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Enhancing the Nutrition of America’s Youth

National Dairy Council, Rosemont, Illinois

	ABSTRACT

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Today, we know more about what foods children should eat for optimal growth and development, as well as future health, than ever before. Yet, many of our nation’s youth are not meeting their nutritional needs and are following a sedentary lifestyle. Overweight among American children has increased dramatically during the past decade. Also, children’s low calcium intake can compromise their bone health and increase their future risk of osteoporosis. Health professionals, parents, educators and others responsible for children can play a key role in enhancing the nutrition of America’s youth. However, they first need to be aware of the important issues regarding children’s nutrition and how best to positively impact children’s nutrition. A recent briefing by experts in child nutrition and a roundtable discussion was held in Washington, DC, to address these topics. This review summarizes the information presented. Focusing on dietary restrictions, such as a low fat diet, was identified as an obstacle to positively impacting children’s nutrition. To improve children’s dietary intake and their ability to learn in school, efforts are being made to increase the availability of and participation in the School Breakfast Program. Parents and other child care providers can serve as role models and positively influence what foods children like and will actually eat. Children are not little adults and, as such, dietary guidelines based on adult data should not be extrapolated to children. Support for the development of separate dietary guidelines for children is growing. These guidelines should be based on sound scientific evidence of efficacy and safety. Enhancing the nutrition of America’s youth is emerging as a priority, both locally (i.e., community school feeding programs) and nationally (i.e., dietary guidelines).

Key words: children, fat, breakfast, calcium, parental role modeling, dietary guidelines

Key teaching points:

• Widespread calcium deficiency among U.S. children is creating a whole generation at increased future risk of osteoporosis. This bone-thinning disease is considered a pediatric problem with geriatric consequences.

• The incidence of overweight is rising among America’s youth. More attention should be paid to changing children’s lifestyles, such as encouraging increased physical activity.

• Parents and other child care providers, by consuming healthful diets and being physically active themselves, can be positive role models for children.

• Focusing on dietary restrictions, such as low fat diets, is an obstacle to achieving optimum nutrition for children.

• Participating in the federal government’s School Breakfast Program improves children’s nutrient intake and their ability to learn. The benefits of this program were recently demonstrated in a Universal School Breakfast pilot program in Minnesota.

• Preschool children need about eight to ten exposures to a new food before they learn to like it. Young children therefore should be given sufficient opportunities to try new foods.

• The optimal environment for child feeding is to offer children a wide variety of healthful foods in moderation, but let children determine whether and how much food to eat.

• Separate dietary guidelines for children could help parents, other child care providers and health professionals focus on the most important child nutrition issues, such as prevention of overweight and sufficient intake of calcium-rich foods to reduce the risk of osteoporosis in later years.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Despite an increasing interest in childhood nutrition, many of today’s youth consume low intakes of essential nutrients that contribute to optimal growth and development and reduce risk of adult-onset chronic diseases. Steps are clearly needed to enhance the nutrition of our nation’s youth. To help identify these steps, the National Institute of Child Health and Human Development, American School Food Service Association and National Dairy Council co-sponsored a national briefing and roundtable discussion on November 17, 1998 in Washington, DC. Experts in the field of child nutrition discussed what children are eating, how to overcome some of the barriers to providing optimum nutrition, why it is important for children to start their day with a healthful breakfast, how parents and other care providers can shape children’s food (and nutrient) intake and why separate dietary guidelines for children should be considered. This review highlights some of the information presented at this briefing. Also, priorities and action steps to enhance children’s nutrition, as identified by participants and presenters, are outlined.

	BACKGROUND

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Today, the focus of childhood nutrition has expanded from preventing nutritional deficiency diseases to also avoiding nutrient overconsumption and reducing the risk of future health problems [1]. This expanded focus in childhood nutrition is in response to the alarming increase in overweight among American children and recognition that children’s eating habits and other lifestyle behaviors (e.g., physical activity) may affect their risk for chronic health problems in later years [2]. The number of children who are overweight has more than doubled during the past decade. Children’s low intake of calcium is another area of high concern [2]. Failure to meet calcium requirements during childhood compromises the achievement of maximal skeletal growth and bone mineralization which, in turn, increases the risk for developing osteoporosis in adulthood.

