from the association ADA REPORTS

Transcription

1 from the association ADA REPORTS Position of the American Dietetic Association: Dietary Guidance for Healthy Children Ages 2 to 11 Years ABSTRACT It is the position of the American Dietetic Association that children ages 2 to 11 years should achieve optimal physical and cognitive development, attain a healthy weight, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity. The health status of American children has generally improved over the past three decades. However, the number of children who are overweight has more than doubled among 2- to 5-year-old children and more than tripled among 6- to 11-year-old children, which has major health consequences. This increase in childhood overweight has broadened the focus of dietary guidance to address children s over consumption of energy-dense, nutrient-poor foods and beverages and physical activity patterns. Health promotion will help reduce dietrelated risks of chronic degenerative diseases, such as cardiovascular disease, type 2 diabetes, cancer, obesity, and osteoporosis. This position paper reviews what US children are eating and explores trends in food and nutrient intakes as well as the impact of school meals on children s diets. Dietary recommendations and guidelines and the benefits of physical activity are also discussed. The roles of parents and caregivers in influencing the development of healthy eating behaviors are highlighted. The American Dietetic Association works with other allied health and food industry professionals to translate dietary recommendations and guidelines into achievable, healthful messages. Specific recommendations to improve the nutritional well-being of children are /04/ $30.00/0 doi: /j.jada provided for dietetics professionals, parents, and caregivers. J Am Diet Assoc. 2004;104: POSITION STATEMENT It is the position of the American Dietetic Association that children ages 2 to 11 years should achieve optimal physical and cognitive development, attain a healthy weight, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity. The health status of children in the United States has improved in some areas over the past three decades, as evidenced by lower rates of infant mortality (1,2) and declines in nutrient deficiency diseases of the past (3). However, despite the improvement in childhood nutrient deficiencies, the number of children who are overweight has increased dramatically since the 1970s (4). Approximately 10.4% of children 2 to 5 years of age and 15.3% of children 6 to 11 years of age are overweight (4). Overweight is now more prevalent among American children, including low-income children, than underweight or growth retardation (5,6). As a consequence, dietary guidance for children has broadened from an earlier focus on issues of under consumption and nutrient deficiencies to over consumption and decreased energy expended in physical activity. The attainment of optimal health through improved diet and an increase in physical activity will promote decreases in chronic diseases (7). Because children younger than 2 years of age and adolescents have unique nutritional requirements and concerns, this ADA position paper focuses primarily on healthy children aged 2 to 11 years. Children with special health care needs may be at increased risk for nutrition-related problems related to their conditions and, therefore, require additional guidance (8). Healthful eating habits in childhood help to prevent chronic undernutrition and growth retardation as well as acute child nutrition problems such as iron-deficiency anemia and dental caries (9). Although chronic undernutrition is now rare in the United States, it is estimated that nearly 11% of all US households (11.5 million households) were food insecure at some time during 2001 (10). The prevalence of hunger in children was six times as high in singlemother families; three times more prevalent among racial and ethnic minorities, particularly blacks and Hispanics; and 10 times more prevalent in households with incomes below 185% of the poverty level (11). Food insecurity has profound effects on children s emotional, behavioral, and cognitive development (12,13). Concerns about food insecurity may be alleviated to some extent by the availability of feeding programs in schools and nutrition assistance programs (14). These programs increase the probability that children will eat breakfast and/or lunch and thus improve their nutritional (15) and educational status (12,16). The incidence of iron-deficiency anemia in the United States has decreased in recent years (17). Iron deficiency has negative effects on a child s motor and mental development and thus on their work capacity (18-20). Continued monitoring of iron status of children is warranted because the prevalence of iron deficiency in vulnerable populations exceeds the 2010 national health objectives (21). Foods high in iron, such as meats and fortified breakfast cereals, or iron supplements, if medically recommended, are important to ensure that iron requirements are met (22). There is a pressing need for US 660 Journal of THE AMERICAN DIETETIC ASSOCIATION 2004 by the American Dietetic Association

