Nutrition Issues

Nutrition Basics

After studying this chapter you will be able to:

▸▸ Define a nutrient.

▸▸ Distinguish between macronutrients and micronutrients.

▸▸ Communicate the messages of MyPlate and the Dietary Guidelines for Americans.

▸▸ Describe appropriate feeding regarding growth and development for infants, toddlers, and young children.

▸▸ Explain the concept of the division of responsibility of feeding.

▸▸ Distinguish between Type 1 and Type 2 diabetes mellitus.

▸▸ Identify various types of food allergies.

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Introduction to Nutrition Basics Chapter 2

2.1 Introduction to Nutrition Basics All living organisms must take in nutrients from their environment to fuel their daily activities and to build and maintain structure. Because children are actively growing, their nutrition is an especially critical and dynamic process. Educators play an important role in the habits chil- dren form in relation to the foods they eat. This chapter provides the foundation of nutrition knowledge necessary to facilitate children’s growth and development, both physically and cognitively.

Nutritional Science

A nutrient is any component of food that our bodies require for biological functions, metab- olism, growth, or maintenance. We need six major nutrients, which can be organized into three categories. The first category, macronutrients, includes those three that we need

in large supply (grams daily). The micronutrients are needed in smaller amounts (micrograms to milli- grams). Finally, there is water, which does much more than keep us hydrated.

Most foods tend to be a good source of nutrients. No food is complete and offers all the nutrients we need. Therefore, eating a well-balanced diet with a lot of

variety helps ensure we meet our nutritional needs while avoiding excesses. It is important to understand the role of nutrients in our bodies, good food sources for each nutrient group, and potential nutrient-related health issues.

Macronutrients

The macronutrients (carbohydrates, protein, and fat) can all be used by the body for energy, which is nutritionally measured in kilocalories (often shortened to calories in lay terms). A kilocalorie is the amount of energy necessary to raise the temperature of 1 liter of water by 1°Celsius at sea level. Though protein can be used for energy, it is best used for build- ing and maintaining body tissue. Therefore, it is important to ensure adequate consumption of carbohydrates and fats so that the protein can serve its primary purpose, especially in a growing child.

Table 2.1: Comparison of the Macronutrients

Macronutrient Primary function Common food sources

Carbohydrate Provide energy Grains, rice, cereals, fruits, vegetables, some dairy

Protein Provide building blocks for tissue growth and maintenance

Meat, poultry, fish, eggs, some dairy. Common plant sources: legumes, beans, tofu (made from soybeans)

Fat Provide concentrated energy

Animal foods (including some dairy), oils

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Introduction to Nutrition Basics Chapter 2

Carbohydrates as Energy

A carbohydrate is exactly what it sounds like: carbon + water (carbo-hydrate). Because water is comprised of oxygen and hydrogen, all carbohydrates contain those three elements: carbon, hydrogen, and oxygen. Although all three categories of macronutrients can provide energy, the preferred source of energy in our diets is carbohydrates, which provide 4 kilocalo- ries per gram. Glucose, the most common form of carbohydrate, is the only source of energy that can be used by the brain. It is for this reason that carbohydrates are the staple of diets all around the world. Carbohydrates are primarily found in plant-based foods, such as grains, cereals, and rice. We also find carbohydrates in fruits, vegetables, and some dairy products, such as milk and yogurt.

Carbohydrates are categorized as simple carbohydrates (mono or disaccharides) or complex carbohydrates (polysaccharides). Simple carbohydrates are molecules that are made up of one (monosaccharide) or two (disaccharide) units and are often referred to as sugars or simple sugars. Monosaccharides include glucose, fructose, and galactose. Combinations of the monosac- charides form disaccharides:

• Glucose + Fructose = Sucrose (also known as table sugar)

• Glucose + Galactose = Lactose (found in dairy foods)

• Glucose + Glucose = Maltose (found in grains)

Sugars occur naturally in foods, such as fructose in fruit, lactose in dairy. These foods are nutrient-dense because they also provide vitamins, minerals, and fiber. Added sugars, such as table sugar and high fructose corn syrup, are frequently used ingredients in other low nutrient-density foods, such as soda, candy, breakfast cereals, and fruit drinks (that are not 100% fruit juice). Sometimes “desirable” nutrients are added to the food in order to try to make these foods seem more complete. However, the more we can rely on whole foods the better. Whole foods are those that have been minimally processed, to provide our bodies with nutrition.

Complex carbohydrates, or polysaccharides, are longer chains of individual sugar units. There are three types of polysaccharides: starch, glycogen, and fiber. Starch is the plant stor- age form of carbohydrate. When we eat these foods, which are packed with carbohydrates, we break down their starch so we can absorb it and then use it for energy and storage. We store relatively small amounts of starch as glycogen in our liver and muscle cells for a backup source of glucose.

The third category of polysaccharides is fiber, which is an indigestible complex carbohy- drate. We do not have the enzymes necessary to break this down. Fiber is often described in terms of its solubility, or how it reacts with water. The gel that is formed by soluble fibers slows digestion, helps us feel full, and then passes through our small intestines into our colons, where it can be digested by good bacteria. Soluble fiber also binds cholesterol, which is why it is described as being heart-healthy. Insoluble fiber does not dissolve in water or get digested by gut bacteria. Although it doesn’t dissolve in water, it does attract water, which helps contribute to the bulk of our stool, important for maintaining regularity. Foods can contain both soluble and insoluble fibers, and both types of fiber are extremely

▲ Grains are an important part of the diet because they contain car- bohydrates, which are the body’s preferred source of energy. © Comstock/Thinkstock

Introduction to Nutrition Basics Chapter 2

important for our health. The best way to get the most out of the fiber in foods is to eat a wide variety to ensure that we hit all our nutritional bases and avoid dietary deficiencies or excesses.

Protein as Building Blocks

Protein is an essential nutrient composed of chains of amino acids for the building and main- taining of body tissue such as muscles, organs, hair, nails, skin, and bones. To grow, children need to take in protein from the diet to build more tissue, whereas an adult needs protein to maintain body tissue. Proteins also make up many of the molecules in our body that are involved in hormones, immunity, fluid balance, and other body processes. Proteins can also be used as a last-resort energy source (also providing 4 calories per gram), but cannot be used to power the brain. If we do not take in enough energy from other sources, protein from the diet, even our own muscles and organs, are sacrificed to make fuel. This means a child’s muscles and organs are at risk for being broken down if that child does not eat enough. The body cannot sustain this and becomes malnourished.

The building blocks of proteins are amino acids. Our bodies need 20 types of amino acids. Each amino acid molecule contains carbon, hydrogen, oxygen, and nitrogen. Carbohydrate and fat do not contain nitrogen, making protein the primary source of nitrogen in our diet.

Long chains of amino acids form proteins, which can also be called polypeptides.

The most well-known protein sources come from animals: meats, fish, poultry, eggs, and some dairy products. Animal proteins are complete sources of protein, as they provide all the amino acids we need. This means that when we eat any kind of animal protein and our digestive system breaks it down, it provides all 20 amino acid building blocks that our bodies need to make tissue. Since they often come along with saturated fat and cholesterol, it is good to choose lean meats in moderation. The protein provided in any single plant food does not contain every amino acid that we require. For example, when we eat rice and break down its protein, it is miss- ing some of the 20 amino acid building blocks that our bodies need. Beans are also missing some amino acids, but not the same ones as rice. When eaten together, beans and rice provide all 20 amino acids.

