Nutrition For Healthy Children and Adolescents Ages 2 To 18 Years

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Nutrition for Healthy Children and Adolescents
Ages 2 to 18 Years
Suzanne Domel Baxter
Physical Growth and Development

A child’s first year of life is marked by rapid growth, with birth weight tripling and birth
length increasing by 50%. After the rapid growth of the first year, physical growth slows
down considerably during the preschool and school years, until the pubertal growth spurt
of adolescence. Birth weight does not quadruple until two years of age, and birth length
does not double until four years of age. A one-year-old child has several teeth, and his/
her digestive and metabolic systems are functioning at or near adult capacity. By one year
of age, most children are walking or beginning to walk; with improved coordination over
the next few years, activity increases dramatically. Although increased activity in turn
increases energy needs, a child’s rate of growth decreases. Growth patterns vary in indi-
vidual children, but each year children from two years to puberty gain an average of 4
1/2 to 6 1/2 pounds (2 to 3 kg) in weight and 2 1/2 to 3 1/2 inches (6 to 8 cm) in height.
As the growth rate declines during the preschool years, a child’s appetite decreases and
food intake may become unpredictable and erratic. Parents and other caregivers need to
know that these changes are normal so that they can avoid struggles with children over
food and eating.
After the first year of life, more significant development occurs in fine and gross motor,
cognitive, and social-emotional areas than during the first year of life. During the second
year of life, children learn to feed themselves independently. By 15 months of age, children
can manage a cup, but with some spilling. At 18 to 24 months of age, children learn to
tilt cups by manipulating their fingers. Children are able to transfer food from bowls to
their mouths with less spilling by 16 to 17 months of age, when well-defined wrist rotation
develops. However, two-year-old children often prefer foods that can be picked up with
their fingers without having to chase it across their plates.
The normal events of puberty and the simultaneous growth spurt are the primary
influences on nutritional requirements during the second decade of life. During puberty,
height and weight increase, many organ systems enlarge, and body composition is altered
due to increased lean body mass and changes in the quantity and distribution of fat. The
© 2002 by CRC Press LLC

242 Handbook of Nutrition and Food
timing of the growth spurt is influenced by genetic as well as environmental factors.

Children who weigh more than average for their height tend to mature early, and vice
versa. Although stature tends to increase most rapidly during the spring and summer,
weight tends to increase either at a fairly steady rate over the entire year or undergoes a
more rapid increase during the autumn. The most rapid linear growth spurt for an average
American boy occurs between 12 and 15 years of age. For the average American girl, the
growth spurt occurs about two years earlier, between 10 and 13 years of age. The growth
spurt during adolescence contributes about 15% to final adult height, and approximately
50% to adult weight. During adolescence, boys tend to gain more weight than girls, and
gain it at a faster rate. Furthermore, the skeletal growth of boys continues for a longer
time than that of adolescent girls. Adolescent boys deposit more muscle mass, and ado-
lescent girls deposit relatively more total body fat. Menarche, which is closely linked to
the growth process, has a lasting impact on nutritional requirements of adolescent girls.
Adolescence is a period of various cognitive challenges. For example, when an adoles-
cent realizes that his or her body is in the process of maturing, he or she may begin to
assess changes in his or her own body size and shape, compare them with those of others,
and form opinions about any differences. Adolescent girls and boys may be very self-
conscious, especially during early and mid-adolescence. According to Piaget’s develop-
mental levels, it is usually during adolescence that abstract thinking supersedes concrete
thinking. Thus, an adolescent may consider his or her body not just as it is, but also as it
might be. In addition, an adolescent can contemplate new or different ways of combining
or eating food. Furthermore, an adolescent can more easily conceptualize nutrients such
as calories and fat, and skillfully manipulate their dietary intake.
Energy and Nutrient Needs

Dietary Reference Intakes and Recommended Dietary Allowances
The Dietary Reference Intakes (DRIs) expand and replace the series of Recommended
Dietary Allowances (RDAs) published beginning in 1941 through 1989 by the Food and
Nutrition Board.1 Although previous RDAs focused on preventing classical nutrient
deficiencies, the DRIs go beyond this to include current knowledge about the role of
nutrients and food components in long-term health. The DRIs are reference values that
are quantitative estimates of nutrient intakes to be used for planning and assessing diets
for healthy people in America and Canada.2 The DRIs include RDAs as goals for intake
by individuals, but also present the following new types of reference values: Estimated
Average Requirement (EAR), Adequate Intake (AI), and Tolerable Upper Intake Level
(UL); these are discussed in detail in another section. Briefly, within the DRI framework,
the RDA serves as a goal for individuals; it is the average daily dietary intake level that
is sufficient to meet the nutrient needs of almost all (97 to 98%) healthy individuals in a
lifestage and gender group. The EAR is a nutrient intake value that is estimated to meet
the nutrient needs of 50% of the healthy individuals in a lifestage and gender group; it
is used to assess adequacy of intakes of population groups, and to develop RDAs. The
AI is used instead of an RDA when sufficient scientific evidence is not available to
calculate an EAR; the AI is based on observed or experimentally determined approxima-
tions of nutrient intake by a lifestage and gender group (or groups) of healthy people.
The UL is the highest level of nutrient intake per day that is likely to pose no risks of
adverse health effects to almost all individuals in the general population. The risk of

Nutrition for Healthy Children and Adolescents Ages 2 to 18 Years 243
TABLE 8.1
Recommended Levels for Individual Intakea for Children and Adolescents
Children Boys Girls
1–3 years 4–8 years 9–13 years 14–18 years 9–13 years 14–18 years
Calcium (mg/d) 500* 800* 1300* 1300* 1300* 1300*
Phosphorus (mg/d) 460 500 1250 1250 1250 1250
Magnesium (mg/d) 80 130 240 410 240 360
Vitamin D (µg/d)bc 5* 5* 5* 5* 5* 5*
Fluoride (mg/d) 0.7* 1* 2* 3* 2* 3*
Thiamin (mg/d) 0.5 0.5 0.9 1.2 0.9 1.0
Riboflavin (mg/d) 0.5 0.6 0.9 1.3 0.9 1.0
Niacin (mg/d)d 6 8 12 16 12 14
Vitamin B6 (mg/d) 0.5 0.6 1.0 1.3 1.0 1.2
Folate (µg/d)e,f 150 200 300 400 300 400
Vitamin B12 (µg/d) 0.9 1.2 1.8 2.4 1.8 2.4
Pantothenic acid (mg/d) 2* 3* 4* 5* 4* 5*
Biotin (µg/d) 8* 12* 20* 25* 20* 25*
Choline (mg/d)g 200* 250* 375* 550* 375* 400*
Vitamin C (mg/d) 15 25 45 75 45 65
Vitamin E (mg/d of α- 6 7 11 15 11 15
tocopherol)h
Selenium (µg/d) 20 30 40 55 40 55
Vitamin A (µg/d) 300 400 600 900 600 700
Vitamin K (µg/d) 30* 55* 60* 75* 60* 75*
Chromium (µg/d) 11* 15* 25* 35* 21* 24*
Copper (µg/d) 340 440 700 890 700 890
Iodine (µg/d) 90 90 120 150 120 150
Iron (mg/d)i 7 10 8 11 8 15
Manganese (mg/d) 1.2* 1.5* 1.9* 2.2* 1.6* 1.6*
Molybdenum (µg/d) 17 22 34 43 34 43
Zinc (mg/d) 3 5 8 8 11 9
a Recommended Dietary Allowances (RDAs) are presented in bold type and Adequate Intakes (AIs) in ordinary
type followed by an asterisk (*). RDAs and AIs may both be used as goals for individual intake. RDAs are
set to meet the needs of almost all (97-98%) individuals in a group. The AI for other life-stage and gender
groups is believed to cover needs of all individuals in the group, but lack of data or uncertainty in the data
prevent being able to specify with confidence the percentage of persons covered by this intake. Adapted from:
Food and Nutrition Board, Institute of Medicine, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium,
Vitamin D, and Fluoride, National Academy Press, Washington, DC, 1997; Food and Nutrition Board, Institute
of Medicine, Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic
Acid, Biotin, and Choline, National Academy Press, Washington, DC, 1998; Food and Nutrition Board, Institute
of Medicine, Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids, National Academy
Press, Washington, DC, 2000; Food and Nutrition Board, Institute of Medicine, Dietary Reference Intakes for
Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon,
Vanadium, and Zinc, National Academy Press, Washington, DC, 2001.
b As cholecalciferol. 1 µg cholecalciferol = 40 IU vitamin D.
c In the absence of adequate exposure to sunlight.
d As niacin equivalents (NE). 1 mg niacin = 60 mg tryptophan.
e As dietary folate equivalent (DFE). 1 DFE = 1 µg food folate = 0.6 µg folic acid (from fortified food or
supplement) consumed with food = 0.5 µg synthetic (supplemental) folic acid taken on an empty stomach.
f In view of evidence linking folate intake with neural tube defects in the fetus, it is recommended that all
women capable of becoming pregnant consume 400 µg synthetic folic acid from fortified foods and/or
supplements in addition to intake of food folate from a varied diet.
g Although AIs have been set for choline, there are few data to assess whether a dietary supply of choline is
needed at all states of the life cycle, and it may be that the choline requirement can by met by endogenous
synthesis at some of these stages.
h DRIs for vitamin E are based on α-tocopherol only and do not include amounts obtained from the other seven
naturally occurring forms historically called vitamin E. RDAs and AIs apply only to intake of 2 R-stereoisomeric
forms of α-tocopherol from food, fortified food, and multivitamins.
i For girls under 14 years who have started to menstruate, one might advise an increased intake to approxi-
mately 2.5 mg/d to what would be advised for a girl of the same characteristics before menarche.

TABLE 8.2
Tolerable Upper Intake Levelsa,b (ULs) for Children and Adolescents
1–3 years 4–8 years 9–13 years 14–18 years
Calcium (g/d) 2.5 2.5 2.5 2.5
Phosphorus (g/d) 3 3 4 4
Magnesium (mg/d)c 65 110 350 350
Vitamin D (µg/d) 50 50 50 50
Fluoride (mg/d) 1.3 2.2 10 10
Niacin (mg/d)d 10 15 20 30
Vitamin B6 (mg/d) 30 40 60 80
Synthetic folic acid (µg/d)d 300 400 600 800
Choline (g/d) 1.0 1.0 2.0 3.0
Vitamin C (mg/d) 400 650 1200 1800
Vitamin E (mg/d α-tocopherol)e 200 300 600 800
Selenium (µg/d) 90 150 280 400
Vitamin A (µg/d performed A) 600 900 1700 2800
Copper (µg/d) 1000 3000 5000 8000
Iodine (µg/d) 200 300 600 900
Iron (mg/d) 40 40 40 45
Manganese (mg/d) 2 3 6 9
Molybdenum (µg/d) 300 600 1100 1700
Zinc (mg/d) 7 12 23 34
Boron (mg/d) 3 6 11 17
Nickel (mg/d soluble nickel salts) 0.2 0.3 0.6 1.0
Vanadium (mg/d)f
a UL = the maximum level of daily nutrient intake that is likely to pose no risk of adverse
effects. Unless otherwise specified, the UL represents total intake from food, water, and
supplements. Currently, ULs are not available for other nutrients. In the absence of ULs, extra
caution may be warranted in consuming levels above recommended intakes.
b Adapted from: Food and Nutrition Board, Institute of Medicine, Dietary Reference Intakes for
Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, National Academy Press, Washing-
ton, DC, 1997; Food and Nutrition Board, Institute of Medicine, Dietary Reference Intakes for
Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline,
National Academy Press, Washington, DC, 1998; Food and Nutrition Board, Institute of
Medicine, Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids, National
Academy Press, Washington, DC, 2000; Food and Nutrition Board, Institute of Medicine,
Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron,
Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc, National Academy Press, Wash-
ington, DC, 2001.
c The UL for magnesium represents intake from a pharmacological agent only and does not
include intake from food and water.
d The ULs for niacin and synthetic folic acid apply to forms obtained from supplements, fortified
foods, or a combination of the two.
e DRIs for vitamin E are based on α-tocopherol only and do not include amounts obtained from
the other seven naturally occurring forms historically called vitamin E. The ULs apply to any
form of supplementary α-tocopherol.
f The UL for adults is 1.8 mg/d of elemental vanadium. It was not possible to establish ULs
for children for vanadium, but the source of intake should be from food only.5
adverse effects increases as intake increases above the UL.2 Although the DRIs are based
on data, scientific judgment was required in setting all reference values because data
were often scanty or drawn from studies with limitations; this is especially true in
deriving DRIs for children and adolescents.2
In 1997, DRIs were published for calcium, phosphorus, magnesium, vitamin D, and
fluoride.2 In 1998, DRIs were published for thiamin, riboflavin, niacin, vitamin B6, folate,
vitamin B12, pantothenic acid, biotin, and choline.3 In 2000, DRIs were published for
vitamin C, vitamin E, and selenium.4 No DRIs were proposed for carotenoids, although

TABLE 8.3
1989 Recommended Dietary Allowances (RDAs) for Children and
Adolescents for Nutrients without Dietary Reference Intakesa
Weightb Heightb Calories Protein
Category Age (years) (kg) (lb) (cm) (in) (kcal/day) (g/day) (g/kg)
Children 1–3 13 29 90 35 1300 16 1.2
4–6 20 44 112 44 1800 24 1.1
7–10 28 62 132 52 2000 28 1.0
Boys 11–14 45 99 157 62 2500 45 1.0
15–18 66 145 176 69 3000 59 0.9
Girls 11–14 46 101 157 62 2200 46 1.0
15–18 55 120 163 64 2200 44 0.8
a Adapted from Food and Nutrition Board, National Research Council, Recom-
mended Dietary Allowances, 10th ed, National Academy Press, Washington, DC,
1989. The RDAs, expressed as average daily intakes over time, are intended
to provide for individual variations among most normal persons as they live
in the U.S. under usual environmental stresses. Diets should be based on a
variety of common foods in order to provide other nutrients for which human
requirements have been less well defined. The RDAs are designed for the
maintenance of good nutrition of practically all healthy people in the U.S.
b The median weights and heights of those under 19 years of age were taken
from Hamill, P. V. V., Drizd, T. A., Johnson, R. B., et al., Am J Clin Nutr, 32,
607, 1979. The use of these figures does not imply that the height-to-weight
ratios are ideal.
existing recommendations for increased consumption of carotenoid-rich fruits and vege-

tables are supported. However, β-carotene supplements are not advisable.4 In 2001, DRIs
were published for vitamin A, vitamin K, boron, chromium, copper, iodine, iron, manga-
nese, molybdenum, nickel, vadadium, and zinc.5 No DRIs were set for arsenic or silicon.5
For boron, nickel, and vanadium, ULs were proposed, but EARs, RDAs, or AIs were not
set.5 The RDAs and AIs for children and adolescents are provided in Table 8.1. The ULs
for children and adolescents are provided in Table 8.2. Additional groups of nutrients and
food components slated for review over the next several years include energy and macro-
nutrients, electrolytes, and other food components.2
Energy
Daily energy needs depend on three major factors: energy expended when at rest, during
physical activity, and as a result of thermogenesis. Resting energy expenditure is the largest
of the three factors unless the physical activity level is very high; thermogenesis is the
smallest. In turn, these factors are affected by individual variables which include age, sex,
body size and composition, genetics, energy intake, physiologic state (e.g., growth, preg-
nancy, lactation), coexisting pathological conditions, and ambient temperature.
Recommended energy allowances for children and adolescents from the 1989 RDAs are
stipulated as kilocalories (kcal)/day based on reference weights for children ages 1 to 10
years in three age groups for both genders combined, and for adolescents ages 11 to 18
years in two age groups for boys and girls separately (see Table 8.3). According to Heald
and Gong, the best way to calculate individual energy requirements for adolescents may
be to use kcal/centimeter (cm) of height; thus, boys 11 to 14 years of age need 15.9 kcal/
cm, boys 15 to 18 years of age need 17.0 kcal/cm, girls 11 to 14 years of age need 14.0
kcal/cm, and girls 15 to 18 years of age need 13.5 kcal/cm.6 In Table 8.4, energy require-
ments for children and adolescents from Pellett7 are stipulated in terms of kcal/day (mean

TABLE 8.4
Energy Requirements for Children and Adolescentsa
Estimated Energy Allowance
Age Weightb Height By Time By Weight By Height
(years) (kg) (cm) (kcal/d (range)) (kcal/kg) (kcal/cm)
Children
1–1.9 11 82 1200 (900–1600) 105 14.0

2–3.9 14 96 1400 (1100–1900) 100 14.6
4–5.9 18 109 1700 (1300–2300) 92 15.6
6–7.9 22 121 1800 (1400–2400) 83 14.9
8–9.9 28 132 1900 (1400–2500) 69 14.4
Boys
10–11.9 36 143 2200 (1700–2900) 61 15.4

12–17.9c 57 169 2700 (2000–3600) 47 16.0
Girls
10–14.9 44 155 2200 (1700–2900) 50 14.2

15–17.9c 56 162 2300 (1700–3000) 41 14.2
a Adapted from Pellett, P. L., Am J Clin Nutr, 51, 711, 1990. Data originate from
original median weights and heights (see original document).
b Weight is rounded to nearest kilogram for age.
c During these years, individual growth rates can vary enormously; thus, allow-
ances should be based on individual weights and the requirements per kg body
weight.
and range), kcal/kilogram (kg), and kcal/cm for children ages 1 to 9.9 years in five groups
for both genders combined, for adolescent boys ages 10 to 17.9 years in two groups, and
for adolescent girls ages 10 to 17.9 years in two groups.
Physical activity patterns are quite variable among children and adolescents, and there
is considerable variability in both the timing and magnitude of the growth spurt. Thus,
recommended energy allowances for children and adolescents assume a wide range within
which energy can be adjusted individually to account for body weight, activity, and rate
of growth. An accepted and practical method for assessing the adequacy of a child’s or
adolescent’s energy intake is to monitor growth by tracking height and weight on growth
charts developed by the National Center for Health Statistics; these charts are provided
in Section 32.
Protein
Protein is essential for growth, development, and maintenance of the body; it also provides
energy. Protein yields 4 kcal/gram (g). Food sources of protein include meat, fish, poultry,
milk, cheese, yogurt, dried beans, peanut butter, nuts, and grain products. Animal proteins
are called “high-quality” or “complete” because they contain all the essential amino acids
in the proportions needed by humans. Vegetable proteins, with the exception of soybeans,
are called “low-quality” or “incomplete” because they have low levels of one or more
essential amino acids. A vegetable protein may be paired with another vegetable protein
or with a small amount of animal protein to provide adequate amounts of all the essential
amino acids. For example, black-eyed peas can be paired with rice, peanut butter with
wheat bread, pasta with cheese, or cereal with milk.

