1. An Ounce of Prevention is worth a pound
Shaping Habits That Shape Obesity
The purpose of this project is to review for pediatricians those factors that result in obesity early in a child’s life and to present evidence-based recommendations for prevention. The intent is to frame the recommendations into one-minute nutrition messages for pediatricians to deliver during well-child checks. Accompanying these messages will be parent educational materials that restate the pediatricians recommendations and explain why they are important for the health and well-being of the baby. This project is focused on the first 24 months of life, the most critical time for establishing feeding behaviors in the infant, leading to lifetime habits.
Ohio Chapter, American Academy
of Pediatrics
Ohio Department of Health
Ohio Dietetics Association

2. Prevalence of Obesity U.S. Adults: 2001-2
Obese 1/3 (30.6%)
Overweight 2/3 (65.7%)
Extreme obesity (5.1%)
All ages
Both sexes
All ethnic groups
All socioeconomic levels
The prevalence of obesity in the U.S. has been steadily rising over the past 2 decades, reaching epidemic proportions. It is in the category of obese (> BMI 30) that the increase has been so striking, while the percent of overweight (BMI 25-30) has remained fairly constant. The rise has been seen across the entire US demographic with greater rates seen among certain ethnic and socioeconomic subpopulations. (Hedley 2004; Freedman 2000).
Source: Hedley et al. 2004; Freedman et al. 2002

3. Prevalence of Overweight in U.S. Children: 2002
Age, yrs
2-5
6-11
12-19
All 6-19
At Risk (> 85%)
(%)
22.6
31.2
30.9
31.0
Overweight (> 95%)
(%)
10.3
15.8
16.1
16.0
Because of changes in their rate of growth as they mature, children cannot be assessed by the same BMI categories as adults. The terminology for children follows CDC terminology, in which children above the 85th percentile on the BMI curve are considered “at risk” of overweight; those above the 95th percentile are considered “overweight”. Although the obesity epidemic is seen across all demographic groups in the US, it is far more prominent among African-American and Hispanic children (Hedley 2001).
* Overweight among non-Hispanic Black (20.5%) and
Mexican-American (22.2%) increased much more rapidly
than among whites between NHANES in ‘88-94 and 2002
Source: Hedley et al. 2004

4. Obesity Among African-American Adults: 2002
Age, yrs
Males
20-39
40-59
Females
Overweight
BMI > 25 %
55.4
65.0
70.3
81.5
Obese
BMI > 30 %
24.7
29.7
46.6
50.6
Extreme
BMI > 40 %
4.1
2.9
11.8
15.1
Source: Hedley et al

5. Overweight Status of African-American Children: 2002
Percentile
Males 85 95
Females
All Ages %
31.0
17.9
40.1
23.2
2-5 yrs %
23.2
8.0
25.6
9.6
6-11 yrs %
20.9
17.0
37.9
22.8
12-19 yrs %
32.1
18.7
41.9
23.6
Source: Hedley et al

6. Class 3 Obesity in the U.S. 1990 through 2000
Class 3 = BMI > 40
2-fold higher risk of mortality than BMI 30
High likelihood of bariatric surgery
Those over age 20 yrs
In population 4.9%
In black females 13.5%
BMI 50
<25 10
Prevalence, % 5
>40 1
The higher the BMI the faster the rate of increase in prevalence over the past dozen years. Those with class 3 obesity (BMI greater than 40 or roughly 100 lbs over ideal body weight) are at highest risk of complications. The current demand for bariatric surgery is being driven by this subpopulation of obese. Of this group, African-American females over 40 yrs of age are showing a prevalence of 15%, representing a serious public health crisis (Hedley 2001; Freedman 2000).
1990
1992
1994
1996
1998
2000
Year
Prevalence increased 3-fold in only a
decade and continues to rise

7. Medical Consequences of Obesity
Psychosocial
Cardiovascular
Lipidemia
Diabetes mellitus
Hypertension
Respiratory
Cardiac
Medical
Polycystic ovary disease
Gall bladder disease
Osteoarthritis
Cancer
Pregnancy and postpartum ???
Mortality
Obesity is not simply a cosmetic or cultural issue. As rising weight exceeds BMI 30, risk for a host of diseases increases, representing a heavy burden on the U.S. healthcare system (Krebs 2003; Dietz 1998b). Economic estimates show that obesity and its complications cost the US taxpayer nearly $120 billion per year plus nearly $4 billion in lost productivity (Finkelstein 2003; Wang 2002; Thorpe 2004; Colditz 1992). Importantly, chronic diseases identified in childhood have a far greater morbidity, mortality and cost associated over the child’s lifespan than those same diseases diagnosed in adulthood. The primary costs associated with obesity morbidity and mortality are the result of hypertension and diabetes care. In addition, the risk of cancer death increases with excess body weight (Calle 2003; Adami 2003; Calle 2004; Caldwell 2004). Several of these complications cluster together, a syndrome known as “metabolic syndrome” or “syndrome X” (hypertension, hyperlipidemia and diabetes) (Cook 2003; Weiss 2004)
Diseases that begin in childhood amplify morbidity – and costs
Source: Krebs & Jacobson 2003; Dietz 1998a; Dietz 1998b; Must 2003.

8. Prevalence of Diabetes in US Has Risen Dramatically –1990 to 2001
As obesity as increased, type II diabetes rates have followed suit. Latest CDC estimates show that in some states over 1 in 10 individuals is now diabetic. Type II diabetes accounts for 50% of the newly diagnosed diabetics in reports from some pediatric centers. In addition, a recent study published in the NEJM suggests that early glucose intolerance may be evident in as many as 25% of overweight children. If, as many suspect, early glucose intolerance is a precursor to later type II diabetes, then many in the current generation of children – especially in ethnic subpopulations – will face a serious health crisis in their young adult years (Narayan 2003; Sinha 2002; Weiss 2003).
And how many overweight adults and kids have pre-diabetes?
Source: Narayan et al. 2003; Sinha et al. 2002; Weiss et al

9. Life-Years Lost from Diabetes in the US
If diagnosed at age 40 years
White
male: yrs
female: yrs
Hispanic
male: yrs
female: yrs
Black
male: yrs
female: yrs
If diagnosed at age 10 years
White
male: yrs
female: yrs
Hispanic
male: yrs
female: yrs
Black
male: yrs
female: yrs
The emerging diabetes rates among adults and children will not only increase morbidity for those affected and healthcare costs for all Americans, but also will significantly shorten lifespan. Depending on gender and race, children diagnosed with diabetes at age 10 years could lose up to 23 life years unless interventions are found. Statistics such as these should be our incentive to design effective prevention strategies from the earliest weeks of life (Narayan 2003).
Source: Narayan et al. 2003

10. “Because of the increasing rates of obesity,
unhealthy eating habits, and physical inactivity,we may see the first generation
that will be less healthy and
have a shorter life expectancy than their parents”
Obesity is already making a significant contribution to the morbidity and mortality in the U.S., a fact that will lead to a substantially shortened life expectancy for this generation of children and young adults if the problem is not controlled. Studies by Fontaine et al. predict a reduction in life years of up to 20 years, depending on race and gender (Carmona 2004; Mokdad 2004; Fontaine 2003; Mokdad 2003)
Richard H. Carmona, MD, MPH, FACS
Surgeon General
U.S. Dept of Health and Human Services, 2004

11. Obesity Risk Increases with the Age of the Child
Obese at 6 years
50% risk of obesity at 35 yrs
Obese at 10 years
% risk
Studies suggest that the risk of maintaining obesity into adulthood increases the longer that the child maintains the extra weight in childhood (Dietz 1998a; Dietz 1998b; Must 2003; Guo 2002; Whitaker 1997; Kvaavik 2003; Bray 2003). The onset of obesity and its ultimate solution will be found in childhood.
Obesity is a pediatric disorder with
adult consequences
Source: Bray 2002, Dietz 1998a, Dietzs 1998b, Guo et al. 2002; Kvaavik et al. 2003; `Must 2003, Whitaker et al. 1997;