These are referred to as incomplete proteins, because when eaten in isolation, they do not provide every single amino acid that our bodies require. However, combinations of these plant foods do hit all our amino acid bases. We call these complementary proteins, protein sources that provide all the amino acids when eaten in combination. Common combinations of complementary proteins are rice and beans, or legumes with grains (e.g., peanut butter and bread, hummus and pita). Soy is an exception and is a plant protein that contains all the amino acids we require. Traditionally, these foods are commonly eaten together at a meal, but our bodies will have the protein building blocks they need as long as complementary proteins are consumed within the same day. Including a variety of plant foods daily can provide complete nutrition for a healthy body while minimizing health risks associated with the relatively high- fat diet that comes with a mostly animal-based diet.

▲ The most well-known sources of proteins are animal products. Since these foods often contain saturated fat and cholesterol, it is good to choose lean meats, and to eat meat in moderation. © Jeffrey Coolidge/Getty Images

Introduction to Nutrition Basics Chapter 2

Fat and Concentrated Energy

Fat, also referred to as a lipid, is the final macronutrient. It is insoluble and composed of carbon, hydrogen, and oxygen. It is a major source of energy, providing 9 kilocalories per gram. While we need to be careful about how much of this concentrated energy source we consume, fats are a necessary part of our diets and should not be overrestricted, particularly in children. In our bodies, fat also serves as insulation and a storage form of energy. Fats allow for the absorption of fat-soluble vitamins (A, D, E, and K) during digestion.

There are distinctions between the types of fat we eat that are important to recognize. We should ensure moderate intake of fats in general and emphasize healthy fat. Healthy unsatu- rated fats (olive, safflower, canola oil) can be divided into monounsaturated and polyunsatu- rated fatty acids. It is notable that there are two kinds of polyunsaturated fats, called essential fatty acids that cannot be made by the body and must be consumed from the diet: linoleic (omega-6) and alpha-linoleic (omega-3) acid. Omega-3 fatty acids are particularly beneficial for promoting heart health. Good sources of omega-3 fatty acids include walnuts, flax, canola, soy, and fish (such as salmon and tuna). These essential fats allow us to make other important fatty acids, such as arachidonic acid (ARA), eicosapentaenoic acid (EPA), and docosahexanoic acid (DHA). ARA and DHA are particularly important in the growth and development of infants and children.

Unlike the essential fatty acids, other fats are not absolutely nec- essary in the diet. Not all fats have health benefits; in fact, certain unhealthy fats are associated with chronic diseases.

• Saturated fats are solid at room temperature and increase the risk of heart disease. Common sources of saturated fats are meats, cheese, butter, and eggs. There are a few plant foods that contain saturated fat, including coconut and palm oil.

• Trans fats are oils that have been hydrogenated (chemi- cally altered) to become solid fat. They also increase the risk of heart disease. These are commonly used in food processing and baking (shortening).

• Cholesterol is a kind of lipid that is found in animal foods only, though it can be made from other fat and does not need to be consumed. We use cholesterol as hormones, cell membranes, and a precursor for bile acids and vita- min D. High-density lipoprotein is the healthy choles- terol that takes fats to the liver to be used in the body or excreted. Low-density lipoprotein is the unhealthy cho- lesterol that is deposited into artery walls and increases the risk of heart disease.

Since any source of fat is a concentrated source of calories, we should not eat fat in excess. When we do, it is important to limit the sources of cholesterol, saturated fat, and trans fat to promote heart health.

Micronutrients

Although micronutrients are needed by the body in smaller amounts than are macronutrients and do not provide energy, they are no less vital to life. Vitamins and minerals are critical for

▲ ”Healthy” fats are unsaturated fats that are found in foods such as olive oil, avocados, or almonds. Although better for the body than saturated fats, aim to choose healthy fats in moderation. © Pornchai

Mittongtare/Getty Images

Introduction to Nutrition Basics Chapter 2

▲ Vegetables and fruits are vital sources of the micronutrients our bodies need. © Martin Poole/Thinkstock

using the macronutrients consumed. Food process- ing and refinement can alter the amount of vitamins and minerals in food. Vitamins, since they are organic compounds, are more vulnerable to storing and cook- ing. Be sure to store fruits and vegetables in airtight containers and at cooler temperatures. Longer cook- ing times and cooking in a solvent (such as boiling in water for water-soluble vitamins) will reduce the vitamin content of the food.

Eating a varied, balanced diet that meets calorie needs is the best way to ensure consumption of the nutrients our bodies need while avoiding excesses. Vitamin and mineral supplements may be of benefit to some people, but they should not act as a replace- ment for a healthy, balanced diet. Supplements increase the likelihood of overconsumption of nutri- ents, which can lead to toxic amounts in the body. Additionally, some of the health benefits attributed to a particular vitamin or mineral may not actually be healthful in isolation, instead being best used by our bodies when consumed in the foods in which they naturally occur. Supplements are appropriate under certain conditions, such as folic acid for women of childbearing age. Fortified foods can be options for people who have conditions that limit their intake of certain foods. For example, someone with a milk protein allergy might benefit from consuming 100% orange juice that has added calcium and vitamin D. However, overconsumption of fortified foods would also increase the chance of toxicities. The supple- ment and food industries have enormous influence in our current food and nutrition culture, but are not regulated under the Food and Drug Administration (FDA). They are not subject to the stringent research and quality control that drugs are.

Vitamins

Vitamins are organic compounds that are required in small amounts to facilitate body processes as cofactors for enzymes that catalyze reactions in the body. They are also involved in immunity, hormone regulation, and maintaining other body functions. The 13 vitamins needed by the human body can

be separated into two categories: water-soluble and fat-soluble.

The water-soluble vitamins are readily absorbed by our bodies. Some vitamins function as antioxidants,

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Introduction to Nutrition Basics Chapter 2

which are substances that destroy free radicals (compounds that cause dam- age). Antioxidants are associated with decreasing the risk of cardiovascular disease and cancer. The B vitamins include thiamin, riboflavin, niacin, pan- tothenic acid, pyridoxine (commonly referred to as B6), biotin, cobalamin (commonly referred to as B12), and folic acid. The water-soluble vitamins are readily absorbed but not easily stored by our bodies. Additionally, since they are water-soluble, they are easily excreted in our urine. Unlike the water- soluble vitamins, the fat-soluble vita- mins differ greatly in their functions. The fat-soluble vitamins are needed in larger amounts and are stored in our bodies, mainly in the liver. They cannot be excreted because they do not dissolve in water. For this reason, we have to be careful not to ingest excessive amounts of these vitamins, or we risk toxicity. Vitamin D is gaining increasing attention today. Its biggest role is in our bone health, as it regulates calcium and phosphorus. Chronic vitamin D deficiency leads to rickets. Because of the lack of vitamin D, the bones do not have sufficient calcium and phosphorus. This causes the bones to be soft and leads to bone deformities, bowed legs and deformities of the bones in the rib cage. In addition to bone health, there is emerging evidence about Vitamin D’s potential role in other areas of health, such as cancer, diabetes, immune system, and blood pressure (Ross et al., 2011). It’s a unique vitamin, in that we can make it with sun exposure.

Another category of nutrients is phytochemicals, which are chemicals that are found in plants and have properties that may offer health benefits or prevent disease. Interestingly, many phytochemicals and vitamins are associated with different-colored fruits and vegetables. By eating fruits and vegetables from all the color groups (red, yellow/orange, white, green, blue/purple, and brown), we are more likely to get a broad spectrum of beneficial nutrients.