2 children to achieve healthy eating and physical activity patterns that reduce the risk of chronic long-term health problems, such as obesity, coronary heart disease, type 2 diabetes, stroke, cancer, and osteoporosis. Childhood adiposity, in and of itself, negatively influences adult mortality and morbidity (23,24). Children who are overweight are more likely than normal-weight children to become obese adults (25-28), which increases lifetime risk of coronary heart disease, hypertension, type 2 diabetes, gallbladder disease (25), osteoarthritis, and some cancers (cervical, breast) (29,30). Children who are overweight also often experience psychologic stress, poor body image, and low self-esteem (31,32). Critical nutrition concerns about US children include excessive intakes of dietary fat, especially saturated fats, and inadequate intakes of foods rich in calcium and fiber. High intakes of saturated fat have been associated with increased plasma total and low-density lipoprotein (LDL) cholesterol in childhood and can ultimately increase the risk of cardiovascular disease. Failure to meet calcium requirements in combination with a sedentary lifestyle in childhood can impede the achievement of maximal skeletal growth and bone mineralization, thereby increasing the diet-related risk of developing osteoporosis later in life (9,33). The important role of dietary fiber in decreasing the risk of several chronic diseases, including heart disease, obesity, diabetes, and colon cancer (34-36), has been recognized by health organizations (37,38). Diets high in fiber also tend to contain less fat, cholesterol, and energy than diets low in fiber (39,40). Given these findings, it has been suggested that major gains in public health would be made if children s diets in the United States were more in line with the Dietary Guidelines for Americans (37) and if physical activity levels were increased (41). Healthful eating habits for elementary children can best be achieved by moderate consumption of a varied diet (21,37) that includes foods from each of the major food groups, as illustrated by the US Department of Agriculture (USDA) Food Guide Pyramid (42) or the Food Guide Pyramid for Young Children for children ages 2 to 6 years (43). WHAT ARE AMERICAN CHILDREN EATING? Dietary intake data have been collected from American children in large nationwide surveys and smaller longitudinal studies (44-53). Despite some survey design differences, the trends in current nutrient intakes and eating patterns of children are consistent. Trends in Dietary Intake Over the past quarter century, the total energy intake of US children increased (54-58). Trends in children s food choices coincide with trends in nutrient intakes and trends in the national food supply (59-61). Cross-sectional data from the Bogalusa Heart Study (50) and the USDA (61,62) showed an overall decline in the total amount of milk, vegetables, soups, breads, grains, and eggs consumed from 1973 to 1994 and an increase in the consumption of fruits, fruit juices, sweetened beverages, poultry, and cheese (52,61,62). While the percentage of total fat from milk, as well as from fats/oils, pork, mixed meats (ie, combination dishes including meat), eggs, and desserts decreased, the percentage of fat from poultry, cheese, and snacks increased. The decrease in the percentage of energy intake from total fats and saturated fats fell from 38% to 33% and 16% to 11%, respectively (50,53,57). While the percentage of energy from total and saturated fats decreased, actual fat intakes did not decrease because total energy intake increased (58). Approximately 68% to 75% of US children exceed the current dietary recommendations for intake of total or saturated fats (53). Between the periods of 1989 to 1991 and 1994 to 1995, the increase in carbohydrate intake among 2- to 17-year-old children and teenagers came primarily from increased intakes of grain mixtures (pizza, pasta, Mexican dishes, and other dough-based dishes) and beverages (particularly soft drinks) (58). Other shifts in food consumption include a decrease in eggs, an increase in poultry, and a substitution of margarine for butter (52,61,62). Current Diet Quality and Food and Nutrient Intake The Healthy Eating Index (HEI) is used to assess diet quality (63). The HEI score for children ages 2 to 9 years determined that most children s diets needed improvement or were poor (64). The percentage of children s diets that were reported to need improvement among children 2 to 3, 4 to 6, and 7 to 9 years was 60%, 76%, and 80%, respectively; diets reported as poor were 4%, 7%, and 8%, respectively (64). On average, the reported energy intakes among school-aged children were 91% of the Recommended Energy Allowance (REA) (56). This is comparable with those of earlier studies (7,53,65,66) and suggests underreporting of energy intake (67,68) or that the RDAs were set higher than children s actual energy needs (69), indicating that many US children are in positive energy balance. Average intakes of most vitamins and minerals for children 2 to 11 years of age exceed 100% of the 1989 RDA (53,70,71). The macronutrient composition of children s diets is similar to that of young adults (72,73). What may be different, however, are the types of foods consumed and their contribution to intakes of specific nutrients (51,52). Lifestyles and eating behaviors, which change throughout the life cycle, influence the types of foods consumed. For example, as children get older, the percentage of total fat from milk decreases, and the percentage of total fat from meats increases (52). Similarly, studies have shown regional and ethnic variations in types of foods consumed and their contribution to the diet, yet the macronutrient composition of children s diets remain unchanged (48,49). Average dietary fiber intake among children ages 3 to 5 years and 6 to 11 years is 11.4 g/day and 13.1 g/day, respectively (39,40,53); these levels of intake have remained virtually unchanged since 1976 (39,74). Vegetables, soups, fruit, and fruit juices contribute close to 40% of the total dietary fiber in the diets of 10-yearold children (39). The food choices of most US children do not meet the recommended food group servings from the Food Guide Pyramid (51). Children are not eating the recommended amount of fruits and vegetables (53,75,76). For children 2 to 9 years of age, 63% are not consuming the recommended number of servings of fruits, and 78% are not consuming the recommended Journal of THE AMERICAN DIETETIC ASSOCIATION 661