12. The State of Ohio’s Teens Youth Risk Behavior Survey 2003
57% participate in organized after-school activities
68% reported participating in vigorous activity in any given week; only 41% attend PE classes
32% watch 3 or more hours of TV per average school day
14% report being overweight, up from 10% in 1999
30% report eating fruits one or more times per day in the past week
38% report eating vegetables one or more times per day in the past week (includes potatoes)
20% report drinking the recommended 3 glasses per day of milk
Habits that are established early in life influence behavior in adolescence. The Ohio Youth Risk Behavior Survey (YRBS) last published in 2003 demonstrates problems and opportunities for intervention to help improve weight and fitness in Ohio’s kids (Bray 2002; Ohio Youth Risk Behavior Survey, 2003).
Source: Bray 2002; Ohio Dept of Health:

13. Nutritional Gaps in U.S. Children
% Children Consuming Daily Recommended Intake
Critical Age
Iron
Phosphorus
Zinc
Vitamin C
Vitamin A
Data available from the National Health and Nutrition Examination Survey (NHANES) and the Continuing Food Survey of Individual Intake (CFSII) surveys show micronutrient deficiencies broadly in the U.S. population of children. These “problem nutrients” become an increasing issue during early school age, a time when children begin to express their independence through eating behavior. However, it is important to stress that the eating habits that result in this pattern of “overfed and undernourished” are laid down in the first years of life and with adequate counseling could be averted.
Magnesium
Folate
Calcium
NHANES, CFSII data compiled by Dr. John Lasekan, Ross Labs

14. Children grow up In 3 environments
HOME
COMMUNITY
Children are raised in 3 environments: home, school and community. In terms of nutrition and activity, the primary and most important influence is at home. Caregivers, especially the child’s mother, have the greatest opportunity to help the child establish good habits (Birch 1998). As the child ages, school offers the next best opportunity to reinforce good habits and guide the child’s choices.
SCHOOL

15. have an opportunity to create a healthful home environment
The issue of obesity
Is multifactorial
but parents,
especially mothers,
have an opportunity to create a healthful home environment
Parental obesity is a critical risk factor for childhood obesity in pre-teen years. An additional factor is lack of parental concern over their child’s weight status (Agras 2004). Low income mothers often fail to recognize overweight in their children. Many feel that it reflects the child’s natural genetic tendencies, irrespective of the environment they create at home (Jain 2001). One-third of mothers of overweight children misclassify their kids as being “about the right weight” (Maynard 2003).

16. Babies are Getting Bigger
Year N
BW (g)
Z score
% SGA
%LGA
1978-9
5626
3419
-0.91
11.1
8.0
80-81
5659
3426
-0.046
10.3
8.4
82-83
6333
3453
0.013
8.9
9.9
84-85
6222
3449
0.050
8.2
10.0
86-87
6192
3465
0.102
7.8
11.2
88-89
6482
3462
0.078
7.5
10.6
90-91
6985
3456
0.077
10.7
92-93
6621
3471
0.098
8.1
11.7
94-96
7079
3476
0.128
7.2
11.5
P value
<0.001
The obesity epidemic may originate even before birth. For several reasons, there has been a steady increase in birth weights over the past 25 years (Kramer 2002; Surkan 2004; Orskou 2003). The percent of babies classified as large for gestational age (LGA), is rising. Studies show that LGA babies are at greater risk for future obesity (Cogswell 1995).
Births > 37 wks GA
Source: Kramer 2002

17. Babies Are Getting Bigger And Moms Are the Reason
McGill University database
Mean birth weight and z-score increased over two decades (p < )
No trends in premie birth weights
Prepregnancy obesity: from 4.7 to 10.6%
Gestational diabetes: a 20-fold increase
As the adult obesity epidemic has taken hold, both pre-pregnancy and within pregnancy weight gain among females has been noted (Kramer 2002; Surkan 2004; Orskou 2003; Cogswell 1995; Thorsdottir 1998; Shapiro 2000; Shapiro 2000; Kinnunen 2003). Mirroring this higher weight, gestational diabetes rates have risen. Maternal weight appears to be an important factor in the increase in LGA babies. However, some studies show that LGA babies may have a lower risk of metabolic syndrome later, including central obesity. So, the relationships of birth weight and the obesity epidemic remain to be clarified.

18. Prenatal Maternal weight gain Breastfeeding
An important predictor of later obesity in the child
Breastfeeding
Encourage breastfeeding
Lower incidence of obesity in breastfed infants
The interaction between the mother and child begins even before birth. Our colleagues in obstetrics will need to carefully monitor weight gain during pregnancy to ensure the best start for the baby. In addition, obstetricians, pediatricians and family physicians all need to encourage breastfeeding as one means of lessening the likelihood of overweight in early life (Li 2003; Rasmussen 2004; Kugyelka 2004). Maternal intention to breastfeed before the birth of the baby is closely correlated with later initiation and duration of breastfeeding (Donath 2003)

19. Is Breastfeeding Protective against Obesity Later in Life?
Von Kries, 1999 German 5-6 yr olds
Hediger, 2001 US 3-5 yr olds
Gillman, 2001 US yr old
Liese, 2001 German 9-10 yr old
Armstrong, 2003 Scottish 3-4 yr olds
Bergman, 2003 German 6 yr olds
Toschke, 2003 Czech 6-14 yr old
In addition to its many psychological, economic and immune-promoting qualities, several observational studies suggest that exclusive breastfeeding is associated with protection from obesity (von Kries 1999; Hediger 2001; Gillman 2001; Liese 2001; Armstrong 2002; Bergmann 2003; Toschke 2002; Parsons 2003; Dine 1979). Some, but not all, studies suggest the effect lasts into later life, even into teen years. A meta-analysis of all these studies was done by Dewey, supporting the possibility of a modest effect on obesity (Dewey 2003). Dewey concludes that “if the association is causal, the effect of breastfeeding is probably small compared to other factors that influence child obesity, such as parental overweight.” Studies by Butte have suggested that differences between breast and bottle-fed infants can be attributed to a higher lean body (muscle) mass in bottle fed infants, accounting for differences in weight for age (Butte 2001; Butte 1995). Differences did not persist after 2 years of age, however. Nevertheless, the act of breastfeeding clearly places the baby in control of intake, something that minimizes the risk of overfeeding early in life (Fomon 2004). In addition, Tabevas has shown that the breastfeeding mother exerts less control over their child’s food intake at 12 months, a factor that has been shown to be associated with better self-adjusted dietary intake in children and which may play a role in the likelihood of later obesity. (Taveras 2004; Birch 2001; Benton 2004)

20. Healthy People 2010 Breastfeeding Recommendations
Increase the proportion of mothers who breastfeed to 75% in the postpartum period
Increase rates to 50% at 6 mos
Increase rates to 25% at 12 mos
Our national goals for nutrition include improvement in the rates of breastfeeding.

21. In-Hospital Breastfeeding Rates 1965-2001
69.5%
61.9%
51.5%
55.0%
46.3%
43.5%
24.7%
The Healthy People 2010 goals include an increase in the proportion of mothers who breastfeed to 75% in the postpartum period, as well as an increase in breastfeeding rates at 6 months to 50% and an increase in rates at 12 mos to 25%. Recent data from the Ross Mother’s Survey demonstrate that gains have been made in breastfeeding rates in the U.S. Current rates of initiation of breastfeeding are the highest since the early 1940s. (Ryan 2002; Ryan 2004)
21.7%

22. Breastfeeding Rates at 6 Months 1971-2001
32.5%
27.1%
17.6%
19.8%
17.2%
At 6 months, breastfeeding rates remain high relative to prior decades, although national goals are higher still (Ryan 2002).
10.4%

23. Largest Increases in In-Hospital Breastfeeding 1996-2001
Demographic
African American
< 20 yrs of age
WIC participant
20-24 yrs of age
High school education
National
1996
37.1
43.3
46.6
52.7
49.2
59.2
2001
52.9
57.2
58.2
65.9
61.1
69.5
% Change
42.6
32.1
24.9
24.5
24.2
17.4
The most striking findings from the Ross Mother’s Survey are the increases in breastfeeding rates among African-Americans, Hispanics, WIC recipients and other subpopulations that have not traditionally embraced breastfeeding (Ryan 2002).
Source: Ryan 2002

