5. Nutrition and Diet
INTRODUCTION
This section of the Guidelines provides recommendations to pediatric care providers
on nutrition and diet for the promotion of cardiovascular (CV) health for their
pediatric patients and families. The section begins with important background information
on nutrition and diet from the 2010 Dietary Guidelines for Americans (2010
DGA) for healthypeople, including healthy children.[1] This is followed by
the Expert Panel's summary of the evidence it reviewed relative to nutrition and
diet for children, which collectively provides a rationale for initiating prevention
efforts early in life. The evidence review and development processes for these Guidelines
are described in detail in Section I. Introduction and in Appendix A. Methodology.
More than the standard systematic review where findings from the included studies
constitute the only basis for recommendations, these Guidelines combine the findings
from a systematic review of the evidence with the Expert Panel's consensus process.
The quality of all relevant data is incorporated and graded based on preidentified
criteria. Because of the large number of included studies and the diverse nature
of the evidence, the Expert Panel also provides a critical overview of the studies
reviewed for this section, highlighting those that, in its judgment, provide the
most important information. Detailed information from each study has been extracted
into the evidence tables, which will be available at
http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm. The conclusions of
the Expert Panel's review of the evidence are then summarized and graded, followed
by age-based recommendations for nutrition and diet in Table 52. Evidence-Based
Dietary Recommendations for Patients of Pediatric Care Providers: Cardiovascular
Health Integrated Lifestyle Diet (CHILD 1). The Expert Panel accepts the 2010 DGA
as containing appropriate recommendations for diet and nutrition in children 2 years
and older. The recommendations in these Guidelines are intended for pediatric care
providers to use with their patients to address CV risk reduction. Where evidence
is inadequate, recommendations are based on a consensus of the Expert Panel. The
recommendations therefore represent the best available evidence when that exists
and expert consensus opinion when it does not. References are listed sequentially
at the end of the section. References from the evidence review are identified by
a unique PubMed identifier (PMID), which appears in bold font. Additional references
do not include the PMID number. There is obvious overlap with the nutrition information
contained in other sections of these Guidelines; additional specific dietary information
relative to lipids, blood pressure (BP), and obesity is located in Section VIII.
High Blood Pressure, Section IX. Lipids and Lipoproteins, andSection X. Overweight
and Obesity.
BACKGROUND
These Guidelines provide evidence-based dietary recommendations to promote CV health
and reduce CV risk that build on previous recommendations for adolescents and children
2 years and older that were established in the 2010 DGA.[1]
The DGAprovides science-based recommendations to promote health and reduce
risk for chronic disease through diet and physical activity for members of the general
public 2 years and older. The DGA is updated every 5 years: www.health.gov/dietaryguidelines.
The recommendations in the DGA form the basis of Federal Government nutrition
program and policy development. The 2010 DGA includes information from
Dietary Reference Intake(DRI) reports of the Institute of Medicine (IOM); information
from the DRIs also was accessed for this section. The 2010 DGA describe
a healthy diet as one that:
- Emphasizes a variety of vegetables, fruit, whole grains, and low-fat dairy products
- Includes protein foods such as lean meats, poultry without skin, seafood, beans
and peas, eggs, processed soy products, nuts, and seeds
- Is low in saturated fat and trans fat, cholesterol, sodium, and added
sugar
- Stays within daily calorie limits
These new pediatric CV Guidelines not only build upon the recommendations for achieving
nutrient adequacy in growing children as stated in the 2010 DGA but also
add evidence regarding the efficacy of specific dietary changes to reduce CV risk
from the current evidence review, for use by pediatric care providers in the care
of their patients. Because the focus of these Guidelines is on CV risk reduction,
the evidence review specifically evaluated dietary fatty acid and energy components
as major contributors to hypercholesterolemia and obesity, as well as dietary composition
and micronutrients as they affect hypertension. New evidence from multiple dietary
trials addressing CV risk reduction in children provides important information for
these recommendations.
ESTIMATED ENERGY REQUIREMENTS
The underlying premise of the 2010DGA is that foods, not supplements, should
constitute the primary basis of a recommended eating plan for children and adolescents.
The dietary recommendations of the 2010 DGA included all of the nutrients
required for growth and health, balanced with energy requirements. On average, children
need greater energy intake per kilogram of body weight than adults to accommodate
the body's demands for growth, and this must be balanced with physical activity
needs. The increasing prevalence of obesity in children reflects a chronic imbalance
between energy intake and expenditure, where calorie intake is in excess of what
is needed for normal growth. An emphasis of the DGA is the importance of
achieving the appropriate energy balance at all ages. Calculations for recommended
daily Estimated Energy Requirements (EER) (contained in the DRI) for children
aged 2 and older by gender and age are provided in Table 5-1 as taken from the DGA.[1]
Because the calculations provide estimates only, monitoring weight status and stage
of growth are important considerations in estimating energy needs.
Table 51. Estimated Calorie Needs per Day by Age, Gender, and Physical Activity
Levela
Estimated amounts of calories needed to maintain caloric balance for various gender
and age groups at three different levels of physical activity. The estimates are
rounded to the nearest 200 calories. An individual's calorie needs may be higher
or lower than these average estimates.
Gender
|
Age (Years)
|
Calorie Requirements (kcals)
by Activity Levelb:
Sedentary
|
Calorie Requirements (kcals)
by Activity Levelb:
Moderately Active
|
Calorie Requirements (kcals)
by Activity Levelb:
Active
|
Child
|
23
|
1,0001,200
|
1,0001,400c
|
1,0001,400c
|
Femaled
|
48
|
1,2001,400
|
1,4001,600
|
1,4001,800
|
Femaled
|
913
|
1,4001,600
|
1,6002,000
|
1,8002,200
|
Femaled
|
1418
|
1,800
|
2,000
|
2,400
|
Femaled
|
1930
|
1,8002,000
|
2,0002,200
|
2,400
|
Male
|
48
|
1,2001,400
|
1,4001,600
|
1,6002,000
|
Male
|
913
|
1,6002,000
|
1,8002,200
|
2,0002,600
|
Male
|
1418
|
2,0002,400
|
2,4002,800
|
2,8003,200
|
Male
|
1930
|
2,4002,600
|
2,6002,800
|
3,000
|
a Based on Estimated Energy Requirements (EER)
equations, using reference heights (average) and reference weights (health) for
each age/gender group. For children and adolescents, reference height and weight
vary. For adults, the reference man is 5 feet 10 inches tall and weighs 154 pounds.
The reference woman is 5 feet 4 inches tall and weighs 126 pounds. EER equations
are from the Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate,
Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC):
The National Academies Press; 2002.
b Sedentary means a lifestyle that includes
only the light physical activity associated with typical day-to-day life. Moderately
active means a lifestyle that includes physical activity equivalent to walking about
1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical
activity associated with typical day-to-day life. Active means a lifestyle that
includes physical activity equivalent to walking more than 3 miles per day at 3
to 4miles per hour, in addition to the light physical activity associated with typical
day-to-day life.
c The calorie ranges shown are to accommodate
needs of different ages within the group. For children and adolescents, more calories
are needed at older ages. For adults, fewer calories are needed at older ages.
d Estimates for females do not include women
who are pregnant or breastfeeding.
SOLID FATS AND ADDED SUGARS
Balancing energy intake with energy expenditure in a growing child is a complex
process. Understanding the concepts of essential versus discretionary calories can
assist pediatric care providers in guiding children and their families toward choosing
nutrient-dense foods to maintain energy balance. Solid fats and added sugars (SOFAS)
are always counted as "discretionary" or nonessential calories. Sources of SOFAS
include "snack" foods, sugar-sweetened beverages, and desserts. Due to the sedentary
behavior of most Americans, few such foods should be consumed, typically no more
than 100200 calories/day (kcal/d) as part of total energy intakefor the age
group and physical activity level. To meet nutrient needs without overconsumption
of calories (energy intake), meals and snacks need to be nutrient dense (high in
nutrients) but as low as possible in saturated and trans fats and with
little or no added sugars. Foods such as fat-free milk, fruits, vegetables, whole-grain
breads, and low-sugar cereals exemplify this concept. Conversely, the sugar in sugar-sweetened
beverages, the fat in whole milk (versus fat-free milk), the fat and added sugar
in chocolate milk (versus fat-free unflavored milk), the fat in high-fat meats (versus
lean meats), and the fat and sugar in cookies, cakes, pastries, granola bars, and
sweetened cereals (versus unsweetened grain foods) are examples of sources of nonessential
calories. Selecting nutrient-dense foods in each food group gives individuals an
effective way to meet their nutrient needs without consuming excess calories. This
approach can be adopted and maintained throughout life to prevent the development
of overweight and obesity. Because the discretionary calorie concept is important
but complex for most consumers, the Expert Panel emphasizes consuming mostly nutrient-dense
foods for meals and snacks.
For growing children, the EER increases with age and with physical activity level,
as do allowances for essential calories and discretionary calories, as shown in
Figures 51 and 52. However, due to the low levels of physical activity
common among most American children, the nonessential, discretionary calorie allowance
is no more than 100400 kilocalories, based on age and activity level. This
is not sufficient to accommodate daily (or regular) consumption of whole milk, high-calorie/low-nutrient-dense
snacks, or desserts and/or sugar-sweetened beverages (see Figures 51 and 52).
Sedentary children who regularly consume energy-dense, nutrient-poor foods are at
risk of developing overweight and obesity and having inadequate nutrition, despite
high calorie intake.
Text description of Figure 5-1.
Figure 5-1. Estimated Energy Requirements (EER) and Discretionary Calorie Allowance
by Level of Activity-(Boys)*
Boys
|
Essential Calories for CHILD 1-2
|
Discretionary Calories#
|
Total
|
2-3 sedentary
|
800
|
200
|
1,000
|
2-3 moderately active
|
1,000
|
200
|
1,200
|
2-3 active
|
1,200
|
200
|
1,400
|
4-8 sedentary
|
1,000
|
200
|
1,200
|
4-8 moderately active
|
1,400
|
200
|
1,600
|
4-8 active
|
1,650
|
300
|
2,000
|
9-13 sedentary
|
1,600
|
200
|
1,800
|
9-13 moderately active
|
1,900
|
300
|
2,200
|
9-13 active
|
2,200
|
400
|
2,600
|
14-18 sedentary
|
1,900
|
300
|
2,200
|
14-18 moderately active
|
2,300
|
400
|
2,700
|
14-18 active
|
2,550
|
650
|
3,200
|
# Discretionary calories for children aged 4-8 are based on
recommended 2 servings of dairy/day.
* Adapted from Gidding et al. Circulation. 112(13).
September 2005.
Text description of Figure 5-2.
Figure 5-2. Estimated Energy Requirements (EER) and Discretionary Calorie Allowance
by Level of Activity-(Girls)*
Girls
|
Essential Calories for CHILD 1-2
|
Discretionary Calories#
|
Total
|
2-3 sedentary
|
800
|
200
|
1,000
|
2-3 moderately active
|
1,000
|
200
|
1,200
|
2-3 active
|
1,200
|
200
|
1,400
|
4-8 sedentary
|
1,000
|
200
|
1,200
|
4-8 moderately active
|
1,400
|
200
|
1,600
|
4-8 active
|
1,500
|
300
|
1,800
|
9-13 sedentary
|
1,450
|
150
|
1,600
|
9-13 moderately active
|
1,800
|
200
|
2,000
|
9-13 active
|
1,900
|
300
|
2,200
|
14-18 sedentary
|
1,600
|
200
|
1,800
|
14-18 moderately active
|
1,800
|
200
|
2,000
|
14-18 active
|
2,100
|
300
|
2,400
|
# Discretionary calories for children aged 4-8 are based on
recommended 2 servings of dairy/day.
