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Special Issue Food Guide Pyramid for Young Children 3 Adapting the Food Guide Pyramid for Children: Defining the Target Audience Etta Saltos 18 Technical Research for the Food Guide Pyramid for Young Children Kristin L. Marcoe 33 Consumer Research: Food Guide Pyramid for Young Children Catherine Tarone 45 Factors Influencing Children's Dietary Practices: A Review Alyson Escobar 56 Expenditures on Children by Families, 1999 MarkLino Research Briefs 75 Are All Food Pyramids Created Equal? Alyson Escobar 78 Report Card on the Diet Quality of Children Mark Lino, Shirley A. Gerrior, P. Peter Basiotis, and Rajen S. Anand 81 Eating Breakfast Greatly Improves Schoolchildren's Diet Quality P. Peter Basiotis, Mark Lino, and Raj enS. Anand Research Summaries 85 90 93 96 101 104 Regular Items 108 110 Research and Evaluation Activities in USDA 113 Journal Abstracts 115 USDA Food Plans: Cost of Food at Home 116 Consumer Prices 117 U.S. Poverty Thresholds Volume 12, Numbers 3&4 1999 Dan Glickman, Secretary U.S. Department of Agriculture Shirley R. Watkins, Under Secretary Food, Nutrition, and Consumer Services Rajen Anand, Executive Director Center for Nutrition Policy and Promotion P. Peter Basiotis, Director Nutrition Policy and Analysis Staff The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence A venue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. ~ditor Julia M. Dinkins Features Editor Mark Lino Managing Editor Jane W. Fleming Contributor Joan C. Courtless Family Economics and Nutrition Review is written and published each quarter by the Center for Nutrition Policy and Promotion, U.S. Department of Agriculture, Washington, DC. The Secretary of Agriculture has determined that publication of this periodical is necessary in the transaction of the public business required by law of the Department. This publication is not copyrighted. Contents may be reprinted without permission, but credit to Family Economics and Nutrition Review would be appreciated. Use of commercial or trade names does not imply approval or consti· tute endorsement by USDA. Family Economics and Nutrition Review is indexed in the following databases: AGRICOLA, Ageline, Economic Literature Index, ERIC, Family Studies, PAIS, and Sociological Abstracts. Family Economics and Nutrition Review is for sale by the Superintendent of Documents. Subscription price is $12.00 per year ($15.00 for foreign addresses). Send subscription orders and change of address to Superin· tendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250·7954. (See subscription form on p. 123.) Original manuscripts are accepted for publi· cation. (See "guidelines for authors' on back inside cover.) Suggestions or comments con· earning this publication should be addressed to Julia M. Dinkins, Editor, Family Economics and Nutrition Review, Center for Nutrition Policy and Promotion, USDA, 1120 20th St. NW, Suite 200 North Lobby, Washington, DC 20036. Phone(202)606-4876. The Family Economics and Nutrition Review Is now available at http://www.usda.gov/cnpp (seep. 121). 3 18 33 45 56 Special Issue Food Guide Pyramid for Young Children Adapting the Food Guide Pyramid for Children; Defining the Target Audience Etta Saltos Technical Research for the Food Guide Pyramid for Young Children Kristin L. Marcoe Consumer Research: Food Guide Pyramid for Young Children Catherine Tarone Factors Influencing Children's Dietary Practices: A Review Alyson Escobar Expenditures on Children by Families, 1999 MarkLino Research Briefs 75 Are All Food Pyramids Created Equal? Alyson Escobar 78 Report Card on the Diet Quality of Children Mark Lino, Shirley A. Gerrior, P. Peter Basiotis, and Rajen S. Anand 81 Eating Breakfast Greatly Improves Schoolchildren's Diet Quality P. Peter Basiotis, Mark Lino, and Rajen S. Anand Research Summaries 85 Contribution of Away-From-Home Foods to American Diet Quality 90 The Rural Poor's Access to Supermarkets and Large Grocery Stores 93 Poverty and Well-Being in Rural America 96 Alternative Employment Arrangements 101 Factors Affecting Nutrient Intake of the Elderly 104 The Food Stamp Program After Welfare Reform Regular Items 108 Federal Statistics: Children's Health 110 113 115 Research and Evaluation Activities in USDA Journal Abstracts USDA Food Plans: Cost of Food at Home 116 Consumer Prices 117 U.S. Poverty Thresholds 118 Index of Articles in 1999 Issues 119 Index of Authors in 19991ssues 120 Reviewers for 1999 Articles Volume 12, Numbers 3&4 1999 2 Would you like to publish in Family Economics and Nutrition Review? Family Economics and Nutrition Review will consider for publication articles concerning economic and nutritional issues related to the health and well-being offamilies. We are especially interested in studies about U.S. population groups at risk-from either an economic or nutritional perspective. Research may be based on primary or secondary data as long as it is national or regional in scope or of national policy interest. Articles may use descriptive or econometric techniques. Family Economics and Nutrition Review has a new feature: Research Briefs. We define Research Briefs as short research articles. Our guidelines are found on the back inside cover of each issue. We invite submission of Research Briefs; manuscripts may contain findings previously presented at poster sessions if not published in proceedings (except for abstract). Manuscripts may be mailed to Julia M. Dinkins, Editor, Family Economics and Nutrition Review, Center for Nutrition Policy and Promotion. See guidelines on back inside cover for complete address. Family Economics and Nutrition Review Etta Saltos USDA Cooperative State Research, Education and Extension Service 1999 Vol. 12 Nos. 3&4 Research Articles Adapting the Food Guide Pyramid for Children: Defining the Target Audience Nutrition educators, as well as the 1995 Dietary Guidelines Advirory Committee, have identified a need for nutrition guidance specifically for children. Because of the variation in children's nutrient needs and eating practices, it is impractical to adapt one food guide for all children. The purpose of the present study, therefore, was to identify the best age group to target for an adapted Food Guide Pyramid for Children. Three potential subgroups between the ages of 2 and 18 were identified: preschool-age (2 through 6 years), school-age (7 through 11 years), and adolescents (12 to 18 years). Subgroups were ranked by reviewing the literature to determine whether the Food Guide Pyramid meets each subgroup's dietary needs, to consider each subgroup's specific nutritional or health problems that an adapted food guide could help address, and to examine user demand for a new food guide. A food guide adapted for use with parents and caregivers of preschool-age children was identified as the greatest need based on children's specific dietary requirements (higher fat intakes as recommended by the 1995 Dietary Guidelines and their need for smaller serving sizes) and user demand (requests from parents, caregivers, and nutrition educators). IT] he USDA's Food Guide, designed to help all healthy Americans 2 years old and over use the Dietary Guidelines for Americans (38), and its graphic representation, the Food Guide Pyramid (Pyramid), have been distributed widely since the Food Guide was first introduced in the mid-1980's. The Pyramid has been used widely in a variety of materials (including posters, textbooks, school curricula, and computer software) by nutrition educators and has also been used by industry on food labels. In materials accompanying the Pyramid, USDA recommends that preschool-age children obtain at least the minimal number of servings from the five major food groups, but this age group can have smaller servings from all food groups except the milk group (38). Nevertheless, nutrition educators have identified a need for nutrition guidance regarding the dietary needs of children,1 and the 1995 Dietary Guidelines Advisory Committee has recommended that the development of separate dietary guidelines for children be considered (7). Adaptation of the Pyramid and its accompanying nutrition guidance materials specifically for children is an important component of the effort to help children apply the Dietary Guidelines for Americans. 1The term "children," in this article, refers to children and adolescents ages 2 through 18 years. 3 The purpose of this study was to define the target audience for a food guide that would be adapted for children by recommending subgroups within the 2- to 18- year age range and ranking the subgroups in order of greatest need based on dietary requirements and user demand for nutrition education materials. Materials reviewed for this study included journal articles, reference materials (including the Recommended Dietary Allowances and nutrition textbooks), and published and unpublished reports from government agencies. Criteria used to define and rank the subgroups included the following: • nutrient needs of children, • nutrition recommendations for children by authoritative bodies, ;;uch as the Dietary Guidelines Advisory Committee, • nutritional status of children, including macronutrient and micronutrient intake and anthropometric measurements, and • children's knowledge and attitudes regarding nutrition. These criteria were used to define subgroups and to list facts in favor of and against adapting a food guide for each subgroup. Nutrient Needs of Children The Recommended Dietary Allowances (RDA) provide information concerning children's nutrient needs, as well as the nutritional needs of the rest of the population (23). The 1989 RDA are expressed for the following age-gender groups: children, ages 1 to 3 years; children, ages 4 to 6 years; children, ages 7 to 10 years; males, ages 11 to 14 years; females, ages 11 to 14 years; males, ages 15 to 18 years; and females, ages 15 to 18 years. 4 The National Academy of Sciences' Food and Nutrition Board, however, is in the process of replacing these RDA with new dietary recommendations: Dietary Reference Intakes (DRI)? DRI were released recently for calcium, phosphorus, magnesium, fluoride, vitamin D, thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline (31,32). Reference intake values were published for the following age groups: 1 to 3 years, 4 through 8 years, 9 through 13 years, and 14 through 18 years. The current RDA (or AI for calcium, fluoride, vitamin D, pantothenic acid, biotin, and choline) for children were (a) extrapolated from infant or adult research results (vitamins A, K, C, B6, B12, riboflavin, niacin, folate, biotin, choline, pantothenic acid, selenium, iodine, and manganese), (b) based on growth and consumption data (energy, protein, iron, phosphorus, and potassium), (c) estimated based on weight (fluoride and vitamin E), 1-he DRI, a set of up to four nutrient-based reference values, consist of the Estimated Average Requirement (EAR), Recommended Dietary Allowances (RDA), Adequate Intake (AI), and Tolerable Upper Intake Level (UL). The EAR refers to the daily intake value that is estimated to meet the nutrient requirement in half of the individuals in a given age-gender group. The RDA consist of the average daily intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in the age-gender group, based on the EAR. The AI is the daily intake value that is estimated to meet the nutrient requirement of nearly all healthy individuals in the age-gender group and is used when an EAR is not available to calculate the RDA. The UL defines the highest level of nutrient intake that is likely to pose no risks of adverse health effects in almost all individuals in the general population. (d) based on studies on balance in children, but not necessarily with all the above age groups (thiamin, zinc, copper, sodium, calcium, and magnesium), or (e) estimated based on biochemical markers (vitamin D) (23,31,32). Because the RDNAI for children were largely extrapolated or calculated rather than determined directly from studies of children, there is no overriding reason for using the RDA age-gender cutoffs for a children's food guide. Information on children's dietary intakes, nutritional status, and dietary recommendationsas well as information on their attitudes, knowledge, and behavior-must also be considered when determining which groups of children are most in need of nutritjon guidance. Nutrition Recommendations for Children Reconunendationsofthe U.S. Government A number of recommendations indicate what constitutes a healthful diet for children. The Dietary Guidelines for Americans, the basis of Federal nutrition policy ( 39 ), provide advice about food choices that promote health and prevent disease among healthy Americans 2 years old and older. The Guidelines advise Americans to eat a varied diet with plenty of grain products, vegetables, and fruits, while moderating their intakes of fat, saturated fat, cholesterol, sugars, salt and sodium, and alcoholic beverages. In addition to emphasizing the benefits of physical activity, the Guidelines provide some specific advice for children: they should be taught to eat grain products; vegetables and fruits; lowfat milk products or other calcium-rich foods; beans, lean meat, poultry, fish or other Family Economics and Nutrition Review protein-rich foods; and to participate in vigorous physical activity. The Guidelines caution that fat should not be restricted for children younger than age3 2, that major efforts to change a child's diet should be accompanied by monitoring of growth at regular intervals by a health professional, and that children should IlQ! consume alcoholic beverages. The Guidelines also recommend that children between the ages of 2 and 5 should gradually adopt a diet so that it contains no more than 30 percent of calories from fat by the time children are about 5 years old(39). The report Healthy People 2010 outlines a national strategy for improving significantly the health of Americans during the 2001 to 2010 decade (42). Included in the 2010 report is a recommendation to reduce fat intake to an average of 30 percent of calories or less and saturated fat intake to an average of less than 10 percent of calories among people 2 years old and older. The National Cholesterol Education Program recommends that total fat intake averages no more than 30 percent of calories (24). These recommendations are consistent with the advice given in the 1990 Dietary Guidelines; the 1995 Dietary Guidelines amended this advice, stating that children between the ages of 2 and 5 should gradually reduce their total fat intake so that by age 5, they are consuming no more than 30 percent of calories from fat. Recommendations of Other Organizations Several organizations provide dietary advice for children that is consistent with the basic principles of the Dietary Guidelines for Americans. The American 3In this paper, the use of the terms "age" and "ages" refers to age in years, unless stated otherwise. 1999 Vol. 12 Nos. 3&4 Academy of Pediatrics, for example, recommends that children eat a wide variety of foods and consume enough calories to support growth and development and to reach or maintain advisable body weight. The Academy also recommends that children over the age of 2 consume, on average, 30 percent of total calories from fat, less than 10 percent of calories from saturated fat, and less than 300 mg of cholesterol per day. However, the Academy cautions that "recommendations that call for 'less than' 30 percent of calories from fat may lead to the inappropriate use of more restrictive diets" (3). The American Heart Association (AHA) concurs with the recommendation of the Dietary Guidelines that children between the ages of 2 and 5 gradually adopt a diet containing 30 percent or less of calories from fat. The AHA also agrees with the Dietary Guidelines' recommendation that diets of young children should maintain the primary emphasis on providing adequate calories and nutrients for normal physical activity, growth, and development ( 17). Some disagree about the age at which children should adopt a lower fat diet. A joint working group of the Canadian Paediatric Society and Health Canada recommended a longer transition period to a diet lower in fat, compared with that recommended by the Dietary Guidelines. The joint working group advised that the transition from the high-fat diet during infancy (about 50 percent of calories from fat) to a diet that includes no more than 30 percent of calories as fat and 10 percent of calories as saturated fat take place between the age of 2 and the end of linear growth (about age 14 for females and 15 for males) ( 14). The rationale for the working group's recommendation was based on ( 1) lack of Other studies have also concluded that it is safe to · recommend that fat intake be limited to 30 percent of calories and saturated fat intake to less than 1 0 percent of calories for children 5 years old and older .... 5 evidence that consuming a diet providing 30 percent of calories as fat and I 0 percent of calories as saturated fat would either reduce illness in later life or provide short-term health benefits and (2) concerns that some children consuming a diet with low fat intakes have lower energy intakes and low intakes of some nutrients. To support their position, the Canadian Paediatric Society and Health Canada cited a publication from the Bogalusa Heart Study in which 24-hour recalls were obtained from about 870 10-yearolds whose diets were stratified by fat intake: those with less than 30 percent of calories from fat had lower intakes of many nutrients than did children with higher fat intakes. The children with the lower percentage of calories from fat also had higher intakes of simple carbohydrates (25). The children enrolled in the Bogalusa Study had not been exposed previously to any dietary intervention programs. Therefore, it cannot be concluded, on the basis of the Bogalusa Study, that children-whose parents and caregivers have been instructed on how to moderate dietary fat intakewill be unable to meet their nutrient requirements on a diet containing 30 percent of calories from fat. Other researchers have concluded that children can safely follow diets containing 30 percent of calories from fat. The Dietary Intervention Study in Children (DISC) is an ongoing, randomized study that is a controlled clinical trial of diets containing lowered fat, saturated fat, and cholesterol. About 660 children ages 8 to 10 who were enrolled in 6 centers, located around the country, were assigned randomly to either control groups or groups receiving behavioral intervention to promote their following a diet prov:ding 28 percent of calories 6 from total fat, less than 8 percent of calories from saturated fat, and less than 150 mg of cholesterol (less than 75 mg/ 1,000 calories) per day. After 3 years, dietary levels of total fat, saturated fat, and cholesterol and blood levels of lowdensity lipoprotein cholesterol (LDL-C) decreased significantly in the intervention group, compared with the control group. The two groups, however, did not differ significantly on measures of growth and development: Height, redblood- cell folate values, serum zinc, retinol and albumin levels, sexual maturation, and psychosocial health. The DISC study found that children grew and developed normally after being instructed on consuming a lower fat diet. The children in the intervention group also had lower LDL-C levels than the controls. The researchers concluded, therefore, that the diet was effective as well as safe (19). Other studies have also concluded that it is safe to recommend that fat intake be limited to 30 percent of calories and saturated fat intake to less than 10 percent of calories for children 5 years old and older (26,29,35). Another recommendation regarding children's diets addresses their requirements for dietary fiber. The Dietary Guidelines recommend that individuals 2 years and older choose a diet with plenty of grain products, vegetables, and fruits to provide adequate fiber. But the Guidelines do not set specific numerical goals for fiber intake. The American Health Foundation published a recommendation that a child's fiber intake be equivalent to his or her age plus 5 grams (g) a day ("age+ 5"), with the recommendation ranging from 8 g a day for a child age 3 to 25 g a day for a person age 20 (44). Nutritional Status of Children Dietary Intake-Energy Data on children's food consumption are provided by several national surveys: DHHS's National Health and Nutrition Examination Survey (NHANES III), USDA's Continuing Survey of Food Intakes by Individuals (CSFII), and the Market Research Corporation of America (MRCA) ( 1,10,16,37). Median energy intakes below 100 percent of the RDA for several age-gender groups were reported in NHANES III results ( 1 0). The CSFII 1994-96 reported that over half of the children 5 years old and younger had energy intakes below the RDA, and about 20 percent had energy intakes below 75 percent of the RDA. About 60 percent of males and 75 percent of females 6 to 19 years old had energy intakes below the RDA (37). Rather than a reflection of actual low intakes of energy by children, these low intakes of energy could be the result of underreporting the foods eaten or of low energy expenditures by children. Several studies have reported that preschool-age children have energy expenditures lower than the RDA (6,11,12). In contrast, the prevalence of overweight among children has been increasing ( 36). According to CSFII 1994-96, about 5 to 10 percent of all children have energy intakes at or above 150 percent of the RDA ( 37). Dietary Intake-Macronutrients and Fiber Food consumption surveys report that, on average, children are consuming more than 30 percent of calories from total fat and more than 10 percent of calories from saturated fat (fig. 1) ( 1,10, 16,37). Kennedy and Goldberg, using CSFII 1989-91 data, reported that over three-fourths of all children exceeded Family Economics and Nutrition Review Figure 1. Percent of calories from total fat and saturated fat in children's diets exceeds recommendations Percent 45 40 35 30 25 20 15 10 5 0 Age and 1-2 years 3-5 years 6-11 years males 6-11 years females 12-19 years males 12-19 years gender females • o/o Calories from total fat D o/o Calories from saturated fat ••••••• Dietary Guidelines recommendation for o/o calories from total fat - • • - • Dietary Guidelines recommendation for o/o calories from saturated fat recommendations for total fat and saturated fat ( 15). Improvement was slight by 1994, when roughly two-thirds of all children exceeded the recommendation for total fat and saturated fat (16). Because of the Guidelines' recommendation for gradual adoption of a diet low in fat, concern is greater for children 5 years and older than it is for children 2 to 5 years old. The CSFTI 1994-96 also reported that adolescent males are consuming more than 300 mg/day of cholesterol, the upper limit of cholesterol intake listed on the Nutrition Facts label (37). Other studies have confirmed the findings regarding children's fat intake: most are consuming more than the recommended levels. About ninety 3- to 5-year-old children enrolled in the Framingham 1999 Vol. 12 Nos. 3&4 Children's Study4 consumed an average of 33 percent of calories from fat (28 ). Albertson and Tobelmann, analyzing 1986-88 MRCA data, reported that among 825 children ages 7 to 12, those who frequently ate ready-to-eat cereal (7 or more times in 14 days) consumed a lower percentage of calories from fat, compared with others who consumed ready-to-eat cereals less frequently: 2 to 6 times in 14 days or less than 2 times in 14 days. However, all three groups consumed more than 30 percent of calories from fat (2). Data from the CSFTI 1994-96 showed that young children's mean intakes of "The longitudinal Framingham Children's Study examined factors related to the development of dietary habits and patterns of physical activity during childhood. dietary fiber met the "age+ 5" recommendation of the American Health Foundation. Children 5 years old and younger had mean fiber intakes of about 11 g a day. However, older children began to fall short of the fiber recommendations: males and females 6 to 11 years old consumed about 14 g and 12 g of fiber per day, respectively; their counterparts 12 to 19 years old consumed about 17 g (males) and 13 g (females) per day (37). Dietary Intake-Micronutrients American children are more likely to get adequate amounts of vitamins and minerals than they are to meet Dietary Guideline recommendations for total fat and saturated fat intake. However, some nutrients are consumed at levels below recommended amounts by some groups 7 in the U.S. population. For example, vitamin E and zinc are consumed at levels below 100 percent of the RDA by most children 2 to 19 years old (37). According to CSFII 1994-96, on the days surveyed, only about 60 percent of children 5 years and younger, 60 percent of females 6 to 11 years old, and only 28 percent of females 12 to 19 years old consumed 100 percent or more of the RDA for iron. Only about one-third each of males and females 12 to 19 years old consumed 100 percent or more of the RDA for vitamin A ( 37). Calcium is another nutrient that children consume at levels below recommendations. Average calcium consumption is below the 1989 RDA for children 12 to 19 years old (fig. 2). In 1994-96, about half of the children 11 years old and younger consumed 100 percent or more of the 1989 RDA for calcium; just over one-third of males 12 to 19 years old and about 15 percent of females 12 to 19 years old consumed 100 percent or more of the calcium RDA (37). Even fewer children ages 9 and older would meet the new Adequate Intake for calcium, which increased to 1,300 mg (31). Compared with other children, adolescents, particularly adolescent females, had the greatest problems in meeting their nutrient requirements. Adolescent females reported the lowest energy intakes in proportion to their energy requirement ( 37). Findings of MRCA data from 1991-94 show that most adolescents ages 11 to 17 consumed less than 2 servings (the minimal number recommended) of fruits a day. Twelve percent of adolescents consumed no fruits in a given day (45). Krebs-Smith et al. examined 3-day data from CSFII 1989-91 for children and adolescents 2 to 18 years old. Even after foods were separated into their 8 component ingredients (e.g., credit is given for vegetables in mixed dishes, such as on pizza or in sandwiches), only one in five children consumed the recommended 5 servings of fruits and vegetables a day. One-quarter of all vegetables that were consumed were French fries. Children from families with higher income consumed more servings of fruits and vegetables, compared with children from families with lower income (18). Data from the CSFII 1994-96 also showed that children's intake of fruits and vegetables was low. Only about one-fourth of children 2 to 11 years old consumed the minimal 3 servings of vegetables a day that are recommended by the Pyramid, and only about 40 percent of females and 55 percent of males 12 to 19 years old met the minimal number of servings. About half of all 2- to 5-yearolds consumed the minimal 2 servings of fruit a day recommended by the Pyramid, but this dropped to about onefourth for males and females 11 to 19 years old ( 37). Low intakes from one food group could explain some of the low nutrient intakes, particularly for vitamins A and C and folate. Sodium intakes for many children are higher than 2,400 mg a day, its upper limit (listed on the Nutrition Facts label). Children 6 years old and older had median sodium intakes greater than 2,400 mg a day according to NHANES data (which includes allowances for salt added at the table and sodium in water and medications) ( 10). In the CSFII 1994-96 (which reports only sodium intake from food), the mean sodium consumption for all children 3 years old and older exceeded 2,400 mg a day. Mean sodium consumption for males ages 12 to 19 years was 4,407 mg a day (37). Anthropometric Indices Weight and height indicators from NHANES III show that underweight is a concern for about 5 percent of 2- to 17-year-olds (only 2 percent of 12- to 17-year-old females) ( 10). Overweight, when defined as a weight for height greater than the 95th percentile, occurred in 10.9 percent of children ages 6 through 17 (36). When overweight was defined as a weight for height greater than the 85th percentile, the incidence of overweight increased to 22 percent ( 36). The prevalence of overweight increased between 1963-65 and 1988-91 among all age-gender groups, with the greatest increase occurring between 1976-80 and 1988-91 (36). A study of the prevalence of overweight among preschool-age children 2 months through 5 years old found that overweight among 4- and 5-year-old females increased from 5.8 percent in 1971-74 to 10 percent in 1988-94. Overweight was defined, in this study ofNHANES data, as being above the 95th percentile of the appropriate measures of the National Center for Health Statistics: weightfor- length or weight-for-stature growth curve. The prevalence of overweight did not increase among younger children. However, the increase in prevalence of overweight in children as young as 4 years old suggests that efforts to prevent overweight should begin in early childhood (27). The increase in obesity is surprising, because many children are reporting energy intakes below the RDA. Lack of physical activity may be responsible for the increase, and the number of hours children watch television has been linked to obesity in this age group (8). Family Economics and Nutrition Review Figure 2. Mean calcium· intakes of older American children below recommended levels Milligrams 1400 1200 1000 800 600 400 200 0 Age and gender 1-2 years 3-5 years 6-11 years males 6-11 years females 12-19 years males 12-19 years females • Calcium intake, mg • 1989 RDA, mg [2J 1997 AI, mg Consumer ResearchChildren's Knowledge and Attitudes About Nutrition When adapting a food guide for children, USDA staff believe it is useful to find out what children know about nutrition, what their attitudes are about foods and nutrition, and what nutrition education programs have been successful. Children have been the target audience for some qualitative and quantitative studies; however, information about their knowledge and attitudes regarding nutrition is far more scarce than information about adult's knowledge and attitudes. Qualitative Studies In late 1991, in preparation for developing nutrition labeling materials for children, 1999 Vol. 12 Nos. 3&4 KIDSNET, Inc., an organization working on children's educational issues (in cooperation with the U.S. Food and Drug Administration [FDA]), sponsored minifocus groups (3 children in each group) with children 6, 8, and 12 years old. The focus groups were designed to examine children's attitudes and behavior regarding food, as well as their awareness and knowledge of the relationship between nutrition and food. Six focus groups (with a mixture of racial and income groups) were conducted in the Washington, DC, area. The children reported having some influence over the foods they eat, particularly breakfast cereals, snack foods, and lunches. Some 6-year-olds even reported making their own lunches. Results from the mini-focus group showed that the children's age influenced their knowledge of nutrition. Twelve-year-old children could name food groups and were aware that carbohydrate, protein, fat, vitamins, and minerals are found in food. Younger children did not have a clear understanding of food groups, and many children thought of vitamins as products that come in a bottle from the drugstore. However, even though the 12-year-old children were fairly knowledgeable about nutrition, their knowledge did not carry over to their own dietary patterns. Taste, instead, was their primary consideration in making food choices. In the words of one 12-year-old participant: "We hear 'Eat right. Don't do drugs.' It's getting boring, like a broken record, so we just tune it out" (30). 