Guía de alimentación en niños y adolescentes

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Guía de alimentación en niños y adolescentes

  1. 1. Dietary Recommendations for Children and Adolescents: A Guide for Practitioners American Heart Association, Samuel S. Gidding, Barbara A. Dennison, Leann L.Birch, Stephen R. Daniels, Matthew W. Gilman, Alice H. Lichtenstein, Karyl Thomas Rattay, Julia Steinberger, Nicolas Stettler and Linda Van Horn Pediatrics 2006;117;544-559 DOI: 10.1542/peds.2005-2374 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/117/2/544 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org by on November 1, 2009
  2. 2. ENDORSED POLICY STATEMENTAMERICAN HEART ASSOCIATION The American Academy of Pediatrics has endorsed and accepted this statement as itsDietary Recommendations for policy.Children and Adolescents: A Guidefor PractitionersAmerican Heart Association, Samuel S. Gidding, MD, Chair, Barbara A. Dennison, MD, Cochair,Leann L. Birch, PhD, Stephen R. Daniels, MD, PhD, Matthew W. Gilman, MD,Alice H. Lichtenstein, DSc, Karyl Thomas Rattay, MD, Julia Steinberger, MD, Nicolas Stettler, MD,Linda Van Horn, PhD, RDThe American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outsiderelationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group arerequired to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts ofinterest. A summary of all such reported relationships can be found at the end of this document.ABSTRACTSince the American Heart Association last presented nutrition guidelines forchildren, significant changes have occurred in the prevalence of cardiovascular riskfactors and nutrition behaviors in children. Overweight has increased, whereassaturated fat and cholesterol intake have decreased, at least as percentage of totalcaloric intake. Better understanding of children’s cardiovascular risk status and www.pediatrics.org/cgi/doi/10.1542/current diet is available from national survey data. New research on the efficacy of peds.2005-2565diet intervention in children has been published. Also, increasing attention has doi:10.1542/peds.2005-2374been paid to the importance of nutrition early in life, including the fetal milieu. This statement was endorsed by the American Academy of Pediatrics on AugustThis scientific statement summarizes current available information on cardiovas- 24, 2005. All endorsements of statementscular nutrition in children and makes recommendations for both primordial and by the American Academy of Pediatricsprimary prevention of cardiovascular disease beginning at a young age. automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.I This statement was approved by the T IS ESTIMATED that 75% to 90% of the cardiovascular disease epidemic is related American Heart Association Science to dyslipidemia, hypertension, diabetes mellitus, tobacco use, physical inactiv- Advisory and Coordinating Committee on July 22, 2005.ity, and obesity; the principal causes of these risk factors are adverse behaviors, Expert peer review of AHA Scientificincluding poor nutrition.1–3 The atherosclerotic process begins in youth, culminat- Statements is conducted at the AHAing in the risk factor–related development of vascular plaque in the third and National Center. For more on AHA statements and guidelines development,fourth decades of life.4–6 Good nutrition, a physically active lifestyle, and absence visit www.americanheart.of tobacco use contribute to lower risk prevalence and either delay or prevent the org/presenter.jhtml?identifier 3023366. ©2005 American Heart Association.onset of cardiovascular disease.2,3 These observations have established the concept Republished with permission. (Circulation.of prevention of the development of cardiovascular risk factors in the first place, 2005;112:2061–2075). A correctionnow called primordial prevention.7 Education, with the support of the health care appeared in Circulation. 2005;112:2375. This version reflects the corrected text.community, combined with health policy and environmental change to support Key Wordsoptimal nutrition and physical activity, are central to this health strategy. AHA scientific statements, adolescents, This document provides dietary and physical activity recommendations for children, diet, nutritionhealthy children; discusses the current content of children’s diets; reviews the Abbreviations AHA—American Heart Associationadverse health consequences of increased intakes of calories (relative to energy FDA—Food and Drug Administrationexpenditure), saturated and trans fat, and cholesterol; and provides age-specific guide- LDL—low-density lipoproteinlines for implementation of the recommended diet, including the period from before Address correspondence to American Heart Association Scientific Publishing Information.birth to 2 years of age. Medical practitioners are the intended audience, and guidelines E-mail: pubauth@heart.orgto implement recommendations in clinical practice settings are provided. Public health PEDIATRICS (ISSN Numbers: Print, 0031-4005;strategies for improving the quality of children’s diets are also discussed. Online, 1098-4275).544 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on November 1, 2009
  3. 3. This scientific statement on optimal cardiovascular TABLE 1 AHA Pediatric Dietary Strategies for Individuals Aged >2nutrition for infants, children, and adolescents revises Years: Recommendations to All Patients and Familiesthe 1982 document on the same topic and also builds on Balance dietary calories with physical activity to maintain normal growththe recent consensus statement on optimal nutrition for 60 min of moderate to vigorous play or physical activity dailythe prevention of many chronic diseases of adulthood.8,9 Eat vegetables and fruits daily, limit juice intakeThis revision responds to the obesity epidemic that has Use vegetable oils and soft margarines low in saturated fat and trans fatty acids instead of butter or most other animal fats in the dietemerged since the publication of the last statement that Eat whole-grain breads and cereals rather than refined-grain productsaddressed children’s nutrition from the American Heart Reduce the intake of sugar-sweetened beverages and foodsAssociation (AHA) and has new focuses on both total Use nonfat (skim) or low-fat milk and dairy products dailycaloric intake and eating behaviors.10,11 This revision Eat more fish, especially oily fish, broiled or bakedstrongly conveys the message that foods and beverages Reduce salt intake, including salt from processed foodsthat fulfill nutritional requirements are appropriate forgrowing and developing infants, children, and adoles-cents. Calorie-dense foods and beverages with minimal TABLE 2 Tips for Parents to Implement AHA Pediatric Dietarynutritional content must return to their role as occa- Guidelinessional discretionary items in an otherwise balanced diet. Reduce added sugars, including sugar-sweetened drinks and juices A critical component of contemporary guidelines is Use canola, soybean, corn oil, safflower oil, or other unsaturated oils in place of solid fats during food preparationthe strength of the scientific evidence base for recom- Use recommended portion sizes on food labels when preparing and serving foodmendations. Whereas the scientific base for understand- Use fresh, frozen, and canned vegetables and fruits and serve at every meal; being the potential harm and benefit of current dietary careful with added sauces and sugarpractices and the relationship to risk factors is strong, the Introduce and regularly serve fish as an entree´scientific base for recommended interventions is weaker Remove the skin from poultry before eating Use