Minerals

Minerals are inorganic substances that yield no energy and are required by the body in small amounts to serve as structural components and facilitators of body processes. The two major classifications of minerals are major minerals (those that are needed in amounts of 100 mg/day or more) and microminerals (those that are needed in amounts of 15 ml/day or less, also known as trace elements). Within the category of major minerals are the electrolytes (sodium, potassium, and chloride), which play a part in the regulation of fluid balance and participate in nerve transmission.

In addition to sodium, potassium, and chloride, the major minerals include calcium, phos- phorus, magnesium, and sulfur. Four of these are particularly important during childhood: sodium, potassium, calcium, and phosphorus. The microminerals include iron, fluoride, zinc, iodine, selenium, copper, chromium, cobalt, and molybdenum. Of these, iron, fluoride, and zinc are of particular importance in health and childhood nutrition.

© Warren Miller/The New Yorker Collection/www.cartoonbank.com

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Nutrition Issues Chapter 2

Water

Water hydrates and serves as a solvent for the chemical reactions that happen constantly in our body. Water also allows for transport of substances within the body. It plays a large role in the regulation of body temperature and makes up a surprisingly large portion of our bodies. An infant’s body can be as much as 75% water, whereas the adult body contains approxi- mately 60% water. Since younger bodies are made of more water, they are more vulnerable to their hydration status. Additionally, infants have immature kidneys, whose major role is water balance. We cannot survive without water for more than a few days. Dehydration can occur from not taking in enough water, as well as from increased water losses. Situations that can lead to too much water loss include vomiting, diarrhea, and fever. Symptoms of dehydration can range from mild thirst, dry mouth, lethargy, and decreased urine output to changes in blood pressure and heartbeat, mental status changes, and loss of consciousness. Thirst is not always a reliable indicator of hydration status. The color of the urine is a better indicator; it should be clear and light. Overhydration can also occur, although less commonly.

2.2 Nutrition Issues Given that childhood is a continuum of growth and development, it is important to be able to recognize issues that may put a child’s nutrition and health at risk. This life cycle is extremely vulnerable to the dangers of poor nutrition.

Food Insecurity

Food insecurity describes a situation in which a household is unable to access sufficient nutritious and safe food due to a lack of resources (U.S. Department of Agriculture [USDA], 2009). Since 1995, the USDA has worked with researchers to assess the food security status of American households. The most recent published data reports that in 2008, 15% of American households experienced food insecurity at some point during the year. This represents roughly 17 million households nationwide and an increase of 11% from 2007 (Nord, Andrews, and Carlson, 2009). The study found that food insecurity was most prevalent in households whose income level was below the poverty line as defined by the U.S. government. Households with children were more likely to experience food insecurity than households without children. Furthermore, children with a single parent were more likely to experience food insecurity than those with two parents. The South represented the region of the United States with the most poverty, followed by the West, Midwest, and Northeast respectively. In terms of racial dispari- ties, food insecurity was most prevalent in Black and Hispanic households.

Understanding the resources available to those who experience food insecurity is an impor- tant part of working with children and families. Assistance programs can be found at both the government and community level.

Malnutrition: Underweight

Malnutrition is a state of nutritional imbalance, most often related to undernutrition. However, it is important to note that overnutrition is also a state of malnutrition. Growth failure (also called failure to thrive) describes a growth pattern that is abnormal and is the result of taking in too few calories. Clinical criteria for diagnosis are more specific and are assessed by health professionals who track a child’s growth for weight and length/height

Nutrition Issues Chapter 2

Table 2.2: Food insecurity assistance programs

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

• Provides supplemental food to pregnant or lactating women, infants, and children (up to the age of 5) of low income.

• Aims to help support the nutrition needs of these high-risk women, infants, and children by providing food packages whose contents are influenced by the Dietary Guidelines for Americans.

• Seeks to provide nutrition education, health referrals, and breast-feeding support as well. • Eligibility: Household income must be at or below 185% of the poverty level. In 2011,

the poverty threshold for a family of four was $22,350. (In order to be eligible for WIC benefits, a family of four would have to earn at or less than $41,348 per year).

Supplemental Nutrition Assistance Program (SNAP)

• Formerly referred to as the Food Stamp Program. • Seeks to provide supplemental relief for individuals who may not have the financial

resources to obtain nutritious food. • Funds are stored on an Electronic Benefit Transfer (EBT) card that can be used as a debit

card at authorized retailers and farmer’s markets to purchase particular food items that are to be consumed at home, such as grains, fruits and vegetables, meats/fish/poultry, and dairy.

• Cannot be used for nonfood items such as household supplies, supplements, alcohol, or tobacco.

• Eligibility: Determined by a number of criteria, including income, resources, deductions, and employment.

The National School Lunch Program (NSLP)

• Federally supported program of the USDA where schools who participate in the NSLP agree to provide lunches that meet these criteria in exchange for cash subsidies and food donations called entitlement foods.

• School lunches must provide for one-third of the Recommended Dietary Allowances of major nutrients (calories, protein, vitamins A and C, minerals iron and calcium).

• Also in accordance with the Dietary Guidelines for Americans, fat can provide no more than 30% of the calories in the meal, with saturated fat being limited to 10% of total calories.

• Families who are at or below 130% of the poverty level are eligible for free nutritionally balanced lunches. Families who fall between 130 and 185% of the poverty level are eligible for reduced-price lunches.

The School Breakfast Program (SBP)

• Similar to the NSLP, however, participating schools are provided with cash subsidies but not entitlement foods.

• Eligibility: Same financial guidelines as NSLP.

The Summer Food Service Program (SFSP)

• Works to bridge the gap for children of low-income families when school is not in session. • Certain groups (such as schools and nonprofit organizations) can apply to sponsor a site in

a low-income community. • Approved sponsors receive support from the FNS to provide meals that meet federal guide-

lines to eligible children.

The Seamless Summer Feeding Option

• Program for schools that participate in NSLP and/or SBP. • Provides meals throughout the summer to eligible children. • A comparison of the NSLP, SBP, Summer Food Service Program, and Seamless Summer

option can be found at the Food and Nutrition Service website: http://www.fns.usda.gov/cnd/SFSP_SeamlessComparisonChart.pdf

The Child and Adult Care Food Program (CACFP)

• Functions in the settings of nonprofit child care centers, before- and after-school programs, and Head Start programs, as well as emergency shelters and adult day care centers.

• Eligibility: Same financial guidelines as NSLP.

Food banks • Large entities that receive and store food to be distributed to community agencies that then provide food for individuals and families.

• Such agencies include food pantries, community meal programs (e.g., Meals on Wheels), soup kitchens, and other hunger-relief agencies.

Nutrition Issues Chapter 2

(along with head circumference in the first two years of life). There can be many contribu- tors to growth failure, both organic and inorganic. Organic causes of failure to thrive are medical conditions, such as physiologic barriers to consuming enough food, increased energy expenditure, or malabsorption (Corrales & Utter, 2005). Nonorganic causes of failure to thrive are social or behavioral issues, such as food insecurity, homelessness, or lack of education/ knowledge about appropriate nutrition and feeding (Corrales & Utter, 2005).

A child who is demonstrating growth failure may require supplemental nutrition under the guidance of a health care provider. In infants, specialized or concentrated formulas may be used. This should only be done under the supervision of a health care professional, as infant’s immature kidneys cannot handle excess protein and electrolytes. Calorie-boosting recipes and/or high-calorie supplements may be used with toddlers and older children. Educators and caregivers may be asked to participate in a child’s routine by communicating feeding histories or continuing behavioral strategies at school that are being implemented at home. When nonorganic factors are at play, educators may be able to forge connections or make referrals to food assistance programs or medical and behavioral specialists in the community.