9 10 ... the increase in prevalence of overweight in children as young as 4 years old suggests that efforts to prevent overweight should begin in early childhood .... The FDA sponsored two focus groups, each consisting of six to eight females 13 to 15 years old from various racial and ethnic groups. The purpose of the focus groups was to determine the types of nutrition messages the participants would find compelling and to determine which format(s)-for messages about calcium-the participants would most likely pay attention to. These focus groups were held in the Washington, DC/Baltimore, MD, metropolitan area. The results revealed that the participants had a fairly good knowledge of nutrition; they could name nutrients and make associations between a nutrient and its function, for example, "calcium makes your bones strong." Participants said they tended to pay more attention to eating a healthful diet when they were actively involved in a sport. (Most were active in at least one sport.) A frequently mentioned barrier to healthful eating was related to school lunches: lunch periods were often rushed and at odd hours of the day. Participants expressed a preference for educational materials that contained bold, bright colors and little or no text (21 ). The International Food Information Council sponsored one focus group with 9- to 12-year-old children and another with 13- and 14-year-olds to evaluate a prototype nutrition brochure. All of the participants had seen the Food Guide Pyramid, and all said they already knew about the importance of eating vegetables, fruits, and grain products. The participants, however, believed these concepts were "boring, because everyone knows that," and they believed that information about eating breakfast, smart snacking, and balance was important. They also thought information about physical activity was important but believed that activities portrayed should be relevant to their age group. Activities such as golf and racquetball were perceived as "adult" sports (9). Because these studies were conducted using locally available samples and were conducted in urban areas, the results must be interpreted cautiously and cannot be generalized to all children. Quantitative Studies The Kellogg Company surveyed children about their nutrition knowledge, attitudes, and behavior. A nationally representative school-based survey was conducted in 1988-89 with 5,000 students in Grades 3 through 12. Over half of the respondents in this survey believed nutrition is "very important"; however, nutrition was considered less important by older children than by younger ones. Almost three-quarters of elementary school students considered nutrition "very important," compared with about half of junior high school students and only about one-third of high school students (13). The Kellogg survey also found that the positive attitudes of many children did not always translate into appropriate behavior, confirming the results of the qualitative studies referred to earlier in this paper. Only about one-third of all school-age children responded "often" (rather than "sometimes" or "rarely") to the statement "I eat the right foods." Children who agreed strongly with the statement that too much cholesterol and saturated fat are bad for health reported eating foods high in these components as often as did other children, thus demonstrating that their knowledge did not change their behavior. The authors of the Kellogg survey suggested that lack of sufficient knowledge could be partially responsible for this disconnectthe children might know that excessive Family Economics and Nutrition Review dietary cholesterol and saturated fat are unhealthful, but they may not know which foods are rich sources of these components ( 13 ). Lack of adult supervision could also account for some of the poor eating habits reported by the participants of the Kellogg survey. About 60 percent of children reported coming home to an empty house at least once a week, with more than one-third coming home alone three or more times a week. These "latchkey" children were more likely to report that they, rather than their parents, have more control over what they eat (60 percent of "latchkey" children; 35 percent of all elementary schoolchildren). Eating away from home frequently could influence children's diets. According to USDA's CSFII 1994-96, about 40 percent of children 5 years old and younger and over two-thirds of children 6 to 19 years old reported eating at least one food item away from home on the day of the survey. The most frequently mentioned sources of food away from home were fast-food restaurants, school or day care, someone else or gift, and stores (37). The Kellogg Survey also found that almost one-third of school-age children believed they were overweight ( 13 ). This figure is somewhat higher than the 22 percent of children 6 to 17 years old who were found to be overweight by NHANES III. This difference raises a possibility: some children whose weight is normal think they are overweight. Thus dieting is a common behavior among children; about 40 percent of all school-age children participating in the Kellogg Survey reported having been on a diet. More females than males reported dieting, and most of the children 1999 Vol. 12 Nos. 3&4 who reported dieting did so for cosmetic reasons rather than for health ( 13 ). Lack of physical activity has been cited as a possible reason for the increase in the percentage of children who are overweight (6,8,11,12). The Kellogg Survey, on the other hand, found that schoolchildren do consider exercise to be important. Elementary schoolchildren reported taking part in physical activity over five times a week; high school students reported being involved in physical activity about four times a week(13). The Youth Risk Behavior Survey, a component of the Youth Risk Behavior Surveillance System (Centers for Disease Control and Prevention), is a national school-based survey of students in Grades 9 through 12. It contains a series of questions, parts of which are nutritionor diet-related. Male students responding to this survey were significantly more likely than female students to consider themselves the "right weight" or "underweight" (86 vs. 66 percent). Female students were significantly more likely than male students to report trying to lose weight at the time of the survey (44 vs. 15 percent). Over one-fourth of female students who considered themselves the "right weight" reported trying to lose weight. And female students were significantly more likely than their male counterparts to report either currently or ever having used inappropriate practices to lose weight: such as, skipping meals, taking diet pills, or inducing vomiting (40). The Youth Risk Behavior Survey asked students in Grades 9 through 12 how often they participated in vigorous activity in the 2 weeks preceding the survey. Vigorous activity was defined as "at least 20 minutes of hard exercise that made you breathe heavily and made your heart beat fast" ( 41 ). About one-third of all students reported being vigorously active three or more times a week, but female students were half as likely than male students to report regular vigorous activity (25 vs. 50 percent), and African American students were less likely than White or Hispanic students to report regular vigorous activity (30 vs. 40 and 35 percent, respectively) (41). Studies of Nutrition Education Prograrns--VVhatVVorks USDA conducted research to evaluate adults' comprehension and perceived usefulness of its food guide and to develop a graphic presentation of the food guide ( 43 ). USDA also conducted research to determine the effectiveness of the resulting graphic of the Food Guide Pyramid with three target audiences: children, consumers with less than a high school education, and lowincome consumers. USDA, in 1991, collaborated with DHHS and contracted with private industry (4) to develop and test graphic alternatives (including a bowl, shopping cart, and dinner plate) to the Food Guide Pyramid for conveying the key concepts of variety, proportionality, and moderation. Qualitative findings indicated that children preferred the Pyramid graphic to the alternatives tested. They, as well, learned the most information from the Pyramid. Teachers also preferred the Pyramid as a teaching tool, compared with the alternatives (4). For the quantitative phase of the research, interviewers questioned 3,017 individuals, including 1,523 children in Grades 2 through 10. The children's responses to the 60-item questionnaire indicated that the Pyramid graphic conveyed the concepts of variety, proportionality, and moderation. Younger children (Grades 2 to 3), 11 12 The Center selected the preschool-age group (2 to 6 years) as the target audience for an adapted food guide . ... however, understood variety more so than proportionality and moderation (4). Effectiveness of Nutrition Education Programs The Food Guide Pyramid adapted for children needed to integrate relevant findings from a recent comprehensive review on the effectiveness of methods used in nutrition education. This review revealed that programs using educational methods directed at behavioral change as a goal were more likely than other programs to be successful-that is, they were more likely to result in some behavioral change than were programs that focused on only distributing information (5). Contento et al. recommended that programs be behaviorally based and appropriately designed for the child's stage of cognitive development ( 5 ). Preschool and early elementary school-age children (4 to 7 years) need activities that allow them to modify their environment. Providing food-based activities and having adults model eating behavior are appropriate for this age group. Also, parents' or other caregivers' involvement with children in this age group is an important factor contributing to success. Older elementary school-age children (8 through about 11 years) still need to have information presented in concrete terms. Food-classification activities and modeling by adults are appropriate for this age group, and involvement with parents and the community is still important for programs targeted for this age group. Adolescents (second decade oflife) move from concrete to abstract thinking and are able to comprehend more abstract information, such as the relationship between diet and health-present and future. They need activities that encourage critical thinking, such as exploring the influence of diet on health and the environment. With this age group, parents' involvement becomes less important, because adolescents are more likely to be influenced by their peers than by their parents or caregivers (5). The quantity and quality of existing nutrition education materials for specific age groups of children must also be considered when selecting a target audience. Recently, Swadener reviewed research related to nutrition education for preschool-age children ( 33 ), and Lytle reviewed research related to nutrition education for school-age children (20). Both found that while many nutrition education materials are directed toward children, improvements and follow-up are needed to determine whether the materials are really effective. Swadener found that many nutrition education materials developed for preschoolchildren did not include an evaluation component, many programs were not conducted for a sufficient time to result in changes in attitudes or behavior, and few programs were designed for use with children from dysfunctional or marginally functional families. Lytle concluded that more tools are needed for assessment of change in children's and adolescents' eating behavior and that adolescents, in particular, could benefit from exposure to strategies that modify behavior. Lytle also found that more programs are needed: ones that target multi-ethnic groups as well as involve families of school-age children. Family Economics and Nutrition Review Pros and cons of adapting the Food Guide Pyramid for use with three groups of children Pros Cons Preschool age (2 through 6 years) Have special needs, re: fat, smaller serving sizes Peer pressure not a problem Can reach them through the Special Supplemental Feeding Program for Women, Infants, and Children and the Child and Adult Care Feeding Program Developmentally a good time to reach (e.g., when food habits are still being formed) Can counteract exposure to television advertising of high-calorie foods Not as many materials targeting this age group as for older children Educational materials must target parents and caregivers, not child directly Fat message (children this age need more fat) may confuse parents, because this need is temporary Elementary school age (7 through 11 years) Think nutrition is important but don't act on it; they are "reachable" Already a large amount of nutrition education material available for this audience (however, not all of it is relevant or appropriate) Beginning to take more responsibility for their own food choices Current food guide already meets nutrient needs Easier to reach (through a single classroom teacher) than younger or older children (where nutrition education may be provided by a diverse group of individuals) Adolescents ( 12 to 18 years) More problems meeting nutrient needs Not many materials targeting this audience Current food guide already meets nutrient needs Difficult audience to reach-need different ways to communicate food guide, not necessarily different food guide Make many of own food choices Need more individualized messages-e.g., for athletes vs. nonathletes Perhaps can tum weight concerns into motivation for change 1999 Vol. 12 Nos. 3&4 13 Decision Point-Target Audience for the Food Guide Pyramid for Children Because of differences in nutrient needs (23,31,32), current food consumption patterns ( 10,16,37), and stages of educational development ( 5 ), a single food guide cannot meet the needs of all children 2 to 18 years old. Based on children's nutrient needs and developmental level, staff of the Center for Nutrition Policy and Promotion identified three age groups for which a Pyramid could be developed: • Preschool and early elementary age (2 through 6 years) • Elementary school age (7 through 11 years) • Middle and high school age (12 to 18 years) The Center staff considered several factors when deciding which age group should be targeted for an adapted food guide: • Does the existing food guide meet this group's dietary needs, or does this group have specific nutritional and health problems that an adapted food guide could help to address? • If the existing food guide meets the group's dietary needs, has it been successful in influencing the group's behavior? Is there a need for an alternate presentation of the existing food guide to better reach this group? • What nutrition education materials exist for this audience? • What are the educational considerations for this group? Will children be able to use the new food guide directly? Will they use the materials with guidance from a parent or caregiver? Or will the materials 14 be developed for the parent or caregiver? • Is there user demand for a new food guide for this group? • What is the social effect of the decision? Will different food guides for different ages create confusion? Based on these factors, Center staff listed pros and cons for developing an adapted food guide for each age group (table) and considered these issues when making the decision regarding the target audience. Implications and Recommendations for a Food Guide for Preschool-Age Children (2 to 6 Years) The Center selected the preschool-age group (2 to 6 years) as the target audience for an adapted food guide because there is a greater need for verifying the scientific basis of the food guide, both from a physiological and developmental viewpoint for 2- to 6-year-olds than for older children. The rationale for this conclusion follows: • Nutrient needs of preschool-age children differ from those of older children. The Dietary Guidelines for Americans recommend that the level of dietary fat be gradually decreased from current levels (about 34 percent of calories from fat) to 30 percent of calories by the time the child is about 5 years old (39). Concerns about undue food and fat restrictions for children in this age group, leading to "failure to thrive," have been expressed by the American Academy of Pediatrics ( 3 ). Because the current Food Guide Pyramid assumes a dietary fat intake of 30 percent of calories, Center staff concluded that additional guidance is needed for parents and caregivers of children less than 5 years old. • Following the release of the Food Guide Pyramid, USDA received numerous questions from the Extension Service; the Dairy Council; the Special Supplemental Food Program for Women, Infants, and Children (WI C); the Child and Adult Care Food Program; and the media. The concern: how to use the food guide with young children, particularly regarding children's need for smaller serving sizes. • Developmental concerns regarding food activities at the preschool level include determining what young children can or should "learn" and addressing the physiological and emotional issues related to food. Because parents and caregivers have a major role in food selection for this age group, Center staff believed these children's attitudes and behavior must also be considered. Adaptation of the food guide for this age group uses the same framework of food groups as the original food guide. Thus the framework blends into later learning activities in school where concepts are added, for example, nutrient content of different types of foods; how foods are grown, processed, and delivered; how different food items are used in different cultures; and how "new" foods have been historically introduced into the American diet. Using the same framework of food groups also makes the new food guide more practical for family food managers to use. The process used to adapt the food guide for the preschool and early elementary-age audience is described elsewhere in this issue (22,34). Family Economics and Nutrition Review References 1. Albertson, A.M., Tobelmann, R.C., and Engstrom, A. 1992. Nutrient intakes of 2- to 10- year-old American children: 10-year trends. Journal of the American Dietetic Association 92:1492-1496. 2. Albertson, A.M. and Tobelmann, R.C. 1993. Impact of ready-to-eat cereal consumption on the diets of children 7-12 years old. Cereal Foods World 38(6):428-431. 3. American Academy of Pediatrics, Committee on Nutrition. 1998. Statement on cholesterol. Pediatrics 101:141-147. 4. Bell Associates, Inc. 1992. An Evaluation of Dietary Guidance Graphic Alternatives. Prepared for U.S. Department of Agriculture, Food and Consumer Services. 5. Contento, I., Balch, G.l., Bronner, Y.L., Paige, D.M., Gross, S.M., Bisignani, L., Lytle, L.A., Maloney, S.K., White, S.L., Olson, C.M., Swadener, S.S., and Randell, J.S. 1995. The effectiveness of nutrition education and implications for nutrition education policy, programs, and research: A review of research. Journal of Nutrition Education 21( 6 ):277-422. 6. Davies, P.S.W., Gregory, J., and White, A. 1995. Energy expenditure in children aged 1.5 to 4.5 years: A comparison with current recommendations for energy intake. European Journal of Clinical Nutrition 49:360-364. 7. Dietary Guidelines Advisory Committee. 1995. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans. U.S. Department of Agriculture, Agricultural Research Service. 8. Dietz, W.H. Jr. and Gortmaker, S.L. 1985. Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics 75:807-812. 9. Edelman Public Relations Worldwide. 1995. Report ofF ocus Groups at Stevens Elementary and Poe Middle School. Topline report submitted to International Food Information Council. 10. Federation of American Societies for Experimental Biology, Life Sciences Research Office. Prepared for the Interagency Board for Nutrition Monitoring and Related Research. 1995. Third Report on Nutrition Monitoring in the United States: Volume 1. U.S. Government Printing Office, Washington, DC, 365 pp. 11. Fontvielle, A.M., Harper, LT., Ferraro, R.T., Spraul, M., and Ravussin, E. 1993. Daily energy expenditure by five-year-old children, measured by doubly labeled water. Journal of Pediatrics 123:200-207. 12. Goran, M.I., Carpenter, W.H., and Poehlman, E.T. 1993. Total energy expenditure in 4- to 6-year-old children. American Journal of Physiology 264:E706-E711. 13. Harris/Scholastic Research. 1989. The Kellogg Children's Nutrition Survey. Conducted for the Kellogg Company, Battle Creek, Michigan. 14. Joint Working Group of the Canadian Paediatric Society and Health Canada. 1993. Nutrition Recommendations Update . .. Dietary Fat and Children. Ottawa, Ontario: Health Canada, Cat. H39-162/l-1993E. 18 pp. 15. Kennedy, E. and Goldberg, J. 1995. What are American children eating? Implications for public policy. Nutrition Reviews 53(5): 111-126. 1999 Vol. 12 Nos. 3&4 15 16 16. Kennedy, E. and Powell, R. 1997. Changing eating patterns of American children: A view from 1996. Journal of the American College of Nutrition 16(6):524-529. 17. Krauss, R.K., Deckelbaum, R.J., Ernst, N., Fisher, E., Howard, B.V., Knopp, R.H., Kotchen, T., Lichtenstein, A.H., McGill, H. C., Pearson, T.A., Prewitt, T.E., Stone, N.J., Van Hom, L., and Weinberg, R. 1996. Dietary Guidelines for healthy American adults: A statement for health professionals from the Nutrition Committee, American Heart Association. Circulation 94:1795-1800. 18. Krebs-Smith, S.M., Cook, A., Subar, A. F., Cleveland, L., Friday, J., and Kahle, L.L. 1996. Fruit & vegetable intakes of children and adolescents in the United States. Archives of Pediatric and Adolescent Medicine 150:81-86. 19. Lauer, R.M., Obarzanek, E., Kwiterovich, P.O., Kimm, S.Y.S., Hunsburger, S.A., Barton, B.A., van Hom, B., Stevens, V.J., Lasser, N.L., Robson, A.M., Franklin, F.A., and SimonsMorton, D.G. 1996. Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol: The Dietary Intervention Study in Children (DISC). Journal of the American Medical Association 273: 1429-1435. 20. Lytle, L.A. 1994. Nutrition Education for School-Aged Children: A Review of Research. Report prepared for U.S. Department of Agriculture, Food and Consumer Service. 21. Macro International. 1995. Adolescent Consumers' Attitudes Toward Calcium Education and Proposed Educational Materials: Focus Groups Report. Prepared for the U.S. Food and Drug Administration. 22. Marcoe, K.L. 1999. Technical research for the Food Guide Pyramid for Young Children. Family Economics and Nutrition Review 12(3&4):18-32. 23. National Academy of Sciences, National Research Council, Food and Nutrition Board. 1989. Recommended Dietary Allowances (1Oth ed. ). National Academy Press, Washington, DC. 24. National Cholesterol Education Program. 1991. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, MD: National Institutes of Health, NIH Publication no. 91-2732. 119 pp. 25. Nicklas, T.A., Webber, L.S., Kaschak, M.L., and Berenson, G.S. 1992. Nutrient adequacy of low fat intakes for children: The Bogalusa Heart Study. Pediatrics 89(2):221-228. 26. Niinikoski, H., Lapinleimu, H., Viikari, J., Ronnemaa, T., Jokinen, E., Seppanen, R., Terho, P., Tuominen, J., Valimaki, 1., and Simell, 0. 1997. Growth until3 years of age in a prospective, randomized trial of a diet with reduced saturated fat and cholesterol. Pediatrics 99(5 ):687 -694. 27. Odgen, C.L., Troiano, R.P., Briefel, R.R., Kuczmarski, R.J., Flegal, K.M., and Johnson, C.L. 1997. Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics 99( 4 ):e1 . 28. Oliveria, S.A., Ellison, R.C., Moore, L.L., Gillman, M.W., Garrahie, E.J., and Singer, M.R. 1992. Parent-child relationships in nutrient intake: The Framingham Children's Study. American Journal of Clinical Nutrition 56:593-598. 29. Shea, S., Basch, C.E., Stein, A.D., Contento, I.R., Irigoyen, M., and Zybert, P. 1993. Is there a relationship between dietary fat and stature or growth in children three to five years of age? Pediatrics 92(4):579-586. Family Economics and Nutrition Review 30. Shugoll Research. 1992. Children's Nutrition Label Focus Group Study. Report prepared for KIDSNET, Inc., Washington, DC. 31. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. 1997. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC. National Academy Press. 32. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. 1998. Dietary Reference Intakes for Folate, Other B Vitamins, and Choline. Washington, DC. National Academy Press. 33. Swadener, S.S. 1994. Nutrition Education for Preschool Children: A Review of Research. Report prepared for U.S. Department of Agriculture, Food and Consumer Service. 34. Tarone, C. 1999. Focus group research on adapting the Food Guide Pyramid for Young Children. F amity Economics and Nutrition Review 12( 3 &4 ):33-44. 35. Tonstad, S. and Sivertsen, M. 1997. Relation between dietary fat and energy and micronutrient intakes. Archives of Diseases of Childhood 76(5 ):416-442. 36. Troiano, R.P., Flegal, K.M., Kuczmarski, R.J., Campbell, S.M., and Johnson, C.L. 1995. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991 . Archives of Pediatric and Adolescent Medicine 149:1085-1091. 37. U.S. Department of Agriculture, Agricultural Research Service. 1998. Food and Nutrient Intakes by Individuals in the United States by Sex and Age, 1994-96, Nationwide Food Surveys. Report No. 96-2.197 pp. 38. U.S. Department of Agriculture, Human Nutrition Information Service. 1992. The Food Guide Pyramid. Home and Garden Bulletin No. 252. 39. U.S. Department of Agriculture and U.S. Department of Health and Human Services. 1995. Nutrition and Your Health: Dietary Guidelines for Americans (4th ed.). U.S. Department of Agriculture. Home and Garden Bulletin No. 232. 40. U.S. Department of Health and Human Services. 1991. Body-weight perceptions and selected weight-management goals and practices of high school students-United States, 1990. Morbidity and Mortality Weekly Reports 40:741,747-750. 41. U.S. Department of Health and Human Services. 1992. Vigorous physical activity among high school students-United States, 1990. Morbidity and Mortality Weekly Reports 41 :33-35. 42. U.S. Department of Health and Human Services. 2000. Healthy People 2010 (Conference Edition in Two Volumes). Washington, DC. 43. Welsh, S.O., Davis, C., and Shaw, A. 1993. USDA's Food Guide: Background and Development. U.S. Department of Agriculture. HNIS Miscellaneous Publication No. 1514. 44. Williams, C.L. 1995. Importance of dietary fiber in childhood. Journal of the American Dietetic Association 95:1140-1146, 1149. 45. Zizza, C. A. and Powell, R. 1996. Characteristics distinguishing adolescents by fruit consumption. Journal of the American Dietetic Association 96:A-91 . 