only lean cuts of meat and reduced-fat meat productsfor several reasons: limited number, statistical power, Limit high-calorie sauces such as Alfredo, cream sauces, cheese sauces, andand scope of intervention studies; limited efficacy of hollandaiseattempted interventions; and lack of generalizability of Eat whole-grain breads and cereals rather than refined products; read labels andstudies of feeding behaviors at younger ages. Histori- ensure that “whole grain” is the first ingredient on the food label of thesecally, most have had small sample size and have not had products Eat more legumes (beans) and tofu in place of meat for some entrees ´ethnic diversity among participants. Nonetheless, given Breads, breakfast cereals, and prepared foods, including soups, may be high inthe current obesity epidemic, sufficient natural history salt and/or sugar; read food labels for content and choose high-fiber, low-salt/and prevalence data exist to justify intervention, al- low-sugar alternativesthough continued evaluation is necessary to identifyoptimal strategies.12 contributions from each food group are calculated ac-DIETARY RECOMMENDATIONS cording to the nutrient-dense forms of foods in eachThe general dietary recommendations of the AHA for group (eg, lean meats and fat-free milk), with the ex-those aged 2 years and older stress a diet that primarily ception of the guidelines for 1-year-old children, whichrelies on fruits and vegetables, whole grains, low-fat and included 2% fat milk. For youth 3 years of age and older,nonfat dairy products, beans, fish, and lean meat.1,13 calorie estimates are based on a sedentary lifestyle. MoreThese general recommendations echo other recent pub- physically active children and adolescents will requirelic health dietary guidelines in emphasizing low intakes additional calories.14,17–19 This table is provided as a start-of saturated and trans fat, cholesterol, and added sugar ing point for dietary counseling; recommendations willand salt; energy intake and physical activity appropriate need to be individualized in clinical practice. Table 4for the maintenance of a normal weight for height; and provides daily recommended intakes of sodium, potas-adequate intake of micronutrients.14–16 Tables 1 and 2 sium, and fiber.18 More complete guidelines for infants,provide strategies for implementing healthy cardiovas- particularly with regard to the transition from breast/cular nutrition. The recently published Dietary Guide- formula-feeding to table foods, will be discussed below.lines for Americans (for those 2 years of age and older) Emphases different from the past include the allow-and American Academy of Pediatrics Nutrition Hand- ance of a more liberal intake of unsaturated fat and abook provide important supporting reference informa- focus on ensuring adequate intakes of omega-3 fattytion with regard to overall diet composition, appropriate acids. There is an emphasis on foods that are rich incaloric intakes at different ages, macronutrients, micro- nutrients and that provide increased amounts of dietarynutrients, portion size, and food choices.14,17,18 Table 3 fiber. The AHA continues to recommend diets low inprovides daily estimated calorie and serving recommen- saturated and trans fats. Healthy foods include fruits,dations for grains, fruits, vegetables, and milk/dairy vegetables, whole grains, legumes, low-fat dairy prod-products by age and gender. Consistent with the Dietary ucts, fish, poultry, and lean meats. Fruits, vegetables,Guidelines for Americans, 2005,14,18 nutrient and energy and fish are often inadequately consumed by children PEDIATRICS Volume 117, Number 2, February 2006 545 Downloaded from www.pediatrics.org by on November 1, 2009
  4. 4. TABLE 3 Daily Estimated Calories and Recommended Servings for Fish is an important food with growing evidence of Grains, Fruits, Vegetables, and Milk/Dairy by Age and potential benefit. However, consumers may have diffi- Gender culty in distinguishing among several health messages 1y 2–3 y 4–8 y 9–13 y 14–18 y about fish consumption. Although strong data associateKilocalories a 900 1000 cardiovascular disease prevention with increased fish Female 1200 1600 1800 consumption, there are also concerns about potential Male 1400 1800 2200 polycarbonate phenols (PCBs) and mercury contamina-Fat, % of total kcal 30–40 30–35 25–35 25–35 25–35 tion.21,22 The Food and Drug Administration (FDA) andMilk/dairy, cupsb 2c 2 2 3 3 AHA stress that seafood is an important part of a healthyLean meat/beans, oz 1.5 2 5 Female 3 5 diet and advocate consumption of a wide variety of Male 4 6 fish and shellfish. Current FDA recommendations withFruits, cupsd 1 1 1.5 1.5 regard to limiting fish intake pertain to women who Female 1.5 may become pregnant or are already pregnant, nursing Male 2 mothers, and young children. The FDA recommendsVegetables, cupsd 3/4 1 Female 1 2 2.5 that people in those categories avoid shark, swordfish, Male 1.5 2.5 3 king mackerel, and tilefish because they contain highGrains, oze 2 3 levels of mercury. Five of the most commonly eaten Female 4 5 6 varieties of fish are low in mercury (shrimp, canned light Male 5 6 7 tuna, salmon, pollack, and catfish). The AHA continuesCalorie estimates are based on a sedentary lifestyle. Increased physical activity will require to recommend 2 servings of fish weekly.23 Recent evi-additional calories: by 0 to 200 kcal/day if moderately physically active and by 200 to 400kcal/day if very physically active. dence suggests that commercially fried fish products,a For youth 2 years and older; adopted from Tables 2 and 3 and Appendix A-2 in US Department likely because they are relatively low in omega-3 fattyof Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans. acids and high in trans fatty acids (if hydrogenated fat is6th ed. Washington, DC: US Government Printing Office; 2005; www.healthierus.gov/dietaryguidelines. Nutrient and energy contributions from each group are calculated according used for preparation), do not provide the same benefitsto the nutrient-dense forms of food in each group (eg, lean meats and fat-free milk). as other sources of fish.24b Milk listed is fat-free (except for children under the age of 2 years). If 1%, 2%, or whole-fat milkis substituted, this will utilize, for each cup, 19, 39, or 63 kcal of discretionary calories and add 2.6,5.1, or 9.0 g of total fat, of which 1.3, 2.6, or 4.6 g are saturated fat. DISCRETIONARY CALORIESc For 1-year-old children, calculations are based on 2% fat milk. If 2 cups of whole milk are The obesity epidemic has prioritized consideration of thesubstituted, 48 kcal of discretionary calories will be utilized. The American Academy of Pediat- complex issue of matching appropriate energy intake torics recommends that low-fat/reduced-fat milk not be started before 2 years of age.d Serving sizes are 1/4 cup for 1 year of age, 1/3 cup for 2 to 3 years of age, and 1/2 cup for 4 energy expenditure.10,11 One approach is the concept ofyears of age. A variety of vegetables should be selected from each subgroup over the week. discretionary calories14 illustrated in Fig 1. Total calorice Half of all grains should be whole grains. TABLE 4 Daily Recommended Intakes of Fiber, Sodium, and Potassium by Age and GenderGender/Age Fiber, ga Sodium, mg Potassium, mg1–3 y 19 1500 30004–8 y Female 25 1900 3800 Male 25 1900 38009–13 y Female 26 2200 4500 Male 31 2200 450014–18 y Female 29 2300 4700 Male 38 2300 4700Adapted from 2005 Dietary Guideline Advisory Committee. Nutrition and your health: dietaryguidelines for Americans. Available at: www.health.gov/dietaryguidelines/dga2005/report/HTML/E translation.htm.a Total fiber preferred minimum 14 g/1000 kcal. Read labels to determine amounts on allpackaged foodsand adolescents. Because the major sources of saturated FIGURE 1fat and cholesterol in children’s diets are full-fat milk Concept of discretionary calories by gender. As daily physical activity increases, moreand cheese and fatty meats, use of low-fat dairy products energy is needed for normal growth. For sedentary children, only small amounts ofand lean cuts of meat in appropriate portion sizes will be discretionary calories can be consumed before caloric intake becomes excessive. Discre- tionary calories for children aged 4 to 8 years are based on 2 servings of dairy per day. Modcritical in meeting dietary needs and nutrient require- act indicates moderately active. Based on estimated calorie requirements and discretion-ments.20 ary calories published in Dietary Guidelines for Americans (2005).14546 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on November 1, 2009