24. Obesity (Pre- or In-Pregnancy Weight) Threatens Breast-feeding (BF)
Pediatric & Pregnancy Nutrition Surveillance Surveys
51,329 women and babies
Pregnant and gestational weight gain + BF
Both pre- and in-pregnancy obesity resulted in:
Less initiation of BF
Shorter duration of BF
Increasing obesity may threaten recent gains in breast-feeding
The current obesity epidemic may threaten recent breastfeeding gains. As maternal obesity increases, the likelihood of initiating and maintaining breastfeeding beyond the first weeks falls rapidly, especially at the highest maternal BMI values (Ryan 2002b).
Source: Li 2003

25. and what to feed their baby
How do
We fix
The
Problem?
To prevent obesity, proper eating and activity habits will need to be established from the first weeks of life. Prevention as a strategy will be more likely to succeed, given the poor long-term results of most weight loss programs.
Train parents in how
and what to feed their baby

26. Where Do Parents Look for Nutrition Information?
#1 Pediatrician/ Family MD
Social environment
Magazines
Internet
Dietitian TV
Nutrition Center
Food labels
Media
There is good reason to believe that pediatricians and family physicians can redirect the feeding habits of parents. Studies show that parents look to physicians first to advise them on nutritional information (van Dillen 2003)
Source: Van Dillen 2003

27. The 12 Well-Child Visits 8 11 4 12 7 3 9 2 5
The schedule of well-child visits affords physicians with 12 opportunities to instruct parents how to safely establish a wide variety of nutritious foods in their baby’s diet, without over-feeding. The secret to directing parental feeding is to anticipate what the family will introduce between the current visit and the next visit. This narrows the focus of attention to a few key messages, easily covered in a minute or two. 6 10
Anticipate problem feeding and activity practices

28. Newborn/First Visit For Breastfed and Formula Fed Infants
Help sustain breastfeeding by building skills and offering resources for support
Iron-based formulas only
Hunger and satiety cues
Babies should regulate their own intake
Crying does not always represent hunger
It is normal for 1-3 month old babies to cry up to 3 hours per day
The most common age for stopping breastfeeding is first few weeks of age (Ryan 2002; Ryan 2002b). At the first office visit, education and resources should be available to aid the mother in maintaining breastfeeding. For mothers who do not breastfeed or who supplement with infant formula, that formula should contain iron (Kleinman, 2004). Randomized, blinded studies have not documented an association between GI symptoms (constipation, pain, diarrhea) and iron in formula, despite parental insistence to the contrary (Oski 1980; Scarlati 1997; Nelson 1988; Hyams 1995; Singhal 2000). Iron is critical for normal neurological development in the first years of life. Overfeeding is often the result of misinterpreting the baby’s signals. It is normal for babies in the first 3 months to cry up to 3 hours per day (McGlaughlin 2001). It is important to teach parents how to interpret their baby’s hunger cues as well as those signals that suggest that the baby is full.

29. How are Infants Fed? Milk Feeding 2000
Physician guidance can alter parental feeding practices. Nowhere is this more evident than in the near-elimination of cow milk intake in the first year of life, following the recommendations of the AAP. Although breastfeeding rates are reaching all-time highs, there are many opportunities for improvement in initiation and extension of breastfeeding. Most mothers chose breastfeeding with supplemental formula. Approximately 85% of infants are fed formula at some point in the first year of life (Ryan 2002a). For this reason, teaching parents to minimize the risk of overfeeding needs to be incorporated into routine well-baby guidance.
Source: Ryan et al. 2002

30. Infants Adjust Their Calories
200
53 kcal/100ml
67 kcal/100 ml
100 kcal/100 ml
180
160
Volume of Intake (mL/kg/day)
140
120
100
130
By 6 weeks, the baby regulates its own energy intake
Babies can regulate their own intake by about the 6-8th week of life. Foman demonstrated this fact in a simple experiment (Fomon 1974). Using a standard formula (67 cal/ 100 ml), he diluted it to 53 cals/ 100 ml or concentrated it to 100 cal/ 100 ml and measured daily consumption (volume). The data show that by the age of 6 weeks or so, infants will adjust the volume of formula consumed to equilibrate daily calories. A similar study was conducted more recently, replicating the results of the Foman study (Brooke 1985). This innate self-regulation needs to be nurtured and not over-ridden by parental feeding practices.
120
Calorie Intake (kal/kg/day)
110
100 90 8 14 28 42 56 84
112
Age (days)
Source: Fomon 2004.

31. From birth to 24 months, the child assumes the eating habits of the family
After examining eating habits over the first 24 months of life, one telling conclusion from the Feeding Infants and Toddlers Study (FITS) was that infants and toddlers assume their family’s eating habits (Dwyer 2004).This is not a good thing given that 2/3 of American adults are overweight. The data from the FITS study illustrates how parental choices for feeding the baby in the first 24 months of life establish habits that are likely to last a lifetime, elevating the risk of future overweight and inappropriate nutrition.
The Feeding Infants
And Toddlers Study (FITS)
Source:Dwyer, 2004

32. FITS Study Methodology
Adds critical information to augment NHANES, CFSII, Ross Mother’s Survey information
5 Gerber sponsored FITS surveys over 30 yrs
Snapshot of eating habits in first 2 years (2002)
Random sample of 3022 (Experian database)
Recruitment and household review
24-hr dietary recall and subject information
Second dietary recall for subset (n=703)
Response rate for recalls 94%
Although there are several large national surveys available examining the nutrition of Americans (NHANES: National Health and Nutrition Examination Survey, the CFSII: Continuing Survey of Intake by Individuals, and the Ross Mother’s Survey), none previously had offered detailed information about feeding during the first months of life. The FITS study details that information by examining 24 hour recall data from a random sample of American households. Thus far there have been 6 FITS studies sponsored by Gerber over the past 30 years, affording a look at how our feeding practices have changed in association with the advent of the obesity epidemic (Devaney 2004a).
Source: Devaney et al. 2004a

33. FITS: Nutrient Intakes 0-24 months of age
Examined transitional times for feeding
4-6 months
7-11 months
12-24 months
Diets found to vary widely day-to-day
Nutrition is good over the first 24 months
Exceeds adequate intake for all nutrients, 0-12 months and almost all nutrients, mos
Vitamin E low mos
Fiber low in toddlers
But energy intake exceeds Estimated Energy Requirement (EER) at all ages
In the FITS study, nutrient intakes were gathered for 3 critical transition periods in the baby’s diet. The FITS 24 hour intake data provides a snapshot of one day’s consumption for the American infant. The macro- and micro-nutrient intakes in the first 12 months exceed the adequate intake (AI) for age, due to the high intake of breast- and formula-intake and the minimal amounts of regular cow milk during this time. Aside from excess energy intake, the American infant receives sound nutrition (Devaney 2004b).
Source: Devaney et al b

34. Energy Intake Infants and Toddlers
Energy intake exceeds EER
4-6 mo 10%
7-11 mo 23%
12-24 mo 31%
Feeding
Breast < EER
BF/ formula = EER
Formula > ERR
Solids and cereals add to energy intakes, especially when coupled with formula
Of interest, at every age tested, reported energy intake exceeded the estimated energy requirement (EER). The excess was so high that researchers speculated that caregivers may be over-reporting food intakes to appear to be a better parent. Estimated energy consumption by breastfed infants fell below the EER, whereas formula increased the energy intake. Of note, the addition of solids and cereal to breast- or formula-feeding promoted excess energy intake (Devaney 2004b).