3 number of servings for vegetables. Average daily servings are 2.0 for fruits and 2.2 for vegetables (77). Similarly, 4-year-old Latino children consumed a mean of 2.8 servings of fruits and vegetables per day (78). For children 6 to 11 years of age, average daily total grain intake was 6.5 servings, whereas daily whole grain intake was 0.9 servings per day (79). The proportion consuming an average of two or more servings of whole grains daily was 12.7%. These data emphasize the need for a total-diet approach that encourages the consumption of fruits, vegetables, and whole grains, with an emphasis on lower-fat options (51). Tracking of Nutrient Intakes in Children Tracking is a term used to indicate the likelihood of a child to remain in a respective rank for nutrient intake in relation to his or her peers. Several longitudinal studies have examined the nutrient intakes of children at 2, 3, and 4 years of age and compared them with intakes in subsequent years to determine whether nutrient intakes tracked over time (80,81). One study found that of preschool children consuming the highest percentage of energy from fat, 57% continued to be high consumers at age 5 to 6 years, and, of those children, 53% remained high consumers at age 7 to 8 years (81). Milk consumption during childhood can also track over time, affecting lifetime milk consumption. Among a sample of elderly adults, the frequency of milk consumption during childhood was found to be the strongest predictor of current milk intake (82). Other evidence indicates that children s food choices track from 6th to 12th grade and, therefore, suggests that health promotion interventions should begin prior to 6th grade, before these patterns become resistant to change (83). As 10-year-old children grow into young adults, their average consumption of mixed meats, fruit/fruit juices, desserts, candy, and milk decreased, and consumption of sugar-sweetened beverages, poultry, salty snacks, seafood, cheese, beef, and condiments increased (84). According to data from the 1989 USDA Continuing Survey of Food Intake of Individuals (CSFII) (85), milk intake declined across all age groups. This pattern of decreasing milk intake with increased age, particularly among females, is consistent with recent studies (86-88). EATING PATTERNS OF CHILDREN Eating patterns are changing among children (89). These eating patterns include increased restaurant food consumption and other eating outside the home, larger portion sizes, shifts in beverage consumption, meal patterns and meal frequency, and school meal participation. Meals at Home and Away From Home The traditional pattern of the family eating at the kitchen table of pre- World War II has changed. Fewer families eat meals together. However, children who eat dinner with their families at home have a better quality diet than those who do not (90). They also tend to have higher intakes of fruits and vegetables; fiber; folate; calcium; iron; and vitamins B-6, B-12, C, and E and lower intakes of saturated and trans-fatty acids, soft drinks, and fried foods (90). In 1997, nearly half of family food expenditures were spent on food and beverages outside the home, with over one-third of the total food dollars spent on fast foods (91). As children age, they consume a higher proportion of meals away from home, with preschool children eating out 18% of the time and middle-school children 26%. Fast-food restaurants accounted for more than half of away-from-home meals (92) and contributed an average of 10% of children s total energy intake (93). Children consuming fast food had higher intakes of fat, saturated fat, cholesterol, and sodium and lower intakes of fiber, calcium, and iron than those who did not (93-95). As the number of single parents (96-98) and the number of women in the work force increase (99,100), it is likely that the percentage of children consuming meals outside the home will continue to increase. Fast-food restaurants need to offer healthier food choices such as fruits, vegetables, and low-fat milk as well as other lower fat food options. Portion Sizes Food portion sizes affect total energy intakes in children (101,102). Recent studies in adults and children suggest that increased portion sizes promote excessive intake at meals (101, ). Children 3 to 5 years of age consumed 25% more of an entrée and 15% more total energy at lunch when presented with portions that were double an age-appropriate standard size (104). Children are consuming significantly more food and beverages today than two decades ago (106). Yet comparing CSFII 1989 to 1991 and 1994 to 1996 data, children 6 to 11 years of age reported larger portion sizes for only two (ready-to-eat cereal and toasted oat rings) of the 107 foods examined, with smaller amounts reported for pizza, chicken, and margarine (102). Trends in Beverage Consumption The milk consumption patterns of Americans have changed markedly over the past half century. In 1945, Americans drank four times more milk than soft drinks, whereas, in 1997, they drank nearly 2.5 times more soft drinks than milk. Annual per capita consumption of milk declined from 31 gallons in 1970 to 24 gallons in 1997 (107). Between 1977 and 1994, milk consumption declined 24% among boys and 32% among girls 6 to 11 years of age (62). During the same period, there were changes in the type of milk that children consumed. The proportion of children drinking reduced-fat or fat-free milk doubled since the late 1970s, and, by 1994, these milk types were consumed more frequently than whole milk (108). During this same time period, carbonated soft drink consumption increased 41% (109). Patterns of total beverage consumption vary by age, gender, ethnicity (110), and geographic location (111). Between 1973 and 1994, the percentage of children in Bogalusa, Louisiana, consuming sugar-sweetened beverages significantly decreased from 64% to 51% (P.01), yet, on average, intakes of soft drinks and coffee with sugar remained the same (Theresa Nicklas, DrPH, personal communication, 8/14/ 03). However, the mean gram amount of tea with sugar consumed increased, reflecting a regional difference in trends and types of sugarsweetened beverages consumed. Soft drink consumption has been negatively associated with milk consump- 662 April 2004 Volume 104 Number 4