1999 Vol. 12 Nos. 3&4 17 Kristin L. Marcoe Center for Nutrition Policy and Promotion 18 Technical Research for the Food Guide Pyramid for Young Children This article describes the technical research for the Food Guide Pyramid for Young Children. Composites for food groups and subgroups were developed using food intake data for children 2 to 6 years old. Data were from the Continuing Survey of Food Intakes by Individuals 1989-91. The composites were used in creating 1 ,300- and 1 ,600-calorie Food Guide Pyramid diet patterns. For children 4 to 6 years old, the 1 ,600-calorie pattern met all nutrient requirements, except for vitamin E. The 1 ,300-calorie pattern provided the ADA for most nutrients for 2- to 3-year-olds and 4- to 6-year-olds. The major exceptions were iron and zinc for both age groups and copper and vitamin E for the 4- to 6-year-olds. When breakfast cereals fortified with iron and zinc were used in the grain composites, the patterns provided recommended levels of these nutrients. Children could improve their diet by making different food choices, in particular, by eating more dark-green and deep-yellow vegetables; legumes; whole grains; and lean meat, poultry, or fish. he Food Guide Pyramid for Young Children ages 2 to 6 years is a nutrition education tool to help teach healthful eating concepts to young children. The technical research conducted in developing and documenting the research base for this food guide followed procedures similar to those described in the development and documentation of the original food guide (1,9). Food selections and serving sizes reported for young children, in a national food consumption survey, were incorporated into diet patterns based on the Food Guide Pyramid to determine whether such patterns would meet nutritional goals. A composite was developed for each Pyramid food group (e.g., meat, poultry, fish) or subgroup (e.g., whole grain). Composites were based on children's actual food choices and reflected the relative use of individual foods within the group or subgroup. An example: the composite for deep-yellow vegetables reflected children's consumption of 89 percent as carrots and 11 percent as other deep-yellow vegetables. A nutrient profile was then calculated for each composite, after which composites and their nutrient profiles were used to calculate expected nutrient levels in 1 ,300- and 1 ,600-calorie diet patterns based on the Food Guide Pyramid. The nutrient totals were then analyzed to determine whether children's nutrient requirements could be met by diet patterns that conform to Pyramid recommendations and that consist of the foods most commonly eaten by children. Family Economics and Nutrition Review Methods Data Sources Data on 3-day food and nutrient intakes reported in the Continuing Survey of Food Intakes by Individuals (CSFII) 1989-91 for 1,053 children 2 to 6 years old were used in this study. This data set was used because when work was started, the data set offered the largest number of individuals and days for analysis. Sample weights were applied to provide estimates that were representative of the population. The data that were used to calculate the nutrient profiles of the composites for the food groups and subgroups came from the U.S. Department of Agriculture's (USDA) Nutrient Data Base for Individual Intake Surveys, Release 7 (1991). The Food Guide Servings Data Base was used to report the amounts of food consumed as numbers of food guide servings. USDA's Center for Nutrition Policy and Promotion (CNPP) developed this data base by using the foods reported in the CSFII 1989-91. The Food Guide Servings Data Base consists of food-item descriptions and the number of Pyramid servings per 100 grams of food. Servings data are provided for the 5 major food groups and 21 subgroups identified in the Food Guide Pyramid. Most foods, including mixed dishes, were broken down into ingredient components, and their food group servings were calculated for more than one food group. When a food code's typical serving size, defined in the Survey Code Book for CSFII 1989-91 and based generally on median serving sizes reported in USDA food consumption surveys, provided less than onefourth of a serving of a Pyramid food group or subgroup, it was usually not 1999 Vol. 12 Nos. 3&4 counted. For example, a serving of oatmeal raisin cookies provided less than one-fourth of a Pyramid serving of raisins, so those raisins were not counted toward fruit servings. These small amounts were not counted because one objective of the original food guidance system was "usability." It is unrealistic to expect Americans to "count" small amounts of some foods toward food group servings. However, if several "other vegetables" like tomatoes and onions were in small amounts in a mixture, and these amounts together added up to at least one-fourth serving, these "other vegetables" were counted toward vegetable servings. Procedures CNPP began the research process by breaking down the foods that were consumed by children 2 to 6 years old, as reported in the CSFII 1989-91, into numbers of food group and subgroup servings. The Food Guide Servings Data Base was used for this process. To identify specific food components, CNPP staff reviewed food codes that contributed food guide servings. All food items with similar food components were grouped in the same item-group. For example, broccoli soup and broccoli casserole both contained cooked broccoli and so were placed in the item-group for cooked broccoli within the subgroup for dark-green vegetables. A composite was then constructed by summing intakes from all the item-groups within a food group, with each item-group being weighted by the numbers of servings reported for children 2 to 6 years old. Then the percentage contributed by each itemgroup in the food group or subgroup was calculated. The total number of servings of cooked broccoli consumed, for example, was divided by the total number of servings of dark-green vegetables consumed. This calculation produced the percentage of the composite for dark-green vegetables that was cooked broccoli. Any item-group totaling less than 1 percent of the composite was combined with another item-group, based on the similarity in nutrient composition or its use in meals. A food code most representative of an item-group was then selected to represent each food-item group in each of the composites. The nutrient values of these food codes were used to calculate the nutrient profiles of the composites. In developing the original nutrient profiles for the food groups and subgroups, researchers included foods with the least amount of fat and without added sugars; thus, the original philosophical goal of flexibility for the food guide was met. The food guide was used to show consumers how to obtain nutrients while allowing them flexibility to choose sources of fat and added sugars within the fat and calorie limits specified (9). In addition, the Food Guide Pyramid is an educational tool to help put the Dietary Guidelines into practice (8). To minimize fat, added sugars, and sodium, CNPP staff used the form of the food item that was lowest in these components. For example, the deepyellow vegetable subgroup contained the item-group for sweet potatoes. To represent the latter in the composite, CNPP used the code for a baked sweet potato without added fat-despite the fact that children usually eat candied sweet potatoes. For most vegetable and cooked-grain item-groups, CNPP used food codes that specified "no salt added in preparation." In a few cases, CNPP used the salted form to represent popular vegetables that are canned. Estimates of the percentage selected 19 20 ... young children ate somewhat different types and amounts of food items within each food group and subgroup than did the total population. in canned form were calculated from data of the food supply ( 4). Non-fortified ready-to-eat and cooked breakfast cereals were used in both the composites for whole grains and enriched grains. Hence nutrient profiles of the composites do not overestimate the nutrients for children who do not eat fortified breakfast cereals. Nutrients added at standard enrichment levels, as in enriched bread, were included in the nutrient profiles for the composites. Folate fortification was not mandated by the Government at the time the CSFII 1989-91 was conducted, so it was not reflected in any of the nutrient profiles for grain products. Once CNPP chose the food code to represent each item-group, we calculated grams of the food code and corresponding nutrient values for its portion of the composite serving. Nutrient values were then summed across all items in the food group or subgroup to determine the composite's nutrient profile per serving. Composites were not developed for the meat alternates (eggs, nuts and seeds) or for the milk, yogurt, and cheese group. The nutrient profiles of a food group or subgroup reflect proportionately the nutrient content of the foods within them; consequently, the nutrient profile of a food group or subgroup most reflects the nutrient content of the most frequently consumed foods within that group. Nutrient profiles for the meat alternates were represented by the nutrients in one large boiled egg and 2 tablespoons of peanut butter, each of which counts as 1 ounce from the meat, poultry, fish group. Peanut butter was 90 percent of young children's servings of nuts and seeds in the CSFII 1989-91 ; thus, peanut butter's nutrient profile was used instead of calculating a composite of all the different nuts and seeds that were consumed in small quantities by young children. All legumes were counted as vegetables in the earlier research on Pyramid food patterns (J) and so were counted similarly in this research project. One-half cup of cooked legumes may be counted as 1 ounce of meat, poultry, or fish rather than 1 serving of vegetables. The nutrient profile for the milk, yogurt, and cheese group was represented by 1 cup of nonfat milk, except for vitamin A. The amount of vitamin A used was the 76 RE per cup found in whole milk, instead of the 149 RE per cup found in fortified nonfat milk. Thus overestimation of vitamin A was avoided for those who consumed non-fortified whole milk products. The data on food intake, which were used to develop the composites, were examined to identify the most popular foods (at the food code level) and preparation styles in each item-group. Amounts reported eaten were also analyzed. For each item-group, the average number of servings per report was calculated. This was the average quantity of a specified food that was eaten by consumers during an eating occasion (at a single time). Then, the average number of servings per report was calculated for each food group or subgroup. The food-group composites and nutrient profiles for young children were compared with another set of composites that were developed for all individuals ages 2 years and older who provided 3 days of data in the CSFII 1989-91 (N=11 ,488). Family Economics and Nutrition Review Methods Data Sources Data on 3-day food and nutrient intakes reported in the Continuing Survey of Food Intakes by Individuals (CSFII) 1989-91 for 1,053 children 2 to 6 years old were used in this study. This data set was used because when work was started, the data set offered the largest number of individuals and days for analysis. Sample weights were applied to provide estimates that were representative of the population. The data that were used to calculate the nutrient profiles of the composites for the food groups and subgroups came from the U.S. Department of Agriculture's (USDA) Nutrient Data Base for Individual Intake Surveys, Release 7 (1991). The Food Guide Servings Data Base was used to report the amounts of food consumed as numbers of food guide servings. USDA's Center for Nutrition Policy and Promotion (CNPP) developed this data base by using the foods reported in the CSFII 1989-91. The Food Guide Servings Data Base consists of food-item descriptions and the number of Pyramid servings per 100 grams of food. Servings data are provided for the 5 major food groups and 21 subgroups identified in the Food Guide Pyramid. Most foods, including mixed dishes, were broken down into ingredient components, and their food group servings were calculated for more than one food group. When a food code's typical serving size, defined in the Survey Code Book for CSFII 1989-91 and based generally on median serving sizes reported in USDA food consumption surveys, provided less than onefourth of a serving of a Pyramid food group or subgroup, it was usually not 1999 Vol. 12 Nos. 3&4 counted. For example, a serving of oatmeal raisin cookies provided less than one-fourth of a Pyramid serving of raisins, so those raisins were not counted toward fruit servings. These small amounts were not counted because one objective of the original food guidance system was "usability." It is unrealistic to expect Americans to "count" small amounts of some foods toward food group servings. However, if several "other vegetables" like tomatoes and onions were in small amounts in a mixture, and these amounts together added up to at least one-fourth serving, these "other vegetables" were counted toward vegetable servings. Procedures CNPP began the research process by breaking down the foods that were consumed by children 2 to 6 years old, as reported in the CSFII 1989-91, into numbers of food group and subgroup servings. The Food Guide Servings Data Base was used for this process. To identify specific food components, CNPP staff reviewed food codes that contributed food guide servings. All food items with similar food components were grouped in the same item-group. For example, broccoli soup and broccoli casserole both contained cooked broccoli and so were placed in the item-group for cooked broccoli within the subgroup for dark-green vegetables. A composite was then constructed by summing intakes from all the item-groups within a food group, with each item-group being weighted by the numbers of servings reported for children 2 to 6 years old. Then the percentage contributed by each itemgroup in the food group or subgroup was calculated. The total number of servings of cooked broccoli consumed, for example, was divided by the total number of servings of dark-green vegetables consumed. This calculation produced the percentage of the composite for dark-green vegetables that was cooked broccoli. Any item-group totaling less than 1 percent of the composite was combined with another item-group, based on the similarity in nutrient composition or its use in meals. A food code most representative of an item-group was then selected to represent each food-item group in each of the composites. The nutrient values of these food codes were used to calculate the nutrient profiles of the composites. In developing the original nutrient profiles for the food groups and subgroups, researchers included foods with the least amount of fat and without added sugars; thus, the original philosophical goal of flexibility for the food guide was met. The food guide was used to show consumers how to obtain nutrients while allowing them flexibility to choose sources of fat and added sugars within the fat and calorie limits specified (9). In addition, the Food Guide Pyramid is an educational tool to help put the Dietary Guidelines into practice (8). To minimize fat, added sugars, and sodium, CNPP staff used the form of the food item that was lowest in these components. For example, the deepyellow vegetable subgroup contained the item-group for sweet potatoes. To represent the latter in the composite, CNPP used the code for a baked sweet potato without added fat-despite the fact that children usually eat candied sweet potatoes. For most vegetable and cooked-grain item-groups, CNPP used food codes that specified "no salt added in preparation." In a few cases, CNPP used the salted form to represent popular vegetables that are canned. Estimates of the percentage selected 19 22 Family Economics and Nutrition Review Table 1. Continued Percent Percent Whole grain Enriched grain WW* bread Rye bread Oatmeal bread WW quick bread Total breads WW crackers Corn tortilla Popcorn Brown rice Total snacks/other WW cereal, RTE* & ck Oatmeal, ck Oat RTE cereals Total cereals Whitebread French bread English muffins Flour tortilla Enr* crackers Total breadlcrx* Enr quick breads Biscuit Cornbread Total quick breads Pasta, noodles White rice Grits Total pasta, rice Enr flour desserts Corn RTE cereals Rice RTE cereals Total cereals 33.2 35.6 4.2 2.5 3.3 2.1 2.4 37.8 45.5 4.2 2.8 9.5 11.6 3.6 5.2 .LQ 17.3 21.2 11.5 16.9 15.9 ' 8.4 17.5 8.0 44.9 33.3 35.1 35.4 1.4 4.0 1.1 2.4 1.4 2.3 4.2 2.8 43.2 46.9 7.1 5.9 1.6 2.7 2.4 3.3 11.1 11.9 13.6 11.5 5.3 6.1 u 1.0 20.4 18.6 14.4 17.8 8.2 3.7 2.7 u 10.9 4.8 1Children 2 to 6 years old and all individuals ages 2 years and older. -Item-group had <1 percent representation in the composite. Meat, poultry, Beef, fresh 18.6 fish Pork, fresh 6.2 Pork, cured 2.9 Lamb 0.7 Total meat cuts 28.4 Ground beef 21.5 Beef lunchmeats 8.1 Pork lunchmeats 4.4 Totallunchmeat 12.5 Liver 0.3 Chicken 23.0 Turkey 3.9 Total poultry 26.9 Lean finfish 3.3 Fatty finfish 1.6 Finfish, end 4.5 Shellfish 1.0 Total rash 10.4 *Abbreviations: ck- cooked, end- canned, DY- deep-yellow, WW- whole wheat, RTE ·ready-to-eat, Enr- enriched, crx.- crackers. Source: CSFII 1989-91, 3-day weighted samples. 1999 Vol. 12 Nos. 3&4 21.4 7.2 3.2 u 32.9 18.8 3.6 4.9 8.5 0.5 21.5 ll 26.6 4.3 1.7 4.2 2.8 13.0 23 Table 2. Nutrient profiles for food proup composites and milk: Nutrient values per serving for young children and all individuals Calories, kcal 24 Sodium,mg 29 Potassium, mg 278 Protein, g 2.6 Fat, g 0.3 Saturated fat, g 0.0 Mono.* fat, g 0.0 Poly.* fat, g 0.1 Cholesterol, mg 0 Carbohydrate, g 4.4 Fiber, g 2.3 Vitamin A, RE 239 Vitamin C, mg 55 Folate, ug 57.9 Vitamin B12, ug 0.0 Calcium,mg 55 Magnesium, mg 29.3 Iron, mg 1.10 Zinc, 0.38 Dark-green vegetable. Broccoli was the predominant vegetable in this composite for children. Of all the composites, the one for dark-green vegetables had the highest vitamin-C value per serving. Cooked broccoli was the largest (74 percent) component and cooked spinach was the second largest (14 percent) component of the composite for darkgreen vegetables (table 1). Thus the high percentage of broccoli helps to explain the high value of vitamin C per serving of this composite: 55 mg 24 0.1 0.0 (table 2). Children consumed much less cooked greens, raw broccoli, and romaine than did all individuals (table 1). Deep-yellow vegetable. This composite was mostly carrots, and it provided the highest amount of vitamin A of any composite. Most (89 percent) of the children's deep-yellow vegetable composite was carrots (table 1). Children ate more raw carrots than cooked carrots. Eaten primarily in candied form, sweet potatoes ranked a distant second in the composite. One serving of the deep-yellow vegetable composite provided 1,685 RE vitamin A for children (table 2). Legume. Pinto beans accounted for the highest percentage of the children's composite for legumes. Of all the composites, this one contained the most calories and fiber per serving. Pinto beans ranked first (35 percent for children) in the legume composite (table 1). The top food codes in the item-group for pinto beans were pinto beans without fat and refried beans Family Economics and Nutrition Review Table 2. Continued . '~: "i·:' i'Y ' Meat, poultry, fish .l Fruit Whole grain Enriched grain (per ounce) MDk% :; AU AU All All lcup Nutrient ·,,. Cblld indiv . Child indiv. Clnld indiv. Child indiv. nonfat Calories, kcal 74 68 80 78 86 83 56 55 86 Sodium, mg 3 2 60 69 104 115 82 67 126 Potassium, mg 237 245 60 56 30 31 89 88 406 Protein, g 0.7 0.8 2.8 2.6 2.3 2.3 7.7 7.7 8.4 Fat, g 0.2 0.2 1.2 l.l 1.1 1.1 2.5 2.4 0.4 Saturated fat, g 0.1 0.1 0.2 0.2 0.2 0.3 0.9 0.9 0.3 Mono. fat, g 0.0 0.0 0.4 0.4 0.5 0.5 1.0 1.0 0.1 Poly. fat, g 0.1 0.1 0.4 0.4 0.3 0.3 0.2 0.2 ' 0.0 Cholesterol, mg 0 0 0 0 2 2 22 24 4 Carbohydrate, g 18.3 16.8 14.9 15.0 16.3 15.5 0.2 0.1 11.9 Fiber, g 1.1 1.2 2.1 2.0 0.6 0.6 0.0 0.0 0.0 Vitamin A, RE 12 28 2 2 2 2 9 18 76 Vitamin C, mg 24 30 0 0 0 0 1 1 2 Folate, ug 23.8 26.9 7.4 7.8 6.5 6.9 2.3 2.4 12.7 Vitamin B12, ug 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.6 0.9 Calcium, mg 13 13 19 20 23 26 4 4 302 Magnesium, mg 12.3 13.5 ' 24.6 23.0 7.4 7.4 6.8 7.0 27.8 Iron, mg 0.34 0.27 0.81 0.76 0.80 0.80 0.55 0.55 0.10 Zinc, mg 0.08 0.10 0.54 0.50 0.20 0.21 """' 1.11 1.10 0.98 1Children 2 to 6 years old and all individuals ages 2 years and older. 2 A composite was not developed for the milk group. The nutrient profile was based on nonfat fluid milk. *Abbreviations: Mono. - monounsaturated; Poly.- polyunsaturated. with added fat. White beans (eaten mostly in pork and beans/baked beans) and kidney beans (eaten mostly in chili con carne with beans) were, respectively, the second and third largest itemgroups. Legumes contributed the most calories and dietary fiber per serving of all the composites; for children, one legume serving provided 108 calories and 5.6 g fiber (table 2). Legumes also provided the most copper per serving of all the composites, 0.20 mg. 1999 Vol. 12 Nos. 3&4 Starchy vegetable. fried potatoes were the starchy vegetable most commonly eaten by young children. White potatoes were the primary constituent of the composite for starchy vegetables (table 1); they were most often eaten with added fat-as potato chips and French fries. Because the composite was created using the form of the food lowest in fat, boiled potatoes were chosen as a proxy for fried potatoes. The smaller amount of baked potatoes in the children's composite, compared with that for all individuals, contributed to a lower potassium value in children's nutrient profile (table 2). The second largest item-group in this composite was com (table 1). Other vegetable. Almost half of children's servings of "other vegetables" were of tomatoes. This composite had one of the smallest servings per report (0.5), because the foods in this subgroup were used in small amounts in many mixed dishes. Tomatoes were the primary component ( 48 percent) of the composite for other 25 Across all the food groups and subgroups, children tended to have smaller serving sizes than did all individuals. "· 26 vegetables; a higher percentage of its cooked form was consumed, compared with its raw form (table 1). Most of the servings of the cooked form were eaten as ingredients in grain mixtures. The main sources of raw tomatoes, other than those eaten by themselves, were Mexican mixtures (taco/tostada) and hamburger sandwiches. The large amount of cooked tomatoes, represented as canned in the composite, was the major contributor to the 100 mg sodium and 205 mg potassium per composite serving (table 2). The second largest item-group in the other vegetable composite for children was cooked green beans (19 percent) (table 1). Lettuce represented 12 percent of the children's composite, and the most frequently consumed food was plain lettuce. One composite serving of other vegetables provided 12 mg vitamin C, second to the dark-green vegetable subgroup, 55 mg per serving (table 2). Whole grain. About 45 percent of this composite was ready-to-eat and cooked cereals; most were fortified. Whole-grain cereals were the largest component of the composite for whole grains (table 1). Both the ready-to-eat and cooked forms of wheat and oat cereals were eaten, and the instant variety was the most consumed type of all the cooked oatmeals. Many of the cereals in the item-groups for wheat and oat cereal were fortified. Children obtained added nutrients by eating these fortified cereals. Wholewheat bread was 33 percent of the composite for whole grains, but crackedwheat bread was the predominant food code in the item-group for whole-wheat bread. Cracked-wheat bread was in this item-group, because the wheat-based breads were grouped together. Corn tortilla had a fairly large representation (10 percent) in the composite for whole grains. Tortilla chips and corn chips were the top food codes in the itemgroup for corn tortilla. For children, one serving from the composite for whole grains provided 2.1 g dietary fiber, 24.6 mg magnesium, and 0.5 mg zinc (table 2). Enriched grain. White bread was the largest component of the children 's composite for enriched grains. White bread was the first (35 percent) and "enriched flour desserts and other sources of enriched flour" (shortened to just "enriched flour desserts") was the second largest component (14 percent) of the enriched-grain composite (table 1). The term "desserts" was used to identify the latter item-group because many of the food codes in it were sweet foods like cookies, doughnuts, pastries, pies, and cakes. Enriched flour in each of these foods was counted toward servings of enriched grains. The enriched flour in pizza crust was also included in this itemgroup. A low-sugar and low-fat food was used to represent the item-group for enriched flour desserts in the composite, but children were consuming added sugars and fat from these foods. The third largest component of this composite was enriched pasta and noodles. The foods in this item-group that were most commonly eaten by children were macaroni and cheese and spaghetti with or without tomato sauce. Corn and rice ready-to-eat cereals combined were 11 percent of the children's composite; most were fortified. Wheat-flour tortillas constituted a separate item-group in the composite for enriched grains, because they were consumed in large amounts. Children ate more wheat-flour tortillas than English muffins or bagels. (Bagels were placed in the item-group for English muffins.) Family Economics and Nutrition Review As expected, the amount of fiber, magnesium, and zinc in the composite for enriched grains was lower than in the composite for whole grains. Meat, poultry, fish. Beef was 48 percent and poultry 27 percent of the children's composite for meat, poultry, and fish. Children ate most of their beef in ground form: 22 percent of their composite for meat, poultry, and fish (table 1). Fresh beef, as in steak and roast beef, was about 19 percent of the children's composite for meat, poultry, and fish. Children's composite also contained about 8 percent beef lunch meatsmostly frankfurters. About 12 percent of the children's composite for meat, poultry, and fish was frankfurters and other lunch meats. Because of their higher fat content or water content or both, 2 ounces of sausages and lunch meats were counted as 1 ounce of lean meat in the Food Guide Servings Data Base. For example, a child who ate a 2-ounce hot dog was credited 1 ounce of lean meat. Chicken, compared with turkey, was the most commonly eaten poultry: 23 versus 4 percent of the children's composite. And it was the roasted chicken breast without skin and chicken nuggets that accounted for 12 percent of all chicken servings. Many of the 188 food codes with poultry servings, which were reported consumed by children, were various fried chicken parts. Fried chicken was not, however, represented as such in the composite, because the leanest form of a food was used. All chicken was represented in the composite by a food code described as "chicken, boneless, not specified as to part, roasted, light or dark meat, skin not eaten." Within the item-group for liver, children ate more chicken liver than beef liver. 1999 Vol. 12 Nos. 3&4 Because children ate less beef liver than did all individuals, the children's composite contained less of vitamins A and B12 (table 2). Canned finfish, mostly tuna in water, was the predominant fish item-group (table 1). For both children and all individuals, the top foods consumed in the item-group for lean finfish were fried. Most servings of fatty finfish were fried catfish for both children and all individuals. Shrimp was the largest component of the item-group for shellfish for children and all individuals, both of whom ate more servings of steamed or boiled shrimp than fried shrimp. The composite for meat, poultry, and fish contributed the most fat and saturated fat of all the composites (table 2). For children, 1 serving of meat, poultry, and fish provided 2.5 g fat, 0.9 g saturated fat, 7.7 g protein, 22 mg cholesterol, 0.5 ug vitamin B12, 0.55 mg iron, and 1.11 mg zinc. Milk. Children consumed more whole milk than did all individuals. Although a composite was not developed for the milk group, because the nutrient profile was to be based on nonfat fluid milk, CNPP did analyze how children consumed their servings of the milk group. Findings showed that about 84 percent of children's servings from the milk group were of fluid milk, 15 percent were of cheese, and 1 percent were of yogurt. Children obtained the bulk of their servings of the milk group by drinking milk: about 92 percent of children's "milk as beverage" servings were whole, 2-percent, 1-percent, or skim milk. The remaining 8 percent of their "milk as beverage" servings were cocoa, milk shakes, chocolate milk, and other flavored milks. Young children consumed a larger percentage of the category entitled "milk as beverage" as whole milk (47 percent) than did all individuals (35 percent). Children had 14 percent of servings from 1-percent or skim milk; all individuals had 21 percent from these types of milk. Ice cream and ice milk were also part (about 4 percent) of children's servings of fluid milk. Children ate less pudding (1 percent of the servings of fluid milk) than ice cream and ice milk. Children also obtained fluid milk in mixtures such as cream sauces and soups, but in small amounts. The milk group is represented by 1 cup skim milk, which provides 8.4 g protein, 86 calories, 0.3 g saturated fat, and 302 mg calcium (table 2). Serving Sizes Across all the food groups and subgroups, children tended to have smaller serving sizes than did all individuals. Children's average intake was 1 serving per report for fruits and juices. When children ate cooked greens, raw broccoli, and romaine (dark-green vegetables), their serving sizes were much smaller than those for all individuals. Children had 0.9 servings, on average, per report. Of all five vegetable subgroups (darkgreen, starchy, etc.), children's number of servings per report (0.4) was the smallest for the deep-yellow vegetable subgroup. Children averaged 0.7 servings per report for legumes and 0.8 servings for starchy vegetables. Among starchy vegetables, children averaged 0.9 servings for potato chips and 0.7 servings for French fries. Children's number of servings per report of other vegetables 27 28 By selecting foods somewhat differently in the food groups and subgroups, children can improve their nutrient intakes. averaged 0.5. The number of servings per report (0.2 for children) for individual item-groups was particularly small for cooked onions, raw celery, and cooked mushrooms, used in small amounts in many mixed dishes. Children had an average of 1.2 servings per report from the composite for whole grains and 1.4 servings per report from the item-group for wholewheat bread. Children averaged 1.2 servings per report across all foods in the composite for enriched grains, 1.4 servings for white bread, and 1.3 servings (a little over V2 cup) for enriched pasta and noodles. The halves of an English muffin or bagel constitute 2 servings of grains; children averaged 1.4 servings per report. For items in the composite for meat, poultry, and fish, children averaged 1.4 ounces per report. For the milk composite, children consumed about 3/4 cup of milk (0.8 servings) per report and 2/3 cup of ice cream per eating occasion. For pudding, the average amount eaten per report was 0.5 servings Ch cup). Generally, the amounts reported for children 2 to 6 years old were about 60 to 80 percent of those for all individuals. This suggests that it is appropriate to continue to use two-thirds of the serving size designated for adults as a serving size for 2- to 3-year-olds when assessing nutrient levels in Food Guide Pyramid patterns for young children ages 2 to 3 (1,9). Two- to three-year-olds need two-thirds of the serving size for adults, except for milk. Two cups of milk are recommended for 2- to 3-year-old children. Four- to six-year-old children need the same serving sizes designated for adults. Food Guide Pyramid Diet Patterns for Young Children The REI for 1- to 3-year-old children is 1,300 calories (2). A 1,600-calorie pattern was considered an appropriate objective for 4- to 6-year-old children. Although the REI for 4- to 6-year-old children is 1,800 calories, food consumption data reported for this age group in the CSFII 1989-91 averaged 1,533 calories. Focus groups with parents, a consumer research aspect of the development of the Food Guide Pyramid for Young Children, indicated that parents were concerned that the amount of food their children ate might not be adequate to meet their nutrient needs.1 It was important to determine whether a diet pattern set at a calorie level close to what children reportedly eat, and based on their reported food choices within food groups, could meet their nutrient requirements. It is not wise to have parents feed their children more food than needed-considering the prevalence of childhood obesity in the United States. CNPP created the diet patterns as follows. For each food group and subgroup composite, the nutrients per Food Guide Pyramid serving were multiplied by the number of servings in the pattern and summed. Discretionary fat was added to bring the level of total fat in . the 1 ,600-calorie pattern to 30 percent of calories and in the 1 ,300-calorie pattern to 34 percent of calories, the actual consumption level in the CSFII 1989-91 for 2- to 3-year-old children. Added sugars, represented as teaspoons of sugar, were then included to bring calories to the levels targeted for the two diet patterns. 