Malnutrition: The Obesity Epidemic

Obesity has risen and continues to rise in the United States, and this alarming trend is occur- ring very rapidly in children. Recent data report that obesity in children has tripled, from approximately 5% in the 1960s to 17% in 2007–2008 (Ogden & Carroll, 2010). Because malnutrition is a term often associated with growth failure, many people do not think of overweight or obesity as a form of malnutrition. However, not only is obesity a form of mal- nutrition, it is often associated with micronutrient deficiencies, as children consume adequate protein and excess calories, but not from nutrient-dense foods.

Overweight and obesity are identified by criteria using weight, height, and weight-for-length in those under 2 years old and body mass index (BMI) in children over 2 years old. BMI is defined as weight (in kilograms) divided by height-squared (in meters). It is important to note that BMI is a screening tool, not a diagnostic tool. It can be used by health pro- fessionals in the context of a child’s growth history to determine overweight or obesity status. Also, a single point in time is not all that telling, but the pattern of growth is extremely valuable information. The health implications of being overweight are tre- mendous, including associations with heart disease, diabetes, and sleep apnea.

The causes of the rise in obesity are multifactorial, and most often, individuals face more than one of these factors. Ultimately, all contribute to an imbal- ance of calories (not enough energy is expended in

comparison to how much is consumed). It is important to recognize that although genetics can contribute to the risk of obesity, genetics alone cannot explain the rapid increase in the prevalence of obesity in our population (Barlow & the Expert Committee, 2007). Genes can be influenced by environmental and behavioral factors, and these are the areas on which to focus when addressing obesity prevention and treatment. At the foundation of weight gain

▲ Helping children achieve a healthy weight is an important role that caregivers play. © Peter Dazeley/Photographer's Choice/Getty Images

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Nutrition Issues Chapter 2

is an imbalance of energy consumed and energy expended. Excessive caloric intake will lead to an increase in body weight that is associated with chronic conditions such as heart disease, Type 2 diabetes, and cancer.

Portion Control

Portion sizes have exploded, and the perception of what is a normal amount of food has shifted dramatically over the last 50 years. In today’s food culture, consumers must become literate in the Nutrition Facts label. It is important to note that what the manufacturer deter- mines to be a serving size of that particular food is not necessarily an appropriate portion size. The Nutrition Facts label identifies the amounts of major nutrients that are contained in a particular serving size of that food. Many convenience foods may be labeled as contain- ing one serving; however, they may actually be more than one portion. Restaurants are another place to pay more attention to portion sizes. Servings at res- taurants aim to please customers and often greatly exceed what is healthy.

In today’s current food culture, people are consum- ing more proteins and starches than vegetables and fruits. Because vegetables and fruits are lower in calories than proteins and starches, decreasing the amount of protein and starch consumed at meals to the appropriate amount and increasing the serv- ings of vegetables and fruits improves overall caloric intake without sacrificing satiety, while improving the intake of the nutrients needed for proper growth and maintenance. For age-appropriate portion sizes, refer to the CACFP guidelines as a starting point (dis- cussed in chapter 4).

Added Sugars

There is a difference between naturally-occurring sugars and those that are added. Naturally occurring sugars include those in fruits and vegetables as well as dairy (lactose). Added sugars occur in foods that have been processed, when manufacturers add it to a food product. It is important to note that the literature does not support the belief that sugar causes hyperac- tivity in children or that it causes diabetes. However, the health risks of added sugars involve displacing nutrient-dense foods and providing excess calories (both increase the risk of weight gain), increased triglycerides, and lower HDL cholesterol (both increase the risk of cardiovas- cular disease). The Dietary Reference Intake (DRI) for added sugar is a maximum of 25% of total calories, and the American Heart Association recommends that men limit themselves to 9 teaspoons and women to 6 teaspoons (Institute of Medicine (IOM), 2005; American Heart Association, 2010).

Intake of sugar-sweetened beverages has increased dramatically for all ages over the past three decades (Ogden, Kit, Carroll, & Park, 2011). The beverage industry heavily markets sugar-sweetened beverages to children, in the form of sodas, fruit punch, sports drinks, and energy drinks. An 8-ounce serving of soda can contain 6–7 teaspoons of added sugar. Sports drinks can contain as much as 4 teaspoons of sugar per 8 ounces, but, few sport drink bottles are limited to 8 ounces. These products are marketed heavily to

▲ Portion sizes have exploded over the years. What is presented as one serving by a manufacturer or restaurant is often much more food than one healthy portion size. © iStockphoto/Thinkstock

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children, yet they are physiologically unnecessary for the vast majority of physical activity. The Committee on Nutrition and the Council on Sports Medicine and Fitness evaluated sports drinks and energy drinks to form the policy statement of the American Academy of Pediatrics (AAP) (2011).

The AAP (2011) encourages water and discourages routine consumption of carbohydrate- containing sports drinks even with physical activity, as they can contribute to poor dental health, unnecessary calorie intake, and increased risk of weight gain. A healthy balanced diet provides the daily requirements for energy and electrolytes, even with physical activity. The Committee stressed that there is no scientific evidence of the need for recently marketed combinations of amino acids for sports recovery. Instead, low-fat milk is a natural food source that provides an optimal amount of carbohydrate and protein. The Committee stated that energy drinks are not appropriate for children, as they contain stimulants, the most com-

mon of which is caffeine, which increases heart rate and blood pressure, can cause sleep disturbances, and can contribute to arrhythmias. In children, still- developing organs (particularly the heart and brain) are a particular concern. The Committee pointed out that in 2005, the amounts of caffeine in some energy drinks could equal 14 cans of caffeinated soda and lead to caffeine toxicity. They also noted that 56% of the calls made to Poison Control regarding caffeine were in people under 19 years old.

It is important to note that 100% fruit juice can be considered a serving of fruit in a portion of 4 to 6 ounces (AAP, 2001b). The beneficial nutrients of juice exist in the fruit from which it was made, along with fiber, which helps promote feelings of satiety.

Since juice has nutritional value, it is often perceived as something that can be offered without limits. However, overconsumption of juice can lead to an imbalance in the amount and con- centration of sugars present in the intestine, which can lead to diarrhea and gastrointestinal discomfort. The AAP has made recommendations on age-appropriate limits of juice intake (AAP, 2001b). If juice is given, it should be offered as part of a meal or snack, not alone, as this will increase the risk of dental caries. It is recommended that infants and toddlers not exceed 4 to 6 ounces daily, and that children not exceed 12 ounces daily (AAP, 2001b).

Sweets are the most obvious nonbeverage source of added sugars. Added sugars also can be found in foods such as breakfast cereals and canned fruit packaged in syrup. To identify food products that are high in levels of added sugars, investigation of the food label requires more than looking at the grams of sugars under “Total Carbohydrate.”

The food label does not separate naturally occur- ring and added sugars. The best place to tease out this information is in the ingredient list. The earlier sugar occurs in the ingredient list, the more sugar has been added. Also keep in mind that added sugars go by many names. Examples include corn syrup/sugars/sweetener, high fructose corn syrup, sucrose, fructose, honey, syrup, molasses, and fruit juice concentrate.

▲ Breakfast cereals are a common source of added sugars and are heavily marketed toward children. Associated Press

Added sugars create nutrient-poor but calorie-dense foods that, when consumed in excess, displace nutrient-dense foods, contribute to the risk of becoming overweight, and increase the odds of obesity.