Proteins in the body are continuously being degraded and resynthesized. Because the
process is not entirely efficient and some amino acids are lost, a continuous supply of
amino acids is needed to replace these losses, even after growth has stopped. The primary
factor that influences protein needs is energy intake because when energy intake is insuf-
ficient, protein is used for energy. Thus, all protein recommendations are based on the
assumption that energy needs are adequately met. In addition, protein recommendations
are based on high-quality protein intakes; appropriate corrections must be made for diets
which customarily provide low-quality proteins.
Table 8.3 provides the 1989 RDAs for high-quality protein in g/day and g/kg of body
weight for children and adolescents. As Table 8.3 indicates, requirements slowly decline
relative to weight during the preschool and elementary school-age years. During the
adolescent years, protein recommendations do not emphasize the growth spurt because
it is small relative to body size. A 14-year-old adolescent who weighs 54 kilograms (kg)
(118.8 pounds) needs 54 g of protein each day; assuming that energy needs are met, this
protein need is met by eating a hamburger (3-ounce meat patty on a bun) and two slices
of cheese pizza.
According to Heald and Gong,6 the most useful method for determining protein needs
for adolescents is to use the 1989 RDAs for protein as they relate to height. For adolescent
boys ages 11-14 and 15-18 years, the protein daily recommendation based on height is
0.29 and 0.34 g/cm height, respectively. For adolescent girls ages 11-14 and 15-18 years,
the protein daily recommendation based on height is 0.29-0.27 g/cm height, respectively.6
Carbohydrates
Children and adolescents should get 55-60% of their daily calories from carbohydrates.8
Complex carbohydrates (starchy foods such as pasta, breads, cereals, rice, and legumes)
should provide the majority of kcal from carbohydrates, and simple carbohydrates (nat-
urally occurring sugars in fruits and vegetables) should provide the rest. Carbohydrate
yields 4 kcal/g. A 4- to 6-year-old child who needs 1800 kcal/day would need about 990
to 1080 kcal (or 248 to 270 g) from carbohydrates daily. An 11- to 14-year-old adolescent
who needs 2500 kcal/day would need about 1375 to 1500 kcal (or 344 to 375 g) from
carbohydrates daily.
Fat and Cholesterol

To promote lower cholesterol levels in all healthy U.S. children ages 2-18 years, the
American Academy of Pediatrics recommends that children older than two years should
gradually adopt a diet that by the age of five years reflects the following five guidelines.9
1. Nutritional adequacy should be achieved by eating a wide variety of foods.

2. Caloric intake should be adequate to support growth and development and to
reach or maintain desirable body weight.
3. Total fat intake over several days should be no more than 30% of total calories
and no less than 20% of total calories.
4. Saturated fat intake should be less than 10% of total calories.
5. Dietary cholesterol intake should be less than 300 milligrams (mg) per day.9
These recommendations are consistent with those of the Dietary Guidelines for Americans,
which were designed to provide advice for healthy Americans age two years and over

about food choices that promote health and prevent disease.10 A precise percentage of
dietary fat intake that supports normal growth and development while maximally reduc-
ing atherosclerosis risk is unknown. Thus, a range of appropriate values averaged over
several days for children and adolescents is recommended based on the available scientific
information. More information regarding the safety of low-fat diets for children is found
in “Low Fat Diets” in this section.
Fat yields 9 kcal/g. Dietary sources of fat include oils, margarine, butter, fried foods,
egg yolks, mayonnaise, salad dressings, ice cream, hard cheese, cream cheese, nuts, fatty
meats, chips, and doughnuts. Table 8.5 provides the fat, saturated fat, and cholesterol
content of various foods.
TABLE 8.5
Total Fat, Saturated Fat, and Cholesterol Content of Various Foods
Total Saturated Cholesterol
Food Amount Fat (g) Fat (g) (mg) Kcal
Almonds, roasted, salted 1 oz 15.3 1.1 0 172
Bacon 2 slices 6.3 2.2 11 73
Bread, white 1 slice 0.9 0.0 0 64
Butter 1t 4.1 2.5 11 36
Cheese, American 1 oz 8.9 5.6 27 106
Cheese, cheddar 1 oz 9.4 6.0 30 114
Chicken breast with skin, roasted 1/2 breast 7.6 2.2 83 193
Chicken breast without skin, roasted 1/2 breast 3.1 0.9 73 142
Coconut, dried, sweetened, flaked 1/3 c 8.1 7.2 0 115
Corn oil 1t 13.6 1.7 0 120
Cottonseed oil 1t 13.6 3.5 0 120
Egg, whole, boiled 1 large 5.3 1.6 213 77
Egg, white only, boiled 1 large 0.0 0.0 0 17
Egg, yolk only, boiled 1 large 5.1 1.6 213 59
Fish, flounder or sole, cooked 3 oz 1.3 0.3 58 99
Ground beef, regular, broiled 3.5 oz 19.5 7.7 101 292
Ground beef, extra lean, broiled 3.5 oz 15.8 6.2 99 265
Ice cream, vanilla, 10% fat 1/2 c 7.3 4.5 29 132
Ice milk, vanilla 1/2 c 2.8 1.7 9 92
Lard (pork fat) 1t 12.8 5.0 12 115
Margarine, corn & hydrogenated corn 1t 3.8 0.7 0 34
Margarine, liquid oil 1t 3.8 0.7 0 34
Milk, whole 1 cup 8.2 5.1 33 150
Milk, 2% 1 cup 4.7 2.9 18 121
Milk, 1% 1 cup 2.6 1.6 10 102
Milk, skim 1 cup 0.4 0.3 4 86
Olive oil 1t 13.5 1.8 0 119
Peanut butter 2t 16.0 3.1 0 188
Peanuts, dry roasted 1 oz 13.9 1.9 0 164
Pecans, raw 1 oz 19.0 2.0 0 190
Pork, lean, roasted 3.5 oz 4.8 1.7 93 166
Safflower oil 1t 13.6 1.2 0 120
Shrimp, boiled 3 oz 0.9 0.2 166 84
Soybean oil 1t 13.6 2.0 0 120
Tuna fish, oil pack, drained 3 oz 7.0 1.3 15 169
Tuna fish, water pack, drained 3 oz 0.7 0.2 25 99
Turkey breast with skin, roasted 3.5 oz 3.5 1.0 42 126
Yogurt, frozen, vanilla, soft serve 1/2 c 4.0 2.5 2 114
Adapted from Bowes, A. D. P., Bowes and Church’s Food Values of Portions Commonly Used, 16 ed,
revised by Pennington, J. A. T., J. B. Lippincott Company, Philadelphia, 1994.

TABLE 8.6
Fiber Content of Foods that Most U.S. Children and
Adolescents Will Eat
Approximate grams of
Food source Serving size dietary fiber
Baked Beans 1c 13
Chili with beans 1c 7
Refried beans 4 oz 6
Brown rice 1c 4
Peanuts (dry roasted) 2 oz 4
Strawberries 1c 4
Whole-wheat bread 2 slices 4
Potato, baked, with skin 1 medium 3.5
Apple 1 medium 3
Banana 1 large 3
Carrot (raw) 1 medium 3
Corn 1/2 c 3
Kiwi 1 large 3
Raisins 1/3 c 3
Whole-grain crackers 1/2 oz 2–3
Cereal 1c 2–3a
Applesauce 1/2 c 2
Broccoli 1/2 c 2
Orange 1 medium 2
Peanut butter 2 Tbsp 2
a Dietary fiber content of cereal varies widely. Best fiber choice for
children has 3+ g per cup.
b Adapted from Williams, C. L., J Am Diet Assoc, 95, 1140, 1995.
Fiber
Fiber has important health benefits such as promoting normal laxation which can be a
problem for many children. In addition, fiber may help reduce the risk of certain chronic
diseases of adulthood such as some cancers, cardiovascular disease, and diabetes. The
American Health Foundation recommends that children ages two years and older consume
a minimal amount of fiber equal to their age plus 5 g/day, and a maximum amount of
age plus 10 g/day, to achieve intakes of a maximum of 35 g/day after the age of 20 years.11,12
This range is thought to be safe even if intake of some vitamins and minerals is marginal.
According to the American Academy of Pediatrics,13 a reasonable daily fiber intake for
children is 0.5 g/kg of body weight to a maximum of 35 g/day. The two recommendations
are similar for children up to age 10 years, but the age plus 5 recommendation is lower
for older adolescents than the recommendation for 0.5 g/kg of body weight.
Fiber intake should be increased gradually through consumption of a variety of fruits,
vegetables, legumes, cereals, and other whole-grain products such as breads and crackers.
Fiber supplements for children are not recommended as a means of meeting dietary fiber
goals.11 Increased intakes of dietary fiber should be accompanied by increased intakes of
water because dietary fiber increases water retention in the colon, which leads to bulkier
and softer stools.11 For most children and adolescents, dietary fiber goals can be met if the
daily diet includes two servings of vegetables, three servings of fruits, two slices of whole
wheat bread, and a serving of breakfast cereal containing three or more grams of fiber.12
Table 8.6 provides a list of foods containing fiber that most U.S. children and adolescents
will eat.

High-fiber diets do have the potential for reduced energy density, reduced kcal intake,
and poor growth, especially in very young children. Furthermore, high-fiber diets may
reduce the bioavailability of minerals such as iron, calcium, and zinc. However, the
potential health benefits of a moderate increase in dietary fiber intake in childhood are
thought to outweigh the potential risks significantly, especially in highly industrialized
countries such as the U.S.11
Selected Vitamins and Minerals

Vitamin D
Throughout the world, the major source of vitamin D for humans is the exposure of the
skin to sunlight; vitamin D that is synthesized in the skin during the summer and fall
months can be stored in the fat for use in the winter, which minimizes requirements for
vitamin D. In nature, very few foods contain vitamin D; thus, children and adolescents
who live in far northern latitudes (e.g., northern Canada and Alaska) may need vitamin
D supplements. Food sources of vitamin D include some fish liver oils, eggs from hens
that have been fed vitamin D, the liver and fat from aquatic mammals such as seals and
polar bears, and the flesh of fatty fish. Foods fortified with vitamin D include milk products
and other foods such as margarine and breakfast cereals; the majority of human intake of
vitamin D is from fortified foods. Fortified milk is supposed to contain 10 µg (400 IU) per
quart regardless of the fat content of milk; however, several recent surveys have indicated
that many milk samples contained less than 8 µg per quart. Although it is well recognized
that vitamin D deficiency causes abnormalities in calcium and bone metabolism, it is
premature to suggest that cancer risk is increased by vitamin D deficiency. The AIs for
vitamin D for children and adolescents (see Table 8.1) were set to cover the needs of almost
all children and adolescents regardless of exposure to sunlight. Currently, there is no
scientific evidence that demonstrates an increased requirement for vitamin D during
puberty even though metabolism of vitamin D increases during puberty to enhance intes-
tinal calcium absorption to provide adequate calcium for the rapidly growing skeleton.2
Folate
Folate is important during periods of increased cell replication and growth due to its role
in DNA synthesis and the formation of healthy red blood cells; thus, the 1998 RDAs for
folate are 1.5 times greater for children age 9 to 13 years than for children age 4 to 8 years
(see Table 8.1). There is strong evidence that the risk of having a fetus with a neural tube
defect decreases with increased intake of folate during the periconceptional period; thus,
it is recommended that all women capable of becoming pregnant take 400 µg of synthetic
folic acid daily, from fortified foods and/or supplements, in addition to consuming food
folate from a varied diet. Folate fortification became mandatory for enriched grain products
in the U.S. effective January 1, 1998. Besides fortified grains and cereals, other food sources
of folate include leafy green vegetables, orange juice, liver, cantalope, yeast, and seeds.3
Calcium
Over 99% of total body calcium is found in teeth and bones. Approximately 45% of adult
skeletal mass is accounted for by skeletal growth during adolescence; thus, achieving and
maintaining adequate calcium intake during adolescence is necessary for the development
of a maximal peak bone mass which may help reduce the risk of osteoporosis later in
adulthood.

TABLE 8.7
Approximate Calcium Content for One Serving of Various Foods
Approximate Calcium Content
Food Serving Size (mg)
Cheese (Swiss) 1.5 oz 405
Cheese (cheddar or jack) 1.5 oz 310
Milk (whole, 1%, 2%, or buttermilk) 1c 300
Yogurt 8 oz 300
Cheese (part skim mozzarella) 1.5 oz 280
Tofu, raw, firm 1/2 c 260
Cheese (American) 2 oz 250
Calcium-fortified orange juice 6 oz 200
Canned sardines (with bones) 2 oz 180
Canned salmon (with bones) 3 oz 180
Cooked greens (collards) 1/2 c 180
Pudding 1/2 c 150
Spinach (cooked) 1/2 c 120*
Frozen yogurt (vanilla, soft serve) 1/2 c 100
Ice cream (vanilla, 10% fat) 1/2 c 85
Cooked greens (mustard, kale) 1/2 c 80
Cottage cheese 1/2 c 75
Spinach (raw) 1c 60*
Orange 1 medium 55
Beans, canned (baked, pinto, or navy) 1/2 c 50
Sweet potatoes (mashed) 1/2 c 40
Broccoli (cooked) 1/2 c 35
Broccoli (raw) 1/2 c 20
* The calcium from spinach is essentially nonbioavailable.
Adapted from Bowes, A. D. P., Bowes and Church’s Food Values of Portions Commonly Used,
16th ed, revised by Pennington, J. A. T., J. B. Lippincott Company, Philadelphia, 1994.
The calcium AIs for adolescents are higher than for children because from age 9 through
18 years (see Table 8.1), calcium retention increases to a peak and then declines. However,
the calcium AIs remain the same for adolescents from age 9 to 18 years because calcium
absorption efficiency decreases. Thus, during this developmental period, measures of
sexual maturity are better predictors of calcium retention than chronological age.2
Major food sources of calcium include milk, yogurt, cheese, and green leafy vegetables.
Calcium-fortified orange juice is also an excellent source of calcium, as is tofu. Table 8.7
contains approximate calcium contents for one serving of various common foods. Vitamin
D (discussed previously in this section) is needed for the body to absorb calcium.
The calcium content of food is generally of greater importance than bioavailability when
evaluating food sources of calcium. The efficiency of calcium absorption is fairly similar
from most foods, including milk and milk products and grains, which are major food
sources of calcium in North American diets. Calcium may be poorly absorbed from foods
such as spinach, beans, sweet potatoes, and rhubarb which are rich in oxalic acid, and
from unleavened bread, raw beans, seeds, nuts and grains, and soy isolates which are rich
in phytic acid. Calcium absorption is relatively high from soybeans, although they contain
large amounts of phytic acid. Compared to calcium absorption from milk, calcium absorp-
tion from spinach is about one tenth, and from dried beans is about half.2
When developing the AIs for calcium, the Food and Nutrition Board of the Institute of
Medicine reviewed concerns regarding factors that affect the calcium requirement.2 For
example, they discussed racial differences in calcium metabolism, that sodium and calcium
excretion are linked in the proximal renal tubule and that many commonly consumed
processed foods are high in sodium, that protein increases urinary calcium excretion, that

caffeine has a modest negative impact on calcium retention, that calcium bioavailability
is reduced in vegetarian diets due to the high oxalate and phytate content, and that exercise
and calcium both influence bone mass. However, the Board concluded that available
evidence did not warrant different calcium intake requirements for individuals according
to their race, sodium consumption, protein intake, caffeine intake, level of physical activity,
or for individuals who consume a vegetarian diet.2
Children and adolescents (and adults) with lactose intolerance develop symptoms of
diarrhea and bloating after ingesting large doses of lactose such as the amount present in
a quart of milk (~46 g). People who generally are lactose digesters include Northern
Europeans, Finns, Hungarians, probably Mongols, the Fulani and Tussi tribes of Africa,
and the Punjabi of India; the remainder of the world’s population are lactose nondigest-
ers.14 However, as digesters intermix reproductively with nondigesters, the rate of lactose
malabsorption falls.14 In general, evidence for lactose malabsorption as a clinical problem
is not manifest until after five to seven years of age, although this age can vary.14 Individ-
uals with lactose intolerance can increase their tolerance to dairy products by drinking
smaller doses of milk (such as eight ounces), or by ingesting fermented products such as
yogurt, hard cheeses, cottage cheese, and acidophilus milk.14 In addition, lactose-free dairy
products are available. Although lactose intolerance may influence intake, lactose-intol-
erant individuals absorb calcium normally from milk; thus, there is no evidence to suggest
that it influences the calcium requirement.2
Iron
According to the American Academy of Pediatrics,15 iron deficiency is the most common
nutritional deficiency in the U.S. Children aged one to two years are the most susceptible
to iron deficiency due to increased iron needs related to rapid growth during the first
two years of life and a relatively low iron content in most infant diets when iron is not
added by supplementation or fortification. Children age 3 to 11 years are at less risk for
iron deficiency until the rapid growth of puberty. Preadolescent school-age children who
consume a strict vegetarian diet are at greater risk for iron deficiency anemia. Adolescent
boys are at risk for iron deficiency anemia during their peak growth period when iron
stores may not meet the demand of rapid growth; however, the iron deficiency anemia
generally corrects itself after the growth spurt. Adolescent girls are at greater risk for
iron deficiency anemia due to blood losses during menstruation. A major consequence
of iron deficiency is that significant iron deficiency adversely affects child development
and behavior. Furthermore, iron deficiency leads to enhanced lead absorption, and
childhood lead poisoning is a well-documented cause of neurologic and developmental
deficits. These consequences, along with evidence that dietary intake during infancy is
a strong determinant of iron status for older infants and younger children, emphasize
the importance of prevention. Significant improvements have been made in the iron
nutritional status of infants and young children in the U.S. during the past two decades,
perhaps because during this same time frame, several changes were made in infant
feeding patterns.15 These changes included increased dietary iron content or iron bio-
availability, increased incidence of breastfeeding, increased use of iron-fortified formula,
and reduced use of whole milk and low-iron formula during the first year of life.15
Dietary iron is classified as “heme” or “non-heme” iron. Heme iron is found in foods
from animals such as meat, fish, and poultry. Non-heme iron is provided by plants; good
sources include dark-green leafy vegetables, tofu, lentils, white beans, dried fruits, and
iron-fortified breads and cereals. On average, healthy people absorb about 5 to 10% of
the iron consumed, and people who are iron deficient absorb about 10 to 20%. Heme iron
is more easily absorbed than non-heme iron. About 20% of heme iron consumed is