1See Tarone (5). Family Economics and Nutrition Review Table 3. Comparison of children's recommended intake with their consumption: Food group and subgroup servings per day All individuals Fruit 1.33 2.00 1.19 1.12 Vegetable 2 servings 3 servings 1.41 servings 2.62 servings Dark-Green 0.29 0.43 0.08 0.13 Deep-Yell ow 0.38 0.57 0.06 0.14 Legume 0.29 0.43 0.08 0.17 Starchy 0.38 0.57 0.61 0.94 Other 0.67 1.00 0.58 1.25 Grain 4 servings 6 servings 4.55 servings 5.50 servings Whole Grain 2.00 3.00 0.96 1.27 Enriched Grain 2.00 3.00 3.59 4.22 Meat, poultry, fish 3.33 llUnces 5.00 ounces 2.55 ounces 4.37 ounces Meat, Poultry, Fish 2.:36 4.57 2.17 3.95 Egg 0. :~9 0.43 0.24 0.32 Nuts and Seeds 0.18 0.0 0.14 0.10 Milk 2.00 2.00 1.94 1.48 Fat, total 49.5 grams 53.4 grams 54.5 grams 70.4 grams Added sugars 7 tsp 6 tsp 13.2 tsp2 19.5 tsp2 Total calories 1,304 kcal 1,613 kcal 1,435 kcal 1,796 kcal 1Calculated by dividing the total weighted number of servings reported over 3 days by 3 and then dividing by the weighted number of people in the ~amples. ~timated extra calories from added sugars in foods and small amounts of foods not accounted for in Food Guide Servings Data Base. The 1,600-calorie pattern contained the minimal number of Food Guide Pyramid servings at the serving size recommended in the original Food Guide Pyramid (table 3). There were 2 servings of fruit, 3 of vegetables, 6 of grains, 5 ounces of meat, and 2 cups of nonfat milk, along with added fat and sugars. The 1 ,300-calorie pattern had the minimal numbers of Food Guide Pyramid food group servings reduced in size by 1999 Vol. 12 Nos. 3&4 one-third for all food groups and subgroups except milk, to represent the one-third smaller serving size estimated for 2- to 3-year-old children. For example, 2 servings of fruit multiplied by two-thirds equaled 1.33 Food Guide Pyramid fruit servings in the 1,300- calorie pattern. A total of 2 cups of milk was included in both diet patterns to meet calcium recommendations. Because there is more fat permitted in the younger child's diet, CNPP substituted peanut butter for a portion of the meat servings in developing the 1 ,300-calorie pattern for 2- to 3-year-old children. This meat alternate, which is higher in fat content, represented the percentage of the meat group that young children consumed as nuts. 29 Table 4. Nutrient levels in Food Guide Pyramid patterns for young children1 Nutrient RDAl.or reeoan.mend8tion ChUd 1-3 1,300-calorle pattern Child 1,600-calorle pattern Child 4-6rs 2-3 CSFI11989-91 consumption Child - - • - • - • - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Kcal - - - - - - - - - - - - - - - • - - - - - - - •• - - - - - - - - - - Calories (avg) 1,300 1 ,800 -1,300 -1 ,300 -1,600 1 ,288 1,533 - - • - • - - - - - - - - - - - - - - Percent of RDA - - - - - - - - - - - - - • - - - - - - - - Protein Calcium Magnesium Iron Zinc Copper Vitamin A Vitamin E VitaminC Niacin Vitamin B6 Folate Vitamin B12 16 g 800mg 80mg 10mg 10mg 0.7mg 400RE 6mg 40mg 9mg l.Omg 50ug 0.7ug 24g 361 800mg 98 120mg 259 lOmg 74 10mg 77 1.0 mg 100 500RE 267 7mg 98 45 mg 169 12mg 122 1.1 mg 104 75 ug 329 l.Oug 513 241 325 305 244 98 109 94 107 173 225 219 169 74 110 96 117 77 107 68 82 70 100 98 81 214 295 177 162 84 89 78 77 150 220 194 186 92 130 143 134 95 133 117 126 219 303 378 295 359 460 492 371 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Percent of Kcal- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Fat3 Saturated fat3 <34 <13.6 . 30 34.1 <10 10.5 34.1 29.8 34.4 34.0 10.5 9.3 13.6 13.3 - - - - • - - - - - - - - - - - - - - - - - - - - - - - - - - - - Milligrams - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Cho1estero14 Sodium4 300 300 161 161 230 182 210 <2,400 <2,400 1,127 1,127 1,485 2,122 2,534 - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - Grams - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Fibe? 8 9-11 12.0 12.0 17.4 8.5 10.4 1Composite nutrient profiles based on children 2 to 6 years old. 2Recommended Dietary Allowances (RDA), 1989. 3U.S. Department of Agriculture and U.S. Department of Health and Human Services, 1995, Nutrition and Your Health: Dietary Guidelines for Americans. 4National Research Council. 1989. Diet and Health. National Academy Press, Washington, DC. 5 American Health Foundation for "age plus 5" per day (Williams et al ., 1995). Source: CSFII 1989-91, 3-day weighted sample. Total nutrient levels in the 1,300- and 1 ,600-calorie patterns were then compared with the 1989 RDA for children 1 to 3 and 4 to 6 years old and with other recommendations, as specified earlier, for fat, saturated fat, cholesterol, sodium, and dietary fiber (table 4). 30 Except for vitamin E (89 percent of the RDA), the 1 ,600-calorie pattern met or exceeded all nutrient requirements for children ages 4 to 6. Vitamin E was also less than the RDA in the 1,300- calorie pattern. However, the levels of vitamin E in the patterns exceeded the amounts consumed by children, as reported in theCSFII 1989-91, because the composite for discretionary fat, which was based on food supply data for individuals of all ages, contained more vegetable fat (rich in vitamin E) than young children ate. The fat Family Economics and Nutrition Review composite had more polyunsaturated fat and less saturated fat than the amount consumed by children. The 1 ,300-calorie pattern provided at least 100 percent of the RDA for most nutrients for both 2- to 3-year-olds and 4- to 6-year-olds. The major exceptions were the trace minerals-iron and zinc for both age groups and copper for the 4- to 6-year-olds. The amount of iron provided by the 1 ,300-calorie pattern was lower than the amount consumed by children, according to the CSFII 1989-91. The reason for this difference: composites for whole grains and enriched grains contained non-fortified breakfast cereals, but the cereals children ate were fortified. Additional analysis showed that when breakfast cereals included in the grain composites were changed to contain iron and zinc at fortification levels, the Food Guide Pyramid patterns provided recommended levels of iron and zinc for children. The 1,300- and 1,600-calorie patterns met or nearly met objectives for fat, saturated fat, cholesterol, sodium, and dietary fiber. At 10.5 percent of calories in the 1 ,300-calorie pattern, saturated fat was somewhat lower than the actual level of consumption targeted for the 2- to 3-year-old child: 13.6 percent. Consumption of Food Groups Table 3 shows the recommended numbers of food group and subgroup servings for the 1,300- and 1 ,600-calorie Food Guide Pyramid patterns developed for young children. The numbers of servings for vegetables, grains, and meat and me~t alternates were derived as follows. Originally when the food guide was developed, the daily servings of vegetables were divided equally among dark-green/deep-yellow, legumes/ 1999 Vol. 12 Nos. 3&4 starchy, and other vegetables (1). For vegetables, "several" servings was defined as 3, so several times a week meant 3 times a week or 317 of 1 serving per day. For the 1 ,600-calorie pattern, 3 vegetable servings were divided into 1 serving each from dark-green/deepyellow, legumes/starchy, and other vegetables. Hence the 317 (0.43) darkgreen and 417 (0.57) deep-yellow provided 1 serving per day, the 0.43 legumes and 0.57 starchy provided another serving, and other vegetables provided the third serving per day. The numbers of grain servings were based on the Food Guide Pyramid recommendation to choose "several" servings a day of foods made from whole grains (6). For the meat and meat alternates, the number of egg servings was based on 3 eggs per week, and the meat, poultry, fish servings were calculated by difference (0.43 eggs subtracted from 5.0 ounces total meat and meat alternates). The Food Guide Servings Data Base used in this study did not quantify the amount of added sugars in foods. These values were estimated from the calories in added sugars in foods and from the calories in small amounts of foods, such as raisins in oatmeal raisin cookies and garnishes and condiments, which were not counted by the Food Guide Servings Data Base. Calories were then expressed as average daily servings of added sugars, in teaspoons. Thus the average daily servings of added sugars may somewhat overestimate actual intakes of sugar. However, these estimated consumption levels of sugars were much higher than the levels of 6 teaspoons and 7 teaspoons (1 ,600- and 1 ,300-calorie patterns, respectively) suggested in the Food 'Guide Pyramid patterns. Conclusions Children ate somewhat differently from the rest of the population, as indicated by composites of the food groups and subgroups, which were based on reported food consumption by young children ages 2 to 6 and all individuals ages 2 and older. However, the variations resulted in few substantial differences in the nutrient profiles of a composite serving of any of the food groups or subgroups. Young children consumed smaller servings of foods, typically 60 to 80 percent of the average amounts for individuals of all ages. A serving that is two-thirds of the original Food Guide Pyramid serving is a reasonable estimate for assessing nutrient levels in patterns for 2- to 3-year-old children. The 1 ,300-calorie Food Guide Pyramid diet pattern, which used the children's composites and nutrient profiles, met or nearly met objectives for most nutrients except for iron, zinc, and copper. The 1 ,600-calorie pattern met all of the objectives except for vitamin E. When iron and zinc were included at regular fortification levels in the ready-to-eat cereals used in the grain composites, diet-pattern levels of these nutrients met the RDA. Breakfast cereals were popular with young children, so ensuring that these cereals are fortified with iron and zinc can contribute substantially to meeting targeted intakes of these nutrients. Copper was less than the RDA in the 1,300-calorie pattern for the 4- to 6- year-old, but the older child would probably be consuming closer to 1,600 calories. Older children could improve their reported copper intake by eating more legumes. Both the 1,300- and 1 ,600-calorie patterns were somewhat 31 low in vitamin E, but they exceeded the CSFII 1989-91 reported consumption levels of this nutrient. It is important to reduce fat in the diet as children age, from 2 to 5 years. Emphasis should also be given to replacing a portion of animal fats with vegetable oils, both to decrease saturated fat intakes and to increase vitamin E intakes. The results of the analysis on the RDA showed that most RDA would be met when the children's composites were used in the diet patterns. By selecting foods somewhat differently in the food groups and subgroups, children can improve their nutrient intakes. Children's diets could be improved by including more servings of vegetables, especially dark-green and deep-yellow vegetables and legumes, and more wholegrain products. Replacing some of the apple and grape juices that children frequently drink with more servings of whole fruit could improve consumption of nutrients and dietary fiber. Replacing some lunch meats with lean meat, poultry, and fish may also improve nutrient intakes. Children's diets could be improved by their choosing foods that contribute more food guide servings and less added sugars. 32 References 1. Cronin, F.J., Shaw, A., Krebs-Smith, S.M., Marsland, P., and Light, L. 1987. Developing a Food Guidance System to implement the Dietary Guidelines. Journal of Nutrition Education 19:281-302. 2. National Academy of Scie.nces, National ResearchthCouncil, Food and Nutrition Board. 1989. Recommended Dietary Allowances (10 ed.). National Academy Press, Washington, DC. 3. National Research Council. 1989. Diet and Health. National Academy Press, Washington, DC. 4. Putnam, J.J. and Allshouse, J.E. 1996. Food Consumption, Prices, and Expenditures, 1996: Annual Data, 1970-94. U.S. Department of Agriculture, Economic Research Service. Statistical Bulletin No. 928. pp. 59, 61 . 5. Tarone, C. 1999. Consumer research: Food Guide Pyramid for Young Children. Family Economics and Nutrition Review 12(3&4):33-44. 6. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. 1996. The Food Guide Pyramid. Home and Garden Bulletin No. 252. 7. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. 1997. U.S. Food Supply Series 1909-1994. (In-house data base.) 8. U. S. Department of Agriculture and U.S. Department of Health and Human Services. 1995. Nutrition and Your Health: Dietary Guidelines for Americans (4th ed.). Home and Garden Bulletin No. 232. 9. Welsh, S.O., Davis, C., and Shaw, A. 1993. USDA 's Food Guide: Background and Development. U.S. Department of Agriculture, Human Nutrition Information Service. Miscellaneous Publication No. 1514. 10. Williams, C.L., Bollella, M., and Wynder, E.L. 1995. A new recommendation for dietary fiber in childhood. Pediatrics 96:985-988. Family Economics and Nutrition Review Catherine Tarone Center for Nutrition Policy and Promotion 1999 Vol. 12 Nos. 3&4 Consumer Research: Food Guide Pyramid for Young Children Developed specifically as a guide for feeding young children, the Food Guide Pyramid for Young Children adapts recommendations of the original Food Guide Pyramid and provides messages, based on the food guide, that are helpful to parents and caregivers in improving the nutritional status of 2- to 6-year-olds. A qualitative consumer research study was conducted to identify needs of the target audience (parents and caregivers of 2- to 6-yearold children), to explore, with this audience, messages based on the food guide, and to evaluate prototype educational materials based on the food guide-based messages directed at behavior change. Parent- and caregiverparticipants recommended emphasizing the message to "eat a variety of foods" as a theme for nutrition education materials that are designed to improve young children's diets. They also suggested that a "child-friendly" graphic of the Food Guide Pyramid would help young children remember the Pyramid. USDA produced a booklet presenting nutrition guidance messages and a "child-friendly" poster of the Food Guide Pyramid. he Food Guide Pyramid is USDA's primary nutrition education tool designed to help healthy Americans select a diet that is consistent with the Dietary Guidelines. The Food Guide Pyramid illustrates patterns of food selection that provide adequate amounts offood energy, protein, vitamins, minerals, and dietary fiber for good health but are moderate in fats, added sugars, and sodium. Adaptation and translation of dietary guidance into dietary practice are important components of any effort to help improve diets, including those of young children. In Phase I of the project to develop a Food Guide Pyramid for Young Children, the Center for Nutrition Policy and Promotion (CNPP) developed the technical nutrition basis for adapting the Food Guide Pyramid (6,7). CNPP staff determined that the nutrients in the foods children consume, if eaten in amounts recommended by the original Food Guide Pyramid, would meet children's nutrient needs. Because Pyramid food groups and recommended numbers of servings resulted in a nutritionally adequate diet for young children, the Pyramid graphic could be adapted for young children. Also during Phase I, eight message concepts emerged from the review of literature (5), discussions were held with nutrition educators, and comparisons were made of actual food group and subgroup consumption with the recommendations of the Food Guide Pyramid, as adapted for young children 33 (6) . The concepts were explored and further developed during Phase II. In support of USDA's nutrition education efforts to translate dietary guidance into consumer behaviors, CNPP conducted a qualitative consumer research study in Phase ll. Qualitative research is particularly useful for gaining insights and a better understanding of the target audience. Qualitative research consists of openended, structured discussions or interviews with individuals or small groups of individuals-the purpose of which is to gather a greater depth of information than can be obtained by using quantitative techniques ( 3 ). CNPP conducted qualitative research because consideration of the target audience, including its wants and needs, is the foundation of this research project to advance dietary guidance for children in a way that motivates behavior change in both adults and children. Recent research on the effectiveness of nutrition education programs, including those with preschool children, found that programs using educational methods directed at behavior change as a goal were more likely to be successful than programs that focused on information dissemination (4). Methods The focus group study was conducted in two rounds. The objectives for the first round were to assess the nutrition information that parents and caregivers of 2- to 6-year-old children needed, to identify the key concerns for nutrition education, to assess familiarity with the Food Guide Pyramid, and to explore nutrition guidance messages (based on the food guide) for young children. The objectives for the second round were to determine whether the prototypes 34 effectively communicated nutrition guidance to the target audience of parents and caregivers of 2- to 6-year-olds. The discussions for the second round were designed to assess consumer reaction to the prototype materials (including their reactions to design and layout, readability, and applicability of the message concepts) and to identify any confusing or misleading information. Samples For the first round, six focus groups, three with parents and three with caregivers, were conducted in January 1998. Parents were screened based on their ethnicity, household income, and educational level. Parents were also screened to ensure that they had at least one child 2- to 6-years-old and had not participated in a focus group within the last 6 months. Caregivers were included if they cared for 2- to 6-year-olds. (They could provide in-home care as well as care in larger facilities.) Twelve people were recruited for each group so that at least eight would attend. Some geographical dispersion was obtained by conducting one focus group with parents and a separate focus group with caregivers in each of three cities-Baltimore (Maryland), Richmond (Virginia), and Chicago (11linois). Fifty-two adults participated in the first round of the study. In July 1998 the second round began. One focus group with parents and another focus group with caregivers were held in each of three cities-Baltimore (Maryland), Richmond (Virginia), and Chicago (11linois)-for a total of six groups. The screening criteria used for the first round were also used for this round. In addition, parents in Richmond and Chicago with 5- to 6-year-olds were screened to have their children participate in a mini-focus group. Twenty-seven parents, 25 caregivers, and 8 children participated in the second round; none had participated in the first round. Procedures For the first round of focus group studies, the moderator, with over 10 years of experience working with focus groups, led each group through the 2-hour sessions. Each focus group began with introductions and an icebreaker, followed by discussions based on the objectives. The discussions identified goals, benefits, and barriers to healthful eating, participants' knowledge of nutrition, and their feeding practices. The session then focused on the nutrition messages of the Food Guide Pyramid and how they apply to young children. Discussions ended on the eight messages regarding nutrition guidance and how to communicate them to young children. All sessions were audio-taped and transcribed to obtain participants' exact responses to questions. Once transcribed, comments were color-coded and grouped according to content; this allowed key discussion themes to be uncovered. The moderator and his staff recorded and reported participants' verbal and nonverbal emotional expressions. After the first round, CNPP developed the text of the materials to be used with the participants in the second round. The prototypes were designed and produced through USDA's Office of Communications Design Center. To emphasize the variety theme, CNPP used the slogan 1-2-3 Variety in all three prototypes. The prototype for the parents, a full-color, 12-page booklet, A Parents' Guide to Using the Food Guide Pyramid, contained an adapted graphic of the Food Guide Pyramid. Also included was general nutrition Family Economics and Nutrition Review information that gives a better understanding of 1. healthful eating, 2. tips on increasing the variety of foods eaten, 3. meal planning and time-saving tips, 4. guidance on specific issues such as serving sizes and fat intake recommendations related to young children, and 5. age-appropriate kitchen activities. The brochure Caregivers: Using the Food Guide Pyramid for Young Children was based on the assumption that most caregivers have access to nutrition education materials and have some knowledge of the Food Guide Pyramid. The brochure contained the new graphic and an explanation of changes made from the original Pyramid graphic, including text to make clear that the adapted Food Guide Pyramid does not replace the original Pyramid. Also included were a list of foods to encourage variety in the diet and a step-by-step food activity designed to involve young children. The third prototype, a poster of the adapted Food Guide Pyramid graphic, showed foods (drawn in a realistic style and shown in single serving sizes when possible) commonly eaten by young children. The names of the food groups were simplified, and the number of servings was represented by a single number rather than a range of numbers. The symbols for fat and sugars were eliminated, and food pictures were used in the tip. One week before the sessions for the second round, parent-recruits were sent the text of the information that was prepared for parents; caregiver-recruits were sent the text of the information that was prepared for the caregiver's 1999 Vol. 12 Nos. 3&4 brochure and the parents' booklet. The recruits were instructed to read the material before attending their sessions; thus, focus group time would be used for discussion rather than be used, to a great extent, for reading. The same moderator who led the first round of focus groups led the 2-hour second-round focus groups. At each session, following introductions and an icebreaker, participants were shown the prototype poster, The Food Guide Pyramid for Young Children, after which it was discussed and put aside. Each parent then received the information booklet A Parents' Guide to Using the Food Guide Pyramid for Young Children, and the moderator led a discussion designed to evaluate the booklet. Caregivers were given the brochure Caregivers: Using the Food Guide Pyramid for Young Children. Following a discussion to evaluate the brochure, each caregiver was given the parent booklet. Throughout these sessions, the participants were asked to read and respond to several sections of text and to the visual presentation of the materials. The mini-focus group sessions with the children began with parents and children in the same room. Following a brief introduction and explanation of the process, the children were taken to a separate room where the moderator showed them a prototype poster of the Food Guide Pyramid. The moderator led the children in a discussion of the poster and the concept of healthful eating. The children were not asked about the other materials intended for adults that required an eighth-grade reading level. As with the first round, · all sessions in the second round were audio-taped, transcribed, color-coded, and grouped according to content. The idea of using the graphic of the Food Guide Pyramid as a teaching tool, as it turns out, was a new concept for some parents. 35 Results The First Round The 27 parent-participants in the first round of the focus group studies had at least one child 2 to 6 years olds; 78 percent were female. Forty-nine percent were African American; 37 percent, White; 11 percent, Hispanic; and 3 percent, Asian. Almost 80 percent had attended or graduated from college; about 40 percent had a household income between $20,000 and $40,000. Of the 25 participants who were caregivers, 24 percent worked in in-home childcare facilities. As a qualitative research method, focus groups are not projectable to any population; however, they provide insight into how the consumer views the world and what the consumer thinks ( 8 ). Findings from this focus group research can be presented under four key discussion themes: Current Feelings Toward Feeding Young Children, Current Behavior and Knowledge, Food Guide Pyramid, and Nutrition and Dietary Behavior. All quotes from participants are taken from the unpublished reports prepared for USDA (1). Current Feelings Toward Feeding Young Children. Identifying the key concerns of parents and caregivers for nutrition education and exploring benefits and barriers to an improved dietary pattern in young children resulted in a key theme. "One of the most important things to teach them at an early age is to set good standards and give them a good foundation as they grow." (Caregiver) 36 "There are a variety of things we try to accomplish through healthy eating ... socialization, nutrition, emotional stability, which are related to food." (Caregiver) "It's important that children learn good nutrition habits, so as they grow older, they will eat right instead of eating at one fast-food place one day and another fast-food place the next day." (Parent) "If you teach them now, they are more apt to continue doing it rather than to introduce them to healthy foods after they have eaten years of junk food. It is easier to do it now." (Parent) Table 1 shows the benefits and barriers in the descending order in which they were mentioned by parents and caregivers. Results showed that these parents and caregivers think alike when discussing the benefits of healthful eating. They were asked: "What are the benefits of preparing healthy meals for younger children?" Most answered, "good health." The second benefit mentioned more often by both groups was, "developing good eating habits at an early age." Caregivers also pointed out that children are better behaved, have longer attention spans, and have energy to do things when they are fed well. When it comes to feeding young children, parents most often mentioned the following barriers to healthful eating: the lack of time to plan and prepare meals, inexperience in dealing with picky eaters, and the negative influences of others. "Time is needed in three different places. You have to plan the meal, purchase it, and prepare it. " "/ need information on what to do with an extremely picky eater who won't eat anything." - "If they are with somebody else, you don't have any control over the foods they eat." Caregivers seemed at ease when discussing nutrition and how they feed young children. Caregivers rarely mention having difficulty with "picky eaters." Instead, they said most children were willing to try a new food if they saw their friends eating the food. Several caregivers said parents were the biggest barrier to improving children's diets. "It's just a lack of knowing what is nutritious for a child. They [parents] think that a bag of chips and a soda are nutritious." "Parents don't know what their children are supposed to eat as a balanced meal. I think it's important that we send the information home to the parents so that they [children] can eat healthy and be consistent with what we do. " Current Behavior and Knowledge. All groups were quite knowledgeable about nutrition, based on the level of discussion of most parents and caregivers. When asked to rate themselves on a scale of 1 to 10 on how well they believe they provide their children with healthful and nutritious meals, parents rated themselves "average" to "above average"; caregivers rated themselves "above average" to "excellent." During further discussion, in spite of their knowledge of nutrition and ratings, many parents expressed feeling ill-equipped to feed their young children a healthful diet. They knew the "why's" but not the "how's." Family Economics and Nutrition Review Table 1. Benefits and barriers to improving children's diets Parents say: Good health Good eating habits Minds work better Better attitude Food is a key part of a loving home Parents say: Lack of knowledge Lack of time to plan meals Lack of time to prepare meals Negative influences of others Picky eaters Cost of food/wasting food "Not enough of the information focuses on children. What we've been doing is taking adult information and applying it to children." (Parent) "/ think of nutrition and feeding my daughter as a challenge every day." (Parent) Most caregivers seemed both knowledgeable and comfortable discussing the "do's" and "don't's" of nutrition as each concept related to young children; caregivers were very comfortable with the "how's." "The goals of Head Start are pretty clear that nutrition is an integral part of the program." During the parents' discussions, firsttime parents of very young children were most concerned about serving 1999 Vol. /2 Nos. 3&4 Benefits to improving diets Caregivers say: Healthy children-less sickness Good eating habits Energy Happy children-happy parents Emotional, cognitive, social growth Food is a key
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Title | Family Economics and Nutrition Review [Volume 12, Number 3-4] |
Date | 1999 |
Contributors (group) | Center for Nutrition Policy and Promotion (U.S.) |
Subject headings |
Home economics--United States--Periodicals Nutrition policy--United State--Periodicals |
Type | Text |
Format | Pamphlets |
Physical description | v. : $b ill. ; $c 28 cm. |
Publisher | Washington, D.C. : U.S. Dept. of Agriculture |
Language | en |
Contributing institution | Martha Blakeney Hodges Special Collections and University Archives, UNCG University Libraries |