* Adapted from Gidding et al. Circulation. 112(13).
September 2005.
Figures 5-1 and 5-2. Concept of discretionary calories by gender. As daily physical
activity increases, more energy is needed for normal growth, unless the child is
overweight or obese and may benefit from limited additional calorie intake as determined
by the health care provider. For sedentary children, only small amounts of discretionary
calories can be consumed before caloric intake becomes excessive. Discretionary
calories represent snacks, desserts, sugar-sweetened beverages, and other nutrient-poor,
energy-dense foods whose intake should not exceed the indicated allowances according
to level of activity. In Figures 5-1 and 5-2, the discretionary calorie allowance
for children ages 4-8 years is based on 2 servings of dairy per day. Mod Act indicates
moderately active. Information is based on estimated calorie requirements and discretionary
calories published in the Dietary Guidelines for Americans (2005).
FORMAT OF THE EVIDENCE REVIEW FOR NUTRITION AND DIET
The results of the evidence review addressing the role of nutrition and diet in
promoting CV health are summarized below. The review encompassed 30 systematic reviews,
12 meta-analyses, 121 randomized controlled trials (RCTs), and 47 observational
studies. Because of the large volume of studies reviewed and the diverse nature
of the evidence, the Expert Panel provides an overview of the studies reviewed,
highlighting those that in its view provide the most important information. Detailed
information from each study has been extracted into the evidence tables and will
be available at http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm.
Results are presented here by dietary component and by age group and are summarized
after each dietary component review. Some studies were not specific to the age groups
addressed in these Guidelines; the Expert Panel used clinical judgment in determining
how best to apply results from those studies to age-specific recommendations. At
the end of each dietary component review, the results are summarized. The conclusions
of the entire evidence review for diet and nutrition, with grades and age-specific
recommendations, appear at the end of this section.
CURRENT DIETARY INTAKE IN CHILDREN AND ADOLESCENTS
Four epidemiologic studies evaluated overall dietary content for children and adolescents.
The Bogalusa Heart Study is a major community-based cohort of more than 1,655 Black
and White children and young adults in Bogalusa, Louisiana, that began in 1973 and
still continues. Participants were originally examined at ages 517 years and
were 52 percent female and 44 percent Black. The Bogalusa investigators developed
and applied a scoring system based on consumption of nutrient-dense foods. Repeated
cross-sectional surveys between 1989 and 2004 showed an overall decline in dietary
quality, with a decrease in the consumption of nutrient-dense foods with increasing
age. This was accompanied by extensive development of overweight and obesity in
this cohort. At age 10 years, 50 percent of children had a good nutrient density
score, but this dropped to only 19 percent by young adulthood.[2]
The Cardiovascular Risk in Young Finns study (Young Finns) is a multicenter longitudinal
cohort study of CV risk from Finland, with 3,956 subjects enrolled at ages 318
years in 1980 and followed with serial lipid evaluation over time. Based on data
from 21 years of followup, two major dietary patterns have been observed beginning
in childhood: a "traditional" pattern characterized by high consumption of
rye, potatoes, butter, sausages, milk, and coffee and a "health-conscious" diet
that includes high consumption of vegetables, legumes and nuts, rye, cheese and
other dairy products, and alcoholic beverages[3] At the latest followup, with
subjects now ages 2439 years, the traditional diet was significantly and independently
associated with higher total cholesterol (TC) and low-density lipoprotein cholesterol
(LDLC) concentrations, apolipoprotein B (apoB), and C-reactive protein (CRP)
in both genders, and with systolic BP and insulin levels among females. The health-conscious
diet was inversely but not significantly associated with the same CV risk factors.[4]
The National Heart, Lung, and Blood Institute National Growth and Health Study (NGHS)
enrolled 2,379 Black and White girls in three different U.S. cities at age 9 years
and followed their nutrition, growth, and development over the next decade. Among
adolescent girls older than age 10 years, lower parental educational attainment
was associated with increased total fat, saturated fat, and cholesterol intake and
decreased carbohydrate intake.[4]
Dietary total and saturated fat intake decreased with increasing age, but less than
half of White girls and less than one-third of Black girls met the 1992 National
Cholesterol Education Program (NCEP) expert panel's recommendations for dietary
fat intake: less than 30 percent of calories from fat and less than 10 percent
from saturated fat. Independent of parental education, living in a two-parent household
was associated with decreased fat and cholesterol intake and increased carbohydrate
intake.[5]
A dietary pattern characterized by high intake of fruits and vegetables, dairy
products, and fiber-rich grains and low intake of sugar, fried foods, burgers, pizza,
and total fat was associated with less adiposity (body mass index (BMI), percentage
of body fat, and waist circumference) over 10-year followup; the difference was
significant for White girls.[5]
A report from the Third National Health and Nutrition Examination Survey (NHANES
III) (19881994) of more than 4,000 youths ages 818 years found that
foods of low-nutrient density (snacks, desserts, etc.) contributed more than 30
percent of daily energy intake, with caloric sweeteners and desserts jointly contributing
nearly 25 percent of daily caloric intake. Intake of food-based vitamins and minerals
decreased as consumption of foods of low-nutrient density increased.[6]
OVERVIEW OF THE EVIDENCE BY DIETARY COMPONENT AND AGE GROUP
Milk and Other Beverage Intake
Age Birth to 12 Months: Human Milk
There is near universal agreement that human milk is the preferred complete nutrition
source for healthy full-term newborns and infants for the first 6 months of life,
with continued breastfeeding recommended until age 12 months. As recommended by
the U.S. Surgeon General, World Health Organization (WHO), American Academy of Pediatrics
(AAP), and American Academy of Family Practice (AAFP), human milk is the preferred
primary source of nourishment in infancy. Human milk is a unique biological fluid
that changes almost daily to meet the nutritional and immunologic needs of the growing
infant. Human milk is high in fat (4555 percent of total calories), saturated
fat, and cholesterol. It provides a rich source of essential fatty acids linoleic
acid (LA) and alpha linoleic acid (ALA) and long-chain polyunsaturated fatty acid
(PUFA) derivatives arachidonic acid (AA) and docosahexaenoic acid (DHA).[7]
Human milk supplies the fat-soluble vitamins A, D, E, and K as well as carotenoids
and bioactive components, with protective functions ranging from immunoglobulins
to oligosaccharides, enzymes, antienzymes, and adrenal steroids, although vitamin
D levels are often inadequate. To prevent vitamin D deficiency, the AAP recommends
supplementation with 400 international units per day (IU/d) for all children.[8] The
new RDA for Vitamin D for those 1-70 years old is 600 IU/day.[9]
The evidence review for these Guidelines identified studies that examined the long-term
CV benefits of breastfeeding, including possibly but not conclusively protective
effects against obesity,[10]
lower serum TC levels and decreased carotid intima-media thickness (cIMT) in adulthood,[11],[12]
and a lower risk of type 2 diabetes mellitus (T2DM).[13] A meta-analysis
of 37 studies compared the late effects of breastfeeding versus formula-feeding
on TC levels in adolescents and adults.[11] In infancy, mean TC was higher
in breast-fed versus formula-fed infants, but this difference disappeared in childhood
and adolescence. Among adults, the TC level of those who had been breast-fed as
infants was lower than the TC level of those who had been formula fed.
Ages Birth to 12 Months: Infant Formula
Infant formulas that meet regulatory requirements for quality and nutrient content
are marketed in the United States and many other countries. These products are designed
to support the normal growth and development of infants. Infant formula products
currently marketed in the United States are iron fortified and contain mixtures
of vegetable oils, including coconut, soy, high-oleic safflower, high-oleic sunflower,
and/or palm olein, plus single-cell oils containing the two long-chain PUFAs DHA
and AA. The DRI recommendations for nutrient intake by infants are based
on the nutrient content of breast milk and include intake of essential fatty acids
that are unsaturated, specifically ALA omega-3 and LA omega-6 fatty acids. The fat
and cholesterol contents of infant formula were varied in several small short-term
RCTs, with subsequent significant differences in intervention infants, compared
with controls for TC, LDLC, triglycerides (TG), and high-density lipoprotein
cholesterol (HDLC); there were no differences between groups in lipoprotein
profiles postweaning.[14],[15],[16],[17]
Transition to Childhood: Ages 12 Months to 2 Years: Introduction of
Cow's Milk
Vitamin-D-fortified cow's milk and other dairy products are excellent sources of
calcium, magnesium, protein, and vitamin D. However, the dairy fat in whole cow's
milk is a major source of atherogenic saturated fat, cholesterol, and calories and
a poor source of the essential fatty acids LA and ALA.
Of particular relevance to the transition from breast milk or infant formula is
the Special Turku Coronary Risk Factor Intervention Project (STRIP) in Finland.
This important trial enrolled 1,062 healthy 7-month-old infants who were randomized
to an intervention or a control group.[18] The intervention group families
received repeated, individualized, nutritionist-delivered, low-saturated-fat counseling
designed to achieve a diet with total fat of 3035 percent of total kcal/d,
a 1:1:1 intake ratio of saturated fatty acids (SFA)/monounsaturated fatty acids
(MUFA)/PUFA/d, cholesterol intake of less than 200 milligrams per day (mg/d), protein
1015 percent of total kcal/d, and carbohydrates 5060 percent of total
kcal/d. Until age 12 months, families were advised to continue with breast- or formula-feeding.
After age 1 year, skim milk was recommended as the primary beverage; in the intervention
group, parents were encouraged to supplement the diet as needed with soft margarines
and vegetable oils until age 24 months to maintain adequate fat intake. The control
group received basic health education and no instructions on the use of dietary
fats.[18]
The children then were followed with serial evaluations, with the first at age 13
months, including dietary assessment with 4-day dietary records, to midadolescence,
with reported findings to age 14 years. The children have been assessed for lipid
results every 2 years and for other nutrition-related measures at irregular intervals.