This new direction in childhood nutrition is reflected in child nutrition programs such as the School Breakfast Program (SBP). When originally introduced, these programs aimed at preventing hunger and nutrient underconsumption. While these objectives remain, the programs have evolved over the years to provide food choices and meals that are consistent with a healthful eating pattern [3]. Also, these programs have incorporated more health education to help improve children’s eating habits and physical activity. Despite the nutritional and educational benefits of the SBP, this program remains underutilized. The challenge to increase participation in the SBP is being met locally and nationally.

Traditionally, parents have been advised to provide their children with a sufficient number of servings of foods from the major food groups to ensure children’s optimal growth and development. However, it is now recognized that children’s nutritional health is influenced by more than just food availability. Over the years, research has elucidated the important role of parents and other child care providers in influencing children’s eating and physical activity patterns [4]. Today, we know that parents’ child feeding practices can affect children’s food preferences, the amount and type of food children eat and their eating behaviors. Parents and other child care providers therefore need education and skills to become effective role models and create environments that will promote optimal growth and development for children, help them attain a healthful weight and potentially reduce future risk of chronic diseases.

The Dietary Guidelines for Americans [5] were developed to provide dietary advice for the general healthy population about food choices that promote health and prevent disease. Historically, these guidelines target all Americans two years of age and over. Recently, recognition that "kids are not little adults" has led to increased support in the scientific community for the development of separate dietary guidelines for children [6]. The availability of age-targeted dietary guidelines could help parents and other child care providers better meet children’s unique nutritional and health needs.

	THE DIETS OF AMERICA’S YOUTH

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Duane Alexander, MD, Director of the National Institute of Child Health and Human Development (NICHHD) at the National Institutes of Health, Bethesda, Maryland, discussed the latest information on what the nation’s children are eating.

Children’s diets are characterized by too much energy (and not enough physical activity), too much fat and sugar and too little fiber (from fruits and vegetables) and too little calcium. Basically, children’s diets can be described as an inverted Food Guide Pyramid [7]. Evidence to support these findings comes from national food intake surveys and individual studies [8–11]. When daily food intakes of children aged two to 19 years were compared with USDA’s Food Guide Pyramid [7], children clearly failed to meet the recommended number of servings for most of the major food groups [10,11]. Only 2% of children met all of the recommendations, and only 10% met the recommendations for four or more food groups.

The US Public Health Service’s Healthy People 2000 goals for the nation include the following three objectives: reduce the prevalence of overweight among children 12 to 19 years to less than 15%, reduce dietary fat to 30% of energy or less and increase calcium intake so at least 50% of people 11 to 24 years of age consume three or more daily servings of calcium-rich foods [12]. According to a mid-course review, these objectives are not being met and, in some cases, are moving in the opposite direction [1]. More than 10% of children aged four to five years and 20% of 12 to 19 year-old adolescents are obese (95% of body mass index) [13]. During the past 20 years the prevalence of obesity has more than doubled for children (and adults). More progress is being made in meeting the objective to reduce dietary fat to 30% or less of energy (kilocalories). Dietary fat intake has decreased to about 33% of energy from a previous 40% of energy [8]. However, no progress has occurred in meeting the health objective to consume three or more daily servings of calcium-rich foods [1]. Milk and other dairy foods are a major source of calcium for children and adolescents (Table 1 [14]). Low intake of these foods contributes to children’s low calcium intake. When compared to the 1997 Dietary Reference Intake (DRI) [15] for calcium, only 12% of females 12 to 19 years of age and 32% of similarly aged males meet their calcium recommendations of 1300 mg/day [8].