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Standards in Nutrition Chapter 2

Screen Time and Physical Activity

Screen time has become an enormous presence in today’s culture, and it has been shown to compete with physical activity. Decreased physical activity is associated with increased risk of pediatric overweight and obesity. Children are exposed to more television at a younger age and for longer durations of time, and more and more children have televisions in their bedrooms (Rideout, Foehr, & Roberts, 2010). The AAP recommends that children 0–2 years old should not watch television, and older children should be limited to 2 hours per day of total screen time. It also recommends no televisions in chil- dren’s bedrooms (AAP, 2001a). If children are lim- ited in the amount of sedentary time they spend in front of the television or computer screen and are encouraged to be more physically active, they will be more likely to grow at a healthy rate. The Expert Committee recommends 60 minutes of vigorous physical activity daily in children. Additionally, the IOM recommends opportunities for physical activ- ity in school settings (Koplan, Liverman, & Kraak, 2005). Encouraging physical activity in young chil- dren is essential to promoting appropriate growth, as well as building good habits for a lifetime of health and well-being.

2.3 Standards in Nutrition Eating a balanced diet of a variety of foods, all in moderation, will help ensure adequate nutri- tion and help avoid deficiencies and excesses. However, it is a difficult food world to navigate in today’s culture. Luckily, there are tools to help communicate these messages, which can be shared in a variety of settings, including the classroom.

Guiding Healthy Eating

Healthy food habits start early, so it is important for those involved in the care and education of children to have some understanding of the science of nutrition and be able to apply that knowledge to the guidelines for healthy eating. Childhood educators have many avenues for influencing healthful eating by teaching lessons, being role models, and creating positive health environments.

Dietary Reference Intake

In the 1940s, the IOM, a nonprofit organization funded by the U.S. National Academy of Sciences, began the practice of setting targets for daily intake of nutrients that should help maintain good health and prevent diseases. These ranges of intake are determined for dif- ferent genders and stages of life. When this began, these were called the Recommended Dietary Allowances (RDA). Over the years, this practice has evolved to become the Dietary Reference Intake (DRI) (Food and Nutrition Information Center, 2010). Overall calories should come from a combination of carbohydrates, protein, and fat according to the range

▲ Children are spending more and more time in front of a screen and less time being physically active. © Hemera/Thinkstock

Standards in Nutrition Chapter 2

of the Acceptable Macronutrient Distribution Ranges (AMDR). Individual nutrients should be consumed within the ranges of the RDA or the Adequate Intake (AI), whichever is available for each particular nutrient based on the scientific literature. Chronic consumption of individual nutrients above the Tolerable Upper Intake Level (UL) should be avoided.

Table 2.3: Categories of the DRIs

Estimated Average Requirement (EAR)

The IOM investigates the literature to estimate the amount of a nutrient required to meet the needs of half (50%) of the population.

This is a statistical tool that is used to determine the RDA; it is not a recommen- dation of level of intake.

Recommended Dietary Allowance (RDA)

Using the EAR, the IOM determines the amount of a nutrient required to meet the needs of nearly all (97–98%) of the population.

Adequate Intake (AI) For nutrients where there may not be sufficient evidence to determine the EAR, and therefore the RDA, the IOM sets the AI. Based on what literature is available, the AI is the next best estimate for how much of a nutrient is needed for healthy individuals. A nutrient will not have both an RDA and an AI.

Tolerable Upper Intake Level (UL)

From the evidence available, the IOM also determines the highest daily intake of a nutrient that can be consumed safely for nearly all (98%) of the population.

Acceptable Macronutrient Distribution Range (AMDR)

The IOM also determines the ranges of intake of the macronutrients that meet nutrient needs and are associated with reducing the risk of chronic diseases. These are expressed as a percent of total calories consumed daily. Carbohydrates 45–65%, Protein 10–35%, and Fat 20–35%.

Using MyPlate as a Guide for Healthy Eating for Young Children

Since the early part of the 1900s, various food guides have been established to help Americans choose the foods to make up a healthy diet. Over the years, the Food Guide Pyramid, MyPyramid, and now MyPlate have been developed to communicate the Dietary Guidelines for Americans. The Dietary Guidelines aim to present nutrition information about how to choose foods to create a balanced diet. The 2010 Dietary Guidelines for Americans are

represented by MyPlate. It also discusses foods to increase, primarily vegetables, fruits, whole grains, and low- or nonfat dairy; and foods to limit, such as those high in salt and added sugars. The message also encourages physical activity and food safety.

MyPlate was new in 2011, so updates are expected. At this time, the children’s version has not yet been updated from MyPyramid. In the meantime, the existing MyPlate materi- als and nutrition education messages are a good starting point for talking with children about choosing healthy foods and drinks. A summary of the major points of the Dietary Guidelines and MyPlate follows:

• Grains: Grains are our major source of starches in the diet. Refined grains undergo the process of milling, which removes the bran and the endosperm, taking along with it fiber, iron, phytochemicals, and some of the B vitamins.

▲ MyPlate communicates the messages of the 2010 Dietary Guidelines for Americans. © U.S. Department of Agriculture/

ChooseMyPlate.gov

Feeding Infants and Toddlers Chapter 2

Grains are often fortified, which means addi- tional nutrients are added that were not present prior to processing (or not in the amounts that have been added). While this has helped counter overt deficiencies, it does not replace all the health benefits lost during refining. Evidence suggests that whole grains are a good source of fiber and are associated with decreased risk of heart disease, lower incidence of Type 2 diabetes, and lower body weight (Bloomgarden, 2004). The first ingredient should be “whole.” Items that contain whole grains are oatmeal, graham flour, brown or wild rice, and popcorn. Next, examine the label for grams of fiber and aim for a product with a higher percent daily value.

• Vegetables and fruits: Aim to make half the plate vegetables and fruits with a little more emphasis on vegetables, and to vary them in color. It is not recommended to take more than half of daily fruit servings in the form of juice.

• Protein: Look for lean protein sources. Choose leaner cuts of meat (greater than 85% lean) and remove visible fat and skin. Incorporate more vegetable sources of proteins.

• Low- or nonfat dairy: The recommendation is for 3 cups daily of low- or nonfat dairy for ages 9 and up, 2½ cups for those 4–8 years old, and 2 cups daily for ages 2–3 years. Soy milk fortified with calcium and vitamins A and D can serve as dairy for the purposes of the Dietary Guidelines.

• Foods/nutrients to increase: Vegetables, fruits, whole grains, low- or nonfat dairy, sea- food, and oils (versus solid fats).

• Foods/nutrients to decrease: Sodium, solid (saturated) fats, cholesterol, added sugars.

• Physical activity: Physical activity does not always have to be sports. For some, being more active in daily activities is a good place to start, such as walking more and taking the stairs.

• Food safety: Limit exposure and contamination by practicing good hand washing and avoiding cross-contamination (USDA, 2011; USDA, 2010).

2.4 Feeding Infants and Toddlers Because children are growing, their nutrition needs change rapidly and frequently throughout childhood. Not only is there rapid physical growth, but there is constant motor and cognitive development as well. Any time of growth is a potentially vulnerable time nutritionally, which is why nutrition is critical throughout all of childhood. During the early years, motor skills are becoming more defined, leading to much more independent feeding. Children are also able to communicate more clearly, requesting and refusing food, making this developmental period incredibly important for teaching valuable nutrition lessons.