From the first intervention assessment at age 13 months onward until age 14 years,
children in the intervention group consumed less total and saturated fat, less cholesterol,
and more carbohydrates and polyunsaturated fat than controls. The percentage of
calories in the intervention group from total fat (saturated fat in parentheses)
was 26 percent (9 percent) at age 13 months, 30 percent (11 percent) at age 24 months,
30 percent (12 percent) at age 4 years, 30 percent (12 percent) at age 7 years,
and 30 percent (11 percent) at age 10 years.[19],[20],[21],[22],[23]
These dietary fat changes translated to significantly lower TC and LDLC
levels until age 7 years; after age 7 years, the latter difference was significant
only for boys.[22],[23]
No harmful effects were reported on growth, micronutrient intake, development, or
neurologic function.[24],[25]
In a subgroup of 78 intervention children and 89 control children assessed at age
9 years, the intervention children had significantly lower insulin levels and lower
homeostatic model assessment of insulin resistance (HOMAIR) than control children.[26]
At age 10 years, followup included about half of the original cohort, as initially
predicted and powered. Results showed that 10.2 percent of girls in the intervention
group were overweight, compared with 18.8 percent of controls (P = 0.04); there
was no difference in overweight prevalence between groups among boys. There was
no significant difference between intervention and control groups in weight for
height or obesity at any single age, thus illustrating energy adequacy despite recommended
reduced fat intake.[27]
For this study, overweight was defined as weight for height greater than 20
percent and obesity greater than 40 percent above the mean weight for height for
Finnish children. In a subgroup assessed at ages 7 and 9 years, intervention children
also had higher nutrition knowledge scores.[28]
Intake of Other Beverages
Infancy/Early Childhood
Consumption of fruit juices, representing a "naturally sweetened" beverage, has
increased over the past 30 years due to increased availability, accessibility, marketing,
and convenience.[29]
Young children tend to be the highest consumers of fruit juices, and some studies
have noted associations between high juice consumption and obesity.[30],[31]
Of note, juice intake was higher and the relationship between juice intake and obesity
was strongest in low-income populations where children participated in public nutrition
programs, such as the Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC) that provide vouchers for juice. Two longitudinal studies of
children participating in the WIC Program found that the increased risk of obesity
with increased juice intake was strongest among children who were already overweight.[30],[31]
The AAP recommends that a serving of natural, unsweetened fruit juice be limited
to 46 fluid ounces and that infants can receive 1 serving per day after age
6 months as part of a meal or snack. After infancy, children ages 16 years
should receive no more than 1 serving of unsweetened fruit juice per day, and children
ages 718 years should limit juice consumption to no more than 2 servings per
day.[32]
This evidence review identified no additional studies in this subject area for these
age groups.
Later Childhood and Adolescence
The Centers for Disease Control and Prevention's (CDC's) 2007 Youth Risk Behavior
Surveillance report found that only 19 percent of male teens and 9 percent
of female teens consumed at least 3 glasses of milk per day.[33] In contrast,
39 percent of males and 29 percent of females consumed at least one 12-ounce
can of soda per day, not including diet soda. Soft drink consumption in the United
States has increased more than 300 percent over the past two decades; 5685 percent
of school-aged children consume at least one soft drink daily. The full impact on
obesity and other CV risk factors from the displacement of calcium, vitamin D, protein,
and other essential nutrients, combined with the increase in calories from sugar,
is as yet unquantified. The NGHS (described previously) reported that higher consumption
of sugar-sweetened beverages was associated with significantly lower milk consumption
and that increased soda consumption predicted greater increases in BMI; BMI increased
0.01 unit for each 100 grams of soda consumed. Consumption of sugar-sweetened beverages
was significantly associated with higher daily calorie intake. For every 100 grams
of soda consumed, average daily calorie intake increased by about 82 calories.[34]
A 2006 systematic review of sugar-sweetened beverage intake and weight gain included
21 (of 30) studies in children and adolescents.[35] The review concluded
that greater consumption of sugar-sweetened beverages is significantly associated
with both weight gain and obesity. Two RCTs reviewed in detail in Section X. Overweight
and Obesity showed significant reductions in overweight and obesity when intake
of sugar-sweetened beverages was limited.[36],[37]
Sports drinks represent a relatively new beverage category. By design, they contain
higher amounts of sodium, refined carbohydrates (sugar), and calories than does
water. No studies in this evidence review dealt with sports drinks, but information
is provided because of their increasing consumption as a sugar-sweetened beverage
and thus their potential impact on children's caloric intake. Originally developed
and marketed for use by trained athletes during competition, sports drinks have
been marketed to the general public and "casual athletes" in recent years. Consumption
by children and adolescents is increasingly common, with or without accompanying
physical activity. In one review of adolescents ages 1118 years, 56.4 percent
reported having consumed a sports drink during the previous week.[38]
Research in adult athletes evaluated under conditions of prolonged exercise with
or without heat stress indicates that beverages containing electrolytes are effective
in maintaining plasma volume and preventing hyponatremia, compared with plain water.[39]
Compared with water, drinks containing electrolytes and refined carbohydrates have
been shown to improve performance in sustained exercise tasks lasting more than
45 minutes.[40]
In studies of young adult competitive athletes, primarily males, sports drinks appear
to be safe and effective during training and competition, especially in hot conditions.[41]
Although it may be reasonable to extrapolate these benefits to adolescents exerting
high levels of energy under similar conditions, the evidence review identified no
research examining the effects of these drinks in children.
SUMMARY OF THE EVIDENCE REVIEW FOR MILK AND OTHER BEVERAGE INTAKE
- Human milk, as the primary source of nutrition in the first year of life, is associated
with CV benefits on late followup in adult life.
- Results of the STRIP trial suggest that the fat content of cow's milk can be safely
reduced in healthy infants when accompanied by counseling on nutrition quality and
energy density, including attention to sufficient fat intake prior to age 2 years,
with benefits on TC and LDLC levels in boys and girls up to age 7 years and
in boys through age 14 years, plus lower rates of obesity and insulin resistance.
- Increased sugar-sweetened beverage intake is associated with obesity in multiple
reports.
OVERVIEW OF THE EVIDENCE FOR DIETARY FAT INTAKE
Background
The evidence that, in adults, a diet lower in fat is associated with reduced development
of cardiovascular disease (CVD) originated with epidemiologic studies dating back
half a century. Dietary fat intake (quantity) and fatty acid type regulate serum
lipids in children as they do in adults, but fat intake may represent a major source
of energy for children, especially infants and toddlers, whose volume capacity is
limited. Energy density can be an important factor among finicky eaters whose total
caloric needs may otherwise not be met. The original NCEP recommendations were published
in 1992 and were based on evidence available at the time. The National Cholesterol
Education Program: Report of the Expert Panel on Blood Cholesterol Levels
in Children and Adolescents recommended a diet with less than 30 percent
of total calories from fat, less than 10 percent from saturated fat, and cholesterol
intake <300 mg/d for all healthy U.S. children 2 years and older.[42]
There is no biologic requirement for SFA, so the limits were intended to help reduce
atherogenic risk without eliminating high-quality animal protein sources. The DRI
recommendations promote the intake of essential fatty acids from unsaturated sources,
specifically ALA and LA omega-6 fatty acids. The acceptable range for intake of
LA is 510 percent of fat calories and for ALA is 0.61.2 percent
of fat calories for children and adults. From the evidence review, dietary pattern
studies in children and adolescents report that higher blood lipid levels are associated
with higher total and saturated fat intake, just as in adults.[4],[5],[6],[7]
The evidence review for these Guidelines also identified a series of studies focused
on evaluating the safety of lower dietary fat and saturated fat content as well
as the efficacy of such diets in lowering serum lipid levels and reducing obesity.
Most important among these studies for the youngest age range is the STRIP trial,
now with 14 years of followup.[18],[19],[20],[21],[22],[23]
STRIP is the only trial examining and reporting health effects from a reduced saturated
fat diet in normal children from infancy through adolescence. The STRIP trial and
each of the other dietary fat interventions identified by the evidence review are
described by age group below.
Infancy
Despite recommendations advocating breast milk or formula in infancy, a 2002 survey
reported that 20 percent of toddlers had been fed whole cow's milk on a daily
basis before age 12 months.[43]
The consequences of whole-milk consumption by infants, with its high protein and
sodium content and reduced LA content, have not been reported. In several RCTs with
small study groups, the fat and cholesterol contents of infant formulas varied,
with subsequent short-term changes in levels of TC, LDLC, and TG in infancy,
but no long-term differences in lipoprotein profiles were demonstrated on followup.[14],[14],[15],[16]
Infancy After Weaning
As described above, many of the data on the safety and efficacy of a diet low in
saturated fat and cholesterol starting in infancy come from the STRIP study, in
which 7-month-old Finnish infants were randomized into either (1) a group whose
parents received counseling from a nutritionist for a diet with total fat of 3035 percent
of total kcal/d and with a 1:1:1 intake ratio of SFA/MUFA/PUFA per day, cholesterol
intake <200 mg/d, protein 1015 percent per day, and carbohydrates
5060 percent per day or (2) a group whose parents received basic health
education and no instructions on the use of fats.[18] From age 12 months
onward, the primary beverage consumed by these children was skim milk. The children
were followed with repeated dietary counseling and serial evaluations, including
dietary assessment using 4-day diet records, the first at age 13 months and extending
now into midadolescence.
Beginning at the age 13-month assessment and extending to age 14 years, children
in the intervention group have consumed significantly less total and saturated fat
and more carbohydrates and polyunsaturated fat, compared with children in the control
group. The total fat content of the diet of the intervention children ranged from
26 to 30.5 percent throughout the 14-year followup period.[19],[20],[21],[22],[23]
This compares with a significantly higher total fat intake of 2833 percent
in control subjects. Saturated fat intake among the intervention children was significantly
lower, ranging from 9.5 percent to 11 percent, compared with 1314 percent
in control subjects. From age 13 months to age 14 years, those in the STRIP intervention
group had lower TC and lower LDLC than the control group; after age 7 years,
the difference was only significant in males.[21],[22],[23]
There were no differences in growth or in pubertal maturation between groups. In
a substudy, serum stanol concentrations were measured to further assess the effect
of replacing milk fat with vegetable fat. Campesterol and sitosterol levels were
increased, but this was not associated with any change in the levels or production
of cholesterol.[44]
The lower total fat and saturated fat diet was associated with important CV health
benefits, including the difference in serum lipids described above.[19],[20],[21],[22]
Assessed at age 9 years, a subgroup of STRIP intervention children also had
significantly lower insulin levels and lower HOMAIR than control children.[26]
Assessed for obesity measures at age 10 years, there were significantly more overweight
females in the control group than in the intervention group; only two intervention
females and one male were obese, compared with eight control females and one male.[27]
For this study, overweight was defined as weight for height greater than 20 percent
and obesity as greater than 40 percent above the mean for Finnish children.
