By adjusting meal sizes and the composition or timing of food intake, 94.5% ± 16.4% of meals were preceded by ID as assessed by diary reports after training. All subjects together significantly decreased their mean energy intake and increased their fruit and vegetable intake (). We assumed that the RMR and TEE groups were identical. Age, anthropometry measures, and clinical assessments coincided. Energy intake decreased from 86.0 ± 17.3 kcal/kg/d to 70.7 ± 18. 8 and from 87.8 ± 13.9 to 71.1 ± 14.6 in the two groups and showed no difference at recruitment from the local population of the same age.7
Afternoon RMR (sleeping MR) fell by −9.6 ± 8.6 kcal/kg/d (−15.4% of the value at recruitment), ie, from 58.6 ± 7.8 to 49.0 ± 9.1 kcal/kg/d (). Daily energy expenditure fell by −12.3 ± 7.2 kcal/kg/d (−15.5%), ie, from 80.1 ± 6.9 kcal/kg/d at recruitment to 67.8 ± 10.0 kcal/kg/d at follow-up (). The physical activity level was 1.4 at recruitment and remained at 1.4, as reported in normal infants of this age.22
Even with no change in physical activity level, diaries reported a significant increase in outdoor living after training (), suggesting no decrease in physical activity after training. The decrease in RMR (−9.6 ± 8.6 kcal/kg/d) showed no difference from the decrease in TEE (−12.3 ± 7.2 kcal/kg/d). These decreases objectively reject equivalence between scheduled and demanded meals (null hypothesis).
Effects of training on food intake, energy expenditure, and fecal emission
Instructions for the first training day interrupted automatic, habitual food administration at mealtimes and implemented habitual evaluation of either the arousal or lack thereof of the child’s hunger manifestations. A habit change may produce powerful effects.23
Social and physical activity levels and healthy growth were maintained and even improved with fruit- and vegetable-rich meals providing modest calories that maintained toddlers in inter-meal intervals until demand. In overweight adults, both high vegetable intake and IH meal onset contributed to decreasing energy intake in comparison with scheduled meals.10
Further, these more detailed studies support our findings over many years that mothers can easily maintain usual mealtimes by adjusting meal content to satiate their toddlers for expected activity in the desired interval between meals.12
ID arises spontaneously as a habit in 20% of untrained toddler–mother pairs, but can be easily learned with coaching.7
For infants and toddlers, the pattern relies on the evaluation of food demand prior to each mealtime, validated in a previous study by BG measurements.7
At the end of the investigation in the laboratory, mothers stated whether their infant was hungry or not hungry, and estimated BG shortly before blood sampling and before breakfast. The 54 hungry infants of the trained group had a significantly lower BG (74.6 ± 7.7 mg/dL) compared to the 16 not-hungry infants (96.3 ± 10.5 mg/dL; P
= 0.001). Moreover, the trained mothers of hungry infants were able to estimate BGs (77.4 ± 3.6 mg/dL; estimation error: 5.8% ± 4.5% of the measured BG) more accurately than the mothers of not-hungry infants (estimated BG: 88.7 ± 5.9 mg/dL; estimation error: 10.9% ± 7.5%; P
= 0.0001). The meaning of this validation is that mothers can recognize food requests as manifestations that arise at a constant (low) BG in their infants, ie, corresponding to a physiologically identifiable condition.7
Our previous data from diaries show that infants under the age of two self-regulate and that mothers correctly recognize their child’s manifestations of hunger. Our present biophysically objective data show that toddlers can spontaneously regulate and significantly reduce their intake by food administration at the time of their hunger manifestations ().7
Internal cues have been generally suggested to address eating patterns in overweight adults, although this intervention is ineffective considering the current obesity epidemic.1
Adults’ meals at mealtimes are powerfully established by habits.23
Adults first require meal suspension to interrupt the habitual pattern in the first training day, and then learn and show the identification of IH by pre-meal BG checking. Taken together, our results indicate that, after two years of age, eating patterns based on offered food become powerfully established.23
Mothers easily acquire the habit of evaluating food demand prior to each mealtime instead of automatically offering food. Thus, BG checking by adults is necessary to learning self-regulation7
and unnecessary below two years of age ().
Both weight and length increased significantly over the 50-day intervention (). Weight for length significantly decreased, which was attributable to the increase in length on the basis of Z-scores, with no change in weight Z-scores (). Weight-for-age showed no change (not presented). The arm and leg skinfold thicknesses showed no significant changes.