Feeding Infants

The first 12 months of life, or infancy, is the most rapid period of growth and development throughout the life cycle. In terms of growth alone, a baby will have doubled in weight by 6 months. By the end of the first year, birth weight will have tripled. There is no other time in

�MyPlate�recommends�making�half� of�the�plate�vegetables�and�fruit,�a� quarter�of�the�plate�grains�(with�an� emphasis�on�whole�grains),�and�a� quarter�of�the�plate�lean�meats�and� proteins.

Feeding Infants and Toddlers Chapter 2

a human’s life when that relative weight gain is normal or healthy. Imagine a 150-pound person growing to 300 pounds within 6 months and to 450 pounds by the end of the year. Because the first year is so critical for growth, it has the high- est energy needs per kilogram of body weight of any stage.

The Breast-fed Infant

Breast milk is the perfect food for babies, so much so that infant formulas are designed to try to match the nutritional content of mature human breast milk. Breast-feeding has been associated with a number of health benefits, such as reduction in respiratory illnesses and reduced risk of obesity (Oddy et al., 2003; Owen et al., 2005; Grummer-Strawn & Mei, 2004; Hedeiger et al., 2001). There are also many sig- nificant economic benefits of breast-feeding. Due to fewer illnesses, infants accrue fewer health care costs, which then reduce loss of productivity and wages due to parental absen- teeism from work to care for a sick infant (Pugh et al., 2002; Ball & Wright, 1999). There is also the significant monetary and environmental cost of producing, purchasing, transport- ing, and disposing of formula and related supplies (Ball & Wright, 1999).

The current recommendation of the AAP, as well as numerous other health organizations, is for exclusive breast-feeding until around the first 6 months of life. It further recommends that breast-feeding be continued throughout the first year of life and then for as long as is mutually desired by mother and child (AAP, 2005). Breast milk is complete nutrition for an infant, and the only additional nutrient needed is vitamin D. The AAP recommends all children receive 400 International Units (IU) of vitamin D within the first few days of life (AAP, 2005). Infants who receive FDA-approved infant formula will receive vitamin D from the formula. Breast-fed infants will require a supplement. This recommendation was made because the evi- dence indicated that vitamin D deficiency may occur early in life, particularly because vitamin D deficiency is widespread in the American population, including among pregnant women (Wagner & Greer, 2008).

Infant Formulas

For some families, the decision may be made to give the baby infant formula. Some situations in which breast-feeding may be contraindicated include:

• Untreated tuberculosis

• Radiation or chemotherapy exposure

• Substance abuse

• Classic galactosemia in the infant (an�inborn�error�of�metabolism�that�results�in�the� inability�to�process�galactose,�which�is�a�product�of�lactose�breakdown�into�glucose� and�galactose).

• Lesion of the herpes-simplex type on the breast

• HIV infection (AAP, 2005)

▲ Infancy is the most rapid period of growth and development. © BananaStock/Thinkstock

Feeding Infants and Toddlers Chapter 2

Regarding HIV infection, breast-feeding is not recommended in the United States and other developed countries with safe water supplies. Formula is the suggested form of nutrition. On the other hand, in developing nations, though the risk of HIV transmission still exists, using unsafe water to prepare formula is associated with a higher risk of gastrointestinal infection, dehydration, and imminent death.

Beyond contraindications, there may be other reasons for which an infant may be formula- fed. In the case of food allergies, following an elimination diet, hypoallergenic formulas may be used as an alternative to the lactating mother. There may also be personal reasons for choosing formula. Whatever the reasons, a mother’s choice on how to feed her child should be respected and supported.

The FDA regulates the production of infant formula to ensure safety, nutritional composition, labeling, and quality control (FDA, 2009). Infant formulas can come as powder to be diluted with water, concentrated liquid (which also needs to be diluted with water), and ready-to- feed. Improper dilution of formula is a serious health risk, whether due to poor understanding of formula preparation or an attempt to make formula last longer during times of economic hardship. Too much water causes hyponatremia (hypo- means low, natr- relates to sodium’s chemical abbreviation of Na, emia- means in the blood), which can lead to swelling of the brain, coma, and death.

Table 2.4: Types of Infant Formulas

Standard formulas

• Most common variety, often referred to as modified cow’s milk-based.

• Butterfat is removed, protein content is decreased, and carbohydrate and vegetable oils are added.

• Within this category there are other products on the market that, though available without a prescription, are best utilized under the recommendation of a health care professional.

Soy infant formulas

• These formulas are most often used for infants with cow’s milk allergy. However it is important to note that adverse reactions to soy occur in 10–14% of infants with cow’s milk allergy (AAP, 2008).

• Soy formula may be of benefit with lactose intolerance. However, as true lactose intoler- ance is extremely rare, those cases should be reviewed with a pediatrician.

• Soy formula is indicated in cases of classical galactosemia.

Hypoallergenic formulas

• These formulas are prepared in two ways: hydrolyzed and elemental.

• The formulas using hydrolyzed proteins have cow’s milk protein that has been broken down into smaller peptides. Because of this, though it is not guaranteed to be symptom- free for an infant suffering from a milk protein allergy, approximately 90% of infants may tolerate it.

• However, for those babies that do not, an elemental formula composed of free amino acid can be used.

Premature formulas

• Premature infants did not complete gestation and have different needs than a full-term infant and have missed out on an important period of fetal growth, development, and nutrient storage.

• Premature formulas have been designed to meet their needs, primarily for calories, protein, calcium, and phosphorus.

• It is important to note that given a premature infant’s underdeveloped gastrointes- tinal and immune systems, there are even more reasons to consider breast milk. There are supplemental products called human milk fortifiers that can be added to pumped breast milk.

Feeding Infants and Toddlers Chapter 2

Introducing Solids

Around 4–6 months of life, the baby will be developmentally ready to start complementary foods. It is sometimes thought that an infant should start solid food because he or she is not full enough from breast milk or formula and is hungry. This is not the case. If the baby is hun- gry, he or she needs food; however, the type of food depends on his or her development. Use developmental cues about physical readiness to start spoon feeding. This stage of feeding is often called complementary feeding, as it complements breast milk or formula, which will continue to provide the bulk of the baby’s calories into the first year of life. The introduction of solids serves to develop feeding skills and present new flavors to build a foundation for a nutritious diet full of variety.

Table 2.5: Complementary Feeding Timeline

Age Feeding development Appropriate foods

4–6 months • Sits and has improved head control

• Tracks food with eyes

• Opens mouth and closes lip over spoon

• Pulls in lip after spoon is removed from mouth

• Moves tongue back and forth versus primarily up and down

• Iron-fortified single-grain cereal as infants’ iron stores are depleted around 6 months of age

• Cereal can be slurry texture to start, then thicker texture as feeding skills develop

• Once taking two feedings of cereal daily, can introduce pureed vegetables, fruits, strained meats

6–8 months • Able to move food to sides of mouth, which allows for chewing

• Able to pick up foods

• Brings foods to mouth

• Can start to try holding and drinking from cup

• Purees can be thicker to be mashed or lumpy

• Age-appropriate finger foods, avoiding choking risks such as hot dogs, whole grapes, meat sticks

• Finger foods can be anything that sticks together

• Cooked, mashed vegetables or fruits

• Strained meats

8–12 months • Improved dexterity with handling finger foods

• Improved skills with feeding and drinking from cup

• Soft cut-up cooked table foods

• Soft cut-up fruits

• Dry cereal or puffs

• Toast and easily dissolvable crackers

• Cheese

• Eggs

It is inappropriate to feed infant cereal from the bottle. Infant cereal should always be fed from the spoon. It is thought by some that the rice cereal in the bottle will help the baby feel fuller and sleep through the night, but this is not the case. It can be a choking risk, and adding rice cereal to the bottle dilutes the nutrient density of the breast milk or formula, particularly in protein.