35. Two-Month Visit Infant Feeding Set expectations:
the baby will increase to oz/day over the next 2 months
Provide 4 oz four to six times per day
No cereal, no baby food, no juices
Nothing added in the bottle
Setting parental expectations for the approximate amount the baby ought to take per day in these early weeks will lessen the likelihood of overfeeding. One means of minimizing overfeeding is to keep bottle size at 4 oz until the larger size is required based on the baby’s demands. Early feeding of solids and cereals promotes excess energy consumption and should be discouraged. Solids added to the bottle will further exaggerate excess energy intake. This practice is often recommended by pediatricians as a remedy for gastroesophageal reflux. Studies have not shown consistent benefit for reflux, which is generally a benign and self-limited discoordination and not a disease (Wenzl 2003; Orenstein 1987; Bailey 1987). Also, because parents and grandparents often believe that cereal in the bottle will help the baby sleep, it can be introduced earlier than recommended. Again, the data is inconsistent that cereal benefits sleep. This practice will either increase the energy load per bottle unnecessarily or will displace the amount of formula taken per day.

36. Not all Crying Needs Food Two Months
Learn to interpret the infant’s cries
Parents eager to “empty the bottle” encourage overeating
Satiety cues between 4-12 weeks:
Turns head away or releases nipple
Falls asleep
Comfort the baby
Rocking, massaging, cuddling, or listening to music
Although caregivers eventually learn to use alternative methods for comforting a crying baby, early in life feeding is often the sole means used to do so. Physicians need to train caregivers in responding appropriately to infant fussiness (Morris 1983).

37. Recommendations for Iron
Healthy People 2010: “…reduce iron-deficiency among children aged one to two years to 5%”
AAP Committee on Nutrition
Supplement breastfed infants with iron
Iron-fortified formula is the appropriate substitute for breastfeeding in the first 12 months
Iron fortified infant cereals and grains, as well as meats are important sources of iron, especially for infants who continue to breastfeed beyond 6 months of age
Iron deficiency has been shown to be critical for normal brain development. Yet many infants and children in the U.S. were found to be deficient, leading the AAP Committee on Nutrition to recommend measures to minimize risk of deficiency (AAP Committee on Nutrition, 1999).

38. Physical Activities Two Months
Minimize stationary devices
Use crib mobiles
Encourage reaching, kicking, stretching, and belly play time
No T.V.

39. 4-Month Visit The addition of cereal
No solids until developmentally ready to use a spoon, usually 4-6 mos of age
Cereal only with a spoon, not in the bottle
Start a single grain, iron-fortified cereal
Portion: increase to 1-2 Tbsp twice daily
First baby food: vegetables at 6 mos
When should cereal be introduced? Although most pediatricians recommend starting cereal between 4-6 months, there are different signals that may indicate readiness. For some, the fact that the baby is no longer satisfied by 32 oz. per day of formula (Dietz, Guide to Your Child’s Nutrition, 1999). One of the best developmental signals of readiness is when the baby can take cereal from a spoon. Visually, the child will close their lips over the spoon when offered and push food from the front to the back of the tongue (Samor 1999, Handbook of Pediatric Nutrition). Parents may ask about giving cereal in the bottle but this not only may limit formula intake, but also may introduce a feeding precedent that can lead to overeating. At the 4 month visit, discuss the introduction of cereal if the baby is developmentally ready to use a spoon. Once solids other than cereal are started, every feeding of solids should start with a vegetable to ensure that the infant establishes the vegetable habit.

40. Excessive Juice is a Risk for Obesity
Both short stature and obesity are tied to excessive intake of juices
Only 100% juice
Only after 6 months of age
Only from a cup, not from a bottle
Limit to 3 oz initially with a maximum of 4-6 oz / day for 1-6 year olds
Taking in an excess of 12 oz. of juice was associated with overweight and obesity in toddlers. The AAP Committee on Nutrition recommends limiting juices to real fruit juice (rather than a fruit drink, which is primarily high-fructose corn syrup and water and a few percent fruit juice). The aim is offer a limit of 4-6 ounces of juice per day, which can serve as one fruit serving. Additional fruit servings ought to come from solid fruits, not juice (AAP Committee on Nutrition 2001; Dennison 1997).

41. Promote Vegetables for Infants & Toddlers
Fail to consume vegetables as a discrete food:
9-11 months 27 %
12 months %
Dark Green Vegetables are consumed by fewer than 10% of toddlers
Deep yellow vegetables decrease from 39% at 9 mos to 14% at 18 mos
Potatoes – consume daily
4-6 mos 3.6%
7-8 mos %
9-11 mos 24.1%
12-14 mos 33.2%
15-18 mos 42.0%
19-24 mos 40.6%
By 24 mos 25% of toddlers consume fried potatoes on any day
The vegetable habit never becomes well established among American children. Initial feeds with baby foods included a vegetable for less than half the babies on any study day. Daily green and yellow vegetable consumption drops rapidly in the second year of life. Consumption of starchy white potatoes, however, increase steadily over the first two years. Fried forms of potatoes account for the majority of vegetables by 24 months of life (Fox 2004).
Source: Fox et al. 2004

42. Infants innately prefer sweet and salty.
Feeding the Baby
Infants innately prefer sweet and salty.
Infants may reject bitter and sour
Infants tend to resist new foods (neophobic)
Infants are born with a preference for sweet and salty. When sugars were added to formula in the first week of life, consumption increased (Nowlis 1976). Pioneering studies by Birch and associates demonstrated that to overcome the baby’s natural aversion to new food tastes and textures, especially when sour or bitter, required more than 10 exposures (Birch 1998; Birch 1987). This is an important developmental barrier that parents need to know about when introducing the baby to solids.

43. More than 10 exposures may be needed to establish a new food.
Implications…
More than 10 exposures may be needed to establish a new food.
Children like and eat what is familiar
Parental eating habits influence the baby’s choices at this age
Birch and others have shown that the magic number may be more than 10 exposures to coax the baby into accepting the new food. Parental modeling of eating behaviors is an important way to improve acceptance (Birch 1982; Galloway 2003). When studies were done on children identified by their caregivers as “picky”, it was found that new foods were rarely offered more than 3-5 times (Carruth 2004).

44. Physical Activities Four Months
Non-restrictive play
Belly play time
Sits with support
Reaches and holds objects
Play gyms
No TV

45. Top 5 Fruits FITS Study, 2004 Age (mos) #1 2 3 4 5 4-6 Applesauce
Baby bananas
Pears
Peaches
Fresh bananas
7-8
9-11
Bananas
Cand applesauce
12-14
Banana
Grapes
Apple
15-18
Apples
Strawberries
19-24
Raisins
What is interesting about this table is the fact that throughout the first two years of life, two fruits dominate the baby’s diet (Fox 2004). Variety -- in terms of taste, texture and type -- ought to be the key concept that parents take away from your counseling about early nutrition. Parental dietary likes and dislikes bias them against offering the baby a full range of available foods (Birch 1998). Warn parents: don’t let personal bias limit your baby’s food experiences. Conversely, parental modeling of food intake is very influential in the baby’s acceptance of new foods.
Source: Fox et al. 2004

46. Start vegetables and offer first at each meal
Six-Month Visit
Start vegetables and offer first at each meal
Add one new food every 3-4 days
Portion sizes
Cereal 2-4 tablespoons twice per day
Vegetables 2 tablespoons twice per day
Fruits 2 tablespoons twice per day
The extrusion reflex is often cited by parents as evidence that the child is showing a dislike for a new food. This has the potential to rapidly limit the variety of foods offered to the baby. To overcome this, parents can offer vegetables at the start of every feeding when the baby is most hungry. Proper portion size needs to be discussed before solids are introduced. Although parents often think in terms of “jars” served; a focus on tablespoons is more appropriate. Approximately 1-2 tablespoons per year of age per serving is an advisable guideline for toddlers between years 1 and 4 (Kleinman Pediatric Nutrition Handbook 2004; Dietz Guide to Your Child’s Nutrition 1998).

