Hildegard Przyrembel
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Principles of Children’s Diets and Eating Food-based dietary guidelines based on the en- ergy and nutrient needs of children, on children’s preferences as well as on health aspects provide advice on food selection, meal composition and meal patterns, including recipes. The main food groups included are of high nutrient density: ce- reals and other starchy foods (bread, pasta, pota- toes, etc.); vegetables, legumes and fruits; milk and dairy products; meat, poultry, eggs and (oily) fish; and fats and oils.
A list of reference amounts of the main food groups, which provide ≥ 90% of the appropriate energy intake and 100% of practically all micro- nutrients, is part of OptimiX ( table 1 ) [3, 4] . In addition, <10% of the energy intake is provided by ‘tolerated’ food groups, often of low nutrient but high energy density. These foods are not prohibited but permitted to meet, for instance, the preferences for sweets of some children and
to permit flexibility in the composition of meals. The amounts of foods are guidance val- ues, with the possibility of choosing within a food group – e.g. instead of milk and milk prod- ucts, cheese can be consumed, based on their equivalency in calcium content (100 ml of milk correspond to about 15 g of hard or 30 g of soft cheese). The amounts shown in table 1 need not to be consumed every day; the aim should be the average amount consumed per week. Vari- ability in daily intake is normal; in children, the variability in daily energy intake can be 50%
around the average. Moreover, small and inac- tive children will eat smaller amounts than ac- tive and big children, and boys will consume more than girls of the same age. From the start, children should be allowed to determine the amounts they wish to eat and not be forced to empty their plates. This will permit them to eat to satiety and help to avoid overnutrition and overweight.
Table 1. Example of adequate amounts of foods to be consumed per day at different ages
Age, years 1 2–3 4–6 7–9 10–12
Total energy, kcal/day 850 950 1,250 1,600 1,900
Recommended foods (≥90% of total energy) Generously
Beverages, ml/day 600 700 800 900 1,000
Vegetables, g/day 120 150 200 220 250
Fruit, g/day 120 150 200 220 250
Potatoes, pasta, flakes, rice, etc., g/day 100 120 150 180 220 Moderately
Milk, milk products, ml or g/day 300 330 350 400 420
Meat, meat products, g/day 30 35 40 50 60
Eggs, n/week 1–2 1–2 2 2 2–3
Fish, g/week 25 35 50 75 90
Sparingly
Oil, butter, margarine, g/day 15 20 25 30 35
Tolerated foods (≤10% of total energy)
Cake, sweets, jam, sugar, etc., max. kcal/day 85 95 125 160 190 Modified 2013 from Kersting et al. [3] and Alexy et al. [4] according to the most recent dietary re- ference values.
120 Przyrembel
Recommended Diet Composition
OptimiX provides about 53% of the energy intake mostly from complex carbohydrates, 33% of the energy from fat mostly of plant origin (saturated fatty acids: 10%; monounsaturated fatty acids:
15%; polyunsaturated fatty acids: 7% of total en- ergy) and 14% of the energy from protein, half of animal and half of plant origin. The energy den- sity is about 70 kcal/100 g, the fiber density 17 g/
1,000 kcal and the water density about 1.2 g/kcal.
The most suitable fat intake for toddlers is not known; it should not be <25% of the energy [2, 5, 6] . Protein sources will reflect country- and cul- ture-specific dietary habits, and plant protein can provide the majority of protein intake. In that case, a variety of plant foods should be consumed, which compensate for each other’s deficiencies in certain indispensable amino acids. A vegan diet with no animal-derived food is not suitable for toddlers.
