Infant dietary patterns and early childhood weight outcomes: a secondary analysis from the Starting Early Program Trial

Infant dietary patterns and early childhood weight outcomes: a secondary analysis from the Starting Early Program Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Infant dietary patterns and early childhood weight outcomes: a secondary analysis from the Starting Early Program Trial Lauren Berube, Christina Kim, Andrea Deierlein, Kathlee Woolf, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8077856/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Limited studies assess how infant dietary patterns impact child weight. The Starting Early Program (StEP) promotes healthy nutrition during pregnancy and infancy and leads to healthier child weight, but whether dietary patterns contribute to weight or mediate StEP weight outcomes has not been studied. Objectives: This secondary analysis identified infant dietary patterns in StEP, determined associations between dietary patterns and child weight outcomes, and examined whether dietary patterns mediated the relationship between StEP and child weight. Methods: Data were from 377 mother-infant dyads enrolled in a randomized trial testing the efficacy of StEP. Infant diet was assessed at 10 months using an interviewer-administered 24-hour recall, and dietary patterns were identified using latent class analysis. Child weights were abstracted from medical records at 12, 24, and 36 months. Associations between infant dietary patterns and weight-for-age z-score (WFAz) and likelihood of being classified as overweight (WFA ≥85 th percentile) were assessed using multivariable linear and logistic regression models. Mediation analyses were used to assess intervention effects on WFAz via impacts on infant dietary patterns. Results: Four classes of infant dietary patterns were identified, characterized by differences in milk feeding and complementary food type and variety: Breastfed-High variety; Formula fed-High variety; Formula fed-Low variety; and Mixed fed-Low variety. Compared to the Breastfed-High variety class, infants in the Formula fed-Low variety class had higher WFAz and were more likely to be classified as overweight at 24 and 36 months. Participation in StEP increased membership in Breastfed-High variety, which mediated the association between StEP and lower WFAz at 24 months. Conclusions: Infant dietary patterns were identified and associated with child obesity risk. StEP promoted an infant dietary pattern that was most consistent with infant feeding guidelines, which mediated intervention effects on child weight. Health sciences/Diseases/Nutrition disorders/Obesity Health sciences/Health care/Nutrition childhood obesity dietary patterns weight-for-age infant feeding prevention Figures Figure 1 Figure 2 Figure 3 Introduction Nearly 13% of children aged 2 to 5 years in the United States (U.S.) are classified as having obesity, and 16% aged 2 to 19 years are classified as overweight ( 1 , 2 ). Childhood obesity persists throughout the lifespan and increases risks of comorbidities like type 2 diabetes and cardiovascular disease,( 3 ) highlighting the need for early prevention. The time from conception until age 2 years is considered a critical period for the development of obesity when nutrition, lifestyle and environmental exposures influence later behaviors and health outcomes ( 4 ). Dietary intake during this period contributes to childhood obesity risk ( 5 , 6 ). Healthy infant feeding practices not only support optimal growth and development ( 7 ), but also establish flavor preferences and eating behaviors that are often maintained throughout childhood ( 8 ), making infancy an important period to promote healthy dietary behaviors. Dietary recommendations for infants promote breastfeeding or iron-fortified formula feeding through the first year of life and the introduction of a variety of nutrient-dense complementary foods (e.g., fruits and vegetables) around 6 months when developmentally ready, with avoidance of cow’s milk, juice, sugar-sweetened beverages, and foods with added sugars, saturated fat, and sodium ( 9 , 10 ). However, data from national surveys indicate that many infants and toddlers in the U.S. are not fed according to these recommendations. Approximately 40% of infants and toddlers do not meet recommended intakes for fruit, and nearly 90% do not meet recommendations for total vegetables ( 9 ). Additionally, 17% of infants consume cow’s milk and 27%, 34%, and 77% consume juice, sweets/sugar-sweetened beverages, and savory snacks, respectively ( 11 , 12 ). These high rates of suboptimal feeding practices highlight the need to understand how early life dietary patterns are related to child weight outcomes, particularly in populations that are disproportionately affected by childhood obesity. Considerable research has examined how individual infant feeding practices, including exclusivity, duration, and intensity of milk-based feedings ( 13 , 14 ) and adherence to complementary food recommendations ( 15 , 16 ), contribute to child weight outcomes. However, studying individual aspects of infant feeding does not sufficiently account for the whole diet and the complex interactions of the multiple dietary components consumed ( 17 ). Infant dietary patterns measure the totality of the diet, considering milk feeding type and amount and variety of complementary foods, but limited studies have assessed how infant dietary patterns impact later child weight status. Latent class analysis (LCA), a person-centered data reduction approach, has been used to identify infant dietary patterns among primarily non-Hispanic white middle- or higher-income populations ( 18 – 20 ). Patterns characterized by foods high in energy density or low in variety were associated with greater weight at 12 months ( 18 ), 24 months ( 20 ), and 6 years ( 19 ). Children from Hispanic and lower-income populations experience the highest rates of obesity ( 1 ), yet there is a lack of research investigating associations between infant dietary patterns and weight in these populations. The Starting Early Program (StEP) is a child obesity prevention intervention that supports optimal child feeding and lifestyle behaviors for Hispanic and low-income families. StEP reduces child weight trajectories through 24 months ( 21 ) and improves maternal infant feeding knowledge, styles, and practices (including increasing breastfeeding and decreasing juice) ( 22 ). Despite these positive impacts on feeding behaviors, it is unclear how StEP impacts infant dietary patterns and whether these dietary patterns contribute to later child weight outcomes. To address these gaps, the current study used LCA to identify distinct classes of infant dietary patterns in the StEP cohort. We aimed to 1) examine associations between dietary patterns and child weight and 2) examine potential impacts of the StEP intervention on dietary patterns and whether these patterns mediate the relationship between StEP and child weight. Methods Study design Data for this secondary analysis were from the StEP trial, a randomized controlled trial to test the impact of a primary care-based child obesity prevention intervention beginning during pregnancy on early child weight outcomes in Hispanic families with low-incomes (ClinicalTrials.gov Identifier: NCT01541761) ( 23 ). Ethics approval was obtained from the Institutional Review Boards of New York University Grossman School of Medicine (Institutional Review Board number: 10-02175) and the New York City Health + Hospitals (System to Track and Approve Research number: StudyTX00001047), and trained bilingual research assistants obtained written informed consent from all participants. A detailed study design of StEP has been published elsewhere ( 21 , 24 ). Study sample At 28 to 32 weeks gestation (baseline), participants were recruited from prenatal clinics affiliated with a large hospital system in New York City. Patients with self-reported Hispanic/Latina ethnicity, fluent in English or Spanish, ≥ 18 years of age with a singleton uncomplicated pregnancy, and planned continuation of pediatric care at the study site were eligible. Participants with a history of severe medical or psychiatric illness or drug/alcohol use disorder, as well as those with fetal abnormalities detected via ultrasound, were excluded. For this secondary analysis, participants with a dietary recall at the 10-month assessment were included in the LCA. Infants ≥ 12 months at the assessment were excluded, as dietary recommendations change at 12 months ( 9 ). Children with ≥ 1 recorded weight at 12, 24, or 36 months were included in the analysis of dietary patterns and child weight. Starting Early Program intervention Participants were randomly assigned to either the standard care or the StEP group. Standard care received standard prenatal and pediatric primary care. StEP received standard primary care visits plus individual counseling sessions after 32 weeks gestational age and at infant age 2 to 3 days, and 15 group nutrition and parenting classes from infant age 1 to 33 months delivered by registered dietitians and certified lactation counselors. Individual counseling sessions reviewed breastfeeding support, and group session topics included feeding, activity, and parenting. Assessments Infant dietary assessment 24-hour dietary recall. At infant age 10 months, participants completed a 24-hour dietary recall modified to collect information about infant feeding, including detailed information on the type (breastmilk vs formula) and of mode (breast vs bottle) of milk feeding, consumption of complementary foods, and self-feeding. Mothers recalled what their infants consumed during the previous day, or, if the previous day was not reflective of usual intake, for a typical 24-hour period, providing the day of the week that was being recalled. Trained bilingual research assistants asked the time and mode (breast or bottle) of feeding, and whether the infant was given food or other beverages. For bottle feeds, mothers reported the milk type (expressed breastmilk, formula, or something else), whether anything was added, and, if so, what was added. For food or other beverages, mothers described the type and quantity of each food item given, how it was prepared, how it was fed, and how much the infant ate. These prompts were repeated to capture all feedings in one 24-hour period and recorded in a paper-based format, which was entered into the Automated Self-Administered 24-Hour Dietary Assessment 2014 (ASA24) tool, developed by the National Cancer Institute (NCI, Bethesda, MD) ( 25 ). Food Pattern Equivalents Database (FPED) values were generated using a SAS program available from the NCI to estimate intake of food groups ( 26 ). Dietary intake variables. Dietary variables were created following guidelines from the Child and Adult Care Food Program (CACFP) Infant Meal Patterns for 6- to 11-month infants ( 27 ) and informed by prior methods ( 18 , 20 ). Using the FPED values, dietary variables were dichotomized to identify daily intake of breastmilk; formula; cow’s milk; other dairy (e.g., yogurt, cheese, cottage cheese); infant cereals; grains (e.g., rice, pasta, bread, crackers, Cheerios); total vegetables (non-starchy and starchy); whole fruits; fruit juice; animal proteins (e.g., meat, poultry, fish, whole egg); legumes (e.g., cooked dry beans, cooked dry peas); and empty calorie foods (e.g., pastries, sugary cereals, salty snacks, French fries). Legumes were separated from animal proteins due to the more frequent consumption of legumes in diets of infants from Hispanic families ( 28 ). Since the recall did not differentiate between 100% fruit juice and other juice drinks, any juice consumed was included in the juice category. Breastfeeding or formula feeding intensity. To determine predominant feeding mode, breastfeeding and formula feeding intensity were estimated as [breastmilk feeds OR formula feeds/(breastmilk feeds + formula feeds + cow’s milk feeds)*100] ( 29 ). Infants with breastfeeding or formula feeding intensity ≥ 80% were considered predominantly breastfed or formula fed, respectively. Infants who were neither predominantly breastfed nor formula fed were considered mixed fed (e.g., 50% of feedings from breastmilk, 50% from formula). Additional dietary variables. Cow’s milk, other dairy, infant cereal, grains, fruits, vegetables, animal proteins, legumes, juice, and empty calorie foods were dichotomized based on the infant meeting or not meeting the recommended number of daily servings ( 27 ). For cow’s milk, juice, and empty calorie foods, the recommendation is 0 servings. For infant cereal, other dairy, grains, animal proteins, and legumes, the recommendation is ≥ 1 serving (> 0 tablespoons per serving). For fruits and