absorbed regardless of how it is prepared and served; however, the absorption rate of
non-heme iron can be increased by eating foods with non-heme iron with either meat,
foods rich in vitamin C, or foods that contain some heme iron at the same meal. Non-
heme iron absorption can be hindered by as much as 50% when tannins, phytates, and
calcium (which are found in foods such as tea, bran, and milk, respectively) are eaten at
the same meal.
The RDAs for iron for children and adolescents are included in Table 8.1. Because the
amount of iron available in the American diet is estimated to be about 5 to 7 mg/1000
kcal, it may be difficult for adolescent girls to obtain 15 mg of iron from dietary sources
alone if their caloric intake is between 2000 and 2400 kcal/day. Groups of adolescents at
special risk of iron deficiency include 1) older adolescent girls due to their increased iron
need and their low dietary intake, 2) pregnant adolescents, and 3) girl athletes such as
runners who may lose iron through occult gastrointestinal bleeding.
The Committee on the Prevention, Detection, and Management of Iron Deficiency Ane-
mia Among U.S. Children and Women of Childbearing Age was established under the
Food and Nutrition Board of the Institute of Medicine; its recommended guidelines were
published in 1993.16 The committee concluded that iron enrichment and fortification of
the U.S. food supply should remain at current levels rather than increasing or decreasing
the levels. Furthermore, it was recommended that dietary sources of iron be consumed
instead of supplemental sources when possible. Iron supplements should be kept out of
reach of children because iron is a very common cause of poisoning in children.16
Zinc
Zinc is needed for protein synthesis, wound healing, and sexual maturation; thus, zinc is
especially important during adolescence due to the rapid rate of growth and sexual
maturation.6 (See Table 8.1 for the RDAs for zinc for children and adolescents.) Adolescents
undergoing rapid growth are at risk for inadequate zinc levels, and should be encouraged
to include zinc-rich foods in their daily diet. Foods high in zinc include red meats, certain
seafood, and whole grains; many breakfast cereals are fortified with zinc. The bioavail-
ability of zinc in foods varies widely. Zinc from whole grain products is less available
than zinc from meat, liver, eggs, and seafood (especially oysters). Furthermore, consump-
tion of phytate-rich foods limits absorption and maintenance of zinc balance.5
Food Guide Pyramid for Young Children

Figure 8.1 illustrates the Food Guide Pyramid for Young Children released by the United
States Department of Agriculture (USDA) in March, 1999.17 The pyramid targets children
two to six years of age; it is an adaptation of the original Food Guide Pyramid18 released
in 1992. The purpose of the new pyramid is to simplify educational messages and focus
on young children’s food preferences and nutritional needs. The new pyramid was devel-
oped by adapting existing food guidance recommendations to meet the specific needs of
young children after actual food patterns of young children were analyzed by USDA’s
Center for Nutrition Policy and Promotion. Table 8.8 provides an overview of changes
made in the new pyramid. The new pyramid continues to emphasize eating a variety of
foods. However, it de-emphasizes fat restriction, recognizing that some fats are necessary
for early growth and development.

Guide P Y R A M I D
F O O D
A Daily Guide for
2-to 6-Year-Olds
U.S. Department of Agriculture USDA is an equal opportunity provider and employer.

Center for Nutrition Policy and Promotion
January 2000
Program Aid 1651
W H AT C O U N T S A S O N E S E R V I N G ?
GRAIN GROUP FRUIT GROUP MEAT GROUP
1 slice of bread 1 piece of fruit or melon wedge 2 to 3 ounces of cooked lean
1/2 cup of cooked rice or pasta 3/4 cup of juice meat, poultry, or fish.
FOOD IS FUN and learning about food 1/2 cup of cooked cereal
1 ounce of ready-to-eat cereal

1/2 cup of canned fruit
1/4 cup of dried fruit 1/2 cup of cooked dry beans,
or 1 egg counts as 1 ounce of lean

is fun, too. Eating foods from the Food VEGETABLE GROUP MILD GROUP meat. 2 tablespoons of peanut
1/2 cup of chopped raw butter count as 1 ounce of meat.
Guide Pyramid and being physically or cooked vegetables
1 cup of milk or yogurt
2 ounces of cheese
1 cup of raw leafy vegetables
active will help you grow healthy and FATS AND SWEETS
Limit calories from these.
strong.
Four- to 6-year-olds can eat these serving sizes. Offer 2- to 3-year-olds less, except for milk.
Two- to 6-year-old children need a total of 2 servings from the milk group each day.
E AT a variety of F O O D S AND ENJOY!

FIGURE 8.1
Food guide pyramid for young children.

TABLE 8.8
Changes Made in the New Food Guide Pyramid for Young Children
• The food groups have shorter names.
• A single number of servings is given for each food group rather than a range of servings.
• Foods are drawn in a realistic style.
• Foods are illustrated in single serving portions when possible.
• Foods included are those commonly eaten by young children such as fruit juice, green beans, breads, cereals,
and pasta. (Although the baked potato is not the most commonly served form of potato, it is illustrated to
encourage children to consume a lower fat version of potato. Also, dark-green leafy vegetables and whole-
grain products are illustrated to encourage children to eat them more often.)
• Abstract symbols for fat and added sugars in the original pyramid have been eliminated.
• The tip of the pyramid has drawings of food items rather than symbols.
• The pyramid is surrounded with illustrations of children engaged in active pursuits, to show the importance
of physical activity.
From Tips for Using the Food Guide Pyramid for Young Children 2 to 6 Years Old, USDA, Center for Nutrition Policy
and Promotion, Washington, DC, 1999, Program Aid 1647.
A booklet entitled Tips for Using the Food Guide Pyramid for Young Children 2 to 6 Years Old
was developed to go along with the new pyramid.19 It includes tips to encourage healthful
eating, basic information about the new pyramid, “child-size” serving sizes, lists of foods
by group to encourage children to eat a variety of foods, suggested kitchen activities for
parents to do with children, snack and meal planning ideas, a chart to track foods eaten
over several days, and “hands-on” food activities for home or child care centers.
Both the original and the new pyramid show how adults, adolescents, and children can
make food choices for a healthful diet as described in the Dietary Guidelines for Americans.10
The five food groups in the pyramid include grains, vegetables, fruits, milk, and meat.
Each group provides some, but not all, of nutrients and energy that children need. No
one food group is more important than another. The grain group forms the base of the
pyramid because the largest number of servings needed each day comes from this group.
Grain products provide vitamins, minerals, complex carbohydrates, and dietary fiber.
Foods from the fruit and vegetable groups provide vitamins, minerals, and dietary fiber.
Foods from the milk group provide calcium. Foods from the meat group (meat, poultry,
fish, eggs, dry beans/peas, and peanut butter) provide protein, iron, and zinc. The small
tip of the pyramid shows fats and sweets (e.g., salad dressing, cream, butter, margarine,
soft drinks, and candy); these foods contain kcal but few vitamins and minerals.
Table 8.9 contains young children’s serving sizes by food group, along with the number
of servings needed from each food group each day. Two- to three-year-olds need the same
variety of foods as four- to six-year-olds but fewer kcal, so offer them smaller amounts
(about 2/3 serving). The one exception is that two- to six-year-olds need a total of two
servings from the milk group each day. Offer children a variety of foods from the five
food groups, and let children decide how much to eat. Table 8.10 contains a sample meal
and snack plan according to food group for one day for four- to six-year-old children.
What are Children and Adolescents Eating?

1989–1991 Continuing Survey of Food Intakes by Individuals (CSFII)
The 1989–1991 CSFII sample consisted of individuals residing in households in the 48
contiguous United States; it included two separate samples, basic and low income. All

TABLE 8.9
Young Children’s Serving Sizes by Food Group
Grain Group (6 servings each day)

Offer whole or mixed grain products for at least 3 of the 6 grain group servings each day.
Whole grain: Enriched:

1/2 cup cooked brown rice 1/2 cup cooked rice, pasta, or grits
2-3 graham cracker squares 1/2 English muffin or bagel
5-6 whole grain crackers 1 slice white, wheat, French or Italian bread
1/2 cup cooked oatmeal 1/2 hamburger or hot dog bun
1/2 cup cooked bulgur 1 small roll
3 cups popped popcorn* 6 crackers (saltine size)
3 rice or popcorn cakes* 1 4-inch pita bread or 1 4-inch pancake
1 ounce ready-to-eat whole grain cereal 1/2 cup cooked farina or other cereal
1 slice pumpernickel, rye, or whole wheat bread 9 3-ring pretzels*
2 taco shells* 1 7-inch flour tortilla
1 7-inch corn tortilla 1 ounce ready-to-eat, unfrosted cereal
Grain products with more fat and sugars:
1 small biscuit, muffin, or piece of cornbread
1/2 medium doughnut
9 animal crackers
Vegetable Group (3 servings each day)
1/2 cup of chopped raw or cooked vegetable

1 cup raw leafy greens
1/2 cup tomato or spaghetti sauce
3/4 cup vegetable juice
1 cup vegetable soup
1 medium (ear of corn, potato)
2 cooked broccoli spears
7-8 raw carrot or celery sticks (3” long)*
10 french fries
5 cherry tomatoes*
Fruit Group (2 servings each day)
1 medium orange, apple, banana, or peach

1/2 grapefruit
1/2 cup cut-up fresh, canned, or cooked fruit
3/4 cup fruit juice
1/4 cup dried fruit*
12 grapes or 11 cherries*
7 medium strawberries
1/2 cup blueberries or raspberries
1 large kiwi
1 small pear
Milk Group (2 servings each day)
For this amount of food … Count this many milk group servings
1 cup milk or 1 cup soy milk (calcium fortified) 1
1/2 cup milk 1/2
1 cup yogurt (8 ounces) 1
1.5 ounces natural cheese 1
2 ounces processed cheese 1
1 string cheese (1 ounce) 2/3
1/2 cup cottage cheese 1/4
1/2 cup ice cream 1/3
1/2 cup frozen yogurt or 1/2 cup pudding 1/2

TABLE 8.9 (Continued)

Young Children’s Serving Sizes by Food Group
Meat Group (2 servings each day)

Two to three ounces of cooked lean meat, poultry, or fish equal one serving of meat. Amounts from the meat group
should total 5 ounces a day for 4- to 6-year-olds and about 3 1/2 ounces a day for 2- to 3-year-olds.
For this amount of food … Count this many ounces

2 ounces cooked lean meat, poultry, or fish 2 ounces
1 egg (yolk and white) 1 ounce
2 tablespoons peanut butter* 1 ounce
1 1/2 frankfurters (2 ounces)* 1 ounce
2 slices bologna or lunchmeat (2 ounces) 1 ounce
1/4 cup drained canned salmon or tuna 1 ounce
1/2 cup cooked kidney, pinto, or white beans 1 ounce
1/2 cup tofu 1 ounce
1 soy burger patty 1 ounce
* May cause choking in 2- and 3-year-old children.
Adapted from Tips for Using the Food Guide Pyramid for Young Children 2 to 6 Years Old, USDA, Center for Nutrition
Policy and Promotion, Washington, DC, 1999, Program Aid 1647.
household members were asked to provide intake information. Each individual provided
three consecutive days of dietary data which consisted of one 24-hour recall and a two-
day food record. A knowledgeable adult (usually the primary meal planner/preparer)
reported the food intakes of household members younger than 12 years.20
Data from the 1989–1991 CSFII have been analyzed numerous ways to provide insight
into what children and adolescents are eating. For example, data were analyzed to deter-
mine dietary sources of nutrients among 4008 U.S. children age 2 to 18 years.21 Results
indicated that fortified foods (e.g., ready-to-eat cereals) were influential contributors of
many vitamins and minerals. Furthermore, low nutrient-dense foods were major contrib-
utors of energy, fats, and carbohydrate, which compromises intakes of more nutrient-dense
foods, and may impede compliance with current dietary guidance.
Data from CSFII 1989–1991 were also analyzed to determine fruit and vegetable con-
sumption among 3148 U.S. children age 2 to 18 years.22 Results indicated that only one in
five children met the recommendation of consuming five or more servings of fruits and
vegetables per day. Intakes of all fruits and of dark green and/or deep yellow vegetables
were very low compared with recommendations. Furthermore, almost one-fourth of all
vegetables consumed by children and adolescents were french fries.
Finally, data from the CSFII 1989–1991 were analyzed to determine what percentage of
children ages 4-6 (n = 603) and 7-10 (n = 782) met the American Health Foundation’s age
plus 5 recommendation for fiber,11,12 and what the leading contributors to total dietary
fiber intake were.23 Results indicated that only 45% of 4- to 6-year-olds and 32% of 7- to
10-year-olds met the age plus 5 rule. Children who met the rule did so by consuming
significantly more high- and low-fiber breads and cereals, fruits, vegetables, legumes, nuts,
and seeds. Furthermore, children who met the rule had significantly higher energy-
adjusted intakes of vitamins A and E, folate, magnesium, and iron compared to children
with low fiber intakes who had significantly higher energy-adjusted intakes of fat and
cholesterol. Surprisingly, low-fiber breads and cereals provided 21 and 19% of total dietary
fiber for 4- to 6-year-olds and 7- to 10-year-olds, respectively, whereas high-fiber breads
and cereals provided only 6% of total dietary fiber for both age groups. Conclusions from
these results include that substituting high-fiber breads and cereals for low-fiber ones
would increase children’s fiber intakes and should be relatively easy to accomplish.23

TABLE 8.10
Sample Meal and Snack Plan according to Food Group for One Day
for Four- to Six-Year-Old Children (Offer two- to three-year-old
children the same variety but smaller portions.)
Grain Vegetable Fruit Milk Meat
Breakfast
Orange juice, 3/4 cup 1

Whole-grain toast, 1 slice 1
Cheerios, 1 oz 1
Milk, 1/2 cup 1/2
Mid-Morning Snack
Graham crackers, 2 squares 1

Cold water, 1/2 cup
Lunch
Tuna Casserole with:

Tuna fish, 2 oz (1/2 cup) 2 oz
Macaroni, 1/2 cup 1
Green peas, 1/2 cup 1
Processed cheese, 1 oz 1/2
Banana, 1 medium 1
Milk, 1/2 cup 1/2
Mid-Afternoon Snack
Animal crackers, 9 1
Peanut butter, 2 Tbsp 1 oz
Cold water, 1/2 cup
Dinner
Chicken, 2 oz 2 oz
Baked potato, 1 medium 1
Broccoli, 1/2 cup 1
Milk, 1/2 cup 1/2
Evening Snack
Whole grain crackers (5) 1

Cold water, 1/2 cup
Total Food Group Servings 6 3 2 2 5 oz

Adapted from Tips for Using the Food Guide Pyramid for Young Children 2 to 6
Years Old, USDA, Center for Nutrition Policy and Promotion, Washington,
DC, 1999, Program Aid 1647.
1994–1996 Continuing Survey of Food Intakes by Individuals (CSFII)

The 1994–1996 CSFII sample consisted of individuals residing in households in the 50
United States, and included an oversampling of the low-income population. Only
selected household members were asked to provide intake information. Each individual
provided two nonconsecutive days of dietary data obtained by the 24-hour recall method

through in-person interviews.20 Proxy interviews were conducted routinely for subjects
under 6 years of age, and children 6 to 11 years of age were asked to describe their own
food intake assisted by an adult household member (referred to as the assistant). The
preferred proxy or assistant was the person responsible for preparing the subject’s
meals.24
To determine how the dietary intake of children and adolescents compared with nutri-
tion recommendations, the Healthy Eating Index (HEI) was used to examine the diets of
5354 American children ages 2 to 18 from USDA’s 1994–1996 CSFII.25 The HEI is computed
on a regular basis by USDA as a summary measure of people’s diet quality. It consists of
10 components, each representing different aspects of a healthful diet. Components 1 to
5 measure the degree to which a person’s diet conforms to USDA’s Food Guide Pyramid
serving recommendations for the five major food groups: grains, vegetables, fruits, milk,
and meat/meat alternatives. Components 6 and 7 measure total fat and saturated fat
consumption, respectively, as percentages of total kcal intake. Components 8 and 9 mea-
sure total cholesterol and sodium intake, respectively. Component 10 measures the degree
of variety in a person’s diet. Each component has a maximum score of ten and a minimum
score of zero. High component scores indicate intakes close to recommended ranges or
amounts; low component scores indicate less compliance with recommended ranges or
amounts. The maximum combined score for the 10 components is 100. An HEI score above
80 implies a good diet, a score between 51 and 80 implies a diet that needs improvement,
and a score less than 51 implies a poor diet.25
Results indicate that most children have a diet that is poor or needs improvement. As
children get older, their overall HEI score declines; thus, the percentage of children with
a diet that needs improvement or is poor increases, and the percentage of children with
a good diet declines. For children ages 2 to 3, 35% have a good diet, and 5% have a poor
diet. For boys 15 to 18 years old, only 6% have a good diet, and 21% have a poor diet.
The decline in diet quality begins between the 2-3 and 4-6 age groups, with the percentage
of children having a good diet falling from 35 to 16%, and the percentage having a diet
that needs improvement rising from 60 to 75%. The decline continues between the 7-10
and 11-14 age groups, with the percentage of children having a good diet falling from 14
to 7%. As indicated by the HEI component scores in Table 8.11, the decline in the quality
of children’s diets as they get older is linked to declines in their fruit and milk consumption.
Fifty-three percent of children ages 2 to 3 meet the recommendation for fruit compared
to only 11 to 12% of children ages 15 to 18. Although 44% of children ages 2 to 3 meet the
recommendation for milk, only 12 and 28% of girls and boys, respectively, ages 15 to 18,
do so. Except for cholesterol and variety to a smaller extent, most children do not meet
most recommendations.25
Further analyses of data from the 1994–1996 CSFII indicated that the quality of a child’s
diet is related to the income of his or her family.26 As indicated in Table 8.12, poor children
are less likely than nonpoor children to have a diet rated as good. For children ages 2-5,
19% of those in a poor household had a good diet compared to 28% of those in a nonpoor
household.
Data from the 1994–1996 CSFII were also analyzed to determine whether carbonated
soft drink consumption was associated with consumption of milk, fruit juice, and the
nutrients concentrated in these beverages among children and adolescents age 2-18 years
(n = 1810).27 Results indicated that adolescents (13-18 years) were more likely to consume
soft drinks than preschool-age children (2-5 years) and school-age children (6-12 years).
Among preschool-age children, school-age children, and adolescents, 49.5, 35.9, and 17.5%,
respectively, did not consume any soft drinks during the two days of dietary recall;
furthermore, the majority of children in each age category were nonconsumers of diet soft

