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This section of the Guidelines provides recommendations to pediatric care providers on nutrition and diet for the promotion of cardiovascular (CV) health for their pediatric patients and families. These Guidelines provide evidence-based dietary recommendations to promote CV health and reduce CV risk that build on previous recommendations for adolescents and children 2 years and older that were established in the 2010 DGA.[1] The DGAprovides science-based recommendations to promote health and reduce risk for chronic disease through diet and physical activity for members of the general public 2 years and older.
These new pediatric CV Guidelines not only build upon the recommendations for achieving nutrient adequacy in growing children as stated in the 2010 DGA but also add evidence regarding the efficacy of specific dietary changes to reduce CV risk from the current evidence review, for use by pediatric care providers in the care of their patients.
The underlying premise of the 2010DGA is that foods, not supplements, should constitute the primary basis of a recommended eating plan for children and adolescents.
Estimated amounts of calories needed to maintain caloric balance for various gender and age groups at three different levels of physical activity.
For growing children, the EER increases with age and with physical activity level, as do allowances for essential calories and discretionary calories, as shown in Figures 5?1 and 5?2.
The results of the evidence review addressing the role of nutrition and diet in promoting CV health are summarized below. The Cardiovascular Risk in Young Finns study (Young Finns) is a multicenter longitudinal cohort study of CV risk from Finland, with 3,956 subjects enrolled at ages 3?18 years in 1980 and followed with serial lipid evaluation over time.
The National Heart, Lung, and Blood Institute National Growth and Health Study (NGHS) enrolled 2,379 Black and White girls in three different U.S.
A report from the Third National Health and Nutrition Examination Survey (NHANES III) (1988?1994) of more than 4,000 youths ages 8?18 years found that foods of low-nutrient density (snacks, desserts, etc.) contributed more than 30 percent of daily energy intake, with caloric sweeteners and desserts jointly contributing nearly 25 percent of daily caloric intake.
There is near universal agreement that human milk is the preferred complete nutrition source for healthy full-term newborns and infants for the first 6 months of life, with continued breastfeeding recommended until age 12 months. Infant formulas that meet regulatory requirements for quality and nutrient content are marketed in the United States and many other countries. Vitamin-D-fortified cow's milk and other dairy products are excellent sources of calcium, magnesium, protein, and vitamin D. Of particular relevance to the transition from breast milk or infant formula is the Special Turku Coronary Risk Factor Intervention Project (STRIP) in Finland.
The Centers for Disease Control and Prevention's (CDC's) 2007 Youth Risk Behavior Surveillance report found that only 19 percent of male teens and 9 percent of female teens consumed at least 3 glasses of milk per day.[33] In contrast, 39 percent of males and 29 percent of females consumed at least one 12-ounce can of soda per day, not including diet soda. Human milk, as the primary source of nutrition in the first year of life, is associated with CV benefits on late followup in adult life. Results of the STRIP trial suggest that the fat content of cow's milk can be safely reduced in healthy infants when accompanied by counseling on nutrition quality and energy density, including attention to sufficient fat intake prior to age 2 years, with benefits on TC and LDL?C levels in boys and girls up to age 7 years and in boys through age 14 years, plus lower rates of obesity and insulin resistance. The evidence that, in adults, a diet lower in fat is associated with reduced development of cardiovascular disease (CVD) originated with epidemiologic studies dating back half a century. Despite recommendations advocating breast milk or formula in infancy, a 2002 survey reported that 20 percent of toddlers had been fed whole cow's milk on a daily basis before age 12 months.[43] The consequences of whole-milk consumption by infants, with its high protein and sodium content and reduced LA content, have not been reported. Beginning at the age 13-month assessment and extending to age 14 years, children in the intervention group have consumed significantly less total and saturated fat and more carbohydrates and polyunsaturated fat, compared with children in the control group. The Dietary Intervention Study in Children (DISC)[45] assessed the safety and efficacy of a reduced-fat dietary intervention among children with moderately elevated LDL?C levels between the 80th and 98th percentiles at baseline.