47. Meats & Proteins for Infants & Toddlers
Age (mos)
Chicken, Turkey
(%)
Hotdogs, Sausages
Beef
Pork, Ham
Fish, shellfish
4-6
2.0 %
0.0 %
0.9 %
0.3 %
7-8
7.3
2.1
2.6
1.7
0.5
9-11
22.4
7.1
7.7
4.0
1.9
12-14
33.0
16.4
16.1
9.7
5.5
15-18
46.9
20.1
16.3
11.3
8.7
19-24
47.3
27.0
19.3
13.9
Quality meats are an important source of protein, energy and iron for babies. Yet one of the meat products highest in these attributes, beef, is less likely to be offered to the infant than meats that are often higher in fat and lower in quality (Fox 2004). The AAP warns parents not to limit fat in the first two years of life and not to impose their own “adult” dietary restrictions on the baby in this critical time of life (Dietz Guide to Your Child’s Nutrition 1998). It is important to ask whether the parent is vegetarian. If so, referral to a registered dietitian would be warranted (Coughlin Handbook of Pediatric Nutrition 1999). Additional sources of iron and quality protein will be required to substitute for the absence of meat.
Source: Fox et al. 2004

48. Common Early Feeding Traps
Anticipate that daily milk intake will fall as baby’s food intake increases
Avoid “combo dinners” and baby desserts
The extrusion reflex is normal and does not mean that the baby doesn’t like the food
New foods require multiple presentations
Focus on new eating experiences and skills
At the 6 month visit, developmental shifts that are about to occur in the baby’s feeding pattern. As solids are successfully introduced, breastmilk or formula intake will fall, naturally. Certain types of solids are more likely to promote over-consumption, such as “combo dinners”. Present each food individually to promote feeding experiences with new foods. The physician should impress on parents that their job is not to deliver the bulk of the baby’s calories in a few solid foods. Rather, it is to provide a wide array of food flavors, colors, textures and feeding experiences – in other words, skill-building around food. The baby will regulate their own intakes based on their hunger and satiety.

49. Physical Activities Six Months
Minimize stationary devices
Sits without support
Starting to crawl
First signs of independent mobility
No T.V. until after 24 months of age

50. Nine-Month Visit Aim to Develop Self-feeding Skills
Offer many new foods and textures
Introduce a cup as the diet advances
Discuss choking hazards
Never use food as reward or bribe
Offer variety: finger and table foods
New food types and textures
Veggies & fruits at every meal
Establish a variety of meats
Aim to
Develop
Self-feeding
Skills
It is important to move from a bottle to a cup to encourage the intake of solid foods in wide variety. This transition from a milk-based diet to an omnivorous one is best accomplished by decreasing the child’s reliance on bottle-feeding. One way to do this is to introduce a cup as finger- and table-foods are increased. Juices, sugared drinks and soft drinks should never be given by bottle. They not only discourage the intake of solids but also can cause problems with growth (both overweight and failure to thrive, ironically) as well as with dental development (baby bottle caries) (Klienman Pediatric Nutrition Handbook 2004).

51. What Infants & Toddlers Drink
Age
(mos)
All Milks
(%)
100% Juice
Fruit Drinks
Soft Drinks
Water
4-6
100
21.3
1.6
0.1
33.7
7-8
45.6
7.1
1.1
56.1
9-11
99.7
55.3
12.4
1.7
66.9
12-14
98.2
56.2
29.1
4.5
72.2
15-18
94.2
57.8
38.6
11.2
74.0
19-24
93.4
61.6
42.6
11.9
77.0
Parents do a good job of maintaining milk intake during the transition to table-foods in the second year of life. However, it is evident that sweetened drinks (non-fruit juice fluids) and soft drinks (carbonated drinks) gain a foothold quickly in the baby’s diet. By 15 months of age half of the babies in the U.S. are offered these drinks on any given day (Skinner 2004). This is unnecessary energy and sugar consumption. Later, in adolescence and young adulthood, the intake of sweetened drinks will become a significant source of excess energy consumption, likely due to the habit being established in the first months of life. Drink choices have a significant effect on the child’s overall nutrition (Marshall 2005). So, parents should be warned about this important feeding trap.
Source: Skinner et al. 2004

52. Nine-Month Visit
Continue breastmilk and/or iron-fortified formula until 12 months
100% fruit juice, 4-6 oz maximum and only from a cup
Avoid all other sugary drinks
¼ cup (2 oz) fruits and vegetables daily
Promote textures to improve skills
It is important to move from a bottle to a cup to encourage the intake of solid foods in wide variety. This transition from a milk-based diet to that of an omnivore is best accomplished by decreasing the child’s preference for bottle-feeding. Not only can extended use of a bottle limit exploration of new foods, but also it can promote dental caries and otitis media, and lead to low iron if milk intake is excessive. Juices, sugared drinks and soft drinks should never be given by bottle. They not only discourage the intake of solids but also can cause problems with growth as well as with dental development. Introduction of finger foods often begins at this age. Daily servings of 4-8 tablespoons (1/8 to ¼ cup) each of fruits and vegetables is appropriate for 9-12 months. Introduce meats and other quality protein foods during this time.

53. AAP Recommendations: Cow’s Milk and Fat Intake
Delay the introduction of cow’s milk until one year of age
Calcium intake for 1-3 year olds should be 500 mg/day
Cow’s milk should be whole milk - not reduced-fat or non-fat - during the second 12 months of life
Fat intake should not be restricted in the first 24 months of life
The AAP Committee on Nutrition urges parents to allow the infant full access to fat during the first 24 months of life (Dietz Guide to Your Child’s Nutrition 1998). So the transition is from breastmilk or infant formula to whole milk, not to 2% or skim milk. Optimal calcium intake for 1-3 year olds (500 mg) can be achieved by offering 4 milk group servings/ day (4 oz each). Each 4 oz of milk contains 150 mg of calcium (NIH Consensus Statement 1994)

54. And now, a word about…TV Age (mos) 0-1 1-2 3-4 >5 hours per day
0-11 83 11 4 3
12-23 52 27
24-35 21 38 25 16
The TV habit starts early. The AAP Committee on Media established a guideline to minimize the “screen habit” in children: no TV or videos in the first 2 years and only 1-2 hours per day for the remainder of childhood and adolescence. Clearly, though, the television habit is one that is laid down in the very early months of life. The consequences of excessive early viewing are evident in later viewing habits, as well as in later obesity (Certain 2002; American Academy of Pediatrics 2001; Robinson 2001; Hancox 2004).
Children watching > 2 hrs a day at age 2 yrs were more likely to watch > 2 hrs a day at 6 yrs too.

55. Television and Obesity Are Linked
TV > 2 hrs/ day in 5-15 yr olds is associated with adult overweight, high cholesterol, and low fitness
Even brief exposure to TV ads can influence a preschooler’s food choices
Mean TV watched by 3-4 yr olds = 2.2 hrs/ day
Maternal obesity and depression correlates with the highest TV viewing by their children
The TV habit is associated with greater food consumption, more influence on family purchases as well as with fitness and family problems (Henry J Kaiser Family Foundation 2004; Borzekowski 2001; Robinson 1999; Burdette 2003). Ask about TV habits and counsel caregivers to minimize the toddler’s access to TV particularly in the first years.

56. Physical Activities Nine Months
Begins to hold cup
Spoon feeds with help
Encourage crawling
Pulls to stand
No T.V.

57. Twelve-Month Visit Introduce regular milk Fluids
Whole milk - not skim or 2%
Taper from 24 oz. to 16 oz. per day
All fluids from a cup
Continue to wean from the bottle
Fluids
Avoid sweetened drinks
Water is best for extra fluid
100%
WHOLE
MILK
Set parental expectations for the intake of milk whenever breast-feeding or formula-feeding is completed at 12 months. Taken from a cup, the child should continue to take in oz. per day, a value that should fall gradually as solids are more accepted. Too much milk can interfere with the child’s acquisition of new foods and result in anemia at a critical age.
The parents may respond to media reports about fat and cholesterol and, as a result, may limit the infant’s milk to skim or 2%. This should be discouraged at this age. The energy from fat in milk is important for toddlers up to 2 years of age (Dietz Guide to Your Child’s Nutrition 1998).

