Development,Evaluation And Application Of Chinese Children Nutrient Profiling System

BackgroundChildhood is a critical period for the development of cognitive,physical and mental health and other social behaviors.Appropriate nutrition in this period is not only the basis of growth and development of children,but also has impact on preventing the occurrence of chronic diseases in adulthood.In recent years,although the dietary nutrition of Chinese children has been improved significantly,they have still been experiencing the double burden of unbalanced dietary structure,malnutrition and overweight and obesity.The unhealthy dietary pattern in childhood can also be traced to adolescence and even adulthood.Therefore,it is important to conduct effective nutrition intervention for the improvement of Chinese children’s health.According to the literature,the ways to improve the children’s dietary quality are generally clear.For example,it is suggested that children should increase the intake of vegetables,fruits and reduce the intake of processed meat and sugar-sweetened beverages.However,how to further improve the nutritional quality of children’s overall diet needs to be clarified.With the increase of processed food and prepackaged food,children have a wider variety of food choices.Ambiguous dietary recommendations cannot help children to evaluate and judge the nutritional value of different foods,thus affecting the improvement of the overall dietary quality level.The development of nutrient profiling system provides an effective way for dietary intervention and further improvement of dietary quality.The nutrient profiling system has been widely used in foreign countries,but no system has been established for Chinese children.In addition,although many dietary indices have been developed to evaluate the overall diet quality of Chinese children,there may be differences in nutrition quality level among different foods.The impact of nutritional quality differences of different foods on the diet quality was not considered by current dietary indices.Therefore,the accuracy of the existing dietary indices,which only compares the food category with the recommended amount in the dietary guidelines,to evaluate the overall dietary quality level of children may be low,and it needs to be modified by adjusting the nutritional quality of food.Furthermore,few studies have investigated the association between children’s diet quality and health outcome,and most of them were conducted in developed countries.The research on the correlation between children’s diet quality and health outcome is limited in China.Therefore,it is important to establish and evaluate the nutrient profiling system,and use the system to evaluate the overall dietary quality level of Chinese children and explore the association between dietary quality and health outcomes such as overweight,obesity and hypertension.In addition,in order to further help Chinese children to build an effective food nutrition information exchange platform and promote the relevant research on children’s food nutrition quality and health outcome,it is necessary to comprehensively evaluate the level of food nutrition quality in the Chinese children food environment.The evaluation results are of great significance for further studies.ObjectiveFirstly,the objective of the study was to design and establish the first nutrient profiling system that suitable for Chinese children’s food nutrition quality level assessment--Chinese Children Nutrient Profiling System（CCNPS）and then evaluate its validity and reliability.Secondly,we aimed to update the dietary index based on CCNPS and analyze the nutritional quality of all kinds of food and the overall diet quality of children in Southwest China,and explore the association between diet quality and health outcomes such as overweight,obesity and hypertension.Finally,we aimed to further collect and improve the food data of the Chinese food composition table and the data of children’s consumption of pre-packaged food,and then evaluate the traditional food and children’s consumption of pre-packaged food based on the CCNPS,so that to provide an evaluation basis for choosing foods with high nutritional quality level for Chinese children,and to further explore children’s food quality and overall diet quality and health outcomes.MethodsBased on the existing nutrient profiling system for children and the decision-making steps for the development of nutrient profiling system formulated by WHO,as well as Nutrient Reference Values,Chinese Dietary Guidelines（2022）,Chinese Dietary Reference Intakes（2013）,and the evidence of diet-health relationships of Chinese children,CCNPS was developed to measure food nutritional quality in Chinese children.Using data from 6504 children aged 3-17 years from the 2004-2011 China Health and Nutrition Survey（CHNS）,the food quality was evaluated with the CCNPS as well as the Ofcom system in the UK and the Nutrient Rich Foods Index（NRF 9.3）in the US.Based on the validity evaluation method that developed by Theresa et al.,the validity and reliability of CCNPS were evaluated by rank sum test analysis,Cochran-Armitage trend test analysis,Spearman correlation analysis,logistics regression abd Cronbach’αcoefficient.The data were retrieved from Southwest China Childhood Nutrition and Growth（SCCNG）,which is a prospective cohort study initiated in January 2013 to investigate the nutritional and lifestyle determinants of children’s growth,with emphasis on overweight/obesity and pubertal development.For the current analysis,we used the baseline survey information of 3006 children age 6-17 years on social demographic information,family information diet and anthropometry measures collected during2020-2022.Height,weight,waist circumference（WC）,systolic pressure and diastolic pressure were measured and indicators of body composition including body mass index（BMI）,waist-to-height ratio（WHt R）were calculated and the overweight,obesity,abdominal obesity,dysarteriotony and hypertension were determined according to the Chinese children related diagnostic criteria.The CCNPS DQI scores of different sociodemographic characteristics and different food and nutrient intake of different dietary quality