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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 5–2. 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 5–1. 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

2–3

1,000–1,200

1,000–1,400c

1,000–1,400c

Femaled

4–8

1,200–1,400

1,400–1,600

1,400–1,800

Femaled

9–13

1,400–1,600

1,600–2,000

1,800–2,200

Femaled

14–18

1,800

2,000

2,400

Femaled

19–30

1,800–2,000

2,000–2,200

2,400

Male

4–8

1,200–1,400

1,400–1,600

1,600–2,000

Male

9–13

1,600–2,000

1,800–2,200

2,000–2,600

Male

14–18

2,000–2,400

2,400–2,800

2,800–3,200

Male

19–30

2,400–2,600

2,600–2,800

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 100–200 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 5–1 and 5–2. However, due to the low levels of physical activity common among most American children, the nonessential, discretionary calorie allowance is no more than 100–400 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 5–1 and 5–2). 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.

Figure 5-1. Bar chart of Estimated Energy Requirements (EER) and Discretionary Calorie Allowance by Level of Activity-(Boys). A text only description with data points follows this graphic.

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.


Figure 5-2. Bar chart of Estimated Energy Requirements (EER) and Discretionary Calorie Allowance by Level of Activity-(Girls). A text only description with data points follows this graphic.

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 5–17 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 3–18 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 24–39 years, the traditional diet was significantly and independently associated with higher total cholesterol (TC) and low-density lipoprotein cholesterol (LDL–C) 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) (1988–1994) of more than 4,000 youths ages 8–18 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 (45–55 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, LDL–C, triglycerides (TG), and high-density lipoprotein cholesterol (HDL–C); 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 30–35 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 10–15 percent of total kcal/d, and carbohydrates 50–60 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 LDL–C 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 (HOMA–IR) 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 4–6 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 1–6 years should receive no more than 1 serving of unsweetened fruit juice per day, and children ages 7–18 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; 56–85 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 11–18 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 LDL–C 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 5–10 percent of fat calories and for ALA is 0.6–1.2 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, LDL–C, 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 30–35 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 10–15 percent per day, and carbohydrates 50–60 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 28–33 percent in control subjects. Saturated fat intake among the intervention children was significantly lower, ranging from 9.5 percent to 11 percent, compared with 13–14 percent in control subjects. From age 13 months to age 14 years, those in the STRIP intervention group had lower TC and lower LDL–C 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 HOMA–IR 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 7–9 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 LDL–C levels between the 80th and 98th percentiles at baseline. Prepubertal boys (N = 362) and girls (N = 301) (initially ages 8–10 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 LDL–C 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 LDL–C 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 LDL–C 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 LDL–C levels was assessed in 174 boys and girls ages 4–10 years with borderline-high or high LDL–C.[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 LDL–C 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 LDL–C levels.[51]

In prepubertal children with heterozygous familial hypercholesterolemia (FH), an RCT of 96 children ages 6–11 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 LDL–C levels were lowered by 4.4 percent and 5.5 percent, respectively. HDL–C, 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 30–35 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 30–35 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 28–30 percent of calories and an average saturated fat intake of 8–10 percent of calories.
  • These levels of total fat and saturated fat intake were shown in RCTs to be associated with lower TC and LDL–C 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 LDL–C 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, LDL–C, 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 LDL–C levels; after age 7 years, the difference in LDL–C 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 LDL–C 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, LDL–C 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 6–11 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 LDL–C levels decreased by 4.4 percent and 5.5 percent, respectively. HDL–C, 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 LDL–C levels in boys and girls ages 4–10 years with borderline-high or high LDL–C.[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. LDL–C 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 cholesterol—the latter to <200 mg/d—with significant decreases in TC and LDL–C 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 LDL–C 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 2–11 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 6–12 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 5–18 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 10–17 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) (1994–1996, 1998) reported only slightly higher mean dietary fiber intakes for youths:  15.2 g/d and 17.7 g/d for males ages 9–13 and 14–18 years, respectively, and 12.9 g/d and 12.8 g/d for females ages 9–13 and 14–18 years, respectively.[84] A more recent report from the NHANES III of more than 4,000 youths ages 8–18 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 2–5 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 1–3 years and 4–8 years, a total fiber intake of 19 g/d and 25 g/d, respectively, is recommended. For males ages 9–13 years, a total fiber intake of 31 g/d is recommended, increasing to 38 g/d for males ages 14–30 years. For females ages 9–30 years, a total fiber intake of 25–26 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 LDL–C 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 BP—reduced dietary sodium, increased physical activity, and weight loss—resulted 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 3–18 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 24–39 years, the traditional diet was significantly and independently associated with higher TC and LDL–C 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 3–6 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 LDL–C 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 HDL–C or TG values. These changes were accompanied by decreased cholesterol absorption. Safety was judged to be excellent. The presence of the apoE–4 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 LDL–C 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 3–5 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 HDL–C levels and higher very-low-density lipoprotein and TG levels, compared with lower TG and LDL–C 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 2–6 years was safe and was associated with significantly decreased TC and LDL–C levels.
  • In children ages 3–5 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 5–2. 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 7–10 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 LDL–C 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 25–35 percent of calories from fat. The 2010 DGA includes the IOM recommendation for 30–40 percent of calories from fat for ages 1–3 years, 25–35 percent of calories from fat for ages 4–18 years, and 20–35 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 15–20 percent from protein and 50–55 percent from carbohydrate sources (no grade). These recommended ranges fall within the acceptable macronutrient distribution range specified by the 2010 DGA:  10–30 percent of calories from protein and 45–65 percent of calories from carbohydrates for children ages 4–18 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 5–1. 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 5–2 (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 5–3 as one example of a heart healthy eating plan using the CHILD 1 recommendations.