vegetables, the recommendation is ≥ 4 servings total (> 0 tablespoons per serving). Separate categories were created for fruits and vegetables, and the recommendation was split into ≥ 2 servings of fruits and ≥ 2 servings of vegetables. Child Weight Outcomes Child weights were obtained from the electronic medical record (EMR) of primary care well-child visits at 12, 24, and 36 months. Sex-specific weight-for-age z-scores (WFAz) at each timepoint was calculated using the World Health Organization Anthro macro ( 30 ). WFA ≥ 85th percentile was defined as overweight. We used WFA instead of weight-for-length due to identified inaccuracies in EMR-obtained length and height measurements, detailed elsewhere ( 21 ). Covariates Maternal age, parity, country of birth, and education were collected from the baseline assessment. Marital status, employment, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were completed at the 10-month assessment. The U.S. Adult Food Security Survey Module assessed food security at 10 months; participants who reported ≥ 3 food insecure conditions were categorized as experiencing household food insecurity ( 31 ). Maternal anthropometric measurements were from the EMR. Pre-pregnancy body mass index (BMI, kg/m 2 ) was calculated using measured weight (≤ 13 weeks gestation) and height or, if unavailable, self-reported values from the baseline assessment. Gestational weight gain (kg) was calculated by subtracting pre-pregnancy weight from delivery weight. Delivery mode, infant sex, and birthweight were from the EMR. Age at introduction of complementary foods and childcare was reported at 10 months. Statistical Analysis To identify discrete, mutually exclusive latent classes of infant dietary patterns, LCA was performed using Mplus version 8.3 (Muthén & Muthén, Los Angeles, CA). We selected LCA rather than an index-based approach because the StEP curriculum did not instruct participants to follow a single dietary pattern; rather, StEP targeted key obesity-related, age-appropriate feeding practices, including milk feeding type (promoting breastfeeding or counseling on healthy formula feeding) and complementary feeding (encouraging a variety of nutrient-dense foods rather than empty calorie foods). Additionally, families who participated in StEP were culturally diverse, and LCA helps identify differences in food consumption across diverse cultural groups. Latent class models with two through five latent classes were compared. The best fitting model was selected based on the Akaike’s Information Criterion (AIC), the Bayesian Information Criterion (BIC), the adjusted Bayesian Information Criterion (ABIC), a parametric bootstrapped likelihood ratio test (BLRT), relative entropy, the number of individuals within each class, and latent class interpretability ( 32 ). After identifying the optimal number of classes, participants were categorized into the class that corresponded to their highest-class membership probability. Descriptive analyses, regression models, and mediation analyses were performed using the Stata Data Analysis and Statistical Software Version 14.2 (StataCorp LLC, College Station, TX). Maternal and infant characteristics were described by latent class membership using one-way analysis of variance or chi-squared tests. Linear regression models were used to analyze the association between latent class membership and WFAz at 12, 24, and 36 months, and logistic regression models were used to analyze the association between latent class membership and likelihood of being classified as overweight at the same timepoints. Regression analyses were adjusted for infant sex, birthweight, delivery mode, maternal age, marital status, education, pre-pregnancy BMI, gestational weight gain, parity, country of birth, household food insecurity, WIC participation, age of introduction of complementary foods, and study group assignment. We ran mediation analyses to determine whether the StEP intervention effects on child WFAz were mediated through 10-month dietary patterns. Since infant dietary patterns were measured at 10 months and milk feeding remains a significant source of energy for infants through 12 months, we expected that any intervention impacts on infant diet would likely mediate intervention effects on weight beyond 12 months. Therefore, the 24-month mediation analysis was adjusted for 12-month WFAz. We did not test for mediation at 36 months because StEP only impacted WFAz through 24 months. Results Of 933 eligible mothers, 566 signed consent, and 533 were randomized. Of those, 399 completed recalls at 10 months. We excluded 22 infants (5.5%) for being ≥ 12 months at the time of assessment. We included 377 participants (193 control, 184 intervention) in the LCA with weight data available for 331 participants (87.8%; 167 control, 164 intervention) at 12 months, 283 participants (75.1%; 130 control 153 intervention) at 24 months, and 228 participants (60.5%; 122 control, 106 intervention) at 36 months (Fig. 1 ). Latent classes of infant dietary patterns at 10 months A four-class solution was determined to be the best fitting model after comparing the fit indices of the latent class profile solutions ( Supplementary Table 1 ) and inspecting latent class interpretability. The model fit indices supported the superiority of both the three-class and four-class over the two-class model, as evidenced by lower AIC, BIC, and ABIC values. Both the three-class and four-class models demonstrated a significant BLRT, indicating better fit compared to models with one fewer class. Although the four-class model did not have the lowest BIC, it was selected as the best-fitting model over the three-class model because all four classes contained more than 10% of the sample, had significant BLRT results, and exhibited the lowest AIC and ABIC values. Additionally, the four-class model allowed for the identification of distinct classes that captured the variety of complementary foods consumed. A five-class model was also examined but ultimately rejected due to an insignificant BLRT and the presence of a class comprising < 5% of the sample. Figure 2 shows the food group item response probabilities for each of the four latent classes. Food group item response probabilities closer to one indicated that the infant was more likely to consume that item, whereas probabilities closer to zero suggested that the infant was less likely to consume that item. Latent classes were labeled based on the high probability (≥ 0.50) of milk feeding mode and variety and developmental appropriateness of nutrient-dense complimentary foods (fruits, vegetables, grains, other dairy, animal protein, and legumes) served. The first class, labeled Breastfed-High variety (36.1% of the sample), was characterized by being predominantly breastfed and consuming a high variety of nutrient-dense complementary foods (fruits, grains, animal proteins). The second class, Formula fed-High variety (25.5%), had a high probability of being predominantly formula fed, consuming a high variety of complementary foods (grains, vegetables, fruits, animal protein), and having juice. The third class, Formula fed-Low Variety (24.1%), had a high probability of being predominantly formula fed and consuming infant cereal. The fourth class, Mixed fed-Low Variety (14.3%), had low probabilities of being predominantly breastfed or formula fed, suggesting mixed feeding, and a low variety of complementary foods (grains and animal proteins). Maternal and infant characteristics Table 1 shows maternal and infant characteristics. The Breastfed-High variety pattern had a greater proportion of mothers who were legally/living as married, born outside the U.S., and in the StEP intervention arm and a lower proportion of mothers who were employed or used childcare at 10 months. The Formula-fed High variety and Formula-fed low variety patterns had a greater proportion of mothers with a high school education or greater. Dietary patterns at 10 months and child weight outcomes at 12, 24, and 36 months In unadjusted analyses, the Formula fed-High Variety and Formula fed-Low variety patterns were associated with greater WFAz at 24 and 36 months ( Supplementary Table 2 ), but there were no associations with likelihood of being classified as overweight. In adjusted analyses ( Table 2 ), compared to the Breastfed-High variety pattern, infants in the Formula fed-High variety pattern had higher WFAz at 24 months, and infants in the Formula fed-Low variety pattern had higher WFAz at 24 and 36 months and higher likelihood of being classified as overweight at 24 and 36 months. There was no association between the Mixed fed-Low variety pattern and weight status at 12, 24, or 36 months. StEP intervention impacts on child weight outcomes at 12 and 24 months as mediated by infant dietary patterns When testing the relationship between intervention group and dietary patterns, StEP participants were 2.4 (95% CI: 1.4, 4.1; p = 0.002) times more likely to be in the Breastfed-High variety pattern compared to the Formula Fed-High variety pattern. We found similar trends when comparing membership of StEP participants in the Breastfed-High variety pattern to the Formula Fed-Low variety pattern (OR: 1.5, 95% CI: 0.9, 2.6, p = 0.121) and the Mixed Fed-Low variety pattern (OR: 1.8, 95% CI: 0.9, 3.4, p = 0.074). Since there were no associations between intervention group and membership in any of the other dietary patterns, we dichotomized the dietary pattern variable for the mediation analysis as membership in the Breastfed-High variety pattern (yes or no). After transforming the variable, we found that StEP participants were 1.9 (95% CI: 1.2, 2.9; p = 0.004) times more likely to be in the Breastfed-High variety pattern compared to not being in this pattern. Figure 3 displays the effect of the StEP intervention on 10-month dietary patterns, the effect of membership in the Breastfed-High variety pattern on WFAz at 12 and 24 months, and the mediated effects of the StEP intervention on WFAz. Mediation analyses indicated a significant indirect pathway between the StEP intervention and WFAz at 24 months (Indirect Effect: -0.04, p = 0.049) via intervention impacts on infant dietary patterns. There was no indirect effect observed for WFAz at 12 months. Discussion In this secondary analysis, we identified four infant dietary patterns: 1) Breastfed-High variety, 2) Formula fed-High variety, 3) Formula fed-Low variety, and 4) Mixed fed-Low variety. The Breastfed-High variety pattern was considered the most consistent with infant feeding guidelines because caregivers served a high variety of nutrient-dense complementary foods and intakes of juice and empty calorie foods were low. Although this pattern was not characterized by ≥ 2 servings of vegetables, most infants received ≥ 1 serving, and vegetable intakes were higher than the Formula fed-Low variety and Mixed fed-Low variety patterns. Compared to the Breastfed-High variety pattern, infants in the Formula fed-High variety pattern had higher WFAz at 24 months, and infants in the Formula fed-Low variety pattern had higher WFAz and greater likelihood of being classified as overweight at 24 and 36 months. StEP participants were more likely to be in the Breastfed-High variety pattern, and participation in StEP was significantly indirectly associated with lower WFAz at 24 months through greater membership in this dietary pattern. Compared to data from national surveys, infants in the current analysis had similar or higher rates of breastfeeding and fruit intake; similar or lower rates of formula feeding and juice consumption; similar rates of vegetable intake; and lower consumption of empty calorie foods ( 12 , 18 ). However, average dietary intakes did not meet recommendations. Most infants were not receiving recommended amounts of fruits, vegetables, and other dairy based on CACFP guidelines ( 27 ), just under half of infants were given juice, and consumption of cow’s milk and empty calorie foods was evident, which may have implications for future dietary habits, food preferences, and health. A main difference between the infant dietary patterns identified in our study compared to other research was the absence of a pattern characterized by empty calorie foods ( 33 ). While the reason for this difference is unclear, participants in the current analysis self-identified as Hispanic or Latina, and most were born outside of the U.S. In qualitative studies, Hispanic or Latina mothers born outside the U.S. reported balancing cultural- and family-based feeding recommendations with evidence-based health information when making decisions about infant feeding, with unprocessed, natural, and homemade cultural foods perceived as the healthiest options ( 34 – 36 ). Additionally, most of the families in our study participated