No side effects, such as fainting or sleepiness, were observed from the training. The mean number of days with diarrheal symptoms dropped from 21.1 ± 12.8 days of the 50 days preceding the initiation of treatment to 1.5 ± 1.8 (days/50 d; P < 0.001) during the interval between the start of the therapeutic dietary regimen and the final follow-up evaluation. In association, days with fever and the use of antibiotics and antipyretics significantly decreased (). The investigators, through daily interaction with participants, noted that both mothers and toddlers maintained good moods, physical and mental effectiveness, and freedom to choose food, except for a shift toward fruits and vegetables. The trained group significantly increased their serum folate and transferrin saturation and decreased their plasma triglycerides ().
Effects of training on toddlers’ symptoms
Effects of training on a few blood parameters
We excluded a control group to avoid interventions on infants without treatment or diagnostic purposes. This exclusion and the low number of investigated subjects prevented us from publishing the present findings on IHMP as a lasting method to stop the worldwide epidemic of fattening, insulin resistance, and the associated immune derangement and vascular risks. The number of investigated infants is also disproportionately low compared to the investigations by diary of mean BG and daily energy intake that we published in the meantime. IHMP reduced energy intake and mean BG in controlled studies on 88 infants after 7 months;12
114 infants after 4 years;14
on 311, 244, 125, and 88 infants during a sequential follow-up with assessments after 5 months and 4, 8, and 12 years, respectively (see in Ciampolini et al15
); on 143 infants after 4 months;7
and in 107 normal-weight adults and 74 overweight adults after five months.10
In adults, the decrease in energy intake and mean BG was associated with decreases in insulin resistance and body weight, except for adults who were normal-weight and insulin-sensitive.10
Moreover, even though the skill of IH recognition was long-lasting,11
the validity of energy intake reports has been questioned.24
Therefore, the rejection of the null hypothesis between scheduled and demanded meals by biophysical, objective measurements completes, validates, and confirms the demonstration that we already obtained from the diaries. We found no significant differences between diary energy intake and total daily expenditure by doubly labeled water at recruitment, in the pre/post longitudinal differences, or after training. Reductions in energy expenditure after training validate all diary decreases in energy intake and mean BG after training. Interruptions of mealtime automatic habitual eating on the first training day, the discovery of IH, and the checking of IH recognition by BG could maintain energy balances, low mean BG levels, insulin sensitivity, and low triglyceride levels and stop recurrent diarrhea, a mild manifestation of subclinical inflammation in infants (proinflammatory and reversible immune deficiency states are synonymous).25
IHMP, as a learned skill, may be remembered and used at subsequent ages to reduce fattening, subclinical inflammation, and metabolic risks.7
At recruitment, the seven toddlers above the median RMR had a mean RMR of 63.8 ± 6.5 kcal/d, which was 17% greater than the seven toddlers below the median RMR (RMR = 53.5 ± 5.3 kcal/kg/d) (). The high-RMR toddlers had a significantly larger RMR pre/post decrease than the low-RMR toddlers (P
< 0.01 for both differences), indicating a larger shift after training (49.0 ± 9.1 kcal/d) in high-RMR toddlers toward the mean RMR of the entire group. We did not observe a similar relationship between the values at recruitment and after training in terms of energy intake and TEE decreases, but we found a similar trend in mean BG in previous investigations on clinically similar toddlers of the same age, as well as in adults.7
Mean BG was the mean of 21 preprandial BG measurements that adults and mothers performed at home before three daily meals and reported in their feeding diaries.7
Mean BG characterized habits in the provision of energy to body cells.7
The associated decreases in both mean BG and RMR substantiate the accuracy in BG estimation by the subjective sensation of weakness, a frequent form of IH reported by older children and adults.7
Animal experiments confirm that hunger and feeding begin as RMRs decrease.31
The respiratory quotient did not show any pre/post differences (122.0 ± 3.8 and 122.5 ± 2.5).
Resting metabolic rate (RMR) decreases (P < 0.01) in seven infants with low RMR at recruitment in comparison with seven infants with high RMR at recruitment (P < 0.01).
In the first days of life, scheduled and demanded feeding are equivalent for new mothers and are dictated by familial and medical customs, current local fashions, and convenience, and care-givers can move to scheduled feeding or to demanded feeding. Our results indicate that demanded feeding is an inherent homeostatic mechanism for the maintenance of healthy weight and activity, and that scheduled feeding risks a pattern of chronic pathologies. The vast increase in children with excess body fat, insulin resistance, diabetes, and the consequent immune deficiency (subclinical inflammation) is clearly related to risks and functional impairments in association with high energy intake, high mean BG, high RMR and TEE, and high insulin resistance, and scheduled meal presentation is associated with these negative sequelae.7
Given the stability of intake habits11
and the simplicity of choosing demanded feeding versus scheduled feeding, an adjustment in advice to new mothers on healthy meal patterns from the first neonatal days is suggested.