In a subgroup assessed at ages 79 years, intervention children had higher
nutrition knowledge scores.[28]
No harmful effects on nutrient adequacy, physiologic development, or neurologic
function were seen over 14 years of followup in those who continued to be followed,
representing more than half the original cohort and adequately powered to assess
the planned outcome measures.[23],[24],[25]
Childhood and Adolescence
The Dietary Intervention Study in Children (DISC)[45] assessed the safety
and efficacy of a reduced-fat dietary intervention among children with moderately
elevated LDLC levels between the 80th and 98th percentiles at baseline. Prepubertal
boys (N = 362) and girls (N = 301) (initially ages 810 years) and their parents
were randomized to either an ongoing, nutritionist-driven, individual and group
intervention or a usual-care group in a six-center clinical trial. A behavioral-based,
nutritionist-tailored intervention with monthly nutritionist visits and telephone
followup was used to promote adherence to a diet similar to the NCEP Step II diet,
with 28 percent of energy from fat, <8 percent from saturated fat,
<9 percent from polyunsaturated fat, and cholesterol intake <150
mg/d. The control group received dietary literature only. At the 3-year followup,
dietary total fat intake averaged 28.6 percent of calories, with a saturated
fat intake of 10.2 percent of calories in the intervention group,
significantly lower than in the usual-care group. This change was accompanied by
small but significant mean differences in LDLC levels (reduction from baseline
of 15.4 mg per deciliter (mg/dL) in the intervention group versus a reduction of
11.9 mg/dL in the control group). Greater sexual maturation and BMI were found to
increase the normal fall in LDLC levels in both groups, which occurs during
adolescence.[46]
At followup after a mean of 7.4 years, children in the intervention group maintained
significantly lower dietary intakes of total fat, saturated fat, and cholesterol,
compared with children in the control group, but there was no longer a significant
difference in LDLC between the two groups. There were no differences in any
of the safety measures, including height or depression scores.[47],[48]
A clinically initiated, home-based, parent-child autotutorial (PCAT) dietary education
program directed at increasing dietary knowledge and reducing fat consumption and
LDLC levels was assessed in 174 boys and girls ages 410 years with borderline-high
or high LDLC.[49]
Intervention families received individualized dietary recommendations to maintain
a total dietary fat intake of less than 30 percent of calories and a saturated
fat intake of less than 10 percent of calories and used tape-recorded nutrition
messages to support appropriate dietary decisions between clinical visits. After
3 months, the PCAT group had significantly lower intakes of total and saturated
fat and calories and lower LDLC levels than an at-risk control group that
received no intervention; there were no significant differences in dietary intake
or lipid levels between PCAT and traditional dietary counseling. Results were maintained
at 1-year followup.[50]
Another office-based, 16-week nutritional education program effectively decreased
intake of total fat, saturated fat, and cholesterol and significantly lowered TC
and LDLC levels.[51]
In prepubertal children with heterozygous familial hypercholesterolemia (FH), an
RCT of 96 children ages 611 years tested a fat-restricted diet with 23 percent
±5 percent of energy from total fat, 8 percent ±2 percent
from saturated fat, 5 percent ±1 percent from polyunsaturated fat,
8 percent ±2 percent from monounsaturated fat, 15 percent
±2 percent from protein, and 62 percent ±5 percent
from carbohydrates, with a cholesterol intake of 67 mg ±28 mg/1,000 kcal,
for 1 year. TC and LDLC levels were lowered by 4.4 percent and 5.5 percent,
respectively. HDLC, TG, apoB, ferritin, weight for height, and height velocity
were unchanged.[52]
The Child and Adolescent Trial for Cardiovascular Health (CATCH) was an RCT to examine
the outcomes of a multilevel school-based intervention, including health behavior
education and school environmental changes, in 56 intervention schools compared
with 40 control schools; effects in 5,106 initially third-grade students from ethnically
diverse backgrounds in California, Louisiana, Minnesota, and Texas were assessed.[53]
In intervention schools, there were school food service modifications to lower fat
and sodium content plus enhanced physical education and classroom health curricula,
both with and without family education. Compared with control schools, children
at intervention schools consumed significantly less total fat from cafeteria lunches
(reduced from 38.9 percent to 31.9 percent of energy for the lunch meal
only) and increased their amounts of vigorous physical activity. Due to limitations
in the full collection of diet assessment methodology, whether total fat and saturated
fat intakes per day were effectively reduced to NCEP guidelines levels of less than
30 percent and less than 10 percent of total calories, respectively, was
only documented in a subsample.[54]
However, after this 2.5-year intervention, there were no differences between the
intervention and control schools regarding children's cholesterol levels, BP, or
body size, nor were there any deleterious effects on growth or development.[55]
Of note, the evidence review for these Guidelines identified no RCT in which dietary
fat intake of 3035 percent was evaluated in children or adolescents.
Even in the STRIP study, which focused on reducing saturated fat intake with dietary
counseling for up to 3035 percent of total calories from fat, total fat
intake of the intervention group never exceeded 30.5 percent from ages 7 months
to 14 years.[18],[19],[20],[21],[22],[23]
Lower total fat intake with nutritionist-tailored diet interventions was associated
with no adverse events under the conditions specified for each trial.
SUMMARY OF THE EVIDENCE REVIEW FOR DIETARY FAT INTAKE
- A diet with total fat at less than 30 percent of calories, saturated fat less
than 10 percent of calories, and cholesterol intake <300 mg/d, as recommended
in the 1992 National Cholesterol Education Program: Report of the Expert Panel
on Blood Cholesterol Levels in Children and Adolescents, is safe for healthy
children; in one large trial, this kind of diet was initiated in infancy through
tailored, nutritionist-delivered intervention and no harmful effects were reported
throughout childhood into adolescence.
- Modifying the type and amount of fat intake in children's diets can be effectively
accomplished by qualified ongoing nutritional guidance and behavioral counseling
for parents and children, preferably along with environmental change.
- Dietary intervention studies in healthy children and in children with hypercholesterolemia
using trained nutritionists safely achieved an average total fat intake of 2830 percent
of calories and an average saturated fat intake of 810 percent of calories.
- These levels of total fat and saturated fat intake were shown in RCTs to be associated
with lower TC and LDLC levels in intervention subjects, compared with control
subjects.
- No harmful, adverse effects of restricting total or saturated fat intake at the
levels described in the reviewed studies were demonstrated through several years
of followup, with one RCT demonstrating no harm for as long as 14 years.
- This evidence review identified no studies evaluating trans fat intake
in children.
OVERVIEW OF THE EVIDENCE FOR DIETARY CHOLESTEROL INTAKE
Cholesterol is found in the membranes of all cells and is the precursor of bile
acids, sex hormones, vitamin D, and other essential biologic elements. Because of
endogenous production, there is no dietary requirement for cholesterol.[56]
However, dietary cholesterol is known to impact plasma lipids; it has been estimated
that in adults on a 2,500 kcal/d diet, serum cholesterol will decrease by about
4 mg/dL for every 100 mg/d decrease in dietary cholesterol.[57] The 1992 National Cholesterol
Education Program: Report of the Expert Panel on Blood Cholesterol Levels
in Children and Adolescents recommended that dietary cholesterol intake
be limited to <300 mg/d in all children and to <200 mg/d in those with elevated
LDLC levels. From the NHANES surveys from the 1970s through 1994, mean dietary
cholesterol intake in male and female children younger than age 13 years and in
females through adolescence achieved the recommended level, averaging <300 mg/d.
However, in males between ages 12 and 19 years, mean intake of cholesterol was 335
mg/d, exceeding the recommended 300 mg/d, regardless of racial/ethnic group.[58]
This evidence review identified 15 RCTs that addressed dietary cholesterol in infancy,
childhood, and adolescence. In several small short-term studies, the fat and cholesterol
contents of infant formula varied, with subsequent changes in levels of TC, LDLC,
and TG in infancy, but there were no demonstrated long-term differences in lipoprotein
profiles.[14],[15],[16],[17]
The STRIP trial, described in detail above, enrolled 1,062 healthy infants who were
randomized to either intervention or control groups beginning at age 7 months. In
addition to the low-saturated-fat diet described above, the intervention group received
repeated, individualized, nutritionist-delivered counseling to maintain a dietary
cholesterol intake of <200 mg/d.18 The children were then followed
with serial evaluations, including dietary assessment using 4-day food records,
until early adolescence. Results demonstrate that from age 13 months onward, children
in the intervention group consumed significantly less total fat, saturated fat,
and cholesterol and had lower TC and LDLC levels; after age 7 years, the difference
in LDLC levels was significant only among boys.[18],[19],[20],[21],[22],[23]
No harmful effects were detected on growth, micronutrient intake, development, or
neurologic function.[23],[24],[25]
Benefits on CV risk factors, especially lipids, described in detail in the preceding
section, were seen, continuing into adolescence.[18],[19],[20],[21],[22],[23],[26],[27]
The DISC trial[45]
described in detail above, was an RCT to assess the safety and efficacy of a reduced-fat
dietary intervention among children with elevated LDLC levels (between the
80th and 98th percentiles) at baseline. The DISC trial used a behavioral-based,
nutritionist-tailored intervention to promote adherence to a diet similar to the
NCEP Step II diet, with 28 percent of energy from fat, <8 percent from
saturated fat, <9 percent from polyunsaturated fat, and cholesterol
intake <75 mg/1,000 kcal/d, not to exceed 150 mg/d. Based on multiple 24-hour
dietary recalls, cholesterol intake was shown to decrease from a mean of 118 mg/100
kcal to 90 mg/100 kcal at 1-year followup; this difference persisted at evaluation
5 years postinitiation. At 3-year evaluation, LDLC levels were significantly
lowered in the intervention group, compared with the control group (reduction from
baseline of 15.4 mg/dL versus 11.9 mg/dL, respectively); this difference was not
sustained at 7-year followup. There were no differences between groups in the prespecified
safety measures of height and serum ferritin.[46],[47]
In prepubertal children with heterozygous FH, an RCT of 96 children ages 611
years tested a fat- and cholesterol-restricted diet (23 percent ±5 percent
of energy from total fat, 8 percent ±2 percent from saturated fat,
5 percent ±1 percent from polyunsaturated fat, 8 percent ±2 percent
from monounsaturated fat,15 percent ±2 percent from protein, and
62 percent ±5 percent from carbohydrates with daily cholesterol
intake of 67 ±28 mg/1,000 kcal).[52] After 1 year, TC and LDLC
levels decreased by 4.4 percent and 5.5 percent, respectively. HDLC,
TG, apoB, and ferritin levels, weight-for-height, and height velocity were unchanged.[52]
The PCAT dietary education program described previously was directed at increasing
dietary knowledge, reducing fat consumption, and decreasing LDLC levels in
boys and girls ages 410 years with borderline-high or high LDLC.[49]
In addition to individualized dietary recommendations to maintain a total dietary
fat intake at less than 30 percent of calories and saturated fat intake at
less than 10 percent of calories, intervention families were trained to limit
cholesterol intake to <300 mg/d. At baseline, cholesterol intake was well below
the 300-mg goal in all subjects, averaging 156.5 ±6.6 mg/d in the intervention
group and 178.4 ±7.7 mg/d in the control group. After 3 months, those in
the PCAT intervention group had significantly lower intakes of total fat, saturated
fat, cholesterol, and calories. Cholesterol intake averaged 133.2 ±8.0 mg/d
in the intervention group but was unchanged at 173.1 ±8.2 mg/d in the control
group. LDLC levels decreased 10 mg/dL in intervention subjects and 3.4 mg/dL
in control subjects. These results were maintained at 1-year followup.[50]
Another office-based, 16-week nutritional education program similarly decreased
intakes of dietary total fat, saturated fat, and cholesterolthe latter to
<200 mg/dwith significant decreases in TC and LDLC levels and no
reported adverse outcomes.[51]
SUMMARY OF THE EVIDENCE REVIEW FOR DIETARY CHOLESTEROL INTAKE
- Usual mean dietary cholesterol intake by children and adolescent females fall below
the level of 300 mg/d previously recommended by the NCEP Pediatric Panel as reported
in the 1992 National Cholesterol Education Program: Report of the Expert Panel
on Blood Cholesterol Levels in Children and Adolescents; in adolescent
males, mean dietary cholesterol intake exceeds this level.
- In multiple RCTs in children with hypercholesterolemia, dietary cholesterol intake
has been safely decreased with nutritional counseling to <200 mg/d, with one
study of healthy children beginning in infancy and followed up through childhood
into adolescence.
- Combined with lower total fat and saturated fat intake, lower cholesterol intake
was associated with significant reductions in serum TC and LDLC levels in
the RCTs that were conducted in children ranging from age 7 months to early adolescence.