A clinically initiated, home-based, parent-child autotutorial (PCAT) dietary education program directed at increasing dietary knowledge and reducing fat consumption and LDL?C levels was assessed in 174 boys and girls ages 4?10 years with borderline-high or high LDL?C.[49] Intervention families received individualized dietary recommendations to maintain a total dietary fat intake of less than 30 percent of calories and a saturated fat intake of less than 10 percent of calories and used tape-recorded nutrition messages to support appropriate dietary decisions between clinical visits. Of note, the evidence review for these Guidelines identified no RCT in which dietary fat intake of 30?35 percent was evaluated in children or adolescents.
Modifying the type and amount of fat intake in children's diets can be effectively accomplished by qualified ongoing nutritional guidance and behavioral counseling for parents and children, preferably along with environmental change.
Dietary intervention studies in healthy children and in children with hypercholesterolemia using trained nutritionists safely achieved an average total fat intake of 28?30 percent of calories and an average saturated fat intake of 8?10 percent of calories. These levels of total fat and saturated fat intake were shown in RCTs to be associated with lower TC and LDL?C levels in intervention subjects, compared with control subjects. No harmful, adverse effects of restricting total or saturated fat intake at the levels described in the reviewed studies were demonstrated through several years of followup, with one RCT demonstrating no harm for as long as 14 years.
Cholesterol is found in the membranes of all cells and is the precursor of bile acids, sex hormones, vitamin D, and other essential biologic elements.
The DISC trial[45] described in detail above, was an RCT to assess the safety and efficacy of a reduced-fat dietary intervention among children with elevated LDL?C levels (between the 80th and 98th percentiles) at baseline. Woodworking workshops 2015 – peters valley, Woodworking workshops 2015 the summer 2016 workshop schedule will be posted in early december. Accredited online colleges georgia: compare 93 schools, Find the best online colleges in georgia, and the most affordable options.
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Actually, they are all part of the same “monster” and they’ve been around a while, lurking under the bed waiting to come out of their dark corners. The section begins with important background information on nutrition and diet from the 2010 Dietary Guidelines for Americans (2010 DGA) for healthypeople, including healthy children.[1] This is followed by the Expert Panel's summary of the evidence it reviewed relative to nutrition and diet for children, which collectively provides a rationale for initiating prevention efforts early in life. Because the focus of these Guidelines is on CV risk reduction, the evidence review specifically evaluated dietary fatty acid and energy components as major contributors to hypercholesterolemia and obesity, as well as dietary composition and micronutrients as they affect hypertension. The dietary recommendations of the 2010 DGA included all of the nutrients required for growth and health, balanced with energy requirements.
Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life.
Understanding the concepts of essential versus discretionary calories can assist pediatric care providers in guiding children and their families toward choosing nutrient-dense foods to maintain energy balance.
However, due to the low levels of physical activity common among most American children, the nonessential, discretionary calorie allowance is no more than 100?400 kilocalories, based on age and activity level. The review encompassed 30 systematic reviews, 12 meta-analyses, 121 randomized controlled trials (RCTs), and 47 observational studies.


The Bogalusa Heart Study is a major community-based cohort of more than 1,655 Black and White children and young adults in Bogalusa, Louisiana, that began in 1973 and still continues. Based on data from 21 years of followup, two major dietary patterns have been observed beginning in childhood: a "traditional" pattern characterized by high consumption of rye, potatoes, butter, sausages, milk, and coffee and a "health-conscious" diet that includes high consumption of vegetables, legumes and nuts, rye, cheese and other dairy products, and alcoholic beverages[3] At the latest followup, with subjects now ages 24?39 years, the traditional diet was significantly and independently associated with higher total cholesterol (TC) and low-density lipoprotein cholesterol (LDL?C) concentrations, apolipoprotein B (apoB), and C-reactive protein (CRP) in both genders, and with systolic BP and insulin levels among females.