Table 5–2. 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)
  • Cholesterol < 300 mg/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)
  • Cholesterol < 300 mg/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)
  • Cholesterol < 300 mg/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

6–8

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

4–5

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

4–5

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

2–3

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

4–5 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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[132] Barton BA, Eldridge AL, Thompson D, Affenito SG, Striegel-Moore RH, Franko DL, Albertson AM, Crockett SJ. The relationship of breakfast and cereal consumption to nutrient intake and body mass index: the National Heart, Lung and Blood Institute Growth and Health Study. J Am Diet Assoc 2005;105:1383-1389.

[133] Sen B. Frequency of family dinner and adolescent body weight status: evidence from the national longitudinal survey of youth, 1997. Obesity (Silver Spring) 2006;14(12):2266-2276.

[134] Gable S, Chang Y, Krull JL. Television watching and frequency of family meals are predictive of overweight onset and persistence in a national sample of school-aged children. J Am Diet Assoc 2007;107(1):53-61.

[135] Taveras EM, Rifas-Shiman SL, Berkey CS, Rockett HR, Field AE, Frazier AL, Colditz GA, Gillman MW. Family dinner and adolescent overweight. Obes Res 2005;13(5):900-906.

[136] Fitzpatrick E, Edmunds LS, Dennison BA. Positive effects of family dinner are undone by television viewing. J Am Diet Assoc 2007;107(4):666-671.

[137] Sugimori H, Yoshida K, Izuno T, Miyakawa M, Suka M, Sekine M, Yamagami T, Kagamimori S. Analysis of factors that influence body mass index from ages 3 to 6 years: A study based on the Toyama cohort study. Pediatr Int 2004;46(3):302-310.

[138] Thompson OM, Ballew C, Resnicow K, Must A, Bandini LG, Cyr H, Dietz WH. Food purchased away from home as a predictor of change in BMI z-score among girls. Int J Obes Relat Metab Disord 2004;28(2):282-289.

[139] Taveras EM, Berkey CS, Rifas-Shiman SL, Ludwig DS, Rockett HR, Field AE, Colditz GA, Gillman MW. Association of consumption of fried food away from home with body mass index and diet quality in older children and adolescents. Pediatrics 2005;116(4):e518-e524.

[140] Taveras EM, Sandora TJ, Shih MC, Ross-Degnan D, Goldmann DA, Gillman MW. The association of television and video viewing with fast food intake by preschool-age children. Obesity (Silver Spring) 2006;14(11):2034-2041.

[141] Phillips SM, Bandini LG, Naumova EN, Cyr H, Colclough S, Dietz WH, Must A. Energy-dense snack food intake in adolescence: longitudinal relationship to weight and fatness. Obes Res 2004;12(3):461-472.

[142] Francis LA, Lee Y, Birch LL. Parental weight status and girls' television viewing, snacking, and body mass indexes. Obes Res 2003;11(1):143-151.

[143] Field AE, Austin SB, Gillman MW, Rosner B, Rockett HR, Colditz GA. Snack food intake does not predict weight change among children and adolescents. Int J Obes Relat Metab Disord 2004;28(10):1210-1216.

[144] Miller SA, Taveras EM, Rifas-Shiman SL, Gillman MW. Association between television viewing and poor diet quality in young children. Int J Pediatr Obes 2008;3(3):168-176.

[145] Story M, Kaphingst KM, French S. The role of schools in obesity prevention. Future Child 2006;16(1):109-142.

[146] Arkansas Center for Health Improvement. Year Four: Arkansas Act 1220 to Combat Childhood Obesity. Accessed at: http://www.achi.net/ChildObDocs/COPHYYear4Evaluation.pdf

[147] The Robert Wood Johnson Foundation. A Report on State Action to Promote Nutrition, Increase Physical Activity and Prevent Obesity, 2008. Accessed at: http://www.rwjf.org/files/researc/balance122007.pdf.    

[148] Foster GD, Sherman S, Borradaile KE, Grundy KM, Vander Veur SS, Nachmani J, Karpyn A, Kumanyika S, Shults J. A policy-based school intervention to prevent overweight and obesity. Pediatrics 2008;121(4):e794-e802.

[149] Story M, Kaphingst KM, Robinson-O'Brien R, Glanz K. Creating Healthy Food and Eating Environments: Policy and Environmental Approaches. Annu Rev Public Health 2008;29: 253-272

[150] The Center for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Increase the Consumption of Fruits and Vegetables. Atlanta: U.S. Department of health and Human Services; 2010. Accessed at: http://www.ncpanbranch.com/Coalitions/pppConference/Strategies%20to%20Increase%20FV%20Consumption.PDF


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