Release Date: September 30, 2005;
Sept. 30, 2005 — Dietary guidelines for children have been updated by the American Heart Association (AHA) and published in the Sept. 27 issue of Circulation.
„Since the AHA last presented nutrition guidelines for children, significant changes have occurred in the prevalence of cardiovascular risk factors and nutrition behaviors in children,“ write Samuel S. Gidding, MD, and colleagues from the AHA. „This scientific statement summarizes current available information on cardiovascular nutrition in children and makes recommendations for both primordial and primary prevention of cardiovascular disease beginning at a young age.“
Although saturated fat and cholesterol intake have decreased, in terms of percentage of total caloric intake, overweight has paradoxically increased. Recent advances in understanding overweight and obesity in children include national survey data linking children’s cardiovascular risk status to current diet; new research on the efficacy of diet intervention in children; and studies focusing on the importance of prenatal and early life nutrition.
„It is estimated that 75% to 90% of the cardiovascular disease epidemic is related to dyslipidemia, hypertension, diabetes mellitus, tobacco use, physical inactivity, and obesity; the principal causes of these risk factors are adverse behaviors, including poor nutrition,“ the guidelines state. „The atherosclerotic process begins in youth, culminating in the risk factor–related development of vascular plaque in the third and fourth decades of life. Good nutrition, a physically active lifestyle, and absence of tobacco use contribute to lower risk prevalence and either delay or prevent the onset of cardiovascular disease.“
On the basis of these observations, the panel recommends strategies for primordial prevention, or preventing the development of cardiovascular risk factors in the first place. These include education, health policy, and environmental change to support optimal nutrition and physical activity. The recommendations address diet composition, total caloric intake, and physical activity. Optimal implementation of the diet in the pediatric group requires that children and all other members of their households actively make the recommended changes.
The AHA statement offers medical practitioners dietary and physical activity recommendations for healthy children; reviews the current content of children’s diets and the adverse health consequences of increased intakes of calories (relative to energy expenditure), saturated and trans fat, and cholesterol; and offers age-specific guidelines for implementation of the recommended diet, including the period from before birth to two years of age. It provides guidelines to implement recommendations in clinical practice as well as public health strategies to improve the quality of children’s diets. It revises the 1982 recommendations, while building on the recent consensus statement on optimal nutrition for the prevention of many chronic diseases of adulthood.
„This revision responds to the obesity epidemic that has emerged since the publication of the last statement that addressed children’s nutrition from the AHA and has new focuses on both total caloric intake and eating behaviors,“ the authors write. „This revision strongly conveys the message that foods and beverages that fulfill nutritional requirements are appropriate for growing and developing infants, children, and adolescents. Calorie-dense foods and beverages with minimal nutritional content must return to their role as occasional discretionary items in an otherwise balanced diet.“
Although there is a strong scientific base for understanding the potential harm and benefit of current dietary practices and the relationship to risk factors, the scientific base for recommended interventions is weakened by limited number, statistical power, and scope of intervention studies; limited efficacy of attempted interventions; and lack of generalizability of studies of feeding behaviors at younger ages.
In contrast to previous guidelines, the revised recommendations allow a more liberal intake of unsaturated fat, focus on ensuring adequate intakes of omega-3 fatty acids, and emphasize foods that are rich in nutrients and that provide increased amounts of dietary fiber. Recommendations that are similar to those in previous guidelines are for restriction of saturated and trans fats and inclusion of fruits, vegetables, whole grains, legumes, low-fat dairy products, fish, poultry, and lean meats. The guidelines note that children and adolescents typically consume insufficient fruits, vegetables, and fish, and that use of appropriate portions of low-fat dairy products and lean cuts of meat will be critical in meeting dietary needs and nutrient requirements. At present, the major sources of saturated fat and cholesterol in children’s diets are full-fat milk and cheese and fatty meats.