in WIC, which aligns to national dietary guidelines and is associated with higher infant and child diet quality ( 37 ). Prior research found that infant dietary patterns characterized by empty calorie foods, juice, and/or low variety of complementary foods were associated with increased child weight outcomes at 2 and 6 years ( 19 , 20 ). While our study found that dietary patterns characterized by juice and low variety were associated with increased weight, we interestingly did not find any associations with the Mixed fed-Low variety pattern. While nearly one-third of infants in this pattern had ≥ 1 serving of empty calorie foods, this proportion is lower than what is reported in research that found associations with weight ( 12 , 18 – 20 ). Additionally, most infants in the Mixed fed-Low variety pattern received some breastmilk, which may have a protective effect on weight ( 38 , 39 ). The exact reasoning for the lack of association is unclear; unmeasured confounding associated with breastfeeding may have occurred. Infant dietary patterns that are characterized by a low variety of nutrient-dense complementary foods limit exposure to flavors and textures, which may prevent food acceptance later in childhood and lead to unhealthy food preferences ( 40 – 42 ). Continued exposure to these dietary patterns increases risks of nutritional deficiencies and obesogenic eating behaviors ( 43 – 45 ), potentially promoting excess energy intake, weight gain, and adiposity ( 33 , 46 ). Of the dietary patterns identified, the Breastfed-High variety pattern was considered the most consistent with infant feeding guidelines. StEP participants were more likely to follow the Breastfed-High variety dietary pattern, suggesting that StEP fostered adoption of guideline-concordant feeding behaviors. This finding aligns with the StEP curriculum, which promotes breastfeeding, optimal infant feeding practices, and modeling healthy behaviors, as well as prior research on the impacts of StEP on infant feeding behaviors, including greater maternal feeding knowledge and style, increased breastfeeding, and decreased juice ( 22 ). We also documented indirect effects of StEP on WFAz at 24 months, but not 12 months, through intervention impacts on membership in the Breastfed-High variety pattern. As milk-based feeding is still a significant form of energy in infants through 12 months, we did not expect that dietary patterns at 10 months would be strongly associated with 12-month WFAz. Rather, we conceptualized that infant dietary patterns may influence later child weight by establishing dietary patterns that continue throughout childhood ( 47 , 48 ). StEP may have facilitated continued support to maintain guideline-concordant dietary patterns beyond infancy, but additional research is needed. Strengths of this analysis include LCA to assess the combination of infant feeding and type and variety of complementary foods in Hispanic and low-income families. Limitations include using a single 24-hour recall to assess infant dietary intake, which may not account for day-to-day variation or reflect usual intake ( 49 ). This limitation may be partly alleviated because mothers were asked to report what their infant ate on a typical day. LCA did not take into account early infant feeding practices, such as breastfeeding and formula feeding duration, intensity, or exclusivity for the first 6 months, time of introduction of complementary foods, or variety of complementary foods beyond what was reported on a single day. Additionally, our study included a culturally diverse sample of Hispanic and low-income families who were from an urban setting, which may not be generalizable to other populations. In conclusion, this study suggests that dietary patterns that are inconsistent with infant feeding guidelines, particularly low variety of nutrient-dense complementary foods, are associated with increased early childhood weight outcomes. StEP promoted a dietary pattern that was most consistent with infant feeding guidelines, which mediated the intervention effects on WFAz at 24 months. Given the importance of early prevention, culturally-relevant interventions that promote healthy nutrition and lifestyle behaviors in infancy may encourage families to provide a variety of developmentally appropriate and nutrient-dense complementary foods that promote health. More research is warranted to understand how dietary patterns change throughout childhood in Hispanic and low-income populations, determine factors that influence dietary patterns, and examine associations with weight outcomes. Abbreviations U.S. United States LCA latent class analysis StEP Starting Early Program WFAz weight-for-age z-score ASA24 Automated Self-Administered 24-Hour Dietary Assessment 2014 NCI National Cancer Institute FPED Food Pattern Equivalents Database CACFP Child and Adult Care Food Program EMR electronic medical record WIC Special Supplemental Nutrition Program for Women, Infants, and Children BMI body mass index AIC Akaike’s Information Criterion BIC Bayesian Information Criterion ABIC adjusted Bayesian Information Criterion BLRT parametric bootstrapped likelihood ratio test Declarations Acknowledgements We would like to thank the StEP staff and study participants. Author contributions LB, AD, KW, MM, and RGdesigned the research; LB, MM, and RG collected and assembled the data;LB and CK analyzed the data; all authors interpreted the data and contributed to manuscript writing and critical revision of manuscript for important intellectual content. All authors have read and approved the final manuscript. Competing Interests We have no competing financial interests to disclose. Data Availability Statement The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Trial Registration ID: NCT01541761 Trial Registry: https://clinicaltrials.gov/study/NCT01541761?intr=starting%20early%20program&rank=2 Disclaimer: Portions of this manuscript were previously posted as part of a dissertation on ProQuest (ProQuest Number:13880601; Available at: http://ezproxy.med.nyu.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdissertations-theses%2Fprenatal-diet-quality-low-income-hispanic-women%2Fdocview%2F2243809994%2Fse-2%3Faccountid%3D35139). Sources of Support: This study was supported by the National Institute of Food and Agriculture, the United States Department of Agriculture (award: 2011-68001-30207), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23HD081077, PI: Rachel Gross). References Stierman B, Afful J, Carroll MD, Chen T-C, Davy O, Fink S, et al. National Health and Nutrition Examination Survey 2017–March 2020 prepandemic data files development of files and prevalence estimates for selected health outcomes. Natl Health Stat Report. 2021; 14(158): 10.15620/cdc:106273 . Fryar C, Carroll M, Afful J. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960–1962 through 2017–2018. NCHS Health E-Stats. 2020. https://www.cdc.gov/nchs/data/hestat/obesity-adult-17-18/obesity-adult.htm#Citation . Accessed November 21, 2022. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016;17(2):95–107. doi: 10.1111/obr.12334 . Bianco-Miotto T, Craig JM, Gasser YP, van Dijk SJ, Ozanne SE. Epigenetics and DOHaD: from basics to birth and beyond. J Dev Orig Health Dis. 2017;8(5):513–9. doi: 10.1017/s2040174417000733 . Woo Baidal JA, Locks LM, Cheng ER, Blake-Lamb TL, Perkins ME, Taveras EM. Risk factors for childhood obesity in the first 1,000 days: a systematic review. Am J Prev Med. 2016;50(6):761–79. doi: 10.1016/j.amepre.2015.11.012 . Hamner HC, Nelson JM, Sharma AJ, Jefferds MED, Dooyema C, Flores-Ayala R, et al. Improving Nutrition in the First 1000 Days in the United States: A Federal Perspective. Am J Public Health. 2022;112(S8):S817-s25. doi: 10.2105/ajph.2022.307028 . Ong KK. Healthy Growth and Development. Nestle Nutr Inst Workshop Ser. 2017;87:141–51. doi: 10.1159/000448964 . Birch LL, Doub AE. Learning to eat: birth to age 2 y. Am J Clin Nutr. 2014;99(3):723S-8S. doi: 10.3945/ajcn.113.069047 . U.S Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th Edition. December 2020. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf . Accessed January 18, 2023. Breastfeeding and the use of human milk. Pediatrics. 2012; 129(3):e827-41. 10.1542/peds.2011–3552 . Bailey RL, Stang JS, Davis TA, Naimi TS, Schneeman BO, Dewey KG, et al. Dietary and complementary feeding practices of US infants, 6 to 12 months: a narrative review of the federal nutrition monitoring data. J Acad Nutr Diet. 2022;122(12):2337-45.e1. doi: 10.1016/j.jand.2021.10.017 . Roess AA, Jacquier EF, Catellier DJ, Carvalho R, Lutes AC, Anater AS, et al. Food Consumption Patterns of Infants and Toddlers: Findings from the Feeding Infants and Toddlers Study (FITS) 2016. J Nutr. 2018;148(suppl_3):1525s-35s. doi: 10.1093/jn/nxy171 . Qiao J, Dai LJ, Zhang Q, Ouyang YQ. A meta-analysis of the association between breastfeeding and early childhood obesity. J Pediatr Nurs. 2020;53:57–66. doi: 10.1016/j.pedn.2020.04.024 . Dewey K, Bazzano L, Davis T, Donovan S, Taveras E, Kleinman R, et al. The duration, frequency, and volume of exclusive human milk and/or infant formula consumption and overweight and obesity: a systematic review. Alexandria (VA): USDA Nutrition Evidence Systematic Review; 2020. English LK, Obbagy JE, Wong YP, Butte NF, Dewey KG, Fox MK, et al. Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review. Am J Clin Nutr. 2019;109(Suppl_7):956s-77s. doi: 10.1093/ajcn/nqy267 . English LK, Obbagy JE, Wong YP, Butte NF, Dewey KG, Fox MK, et al. Timing of introduction of complementary foods and beverages and growth, size, and body composition: a systematic review. Am J Clin Nutr. 2019;109(Suppl_7):935s-55s. doi: 10.1093/ajcn/nqy267 . Reedy J, Subar AF, George SM, Krebs-Smith SM. Extending methods in dietary patterns research. Nutrients. 2018;10(5). doi: 10.3390/nu10050571 . Rose CM, Savage JS, Birch LL. Patterns of early dietary exposures have implications for maternal and child weight outcomes. Obesity (Silver Spring, Md). 2016;24(2):430–8. Rose CM, Birch LL, Savage JS. Dietary patterns in infancy are associated with child diet and weight outcomes at 6 years. International journal of obesity (2005). 2017;41(5):783-8. doi: 10.1002/oby.21349 . Hohman EE, Paul IM, Birch LL, Savage JS. INSIGHT responsive parenting intervention is associated with healthier patterns of dietary exposures in infants. Obesity (Silver Spring, Md). 2017;25(1):185–91. doi: 10.1038/ijo.2017.27 . Messito MJ, Mendelsohn AL, Katzow MW, Scott MA, Vandyousefi S, Gross RS. Prenatal and pediatric primary care-based child obesity prevention program: a randomized trial. Pediatrics. 2020;146(4). doi: 10.1542/peds.2020-0709 . Messito MJ, Katzow MW, Mendelsohn AL, Gross RS. Starting Early Program impacts on feeding at infant 10 months age: a randomized controlled trial. Child Obes. 2020;16(S1):S4-s13. doi: 10.1089/chi.2019.0236 . Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Randomized controlled trial of a primary care-based child obesity prevention intervention on infant feeding practices. J Pediatr. 2016;174:171- 7.e2 . doi:10.1016/j.jpeds.2016.03.060. Kim CN, Messito MJ, Katzow M, Duh-Leong C, Gross RS. Child obesity prevention from pregnancy: long-term follow-up of the Starting Early Program Trial. Pediatrics. 2025;155(5). doi: 10.1542/peds.2024-069421 . Subar AF, Kirkpatrick SI, Mittl B, Zimmerman TP, Thompson FE, Bingley C, et al. The Automated Self-Administered 24-hour dietary recall (ASA24): a resource for researchers, clinicians, and educators from the National Cancer Institute. J Acad Nutri Diet. 2012;112(8):1134–7. doi: 10.1016/j.jand.2012.04.016 . National Cancer Institute. Calculating Food Patterns Equivalents Database (FPED) Food Group Equivalents. Reviewing and Cleaning ASA24 Data. https://epi.grants.cancer.gov/asa24/resources/cleaning.html#calculate . Accessed February 21, 2019. United States Department of Agriculture. Child and Adult Care Food Program (CACFP) Infant Meal Patterns. 2022. https://www.fns.usda.gov/cacfp/nutrition-standards/infant-meal-patterns . Accessed February 21, 2019. Mennella JA, Ziegler P, Briefel R, Novak T. Feeding Infants and Toddlers Study: the types of foods fed to Hispanic infants and toddlers. J Am Diet Assoc. 2006;106(1 Suppl 1):S96-106. doi: 10.1016/j.jada.2005.09.038 . Li R, Fein SB, Grummer-Strawn LM. Association of breastfeeding intensity and bottle-emptying behaviors at early infancy with infants' risk for excess weight at late infancy. Pediatrics. 2008;122 Suppl 2:S77-84. doi: 10.1542/peds.2008-1315j . World Health Organization. World Health Organization anthro for personal computers, version 3.2.2, 2011: software for assessing growth and development of the world's children. 2011. http://www.who.int/childgrowth/software/en/ . Accessed August 21, 2018. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security (Revised 2000). USDA Food and Nutrition Service. 2020. https://www.fns.usda.gov/research/guide-measuring-household-food-security-revised-2000 . Accessed August 21, 2018. Nylund KL, Tihomir A, and Muthén BO. Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study. Struct Equ Modeling. 2007;14(4):535–69. doi: 10.1080/10705510701575396 . Thompson AL. Evaluating the pathways linking complementary feeding practices to obesity in early life. Nutr Rev. 2020;78(Suppl 2):13–24. doi: 10.1093/nutrit/nuz057 . MacMillan Uribe AL, Rudt HG, Leak TM. Cultural influences on infant and toddler feeding among low-income Latinx mothers. Matern Child Nutr. 2022;18(4):e13342. doi: 10.1111/mcn.13342 . Beck AL, Hoeft KS, Takayama JI, Barker JC. Beliefs and practices regarding solid food introduction among Latino parents in Northern California. Appetite. 2018;120:381–7. doi: 10.1016/j.appet.2017.09.023 . Cheney AM, Nieri T, Davis E, Prologo J, Valencia E, Anderson AT, et al. The sociocultural factors underlying Latina mothers' infant feeding practices. Glob Qual Nurs Res. 2019;6:2333393618825253. doi: 10.1177/2333393618825253 . Caulfield LE, Bennett WL, Gross SM, Hurley KM, Ogunwole SM, Venkataramani M, et al. Maternal and child outcomes associated with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Agency for Healthcare Research and Quality Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022. Koletzko B, Godfrey KM, Poston L, Szajewska H, van Goudoever JB, de Waard M, et al. Nutrition during pregnancy, lactation and early childhood and its implications for maternal and long-term child health: the Early Nutrition project recommendations. Ann Nutr Metab. 2019;74(2):93–106. doi: 10.1159/000496471 . Ventura AK. Does breastfeeding shape food preferences? links to obesity. Ann Nutr Metab. 2017;70 Suppl 3:8–15. doi: 10.1159/000478757 . Anzman-Frasca S, Ventura AK, Ehrenberg S, Myers KP. Promoting healthy food preferences from the start: a narrative review of food preference learning from the prenatal period through early childhood. Obes Rev. 2018;19(4):576–604. doi: 10.1111/obr.12658 . Maier-Nöth A. Early development of food preferences and healthy eating habits in infants and young children. Nestle Nutr Inst Workshop Ser. 2019;91:11–20. doi: 10.1159/000493674 . Emmett PM, Hays NP, Taylor CM. Antecedents of picky eating behaviour in young children. Appetite. 2018;130:163–73. doi: 10.1016/j.appet.2018.07.032 . Evans C, Hutchinson J, Christian MS, Hancock N, Cade JE. Measures of low food variety and poor dietary quality in a cross-sectional study of London school children. Eur J Clin Nutr. 2018;72(11):1497–505. doi: 10.1038/s41430-017-0070-1 . Steyn NP, Nel JH, Nantel G, Kennedy G, Labadarios D. Food variety and dietary diversity scores in children: are they good indicators of dietary adequacy? Public Health Nutr. 2006;9(5):644–50. Taylor CM, Wernimont SM, Northstone K, Emmett PM. Picky/fussy eating in children: review of definitions, assessment, prevalence and dietary intakes. Appetite. 2015;95:349–59. doi: 10.1016/j.appet.2015.07.026 . Thompson AL, Bentley ME. The critical period of infant feeding for the development of early disparities in obesity. Soc Sci Med. 2013;97:288–96. doi: 10.1016/j.socscimed.2012.12.007 . Lioret S, Betoko A, Forhan A, Charles MA, Heude B, de Lauzon-Guillain B. Dietary patterns track from infancy to preschool age: cross-sectional and longitudinal perspectives. J Nutr. 2015;145(4):775–82. doi: 10.3945/jn.114.201988 . Luque V, Escribano J, Closa-Monasterolo R, Zaragoza-Jordana M, Ferré N, Grote V, et al. Unhealthy dietary patterns established in infancy track to mid-childhood: the EU Childhood Obesity Project. J Nutr. 2018;148(5):752–9. doi: 10.1093/jn/nxy025 . Thompson FE, Kirkpatrick SI, Subar AF, Reedy J, Schap TE, Wilson MM, et al. The National Cancer Institute's Dietary Assessment Primer: a resource for diet research. J Acad Nutr Diet. 2015;115(12):1986–95. doi: 10.1016/j.jand.2015.08.016 . Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations There is NO conflict of interest to disclose Supplementary Files IJOSupplementalTable111.07.25.docx Supplemental Table 1 IJOTable1.docx Table 1 IJOSupplementalTable211.07.25.docx Supplemental Table 2 IJOTable2.docx Table 2 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":208888,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant flowchart. StEP: Starting Early Program.\u003c/p\u003e","description":"","filename":"IJOStEPFigure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/4e92ca18118f556211ff482e.jpg"},{"id":96711184,"identity":"acd82631-8e6e-4485-90d8-af04b04cdb59","added_by":"auto","created_at":"2025-11-25 10:11:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":221662,"visible":true,"origin":"","legend":"\u003cp\u003eDaily food group item response probabilities for the four latent classes of infant dietary patterns at 10-months in the Starting Early Program Trial (N=377). Food group items that have a probability ≥0.5 characterize the dietary pattern.\u003c/p\u003e","description":"","filename":"IJOStEPFigure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/069b1a2d8b61bfc117589260.jpg"},{"id":96711455,"identity":"b5436086-6f62-4d2a-beff-a99bc01c3fa7","added_by":"auto","created_at":"2025-11-25 10:12:02","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":136570,"visible":true,"origin":"","legend":"\u003cp\u003eIndirect effects of the Starting Early Program Trial on child weight-for-age z-score at 12 and 24 months through dietary patterns at 10 months\u003cstrong\u003e. \u003c/strong\u003eStEP: Starting Early Program; OR: odds ratio; DE: direct effect; IDE: indirect effect. Mediation analysis at 24 months adjusted for weight-for-age z-score at 12 months\u003c/p\u003e","description":"","filename":"IJOStEPFigure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/8cb9f6fa609c4ef302d7c923.jpg"},{"id":100796112,"identity":"43dcf0da-fce5-4479-9504-709f1d3b441b","added_by":"auto","created_at":"2026-01-21 13:40:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1262872,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/39a318cb-8e20-4d89-97b0-c0d86c928582.pdf"},{"id":96693692,"identity":"7cf3d334-3e63-4279-9706-8d49bd4ed674","added_by":"auto","created_at":"2025-11-25 07:13:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15872,"visible":true,"origin":"","legend":"Supplemental Table 1","description":"","filename":"IJOSupplementalTable111.07.25.docx","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/f7dc9dc161868cd9a284b01e.docx"},{"id":96693695,"identity":"6e9fd0e6-e809-4797-878e-91d57f39740f","added_by":"auto","created_at":"2025-11-25 07:13:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22561,"visible":true,"origin":"","legend":"Table 1","description":"","filename":"IJOTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/52c6002661b5083f567cd44c.docx"},{"id":96710962,"identity":"2b69498c-e1ac-42bb-9ffb-0fb834d421ec","added_by":"auto","created_at":"2025-11-25 10:11:26","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16613,"visible":true,"origin":"","legend":"Supplemental Table 2","description":"","filename":"IJOSupplementalTable211.07.25.docx","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/f076efd98dc8f70584a780d9.docx"},{"id":96693704,"identity":"acc8929d-e835-4fc3-8e4b-9710f432186a","added_by":"auto","created_at":"2025-11-25 07:13:52","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":17024,"visible":true,"origin":"","legend":"Table 2","description":"","filename":"IJOTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8077856/v1/cbb84c2e28643667ab2386d2.docx"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose","formattedTitle":"Infant dietary patterns and early childhood weight outcomes: a secondary analysis from the Starting Early Program Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNearly 13% of children aged 2 to 5 years in the United States (U.S.) are classified as having obesity, and 16% aged 2 to 19 years are classified as overweight (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Childhood obesity persists throughout the lifespan and increases risks of comorbidities like type 2 diabetes and cardiovascular disease,(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) highlighting the need for early prevention. The time from conception until age 2 years is considered a critical period for the development of obesity when nutrition, lifestyle and environmental exposures influence later behaviors and health outcomes (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Dietary intake during this period contributes to childhood obesity risk (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Healthy infant feeding practices not only support optimal growth and development (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), but also establish flavor preferences and eating behaviors that are often maintained throughout childhood (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), making infancy an important period to promote healthy dietary behaviors.\u003c/p\u003e\u003cp\u003eDietary recommendations for infants promote breastfeeding or iron-fortified formula feeding through the first year of life and the introduction of a variety of nutrient-dense complementary foods (e.g., fruits and vegetables) around 6 months when developmentally ready, with avoidance of cow\u0026rsquo;s milk, juice, sugar-sweetened beverages, and foods with added sugars, saturated fat, and sodium (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, data from national surveys indicate that many infants and toddlers in the U.S. are not fed according to these recommendations. Approximately 40% of infants and toddlers do not meet recommended intakes for fruit, and nearly 90% do not meet recommendations for total vegetables (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Additionally, 17% of infants consume cow\u0026rsquo;s milk and 27%, 34%, and 77% consume juice, sweets/sugar-sweetened beverages, and savory snacks, respectively (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These high rates of suboptimal feeding practices highlight the need to understand how early life dietary patterns are related to child weight outcomes, particularly in populations that are disproportionately affected by childhood obesity.\u003c/p\u003e\u003cp\u003eConsiderable research has examined how individual infant feeding practices, including exclusivity, duration, and intensity of milk-based feedings (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and adherence to complementary food recommendations (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), contribute to child weight outcomes. However, studying individual aspects of infant feeding does not sufficiently account for the whole diet and the complex interactions of the multiple dietary components consumed (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Infant dietary patterns measure the totality of the diet, considering milk feeding type and amount and variety of complementary foods, but limited studies have assessed how infant dietary patterns impact later child weight status. Latent class analysis (LCA), a person-centered data reduction approach, has been used to identify infant dietary patterns among primarily non-Hispanic white middle- or higher-income populations (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Patterns characterized by foods high in energy density or low in variety were associated with greater weight at 12 months (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), 24 months (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), and 6 years (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Children from Hispanic and lower-income populations experience the highest rates of obesity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), yet there is a lack of research investigating associations between infant dietary patterns and weight in these populations.\u003c/p\u003e\u003cp\u003eThe Starting Early Program (StEP) is a child obesity prevention intervention that supports optimal child feeding and lifestyle behaviors for Hispanic and low-income families. StEP reduces child weight trajectories through 24 months (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) and improves maternal infant feeding knowledge, styles, and practices (including increasing breastfeeding and decreasing juice) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Despite these positive impacts on feeding behaviors, it is unclear how StEP impacts infant \u003cem\u003edietary patterns\u003c/em\u003e and whether these dietary patterns contribute to later child weight outcomes. To address these gaps, the current study used LCA to identify distinct classes of infant dietary patterns in the StEP cohort. We aimed to 1) examine associations between dietary patterns and child weight and 2) examine potential impacts of the StEP intervention on dietary patterns and whether these patterns mediate the relationship between StEP and child weight.