Skip left side navigation and go to content
5. Nutrition and Diet
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. 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/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. The conclusions of the Expert Panel's review of the evidence are then summarized and graded, followed by age-based recommendations for nutrition and diet in Table 52. Evidence-Based Dietary Recommendations for Patients of Pediatric Care Providers: Cardiovascular Health Integrated Lifestyle Diet (CHILD 1). The Expert Panel accepts the 2010 DGA as containing appropriate recommendations for diet and nutrition in children 2 years and older. The recommendations in these Guidelines are intended for pediatric care providers to use with their patients to address CV risk reduction. Where evidence is inadequate, recommendations are based on a consensus of the Expert Panel. The recommendations therefore represent the best available evidence when that exists and expert consensus opinion when it does not. References are listed sequentially at the end of the section. References from the evidence review are identified by a unique PubMed identifier (PMID), which appears in bold font. Additional references do not include the PMID number. There is obvious overlap with the nutrition information contained in other sections of these Guidelines; additional specific dietary information relative to lipids, blood pressure (BP), and obesity is located in Section VIII. High Blood Pressure, Section IX. Lipids and Lipoproteins, andSection X. Overweight and Obesity.
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. 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:
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. Because the calculations provide estimates only, monitoring weight status and stage of growth are important considerations in estimating energy needs.
Table 51. Estimated Calorie Needs per Day by Age, Gender, and Physical Activity Levela
Estimated amounts of calories needed to maintain caloric balance for various gender and age groups at three different levels of physical activity. The estimates are rounded to the nearest 200 calories. An individual's calorie needs may be higher or lower than these average estimates.
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.
SOLID FATS AND ADDED SUGARS
Balancing energy intake with energy expenditure in a growing child is a complex process. Understanding the concepts of essential versus discretionary calories can assist pediatric care providers in guiding children and their families toward choosing nutrient-dense foods to maintain energy balance. Solid fats and added sugars (SOFAS) are always counted as "discretionary" or nonessential calories. Sources of SOFAS include "snack" foods, sugar-sweetened beverages, and desserts. Due to the sedentary behavior of most Americans, few such foods should be consumed, typically no more than 100200 calories/day (kcal/d) as part of total energy intakefor the age group and physical activity level. To meet nutrient needs without overconsumption of calories (energy intake), meals and snacks need to be nutrient dense (high in nutrients) but as low as possible in saturated and trans fats and with little or no added sugars. Foods such as fat-free milk, fruits, vegetables, whole-grain breads, and low-sugar cereals exemplify this concept. Conversely, the sugar in sugar-sweetened beverages, the fat in whole milk (versus fat-free milk), the fat and added sugar in chocolate milk (versus fat-free unflavored milk), the fat in high-fat meats (versus lean meats), and the fat and sugar in cookies, cakes, pastries, granola bars, and sweetened cereals (versus unsweetened grain foods) are examples of sources of nonessential calories. Selecting nutrient-dense foods in each food group gives individuals an effective way to meet their nutrient needs without consuming excess calories. This approach can be adopted and maintained throughout life to prevent the development of overweight and obesity. Because the discretionary calorie concept is important but complex for most consumers, the Expert Panel emphasizes consuming mostly nutrient-dense foods for meals and snacks.
For growing children, the EER increases with age and with physical activity level, as do allowances for essential calories and discretionary calories, as shown in Figures 51 and 52. However, due to the low levels of physical activity common among most American children, the nonessential, discretionary calorie allowance is no more than 100400 kilocalories, based on age and activity level. This is not sufficient to accommodate daily (or regular) consumption of whole milk, high-calorie/low-nutrient-dense snacks, or desserts and/or sugar-sweetened beverages (see Figures 51 and 52). Sedentary children who regularly consume energy-dense, nutrient-poor foods are at risk of developing overweight and obesity and having inadequate nutrition, despite high calorie intake.
Text description of Figure 5-1.
Figure 5-1. Estimated Energy Requirements (EER) and Discretionary Calorie Allowance by Level of Activity-(Boys)*
Text description of Figure 5-2.
Figure 5-2. Estimated Energy Requirements (EER) and Discretionary Calorie Allowance by Level of Activity-(Girls)*
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/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. Results are presented here by dietary component and by age group and are summarized after each dietary component review. Some studies were not specific to the age groups addressed in these Guidelines; the Expert Panel used clinical judgment in determining how best to apply results from those studies to age-specific recommendations. At the end of each dietary component review, the results are summarized. The conclusions of the entire evidence review for diet and nutrition, with grades and age-specific recommendations, appear at the end of this section.
CURRENT DIETARY INTAKE IN CHILDREN AND ADOLESCENTS
Four epidemiologic studies evaluated overall dietary content for children and adolescents. The Bogalusa Heart Study is a major community-based cohort of more than 1,655 Black and White children and young adults in Bogalusa, Louisiana, that began in 1973 and still continues. Participants were originally examined at ages 517 years and were 52 percent female and 44 percent Black. The Bogalusa investigators developed and applied a scoring system based on consumption of nutrient-dense foods. Repeated cross-sectional surveys between 1989 and 2004 showed an overall decline in dietary quality, with a decrease in the consumption of nutrient-dense foods with increasing age. This was accompanied by extensive development of overweight and obesity in this cohort. At age 10 years, 50 percent of children had a good nutrient density score, but this dropped to only 19 percent by young adulthood.
The Cardiovascular Risk in Young Finns study (Young Finns) is a multicenter longitudinal cohort study of CV risk from Finland, with 3,956 subjects enrolled at ages 318 years in 1980 and followed with serial lipid evaluation over time. Based on data from 21 years of followup, two major dietary patterns have been observed beginning in childhood: a "traditional" pattern characterized by high consumption of rye, potatoes, butter, sausages, milk, and coffee and a "health-conscious" diet that includes high consumption of vegetables, legumes and nuts, rye, cheese and other dairy products, and alcoholic beverages At the latest followup, with subjects now ages 2439 years, the traditional diet was significantly and independently associated with higher total cholesterol (TC) and low-density lipoprotein cholesterol (LDLC) concentrations, apolipoprotein B (apoB), and C-reactive protein (CRP) in both genders, and with systolic BP and insulin levels among females. The health-conscious diet was inversely but not significantly associated with the same CV risk factors.
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. 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. 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.
A report from the Third National Health and Nutrition Examination Survey (NHANES III) (19881994) of more than 4,000 youths ages 818 years found that foods of low-nutrient density (snacks, desserts, etc.) contributed more than 30 percent of daily energy intake, with caloric sweeteners and desserts jointly contributing nearly 25 percent of daily caloric intake. Intake of food-based vitamins and minerals decreased as consumption of foods of low-nutrient density increased.
OVERVIEW OF THE EVIDENCE BY DIETARY COMPONENT AND AGE GROUP
Milk and Other Beverage Intake
Age Birth to 12 Months: Human Milk
There is near universal agreement that human milk is the preferred complete nutrition source for healthy full-term newborns and infants for the first 6 months of life, with continued breastfeeding recommended until age 12 months. As recommended by the U.S. Surgeon General, World Health Organization (WHO), American Academy of Pediatrics (AAP), and American Academy of Family Practice (AAFP), human milk is the preferred primary source of nourishment in infancy. Human milk is a unique biological fluid that changes almost daily to meet the nutritional and immunologic needs of the growing infant. Human milk is high in fat (4555 percent of total calories), saturated fat, and cholesterol. It provides a rich source of essential fatty acids linoleic acid (LA) and alpha linoleic acid (ALA) and long-chain polyunsaturated fatty acid (PUFA) derivatives arachidonic acid (AA) and docosahexaenoic acid (DHA). 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. The new RDA for Vitamin D for those 1-70 years old is 600 IU/day.