  5. 5. intake is the sum of essential calories, the total energy A meta-analysis of adult studies of low-saturated fat,intake necessary to meet recommended nutrient in- low-cholesterol diets suggested that introduction of thetakes, and discretionary calories, the additional calories diet lowers low-density lipoprotein (LDL) cholesterol annecessary to meet energy demand and for normal average of 12%, with a 1.93 mg/dL decline in LDLgrowth.18 The figure shows essential calories and discre- cholesterol for every 1% decline in saturated fat.38 Fur-tionary calories; these increase with age and increasing ther restricting saturated fat from 10% of total energy tolevels of physical activity. There is a large difference in 7% (the Therapeutic Lifestyle Change diet) increased thethe discretionary calorie allowance among sedentary, LDL cholesterol reduction to 16%.38,39 Pediatric confir-moderately active, and active children, with more phys- mation of adult studies showing safety and efficacy of aically active children needing more energy from food to low-cholesterol and low-saturated fat diet has emerged.maintain normal growth. For young sedentary children, The Dietary Intervention Study in Children (DISC) wasthe amount of total energy intake that can come from a randomized trial of a low-saturated fat, low-cholesterolfoods used purely as a source of energy, 100 to 150 diet conducted over 3 years in US children initially pre-calories, is less than that provided by a usual portion size pubertal and aged 8 to 11 years.35 The Special Turku Riskof most low-nutrient-dense snacks and beverages. With Intervention Program (STRIP) was a randomized dietaryincreasing activity, this discretionary calorie amount intervention trial begun at weaning (age 7 months)may increase to 200 to 500 calories, depending on the with parental dietary education continued through theage and gender of the child and the level of physical age of 7 years.40–42 Both studies achieved diets in inter-activity. The message portrayed by Fig 1 is clear: To be vention groups consistent with current recommenda-sedentary, have a nutritionally adequate diet, and to tions for therapeutic lifestyle changes to lower elevatedavoid excessive caloric intake in contemporary society is cholesterol levels, with total fat 30% of total caloriesdifficult.25 The challenge to health care providers and and cholesterol intake 200 mg/day.39 Saturated fat in-public health professionals is to translate the complex take, although not 7% of total calories, was signifi-science-based energy balance message from Fig 1 into cantly less than in children assigned to usual care. Acrosseffective practice and public health policy.25a Consuming a wide array of safety measures, including measures ofdiets that include primarily nutrient-dense forms of the growth, neurologic development, metabolic function,foods listed in Table 3, participating in regular moderate and nutrient adequacy, no adverse effects of the recom-to vigorous physical activity most days of the week for at mended intervention diets were observed.40,43–45 LDLleast 1 hour per day, and limiting video screen time to cholesterol levels were significantly lower among chil- 2 hours per day will help accomplish this goal. dren receiving dietary intervention in the DISC study and in boys receiving dietary intervention in the STRIPScientific Support for Current Dietary Recommendations study compared with controls.35,42 Most importantly, inThe importance of dietary saturated and trans fat and both studies children receiving dietary intervention werecholesterol to the development of elevated cholesterol significantly more likely to make healthy food choices.25and subsequent cardiovascular disease as well as other Three-year follow-up of children with severe hyperlip-cardiovascular risk factors has been extensively studied idemia who were following recommended therapeuticand reviewed. Pathologic evidence demonstrates that as lifestyle changes showed no adverse effects on growththe number of cardiovascular risk factors increases, so and development.46does the evidence of atherosclerosis in the aorta and The relationship between obesity and multiple cardio-coronary arteries beginning in early childhood.4,5,26 Evi- vascular risk factors, including elevated blood pressure,dence of increased carotid artery intima-media thickness dyslipidemia, low physical fitness, and insulin resis-and coronary artery calcium measured by electron beam tance/diabetes mellitus, is well established.10,47–49 Bothcomputed tomography among 29- to 39-year-old young excess caloric intake and physical inactivity are stronglyadults who have been monitored from childhood further associated with obesity.50 Studies of weight loss in over-documents that the significant precursors of adult ath- weight individuals consistently show improvement inerosclerosis are obesity, elevated blood pressure, and obesity-related comorbidities, particularly when inter-dyslipidemia.6,27,28 Epidemiologic data from longitudinal ventions include regular exercise in the treatment pro-studies provide further evidence that overweight, hyper- gram.51–53 Population-based cross-sectional studies ofcholesterolemia, and hypertension track over time from secular trends in cardiovascular risk have shown strongchildhood into adult life and that lifestyle choices, eg, associations between increasing prevalence of obesitydiet, excess caloric intake, physical inactivity, and ciga- and increasing blood pressure levels but inconsistentrette smoking, influence these risk factors.29–34 Interven- trends in dyslipidemia.47,54,55 Longitudinal studies of sec-tion studies aimed at measuring the efficacy and safety of ular trends in children, however, have shown strongdiets reduced in total and saturated fat and cholesterol relationships between increases in adiposity and adversehave also now contributed evidence at both the clinical trends in blood pressure and lipids.56 Maintaining bodyand school-based levels.35–37 mass index (BMI) is beneficial, even without weight PEDIATRICS Volume 117, Number 2, February 2006 547 Downloaded from www.pediatrics.org by on November 1, 2009