4 tion and found to have a dilutional effect on the intakes of many essential micronutrients, including calcium, phosphorus, folate, vitamin A, and vitamin C (112). Furthermore, children s total energy intake was found to be positively associated with soft drink consumption. In contrast, one study found no association between soft drink consumption and calcium intake among children (113). Whether milk has simply become less popular or whether soft drinks have been substituted for them remains to be determined in longitudinal studies. Meal Patterns and Meal Frequency Breakfast consumption declined significantly between 1965 and 1991 among children and adolescents (114). Approximately 10% of children skip breakfast (Biing-Hwan Lin, PhD, personal communication, 6/4/03). Of the children who consume breakfast, 49% eat breakfast at home, and 51% eat breakfast at school (115). Only 2% of children skip lunch (89). Thus, while the percentage of children consuming a school lunch significantly decreased from 90% to 78% between 1973 and 1994 (90), the percentage of 10-year-old children bringing lunch from home increased from 1% to 11% during this period. Snacking has increased significantly in the United States. Ninetyeight percent of 6- to 18-year-old students reported at least three daily eating occasions, and more than 50% reported five or more (116). Sixty-six percent of students consumed an afternoon snack, and nearly that percentage consumed an evening snack, yet only 15% consumed a snack in the morning. The specific eating occasions differed somewhat by age and gender, and younger students were more likely to consume breakfast, lunch, and an afternoon snack (116). From 1977 to 1996, the percentage of children ages 6 to 11 years consuming snacks increased from 76% to 91% (117). Most children reported eating at least one snack per day (118), and over one-third of the children consumed at least four or more different daily snacks (119). Approximately 82% of children 6 to 11 years old consumed snacks, which provided for 20% of total daily energy intake and 19% of total fat and saturated fat intake (53,117). Impact of School Meals on Children s Diets More than 25 million children participate in the National School Lunch Program (NSLP) daily (120). Children participating in the NSLP are more likely than nonparticipants to consume more vegetables, milk and milk products, and meat and meat substitutes and fewer soft drinks and/or fruit drinks (55), thereby consuming greater amounts of calcium, riboflavin, phosphorus, magnesium, zinc, thiamin, and vitamins B6 and B12 than nonparticipants. The contribution of school meals to total daily intake of vitamins and minerals ranges from 45% for iron (RDA) to 77% for calcium (RDA). School lunches provide 35% of total energy intake, with 33% of the energy coming from fat and 12% from saturated fatty acids. One-third of the total sodium intake and 8% of total sucrose intake comes from school lunch. For some 10-year-old children, approximately 50% to 60% of total daily intake of energy, protein, cholesterol, carbohydrate, and sodium comes from school meals (121). Breakfast is an important meal for growing children. Some studies have documented a significant positive relationship between eating breakfast and school performance ( ), but more research in this area is needed. However, the relationship between eating breakfast and overall nutrient intakes of children is well established ( ). Children who consumed breakfast had significantly better Healthy Eating Index (HEI) scores for grains, fruits, milk products, and variety and hence a better diet quality than children who did not (129). Children who skip breakfast (approximately 14%) have total nutrient intakes that are lower than children who consume breakfast at school or at home (126). Furthermore, children who participate in the School Breakfast Program (SBP) have higher intakes of many vitamins and minerals than those who consume breakfast at home (115) or skip breakfast (126). In addition to the SBP and NSLP, many schools also offer à la carte foods and beverages during breakfast or lunch or in after-school programs, as well as in school stores, snack bars, vending machines, and concession stands (125, ). The percentage of elementary schools offering à la carte foods and beverages is much lower than the percentage of middle and high schools (131). Forty-three percent of elementary schools reported having a school store, canteen, or snack bar, or one or more vending machines at the school compared with 98% of the senior high schools (131). Among the elementary schools with a school store, canteen, snack bar, or vending machine, the foods and beverages most commonly sold were milk (2% or whole), 100% fruit or vegetable juice, fruit drinks, soft drinks, sports drinks, crackers, salty snacks including low-fat varieties, and baked goods such as cookies, cakes, and pastries (131). Foods in à la carte menus varied greatly in their nutritional value (130,131,133). Thirty percent to 46% of elementary schools reported offering pizza, hamburgers, sandwiches, lettuce, vegetable or bean salads, french fried potatoes, and other vegetables à la carte. The majority of the schools that offered salad dressings made a low-fat variety available (131). Although there were some lowfat food and beverage choices offered, they were a small percentage of total sales. Health care professionals and educators need to promote continually energy balance, moderation, and healthy eating patterns that are consistent with the federal dietary and nutrition guidelines. Schools and communities have a shared responsibility to provide all students with access to high-quality affordable foods and beverages. Foods and beverages available and consumed by children in schools should contribute to dietary patterns consistent with the Dietary Reference Intakes, Dietary Guidelines for Americans, and the Food Guide Pyramid, which contribute to the development of lifelong healthful eating habits (9,21,37,38,42,43). These recommendations are consistent with the ADA s statement on competitive foods in school nutrition programs (134). Increasingly, schools are moving toward eliminating competitive foods (135), developing nutrient and portion size standards for competitive foods, and calling for national policies in these areas (136). Whether or not these approaches and policies will have a major impact on eating habits of children is yet to be determined. Beginning with the l Journal of THE AMERICAN DIETETIC ASSOCIATION 663