OVERVIEW OF THE EVIDENCE REVIEW FOR INTERVENTIONS TO INCREASE FRUIT AND VEGETABLE
INTAKE
Background
Consumption of fruits and vegetables is advocated in the U.S. Department of Agriculture
(USDA) MyPlate.[59]
Most fruits and vegetables are plentiful in micronutrients and low in energy density.
Because of their high fiber content, some studies suggest that fruits and vegetables
can also contribute to feelings of satiety without excessive energy intake. As described
in the section on dietary patterns, higher intake of fruits and vegetables in epidemiologic
studies has been associated with less adiposity and lower BP and cholesterol levels.[4],[5]
The DGA concluded that some evidence exists to support the conclusion that
there is an association between higher vegetable and fruit intake and less adiposity
in children.[1]
Despite the high nutrient value of fruits and vegetables, children have inadequate
intake of fruits and vegetables. In a national survey from 1999 to 2002, only one-fourth
of children ages 211 years were found to consume at least three servings per
day of vegetables, and fewer than half consumed at least two fruit servings per
day.[60]
The Expert Panel focused its review on evidence supporting effective interventions
to increase the intake of fruits and vegetables among children. None of the identified
studies were interventions in children younger than age 4 years.
Childhood and Adolescence
Four systematic reviews and one meta-analysis addressed fruit and vegetable intake
as primary outcome measures. The body of evidence presented here evaluates the effectiveness
of various interventions on the consumption of fruits and vegetables, rather than
evidence of the relationship between fruit and vegetable intake and CV risk factors.
A 1998 meta-analysis[61]
evaluated the results of 12 elementary-school-based studies (published between 1980
and 1996) on heart healthy eating behaviors, including fruit and vegetable intake.
Three were RCTs, which were included in this evidence review.[62],[63],[64]
The results translated into a weighted standard effect size of 0.24, suggesting
that school-based programs have a small but significant effect on fruit and vegetable
intake as part of a heart healthy eating pattern. A systematic review published
in 2002 evaluated the efficacy of behavioral interventions to modify dietary fat
intake and fruit and vegetable intake in children and adults in studies published
between 1975 and 1999.[65]
That review included four studies from this evidence review[55],[63],[65],[66],[67]and
concluded that more than three-fourths of all studies reported significant increases
in fruit and vegetable intake, averaging 0.6 more servings per day; studies in children
were not reported separately. Interventions were reported to be more successful
in populations identified as being at risk for or diagnosed with disease, suggesting
that results in the healthy pediatric population might have been less significant.
A 2005 systematic review[68]
focused on studies in children ages 612 years published between 1990 and March
2005 and included four studies from this evidence review.[55],[66],[67],[69]
The review concluded that availability, accessibility, and taste preferences were
the determinants most consistently and positively related to higher consumption
of fruits and vegetables. Among interventions, multicomponent school-based interventions
were the most successful. The most recent systematic review from 2006 evaluated
worldwide intervention studies (published any time before April 2004) designed to
increase fruit and vegetable intake in children and adults.[70] A total of 15
studies focused on subjects ages 518 years; of these, 11 were RCTs, 10 of
which were included in this evidence review.[55],[63],[65],[67],[71],[72],[73][74],[75]
Overall, 10 of the 15 studies showed a significant positive effect, ranging from
an increase of 0.3 to 0.99 servings per day. The evidence was strongest for multicomponent
interventions.
As indicated by the findings of the systematic reviews, most intervention studies
addressing enhanced fruit and vegetable intake used multicomponent school-based
strategies. The types of interventions varied and included such approaches as multimedia
games, traditional classroom instruction, reward systems, and computer-based education.
Many studies focused on obesity and addressed lower fat intake, especially lower
saturated fat intake, and/or increased physical activity in addition to increased
intake of fruits and vegetables.[45],[73][74],[75] Several studies
targeted parents, teachers, and food service workers as well as children.[53],[67],[72],[74] Most
demonstrated a modest, often short-term increase in fruit and vegetable intake.
The most successful interventions provided fruits and vegetables free of charge,
added them routinely to school meals or in supplemental food packages to families,
and/or included children in preparing or taste-testing fruits and vegetables. Accessibility
and availability were important aspects of successful interventions, compared with
educational interventions alone[55],[76],[77];
the latter tended to result in an increase in knowledge but no increase in intake
of fruits and vegetables.[28],[72],[75],[78]
A reward system in one study resulted in increased fruit and vegetable intake during
the school lunch period.[79]
However, these gains disappeared when the reward system was removed. A computer-game-based
intervention was associated with better nutritional knowledge and better overall
food choices than a conventional curriculum among students in the last three grades
of primary school, but there was no significant impact on fruit and vegetable intake.[80]
SUMMARY OF THE EVIDENCE FOR INTERVENTIONS TO INCREASE FRUIT AND VEGETABLE INTAKE
- Intake of fruits and vegetables by children ages 5 years and older can be modestly
increased through a variety of interventions, but almost all have been school based
and have advocated a stronger parental component.
- Because most studies have addressed multiple aspects of dietary change and lifestyle
modification, the independent effects of fruit and vegetable intake on child weight
gain and BMI outcomes are often unclear.
- Providing more fruits and vegetables to children results in increased intake.
- Allowing children to prepare and taste fruits and vegetables enhances their acceptance
of these foods.
- Interventions aimed at increasing children's nutritional knowledge less consistently
result in an increase in children's intake of fruits and vegetables.
- Fruit and vegetable intake tends to decline as children reach the middle school
and high school years.
OVERVIEW OF THE EVIDENCE FOR DIETARY FIBER INTAKE
Background
The DGA identified whole grains as an important source of fiber, which
is a component of good nutrition.[1]
Dietary fiber is the nondigestible carbohydrate component of plant foods that include
fruits, vegetables, legumes, and nuts as well as whole grains. Functional or supplemental
fiber refers to nondigestible, nonnutrient-contributing carbohydrate supplements,
which have been shown to have some beneficial physiologic effects in adults but
which are not required if dietary sources of fiber are adequate. Functional/supplemental
fiber is addressed in the dietary supplements section below. The 2002/2005 IOM DRI
report for residents of the United States and Canada specifically addressed dietary
fiber intake as important for laxation, attenuation of blood glucose levels, and
normalization of serum cholesterol levels in adults.[81] The DRI
report includes specific recommendations for fiber intake in children beginning
at age 12 months, extrapolated from adult levels. The evidence review for these
Guidelines identified no studies of dietary fiber intake in young children.
Childhood and Adolescence
Past concerns that extreme high-fiber diets could cause excessive loss of calories,
protein, and fat in growing children have been addressed in a series of reports
demonstrating that high-fiber diets are associated with a more nutrient-dense eating
pattern, whereas low-fiber diets are associated with lower nutrient density, higher
calorie intake, and increased obesity.[82] From this evidence review,
the Bogalusa Heart Study, described previously in this section, examined age and
secular trends between 1976 and 1988 in dietary fiber intake by youths ages 1017
years. Total dietary fiber intake, assessed by dietary recalls, was low, with a
mean intake of 12 grams per day (g/d) or 5 g/1,000 kcal, with no change over the
period of observation. When children were stratified by quartiles of fiber intake,
the percentages of calories from dietary total fat and saturated fat were lower,
and the percentage of calories from carbohydrates was higher in children with high
fiber intakes.[83]
The USDA Agricultural Research Service's Continuing Survey of Food Intake by Individuals
(CFSII) (19941996, 1998) reported only slightly higher mean dietary fiber
intakes for youths: 15.2 g/d and 17.7 g/d for males ages 913 and 1418
years, respectively, and 12.9 g/d and 12.8 g/d for females ages 913 and 1418
years, respectively.[84]
A more recent report from the NHANES III of more than 4,000 youths ages 818
years found that dietary fiber intake was inversely related to low-nutrient-density
food consumption: high dietary fiber intake was consistently associated with
higher nutrient intake. Conversely, intake of vitamins and minerals decreased as
consumption of low-nutrient-density foods increased.7
In another analysis based on data from the CFSII, children ages 25 years with
high fiber intake were found to consume diets with higher nutrient density, compared
with those with low fiber intake.[85]
The Avon Longitudinal Study of Parents and Children found a relationship between
lower dietary intake of fiber and higher fat mass as assessed by dual energy densitometry.[86]
At age 9 years, a high-calorie, low-fiber, low-fat diet score was correlated with
a significantly higher odds ratio for greater adiposity. Analysis of NHANES data
from 1999 to 2000 used popcorn consumption as a proxy for fiber intake. Among individuals
older than 4 years, popcorn consumers had a 25 percent higher intake of whole
grains and a 25 percent higher daily fiber intake, compared with nonconsumers.[87]
In the DRI, the recommended average daily intake of total fiber for children
and adolescents is based on data for adults reporting that a preponderance of the
evidence indicated that 14 g/1,000 kcal reduced the risk of coronary heart disease.[81]
Extrapolating from this, the DRI recommended total dietary fiber intakes
for each age and gender group of children and adolescents as a product of the median
energy intake and this recommended total fiber intake (14 g/1,000 kcal). Thus, for
children ages 13 years and 48 years, a total fiber intake of 19 g/d
and 25 g/d, respectively, is recommended. For males ages 913 years, a total
fiber intake of 31 g/d is recommended, increasing to 38 g/d for males ages 1430
years. For females ages 930 years, a total fiber intake of 2526 g/d
is recommended. The AAP recommends more moderate goals for fiber intake for children,
age plus 5 g/d for young children, increasing to an adult goal of 22 g/d at around
age 15 years.[87]
Dietary fiber should come from foods such as fruits, vegetables, whole grains, nuts,
and legumes rather than from fiber supplements.
SUMMARY OF THE EVIDENCE REVIEW FOR DIETARY FIBER INTAKE
- Higher dietary fiber intake is associated with high-nutrient-dense diets in children
and adolescents.
- Existing recommendations for dietary fiber intake are extrapolated from those for
adults.
- Dietary fiber should come from foods such as fruits, vegetables, whole grains, nuts,
and legumes rather than from fiber supplements.
OVERVIEW OF THE EVIDENCE FOR MULTICOMPONENT DIETARY INTERVENTIONS
Many studies have evaluated dietary obesity prevention interventions that focus
on lowering fat intake and increasing fruit and vegetable intake. Most of these
were school based and were designed to both improve nutrition and increase physical
activity; these studies are described in Section VI. Physical Activity and Section
X. Overweight and Obesity in these Guidelines.[71],[72],[73],[74],[80],[88],[89],[90],[91],[92]
The age groups addressed ranged from preschoolers to teenagers and study sizes
from 213 to more than 5,000 subjects. Most studies were successful in improving
dietary quality, with small decreases in fat intake, small increases in fruit and
vegetable intake, and small increases in physical activity; however, measures of
obesity rarely changed. None of these studies focused on infancy or early childhood.
Later Childhood and Adolescence
The CATCH study described earlier in this section was the largest, most comprehensive,
multicomponent CV health intervention ever conducted for middle-school-aged children.
The 3-year study achieved significant improvement in diet (lower dietary saturated
fat intake at the lunchtime meal) and physical activity (more time spent in vigorous
physical activity) among children in intervention schools, compared with those in
control schools.53,54,55 These beneficial changes, however,
were not associated with any difference in lipid levels, the study's primary outcome.