  6. 6. loss, because this prevents worsening of risk status.57 a shift away from high-fiber fruits and vegetables as wellMaintenance of body weight during normal growth will as a general decline in fruit and vegetable consumptionimprove BMI and cardiovascular risk status. Although other than potatoes.62–67 Fried potatoes make up a sub-primary prevention trials of reduction of daily caloric stantial portion of the vegetable intake.67 Sugar con-intake in at-risk children are under way, the evidence sumption has increased, particularly in preschool chil-for harm from excess caloric intake is sufficient to sup- dren.68 With regard to micronutrients, the shift in dietaryport public health efforts for obesity prevention.11,58,59 patterns has resulted in median intakes below recom- mended values of many important nutrients during ad-What Children Currently Eat olescence.69 Sodium intake is far in excess of recom-It is important to understand the gap between current mended levels, whereas calcium and potassium intakesdietary practices and recommended diets for infants, are below recommended levels.69–71children, and adolescents. Sufficient population-baseddata exist to identify the magnitude of the problem Implementation of Dietary Recommendations Includingconfronting those interested in improving cardiovascular Considerations for Specific Age Groupshealth in youth. Areas to consider include appropriate- This section reviews age-specific pediatric research onness of total caloric intake, eating patterns, balance of cardiovascular and general nutrition. Although in somefoods/beverages chosen from each food group, and in- areas there is a reasonable body of work about which totake of specific nutrients. Published data evaluate each make useful judgments, in many areas studies haveof these areas with age and gender as important associ- significant methodologic limitations: small sample size,ated considerations. confounding by a variety of factors (including cultural For infants, it is encouraging that 76% of mothers factors), and difficulty of using classic randomized trialhave initiated breastfeeding.60 However, maintenance of designs to answer pertinent research questions. Never-breastfeeding for the first 4 to 6 months of life has been theless, the current dietary pattern of contemporaryless successful. Only 4% of infants participating in the children mandates change. The recommendations pro-Special Supplemental Nutrition Program for Women, vided herein are based on expert consensus of emergingInfants, and Children (WIC) and 17% of the nonpartic- evidence. Their purpose is to improve the nutritionalipants remain exclusively breastfed at 6 months of age. quality, amount, and pattern of food consumption byThis suggests a strong socioeconomic status gradient in children and their families. Although the narrative em-breastfeeding behavior. By 4 to 6 months, 66% of in- phasizes nutrition to improve cardiovascular risk, it isfants have received grain products, 40% vegetables, recognized that optimal nutrition for overall health and42% fruits, 14% meat, and 0.6% some type of sweet- normal growth is the preeminent goal.ened beverages.61 By 9 to 11 months, 98% of infants Recommendations for children’s nutrition considerhave received grain products, 73% vegetables, 76% the family and cultural milieu.72,73 It has been decadesfruits, 79% meat, and 11% some type of sweetened since the majority of meals were consumed within thebeverages.61 Sweetened beverages have been consumed home.60–67 Sources of nourishment include schools,by 28% of the 12- to 14-month-old children, 37% of the child-care and after-school youth programs, restaurants,15- to 18-month-old children, and 44% of the 19- to vending machines, convenience stores, work sites, and24-month-old children.61 During the transition from a foods prepared by industry designed for minimal prepa-milk-based diet to adult foods, the types of vegetables ration time in the household.74 Common situations af-consumed change adversely. Deep-yellow vegetables are fecting food preparation include households in whichconsumed by 39% of children at 7 to 8 months and by both parents work, single-parent households, and work13% at 19 to 24 months, whereas French fries become schedules that demand that parents be away from homethe most commonly consumed vegetable by this age.61 at mealtime. Likewise, children have complex schedulesSimilarly, fruit consumption declines to the point where that demand frequent meals away from home. Schoolsone third of 19- to 24-month-old children consume no provide less education on food preparation (eg, homefruit, whereas 60% consume baked desserts, 20% economics) than in the past.candy, and 44% sweetened beverages on a given day.61 Culture-specific dietary practices can influence the Significant adverse changes have occurred in older diet both for better and for worse. A specific problem ischildren’s food consumption.62 These include a reduc- the folk belief that a fat infant or chubby toddler istion in regular breakfast consumption, an increase in healthy. Popular fad diets often mix helpful and harmfulconsumption of foods prepared away from the home, an components in their educational messages. Layered onincrease in the percentage of total calories from snacks, top of this is a largely unregulated media dedicated toan increase in consumption of fried and nutrient-poor selling large quantities of a wide array of foods and foodfoods, a significant increase in portion size at each meal, products of poor nutritional value. Despite unparalleledand an increase in consumption of sweetened beverages, availability of nutrition resources, sifting through thewhereas dairy product consumption has decreased, and food-message bombardment is often the most difficult548 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on November 1, 2009
  7. 7. task facing a parent interested in providing proper nu- and glucose intolerance, are also at higher risk of futuretrition for his or her family. Teaching those involved in obesity.89,90supervision of children’s diets to consume a healthful It is important for parents or parents-to-be to obtain adiet themselves and thus provide consistent role model healthy weight, because children whose mothers arebehavior improves diet quality.73,75 Table 5 provides a obese early in pregnancy are more likely to be over-summary of areas in which adult influences are most weight as young children.91 A similar effect is seen inimportant with regard to childhood nutrition.76–81 Par- children whose parents are or become obese during theirents choose the time for meals and snacks and the childhood.31 To ensure optimal growth of the fetus, preg-types of foods and beverages to be served. Children can nant women must optimize their nutrition and weightthen choose how much to consume. Parents, guardians, gain during pregnancy, according to the Institute ofand caregivers must provide appropriate role modeling Medicine guidelines.92 Excessive maternal weight gainthrough their own behavior, that is, influence children has been associated with a two- to threefold increasedto “do as I do” rather than “do as I say.” A similar risk that the mother will be overweight after a pregnan-responsibility falls on those who attempt to provide re- cy.93 This may increase subsequent offspring risk duringliable information to parents and educators in an effort adolescence for obesity, impaired glucose tolerance, im-to counterbalance adverse folk/cultural practices, media paired insulin secretion, and type 2 diabetes. Studies ofinfluences, and other sources of disinformation. Also maternal nutrition, for example, assessments of proteincritical to implementation of nutritional change is the and calcium intake, suggest that maternal diet duringsocial perception of risk.82 Unless people believe that pregnancy may influence offspring’s blood pressure.94,95certain dietary practices are harmful or food providers However, evidence is insufficient to make specific rec-believe that their actions endanger their clients, motiva- ommendations about nutrition during pregnancy basedtion to change will be limited. Increasing social pressure on future cardiovascular disease.for eating properly can counteract the ubiquitous pres- Human milk is