TABLE 8.11
Healthy Eating Index (HEI): Overall and Component Mean Scores for Children, 1994–1996a,b
Children Children Children Girls Boys Girls Boys
Age (years) 2–3 4–6 7–10 11–14 11–14 15–18 15–18
Overall HEI Score 73.8 67.8 66.6 63.5 62.2 60.9 60.7
1. Grains 8.3 7.2 7.6 6.7 7.2 6.3 7.5
(54) (27) (31) (16) (29) (17) (34)
2. Vegetables 5.9 4.9 5.1 5.5 5.4 5.8 6.3
(31) (16) (20) (24) (23) (26) (35)
3. Fruits 7.0 5.3 4.3 3.9 3.5 3.1 2.8
(53) (29) (18) (14) (9) (12) (11)
4. Milk 7.2 7.4 7.6 5.2 6.2 4.2 6.1
(44) (44) (49) (15) (27) (12) (28)
5. Meat 6.3 5.3 5.5 5.7 6.5 5.8 6.9
(28) (14) (17) (15) (28) (21) (36)
6. Total fat 7.4 7.3 7.2 7.2 6.8 7.1 6.8
(40) (38) (35) (37) (33) (38) (34)
7. Saturated fat 5.4 5.6 5.7 5.8 5.7 6.6 6.0
(27) (28) (28) (31) (32) (42) (35)
8. Cholesterol 9.0 8.9 8.7 8.5 7.6 8.4 6.7
(83) (83) (80) (78) (69) (77) (58)
9. Sodium 8.8 8.1 6.8 7.1 5.2 6.9 3.7
(64) (53) (34) (39) (21) (37) (15)
10. Variety 8.4 7.9 8.1 7.8 8.1 6.7 7.8
(64) (53) (54) (51) (58) (37) (51)
a Parentheses contain % of children meeting dietary recommendations for each component.
b From Report Card on the Diet Quality of Children. Nutrition Insights, Insight 9, October, 1998, issued by the
Center for Nutrition Policy and Promotion, USDA, http://www.usda.gov/cnpp (accessed July 21, 1999).
TABLE 8.12
Percentage of Children Ages 2 to 18 by Age, Poverty Status, and
Diet Quality as Measured by the Healthy Eating Index, Three-Year
Average 1994–1996
Characteristic Good Dieta Needs Improvementa Poor Dieta
Ages 2-5
At or below poverty 19 70 11
Above poverty 28 65 7
Ages 6-12
At or below poverty 10 78 12
Ages 13-18
At or below poverty 3b 72 25
a A Healthy Eating Index (HEI) score above 80 implies a good diet, a score
between 51 and 80 implies a diet that needs improvement, and a score
less than 51 implies a poor diet.
b Sample size relatively small to make reliable comparisons.
Adapted from Federal Interagency Forum on Child and Family Statistics,
America’s Children: Key National Indicators of Well-Being, 1999. Federal Inter-
agency Forum On Child and Family Statistics, Washington, DC, US Gov-
ernment Printing Office. The report is also available on the World Wide
Web: http://childstats.gov.

drinks (94.9, 89.0, and 85.9%, respectively). White preschool-age children and adolescents
were more likely to consume soft drinks than black preschool-age children and adoles-
cents. Among adolescents, boys were more likely than girls to consume soft drinks.
Among preschool-age children and adolescents, those who resided in central city metro-
politan statistical areas (within a metropolitan area containing the largest population)
were more likely to consume soft drinks than those residing in noncentral city metropol-
itan statistical areas (within a metropolitan area not containing the largest population).
No significant differences in soft drink consumption were found by poverty status or
region of the country. In general, soft drink consumption was inversely associated with
consumption of milk, fruit juice, and the nutrients concentrated in these beverages. For
all age groups, energy intake was higher among those in the highest soft drink consump-
tion category compared with nonconsumers. These results indicate that nutrition educa-
tion messages for children and/or their parents should encourage limited consumption
of soft drinks.27
1994–1996 and 1998 Continuing Survey of Food Intakes by Individuals (CSFII)

The Supplemental Children’s Survey to the 1994–1996 CSFII (CSFII 1998) was con-
ducted to add intake data from 5559 children age birth through 9 years to the intake
data collected from 4253 children of the same age who participated in the CSFII
1994–1996. The CSFII 1998 was designed to be combined with the CSFII 1994–1996;
thus, approaches to sample selection, data collection, data file preparation, and weight-
ing were consistent.28
Analyses of data from the 1994–1996 and 1998 CSFII provide some of the most recent
insight into the dietary intake of children and adolescents nationwide. Tables 8.13 through
8.17 include national probability estimates based on all four years of the CSFII (1994–1996
and 1998) for children ages 9 years and under, and on CSFII 1994–1996 only for individ-
uals age 10 years and over.28 As indicated in Table 8.13, mean intakes as percentages of
the 1989 RDAs meet or exceed the RDAs for most nutrients for both girls and boys of
all ages. The most notable exception is for calcium for girls ages 12 to 19 years, for which
mean intake as a percentage of the RDA for this group is only 64%, down from 102% for
girls ages 6 to 11 years. As indicated in Table 8.14, the percentages of children with diets
meeting 100% of the 1989 RDAs is around or below 50% for energy, vitamin E, and zinc
for both boys and girls, and for vitamin A and calcium for girls. For all nutrients for all
ages of children, the percentages of children with diets meeting 100% of the 1989 RDAs
is higher for males than females. Furthermore, in general, the percentages of children
with diets meeting 100% of the 1989 RDAs decreases as children get older, especially
between the 6-11 and 12-19 year age groups, and more so for girls than boys. As indicated
in Table 8.15, the mean percentages of kcal from protein, total fat, saturated fat, and
carbohydrate in the diets of children and adolescents closely follows nutrition recom-
mendations. However, as indicated in Table 8.16, although the diets of many children do
meet recommendations for cholesterol, most children do not meet recommendations for
total fat or saturated fat. Breakfast consumption declines as children get older; ~97% of
children ages 2 to 5 years eat breakfast, compared to ~93% of children ages 6 to 11 years
and ~76% of children ages 12 to 19 years (data not shown). Although ~80% of children
of all ages from 2 to 18 years consume vegetables, the percentages of children consuming
fruits and fruit juices declines as children get older, from ~73% for children ages 2 to 5
years to ~59% for children ages 6 to 11 years, to ~45% for children ages 12 to 19 years
(data not shown).28

TABLE 8.13
Nutrient Intakes: Mean Intakes as Percentages of the 1989 Recommended Dietary Allowances
Intakes by Individuals 1994–1996, 1998
Sex and
Age Sample Food Vitamin A Vitamin Vitamin
(Years) Size Energy Protein (µg RE) E C Thiamin Riboflavin Niacin
- - - - - - Number - - - - - - - - - - - - - - - - - - - - - Percentages of 1989 RDA - - - - - - - - - - - - - - - - - - - - -
Boys & Girls
1–2 2118 102 307 185 79 257 161 213 142

3–5 4574 103 281 179 88 240 170 193 155
Boys
6–9 787 103 258 147 98 227 175 190 164

6–11 1031 101 244 139 96 226 172 186 161
12–19 737 99 184 108 93 213 150 155 148
Girls
6–9 704 91 227 127 89 214 150 162 139

6–11 969 91 214 121 91 208 149 160 138
12–19 732 87 145 100 88 171 131 135 126
Adapted from USDA, Agricultural Research Service, Food and Nutrient Intakes by Children 1994–96, 1998, 1999,
bhnrc/foodsurvey/home.htm (accessed December 22, 1999).

(RDAs), by Sex and Age, Children 19 Years of Age and Under, One Day, Continuing Survey of Food
Sex and
Age Vitamin Vitamin
(Years) B6 Folate B12 Calcium Phosphorus Magnesium Iron Zinc Selenium
- - - - - - Number - - - - - - - - - - - - - - - - - - - - - Percentages of 1989 RDA - - - - - - - - - - - - - - - - - - - - -
Boys & Girls
1–2 130 396 457 107 121 234 108 74 299

3–5 144 424 421 108 136 204 132 92 375
Boys
6–9 136 319 337 122 159 156 158 109 334
6–11 133 298 326 116 152 146 161 107 318
12–19 117 180 292 95 136 92 169 96 263
Girls
6–9 115 237 307 106 138 140 136 94 297

6–11 114 248 283 102 134 129 130 93 276
12–19 104 138 190 64 92 77 91 82 178
Online, ARS Food Surveys Research Group, available on the “Products” page at http://www.barc.usda.gov/

TABLE 8.14
Nutrient Intakes: Percentage of Children with Diets Meeting 100% of the 1989 Recommended Dietary
Individuals 1994–1996, 1998
Sex and
Age Sample Food Vitamin A Vitamin Vitamin
(Years) Size Energy Protein (µg RE) E C Thiamin Riboflavin Niacin
- - - - - - Number - - - - - - - - - - - - - - - - - - - - - Percentage of Children - - - - - - - - - - - - - - - - - - - - -
Boys & Girls
1–2 2023 45.1 98.9 78.5 19.0 81.4 85.7 95.1 71.8
3–5 4386 44.6 99.1 75.5 25.2 79.6 89.6 93.1 82.7
Boys
6–9 758 46.3 98.7 66.3 35.5 77.4 93.4 93.5 87.2
10–11 991 42.9 97.8 63.2 33.4 78.3 90.2 92.2 86.0
12–19 696 39.4 90.4 35.9 35.4 67.5 76.0 76.8 75.8
Girls
6–9 665 26.3 98.9 53.5 28.0 77.8 83.4 85.7 77.0
10–11 922 27.9 95.3 50.4 27.7 75.1 80.5 83.8 74.7
12–19 702 25.2 76.2 30.6 24.0 57.7 68.0 64.4 61.9
Adapted from USDA, Agricultural Research Service, Food and Nutrient Intakes by Children 1994-96, 1998, 1999,

Allowances (RDAs), by Sex and Age, Two-Day Average, Continuing Survey of Food Intake by
Sex and
Age Vitamin Vitamin
(Years) B6 Folate B12 Calcium Phosphorus Magnesium Iron Zinc Selenium
- - - - - - Number - - - - - - - - - - - - - - - - - - - - Percentage of Children - - - - - - - - - - - - - - - - - - - -
Boys & Girls
1–2 65.5 99.0 99.0 49.9 65.6 97.4 44.5 15.2 97.9
3–5 75.7 99.1 98.0 48.4 75.3 95.2 65.7 30.4 99.7
Boys
6–9 68.9 96.6 97.9 63.0 89.9 85.6 82.9 49.6 99.4
10–11 67.9 95.5 97.8 57.2 83.3 77.2 81.6 47.0 99.1
12–19 53.8 73.2 92.5 36.2 72.9 33.4 83.2 34.6 97.4
Girls
6–9 56.1 95.6 96.9 47.3 78.9 80.2 69.5 32.7 99.3
10–11 55.1 90.6 93.9 43.2 73.1 68.3 61.5 31.9 98.3
12–19 42.4 58.3 73.9 13.4 33.6 17.8 27.5 23.9 86.4

TABLE 8.15
Nutrient Intakes: Mean Percentage of Calories from Protein, Total Fat, Saturated
Fat, and Carbohydrate, by Sex and Age, One-Day, Continuing Survey of Food
Intakes by Individuals 1994–1996, 1998
Sex and Age Sample Size Protein Total Fat Saturated Fat Carbohydrate
(Years) Number - - - - - - - - - - - - - Percentage of kcal - - - - - - - - - - - - -
Boys & Girls
1–2 2118 14.8 32.4 13.3 54.3

3–5 4574 14.2 32.2 12.1 55.2
Boys
6–9 787 14.0 32.5 12.0 54.9

6–11 1031 14.0 32.6 12.0 54.8
12–19 737 14.4 33.1 11.7 53.2
Girls
6–9 704 13.9 32.4 11.9 55.2

6–11 969 13.9 32.6 11.9 54.9
12–19 732 14.0 32.2 11.3 55.0
Adapted from USDA, Agricultural Research Service, Food and Nutrient Intakes by Children 1994-
96, 1998, 1999, Online, ARS Food Surveys Research Group, available on the “Products” page
at http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm (accessed December 22, 1999).
TABLE 8.16
Nutrient Intakes: Percentage of Children with Diets Meeting Recommendations for Total Fat,
Saturated Fatty Acids, and Cholesterol, by Sex and Age, Two-Day Average, Continuing Survey of
Food Intakes by Individuals 1994–1996, 1998
Total Fat Intake at or Saturated Fatty Acid Intake Cholesterol Intake at or
Sex and Age below 30% of kcal below 10% of kcal below 300 Milligrams
(Years) Sample Size - - - - - - - - - - - - - - - - - - Percentage of Children - - - - - - - - - - - - - - - - - -
Boys & Girls
1–2 2023 34.2 18.2 85.5

3–5 4386 33.0 22.6 84.6
Boys
6–9 758 30.5 22.5 80.4

10–11 991 31.3 24.9 79.1
12–19 696 30.4 27.6 55.9
Girls
6–9 665 32.6 23.4 86.2

10–11 922 33.5 24.5 85.5
12–19 702 35.4 33.5 80.9
Adapted from USDA, Agricultural Research Service, Food and Nutrient Intakes by Children 1994-96, 1998, 1999,

Vitamin-Mineral Supplements
According to the Food and Nutrition Board, the “RDAs can typically be met or closely
approximated by diets that are based on the consumption of a variety of foods from diverse
food groups that contain adequate energy.”1,29 According to the American Dietetic Asso-
ciation,30 children can best achieve healthful eating habits by consuming a varied diet in
moderation10 that includes foods from each of the major food groups, as illustrated by the
Food Guide Pyramid.18 Routine supplementation is not necessary for healthy growing
children who consume a varied diet, according to the American Academy of Pediatrics.31
If parents wish to give supplements to their children, a standard pediatric vitamin-mineral
product with nutrients in amounts no larger than the RDA may be given. Megadose levels
should be discouraged due to potential toxic effects. Parents should be cautioned to keep
vitamin-mineral supplements out of the reach of children because the taste, shape, and
color of most pediatric preparations make them quite appealing to children.
Although the American Academy of Pediatrics advocates that routine vitamin-mineral
supplementation is not necessary for healthy growing children who eat a varied diet, it
does identify five groups of children at nutritional risk who may benefit from supplemen-
tation.31 These groups are identified in Table 8.17. Dietary intake over several days should
be assessed by a Registered Dietitian to determine if an individual child from one of these
groups needs to take a supplement.
TABLE 8.17
Five Groups of Children at Nutritional Risk Who May Benefit from Vitamin-Mineral
Supplementation
• Children from deprived families or who suffer parental neglect or abuse
• Children with anorexia or an inadequate appetite or who consume a fad diet
• Children with chronic disease (e.g., cystic fibrosis, inflammatory bowel disease, hepatic disease)
• Children who participate in a dietary program for managing obesity
• Children who consume a vegetarian diet without adequate dairy products
From Committee on Nutrition, American Academy of Pediatrics, Feeding from Age One Year to Adolescence,
Pediatric Nutrition Handbook, 4th ed., Kleinman, R. E., Ed., American Academy of Pediatrics, Elk Grove Village,
IL, 1998, pg 125, with permission.
Development of Preschool Children’s Food Preferences and Consumption