The good news is that osteoporosis is preventable. Numerous scientific studies indicate that increasing intake of calcium or calcium-rich foods during childhood and adolescence benefits bone health [18–21]. Several calcium intervention studies support a calcium intake of at least the 1997 DRI of 1300 mg/day for adolescents [15] and perhaps closer to the upper optimal calcium intake of 1500 mg/day recommended by the National Institutes of Health [16] and supported by the American Medical Association [22].

To help solve the calcium crisis, the NICHHD has launched a public information campaign called "Milk Matters" [17]. This campaign is alerting health professionals and others to the essential role of calcium in the diet and the importance of milk as a major source of this nutrient. The NICHHD recommends that children and adolescents consume three to four servings of milk throughout the day to meet their calcium needs [17]. To spread the calcium message, NICHHD has created partnerships with a number of health professional and other organizations [18].

	BATTLING THE BARRIERS: BREAKING THROUGH TO ACHIEVE OPTIMUM NUTRITION FOR KIDS

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Fima Lifshitz, MD, Chief of Staff at Miami Children’s Hospital in Miami, Florida, identified an inappropriate concern about children’s fat intake as a major barrier to achieving optimum nutrition for children. Fat is an essential component of a nutritionally balanced diet for infants and growing children [23]. However, excess dietary fat intake may contribute to obesity, coronary heart disease and other chronic diseases in some individuals [23]. Therefore, various health professional organizations recommend that dietary fat intake be reduced to 30% or less of energy for all healthy Americans over the age of two years [24,25]. However, children are not little adults, and it cannot be assumed that what may be good for adults is necessarily good for children [23].

Consuming a low fat diet during childhood may confer little or no benefit and may have potentially harmful effects [23]. In the DISC (Dietary Intervention Study in Children) study [26], blood cholesterol levels were reduced by less than 2% (3.23 mg/dL) in children aged eight to ten years who consumed a low fat diet (28% of kilocalories) for three years compared to the usual care group which consumed 33% of calories from fat. Dietary restrictions early in life may not necessarily induce a long-lasting decrease in blood cholesterol levels in children or reduce the incidence of coronary heart disease in later years. Moreover, intake of a low fat, low cholesterol diet during childhood may provide insufficient energy and other essential nutrients such as zinc, calcium, iron, magnesium, folic acid and vitamin B₁₂ for optimal growth and development [23,27,28]. Also, this diet may increase energy intake as well as contribute to excess sugar intake [27,28]. Although low fat diets consumed under carefully controlled conditions generally do not compromise children’s growth, nutritional growth retardation has been reported in children who followed a low fat diet under unsupervised conditions or as a result of parents’ concern that their children might become overweight or develop coronary heart disease in later years [23].

Because the beneficial effects of low fat diets have not been confirmed for children and because such diets may potentially lead to nutrient deficiencies and perhaps decreased growth, it appears prudent to advise against marked reductions in dietary fat intake throughout childhood [23,29–31]. Dietary guidelines for children should emphasize moderation and a wide variety of healthful food choices [6,23]. Recent health professional and government organizations recommend that children about two years of age gradually adopt a diet that, by about five years of age, provides no more than 30% of energy from fat [5,24,25]. Before two years of age, when rapid growth and development require high energy intakes, children’s fat intake should not be restricted [25]. The use of low fat diets containing 20% of energy or less is not recommended for children [25,32]. Cessation of smoking and participating in regular physical activity help to reduce risk of coronary heart disease. For this reason, more attention should be paid to changing children’s lifestyles by promoting regular physical activity and avoiding or stopping risky behaviors.

	THE BREAKFAST BONUS: BENEFITS OF THE MORNING MEAL

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Mary Begalle, MS, RD, Director, Food and Nutrition Services, at the Minnesota Department of Children, Families, and Learning discussed why a healthful breakfast, as offered by the federal government’s School Breakfast Program (SBP), is important to children’s health and ability to learn. The SBP began as a pilot program in 1966 and was permanently authorized by Congress in 1975 [33]. During the past decade, the number of schools participating in this program has significantly increased [34], largely as a result of efforts made by hunger advocacy groups such as the Food Research and Action Council [35]. Today, over 73% of the nation’s schools that offer lunch (i.e., National School Lunch Program) also offer breakfast [36]. Despite this progress, the SBP remains underutilized [33]. Several factors, including a perceived social stigma associated with the program, are identified as barriers to participating in the SBP [30]. A recent national survey found that older children are less likely to eat breakfast than younger children [37].