5 school year, schools participating in the USDA s national school meals programs were required to serve meals during the course of the school week that adhered to the Dietary Guidelines for Americans (137). Although such targets have still not been completely achieved, this emphasis encourages the integration of school foodservice with classroom nutrition education; reinforces messages on healthful eating, which emphasizes the total diet and not any single food or nutrient; and gives students opportunities to practice healthful eating skills (9). Across the country, NSLP and NSBP school meals are becoming more in line with health recommendations (125,138). Dietetics professionals should partner with child nutrition programs in promoting school environments that are conducive to providing healthy food and beverage choices that contribute to dietary patterns consistent with Federal and national nutrition recommendations and guidelines. DIETARY RECOMMENDATIONS AND GUIDELINES FOR CHILDREN In 2002 the Institute of Medicine s Food and Nutrition Board released the Dietary Reference Intakes (DRIs) for energy, carbohydrates including added sugars, protein, amino acids, fiber, fat, fatty acids, and cholesterol (38). The DRIs updated the Recommended Dietary Allowances (RDAs) published in Key recommendations for children are summarized in Figure 1. Some evidence suggests that, among children, reduced intakes of certain micronutrients can occur with the consumption of low-fat (eg, 30% of energy from fat) diets. On the other hand, high fat intakes (eg, 35% of energy from fat) may increase the risk of obesity and cardiovascular disease. Dietary fat provides energy, which is important for younger children who have limited gastric capacity, especially during the transition from a diet high in milk to a mixed diet. The DRIs recommend a gradual transition from the high fat intake during infancy to an Acceptable Macronutrient Distribution Range (AMDR) for adults (20% to 35% of energy). Therefore, the AMDR for fat consumption is 30% to 40% of energy for children ages 1 to 3 years and 25% Acceptable macronutrient distribution ranges (ADMR) as a percent of energy intake for carbohydrate, fat, and protein Carbohydrates 45% to 65% of total calories Fat 30% to 40% of energy for 1 to 3 years and 25% to 35% of energy for 4 to 18 years Protein 5% to 20% for young children and 10% to 30% for older children Added sugars should not exceed 25% of total calories (to ensure sufficient intake of essential micronutrients). This is a maximum suggested intake and not the amount recommended for achieving a healthy diet. Consumption of saturated fat, trans fatty acids, and cholesterol should be as low as possible while maintaining a nutritionally adequate diet Adequate intake for total fiber Children 1 to 3 years: 19 g total fiber/day, 4 to 8 years: 25 g/day, boys 9 to 13 years: 31 g/day, girls 9 to 13 years: 26 g/day Figure 1. Dietary Reference Intakes. to 35% of energy for children ages 4 to 18 years. The AMDR for carbohydrates is the same for children as adults (45% to 65% of energy). Added sugars are defined as sugars and syrups that are added to foods during processing or preparation (139). The DRIs did not set a daily intake of added sugars for a healthful diet for children; however, a maximal intake level of 25% or less of energy from added sugars was suggested. This value was based on the observation that decreased intakes of key micronutrients, notably calcium, occurred when intakes of added sugars exceeded this level. For example, in children 4 to 8 years of age, when added sugars exceeded 25% of total energy, only 41% of the children met the AI for calcium. On the other hand, 95% of children who consumed 5% to 10% of energy from added sugars met the AI for calcium (38). From 1994 to 1996, the average intake of added sugars by 6- to 11-year-old children was 18.6% of total energy intake (140). However, from 1988 to 1994, 13% of children 4 to 8 years of age and 21% of children 9 to 13 years of age had added sugars intakes that exceeded 25% of their total energy intakes (38). The USDA Food Guide Pyramid recommendation to use added sugars sparingly with suggested intakes in teaspoons for various energy intakes can be used as a guide. This strategy would result in an intake of between 6% and 10% of energy from added sugars depending on the total energy requirements. This approach has limitations because most sugars are not visible in food and beverages, and added sugars are not listed on food labels, making the content of added sugars in food products and recipes difficult to determine. Recommendations have also been made that children should increase their fruit and vegetable consumption to five or more servings daily (21). Qualitative guidelines put forth in the Dietary Guidelines for Americans (37), the Food Guide Pyramid (42), and the Food Guide Pyramid for Children (43) are excellent tools for educating consumers on how to achieve the dietary recommendations. The DRI for calcium exceeds the 1989 RDA for calcium by 500 mg for children ages 9 and 10 years (1989 RDA 800 mg, 1997 DRI 1,300 mg) (141). However, it is an AI, not an RDA, and, therefore, by definition, it is higher than estimated requirements for safety reasons. There is some evidence that calcium intakes at levels above the 1989 RDA can increase bone mineral density in children (142,143), thus decreasing risk of developing osteoporosis later in life (33). However, these data are difficult to interpret because they are based on calcium balance studies. In situations of short-term increases in intakes, the changes in calcium balance may be temporary, and, hence, changes seen in bone mineral density may not be permanent. More research is needed. However, careful menu planning is required to meet children s calcium needs without a source of milk or dairy products in the diet (144). Among a large sample of US children, only those with a source of milk in the noontime meal met or exceeded 100% of the 1989 RDA for calcium (145). Thus, including two to three servings a day of milk or dairy products in 664 April 2004 Volume 104 Number 4