Patterns
Widespread evidence indicates that the nutrition guidelines are not being followed by
most children. For example, most children consume far too few fruits and vegetables,22,32-
34 and the majority of children still exceed daily recommendations for total fat, saturated
fat, and cholesterol.35 Furthermore, the incidence of childhood obesity has increased dra-
matically during the last three decades.36,37 To help understand why children eat less of
what is recommended by nutrition guidelines and more of what is not recommended,
and why the incidence of childhood obesity is increasing, Birch and Fisher38 recommend
that consideration be given to factors that impact children’s food preferences and con-

sumption patterns. Extensive evidence suggests that children’s food preferences are
shaped by early experience with food and eating, and that family environment and
practices used by parents and other adults (e.g., school staff) may permanently affect
dietary practices of children.39 Birch and colleagues40 have repeatedly found that exposure
to food, as well as the social environment in which it is eaten, are crucial in the develop-
ment of preschool children’s food preferences and consumption patterns. Research indi-
cates that children’s food preferences are major determinants of consumption;41-45
therefore, not eating certain items (such as vegetables) is related to low preferences.
Furthermore, research indicates that preschool children’s preferences for dietary fat are
related to their levels of body fat.45
Learning to Eat
During the first years of life, an enormous amount of learning about food and eating
occurs as infants transition from consuming only milk to consuming a variety of foods,38
and from eating when depleted or hungry to eating due to a variety of social, cultural,
environmental, and/or physiological cues.46 According to Birch and Fisher,38 this transition
from univore to omnivore is shaped by the infant’s innate preference for sweet and salty
tastes and the rejection of sour and bitter tastes,47 and by the predisposition of infants and
children to be neophobic or to reject new foods.48 A child’s experience with food and
flavors is shaped beginning with the parents’ decision to breastfeed or formula-feed.38
Limited research indicates that breastfed infants eat more of new foods than formula-fed
infants, which suggests that the varied flavors in breastmilk facilitate the breastfed infant’s
acceptance of new foods during the weaning period.49
Exposure to Food and Preschool Children’s Food Preferences and Consumption

Table 8.18 includes three studies by Birch and colleagues50-52 which indicate that preschool
children’s neophobia or rejection of new foods can be overcome by exposure. Results from
TABLE 8.18
Research Concerning Exposure to Food and Preschool Children’s Food Preferences and
Consumption
Reference Authors and Year Subjects Study Design Results
50 Birch and Marlin, 14 two-year-olds Each child received Later, children ate
1982 2-20 exposures to 5 more of items with
novel fruits or higher exposures
cheeses over 25-26 when given pairs of
days items and asked to
taste both and pick
one to eat more of
51 Birch et al., 1987 43 children in 3 age Each child received 5, For all age groups,
groups: 26, 38, or 64 10, or 15 exposures to preferences increased
months old 7 new fruits; asked to significantly only
taste some and look at when foods were
others tasted
52 Sullivan and Birch, 39 children, 4-5 years Each child tasted 1 of 3 Preferences increased
1990 old versions of tofu with exposure
(sweetened, salty, or regardless of added
plain) 15 times over sugar, salt, or plain;
several weeks 10 exposures needed

these studies indicate that preschool children’s food preferences are learned through
repeated exposure to foods.
Social Environment of Eating and Preschool Children’s Food Preferences and

Consumption
Although exposure and availability are necessary for children to learn to accept new foods,
the social environment of eating is also important. Children learn about what to eat and
why to eat, and receive reinforcements and incentives for eating from their families and
the larger environment.53 Most of this learning occurs during routine mealtime experi-
ences, in the absence of formal teaching.40 For example, adults who want children to eat
healthful foods (e.g., vegetables) may bribe children with rewards for eating healthful
foods. However, research indicates that such practices actually lead children to dislike the
healthful foods, which is not what adults intend. The five studies54-58 included in Table
8.19 indicate the importance of the social environment of eating and food contingencies
(i.e., “if you eat __, then you can __”) on preschool children’s food preferences and
consumption. Results from another study of influential factors of caregiver behavior at
lunch in early child-care programs indicated that although caregivers believed they pos-
itively influenced children’s eating behaviors, observed behaviors of caregivers at meal-
times were inconsistent with expert recommendations.59
Adult Influences on Preschool Children’s Ability to Self-Regulate Caloric

Intake
Infants are born with the ability to self-regulate their kcal intake by adjusting their formula
intake when the kcal level of the formula changes60 and when solid foods are added.61
Preschool children are able to adjust the kcal eaten in a snack or meal, based on the kcal
eaten in a preload snack.62,63 Furthermore, preschool children are able to adjust the kcal
eaten at various meals and snacks during the day so that the number of kcal consumed
in a 24-hour period is relatively constant.64 Although children have the ability to self-
regulate their kcal intake, the two studies65,66 included in Table 8.20 indicate that this ability
may be negatively impacted by child-feeding practices that encourage or restrict children’s
eating. Using observations of family meal times, Klesges and colleagues67 found that
parental prompts, especially encouragements to eat, were highly correlated to preschool
children’s relative weight, and increased the probability that a child would eat. Further-
more, a child’s refusal to eat usually led to a parental prompt to eat more food, whereas
a child’s food request was not likely to elicit either a parental prompt to eat or subsequent
eating by the child.
According to Birch,46 child feeding practices that encourage children to eat in response
to external cues instead of internal cues regarding hunger and satiety “may form the basis
for the development of individual differences in styles of intake control that exist among
adults. Some of the problems of energy balance seen in adulthood may result from styles
of intake control in which hunger and satiety cues are not particularly central.” According
to the American Dietetic Association,30 “perhaps some of the best advice regarding child
feeding practices continues to be the division of parental and child responsibility advo-
cated by Satter.” Satter advocates that parents (or adults) are responsible for presenting a
variety of nutritious and safe foods to children at regular meal- and snack-times, as well
as the physical and emotional setting of eating; children are responsible for deciding how
much, if any, they will eat.68,69

TABLE 8.19
Research Concerning Social Environment of Eating and Preschool Children’s Food Preferences and
Consumption
54 Birch et al., 1980 64 children, 3-4 years Children given sweet Preferences increased
old; 16 per context or nonsweet foods when foods
(with initially neutral presented as rewards,
preferences) over or paired with adult
several weeks in 1 of greeting; effects
4 contexts: lasted longer than 6
1) as reward for weeks after contexts
behavior, 2) paired ended; suggest
with adult greeting, positive social
3) as nonsocial contexts can be used
behavior (put in to increase
child’s locker), or 4) at preferences for foods
snack time not liked but more
nutritious
55 Birch et al., 1982 12 children, 3-5 years Children told if they Instrumental (“if”) use
old drank juice, then they of juice reduced
could play preferences for it
56 Birch et al., 1984 31 children, 3-5 years Children told if they Instrumental (“if”) use
old drank milk drink, of milk beverage
then they received reduced preferences
verbal praise or a for it
movie
57 Newman and 86 children, 4-7 years Children told that if “If” snacks became less
Taylor, 1992 old they ate one snack, preferred and “then”
then they could eat snacks became more
another snack (with preferred
both of neutral
preference initially)
58 Hendy, 1999 64 preschool children To encourage Choice-offering and
acceptance of 4 new reward were more
fruits and vegetables effective than other
during 3 preschool actions; Hendy
lunches, teachers concluded that
used 1 of 5 actions: dessert rewards are
1) choice-offering not needed because
(“Do you want any of the less expensive
this?”), 2) reward and more nutritious
(special dessert), action of choice-
3) insisting children offering works as
try one bite, 4) well
modeling by teacher,
or 5) simple exposure
Feeding Toddlers and Preschool Children

Young children cannot innately choose a well-balanced diet. They depend on adults to
offer them a variety of nutritious and developmentally appropriate foods. A child’s intake
at individual meals may vary considerably, but the total daily caloric intake remains fairly
constant.64 Many parents become anxious about the adequacy of their young child’s diet
or frustrated with their child’s unpredictable eating behavior which may include refusals

TABLE 8.20
Research Concerning Adult Influences on Preschool Children’s Ability to Self-Regulate Caloric
Intake
65 Birch et al., 1987 22 children, 4 years old Flavored pudding Only children
preload of different encouraged to focus
kcal followed by ad on internal cues
lib snacks; children showed sensitivity to
encouraged to focus kcal density of
on either internal preload by
cues (hunger, satiety) decreasing kcal eaten
or external cues (time in snack after preload
of day, amount left, that was high in kcal
rewards) (and vice versa)
66 Johnson and Birch, 77 children, 3-5 years Preload snacks of Children with greater
1994 old different kcal body fat stores were
followed by ad lib less able to regulate
foods; children’s kcal consumption in
body fat measured; response to
mothers completed alterations in preload
questionnaire snacks; more
regarding their controlling mothers
degree of control of had children who
what and how much showed less ability to
their children ate self-regulate
(r = 0.67).
to eat certain foods, and food jags. Parents may resort to feeding tactics such as bribery,
clean your plate rules, struggles, or short-order cooking to encourage their child to eat. A
more healthful approach is Satter’s division of feeding responsibility (see “Adult Influ-
ences on Preschool Children’s Ability to Self-Regulate Caloric Intake” in this section).
Table 8.21 contains suggestions for concerns parents commonly encounter when feeding
young children. Table 8.22 contains healthful eating tips to use with young children.
Snacks
Most young children fare best when fed four to six times a day, due to their smaller
stomach capacities and fluctuating appetites. Snacks should be considered minimeals by
contributing to the total day’s nutrient intake. Snacks generally accepted by many children
include fresh fruit, cheese, whole-grain crackers, breads (e.g., bagels, tortilla), milk, raw
vegetables, 100% fruit juices, sandwiches, peanut butter on crackers or bread, and yogurt.
Choking
Young children should always be watched while eating meals and snacks because they
are at risk for choking on food. Children remain at risk for choking on food until around
age four years when they can chew and swallow better. Foods most likely to cause
problems include ones that are hard, round, and do not readily dissolve in saliva. Table
8.23 contains a list of foods that may cause choking, along with some tips to decrease
young children’s risk of choking. Any food can cause choking if the child is not supervised
while eating, if the child runs while eating, or if too much food is stuffed in the mouth.

TABLE 8.21
Suggestions for Concerns Parents Commonly Encounter when Feeding Children
If a child refuses to try new foods
• Remember, this is normal! Continue to offer each new food twice per week for a total of 10-12 times.
• Serve a new food with familiar ones.
• Ask the child if s/he would like to try some of the new food, but avoid forcing or bribing the child to eat the
new food. Be an effective role model and eat some of the new food yourself.
• Involve the child in shopping for and preparing the new food.
If a child refuses to eat what is served
• Remember, children may have strong likes and dislikes, but this does not mean they need to be served different
foods than the rest of the family.
• Allow the child to choose from the foods available at a meal what s/he will eat, but avoid forcing or bribing
him/her to eat.
• Include at least one food at each meal that you know your child will eat, but do not cater to a child’s likes
or dislikes. Avoid becoming a short-order cook. The less attention paid to this behavior, the better.
If a child is stuck on a food jag or wants to eat the same food over and over
• Children may want to eat only one or two foods day after day, meal after meal; common food jags occur with
peanut butter and jelly sandwiches, pizza, macaroni and cheese, and dry cereal with milk.
• Relax, and realize this is normal and temporary. Refuse to call attention to the behavior.
• Continue to offer regular meal, but do not force or bribe the child to eat it.
• Serve the food jag item as you normally would (maybe once or twice a week).
If a child refuses to eat meat
• Tough meat is often difficult for children to chew. Offer bite-size pieces of tender, moist meat, poultry, or fish.
• Use meat in casseroles, meatloaf, soup, spaghetti sauce, pizza, or burritos.
• Try other high-protein foods such as eggs, beans, and peanut butter.
If a child refuses to drink milk
• Offer cheese, cottage cheese, yogurt, or pudding either alone or in combination dishes (such as macaroni and
cheese, pizza, cheese sauce, banana pudding).
• Use milk when cooking hot cereals, scrambled eggs, macaroni and cheese, soup, and other recipes.
• Use calcium-fortified juices.
If a child refuses to eat vegetables and fruits
• Offer more fruits if a child refuses vegetables, and vice versa.

• Avoid over-cooking vegetables; serve vegetables steamed or raw (if appropriate). Include dips or sauces (e.g.,
applesauce with broccoli or carrots).
• Include vegetables in soups and casseroles.
• Continue to offer a variety of fruits and vegetables.
If a child eats too many sweets
• Avoid using sweets as a bribe or reward.

• Limit the purchase and preparation of sweet foods in the home.
• Incorporate sweets into meals instead of snacks for better dental health.
• Try using fruit as dessert.
Adapted from Lucas, B., Normal Nutrition from Infancy through Adolescence, Handbook of Pediatric Nutrition,
Queen, P. M., Lang, C. E., Eds., Aspen, Gaithersburg, MD, 1993, pg 145.

TABLE 8.22
Healthful Eating Tips to Use with Young Children
Be Patient
Because young children are often afraid to try new foods...

• Offer a new food more than once; food may be accepted when it becomes familiar to the child.
• Offer new foods in small “try me” portions (one to two tablespoons) and let the child ask for more.
• Show the child how the rest of the family enjoys the new food.
Be a Planner
Most children need three regular meals plus one or two snacks each day.
• For breakfast and lunch, offer foods from three or more of the five pyramid food groups.
• For the main meal, offer foods from four or more of the five pyramid food groups.
• For snacks, offer foods from two or more of the five pyramid food groups. Make sure that snacks are not
served too close to mealtime.
Be a Healthful Role Model
Remember, what you do can mean more than what you say.
Children learn about how and what to eat from routine eating experiences.
• Eat meals with children whenever possible.
• Try new foods and new preparation methods.
• Walk, run, and play with children instead of just watching them.
Be Adventurous
• Take children grocery shopping and let them choose a new vegetable or fruit from two or three choices.
• Have a weekly “family try-a-new-food” night.
• At home, allow children to help you wash and prepare food.
Be Creative
• Encourage children to invent a new snack or sandwich from three or four healthful ingredients you provide.
• Try a new bread or whole grain cracker.
• Talk about food groups in the new snack or sandwich, how they taste — smooth, crunchy, sweet, juicy, chewy,
and how colorful the items are.
Adapted from Tips for Using Food Guide Pyramid for Young Children, USDA, Center for Nutrition Policy and
Promotion, Washington, DC, 1999, Program Aid 1647.
Excessive Fruit Juice Consumption

Fruit juice, especially apple, is a common beverage for young children. Although fruit
juice is a healthful, low-fat, nutritious beverage, there are some health concerns regarding
excessive fruit juice consumption by young children. For example, drinking fruit juice
helps fulfill nutrition recommendations to eat more fruits and vegetables. However, as
children increase their intake of fruit juices, they may decrease their intake of milk,70 which
can decrease their intake of calcium unless the juice is calcium-fortified. This is a concern
because results from the CSFII 1994–1996, 1998 indicated that only ~50% of children ages
one to five years met the 1989 RDAs for calcium.28 Carbohydrate malabsorption is common
following the ingestion of several fruit juices in young children with chronic nonspecific
diarrhea as well as in healthy young children.71 In 1991, a policy statement by the Com-
mittee on Nutrition of the American Academy of Pediatrics recommended that parents
be cautioned about young children’s potential gastrointestinal problems associated with
the ingestion of excessive amounts of juices containing sorbitol (e.g., apple, pear, and
prune), which is a naturally occurring but nonabsorbable sugar alcohol.72 Excess fruit juice

TABLE 8.23
Choking in Young Children
Foods that May Cause Choking in Young Children
• frankfurters (hot dogs) • raisins • popcorn

• chunks of meat • whole grapes • chips
• nuts and seeds • cherries with pits • pretzels
• peanut butter (spoonful) • large pieces of fruit • marshmallows
• raw carrots or celery • round or hard candy
Tips to Decrease Young Children’s Risk of Choking
• Cut frankfurters lengthwise into thin strips.

• Cook carrots or celery until slightly soft and then cut into sticks.
• Cut grapes or cherries into small pieces.
• Spread a thin layer of peanut butter on a cracker instead of allowing young
children to eat peanut butter from a spoon.
• Insist that young children sit down while eating so they can concentrate on
chewing and swallowing.
• Always watch young children while they eat meals and snacks.
• Discourage allowing a young child to eat in the car if the only adult present is
driving because it may be difficult for the adult to quickly aide a choking child.
Adapted from Tips for Using the Food Guide Pyramid for Young Children 2 to 6 Years
Old, USDA, Center for Nutrition Policy and Promotion, Washington, DC, 1999,
Program Aid 1647.
consumption may present a contributing factor in nonorganic failure to thrive.73 Drinking

12 or more fluid ounces of fruit juice per day is associated with short stature and with
obesity in young children;74 thus, it is recommended that parents and caretakers limit
young children’s consumption of fruit juice to less than 12 ounces per day.70,74
Low-Fat Diets
Emphasis regarding low-fat, low-cholesterol diets has increased during the past decade,
as has the debate over whether low-fat diets are appropriate for children.75-80 Parental
concern about later atherosclerosis or obesity has led to failure to thrive in some infants
age 7 to 22 months who were fed very low-fat, calorie-restricted diets.81 The American
Academy of Pediatrics Committee on Nutrition supports recommendations that children
older than two years follow a diet with a maximum of 30% of calories from fat and no
more than 300 mg of cholesterol per day.9 (Ages two to five years represent a transition
between the higher fat intake during infancy and the population-based recommended fat
intake). Nonfat and low-fat milks are not recommended for use during the first two years
of life.
The Special Turku coronary Risk factor Intervention Project for Babies (STRIP Baby Trial)
evaluated the effects of a low-saturated fat diet on growth during the first three years of
life in 1062 healthy infants who were randomized at age seven months into an intervention
group (n = 540) or control group (n = 522).82 The intervention consisted of individualized
dietary counseling provided to parents at one- to six-month intervals to reduce risk factors
to atherosclerosis. Results indicated that mean fat intake of children in both groups was
lower than expected, especially during the first two years of life. The true mean of the
height of intervention boys was at most 0.34 cm more or 0.57 cm less, and the weight was
at most 0.19 kg more or 0.22 kg less than that of control boys. The respective values for
girls were at most 0.77 cm more or 0.16 cm less and at most 0.42 kg more or 0.04 kg less.