For children older than two years and their families, the AHA recommends balancing dietary calories with physical activity to maintain normal growth, 60 minutes daily of moderate to vigorous play or physical activity, daily intake of vegetables and fruits (with limited juice intake), use of vegetable oils and soft margarines low in saturated fat and trans fatty acids instead of butter or most other animal fats, consumption of more whole grain breads and cereals rather than refined-grain products, reduced intake of sugar-sweetened beverages and foods, daily use of nonfat (skim) or low-fat milk and dairy products, increased consumption of fish (especially oily fish, broiled or baked), and reduced salt intake, including salt from processed foods.
To meet these recommendations, the guidelines recommend that parents reduce added sugars, including sugar-sweetened drinks and juices; use canola, soybean, corn oil, safflower oil, or other unsaturated oils instead of solid fats during food preparation; use recommended portion sizes on food labels when preparing and serving food; use fresh, frozen, and canned vegetables and fruits at every meal; limit added sauces and sugar; regularly serve fish as an entrée; remove the skin from poultry before eating; use only lean cuts of meat and reduced-fat meat products; limit high-calorie sauces; eat whole grain breads and cereals rather than refined products; replace meat with legumes and tofu for some entrées; and replace breads, breakfast cereals, and prepared foods that are high in salt and/or sugar with high-fiber, low-salt, low-sugar alternatives.
Parent and caregiver responsibilities for children’s nutrition are choosing breast-feeding for first nutrition, maintaining it for 12 months if possible; controlling when food can be eaten; providing a social context for eating behavior; teaching about food and nutrition; counteracting inaccurate information from the media and other influences; teaching other care providers about proper food choices for children; serving as role models for healthy eating; and promoting and participating in regular daily physical activity.
The guidelines recommend breast-feeding as the exclusive source of nutrition for the first four to six months of life. To improve nutritional quality after weaning, they recommend delaying introduction of 100% juice until at least six months of age and limiting it to no more than 4 to 6 oz. per day; responding to satiety clues and not overfeeding; introducing healthy foods and continuing to offer them if initially refused; and avoiding foods without overall nutritional value.
Strategies to improving nutrition in young children are for parents, not children, to choose meal times; provide a wide variety of nutrient-dense foods, such as fruits and vegetables, instead of high-energy-density/nutrient-poor „junk“ foods; age-appropriate portion size; use of nonfat or low-fat dairy products as sources of calcium and protein; limiting snacking and use of juice or sweetened beverages; limiting sedentary behaviors; allowing children with normal body mass index to self-regulate total caloric intake; and having regular family meals to promote social interaction and role model food-related behavior.
The guidelines also provide nutritional strategies for schools and discuss legislation being considered to improve children’s nutrition.
Some of the guidelines authors report various financial arrangements with the U.S. Department of Agriculture; National Institutes of Health; Dairy Management Inc.; National Cattlemen’s Beef Association; Mars, Inc.; National Dairy Council Speakers Bureau; Brands Global Advisory Council on Health, Nutrition and Fitness; U.S. Potato Board; Cadbury; Grain Foods Foundation; and/or International Food Information Council.
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:
According to the current authors, recent research has shown an increase in overweight and obese children with an increase in risk factors for cardiovascular disease, and it is estimated that 75% to 90% of the current cardiovascular disease epidemic is related to dyslipidemia, tobacco use, inactivity, and obesity. Poor nutrition is a contributor to these risk factors. The health strategy of education with support of the healthcare community and health policy change, is central to reducing cardiovascular risk. The AHA has revised its 1982 document on dietary recommendations for children to reflect total caloric intake and eating behaviors and to follow a consensus statement on chronic diseases of adulthood published by Krauss and colleagues in the Oct. 31, 2000, issue of Circulation.
The current guidelines make use of recent studies addressing the role of interventions that influence cardiovascular risk in children, with the limitation that generalization from feeding behaviors at younger ages may not be appropriate.
Pearls for Practice