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.

Circulation. 2005;112:2061-2075

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

• Describe age-specific updated AHA dietary guidelines for children.
• Identify key points in management of hypercholesterolemia, obesity, and other cardiovascular risk factors in children.

Clinical Context

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.

Study Highlights

• General dietary recommendations for children age 2 years and older stress fruits and vegetables, whole grains, low-fat and nonfat dairy products, beans, fish, and lean meat.
• The guidelines follow recommendations for adults for lower intakes of trans and saturated fats, cholesterol, and added sugar and salt; physical activity; and maintenance of normal weight for height.
• The guidelines follow from observations that overweight, hypercholesterolemia, and hypertension track from childhood into adult life and that lifestyle choices (such as nutrition, physical inactivity, and smoking) influence these risk factors.
• Calorie estimates with serving sizes provided in a table are based on age group (1 year, 2 – 3 years, 4 – 8 years, 9 – 13 years, and 14 – 18 years), consistent with the Dietary Guidelines for Americans 2005.
• Guidelines for 1-year-old children include 2%-fat milk instead of fat-free milk. For those aged 3 years or older, daily caloric intakes are based on a sedentary lifestyle.
• Micronutrient intake guides are provided in a table.
• A more liberal intake of unsaturated fat with a focus on adequate omega-3 fatty acid intake and increased fiber intake is recommended.
• The AHA in agreement with the U.S. Food and Drug Administration (FDA) advises limiting fish intake in women who may become pregnant or lactating and in young children owing to concerns about potential polycarbonate phenols and mercury contamination. These individuals should avoid shark, swordfish, king mackerel, and tilefish because of high levels of mercury.
• Five fish types low in mercury are shrimp, canned light tuna, salmon, Pollack, and catfish.
• 2 servings of fish weekly are recommended by the AHA.
• A distinction is made between essential and discretionary calories to account for different levels of physical activity. The discretionary caloric intake increase recommended for physical activity ranges from 100 to 150 calories to 200 to 500 calories.
• Pediatric studies confirm adult studies‘ conclusions that restricting saturated fat intake from 10% to 7% may reduce low-density lipoprotein cholesterol by as much as 16%.
• Total fat intake in children may be restricted to less than 30% of total calories and cholesterol intake to less than 200 mg daily with no adverse effects on growth, neurologic development, metabolic function, and nutrient adequacy observed.
• Although breast-feeding initiation rate is high at 76%, maintenance of breast-feeding among U.S. women has been poor with less than 17% of infants breast-fed at 6 months. Of concern are intake of baked desserts, fried foods, and sweetened beverages and decreases in fruit intake in children of infant and toddler age.
• Patient education should address cultural beliefs.
• Children whose mothers are obese early in pregnancy are twice as likely to be overweight as young children. Low-birth weight, large for gestational age, and rapid weight gain in the first 4 to 6 months of life are risk factors for later obesity.
• Physicians should counsel mothers to breast-feed and identify rapid weight gain to help correct overfeeding.
• Children with increased self-regulation of diet at an early age may better withstand the current food surplus environment.
• The AHA recommends that parents choose meal times, promote social interaction and parental role modeling for eating behaviors during meal times, use low-fat dairy products as sources of calcium and protein, give recommended portion sizes, and limit video and television watching to less than 2 hours daily.

Pearls for Practice

• Key recommendations of the AHA dietary guidelines for children are based on prevention of obesity with maintenance of healthy weight, regulation of trans and saturated fat intake, and increase in fruit, vegetable, fiber, and fish intake.
• To reduce cardiovascular risk, the AHA recommends that parents choose meal times, promote social interaction and parental role modeling for eating behaviors during meal times, use low-fat dairy products as sources of calcium and protein, give recommended portion sizes, and limit video and television watching to less than two hours daily.