According to several studies, children who participate in the SBP have lower rates of absenteeism, improved academic performance in school and better nutrition [38–47]. Also, children’s nutritional intake has been demonstrated to be better when they eat breakfast at school than at home [45,46]. A recent study conducted in public schools in Baltimore and Philadelphia revealed that participating in a universally free SBP improved children’s academic performance (e.g., improved math scores), attendance and psychosocial functioning [43].

Recognition of the educational and nutritional benefits of consuming breakfast has led to efforts to increase participation in the SBP. Offering universally free breakfasts is regarded as one way to increase participation in this program. In 1994, Minnesota established a Universal School Breakfast pilot program [48]. Participating in this pilot breakfast program has had several positive effects, particularly in terms of students’ ability to learn and their nutritional status. Test scores, specifically composite math and reading percentile scores, improved in the children participating in the pilot program. Also, children’s nutrient intake of both macro- and micro-nutrients increased. The percentage of energy from fat was below the national average for children and adults.

Students participating in the pilot breakfast program were more attentive and present in the classroom more consistently, were more energetic at the start of the day and their mid-morning hunger was noticeably decreased. The school breakfast also significantly reduced discipline referrals to the principal’s office and classroom disruption. In addition, children’s visits to the health office because of complaints of stomach aches or headaches were dramatically reduced. The social benefits of the pilot breakfast program were an unexpected finding. The program gave students an opportunity to interact with other students, teachers, parents and community members. Some school principals believed that the relationship between the teachers and students was greatly improved as a result of the pilot breakfast program. Students’ teachers and parents also viewed the program favorably.

A number of challenges related to increasing participation in the SBP lie ahead. Competition for student dollars is seriously compromising nutrition in our nation’s schools. Because public education in the U.S. is under-funded, local school districts are looking for revenue wherever they can get it (e.g., from vending sales, school stores and exclusive contracts with soft drink companies) to support their educational programs.

Concern that millions of children were coming to school hungry and ill-prepared to learn led Congress to initially authorize a pilot school breakfast program in 1966. Today, 33 years later, hunger among U.S. children remains a critical problem [49]. Further, it is well documented that hunger interferes with children’s ability to learn [50]. Yet, the United States is the only major industrialized nation that does not include breakfast for all students as an integral part of the school day. Clearly, this situation is a public policy challenge of high priority.

	PRACTICE WHAT YOU PREACH: THE VALUE OF PARENTAL ROLE MODELING AT MEALTIME

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Susan Johnson, PhD, Assistant Professor, Center for Human Nutrition at the University of Colorado Health Sciences Center, discussed some of the child feeding challenges parents and child care providers face and how their child feeding practices impact what foods children like and will actually eat. Part of the challenge relates to understanding a young child’s capabilities and stage of development and matching these capabilities with their nutrition needs. Parents and other child care providers need to know what is an optimal environment in which to establish healthful eating habits during childhood. They also need to understand how children’s food preferences are acquired [51]. For example, some parents may not know that certain tastes are innately preferred, whereas other tastes must be acquired. Also, many parents may not appreciate that children need repeated opportunities to learn to like new or unfamiliar foods [51,52].

During the first years of life, children move from an exclusive milk diet to one with a variety of foods. This transition from univore to omnivore is influenced by the child’s innate preferences for sweet and salty tastes [51]. Children’s dislike for sour and bitter tastes is also innate [4]. Some evidence indicates that breast-fed infants are more likely than formula-fed infants to readily accept new flavors and foods [4,53].

When children reach the so-called "terrible twos" they often reject new foods (a condition called neophobia or fear of new foods) [4]. Repeated exposure to new foods is the single most important way to get a child through the neophobic period [52,53,54]. Studies indicate that it takes about eight to ten exposures to a new food before a child learns to like that food.

