The objective of this study was to perform a food group-based analysis of low-income, minority, preschool children, rather than studying individual nutrient intake
[18–20]. Significant differences were identified between Hispanic and African American children, suggesting influences of social and cultural practices on dietary patterns. Previous studies have used methodologies such as dietary scoring to analyze food patterns among large population groups
[2, 21, 22]. We decided not to adopt a pre-existing scoring mechanism because these were designed and validated only for children over the age of 2 years, while the goal of this study is to evaluate the food patterns of children aged 1 to 5 years of age. This methodology employing servings per food groups as the unit of analysis to assess dietary patterns have been previously reported as a validated method to assess nutrient intake
Hispanics consumed a much larger proportion of fruits and whole fruits in their diet than African Americans which is consistent with previous studies
. However this study is the first to report it for this age group. Culturally, high fruit consumption is common among Hispanics, especially in families that migrate from rural areas, as are the majority of Hispanic migrants residing in urban Georgia
. While confirming previous findings, our results also provide further insight on this behavior, showing that not only is total and whole fruit consumption higher than that of African Americans, but juice consumption is also very high in this population, accounting for half of their total fruit intake, and 10.3% of their caloric intake. This, in addition to the high intake of sweet drinks in both Hispanic and African American children, is a relevant finding as investigators recently reported lack of activation of satiety signals in the gut with liquid food as opposed to solids
[28, 29]. Also fructose overrides the regulatory glycolytic step leading to higher rates of fat production in the liver, increasing abdominal fat deposition
[30–32]. Moreover, sweetened beverages, including fruit juices, are associated with negative health outcomes due to increase adiposity gain in low-income children
. Carbohydrate malabsorption is also high in infants consuming sorbitol-containing juices with high fructose-to-glucose ratio which has a negative impact on metabolism and activity
. The American Academy of Pediatrics
 recommends reducing overall fruit juice intake among children and replacing it with whole fruits due to these documented negative effects associated with intake of large volumes of fruit juices.
As in previous studies, Hispanics were found to have a significantly higher intake of dairy products than African Americans (16.6 ± 8.4% vs. 9.3 ± 6.4%)
[36–40]. Milk and other dairy products constitute a primary source of calcium, especially for children
[41–43]. Vitamin D intake for both groups was found to be extremely low, with more than 95% of the studied population not meeting the RDA. Vitamin D status and consumption in this population has been evaluated and extensively discussed
African American children had a higher consumption of meats than Hispanic children which contributed to the higher number of African American children exceeding the recommended distribution for protein (11.1% vs. 2.4% for Hispanics). These findings are consistent with previous knowledge of food habits among African Americans in the US, particularly in the South, where high meat, egg and poultry intake is common
[44–47]. The lower intake of meats by Hispanics could contribute to their higher prevalence of low iron intake reported. However, more Hispanics than African Americans met the RDA for zinc (97.6% vs. 92.1%). This is a noteworthy finding as the main dietary source of zinc and iron is meat
[9, 43]. The other rich sources of zinc consumed by both groups include dairy products and legumes
[9, 48, 49].
Based on these results, we recommend the following strategies to improve the diet quality of low-income, preschool Hispanics: 1) Encourage a high fruit intake among this group, while deemphasizing the need for fruit juices; 2) Maintain current levels of dairy intake, while promoting the use of low-fat dairy products, emphasizing these are safe for healthy children over the age of two years; 3) Increase the intake of iron-rich products such as meat, poultry and legumes. 4) Provide information on the appropriate portion sizes to prevent high calorie diets, which in this population may be also associated to less healthy dietary patterns. 5) Emphasize the use of culturally appropriate preparations to combine cereals and legumes to provide a high quality protein, yet low-fat meal. A good example for this is the combination of corn tortillas with black beans. For preschool, low-income African Americans, our results suggest that: 1) A higher total fruit intake should be promoted, while emphasizing the consumption of whole fruit as opposed to juices; 2) Meat intake should be reduced if the intake of protein is excessive. Replacing some of the animal protein with vegetable protein, which contains other vital nutrients is also recommended; 3) Portion sizes should be reduced globally due to obesity being partly driven by a higher caloric intake in this population. Finally, our data suggests the following strategies should take place for both Hispanics and African Americans: 1) Increase vegetable intake by incorporating one or two vegetable portions at both lunch and dinner; 2) Reduce the consumption of sweets with a strong emphasis on the reduction of sweet beverage intake; 3) Encourage healthy snacking by encouraging more nutrient dense foods and discouraging empty calories. This includes reducing exposure to fast food which has been shown in other studies to be a significant contributor to childhood obesity
. For interventions to have a higher probability of success, culturally appropriate strategies should be adopted to improve nutrition behaviors in these groups. The promotion of traditional corn tortillas (high in calcium, fiber and low in calories) among Hispanics rather than flour tortillas (higher in fat and calories) is a good example.
Many of the limitations of this study are due to the sample size and that this is the secondary analysis of existing data. The original sample size calculation was based on identifying differences in serum micronutrient levels and the study was not powered to identify differences between food groups
[9, 10]. There was also a higher representation of African-American children in the families who completed food diaries. The data collected did not measure or control for physical activity levels, fast-food intake and environmental influences. It has been reported that Hispanic and African-American children have lower levels of physical activity than the rest of the population
. Investigators have also observed that obese infants have lower activity levels, compared to non-obese infants and could in turn lead to obese preschoolers
. Fast-food is known to be a major contributor to childhood obesity, and its consumption is highly prevalent among all groups of children. It is highest in African Americans, particularly those residing in the South. Children with a high intake of fast-food have been reported to have higher total caloric intake, higher fat, sugar and sodium intake, and lower intake of fruits and vegetables
. The effect of contextual factors such as the food environment (higher density of fast-food outlets in low-income neighborhoods) should be addressed in future studies
[53, 54]. Foreign-born Hispanics are at lower risk for obesity and have healthier dietary patterns than US born Hispanics
[55–58]. The level of acculturation has also been found to be an important contributor to obesity independent of duration of residence in the US
[56, 58–61]. These facts have led to the healthy immigrant effect or the immigrant paradox hypothesis. It highlights the fact that upon arrival, Hispanic immigrants are the healthiest of all groups in the US, and have a diet high in fruits and vegetables and low in fat. After time, presumably due to environmental influences, these Hispanics become the unhealthiest group as they begin to consume a high-fat, high-protein diet, also low in fruits and vegetables, and increase their fast-food intake
[62, 63]. Studies addressing the influence of diet on obesity in Hispanics should control for these social influence factors. It is also necessary to explore the potential complex gene-environment interaction, which in combination with caloric intake and dietary patterns could have a role in this observed obesity epidemic among minority groups.