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eData for this secondary analysis were from the StEP trial, a randomized controlled trial to test the impact of a primary care-based child obesity prevention intervention beginning during pregnancy on early child weight outcomes in Hispanic families with low-incomes (ClinicalTrials.gov Identifier: NCT01541761) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Ethics approval was obtained from the Institutional Review Boards of New York University Grossman School of Medicine (Institutional Review Board number: 10-02175) and the New York City Health\u0026thinsp;+\u0026thinsp;Hospitals (System to Track and Approve Research number: StudyTX00001047), and trained bilingual research assistants obtained written informed consent from all participants. A detailed study design of StEP has been published elsewhere (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy sample\u003c/h3\u003e\n\u003cp\u003eAt 28 to 32 weeks gestation (baseline), participants were recruited from prenatal clinics affiliated with a large hospital system in New York City. Patients with self-reported Hispanic/Latina ethnicity, fluent in English or Spanish, \u0026ge;\u0026thinsp;18 years of age with a singleton uncomplicated pregnancy, and planned continuation of pediatric care at the study site were eligible. Participants with a history of severe medical or psychiatric illness or drug/alcohol use disorder, as well as those with fetal abnormalities detected via ultrasound, were excluded.\u003c/p\u003e\u003cp\u003eFor this secondary analysis, participants with a dietary recall at the 10-month assessment were included in the LCA. Infants\u0026thinsp;\u0026ge;\u0026thinsp;12 months at the assessment were excluded, as dietary recommendations change at 12 months (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Children with \u0026ge;\u0026thinsp;1 recorded weight at 12, 24, or 36 months were included in the analysis of dietary patterns and child weight.\u003c/p\u003e\n\u003ch3\u003eStarting Early Program intervention\u003c/h3\u003e\n\u003cp\u003eParticipants were randomly assigned to either the standard care or the StEP group. Standard care received standard prenatal and pediatric primary care. StEP received standard primary care visits plus individual counseling sessions after 32 weeks gestational age and at infant age 2 to 3 days, and 15 group nutrition and parenting classes from infant age 1 to 33 months delivered by registered dietitians and certified lactation counselors. Individual counseling sessions reviewed breastfeeding support, and group session topics included feeding, activity, and parenting.\u003c/p\u003e\n\u003ch3\u003eAssessments\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eInfant dietary assessment\u003c/h2\u003e\u003cp\u003e\u003cem\u003e24-hour dietary recall.\u003c/em\u003e At infant age 10 months, participants completed a 24-hour dietary recall modified to collect information about infant feeding, including detailed information on the type (breastmilk vs formula) and of mode (breast vs bottle) of milk feeding, consumption of complementary foods, and self-feeding. Mothers recalled what their infants consumed during the previous day, or, if the previous day was not reflective of usual intake, for a typical 24-hour period, providing the day of the week that was being recalled. Trained bilingual research assistants asked the time and mode (breast or bottle) of feeding, and whether the infant was given food or other beverages. For bottle feeds, mothers reported the milk type (expressed breastmilk, formula, or something else), whether anything was added, and, if so, what was added. For food or other beverages, mothers described the type and quantity of each food item given, how it was prepared, how it was fed, and how much the infant ate. These prompts were repeated to capture all feedings in one 24-hour period and recorded in a paper-based format, which was entered into the Automated Self-Administered 24-Hour Dietary Assessment 2014 (ASA24) tool, developed by the National Cancer Institute (NCI, Bethesda, MD) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Food Pattern Equivalents Database (FPED) values were generated using a SAS program available from the NCI to estimate intake of food groups (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cem\u003eDietary intake variables.\u003c/em\u003e Dietary variables were created following guidelines from the Child and Adult Care Food Program (CACFP) Infant Meal Patterns for 6- to 11-month infants (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and informed by prior methods (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Using the FPED values, dietary variables were dichotomized to identify daily intake of breastmilk; formula; cow\u0026rsquo;s milk; other dairy (e.g., yogurt, cheese, cottage cheese); infant cereals; grains (e.g., rice, pasta, bread, crackers, Cheerios); total vegetables (non-starchy and starchy); whole fruits; fruit juice; animal proteins (e.g., meat, poultry, fish, whole egg); legumes (e.g., cooked dry beans, cooked dry peas); and empty calorie foods (e.g., pastries, sugary cereals, salty snacks, French fries). Legumes were separated from animal proteins due to the more frequent consumption of legumes in diets of infants from Hispanic families (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Since the recall did not differentiate between 100% fruit juice and other juice drinks, any juice consumed was included in the juice category.\u003c/p\u003e\u003cp\u003e\u003cem\u003eBreastfeeding or formula feeding intensity.\u003c/em\u003e To determine predominant feeding mode, breastfeeding and formula feeding intensity were estimated as [breastmilk feeds OR formula feeds/(breastmilk feeds\u0026thinsp;+\u0026thinsp;formula feeds\u0026thinsp;+\u0026thinsp;cow\u0026rsquo;s milk feeds)*100] (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Infants with breastfeeding or formula feeding intensity\u0026thinsp;\u0026ge;\u0026thinsp;80% were considered predominantly breastfed or formula fed, respectively. Infants who were neither predominantly breastfed nor formula fed were considered mixed fed (e.g., 50% of feedings from breastmilk, 50% from formula).\u003c/p\u003e\u003cp\u003e\u003cem\u003eAdditional dietary variables.\u003c/em\u003e Cow\u0026rsquo;s milk, other dairy, infant cereal, grains, fruits, vegetables, animal proteins, legumes, juice, and empty calorie foods were dichotomized based on the infant meeting or not meeting the recommended number of daily servings (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). For cow\u0026rsquo;s milk, juice, and empty calorie foods, the recommendation is 0 servings. For infant cereal, other dairy, grains, animal proteins, and legumes, the recommendation is \u0026ge;\u0026thinsp;1 serving (\u0026gt;\u0026thinsp;0 tablespoons per serving). For fruits and vegetables, the recommendation is \u0026ge;\u0026thinsp;4 servings total (\u0026gt;\u0026thinsp;0 tablespoons per serving). Separate categories were created for fruits and vegetables, and the recommendation was split into \u0026ge;\u0026thinsp;2 servings of fruits and \u0026ge;\u0026thinsp;2 servings of vegetables.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eChild Weight Outcomes\u003c/h2\u003e\u003cp\u003eChild weights were obtained from the electronic medical record (EMR) of primary care well-child visits at 12, 24, and 36 months. Sex-specific weight-for-age z-scores (WFAz) at each timepoint was calculated using the World Health Organization Anthro macro (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). WFA\u0026thinsp;\u0026ge;\u0026thinsp;85th percentile was defined as overweight. We used WFA instead of weight-for-length due to identified inaccuracies in EMR-obtained length and height measurements, detailed elsewhere (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eMaternal age, parity, country of birth, and education were collected from the baseline assessment. Marital status, employment, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were completed at the 10-month assessment. The U.S. Adult Food Security Survey Module assessed food security at 10 months; participants who reported\u0026thinsp;\u0026ge;\u0026thinsp;3 food insecure conditions were categorized as experiencing household food insecurity (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Maternal anthropometric measurements were from the EMR. Pre-pregnancy body mass index (BMI, kg/m\u003csup\u003e2\u003c/sup\u003e) was calculated using measured weight (\u0026le;\u0026thinsp;13 weeks gestation) and height or, if unavailable, self-reported values from the baseline assessment. Gestational weight gain (kg) was calculated by subtracting pre-pregnancy weight from delivery weight. Delivery mode, infant sex, and birthweight were from the EMR. Age at introduction of complementary foods and childcare was reported at 10 months.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eTo identify discrete, mutually exclusive latent classes of infant dietary patterns, LCA was performed using Mplus version 8.3 (Muth\u0026eacute;n \u0026amp; Muth\u0026eacute;n, Los Angeles, CA). We selected LCA rather than an index-based approach because the StEP curriculum did not instruct participants to follow a single dietary pattern; rather, StEP targeted key obesity-related, age-appropriate feeding practices, including milk feeding type (promoting breastfeeding or counseling on healthy formula feeding) and complementary feeding (encouraging a variety of nutrient-dense foods rather than empty calorie foods). Additionally, families who participated in StEP were culturally diverse, and LCA helps identify differences in food consumption across diverse cultural groups. Latent class models with two through five latent classes were compared. The best fitting model was selected based on the Akaike\u0026rsquo;s Information Criterion (AIC), the Bayesian Information Criterion (BIC), the adjusted Bayesian Information Criterion (ABIC), a parametric bootstrapped likelihood ratio test (BLRT), relative entropy, the number of individuals within each class, and latent class interpretability (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). After identifying the optimal number of classes, participants were categorized into the class that corresponded to their highest-class membership probability.\u003c/p\u003e\u003cp\u003eDescriptive analyses, regression models, and mediation analyses were performed using the Stata Data Analysis and Statistical Software Version 14.2 (StataCorp LLC, College Station, TX). Maternal and infant characteristics were described by latent class membership using one-way analysis of variance or chi-squared tests. Linear regression models were used to analyze the association between latent class membership and WFAz at 12, 24, and 36 months, and logistic regression models were used to analyze the association between latent class membership and likelihood of being classified as overweight at the same timepoints. Regression analyses were adjusted for infant sex, birthweight, delivery mode, maternal age, marital status, education, pre-pregnancy BMI, gestational weight gain, parity, country of birth, household food insecurity, WIC participation, age of introduction of complementary foods, and study group assignment. We ran mediation analyses to determine whether the StEP intervention effects on child WFAz were mediated through 10-month dietary patterns. Since infant dietary patterns were measured at 10 months and milk feeding remains a significant source of energy for infants through 12 months, we expected that any intervention impacts on infant diet would likely mediate intervention effects on weight beyond 12 months. Therefore, the 24-month mediation analysis was adjusted for 12-month WFAz. We did not test for mediation at 36 months because StEP only impacted WFAz through 24 months.