Among adults, the TC level of those who had been breast-fed as infants was lower than the TC level of those who had been formula fed.
However, the dairy fat in whole cow's milk is a major source of atherogenic saturated fat, cholesterol, and calories and a poor source of the essential fatty acids LA and ALA.
Two longitudinal studies of children participating in the WIC Program found that the increased risk of obesity with increased juice intake was strongest among children who were already overweight.[30],[31] The AAP recommends that a serving of natural, unsweetened fruit juice be limited to 4?6 fluid ounces and that infants can receive 1 serving per day after age 6 months as part of a meal or snack. Soft drink consumption in the United States has increased more than 300 percent over the past two decades; 56?85 percent of school-aged children consume at least one soft drink daily. By design, they contain higher amounts of sodium, refined carbohydrates (sugar), and calories than does water. Dietary fat intake (quantity) and fatty acid type regulate serum lipids in children as they do in adults, but fat intake may represent a major source of energy for children, especially infants and toddlers, whose volume capacity is limited. The children were followed with repeated dietary counseling and serial evaluations, including dietary assessment using 4-day diet records, the first at age 13 months and extending now into midadolescence.
Prepubertal boys (N = 362) and girls (N = 301) (initially ages 8?10 years) and their parents were randomized to either an ongoing, nutritionist-driven, individual and group intervention or a usual-care group in a six-center clinical trial. After 3 months, the PCAT group had significantly lower intakes of total and saturated fat and calories and lower LDL?C levels than an at-risk control group that received no intervention; there were no significant differences in dietary intake or lipid levels between PCAT and traditional dietary counseling. Panda's main aim is to remove content that's thin, low-quality or spammy from rankings so that the user gets the highest quality results. The evidence review and development processes for these Guidelines are described in detail in Section I. The recommendations in the DGA form the basis of Federal Government nutrition program and policy development.
New evidence from multiple dietary trials addressing CV risk reduction in children provides important information for these recommendations. On average, children need greater energy intake per kilogram of body weight than adults to accommodate the body's demands for growth, and this must be balanced with physical activity needs. Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4miles per hour, in addition to the light physical activity associated with typical day-to-day life.
Solid fats and added sugars (SOFAS) are always counted as "discretionary" or nonessential calories. As daily physical activity increases, more energy is needed for normal growth, unless the child is overweight or obese and may benefit from limited additional calorie intake as determined by the health care provider.
Because of the large volume of studies reviewed and the diverse nature of the evidence, the Expert Panel provides an overview of the studies reviewed, highlighting those that in its view provide the most important information.
Participants were originally examined at ages 5?17 years and were 52 percent female and 44 percent Black. Surgeon General, World Health Organization (WHO), American Academy of Pediatrics (AAP), and American Academy of Family Practice (AAFP), human milk is the preferred primary source of nourishment in infancy. After infancy, children ages 1?6 years should receive no more than 1 serving of unsweetened fruit juice per day, and children ages 7?18 years should limit juice consumption to no more than 2 servings per day.[32] This evidence review identified no additional studies in this subject area for these age groups. The full impact on obesity and other CV risk factors from the displacement of calcium, vitamin D, protein, and other essential nutrients, combined with the increase in calories from sugar, is as yet unquantified. No studies in this evidence review dealt with sports drinks, but information is provided because of their increasing consumption as a sugar-sweetened beverage and thus their potential impact on children's caloric intake.
Energy density can be an important factor among finicky eaters whose total caloric needs may otherwise not be met.
Saturated fat intake among the intervention children was significantly lower, ranging from 9.5 percent to 11 percent, compared with 13?14 percent in control subjects. Our aim is to help digital marketers, content creators and bloggers create quality content, increase traffic and improve sales.
The 2010 DGA includes information from Dietary Reference Intake(DRI) reports of the Institute of Medicine (IOM); information from the DRIs also was accessed for this section.