The CATCH study was not focused on obesity, and the improvements noted in lunchtime
dietary intake had no significant impact on BMI, further illustrating the potential
value of more comprehensive, family-based recommendations.
SUMMARY OF THE EVIDENCE FOR MULTICOMPONENT DIETARY INTERVENTIONS
Many studies have evaluated dietary interventions designed to improve CV risk factors
in children, with a focus on lowering fat intake, increasing fruit and vegetable
intake, and increasing physical activity levels. Most were successful in improving
dietary quality, with small decreases in fat intake, small increases in fruit and
vegetable intake, and small increases in physical activity; however, measures of
CV risk factors, including BMI, blood lipids, and BP, did not change.
OVERVIEW OF THE EVIDENCE FOR Dietary Patterns
Background
Nutrients and food groups are not consumed in isolation but in combinations as part
of a dietary pattern, a concept that has been shown to be useful in studying nutrition.
From epidemiologic studies in adults, diets that are higher in fruits and vegetables
and low-fat dairy foods and lower in prepared foods, salt/sodium, and saturated
fat have been shown to be associated with reduced CV risk, including lower BP, optimal
lipid profile patterns, and lower prevalence of obesity. Dietary pattern studies
in adults have tested a Mediterranean-type diet and the Dietary Approaches to Stop
Hypertension (DASH) diet. The former is a broadly defined diet that is high in fruits
and vegetables, bread, potatoes, beans, nuts, and seeds, with olive oil and in some
reports a high-linolenic-acid margarine as the primary fat sources, and low to moderate
amounts of fish and poultry and little red meat. In adults, the Mediterranean diet
has been shown to significantly decrease recurrent cardiac events when initiated
after first myocardial infarction in adults.[93]
In the DASH intervention feeding trial in adults, a diet rich in fruits and vegetables,
low-fat or fat-free dairy products, whole grains, fish, poultry, beans, seeds, and
nuts substantially reduced both systolic and diastolic BPs among adults with stage
1 hypertension or prehypertension.[94] The DASH diet is also lower
in sweets and added sugars, fats, and red meat than the typical U.S. diet. Although
originally tested for effects on BP, consumption of the DASH diet was also associated
with reduced total and saturated fat intake and a significant decrease in LDLC
level.[95]
Reduced dietary sodium in addition to following the DASH diet achieved the largest
BP reductions.
[96] In observational studies,
sustained adherence to a DASH-style diet has been shown to be associated with lower
risk of coronary heart disease and stroke in both men and women on long-term followup.[97],[98]
When tested in free-living conditions in adults, the Premier Research Group reported
that a behavioral intervention, including the DASH dietary pattern along with other
lifestyle changes to reduce BPreduced dietary sodium, increased physical activity,
and weight lossresulted in increased intake of dietary fiber, weight loss,
and reductions in BP and lipid levels among adults with prehypertension or hypertension.[99]
Childhood and Adolescence
The evidence review for these Guidelines identified no dietary pattern studies in
infants, but such studies in older children have been emerging. As described previously,
the Young Finns study, begun when subjects were ages 318 years, evaluated
two major dietary patterns: a "traditional" pattern characterized by high
consumption of rye, potatoes, butter, sausages, milk, and coffee and a "health-conscious"
diet with high consumption of vegetables, legumes and nuts, cheese and other dairy
products, and, in older subjects, alcoholic beverages.[4] At 21-year followup,
with subjects then ages 2439 years, the traditional diet was significantly
and independently associated with higher TC and LDLC levels, apo B, and CRP
values in both genders and higher systolic BP and insulin levels among women; the
health-conscious diet was associated with better CV risk status but the latter correlation
did not achieve statistical significance.[4]
From the NGHS, a dietary pattern characterized by high intake of fruits and vegetables,
low fat dairy products, and grains and low intakes of sugar, fried foods, burgers,
and pizza was associated with less adiposity over 10-year followup.[6]
From the Framingham Children's Study, data from 95 children ages 36 years
at enrollment indicate that, in adolescence, those with consistently higher intakes
of fruits and vegetables and dairy products had significantly lower systolic BP
levels.[100]
An RCT of the DASH diet in 57 adolescents with prehypertension or hypertension found
at 3-month followup that the DASH diet group had a significantly greater decrease
in systolic BP associated with higher intakes of fruits, low-fat dairy products,
potassium, and magnesium and a greater decrease in dietary total fat intake than
the usual-care group.[101]
There were no adverse effects.
SUMMARY OF THE EVIDENCE REVIEW FOR DIETARY PATTERNS
- There is emerging evidence in children and adolescents that a composite healthy
eating pattern is feasible and is associated with reduced CV risk factors.
- The DASH dietary pattern was tested in only one RCT in adolescents, but the benefit
may be extrapolated from studies in adults.
OVERVIEW OF THE EVIDENCE FOR INTAKE OF DIETARY SUPPLEMENTS
This evidence review identified several small studies that reported short-term effects
of dietary supplements in children, often in the absence of dietary assessment data.
Regardless, the findings are summarized below by age group for the purpose of providing
available evidence on these topics as identified by the evidence review.
Infancy/Early Childhood
Fish Oil
To investigate whether maternal intake of n-3 long-chain PUFA during lactation or
current macronutrient intake affects children's BP, mothers with low fish intake
were randomized to receive fish oil or olive oil daily during the first 4 months
of lactation.[102]
At age 2.5 years, no significant effect of maternal fish oil intake on children's
BP was detected.
Plant Sterols
The effect of replacing dietary fat with plant stanol ester was investigated in
a subset of 6-year-old children from the STRIP study.[103],[104]
TC and LDLC levels decreased 5.4 percent and 7.5 percent,
respectively, among children who consumed a plant stanol-enriched margarine, compared
with placebo. There were no effects on HDLC or TG values. These changes were
accompanied by decreased cholesterol absorption. Safety was judged to be excellent.
The presence of the apoE4 variant did not affect the response to plant stanols.[105]
There was no significant difference in cholesterol absorption between boys and girls,
but there was a greater decrease in the LDLC level in boys (9.1 percent)
than in girls (5.8 percent). The plant stanol results were confirmed in a short-term
study of U.S. preschool children.[106]
Calcium
In a study designed to evaluate whether there is an association between calcium
intake and change in body fat in children ages 35 years, calcium supplementation
did not reduce gain in fat mass when baseline calcium intake was adequate.[107]
Adolescence
Fiber Supplements
Evidence of the use of fiber supplements in children is limited. In a small, 2-month
RCT of 60 overweight adolescents, no significant difference was noted in weight
change among subjects who received a fiber supplement (glucomannan), compared with
placebo; dietary fiber intake was not assessed. At followup, the glucomannan group
had lower HDLC levels and higher very-low-density lipoprotein and TG levels,
compared with lower TG and LDLC values in the placebo group, suggesting no
benefit and a potentially adverse impact of the supplement.[108]
SUMMARY Of THE EVIDENCE FOR INTAKE OF DIETARY SUPPLEMENTS
- Evidence on the health effects of dietary supplements in children is limited.
- Short-term replacement of dietary fat with plant stanol ester in healthy children
ages 26 years was safe and was associated with significantly decreased TC
and LDLC levels.
- In children ages 35 years, supplemental calcium did not reduce gain in fat
mass when baseline intake of calcium was adequate in one study.
- Maternal fish oil supplementation during lactation in healthy infants was not associated
with any differences in children's BP at age 2.5 years in one study.
- Very limited evidence regarding use of fiber supplements in children suggests no
benefit and possible adverse effects.
DEVELOPMENT OF FOOD PREFERENCES AND EATING BEHAVIORS
The development of food preferences in childhood is important because early preference
patterns have a long-term influence on dietary intake later in life.[109],[110]
Research in this area generally does not include RCTs that address CV risk factors,
and no studies were identified in this evidence review; however, because this is
such an important precept, a brief review of knowledge in the area is provided below.
Children's food preferences develop from a complex interplay of innate, familial,
and environmental factors. There are innate preferences for sweet and salty tastes
demonstrated from early infancy, and genetic propensities toward certain food groups
have been shown in twin studies.[111],[112],[113]
One of the most important influences in the development of taste preferences is
experience. Maternal diets have been shown to be experienced by the fetus and the
breast-fed baby, and specific exposures have been shown to affect an infant's subsequent
dietary preferences.[114]
Repeated exposures to selected foods, including fruits and vegetables, in early
infancy have been shown to be associated with acceptance and then preference for
these foods. Between 5 and 14 exposures to a new food are needed to see increased
preference in both infants and children.[115],[116] Some research
indicates that acceptance of textured foods is determined by earlier experience.[117]
Early exposure to culture-specific foods and dietary styles gives rise to subsequent
differences in food preferences, evident in the widely varying food preferences
of children in different cultures.[118]
Parents powerfully shape children's early experiences with food, deciding what foods
are made available and accessible and determining quantities provided and eating
patterns. Parents and siblings model eating behavior from birth onward, and parent-child
and sibling similarities in food preferences and eating behavior have been described.[119],[120],[121],[122]
In addition, parental feeding style, principally feeding restriction, has been suggested
to enhance the appeal of energy-dense, nutrient-poor foods, leading to overeating
of these foods when access is gained and potentially contributing to excess weight
gain.[123],[124]
Finally, exposure to television and its associated child-oriented food commercials
has been associated with food choices and higher food intake.[125],[126]
In pediatric care, questions about feeding and diet are a dominant source of concern,
especially in infancy. This period of opportunity allows pediatric care providers
to introduce heart healthy, calorie-balanced eating patterns at a time when food
preferences, eating patterns, and lifestyle behaviors are being formed. Routine,
regularly scheduled well-child visits to the pediatric care provider allow for reinforcement
of healthy eating patterns throughout childhood and into young adulthood.
Healthy Eating Behaviors
Background
A number of eating behaviors in children and adolescents may promote or detract
from a healthy nutrition pattern. These include eating breakfast (both frequency
and quality); eating meals with family members ("family dinner"); eating away from
home, especially fast food; eating school lunch; and both quality of snack foods
and frequency of snacking. In addition, during early childhood, the quality of the
mother-child feeding interaction may affect future weight gain. The search strategy
for the Expert Panel recommendations prioritized results from RCTs, but none were
identified among children or adolescents for these eating behaviors. Thus, the Expert
Panel carefully reviewed existing observational studies and extracted potentially
useful findings. Limitations inherent in all observational studies include the inability
to adequately control for confounding factors. Also, most of these studies are cross-sectional,
thereby making it unclear whether an "exposure" causes an "outcome." The
lack of high-quality evidence for these eating behaviors automatically requires
that any resulting recommendations result from Expert Panel consensus, which is
ranked lower than evidence-based recommendations. None of the reported studies addresses
infancy or early childhood.