58. Cereals Infants & Toddlers
Age
(mos)
Any Grain
(%)
Infant Cereal
Non-Sweet
Sweet Cereal
Cereal Bars
4-6
65.8
64.8
0.5
0.0
7-8
91.5
81.2
17.0
1.8
1.1
9-11
97.5
63.8
37.0
9.0
3.4
12-14
97.8
23.9
44.5
17.7
9.8
15-18
98.6
9.2
40.6
26.4
10.0
19-24
99.2
3.1
31.9
22.7
9.7
Grains, particularly in the form of cereals, are an important part of the transition to table-foods at the end of the first year (Fox 2004). A reasonable portion size at 12 months is ½ cup serving of cold, non-sweetened cereal. However, the cereal choices that parents make are not always ideal. Sweetened cereals and cereal bars, which are often little better than cookies, should be discouraged. Whole grain cereals is one habit that parents should seek to establish from the first introduction of regular cereal.
Source: Fox et al. 2004

59. Twelve Months Solid foods Emphasize eating skills and experiences
3 regular meals & 2-3 planned snacks
Avoid “grazing” throughout the day
Emphasize vegetables and fruits
Appropriate serving size is 1/2 cup of fresh (or 1/3 cup canned) fruits/ vegetables per serving per meal
As children get older they eat away from home more often – at relatives, daycare, in car and at restaurants with their family (see the ongoing USDA survey, “What we eat in America” at As a result, food variety begins to diminish for the child. Graze feeding throughout the day discourages nutritious eating and emphasizes snack food intake. Fruits and vegetables (other than the potato) are a special problem for American children. Parents need to surround their toddlers with fruits and vegetables at every meal, every day if they are going to establish a lifelong 5-a-day habit.

60. Parental Control Measures Usually Backfire
Restricting “bad” (ie, palatable and enjoyable) foods encourages their consumption and raises a desire for future intake
Avoid a mixed message that forbidden foods are “bad” except on special occasions
Avoid food as a comfort or a reward
Categorical thinking about “good” and “bad” foods is common and inappropriate
Parental controls over food change the child’s valuation of the foods that they have forced on them or restricted. Controls also impose an external regulation system that encourages the child to disregard their own internal hunger and satiety cues. External controls often lead to overeating, as evidenced by children who are coaxed by adults to eat beyond their point of satiety. Adults are more tuned into external, social eating cues than to internal cues for food (Birch 2001; Birch 2003; Birch 2003; Birch 1998). Young children, on the other hand, adjust their intake based on internal hunger and satiety cues, a practice that will minimize the likelihood of overeating (Birch 2001; Birch 2003; Birch and Fisher 1998; Birch 1982; Birch 1998).

61. Physical Activities Twelve Months
Push toys
Walking
Running
Unrestrictive play
Never inactive for more than 60 mins
No T.V.
For young children, physical activity is natural and part of daily life. Unstructured movement is essential. Infants should never be inactive for more than 60 minutes at any time during the day. To assure that they stay active, the AAP recommends no T.V. before age 2 years. Offer the child the opportunity to be active throughout the day at home, on walks, in the park and at the playground.

62. 15- and 18-Month Visits No more bottle Snack times Meal times
Whole milk from a cup in four 4-oz servings / day
Milk limit 16 oz/day
100% fruit juice 6 oz/ day
No bottle and no “sippy” cup
Snack times
2-3 planned snacks per day
Watch portion size, nutritional value
Meal times
3 meals per day
Variety of color, texture, and tastes
New foods at the start of the meal
10 exposures of each new food
Regular, planned high-quality meals and snacks are the cornerstone to building a healthful diet. Continuous availability of food (grazing) is detrimental to establishing good feeding habits. American children consume approximately 30% of their daily calories as snack-type foods that tend to be high in energy and low in nutrient value (Kant 2003; Jahns 2001). Snacks merit a special warning to parents of infants in the month age group. The establishment of nutritious snack food habits early in life is important to promote a balanced diet later.

63. Caution: Choking Hazards!
Nuts
Grapes
Apple chunks, slices
Sausages
Popcorn
Round candies
Hard chunks of uncooked veggies
Hot dogs
Parents need to be reminded of the troublesome foods for babies. Some, such as nuts and popcorn, need to be avoided until the child has well-established eating and chewing skills.
Some foods are dangerous because
the infant can’t chew or coordinate swallows and lacks a full set of teeth.

64. Safe Snacks for the Toddler
Cheese
Yogurt
Saltines
Graham crackers
Pretzels
Bagel, bread, toast
Whole wheat crackers
Fruit (watch for seeds and peels)
Fruit smoothies
Steamed veggies
Puddings
Unsweetened cereals
Mashed/ finely cut meats or fish
So, what are nutritious snacks that parents can feel confident offering to their infant? Here’s a list compiled from a series of publications of the American Dietetics Association. One feeding habit that has quickly become entrenched in the U.S. is eating on-the-go. Snacks in zip-lock baggies seem to be everywhere in our culture. Parents should be cautioned not to establish this habit of graze feeding and not to use snack foods and drinks as pacifiers for comforting the infant.
Avoid the habit of snacking in the car and on the go

65. Infants Don’t Need Desserts
Desserts and Sweets
Age
(mos)
Any Dessert
(%)
Baby Desserts
Cakes, Pastries, Cookies
Candy
4-6
10.4
4.2
4.3
0.0
7-8
45.8
17.7
27.0
1.1
9-11
61.1
17.0
40.9
3.2
12-14
78.8
6.0
50.5
10.2
15-18
88.8
2.3
60.2
15.2
19-24
90.5
61.6
20.0
Particularly troubling are the data on sweets in infancy. Over 90% of American parents offer their infants a dessert and 20% offer candy on any given day (Fox 2004). The child is too young to know better and too young to ask for sweets, so the problem rests with parental judgment in this case. It is important that pediatricians anticipate this behavior and steer the parents toward more nutritious selections. The critical message: kids don’t need dessert to finish off a meal. It’s another habit to avoid.
Infants Don’t Need Desserts
Source: Fox et al ???

66. Meals are social occasions
15- and 18-Month Visits
Meals are social occasions
Establish family meals
Adults should act as role models during meals
Milk with meals
Limit desserts, avoid candy
TV off during meals
Meal times are social occasions. Family meal times allow the child an opportunity to observe normal eating behavior modeled by his or her parents. Eating a variety of foods, trying new foods, repeatedly offering foods previously rejected by the child, and experimentation with food combinations gives the child the encouragement to explore. Television during mealtimes encourages over-eating and dilutes the social impact of the family meal (Robinson 2001; Hancox 2004).

67. National Recommendations Fiber = ‘Age plus 5’
Fiber should equal the age of the child plus 5 grams a day
For a 2-year old that would be g = 7 g/day
Maximum = age + 10 g/day
Emphasize whole grains to boost fiber
The American diet is low in fiber foods and whole grains for all age groups. Here’s a simple way to determine what the child needs: the child’s age plus 5 grams. For example, fiber intake should reach 5 grams/ day by 12 months of age. But to achieve this intake on a daily basis requires establishing and maintaining a broad and nutritious selection of whole grain and fiber-rich foods for the infant, toddler and child (Klienman Pediatric Nutrition Handbook 2004; Marcason 2005; Hampl 1998; Harnack 2003).

68. Dietary Fiber Intake of 4 to 10-yr-old US Children
Children who meet the ‘Age plus 5’ rule
4-6 year olds 45%
7-10 year olds 32%
Children who meet this rule consume more breads, cereals, fruits, vegetables, nuts, legumes and seeds
Low fiber intakes are associated with higher fat and cholesterol
The new Dietary Guidelines for Americans published in 2005 emphasized the need for more whole grains and fiber. Yet studies show that children rarely achieve recommended levels on a consistent basis. Caregivers need to emphasize meals and snacks that promote this category of foods (Hampl 1998; Harnack 2003).