The increasing prevalence of obesity in children reflects a chronic imbalance between energy intake and expenditure, where calorie intake is in excess of what is needed for normal growth.
Sedentary children who regularly consume energy-dense, nutrient-poor foods are at risk of developing overweight and obesity and having inadequate nutrition, despite high calorie intake. For sedentary children, only small amounts of discretionary calories can be consumed before caloric intake becomes excessive. The Bogalusa investigators developed and applied a scoring system based on consumption of nutrient-dense foods. Human milk is a unique biological fluid that changes almost daily to meet the nutritional and immunologic needs of the growing infant. The DRI recommendations for nutrient intake by infants are based on the nutrient content of breast milk and include intake of essential fatty acids that are unsaturated, specifically ALA omega-3 and LA omega-6 fatty acids.
After age 1 year, skim milk was recommended as the primary beverage; in the intervention group, parents were encouraged to supplement the diet as needed with soft margarines and vegetable oils until age 24 months to maintain adequate fat intake. Originally developed and marketed for use by trained athletes during competition, sports drinks have been marketed to the general public and "casual athletes" in recent years. The original NCEP recommendations were published in 1992 and were based on evidence available at the time. Sometimes, all you need is one powerful graph, chart or image to instantly convey the big picture.
An emphasis of the DGA is the importance of achieving the appropriate energy balance at all ages.
Discretionary calories represent snacks, desserts, sugar-sweetened beverages, and other nutrient-poor, energy-dense foods whose intake should not exceed the indicated allowances according to level of activity. Results are presented here by dietary component and by age group and are summarized after each dietary component review.


Repeated cross-sectional surveys between 1989 and 2004 showed an overall decline in dietary quality, with a decrease in the consumption of nutrient-dense foods with increasing age. Human milk is high in fat (45?55 percent of total calories), saturated fat, and cholesterol.
The control group received basic health education and no instructions on the use of dietary fats.[18] The children then were followed with serial evaluations, with the first at age 13 months, including dietary assessment with 4-day dietary records, to midadolescence, with reported findings to age 14 years. Consumption of sugar-sweetened beverages was significantly associated with higher daily calorie intake. Consumption by children and adolescents is increasingly common, with or without accompanying physical activity. In a substudy, serum stanol concentrations were measured to further assess the effect of replacing milk fat with vegetable fat.
In several small short-term studies, the fat and cholesterol contents of infant formula varied, with subsequent changes in levels of TC, LDL?C, and TG in infancy, but there were no demonstrated long-term differences in lipoprotein profiles.[14],[15],[16],[17] The STRIP trial, described in detail above, enrolled 1,062 healthy infants who were randomized to either intervention or control groups beginning at age 7 months. More than the standard systematic review where findings from the included studies constitute the only basis for recommendations, these Guidelines combine the findings from a systematic review of the evidence with the Expert Panel's consensus process.
Calculations for recommended daily Estimated Energy Requirements (EER) (contained in the DRI) for children aged 2 and older by gender and age are provided in Table 5-1 as taken from the DGA.[1] Because the calculations provide estimates only, monitoring weight status and stage of growth are important considerations in estimating energy needs. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. To meet nutrient needs without overconsumption of calories (energy intake), meals and snacks need to be nutrient dense (high in nutrients) but as low as possible in saturated and trans fats and with little or no added sugars. In Figures 5-1 and 5-2, the discretionary calorie allowance for children ages 4-8 years is based on 2 servings of dairy per day. Some studies were not specific to the age groups addressed in these Guidelines; the Expert Panel used clinical judgment in determining how best to apply results from those studies to age-specific recommendations.