Throughout the rest of infancy, foods and textures can continue to be added to baby’s diet according to developmental readiness. It is important to pay attention to the infant’s feeding cues. Feeding a child is a wonderful experience that nurtures both baby and caregiver physi- cally and emotionally. By paying attention to feeding cues, a caregiver will provide a healthy and happy environment for the baby.

Feeding Infants and Toddlers Chapter 2

Certain foods should not be introduced in infancy because infants’ digestive systems are still maturing. This is sometimes called a leaky gut or gut permeable, because it lets things through that a mature gut would not, including bacteria, toxins, and protein. Honey is a vehicle for Clostridium�botulinum, the bacteria responsible for botu- lism, and should not be given in any form to infants. Botulism causes muscle paralysis, which is why small doses of the toxin are used for the cosmetic treatment Botox to give the appearance of smooth skin. The spores of these bacteria can grow in the infant’s intes- tines, which may allow toxins to pass through. Because the baby’s muscles aren’t contracting properly, many problems can occur: leth- argy, feeding problems, poor muscle control, low tone, constipation, respiratory problems or failure, and potentially death.

Infants should not transition to cow’s milk before 1 year of age (Leung & Suave, 2003). Cow’s milk increases the risk of anemia in infants because it is a poor source of iron. Additionally, because babies’ intestines are still maturing, the large protein molecules of cow’s milk can cause damage and lead to bleeding. The protein con- tent of cow’s milk is much higher than that of breast milk or formula, about double the amount of protein per volume. Because infants’ kidneys are still developing, this protein load is a very dangerous risk for renal damage. Water should not be offered as a primary bever- age, as infants would be very susceptible to hyponatremia. Water as an occasional drink in a cup can be offered. Some juice may be offered during later infancy, and guidelines for the use of juice have been established by the AAP (AAP, 2001b).

Special Considerations When Feeding Infants

Special feeding needs during infancy warrant swift attention from involved caregivers and medical providers to limit the potential harm from suboptimal nutrient intake. Feeding prob- lems in early infancy often relate to the infant’s ability to take in food safely. Infants with developmental or motor delay may have difficulty safely taking in nutrition. Additionally, some infants with congenital conditions may have low muscle tone, which can affect the strength and efficiency of their feeding. In any of these situations, evaluation from medical profession- als may offer strategies to assist feeding, such as different bottles or nipples or breast-feeding techniques. Infants who have difficulty nursing may benefit from consultation with a lactation counselor or from resources such as La Leche League (http://www.llli.org/).

Another scenario that often requires special attention to feeding is prematurity. As the health benefits of breast milk are well established and the need for promoting immunity is height- ened, breast milk is recommended as the primary source of nutrition in premature infants (AAP, 2005). Human milk fortifiers can be added to breast milk to increase the nutritional content to meet a premature infant’s needs. For those not being fed breast milk, specialized formulas are available. Feeding advancement should follow the cues of the infant on readiness to start solids. The chronological age reflects when the child was born, but corrected age (sometimes called gestational age) may often be a better representation of needs.

Some infants are born with oral birth defects that may make feeding difficult. An example of this is cleft palate, which results from the roof of the mouth not forming properly, and

▲ Complementary feeding serves to introduce flavors and textures, develop feeding skills, and com- plement the nutritional needs of growing infants. © BananaStock/Thinkstock

Feeding Infants and Toddlers Chapter 2

is characterized by an opening that prevents the pressure in the mouth from the tongue to allow for swallowing to occur normally. Surgical repair of the cleft palate typically occurs after a few months, so feeding strategies need to be in place to prevent malnutrition, particularly to ensure for safe surgery. Specialized bottles, nipples, and holding techniques are employed. Babies with cleft palate are fed upright, to prevent the flow of food into the nasal cavity, ver- sus the cradling or football hold that is typically used for other infants.

Feeding problems in an infant may slow growth while the problem is being addressed. The infant may continue to be at risk for slow growth even once feeding strategies are in place, depending on the condition. In these situations, fortified feedings of higher caloric density may be employed. Breast milk and standard infant formula provide 20 calories per ounce. Concentrated formula recipes should be considered a prescription and should be used under the supervision of a health professional to ensure safety of the baby’s immature kidneys.

Toddler Nutrition

The next stage of early childhood is the toddler years, 1 to 3 years old. Toddlers have likely already begun to assert some growing independence. It is important for caregivers to nurture this development by providing healthful options from which to make choices and sharing les- sons to last a lifetime of nutritious eating. Developmentally, they are now able to walk and will soon start to run. This can make meal times challenging, as toddlers may be tempted to use their newfound motor skills to run away from the table. It is important to start the habit of setting established meal and snack times during this age so that they learn a healthy schedule of eating. Parents often find that their children “eat better” at child care than they do at home. Child care settings have structure that may not always be as well implemented at home. Additionally, the child care setting enables children to imitate and learn from their peers. Hand and finger skills are developing and self-feeding will start to involve utensils. Toddlers will grip the spoon or fork in their fist, as they have not developed dexterity yet. It is good to understand that they will likely continue to still finger feed at times, but, encourage the spoon and fork, and praise their efforts.

Nutritional Needs

From infancy, the growth rate slows as the child matures; however, toddlers are still in a rela- tively rapid growth period. Important nutrients for growth and development include vitamin D, calcium, iron, and zinc. Upon turning 1, a toddler can transition to whole cow’s milk from breast milk or formula (2% or lower milk is not likely to provide sufficient calories for growth). Be cautious with flavored milks, as they contain unnecessary added sugar. Appropriate con- sumption of two to three servings of low-fat or nonfat dairy will meet calcium requirements and provide some vitamin D. It is appropriate to use a vitamin D supplement to meet daily needs. Avoid overconsumption of milk, as it is associated with iron-deficiency anemia. Because little ones are on the go, it can be tempting to let them have juice, but remember to avoid juice between meals and snacks. Toddlers’ growing mobility also means that it can be easy to get off schedule; a routine of three meals and two to three snacks a day will provide sufficient calories and nutrients throughout the day to support their active and growing lives.

By 1 year, the toddler is taking in more table foods and different textures. It is important to continue to provide increasing firmness in textures and avoid choking risks. Toddlers should be getting a variety of foods from all the food groups. With the portion distortion of today’s food climate, it can be surprising that toddlers do not need very big serving sizes. The CACFP

Feeding Preschoolers and School-Age Children Chapter 2

guidelines can help figure out a starting place for appropriate portion sizes for all ages (Food and Nutrition Service, n.d.). One way to help is to use child-sized serving plates. Another tip is to start with 1 tablespoon of each food group for every year of age. With the inclusion of whole milk as a primary beverage, appropriate portion sizes of a variety of foods from all the food groups will provide adequate calories for growth and development, and meet overall nutrient needs.

Special Considerations When Feeding Toddlers

Toddlers are in a period of cognitive development that includes a growing sense of and desire for independence. Food jags are common in toddlers, and they may prefer only a few foods day in and day out. These phases are relatively short-lived. Also, toddlers may display resis- tance to trying new foods. Developmentally, this could be a protective mechanism to prevent newly mobile youngsters from eating something new that could be dangerous before their mothers could stop them. Resistance to a new food is not always picky eating, but it can become so over time.