uniquely superior for infant feedingence of food and food marketing of energy-dense, nu- and is the reference against which other infant feedingtrient-poor choices. strategies must be measured.96 Breast milk is rich in both saturated fat and cholesterol but low in sodium. There has been substantial work on the relationship of breast-Birth to 2 Years feeding to both future cardiovascular events and cardio-There has been considerable interest in the influence of vascular risk factors. Although pooling estimates fromboth the intrauterine environment and infant nutrition these studies is difficult because of differences in expo-on future cardiovascular risk.83,84 It has been hypothe- sure and outcome assessment, recent meta-analysessized that “programming” of future cardiovascular re- have suggested no meaningful impact of breastfeedingsponses is established either in the womb or in response on subsequent cardiovascular or all-cause mortality into feeding exposures early in life. Animal models support adulthood.97 Other systematic reviews, however, suggestthe programming hypothesis, but there are as yet few benefits of breastfeeding, particularly in the preventionhuman experimental data.85–87 Lower birth weight, be- of future obesity.98,99 Several studies suggest that breast-cause of presumed intrauterine malnutrition and asso- feeding leads to lower blood pressure later in child-ciation with rapid postnatal rapid weight gain, is associ- hood.100,101 Although breastfeeding is associated withated with central adiposity, the metabolic syndrome, higher blood cholesterol levels at 1 year of age, it maydiabetes mellitus, and cardiovascular disease outcomes also result in lower blood cholesterol levels in adults.102in adulthood.88 Infants large for gestational age, probably Rapid weight gain during the first 4 to 6 months of life isthrough consequences of maternal insulin resistance associated with future risk of overweight103,106; studies suggest that partially breastfed and formula-fed infants consume 20% more total calories per day than do ex- TABLE 5 Parent, Guardian, and Caregiver Responsibilities for clusively breastfed infants.104,105 Physicians should iden- Children’s Nutrition tify infants who are gaining weight rapidly and/or whoseChoose breastfeeding for first nutrition; try to maintain for 12 mo weight-to-length percentile exceeds the 95th percentileControl when food is available and when it can be eaten (nutrient quality, portion to help correct overfeeding if present. size, snacking, regular meals) At least 2 behavioral benefits of breastfeeding mayProvide social context for eating behavior (family meals, role of food in social lead to reduced cardiovascular risk, but the impact of intercourse) these has not been studied in large trials.107–110 The firstTeach about food and nutrition at the grocery store, when cooking mealsCounteract inaccurate information from the media and other influences potential benefit may be better self-regulation of intake.Teach other care providers (eg, daycare, babysitters) about what you want your Compared with parents who bottle-feed, mothers who children to eat breastfeed appear to allow the infant to take an activeServe as role models and lead by example; “do as I do” rather than “do as I say” role in controlling intake, possibly promoting maternalPromote and participate in regular daily physical activity feeding practices that can foster better self-regulation of PEDIATRICS Volume 117, Number 2, February 2006 549 Downloaded from www.pediatrics.org by on November 1, 2009
  8. 8. energy intake as the child grows up.108 Children withimproved self-regulation may better withstand the cur-rent food-surplus environment.111 The second potentialbenefit relates to taste preference.112–116 Both amnioticfluid and breast milk provide flavor exposure to the fetusand infant. These exposures influence taste preferenceand food choices after weaning. Thus, exposure tohealthier foods through maternal food consumptionduring pregnancy and lactation may improve acceptanceof healthy foods after weaning. Because infant responsesto taste are different from mature taste, these early ex-posures may be critical in determining food preferencelater in life. A critical social problem for mothers interested inbreastfeeding in the United States is the lack of a tolerantsocial structure.117 Breastfeeding rates decline rapidly be-tween 2 and 3 months, which is when many mothersreturn to work or school.118,119 Full-time employment is FIGURE 2consistently associated with shorter periods of breast- Dramatic change in food sources during the first 2 years of life. Diet is initially based onfeeding.120–123 In Scandinavian countries, where women breast milk at birth and transitions to conventional foods by 2 years, although dairy products remain a major source of energy and nutrition. (Reproduced with permissionroutinely receive paid maternity benefits (eg, 42 weeks from Lederman SA, Akabas SR, Moore BJ, et al. Summary of the Presentations at thewith full pay or 52 weeks at 80% of salary in Norway), Conference on Preventing Childhood Obesity, December 8, 2003. Pediatrics. 2004;114:women far surpass the US Healthy People 2010 goals for 1146 –1173; adapted from Briefel RR, Reidy K, Karwe V, Devaney B. Feeding infants and toddlers study: improvements needed in meeting infant feeding recommendations.breastfeeding. In Norway, 97% of women are breast- J Am Diet Assoc. 2004;104(1 suppl 1):s31–s37 and Skinner JD, Ziegler P, Ponza M. Transi-feeding when they leave the hospital, 80% are breast- tions in infants’ and toddlers’ beverage patterns. J Am Diet Assoc. 2004;104(suppl 1):s45–feeding at 3 months, and 36% are breastfeeding at 12 s50.)months.124 Most African and Asian countries are highlysupportive of breastfeeding. Policies enacted within theworkplace and public places can also help to overcome ing of food intake, these data might also explain the risebarriers to breastfeeding.117,125 in the prevalence of overweight at very young ages.129,130 The period from weaning to consumption of a mature For those participating in public nutrition assistancediet, from 4 to 6 months to 2 years of age, represents programs (US Department of Agriculture 2002), thea radical shift in pattern of food consumption (Fig foods supplied for infants and children are limited in2),17,126,126a,129,130 but there has been very little research on variety, reflecting more closely the nutritional concernsthe best methods to achieve optimal nutritional intakes of the 1970s, when the program was designed (inade-during this transition. Infants mature from receiving all quate calories, protein, vitamin A, vitamin C, and iron),nutrition from a milk-based diet to a diet chosen from than nutritional concerns today (excess calories, fat, andthe range of adult foods, in part self-selected and in part sugar and inadequate fruits, vegetables, and wholeprovided by caregivers. Transition to other sources of grains).131 Moreover, beverages provided to most chil-nutrients should begin at 4 to 6 months of age to ensure dren are not optimal. Children aged 1 to 5 years enrolledsufficient micronutrients in the diet, but the best meth- in the Special Supplemental Nutrition Program forods for accomplishing this task are essentially un- Women, Infants, and Children receive twice the amountknown.15,126 Current feeding practices and guidelines are of fruit juice (9.5 fl oz/day) currently recommended,influenced by small-scale studies of infant feeding be- and most participants also receive or choose wholehavior, idiosyncratic parental behavior, and popular milk.14,17,131,132 For formula-fed infants, there may also beopinion.17,60,127,128 a role for