6 children s diets is recommended (37,43). These amounts can be tolerated by virtually all children if the servings are spread throughout the day and consumed with other foods ( ). People with lactose intolerance can be educated that dairy products can, in most cases, be gradually added to their everyday eating lifestyles (150). Calcium-fortified foods can also help children meet dietary calcium requirements (151). Can children follow these recommendations and have adequate intake of energy, protein, vitamins, and minerals? Studies have consistently shown that children can follow the Dietary Guidelines without compromising intake of energy and essential vitamins and minerals for growth ( ). Data from the Child and Adolescent Study for Cardiovascular Health (CATCH) showed that vitamin and nutrient density of foods in the diet increased with decreasing fat intake (162). Computer modeling studies suggest that the RDA for most minerals, trace elements, and vitamins can be met within a fat-reduced, balanced diet, without major changes in meal patterns or dietary habits ( ). Exclusive use of selected fat reduction strategies (ie, nonfat milk instead of reduced-fat or whole milk, lean meats instead of higher-fat meats, or fat-modified products instead of full-fat products) can facilitate achievement of the current dietary recommendations in children (166). Yet children s overall nutrient intake differs depending on the fat reduction strategies used to achieve the current dietary recommendations. Dietetics professionals working with children and their parents should be aware of the potential pitfalls of specific fat reduction strategies as well as ways to overcome them. The body of evidence from research now indicates that children can safely consume a diet that conforms to the US Dietary Guidelines and the DRIs for total and saturated fat intakes, as long as energy intake is adequate and there is variety and moderation in the diet. Long-Term Health Benefits of Following Eating Patterns That Conform to Current Dietary Recommendations Childhood eating patterns can have long-term health effects. Although heart disease generally does not become symptomatic until adulthood, risk factors associated with coronary artery and hypertensive cardiovascular disease may develop during childhood ( ). Dietary intake is a major environmental determinant of cardiovascular disease, the number one killer in the United States. Yet limited information is available about the influence of diet on cardiovascular disease risk early in life. Descriptive studies of diets of children and young adults (44-47,49,51-53,72,172,173), observations of diets in different international populations (174), and observations of serum lipoprotein changes with diet manipulation in children ( ) show that dietary intake relates to cardiovascular disease risk factors. Children with hypercholesterolemia consuming diets containing 30% of energy from fat not only grow and develop normally, but they also have decreases in their elevated LDL cholesterol levels (156). PHYSICAL ACTIVITY Children need to be physically active every day to achieve healthful weights (175) and promote the attainment of psychologic well-being (175) and optimal bone health (176). The Year 2000 Dietary Guidelines for Americans recommend choosing a lifestyle that combines sensible eating with regular physical activity (37,177). In June 2002, the president issued the President s Health and Fitness Initiative and challenged all children to participate in at least 60 minutes of physical activity each day (178). The recommendation that children should engage in at least 1 hour of moderately intense physical activity per day was reinforced with the release of the DRIs for macronutrients in September 2002 (38). Although US children are more active than adults, a Centers for Disease Control and Prevention (CDC) survey showed that 48% of girls and 26% of boys do not exercise vigorously on a regular basis (41). At the same time, participation in school-based physical education classes is declining: Daily enrollment dropped from 42% of students in 1991 to 25% in 1995 (175). Vigorous activity levels are the lowest among girls (179,180), non-hispanic blacks, and Mexican Americans (179). In addition, a quarter of all US children watch 4 or more hours of television each day, and hours of television watched is positively associated with increased body mass index and skin fold thickness (179). In one study, almost 40% of preschool children had a television set in their bedroom. These children were more likely to be overweight and spend more time watching TV/video than children without a TV in their bedroom. Educational efforts about limiting child TV/video viewing and keeping the TV out of the child s bedroom need to begin before the age of 2 years (181). Recently, the American Academy of Pediatrics issued a policy statement (182) that recommends that television and video time be limited to a maximum of 2 hours per day. In 1997, the CDC published guidelines for school and community programs aimed at promoting physical activity among young people. Included in the guidelines is a recommendation for daily physical education in schools and suggestions on how to develop effective programs that modify the focus from competitive sports to one of an active lifestyle through enjoyable participation in physical activity (41,183). The Kid s Activity Pyramid (Figure 2) identifies physical activities to promote for children and sedentary activities to limit (184). Health care professionals, parents, educators, and other childcare providers can use the Kid s Activity Pyramid as a teaching tool along with the recommendations established by various US government agencies (21,37,183,185). Dietetics professionals should promote such measures and advocate more physical activity for children in schools, homes, and elsewhere. ROLE OF PARENTS AND CAREGIVERS IN THE DEVELOPMENT OF HEALTHY EATING BEHAVIORS Environmental and personal factors have an important influence on dietary behavior. Factors other than health concerns, such as taste preferences, cultural norms, and food availability, influence dietary behavior when it comes to making food choices (186). Parents have a major impact on their children s eating and physical activity patterns. Food habits and nutrient intakes aggregate in families, with strong associations found be- Journal of THE AMERICAN DIETETIC ASSOCIATION 665