Meals and Meal Patterns
Whenever possible, meals should be consumed in the company of others and at regular times, while snacking should be avoided. The distribution of basic and tolerated foods over different meals can vary, but all meals together should add up to pro- vide an adequate intake of all nutrients and en- ergy. Toddlers will need more frequent meals than older children. The types of meal, both hot and cold, and the time of day at which they are consumed will vary between countries and fami- lies. Both cold and hot meals should be accompa- nied by a beverage. Cold meals will mostly consist of bread and cereals, dairy products, and raw fruit and vegetables, and thus provide the majority of the daily carbohydrate, fiber and calcium intake besides significant percentages of vitamin C and folate intake. Hot meals are based on potatoes, rice or pasta, vegetables and salads, while meat or fish serves as a supplement and therefore need
not be eaten every day of the week. Hot meals thus contribute significantly to the intake of numerous vitamins and minerals such as vitamins B 6 and B 12 , magnesium, phosphorus and iodine.
Choice of Foods
Foods particularly manufactured and specially fortified with nutrients are not a necessary part of a healthy toddler’s diet, although a wide variety of such foods is available and is convenient to use. In circumstances where nutrient-dense foods are scarce, fortification or supplementation can, however, become necessary, particularly with re- gard to iron, iodine, zinc and calcium. Self-pre- pared food for toddlers should not be salted. Low- salt varieties of processed foods should be chosen.
Bread and cereals , but also rice and pasta, should preferably be wholegrain products, which contain B vitamins, magnesium, iron, fiber, pro- tein and unsaturated fatty acids. A mixture of wholegrain and more refined products may be better accepted by young children.
Vegetables and fruits , if not served raw, should be boiled as briefly and in as little water as pos- sible to reduce inevitable losses of vitamins, min- erals and secondary plant substances such as ca- rotenoids, phytosterins and polyphenols. While the primary choice of fruit, legumes and vegeta- bles should be those which are in season, it may be necessary to be more flexible in the case of strong dislikes. Fruit juices can substitute for fruit in exceptional cases.
Milk and dairy products are indispensable in all children’s diets as sources of calcium and oth- er minerals as well as of vitamins. From the age of about 2 years, whole milk and milk products can be replaced by reduced-fat products.
Meat and meat products are important be- cause of well-available iron and zinc, particularly for toddlers and young children. Moreover, they provide high-quality protein and important B vi- tamins. Products low in fat should be preferred.
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 118–121 DOI: 10.1159/000360329
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Heme iron also increases the absorption of iron from plant food.
Fish is an important source of iodine and long-chain n–3 fatty acids and should be eaten at least once a week. Many children only accept braised and fried fish, which might be high in fat.
To increase the quality of the fat consumed, at least half of the total fat intake – both ‘hidden’
and visible – should come from plant oils, prefer- ably those with a high content of mono- and polyunsaturated fatty acids and which contain some α-linolenic acid (rapeseed, soy, flaxseed) and sufficient vitamin E. These oils are practi- cally free of trans- fatty acids. An overall low fat use will further reduce the total intake of satu- rated and trans- fatty acids.
Beverages should preferably be offered to tod- dlers from a cup and should be free of or low in energy (water or unsweetened herbal or fruit teas). Milk is not to be regarded as a beverage but as a food. Fruit juices can contain valuable vita-
mins and minerals but, if undiluted, are high in sugars (>10% of weight). Fruit-based beverages, lemonades and cola beverages often contain large amounts of sugar and are unsuitable for relief of thirst. Sugar-sweetened beverages tend to be overconsumed, which can result in a positive en- ergy balance and overweight [7–9] .
Conclusions
• Dietary recommendations for toddlers (1–3 years of age) gradually approach those for chil- dren, adolescents and adults; the percentage of energy derived from fat should decrease from
>40% to around 30%
• Children should be permitted (within reason- able limits) to determine the amount of food they consume from a range of basic food groups • Preferences for taste should be respected to a
certain degree
7 Kranz S, Smiciklas-Wright H, Siega-Riz AM, Mitchell AD: Adverse effect of high added sugar consumption on dietary intake in American preschoolers. J Pedi- atr 2005; 146: 105–111.
