding prior to 4 months of age. Whether the item was fed, and if so, at what frequency in the past week was asked. The items that were covered were: infant cereal; other cereals and starches; fruits; vegetables; french fries; meat, chicken, combination dinners; peanut butter or nut foods; eggs; sweet foods like cookies and/or cakes. A response of ‘yes’ to any of these categories was considered as an introduction to complementary foods. We did not include liquids, such as water, sugar water, herbal teas, or fruit juices in the definition of early introduction of complementary foods because our focus was on the relation between early introduction of solid foods and adding cereal in the bottle later in infancy.

Information on adding cereal into the bottle and nutrient intake was collected by administering 24-hour diet recalls at the 6 and 9-month interviews. The 24-hour recalls were conducted using the multiple pass method, utilizing the Nutrition Data System for Research (NDSR) software developed by the Nutrition Coordinating Center (NCC), University of Minnesota, Minneapolis, MN. The day before the recall, we sent participants pictures of standard sippy cups, formula bottles, and spoons to help them report portion sizes. Each research assistant involved in conducting a 24-hour recall completed a 2-day NDSR Certification training and a minimum of ten practice 24-hour recalls. The recall was conducted using the multiple pass method, noting down times of feeding, a detail description of each feed and reading aloud the entire recall to ensure that no feedings were missed. For each feeding, detailed information was collected on food types, amounts and preparation steps. We also noted the amount of food that was prepared and the amount that was consumed by the infant. For instance, we collected information on the brand and type of formula (powdered, ready to use, concentrate etc.). For powdered formula, the most common type reported by participants, we asked for its amount (in scoops), the amount of water added (in ounces), and whether anything else was added. If cereal was added, we collected information on the brand, type (rice, oats, multigrain etc.) and amount added. Finally, for each feeding episode, we collected information on the quantity of the prepared food or liquid that the infant consumed, to adjust and measure the total calorie and nutrient intake.

For infants who were fed at the breast during the recall day, we adjusted the breastmilk amount based on values using previous literature (Haisma et al., 2003; Wells et al., 2012; Tongchom et al., 2020). For the 6-months, the total breastmilk and formula volume was adjusted to a total of 835 mL/day if no other complementary foods were given. For infants who were consuming complementary foods, the total volume was adjusted to 675 mL/day. At 9-months, the total breastmilk and formula volume was adjusted to 600 mL per day. No adjustments were made for pumped breast milk feeding, since participants were able to report the specific amount.

From the 201 participants, we used a randomization procedure to select 20 (10%) at 6- and 9-months to conduct a line-by-line quality check of the 24-hour recalls. No disputes or unusual information were found based on the average frequency of feeding, the average time between feedings and portion size of complementary foods. All the 24-hour recalls were reported as ‘high quality’ by the interviewers based on the accuracy at which the information was provided by the participants and the overall recall experience. All the 24-hour recalls were confirmed by the mothers as, “close to the amount the infant usually eats” versus less or more than usual.

The NDSR database includes calorie and nutrient values of more than 1,000 baby products, including dairy and non-dairy formulas, fruit and vegetable pouches, and jar foods, to generate nutrient values per food item and to compute total calorie and nutrient intake per day. For this study, we utilized the NDSR file computing calorie intake, macronutrients (in gms) and percent calories from macronutrients per recall or per day to examine study objectives.

STATISTICAL ANALYSES

The analyses followed a pre-specified statistical plan, and was carried out using SPSS software (IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). We began by examining continuous variables for outliers and homogeneity of variance to confirm that mean differences were not unduly influenced by extreme values. For categorical variables, data quality checks were conducted to identify any unexpected values or reasons for missing cases. All data entry errors were resolved, and the sample size was adjusted for missing cases. Descriptive statistics were used to examine socio-demographic characteristics, breastfeeding rates, and other feeding practices at 4-, 6- and 9-months of age. Binary logistic regression was conducted to estimate how socio-demographic variables and food security status were related to early complementary feeding. All categorical variables were entered with a specific reference value and multicollinearity was tested to ensure it was not affecting odds estimation. Bivariate Chi-square tests were used to compare differences in breastfeeding rates between participants who did or did not give complementary foods prior to 4-months. Similarly, the practice of adding cereal into the bottle was compared between those who gave complementary food prior to 4-months vs. not. Lastly, we used analysis of variance (ANOVA) to test whether, after controlling for infant sex, adding cereal into the formula bottle was related to total calorie and macronutrient intake.

