The most recent representative large national sample of the eating habits of infants and young children is the Feeding Infants and Toddlers Study (FITS 2002), a large national sample of infants and toddlers 4 to 24 months of age performed by Mathematica Policy Inc and sponsored by Gerber Products Company, now part of Nestle.1 Researchers of FITS 2002 collected data on the eating habits, food choices, portion sizes, and dietary intakes of 3022 infants and toddlers within the age parameters of the study. Nutrient intakes, food consumption patterns, eating habits, and food choices were compared with healthy-eating recommendations.
The 2008 Feeding Infants and Toddlers Study (FITS 2008), also sponsored by Gerber, was an updated and expanded version of the prior study on the intakes of 3378 infants, toddlers, and preschoolers younger than 5 years.2 It described the current feeding and consumption patterns of infants, toddlers, and preschoolers; identified any changes since 2002; and compared them with current recommendations.
AREAS OF CONCERN
Table 1 describes key characteristics of FITS 2002 and FITS 2008, progress, and room for improvement. The specific findings are described below.
Despite progress, infants' and toddlers' eating habits still need improvement.
In FITS 2002, the infants' and toddlers' intakes were nutritionally adequate. However, some areas needed improvement. For example, toddlers 12 to 24 months had inadequate dietary intakes of iron, fiber, and vitamin E. Five percent of infants 9 to 11 months and 35% of older infants 19 to 24 months of age were given low-fat or reduced-fat milk. A surprising 27% of infants 7 to 11 months did not consume even a single serving of fruits or vegetables on a given day. Among 15- to 18-month-olds, French fries were the most commonly consumed vegetable. Also, the daily consumption of desserts, sweets, and sweetened beverages had increased significantly with age from 36% among infants 6 to 8 months to 91% among older toddlers 19 to 24 months.3
In FITS 2008, there were several areas still in need of improvement. Fruit and vegetable consumption remained low. The proportion of infants and toddlers not consuming any vegetables changed very little from 2002, other than a lower consumption of French fries among 18- to 21-month-olds. Twenty-fiver percent of toddlers still did not consume a single serving of fruit on a given day, and 30% did not eat a single serving of vegetables.4 Consumption of whole fruit and 100% fruit juice was also lower among toddlers 9 to 12 months of age than in 2002. Consumption of French fries was lower among older toddlers than in 2002, but fries continued to be the most popular vegetable among preschoolers with respect to excess. Also of concern was that fully 71% of toddlers and 84% of preschoolers consumed more sodium than recommended.
IMPROVEMENTS
Among the positive results in FITS 2008 were longer breast-feeding and more infants 4 to 6 months of age being breast-fed than in 2002. Fewer infants and toddlers 6 to 21 months of age were consuming sweets, desserts, candy, and sweetened beverages compared with the findings in 2002. Sweetened beverage consumption had also declined significantly among toddlers both in the 12- to 15- and 18-to 21-month age groups in 2008.
PROBLEMS REMAINING
The FITS telephone surveys were unable to determine rates of obesity among infants, toddlers, and preschoolers. However, the National Health and Nutrition Examination Survey (NHANES),5 monitors the national prevalence of overweight and obesity among children and adolescents and has produced such statistics. In the 2007-2008 NHANES, obesity had increased 10.4% among children 2 to 5 years of age from 5.0% in 1971. Fully 9.5% of infants and toddlers were at or above the 95th percentile of the weight-for-recumbent-length growth charts.5,6 Between 1999-2000 and 2007-2008 obesity rates appeared to stabilize, and no significant trends in the prevalence of obesity were evident for any age group, although they were still higher than desired.
The 2002 and 2008 FITS survey data and other recent surveys suggest that some gaps exist between current dietary practices and recommended eating patterns for infants, toddlers, and preschoolers. These findings emphasize that food and beverage choices made by caregivers have an enormous impact, not only on the child's immediate nutrition, but also on the development of healthy-eating patterns as the child grows older.
CURRENT FEEDING RECOMMENDATIONS
Feeding recommendations have addressed issues such as breast-feeding duration; when to introduce complementary foods; poor iron status in some groups; low fruit and vegetable consumption; excessive intakes of sodium, saturated fat, and sweets and sweetened beverage; and increased obesity among infants and children. Current feeding recommendations for infants, toddlers, and preschoolers are detailed below.