8 Ludwig DS, Peterson KE, Gortmaker SL:
Relation between consumption of sugar- sweetened drinks and childhood obesity.
Lancet 2001; 357: 505–508.
9 Welsh JA, Cogswell ME, Rogers S, Rock- ett H, Mei Z, Grummer-Strawn LM:
Overweight among low-income pre- school children associated with the con- sumption of sweet drinks: Missouri, 1999–2002. Pediatrics 2005; 115:e223–
e229.
References
1 Young EM, Fors SW, Hayes DM: Asso- ciations between perceived parent be- haviors and middle school student fruit and vegetable consumption. J Nutr Educ Behav 2004; 36: 2–8.
2 Gidding SS, Dennison BA, Birch LL, Daniels SR, Gilman MW, Lichtenstein AH, Rattay KT, Steinberger J, Stettler N, van Horn L; American Heart Associa- tion: Dietary recommendations for chil- dren and adolescents: a guide for practi- tioners. Pediatrics 2006; 117: 544–559.
3 Kersting M, Alexy U, Clausen K: Using the concept of Food Based Dietary Guidelines to develop an Optimized Mixed Diet (OMD) for German children and adolescents. J Pediatr Gastroenterol Nutr 2005; 40: 301–308.
4 Alexy U, Clausen K, Kersting M: Nutri- tion of healthy children and adolescents according to the Optimised Mixed Diet concept. Ernọhrungsumschau 2008; 3:
169–177.
5 Agostoni C, Decsi T, Fewtrell M, Goulet O, Kolacek S, Koletzko B, Michaelsen KF, Moreno L, Puntis J, Rigo J, Shamir R, Szajewska H, Turck D, van Goud- oever J; ESPGHAN Committee on Nutri- tion: Complementary feeding: a com- mentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008; 46: 99–110.
6 Hilbig A, Kersting M: Effects of age and time on energy and macronutrient in- take in German infants and young chil- dren: results of the DONALD study.
J Pediatr Gastroenterol Nutr 2006; 43:
518–524.
2 Nutrition of Healthy Infants, Children and Adolescents
Key Words
Adolescence ã Nutrition ã Adolescent health
Key Messages
• Adolescents (10–19 years of age) represent one fifth of the global population and are considered a healthy age group who will eventually enter the work force and raise the economic productivity of any country
• It is a critical period marking phenomenal changes including rapid physical, psychosocial, sexual and cognitive maturation, and hence the nutrient needs are higher in adolescence than at any other time in the life cycle
• Nutritional interventions for adolescents need to be tailored to the developmental level of each indi- vidual adolescent to respond to their needs and should be delivered on a platform where they can be reached
• Adolescent nutrition research must move towards identifying how effective intervention components can be embedded within health, education and care systems and achieve a long-term sustainable impact © 2015 S. Karger AG, Basel
Introduction
Adolescents (10–19 years of age) represent one fifth of the global population and are considered a healthy age group who will eventually enter the work force and raise the economic productivity of any country. There are 1.2 billion adolescents in the world, 90% of whom live in low- and middle- income countries (LMICs), and they make up 12% of the population in industrialized countries compared with 19% in LMICs [1] .
Adolescence is a critical period marking phe- nomenal changes including rapid physical, psy- chosocial, sexual and cognitive maturation, and hence the nutrient needs are higher in adoles- cence than at any other time in the life cycle.
Healthy eating in childhood and adolescence is important for proper growth and development, as optimal nutrition is a prerequisite for achiev- ing the full growth potential and failure to achieve optimal nutrition may lead to delayed and stunt- ed linear growth. Furthermore, healthy nutrition can also help prevent diet-related chronic diseas- es such as obesity, type 2 diabetes, cardiovascular diseases, pulmonary, hepatic and renal diseases, cancer and osteoporosis [2, 3] . It has been high- lighted that nutrition interventions for adoles-
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 122–126 DOI: 10.1159/000367879