Childhood and Adolescence
Although the evidence in children is limited, eating breakfast may reduce excessive
weight gain, hypothetically by enhancing satiety through high-fiber cereal and/or
whole-grain intake, reducing hunger and overeating at lunchtime, and/or providing
other foods as part of breakfast such as fruits or products that may contribute
further to improved nutrition density while aiding appetite regulation. In adults,
a small number of prospective observational studies and short-term RCTs suggest
that eating breakfast may reduce weight or prevent weight gain.[127],[128],[129]
In children and adolescents, prospective studies are few, and trials are lacking.[130],[131]
In the NGHS, 2,379 White and Black girls were followed annually from ages 9 to 19
years. Frequency of breakfast eating declined with age. The number of days per week
when breakfast was eaten was associated with higher calcium and fiber intakes and
was predictive of lower BMI, but the independent effect of eating breakfast on BMI
was not significant after parental educational attainment, overall energy intake,
and physical activity were included in the analysis.[132] Eating breakfast
may have beneficial effects on cognition and school performance.[130]
In some observational, primarily cross-sectional, studies of children and adolescents,
eating dinner or other meals with one's family has been associated with more healthful
dietary patterns. The few existing prospective studies suggest that increased frequency
of family meals is associated with less excessive weight gain, but confounding is
possible, and mechanisms are unclear.[133],[134],[135]
In preschool children, the association of healthful diets with the greater frequency
of eating dinner as a family was counteracted by a higher frequency of watching
television during the meal.[136]
The existing literature conflates eating away from home, eating certain foods or
nutrients (such as fried foods) away from home, and fast-food consumption. Furthermore,
the definition of "fast food" is not entirely clear. Nevertheless, several cross-sectional
and a small number of prospective studies suggest that eating foods away from home,
especially from fast-food establishments, may contribute to excessive weight gain.[137],[138],[139]
In a study of preschool children, each 1 hour per day increase in television/video
watching was significantly associated with greater consumption of fast food.[140]
A few, mostly cross-sectional, studies correlate the intake of snack foods, which
tend to be relatively low in dietary quality, or snacking behavior with weight status.
In the few longitudinal studies available, however, evidence argues against a substantial
effect of snack food consumption.134,[141],[142],[143]
In a study of children age 3 years, daily hours of television viewing were significantly
associated with higher intakes of sugar-sweetened beverages, fast food, red and
processed meats, total energy intake, and percentage of energy intake from trans
fats and lower intakes of fruits and vegetables, calcium, and fiber.[144]
PUBLIC HEALTH APPROACHES
Clinicians should be cognizant of public health approaches, such as the WIC Program
and other school- and community-based programs, that have the potential to significantly
affect children's dietary intakes. For additional information about public health
approaches, readers are encouraged to consult The Guide to Community Preventive
Services, coordinated by the CDC, which provides evidence-based reviews
of public health approaches(http://www.thecommunityguide.org/index.html).
Because public health initiatives have the potential to affect the nutrition of
children and adolescents, these approaches are an important avenue for advocacy
by pediatric care providers. Key issues are summarized below.
Because many U.S. children obtain a large proportion of daily energy in the school
setting, changing children's eating habits and dietary intakes at school could potentially
influence both nutrition and weight status, as well as CV risk factors such as hypertension
and dyslipidemia. Indeed, many of the intervention studies described in this section
are school based. Although foods and beverages served as part of the USDA-reimbursable
school breakfast or school lunch programs must meet dietary standards, foods sold
in the cafeteria in competition with school lunch or school breakfast, sold in vending
machines or school stores, or sold for fundraising events are not required to meet
these standards. Some States and local school districts have been successful in
changing the school food environment and, thus, children's eating habits.[145]
Preliminary evidence suggests that improved nutrition standards, in conjunction
with increases in physical activity and education, have increased awareness and
may have begun to affect students' overweight rates.[146],[147]
A multicomponent school nutrition policy initiative randomized 10 schools in which
at least 50 percent of students were eligible for free or reduced-price meals.
After 2 years, among 1,349 initially fourth- through sixth-graders, there was a
50 percent reduction in the incidence of overweight, with significantly fewer
children in the intervention schools than in the control schools becoming overweight.
The prevalence of overweight was also lower in the intervention schools. No differences,
however, were observed in the incidence, prevalence, or remission of obesity at
2-year followup.[148]
The findings suggest to the Expert Panel that public health approaches to overweight
may have significant impact but that more intensive intervention may be needed for
obese children. In addition, public health approaches can increase supportive environments
for fruit and vegetable intake.[149],[150] (Story 2008; CDC
Guide to F&V 2010). Because public health initiatives have the potential to
affect the nutrition of children and adolescents, this is an important avenue for
advocacy by pediatric care providers.
CONCLUSIONS AND GRADING OF THE EVIDENCE REVIEW FOR DIET AND NUTRITION IN CARDIOVASCULAR
RISK REDUCTION
The Expert Panel concluded that there is strong and consistent evidence that good
nutrition beginning at birth has profound health benefits, with the potential to
decrease future risk for CVD. The Expert Panel accepts the 2010 DGA as
containing appropriate recommendations for diet and nutrition in children age 2
years and older. The recommendations in these Guidelines are intended for pediatric
care providers to use with their patients to address CV risk reduction. The conclusions
of the Expert Panel's review of the entire body of evidence in a specific nutrition
area with grades are summarized below. The age- and evidence-based recommendations
of the Expert Panel follow in Table 52. Where evidence is inadequate yet nutrition
guidance is needed, recommendations for pediatric care providers are based on a
consensus of the Expert Panel (Grade D).
In accordance with the Surgeon General's Office, the WHO, the AAP, and the AAFP,
exclusive breast-feeding is recommended for the first 6 months of life. Continued
breast-feeding is recommended to at least age 12 months, with the addition of complementary
foods. If breast-feeding per se is not possible, feeding human milk by bottle is
second best, with formula-feeding as the third choice.
- Long-term followup studies consistently demonstrate that infants who were breast-fed
have sustained CV health benefits, including lower cholesterol levels, reduced prevalence
of T2DM, lower measures of subclinical disease (e.g., cIMT), and possibly lower
BMI in adulthood (Grade B).
- Ongoing nutrition counseling has been effective in helping children and families
to adopt and sustain recommended diets for both nutrient adequacy and reducing CV
risk (Grade A).
- Within appropriate age- and gender-based requirements for growth and nutrition,
in normal children and in children with hypercholesterolemia, intake of total fat
can be safely limited to 30 percent of total calories, saturated fat intake
limited to 710 percent of calories, and dietary cholesterol limited to
300 mg/d. Under the guidance of qualified nutritionists, this dietary composition
has been shown to result in lower TC and LDLC levels, less obesity, and less
insulin resistance (Grade A). Under similar conditions and with ongoing followup,
these levels of fat intake may have similar effects starting in infancy (Grade B).
Fats are important to infant diets due to their role in brain and cognitive development.
Fat intake in infants younger than 12 months of age should not be restricted without
medical indication.
- The remaining 20 percent of fat intake should comprise a combination of monosaturated
and polyunsaturated fats (Grade D). Intake of trans fats should be limited
as much as possible (Grade D).
- The current NCEP guidelines recommend that adults consume 2535 percent
of calories from fat. The 2010 DGA includes the IOM recommendation for
3040 percent of calories from fat for ages 13 years, 2535 percent
of calories from fat for ages 418 years, and 2035 percent of calories
from fat for adults. For growing children, milk provides essential nutrients, including
protein, calcium, magnesium, and vitamin D, that are not readily available elsewhere
in the diet. Consumption of fat-free milk in childhood starting at age 2 years and
through adolescence optimizes these benefits, without compromising nutrient quality
while avoiding excess saturated fat and calorie intake (Grade A). Between ages 1
and 2 years, as children transition from breast milk or formula, milk reduced in
fat (ranging from 2 percent milk to fat-free milk) can be used based on the
child's growth, appetite, intake of other nutrient-dense foods, intake of other
sources of fat, and risk for obesity and CVD. Milk with reduced fat should be used
only in the context of an overall diet that supplies 30 percent of calories
from fat. Dietary intervention should be tailored to each specific child's needs.
- Optimal intakes of total protein and total carbohydrates in children were not specifically
addressed, but with a recommended total fat intake of 30 percent of energy,
the Expert Panel recommends that the remaining 70 percent of calories include
1520 percent from protein and 5055 percent from carbohydrate
sources (no grade). These recommended ranges fall within the acceptable macronutrient
distribution range specified by the 2010 DGA: 1030 percent
of calories from protein and 4565 percent of calories from carbohydrates
for children ages 418 years.
- Sodium intake was not addressed by the evidence review for this section on nutrition
and diet. From the evidence review for Section VIII. High Blood Pressure, lower
sodium intake is associated with lower systolic and diastolic BPs in infants, children,
and adolescents.
- Plant-based foods are important low-calorie sources of nutrients, including vitamins
and fiber, in the diets of children; increasing access to fruits and vegetables
has been shown to increase their intake (Grade A). However, increasing fruit and
vegetable intake is an ongoing challenge.
- Reduced intake of sugar-sweetened beverages is associated with decreased obesity
measures (Grade B). Specific information about fruit juice intake is too limited
for an evidence-based recommendation. Recommendations for intake of naturally sweetened
fruit juice (without added sugar) in infants are a consensus of the Expert Panel
(Grade D) and are in agreement with those of the AAP.
- Per the 2010 DGA, energy intake should not exceed energy needed for adequate
growth and physical activity. Calorie intake needs to match growth demands and physical
activity needs. Estimated calorie requirements by gender and age group at three
levels of physical activity from the 2010 DGA are shown in Table 51.
For children of normal weight whose activity is minimal, most calories are needed
to meet nutritional requirements, leaving only about 10 percent of calorie
intake from discretionary sources (e.g., foods with added fat and sugar) (Grade
D).
- Dietary fiber intake is inversely associated with energy density and with increased
levels of body fat and is positively associated with nutrient density (Grade B).
A daily total dietary fiber intake from food sources of at least age plus 5 g for
young children up to 14 g/1,000 kcal for older children and adolescents is recommended
(Grade D).
- The Expert Panel supports the recommendation of the AAP for vitamin D supplementation
with 400 IU/d for all infants and 600 IU/day for children over 1 years old. No other
vitamin, mineral, or dietary supplements are recommended (Grade D).
- Use of dietary patterns modeled on those shown to be beneficial in adults (such
as the DASH pattern) is a promising approach to improving nutrition and decreasing
CV risk (Grade B).
- All dietary recommendations must be interpreted by the pediatric care provider for
each child and family to address individual diet and growth patterns and patient
sensitivities such as lactose intolerance and food allergies (Grade D).
As stated above, these dietary recommendations to promote CV health in children
under the care of pediatric care providers are based on the results of the evidence
review and the population recommendations are consistent with the DGA.
Graded, age-specific recommendations for pediatric care providers to use in reducing
CV risk in their patients are summarized in Table 52 (CHILD 1) and are designed
to support implementation of the findings of the evidence review. CHILD 1 is the
first stage in dietary change for children with identified dyslipidemia, overweight
and obesity, risk factor clustering, and high-risk medical conditions who may ultimately
require more intensive dietary change. More intensive recommendations to be implemented
if needed for children with these conditions appear in the designated sections of
these Guidelines. CHILD 1 is also the recommended diet for children with a positive
family history of early CV disease, dyslipidemia, obesity, primary hypertension,
diabetes, or children exposure to smoking in the home. Any dietary modification
must provide nutrients and calories needed for optimal growth and development. Likewise,
recommended intakes are adequately met by a DASH-style eating plan, which emphasizes
fat-free/low-fat milk and dairy products and increased intake of fruits and vegetables.
This pattern has been modified for use in children age 4 years and older based on
daily energy needs and is shown in Table 53 as one example of a heart healthy
eating plan using the CHILD 1 recommendations.