Source collection | Government Documents Collection (UNCG University Libraries) |
Rights statement | http://rightsstatements.org/vocab/NoC-US/1.0/ |
Additional rights information | NO COPYRIGHT - UNITED STATES. This item has been determined to be free of copyright restrictions in the United States. The user is responsible for determining actual copyright status for any reuse of the material. |
SUDOC number | A 77.245:12/3-4 |
Digital publisher | The University of North Carolina at Greensboro, University Libraries, PO Box 26170, Greensboro NC 27402-6170, 336.334.5482 |
Full-text | Special Issue Food Guide Pyramid for Young Children 3 Adapting the Food Guide Pyramid for Children: Defining the Target Audience Etta Saltos 18 Technical Research for the Food Guide Pyramid for Young Children Kristin L. Marcoe 33 Consumer Research: Food Guide Pyramid for Young Children Catherine Tarone 45 Factors Influencing Children's Dietary Practices: A Review Alyson Escobar 56 Expenditures on Children by Families, 1999 MarkLino Research Briefs 75 Are All Food Pyramids Created Equal? Alyson Escobar 78 Report Card on the Diet Quality of Children Mark Lino, Shirley A. Gerrior, P. Peter Basiotis, and Rajen S. Anand 81 Eating Breakfast Greatly Improves Schoolchildren's Diet Quality P. Peter Basiotis, Mark Lino, and Raj enS. Anand Research Summaries 85 90 93 96 101 104 Regular Items 108 110 Research and Evaluation Activities in USDA 113 Journal Abstracts 115 USDA Food Plans: Cost of Food at Home 116 Consumer Prices 117 U.S. Poverty Thresholds Volume 12, Numbers 3&4 1999 Dan Glickman, Secretary U.S. Department of Agriculture Shirley R. Watkins, Under Secretary Food, Nutrition, and Consumer Services Rajen Anand, Executive Director Center for Nutrition Policy and Promotion P. Peter Basiotis, Director Nutrition Policy and Analysis Staff The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence A venue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. ~ditor Julia M. Dinkins Features Editor Mark Lino Managing Editor Jane W. Fleming Contributor Joan C. Courtless Family Economics and Nutrition Review is written and published each quarter by the Center for Nutrition Policy and Promotion, U.S. Department of Agriculture, Washington, DC. The Secretary of Agriculture has determined that publication of this periodical is necessary in the transaction of the public business required by law of the Department. This publication is not copyrighted. Contents may be reprinted without permission, but credit to Family Economics and Nutrition Review would be appreciated. Use of commercial or trade names does not imply approval or consti· tute endorsement by USDA. Family Economics and Nutrition Review is indexed in the following databases: AGRICOLA, Ageline, Economic Literature Index, ERIC, Family Studies, PAIS, and Sociological Abstracts. Family Economics and Nutrition Review is for sale by the Superintendent of Documents. Subscription price is $12.00 per year ($15.00 for foreign addresses). Send subscription orders and change of address to Superin· tendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250·7954. (See subscription form on p. 123.) Original manuscripts are accepted for publi· cation. (See "guidelines for authors' on back inside cover.) Suggestions or comments con· earning this publication should be addressed to Julia M. Dinkins, Editor, Family Economics and Nutrition Review, Center for Nutrition Policy and Promotion, USDA, 1120 20th St. NW, Suite 200 North Lobby, Washington, DC 20036. Phone(202)606-4876. The Family Economics and Nutrition Review Is now available at http://www.usda.gov/cnpp (seep. 121). 3 18 33 45 56 Special Issue Food Guide Pyramid for Young Children Adapting the Food Guide Pyramid for Children; Defining the Target Audience Etta Saltos Technical Research for the Food Guide Pyramid for Young Children Kristin L. Marcoe Consumer Research: Food Guide Pyramid for Young Children Catherine Tarone Factors Influencing Children's Dietary Practices: A Review Alyson Escobar Expenditures on Children by Families, 1999 MarkLino Research Briefs 75 Are All Food Pyramids Created Equal? Alyson Escobar 78 Report Card on the Diet Quality of Children Mark Lino, Shirley A. Gerrior, P. Peter Basiotis, and Rajen S. Anand 81 Eating Breakfast Greatly Improves Schoolchildren's Diet Quality P. Peter Basiotis, Mark Lino, and Rajen S. Anand Research Summaries 85 Contribution of Away-From-Home Foods to American Diet Quality 90 The Rural Poor's Access to Supermarkets and Large Grocery Stores 93 Poverty and Well-Being in Rural America 96 Alternative Employment Arrangements 101 Factors Affecting Nutrient Intake of the Elderly 104 The Food Stamp Program After Welfare Reform Regular Items 108 Federal Statistics: Children's Health 110 113 115 Research and Evaluation Activities in USDA Journal Abstracts USDA Food Plans: Cost of Food at Home 116 Consumer Prices 117 U.S. Poverty Thresholds 118 Index of Articles in 1999 Issues 119 Index of Authors in 19991ssues 120 Reviewers for 1999 Articles Volume 12, Numbers 3&4 1999 2 Would you like to publish in Family Economics and Nutrition Review? Family Economics and Nutrition Review will consider for publication articles concerning economic and nutritional issues related to the health and well-being offamilies. We are especially interested in studies about U.S. population groups at risk-from either an economic or nutritional perspective. Research may be based on primary or secondary data as long as it is national or regional in scope or of national policy interest. Articles may use descriptive or econometric techniques. Family Economics and Nutrition Review has a new feature: Research Briefs. We define Research Briefs as short research articles. Our guidelines are found on the back inside cover of each issue. We invite submission of Research Briefs; manuscripts may contain findings previously presented at poster sessions if not published in proceedings (except for abstract). Manuscripts may be mailed to Julia M. Dinkins, Editor, Family Economics and Nutrition Review, Center for Nutrition Policy and Promotion. See guidelines on back inside cover for complete address. Family Economics and Nutrition Review Etta Saltos USDA Cooperative State Research, Education and Extension Service 1999 Vol. 12 Nos. 3&4 Research Articles Adapting the Food Guide Pyramid for Children: Defining the Target Audience Nutrition educators, as well as the 1995 Dietary Guidelines Advirory Committee, have identified a need for nutrition guidance specifically for children. Because of the variation in children's nutrient needs and eating practices, it is impractical to adapt one food guide for all children. The purpose of the present study, therefore, was to identify the best age group to target for an adapted Food Guide Pyramid for Children. Three potential subgroups between the ages of 2 and 18 were identified: preschool-age (2 through 6 years), school-age (7 through 11 years), and adolescents (12 to 18 years). Subgroups were ranked by reviewing the literature to determine whether the Food Guide Pyramid meets each subgroup's dietary needs, to consider each subgroup's specific nutritional or health problems that an adapted food guide could help address, and to examine user demand for a new food guide. A food guide adapted for use with parents and caregivers of preschool-age children was identified as the greatest need based on children's specific dietary requirements (higher fat intakes as recommended by the 1995 Dietary Guidelines and their need for smaller serving sizes) and user demand (requests from parents, caregivers, and nutrition educators). IT] he USDA's Food Guide, designed to help all healthy Americans 2 years old and over use the Dietary Guidelines for Americans (38), and its graphic representation, the Food Guide Pyramid (Pyramid), have been distributed widely since the Food Guide was first introduced in the mid-1980's. The Pyramid has been used widely in a variety of materials (including posters, textbooks, school curricula, and computer software) by nutrition educators and has also been used by industry on food labels. In materials accompanying the Pyramid, USDA recommends that preschool-age children obtain at least the minimal number of servings from the five major food groups, but this age group can have smaller servings from all food groups except the milk group (38). Nevertheless, nutrition educators have identified a need for nutrition guidance regarding the dietary needs of children,1 and the 1995 Dietary Guidelines Advisory Committee has recommended that the development of separate dietary guidelines for children be considered (7). Adaptation of the Pyramid and its accompanying nutrition guidance materials specifically for children is an important component of the effort to help children apply the Dietary Guidelines for Americans. 1The term "children," in this article, refers to children and adolescents ages 2 through 18 years. 3 The purpose of this study was to define the target audience for a food guide that would be adapted for children by recommending subgroups within the 2- to 18- year age range and ranking the subgroups in order of greatest need based on dietary requirements and user demand for nutrition education materials. Materials reviewed for this study included journal articles, reference materials (including the Recommended Dietary Allowances and nutrition textbooks), and published and unpublished reports from government agencies. Criteria used to define and rank the subgroups included the following: • nutrient needs of children, • nutrition recommendations for children by authoritative bodies, ;;uch as the Dietary Guidelines Advisory Committee, • nutritional status of children, including macronutrient and micronutrient intake and anthropometric measurements, and • children's knowledge and attitudes regarding nutrition. These criteria were used to define subgroups and to list facts in favor of and against adapting a food guide for each subgroup. Nutrient Needs of Children The Recommended Dietary Allowances (RDA) provide information concerning children's nutrient needs, as well as the nutritional needs of the rest of the population (23). The 1989 RDA are expressed for the following age-gender groups: children, ages 1 to 3 years; children, ages 4 to 6 years; children, ages 7 to 10 years; males, ages 11 to 14 years; females, ages 11 to 14 years; males, ages 15 to 18 years; and females, ages 15 to 18 years. 4 The National Academy of Sciences' Food and Nutrition Board, however, is in the process of replacing these RDA with new dietary recommendations: Dietary Reference Intakes (DRI)? DRI were released recently for calcium, phosphorus, magnesium, fluoride, vitamin D, thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline (31,32). Reference intake values were published for the following age groups: 1 to 3 years, 4 through 8 years, 9 through 13 years, and 14 through 18 years. The current RDA (or AI for calcium, fluoride, vitamin D, pantothenic acid, biotin, and choline) for children were (a) extrapolated from infant or adult research results (vitamins A, K, C, B6, B12, riboflavin, niacin, folate, biotin, choline, pantothenic acid, selenium, iodine, and manganese), (b) based on growth and consumption data (energy, protein, iron, phosphorus, and potassium), (c) estimated based on weight (fluoride and vitamin E), 1-he DRI, a set of up to four nutrient-based reference values, consist of the Estimated Average Requirement (EAR), Recommended Dietary Allowances (RDA), Adequate Intake (AI), and Tolerable Upper Intake Level (UL). The EAR refers to the daily intake value that is estimated to meet the nutrient requirement in half of the individuals in a given age-gender group. The RDA consist of the average daily intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in the age-gender group, based on the EAR. The AI is the daily intake value that is estimated to meet the nutrient requirement of nearly all healthy individuals in the age-gender group and is used when an EAR is not available to calculate the RDA. The UL defines the highest level of nutrient intake that is likely to pose no risks of adverse health effects in almost all individuals in the general population. (d) based on studies on balance in children, but not necessarily with all the above age groups (thiamin, zinc, copper, sodium, calcium, and magnesium), or (e) estimated based on biochemical markers (vitamin D) (23,31,32). Because the RDNAI for children were largely extrapolated or calculated rather than determined directly from studies of children, there is no overriding reason for using the RDA age-gender cutoffs for a children's food guide. Information on children's dietary intakes, nutritional status, and dietary recommendationsas well as information on their attitudes, knowledge, and behavior-must also be considered when determining which groups of children are most in need of nutritjon guidance. Nutrition Recommendations for Children Reconunendationsofthe U.S. Government A number of recommendations indicate what constitutes a healthful diet for children. The Dietary Guidelines for Americans, the basis of Federal nutrition policy ( 39 ), provide advice about food choices that promote health and prevent disease among healthy Americans 2 years old and older. The Guidelines advise Americans to eat a varied diet with plenty of grain products, vegetables, and fruits, while moderating their intakes of fat, saturated fat, cholesterol, sugars, salt and sodium, and alcoholic beverages. In addition to emphasizing the benefits of physical activity, the Guidelines provide some specific advice for children: they should be taught to eat grain products; vegetables and fruits; lowfat milk products or other calcium-rich foods; beans, lean meat, poultry, fish or other Family Economics and Nutrition Review protein-rich foods; and to participate in vigorous physical activity. The Guidelines caution that fat should not be restricted for children younger than age3 2, that major efforts to change a child's diet should be accompanied by monitoring of growth at regular intervals by a health professional, and that children should IlQ! consume alcoholic beverages. The Guidelines also recommend that children between the ages of 2 and 5 should gradually adopt a diet so that it contains no more than 30 percent of calories from fat by the time children are about 5 years old(39). The report Healthy People 2010 outlines a national strategy for improving significantly the health of Americans during the 2001 to 2010 decade (42). Included in the 2010 report is a recommendation to reduce fat intake to an average of 30 percent of calories or less and saturated fat intake to an average of less than 10 percent of calories among people 2 years old and older. The National Cholesterol Education Program recommends that total fat intake averages no more than 30 percent of calories (24). These recommendations are consistent with the advice given in the 1990 Dietary Guidelines; the 1995 Dietary Guidelines amended this advice, stating that children between the ages of 2 and 5 should gradually reduce their total fat intake so that by age 5, they are consuming no more than 30 percent of calories from fat. Recommendations of Other Organizations Several organizations provide dietary advice for children that is consistent with the basic principles of the Dietary Guidelines for Americans. The American 3In this paper, the use of the terms "age" and "ages" refers to age in years, unless stated otherwise. 1999 Vol. 12 Nos. 3&4 Academy of Pediatrics, for example, recommends that children eat a wide variety of foods and consume enough calories to support growth and development and to reach or maintain advisable body weight. The Academy also recommends that children over the age of 2 consume, on average, 30 percent of total calories from fat, less than 10 percent of calories from saturated fat, and less than 300 mg of cholesterol per day. However, the Academy cautions that "recommendations that call for 'less than' 30 percent of calories from fat may lead to the inappropriate use of more restrictive diets" (3). The American Heart Association (AHA) concurs with the recommendation of the Dietary Guidelines that children between the ages of 2 and 5 gradually adopt a diet containing 30 percent or less of calories from fat. The AHA also agrees with the Dietary Guidelines' recommendation that diets of young children should maintain the primary emphasis on providing adequate calories and nutrients for normal physical activity, growth, and development ( 17). Some disagree about the age at which children should adopt a lower fat diet. A joint working group of the Canadian Paediatric Society and Health Canada recommended a longer transition period to a diet lower in fat, compared with that recommended by the Dietary Guidelines. The joint working group advised that the transition from the high-fat diet during infancy (about 50 percent of calories from fat) to a diet that includes no more than 30 percent of calories as fat and 10 percent of calories as saturated fat take place between the age of 2 and the end of linear growth (about age 14 for females and 15 for males) ( 14). The rationale for the working group's recommendation was based on ( 1) lack of Other studies have also concluded that it is safe to · recommend that fat intake be limited to 30 percent of calories and saturated fat intake to less than 1 0 percent of calories for children 5 years old and older .... 5 evidence that consuming a diet providing 30 percent of calories as fat and I 0 percent of calories as saturated fat would either reduce illness in later life or provide short-term health benefits and (2) concerns that some children consuming a diet with low fat intakes have lower energy intakes and low intakes of some nutrients. To support their position, the Canadian Paediatric Society and Health Canada cited a publication from the Bogalusa Heart Study in which 24-hour recalls were obtained from about 870 10-yearolds whose diets were stratified by fat intake: those with less than 30 percent of calories from fat had lower intakes of many nutrients than did children with higher fat intakes. The children with the lower percentage of calories from fat also had higher intakes of simple carbohydrates (25). The children enrolled in the Bogalusa Study had not been exposed previously to any dietary intervention programs. Therefore, it cannot be concluded, on the basis of the Bogalusa Study, that children-whose parents and caregivers have been instructed on how to moderate dietary fat intakewill be unable to meet their nutrient requirements on a diet containing 30 percent of calories from fat. Other researchers have concluded that children can safely follow diets containing 30 percent of calories from fat. The Dietary Intervention Study in Children (DISC) is an ongoing, randomized study that is a controlled clinical trial of diets containing lowered fat, saturated fat, and cholesterol. About 660 children ages 8 to 10 who were enrolled in 6 centers, located around the country, were assigned randomly to either control groups or groups receiving behavioral intervention to promote their following a diet prov:ding 28 percent of calories 6 from total fat, less than 8 percent of calories from saturated fat, and less than 150 mg of cholesterol (less than 75 mg/ 1,000 calories) per day. After 3 years, dietary levels of total fat, saturated fat, and cholesterol and blood levels of lowdensity lipoprotein cholesterol (LDL-C) decreased significantly in the intervention group, compared with the control group. The two groups, however, did not differ significantly on measures of growth and development: Height, redblood- cell folate values, serum zinc, retinol and albumin levels, sexual maturation, and psychosocial health. The DISC study found that children grew and developed normally after being instructed on consuming a lower fat diet. The children in the intervention group also had lower LDL-C levels than the controls. The researchers concluded, therefore, that the diet was effective as well as safe (19). Other studies have also concluded that it is safe to recommend that fat intake be limited to 30 percent of calories and saturated fat intake to less than 10 percent of calories for children 5 years old and older (26,29,35). Another recommendation regarding children's diets addresses their requirements for dietary fiber. The Dietary Guidelines recommend that individuals 2 years and older choose a diet with plenty of grain products, vegetables, and fruits to provide adequate fiber. But the Guidelines do not set specific numerical goals for fiber intake. The American Health Foundation published a recommendation that a child's fiber intake be equivalent to his or her age plus 5 grams (g) a day ("age+ 5"), with the recommendation ranging from 8 g a day for a child age 3 to 25 g a day for a person age 20 (44). Nutritional Status of Children Dietary Intake-Energy Data on children's food consumption are provided by several national surveys: DHHS's National Health and Nutrition Examination Survey (NHANES III), USDA's Continuing Survey of Food Intakes by Individuals (CSFII), and the Market Research Corporation of America (MRCA) ( 1,10,16,37). Median energy intakes below 100 percent of the RDA for several age-gender groups were reported in NHANES III results ( 1 0). The CSFII 1994-96 reported that over half of the children 5 years old and younger had energy intakes below the RDA, and about 20 percent had energy intakes below 75 percent of the RDA. About 60 percent of males and 75 percent of females 6 to 19 years old had energy intakes below the RDA (37). Rather than a reflection of actual low intakes of energy by children, these low intakes of energy could be the result of underreporting the foods eaten or of low energy expenditures by children. Several studies have reported that preschool-age children have energy expenditures lower than the RDA (6,11,12). In contrast, the prevalence of overweight among children has been increasing ( 36). According to CSFII 1994-96, about 5 to 10 percent of all children have energy intakes at or above 150 percent of the RDA ( 37). Dietary Intake-Macronutrients and Fiber Food consumption surveys report that, on average, children are consuming more than 30 percent of calories from total fat and more than 10 percent of calories from saturated fat (fig. 1) ( 1,10, 16,37). Kennedy and Goldberg, using CSFII 1989-91 data, reported that over three-fourths of all children exceeded Family Economics and Nutrition Review Figure 1. Percent of calories from total fat and saturated fat in children's diets exceeds recommendations Percent 45 40 35 30 25 20 15 10 5 0 Age and 1-2 years 3-5 years 6-11 years males 6-11 years females 12-19 years males 12-19 years gender females • o/o Calories from total fat D o/o Calories from saturated fat ••••••• Dietary Guidelines recommendation for o/o calories from total fat - • • - • Dietary Guidelines recommendation for o/o calories from saturated fat recommendations for total fat and saturated fat ( 15). Improvement was slight by 1994, when roughly two-thirds of all children exceeded the recommendation for total fat and saturated fat (16). Because of the Guidelines' recommendation for gradual adoption of a diet low in fat, concern is greater for children 5 years and older than it is for children 2 to 5 years old. The CSFTI 1994-96 also reported that adolescent males are consuming more than 300 mg/day of cholesterol, the upper limit of cholesterol intake listed on the Nutrition Facts label (37). Other studies have confirmed the findings regarding children's fat intake: most are consuming more than the recommended levels. About ninety 3- to 5-year-old children enrolled in the Framingham 1999 Vol. 12 Nos. 3&4 Children's Study4 consumed an average of 33 percent of calories from fat (28 ). Albertson and Tobelmann, analyzing 1986-88 MRCA data, reported that among 825 children ages 7 to 12, those who frequently ate ready-to-eat cereal (7 or more times in 14 days) consumed a lower percentage of calories from fat, compared with others who consumed ready-to-eat cereals less frequently: 2 to 6 times in 14 days or less than 2 times in 14 days. However, all three groups consumed more than 30 percent of calories from fat (2). Data from the CSFTI 1994-96 showed that young children's mean intakes of "The longitudinal Framingham Children's Study examined factors related to the development of dietary habits and patterns of physical activity during childhood. dietary fiber met the "age+ 5" recommendation of the American Health Foundation. Children 5 years old and younger had mean fiber intakes of about 11 g a day. However, older children began to fall short of the fiber recommendations: males and females 6 to 11 years old consumed about 14 g and 12 g of fiber per day, respectively; their counterparts 12 to 19 years old consumed about 17 g (males) and 13 g (females) per day (37). Dietary Intake-Micronutrients American children are more likely to get adequate amounts of vitamins and minerals than they are to meet Dietary Guideline recommendations for total fat and saturated fat intake. However, some nutrients are consumed at levels below recommended amounts by some groups 7 in the U.S. population. For example, vitamin E and zinc are consumed at levels below 100 percent of the RDA by most children 2 to 19 years old (37). According to CSFII 1994-96, on the days surveyed, only about 60 percent of children 5 years and younger, 60 percent of females 6 to 11 years old, and only 28 percent of females 12 to 19 years old consumed 100 percent or more of the RDA for iron. Only about one-third each of males and females 12 to 19 years old consumed 100 percent or more of the RDA for vitamin A ( 37). Calcium is another nutrient that children consume at levels below recommendations. Average calcium consumption is below the 1989 RDA for children 12 to 19 years old (fig. 2). In 1994-96, about half of the children 11 years old and younger consumed 100 percent or more of the 1989 RDA for calcium; just over one-third of males 12 to 19 years old and about 15 percent of females 12 to 19 years old consumed 100 percent or more of the calcium RDA (37). Even fewer children ages 9 and older would meet the new Adequate Intake for calcium, which increased to 1,300 mg (31). Compared with other children, adolescents, particularly adolescent females, had the greatest problems in meeting their nutrient requirements. Adolescent females reported the lowest energy intakes in proportion to their energy requirement ( 37). Findings of MRCA data from 1991-94 show that most adolescents ages 11 to 17 consumed less than 2 servings (the minimal number recommended) of fruits a day. Twelve percent of adolescents consumed no fruits in a given day (45). Krebs-Smith et al. examined 3-day data from CSFII 1989-91 for children and adolescents 2 to 18 years old. Even after foods were separated into their 8 component ingredients (e.g., credit is given for vegetables in mixed dishes, such as on pizza or in sandwiches), only one in five children consumed the recommended 5 servings of fruits and vegetables a day. One-quarter of all vegetables that were consumed were French fries. Children from families with higher income consumed more servings of fruits and vegetables, compared with children from families with lower income (18). Data from the CSFII 1994-96 also showed that children's intake of fruits and vegetables was low. Only about one-fourth of children 2 to 11 years old consumed the minimal 3 servings of vegetables a day that are recommended by the Pyramid, and only about 40 percent of females and 55 percent of males 12 to 19 years old met the minimal number of servings. About half of all 2- to 5-yearolds consumed the minimal 2 servings of fruit a day recommended by the Pyramid, but this dropped to about onefourth for males and females 11 to 19 years old ( 37). Low intakes from one food group could explain some of the low nutrient intakes, particularly for vitamins A and C and folate. Sodium intakes for many children are higher than 2,400 mg a day, its upper limit (listed on the Nutrition Facts label). Children 6 years old and older had median sodium intakes greater than 2,400 mg a day according to NHANES data (which includes allowances for salt added at the table and sodium in water and medications) ( 10). In the CSFII 1994-96 (which reports only sodium intake from food), the mean sodium consumption for all children 3 years old and older exceeded 2,400 mg a day. Mean sodium consumption for males ages 12 to 19 years was 4,407 mg a day (37). Anthropometric Indices Weight and height indicators from NHANES III show that underweight is a concern for about 5 percent of 2- to 17-year-olds (only 2 percent of 12- to 17-year-old females) ( 10). Overweight, when defined as a weight for height greater than the 95th percentile, occurred in 10.9 percent of children ages 6 through 17 (36). When overweight was defined as a weight for height greater than the 85th percentile, the incidence of overweight increased to 22 percent ( 36). The prevalence of overweight increased between 1963-65 and 1988-91 among all age-gender groups, with the greatest increase occurring between 1976-80 and 1988-91 (36). A study of the prevalence of overweight among preschool-age children 2 months through 5 years old found that overweight among 4- and 5-year-old females increased from 5.8 percent in 1971-74 to 10 percent in 1988-94. Overweight was defined, in this study ofNHANES data, as being above the 95th percentile of the appropriate measures of the National Center for Health Statistics: weightfor- length or weight-for-stature growth curve. The prevalence of overweight did not increase among younger children. However, the increase in prevalence of overweight in children as young as 4 years old suggests that efforts to prevent overweight should begin in early childhood (27). The increase in obesity is surprising, because many children are reporting energy intakes below the RDA. Lack of physical activity may be responsible for the increase, and the number of hours children watch television has been linked to obesity in this age group (8). Family Economics and Nutrition Review Figure 2. Mean calcium· intakes of older American children below recommended levels Milligrams 1400 1200 1000 800 600 400 200 0 Age and gender 1-2 years 3-5 years 6-11 years males 6-11 years females 12-19 years males 12-19 years females • Calcium intake, mg • 1989 RDA, mg [2J 1997 AI, mg Consumer ResearchChildren's Knowledge and Attitudes About Nutrition When adapting a food guide for children, USDA staff believe it is useful to find out what children know about nutrition, what their attitudes are about foods and nutrition, and what nutrition education programs have been successful. Children have been the target audience for some qualitative and quantitative studies; however, information about their knowledge and attitudes regarding nutrition is far more scarce than information about adult's knowledge and attitudes. Qualitative Studies In late 1991, in preparation for developing nutrition labeling materials for children, 1999 Vol. 12 Nos. 3&4 KIDSNET, Inc., an organization working on children's educational issues (in cooperation with the U.S. Food and Drug Administration [FDA]), sponsored minifocus groups (3 children in each group) with children 6, 8, and 12 years old. The focus groups were designed to examine children's attitudes and behavior regarding food, as well as their awareness and knowledge of the relationship between nutrition and food. Six focus groups (with a mixture of racial and income groups) were conducted in the Washington, DC, area. The children reported having some influence over the foods they eat, particularly breakfast cereals, snack foods, and lunches. Some 6-year-olds even reported making their own lunches. Results from the mini-focus group showed that the children's age influenced their knowledge of nutrition. Twelve-year-old children could name food groups and were aware that carbohydrate, protein, fat, vitamins, and minerals are found in food. Younger children did not have a clear understanding of food groups, and many children thought of vitamins as products that come in a bottle from the drugstore. However, even though the 12-year-old children were fairly knowledgeable about nutrition, their knowledge did not carry over to their own dietary patterns. Taste, instead, was their primary consideration in making food choices. In the words of one 12-year-old participant: "We hear 'Eat right. Don't do drugs.' It's getting boring, like a broken record, so we just tune it out" (30). 