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf 933 eligible mothers, 566 signed consent, and 533 were randomized. Of those, 399 completed recalls at 10 months. We excluded 22 infants (5.5%) for being \u0026ge;\u0026thinsp;12 months at the time of assessment. We included 377 participants (193 control, 184 intervention) in the LCA with weight data available for 331 participants (87.8%; 167 control, 164 intervention) at 12 months, 283 participants (75.1%; 130 control 153 intervention) at 24 months, and 228 participants (60.5%; 122 control, 106 intervention) at 36 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLatent classes of infant dietary patterns at 10 months\u003c/h2\u003e\u003cp\u003eA four-class solution was determined to be the best fitting model after comparing the fit indices of the latent class profile solutions (\u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e) and inspecting latent class interpretability. The model fit indices supported the superiority of both the three-class and four-class over the two-class model, as evidenced by lower AIC, BIC, and ABIC values. Both the three-class and four-class models demonstrated a significant BLRT, indicating better fit compared to models with one fewer class. Although the four-class model did not have the lowest BIC, it was selected as the best-fitting model over the three-class model because all four classes contained more than 10% of the sample, had significant BLRT results, and exhibited the lowest AIC and ABIC values. Additionally, the four-class model allowed for the identification of distinct classes that captured the variety of complementary foods consumed. A five-class model was also examined but ultimately rejected due to an insignificant BLRT and the presence of a class comprising\u0026thinsp;\u0026lt;\u0026thinsp;5% of the sample.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the food group item response probabilities for each of the four latent classes. Food group item response probabilities closer to one indicated that the infant was more likely to consume that item, whereas probabilities closer to zero suggested that the infant was less likely to consume that item. Latent classes were labeled based on the high probability (\u0026ge;\u0026thinsp;0.50) of milk feeding mode and variety and developmental appropriateness of nutrient-dense complimentary foods (fruits, vegetables, grains, other dairy, animal protein, and legumes) served. The first class, labeled Breastfed-High variety (36.1% of the sample), was characterized by being predominantly breastfed and consuming a high variety of nutrient-dense complementary foods (fruits, grains, animal proteins). The second class, Formula fed-High variety (25.5%), had a high probability of being predominantly formula fed, consuming a high variety of complementary foods (grains, vegetables, fruits, animal protein), and having juice. The third class, Formula fed-Low Variety (24.1%), had a high probability of being predominantly formula fed and consuming infant cereal. The fourth class, Mixed fed-Low Variety (14.3%), had low probabilities of being predominantly breastfed or formula fed, suggesting mixed feeding, and a low variety of complementary foods (grains and animal proteins).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eMaternal and infant characteristics\u003c/h2\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e shows maternal and infant characteristics. The Breastfed-High variety pattern had a greater proportion of mothers who were legally/living as married, born outside the U.S., and in the StEP intervention arm and a lower proportion of mothers who were employed or used childcare at 10 months. The Formula-fed High variety and Formula-fed low variety patterns had a greater proportion of mothers with a high school education or greater.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDietary patterns at 10 months and child weight outcomes at 12, 24, and 36 months\u003c/h2\u003e\u003cp\u003eIn unadjusted analyses, the Formula fed-High Variety and Formula fed-Low variety patterns were associated with greater WFAz at 24 and 36 months (\u003cb\u003eSupplementary Table\u0026nbsp;2\u003c/b\u003e), but there were no associations with likelihood of being classified as overweight. In adjusted analyses (\u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e), compared to the Breastfed-High variety pattern, infants in the Formula fed-High variety pattern had higher WFAz at 24 months, and infants in the Formula fed-Low variety pattern had higher WFAz at 24 and 36 months and higher likelihood of being classified as overweight at 24 and 36 months. There was no association between the Mixed fed-Low variety pattern and weight status at 12, 24, or 36 months.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStEP intervention impacts on child weight outcomes at 12 and 24 months as mediated by infant dietary patterns\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhen testing the relationship between intervention group and dietary patterns, StEP participants were 2.4 (95% CI: 1.4, 4.1; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) times more likely to be in the Breastfed-High variety pattern compared to the Formula Fed-High variety pattern. We found similar trends when comparing membership of StEP participants in the Breastfed-High variety pattern to the Formula Fed-Low variety pattern (OR: 1.5, 95% CI: 0.9, 2.6, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.121) and the Mixed Fed-Low variety pattern (OR: 1.8, 95% CI: 0.9, 3.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.074). Since there were no associations between intervention group and membership in any of the other dietary patterns, we dichotomized the dietary pattern variable for the mediation analysis as membership in the Breastfed-High variety pattern (yes or no). After transforming the variable, we found that StEP participants were 1.9 (95% CI: 1.2, 2.9; p\u0026thinsp;=\u0026thinsp;0.004) times more likely to be in the Breastfed-High variety pattern compared to not being in this pattern.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displays the effect of the StEP intervention on 10-month dietary patterns, the effect of membership in the Breastfed-High variety pattern on WFAz at 12 and 24 months, and the mediated effects of the StEP intervention on WFAz. Mediation analyses indicated a significant indirect pathway between the StEP intervention and WFAz at 24 months (Indirect Effect: -0.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.049) via intervention impacts on infant dietary patterns. There was no indirect effect observed for WFAz at 12 months.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this secondary analysis, we identified four infant dietary patterns: 1) Breastfed-High variety, 2) Formula fed-High variety, 3) Formula fed-Low variety, and 4) Mixed fed-Low variety. The Breastfed-High variety pattern was considered the most consistent with infant feeding guidelines because caregivers served a high variety of nutrient-dense complementary foods and intakes of juice and empty calorie foods were low. Although this pattern was not characterized by \u0026ge;\u0026thinsp;2 servings of vegetables, most infants received\u0026thinsp;\u0026ge;\u0026thinsp;1 serving, and vegetable intakes were higher than the Formula fed-Low variety and Mixed fed-Low variety patterns. Compared to the Breastfed-High variety pattern, infants in the Formula fed-High variety pattern had higher WFAz at 24 months, and infants in the Formula fed-Low variety pattern had higher WFAz and greater likelihood of being classified as overweight at 24 and 36 months. StEP participants were more likely to be in the Breastfed-High variety pattern, and participation in StEP was significantly indirectly associated with lower WFAz at 24 months through greater membership in this dietary pattern.\u003c/p\u003e\u003cp\u003eCompared to data from national surveys, infants in the current analysis had similar or higher rates of breastfeeding and fruit intake; similar or lower rates of formula feeding and juice consumption; similar rates of vegetable intake; and lower consumption of empty calorie foods (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, average dietary intakes did not meet recommendations. Most infants were not receiving recommended amounts of fruits, vegetables, and other dairy based on CACFP guidelines (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), just under half of infants were given juice, and consumption of cow\u0026rsquo;s milk and empty calorie foods was evident, which may have implications for future dietary habits, food preferences, and health.\u003c/p\u003e\u003cp\u003eA main difference between the infant dietary patterns identified in our study compared to other research was the absence of a pattern characterized by empty calorie foods (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). While the reason for this difference is unclear, participants in the current analysis self-identified as Hispanic or Latina, and most were born outside of the U.S. In qualitative studies, Hispanic or Latina mothers born outside the U.S. reported balancing cultural- and family-based feeding recommendations with evidence-based health information when making decisions about infant feeding, with unprocessed, natural, and homemade cultural foods perceived as the healthiest options (\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Additionally, most of the families in our study participated in WIC, which aligns to national dietary guidelines and is associated with higher infant and child diet quality (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrior research found that infant dietary patterns characterized by empty calorie foods, juice, and/or low variety of complementary foods were associated with increased child weight outcomes at 2 and 6 years (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). While our study found that dietary patterns characterized by juice and low variety were associated with increased weight, we interestingly did not find any associations with the Mixed fed-Low variety pattern. While nearly one-third of infants in this pattern had\u0026thinsp;\u0026ge;\u0026thinsp;1 serving of empty calorie foods, this proportion is lower than what is reported in research that found associations with weight (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Additionally, most infants in the Mixed fed-Low variety pattern received some breastmilk, which may have a protective effect on weight (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The exact reasoning for the lack of association is unclear; unmeasured confounding associated with breastfeeding may have occurred. Infant dietary patterns that are characterized by a low variety of nutrient-dense complementary foods limit exposure to flavors and textures, which may prevent food acceptance later in childhood and lead to unhealthy food preferences (\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Continued exposure to these dietary patterns increases risks of nutritional deficiencies and obesogenic eating behaviors (\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), potentially promoting excess energy intake, weight gain, and adiposity (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOf the dietary patterns identified, the Breastfed-High variety pattern was considered the most consistent with infant feeding guidelines. StEP participants were more likely to follow the Breastfed-High variety dietary pattern, suggesting that StEP fostered adoption of guideline-concordant feeding behaviors. This finding aligns with the StEP curriculum, which promotes breastfeeding, optimal infant feeding practices, and modeling healthy behaviors, as well as prior research on the impacts of StEP on infant feeding behaviors, including greater maternal feeding knowledge and style, increased breastfeeding, and decreased juice (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). We also documented indirect effects of StEP on WFAz at 24 months, but not 12 months, through intervention impacts on membership in the Breastfed-High variety pattern. As milk-based feeding is still a significant form of energy in infants through 12 months, we did not expect that dietary patterns at 10 months would be strongly associated with 12-month WFAz. Rather, we conceptualized that infant dietary patterns may influence later child weight by establishing dietary patterns that continue throughout childhood (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). StEP may have facilitated continued support to maintain guideline-concordant dietary patterns beyond infancy, but additional research is needed.\u003c/p\u003e\u003cp\u003eStrengths of this analysis include LCA to assess the combination of infant feeding and type and variety of complementary foods in Hispanic and low-income families. Limitations include using a single 24-hour recall to assess infant dietary intake, which may not account for day-to-day variation or reflect usual intake (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). This limitation may be partly alleviated because mothers were asked to report what their infant ate on a typical day. LCA did not take into account early infant feeding practices, such as breastfeeding and formula feeding duration, intensity, or exclusivity for the first 6 months, time of introduction of complementary foods, or variety of complementary foods beyond what was reported on a single day. Additionally, our study included a culturally diverse sample of Hispanic and low-income families who were from an urban setting, which may not be generalizable to other populations.