The importance of consuming a large variety of nutritious foods is recognized within national food guidelines
. The ARFS-P was developed to reflect the food behaviors and eating habits recommended in such guidelines. The use of brief tools is convenient for clinicians and allows for rapid individualized feedback and early interventions targeting improvements in diet quality. This is important given recent reviews of diet quality indices in children suggesting healthier diet patterns are associated with cognition, behavior, and anthropometric factors
[6, 7]. Associations between diet quality indices and short and long term health outcomes, such as blood pressure, asthma, blood lipids, inflammation factors and dental caries, has also been recognized
This study is novel in applying this approach to assess diet quality in a pre-school population. We have previously validated this diet quality scoring method, which uses a food-based approach in an older pediatric population aged 9–16 years
. While diet quality scores have been constructed for use in children, recent reviews have highlighted the need for additional studies in more diverse population samples with analyses adjusted more fully for potential confounders
[6, 7] and a specific need for further studies in children under the age of five years
[6, 7, 26]. The ARFS-P was calculated from intakes of whole foods rather than nutrient intakes, making this method of interest when information about usual food intake, as opposed to nutrients, is sought or when feedback to individuals about their food patterns would be useful.
While few DQIs have been developed specifically for use with toddler populations
, findings from this study are similar to other diet quality validation studies in toddlers, including the FFQ DQI developed for pre-schoolers in which significant correlations were found between their DQI and nutrients such as protein, fibre, calcium and zinc
, as we did in this study (r = 0.220, p < 0.001; r = 0.125, p = 0.008; r = 0.164, p = 0.011; r = 0.173, p < 0.001; respectively). However, we found a strong relationship between ARFS-P and β-carotine where they did not; differences such as these are not surprising since they used Pearson's correlations that do not allow for controlling for influences of, for instance total energy and age. Other validation studies of diet quality scores, such as the Healthy Eating index
, found strong relationships with dietary intake, including fibre, folate and vitamin C, as did we (r = 0.125, p = 0.008; r = 0.141, p = 0.018; r = 0.441, p < 0.001; respectively).
Strategies to enhance diet quality need to focus on increasing the variety of nutrient-dense foods in a child’s diet, and reducing consumption of discretionary choices. Results of the current study indicate that each of the ARFS component scores were low compared to the total maximum point available, particularly for sub-scales of fruit and vegetables. This suggests that increasing the variety of fruit and vegetables consumed regularly could be important areas to target improvements in diet quality. Other areas, in descending order, could include lean meat and vegetarian protein alternatives. This suggests that public health messages targeting increases in the variety amongst healthful foods that are consumed each week, could offer a new approach to nutrition promotion.
This study found that ARFS-P scores were highly related to both nutrient intakes and consumption patterns of children aged two to five years. The sensitivity of this DQS is demonstrated by its ability to detect significant changes in macronutrient and micronutrient intake per unit change in ARFS-P. By way of example, the positive beta-coefficient of β-carotene with total ARFS-P means that an increase in total ARFS-P corresponds to an increase in pre-schooler β-carotene intake, on average. A similar trend was evident when considering intake of food groups and ARFS-P. Consequently the use of the ARFS-P was valid in assessing the eating patterns and nutrient intakes of the study population. Marginal significance was reached with saturated fat and cholesterol, providing some evidence that younger children may have been consuming more saturated fat and cholesterol than their older counterparts.
Strengths and limitations
Anthropometric data, such as weight, were not obtained from this population, since the primary outcome measure of the FHFK randomized controlled trial was changes to dietary intake. As a consequence, the relationship between weight status and ARFS-P could not be explored. However, unpublished data collected in 2008 as part of the Before School Screening program for 4–5 year olds (n = 571) in the same study locations suggested that rates of overweight and obesity were higher than the NSW average
, with 26.8% of children overweight or obese (27.3% male, 26.3% female). Despite a previous study suggesting that the FFQ was relatively accurate when assessing total energy intake at the group level
, over –and under-reporting of dietary intake and physical activity level were not assessed in the current study. The relatively small sample from rural locations reduces the generalizability and hence results should be interpreted with caution.
The effect of parental bias must also be considered when interpreting results as a caregiver completed the AES-P on their child’s behalf. This may exacerbate the over reporting bias already associated with the use of an FFQ
 and may increase the chance that the data is incomplete or that intake has been underestimated
. Future studies should consider obtaining dietary intake reports from both parents, or where appropriate, with the child present to try to reduce reporting biases
Some limitations of calculating and using ARFS to determine usual diet quality have been previously published
, including that the national nutrient databases used in this study does not accurately reflect population consumption of folate as fortification of breads, cereals and cereal products is not accounted for within the database, hence results obtained for FFQ folate intake are likely to be lower than true intake.
Implications for research and practice
The ARFS-P allows for the rapid measurement of diet quality of children aged 2–5 years in a single continuous variable. It was derived from a validated FFQ for young children, and provides researchers the opportunity to use an independent measure of intake, or calculated secondarily, from the AES-P FFQ. Its calculation is less onerous than methods that require derivation of nutrient based sub-scales. This means that the provision of feedback based on overall score can potentially be in real-time.
Based on the finding in the current study, the ARFS-P method for scoring diet quality could be applied to other FFQs, in other populations, age groups, and in other settings. This could include testing its use as a self-monitoring tool or within clinical practice. If validated in these settings it would be a convenient tool that could be used by a variety of health professionals to assess and monitor dietary patterns.