Children’s Dietary Inflammatory Index: Association with sociodemographic and behavioral factors, cardiometabolic risk, and inflammatory markers (PASE study)
Authors:   , Suhett Lara Gomes 
Published: August 2022

The Children’s Dietary Inflammatory Index (C-DII) is a novel method of estimating the quality and the inflammatory properties of pediatric population’s diet. The possible determinants of the dietary inflammatory potential, as well as the health consequences of the pro-inflammatory diet in childhood remains unclear. Thus, we aimed to evaluate the association of the C-DII scores with sociodemographic and behavioral factors, cardiometabolic risk, and inflammatory markers in schoolchildren. The systematic review was performed according to the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines and registered in PROSPERO (CRD42019123939). This is a cross-sectional representative study carried out with participants from the Schoolchildren Health Assessment Survey (PASE - 2015), which was approved by the Ethics Committee on Human Research of the Universidade Federal de Viçosa (UFV), process no. 663,171/2014. The sample consisted of 378 children between the ages of 8 and 9 years enrolled in all public and private schools from the urban area of Viçosa, Minas Gerais, Brazil. The parents’ participants signed the Informed Consent Terms. To evaluate food consumption, breakfast habit, and to calculate C-DII scores, three 24-hour recall were applied on non-consecutive days, including one day of weekend. Sixteen food- parameters were used for the C-DII calculation and the index was adjusted per 1000 kcal consumed. A semi-structured questionnaire was applied to obtain sociodemographic and screen time information. Anthropometric measures (weight and height), body fat distributions (total, truncal, gynoid, android), body mass index (BMI) calculation, and biochemical analysis were performed to assess the cardiometabolic risk. The body composition was evaluated by dual energy X-ray absorptiometry (DXA). Blood samples were collected after 12h of fasting for the analysis of lipid profile (total cholesterol and fractions, triglycerides) and inflammation markers (serum adipokines). The atherogenic indexes (Castelli risk index I, Castelli index risk II, lipoprotein combine index (LCI), atherogenic index of plasma (AIP), and atherogenic coefficient (AC)) of the sample were calculated. At the end of the study, all children received the results of their tests and individual nutritional guidance. The statistical analyses were realized in the Social Package Statistical Science (SPSS) program version 23.0 and Stata®8 version 14. Multivariable linear regression models were proposed to establish the relationship of C-DII with the dependent and independent variables and possible interactions. For all hypotheses, the level of statistical significance considered was α=5%. In the systematic review, all included papers found a positive association of the DII or C-DII with cardiometabolic and inflammatory markers in children and adolescents. The mean ± standard deviation (SD) of C- DII score was 0.60 ± 0.94 and ranged from −2.16 (maximum anti-inflammatory diet) to 2.75 (maximum pro-inflammatory diet). Breakfast skipping was associated to a higher intake of lipids, monounsaturated fat, and polyunsaturated fat, and lower intake of carbohydrate, calcium, and magnesium. Children skipping breakfast at least one day of the three 24HR had higher C- DII scores. We did not identified interaction between breakfast skipping and sociodemographic factors (sex, age, race, and household per capita income) in relation to C-DII scores. However, the association between breakfast skipping and C-DII was more pronounced in children with sedentary behavior. Children with hypercholesterolemia and hypertriglyceridemia had higher C-DII scores. The C-DII was directly associated with atherogenic indexes and with the accumulation of altered dyslipidemia markers (high TC + high LDL-cholesterol + high TAG + low HDL-cholesterol). Non-White children and students from public schools were more likely to have a pro-inflammatory diet. Additionally, the C-DII was inversely associated with household per capita income. The C-DII was not associated with central and total body fat. However, the index was modestly inversely associated with adiponectin and RBP4, and modestly directly associated with chemerin. We conclude that breakfast skipping was associated with C-DII scores with significant interaction with sedentary behavior. A pro- inflammatory diet was positively associated with sociodemographic characteristics (non-white children, residents in poorer communities) and unhealthy outcomes (cardiometabolic and inflammatory markers) in Brazilian schoolchildren. These results reinforce the importance of effective public health policies and nutritional interventions targeting individuals with unhealthy behaviors and in social vulnerability to promote healthy eating and lifestyle habits since childhood. Keywords: Child. Food intake. Adiposity. Inflammation. Cardiovascular diseases. Socioeconomic factors. Nutritional Epidemiology.