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, lower serum TC levels and decreased carotid intima-media thickness (cIMT) in adulthood,, and a lower risk of type 2 diabetes mellitus (T2DM). A meta-analysis of 37 studies compared the late effects of breastfeeding versus formula-feeding on TC levels in adolescents and adults. In infancy, mean TC was higher in breast-fed versus formula-fed infants, but this difference disappeared in childhood and adolescence. Among adults, the TC level of those who had been breast-fed as infants was lower than the TC level of those who had been formula fed.
Ages Birth to 12 Months: Infant Formula
Infant formulas that meet regulatory requirements for quality and nutrient content are marketed in the United States and many other countries. These products are designed to support the normal growth and development of infants. Infant formula products currently marketed in the United States are iron fortified and contain mixtures of vegetable oils, including coconut, soy, high-oleic safflower, high-oleic sunflower, and/or palm olein, plus single-cell oils containing the two long-chain PUFAs DHA and AA. The DRI recommendations for nutrient intake by infants are based on the nutrient content of breast milk and include intake of essential fatty acids that are unsaturated, specifically ALA omega-3 and LA omega-6 fatty acids. The fat and cholesterol contents of infant formula were varied in several small short-term RCTs, with subsequent significant differences in intervention infants, compared with controls for TC, LDLC, triglycerides (TG), and high-density lipoprotein cholesterol (HDLC); there were no differences between groups in lipoprotein profiles postweaning.,,,
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. The intervention group families received repeated, individualized, nutritionist-delivered, low-saturated-fat counseling designed to achieve a diet with total fat of 3035 percent of total kcal/d, a 1:1:1 intake ratio of saturated fatty acids (SFA)/monounsaturated fatty acids (MUFA)/PUFA/d, cholesterol intake of less than 200 milligrams per day (mg/d), protein 1015 percent of total kcal/d, and carbohydrates 5060 percent of total kcal/d. Until age 12 months, families were advised to continue with breast- or formula-feeding. After age 1 year, skim milk was recommended as the primary beverage; in the intervention group, parents were encouraged to supplement the diet as needed with soft margarines and vegetable oils until age 24 months to maintain adequate fat intake. The control group received basic health education and no instructions on the use of dietary fats. 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.,,,, These dietary fat changes translated to significantly lower TC and LDLC levels until age 7 years; after age 7 years, the latter difference was significant only for boys., No harmful effects were reported on growth, micronutrient intake, development, or neurologic function., In a subgroup of 78 intervention children and 89 control children assessed at age 9 years, the intervention children had significantly lower insulin levels and lower homeostatic model assessment of insulin resistance (HOMAIR) than control children. 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. 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.
Intake of Other Beverages
Consumption of fruit juices, representing a "naturally sweetened" beverage, has increased over the past 30 years due to increased availability, accessibility, marketing, and convenience. Young children tend to be the highest consumers of fruit juices, and some studies have noted associations between high juice consumption and obesity., 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., The AAP recommends that a serving of natural, unsweetened fruit juice be limited to 46 fluid ounces and that infants can receive 1 serving per day after age 6 months as part of a meal or snack. After infancy, children ages 16 years should receive no more than 1 serving of unsweetened fruit juice per day, and children ages 718 years should limit juice consumption to no more than 2 servings per day. 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. In contrast, 39 percent of males and 29 percent of females consumed at least one 12-ounce can of soda per day, not including diet soda. Soft drink consumption in the United States has increased more than 300 percent over the past two decades; 5685 percent of school-aged children consume at least one soft drink daily. The full impact on obesity and other CV risk factors from the displacement of calcium, vitamin D, protein, and other essential nutrients, combined with the increase in calories from sugar, is as yet unquantified. The NGHS (described previously) reported that higher consumption of sugar-sweetened beverages was associated with significantly lower milk consumption and that increased soda consumption predicted greater increases in BMI; BMI increased 0.01 unit for each 100 grams of soda consumed. Consumption of sugar-sweetened beverages was significantly associated with higher daily calorie intake. For every 100 grams of soda consumed, average daily calorie intake increased by about 82 calories. A 2006 systematic review of sugar-sweetened beverage intake and weight gain included 21 (of 30) studies in children and adolescents. 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.,
Sports drinks represent a relatively new beverage category. By design, they contain higher amounts of sodium, refined carbohydrates (sugar), and calories than does water. No studies in this evidence review dealt with sports drinks, but information is provided because of their increasing consumption as a sugar-sweetened beverage and thus their potential impact on children's caloric intake. Originally developed and marketed for use by trained athletes during competition, sports drinks have been marketed to the general public and "casual athletes" in recent years. Consumption by children and adolescents is increasingly common, with or without accompanying physical activity. In one review of adolescents ages 1118 years, 56.4 percent reported having consumed a sports drink during the previous week. 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. Compared with water, drinks containing electrolytes and refined carbohydrates have been shown to improve performance in sustained exercise tasks lasting more than 45 minutes. 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. 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
OVERVIEW OF THE EVIDENCE FOR DIETARY FAT INTAKE
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. There is no biologic requirement for SFA, so the limits were intended to help reduce atherogenic risk without eliminating high-quality animal protein sources. The DRI recommendations promote the intake of essential fatty acids from unsaturated sources, specifically ALA and LA omega-6 fatty acids. The acceptable range for intake of LA is 510 percent of fat calories and for ALA is 0.61.2 percent of fat calories for children and adults. From the evidence review, dietary pattern studies in children and adolescents report that higher blood lipid levels are associated with higher total and saturated fat intake, just as in adults.,,, 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.,,,,, 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.
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. The consequences of whole-milk consumption by infants, with its high protein and sodium content and reduced LA content, have not been reported. In several RCTs with small study groups, the fat and cholesterol contents of infant formulas varied, with subsequent short-term changes in levels of TC, LDLC, and TG in infancy, but no long-term differences in lipoprotein profiles were demonstrated on followup.,,,
Infancy After Weaning
As described above, many of the data on the safety and efficacy of a diet low in saturated fat and cholesterol starting in infancy come from the STRIP study, in which 7-month-old Finnish infants were randomized into either (1) a group whose parents received counseling from a nutritionist for a diet with total fat of 3035 percent of total kcal/d and with a 1:1:1 intake ratio of SFA/MUFA/PUFA per day, cholesterol intake <200 mg/d, protein 1015 percent per day, and carbohydrates 5060 percent per day or (2) a group whose parents received basic health education and no instructions on the use of fats. 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.,,,, This compares with a significantly higher total fat intake of 2833 percent in control subjects. Saturated fat intake among the intervention children was significantly lower, ranging from 9.5 percent to 11 percent, compared with 1314 percent in control subjects. From age 13 months to age 14 years, those in the STRIP intervention group had lower TC and lower LDLC than the control group; after age 7 years, the difference was only significant in males.,, 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. The lower total fat and saturated fat diet was associated with important CV health benefits, including the difference in serum lipids described above.,,, Assessed at age 9 years, a subgroup of STRIP intervention children also had significantly lower insulin levels and lower HOMAIR than control children. 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. For this study, overweight was defined as weight for height greater than 20 percent and obesity as greater than 40 percent above the mean for Finnish children. In a subgroup assessed at ages 79 years, intervention children had higher nutrition knowledge scores. 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.,,
Childhood and Adolescence
The Dietary Intervention Study in Children (DISC) assessed the safety and efficacy of a reduced-fat dietary intervention among children with moderately elevated LDLC levels between the 80th and 98th percentiles at baseline. Prepubertal boys (N = 362) and girls (N = 301) (initially ages 810 years) and their parents were randomized to either an ongoing, nutritionist-driven, individual and group intervention or a usual-care group in a six-center clinical trial. A behavioral-based, nutritionist-tailored intervention with monthly nutritionist visits and telephone followup was used to promote adherence to a diet similar to the NCEP Step II diet, with 28 percent of energy from fat, <8 percent from saturated fat, <9 percent from polyunsaturated fat, and cholesterol intake <150 mg/d. The control group received dietary literature only. At the 3-year followup, dietary total fat intake averaged 28.6 percent of calories, with a saturated fat intake of 10.2 percent of calories in the intervention group, significantly lower than in the usual-care group. This change was accompanied by small but significant mean differences in LDLC levels (reduction from baseline of 15.4 mg per deciliter (mg/dL) in the intervention group versus a reduction of 11.9 mg/dL in the control group). Greater sexual maturation and BMI were found to increase the normal fall in LDLC levels in both groups, which occurs during adolescence. At followup after a mean of 7.4 years, children in the intervention group maintained significantly lower dietary intakes of total fat, saturated fat, and cholesterol, compared with children in the control group, but there was no longer a significant difference in LDLC between the two groups. There were no differences in any of the safety measures, including height or depression scores.,
A clinically initiated, home-based, parent-child autotutorial (PCAT) dietary education program directed at increasing dietary knowledge and reducing fat consumption and LDLC levels was assessed in 174 boys and girls ages 410 years with borderline-high or high LDLC. Intervention families received individualized dietary recommendations to maintain a total dietary fat intake of less than 30 percent of calories and a saturated fat intake of less than 10 percent of calories and used tape-recorded nutrition messages to support appropriate dietary decisions between clinical visits. After 3 months, the PCAT group had significantly lower intakes of total and saturated fat and calories and lower LDLC levels than an at-risk control group that received no intervention; there were no significant differences in dietary intake or lipid levels between PCAT and traditional dietary counseling. Results were maintained at 1-year followup. Another office-based, 16-week nutritional education program effectively decreased intake of total fat, saturated fat, and cholesterol and significantly lowered TC and LDLC levels.