\u003c/p\u003e\u003cp\u003eIn conclusion, this study suggests that dietary patterns that are inconsistent with infant feeding guidelines, particularly low variety of nutrient-dense complementary foods, are associated with increased early childhood weight outcomes. StEP promoted a dietary pattern that was most consistent with infant feeding guidelines, which mediated the intervention effects on WFAz at 24 months. Given the importance of early prevention, culturally-relevant interventions that promote healthy nutrition and lifestyle behaviors in infancy may encourage families to provide a variety of developmentally appropriate and nutrient-dense complementary foods that promote health. More research is warranted to understand how dietary patterns change throughout childhood in Hispanic and low-income populations, determine factors that influence dietary patterns, and examine associations with weight outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eU.S.\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLCA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003elatent class analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eStEP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStarting Early Program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWFAz\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eweight-for-age z-score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASA24\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAutomated Self-Administered 24-Hour Dietary Assessment 2014\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Cancer Institute\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFPED\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFood Pattern Equivalents Database\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCACFP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChild and Adult Care Food Program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEMR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eelectronic medical record\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSpecial Supplemental Nutrition Program for Women, Infants, and Children\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebody mass index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAkaike\u0026rsquo;s Information Criterion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBayesian Information Criterion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eABIC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eadjusted Bayesian Information Criterion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBLRT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eparametric bootstrapped likelihood ratio test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the StEP staff and study participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLB, AD, KW, MM, and RGdesigned the research; LB, MM, and RG collected and assembled the data;LB and CK analyzed the data; all authors interpreted the data and contributed to manuscript writing and critical revision of manuscript for important intellectual content. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe have no competing financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration ID:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNCT01541761\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registry:\u0026nbsp;\u003c/strong\u003ehttps://clinicaltrials.gov/study/NCT01541761?intr=starting%20early%20program\u0026amp;rank=2\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePortions of this manuscript were previously posted as part of a dissertation on ProQuest (ProQuest Number:13880601; Available at: http://ezproxy.med.nyu.edu/login?qurl=https%3A%2F%2Fwww.proquest.com%2Fdissertations-theses%2Fprenatal-diet-quality-low-income-hispanic-women%2Fdocview%2F2243809994%2Fse-2%3Faccountid%3D35139).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of Support:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Institute of Food and Agriculture, the United States Department of Agriculture (award: 2011-68001-30207), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (K23HD081077, PI: Rachel Gross).\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStierman B, Afful J, Carroll MD, Chen T-C, Davy O, Fink S, et al. National Health and Nutrition Examination Survey 2017\u0026ndash;March 2020 prepandemic data files development of files and prevalence estimates for selected health outcomes. Natl Health Stat Report. 2021; 14(158):\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15620/cdc:106273\u003c/span\u003e\u003cspan address=\"10.15620/cdc:106273\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFryar C, Carroll M, Afful J. Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960\u0026ndash;1962 through 2017\u0026ndash;2018. NCHS Health E-Stats. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/nchs/data/hestat/obesity-adult-17-18/obesity-adult.htm#Citation\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/nchs/data/hestat/obesity-adult-17-18/obesity-adult.htm#Citation\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed November 21, 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSimmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016;17(2):95\u0026ndash;107. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/obr.12334\u003c/span\u003e\u003cspan address=\"10.1111/obr.12334\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBianco-Miotto T, Craig JM, Gasser YP, van Dijk SJ, Ozanne SE. Epigenetics and DOHaD: from basics to birth and beyond. J Dev Orig Health Dis. 2017;8(5):513\u0026ndash;9. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/s2040174417000733\u003c/span\u003e\u003cspan address=\"10.1017/s2040174417000733\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWoo Baidal JA, Locks LM, Cheng ER, Blake-Lamb TL, Perkins ME, Taveras EM. Risk factors for childhood obesity in the first 1,000 days: a systematic review. Am J Prev Med. 2016;50(6):761\u0026ndash;79. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amepre.2015.11.012\u003c/span\u003e\u003cspan address=\"10.1016/j.amepre.2015.11.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHamner HC, Nelson JM, Sharma AJ, Jefferds MED, Dooyema C, Flores-Ayala R, et al. Improving Nutrition in the First 1000 Days in the United States: A Federal Perspective. Am J Public Health. 2022;112(S8):S817-s25. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2105/ajph.2022.307028\u003c/span\u003e\u003cspan address=\"10.2105/ajph.2022.307028\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOng KK. Healthy Growth and Development. Nestle Nutr Inst Workshop Ser. 2017;87:141\u0026ndash;51. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000448964\u003c/span\u003e\u003cspan address=\"10.1159/000448964\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBirch LL, Doub AE. Learning to eat: birth to age 2 y. Am J Clin Nutr. 2014;99(3):723S-8S. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3945/ajcn.113.069047\u003c/span\u003e\u003cspan address=\"10.3945/ajcn.113.069047\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eU.S Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020\u0026ndash;2025. 9th Edition. December 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf\u003c/span\u003e\u003cspan address=\"https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed January 18, 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBreastfeeding and the use of human milk. Pediatrics. 2012; 129(3):e827-41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2011\u0026ndash;3552\u003c/span\u003e\u003cspan address=\"10.1542/peds.2011\u0026ndash;3552\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBailey RL, Stang JS, Davis TA, Naimi TS, Schneeman BO, Dewey KG, et al. Dietary and complementary feeding practices of US infants, 6 to 12 months: a narrative review of the federal nutrition monitoring data. J Acad Nutr Diet. 2022;122(12):2337-45.e1. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jand.2021.10.017\u003c/span\u003e\u003cspan address=\"10.1016/j.jand.2021.10.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoess AA, Jacquier EF, Catellier DJ, Carvalho R, Lutes AC, Anater AS, et al. Food Consumption Patterns of Infants and Toddlers: Findings from the Feeding Infants and Toddlers Study (FITS) 2016. J Nutr. 2018;148(suppl_3):1525s-35s. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jn/nxy171\u003c/span\u003e\u003cspan address=\"10.1093/jn/nxy171\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQiao J, Dai LJ, Zhang Q, Ouyang YQ. A meta-analysis of the association between breastfeeding and early childhood obesity. J Pediatr Nurs. 2020;53:57\u0026ndash;66. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pedn.2020.04.024\u003c/span\u003e\u003cspan address=\"10.1016/j.pedn.2020.04.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDewey K, Bazzano L, Davis T, Donovan S, Taveras E, Kleinman R, et al. The duration, frequency, and volume of exclusive human milk and/or infant formula consumption and overweight and obesity: a systematic review. Alexandria (VA): USDA Nutrition Evidence Systematic Review; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEnglish LK, Obbagy JE, Wong YP, Butte NF, Dewey KG, Fox MK, et al. Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review. Am J Clin Nutr. 2019;109(Suppl_7):956s-77s. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ajcn/nqy267\u003c/span\u003e\u003cspan address=\"10.1093/ajcn/nqy267\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEnglish LK, Obbagy JE, Wong YP, Butte NF, Dewey KG, Fox MK, et al. Timing of introduction of complementary foods and beverages and growth, size, and body composition: a systematic review. Am J Clin Nutr. 2019;109(Suppl_7):935s-55s. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ajcn/nqy267\u003c/span\u003e\u003cspan address=\"10.1093/ajcn/nqy267\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReedy J, Subar AF, George SM, Krebs-Smith SM. Extending methods in dietary patterns research. Nutrients. 2018;10(5). doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/nu10050571\u003c/span\u003e\u003cspan address=\"10.3390/nu10050571\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRose CM, Savage JS, Birch LL. Patterns of early dietary exposures have implications for maternal and child weight outcomes. Obesity (Silver Spring, Md). 2016;24(2):430\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRose CM, Birch LL, Savage JS. Dietary patterns in infancy are associated with child diet and weight outcomes at 6 years. International journal of obesity (2005). 2017;41(5):783-8. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/oby.21349\u003c/span\u003e\u003cspan address=\"10.1002/oby.21349\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHohman EE, Paul IM, Birch LL, Savage JS. INSIGHT responsive parenting intervention is associated with healthier patterns of dietary exposures in infants. Obesity (Silver Spring, Md). 2017;25(1):185\u0026ndash;91. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/ijo.2017.27\u003c/span\u003e\u003cspan address=\"10.1038/ijo.2017.27\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMessito MJ, Mendelsohn AL, Katzow MW, Scott MA, Vandyousefi S, Gross RS. Prenatal and pediatric primary care-based child obesity prevention program: a randomized trial. Pediatrics. 2020;146(4). doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2020-0709\u003c/span\u003e\u003cspan address=\"10.1542/peds.2020-0709\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMessito MJ, Katzow MW, Mendelsohn AL, Gross RS. Starting Early Program impacts on feeding at infant 10 months age: a randomized controlled trial. Child Obes. 2020;16(S1):S4-s13. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/chi.2019.0236\u003c/span\u003e\u003cspan address=\"10.1089/chi.2019.0236\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Randomized controlled trial of a primary care-based child obesity prevention intervention on infant feeding practices. J Pediatr. 2016;174:171-\u003cdiv class=\"ExternalRefDOI\"\u003e7.e2\u003c/div\u003e. doi:10.1016/j.jpeds.2016.03.060.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim CN, Messito MJ, Katzow M, Duh-Leong C, Gross RS. Child obesity prevention from pregnancy: long-term follow-up of the Starting Early Program Trial. Pediatrics. 