clearer prescriptive feeding advice for parents Food-consumption data suggest that infants are cur- to understand their infant’s satiety cues and appropriaterently exposed to a wide variety of “kid” foods that tend energy intake than is currently the norm. Table 6 pro-to be high in fat and sugar, including excess juice, juice- vides a number of strategies to improve general andbased sweetened beverages, French fries, and nutrient- cardiovascular nutrition during this transitional stage.poor snacks.61 Usual food intakes of infants and young When normal growth is present, overfeeding may resultchildren may exceed estimated energy requirements. from arbitrarily increasing amounts fed to achieve spe-For infants aged 0 to 6 months, reported intakes exceed cific portion sizes per meal rather than allowing infantsrequirements by 10% to 20%; for children aged 1 to 4 and toddlers to self-regulate. New healthy foods mayyears, intakes exceed requirements by 20% to 35%. need to be introduced repeatedly, as many as 10 times,Although some of these reports may reflect overreport- to establish taste preferences.133550 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on November 1, 2009
  9. 9. TABLE 6 Improving Nutritional Quality After Weaning mal weight gain in the next year can be given. BloodMaintain breastfeeding as the exclusive source of nutrition for the first 4–6 mo of pressure screening and cholesterol measurement, if in- life dicated, are begun in this age range.7Delay the introduction of 100% juice until at least 6 mo of age and limit to no more than 4–6 oz/day; juice should only be fed from a cup Ages 6 Years and AboveRespond to satiety clues and do not overfeed; infants and young children can As children grow up, sources of food and influences on usually self-regulate total caloric intake; do not force children to finish meals if not hungry, because they often vary caloric intake from meal to meal eating behavior increase. Social constraints on familiesIntroduce healthy foods and continue offering if initially refused; do not introduce may necessitate the presence of multiple caregivers, eat- foods without overall nutritional value simply to provide calories ing out, and frequent fast food consumption. Many chil- dren, because of parental work schedules, are home alone and prepare their own snacks and meals. By earlyAge 2 to 6 Years adolescence, peer pressure begins to usurp parental au-At this age, recommendations for diet content are similar thority, and fad diets may be initiated. Many meals andto those for older individuals. Challenges here relate to snacks are routinely obtained outside the home, oftenproviding quality nutrient intake and avoiding excess without supervision. Sites include schools, friends’caloric intake. Dairy products are a major source of homes, child-care centers, and social events. Older chil-saturated fat and cholesterol in this age group, and dren have discretionary funds to use for self-selectedtherefore a transition to low-fat milk and other dairy foods. Current eating patterns do not at all resemble theproducts is important.34,134 Sweetened beverages and “norm” of providing at least breakfast, dinner, and aother sugar-containing snacks are a major source of single snack at home with lunch carried to school orcaloric intake.135,136 Table 7 provides a list of strategies for purchased from a health-conscious cafeteria. For exam-managing nutrition in young children.77,78,137–141 Parents ple, current diet studies suggest that many children doshould remember that they are responsible for choosing not eat breakfast and get at least one third of caloriesfoods that are eaten and when and where they are from snacks. Sweetened beverage intakes contribute sig-eaten. The child is responsible for whether he or she nificantly to total caloric intake.144 Sweetened beverageswants to eat and how much. Two natural parental im- and naturally sweet beverages, such as fruit juice, shouldpulses, pressuring children to eat and restricting access to be limited to 4 to 6 oz per day for children 1 to 6 yearsspecific foods, are not recommended because they often old, and to 8 to 12 oz per day for children 7 to 18 yearslead to overeating, dislikes, and paradoxical interest in old.144,145 These snacks often contribute to excess con-forbidden items.142,143 sumption of discretionary calories and/or supplant the Health care providers must provide useful advice to intake of foods containing essential nutrients.25,146parents, but they are constrained by time pressures in Adolescence is a nutritionally vulnerable develop-the typical health maintenance office visit. In addition to mental stage because growth rate accelerates. Amplifiedthe information in Table 7, advice on caloric/energy caloric and global nutrition needs due to pubertalvalues of food, particularly nutrient-poor foods, can be growth stimulate appetite. The combination of centrallyprovided in a relatively short period of time. At office driven appetite stimulation and an increasingly seden-visits, BMI percentile can be plotted, the appropriateness tary lifestyle due to a decline in recreational sports par-of weight gain in the last year can be assessed from ticipation augments obesity.50 Parallel to the psychoso-standard growth curves, and recommendations for opti- cial transition from dependence on parental authority to independent thought processes, food choices and pur- chases are increasingly made by the adolescent. Peer TABLE 7 Improving Nutrition in Young Children pressure for conformity, in part driven by media promo-Parents choose meal times, not children tion of fast food directly to teens, makes overeatingProvide a wide variety of nutrient-dense foods such as fruits and vegetables natural. Currently, adolescents have an increased intake instead of high-energy-density/nutrient-poor foods such as salty snacks, ice of sweetened beverages, French fries, pizza, and fast food cream, fried foods, cookies, and sweetened beverages entrees, including hamburgers, and a consequent lack of ´Pay attention to portion size; serve portions appropriate for the child’s size and age recommended fruits, vegetables, dairy foods, wholeUse nonfat or low-fat dairy products as sources of calcium and protein grains, lean meats, and fish. This change in eating pat-Limit snacking during sedentary behavior or in response to boredom and tern results in consumption of excess fat, saturated fat, particularly restrict use of sweet/sweetened beverages as snacks (eg, juice, trans fats, and added sugars along with insufficient con- soda, sports drinks) sumption of micronutrients such as calcium, iron, zinc,Limit sedentary behaviors, with no more than 1–2 h/day of video screen/television and no television sets in children’s bedrooms and potassium, as well as vitamins A, D, and C and folicAllow self-regulation of total caloric intake in the presence of normal BMI or acid.146,147 weight for height Counseling of older children and adolescents must beHave regular family meals to promote social interaction and role model food- individualized to accommodate the range of contempo- related behavior rary lifestyles; less success is achieved at older ages. PEDIATRICS Volume 117, Number 2, February 2006 551 Downloaded from www.pediatrics.org by on November 1, 2009