Dietary Reference Intakes of Macronutrients
Table 2 presents the latest dietary references intakes for macronutrients for infants and children, as well as the most recent (2010) dietary references intakes for calcium and vitamin D and other micronutrients that were considered problems for infants and children in FITS 2002 and 2008.7
With few exceptions, nutrient intakes in both FITS 2002 and 2008 were met. Exceptions included sodium, saturated fat, and energy intakes, which were excessive. In FITS 2008, sodium intakes were substantially higher than recommendations among toddlers and preschoolers, as 78% of preschoolers 24 to 72 months of age had exceeded the upper tolerable limit for sodium. Also, 76% of preschoolers had diets that exceeded 10% of energy as saturated fat, but were below the acceptable macronutrient distribution range for fat. Unfortunately, information on energy intakes of the infants, toddlers, and preschoolers surveyed in FITS 2008 could not be evaluated directly against the estimated energy requirements, because body weights and heights on the day of diet assessment were not available. However, the evidence from the 2007-2008 NHANES reveals that a growing number of infants, toddlers, and preschoolers are becoming overweight and obese, suggesting that excessive energy intake remains a problem.
Current child-feeding recommendations point the way forward.
Dietary Guidelines for Americans
Dietary guidelines for infants, toddlers, and preschoolers are established to help parents to initiate and sustain appropriate feeding patterns. Many of these recommendations for children younger than 5 years come from the 2005 and 2010 Dietary Guidelines, which aim to help translate scientific evidence into practical behaviors and practices that promote healthy living and prevent diet-related diseases for all Americans.8,9
In contrast to the 2005 Dietary Guidelines, the 2010 Dietary Guidelines have singled out overweight and obesity for attention in young children 2 years or older. They also focus on a "total diet" approach, with an emphasis on energy balance and nutrient adequacy. Table 3 provides key messages for children 2 years or older from the 2010 Dietary Guidelines Advisory Report that includes topics such as solid fats, added sugars, and physical activity needs based on age.
Healthy People
Healthy People 2010 provided health promotion and disease prevention objectives for Americans to achieve by 2010.10 The Healthy People 2020 nutrition objectives continue to focus on health promotion and disease prevention. Like the 2010 objectives, it also emphasizes that efforts to change eating habits and weight should address individual behaviors, along with policies and environments that support these behaviors in settings such as schools, work sites, healthcare organizations, and communities.11
The 2 overarching goals of both the 2010 and 2020 objectives are to increase the quality and number of healthy years of life for Americans and to eliminate health disparities. Table 4 compares the objectives, baselines, and targets for children 5 years or younger for both Healthy People 2010 and 2020 and demonstrates that progress and backsliding have occurred since the previous decade.
Recent American Academy of Pediatrics Statements
The American Academy of Pediatrics offers recommendations for infants that address issues such as breast-feeding frequency and duration; formula preparation, frequency, and amount; the introduction of complementary foods; iron supplementation; juice consumption; and physical activity, among others.12-14 For children older than 2 years, the American Academy of Pediatrics focuses on emphasizing family mealtimes, energy balance, portion control, and physical activity. Detailed recommendations are provided in Table 5.
US Department of Agriculture's MyPyramid
Table 6 describes dietary patterns for different energy intake levels for children 2 years or older. The US Department of Agriculture Food Guide Pyramid, now called MyPyramid, is designed to identify individual dietary patterns and to provide adequate nutrient intakes while meeting but not exceeding energy needs.15 There are 5 food groups within the pyramid: grains, vegetables, fruits, dairy, and protein foods. The purpose of the pyramid is to educate consumers and to help translate the nutritional recommendations from the most recent Dietary Guidelines on the kinds and amounts of food an individual should consume in a given day.
Physical Activity
Physical activity helps to control weight and reduce obesity risk. For children, regular physical activity and exercise are especially important for building muscles, joints, and strong bones. According to the National Association of Sports and Physical Education, an organization of professionals supporting and assisting professionals involved in all specialties related to achieving a healthy and active lifestyle, children from birth to age 5 years should engage daily in physical activity that promotes movement skillfulness and foundations of health-related fitness.16 Therefore, the National Association of Sports and Physical Education developed specific guidelines for the physical activity of children from birth to age 5 years. Table 7 provides a summary of those recommendations.