7 Figure 2. US Department of Agriculture Kid s Activity Pyramid. tween mothers and their children for milk type and amount (187) and the macronutrients cholesterol, calcium, and potassium (188). The most influential aspect of the young child s immediate environment is the family ( ). Early parental influence is associated with the development of a child s relationship with food later in life (195). For example, young adult eating habits such as eating all food on the plate, using food as an incentive or threat, eating dessert, and eating regularly scheduled meals were related to the same feeding practices reportedly used by their parents during their childhood (196). Consideration of nutrition by young adults when selecting food was related to the memory of their parents talking about nutrition during childhood (195). Parents can influence children s dietary practices in at least five areas (191): availability and accessibility of foods (75,194, ), meal structure (90,114,117,194, ), adult food modeling (194, ), food socialization practices (194, ) and food-related parenting style (194,210, ). Early childhood and the social environment in which the child is fed are widely assumed to be critical to the establishment of lifelong healthful eating habits. However, data on the processes whereby parents and other caregivers influenced children s eating habits have not been systematically studied and continue to be poorly understood. More research is needed to identify the circumstances (characteristics of the caregiver, caregiver behavior, and environmental setting) under which alternative food-related parenting styles result in healthier eating habits of children, as well as the longterm consequences of such practices (194). Children s preferences for energydense foods along with high total fat intakes (219) and increased sedentary activities (220) are positively associated with parental adiposity. Among African American parents, modeling of healthful dietary behavior was positively associated with low-fat eating patterns, lower dietary fat intake, and higher consumption of fruits and vegetables in their children (208). It is well known that children won t eat what they don t like (221). It is important to realize, however, that children s food preferences are learned through repeated exposure to foods. With a minimum of eight to 10 exposures to a food, children will develop an increased preference for that food (222). Thus, parents and other child caregivers can provide opportu- 666 April 2004 Volume 104 Number 4

8 nities for children to learn to like a variety of nutritious foods by regularly exposing them to these foods. Young children (ages 3 to 5 years) adjust their meal size according to the energy density of food available (223) and are able to adjust their food intake across successive meals to regulate tightly energy intake for 24-hour periods (224). However, child feeding practices influence children s responsiveness to energy density and meal size (225). When parents assume control of meal size or coerce children to eat rather than allowing them to focus on their internal cues of hunger, children s ability to regulate meal size in response to energy density is diminished (226). This response may be especially problematic among girls with high body mass index and may contribute to the chronic dieting and dietary restraint that has become common among American girls (226). In summary, perhaps some of the best advice regarding child feeding practices continues to be the division of parental and child responsibility advocated by Satter (227), who states that parents are responsible for presenting a variety of healthful foods to children and deciding the manner in which these foods are presented and that children are responsible for whether and how much they eat. IMPLICATIONS FOR PUBLIC POLICY Dietetics professionals have a responsibility to develop practical methods to begin prevention of chronic disease early in life. Prevention strategies, both the high-risk (156,228) and public health approaches (158,170,229,230), encourage primary intervention and follow the dictum of first do no harm. As quoted from Berenson and colleagues (231), their central thrust should be to help young generations grow up with healthful habits from the beginning, liberated from the harm of adverse lifestyles that were unwitting consequences of 20th century economic development. Early intervention through lifestyle modification and culturally appropriate food selection within the context of the total diet has the potential to significantly reduce the future incidence of adult chronic diseases. The school is consistently recognized as an appropriate site for health education and promotion (9). Much of the early research in school health education focused on knowledge-based classroom programs. These early studies typically reported positive changes in student knowledge and attitudes but failed to improve health behaviors or positive changes in physiologic risk; many knowledge-based studies did not consider multiple factors in the etiology of health behaviors. Eating habits are influenced by the interaction between individuals and their social, cultural, and physical environments, not simply