In prepubertal children with heterozygous familial hypercholesterolemia (FH), an RCT of 96 children ages 611 years tested a fat-restricted diet with 23 percent ±5 percent of energy from total fat, 8 percent ±2 percent from saturated fat, 5 percent ±1 percent from polyunsaturated fat, 8 percent ±2 percent from monounsaturated fat, 15 percent ±2 percent from protein, and 62 percent ±5 percent from carbohydrates, with a cholesterol intake of 67 mg ±28 mg/1,000 kcal, for 1 year. TC and LDLC levels were lowered by 4.4 percent and 5.5 percent, respectively. HDLC, TG, apoB, ferritin, weight for height, and height velocity were unchanged.
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. 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. 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.
Of note, the evidence review for these Guidelines identified no RCT in which dietary fat intake of 3035 percent was evaluated in children or adolescents. Even in the STRIP study, which focused on reducing saturated fat intake with dietary counseling for up to 3035 percent of total calories from fat, total fat intake of the intervention group never exceeded 30.5 percent from ages 7 months to 14 years.,,,,, 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
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. 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. The 1992 National Cholesterol Education Program: Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents recommended that dietary cholesterol intake be limited to <300 mg/d in all children and to <200 mg/d in those with elevated LDLC levels. From the NHANES surveys from the 1970s through 1994, mean dietary cholesterol intake in male and female children younger than age 13 years and in females through adolescence achieved the recommended level, averaging <300 mg/d. However, in males between ages 12 and 19 years, mean intake of cholesterol was 335 mg/d, exceeding the recommended 300 mg/d, regardless of racial/ethnic group. This evidence review identified 15 RCTs that addressed dietary cholesterol in infancy, childhood, and adolescence. In several small short-term studies, the fat and cholesterol contents of infant formula varied, with subsequent changes in levels of TC, LDLC, and TG in infancy, but there were no demonstrated long-term differences in lipoprotein profiles.,,, The STRIP trial, described in detail above, enrolled 1,062 healthy infants who were randomized to either intervention or control groups beginning at age 7 months. In addition to the low-saturated-fat diet described above, the intervention group received repeated, individualized, nutritionist-delivered counseling to maintain a dietary cholesterol intake of <200 mg/d.18 The children were then followed with serial evaluations, including dietary assessment using 4-day food records, until early adolescence. Results demonstrate that from age 13 months onward, children in the intervention group consumed significantly less total fat, saturated fat, and cholesterol and had lower TC and LDLC levels; after age 7 years, the difference in LDLC levels was significant only among boys.,,,,, No harmful effects were detected on growth, micronutrient intake, development, or neurologic function.,, Benefits on CV risk factors, especially lipids, described in detail in the preceding section, were seen, continuing into adolescence.,,,,,,,
The DISC trial described in detail above, was an RCT to assess the safety and efficacy of a reduced-fat dietary intervention among children with elevated LDLC levels (between the 80th and 98th percentiles) at baseline. The DISC trial used a behavioral-based, nutritionist-tailored intervention to promote adherence to a diet similar to the NCEP Step II diet, with 28 percent of energy from fat, <8 percent from saturated fat, <9 percent from polyunsaturated fat, and cholesterol intake <75 mg/1,000 kcal/d, not to exceed 150 mg/d. Based on multiple 24-hour dietary recalls, cholesterol intake was shown to decrease from a mean of 118 mg/100 kcal to 90 mg/100 kcal at 1-year followup; this difference persisted at evaluation 5 years postinitiation. At 3-year evaluation, LDLC levels were significantly lowered in the intervention group, compared with the control group (reduction from baseline of 15.4 mg/dL versus 11.9 mg/dL, respectively); this difference was not sustained at 7-year followup. There were no differences between groups in the prespecified safety measures of height and serum ferritin.,
In prepubertal children with heterozygous FH, an RCT of 96 children ages 611 years tested a fat- and cholesterol-restricted diet (23 percent ±5 percent of energy from total fat, 8 percent ±2 percent from saturated fat, 5 percent ±1 percent from polyunsaturated fat, 8 percent ±2 percent from monounsaturated fat,15 percent ±2 percent from protein, and 62 percent ±5 percent from carbohydrates with daily cholesterol intake of 67 ±28 mg/1,000 kcal). After 1 year, TC and LDLC levels decreased by 4.4 percent and 5.5 percent, respectively. HDLC, TG, apoB, and ferritin levels, weight-for-height, and height velocity were unchanged.
The PCAT dietary education program described previously was directed at increasing dietary knowledge, reducing fat consumption, and decreasing LDLC levels in boys and girls ages 410 years with borderline-high or high LDLC. In addition to individualized dietary recommendations to maintain a total dietary fat intake at less than 30 percent of calories and saturated fat intake at less than 10 percent of calories, intervention families were trained to limit cholesterol intake to <300 mg/d. At baseline, cholesterol intake was well below the 300-mg goal in all subjects, averaging 156.5 ±6.6 mg/d in the intervention group and 178.4 ±7.7 mg/d in the control group. After 3 months, those in the PCAT intervention group had significantly lower intakes of total fat, saturated fat, cholesterol, and calories. Cholesterol intake averaged 133.2 ±8.0 mg/d in the intervention group but was unchanged at 173.1 ±8.2 mg/d in the control group. LDLC levels decreased 10 mg/dL in intervention subjects and 3.4 mg/dL in control subjects. These results were maintained at 1-year followup. 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 LDLC levels and no reported adverse outcomes.
SUMMARY OF THE EVIDENCE REVIEW FOR DIETARY CHOLESTEROL INTAKE
OVERVIEW OF THE EVIDENCE REVIEW FOR INTERVENTIONS TO INCREASE FRUIT AND VEGETABLE INTAKE
Consumption of fruits and vegetables is advocated in the U.S. Department of Agriculture (USDA) MyPlate. 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., 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. Despite the high nutrient value of fruits and vegetables, children have inadequate intake of fruits and vegetables. In a national survey from 1999 to 2002, only one-fourth of children ages 211 years were found to consume at least three servings per day of vegetables, and fewer than half consumed at least two fruit servings per day. 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 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.,, 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. That review included four studies from this evidence review,,,,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 focused on studies in children ages 612 years published between 1990 and March 2005 and included four studies from this evidence review.,,, 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. A total of 15 studies focused on subjects ages 518 years; of these, 11 were RCTs, 10 of which were included in this evidence review.,,,,,,, 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.,, Several studies targeted parents, teachers, and food service workers as well as children.,,, 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,,; the latter tended to result in an increase in knowledge but no increase in intake of fruits and vegetables.,,, A reward system in one study resulted in increased fruit and vegetable intake during the school lunch period. 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.