More recently, First Lady Michelle Obama launched Let's Move-America's Move to Raise a Healthier Generation of Kids, a national campaign to curb the child obesity epidemic in the United States.17 Through the Let's Move Web site, parents, educators, health professionals, and community leaders are able to easily access resources to help engage children in healthy lifestyle behaviors and fulfill the desired physical activity recommendations.
PRACTICAL STEPS TO TAKE NEXT
Although these professional associations provide much useful advice on feeding strategies, a renewed focus is needed if the recommendations are to be put into practice and lead to improved overall eating habits. Transition periods such as the 6- to 24-month-age period need more attention, as it is during this time that adding variety and healthier food choices in appropriate portion sizes should begin. Table 8 provides such guidance. Key points include exclusive breast-feeding until 6 months of age, introducing complementary foods during developmental milestones such as when the child can make chewing gestures or shows interest in food, weaning from the bottle, and limiting excessive milk and juice intake.18-20
Another challenge that parents and caregivers face is sustaining and enhancing these healthy-eating patterns throughout the preschool years. Recent reports indicate that the major contributors to excess energy intakes in older toddlers 2 years or older are sugar-sweetened beverages, grain-based desserts, and foods high in solid fats.21Table 9 provides suggestions for toddlers 2 years or older on positive eating patterns and avoidance of excess calorie consumption. Key topics include meal consistency, food refusal, structured and unstructured playtime, food purchasing, meal preparation, and portion control.18-20
The most recent NHANES data indicate that the prevalence of infant and childhood obesity is no longer increasing, nor has it declined; it appears to be stable.5 Although this stabilization may be due in part to the many efforts underway aimed at preventing childhood obesity, more time is needed before a decrease in fatness is evident. Table 10 summarizes those specific community-wide intervention strategies suggested by a committee of the Institute of Medicine, National Academy of Sciences, on ways to overcome the rising obesity rates among children.22 The effectiveness of these recommendations has not yet been tested, but they represent the best thinking of experts at present.
CONCLUSIONS
The FITS 2008 survey suggested that parents were breast-feeding longer, delaying the introduction of complementary foods, and limiting fruit juice, sweetened beverages, and sweets in feeding young children. However, low intakes of iron-rich foods such as fortified infant cereal among some infants 9 to 12 months of age, the use of cow's milk prior to 1 year of age, and low fruit and vegetable consumption among older infants 12 to 24 months of age continued to be of concern. Excessive sodium intake was common in both 2002 and 2008. The tolerable upper intake level for sodium was exceeded by a majority of toddlers and preschoolers and is likely related in part to salty snack intake and the increased use of canned and processed foods often given at this age, as reported by the findings in FITS 2008. Although use of reduced-fat milk in the second year of life is contraindicated, it is not clear if this has any adverse effects.
Because children's diets largely reflect eating patterns within the household, nutrition professionals should use family-focused approaches to fostering the development of healthy-eating habits. Practitioners should encourage parents and caregivers to expose young children to a wide variety of fruits and vegetables and to limit consumption of low-nutrient, energy-dense foods and beverages, whether they are consumed as snacks or as part of meals.
In the introduction of complementary foods, practitioners should reinforce the consumption of iron-fortified infant cereal followed by fruits and vegetables in appropriate portion sizes. A recent statement by the Committee of Nutrition of the American Academy of Pediatrics provides specific guidance for this period. After age 2 years, eating patterns should be consistent with the 2010 Dietary Guidelines for Americans, and the amounts of food in each meal should be based on the components provided by MyPyramid, specifying a wide variety of fruits and vegetables, at least half of grains to be in the form of whole grains, and monitoring portion control. For preschoolers, caretakers are encouraged to provide alternatives to high-sodium finger foods such as French fries, crackers, and deli meats. To combat the ease of processed foods, caretakers should have quick, easy, and portable snacks that are nutrient-rich such as already peeled sweet potatoes or summer squash, low-fat cheese sticks, or whole fruits such as apples or grapes cut into bite-size portions.
A focus on healthy eating should include everyone in the family, not just the children.
Food preferences start early in life and are likely to last throughout adulthood. Therefore, educating caregivers to be good role models, implementing good dietary practices for the whole family, and delaying less desirable dietary practices are important goals for determining overall health. Although the findings in both FITS 2002 and 2008 indicate that caretakers have heard the messages about how to feed infants and are generally doing a good job, confusion remains regarding feeding transition periods, especially 6 to 24 months of age, and how to sustain these proper feeding behaviors among toddlers and preschoolers. More research is needed in these areas.
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