Furthermore, there were similar numbers of slim children in both groups. The authors
concluded that a supervised, low-saturated fat, low-cholesterol diet had no influence on
growth of children in the study between 7 and 36 months of age.82 Follow-up analyses
were conducted on intervention and control children who were followed for more than
two years (n = 848) to study the fat and energy intakes of children with different growth
patterns. Results indicated that relative fat intakes (as percent of energy intake) were
similar in children showing highly different height gain patterns. Furthermore, children
with consistently low fat intake grew equally to the children with higher fat intake. The
authors concluded that moderate supervised restriction of fat intake to values between
25 and 30% of kcal is compatible with normal growth in children ages 7 to 36 months.83
The safety and efficacy of lower fat diets in pubertal children have been indicated by
results from the Dietary Intervention Study in Children (DISC). The three-year, six-center
randomized controlled trial involved 663 children; at baseline, boys (n = 362) and girls (n
= 301) had a mean age of 9.7 and 9.0 years, respectively.84 An intervention group (n = 334)
followed a diet with 28% of kcal from total fat, ~10% of kcal from saturated fat, and 95
mg/day of cholesterol. A comparable usual care group (n=329) consumed ~33% of kcal
from total fat, ~12% of kcal from saturated fat, and 113 mg/day of cholesterol. The
intervention group had significant but modestly lower levels of LDL-cholesterol and
maintained a psychologic well-being; however, there were no differences in height, weight,
or serum ferritin levels in the two groups. The authors concluded that a properly designed
dietary intervention is effective in achieving modest lowering of LDL cholesterol levels
over three years while maintaining adequate growth, iron stores, nutritional adequacy,
and psychological well-being during the critical growth period of adolescence. Further-
more, “an important public health inference from the DISC results is that current dietary
recommendations for healthy children, which are less restricted in total fat than the DISC
diet, can be advocated safely, particularly when children are under health care that follows
their growth and development.”84 Follow-up analyses were conducted to assess the rela-
tionship between energy intake from fat and anthropometric, biochemical, and dietary
measures of nutritional adequacy and safety.85 Results indicated that lower fat intakes
during puberty were nutritionally adequate for growth and maintenance of normal levels
of nutritional biochemical measures; furthermore, they were associated with beneficial
effects on blood folate and hemoglobin. Lower fat diets were related to lower self-reported
intakes of several nutrients (i.e., calcium, zinc, magnesium, phosphorus, vitamin B12,
thiamin, niacin, and riboflavin); however, no adverse effects were observed on blood
biochemical measures of nutritional status. The authors concluded that “current public
health recommendations for moderately lower fat intakes in children during puberty may
be followed safely.”85
Further evidence regarding the safety and efficacy of lower fat diets in upper elementary
school children (third through fifth grades) has been provided by the Child and Adolescent
Trial for Cardiovascular Health (CATCH), which is described more fully later in this
section. Results from CATCH failed to indicate any evidence of deleterious effects of the
three-year intervention on growth or development of children who were third-graders at
the beginning of the intervention.86
Group Feeding
Many young children spend some or most days away from home in child care centers,
preschools, Head Start programs, or home child care centers, where they may eat up to
two meals and two snacks daily. Federal and state regulations or guidelines exist for food
service in child care centers, Head Start programs, and preschool programs in public

schools. Some centers participate in USDA-sponsored child nutrition programs. When

choosing a child care center or preschool, parents should be encouraged to consider the
feeding program, including food variety, quality, safety, cultural aspects, and develop-
mental appropriateness. Peer pressure regarding food and eating among preschoolers is
evident in a study by Birch which indicated that the food selections and eating behaviors
of preschool children influenced the food preferences and eating behaviors of other
preschool children.87
Portion Sizes
Portion sizes for young children are small, especially when compared with adult portions.
A rule-of-thumb method is to initially offer one tablespoon of each food for every year of
age for preschool children; more food may be provided according to appetite.
Limited research indicates the effects of portion size on children’s food intake.88 Sixteen
younger (three years) and 16 older (five years) preschool children participated in three
lunches during their usual lunchtime at day-care. Each lunch consisted of macaroni and
cheese served in either small, medium, or large portion sizes, along with set portion sizes
of carrot sticks, applesauce, and milk. Results indicated that older preschoolers consumed
more macaroni and cheese when served the large portion compared to the small portion
(p<0.002). However, portion sizes did not significantly affect food intake among younger
preschoolers. These results indicate the important role of portion size in shaping children’s
dietary intake, and imply that portion size can either promote or prevent the development
of overweight among older preschool children. Furthermore, these results indicate the
importance of encouraging preschool children to focus on their own internal cues of
hunger and satiety instead of “eating everything to clean the plate.”88
Feeding School-Age Children

During the school-age years (ages 6-12), steady growth is paralleled by increased food
intake. Although children tend to eat fewer times a day, after-school snacks are common.
Studies indicate that eating breakfast is related positively to children’s cognitive function
and school performance, especially for undernourished children (for a review, see Refer-
ence 89). Specifically, schoolchildren who had fasted both overnight and in the morning,
particularly children who were nutritionally at risk, demonstrated slower stimulus dis-
crimination, increased errors, and slower memory recall.90 According to Grantham-McGre-
gor, “studies to date have provided insufficient evidence to determine whether children’s
long-term scholastic achievement is improved by eating breakfast daily.”91
Although eating breakfast is important, research indicates that between 6 and 16% of
elementary school children skip breakfast.92-94 Furthermore, between 1965 and 1991, break-
fast consumption declined significantly for each age group of children (1-4 years, 5-7 years,
8-10 years) and adolescents (11-14 years and 15-18 years), especially for older adolescents
age 15-18 years; breakfast was consumed by 89.7% of boys and 84.4% of girls in 1965, and
by 74.9 and 64.7%, respectively, in 1991.95 Children who skip breakfast tend to have a
lower kcal intake and consume fewer nutrients than children who eat breakfast.92,93 During
the upper elementary years, children may skip breakfast due to time constraints, because
school starts early, due to the responsibility of getting themselves ready in the morning,
or simply because they do not feel like eating. When breakfast nutrient consumption

patterns of third graders were examined using baseline data from CATCH, 94% of the
1872 children from 96 public schools in four states reported eating breakfast on the day
of the survey.92 Of the 94% who ate breakfast, 80% ate at home, 13% ate at school, 3% ate
at both home and school, and 4% ate breakfast elsewhere.
National School Lunch and Breakfast Programs

One in ten children gets two of their three major meals in school, and more than half get
one of their three major meals in school.96 The National School Lunch Program (NSLP) is
a federally assisted meal program available in almost 99% of all public schools and to
about 92% of all students in the country.97 On a typical day, about 58% of the students to
whom it is available participate. Regulations stipulate that a NSLP lunch provide one-
third of the RDAs for kcal, protein, iron, calcium, and vitamins A and C. Schools may
choose one of four systems for planning their menus; two options are based on a com-
puterized nutritional analysis of the week’s menu, and the other two options are based
on minimum component quantities of meat or meat alternate, vegetables and fruits, grains
and breads, and milk.97
The School Breakfast Program (SBP) is available to approximately half of the nation’s
students in more than 70,000 schools.98 On a typical day, about 7.2 million children par-
ticipate. Regulations stipulate that a SBP breakfast provide one-fourth of the RDAs for
kcal, protein, iron, calcium, and vitamins A and C.98
Any child at a participating school may purchase a NSLP lunch or SBP breakfast.
Children from families with incomes at or below 130% of the poverty level are eligible for
free breakfasts and lunches. Those between 130 and 185% of the poverty level are eligible
for reduced-price breakfasts and lunches. The federal government reimburses the schools
for each breakfast and lunch that meets SBP and NSLP requirements, respectively.97,98
Impact of School Meals on Children’s Dietary Intake

The School Nutrition Dietary Assessment Study (SNDAS) collected information on school
meals from a nationally representative sample of schools (n=545) and 24-hour recalls
from approximately 3350 students from these schools in spring, 1992.99 Results from the
SNDAS regarding dietary intakes of NSLP participants and nonparticipants100 indicated
that 1) NSLP participants had higher lunch intakes of vitamin A, calcium, and zinc, and
lower intakes of vitamin C than nonparticipants who ate lunch; 2) NSLP participants’
lunches provided a higher percentage of kcal from fat and saturated fat, and a lower
percentage of carbohydrate than nonparticipants’ lunches; 3) NSLP participants were
more than twice as likely as nonparticipants to consume milk and milk products at lunch;
and 4) NSLP participants also consumed more meat, poultry, fish, and meat mixtures
than nonparticipants.
Results from the SNDAS regarding dietary intakes of SBP participants and
nonparticipants100 indicated that 1) SBP participants had higher average breakfast intakes
of kcal, protein, and calcium, and derived a greater proportion of kcal from fat and saturated
fat than nonparticipants; 2) SBP participants were three times more likely than nonpartic-
ipants to consume meat, poultry, fish, or meat mixtures at breakfast; and 3) SBP participants
were also more likely than nonparticipants to consume milk or milk products at breakfast.
The most surprising finding from the SNDAS was that the presence of the SBP in schools
did not affect the likelihood that a student ate breakfast before starting school. Research is
needed to determine the best ways to encourage elementary school students to consume
healthful breakfasts. Universal school breakfast, which allows all students to eat school

breakfast for free, has been advocated by some as a means to increase the percentage of
children who eat breakfast. However, results from the SNDAS indicated that approximately
42% of children who were eligible for free or reduced price school breakfast did not eat
it.94 Perhaps scheduling the SBP for classes to eat as a part of regular school hours (similar
to the NSLP) is needed to increase the percentage of children who eat breakfast.
Results from a study by Baranowski et al.101 indicate the important contribution that
school lunch makes in increasing children’s consumption of fruits and vegetables. Differ-
ences in children’s consumption of fruits and vegetables by meal and day of the week
were assessed using seven-day food records completed by 2984 third-graders from 48
elementary schools in the Atlanta, Georgia area. Results indicated that fruits and vegeta-
bles were most frequently consumed at weekday lunch, and second most frequently at
dinner. Participation in school lunch accounted for a substantial proportion of fruits and
vegetables consumed at lunch. Few fruits and vegetables were consumed at breakfast or
snack.101
Impact of Elementary Schools on Older Children’s Food Preferences and Consumption

Patterns
The impact of exposure and social environment on preschool children’s food preferences
and consumption is discussed earlier in this section. Limited research indicates that expo-
sure to food also plays a role in older children’s food preferences and consumption. Results
from a study by Hearn et al.102 indicated that availability and accessibility to fruits and
vegetables (as assessed by telephone interviews with parents) was positively related to
upper elementary school children’s preferences and consumption. Furthermore, children
ate more fruits and vegetables for lunch at schools that offered more fruits and vegetables
for lunch.
Research with upper elementary school children indicates that they prefer vegetables
less than fruits.43,103,104 Results from focus groups with ~600 fourth- and fifth-grade students
from Georgia, Alabama, and Minnesota indicate that children predominantly believe that
vegetables taste “nasty”104 and “if it’s good for you, then it must taste bad”103,104 which is
related to statements made by adults such as “I don’t care if they don’t taste good; eat
your vegetables because they’re good for you.”104 Research concerning the influence of a
variety of psychological and social factors on children’s fruit and vegetable consumption
indicates that preferences are the strongest predictors.44,105 This implies that interventions
that alter children’s preferences for fruits and vegetables will be more effective in increas-
ing their consumption than other strategies pursued to date. However, intensive school-
based interventions designed to specifically increase children’s preferences for fruits and
vegetables have had limited success.32,106,107 Furthermore, although some elementary
school programs have helped children to improve their dietary intake,108 intensive inter-
ventions specifically designed to increase children’s fruit and vegetable consumption have
had only limited success.32,106,107,109-111 Finally, schools may represent a potentially useful
setting for preventing childhood obesity, but comprehensive elementary school programs
in the U.S. such as CATCH and Know Your Body have not had major effects on children’s
body weight.108,112,113 Perhaps the limited success of elementary school-based interventions
to date to increase children’s preferences for and consumption of fruits and vegetables,
and to help prevent childhood obesity is because the interventions have not attempted to
educate school staff and parents about how their behaviors impact children’s food pref-
erences and consumption patterns.
Children have acquired knowledge about eating and have developed food preferences
by the time they enter school; however, their food preferences and consumption patterns

are continually modified because they eat daily.114 More than 95% of children in the U.S.
are enrolled in school, where they may eat one or two meals per school day.115 Thus,
elementary schools play a critical role in shaping children’s food acceptance patterns and
can therefore help to improve their diet.116 No other public institution has as much con-
tinuous and intensive contact with children during their first two decades of life than
public schools.113 Elementary school staff have a greater potential influence on a child’s
health than any other group outside of the home.117 School-based programs offer a sys-
tematic and efficient means to improve the health of youth in America by promoting
positive lifestyles.118 Health promotion programs in elementary schools have the potential
to help prevent chronic diseases in U.S. adults.117 Although school-based health programs
may promote healthful lifestyles, classroom lessons are not sufficient to produce lasting
changes in students’ eating behaviors.53 In fact, curriculum-based nutrition education in
schools has had minimal effects on student’s eating behavior.119 Children’s food prefer-
ences and consumption are influenced by the elementary school environment through
familiarity and reinforcement.120 Students of public elementary schools generally attend
for 7 hours a day, 180 days a year. Although students have options for obtaining food in
schools, the most prominent federally supported programs are the SBP and the NSLP.
Elementary school breakfast and lunch menus typically follow a cycle that repeats
several times during the school year; thus, children are provided with repeated exposures
to healthful foods (e.g., fruits and vegetables).121 However, elementary schools also provide
children with repeated exposures to other foods (e.g., candy and pizza) which are used
by school staff as rewards.53,122-124 Unfortunately, the social context in which vegetables are
often offered at school (e.g., “If you eat your peas, then you can eat your cookie”) probably
negatively affects preferences for them, thereby potentially decreasing their consump-
tion.121 However, the social context in which candy and pizza are offered probably posi-
tively affects preferences for those foods, thereby potentially increasing their
consumption.121 These repeated exposures to vegetables and foods such as candy and
pizza in negative and positive social contexts, respectively, provide the associative learning
that help children develop food consumption patterns that are inconsistent with nutrition
guidelines40 which recommend increased intake of vegetables but moderation in sugar
and fat intake.10,29,125,126 In addition, school staff often encourage children to finish all of
their food, regardless of whether or not the children are still hungry,122 which encourages
children to disregard their own feelings of hunger and satiety.
Concern regarding the impact of school staff on children’s food preferences and con-
sumption patterns has been voiced by several government and professional groups.
According to the Centers for Disease Control and Prevention,116 students need exposure
to healthful foods as well as the support of people around them, and teachers need to be
discouraged from using food for disciplining or rewarding students. According to the
American Dietetic Association, “… the nutrition goals of the National School Lunch
Program and School Breakfast Program should be supported and extended through school
district policies that create an overall school environment with learning experiences that
enable students to develop lifelong, healthful eating habits.”127 Furthermore, the American
Dietetic Association recommends that school meals be served in an environment that
encourages their acceptance,128 or a setting and atmosphere that encourages their con-
sumption,127 which may be interpreted to mean an environment that avoids the use of
food contingencies. A joint statement by the American Dietetic Association, Society for
Nutrition Education, and the American School Food Service Association indicates that
schools are to be healthful environments where the cafeteria and food-related policy allow
students the opportunity to make healthful food choices and provide them with models
of healthful food practices.129

Considerable research has been conducted concerning the impact of exposure and the
social context of eating on preschool children’s food preferences, consumption, self-regu-
lation of intake, and adiposity. However, research of this type is needed with older
children. According to Hill and Trowbridge,39 insights gained from research concerning
children’s food preferences and consumption patterns “can assist in developing interven-
tions to improve child-feeding practices, which may lead to development of healthier
eating patterns.” Parents and school staff need to expose children to healthful foods,
provide opportunities for children to learn to like rather than dislike healthful foods,
encourage children to respect their own feelings of hunger and satiety, and reduce the
extent to which learning and experience potentiate children’s liking for high-sugar and/
or high-fat foods.130 Interventions to increase children’s consumption of foods consistent
with nutrition guidelines and to prevent childhood obesity must educate adults about
their role in the development of children’s food preferences and consumption patterns,
specifically exposure to food, the social context of eating (e.g., food rewards and contin-
gencies), and adult influences on children’s ability to self-regulate caloric intake. Table
8.24 provides five practical applications for adults to use when feeding children.
TABLE 8.24
Five Practical Applications for Adults to Use when Feeding Children
• Offer a variety of healthful foods in a positive environment at regular meal and snack times.
• Instead of requiring children to finish all of their food, encourage them to respect their own feelings of hunger
and satiety. Use choice-offering statements such as “If you’re still hungry, there’s more ___” or “If you’re full,
then you don’t have to eat any more.”
• To help children learn to eat a variety of foods, continue to offer new foods even if a new food is initially
rejected. Ten to 12 exposures at two per week may be needed before a child learns to accept a new food.
• To encourage children to eat or to try new foods, use choice-offering statements such as “Would you like to
try/taste your ___?” Avoid rewarding or bribing children for eating. Also, avoid using food contingencies
(e.g., “If you eat your ___, then you can ___.”)
• Instead of using food as a reward, use non-food items such as stickers or a token economy (e.g., wherein
tokens are exchanged for tangible non-food rewards such as shoe laces, wrist bands, play time).
Childhood Obesity
Overwhelming evidence indicates that the incidence of obesity among children and ado-
lescents has increased dramatically during the last three decades.36,37 According to Dietz,
“obesity is now the most prevalent nutritional disease of children and adolescents in the
United States.”131 Critical periods during the childhood years for the development of
obesity include the period of adiposity rebound that occurs between five and seven years
of age, and adolescence.131 The causes of childhood obesity are multifactorial, including
both genetics and environment. Inactivity appears to play a major role in the increasing
rate of childhood obesity, as does television viewing. Results from the Third National
Health and Nutrition Examination Survey indicated that children ages 8 to 16 years who
watched four or more hours of television each day had greater body fat and greater body
mass index than children who watched television less than two hours each day.132 With
the advances in technology, especially regarding computers, more children are spending
more hours in sedentary states. Preventing childhood obesity is more desirable than trying
to treat obesity during adolescence and adulthood. One critical component of obesity
prevention is increased physical activity; another is educating adults regarding the devel-
opment of children’s food preferences and food consumption patterns. The topic of child-
hood obesity is covered thoroughly in Section 70.