RESULTS

As shown in Table 1, most participants identified as either African American (42.8%) or of Latinx origin (35.3%). The mothers’ average age was 29.8 years and they were living in a household size of about 4 individuals in total. Among participants, household income was approximately $1700 per month. Most mothers (83.6%) participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and 49.8% participated in the Supplemental Nutrition Assistance Program. Less than half (38.1%) were employed part-time or full-time, and 57.7% had a high school or equivalent level of education. Over one-third (37.3%) reported marginal to very low food security. Among the 201 infants receiving formula at 4 months of age, 29.4% had received complementary foods and 42.8% were partially breastfed. Adding cereal into the bottle assessed by using 24-h recall data showed that at 6 months 29.9%, and at 9 months 14.4% of the infants had received cereal-added formula bottle at least once on the previous day.

Table 1:

Sociodemographic characteristics and feeding practices among low-income mother infant dyads at 4 months of age (n = 201)

Characteristics	Mean (SD)
Mother’s age (in years)	29.8 (6.1)
Household size	4.5 (1.7)
Household income ($, monthly) a	1708.8 (1506.8)
	n (%)
Race/Ethnicity
African American	86 (42.8)
Latinx	71 (35.3)
Non-Hispanic White	20 (10.0)
Othersb	24 (11.9)
Marital Status
Single/Divorced	123 (61.2)
Married/Living with partner	78 (38.8)
Education
Less than High School	42 (20.9) c
High School/GED	116 (57.7)
College degree	43 (21.4)
Employment Status b
Employed (full/part time)	76 (38.1)
Unemployed	125 (61.9)
Food Security Status
High	126 (62.7)
Marginal/Low/Very Low	75 (37.3)
Primiparous Parity	80 (40.0)
Participation in WIC	168 (83.6)
Participation in SNAP	100 (49.8)
Infant Sex: Male	96 (47.8)
Introduced complementary foods < 4 months of age	59 (29.4)
Breastfeeding at 4 months of age	86 (42.8)
Adding cereal into the formula bottle at 6 months d	60 (29.9)
Added cereal into the bottle at 9 months d	29 (14.4)

^aIncome sample size=171 (remaining 30 reported either “don’t know” or “refused to provide information”)

^bOther groups include Asian, Pacific Islander, Mixed and Native American

^cEmployment status at 4 months

^dAdding cereal to the bottle was based on the 24-hour recall; WIC: Special Supplemental Program for Women, Infants and Children; SNAP: Supplemental Nutrition Assistance Program.

As shown in Table 2, the Latinx group compared to non-Hispanic white group had a lower likelihood of feeding infants anything other than formula or breastmilk before 4 months (β: −2.08, OR:0.12, 95% CI: 0.03, 0.49; p = 0.00). The odds of giving complementary foods before 4 months (β: −1.20, OR:0.30, 95% CI: 0.13, 0.65; p = 0.00) were on average 70% lower among mothers who were not employed compared to mothers who were employed. When mothers were experiencing marginal to very low food security, the odds of an early introduction to complementary foods were 149% higher compared to mothers who reported they were fully food-secure (β: 0.91, OR 2.49, 95% CI: 1.09, 5.68; p = 0.03). Among mothers who introduced complementary foods before 4 months, infant cereal was the most common item (78%), followed by fruits and vegetables in a puree, mash, or pouch form (48%).

Table 2:

Sociodemographic predictors of early introduction (< 4 months of age) to complementary foods among infants in low-income households (n = 201)^a

Characteristicsb	B (SE)	OR	CI	P
Race/Ethnicity
Non-Hispanic White	Ref.
African American	0.31(0.54)	1.37	0.47 – 3.98	0.55
Latinx	−2.08 (0.70)	0.12	0.03 – 0.49	0.00
Other	−1.04 (0.73)	0.35	0.08 – 1.49	0.15
Employment status
Employed (Full/Part-time)	Ref.
Not employed	−1.20 (0.39)	0.30	0.13 – 0.65	0.00
Education status
High school completion or more	Ref.
Less than high school	0.11 (0.60)	1.12	0.34 – 3.70	0.84
Marital Status
Married/living with partner	Ref.
Single/Divorced	−0.32 (0.45)	0.72	0.29 – 1.74	0.46
Food security status
High	Ref.
Marginal/Low/Very low	0.91 (0.42)	2.49	1.09 –5.68	0.03
Parity
Multiparous	Ref.
Primiparous	−0.13 (0.38)	0.87	0.41 – 1.85	0.72
Maternal age (Continuous)	−0.02 (0.03)	0.99	0.93 – 1.06	0.94

^aBinary logistic regression test; OR: Odds Ratio; CI: Confidence Interval; Outcome variable: Introduced complementary foods (1) or not (0) prior to 4 months; sociodemographic characteristic information was collected at infant age 4 months ± 10 days of age.

