Background
Rapid demographic and epidemiologic changes brought by urbanization, modernization, and technological development have escalated the nutrition transition in many Eastern Mediterranean countries [
1], including Lebanon [
2]. Young children may be amongst the most vulnerable population groups to the ongoing nutrition transition, as their diets are becoming increasingly energy-dense while being poor in fiber and several micronutrients [
3]. This is of concern given that adequate nutrition in early childhood is crucial for optimal physical, motor and cognitive development [
4], and for setting the stage for healthy adolescence/young adulthood [
4].
Previous studies conducted in Lebanon have reported a triple burden of malnutrition (underweight, nutrient deficiencies and overweight/obesity) among infants and young children, and the intake of several micronutrients has been described as inadequate in this age group [
2,
4,
5]. The intakes of iron, zinc, calcium, vitamin D, vitamin A, and folate were shown to be low in a substantial proportion of infants and children aged 0–4 years [
5]. In specific, intakes of iron and zinc were inadequate in 45.3% and 21.6% of Lebanese infants aged 6-11.9 months, respectively while vitamin D and calcium were below the Estimated Average Requirement (EAR) among 84.7% and 44.6% of Lebanese toddlers, respectively [
5]. Inadequate intakes of micronutrients may contribute to the development of overt deficiencies, leading to detrimental health outcomes on the short-term as well as the long-term [
6]. For instance, iron deficiency can adversely affect cognitive functions and psychomotor development, while also inducing or exacerbating deficiencies of other essential nutrients [
7]. Many studies have identified zinc deficiency as a key contributor to stunting in children [
8‐
10] in addition to being a risk factor for the manifestation of malnutrition, diarrhea, pneumonia and impaired wound healing [
9]. Vitamin D deficiency and low dietary intakes of both vitamin D and calcium may lead to the establishment of rickets in children [
11]. Vitamin A plays a key role in the regulation of several vital physiological processes throughout the life cycle and its deficiency is the leading cause of preventable blindness among young children, while also contributing to immune dysfunction, frequent infections, and improper growth processes [
12‐
14]. Folate is also known to play a crucial role in optimal neural function and repair, and its deficiency is associated with the establishment of several neurodevelopmental disorders [
15]. Available studies also suggest that young children in Lebanon do not meet the recommended intake levels of fiber [
5], an important nutrient for the functioning of the gastrointestinal tract (providing bulk to the stool, preventing constipation), the development of a healthy gut microbiome, and the prevention of excessive weight gain and several cardio-metabolic abnormalities [
16,
17].
Food sources of micronutrients and fiber may differ between countries, as a reflection of the cultural dietary practices. It is in this context that we have conducted this study, with the aim of (1) identifying the top food sources of fiber, iron, zinc, calcium, vitamin D, vitamin A, and folate amongst infants and young children in Lebanon and (2) evaluating the evolution of food sources of these nutrients from the beginning of the complementary feeding journey up until the age of 47.9 months. The analyses undertaken in this study were conducted based on the Feeding Infants and Toddlers Study (FITS) protocol [
18]. The study findings will contribute to a better understanding of the main food sources of key nutrients in an Eastern Mediterranean country and hence to the development of culture-specific interventions aimed at improving the nutritional adequacy of diets in early childhood.
Discussion
The findings of this study provide a comprehensive picture of the major dietary sources of fiber and several micronutrients of concern among infants and young children in Lebanon and an insight into the changes in food consumption patterns with age.