9 10 ... the increase in prevalence of overweight in children as young as 4 years old suggests that efforts to prevent overweight should begin in early childhood .... The FDA sponsored two focus groups, each consisting of six to eight females 13 to 15 years old from various racial and ethnic groups. The purpose of the focus groups was to determine the types of nutrition messages the participants would find compelling and to determine which format(s)-for messages about calcium-the participants would most likely pay attention to. These focus groups were held in the Washington, DC/Baltimore, MD, metropolitan area. The results revealed that the participants had a fairly good knowledge of nutrition; they could name nutrients and make associations between a nutrient and its function, for example, "calcium makes your bones strong." Participants said they tended to pay more attention to eating a healthful diet when they were actively involved in a sport. (Most were active in at least one sport.) A frequently mentioned barrier to healthful eating was related to school lunches: lunch periods were often rushed and at odd hours of the day. Participants expressed a preference for educational materials that contained bold, bright colors and little or no text (21 ). The International Food Information Council sponsored one focus group with 9- to 12-year-old children and another with 13- and 14-year-olds to evaluate a prototype nutrition brochure. All of the participants had seen the Food Guide Pyramid, and all said they already knew about the importance of eating vegetables, fruits, and grain products. The participants, however, believed these concepts were "boring, because everyone knows that," and they believed that information about eating breakfast, smart snacking, and balance was important. They also thought information about physical activity was important but believed that activities portrayed should be relevant to their age group. Activities such as golf and racquetball were perceived as "adult" sports (9). Because these studies were conducted using locally available samples and were conducted in urban areas, the results must be interpreted cautiously and cannot be generalized to all children. Quantitative Studies The Kellogg Company surveyed children about their nutrition knowledge, attitudes, and behavior. A nationally representative school-based survey was conducted in 1988-89 with 5,000 students in Grades 3 through 12. Over half of the respondents in this survey believed nutrition is "very important"; however, nutrition was considered less important by older children than by younger ones. Almost three-quarters of elementary school students considered nutrition "very important," compared with about half of junior high school students and only about one-third of high school students (13). The Kellogg survey also found that the positive attitudes of many children did not always translate into appropriate behavior, confirming the results of the qualitative studies referred to earlier in this paper. Only about one-third of all school-age children responded "often" (rather than "sometimes" or "rarely") to the statement "I eat the right foods." Children who agreed strongly with the statement that too much cholesterol and saturated fat are bad for health reported eating foods high in these components as often as did other children, thus demonstrating that their knowledge did not change their behavior. The authors of the Kellogg survey suggested that lack of sufficient knowledge could be partially responsible for this disconnectthe children might know that excessive Family Economics and Nutrition Review dietary cholesterol and saturated fat are unhealthful, but they may not know which foods are rich sources of these components ( 13 ). Lack of adult supervision could also account for some of the poor eating habits reported by the participants of the Kellogg survey. About 60 percent of children reported coming home to an empty house at least once a week, with more than one-third coming home alone three or more times a week. These "latchkey" children were more likely to report that they, rather than their parents, have more control over what they eat (60 percent of "latchkey" children; 35 percent of all elementary schoolchildren). Eating away from home frequently could influence children's diets. According to USDA's CSFII 1994-96, about 40 percent of children 5 years old and younger and over two-thirds of children 6 to 19 years old reported eating at least one food item away from home on the day of the survey. The most frequently mentioned sources of food away from home were fast-food restaurants, school or day care, someone else or gift, and stores (37). The Kellogg Survey also found that almost one-third of school-age children believed they were overweight ( 13 ). This figure is somewhat higher than the 22 percent of children 6 to 17 years old who were found to be overweight by NHANES III. This difference raises a possibility: some children whose weight is normal think they are overweight. Thus dieting is a common behavior among children; about 40 percent of all school-age children participating in the Kellogg Survey reported having been on a diet. More females than males reported dieting, and most of the children 1999 Vol. 12 Nos. 3&4 who reported dieting did so for cosmetic reasons rather than for health ( 13 ). Lack of physical activity has been cited as a possible reason for the increase in the percentage of children who are overweight (6,8,11,12). The Kellogg Survey, on the other hand, found that schoolchildren do consider exercise to be important. Elementary schoolchildren reported taking part in physical activity over five times a week; high school students reported being involved in physical activity about four times a week(13). The Youth Risk Behavior Survey, a component of the Youth Risk Behavior Surveillance System (Centers for Disease Control and Prevention), is a national school-based survey of students in Grades 9 through 12. It contains a series of questions, parts of which are nutritionor diet-related. Male students responding to this survey were significantly more likely than female students to consider themselves the "right weight" or "underweight" (86 vs. 66 percent). Female students were significantly more likely than male students to report trying to lose weight at the time of the survey (44 vs. 15 percent). Over one-fourth of female students who considered themselves the "right weight" reported trying to lose weight. And female students were significantly more likely than their male counterparts to report either currently or ever having used inappropriate practices to lose weight: such as, skipping meals, taking diet pills, or inducing vomiting (40). The Youth Risk Behavior Survey asked students in Grades 9 through 12 how often they participated in vigorous activity in the 2 weeks preceding the survey. Vigorous activity was defined as "at least 20 minutes of hard exercise that made you breathe heavily and made your heart beat fast" ( 41 ). About one-third of all students reported being vigorously active three or more times a week, but female students were half as likely than male students to report regular vigorous activity (25 vs. 50 percent), and African American students were less likely than White or Hispanic students to report regular vigorous activity (30 vs. 40 and 35 percent, respectively) (41). Studies of Nutrition Education Prograrns--VVhatVVorks USDA conducted research to evaluate adults' comprehension and perceived usefulness of its food guide and to develop a graphic presentation of the food guide ( 43 ). USDA also conducted research to determine the effectiveness of the resulting graphic of the Food Guide Pyramid with three target audiences: children, consumers with less than a high school education, and lowincome consumers. USDA, in 1991, collaborated with DHHS and contracted with private industry (4) to develop and test graphic alternatives (including a bowl, shopping cart, and dinner plate) to the Food Guide Pyramid for conveying the key concepts of variety, proportionality, and moderation. Qualitative findings indicated that children preferred the Pyramid graphic to the alternatives tested. They, as well, learned the most information from the Pyramid. Teachers also preferred the Pyramid as a teaching tool, compared with the alternatives (4). For the quantitative phase of the research, interviewers questioned 3,017 individuals, including 1,523 children in Grades 2 through 10. The children's responses to the 60-item questionnaire indicated that the Pyramid graphic conveyed the concepts of variety, proportionality, and moderation. Younger children (Grades 2 to 3), 11 12 The Center selected the preschool-age group (2 to 6 years) as the target audience for an adapted food guide . ... however, understood variety more so than proportionality and moderation (4). Effectiveness of Nutrition Education Programs The Food Guide Pyramid adapted for children needed to integrate relevant findings from a recent comprehensive review on the effectiveness of methods used in nutrition education. This review revealed that programs using educational methods directed at behavioral change as a goal were more likely than other programs to be successful-that is, they were more likely to result in some behavioral change than were programs that focused on only distributing information (5). Contento et al. recommended that programs be behaviorally based and appropriately designed for the child's stage of cognitive development ( 5 ). Preschool and early elementary school-age children (4 to 7 years) need activities that allow them to modify their environment. Providing food-based activities and having adults model eating behavior are appropriate for this age group. Also, parents' or other caregivers' involvement with children in this age group is an important factor contributing to success. Older elementary school-age children (8 through about 11 years) still need to have information presented in concrete terms. Food-classification activities and modeling by adults are appropriate for this age group, and involvement with parents and the community is still important for programs targeted for this age group. Adolescents (second decade oflife) move from concrete to abstract thinking and are able to comprehend more abstract information, such as the relationship between diet and health-present and future. They need activities that encourage critical thinking, such as exploring the influence of diet on health and the environment. With this age group, parents' involvement becomes less important, because adolescents are more likely to be influenced by their peers than by their parents or caregivers (5). The quantity and quality of existing nutrition education materials for specific age groups of children must also be considered when selecting a target audience. Recently, Swadener reviewed research related to nutrition education for preschool-age children ( 33 ), and Lytle reviewed research related to nutrition education for school-age children (20). Both found that while many nutrition education materials are directed toward children, improvements and follow-up are needed to determine whether the materials are really effective. Swadener found that many nutrition education materials developed for preschoolchildren did not include an evaluation component, many programs were not conducted for a sufficient time to result in changes in attitudes or behavior, and few programs were designed for use with children from dysfunctional or marginally functional families. Lytle concluded that more tools are needed for assessment of change in children's and adolescents' eating behavior and that adolescents, in particular, could benefit from exposure to strategies that modify behavior. Lytle also found that more programs are needed: ones that target multi-ethnic groups as well as involve families of school-age children. Family Economics and Nutrition Review Pros and cons of adapting the Food Guide Pyramid for use with three groups of children Pros Cons Preschool age (2 through 6 years) Have special needs, re: fat, smaller serving sizes Peer pressure not a problem Can reach them through the Special Supplemental Feeding Program for Women, Infants, and Children and the Child and Adult Care Feeding Program Developmentally a good time to reach (e.g., when food habits are still being formed) Can counteract exposure to television advertising of high-calorie foods Not as many materials targeting this age group as for older children Educational materials must target parents and caregivers, not child directly Fat message (children this age need more fat) may confuse parents, because this need is temporary Elementary school age (7 through 11 years) Think nutrition is important but don't act on it; they are "reachable" Already a large amount of nutrition education material available for this audience (however, not all of it is relevant or appropriate) Beginning to take more responsibility for their own food choices Current food guide already meets nutrient needs Easier to reach (through a single classroom teacher) than younger or older children (where nutrition education may be provided by a diverse group of individuals) Adolescents ( 12 to 18 years) More problems meeting nutrient needs Not many materials targeting this audience Current food guide already meets nutrient needs Difficult audience to reach-need different ways to communicate food guide, not necessarily different food guide Make many of own food choices Need more individualized messages-e.g., for athletes vs. nonathletes Perhaps can tum weight concerns into motivation for change 1999 Vol. 12 Nos. 3&4 13 Decision Point-Target Audience for the Food Guide Pyramid for Children Because of differences in nutrient needs (23,31,32), current food consumption patterns ( 10,16,37), and stages of educational development ( 5 ), a single food guide cannot meet the needs of all children 2 to 18 years old. Based on children's nutrient needs and developmental level, staff of the Center for Nutrition Policy and Promotion identified three age groups for which a Pyramid could be developed: • Preschool and early elementary age (2 through 6 years) • Elementary school age (7 through 11 years) • Middle and high school age (12 to 18 years) The Center staff considered several factors when deciding which age group should be targeted for an adapted food guide: • Does the existing food guide meet this group's dietary needs, or does this group have specific nutritional and health problems that an adapted food guide could help to address? • If the existing food guide meets the group's dietary needs, has it been successful in influencing the group's behavior? Is there a need for an alternate presentation of the existing food guide to better reach this group? • What nutrition education materials exist for this audience? • What are the educational considerations for this group? Will children be able to use the new food guide directly? Will they use the materials with guidance from a parent or caregiver? Or will the materials 14 be developed for the parent or caregiver? • Is there user demand for a new food guide for this group? • What is the social effect of the decision? Will different food guides for different ages create confusion? Based on these factors, Center staff listed pros and cons for developing an adapted food guide for each age group (table) and considered these issues when making the decision regarding the target audience. Implications and Recommendations for a Food Guide for Preschool-Age Children (2 to 6 Years) The Center selected the preschool-age group (2 to 6 years) as the target audience for an adapted food guide because there is a greater need for verifying the scientific basis of the food guide, both from a physiological and developmental viewpoint for 2- to 6-year-olds than for older children. The rationale for this conclusion follows: • Nutrient needs of preschool-age children differ from those of older children. The Dietary Guidelines for Americans recommend that the level of dietary fat be gradually decreased from current levels (about 34 percent of calories from fat) to 30 percent of calories by the time the child is about 5 years old (39). Concerns about undue food and fat restrictions for children in this age group, leading to "failure to thrive," have been expressed by the American Academy of Pediatrics ( 3 ). Because the current Food Guide Pyramid assumes a dietary fat intake of 30 percent of calories, Center staff concluded that additional guidance is needed for parents and caregivers of children less than 5 years old. • Following the release of the Food Guide Pyramid, USDA received numerous questions from the Extension Service; the Dairy Council; the Special Supplemental Food Program for Women, Infants, and Children (WI C); the Child and Adult Care Food Program; and the media. The concern: how to use the food guide with young children, particularly regarding children's need for smaller serving sizes. • Developmental concerns regarding food activities at the preschool level include determining what young children can or should "learn" and addressing the physiological and emotional issues related to food. Because parents and caregivers have a major role in food selection for this age group, Center staff believed these children's attitudes and behavior must also be considered. Adaptation of the food guide for this age group uses the same framework of food groups as the original food guide. Thus the framework blends into later learning activities in school where concepts are added, for example, nutrient content of different types of foods; how foods are grown, processed, and delivered; how different food items are used in different cultures; and how "new" foods have been historically introduced into the American diet. Using the same framework of food groups also makes the new food guide more practical for family food managers to use. The process used to adapt the food guide for the preschool and early elementary-age audience is described elsewhere in this issue (22,34). Family Economics and Nutrition Review References 1. Albertson, A.M., Tobelmann, R.C., and Engstrom, A. 1992. Nutrient intakes of 2- to 10- year-old American children: 10-year trends. Journal of the American Dietetic Association 92:1492-1496. 2. Albertson, A.M. and Tobelmann, R.C. 1993. Impact of ready-to-eat cereal consumption on the diets of children 7-12 years old. Cereal Foods World 38(6):428-431. 3. American Academy of Pediatrics, Committee on Nutrition. 1998. Statement on cholesterol. Pediatrics 101:141-147. 4. Bell Associates, Inc. 1992. An Evaluation of Dietary Guidance Graphic Alternatives. Prepared for U.S. Department of Agriculture, Food and Consumer Services. 5. Contento, I., Balch, G.l., Bronner, Y.L., Paige, D.M., Gross, S.M., Bisignani, L., Lytle, L.A., Maloney, S.K., White, S.L., Olson, C.M., Swadener, S.S., and Randell, J.S. 1995. The effectiveness of nutrition education and implications for nutrition education policy, programs, and research: A review of research. Journal of Nutrition Education 21( 6 ):277-422. 6. Davies, P.S.W., Gregory, J., and White, A. 1995. Energy expenditure in children aged 1.5 to 4.5 years: A comparison with current recommendations for energy intake. European Journal of Clinical Nutrition 49:360-364. 7. Dietary Guidelines Advisory Committee. 1995. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans. U.S. Department of Agriculture, Agricultural Research Service. 8. Dietz, W.H. Jr. and Gortmaker, S.L. 1985. Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics 75:807-812. 9. Edelman Public Relations Worldwide. 1995. Report ofF ocus Groups at Stevens Elementary and Poe Middle School. Topline report submitted to International Food Information Council. 10. Federation of American Societies for Experimental Biology, Life Sciences Research Office. Prepared for the Interagency Board for Nutrition Monitoring and Related Research. 1995. Third Report on Nutrition Monitoring in the United States: Volume 1. U.S. Government Printing Office, Washington, DC, 365 pp. 11. Fontvielle, A.M., Harper, LT., Ferraro, R.T., Spraul, M., and Ravussin, E. 1993. Daily energy expenditure by five-year-old children, measured by doubly labeled water. Journal of Pediatrics 123:200-207. 12. Goran, M.I., Carpenter, W.H., and Poehlman, E.T. 1993. Total energy expenditure in 4- to 6-year-old children. American Journal of Physiology 264:E706-E711. 13. Harris/Scholastic Research. 1989. The Kellogg Children's Nutrition Survey. Conducted for the Kellogg Company, Battle Creek, Michigan. 14. Joint Working Group of the Canadian Paediatric Society and Health Canada. 1993. Nutrition Recommendations Update . .. Dietary Fat and Children. Ottawa, Ontario: Health Canada, Cat. H39-162/l-1993E. 18 pp. 15. Kennedy, E. and Goldberg, J. 1995. What are American children eating? Implications for public policy. Nutrition Reviews 53(5): 111-126. 1999 Vol. 12 Nos. 3&4 15 16 16. Kennedy, E. and Powell, R. 1997. Changing eating patterns of American children: A view from 1996. Journal of the American College of Nutrition 16(6):524-529. 17. Krauss, R.K., Deckelbaum, R.J., Ernst, N., Fisher, E., Howard, B.V., Knopp, R.H., Kotchen, T., Lichtenstein, A.H., McGill, H. C., Pearson, T.A., Prewitt, T.E., Stone, N.J., Van Hom, L., and Weinberg, R. 1996. Dietary Guidelines for healthy American adults: A statement for health professionals from the Nutrition Committee, American Heart Association. Circulation 94:1795-1800. 18. Krebs-Smith, S.M., Cook, A., Subar, A. F., Cleveland, L., Friday, J., and Kahle, L.L. 1996. Fruit & vegetable intakes of children and adolescents in the United States. Archives of Pediatric and Adolescent Medicine 150:81-86. 19. Lauer, R.M., Obarzanek, E., Kwiterovich, P.O., Kimm, S.Y.S., Hunsburger, S.A., Barton, B.A., van Hom, B., Stevens, V.J., Lasser, N.L., Robson, A.M., Franklin, F.A., and SimonsMorton, D.G. 1996. Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol: The Dietary Intervention Study in Children (DISC). Journal of the American Medical Association 273: 1429-1435. 20. Lytle, L.A. 1994. Nutrition Education for School-Aged Children: A Review of Research. Report prepared for U.S. Department of Agriculture, Food and Consumer Service. 21. Macro International. 1995. Adolescent Consumers' Attitudes Toward Calcium Education and Proposed Educational Materials: Focus Groups Report. Prepared for the U.S. Food and Drug Administration. 22. Marcoe, K.L. 1999. Technical research for the Food Guide Pyramid for Young Children. Family Economics and Nutrition Review 12(3&4):18-32. 23. National Academy of Sciences, National Research Council, Food and Nutrition Board. 1989. Recommended Dietary Allowances (1Oth ed. ). National Academy Press, Washington, DC. 24. National Cholesterol Education Program. 1991. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Bethesda, MD: National Institutes of Health, NIH Publication no. 91-2732. 119 pp. 25. Nicklas, T.A., Webber, L.S., Kaschak, M.L., and Berenson, G.S. 1992. Nutrient adequacy of low fat intakes for children: The Bogalusa Heart Study. Pediatrics 89(2):221-228. 26. Niinikoski, H., Lapinleimu, H., Viikari, J., Ronnemaa, T., Jokinen, E., Seppanen, R., Terho, P., Tuominen, J., Valimaki, 1., and Simell, 0. 1997. Growth until3 years of age in a prospective, randomized trial of a diet with reduced saturated fat and cholesterol. Pediatrics 99(5 ):687 -694. 27. Odgen, C.L., Troiano, R.P., Briefel, R.R., Kuczmarski, R.J., Flegal, K.M., and Johnson, C.L. 1997. Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics 99( 4 ):e1 . 28. Oliveria, S.A., Ellison, R.C., Moore, L.L., Gillman, M.W., Garrahie, E.J., and Singer, M.R. 1992. Parent-child relationships in nutrient intake: The Framingham Children's Study. American Journal of Clinical Nutrition 56:593-598. 29. Shea, S., Basch, C.E., Stein, A.D., Contento, I.R., Irigoyen, M., and Zybert, P. 1993. Is there a relationship between dietary fat and stature or growth in children three to five years of age? Pediatrics 92(4):579-586. Family Economics and Nutrition Review 30. Shugoll Research. 1992. Children's Nutrition Label Focus Group Study. Report prepared for KIDSNET, Inc., Washington, DC. 31. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. 1997. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC. National Academy Press. 32. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. 1998. Dietary Reference Intakes for Folate, Other B Vitamins, and Choline. Washington, DC. National Academy Press. 33. Swadener, S.S. 1994. Nutrition Education for Preschool Children: A Review of Research. Report prepared for U.S. Department of Agriculture, Food and Consumer Service. 34. Tarone, C. 1999. Focus group research on adapting the Food Guide Pyramid for Young Children. F amity Economics and Nutrition Review 12( 3 &4 ):33-44. 35. Tonstad, S. and Sivertsen, M. 1997. Relation between dietary fat and energy and micronutrient intakes. Archives of Diseases of Childhood 76(5 ):416-442. 36. Troiano, R.P., Flegal, K.M., Kuczmarski, R.J., Campbell, S.M., and Johnson, C.L. 1995. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991 . Archives of Pediatric and Adolescent Medicine 149:1085-1091. 37. U.S. Department of Agriculture, Agricultural Research Service. 1998. Food and Nutrient Intakes by Individuals in the United States by Sex and Age, 1994-96, Nationwide Food Surveys. Report No. 96-2.197 pp. 38. U.S. Department of Agriculture, Human Nutrition Information Service. 1992. The Food Guide Pyramid. Home and Garden Bulletin No. 252. 39. U.S. Department of Agriculture and U.S. Department of Health and Human Services. 1995. Nutrition and Your Health: Dietary Guidelines for Americans (4th ed.). U.S. Department of Agriculture. Home and Garden Bulletin No. 232. 40. U.S. Department of Health and Human Services. 1991. Body-weight perceptions and selected weight-management goals and practices of high school students-United States, 1990. Morbidity and Mortality Weekly Reports 40:741,747-750. 41. U.S. Department of Health and Human Services. 1992. Vigorous physical activity among high school students-United States, 1990. Morbidity and Mortality Weekly Reports 41 :33-35. 42. U.S. Department of Health and Human Services. 2000. Healthy People 2010 (Conference Edition in Two Volumes). Washington, DC. 43. Welsh, S.O., Davis, C., and Shaw, A. 1993. USDA's Food Guide: Background and Development. U.S. Department of Agriculture. HNIS Miscellaneous Publication No. 1514. 44. Williams, C.L. 1995. Importance of dietary fiber in childhood. Journal of the American Dietetic Association 95:1140-1146, 1149. 45. Zizza, C. A. and Powell, R. 1996. Characteristics distinguishing adolescents by fruit consumption. Journal of the American Dietetic Association 96:A-91 . 