SUMMARY OF THE EVIDENCE FOR INTERVENTIONS TO INCREASE FRUIT AND VEGETABLE INTAKE
OVERVIEW OF THE EVIDENCE FOR DIETARY FIBER INTAKE
The DGA identified whole grains as an important source of fiber, which is a component of good nutrition. 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. 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. From this evidence review, the Bogalusa Heart Study, described previously in this section, examined age and secular trends between 1976 and 1988 in dietary fiber intake by youths ages 1017 years. Total dietary fiber intake, assessed by dietary recalls, was low, with a mean intake of 12 grams per day (g/d) or 5 g/1,000 kcal, with no change over the period of observation. When children were stratified by quartiles of fiber intake, the percentages of calories from dietary total fat and saturated fat were lower, and the percentage of calories from carbohydrates was higher in children with high fiber intakes. The USDA Agricultural Research Service's Continuing Survey of Food Intake by Individuals (CFSII) (19941996, 1998) reported only slightly higher mean dietary fiber intakes for youths: 15.2 g/d and 17.7 g/d for males ages 913 and 1418 years, respectively, and 12.9 g/d and 12.8 g/d for females ages 913 and 1418 years, respectively. A more recent report from the NHANES III of more than 4,000 youths ages 818 years found that dietary fiber intake was inversely related to low-nutrient-density food consumption: high dietary fiber intake was consistently associated with higher nutrient intake. Conversely, intake of vitamins and minerals decreased as consumption of low-nutrient-density foods increased.7 In another analysis based on data from the CFSII, children ages 25 years with high fiber intake were found to consume diets with higher nutrient density, compared with those with low fiber intake.
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. 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.
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. Extrapolating from this, the DRI recommended total dietary fiber intakes for each age and gender group of children and adolescents as a product of the median energy intake and this recommended total fiber intake (14 g/1,000 kcal). Thus, for children ages 13 years and 48 years, a total fiber intake of 19 g/d and 25 g/d, respectively, is recommended. For males ages 913 years, a total fiber intake of 31 g/d is recommended, increasing to 38 g/d for males ages 1430 years. For females ages 930 years, a total fiber intake of 2526 g/d is recommended. The AAP recommends more moderate goals for fiber intake for children, age plus 5 g/d for young children, increasing to an adult goal of 22 g/d at around age 15 years. 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
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.,,,,,,,,, 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
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.
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. The DASH diet is also lower in sweets and added sugars, fats, and red meat than the typical U.S. diet. Although originally tested for effects on BP, consumption of the DASH diet was also associated with reduced total and saturated fat intake and a significant decrease in LDLC level. Reduced dietary sodium in addition to following the DASH diet achieved the largest BP reductions.  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., 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.
Childhood and Adolescence
The evidence review for these Guidelines identified no dietary pattern studies in infants, but such studies in older children have been emerging. As described previously, the Young Finns study, begun when subjects were ages 318 years, evaluated two major dietary patterns: a "traditional" pattern characterized by high consumption of rye, potatoes, butter, sausages, milk, and coffee and a "health-conscious" diet with high consumption of vegetables, legumes and nuts, cheese and other dairy products, and, in older subjects, alcoholic beverages. At 21-year followup, with subjects then ages 2439 years, the traditional diet was significantly and independently associated with higher TC and LDLC levels, apo B, and CRP values in both genders and higher systolic BP and insulin levels among women; the health-conscious diet was associated with better CV risk status but the latter correlation did not achieve statistical significance.
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. From the Framingham Children's Study, data from 95 children ages 36 years at enrollment indicate that, in adolescence, those with consistently higher intakes of fruits and vegetables and dairy products had significantly lower systolic BP levels.
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. There were no adverse effects.
SUMMARY OF THE EVIDENCE REVIEW FOR DIETARY PATTERNS
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.
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. At age 2.5 years, no significant effect of maternal fish oil intake on children's BP was detected.
The effect of replacing dietary fat with plant stanol ester was investigated in a subset of 6-year-old children from the STRIP study., TC and LDLC levels decreased 5.4 percent and 7.5 percent, respectively, among children who consumed a plant stanol-enriched margarine, compared with placebo. There were no effects on HDLC or TG values. These changes were accompanied by decreased cholesterol absorption. Safety was judged to be excellent. The presence of the apoE4 variant did not affect the response to plant stanols. There was no significant difference in cholesterol absorption between boys and girls, but there was a greater decrease in the LDLC level in boys (9.1 percent) than in girls (5.8 percent). The plant stanol results were confirmed in a short-term study of U.S. preschool children.
In a study designed to evaluate whether there is an association between calcium intake and change in body fat in children ages 35 years, calcium supplementation did not reduce gain in fat mass when baseline calcium intake was adequate.
Evidence of the use of fiber supplements in children is limited. In a small, 2-month RCT of 60 overweight adolescents, no significant difference was noted in weight change among subjects who received a fiber supplement (glucomannan), compared with placebo; dietary fiber intake was not assessed. At followup, the glucomannan group had lower HDLC levels and higher very-low-density lipoprotein and TG levels, compared with lower TG and LDLC values in the placebo group, suggesting no benefit and a potentially adverse impact of the supplement.
SUMMARY Of THE EVIDENCE FOR INTAKE OF DIETARY SUPPLEMENTS
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., 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.,, 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. 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., Some research indicates that acceptance of textured foods is determined by earlier experience. 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.
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.,,, 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., Finally, exposure to television and its associated child-oriented food commercials has been associated with food choices and higher food intake.,
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
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.,, In children and adolescents, prospective studies are few, and trials are lacking., 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. Eating breakfast may have beneficial effects on cognition and school performance.
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.,, 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.
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.,, 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.
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,,, 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.
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. 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., 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. 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., (Story 2008; CDC Guide to F&V 2010). Because public health initiatives have the potential to affect the nutrition of children and adolescents, this is an important avenue for advocacy by pediatric care providers.
CONCLUSIONS AND GRADING OF THE EVIDENCE REVIEW FOR DIET AND NUTRITION IN CARDIOVASCULAR RISK REDUCTION
The Expert Panel concluded that there is strong and consistent evidence that good nutrition beginning at birth has profound health benefits, with the potential to decrease future risk for CVD. The Expert Panel accepts the 2010 DGA as containing appropriate recommendations for diet and nutrition in children age 2 years and older. The recommendations in these Guidelines are intended for pediatric care providers to use with their patients to address CV risk reduction. The conclusions of the Expert Panel's review of the entire body of evidence in a specific nutrition area with grades are summarized below. The age- and evidence-based recommendations of the Expert Panel follow in Table 52. Where evidence is inadequate yet nutrition guidance is needed, recommendations for pediatric care providers are based on a consensus of the Expert Panel (Grade D).
In accordance with the Surgeon General's Office, the WHO, the AAP, and the AAFP, exclusive breast-feeding is recommended for the first 6 months of life. Continued breast-feeding is recommended to at least age 12 months, with the addition of complementary foods. If breast-feeding per se is not possible, feeding human milk by bottle is second best, with formula-feeding as the third choice.
As stated above, these dietary recommendations to promote CV health in children under the care of pediatric care providers are based on the results of the evidence review and the population recommendations are consistent with the DGA. Graded, age-specific recommendations for pediatric care providers to use in reducing CV risk in their patients are summarized in Table 52 (CHILD 1) and are designed to support implementation of the findings of the evidence review. CHILD 1 is the first stage in dietary change for children with identified dyslipidemia, overweight and obesity, risk factor clustering, and high-risk medical conditions who may ultimately require more intensive dietary change. More intensive recommendations to be implemented if needed for children with these conditions appear in the designated sections of these Guidelines. CHILD 1 is also the recommended diet for children with a positive family history of early CV disease, dyslipidemia, obesity, primary hypertension, diabetes, or children exposure to smoking in the home. Any dietary modification must provide nutrients and calories needed for optimal growth and development. Likewise, recommended intakes are adequately met by a DASH-style eating plan, which emphasizes fat-free/low-fat milk and dairy products and increased intake of fruits and vegetables. This pattern has been modified for use in children age 4 years and older based on daily energy needs and is shown in Table 53 as one example of a heart healthy eating plan using the CHILD 1 recommendations.