Adding cereal to the bottle was more common at 6 months (47.5%) than at 9 months (16.9%). As shown in figure 1, breastfeeding was significantly lower among those who fed complementary foods to infants prior to 4 months of age (p=0.01). Early introduction to solid foods was also associated with adding cereal into the bottle at 6 months (p<0.01, Figure 1). However, this association was not significant at 9 months.

Figure 1:

Differences in breastfeeding and adding cereal to the bottle practice between infants who were not fed versus infants who were fed complementary food prior to 4 months

^an=201; ^bn=185. Chi-square test with *p=0.01, ***p<0.01

At 6 months, after controlling for sex, adding cereal to the bottle was associated with increased caloric, carbohydrate, and protein intake. Infants who received formula with added infant cereal consumed on average of 165 more calories than infants who received formula with no infant cereal (F (2, 199) = 15.51, p<.001). The mean total carbohydrate intake was 33.28 grams higher (F (2,199) = 16.22, p <.001), and the mean protein intake was 3.75 grams higher (F (2,199) = 12.14, p <.001) among infants who received cereal in the formula bottle, compared to infants with no added cereal. The mean percentage of calories from carbohydrates was significantly higher among infants who received cereal in the formula bottle (p<.001), however, in contrast, the mean percentage of calories from fat was significantly lower for infants who received cereal in the bottle (p<.001, Table 3).

Table 3:

Differences in total calorie and macronutrients intake among infants at 6 and 9 months based on receiving cereal in the formula bottle versus not^a

	6 -month (n=201)			9 -month (n=185)
	Mean differencesb	F	P	Mean differencesb	F	P
Total Calories (kcal)	165.16	15.51	<.001	158.90	4.08	0.044
Total Carbohydrates (gms)	33.28	16.22	<.001	27.61	8.48	0.004
Total Protein (gms)	3.75	12.14	<.001	3.94	2.86	0.092
Total Fat (gms)	1.47	0.65	0.421	0.68	0.07	0.791
% Carbohydrates	5.27	36.57	<.001	3.54	7.52	0.006
% Protein	−0.08	0.31	0.574	0.80	2.72	0.100
% Fat	−5.42	35.56	<.001	−4.78	15.79	<.001
Formula intake (in servings)c	0.00	0.00	0.983	0.72	1.87	0.172

^aNutrient values are based on the 24-hour feeding recall done at 6 or 9 months, the sample size for 6 months = 201; for 9 months = 185, 16 recalls removed due to incomplete/missing/poor quality recalls.

^bMean difference between infants fed cereal with formula one or more times versus no such practice of adding cereal into the formula bottle;

^cFormula intake represents servings, with one serving representing 5 fluid ounces. During the recall the following information was collected for amount prepared; amount of formula (scoops), water (ounces) and infant cereal (teaspoons or tablespoons) and amount consumed by infant.

At 9-months, similar patterns were seen. Adding cereal into the bottle was associated with an average intake of 158 additional calories per day (F (2,183) = 4.08, p =0.04) and 27.61 additional grams of carbohydrates per day (F (2,183) = 8.48, p = 0.004), compared to infants who did not receive cereal in their formula. Similarly, the mean percentage of calories from carbohydrates was significantly higher, while the mean percentage of calories from fat was significantly lower among 9-month-old infants fed cereal with formula in the bottle. The total formula intake was not significantly different between the groups at either 6 or 9 months of age (Table 3).

DISCUSSION

This study involving mother-infant dyads from low-income and primarily minority families indicates that early introduction to complementary foods is a common practice, as about one-third of mothers gave complementary foods before 4 months. Similarly, in the large national survey studies, the prevalence of introduction to complementary foods prior to 4 months of age was found in the range of 30% to 40% (Orozco et al., 2020; Barrera et al., 2018; Clayton et al., 2013; Siega-Riz et al., 2010; Grummer-Strawn et al., 2008). These findings illustrate that early introduction to complementary foods persists, and formula feeding, and discontinuation of breastfeeding plays a role in occurrence of this practice. It is also recognized that part of the issue is inconsistency in the recommendation. In the 2020 national report summarizing existing feeding guidelines, it was noted that the recommendation by different agencies and groups on introduction to complementary foods ranges from : 1) not before 4 months; 2) between 4 and 6 months; 3) around 6 months of age (National Academies of Sciences, Engineering, and Medicine Report, 2020).