1999 Vol. 12 Nos. 3&4 17 Kristin L. Marcoe Center for Nutrition Policy and Promotion 18 Technical Research for the Food Guide Pyramid for Young Children This article describes the technical research for the Food Guide Pyramid for Young Children. Composites for food groups and subgroups were developed using food intake data for children 2 to 6 years old. Data were from the Continuing Survey of Food Intakes by Individuals 1989-91. The composites were used in creating 1 ,300- and 1 ,600-calorie Food Guide Pyramid diet patterns. For children 4 to 6 years old, the 1 ,600-calorie pattern met all nutrient requirements, except for vitamin E. The 1 ,300-calorie pattern provided the ADA for most nutrients for 2- to 3-year-olds and 4- to 6-year-olds. The major exceptions were iron and zinc for both age groups and copper and vitamin E for the 4- to 6-year-olds. When breakfast cereals fortified with iron and zinc were used in the grain composites, the patterns provided recommended levels of these nutrients. Children could improve their diet by making different food choices, in particular, by eating more dark-green and deep-yellow vegetables; legumes; whole grains; and lean meat, poultry, or fish. he Food Guide Pyramid for Young Children ages 2 to 6 years is a nutrition education tool to help teach healthful eating concepts to young children. The technical research conducted in developing and documenting the research base for this food guide followed procedures similar to those described in the development and documentation of the original food guide (1,9). Food selections and serving sizes reported for young children, in a national food consumption survey, were incorporated into diet patterns based on the Food Guide Pyramid to determine whether such patterns would meet nutritional goals. A composite was developed for each Pyramid food group (e.g., meat, poultry, fish) or subgroup (e.g., whole grain). Composites were based on children's actual food choices and reflected the relative use of individual foods within the group or subgroup. An example: the composite for deep-yellow vegetables reflected children's consumption of 89 percent as carrots and 11 percent as other deep-yellow vegetables. A nutrient profile was then calculated for each composite, after which composites and their nutrient profiles were used to calculate expected nutrient levels in 1 ,300- and 1 ,600-calorie diet patterns based on the Food Guide Pyramid. The nutrient totals were then analyzed to determine whether children's nutrient requirements could be met by diet patterns that conform to Pyramid recommendations and that consist of the foods most commonly eaten by children. Family Economics and Nutrition Review Methods Data Sources Data on 3-day food and nutrient intakes reported in the Continuing Survey of Food Intakes by Individuals (CSFII) 1989-91 for 1,053 children 2 to 6 years old were used in this study. This data set was used because when work was started, the data set offered the largest number of individuals and days for analysis. Sample weights were applied to provide estimates that were representative of the population. The data that were used to calculate the nutrient profiles of the composites for the food groups and subgroups came from the U.S. Department of Agriculture's (USDA) Nutrient Data Base for Individual Intake Surveys, Release 7 (1991). The Food Guide Servings Data Base was used to report the amounts of food consumed as numbers of food guide servings. USDA's Center for Nutrition Policy and Promotion (CNPP) developed this data base by using the foods reported in the CSFII 1989-91. The Food Guide Servings Data Base consists of food-item descriptions and the number of Pyramid servings per 100 grams of food. Servings data are provided for the 5 major food groups and 21 subgroups identified in the Food Guide Pyramid. Most foods, including mixed dishes, were broken down into ingredient components, and their food group servings were calculated for more than one food group. When a food code's typical serving size, defined in the Survey Code Book for CSFII 1989-91 and based generally on median serving sizes reported in USDA food consumption surveys, provided less than onefourth of a serving of a Pyramid food group or subgroup, it was usually not 1999 Vol. 12 Nos. 3&4 counted. For example, a serving of oatmeal raisin cookies provided less than one-fourth of a Pyramid serving of raisins, so those raisins were not counted toward fruit servings. These small amounts were not counted because one objective of the original food guidance system was "usability." It is unrealistic to expect Americans to "count" small amounts of some foods toward food group servings. However, if several "other vegetables" like tomatoes and onions were in small amounts in a mixture, and these amounts together added up to at least one-fourth serving, these "other vegetables" were counted toward vegetable servings. Procedures CNPP began the research process by breaking down the foods that were consumed by children 2 to 6 years old, as reported in the CSFII 1989-91, into numbers of food group and subgroup servings. The Food Guide Servings Data Base was used for this process. To identify specific food components, CNPP staff reviewed food codes that contributed food guide servings. All food items with similar food components were grouped in the same item-group. For example, broccoli soup and broccoli casserole both contained cooked broccoli and so were placed in the item-group for cooked broccoli within the subgroup for dark-green vegetables. A composite was then constructed by summing intakes from all the item-groups within a food group, with each item-group being weighted by the numbers of servings reported for children 2 to 6 years old. Then the percentage contributed by each itemgroup in the food group or subgroup was calculated. The total number of servings of cooked broccoli consumed, for example, was divided by the total number of servings of dark-green vegetables consumed. This calculation produced the percentage of the composite for dark-green vegetables that was cooked broccoli. Any item-group totaling less than 1 percent of the composite was combined with another item-group, based on the similarity in nutrient composition or its use in meals. A food code most representative of an item-group was then selected to represent each food-item group in each of the composites. The nutrient values of these food codes were used to calculate the nutrient profiles of the composites. In developing the original nutrient profiles for the food groups and subgroups, researchers included foods with the least amount of fat and without added sugars; thus, the original philosophical goal of flexibility for the food guide was met. The food guide was used to show consumers how to obtain nutrients while allowing them flexibility to choose sources of fat and added sugars within the fat and calorie limits specified (9). In addition, the Food Guide Pyramid is an educational tool to help put the Dietary Guidelines into practice (8). To minimize fat, added sugars, and sodium, CNPP staff used the form of the food item that was lowest in these components. For example, the deepyellow vegetable subgroup contained the item-group for sweet potatoes. To represent the latter in the composite, CNPP used the code for a baked sweet potato without added fat-despite the fact that children usually eat candied sweet potatoes. For most vegetable and cooked-grain item-groups, CNPP used food codes that specified "no salt added in preparation." In a few cases, CNPP used the salted form to represent popular vegetables that are canned. Estimates of the percentage selected 19 20 ... young children ate somewhat different types and amounts of food items within each food group and subgroup than did the total population. in canned form were calculated from data of the food supply ( 4). Non-fortified ready-to-eat and cooked breakfast cereals were used in both the composites for whole grains and enriched grains. Hence nutrient profiles of the composites do not overestimate the nutrients for children who do not eat fortified breakfast cereals. Nutrients added at standard enrichment levels, as in enriched bread, were included in the nutrient profiles for the composites. Folate fortification was not mandated by the Government at the time the CSFII 1989-91 was conducted, so it was not reflected in any of the nutrient profiles for grain products. Once CNPP chose the food code to represent each item-group, we calculated grams of the food code and corresponding nutrient values for its portion of the composite serving. Nutrient values were then summed across all items in the food group or subgroup to determine the composite's nutrient profile per serving. Composites were not developed for the meat alternates (eggs, nuts and seeds) or for the milk, yogurt, and cheese group. The nutrient profiles of a food group or subgroup reflect proportionately the nutrient content of the foods within them; consequently, the nutrient profile of a food group or subgroup most reflects the nutrient content of the most frequently consumed foods within that group. Nutrient profiles for the meat alternates were represented by the nutrients in one large boiled egg and 2 tablespoons of peanut butter, each of which counts as 1 ounce from the meat, poultry, fish group. Peanut butter was 90 percent of young children's servings of nuts and seeds in the CSFII 1989-91 ; thus, peanut butter's nutrient profile was used instead of calculating a composite of all the different nuts and seeds that were consumed in small quantities by young children. All legumes were counted as vegetables in the earlier research on Pyramid food patterns (J) and so were counted similarly in this research project. One-half cup of cooked legumes may be counted as 1 ounce of meat, poultry, or fish rather than 1 serving of vegetables. The nutrient profile for the milk, yogurt, and cheese group was represented by 1 cup of nonfat milk, except for vitamin A. The amount of vitamin A used was the 76 RE per cup found in whole milk, instead of the 149 RE per cup found in fortified nonfat milk. Thus overestimation of vitamin A was avoided for those who consumed non-fortified whole milk products. The data on food intake, which were used to develop the composites, were examined to identify the most popular foods (at the food code level) and preparation styles in each item-group. Amounts reported eaten were also analyzed. For each item-group, the average number of servings per report was calculated. This was the average quantity of a specified food that was eaten by consumers during an eating occasion (at a single time). Then, the average number of servings per report was calculated for each food group or subgroup. The food-group composites and nutrient profiles for young children were compared with another set of composites that were developed for all individuals ages 2 years and older who provided 3 days of data in the CSFII 1989-91 (N=11 ,488). Family Economics and Nutrition Review Methods Data Sources Data on 3-day food and nutrient intakes reported in the Continuing Survey of Food Intakes by Individuals (CSFII) 1989-91 for 1,053 children 2 to 6 years old were used in this study. This data set was used because when work was started, the data set offered the largest number of individuals and days for analysis. Sample weights were applied to provide estimates that were representative of the population. The data that were used to calculate the nutrient profiles of the composites for the food groups and subgroups came from the U.S. Department of Agriculture's (USDA) Nutrient Data Base for Individual Intake Surveys, Release 7 (1991). The Food Guide Servings Data Base was used to report the amounts of food consumed as numbers of food guide servings. USDA's Center for Nutrition Policy and Promotion (CNPP) developed this data base by using the foods reported in the CSFII 1989-91. The Food Guide Servings Data Base consists of food-item descriptions and the number of Pyramid servings per 100 grams of food. Servings data are provided for the 5 major food groups and 21 subgroups identified in the Food Guide Pyramid. Most foods, including mixed dishes, were broken down into ingredient components, and their food group servings were calculated for more than one food group. When a food code's typical serving size, defined in the Survey Code Book for CSFII 1989-91 and based generally on median serving sizes reported in USDA food consumption surveys, provided less than onefourth of a serving of a Pyramid food group or subgroup, it was usually not 1999 Vol. 12 Nos. 3&4 counted. For example, a serving of oatmeal raisin cookies provided less than one-fourth of a Pyramid serving of raisins, so those raisins were not counted toward fruit servings. These small amounts were not counted because one objective of the original food guidance system was "usability." It is unrealistic to expect Americans to "count" small amounts of some foods toward food group servings. However, if several "other vegetables" like tomatoes and onions were in small amounts in a mixture, and these amounts together added up to at least one-fourth serving, these "other vegetables" were counted toward vegetable servings. Procedures CNPP began the research process by breaking down the foods that were consumed by children 2 to 6 years old, as reported in the CSFII 1989-91, into numbers of food group and subgroup servings. The Food Guide Servings Data Base was used for this process. To identify specific food components, CNPP staff reviewed food codes that contributed food guide servings. All food items with similar food components were grouped in the same item-group. For example, broccoli soup and broccoli casserole both contained cooked broccoli and so were placed in the item-group for cooked broccoli within the subgroup for dark-green vegetables. A composite was then constructed by summing intakes from all the item-groups within a food group, with each item-group being weighted by the numbers of servings reported for children 2 to 6 years old. Then the percentage contributed by each itemgroup in the food group or subgroup was calculated. The total number of servings of cooked broccoli consumed, for example, was divided by the total number of servings of dark-green vegetables consumed. This calculation produced the percentage of the composite for dark-green vegetables that was cooked broccoli. Any item-group totaling less than 1 percent of the composite was combined with another item-group, based on the similarity in nutrient composition or its use in meals. A food code most representative of an item-group was then selected to represent each food-item group in each of the composites. The nutrient values of these food codes were used to calculate the nutrient profiles of the composites. In developing the original nutrient profiles for the food groups and subgroups, researchers included foods with the least amount of fat and without added sugars; thus, the original philosophical goal of flexibility for the food guide was met. The food guide was used to show consumers how to obtain nutrients while allowing them flexibility to choose sources of fat and added sugars within the fat and calorie limits specified (9). In addition, the Food Guide Pyramid is an educational tool to help put the Dietary Guidelines into practice (8). To minimize fat, added sugars, and sodium, CNPP staff used the form of the food item that was lowest in these components. For example, the deepyellow vegetable subgroup contained the item-group for sweet potatoes. To represent the latter in the composite, CNPP used the code for a baked sweet potato without added fat-despite the fact that children usually eat candied sweet potatoes. For most vegetable and cooked-grain item-groups, CNPP used food codes that specified "no salt added in preparation." In a few cases, CNPP used the salted form to represent popular vegetables that are canned. Estimates of the percentage selected 19 22 Family Economics and Nutrition Review Table 1. Continued Percent Percent Whole grain Enriched grain WW* bread Rye bread Oatmeal bread WW quick bread Total breads WW crackers Corn tortilla Popcorn Brown rice Total snacks/other WW cereal, RTE* & ck Oatmeal, ck Oat RTE cereals Total cereals Whitebread French bread English muffins Flour tortilla Enr* crackers Total breadlcrx* Enr quick breads Biscuit Cornbread Total quick breads Pasta, noodles White rice Grits Total pasta, rice Enr flour desserts Corn RTE cereals Rice RTE cereals Total cereals 33.2 35.6 4.2 2.5 3.3 2.1 2.4 37.8 45.5 4.2 2.8 9.5 11.6 3.6 5.2 .LQ 17.3 21.2 11.5 16.9 15.9 ' 8.4 17.5 8.0 44.9 33.3 35.1 35.4 1.4 4.0 1.1 2.4 1.4 2.3 4.2 2.8 43.2 46.9 7.1 5.9 1.6 2.7 2.4 3.3 11.1 11.9 13.6 11.5 5.3 6.1 u 1.0 20.4 18.6 14.4 17.8 8.2 3.7 2.7 u 10.9 4.8 1Children 2 to 6 years old and all individuals ages 2 years and older. -Item-group had <1 percent representation in the composite. Meat, poultry, Beef, fresh 18.6 fish Pork, fresh 6.2 Pork, cured 2.9 Lamb 0.7 Total meat cuts 28.4 Ground beef 21.5 Beef lunchmeats 8.1 Pork lunchmeats 4.4 Totallunchmeat 12.5 Liver 0.3 Chicken 23.0 Turkey 3.9 Total poultry 26.9 Lean finfish 3.3 Fatty finfish 1.6 Finfish, end 4.5 Shellfish 1.0 Total rash 10.4 *Abbreviations: ck- cooked, end- canned, DY- deep-yellow, WW- whole wheat, RTE ·ready-to-eat, Enr- enriched, crx.- crackers. Source: CSFII 1989-91, 3-day weighted samples. 1999 Vol. 12 Nos. 3&4 21.4 7.2 3.2 u 32.9 18.8 3.6 4.9 8.5 0.5 21.5 ll 26.6 4.3 1.7 4.2 2.8 13.0 23 Table 2. Nutrient profiles for food proup composites and milk: Nutrient values per serving for young children and all individuals Calories, kcal 24 Sodium,mg 29 Potassium, mg 278 Protein, g 2.6 Fat, g 0.3 Saturated fat, g 0.0 Mono.* fat, g 0.0 Poly.* fat, g 0.1 Cholesterol, mg 0 Carbohydrate, g 4.4 Fiber, g 2.3 Vitamin A, RE 239 Vitamin C, mg 55 Folate, ug 57.9 Vitamin B12, ug 0.0 Calcium,mg 55 Magnesium, mg 29.3 Iron, mg 1.10 Zinc, 0.38 Dark-green vegetable. Broccoli was the predominant vegetable in this composite for children. Of all the composites, the one for dark-green vegetables had the highest vitamin-C value per serving. Cooked broccoli was the largest (74 percent) component and cooked spinach was the second largest (14 percent) component of the composite for darkgreen vegetables (table 1). Thus the high percentage of broccoli helps to explain the high value of vitamin C per serving of this composite: 55 mg 24 0.1 0.0 (table 2). Children consumed much less cooked greens, raw broccoli, and romaine than did all individuals (table 1). Deep-yellow vegetable. This composite was mostly carrots, and it provided the highest amount of vitamin A of any composite. Most (89 percent) of the children's deep-yellow vegetable composite was carrots (table 1). Children ate more raw carrots than cooked carrots. Eaten primarily in candied form, sweet potatoes ranked a distant second in the composite. One serving of the deep-yellow vegetable composite provided 1,685 RE vitamin A for children (table 2). Legume. Pinto beans accounted for the highest percentage of the children's composite for legumes. Of all the composites, this one contained the most calories and fiber per serving. Pinto beans ranked first (35 percent for children) in the legume composite (table 1). The top food codes in the item-group for pinto beans were pinto beans without fat and refried beans Family Economics and Nutrition Review Table 2. Continued . '~: "i·:' i'Y ' Meat, poultry, fish .l Fruit Whole grain Enriched grain (per ounce) MDk% :; AU AU All All lcup Nutrient ·,,. Cblld indiv . Child indiv. Clnld indiv. Child indiv. nonfat Calories, kcal 74 68 80 78 86 83 56 55 86 Sodium, mg 3 2 60 69 104 115 82 67 126 Potassium, mg 237 245 60 56 30 31 89 88 406 Protein, g 0.7 0.8 2.8 2.6 2.3 2.3 7.7 7.7 8.4 Fat, g 0.2 0.2 1.2 l.l 1.1 1.1 2.5 2.4 0.4 Saturated fat, g 0.1 0.1 0.2 0.2 0.2 0.3 0.9 0.9 0.3 Mono. fat, g 0.0 0.0 0.4 0.4 0.5 0.5 1.0 1.0 0.1 Poly. fat, g 0.1 0.1 0.4 0.4 0.3 0.3 0.2 0.2 ' 0.0 Cholesterol, mg 0 0 0 0 2 2 22 24 4 Carbohydrate, g 18.3 16.8 14.9 15.0 16.3 15.5 0.2 0.1 11.9 Fiber, g 1.1 1.2 2.1 2.0 0.6 0.6 0.0 0.0 0.0 Vitamin A, RE 12 28 2 2 2 2 9 18 76 Vitamin C, mg 24 30 0 0 0 0 1 1 2 Folate, ug 23.8 26.9 7.4 7.8 6.5 6.9 2.3 2.4 12.7 Vitamin B12, ug 0.0 0.0 0.0 0.0 0.0 0.0 0.5 0.6 0.9 Calcium, mg 13 13 19 20 23 26 4 4 302 Magnesium, mg 12.3 13.5 ' 24.6 23.0 7.4 7.4 6.8 7.0 27.8 Iron, mg 0.34 0.27 0.81 0.76 0.80 0.80 0.55 0.55 0.10 Zinc, mg 0.08 0.10 0.54 0.50 0.20 0.21 """' 1.11 1.10 0.98 1Children 2 to 6 years old and all individuals ages 2 years and older. 2 A composite was not developed for the milk group. The nutrient profile was based on nonfat fluid milk. *Abbreviations: Mono. - monounsaturated; Poly.- polyunsaturated. with added fat. White beans (eaten mostly in pork and beans/baked beans) and kidney beans (eaten mostly in chili con carne with beans) were, respectively, the second and third largest itemgroups. Legumes contributed the most calories and dietary fiber per serving of all the composites; for children, one legume serving provided 108 calories and 5.6 g fiber (table 2). Legumes also provided the most copper per serving of all the composites, 0.20 mg. 1999 Vol. 12 Nos. 3&4 Starchy vegetable. fried potatoes were the starchy vegetable most commonly eaten by young children. White potatoes were the primary constituent of the composite for starchy vegetables (table 1); they were most often eaten with added fat-as potato chips and French fries. Because the composite was created using the form of the food lowest in fat, boiled potatoes were chosen as a proxy for fried potatoes. The smaller amount of baked potatoes in the children's composite, compared with that for all individuals, contributed to a lower potassium value in children's nutrient profile (table 2). The second largest item-group in this composite was com (table 1). Other vegetable. Almost half of children's servings of "other vegetables" were of tomatoes. This composite had one of the smallest servings per report (0.5), because the foods in this subgroup were used in small amounts in many mixed dishes. Tomatoes were the primary component ( 48 percent) of the composite for other 25 Across all the food groups and subgroups, children tended to have smaller serving sizes than did all individuals. "· 26 vegetables; a higher percentage of its cooked form was consumed, compared with its raw form (table 1). Most of the servings of the cooked form were eaten as ingredients in grain mixtures. The main sources of raw tomatoes, other than those eaten by themselves, were Mexican mixtures (taco/tostada) and hamburger sandwiches. The large amount of cooked tomatoes, represented as canned in the composite, was the major contributor to the 100 mg sodium and 205 mg potassium per composite serving (table 2). The second largest item-group in the other vegetable composite for children was cooked green beans (19 percent) (table 1). Lettuce represented 12 percent of the children's composite, and the most frequently consumed food was plain lettuce. One composite serving of other vegetables provided 12 mg vitamin C, second to the dark-green vegetable subgroup, 55 mg per serving (table 2). Whole grain. About 45 percent of this composite was ready-to-eat and cooked cereals; most were fortified. Whole-grain cereals were the largest component of the composite for whole grains (table 1). Both the ready-to-eat and cooked forms of wheat and oat cereals were eaten, and the instant variety was the most consumed type of all the cooked oatmeals. Many of the cereals in the item-groups for wheat and oat cereal were fortified. Children obtained added nutrients by eating these fortified cereals. Wholewheat bread was 33 percent of the composite for whole grains, but crackedwheat bread was the predominant food code in the item-group for whole-wheat bread. Cracked-wheat bread was in this item-group, because the wheat-based breads were grouped together. Corn tortilla had a fairly large representation (10 percent) in the composite for whole grains. Tortilla chips and corn chips were the top food codes in the itemgroup for corn tortilla. For children, one serving from the composite for whole grains provided 2.1 g dietary fiber, 24.6 mg magnesium, and 0.5 mg zinc (table 2). Enriched grain. White bread was the largest component of the children 's composite for enriched grains. White bread was the first (35 percent) and "enriched flour desserts and other sources of enriched flour" (shortened to just "enriched flour desserts") was the second largest component (14 percent) of the enriched-grain composite (table 1). The term "desserts" was used to identify the latter item-group because many of the food codes in it were sweet foods like cookies, doughnuts, pastries, pies, and cakes. Enriched flour in each of these foods was counted toward servings of enriched grains. The enriched flour in pizza crust was also included in this itemgroup. A low-sugar and low-fat food was used to represent the item-group for enriched flour desserts in the composite, but children were consuming added sugars and fat from these foods. The third largest component of this composite was enriched pasta and noodles. The foods in this item-group that were most commonly eaten by children were macaroni and cheese and spaghetti with or without tomato sauce. Corn and rice ready-to-eat cereals combined were 11 percent of the children's composite; most were fortified. Wheat-flour tortillas constituted a separate item-group in the composite for enriched grains, because they were consumed in large amounts. Children ate more wheat-flour tortillas than English muffins or bagels. (Bagels were placed in the item-group for English muffins.) Family Economics and Nutrition Review As expected, the amount of fiber, magnesium, and zinc in the composite for enriched grains was lower than in the composite for whole grains. Meat, poultry, fish. Beef was 48 percent and poultry 27 percent of the children's composite for meat, poultry, and fish. Children ate most of their beef in ground form: 22 percent of their composite for meat, poultry, and fish (table 1). Fresh beef, as in steak and roast beef, was about 19 percent of the children's composite for meat, poultry, and fish. Children's composite also contained about 8 percent beef lunch meatsmostly frankfurters. About 12 percent of the children's composite for meat, poultry, and fish was frankfurters and other lunch meats. Because of their higher fat content or water content or both, 2 ounces of sausages and lunch meats were counted as 1 ounce of lean meat in the Food Guide Servings Data Base. For example, a child who ate a 2-ounce hot dog was credited 1 ounce of lean meat. Chicken, compared with turkey, was the most commonly eaten poultry: 23 versus 4 percent of the children's composite. And it was the roasted chicken breast without skin and chicken nuggets that accounted for 12 percent of all chicken servings. Many of the 188 food codes with poultry servings, which were reported consumed by children, were various fried chicken parts. Fried chicken was not, however, represented as such in the composite, because the leanest form of a food was used. All chicken was represented in the composite by a food code described as "chicken, boneless, not specified as to part, roasted, light or dark meat, skin not eaten." Within the item-group for liver, children ate more chicken liver than beef liver. 1999 Vol. 12 Nos. 3&4 Because children ate less beef liver than did all individuals, the children's composite contained less of vitamins A and B12 (table 2). Canned finfish, mostly tuna in water, was the predominant fish item-group (table 1). For both children and all individuals, the top foods consumed in the item-group for lean finfish were fried. Most servings of fatty finfish were fried catfish for both children and all individuals. Shrimp was the largest component of the item-group for shellfish for children and all individuals, both of whom ate more servings of steamed or boiled shrimp than fried shrimp. The composite for meat, poultry, and fish contributed the most fat and saturated fat of all the composites (table 2). For children, 1 serving of meat, poultry, and fish provided 2.5 g fat, 0.9 g saturated fat, 7.7 g protein, 22 mg cholesterol, 0.5 ug vitamin B12, 0.55 mg iron, and 1.11 mg zinc. Milk. Children consumed more whole milk than did all individuals. Although a composite was not developed for the milk group, because the nutrient profile was to be based on nonfat fluid milk, CNPP did analyze how children consumed their servings of the milk group. Findings showed that about 84 percent of children's servings from the milk group were of fluid milk, 15 percent were of cheese, and 1 percent were of yogurt. Children obtained the bulk of their servings of the milk group by drinking milk: about 92 percent of children's "milk as beverage" servings were whole, 2-percent, 1-percent, or skim milk. The remaining 8 percent of their "milk as beverage" servings were cocoa, milk shakes, chocolate milk, and other flavored milks. Young children consumed a larger percentage of the category entitled "milk as beverage" as whole milk (47 percent) than did all individuals (35 percent). Children had 14 percent of servings from 1-percent or skim milk; all individuals had 21 percent from these types of milk. Ice cream and ice milk were also part (about 4 percent) of children's servings of fluid milk. Children ate less pudding (1 percent of the servings of fluid milk) than ice cream and ice milk. Children also obtained fluid milk in mixtures such as cream sauces and soups, but in small amounts. The milk group is represented by 1 cup skim milk, which provides 8.4 g protein, 86 calories, 0.3 g saturated fat, and 302 mg calcium (table 2). Serving Sizes Across all the food groups and subgroups, children tended to have smaller serving sizes than did all individuals. Children's average intake was 1 serving per report for fruits and juices. When children ate cooked greens, raw broccoli, and romaine (dark-green vegetables), their serving sizes were much smaller than those for all individuals. Children had 0.9 servings, on average, per report. Of all five vegetable subgroups (darkgreen, starchy, etc.), children's number of servings per report (0.4) was the smallest for the deep-yellow vegetable subgroup. Children averaged 0.7 servings per report for legumes and 0.8 servings for starchy vegetables. Among starchy vegetables, children averaged 0.9 servings for potato chips and 0.7 servings for French fries. Children's number of servings per report of other vegetables 27 28 By selecting foods somewhat differently in the food groups and subgroups, children can improve their nutrient intakes. averaged 0.5. The number of servings per report (0.2 for children) for individual item-groups was particularly small for cooked onions, raw celery, and cooked mushrooms, used in small amounts in many mixed dishes. Children had an average of 1.2 servings per report from the composite for whole grains and 1.4 servings per report from the item-group for wholewheat bread. Children averaged 1.2 servings per report across all foods in the composite for enriched grains, 1.4 servings for white bread, and 1.3 servings (a little over V2 cup) for enriched pasta and noodles. The halves of an English muffin or bagel constitute 2 servings of grains; children averaged 1.4 servings per report. For items in the composite for meat, poultry, and fish, children averaged 1.4 ounces per report. For the milk composite, children consumed about 3/4 cup of milk (0.8 servings) per report and 2/3 cup of ice cream per eating occasion. For pudding, the average amount eaten per report was 0.5 servings Ch cup). Generally, the amounts reported for children 2 to 6 years old were about 60 to 80 percent of those for all individuals. This suggests that it is appropriate to continue to use two-thirds of the serving size designated for adults as a serving size for 2- to 3-year-olds when assessing nutrient levels in Food Guide Pyramid patterns for young children ages 2 to 3 (1,9). Two- to three-year-olds need two-thirds of the serving size for adults, except for milk. Two cups of milk are recommended for 2- to 3-year-old children. Four- to six-year-old children need the same serving sizes designated for adults. Food Guide Pyramid Diet Patterns for Young Children The REI for 1- to 3-year-old children is 1,300 calories (2). A 1,600-calorie pattern was considered an appropriate objective for 4- to 6-year-old children. Although the REI for 4- to 6-year-old children is 1,800 calories, food consumption data reported for this age group in the CSFII 1989-91 averaged 1,533 calories. Focus groups with parents, a consumer research aspect of the development of the Food Guide Pyramid for Young Children, indicated that parents were concerned that the amount of food their children ate might not be adequate to meet their nutrient needs.1 It was important to determine whether a diet pattern set at a calorie level close to what children reportedly eat, and based on their reported food choices within food groups, could meet their nutrient requirements. It is not wise to have parents feed their children more food than needed-considering the prevalence of childhood obesity in the United States. CNPP created the diet patterns as follows. For each food group and subgroup composite, the nutrients per Food Guide Pyramid serving were multiplied by the number of servings in the pattern and summed. Discretionary fat was added to bring the level of total fat in . the 1 ,600-calorie pattern to 30 percent of calories and in the 1 ,300-calorie pattern to 34 percent of calories, the actual consumption level in the CSFII 1989-91 for 2- to 3-year-old children. Added sugars, represented as teaspoons of sugar, were then included to bring calories to the levels targeted for the two diet patterns. 