  10. 10. Current dietary practices and readiness to change must Health (CATCH), was a multicenter intervention thatbe understood before family-based intervention is at- included nutrition education, a cafeteria intervention,tempted.148 Parental role modeling is important in estab- changes in physical education programs, and parentallishing children’s food choices.53,78,132 Depending on their education. The fat content of school lunch but not schoolown food choices, parents can be either positive or neg- breakfast was modified, and blood cholesterol levels andative role models.81 children’s weight status were unchanged.36,151,152 Other school studies have shown improvements in fruit (butPublic Health Issues not vegetable) intake.153–155 High-quality foods sold inModern life extends the umbrella of social responsibility vending machines will be selected if they are competi-for provision of appropriate nutrition and nutrition tively priced.62 An intervention that included nutritionknowledge beyond the home to government, the health education, a cafeteria intervention, changes in physicalprofessions, schools, the food industry, and the media. It activity, and a parent component for younger childrenis beyond the scope of this document to evaluate the attending Head Start programs was successful in decreas-large public health effort related to overweight and nu- ing children’s blood cholesterol levels but did not affecttrition now being undertaken. Some important areas are the prevalence of childhood overweight.156highlighted below. Because there is little scientific infor- Physical education programs are often subject to bud-mation to guide current policy directed at changing eat-ing behaviors, it is strongly recommended that evalua- get constraints. The percentage of pupils attending phys-tion, safety, and efficacy tools be incorporated into policy ical education classes has decreased. For example, in aimplementation. study of a representative sample of US high schools, Schools have become a battleground for fighting the participation rates fell from 79% in ninth grade to 36%obesity epidemic.149,150 Cafeterias are under attack for in 12th grade.157 In addition, participation in school-serving unhealthy food, yet the food provided is con- sponsored after-school teams is frequently limited tostrained by budgetary and regulatory issues largely ex- elite athletes, limiting the opportunity for high school-ternal to public health concerns. US Department of Ag- aged students to engage in regular physical activity.riculture guidelines require school food programs to Media has a pervasive influence on children’s foodprovide minimum quantities of specific nutrients over a choices. Children, including the very young, are heavily3- to 7-day span but do not address maximum food marketed by the food industry. Time spent watchingamounts. Vending machines and competing nutrient- television is directly related to children’s food requests.poor foods provide excess calories but also provide rev- The most frequently advertised foods are high-sugarenue to support school programs. Table 8 summarizes breakfast cereals, fast food restaurant products, sweet-some strategies currently being implemented in many ened beverages, frozen dinners, cookies, and candy.locales. Fruits and vegetables are almost never advertised. Nutrition education in schools is considered useful in Watching television during meals is associated with in-improving knowledge about nutrition, but few studies creased frequency of poor food choices and decreasedsuggest that it is effective in altering eating behaviors in frequency of good choices.77,158–160 Several Europeanthe absence of environmental change.150 The largest countries now have restrictions on advertising to chil-study, the Child and Adolescent Trial for Cardiovascular dren as well as school-based marketing. State and local governments are now becoming active in the effort to control obesity on a wide variety of TABLE 8 Strategies for Schools fronts. For example, several states have adopted legisla-Identify a “champion” within the school to coordinate healthy nutrition programs tion mandating that school staff report to parents theEstablish a multidisciplinary team including student representation to assess all BMI status of their children. Changes in food labeling, aspects of the school environment using the School Health Index (Centers for Disease Control and Prevention) or similar assessment taxes on certain types of foods, restrictions on foodsIdentify local, regional, and national nutrition programs; select those proven provided to children in government-sponsored pro- effective (www.ActionForHealthyKids.org) grams, and requiring restaurants to provide nutritionDevelop policies that promote student health and identify nutrition issues within information are examples of regulations under consid- the school (www.nasbe.org/HealthySchools/healthy eating.html)Work to make predominantly healthful foods available at school and school eration.11,161 Strategy types are summarized in Table 9. functions by influencing food and beverage contracts, adapt marketing Given the widening discrepancy between recommended techniques to influence students to make healthy choices, and restrict in- dietary guidelines and current dietary intake, a reevalu- school availability of and marketing of poor food choices ation of federal agricultural policies may be warranted.Maximize opportunities for all physical activity and fitness programs (competitive and intramural sports); utilize coaches/teachers as role models Strategies for food subsidies and taxation should reflectLobby for regulatory changes that improve a school’s ability to serve nutritious health goals. Foods made available and served through food public nutrition programs must be consistent with cur-Ban food advertising on school campuses rent recommendations.552 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on November 1, 2009
  11. 11. TABLE 9 Types of Legislation Under Consideration to Improve Expert Panel on Blood Cholesterol Levels in Children Children’s Nutrition and Adolescents published since its publication in 1992,Measurement of BMI by school staff for health surveillance and/or to report but the National Cholesterol Education Program (NCEP) information to parents generally recommends restriction of saturated fat intakeRestriction of certain types of food and beverages available on school grounds to 7% of total calories and restriction of cholesterolTaxation of specific foods or sedentary forms of entertainment intake to 200 mg/day for treatment of elevated LDLEstablishment of local school wellness policies using a multidisciplinary team of cholesterol levels.39,163 There are now data from random- school staff and community volunteers (mandated for schools participating in federal reimbursable school lunch, breakfast, or milk programs) ized trials demonstrating that such diets are safe in chil-Food-labeling regulations, including appropriate descriptions of portion sizes (eg, dren as young as 7 months of age.40,42,44,45 Efficacy is a medium-sized sugar-containing drink should be 6–8 oz) variable, however, and unless the diet is extremely highRegulation of food advertising directed at children in saturated fat before changes are made, it is unlikely that diet alone will be sufficient to achieve target levels for LDL cholesterol in those with genetic dyslipidemiasTherapeutic Lifestyle Changes for Treatment of Hypertension and LDL cholesterol 190 mg/dL. Increased intake ofand Hypercholesterolemia soluble fiber is recommended as an adjunct to the re-There are currently established consensus guidelines for duced intakes of saturated fatty acids and cholester-the role of diet in the management of children with ol.14,167 Recently plant sterols and stanols have beenestablished cardiovascular risk factors. Cut points for used, often in margarines, to lower LDL cholesteroldiagnosing dyslipidemia and hypertension are provided through inhibition of cholesterol absorption. Adult stud-in Table 10.7,39,162,163 The Fourth Pediatric Report