Table 52. Evidence-Based Recommendations for Patients of Pediatric Care Providers: Cardiovascular Health Integrated Lifestyle Diet (CHILD 1)
CHILD 1 is the recommended first step diet for all children and adolescents at elevated cardiovascular risk.
Grades reflect the findings of the evidence review.
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.
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.)
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.
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.
 U.S. Department of Agriculture and U.S. Departent of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, 2011.
 Demory-Luce D, Morales M, Nicklas T, Baranowski T, Zakeri I, Berenson G. Changes in food group consumption patterns from childhood to young adulthood: the Bogalusa Heart Study. J Am Diet Assoc 2004;104(11):1684-1691. (PM:15499355)
 Mikkilä V, Räsänen L, Raitakari OT, Marniemi J, Pietinen P, Rönnemaa T, Viikari J. Major dietary patterns and cardiovascular risk factors from childhood to adulthood. The Cardiovascular Risk in Young Finns Study. Br J Nutr 2007;98(1):218-225. (PM:17367571)
 Kronsberg SS, Obarzanek E, Affenito SG, Crawford PB, Sabry ZI, Schmidt M, Striegel-Moore R, Kimm SY, Barton BA. Macronutrient intake of black and white adolescent girls over 10 years: the NHLBI Growth and Health Study. J Am Diet Assoc 2003;103(7):852-860. (PM:12830023)
 Ritchie LD, Spector P, Stevens MJ, Schmidt MM, Schreiber GB, Striegel-Moore RH, Wang MC, Crawford PB. Dietary patterns in adolescence are related to adiposity in young adulthood in black and white females. J Nutr 2007;137(2):399-406. (PM:17237318)
 Kant AK. Reported consumption of low-nutrient-density foods by American children and adolescents: nutritional and health correlates, NHANES III, 1988 to 1994. Arch Pediatr Adolesc Med 2003;157(8):789-796. (PM:12912785)
 Picciano MF, McDonald S. In Eds Shils M, Shike M, Ross AC, Caballero B, Cousins R. Modern Nutrition in Health and Disease. 10th Edition. Lippincott, Williams & Wilkins, Baltimore, MD, 2006 Lactation pp 797-817.
 Abrams SA. Dietary guidelines for calcium and vitamin D: A new era. Pediatrics 2011;127: 566-568.
 IOM (Institute of Medicine). 2011. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press.
 Arenz S, Rückerl R, Koletzko B, von Kries R. Breast-feeding and childhood obesity--a systematic review. Int J Obes Relat Metab Disord 2004;'28(10):1247-1256. (PM:15314625)
 Owen CG, Whincup PH, Odoki K, Gilg JA, Cook DG. Infant feeding and blood cholesterol: A study in adolescents and systematic review. Pediatrics 2002;110(3): 597-608. (PM:12205266)
 Schack-Nielsen L, Michaelsen KF. Breast feeding and future health. Curr Opin Clin Nutr Metab Care 2006;9(3):289-296. (PM:16607131)
 Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Am J Clin Nutr 2006;84(5):1043-1054. (PM:17093156)
 Demmers TA, Jones PJ, Wang Y, Krug S, Creutzinger V, Heubi JE. Effects of early cholesterol intake on cholesterol biosynthesis and plasma lipids among infants until 18 months of age. Pediatrics 2005;115(6):1594-1601. (PM:15930221)
 Bayley TM, Alasmi M, Thorkelson T, Jones PJ, Corcoran J, Krug-Wispe S, Tsang RC. Longer term effects of early dietary cholesterol level on synthesis and circulating cholesterol concentrations in human infants. Metabolism 2002;51(1):25-33. (PM:11782868)
 Mize CE, Uauy R, Kramer R, Benser M, Allen S, Grundy SM. Lipoprotein-cholesterol responses in healthy infants fed defined diets from ages 1 to 12 months: comparison of diets predominant in oleic acid versus linoleic acid, with parallel observations in infants fed a human milk-based diet. J Lipid Res 1995;36(6):1178-1187. (PM:7665996)
 Decsi T, Fekete M, Koletzko B. Plasma lipid and apolipoprotein concentrations in full term infants fed formula supplemented with long-chain polyunsaturated fatty acids and cholesterol. Eur J Pediatr 1997;156(5):397-400. (PM:9177986)
 Lapinleimu H, Viikari J, Jokinen E, Salo P. Prospective randomised trial in 1062 infants of diet low in saturated fat and cholesterol. Lancet 345:471-476.
 Lapinleimu H, Viikari J, Rönnemaa T, Välimäki I, Tuominen J, Marniemi J, Ehnholm C, Jokinen E, Simell O. Apolipoprotein E polymorphism and serum lipids in a randomized, prospective trial of an infant diet with reduced saturated fat and cholesterol. Pediatrics 1996;98(4 Pt 1):757-762. (PM:8885957)
 Simell O, Rönnemaa T, Lapinleimu H, Routi T, Lagstrom H, Salo P, Jokinen E, Viikari J. Special Turku Coronary Risk factor Intervention Project for Babies (STRIP). Am J Clin Nutr 2000;72(5 Suppl):1316S-1331S
 Salo P, Viikari J, Rask-Nissilä L, Hämäläinen M, Rönnemaa T, Seppänen R, Simell O. Effect of low-saturated fat, low-cholesterol dietary intervention on fatty acid compositions in serum lipid fractions in 5-year-old children. The STRIP project. Eur J Clin Nutr. 1999 Dec;53(12):927-32.(PM:10602349)
 Talvia S, Lagström H, Räsänen M, Salminen M, Räsänen L, Salo P, Viikari J, Rönnemaa T, Jokinen E, Vahlberg T, Simell O. A randomized intervention since infancy to reduce intake of saturated fat: calorie (energy) and nutrient intakes up to the age of 10 years in the Special Turku Coronary Risk Factor Intervention Project. Arch Pediatr Adolesc Med 2004;158(1):41-47. (PM:14706957)
 Niinikoski H, Lagström H, Jokinen E, Siltala M, Rönnemaa T, Viikari J, Raitakari OT, Jula A, Marniemi J, Näntö-Salonen K, Simell O. Impact of repeated dietary counseling between infancy and 14 years of age on dietary intakes and serum lipids and lipoproteins: the STRIP study. Circulation 2007;116(9):1032-1040. (PM:17698729)
 Niinikoski H, Koskinen P, Punnonen K, Seppänen R, Viikari J, Rönnemaa T, Irjala K, Simell O. Intake and indicators of iron and zinc status in children consuming diets low in saturated fat and cholesterol: the STRIP baby study. Special Turku Coronary Risk Factor Intervention Project for Babies. Am J Clin Nutr 1997;66(3):569-574. (PM:9280175)
 Rask-Nissilä L, Jokinen E, Terho P, Tammi A, Lapinleimu H, Rönnemaa T, Viikari J, Seppänen R, Korhonen T, Tuominen J, Välimäki I, Simell O. Neurological development of 5-year-old children receiving a low-saturated fat, low-cholesterol diet since infancy: A randomized controlled trial. JAMA 2000;284(8):993-1000. (PM:10944645)
 Kaitosaari T, Ronnemaa T, Viikari J, Arffman M, Marniemi J, Kallo K, Pahkala K, Jokinen E, Simell O. Low saturated fat dietary counseling starting in infancy improves insulin sensitivity in 9-year-old healthy children: the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) study. Diabetes Care 2006;19:781-785.