In line with findings reported by other studies [
26], fiber intakes were far below the recommendations in our study sample although beans and legumes, vegetables, and fruits were identified as the top sources of fiber for infants and young children aged 6-47.9 months. Given that the ranking of a food as a source of nutrient reflects not only the concentration of a nutrient in a food but also the frequency of consumption of the food, the low intake of fiber can be explained by the fact that these food groups rich in fiber were not being consumed in sufficient amounts. In fact, a previous study conducted by our group on the same population showed that adherence to fruits and vegetables recommendations was low in those aged 12-47.9 months [
5]. The present study has also identified that the contribution of fruits to fiber intake decreased with older age groups. These findings are consistent with those reported by the FITS study in the United Arab Emirates [
27] where fruits had a greater percent contribution to fiber intake among infants as compared to preschoolers. However, unlike findings reported from United Arab Emirates [
27], our study findings indicate a low contribution of grains to fiber intakes in Lebanese infants and young children and this may at least partially explain the fact that a small percentage of toddlers and preschoolers met the fiber AI levels. It is important to note here that grains were consumed in their refined, low fiber forms, and only 54 children of the study participants (7.1%) had reported whole grain consumption (data not shown). These findings, therefore, highlight the importance of initiating complementary feeding practices that focus on promoting adequate fiber intake through the consumption fruits, vegetables, beans and legumes, as well as whole-grains. The adoption of a high fiber grain-based diet would be a practical and energy-neutral strategy for increasing fiber intakes as well as closing the gap between fiber intakes and fiber recommendations. This has been actually proposed by a group of nutrition researchers, educators, and communicators during the roundtable discussions “Filling America’s Fiber Gap: Probing Realistic Solutions” [
28], given that the Dietary Guidelines for Americans 2015–2020 has recommended that at least half of the grains be consumed as whole grains [
29].
This study has also observed that I/YC formula and cow’s milk constitute major food sources of vitamin D among children aged 6-47.9 months. However, the prevalence of vitamin D inadequacy is still high among these children. A previous study conducted on the same population has shown that only half of the children are adhering to the AHA/AAP Dietary Recommendations for milks and dairy [
5], and hence more efforts ought to be made in promoting adequate milk/dairy intake in these age groups. In fact, several studies have showed that adequate intake of milk and dairy products is associated with improved bone health, reduction of the risk of developing type 1 diabetes, and long-term programming of the immune response pattern [
30]. Among infants, cow’s milk was found to contribute substantially to zinc, calcium, and vitamin D intakes. Similar findings were reported by a study conducted among infants and children in Mexico [
23]. This is of concern given that cow’s milk introduction before the age of 1 year can lead to cow’s milk allergy and iron-deficiency anemia [
31]. It is, therefore, very important to encourage mothers to transition to iron-fortified formula rather than cow’s milk, if the optimal food in infancy, which is human breast milk, is not available.
Of concern also is the finding that sweetened beverages and sweet bakery were among the top food sources contributing to different nutrients intakes, including fiber, iron, zinc, calcium, vitamin A, and folate among the three age groups. Contribution of sweet bakery (which includes traditional sweets, cakes, pies, biscuits, cookies, bars, brownies, and muffins) to fiber, iron, and folate was even observed among infants, and this is aligned with similar observations from different countries, namely Philippines [
32], Mexico [
23], United States [
33], China [
34], and United Arab Emirates [
27]. Early consumption of sweetened food and/or beverages and the high contribution of these foods to different nutrients at an older age (24-47.9 months) is another alarming finding in this study. For example, sweet bakery was the top contributor to iron intake and the fifth contributor to fiber, calcium, and folate intakes. As they grow, infants experience physiological shifts in nutrient and energy requirements that can no longer be supported by breast milk alone [
32]. Therefore, promoting intakes of complementary foods that are nutrient-dense, i.e., relatively low in calories and high in vitamins and minerals, in lieu of sweet bakery and sweetened beverages may be one strategy to improve dietary intakes of nutrients and diet quality in this population and thus establish healthy eating habits from early childhood [
35].
Our findings with regards to the high contribution of I/YC formula and baby cereals to iron, zinc, calcium, vitamin D, vitamin A (no significant contribution from baby cereals), as well as folate intakes among infants and toddlers align with what was found among children in the United Arab Emirates [
27], South Africa [
36], Mexico [
23], and France [
37]. The percent contribution of baby cereals to these nutrients was higher among infants than in toddlers and this can be attributed to the fact that baby cereals are the first foods to be introduced to infants in countries of the MENA region, including Lebanon [
38]. Moreover, I/YC formula and baby cereals are fortified food sources, and this explains their important contribution to these nutrients’ intakes. Previous studies have shown that the consumption of fortified food products may be an effective strategy in improving nutrient intakes amongst children [
39‐
42]. Bread is also another staple food source that is consumed in large quantities in the region and for which wheat flour fortification would be a simple, inexpensive and effective strategy for supplying vitamins and minerals to the diets of large segments of the region’s population [
43]. However, all flour in Lebanon is still produced in industrial mills and none is fortified as Lebanon does not have mandatory or voluntary wheat flour fortification [
43]. The difficulty in harmonizing standards and procedures for inspection, and coordinating the involvement of three government ministries; an inactive national coordination committee on wheat flour fortification; the high cost of the proposed measures; and the absence of testing for iron in wheat flour are all challenges for wheat flour fortification in Lebanon [
43]. These challenges should be addressed to implement and formulate relevant legislations of fortification in Lebanon [
43,
44], knowing that the Flour Fortification Initiative revealed that all Middle Eastern countries have invested in mandatory micronutrient fortification of wheat flour for locally manufactured and imported products with the exception of Lebanon [
44].