Children may develop an aversion to a specific food if they experience an oral trauma (e.g., nausea, vomiting) around the time that food is eaten. Food aversions can limit the variety of foods consumed. Serving a food that is disliked with a favorite food may eventually increase its acceptance. Children also are predisposed to learn to prefer energy-dense foods and can adjust their food intake at meals to regulate energy intake over a 24-hour period [4,51,55–57]. Basically, children like foods that are sweet and salty, that they are familiar with and that are high in energy.

Parents and child care providers can influence children’s food preferences in a variety of ways. The social context in which foods are offered affects children’s acceptance of foods [4,51,58]. When young children are given food by someone they look up to, such as a parent or teacher, acceptance for that food increases. In addition, children can influence each other in their developing likes and dislikes [59]. Peers can actually make it easier for child care providers to encourage a child to try more new foods. Also, when foods are paired with positive attention or praise, preference for that food increases. Restricting children’s access to specific foods may actually promote their overconsumption. New research indicates that when mothers restrict their children’s intake of high fat, energy-dense foods, these children are more likely to increase their intake of these foods under unsupervised conditions than children with greater access to these foods [4].

External and internal cues also influence which foods children prefer and how much food they will eat [51]. Research indicates that in optimal environments preschool children can self-regulate the amount of food they eat over a 24-hour period [55]. When children focus internally or decide to eat based on whether they feel hungry or full, they are able to adjust how much they eat to reflect the energy density of the food offered. However, when children are encouraged to focus on external cues such as cleaning their plate or the time of day on the clock, they are not responsive to the energy content of foods [51].

Child feeding practices influence children’s responsiveness to energy density [4]. Certain families are very permissive about foods and do not offer a large variety because they believe that children will not eat many different foods. These families allow a lot of grazing and convenience foods in the home, permissiveness which leads to inappropriate snacking. Children in these households may become either obese or fail to thrive. When parents control meal size or coerce children to eat, children’s ability to regulate meal size in response to energy density is decreased [60]. Controlling child-feeding practices, as can occur when parents are overly concerned about their own weight as well as that of their children, can lead children, especially girls, to become obese [4,60]. The best environment for a child to develop healthful eating habits in, or internal cues to self-regulation in eating, is one in which there is a division of parental and child responsibility [61,62]. Parents are responsible for offering children a wide variety of healthful foods in moderation, but children are responsible for whether and how much they eat [61,62].

	KIDS AREN’T LITTLE ADULTS: EXPLORING THE VALUE OF SEPARATE DIETARY GUIDELINES FOR CHILDREN

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Stanley H. Zlotkin, MD, PhD, Professor, Department of Pediatrics and Nutritional Sciences at the University of Toronto and Senior Scientist at the Research Institute of the Hospital for Sick Children, discussed the value of dietary guidelines specifically for children. The two most important nutrition-related issues in pediatrics are the prevention of overweight and of osteoporosis. Both these diseases are epidemic in North America. Without specific guidelines that are tailored to the unique needs of children, it is difficult for both parents and health professionals to focus on these most important health issues.

The 1990 Nutrition Recommendations for Canadians Report [31] advised all healthy Canadians above the age of two years to consume a diet containing no more than 30% of total energy as fat and no more than 10% of energy as saturated fat (i.e., 30:10 diet). Questions raised primarily by pediatricians and dietitians regarding the scientific evidence supporting this recommendation for growing children led to the development of a Joint Working Group from the Canadian Paediatric Society and Health Canada [30]. This Working Group was charged with examining whether the scientific evidence supported the dietary recommendation to restrict fat intake for growing children [31]. The following four questions were asked by the Working Group to help determine whether a nutritional recommendation should be aimed at children: Does the recommendation have value for the child during childhood? Is there value for the child later in life as an adult? Is it safe? Is it worth it, or are there significant cultural or socioeconomic factors which would argue against making the dietary recommendation?