 Hakanen M, Lagstrom H, Kaitosaari T, Niinikoski H, Nanto-Salonen K, Sillanmaki L, Viikari J, Ronnemaa T, Simell O. Development of overweight in an atherosclerosis prevention trial starting in early childhood. The STRIP study. Int J Obes 2006; 30:618-626.
 Räsänen M, Niinikoski H, Keskinen S, Heino T, Lagström H, Simell O, Helenius H, Rönnemaa T, Viikari J. Impact of nutrition counselling on nutrition knowledge and nutrient intake of 7- to 9-y-old children in an atherosclerosis prevention project. Eur J Clin Nutr 2004;58(1):162-172. (PM:14679382)
 Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics 2008;121(6):e1604-e1614. (PM:18519465)
 Faith MS, Dennison BA, Edmunds LS, Stratton HH. Fruit juice intake predicts increased adiposity gain in children from low-income families: weight status-by-environment interaction. Pediatrics 2006;118(5):2066-2075.
 Welsh JA, Cogswell ME, Rogers S, Rockett H, Mei Z, Grummer-Strawn LM. Overweight among low-income preschool children associated with the consumption of sweet drinks: Missouri, 1999-2002. Pediatrics 2005;115(2):e223-e229.
 American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001;107(5):1210-1213.
 Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, Harris WA, Lowry R, McManus T, Chyen D, Lim C, Brener ND, Wechsler H; Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance--United States, 2007. MMWR Surveill Summ 2008;57(4):1-131.
 Striegel-Moore RH, Thompson D, Affenito SG, Franko DL, Obarzanek E, Barton BA, Schreiber GB, Daniels SR, Schmidt M, Crawford PB. Correlates of beverage intake in adolescent girls: the National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatr 2006;148(2):183-187. (PM:16492426)
 Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84(2):274-288. (PM:16895873)
 James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004;328(7450):1237. (PM:15107313)
 Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006;117(3):673-680. (PM:16510646)
 O'Dea JA. Consumption of nutritional supplements among adolescents: usage and perceived benefits. Health Educ Res 2003;18(1):98-107.
 Vrijens DM, Rehrer NJ. Sodium-free fluid ingestion decreases plasma sodium during exercise in the heat. J Appl Physiol 1999;86(6):1847-1851.
 Haub MD, Haff GG, Potteiger JA. The effect of liquid carbohydrate ingestion on repeated maximal effort exercise in competitive cyclists. J Strength Cond Res 2003;17(1):20-25.
 von Duvillard SP, Arciero PJ, Tietjen-Smith T, Alford K. Sports drinks, exercise training, and competition. Curr Sports Med Rep 2008;7(4):202-208.
 NCEP Expert Panel of Blood Cholesterol Levels in Children and Adolescents. National Cholesterol Education Program (NCEP): Highlights of the Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics 1992;89:495-501. (PM:1741227)
 Fox MK, Pac S, Devaney B Jankowski L. Feeding infants and toddlers study: What foods are infants and toddlers eating? J Am Dietetic Assoc 2004;104:S22-S30.
 Tammi A, Rönnemaa T, Valsta L, Seppänen R, Rask-Nissilä L, Miettinen TA, Gylling H, Viikari J, Anttolainen M, Simell O. Dietary plant sterols alter the serum plant sterol concentration but not the cholesterol precursor sterol concentrations in young children (the STRIP Study). Special Turku Coronary Risk Factor Intervention Project. J Nutr 2001;131(7):1942-1945. (PM:11435511)
 Lauer RM, Obarzanek E, Hunsberger SA, Van Horn L, Hartmuller VW, Barton BA, Stevens VJ, Kwiterovich PO Jr, Franklin FA Jr, Kimm SY, Lasser NL, Simons-Morton DG. Efficacy and safety of lowering dietary intake of total fat, saturated fat, and cholesterol in children with elevated LDL cholesterol: the Dietary Intervention Study in Children. Am J Clin Nutr. 2000;72(5 Suppl):1332S-1342S. (PM:11063475)
 Kwiterovich PO Jr, Barton BA, McMahon RP, Obarzanek E, Hunsberger S, Simons-Morton D, Kimm SY, Friedman LA, Lasser N, Robson A, Lauer R, Stevens V, Van Horn L, Gidding S, Snetselaar L, Hartmuller VW, Greenlick M, Franklin F Jr. Effects of diet and sexual maturation on low-density lipoprotein cholesterol during puberty: the Dietary Intervention Study in Children (DISC). Circulation 1997;96(8):2526-2533. (PM:9355889)
 Obarzanek E, Kimm SY, Barton BA, Van Horn LL, Kwiterovich PO Jr, Simons-Morton DG, Hunsberger SA, Lasser NL, Robson AM, Franklin FA Jr, Lauer RM, Stevens VJ, Friedman LA, Dorgan JF, Greenlick MR; DISC Collaborative Research Group. Long-term safety and efficacy of a cholesterol-lowering diet in children with elevated low-density lipoprotein cholesterol: seven-year results of the Dietary Intervention Study in Children (DISC). Pediatrics 2001;107(2):256-264. (PM:11158455)
 Van Horn L, Obarzanek E, Friedman LA, Gernhofer N, Barton B. Children's adaptations to a fat-reduced diet: the Dietary Intervention Study in Children (DISC). Pediatrics 2005;115(6):1723-1733. (PM:15930237)
 Shannon BM, Tershakovec AM, Martel JK, Achterberg CL, Cortner JA, Smiciklas-Wright HS, Stallings VA, Stolley PD. Reduction of elevated LDL-cholesterol levels of 4- to 10-year-old children through home-based dietary education. Pediatrics 1994;94(6 Pt 1):923-927. (PM:7971012)
 Tershakovec AM, Shannon BM, Achterberg CL, McKenzie JM, Martel JK, Smiciklas-Wright H, Pammer SE, Cortner JA. One-year follow-up of nutrition education for hypercholesterolemic children. Am J Public Health 1998;88(2):258-261. (PM:9491017)
 Kuehl KS, Cockerham JT, Hitchings M, Slater D, Nixon G, Rifai N. Effective control of hypercholesterolemia in children with dietary interventions based in pediatric practice. Prev Med 1993;22(2):154-166. (PM:8483855)
 Tonstad S, Knudtzon J, Sivertsen M, Refsum H, Ose L. Efficacy and safety of cholestyramine therapy in peripubertal and prepubertal children with familial hypercholesterolemia. J Pediatr 1996;129(1):42-49. (PM: 8757561)
 Luepker RV, Perry CL, McKinlay SM, Nader PR, Parcel GS, Stone EJ, Webber LS, Elder JP, Feldman HA, Johnson CC. Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA 1996;275(10):768-776. (PM:8598593)
 Lytle LA, Stone EJ, Nichaman MZ, Perry CL, Montgomery DH, Nicklas TA, Zive MM, Mitchell P, Dwyer JT, Ebzery MK, Evans MA, Galati TP. Changes in nutrient intake of elementary school children following a school-based intervention: results from the CATCH study. Prev Med 1996;25:465-477.
 Nader PR, Stone EJ, Lytle LA, Perry CL, Osganian SK, Kelder S, Webber LS, Elder JP, Montgomery D, Feldman HA, Wu M, Johnson C, Parcel GS, Luepker RV. Three-year maintenance of improved diet and physical activity: the CATCH cohort. Child and Adolescent Trial for Cardiovascular Health. Arch Pediatr Adolesc Med 1999;153(7):695-704. (PM:10401802)
 Kritchevsky D. Cholesterol and other dietary sterols. In Modern Nutrition in Health and Disease. Edited by Shils M, Shike M, Ross AC, Caballero B, Cousins R. Tenth edition. 2006. Lippincott, Williams and Wilkens. New York, NY. Pp 123-135.
 Grundy S, Barrett-Connor E, Rudel L, Miettinen T, Spector A. Workshop on the impact of dietary cholesterol on plasma lipoproteins and atherogenesis. Arteriosclerosis 1988;8:95-101.