2025;155(5). doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2024-069421\u003c/span\u003e\u003cspan address=\"10.1542/peds.2024-069421\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSubar AF, Kirkpatrick SI, Mittl B, Zimmerman TP, Thompson FE, Bingley C, et al. The Automated Self-Administered 24-hour dietary recall (ASA24): a resource for researchers, clinicians, and educators from the National Cancer Institute. J Acad Nutri Diet. 2012;112(8):1134\u0026ndash;7. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jand.2012.04.016\u003c/span\u003e\u003cspan address=\"10.1016/j.jand.2012.04.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Cancer Institute. Calculating Food Patterns Equivalents Database (FPED) Food Group Equivalents. Reviewing and Cleaning ASA24 Data. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://epi.grants.cancer.gov/asa24/resources/cleaning.html#calculate\u003c/span\u003e\u003cspan address=\"https://epi.grants.cancer.gov/asa24/resources/cleaning.html#calculate\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed February 21, 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnited States Department of Agriculture. Child and Adult Care Food Program (CACFP) Infant Meal Patterns. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.fns.usda.gov/cacfp/nutrition-standards/infant-meal-patterns\u003c/span\u003e\u003cspan address=\"https://www.fns.usda.gov/cacfp/nutrition-standards/infant-meal-patterns\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed February 21, 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMennella JA, Ziegler P, Briefel R, Novak T. Feeding Infants and Toddlers Study: the types of foods fed to Hispanic infants and toddlers. J Am Diet Assoc. 2006;106(1 Suppl 1):S96-106. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jada.2005.09.038\u003c/span\u003e\u003cspan address=\"10.1016/j.jada.2005.09.038\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi R, Fein SB, Grummer-Strawn LM. Association of breastfeeding intensity and bottle-emptying behaviors at early infancy with infants' risk for excess weight at late infancy. Pediatrics. 2008;122 Suppl 2:S77-84. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.2008-1315j\u003c/span\u003e\u003cspan address=\"10.1542/peds.2008-1315j\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. World Health Organization anthro for personal computers, version 3.2.2, 2011: software for assessing growth and development of the world's children. 2011. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.who.int/childgrowth/software/en/\u003c/span\u003e\u003cspan address=\"http://www.who.int/childgrowth/software/en/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed August 21, 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBickel G, Nord M, Price C, Hamilton W, Cook J. Guide to Measuring Household Food Security (Revised 2000). USDA Food and Nutrition Service. 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.fns.usda.gov/research/guide-measuring-household-food-security-revised-2000\u003c/span\u003e\u003cspan address=\"https://www.fns.usda.gov/research/guide-measuring-household-food-security-revised-2000\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed August 21, 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNylund KL, Tihomir A, and Muth\u0026eacute;n BO. Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study. Struct Equ Modeling. 2007;14(4):535\u0026ndash;69. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/10705510701575396\u003c/span\u003e\u003cspan address=\"10.1080/10705510701575396\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThompson AL. Evaluating the pathways linking complementary feeding practices to obesity in early life. Nutr Rev. 2020;78(Suppl 2):13\u0026ndash;24. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/nutrit/nuz057\u003c/span\u003e\u003cspan address=\"10.1093/nutrit/nuz057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacMillan Uribe AL, Rudt HG, Leak TM. Cultural influences on infant and toddler feeding among low-income Latinx mothers. Matern Child Nutr. 2022;18(4):e13342. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/mcn.13342\u003c/span\u003e\u003cspan address=\"10.1111/mcn.13342\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBeck AL, Hoeft KS, Takayama JI, Barker JC. Beliefs and practices regarding solid food introduction among Latino parents in Northern California. Appetite. 2018;120:381\u0026ndash;7. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.appet.2017.09.023\u003c/span\u003e\u003cspan address=\"10.1016/j.appet.2017.09.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheney AM, Nieri T, Davis E, Prologo J, Valencia E, Anderson AT, et al. The sociocultural factors underlying Latina mothers' infant feeding practices. Glob Qual Nurs Res. 2019;6:2333393618825253. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2333393618825253\u003c/span\u003e\u003cspan address=\"10.1177/2333393618825253\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCaulfield LE, Bennett WL, Gross SM, Hurley KM, Ogunwole SM, Venkataramani M, et al. Maternal and child outcomes associated with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Agency for Healthcare Research and Quality Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoletzko B, Godfrey KM, Poston L, Szajewska H, van Goudoever JB, de Waard M, et al. Nutrition during pregnancy, lactation and early childhood and its implications for maternal and long-term child health: the Early Nutrition project recommendations. Ann Nutr Metab. 2019;74(2):93\u0026ndash;106. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000496471\u003c/span\u003e\u003cspan address=\"10.1159/000496471\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVentura AK. Does breastfeeding shape food preferences? links to obesity. Ann Nutr Metab. 2017;70 Suppl 3:8\u0026ndash;15. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000478757\u003c/span\u003e\u003cspan address=\"10.1159/000478757\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnzman-Frasca S, Ventura AK, Ehrenberg S, Myers KP. Promoting healthy food preferences from the start: a narrative review of food preference learning from the prenatal period through early childhood. Obes Rev. 2018;19(4):576\u0026ndash;604. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/obr.12658\u003c/span\u003e\u003cspan address=\"10.1111/obr.12658\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaier-N\u0026ouml;th A. Early development of food preferences and healthy eating habits in infants and young children. Nestle Nutr Inst Workshop Ser. 2019;91:11\u0026ndash;20. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000493674\u003c/span\u003e\u003cspan address=\"10.1159/000493674\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEmmett PM, Hays NP, Taylor CM. Antecedents of picky eating behaviour in young children. Appetite. 2018;130:163\u0026ndash;73. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.appet.2018.07.032\u003c/span\u003e\u003cspan address=\"10.1016/j.appet.2018.07.032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans C, Hutchinson J, Christian MS, Hancock N, Cade JE. Measures of low food variety and poor dietary quality in a cross-sectional study of London school children. Eur J Clin Nutr. 2018;72(11):1497\u0026ndash;505. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41430-017-0070-1\u003c/span\u003e\u003cspan address=\"10.1038/s41430-017-0070-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSteyn NP, Nel JH, Nantel G, Kennedy G, Labadarios D. Food variety and dietary diversity scores in children: are they good indicators of dietary adequacy? Public Health Nutr. 2006;9(5):644\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaylor CM, Wernimont SM, Northstone K, Emmett PM. Picky/fussy eating in children: review of definitions, assessment, prevalence and dietary intakes. Appetite. 2015;95:349\u0026ndash;59. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.appet.2015.07.026\u003c/span\u003e\u003cspan address=\"10.1016/j.appet.2015.07.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThompson AL, Bentley ME. The critical period of infant feeding for the development of early disparities in obesity. Soc Sci Med. 2013;97:288\u0026ndash;96. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.socscimed.2012.12.007\u003c/span\u003e\u003cspan address=\"10.1016/j.socscimed.2012.12.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLioret S, Betoko A, Forhan A, Charles MA, Heude B, de Lauzon-Guillain B. Dietary patterns track from infancy to preschool age: cross-sectional and longitudinal perspectives. J Nutr. 2015;145(4):775\u0026ndash;82. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3945/jn.114.201988\u003c/span\u003e\u003cspan address=\"10.3945/jn.114.201988\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuque V, Escribano J, Closa-Monasterolo R, Zaragoza-Jordana M, Ferr\u0026eacute; N, Grote V, et al. Unhealthy dietary patterns established in infancy track to mid-childhood: the EU Childhood Obesity Project. J Nutr. 2018;148(5):752\u0026ndash;9. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/jn/nxy025\u003c/span\u003e\u003cspan address=\"10.1093/jn/nxy025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThompson FE, Kirkpatrick SI, Subar AF, Reedy J, Schap TE, Wilson MM, et al. The National Cancer Institute's Dietary Assessment Primer: a resource for diet research. J Acad Nutr Diet. 2015;115(12):1986\u0026ndash;95. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jand.2015.08.016\u003c/span\u003e\u003cspan address=\"10.1016/j.jand.2015.08.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"childhood obesity, dietary patterns, weight-for-age, infant feeding, prevention","lastPublishedDoi":"10.21203/rs.3.rs-8077856/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8077856/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eLimited studies assess how infant dietary patterns impact child weight. The Starting Early Program (StEP) promotes healthy nutrition during pregnancy and infancy and leads to healthier child weight, but whether dietary patterns contribute to weight or mediate StEP weight outcomes has not been studied.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThis secondary analysis identified infant dietary patterns in StEP, determined associations between dietary patterns and child weight outcomes, and examined whether dietary patterns mediated the relationship between StEP and child weight.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eData were from 377 mother-infant dyads enrolled in a randomized trial testing the efficacy of StEP. Infant diet was assessed at 10 months using an interviewer-administered 24-hour recall, and dietary patterns were identified using latent class analysis. Child weights were abstracted from medical records at 12, 24, and 36 months. Associations between infant dietary patterns and weight-for-age z-score (WFAz) and likelihood of being classified as overweight (WFA ≥85\u003csup\u003eth\u003c/sup\u003e percentile) were assessed using multivariable linear and logistic regression models. Mediation analyses were used to assess intervention effects on WFAz via impacts on infant dietary patterns.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFour classes of infant dietary patterns were identified, characterized by differences in milk feeding and complementary food type and variety: Breastfed-High variety; Formula fed-High variety; Formula fed-Low variety; and Mixed fed-Low variety. Compared to the Breastfed-High variety class, infants in the Formula fed-Low variety class had higher WFAz and were more likely to be classified as overweight at 24 and 36 months. Participation in StEP increased membership in Breastfed-High variety, which mediated the association between StEP and lower WFAz at 24 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eInfant dietary patterns were identified and associated with child obesity risk. StEP promoted an infant dietary pattern that was most consistent with infant feeding guidelines, which mediated intervention effects on child weight.\u003c/p\u003e","manuscriptTitle":"Infant dietary patterns and early childhood weight outcomes: a secondary analysis from the Starting Early Program Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-25 07:13:47","doi":"10.21203/rs.3.rs-8077856/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1e839553-6798-4ccb-b48d-21383b7c7b81","owner":[],"postedDate":"November 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57898928,"name":"Health sciences/Diseases/Nutrition disorders/Obesity"},{"id":57898929,"name":"Health sciences/Health care/Nutrition"}],"tags":[],"updatedAt":"2026-01-19T19:00:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-25 07:13:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8077856","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8077856","identity":"rs-8077856","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}