Amongst toddlers and preschoolers, meat and fish ranked as a major contributor to iron intakes. This is an important finding, given that regular consumption of animal-based foods can prevent a decrease in hemoglobin in late infancy [
45]. However, attention should be warranted for the inclusion of lean red meats as part of a healthy, varied diet during this critical phase of children’s development process, especially that earlier studies conducted in Lebanon have highlighted that, with the ongoing nutrition transition, the intakes of meat and poultry are following an increasing trend [
46]. At the same time, this finding highlights concerns about the affordability of lean red meat, underscoring the need for targeted interventions to ensure that lean meat remain economically accessible to families facing financial constraints, particularly after the pressing economic, political, environmental, and health constraints that Lebanon has been witnessing [
47]. In line with findings reported in the FITS study conducted in United Arab Emirates [
27], herbs and seasonings have also contributed markedly to iron intakes among preschoolers. This is mainly contributed by dried thyme (za’atar) followed by dried spearmint, both of which are local herbs that are widely consumed in Lebanon in salads or as a spread on bread for dried thyme (za’atar) when mixed with olive oil [
48]. It is worth noting that though dried thyme leaves are particularly rich in iron (117.2 mg/100 g of dry matter), a study has revealed that the bioavailability of iron in thyme is low [
49].
Strengths and limitations
This study is a nationally representative, cross-sectional study of infants and children in Lebanon. To our knowledge, this is the only analysis to date that specifically explores the top sources of key nutrients among 3 distinct age groups of infants and children, allowing us to better capture the changes in food consumption practices that occur in early life. However, the results of this study ought to be interpreted in light of the following limitations. This study was a cross-sectional in design, so it was not possible to assess the longitudinal changes in the food sources of key micronutrients with time among the same individuals. Dietary intake assessment relies on a single 24-HR, which may not reflect usual intakes. Therefore, further studies should include more than one 24-HR, at least for a subsample of the population. Despite the well-acknowledged limitations of the 24-HR approach, such as reliance on memory and possible day-to-day variation, the 24-HR may provide accurate estimates of energy intake at the population level, especially that dietary data was collected by the multiple pass approach in this study [
50,
51]. Well-trained research nutritionists administered all recalls in order to attenuate interviewer errors. Another limitation is the use of the USDA database in nutrient intake estimation, given the lack of food composition databases that are specific to Lebanon or even the region. The USDA database may not correctly capture the nutrient composition of local food varieties in Lebanon and may thus represent a source of error in intake estimations [
52]. In addition, the USDA database does not include many of the composite traditional dishes consumed in the country. In order to address this limitation and be able to assess nutrient intakes from mixed traditional dishes, we have added standardized recipes to the Nutritionist Pro software using single food items [
52]. Moreover, dietary intakes of micronutrients considered for this study reflect intakes from diet only and dietary supplement intakes were not accounted for. Future research in Lebanon should assess supplement use and its impact on nutrient intake and adequacy among this population. Finally, given that the survey was conducted in 2012, its findings may underestimate the effects of the nutrition transition on dietary intakes in young children.
Conclusions
In conclusion, this study showed that a substantial proportion of Lebanese infants and young children had inadequate intakes of key nutrients, including fiber, iron, zinc, calcium, vitamin D, vitamin A, and folate. It also identified the main food sources for these nutrients, by age group. The results showed that in addition to milk sources, vegetables, beans and legumes, breads, meats, and rice and pasta, sweet bakery and sweetened beverages have contributed to nutrients intakes from early ages. This calls for implementing initiatives and designing approaches to support nutrition education and improve nutrient intakes in infancy and early childhood, and hence improve the nutritional status of this population group.
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