1See Tarone (5). Family Economics and Nutrition Review Table 3. Comparison of children's recommended intake with their consumption: Food group and subgroup servings per day All individuals Fruit 1.33 2.00 1.19 1.12 Vegetable 2 servings 3 servings 1.41 servings 2.62 servings Dark-Green 0.29 0.43 0.08 0.13 Deep-Yell ow 0.38 0.57 0.06 0.14 Legume 0.29 0.43 0.08 0.17 Starchy 0.38 0.57 0.61 0.94 Other 0.67 1.00 0.58 1.25 Grain 4 servings 6 servings 4.55 servings 5.50 servings Whole Grain 2.00 3.00 0.96 1.27 Enriched Grain 2.00 3.00 3.59 4.22 Meat, poultry, fish 3.33 llUnces 5.00 ounces 2.55 ounces 4.37 ounces Meat, Poultry, Fish 2.:36 4.57 2.17 3.95 Egg 0. :~9 0.43 0.24 0.32 Nuts and Seeds 0.18 0.0 0.14 0.10 Milk 2.00 2.00 1.94 1.48 Fat, total 49.5 grams 53.4 grams 54.5 grams 70.4 grams Added sugars 7 tsp 6 tsp 13.2 tsp2 19.5 tsp2 Total calories 1,304 kcal 1,613 kcal 1,435 kcal 1,796 kcal 1Calculated by dividing the total weighted number of servings reported over 3 days by 3 and then dividing by the weighted number of people in the ~amples. ~timated extra calories from added sugars in foods and small amounts of foods not accounted for in Food Guide Servings Data Base. The 1,600-calorie pattern contained the minimal number of Food Guide Pyramid servings at the serving size recommended in the original Food Guide Pyramid (table 3). There were 2 servings of fruit, 3 of vegetables, 6 of grains, 5 ounces of meat, and 2 cups of nonfat milk, along with added fat and sugars. The 1 ,300-calorie pattern had the minimal numbers of Food Guide Pyramid food group servings reduced in size by 1999 Vol. 12 Nos. 3&4 one-third for all food groups and subgroups except milk, to represent the one-third smaller serving size estimated for 2- to 3-year-old children. For example, 2 servings of fruit multiplied by two-thirds equaled 1.33 Food Guide Pyramid fruit servings in the 1,300- calorie pattern. A total of 2 cups of milk was included in both diet patterns to meet calcium recommendations. Because there is more fat permitted in the younger child's diet, CNPP substituted peanut butter for a portion of the meat servings in developing the 1 ,300-calorie pattern for 2- to 3-year-old children. This meat alternate, which is higher in fat content, represented the percentage of the meat group that young children consumed as nuts. 29 Table 4. Nutrient levels in Food Guide Pyramid patterns for young children1 Nutrient RDAl.or reeoan.mend8tion ChUd 1-3 1,300-calorle pattern Child 1,600-calorle pattern Child 4-6rs 2-3 CSFI11989-91 consumption Child - - • - • - • - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Kcal - - - - - - - - - - - - - - - • - - - - - - - •• - - - - - - - - - - Calories (avg) 1,300 1 ,800 -1,300 -1 ,300 -1,600 1 ,288 1,533 - - • - • - - - - - - - - - - - - - - Percent of RDA - - - - - - - - - - - - - • - - - - - - - - Protein Calcium Magnesium Iron Zinc Copper Vitamin A Vitamin E VitaminC Niacin Vitamin B6 Folate Vitamin B12 16 g 800mg 80mg 10mg 10mg 0.7mg 400RE 6mg 40mg 9mg l.Omg 50ug 0.7ug 24g 361 800mg 98 120mg 259 lOmg 74 10mg 77 1.0 mg 100 500RE 267 7mg 98 45 mg 169 12mg 122 1.1 mg 104 75 ug 329 l.Oug 513 241 325 305 244 98 109 94 107 173 225 219 169 74 110 96 117 77 107 68 82 70 100 98 81 214 295 177 162 84 89 78 77 150 220 194 186 92 130 143 134 95 133 117 126 219 303 378 295 359 460 492 371 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Percent of Kcal- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Fat3 Saturated fat3 <34 <13.6 . 30 34.1 <10 10.5 34.1 29.8 34.4 34.0 10.5 9.3 13.6 13.3 - - - - • - - - - - - - - - - - - - - - - - - - - - - - - - - - - Milligrams - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Cho1estero14 Sodium4 300 300 161 161 230 182 210 <2,400 <2,400 1,127 1,127 1,485 2,122 2,534 - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - Grams - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Fibe? 8 9-11 12.0 12.0 17.4 8.5 10.4 1Composite nutrient profiles based on children 2 to 6 years old. 2Recommended Dietary Allowances (RDA), 1989. 3U.S. Department of Agriculture and U.S. Department of Health and Human Services, 1995, Nutrition and Your Health: Dietary Guidelines for Americans. 4National Research Council. 1989. Diet and Health. National Academy Press, Washington, DC. 5 American Health Foundation for "age plus 5" per day (Williams et al ., 1995). Source: CSFII 1989-91, 3-day weighted sample. Total nutrient levels in the 1,300- and 1 ,600-calorie patterns were then compared with the 1989 RDA for children 1 to 3 and 4 to 6 years old and with other recommendations, as specified earlier, for fat, saturated fat, cholesterol, sodium, and dietary fiber (table 4). 30 Except for vitamin E (89 percent of the RDA), the 1 ,600-calorie pattern met or exceeded all nutrient requirements for children ages 4 to 6. Vitamin E was also less than the RDA in the 1,300- calorie pattern. However, the levels of vitamin E in the patterns exceeded the amounts consumed by children, as reported in theCSFII 1989-91, because the composite for discretionary fat, which was based on food supply data for individuals of all ages, contained more vegetable fat (rich in vitamin E) than young children ate. The fat Family Economics and Nutrition Review composite had more polyunsaturated fat and less saturated fat than the amount consumed by children. The 1 ,300-calorie pattern provided at least 100 percent of the RDA for most nutrients for both 2- to 3-year-olds and 4- to 6-year-olds. The major exceptions were the trace minerals-iron and zinc for both age groups and copper for the 4- to 6-year-olds. The amount of iron provided by the 1 ,300-calorie pattern was lower than the amount consumed by children, according to the CSFII 1989-91. The reason for this difference: composites for whole grains and enriched grains contained non-fortified breakfast cereals, but the cereals children ate were fortified. Additional analysis showed that when breakfast cereals included in the grain composites were changed to contain iron and zinc at fortification levels, the Food Guide Pyramid patterns provided recommended levels of iron and zinc for children. The 1,300- and 1,600-calorie patterns met or nearly met objectives for fat, saturated fat, cholesterol, sodium, and dietary fiber. At 10.5 percent of calories in the 1 ,300-calorie pattern, saturated fat was somewhat lower than the actual level of consumption targeted for the 2- to 3-year-old child: 13.6 percent. Consumption of Food Groups Table 3 shows the recommended numbers of food group and subgroup servings for the 1,300- and 1 ,600-calorie Food Guide Pyramid patterns developed for young children. The numbers of servings for vegetables, grains, and meat and me~t alternates were derived as follows. Originally when the food guide was developed, the daily servings of vegetables were divided equally among dark-green/deep-yellow, legumes/ 1999 Vol. 12 Nos. 3&4 starchy, and other vegetables (1). For vegetables, "several" servings was defined as 3, so several times a week meant 3 times a week or 317 of 1 serving per day. For the 1 ,600-calorie pattern, 3 vegetable servings were divided into 1 serving each from dark-green/deepyellow, legumes/starchy, and other vegetables. Hence the 317 (0.43) darkgreen and 417 (0.57) deep-yellow provided 1 serving per day, the 0.43 legumes and 0.57 starchy provided another serving, and other vegetables provided the third serving per day. The numbers of grain servings were based on the Food Guide Pyramid recommendation to choose "several" servings a day of foods made from whole grains (6). For the meat and meat alternates, the number of egg servings was based on 3 eggs per week, and the meat, poultry, fish servings were calculated by difference (0.43 eggs subtracted from 5.0 ounces total meat and meat alternates). The Food Guide Servings Data Base used in this study did not quantify the amount of added sugars in foods. These values were estimated from the calories in added sugars in foods and from the calories in small amounts of foods, such as raisins in oatmeal raisin cookies and garnishes and condiments, which were not counted by the Food Guide Servings Data Base. Calories were then expressed as average daily servings of added sugars, in teaspoons. Thus the average daily servings of added sugars may somewhat overestimate actual intakes of sugar. However, these estimated consumption levels of sugars were much higher than the levels of 6 teaspoons and 7 teaspoons (1 ,600- and 1 ,300-calorie patterns, respectively) suggested in the Food 'Guide Pyramid patterns. Conclusions Children ate somewhat differently from the rest of the population, as indicated by composites of the food groups and subgroups, which were based on reported food consumption by young children ages 2 to 6 and all individuals ages 2 and older. However, the variations resulted in few substantial differences in the nutrient profiles of a composite serving of any of the food groups or subgroups. Young children consumed smaller servings of foods, typically 60 to 80 percent of the average amounts for individuals of all ages. A serving that is two-thirds of the original Food Guide Pyramid serving is a reasonable estimate for assessing nutrient levels in patterns for 2- to 3-year-old children. The 1 ,300-calorie Food Guide Pyramid diet pattern, which used the children's composites and nutrient profiles, met or nearly met objectives for most nutrients except for iron, zinc, and copper. The 1 ,600-calorie pattern met all of the objectives except for vitamin E. When iron and zinc were included at regular fortification levels in the ready-to-eat cereals used in the grain composites, diet-pattern levels of these nutrients met the RDA. Breakfast cereals were popular with young children, so ensuring that these cereals are fortified with iron and zinc can contribute substantially to meeting targeted intakes of these nutrients. Copper was less than the RDA in the 1,300-calorie pattern for the 4- to 6- year-old, but the older child would probably be consuming closer to 1,600 calories. Older children could improve their reported copper intake by eating more legumes. Both the 1,300- and 1 ,600-calorie patterns were somewhat 31 low in vitamin E, but they exceeded the CSFII 1989-91 reported consumption levels of this nutrient. It is important to reduce fat in the diet as children age, from 2 to 5 years. Emphasis should also be given to replacing a portion of animal fats with vegetable oils, both to decrease saturated fat intakes and to increase vitamin E intakes. The results of the analysis on the RDA showed that most RDA would be met when the children's composites were used in the diet patterns. By selecting foods somewhat differently in the food groups and subgroups, children can improve their nutrient intakes. Children's diets could be improved by including more servings of vegetables, especially dark-green and deep-yellow vegetables and legumes, and more wholegrain products. Replacing some of the apple and grape juices that children frequently drink with more servings of whole fruit could improve consumption of nutrients and dietary fiber. Replacing some lunch meats with lean meat, poultry, and fish may also improve nutrient intakes. Children's diets could be improved by their choosing foods that contribute more food guide servings and less added sugars. 32 References 1. Cronin, F.J., Shaw, A., Krebs-Smith, S.M., Marsland, P., and Light, L. 1987. Developing a Food Guidance System to implement the Dietary Guidelines. Journal of Nutrition Education 19:281-302. 2. National Academy of Scie.nces, National ResearchthCouncil, Food and Nutrition Board. 1989. Recommended Dietary Allowances (10 ed.). National Academy Press, Washington, DC. 3. National Research Council. 1989. Diet and Health. National Academy Press, Washington, DC. 4. Putnam, J.J. and Allshouse, J.E. 1996. Food Consumption, Prices, and Expenditures, 1996: Annual Data, 1970-94. U.S. Department of Agriculture, Economic Research Service. Statistical Bulletin No. 928. pp. 59, 61 . 5. Tarone, C. 1999. Consumer research: Food Guide Pyramid for Young Children. Family Economics and Nutrition Review 12(3&4):33-44. 6. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. 1996. The Food Guide Pyramid. Home and Garden Bulletin No. 252. 7. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. 1997. U.S. Food Supply Series 1909-1994. (In-house data base.) 8. U. S. Department of Agriculture and U.S. Department of Health and Human Services. 1995. Nutrition and Your Health: Dietary Guidelines for Americans (4th ed.). Home and Garden Bulletin No. 232. 9. Welsh, S.O., Davis, C., and Shaw, A. 1993. USDA 's Food Guide: Background and Development. U.S. Department of Agriculture, Human Nutrition Information Service. Miscellaneous Publication No. 1514. 10. Williams, C.L., Bollella, M., and Wynder, E.L. 1995. A new recommendation for dietary fiber in childhood. Pediatrics 96:985-988. Family Economics and Nutrition Review Catherine Tarone Center for Nutrition Policy and Promotion 1999 Vol. 12 Nos. 3&4 Consumer Research: Food Guide Pyramid for Young Children Developed specifically as a guide for feeding young children, the Food Guide Pyramid for Young Children adapts recommendations of the original Food Guide Pyramid and provides messages, based on the food guide, that are helpful to parents and caregivers in improving the nutritional status of 2- to 6-year-olds. A qualitative consumer research study was conducted to identify needs of the target audience (parents and caregivers of 2- to 6-yearold children), to explore, with this audience, messages based on the food guide, and to evaluate prototype educational materials based on the food guide-based messages directed at behavior change. Parent- and caregiverparticipants recommended emphasizing the message to "eat a variety of foods" as a theme for nutrition education materials that are designed to improve young children's diets. They also suggested that a "child-friendly" graphic of the Food Guide Pyramid would help young children remember the Pyramid. USDA produced a booklet presenting nutrition guidance messages and a "child-friendly" poster of the Food Guide Pyramid. he Food Guide Pyramid is USDA's primary nutrition education tool designed to help healthy Americans select a diet that is consistent with the Dietary Guidelines. The Food Guide Pyramid illustrates patterns of food selection that provide adequate amounts offood energy, protein, vitamins, minerals, and dietary fiber for good health but are moderate in fats, added sugars, and sodium. Adaptation and translation of dietary guidance into dietary practice are important components of any effort to help improve diets, including those of young children. In Phase I of the project to develop a Food Guide Pyramid for Young Children, the Center for Nutrition Policy and Promotion (CNPP) developed the technical nutrition basis for adapting the Food Guide Pyramid (6,7). CNPP staff determined that the nutrients in the foods children consume, if eaten in amounts recommended by the original Food Guide Pyramid, would meet children's nutrient needs. Because Pyramid food groups and recommended numbers of servings resulted in a nutritionally adequate diet for young children, the Pyramid graphic could be adapted for young children. Also during Phase I, eight message concepts emerged from the review of literature (5), discussions were held with nutrition educators, and comparisons were made of actual food group and subgroup consumption with the recommendations of the Food Guide Pyramid, as adapted for young children 33 (6) . The concepts were explored and further developed during Phase II. In support of USDA's nutrition education efforts to translate dietary guidance into consumer behaviors, CNPP conducted a qualitative consumer research study in Phase ll. Qualitative research is particularly useful for gaining insights and a better understanding of the target audience. Qualitative research consists of openended, structured discussions or interviews with individuals or small groups of individuals-the purpose of which is to gather a greater depth of information than can be obtained by using quantitative techniques ( 3 ). CNPP conducted qualitative research because consideration of the target audience, including its wants and needs, is the foundation of this research project to advance dietary guidance for children in a way that motivates behavior change in both adults and children. Recent research on the effectiveness of nutrition education programs, including those with preschool children, found that programs using educational methods directed at behavior change as a goal were more likely to be successful than programs that focused on information dissemination (4). Methods The focus group study was conducted in two rounds. The objectives for the first round were to assess the nutrition information that parents and caregivers of 2- to 6-year-old children needed, to identify the key concerns for nutrition education, to assess familiarity with the Food Guide Pyramid, and to explore nutrition guidance messages (based on the food guide) for young children. The objectives for the second round were to determine whether the prototypes 34 effectively communicated nutrition guidance to the target audience of parents and caregivers of 2- to 6-year-olds. The discussions for the second round were designed to assess consumer reaction to the prototype materials (including their reactions to design and layout, readability, and applicability of the message concepts) and to identify any confusing or misleading information. Samples For the first round, six focus groups, three with parents and three with caregivers, were conducted in January 1998. Parents were screened based on their ethnicity, household income, and educational level. Parents were also screened to ensure that they had at least one child 2- to 6-years-old and had not participated in a focus group within the last 6 months. Caregivers were included if they cared for 2- to 6-year-olds. (They could provide in-home care as well as care in larger facilities.) Twelve people were recruited for each group so that at least eight would attend. Some geographical dispersion was obtained by conducting one focus group with parents and a separate focus group with caregivers in each of three cities-Baltimore (Maryland), Richmond (Virginia), and Chicago (11linois). Fifty-two adults participated in the first round of the study. In July 1998 the second round began. One focus group with parents and another focus group with caregivers were held in each of three cities-Baltimore (Maryland), Richmond (Virginia), and Chicago (11linois)-for a total of six groups. The screening criteria used for the first round were also used for this round. In addition, parents in Richmond and Chicago with 5- to 6-year-olds were screened to have their children participate in a mini-focus group. Twenty-seven parents, 25 caregivers, and 8 children participated in the second round; none had participated in the first round. Procedures For the first round of focus group studies, the moderator, with over 10 years of experience working with focus groups, led each group through the 2-hour sessions. Each focus group began with introductions and an icebreaker, followed by discussions based on the objectives. The discussions identified goals, benefits, and barriers to healthful eating, participants' knowledge of nutrition, and their feeding practices. The session then focused on the nutrition messages of the Food Guide Pyramid and how they apply to young children. Discussions ended on the eight messages regarding nutrition guidance and how to communicate them to young children. All sessions were audio-taped and transcribed to obtain participants' exact responses to questions. Once transcribed, comments were color-coded and grouped according to content; this allowed key discussion themes to be uncovered. The moderator and his staff recorded and reported participants' verbal and nonverbal emotional expressions. After the first round, CNPP developed the text of the materials to be used with the participants in the second round. The prototypes were designed and produced through USDA's Office of Communications Design Center. To emphasize the variety theme, CNPP used the slogan 1-2-3 Variety in all three prototypes. The prototype for the parents, a full-color, 12-page booklet, A Parents' Guide to Using the Food Guide Pyramid, contained an adapted graphic of the Food Guide Pyramid. Also included was general nutrition Family Economics and Nutrition Review information that gives a better understanding of 1. healthful eating, 2. tips on increasing the variety of foods eaten, 3. meal planning and time-saving tips, 4. guidance on specific issues such as serving sizes and fat intake recommendations related to young children, and 5. age-appropriate kitchen activities. The brochure Caregivers: Using the Food Guide Pyramid for Young Children was based on the assumption that most caregivers have access to nutrition education materials and have some knowledge of the Food Guide Pyramid. The brochure contained the new graphic and an explanation of changes made from the original Pyramid graphic, including text to make clear that the adapted Food Guide Pyramid does not replace the original Pyramid. Also included were a list of foods to encourage variety in the diet and a step-by-step food activity designed to involve young children. The third prototype, a poster of the adapted Food Guide Pyramid graphic, showed foods (drawn in a realistic style and shown in single serving sizes when possible) commonly eaten by young children. The names of the food groups were simplified, and the number of servings was represented by a single number rather than a range of numbers. The symbols for fat and sugars were eliminated, and food pictures were used in the tip. One week before the sessions for the second round, parent-recruits were sent the text of the information that was prepared for parents; caregiver-recruits were sent the text of the information that was prepared for the caregiver's 1999 Vol. 12 Nos. 3&4 brochure and the parents' booklet. The recruits were instructed to read the material before attending their sessions; thus, focus group time would be used for discussion rather than be used, to a great extent, for reading. The same moderator who led the first round of focus groups led the 2-hour second-round focus groups. At each session, following introductions and an icebreaker, participants were shown the prototype poster, The Food Guide Pyramid for Young Children, after which it was discussed and put aside. Each parent then received the information booklet A Parents' Guide to Using the Food Guide Pyramid for Young Children, and the moderator led a discussion designed to evaluate the booklet. Caregivers were given the brochure Caregivers: Using the Food Guide Pyramid for Young Children. Following a discussion to evaluate the brochure, each caregiver was given the parent booklet. Throughout these sessions, the participants were asked to read and respond to several sections of text and to the visual presentation of the materials. The mini-focus group sessions with the children began with parents and children in the same room. Following a brief introduction and explanation of the process, the children were taken to a separate room where the moderator showed them a prototype poster of the Food Guide Pyramid. The moderator led the children in a discussion of the poster and the concept of healthful eating. The children were not asked about the other materials intended for adults that required an eighth-grade reading level. As with the first round, · all sessions in the second round were audio-taped, transcribed, color-coded, and grouped according to content. The idea of using the graphic of the Food Guide Pyramid as a teaching tool, as it turns out, was a new concept for some parents. 35 Results The First Round The 27 parent-participants in the first round of the focus group studies had at least one child 2 to 6 years olds; 78 percent were female. Forty-nine percent were African American; 37 percent, White; 11 percent, Hispanic; and 3 percent, Asian. Almost 80 percent had attended or graduated from college; about 40 percent had a household income between $20,000 and $40,000. Of the 25 participants who were caregivers, 24 percent worked in in-home childcare facilities. As a qualitative research method, focus groups are not projectable to any population; however, they provide insight into how the consumer views the world and what the consumer thinks ( 8 ). Findings from this focus group research can be presented under four key discussion themes: Current Feelings Toward Feeding Young Children, Current Behavior and Knowledge, Food Guide Pyramid, and Nutrition and Dietary Behavior. All quotes from participants are taken from the unpublished reports prepared for USDA (1). Current Feelings Toward Feeding Young Children. Identifying the key concerns of parents and caregivers for nutrition education and exploring benefits and barriers to an improved dietary pattern in young children resulted in a key theme. "One of the most important things to teach them at an early age is to set good standards and give them a good foundation as they grow." (Caregiver) 36 "There are a variety of things we try to accomplish through healthy eating ... socialization, nutrition, emotional stability, which are related to food." (Caregiver) "It's important that children learn good nutrition habits, so as they grow older, they will eat right instead of eating at one fast-food place one day and another fast-food place the next day." (Parent) "If you teach them now, they are more apt to continue doing it rather than to introduce them to healthy foods after they have eaten years of junk food. It is easier to do it now." (Parent) Table 1 shows the benefits and barriers in the descending order in which they were mentioned by parents and caregivers. Results showed that these parents and caregivers think alike when discussing the benefits of healthful eating. They were asked: "What are the benefits of preparing healthy meals for younger children?" Most answered, "good health." The second benefit mentioned more often by both groups was, "developing good eating habits at an early age." Caregivers also pointed out that children are better behaved, have longer attention spans, and have energy to do things when they are fed well. When it comes to feeding young children, parents most often mentioned the following barriers to healthful eating: the lack of time to plan and prepare meals, inexperience in dealing with picky eaters, and the negative influences of others. "Time is needed in three different places. You have to plan the meal, purchase it, and prepare it. " "/ need information on what to do with an extremely picky eater who won't eat anything." - "If they are with somebody else, you don't have any control over the foods they eat." Caregivers seemed at ease when discussing nutrition and how they feed young children. Caregivers rarely mention having difficulty with "picky eaters." Instead, they said most children were willing to try a new food if they saw their friends eating the food. Several caregivers said parents were the biggest barrier to improving children's diets. "It's just a lack of knowing what is nutritious for a child. They [parents] think that a bag of chips and a soda are nutritious." "Parents don't know what their children are supposed to eat as a balanced meal. I think it's important that we send the information home to the parents so that they [children] can eat healthy and be consistent with what we do. " Current Behavior and Knowledge. All groups were quite knowledgeable about nutrition, based on the level of discussion of most parents and caregivers. When asked to rate themselves on a scale of 1 to 10 on how well they believe they provide their children with healthful and nutritious meals, parents rated themselves "average" to "above average"; caregivers rated themselves "above average" to "excellent." During further discussion, in spite of their knowledge of nutrition and ratings, many parents expressed feeling ill-equipped to feed their young children a healthful diet. They knew the "why's" but not the "how's." Family Economics and Nutrition Review Table 1. Benefits and barriers to improving children's diets Parents say: Good health Good eating habits Minds work better Better attitude Food is a key part of a loving home Parents say: Lack of knowledge Lack of time to plan meals Lack of time to prepare meals Negative influences of others Picky eaters Cost of food/wasting food "Not enough of the information focuses on children. What we've been doing is taking adult information and applying it to children." (Parent) "/ think of nutrition and feeding my daughter as a challenge every day." (Parent) Most caregivers seemed both knowledgeable and comfortable discussing the "do's" and "don't's" of nutrition as each concept related to young children; caregivers were very comfortable with the "how's." "The goals of Head Start are pretty clear that nutrition is an integral part of the program." During the parents' discussions, firsttime parents of very young children were most concerned about serving 1999 Vol. /2 Nos. 3&4 Benefits to improving diets Caregivers say: Healthy children-less sickness Good eating habits Energy Happy children-happy parents Emotional, cognitive, social growth Food is a key |
OCLC number | 888048641 |
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