Table 52. Evidence-Based Recommendations for Patients of Pediatric Care Providers:
Cardiovascular Health Integrated Lifestyle Diet (CHILD 1)
CHILD 1 is the recommended first step diet for all children and adolescents at elevated
cardiovascular risk.
Grades reflect the findings of the evidence review.
Recommendation levels the consensus opinion of the Expert Panel.
Supportive actions represent expert consensus suggestions from
the Expert Panel provided to support implementation of the recommendations; they
are not graded.
Birth - 6 months
|
Infants should be exclusively breast fed (no supplemental formula or other foods)
until age 6 months.a
|
Grade B
Strongly recommend
|
6 - 12 months
|
Continue breast-feedinga until at least age
12 months while gradually adding solids; transition to iron-fortified formula until
12 months if reducing breastfeeding
|
Grade B
Strongly recommend
|
6 - 12 m (cont.d)
|
Fat intake in infants less than 12 months of age should not be restricted without
medical indication.
|
Grade D
Recommend
|
6 - 12 months (cont.d)
|
Limit other drinks to 100% fruit juice < 4 oz/d; No sweetened beverages; encourage
water.
|
Grade D
Recommend
|
12 - 24 months
|
Transition to reduced-fatb (2% to fat-free)
unflavored cow's milkc (see Supportive Actions
bullet 1)
|
Grade B
Recommend
|
12 - 24 months (cont.d)
|
Limit/avoid sugar-sweetened beverage intake; encourage water
|
Grade B
Strongly recommend
|
12 - 24 months (cont.d)
|
Transition to table food with:
|
|
12 - 24 months (cont.d)
|
- Total fat 30% of daily kcal/EERd
|
Grade B
Recommend
|
12 - 24 months (cont.d)
|
- Saturated fat 8-10% of daily kcal/EER
|
Grade B
Recommend
|
12 - 24 months (cont.d)
|
- Avoid trans fat as much as possible
|
Grade D
Strongly recommend
|
12 - 24 months (cont.d)
|
- Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER
|
Grade D
Recommend
|
12 - 24 months (cont.d)
|
|
Grade B
Strongly recommend
|
12 - 24 months (cont.d)
|
Supportive actions:
- The fat content of cow's milk to introduce at age 12-24 months should be decided
together by parents and health care providers based on the child's growth, appetite,
intake of other nutrient-dense foods, intake of other sources of fat, and potential
risk for obesity and CVD.
- Limit 100 percent fruit juice (from a cup) no more than 4 oz/d
- Limit sodium intake
- Consider DASH-type diet rich in fruits, vegetables, whole grains, low-fat/fat-free
milk and milk products; lower in sugar (Table 5-3)
|
|
2 -10 years
|
Primary beverage: Fat-free unflavored milk
|
Grade A
Strongly recommend
|
2 -10 years (cont.d)
|
Limit/avoid sugar sweetened beverages; encourage water.
|
Grade B
Recommend
|
2 -10 years (cont.d)
|
Fat content:
|
|
2 -10 years (cont.d)
|
- Total fat 25-30% of daily kcal/EERd
|
Grade A
Strongly recommend
|
2 -10 years (cont.d)
|
- Saturated fat 8-10% of daily kcal/ EER
|
Grade A
Strongly recommend
|
2 -10 years (cont.d)
|
- Avoid trans fats as much as possible
|
Grade D
Recommend
|
2 -10 years (cont.d)
|
- Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER
|
Grade D
Recommend
|
2 -10 years (cont.d)
|
|
Grade A
Strongly recommend
|
2 -10 years (cont.d)
|
Encourage high dietary fiber intake from foodse
|
Grade B
Recommend
|
2 -10 years (cont.d)
|
Supportive actions:
- Teach portions based on EER for age/sex/age(Table 5-1)
- Encourage moderately increased energy intake during periods of rapid growth and/or
regular moderate-to-vigorous physical activity
- Encourage dietary fiber from foods: Age plus 5 g/de
- Limit naturally sweetened juice (no added sugar) to 4 oz/d
- Limit sodium intake
- Support DASH-style eating plan as outlined below (Table 5-3)
|
|
11–21 years
|
Primary beverage: Fat-free unflavored milk
|
Grade A
Strongly recommend
|
11–21 years
(cont.d)
|
Limit/ avoid sugar sweetened beverages; encourage water.
|
Grade B
Recommend
|
11–21 years
(cont.d)
|
Fat content:
|
|
11–21 years
(cont.d)
|
- Total fat 25-30% of daily kcal/EERd
|
Grade A
Strongly recommend
|
11–21 years
(cont.d)
|
- Saturated fat 8-10% of daily kcal/ EER
|
Grade A
Strongly recommend
|
11–21 years
(cont.d)
|
- Avoid trans fat as much as possible
|
Grade D
Recommend
|
11–21 years
(cont.d)
|
- Monounsaturated and polyunsaturated fat up to 20% Grade D of daily kcal/ EER
|
Grade D
Recommend
|
11–21 years
(cont.d)
|
|
Grade A
Strongly recommend
|
11–21 years
(cont.d)
|
Encourage high dietary fiber intake from foodse
|
Grade B
Recommend
|
11–21 years
(cont.d)
|
Supportive actions:
- Teach portions based on EER for age/sex/activity (Table 5-2)
- Encourage moderately increased energy intake during periods of rapid growth and/or
regular moderate to vigorous physical activity
- Advocate dietary fiber: Goal of 14 g/1,000 kcal e
- Limit naturally sweetened juice (no added sugar) to 4-6 oz/d
- Limit sodium intake
- Encourage healthy eating habits: Breakfast every day, eating meals as a family,
limiting fast food meals.
- Support DASH-style eating plan as outlined below (Table 5-3)
|
|
a Infants that cannot be fed directly at the
breast should be fed expressed milk. Infants for whom expressed milk is not available
should be fed iron-fortified infant formula.
b Toddlers 12-24 m of age with a family history
of obesity, heart disease, or high cholesterol, should discuss transition to reduced-fat
milk with pediatric care provider after 12 months of age.
c Continued breast-feeding is still appropriate
and nutritionally superior to cow's milk. Milk reduced in fat should be used only
in the context of an overall diet that supplies 30% of calories from fat.
d EER = Estimated Energy Requirements/d for
age/gender (Table 5-1)
e Naturally fiber-rich foods are recommended
(fruits, vegetables, whole grains); fiber supplements are not advised. Limit refined
carbohydrates (sugars, white rice, and white bread)
Table 5-3. DASH-Style Eating Plan: Servings per Day by Food Group and Total Energy
Intake
(Table 5-1 provides Estimated Energy Requirements (EER) by age, gender, and activity
level. EER and discretionary calorie allowance by age and level of activity for
boys and girls are shown in Figures 5-1 and 5-2.)
Food Group
|
1,200 Calories
|
1,400 Calories
|
1,600 Calories
|
1,800 Calories
|
2,000 Calories
|
2,600 Calories
|
Serving Sizes
|
Examples and Notes
|
Significance of Each Food Group to the DASH Eating Plan
|
Grains*
|
4-5
|
5-6
|
6
|
6
|
68
|
10-11
|
1 slice bread
1 oz dry cereal**
½ cup cooked rice, pasta, or cereal**
|
Whole wheat bread and rolls, whole wheat pasta, English muffin, pita bread, bagel,
cereals, grits, oatmeal, brown rice, unsalted pretzels and popcorn
|
Major sources of energy and fiber
|
Vegetables
|
3-4
|
3-4
|
3-4
|
4-5
|
45
|
5-6
|
1 cup raw leafy vegetable
½ cup cut-up raw or cooked vegetable
½ cup vegetable juice
|
Broccoli, carrots, collards, green beans, green peas, kale, lima beans, potatoes,
spinach, squash, sweet potatoes, tomatoes
|
Rich sources of potassium, magnesium, and fiber
|
Fruits
|
3-4
|
4
|
4
|
4-5
|
45
|
5-6
|
1 medium fruit
¼ cup dried fruit
½ cup fresh, frozen, or canned fruit
½ cup fruit juice
|
Apples, apricots, bananas, dates, grapes, oranges, grapefruit, grapefruit juice,
mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines
|
Important sources of potassium, magnesium, and fiber
|
Fat-free or low-fat milk and milk products
|
2-3
|
2-3
|
2-3
|
2-3
|
23
|
3
|
1 cup milk or yogurt
1½ oz cheese
|
Fat-free milk or buttermilk, fat-free, low-fat, or reduced-fat cheese, fat-free/low-fat
regular or frozen yogurt
|
Major sources of calcium and protein
|
Lean meats, poultry, and fish
|
3 or less
|
3-4 or less
|
3-4 or less
|
6 or less
|
6 or less
|
6 or less
|
1 oz cooked meats, poultry, or fish
1 egg
|
Select only lean; trim away visible fats; broil, roast, or poach; remove skin from
poultry
|
Rich sources of protein and magnesium
|
Nuts, seeds, and legumes
|
3 per week
|
3 per week
|
3-4 per week
|
4 per week
|
45 per week
|
1
|
1/3 cup or 1½ oz nuts
2 Tbsp peanut butter
2 Tbsp or ½ oz seeds
½ cup cooked legumes (dry beans and peas)
|
Almonds, filberts, mixed nuts, peanuts, walnuts, sunflower seeds, peanut butter,
kidney beans, lentils, split peas
|
Rich sources of energy, magnesium, protein, and fiber
|
Fats and oils
|
1
|
1
|
2
|
2-3
|
2-3
|
3
|
1 tsp soft margarine
1 tsp vegetable oil
1 Tbsp mayonnaise
2 Tbsp salad dressing
|
Soft margarine, vegetable oil (such as canola, corn, olive, or safflower), low-fat
mayonnaise, light salad dressing
|
The DASH study had 27 percent of calories as fat, including fat in or added to foods
|
Sweets and added sugars
|
3 or less per week
|
3 or less per week
|
3 or less per week
|
5 or less per week
|
5 or less per week
|
≤ 2
|
1 Tbsp sugar
1 Tbsp jelly or jam
½ cup sorbet, gelatin
1 cup lemonade
|
Fruit-flavored gelatin, fruit punch, hard candy, jelly, maple syrup, sorbet and
ices, sugar
|
Sweets should be low in fat
|
The Food and Drug Administration (FDA) and the Environmental Protection Agency are
advising women of childbearing age who may become pregnant, pregnant women, nursing
mothers, and young children to avoid some types of fish and shellfish and eat fish
and shellfish that are low in mercury. For more information, call the FDA's food
information line toll free at 1-888-SAFEFOOD or visit
http://www.cfsan.fda.gov/~dms/admehg3.html.
* Whole grains are recommended for most grain
servings as a good source of fiber and nutrients.
** Serving sizes vary between 1/2 cup and
1-1/4 cups, depending on cereal type. Check product's Nutrition Facts label.
Because eggs are high in cholesterol,
limit egg yolk intake to no more than four per week; two egg whites have the same
protein content as 1 oz meat.
Fat content changes serving amount
for fats and oils. For example, 1 Tbsp regular salad dressing = 1 serving; 1 Tbsp
low-fat dressing = 1/2 serving; 1 Tbsp fat-free dressing = zero servings. Abbreviations:
oz = ounce; Tbsp = tablespoon; tsp = teaspoon.
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