of the ies have shown reductions of 4% to 11% without ad-National High Blood Pressure Education Program rec- verse events.168 One randomized, controlled trial in chil-ommends a diet consistent with the current recommen- dren showed that 20 g/day of plant sterol-containingdations for children with hypertension.162 For over- margarine lowered LDL cholesterol 8%.169 These prod-weight children, weight loss is the initial therapeutic ucts may be used, although caution is recommendedstrategy. The Dietary Approaches to Stop Hypertension with regard to the potential for decreased absorption of(DASH) study has recently shown that implementation fat-soluble vitamins and -carotene. Formal recommen-of a diet rich in fruits, vegetables, nonfat dairy products, dation of their use for children awaits clinical trial da-and whole grains can effectively lower blood pressure in ta.42,170–177adults with hypertension.164 Although there are no com-parable clinical trial data in children, there is no reasonto suspect that the DASH diet would not be safe to SUMMARYimplement in older children and adolescents as long as This scientific statement updates nutrition recommenda-protein and calorie needs are met.165,166 tions for the promotion of cardiovascular health among There has not been an update of the Report of the children. Recommendations have been made with re- gard to diet composition, total caloric intake, and phys- ical activity. Implementation requires that children and TABLE 10 Consensus Guidelines for Diagnosis of Hypertension and all other members of their households actively make the Dyslipidemia in Children recommended changes. Adverse recent trends in chil- dren’s diets have been noted. Cardiovascular nutrition Hypertension Guideline issues surrounding the first 2 years of life have beenPrehypertension Systolic or diastolic blood pressure 90th percentile for age and gender or 120/80 mm Hg, addressed. Strategies to improve implementation of the whichever is less recommended diet have been presented. A brief over-Stage 1 hypertension Systolic or diastolic blood pressure 95th view of public health issues related to nutrition is in- percentile for age and gender on 3 consecutive cluded. visits or 140/90 mm Hg, whichever is lessStage 2 hypertension Systolic or diastolic blood pressure 99th percentile 5 mm Hg for age and gender or ACKNOWLEDGMENTS 160/110 mm Hg, whichever is less The authors acknowledge the contributions of manyTotal cholesterol, mg/dL Borderline 170 additional experts who reviewed portions of the material Abnormal 200 presented or supplied additional expertise. These includeLDL cholesterol, mg/dL Julie Mennella, PhD, Gary A. Emmett, MD, and Penny Borderline 100 Kris-Etherton, PhD. Carol Muscar provided invaluable Abnormal 130 support in the preparation of the manuscript and itsHDL cholesterol, mg/dL Abnormal 40 editing. The AHA thanks the Nemours Health and Pre-Triglycerides, mg/dL vention Services group for providing meeting space and Abnormal 200 organizational support to the investigators and AHAHDL indicates high-density lipoprotein. staff, facilitating the rapid completion of this report. PEDIATRICS Volume 117, Number 2, February 2006 553 Downloaded from www.pediatrics.org by on November 1, 2009
  12. 12. Writing Group Disclosures Writing Group Employment Research Grant Other Speakers Ownership Consultant/Advisory Board Other Member Research Bureau/ Interest Support HonorariaSamuel Gidding Nemours Foundation None None None None None NoneBarbara Dennison New York State National Institute of None None None Bassett Healthcare-Research Scientist; Mead Johnson Nutritionals- None Department of Diabetes and Consultant Toddler/Children Panel; American Dairy Health Digestive and Association-Consultant; University of North Carolina- Kidney Diseases– Consultant grantee USDA- Improving Human Nutrition-granteeStephen Daniels Children’s Hospital None None None None None None CincinnatiLinda Van Horn Northwestern None None None None Journal of the American Dietetic Association-Editor in Chief None University- Feinberg School of MedicineJulia Steinberger University of None None None None American Phytotherapy Research Lab-Consultant None MinnesotaAlice Lichtenstein Tufts University None None None None None NoneLeann Bircha Pennsylvania State National Institute of None None None Institute of Medicine Committee on Prevention of Childhood None University Child Health & Obesity in Children and Youth-Chair Human Development- Grantee; Dairy Management Inc- Grantee; USDA- CSREES-Grantee (coinvestigator)Nicolas Stettler University of None None None None European Society for Pediatric Research-Member; International None Pennsylvania Epidemiological Association-Member; World Heart School of Federation-Member; Swiss Pediatric Society-Member; Swiss Medicine Medical Society-Member; American Society for Nutritional Sciences-Member; American Society for Clinical Nutrition- Member; North American Association for the Study of Obesity- Member; Children Are Our Messengers: Changing the Health Message, International Society on Hypertension in Blacks- Advisory Committee Member; Community Health Centers, Child Health Project, US Department of Health and Human Services-Consultant; Early Origins of Adult Health Working Group, National Children’s Study-Core Member; Society for Pediatric Research-Member; Comprehensive School Nutrition Policy Task Force, US Department of Agriculture/ Food-Consultant; National High Blood Pressure Education Program on Blood Pressure in Children and Adolescents; Institute of Medicine Committee on Nutrient Relationships in SeafoodMatthew Gillman Harvard University None None None None None NoneKaryl Rattay Nemours Health and None None None None None None Prevention ServicesCSREES indicates Cooperative State Research, Education, and Extension Service. This table represents the relationships of writing group members that may be perceived as actual or reasonablyperceived conflicts of interest as reported on the Disclosure Questionnaire that all members of the writing group are required to complete and submit. A relationship is considered “significant” if (1)the person receives $10 000 during any 12-month period or 5% of the person’s gross income or (2) the person owns 5% of the voting stock or share of the entity or owns $10 000 of thefair market value of the entity. A relationship is considered “modest” if it is less than “significant” under the preceding definiition.a Modest.Reviewer Disclosures Reviewer Employment Research Grant Other Research Speakers Ownership Consultant/Advisory Other Support Bureau/Honoraria Interest BoardFrank Greer University of Wisconsin- None None None None None None MadisonNancy F. Krebs The Children’s Hospital None None None None None NoneKristie Lancaster New York University None None None None None NoneWilliam Neal West Virginia University None None None None None NoneTheresa A. Nicklas Baylor College of Medicine USDA; National Dairy Management Inc; National Dairy Council None Brands Global Advisory International Food Institutes of National Speakers Bureau; Council on Health, Information Health Cattlemen’s Beef National Cattlemen’s Nutrition and Fitness; Council Expert Association; Mars, Beef Association US Potato Board’s Resource to Inc Speakers Bureau Scientific Advisory Media; 2005 Panel; Cadbury Dietary Scientific Advisory Guidelines Committee; Grain Advisory Foods Foundation Committee Scientific Advisory BoardThis table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire that all reviewers arerequired to complete and submit.554 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on November 1, 2009

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