Scientific evidence to support the efficacy of a fat-restricted diet for children during childhood was found to be lacking [26,31,63]. Further, no controlled studies demonstrated the effectiveness of a fat-restricted diet during childhood in reducing the risk of adult cardiovascular disease [31]. In fact, it is doubtful whether any such study will ever be conducted considering the logistics involved (i.e., following children for 60 to 70 years). Regarding the feasibility and safety of a 30:10 fat diet for children, such diets are feasible, but care must be taken to meet children’s needs for energy and other essential nutrients [31]. In the Bogalusa Heart Study, a larger percentage of children consuming low fat diets (<30% of energy) were not meeting recommended intakes of several vitamins and minerals than of children with higher fat intakes (>40% of energy) [27]. Also, children consuming lower fat diets consumed more simple sugars than those with higher fat intakes. If dietary inadequacies occur in children under supervised conditions, the potential for low fat diets to adversely affect the nutritional adequacy of children’s diets under unsupervised conditions can be expected to be even greater [31].

Based on their findings, the Joint Working Group concluded that from the age of two to the end of linear growth (about age 18), there should be a gradual transition from the higher fat diet of infancy (about 50% of energy) to a diet that includes no more than 30% of energy as fat and no more than 10% of energy as saturated fat [30]. During this transition, energy intake should be sufficient to support normal growth and development. Food patterns should emphasize variety and moderation and not restrict any food or food group. Physical activity should also be emphasized.

Although there is no scientific evidence to support public policy to reduce children’s fat intake to lower their risk of cardiovascular disease in later life, there is good evidence to support an increase in calcium intake during the early years to reduce the risk of osteoporosis in adulthood [15,16]. The same four criteria used to examine the evidence regarding fat recommendations for children can also be used to assess calcium recommendations for children. Based on evidence regarding these criteria, a public policy to increase children’s calcium intake can clearly be supported.

Nutrition guidelines for children should be evidence-based as much as possible. Before a dietary recommendation is made, it is critical to question the value of the recommendation during childhood, the value to children in adulthood, the safety, and whether it is worth it both culturally and socioeconomically. Children are only children for a relatively short period of time. During this time, eating and food should be fun as well as support growth and development.

	PRIORITIES AND ACTION STEPS

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Following the formal presentations, audience participants identified priorities and action steps related to specific topic areas to help enhance the nutrition of America’s youth. The following is a brief overview of their suggestions.

Battling the Barriers: Breaking Through to Achieve Optimum Nutrition for Kids
Priorities identified in this area included the development of guidelines for children that convey nutrition, physical activity and overall wellness. Too often, nutrient restrictions are emphasized, such as imposing the 30% of energy from fat regulation in school meals, instead of focusing on the more important message of providing overall healthful diets. Making nutrition in the classroom and regular physical activity in schools mandatory was recommended to help convey an overall wellness message for children. The need for more flexible dietary guidelines for children was recognized. Action steps to accomplish these recommendations included obtaining the help of legislators to make nutrition and regular physical activity mandatory in schools, using health professionals and the media to convey positive messages about nutrition and physical activity for children and defining balance and moderation rather than speaking in terms of 30% of energy from fat and milligrams of calcium.

The Breakfast Bonus: Benefits of the Morning Meal
The availability of a free school breakfast for all children in the U.S. was recognized as a priority. A cost benefit analysis was recommended to make a more compelling argument for why a universal school breakfast program should be implemented. Another priority is forming public and private partnerships, as well as using public service announcements and PTA meetings, to educate parents, health professionals, teachers, school superintendents and others about the nutritional and educational benefits of school breakfasts for children. Emphasis needs to be placed on integrating the school breakfast program into the school day and increasing funding for nutrition education in the classroom.

Practice What You Preach: The Value of Parental Role Modeling at Mealtime
To help parents and other child care providers serve as role models, these individuals need to be educated about nutrition and physical activity for growing children. Developing flyers with nutrition and physical activity information for young children to take home from school to their parents was suggested. Also, encouraging parents to buy and eat more vegetables and other foods that they want their children to eat was recommended to help parents and others become better role models for healthful eating habits. The need to provide physicians with nutrition information was also recognized.