It provides a rich source of essential fatty acids linoleic acid (LA) and alpha linoleic acid (ALA) and long-chain polyunsaturated fatty acid (PUFA) derivatives arachidonic acid (AA) and docosahexaenoic acid (DHA).[7] Human milk supplies the fat-soluble vitamins A, D, E, and K as well as carotenoids and bioactive components, with protective functions ranging from immunoglobulins to oligosaccharides, enzymes, antienzymes, and adrenal steroids, although vitamin D levels are often inadequate. The children have been assessed for lipid results every 2 years and for other nutrition-related measures at irregular intervals.
The quality of all relevant data is incorporated and graded based on preidentified criteria. Foods such as fat-free milk, fruits, vegetables, whole-grain breads, and low-sugar cereals exemplify this concept. From the first intervention assessment at age 13 months onward until age 14 years, children in the intervention group consumed less total and saturated fat, less cholesterol, and more carbohydrates and polyunsaturated fat than controls. The DRI recommendations promote the intake of essential fatty acids from unsaturated sources, specifically ALA and LA omega-6 fatty acids. Because of the large number of included studies and the diverse nature of the evidence, the Expert Panel also provides a critical overview of the studies reviewed for this section, highlighting those that, in its judgment, provide the most important information. Conversely, the sugar in sugar-sweetened beverages, the fat in whole milk (versus fat-free milk), the fat and added sugar in chocolate milk (versus fat-free unflavored milk), the fat in high-fat meats (versus lean meats), and the fat and sugar in cookies, cakes, pastries, granola bars, and sweetened cereals (versus unsweetened grain foods) are examples of sources of nonessential calories.
Information is based on estimated calorie requirements and discretionary calories published in the Dietary Guidelines for Americans (2005).
The conclusions of the entire evidence review for diet and nutrition, with grades and age-specific recommendations, appear at the end of this section. Selecting nutrient-dense foods in each food group gives individuals an effective way to meet their nutrient needs without consuming excess calories.
From the evidence review, dietary pattern studies in children and adolescents report that higher blood lipid levels are associated with higher total and saturated fat intake, just as in adults.[4],[5],[6],[7] The evidence review for these Guidelines also identified a series of studies focused on evaluating the safety of lower dietary fat and saturated fat content as well as the efficacy of such diets in lowering serum lipid levels and reducing obesity. The conclusions of the Expert Panel's review of the evidence are then summarized and graded, followed by age-based recommendations for nutrition and diet in Table 5?2.
This approach can be adopted and maintained throughout life to prevent the development of overweight and obesity.
There was no significant difference between intervention and control groups in weight for height or obesity at any single age, thus illustrating energy adequacy despite recommended reduced fat intake.[27]For this study, overweight was defined as weight for height greater than 20 percent and obesity greater than 40 percent above the mean weight for height for Finnish children.
Most important among these studies for the youngest age range is the STRIP trial, now with 14 years of followup.[18],[19],[20],[21],[22],[23] STRIP is the only trial examining and reporting health effects from a reduced saturated fat diet in normal children from infancy through adolescence.
Evidence-Based Dietary Recommendations for Patients of Pediatric Care Providers: Cardiovascular Health Integrated Lifestyle Diet (CHILD 1).
Because the discretionary calorie concept is important but complex for most consumers, the Expert Panel emphasizes consuming mostly nutrient-dense foods for meals and snacks. The STRIP trial and each of the other dietary fat interventions identified by the evidence review are described by age group below. The Expert Panel accepts the 2010 DGA as containing appropriate recommendations for diet and nutrition in children 2 years and older.
The recommendations in these Guidelines are intended for pediatric care providers to use with their patients to address CV risk reduction. Where evidence is inadequate, recommendations are based on a consensus of the Expert Panel. The recommendations therefore represent the best available evidence when that exists and expert consensus opinion when it does not.
References from the evidence review are identified by a unique PubMed identifier (PMID), which appears in bold font. There is obvious overlap with the nutrition information contained in other sections of these Guidelines; additional specific dietary information relative to lipids, blood pressure (BP), and obesity is located in Section VIII.




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