Influences from Peers and Media

Children’s food preferences and consumption patterns can be altered either positively or
negatively by peers and the media. For example, results from the Third National Health
and Nutrition Examination Survey indicated that approximately 26% of U.S. children ages
8 to 16 years watched four or more hours of television each day, and that as hours of
television viewing increased, so did body fat and body mass index.132 Unfortunately,
research indicates that food advertisements aired during children’s Saturday morning
television programming are generally contrary to nutrition recommendations.133
Sugar and Aspartame

Although there are widespread beliefs that both sugar (i.e., sucrose) and aspartame pro-
duce hyperactivity and other behavioral problems in children, both dietary challenge and
dietary replacement studies have demonstrated that sugar has little if any adverse effects
on behavior.134 For example, Wolraich et al.135 conducted a double-blind controlled trial
with 25 normal preschool children and 23 school-age children who were described by
their parents as sensitive to sugar. The different diets that children and their families
followed for each of three consecutive three-week periods were either high in sucrose,
aspartame, or saccharin (placebo). Children’s behavior and cognitive performance were
evaluated weekly. Results strongly indicated that even when intake exceeded typical
dietary levels, neither sucrose nor aspartame had discernible cognitive or behavioral
effects in normal preschool children or in school-age children who were believed to be
sensitive to sugar. Furthermore, the few differences associated with the ingestion of sucrose
were more consistent with a slight calming effect than with hyperactivity.135 Results from
a 1995 meta-analytic synthesis of 16 reports containing 23 controlled double-blind chal-
lenge studies found that sugar did not affect the behavior or cognitive performance of
children; however, a small effect of sugar or effects on subsets of children could not be
ruled out.136
According to Kanarek,134 the strong belief of parents, educators, and medical profession-
als that sugar has adverse effects on children’s behavior may be attributed to several
factors. First, adults may misconceive the relationship between sugar and behavior. Chil-
dren in general have difficulty altering their behavior in response to changing environ-
mental conditions, such as shifting from the unstructured nature of a party or snack time
at school to the more rigorous demands of classwork. If the party or snack included foods
with a high sugar content, adults may relate the child’s sugar intake with behavioral
problems as the child tries to adapt from an unstructured activity to one with structure.
Second, sugar-containing foods such as candy are often forbidden or given to children in
very limited amounts; the prohibited nature of these foods may contribute to the belief
which associates them with increased activity. Finally, expectations of both adults and
children could promote the idea that sugar leads to hyperactivity. Children hear adults
comment that “too much sugar makes children hyper” and children believe them and act
accordingly to fulfill the prophecy.134
Although experimental evidence fails to indicate that sugar affects children’s behavior
and cognition, children should not have unlimited access to sugar, because undernutrition
may occur if foods with essential nutrients are replaced by kcal from sugar; furthermore,
sugar (and starch) can promote tooth decay. On the Food Guide Pyramid,18 sweets are
located at the tip along with fats and oils, indicating that these foods should be used
sparingly. According to the Dietary Guidelines for Americans,10 the diet should be mod-
erate in sugars, especially if kcal needs are low. The position of the American Dietetic

Association regarding the use of nutritive and nonnutritive sweeteners137 is that “consum-
ers can safely enjoy a range of nutritive and nonnutritive sweeteners when consumed in
moderation and within the context of a diet consistent with the Dietary Guidelines for
Americans.”
Feeding Adolescents
Characteristics of Food Habits of Adolescents
Adolescents often experience newly found independence, busy schedules, searches for
self-identification, dissatisfaction with body image, difficulty accepting existing values,
and a desire for peer acceptance. Each of these events may help explain changes in food
habits of adolescents. Common characteristics of food habits of adolescents include an
increased tendency to skip meals (especially breakfast and lunch), eating more meals
outside the home, increased snacking (especially on candy), consumption of fast foods,
and dieting.138
Insight regarding adolescents’ perceptions about factors influencing their food choices
and eating behaviors was provided from focus groups with 141 seventh- or tenth-graders
(40% white, 25% Asian-American, 21% African-American, 7% multiracial, 6% Hispanic,
1% Native American) from two urban schools in St. Paul, Minnesota.139 Factors identified
by the adolescents as being most influential on their food choices included hunger and
food cravings, appeal of food (primarily taste), time considerations of themselves and their
parents, and convenience of food. Factors identified by the adolescents to be of secondary
importance included food availability, parental influences on eating behavior (including
the family’s culture or religion), perceived benefits of food (e.g., for health, energy, body
shape), and situational factors (e.g., place, time). Additional factors discussed included
mood, body image concerns, habit, cost, media influences, and vegetarian lifestyle choices.
A sense of urgency about personal health in relation to other concerns, and taste preferences
for other foods were major barriers to eating more fruits, vegetables, and dairy products
and eating fewer high-fat foods. Suggestions provided by the adolescents to help adoles-
cents eat a more healthful diet included making healthful food taste and look better, making
healthful food more available and convenient, limiting the availability of unhealthful
options, teaching them good eating habits at an early age, and changing social norms to
make it “cool” to eat healthfully. These results suggest that if interventions to improve
adolescent nutrition are to be effective, they need to have adolescent input and address a
broad range of factors, especially environmental factors (e.g., increased availability and
promotion of appealing, convenient foods in homes, schools, and restaurants).139
The Minnesota Adolescent Health Survey (MAHS) was completed by more than 30,000
adolescents from 1986 through 1987. The MAHS was a comprehensive assessment of
adolescent health status, health behaviors, and psychosocial factors; although it included
relatively few nutrition-related items, a wealth of knowledge about adolescent nutrition
was gained. Neumark-Sztainer et al. summarized the knowledge learned from a decade
of subsequent analyses of data collected in the MAHS, as well as implications for working
with youth.140 Major concerns identified included overweight status, unhealthful weight-
control practices, and high prevalence rates of inadequate intakes of fruits, vegetables,
and dairy products. Risk factors for inadequate food intake patterns or unhealthful weight-
control practices included low socioeconomic status, minority status, chronic illness, poor
school achievement, low family connectedness, weight dissatisfaction, overweight, homo-

sexual orientation among boys, and use of health-compromising behaviors. The results
suggest a need for innovative outreach strategies that include educational and environ-
mental approaches to improve adolescent eating behaviors. A critical issue that needs to
be addressed is the validity of adolescents’ self-reported behaviors.140
Youth Risk Behavior Surveillance — United States, 1997

The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority
health-risk behaviors among high school youth in grades 9 through 12.141 In 1997, as part
of the YRBSS, the Centers for Disease Control and Prevention conducted a national school-
based Youth Risk Behavior Survey (YRBS) that resulted in 16,262 questionnaires completed
by students in 151 schools. Table 8.25 provides an overview of results from the YRBS for
dietary behaviors including fruit and vegetable consumption, fat consumption, perceived
overweight, attempted weight loss, laxative use or vomiting, diet pill use, dieting, and
exercising to either lose weight or keep from gaining it.141
TABLE 8.25
Results Regarding Dietary Behaviors from the Youth Risk Behavior Survey, United States, 1997
Dietary Behavior Percentage of Students*
Ate five or more servings of fruits and vegetables (defined as fruit, fruit juice, green
salad, or cooked vegetables) during day prior to survey:
Overall 29
Boys 32a
Girls 26a
Ate two or fewer servings of foods typically high in fat content (defined as
hamburgers, hot dogs, or sausage; french fries or potato chips; and cookies,
doughnuts, pie, or cake) during day prior to survey:
Overall 62
Girls 71a
Boys 56a
Hispanics 64b
Whites 63b
Blacks 55b
White girls 73c
Black girls 63c
Hispanic boys 60d
Black boys 47d
Girls in grade 12 77e
Girls in grade 9 65e
Boys in grade 12 59f
Boys in grade 10 52f
Boys in grade 11 61g
Boys in grade 9 50g
Boys in grade 10 52g
Considered themselves overweight:
Overall 27
Girls 34a
Boys 22a
Hispanics 30b
Blacks 24b
Hispanic boys 27c
White boys 22c
Black boys 15c
Tried to lose weight during the 30 days preceding the survey:
Overall 40
Girls 60a
Boys 23a


Results Regarding Dietary Behaviors from the Youth Risk Behavior Survey, United States, 1997
Dietary Behavior Percentage of Students*
Hispanics 46b
Blacks 36b
White girls 62c
Hispanic girls 61c
Black girls 51c
Hispanic boys 33d
White boys 22d
Black boys 20d
Used laxatives or vomited during the 30 days preceding the survey to lose weight
or keep from gaining it:
Overall 5
Girls 8a
Boys 2a
Hispanics 7b
Whites 4b
Hispanic girls 10c
Black girls 6c
Black boys 4d
White boys 2d
Used diet pills during the 30 days preceding the survey to lose weight or keep from
gaining it:
Overall 5
Girls 8a
Boys 2a
Dieted to either lose weight or keep from gaining it during the 30 days preceding
the survey:
Overall 30
Girls 46a
Boys 18a
Hispanics 33b
Whites 30b
Blacks 25b
White girls 48c
Hispanic girls 46c
Black girls 34c
Hispanic boys 23d
White boys 17d
Black boys 16d
Exercised to either lose weight or keep from gaining it during the 30 days preceding
the survey:
Overall 52
Girls 65a
Boys 40a
Hispanics 56b
Whites 52b
Blacks 44b
White girls 70c
Hispanic girls 65c
Black girls 49c
Hispanic boys 48d
White boys 39d
Black boys 38d
* Percentages with the same letter within a dietary behavior are significantly different.
Adapted from Kann, L., Kinchen, S. A., Williams, B. I., et al, Youth Risk Behavior Surveillance - United States, 1997,
In CDC Surveillance Summaries, MMWR 47 (No. SS-3), 1998; available at http://www.cdc.gov/.

Health Behaviour in School-Aged Children: A WHO Cross-National Study International

Report, 1997–1998
The Health Behaviour in School-Aged Children Study is a unique cross-national research
study conducted in collaboration with the World Health Organization (WHO) Regional
Office for Europe.142 The first survey was carried out in 1983–1984; since 1985, surveys
have been conducted at four-year intervals in a growing number of countries. The study
looks at 11-, 13-, and 15-year old children’s attitudes and experiences concerning a wide
range of health related behaviors and lifestyle issues. The 1997–1998 survey included more
than 123,227 children from 26 European countries and regions, Canada, and the U.S. The
1997–1998 sample of children from the U.S. included 5168 children; of these, there were
2395 boys and 2774 girls, 1558 11-year-olds, 1803 13-year-olds, and 1808 15-year-olds.
Results indicated that for the most part, U.S. children were less likely to have a good diet
than were children in other countries. Specifically, U.S. children were less likely to eat fruit
and vegetables each day than were children in the majority of other countries. Children
in the U.S. were more likely to eat potato chips and french fries every day, as well as
sweets or chocolate, than were children in most other countries. Children in the U.S.
ranked among the top three or four countries for consuming soft drinks every day. For
all countries, boys were more likely to drink more milk and eat more junk foods and fried
foods, and girls were more likely to eat fruit and vegetables each day. However, fruit and
vegetable consumption decreased with age. Concerns about body size and dieting behav-
ior increased with age for girls in all countries, but decreased for boys. Children in the
U.S. were more likely than children in any other country to report that they were dieting
or should be on a diet (47, 53, and 62% of 11-, 13-, and 15-year-old U.S. girls, respectively,
and 34, 33, and 29% of 11-, 13-, and 15-year-old U.S. boys, respectively). For all countries,
children with mothers or fathers with high socioeconomic status had the highest levels
of daily consumption of healthy food items, and those with mothers or fathers whose
status was low had the highest daily consumption of less nutritious food items. These
results emphasize important relationships between age, gender, country, and socioeco-
nomic status on food intake and dieting habits.142
Feeding Adolescents at School

Some research regarding feeding adolescents at school has been conducted. For example,
one study surveyed 2566 adolescents in grades 6, 7, and 8 (which covers ages 10 to 15
years) to assess their perceptions of school food service and nutrition programs.143 Results
indicated that the top predictors of satisfaction were school menus which include food
that students like, quality of the food choices, and prices that are acceptable for what
students get. Girls were more satisfied with school-prepared foods than boys, perhaps
because girls mature faster than boys during these years, which may be reflected as
willingness to try new foods at an earlier age. Sixth-grade students were more satisfied
than either seventh- or eighth-grade students. This may be because as adolescents move
into the early teenage years, they become more independent from their parents and begin
making their own decisions instead of eating school meals because their parents want or
expect them to do so.143
Another study examined the effects of pricing strategies on sales of fruits and vegetables
with adolescents in two high schools (1431 students at one urban school and 1935 students
at the other suburban school).144 Fruit, carrot, and salad purchases were monitored in
each school cafeteria during an initial baseline period. Next, prices for these items were
reduced by 50%, and sales were monitored. Finally, prices were returned to baseline, and

sales were monitored for an additional three weeks. Results indicated that even though
promotion was minimal, lower pricing significantly increased sales for fruit and carrots
but not salads among high school students. However, the magnitude of the intervention
effects differed by school, which suggests that contextual factors (e.g., packaging, display)
may modify pricing effects. These results imply that adolescents can be encouraged to
select fruits and vegetables when the prices of these items are lowered, and that this may
occur without measurable changes in the overall a la carte sales revenue or the number
of meal pattern customers, which are both important considerations for school food
service revenues.144
Caffeine
Caffeine is a stimulant for the central nervous system; it tends to decrease drowsiness
and reduce the sense of fatigue, but too much can cause palpitations, stomach upset,
insomnia, and anxiety. Its effects vary among individuals, depending on the amount
ingested, body size of the individual, and personal tolerance. Some people are able to
build up a tolerance to caffeine through regular use; others are more sensitive to it. If
someone who has regularly consumed caffeine suddenly stops using it, mild withdrawal
symptoms (e.g., headaches, craving for caffeine) may occur. Substantial amounts of caf-
feine are found in several soft drinks, coffee, tea, and some pain relievers; smaller amounts
are found in chocolate and foods with cocoa. Consumption of caffeine increases during
adolescence with greater intakes of soft drinks, tea, and coffee. This can be a concern
because caffeine has a modest negative impact on calcium retention, yet consumption of
milk and other foods high in calcium decreases as children get older.25,28 Furthermore, the
stimulating effect of caffeine may set the stage for needing stimulation; although caffeine
is classified as a drug, society is very accepting of this stimulant and has not considered
it a nuisance.145
Vegetarian Diets
During the adolescent years, when there is increased independence and decision making
and greater influence by peers and role models, vegetarian diets may be relatively com-
mon. There is considerable variation in the eating patterns of vegetarians. For the lacto-
ovo-vegetarian, the eating pattern is based on grains, vegetables, fruits, legumes, seeds,
nuts, dairy products, and eggs; meat, fish, and poultry are excluded. For the vegan, or
total vegetarian, the eating pattern is similar to the lacto-ovo-vegetarian pattern except
for the additional exclusion of eggs, dairy, and other animal products. However, consid-
erable variation may exist in the extent to which animal products are avoided within both
of these patterns.146
According to the American Dietetic Association, “well-planned vegan and lacto-ovo-
vegetarian diets are appropriate for all stages of the life cycle, including pregnancy and
lactation.”146 Appropriately planned vegan and lacto-ovo-vegetarian diets satisfy nutrient
needs of infants, children, and adolescents and promote normal growth.147 Dietary defi-
ciencies are more common in populations with very restrictive diets. All vegan children
need a reliable source of vitamin B12; in addition, vitamin D supplements or fortified foods
should be used if sun exposure is limited. Emphasis should be placed on foods rich in
calcium, iron, and zinc. Vegetarian children can be helped to meet energy needs through
frequent meals and snacks, as well as the use of some refined foods and foods higher in
fat.146 Section 40 contains additional information regarding vegetarian diets.