In our sample, Latinx mothers were less likely to feed complementary foods to infants prior to 4 months of age than non-Latinx mothers, which is similar to the trend seen in other studies (Clayton et al., 2013; Orozco et al., 2020; Chiang et al., 2020; English et al., 2019). For instance, in a study conducted by the CDC involving data from the 2016 to 2018 National Survey of Children’s Health found that the prevalence of early complementary feeding was significantly higher among the African American group (40.5%), compared to the Latinx group (29.9%), and the common reasons cited were infants big appetite and/or not satisfied with just formula or breastmilk (Clayton et al., 2013). Additionally, it is possible that caregivers add cereal in the bottle to address gastroesophageal reflux commonly seen among infants. The reflux is associated with fussiness, coughing, and gagging during feeding. To address the symptoms, caregivers may use cereal as a thickening agent. However, commercially thickened formulas have been shown to be more effective than supplementing standard formulas with cereal due to the better viscosity and digestibility (Salvatore et al., 2018). Other studies have shown that mothers often add cereal into the bottle to help their infants gain weight (Thompson & Bentley, 2013; Fildes et al., 2015; Lucas et al. 2017).

Our study showed that mothers who experienced marginal to very low levels of household food security were more likely to introduce complementary foods early. Similarly, other qualitative and quantitative studies have found that due to poor formula affordability food insecure caregivers often resort to complementary foods to feed their infants when formula supply is running low (Orr et al., 2019; Burkhardt et al., 2012; Frank, 2015; Partyka et al., 2010). It is also possible that in households with low levels of food security, experiences of hunger and anxiety related to food affordability may lead mothers to misinterpret infant fussiness as a sign of hunger, driving them to add cereal to the formula to ensure the infant is well fed and not experiencing hunger. However, further research is needed to confirm if feeding cereal-added formula bottle is more common among low-income families and whether it is mediated by food insecurity due to poor formula affordability and economic hardship.

Early introduction of complementary foods could potentially increase the risk of rapid weight gain in infants. In a study of 881 British children, the early introduction of complementary food was associated with higher energy intake at 4 months and higher body mass index (BMI) in early childhood among formula-fed infants (Ong et al., 2006). In another study, the early introduction of complementary food was associated with a higher BMI among children who were breastfed for less than 4 months (Differding et al., 2020). These positive associations may be attributed to the pattern of starting early solid feeding by adding cereal in the formula bottle, which continues then throughout infancy.

At both 6 and 9 months, adding cereal into the bottle was associated with an increase in calorie intake by approximately 100 calories. A multi-country longitudinal study examining total calorie intake from early infancy to 5 years among 5500 children documented that a higher calorie intake during infancy was a strong predictor of being overweight at age 5 (Beyerlein et al., 2017). Similarly, increased calorie intake of about an additional 100 calories per day or about 10% above the daily requirement among infants has been associated with rapid weight gain (Thompson & Bentley, 2013).

Our study should be interpreted considering several methodological limitations. First, the study examines adding cereal into the bottle at 6 and 9 months compared to early infancy i.e., prior to 6 months when bottle feeding is more common and adding cereal into the bottle might be done even more frequently. Although multiple recalls at each age may be preferable, other studies have provided evidence that using a single 24-hour recall can yield adequate results when calculating estimates of nutrient intake (Butte et al., 2010; Bailey et al., 2018). Third, although our study represents a diverse group of mothers and infants from minority backgrounds, they were from one clinic site and may not be representative of other groups, limiting generalizability. Lastly, we asked about food insecurity prior to or early in the pandemic, but there was increase in food insecurity in low-income communities during the pandemic (Kowalski, 2021), suggesting that our estimates may have been low.

RESEARCH AND PRACTICAL IMPLICATIONS

This study indicates that adding cereal into the bottle at 6 and 9 months increases the risk of overfeeding since it contributes approximately an additional 10% of the average daily calorie intake among infants. Future research is needed to examine the association between adding infant cereal to the bottle and weight gain during infancy and childhood. Further, it will be critical to understand how feeding practices affects appetite development and whether early introduction to solids and related practices leads to development of low satiety trait or ‘heavy’ appetite among children. It is also interesting to note that compare to spoon feeding, the practice of giving cereal through bottle continues at 6 and 9 months.

Inclusion of feeding recommendations in the 2020–2025 DGA has highlighted the importance of optimal nutrition during infancy to ensure a strong foundation and reduce the risk for poor health later in life. However, it should be recognized that following these recommendations requires stability and consistent access to healthy foods. Hence, as highlighted in the 2022 White House Conference on Hunger, Nutrition, and Health, strengthening social protection programs, and promoting equity are critical to allow families to put dietary recommendations into practice.

Data Sharing:

Data collected for this study are not available for public use to maintain confidentially of the participants recruited from the specific location/clinic. The lead author has full access to the data reported.