The Dastatuz Project

A quasi-experimental, multicentre, controlled and prospective intervention study is proposed. Guidelines from the TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) statement for non-randomised control trials on behavioural and public health interventions will be followed meticulously in order to follow a realistic scenario which could be easily reproduced onwards. Initially, mothers in the third trimester of pregnancy (n=384) will be assigned to different diet profiles according to their own food preferences (Standard diet, SD vs. High Fruit and Vegetable diet, HFV); next, caregivers' willingness to perform weaning following one or other approach will be the base to establish groups (Spoon feeding, SF vs. Baby Led Weaning, BLW, respectively). Regardless of their distribution, all of them will receive the current standard recommendations and care. Intervention groups will receive additional diet recommendations during pregnancy, breastfeeding and weaning. The study implies a time period from the third trimester of the pregnancy until children are 18 months old. Follow-up, sampling and/or measurements will be performed at 6-7th months of pregnancy, before delivery; 2nd, 4th, 6th, 12th and 18t months from birth. Moreover, 5-6 meetings are going to be held either at the Outpatient Consultation of the Txagorritxu Hospital (Vitoria-Gasteiz) or at the Faculty of Psychology of the University of the Basque Country (Donostia-San Sebastian), where material and information are going to be given to the participants.

Procedure Baseline questionnaire and dietary assessment will be the base for group blind assignment. Those below the national (Spain) mean consumption of fruits and vegetable (about 414 g/person/day) or/and those who claim to have difficulties achieving the recommended portions will be included in the control group (SD, see arms of the intervention). When a fruit consumption of one standard deviation bellow the mean is detected, dietetic assessment will be performed in order to encourage, at least, the mean intake. Those above the national (Spain) mean consumption of fruits and vegetable (about 414 g/person/day) will be included in the experimental group (HFV, see arms of the intervention). During the study, they will be encouraged and assessed to achieve even a higher intake, 800 g/person/day. If a significant FV decrease in their diet is detected in the follow-ups, dietetic assessment will be performed in order to restore the initial intake. For weaning groups, those better disposed to follow a spoon-feeding approach will be included in the control group (SF, see arms of the intervention); and those better disposed to follow a baby-led approach will be included in the intervention group (BLW, see arms of the intervention).

Several measuring tools are proposed to obtain objective data along the designed project:

QUESTIONNAIRES

• Q1: Participants will complete this questionnaire during recruitment and it will collect information about their socio-economic and psychological status, her actual diet profile and her expectations about the feeding of her future baby. It will also contain a question regarding preferred contact method (email/telephone/post).
• Q2: This is a follow-up questionnaire (completed by online questionnaires) which will assess the adherence to the diet of the mother along pregnancy. Moreover, it will also collect information about the psychological aspect, such as the parental stress level of participants.
• q1: It is a short questionnaire on the breastfeeding efficacy that will be completed on the second week post-partum. It has been used to predict breastfeeding duration and exclusivity.
• Q3: It is very similar to the Q2 questionnaire, but parameters will be studied during lactation.
• Q4: This will also be a follow-up questionnaire. Although it is quite similar to Q3, this one includes a new questionnaire about parental feeding styles.

SAMPLES: Milk samples from the mothers will be collected along the second or third month of breastfeeding. Instructions will be given to the mothers as follows: collect approximately 50mL-100mL in a sterilized container and freeze it (-20ºC) within 5 min of expression; if the samples are going to be delivered right after the extraction they could be maintained at 4ºC. Participants will be given sample carrier and transporting containers in order to deliver them to one of the two collection points of the Biobanco. Samples will be transported to the main center of the Biobanco in Galdakao and maintained frozen at -25ºC until analysis in which composition profile and viscosity and other physical properties (i.e. shear stress) will be assessed by Infrared Spectroscopy MilkoScan (Foss Electric, Denmark), gas chromatographic- mass spectrometry (GC-MS) and rheometry techniques (rheometer AR1000, TA Instruments). Nutritional analysis will be carried out at the Galdakao center of the Biobanco and rheological analysis at the Faculty of Pharmacy of the Unviersity of the Basque Country.

OBSERVATIONS: At 6, 8 and 12 months from birth, prior to paediatric consultation, each family will record for 24h the food intake of the child indicating: food consumed and its composition or commercial brand, if necessary; family will also report cooking method and will record the weight of food consumed.

Some days after the paediatric control of the 6th, 8th and 12th month parents will be contacted by phone to gather information about foods which might be new for the child, and therefore, has never tried them. According to the answers received, some recipes will be sent by e-mail to each family, together with instructions of how to offer these foods to the baby (moments, times, circumstances). Parents will be asked to record a video of these mealtimes and send to the research team. Times swallowed and acceptance or rejection signs will be studied. These records will only be used for research purposes stated in this project, and always previous informed consent signed by the parents or tutors of the child. In addition, Q4 will be sent to the families, by email, as an online questionnaire. It will gather information from the parents about the eating behaviour of the child. This last questionnaire will also record weight/height data and psychological features of the child.

ALLERGEN RISK: In addition to the above mentioned measurements, allergen risk will be assessed comparatively (spoon diet vs baby led), following general risk assessment procedures. This is a well characterized gap which remains understudied, as it is recognised in the literature. Exposition analysis will be performed using data from the 24 hours diet records until 12 months from birth. Main allergens, mentioned at Regulation 1169/2011 (CE) of the European Parliament and of the Council of 25 October 2011on the provision of food information to consumers, will be assessed. Moreover, especial attention will be paid to FODMAPS, which today arise interest as a potential reason to the permanence of celiac-like symptoms, even when in theory a gluten free diet is being correctly followed. Analysis will be based on the 24h food diary transmitted by families. Ingredients used on the meals preparation will be taken into consideration. A procedure established by the Food Standard Agency will be followed.