69. Recommendations for Grains and Whole Grains for Children
Healthy People 2010: “Increase the proportion of persons aged 2 and older who consume at least 6 daily servings of grain products, with at least 3 being whole grains”
Serving is defined by the USDA Dietary Guidelines for Americans 2005: 3 or more ounce equivalents of whole grain products per day (at least ½ of grains from whole grains)
Primary sources of whole grains for children:
Ready-to-eat cereals Yeast breads
Corn & other chips Popcorn
Hot breakfast cereals crackers
The new Dietary Guidelines for Americans ( define a serving in terms of cups or ounces to clarify the daily recommended amounts for each category of foods. For whole grains, at least 3 ounce-equivalents per day are recommended (Harnack 2003).

70. Whole Grain Intakes are Poor Continuing Survey of Food Intakes by Individuals 1994-6
Age
Total Grains
Whole Grains
Mean Servings/ Day
2-18 years
6.6
0.9
2-5 years
5.0
0.8
6-11 years
6.5
12-18 years
7.7
1.0
Source: Harnack et al

71. Satter, J Am Diet Assoc. 1986; 16:355
The Parent’s Role
“It is the parent’s responsibility to offer the child a healthful variety of foods and a supportive eating environment ...
Ellen Satter has reduced the parental role to this simple rule (Satter 1986)
Satter, J Am Diet Assoc. 1986; 16:355
Source: Satter 1986

72. The Child’s Role
…and it is the child’s responsibility to decide when and how much to eat.”
If parents fulfill their responsibility with careful consideration, the child can easily perform their role.
Source: Satter 1986

73. Two Years Activity: Milk Meals Only planned TV & only 1 hour per day
Planned time outdoors every day
Milk
Milk at every meal
Switch from whole milk to 2%
Meals
Begin to decrease the fat content of foods
Appropriate portion sizes at home and away: 1 Tbsp per year of age
After the age of two, the child no longer needs a diet with as much fat content. At this point parents ought to gradually wean the child from high fat foods. The first switch can come in the form of a lower fat milk. Dairy remains the number one source of fat and cholesterol in a 2-5 year old’s diet (Thompson 1994). Meats, sweet pastries, and snack foods are other important targets for reducing fat and cholesterol. At 24 months if there is a strong parental history of obesity or concern on the part of the physician, then rapid weaning to skim milk is a ready target to lessen daily calories. For all children, the target should be “skim by school”. To get there, the family’s taste for less butterfat in milk will need to be redirected.

74. Subjects for More In-Depth Discussion with Parents
Parents “bias” a child’s food choices
The picky eater grows up just fine
Food jags are normal
Plate and glass sizes alter intake
Food dislikes over time
The problem of “dessert”
Avoid in-car snacking
Food rules should be shared with daycare provider, grandparents
Eating out with a child
Letting the child direct their own intake

75. The Problem of “Dessert”
A place in a balanced meal for dessert foods
Not a required part of meal planning though
Not necessary at every meal
Not a reward or bribe for eating other foods
OK to use fruit, yogurt, cheese
OK for celebrations away from home
Here are some simple dessert rules for parents to follow in order to avoid having their child snared by the dessert habit. Desserts have a place in the normal diet, but a small place. It should not be included in meal planning and isn’t necessary at all. Desserts should never be used as a reward or bribe. Birch and associates have shown that the end result is over-valuing the dessert food and de-valuing the food that the parent was trying to encourage (Birch 2001; Birch 2003; Birch and Fisher 1998). The positive: use the right foods as dessert, such as fruits, yogurt and cheese. Good habits in place of bad ones.

76. Split meals between kids or share yours
Eating at Restaurants
Split meals between kids or share yours
Recall portion size: ¼ the adult portion
Buffets promote overconsumption
Drinks: ask for milk with the kids’ meals
Pre-meal: watch out for breads & crackers
Salad dressing: serve on the side, use as dip
Eating out is a tricky time. The list of selections is often limited, especially in the area of dairy, fruit and vegetables. In addition, portion sizes are overwhelming, even in “child sized” meals. Packaged meals are frequently a combination of less nutritious options, increasing caloric density but minimizing nutrient quality. Here are some tips that parents can use for their child and themselves. Both adults and children tend to consume more when faced with larger portion sizes (Fisher 2003). Other factors than satiety are clearly at play during meal times. Parents need to recognize this and take great care with portion size when serving their family, especially when eating away from home.

77. Two-Year Visit Meals: All 5 food groups daily
Begin to decrease the fat content
Appropriate portion sizes at home and away: 1 Tbsp per year of age or ¼ of an adult portion
Plate and cup size matters
Food “jags” are typical & normal
A variety of textures, colors, flavors
Don’t bias your child’s food choices 2%
After the age of two, the child no longer needs a diet with as much fat content. At this point parents ought to gradually wean the child from high fat foods. The first switch can come in the form of a lower fat milk. Dairy remains the number one source of fat and cholesterol in a 2-5 year old’s diet (Thompson 1994). Meats, sweet pastries, and snack foods are other important targets for reducing fat and cholesterol.

78. Top 10 Sources of Dietary Fats for Children 2-5 yrs
Total Fat
Rank
Sat. Fat
Whole milk
11.3 1
17.8
Sweet grain products
8.5 2
6.5 6
Franks, sausage, meat
8.1 3
7.6
Mainly grain mix
7.3 4
7.4
Nut buttters, nuts, seeds
5.8 5
2.4 14
Natural/ processed cheese
5.2
8.2
Beef
5.1 7
5.3 8
Butter/margarine
4.9
4.2 9
Salty snacks
4.6
3.4 11
Low fat milk (1-2%) 10
Fat is not the “cause” of obesity. Still, fats contain approximately 7 calories per gram, compare with approximately 4 calories for carbohydrates and proteins. So awareness of the key sources of fat in a child’s diet will allow parents and physicians to tailor the selections to lessen caloric over-consumption on a chronic basis.
Source: Thompson & Dennison, 1994

79. Milk Intake of Infants & Toddlers
Age
(mos)
Breast
(%)
Formula
Cowmilk
Low-fat
4-6
39.6
74.1
0.8
0.3
7-8
25.7
82.2
2.9
0.5
9-11
21.3
75.0
20.3
5.3
12-14
13.6
21.2
84.8
17.7
15-18
4.2
5.1
88.3
20.7
19-24
4.5
1.5
87.7
38.1
Low fat milk is not yet the norm in the U.S., although consumption rates are rising. Encouraging “skim by school” will give the parents a target for the whole family, eliminating one source of saturated fat while retaining the very valuable nutrient contribution that milk makes to child nutrition (Skinner 2004).
Source: Fox et al. 2004

80. Drinks Matter Early Food Preferences Predict Future Food Preferences
The “displacement theory” is real
Calcium intake falls as milk is replaced
Vitamin C rises as juices replace milks
Beverages are important:
They provide >1/3 of daily calcium, Vits A, C, D, protein and zinc
Fruit drinks are too common :
By 2 years 40% drink them daily and 5% drink > 16 oz/d
Soft drinks are unnecessary:
>11% toddlers months consume them daily
Drinks are not just a selection of one beverage; it is also a rejection of another. Displacement of milk by other drinks has been a phenomenon that has accelerated over the past several decades as other choices entered the marketplace. Even in the first months of life, this study showed that as sweetened drinks increased, milk decreased Fox 2004). As dairy products decrease, the nutritional quality of a child’s diet falls (Skinner 2004). Parents need to be aware that if they stock the home environment with sweetened drinks, milk intake will almost certainly fall. From a nutritional perspective, this is a hazardous trade-off.
Source: Skinner et al. 2004

81. Physical Activites Two Years
Encourage active play with other children
Marching
Jumping
Climbing
Limit T.V. to 1-2 hours per day
Get outside
After the age of 2 years, the AAP recommends that T.V. be limited to 1-2 hours per day. The programs should be carefully chosen to stimulate the child’s mind and explore their world. Importantly, caregivers should make every effort to get the child outside. Kids are naturally active. Getting outdoors opens up their world and stimulates their curiosity (American Association of Health, Physical Education, Recreation and Dance, American Academy of Pediatrics Committee on School Health, School Health Policy and Practice, Chapter 8 – Physical Activity, 6th Edition, 2004).