 Troiano RP, Briefel RR, Carroll, MD, Bialostosky, K. Energy and fat intakes of children and adolescents in the United States: Data from the National Health and Nutrition Examination Surveys. Am J Clin Nutr 2000; 72 (Suppl):1343S-1353S.
 United States Department of Agriculture. MyPlate. 2011. Accessed at: www.choosemyplate.gov.
 Cook A, Friday J. Pyramid serving intakes in the US, 1999-2002, 1 day. Beltsville, MD. Agricultural research Service, USDA, 2005.
 McArthur DB. Heart healthy eating behaviors of children following a school-based intervention: a meta-analysis. Issues Compr Pediatr Nurs 1998;21(1):35-48. (PM:10188424)
 Nader PR, Sallis JF, Patterson TL, Abramson IS, Rupp JW, Senn KL, Atkins CJ, Roppe BE, Morris JA, Wallace JP. A family approach to cardiovascular risk reduction: results from the San Diego Family Health Project. Health Educ Q. 1989;16(2):229-44. (PM:2732065)
 Perry CL, Bishop DB, Taylor G, Murray DM, Mays RW, Dudovitz BS, Smyth M, Story M. Changing fruit and vegetable consumption among children: the 5-a-Day Power Plus program in St. Paul, Minnesota. Am J Public Health 1998;88(4):603-609. (PM:9551002)
 McKenzie J, Dixon LB, Smiciklas-Wright H, Mitchell D, Shannon B, Tershakovec A. Change in nutrient intakes, number of servings, and contributions of total fat from food groups in 4- to 10-year-old children enrolled in a nutrition education study. J Am Diet Assoc 1996;96(9):865-873. (PM:8784330)
 Ammerman AS, Lindquist CH, Lohr KN, Hersey J. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Prev Med 2002;35(1):25-41. (PM:12079438)
 Baranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Lin LS, Smith M, Wang DT. Gimme 5 fruit, juice, and vegetables for fun and health: outcome evaluation. Health Educ Behav 2000;27(1):96-111. (PM:10709795)
 Reynolds KD, Franklin FA, Binkley D, Raczynski JM, Harrington KF, Kirk KA, Person S. Increasing the fruit and vegetable consumption of fourth-graders: results from the high 5 project. Prev Med 2000;30(4):309-319. (PM:10731460)
 Blanchette L, Brug J. Determinants of fruit and vegetable consumption among 6-12-year-old children and effective interventions to increase consumption. J Hum Nutr Diet 2005;18(6):431-443. (PM:16351702)
 Baranowski T, Baranowski J, Cullen KW, Marsh T, Islam N, Zakeri I, Honess-Morreale L, deMoor C. Squire's Quest! Dietary outcome evaluation of a multimedia game. Am J Prev Med 2003;24(1):52-61. (PM:12554024)
 Knai C, Pomerleau J, Lock K, McKee M. Getting children to eat more fruit and vegetables: a systematic review. Prev Med 2006;42(2):85-95. (PM:16375956)
 Birnbaum AS, Lytle LA, Story M, Perry CL, Murray DM. Are differences in exposure to a multicomponent school-based intervention associated with varying dietary outcomes in adolescents? Health Educ Behav 2002;29(4):427-443. (PM:12137237)
 Lytle LA, Murray DM, Perry CL, Story M, Birnbaum AS, Kubik MY, Varnell S. School-based approaches to affect adolescents' diets: results from the TEENS study. Health Educ Behav 2004;31(2):270-287. (PM:15090126)
 Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med 1999;153(4):409-418. (PM:10201726)
 Cottrell L, Spangler-Murphy E, Minor V, Downes A, Nicholson P, Neal WA. A kindergarten cardiovascular risk surveillance study: CARDIAC-Kinder. Am J Health Behav 2005;29(6):595-606. (PM:16336114)
 Dixon LB, Tershakovec AM, McKenzie J, Shannon B. Diet quality of young children who received nutrition education promoting lower dietary fat. Public Health Nutr 2000;3(4):411-416. (PM:11135795)
 Haerens L, De B, I, Maes L, Vereecken C, Brug J, Deforche B. The effects of a middle-school healthy eating intervention on adolescents' fat and fruit intake and soft drinks consumption. Public Health Nutr 2007;10(5):443-449. (PM:17411463)
 Reinaerts E, de Nooijer J, Candel M, de Vries N. Increasing children's fruit and vegetable consumption: distribution or a multicomponent programme? Public Health Nutr 2007;10(9):939-947. (PM:17381944)
 Bere E, Veierod MB, Bjelland M, Klepp KI. Outcome and process evaluation of a Norwegian school-randomized fruit and vegetable intervention: Fruits and Vegetables Make the Marks (FVMM). Health Educ Res 2006;21(2):258-267. (PM:16219631)
 Hendy HM, Williams KE, Camise TS. "Kids Choice" school lunch program increases children's fruit and vegetable acceptance. Appetite 2005;45(3):250-263. (PM:16157415)
 Turnin MC, Tauber MT, Couvaras O, Jouret B, Bolzonella C, Bourgeois O, Buisson JC, Fabre D, Cance-Rouzaud A, Tauber JP, Hanaire-Broutin H. Evaluation of microcomputer nutritional teaching games in 1,876 children at school. Diabetes Metab 2001;27(4 Pt 1):459-464. (PM:11547219)
 Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Chapter 7: Dietary, Functional and Total Fiber. Institute of Medicine. National Academies Press, 2002. Washington, DC, pp. 229-421.
 Williams CL, Bollella M. Is a high-fiber diet safe for children? Pediatrics 1995;96(5 Pt 2):1014-1019.
 Nicklas TA, Myers L, Berenson GS. Dietary fiber intake of children: the Bogalusa Heart Study. Pediatrics 1995;96(5 Pt 2):988-994. (PM:7494678)
 USDA Agricultural Research Service. USDA's 1994-96 Continuing Survey of Food Intakes by Individuals and 1994-96 Diet and Knowledge Survey. 1999. Accessed at: www.ars.usda.gov/services/docs.htm?docid=7760. Accessed 8/12/2008.
 Kranz S, Mitchell DC, Siega-Riz AM, Smiciklas-Wright H. Dietary fiber intake by American preschoolers is associated with more nutrient-dense diets. J Am Diet Assoc 2005;105(2):221-225.
 Johnson L, Mander AP, Jones LR, Emmett PM, Jebb SA. Energy-dense, low-fiber, high-fat dietary pattern is associated with increased fatness in childhood. Am J Clin Nutr 2008;87(4):846-854.
 American Academy of Pediatrics Committee on Public Education. Carbohydrate and dietary fiber. In Re K, ed. Pediatric Nutrition Handbook. Elk Grove Village, IL: American Academy of Pediatrics Committee on Nutrition; 2004:247-253.
 Haerens L, Deforche B, Maes L, Stevens V, Cardon G, De B, I. Body mass effects of a physical activity and healthy food intervention in middle schools. Obesity (Silver Spring) 2006;14(5):847-854. (PM:16855194)
 Fitzgibbon ML, Stolley MR, Schiffer L, Van HL, KauferChristoffel K, Dyer A. Two-year follow-up results for Hip-Hop to Health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. J Pediatr 2005;146(5):618-625. (PM:15870664)
 Warren JM, Henry CJ, Lightowler HJ, Bradshaw SM, Perwaiz S. Evaluation of a pilot school programme aimed at the prevention of obesity in children. Health Promot Int 2003;18(4):287-296. (PM:14695360)
 Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH, Cade J. Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. BMJ 2001;323(7320):1029-1032. (PM:11691759)
 Himes JH, Ring K, Gittelsohn J, Cunningham-Sabo L, Weber J, Thompson J, Harnack L, Suchindran C. Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren. Prev Med 2003;37(6 Pt 2):S55-S61. (PM:14636809)
 De Lorgerol M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999;99(6):779-785.
 Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997;336(16):1117-1124.