levels were examined by t test,variance analysis and Wilcoxon rank-sum test.The correlations between the total CCNPS DQI scores and BMI,waist circumference,ratio of waist circumference increase and blood pressure were determined by rank correlation.Multivariate logistic regression was used to estimate ORs and 95%CIs for the associations between tertiles of CCNPS DQI scores and overweight,obesity,abdominal obesity,dysarteriotony and hypertension.The food data information of the latest edition of China Food Composition List was improved based on the food databases from other countries.The information of children’s consumption of prepackaged food was collected based on the 24-hour dietary information of children in the SCCNG cohort for 3 days.The nutritional information of children’s consumption of prepackaged food was calculated by Python.The food nutritional quality was evaluated by CCNPS.Results1.Development of the CCNPSThe CCNPS consists of 9 dimensions,including 38 indicators(i.e.Protein dimension（protein）,fat dimension（fat）,dietary fiber dimension（dietary fiber）,vitamin dimension(vitamin A,vitamin D,vitamin E,vitamin K,vitamin B1,vitamin B2,vitamin B₆,vitamin B₁₂,pantothenic acid,folic acid,niacin,vitamin C,choline,biotin),mineral dimension（calcium,phosphorus,potassium,sodium,Iron,magnesium,zinc,selenium,iodine,copper）,dimension of food additives（nitrites,artificial sweeteners and colors,alcohol,added sugars）,dimension of processing（food processing level,frying）,dimension of specific lipids（saturated fatty acids,cholesterol,trans fatty acids）and dimension of nutritional properties（GI level,rich phytochemicals）.Each dimension contributed-10 to 0 points or 0 to 10 points,with the total score ranging from-60 to 50.A higher CCNPS scores indicating better nutritional quality of the food.2.Evaluation of reliability and validity of the CCNPSThe CCNPS can evaluated the nutritional quality of all foods,and the CCNPS indicators included Ofcom system and NRF9.3 system evaluation content,indicating the good face validity and content validity.The CCNSPS was able to distinguish the food nutritional quality of different categories of food.The scores of each dimension of different categories of food and the scores of each dimension under different CCNPS score levels were also varied,indicating the good discriminative validity.The trend test results of CCNPS and Ofcom system food nutrition quality assessment showed good consistency（P<0.0001）.Besides,NRF9.3 system score was strongly correlated with CCNPS score（r=0.76）,indicating the good convergence validity.The CCNPS DQI was able to distinguish the differences of diet quality between children living urban and rural areas,and those with different parental education levels（P<0.0001）,indicating the good prediction validity.In addition,the standardized and unstandardized Cronbach’αcoefficients of CCNPS were 0.70 and 0.72,respectively,indicating good internal consistency.3.Assessment of diet quality of children in Southwest China based on CCNPS and analysis of association between diet quality and health outcomeThe average CCNPS DQI score of children in Southwest China was 140.8±48.The CCNPS DQI score of children who were boys,aged younger,lived in cities,had higher parental education level and family income was significantly higher（P<0.05）.The CCNPS DQI score was negatively correlated with BMI SDS,WC,WHt R,systolic blood pressure and diastolic blood pressure（P<0.05）.Furthermore,a higher diet quality score was associated with lower risk of overweight/obesity（OR=0.45,95%CI:0.26-0.78）and abdominal obesity（OR=0.25,95%CI:0.14-0.45）,after adjusting for gender,age,urban-rural difference,parental/maternal education level,family annual income and total energy intake.No association was observed between the diet quality and the risk of dysarteriotony and hypertension.4.Evaluation of food quality of food data in Chinese food composition and children’s consumption of pre-packaged food data based on CCNPSA total of 2702 kinds of foods were included in the Chinese food composition list.Among all food categories,the number of vegetables and products and milk and products was the largest,with 336 and 268 species and accounting for 12.4%and 9.9%,respectively.Eggs and products were the least species,only 32 species（1.2%）.The top three food categories in CCNPS score were mushroom and algae food（40.9 points,）vegetables and products（40.0 points）,and dried beans and products（32.1 points）.The CCNPS scores of alcoholic beverages and oils were the lowest,which were-6.4 points and-5.7 points,respectively.A total of 3138 pre-packaged foods consumed by children were included in the study.Among all pre-packaged foods,the number of baked and puffed foods and Seasoned flour products was largest,with 596 and 454 and accounting for 19.0%and14.5%,respectively.Prepared food were the least species,only 91 species（2.9%）.The soybeans and products and nuts and seeds have the highest CCNPS score,with 31.8points and 25.0 points,respectively.The CCNPS scores of sugar-sweetened beverages,confectionery,baked and puffed foods were the lowest,which were-6.1 points and 03points,and 0.6 points,respectively.ConclusionThe Chinese Children Nutrient Profiling System can be used to rank-order food quality of Chinese children,and has acceptable reliability and validity.The diet quality of children in Southwest China needs to be improved,especially to increase the consumption of potatoes,fruits,nuts and seeds,milk,as well as seafood.Meanwhile,children should increase the average intake and choose foods with higher nutritional quality.The diet quality is related to the risk of overweight/obesity and abdominal obesity in children.Thus,the current situation of overweight/obesity in Chinese children can be enhanced by improving the diet quality and the children with lower socioeconomic status should be paid more attention.There are significant differences in the nutritional quality between traditional foods and pre-packaged foods,different categories of foods and the same kind of foods.Therefore,the children’s food information exchange platform can be built and the effect of overall diet quality on children’s health outcomes can be explored according to different food CCNPS score.