Energy Drinks

A validated, semi-quantitative 32-item Beverage Intake Assessment Questionnaire (BIAQ) [10 (link)] and a 143-item validated semi-quantitative FFQ (38) specifying usual portion sizes, were administered by trained dietitians to assess habitual fluid and dietary intakes, respectively. These two questionnaires have been validated within populations of older, Spanish individuals, which are analogous to the current study population, and both have been found to be reproducible with relative validity [10 (link), 38 (link)]. The BIAQ recorded the frequency of consumption of various beverage types during the month prior to the visit date. The average daily fluid intake from beverages was estimated from the servings of each type of beverage. The questionnaire items on beverages included: tap water, bottled water, natural fruit juices, bottled fruit juices, natural vegetable juices, bottled vegetable juices, whole milk, semi-skimmed milk, skimmed milk, drinking yogurt, milkshakes, vegetable drinks, soups, jellies and sorbets, soda, light/zero soda, espresso, coffee, tea, beer, non-alcoholic beer, wine, spirits, mixed alcoholic drinks, energy drinks, sports drinks, meal replacement shakes, and other beverages. The water and nutrient contents of the beverages were estimated mainly using the CESNID Food Composition Tables [39 ], complemented with data from the BEDCA Spanish Database of Food Composition [40 ].
The FFQ collected data on food intake based on the year prior to the visit according to nine possible frequency categories, which ranged from “never or almost never” to “> 6 portions/day” and based on the dietary guidelines for the Spanish population [41 ]. The information collected was converted into grams per day, multiplying portion sizes by consumption frequency and dividing the result by the period assessed. Ten food groups composed of vegetables, fruits, legumes, cereals, dairy beverages, meat and poultry, fats, nuts, fish/seafood, and other foods were determined to assess the contribution of foods to total water intake. Food groups and energy intake were estimated using Spanish food composition tables [42 , 43 ]. Drinking water intake, water intake from all fluids, total water intake, EFSA total fluid water intake (TFWI), and EFSA total water intake (TWI) were computed (descriptions summarized in Additional file 1: Table S1). Drinking water intake was estimated based on tap and bottled water intakes based on BIAQ responses. Water intake from all fluids was computed from tap and bottled water, plus water from other beverages based on responses to the BIAQ. Total water intake encompassed water intake from all fluids in addition to water present in food sources based on responses to the FFQ. Water intake was further categorized based on established reference values. The EFSA recommendations for total water intake (EFSA TWI) for older adults (2.5 L/day and 2.0 L/day for men and women, respectively) in conditions of moderate environmental temperature and moderate physical activity [20 ] were used as reference values. Further categorizations were determined based on total water intake from fluids alone, based on EFSA recommendations (EFSA TFWI), where recommended levels for older adults are set to at least 2.0 L/day and 1.6 L/day for men and women, respectively [20 ].

Parents and children in the technology group received the mHealth nutrition intervention plus training in behavior change strategies. The intervention incorporated core behavior change strategies that have been tested extensively in family-based behavior modification research, including obesity prevention trials (46 (link)), and were familiar to families with children who have ASD (58 , 59 ). The unique features of this mHealth intervention were that it (1) reinforced healthy food choices in autistic youth by using behavioral strategies tailored to the specific needs and learning styles of children on the autism spectrum (e.g., visual depictions, concrete descriptions with “scripts”, and routines for abstract concepts), (2) included a high level of personalization to align dietary goals with individual food preferences and sensory sensitivities, and (3) involved parents as “agents of change.” Specifically, children were reinforced for making healthy food choices while limiting less healthy food choices in their daily lives by earning points towards a prize. Targeted healthy foods included fresh, canned, and frozen FV. Parents were instructed to omit energy-dense toppings and sauces on FV. Targeted less healthy foods included SSS (e.g., all types of chips, popcorn, pretzels, party mixes, ice cream, candy, cookies, cakes/pies, sweet rolls, pastries) and SSB (e.g., sugar-sweetened sodas, fruit drinks/punches and fruit juices, sport drinks, and energy drinks).
The intervention also included behavioral training for children via an interactive nutrition education game to facilitate healthier food choices. This involved a “Nutrition Ninja” virtual character, which was directed by the parent and interacted by the child to set and reinforce dietary goals. The inclusion of this virtual character who acted positively towards the child aimed to make the child feel comfortable with technology-mediated communication and offer support for performing the desired behavior, consistent with the Proteus effect (60 (link)–62 (link)). The goals were very prescriptive and were tailored to children's food preferences and sensory sensitivities by letting them customize dietary targets (e.g., add dip to a vegetable, eat a vegetable raw or cooked, have it served hot or cold). Even small goals, such as touching or smelling a novel food before tasting it, were encouraged. Children received frequent visual and personalized feedback and positive reinforcement to support their unique learning styles. The individual training components for parents and children are summarized in Table 1.