Eating Disorders
Anorexia nervosa and bulimia may affect about one million adolescents. Eating disorders
are thought to occur for a variety of reasons which include poor self-concept, pressure to
be thin, body shape and size, depression, and biological errors in organ function or
structure. Up to 10% of these adolescents may die prematurely as a result of eating
disorders.145 Most eating disorder patients develop the problem during adolescence; how-
ever, it may be difficult to distinguish an adolescent with “normal” eating habits from one
with an eating disorder, due to some of the psychologic changes which occur during
adolescence.6 More information regarding eating disorders may be found in Section 68.
Teen Pregnancy
Nutrient needs rise considerably during pregnancy; for adolescents who are pregnant,
nutritional considerations are paramount, especially if they are still growing. For adoles-
cent girls, linear growth typically is not completed until approximately four years after
the onset of menarche. Some indication of physiologic maturity and growth potential may
be obtained from gynecologic age, which is the difference between chronologic age and
age at menarche. A young adolescent girl (i.e., gynecologic age of two years or less) who
becomes pregnant may still be growing; thus, her nutrient requirements must meet her
own needs for growth and development, as well as the extra demands of fetal growth.6
Eating habits of adolescents (e.g., skipped meals, increased snacking, consumption of fast
foods, and dieting) create a health risk for pregnant adolescents because during pregnancy,
nutritional needs for the fetus are met before needs of the mother.145 Adolescents who are
pregnant should be cautioned against skipping meals, especially breakfast, because skip-
ping meals may increase the risk of ketosis.138 More information regarding teen pregnancy
may be found in Section 5.
Health Promotion and Disease Prevention

Healthy People 2010 Nutrition Objectives for Children and Adolescents
Table 8.26 includes Healthy People 2010 nutrition objectives, as well as dental objectives
related to nutrition, for children and adolescents.126 The nutrition objectives address reduc-
ing weight, reducing growth retardation, improving eating behavior (e.g., increasing con-
sumption of fruit, vegetables, grain products, and calcium products; decreasing
consumption of fat, saturated fat, and sodium), reducing iron deficiency, and improving
meals and snacks at school. The dental objectives related to nutrition address dental caries,
untreated dental decay, and school-based health centers with oral health components.
“5 A Day for Better Health” Program

The national “5 A Day for Better Health” Program was instituted in 1991 to encourage
Americans to eat five or more servings of fruits and vegetables every day. The program
is a public-private partnership between the National Cancer Institute (NCI) and the Pro-
duce for Better Health Foundation (a nonprofit foundation representing the fruit and
vegetable industry); it includes retail, media, community, and research components.148 At

TABLE 8.26
19-3. Reduce the proportion of children and adolescents who are overweight or obese (defined as at or
above the gender- and age-specific 95th percentile of BMI).
Reduction in Overweight or
Objective Obese Children and Adolescents* 2010 Target 1988–1994 Baseline
19-3a. Children and adolescents aged 6 to 11 years 5% 11%
19-3b. Children and adolescents aged 12 to 19 years 5% 10%
19-3c. Children and adolescents aged 6 to 19 years 5% 11%
* Defined as at or above the gender- and age-specific 95th percentile of BMI based on the revised
CDC growth charts for the U.S.
19-4. Reduce growth retardation (defined as height-for-age below the fifth percentile in the age-gender
appropriate population using the 1977 NCHS/CDC growth charts) among low-income children under
age 5 years.
Target: 5% Baseline: 8%
19-5. Increase the proportion of persons age 2 years and older who consume at least two daily servings of
fruit.
19-6. Increase the proportion of persons age 2 years and older who consume at least three daily servings
of vegetables, with at least one-third being dark green or orange vegetables.
19-7. Increase the proportion of persons age 2 years and older who consume at least six daily servings of
grain products, with at least three being whole grains.
19-8. Increase the proportion of persons age 2 years and older who consume less than 10 percent of calories
from saturated fat.
19-9. Increase the proportion of persons age 2 years and older who consume no more than 30 percent of
calories from total fat.
19-10. Increase the proportion of persons age 2 years and older who consume 2400 mg or less of sodium
daily (from foods, dietary supplements, tap water, and salt use at the table).
19-11. Increase the proportion of persons aged two years and older who meet dietary recommendations for
calcium (based on consideration of calcium from foods, dietary supplements, and antacids).
19-12. Reduce iron deficiency among young children and females of childbearing age.
Objective Reduction in Iron Deficiency* 2010 Target 1988-1994 Baseline

19-12a. Children age 1 to 2 years 9% 5%
19-12b. Children age 3 to 4 years 1% 4%
19-12c. Nonpregnant females age 12 to 49 years 7% 11%
* Iron deficiency is defined as having abnormal results for two or more of the following tests: serum
ferritin concentration, erythrocyte protoporphyrin, or transferrin saturation.
19-15. (Developmental) Increase the proportion of children and adolescents aged 6 to 19 years whose intake
of meals and snacks at school contributes to good overall dietary quality.
21-1. Reduce the proportion of children and adolescents who have dental caries experience in their primary
or permanent teeth.
Reduction of Dental Caries in Primary and/or

Objective Permanent Teeth 2010 Target 1988–1994 Baseline
21-1a. Young children 11% 18%
21-1b. Children 42% 52%
21-1c. Adolescents 51% 61%


21-2. Reduce the proportion of children, adolescents, and adults with untreated dental decay.
Objective Reduction of Untreated Dental Decay 2010 Target 1988-1994 Baseline

21-2a. Young children 9% 16%
21-2b. Children 21% 29%
21-2c. Adolescents 15% 20%
21-13. (Developmental) Increase the proportion of school-based health centers with an oral health component.
Adapted from US Department of Health and Human Services, Healthy People 2010, 2nd ed., US Government
Printing Office, Superintendent of Documents, Washington, DC, November, 2000. Available online at
http://www.health.gov/healthypeople (accessed July 30, 2001).
the beginning of the program in 1991, a baseline survey with adults indicated that only
23% reported consuming five or more daily servings of fruits and vegetables.149 The NCI
funded nine studies in the spring of 1993 to develop, implement, and evaluate interventions
in specific community channels to increase the consumption of fruits and vegetables in
specific target populations; four of the nine projects used school-based programs to target
children or adolescents.150 Of these four projects, one targeted fourth-grade students and
their parents,110 two targeted fourth- and fifth-grade students,106,109 and one targeted high
school students.111 Although all four interventions increased daily consumption of fruits
and vegetables, the increases were small for three interventions and ranged from 0.2 servings
for “Gimme 5 Fruit, Juice, and Vegetables for Fun and Health” in Georgia,106 0.4 servings
for “Gimme 5: A Fresh Nutrition Concept for Students” in New Orleans,111 and 0.6 servings
for “5 A Day Power Plus” in Minnesota.109 Increases were larger, at 1.4 servings for “High
Five” in Alabama, possibly because classroom lessons were delivered by trained curriculum
coordinators instead of classroom teachers.110 Perhaps the limited success of school-based
interventions to date is because they have not attempted to educate school staff about how
their behaviors impact children’s food acceptance patterns as discussed earlier.
Child Nutrition and Health Campaign

Launched in October, 1995, the Child Nutrition and Health Campaign is sponsored by
the American Dietetic Association/Foundation, Kellogg Company, and National Dairy
Council.151 The campaign focuses on five major objectives:
1. Convene a nationally recognized panel of experts on child nutrition to address

the nutritional needs of children, provide leadership to the campaign, and guide
the development of messages for the campaign.
2. Educate parents, children, and health care professionals about the links among
healthful childhood nutrition, classroom performance, and health during the
adult years.
3. Publicize the important roles of high-carbohydrate, low-fat breakfast foods and
healthful snacks for children’s nutrition.
4. Fund research on the behavioral aspects of achieving healthful nutrition in chil-
dren and on the development of lifelong healthful eating habits.
5. Launch a multi-year, multifaceted campaign to improve children’s nutrition and
health and to build strategic coalitions to spread the messages of the campaign.151

Five papers which review the scientific literature regarding links between nutrition and
cognition have been published.12,35,89,152,153 An intensive media program was developed to
bring three key messages to various audiences through publications, public service
announcements, news releases, consumer education activities, professional kits, and a
video. The three key messages are: 1) give children a healthy start to their day, 2) get
children (and adults) moving for the fun of it, and 3) grownups: be a role model.151
USDA School Meals Initiative for Healthy Children and Team Nutrition
The USDA School Meals Initiative (SMI) for Healthy Children underscores the national
health responsibility to provide children with school meals consistent with the Dietary
Guidelines for Americans and current scientific nutrition recommendations; the vision of
the SMI is to “improve the health and education of children through better nutrition.”154
Team Nutrition was established by USDA as a nationwide integrated initiative to help
implement the SMI; the goal of Team Nutrition is to “improve the health and education
of children by creating innovative public and private partnerships that promote food
choices for a healthful diet through the media, schools, families, and the community.”
Team Nutrition exists to empower schools in all 50 states to serve meals that meet the
Dietary Guidelines for Americans, and to teach and motivate children in grades pre-
kindergarten through 12 to make healthy eating choices. The four Dietary Guidelines for
Americans that Team Nutrition focuses on are 1) eat a variety of foods, 2) eat more fruits,
vegetables and grains, 3) eat lower fat foods more often, and 4) be physically active.
Helping every child in the nation to have the opportunity to learn how to eat for good
health is made possible by extensive, strategic public-private partnerships and approxi-
mately 300 Team Nutrition Supporters who represent all of the industries that touch
children’s lives, including nutrition and health, education, food and agriculture, consumer,
media and technology, and government.154 Table 8.27 lists common values shared by
supporters of Team Nutrition.
TABLE 8.27
Common Values Shared by Supporters of Team Nutrition
• Children should be empowered to make food choices that reflect the Dietary Guidelines for Americans.
• Good nutrition and physical activity are essential to children’s health and educational success.
• School meals that meet the Dietary Guidelines for Americans should appeal to children and taste good.
• Programs must build upon the best science, education, communication and technical resources available.
• Public/private partnerships are essential to reaching children to promote food choices for a healthful diet.
• Messages to children should be age appropriate and delivered in a language they speak, through media they
use, in ways that are entertaining and actively involve them in learning.
• The focus should be on positive messages regarding food choices children can make.
• It is critical to stimulate and support action and education at the national, state, and local levels to successfully
change children’s eating behaviors.
From http://www.fns.usda.gov/tn/Missions/index.htm (accessed January 29, 2000).
The Child and Adolescent Trial for Cardiovascular Health (CATCH)

CATCH was a four-center, randomized field trial that evaluated the effectiveness of a
school-based cardiovascular health promotion program.155 A total of 5106 ethnically
diverse students (who were third-graders at baseline and fifth-graders at the end of the
intervention) participated in 56 intervention and 40 control public schools in California,
Louisiana, Minnesota, and Texas. Of the 56 intervention schools, 28 schools participated

in a third-grade through fifth-grade intervention which included school food service

modifications, enhanced physical education, and classroom health curricula; the other 28
schools received these components plus family education. Results at the end of the three-
year intervention indicated that the percentage of energy from fat in intervention school
lunches fell significantly more (from 38.7 to 31.9%) than in control school lunches (from
38.9 to 36.2%) (p<0.001). The intensity of physical activity in physical education classes
increased significantly in intervention schools compared with control schools (p<0.02).
The percentage of energy from fat from 24-hour recalls among intervention school students
was significantly reduced (from 32.7 to 30.3%) compared with that among control school
students (from 32.6 to 32.2%, p<0.001). Intervention students reported significantly more
daily vigorous activity than controls (58.6 vs. 46.5 minutes, p<0.003). However, no signif-
icant differences were detected in blood pressure, body size, and cholesterol measures for
students at the intervention schools compared to those at the control schools.86
A three-year followup was conducted with 3714 students (73%) of the initial CATCH
cohort of 5106 students.156 End-point comparisons were made between students from
intervention and control schools to determine whether changes at the end of intervention
in grade five were maintained through grade eight. Results for eighth-graders indicated
that self-reported daily energy intake from fat remained lower for intervention than control
students (30.6 vs. 31.6%, p = 0.01). Intervention students maintained significantly higher
daily vigorous physical activity than controls (p = .001), although differences narrowed
over time. Significant differences in favor of intervention students persisted at grade eight
for dietary knowledge and dietary intentions, but not for social support for physical
activity. No significant differences were noted for BMI, blood pressure, or serum lipid and
cholesterol levels. In summary, followup of the CATCH cohort suggests that behavior
changes from the intervention were sufficient to produce effects detectable three years
later. However, differences between the intervention and control groups were narrowing
in magnitude over time. Additional research is needed to determine how best to maintain
the intervention effects long-term.156
Food Safety
The Fight Bac!™ campaign is a partnership of industry, government, and consumer groups
dedicated to reducing the incidence of foodborne illness.157 The multifaceted campaign
includes television and radio public service announcements in several languages, media
mailings, newspaper articles, publications, World Wide Web (www.fightbac.org), commu-
nity action kits, supermarket action kits, exhibit and convention kits, and educator kits
for grades kindergarten through three and four through six. Launched in October, 1997,
the eye-catching Fight Bac!™ cartoon character teams up with the following four critical
messages to teach consumers about safe food handling: clean, separate, cook, and chill.157
Table 8.28 provides more details regarding these four messages.
Children, adolescents, and adults of all ages need to understand the important role they
play in decreasing the incidence of foodborne illnesses through proper hand washing as
well as safe food preparation and storage. According to the Hospitality Institute of Tech-
nology and Management,158 hands should be washed with soap, a fingernail brush with
soft bristles, and a large volume of flowing warm water to ensure adequate removal of
pathogenic microorganisms (e.g., those from fecal sources) from fingertips and under
fingernails. Fingernails should be neatly trimmed to less than 1/16 inch to make them
easier to clean. When working with food, hand washing without the fingernail brush is
sufficient because the pathogen count is much lower. Table 8.29 describes the double and
single methods of hand washing. Although young children may be encouraged to wash

TABLE 8.28
Details Regarding the Four Critical Messages of the Fight Bac!™ Campaign
Clean: Wash Hands and Surfaces Often
• Wash hands with hot soapy water before handling food.

• Wash hands with hot soapy water after using the bathroom, changing diapers, and touching animals.
• Wash dishes, utensils, cutting boards, and counter tops with hot soapy water after preparing each food item
and before preparing the next food item.
• Use paper towels to dry hands and clean kitchen surfaces.
Separate: Don’t Cross-Contaminate
• Keep raw meat, poultry, and seafood separate from other foods in grocery carts and refrigerators.
• Use a different cutting board for preparing raw meats.
• Wash hands, cutting boards, dishes, and utensils with hot soapy water after they come in contact with raw
meat, poultry, or seafood.
• Do not place cooked food on a plate or serving dish that previously held raw meat, poultry, or seafood.
Cook: Cook to Proper Temperatures
• To make sure that meat, poultry, casseroles, etc. are cooked all the way through, use a clean thermometer.
• Cook roasts and steaks to at least 145°F; cook whole poultry to 180°F.
• Cook ground beef to at least 160°F. Do not eat ground beef that is still pink inside.
• Cook eggs until the white and yolk are firm.
• Do not eat foods that contain raw eggs or only partially cooked eggs.
• Cook fish until it is opaque and flakes easily with a fork.
• When microwaving foods, make sure there are not cold spots by stirring and rotating food for even heating.
• Reheat sauces, soups, and gravies to a boil. Heat other leftovers thoroughly to at least 165°F.
Chill: Refrigerate Promptly
• Refrigerate or freeze prepared foods and leftovers within two hours or sooner.
• Defrost food in the refrigerator, under cold running water, or in the microwave, but never at room temperature.
• Marinate foods in the refrigerator.
• Divide large amounts of leftovers into small, shallow containers for quick cooling in the refrigerator.
• Avoid packing the refrigerator because cool air must circulate to keep food safe.
Adapted from Fight Bac!™ Four Simple Steps to Food Safety, Partnership for Food Safety Education,
www.fightbac.org (accessed January 11, 2000).
their hands long enough for them to sing their “A, B, Cs” slowly, the amount of lathering
and the volume of water used to wash off the lathering appear to be more important than
the length of time spent washing.158
Dental Health
Nutrition is an integral component of oral health.159 Nutrition and diet may affect the
development and progression of diseases of the oral cavity. Likewise, oral infectious
diseases and acute, chronic, and terminal systemic diseases with oral manifestations, affect
diet and nutritional status. The primary factors to be considered in determining the
cariogenic, cariostatic, and anticariogenic properties of the diet include the form of the
food (liquid, solid and sticky, long lasting), frequency of consumption of sugar and other
fermentable carbohydrates, nutrient composition, sequence of food intake, and combina-
tions of foods.159
Because children of all ages eat frequently, snacks should emphasize foods that are low
in sucrose, are not sticky, and that stimulate saliva flow which helps limit acid production
in the mouth.160 Protein foods such as nuts and cheese may provide nutritional and dental

TABLE 8.29
Two Methods of Hand Washing
Double Wash Procedure (to be used to remove fecal pathogens and other pathogenic microorganisms
from skin surfaces when entering the kitchen, after using the toilet, after cleaning up vomitus or fecal
material, or after touching sores or bandages):
First wash using the fingernail brush (~7 seconds required to complete):
• Turn on water so it runs at 2 gallons per minute with a temperature of 110 to 115°F. Place hands, lower arms,
and fingernail brush under flowing water and thoroughly wet them.
• Apply 1/2 to 1 teaspoon of hand soap or detergent to fingernail brush.
• Brush and lather hand surfaces with tips of bristles on fingernail brush under flowing water, especially
fingertips and around and under fingernails. Build a good lather.
• Continue to use fingernail brush under water until there is no more soapy lather on hands, lower arms, or
nail brush. Hazardous microorganisms in the lather are only removed to a safe level when all the soap is
rinsed off the hands, arms, and fingertips.
• Place nail brush on holder with bristles up so bristles can dry.
Second wash without the fingernail brush (~13 seconds required to complete):
• Apply 1/2 to 1 teaspoon of hand soap or detergent to hands.
• While adding warm water as necessary, rub hands together to produce a good lather; lathering must extend
from fingertips to shirt sleeves.
• After lathering, rinse all of lather from fingertips, hands, and arms in flowing water. The volume of water
used for rinsing hands, not the time of the wash, is the critical factor.
• Thoroughly dry hands and arms using disposable paper towels. Discard paper towels in waste container
without touching container.
Single Wash Procedure (to be used to remove normal low levels of pathogens before and after eating
and drinking; after handling garbage; after handling dirty dishes or utensils; between handling raw and
cooked foods; after blowing or wiping nose; after touching skin, hair, or soiled clothes; and as often as
necessary to keep hands clean after they become soiled):
• Wet hands and lower arms with warm water.
• Follow directions above for “Second wash without the fingernail brush.”
Adapted from Snyder, O. P., Hospitality Institute of Technology and Management, 1998, http://www.hi-tm.com/
Documents/Safehands.html (accessed January 11, 2000).
benefits because some protein foods are thought to have a protective effect against caries.
When desserts are consumed, it is best if they are eaten with meals. Chewing sugarless
gum after snacks containing fermentable carbohydrate may benefit school-age children
and adolescents. The efforts of dietary control are complemented by good oral hygiene.
A fluoride supplement is recommended into the teen years if the water supply is not
fluoridated.160
Maxillary anterior caries (baby bottle tooth decay or BBTD) is the major nutrition-related
dental disease found in infants and preschool children; it appears to be related to feeding
behaviors after longer bottle or breastfeeding.159 The primary cause of BBTD is prolonged
exposure of the teeth to a sweetened liquid such as formula, milk, juice, soda pop, or other
sweetened drinks.160 This often occurs when a child is routinely given a bottle at bedtime
or naptime, because the liquid pools around the teeth during sleep, saliva flow decreases,
and the child may continue to suck liquid over an extended period of time. Toddlers are
also at high risk if they hold their own bottle and have access to it anytime throughout
the day. The primary strategy to prevent BBTD is education. Parents and child care
providers should be encouraged to avoid putting an infant or young child to sleep with
a bottle, and to use a cup to offer juices and liquids other than breast milk or formula.160
Section 54 provides additional information regarding the prevention of dental caries in
children and adolescents.

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2705_frame_C08 Page 241 Wednesday, September 19, 2001 1:15 PM

Suzanne Domel Baxter

Physical Growth and Development

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242 Handbook of Nutrition and Food

timing of the growth spurt is influenced by genetic as well as environmental factors.

Energy and Nutrient Needs

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