by knowledge of the healthfulness of foods. Nutrition messages need to be developmentally appropriate with specific behavioral messages to help children make informed food choices (232). There are several successful programs that incorporated the multicomponent prevention model, beginning in elementary school and extending to high school (159,167,170,229,230). This multicomponent prevention model incorporates a broad spectrum of schoolrelated activities and services that intersect to provide students, and perhaps their families, with exposure to a range of cognitive, effective, and skill development opportunities that can foster improved health (233). Some examples of these programs include a health curriculum for students and parents, healthful school meal environment, school health services, and school-community linkages. Finally, the high prevalence of prolonged food insufficiency and episodic hunger among low-income children (12) indicates a continued need for sustained government funding of food and nutrition programs designed to create a safety net for such children. Safety net programs include the USDA Food Stamp Program; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); school breakfast programs; school lunch programs; and the Child and Adult Care Feeding Program. CONCLUSION Most American children do not meet the Food Guide Pyramid (43) recommendations for the fruit, grain, and dairy groups. In addition, the majority of children do not meet the Dietary Guidelines for Americans recommendations (37) for total and saturated fats. The dietary guidelines are meant to be an achievable goal for all Americans over the age of 2 years. The strategies to achieve those guidelines should reflect age, gender, ethnic, and regional differences in food consumption patterns. The best tool for helping the US public meet the US Dietary Guidelines is the USDA s Food Guide Pyramid (42). The Food Guide Pyramid for Young Children is based on actual eating patterns of this group (Figure 3) (43). USDA analyzed the diets of children ages 2 to 6 years then adapted the recommended eating patterns to meet their specific needs (43). Key messages of the US Dietary Guidelines are the ABCs for good health (Aim for fitness, Build a healthy base, Choose sensibly) (37). These key messages need to be sensitive to cultural diversity. Various ethnic food guide pyramids and a vegetarian meal-planning pyramid are available from the USDA and other sources (234,235). In addition to providing the key messages, there is a need to incorporate behavioral strategies that build on enhancing self-efficacy and self-esteem in children. Children need to develop confidence that they can successfully change their eating and physical activity patterns. Parents and other caregivers need to be educated on mealtime behaviors that promote the adoption of healthier eating behaviors early in life (194). The ongoing need for nutrition intervention and education with the US pediatric population (51) and their parents and caregivers (194) can and should be met by dietetics professionals who have the training and skills to meet those needs. Dietetics professionals can take an active role in promoting dietary recommendations and guidelines for children after the age of 2 years. The ADA has joined forces with many other health professional organizations as well as the food and beverage industries to work toward translating dietary recommendations and guidelines into achievable and healthful messages for all children in the United States. RECOMMENDATIONS FOR DIETETICS PROFESSIONALS Support and promote the Dietary Guidelines for Americans for healthy children after the age of 2 years; support and promote use of the USDA s Food Guide Pyramid as a Journal of THE AMERICAN DIETETIC ASSOCIATION 667

9 Figure 3. US Department of Agriculture Food Guide Pyramid for Young Children. 668 April 2004 Volume 104 Number 4

10 guide for meeting dietary recommendations (43) with use of the Food Guide Pyramid for Young Children ages 2 to 6 years (Figure 2); support and promote healthful dietary patterns among diverse ethnic groups, taking into consideration regional and cultural differences; support and promote use of the Fitness Pyramid for Kids to encourage physical activity among children (Figure 3); support and promote implementation of the Dietary Guidelines for Americans in school meals by strengthening nutrition education and promotion in school nutrition programs, including the implementation of integrated nutrition education curricula designed to teach students how to make informed dietary selections based on balance, variety, and moderation and the fundamental premise that all foods can fit into a healthful diet; support the availability of foods and beverages that contribute to dietary patterns consistent with federal nutrition and dietary guidelines throughout the day on the school premises (14); publicize existing comprehensive health education programs, such as the Child and Adolescent Trial for Cardiovascular Health (CATCH) (230), Gimme 5 (236,237), Know Your Body (238,239), Heart Smart (170,228,240,241), Healthy Start (242), and Planet Health (243); develop and implement programs for educating parents and caregivers on how to foster more healthful lifestyles in the home and school/ daycare environments through the use of authoritative feeding behaviors (194); foster communication by building partnerships across health-related disciplines and professional organizations; conduct effective nutrition education training programs for physicians, child nutrition personnel, and other health care providers on strategies that can be used with children that promote healthier eating habits; advocate for the need to increase federal and state funding of nutrition intervention programs; and support more nutrition studies on young children, specifically in the areas of (a) total added sugars intake and health outcomes, (b) children s fiber intake, and (c) better documentation of energy expenditure. 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