 Obarzanek E, Sacks FM, Vollmer WM, Bray GA, Miller ER 3rd, Lin PH, Karanja NM, Most-Windhauser MM, Moore TJ, Swain JF, Bales CW, Proschan MA; DASH Research Group. Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) Trial. Am J Clin Nutr 2001;74(1):80-89.
 Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek E, Conlin PR, Miller ER 3rd, Simons-Morton DG, Karanja N, Lin PH; DASH Collaborative Research Group. N Engl J Med 2001;344(1): 3-10.
 Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med 2008;168(7):713-720.
 Folsom AR, Parker ED, Harnack LJ. Degree of concordance with DASH diet guidelines and incidence of hypertension and fatal cardiovascular disease. Am J Hypertens 2007;20(3):225-232.
 Elmer PJ, Obarzanek E, Vollmer WM, Simons-Morton D, Stevens VJ, Young DR, Lin PH, Champagne C, Harsha DW, Svetkey LP, Ard J, Brantley PJ, Proschan MA, Erlinger TP, Appel LJ; PREMIER Collaborative Research Group. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med 2006;144(7):485-495.
 Moore LL, Singer MR, Bradlee ML, Djoussé L, Proctor MH, Cupples LA, Ellison RC. Intake of fruits, vegetables, and dairy products in early childhood and subsequent blood pressure change. Epidemiology 2005;16(1):4-11.
 Couch SC, Saelens BE, Levin L, Dart K, Falciglia G, Daniels SR. The efficacy of a clinic-based behavioral nutrition intervention emphasizing a DASH-type diet for adolescents with elevated blood pressure. J Pediatr 2008;152(4):494-501. (PM:18346503)
 Ulbak J, Lauritzen L, Hansen HS, Michaelsen KF. Diet and blood pressure in 2.5-y-old Danish children. Am J Clin Nutr 2004;79(6):1095-1102. (PM:15159241)
 Tammi A, Rönnemaa T, Gylling H, Rask-Nissilä L, Viikari J, Tuominen J, Pulkki K, Simell O. Plant stanol ester margarine lowers serum total and low-density lipoprotein cholesterol concentrations of healthy children: the STRIP project. Special Turku Coronary Risk Factors Intervention Project. J Pediatr 2000;136(4):503-510. (PM:10753249)
 Tammi A, Ronnemaa T, Valsta L, Seppanen R, Rask-Nissila L, Miettinen TA, Gylling H, Viikari J, Anttolainen M, Simell O. Dietary plant sterols alter the serum plant sterol concentration but not the cholesterol precursor sterol concentrations in young children (the STRIP study). Special Turku Coronary Risk Factor Intervention Project. J Nutr 2001;131:1942-1945. (PM:11435511)
 Tammi A, Rönnemaa T, Miettinen TA, Gylling H, Rask-Nissilä L, Viikari J, Tuominen J, Marniemi J, Simell O. Effects of gender, apolipoprotein E phenotype and cholesterol-lowering by plant stanol esters in children: the STRIP study. Special Turku Coronary Risk Factor Intervention Project. Acta Paediatr 2002;91(11):1155-1162. (PM:12463311)
 Williams CL, Bollella MC, Strobino BA, Boccia L, Campanaro L. Plant stanol ester and bran fiber in childhood: effects on lipids, stool weight and stool frequency in preschool children. J Am Coll Nutr 1999;18(6):572-581. (PM:10613408)
 DeJongh ED, Binkley TL, Specker BL. Fat mass gain is lower in calcium-supplemented than in unsupplemented preschool children with low dietary calcium intakes. Am J Clin Nutr 2006;84(5):1123-1127. (PM:17093165)
 Vido L, Facchin P, Antonello I, Gobber D, Rigon F. Childhood obesity treatment: double blinded trial on dietary fibres (glucomannan) versus placebo. Padiatr Padol 1993;28(5):133-136. (PM:8247594)
 Birch LL. Development of food preferences. Annu Rev Nutr 1999;19:41-62.
 Kelder SH, Perry CL, Klepp KI, Lytle LL. Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. Am J Public Health 1994;84(7):1121-1126.
 Bartoshuk LM, Beauchamp GK. Chemical senses. Annu Rev Psychol 1994;45:419-449.
 Beauchamp GK, Cowart BJ, Mennella JA, Marsh RR. Infant salt taste: developmental, methodological, and contextual factors. Dev Psychobiol 1994;27(6):353-365.
 Krondl M, Coleman P, Wade J, Milner J. A twin study examining the genetic influence on food selection. Hum Nutr Appl Nutr 1983;37 A(3):189-198.
 Mennella JA, Jagnow CP, Beauchamp GK. Prenatal and postnatal flavor learning by human infants. Pediatrics 2001;107(6):E88.
 Maier A, Chabanet C, Schaal B. Effects of repeated exposure on acceptance of initially disliked vegetables in 7 month old infants. Food Qual Pref 2007;18: 1023-1032.
 Wardle J, Cooke LJ, Gibson EL, Sapochnik M, Sheiham A, Lawson M. Increasing children's acceptance of vegetables; a randomized trial of parent-led exposure. Appetite 2003;40(2):155-162.
 Forestell CA, Mennella JA. Early determinants of fruit and vegetable acceptance. Pediatrics 2007;120(6):1247-1254.
 Rozin P. Acquisition of stable food preferences. Nutr Rev 1990;48(2):106-113.
 Pliner P. Family resemblance in food preferences. J Nutr Educ 1983;15:137-140.
 Pliner P, Pelchat ML. Similarities in food preferences between children and their siblings and parents. Appetite 1986;7(4):333-342.
 Lau RR, Quadrel MJ, Hartman KA. Development and change of young adults' preventive health beliefs and behavior: influence from parents and peers. J Health Soc Behav 1990;31(3):240-259.
 Nguyen VT, Larson DE, Johnson RK, Goran MI. Fat intake and adiposity in children of lean and obese parents. Am J Clin Nutr 1996;63(4):507-513.
 Faith MS, Scanlon KS, Birch LL, Francis LA, Sherry B. Parent-child feeding strategies and their relationships to child eating and weight status. Obes Res 2004;12(11):1711-1722.
 Taveras EM, Rifas-Shiman SL, Scanlon KS, Grummer-Strawn LM, Sherry B, Gillman MW. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics 2006;118(6):2341-2348.
 Chamberlain LJ, Wang Y, Robinson TN. Does children's screen time predict requests for advertised products? Cross-sectional and prospective analyses. Arch Pediatr Adolesc Med 2006;160(4):363-368.
 Halford JCG, Gillespie J, Brown V, Pontin EE, Dovey TM. The effect of television food advertisements/ commercials on food consumption in children. Appetite 2004;42:221-225.
 Timlin MT, Pereira MA. Breakfast frequency and quality in the etiology of adult obesity and chronic diseases. Nutr Rev 2007;65(6 Pt 1):268-281.
 Song WO, Chun OK, Obayashi S, Cho S, Chung CE. Is consumption of breakfast associated with body mass index in US adults? J Am Diet Assoc 2005;105(9):1373-1382.
 Carson T, Siega-Riz AM, Popkin BM. The importance of breakfast meal type to daily nutrient intake: differences by age and ethnicity. Cereal Foods World. 1999;44:414-422.
 Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc 2005;105(5):743-760.
 Timlin MT, Pereira MA, Story M, Neumark-Sztainer D. Breakfast eating and weight change in a 5-year prospective analysis of adolescents: Project EAT (Eating Among Teens). Pediatrics 2008;121(3):e638-e645.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 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.
 Story M, Kaphingst KM, French S. The role of schools in obesity prevention. Future Child 2006;16(1):109-142.
 Arkansas Center for Health Improvement. Year Four: Arkansas Act 1220 to Combat Childhood Obesity. Accessed at: http://www.achi.net/ChildObDocs/COPHYYear4Evaluation.pdf
 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.
 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.
 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
 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
Back to Table of Contents