82. Three- and Four-Year Visits
Meal times
Planned meal & snack times
Establish a family mealtime free of TV
Move toward skim milk
Variety: fruits, vegetables, whole grains
Limit potatoes
Avoid the TV & Food habit
Limit TV to 1-2 hrs per day
Help child choose what to watch
TV contributes to obesity a couple of ways. Obviously, it decreases time spent in physical activity. Dietary energy and fat intake rise as TV time increases. In addition, kids in front of the TV are more influenced by the commercials, the majority of which are for energy-dense, high fat and high sugar foods (Robinson 2001; Borzekowski 2001). In one study, an in-school educational program intended to reduce TV and screen time was found to decrease BMI, skinfold thickness, waist size and waist-to-hip ratio. Viewing time and meals in front of the TV both decreased (Robinson 1999). The AAP recommends that children not be exposed to TV in the first 2 years and that TV be limited to a maximum of 1-2 hours per day for all children thereafter (American Academy of Pediatrics 2001).

83. Physical Activities Three / Four Years
Throwing and bouncing balls
Jumping
Running
Ride tricycle
Unstructured play at least 30 minutes/ day
Structured play at least 60 minutes/ day
T.V. limited to 1-2 hours per day

84. Five- and Six-Year Visits
Daily diet suggestions
A nutritious breakfast every day
School lunch or a quality brown bag lunch
Milk and dairy at every meal
Fruits and vegetables in abundance
Plan healthful snacks for after-school time
Limit soft drinks and fruit drinks
Caution when eating at restaurants – share your meal with your child
The child just starting school will begin being shaped by the choices his parents make for him or her. But by the 3rd to 5th grade, the child will increasingly exert independence about food. So it’s especially important to establish good habits and broad taste preferences early as a foundation.

85. USDA Food and Nutrition Report No. CN-01-CD1
Eating a School Lunch Promotes Better Nutrition ?Eating a Lunch While at School ? - or take out pic of lunch box from home
Consume twice the servings of fruits and vegetables
Higher intake of milk and dairy
Larger amounts of meat
Greater amount of grains
More vitamins and minerals
NSLP impact holds true for lunch and for 24-hour intake
The National School Lunch Program (NSLP) provides 1/3 of the Recommended Daily Allowance for children in a balanced meal. It’s impact on the daily nutrition of participants is well-documented (USDA Food and Nutrition Report No. CN-01-CD1). Alternatives to the NSLP -- the brown bag lunch -- often are not well-balanced and miss the opportunity to provide fruits and vegetables. Packed lunches often include sugar-sweetened drinks rather than milk or real fruit juice. For example, the most popular brown bag it the US is the “Lunchable”-style pre-packed lunch.
USDA Food and Nutrition Report No. CN-01-CD1

86. Daily activity suggestions
Five Years
Daily activity suggestions
Plan outdoor time and reading time daily
Limit “screens” to 1-2 hrs/ day, including
computers
games TV
movies
One factor that has been linked to obesity consistently is television viewing (Certain 2002; Robinson 2001; Hancox 2004; Burdette 2003; Borzekowski 2001; Robinson 1999; American Academy of Pediatrics 2003). Screens, including TV, computers, games, videos, movie theaters, contribute significantly to sedentary behavior. From the first year on, parents need to be reminded to structure screen use during the day, limiting the total amount to no more than 2 hours (American Academy of Pediatrics 2003).
Decreased TV viewing has been proven to alter obesity

87. Obesity & Psychological Issues
Victimization/ bullying
Sense of alienation
Depression
Behavioral problems
Lifelong psychological issues
Low self-esteem
A cycle of food, depression and inactivity
Perhaps the most devastating and chronic consequences of obesity in childhood are psychological (Schwimmer 2003; Strauss 2003; Janssen 2004). Obese children are more likely to be victims of bullying and to perpetrate bullying, as well. Social marginalization may amplify the social and emotional consequences of overweight in adolescence, significantly lowering quality of life. Schools need to be points of intervention to anticipate and prevent social ostracism for overweight students.

88. Energy-Dense Nutrient-Poor Foods Definition
Tip of the Food Pyramid: fats, oils, sugars
NHANES III : 4,265 foods classified
Foods are considered to be in the EDNP group if they are not part of the following food groups:
Dairy – milk, buttermilk, cheese yogurt
Fruit – fresh, frozen, canned, juice
Grains – bread, cereal, pasta, rice
Meat & Beans – meat, fish, poultry, eggs, beans, nuts, seeds
Vegetables – raw, fresh, frozen, canned, juices
Mixed – foods from several groups

89. Energy-Dense, Nutrient-Poor Foods NHANES III
EDNP foods = nearly 1/3 of daily energy intake
As EDNP foods increased
Mean daily total calories increased
Percent energy from carbs increased
Percent energy from fat increased
Fiber, protein, vitamins, decreased
carotenoids, iron, calcium, folate decreased
As EDNP foods increase, nutrition from other 5 food groups falls = displacement
Source: Kant 2000

90. Snacking Among Children 1977 to 1996
3 dietary surveys in children 2-18 yrs (N = 21,236)
“Snack” = foods grouped outside of meals
Snacking adds 30% kcal to the diet
Highest snack intake is among 2-5 year olds
Energy per snack rose only 3% in 20 yrs
Energy density is greater than meals
Increased frequency, not size of snacks is the trend in America
The consistent trend in the U.S. is more frequent eating occasions, not more calories consumed per eating occasion (Jahns 2001). Snacking is a problem because the foods chosen tend to be high in energy density and low in nutritional value.
Source: Jahns et al. 2001

91. American Dietetic Association Snack Guidelines Preschool-/ School-Age
Continue 2-3 planned snacks for preschool age and 1-3 for school age children
Aim for variety of texture, taste, and color
Adjust portion size to age
Allow the child to respond to internal cues of hunger and fullness
Healthy snacks are whole grains (breads, cereals, crackers), fruits and veggies, lean meats, and dairy products (low-fat cheese, pudding, yogurt)
Nutritious snacks should be the only thing in a child’s environment, whether at home, at a caregiver’s or at school or pre-school. The same principles apply to snacks as to meals in terms of establishing the habit of healthy eating. Portion size should be appropriate and as a simple guide for parents, all snacks should contribute to the child’s overall daily nutrition. One way to ensure this is to think about snacks or snack combinations that offer nutrients represented in more than one food group (grains/ cereals, dairy, fruits, vegetables, lean meats). Variety in taste, texture and color of foods is important, too. (Nevin-Folino American Dietetics Association 2003)

92. Eating Out with Your Child
Include at least two different food groups
Limit sweets to one per meal
Only one fried food per meal
Assure that all foods, especially desserts and drinks, are child-sized
Source: Satter 1986

93. Control Portion Sizes When Eating Out
Share your meal or order a half-portion
Order an appetizer as an entrée
Take half your meal home
Be aware and stop eating when you feel full
Avoid super-sized sweetened drinks
When traveling, pack nutritious snacks
Weight Control Information Network, NIDDK, Jan 2003

94. More Tips for Portion Control
Before eating, assess your hunger
Eat slowly and appreciate your food
Eat small meals more frequently to avoid hunger
Measure your food portions to hone your portion perception
Skip “family style” servings except for veggies
Always serve salad dressing on the side
Interpret labels in terms of single servings
Susan Burke, MS, RD, CDE

95. Menu Hints While Eating Out
English muffin, toast, bagel NOT croissant, biscuit, pastry
Ham NOT sausage
Low-fat milk, fruit juice or water NOT soft drinks or shakes
Baked, broiled or poached NOT fried
Catsup, mustard, BBQ sauce, salsa NOT mayo and cheese on burgers
On the side: low-fat dressing, sour cream, gravy, sauces
With (NOT before) the meal: bread, non-water drinks, chips
American Dietetic Association,
If your Child is Overweight: A Guide for Parents

96. Summary Childhood obesity can be prevented
No one factor causes obesity and no one intervention will stop it
Physician’s most important role will be in developing sound eating and activity habits
At each well-child visit review the child’s BMI status and deliver core messages
Advocate for better school & community policies that support your well-child advice