Kids Aren’t Little Adults: Exploring the Value of Separate Dietary Guidelines for Children
A priority message is that too much energy and too little calcium place children at risk of overweight and, in later years, osteoporosis, respectively. A key action step is to encourage the American Academy of Pediatrics to develop a physician position statement supporting separate dietary guidelines for children. Dietary guidelines should define how much calcium children need in terms of servings of calcium-rich foods. Keeping nutrition messages simple and tailoring them to children was recommended. Also, the need to explore non-traditional avenues for educating children about nutrition and integrating nutrition education in unique ways into the school day, perhaps as part of computer labs, was identified. Although preventing overweight is a priority, the focus for children should be on healthful eating habits (not dietary restrictions), physical activity and nutrition (food) education. The need for more research on factors influencing food choices and decisions regarding physical activity, as well as community strategies to encourage children to become more physically active, was identified. Also, making eating and food fun, such as by offering after-school cooking classes to children, was recommended to help enhance the nutrition of America’s youth.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION BACKGROUND THE DIETS OF AMERICA’S... BATTLING THE BARRIERS: BREAKING... THE BREAKFAST BONUS: BENEFITS... PRACTICE WHAT YOU PREACH:... KIDS AREN’T LITTLE ADULTS:... PRIORITIES AND ACTION STEPS CONCLUSIONS REFERENCES

 
Interest in children’s nutrition has never been greater. This interest stems from new knowledge of important issues regarding children’s nutrition. First, accumulating research has provided more information on children’s nutrient needs, such as their high energy needs to support growth and development, and their high calcium needs to protect their bone health and reduce future risk of osteoporosis. Second, research has also identified critical nutrition-related problems among children, including the rise in overweight and low calcium intakes of this population group. Today, children’s diets are out of balance with Food Guide Pyramid recommendations. Third, knowledge that participation in the federal government’s School Breakfast Program benefits children nutritionally and academically has led to greater efforts to increase the availability of and participation in this program. Fourth, parents and other child care providers are learning that they can impact children’s food preferences, eating behaviors and physical activity in a variety of ways, for example, by serving as role models. Fifth, as a result of new knowledge that children differ from adults psychologically, nutritionally and physiologically, health professionals are beginning to appreciate the need for dietary guidelines specifically targeted toward children.

Parents and other child care providers, as well as health professionals, are seeking guidance and tools at both the local and national level to create an environment for children that fosters a healthful lifestyle to promote optimal growth and development and reduce future risk of chronic diseases. This environment should be conducive to consuming a variety of healthful foods in moderation, not food restrictions, and encouraging physical activity in children.

	ACKNOWLEDGMENTS

 
This review is based on presentations by Duane Alexander, MD, "The Diets of America’s Youth," Fima Lifshitz, MD, "Battling the Barriers: Breaking Through to Achieve Optimum Nutrition for Kids," Mary Begalle, MS, RD, "The Breakfast Bonus: Benefits of the Morning Meal," Susan Johnson, PhD, "Practice What You Preach: The Value of Parental Role Modeling at Mealtime," and Stanley H. Zlotkin, MD, PhD, "Kids Aren’t Little Adults: Exploring the Value of Separate Dietary Guidelines for Children." Participants recommended priorities and action steps to enhance the nutrition of America’s youth.

Enhancing the Nutrition of America’s Youth briefing and roundtable was co-sponsored by the National Institute of Child Health and Human Development, American School Food Service Association, and National Dairy Council.

	FOOTNOTES

 
Address reprint requests to: Gregory D. Miller, PhD, FACN, Vice President, Nutrition Research and Technology Transfer, National Dairy Council, 10255 West Higgins Road, Suite 900, Rosemont, IL 60018-5616.

Received February 1, 1999. Accepted August 1, 1999.

	REFERENCES

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