A concept referred to as the division of responsibility of feeding was developed by Ellyn Satter (Satter, 2000). She explains that the adult is responsible for providing the what, when, and where of food. Although the adult is responsible for coordinating mealtime, the child determines whether and how much he or she eats. It is important not to pressure a child into eating the new food; allow the child to refuse it. Additionally, it should not be removed from the child’s plate when it has been refused. The new food should continue to be offered at other meal opportunities, as research has shown that it can take 10 or more presentations of a new food before a child will accept it. When offering a new food, be sure to include foods that the child is known to eat willingly. Offer a reasonable amount of the new food so the child is not overwhelmed with the novel food. When trying a new food, try offering it in a way that is famil- iar, perhaps a similar texture to a favorite food. Offer praise when they do try the new food. If it is spit out, do not reprimand the child, or pay any attention to spitting it out. Instead, praise him or her on being brave and trying the new food. This will help keep the child open to trying new food again. Caregivers should be good role models and eat a variety of foods themselves. Children will learn from observation that the foods they are refusing are part of normal eating. Also, it can be helpful to limit the foods offered at a meal or eating episode. For example, open the pantry and ask, “Would you like oatmeal or cereal for breakfast today?” rather than, “What do you want to eat for breakfast?” This can give the toddler the opportunity to assert indepen- dence within a framework of nutritious foods with which the caregiver can feel comfortable.

2.5 Feeding Preschoolers and School-Age Children At the age of approximately 4 years, children become preschoolers and enter into the next phase of growth. Physically, they continue to slow down the velocity of growth. Along with this, they are continuing to expand their independence and motor skills. These are key years for involving children in their food choices and preparation as part of building a healthy nutri- tion knowledge foundation that can last a lifetime.

Preschooler Nutrition

As with all stages of childhood, the preschool years offer a period of noticeable develop- ment, both physically and developmentally. Physically, they are in greater control of their little

Feeding Preschoolers and School-Age Children Chapter 2

bodies. Hopefully, good habits of sitting for eating episodes are already in place to keep these meals and snacks successful. Fine motor skills are develop- ing as well. Spoons and forks will be gripped like an adult, and carefully monitored use of a knife can be introduced.

Preschoolers may demonstrate food rituals in the way food is cut, or whether foods touch each other on the plate. They may prefer food that is not too hot or too cold. Their hand skills are improving, but they may still struggle with foods that have layers, such as salads. Bite-sized pieces of raw vegetables may be easier for them to manipulate and enjoy. They are not yet adept at using a knife. Continue to offer foods that are cut up into small pieces and begin to help them practice cutting foods with a knife. Offer different textures at the same meal, such as soft and moist foods with crunchy and

chewy options. Grazing, or allowing a child to eat continuously during the day, should be discouraged, as it tends to prevent children from taking appropriate amounts of nutrient- dense foods at meals.

Nutritional Needs

Remember that an infant triples his or her birth weight by the end of the first year—that’s a 300% increase. During the second year of life, a toddler’s weight increases approximately 120%, and during the third year, approximately 110%. Each year, the child gains a smaller proportion of body weight and is becoming leaner. Because of this, eating can become more variable, and the child may have “good” and “bad” eating days. Keep in mind that intake typically averages out over time and supports normal growth. The nutrients of calcium, vita- min D, iron, and zinc remain particularly important. It is appropriate at this time to switch from whole milk to low-fat (1%) milk. Milk and water should still be the primary beverages. Again, flavored milk should be used with caution since it contains unnecessary added sugars. Fruit juice should be limited to meals and snacks and be limited in total intake.

Oral skills do not limit textures at this age; however it is still important to be aware of chok- ing hazards. Distorted portion sizes can be intimidating, so it is still advisable to use age- appropriate sized dinner ware. It can also be beneficial to allow children to serve themselves. The MyPlate guide has not yet expanded to include materials and specifics for preschoolers; however, the previous guide MyPyramid has very good resources for this age group and can be found through the MyPlate website (http://www.choosemyplate.gov/preschoolers.html).

Picky Eaters

Picky eating typically starts during the toddler years and can continue into preschool and even school years. The tips described for toddlers can be applied to preschoolers. If feeding behav- iors become problematic, it is important to try to maintain a positive feeding environment. Preschoolers have become more skilled with their hands, and this is a great time to get them involved with the food preparation process. Children are much more likely to try a new food if they had some part in making it. They will be much more invested in it.

▲ Early childhood educators should have a basic understanding of the nutritional needs of young children, so that they may encourage young chil- dren to develop healthy eating habits early in life. © Stockbyte/Thinkstock

Feeding Preschoolers and School-Age Children Chapter 2

Special Considerations When Feeding Preschoolers

Anemia is a disorder of red blood cells. The most common type that may be seen in young children is iron-deficiency anemia, often seen in picky eaters who take in disproportionate amounts of milk. Children with anemia should have this issue addressed by their health care provider. Most likely, iron supplementation will be prescribed. Parents can offer more iron-rich foods and cook in cast-iron cookware. Remember, iron from plant sources is best absorbed if vitamin C is consumed at the same time.

Bone health is critical in the early years. Remember that rickets results from vitamin D defi- ciency. Milk is fortified with vitamin D, but the amounts are variable. Vitamin D is not preva- lent in food and supplementation is often warranted. Calcium is also critical for bone health.

School-Age Child Nutrition

School-aged children are those between ages 6 and 12. Motor skills are not going through the rapid development of previous years, and self-feeding is no longer a learning process. School-age children spend more time at school and with their peers and are more aware of their environments. School meals will be addressed in chapter 4. Children may become involved in after-school activities and organized sports. The time that parents have with their children begins to compete with these sorts of activities, and accommodating good nutrition can be challenging.

Nutritional Needs

The rate of growth during this period continues at a steady pace slower than the previous 5 years of life. Nutritional needs continue to increase with growing bodies. As their bodies are still growing, the same nutrients that are heavily involved in growth are important: calcium, vitamin D, iron, and zinc.

Special Considerations When Feeding School-Age Children

As children’s days become longer with the attendance of school, breakfast may become sac- rificed during the sleepy, busy morning. The importance of breakfast in relation to health and learning is well-recognized. Children who eat breakfast demonstrate improved attendance, memory, and test performance (Rampersaud et al., 2005). They also consume more calories in a day, but are less likely to be overweight (Deshmukh-Taskar et al., 2010). On the other hand, children who skip breakfast are associated with less healthy nutritional profiles, higher waist circumference (a proxy for cardiovascular risk), and BMIs that classify as obese (Deshmukh- Taskar et al., 2010).

Whole-grain, low-sugar fortified cereal with low-fat or nonfat milk would start the day off with a simple, yet fast, nutrient-dense breakfast. For breakfast on the go, try a whole-grain toast with 1 tablespoon of peanut butter and a glass of low-fat or nonfat milk, or a whole- wheat 4- to 6-inch tortilla with a slice of low-fat cheese and sliced fruit or vegetable (try apple or bell pepper slices) wrapped into a roll.

By definition, diabetes relates directly to high blood sugar and the long-term complications are both microvascular (retinopathy or blindness, kidney failure, nerve problems that could lead to amputation) and macrovascular (increased risk of cardiovascular disease and stroke). Type 1 diabetes mellitus results from autoimmune destruction of the pancreas, which secretes insulin. Without the ability to produce insulin, blood glucose is not able to enter the

Feeding Preschoolers and School-Age Children Chapter 2

cells appropriately, causing high blood sugar. To administer the proper amount of insulin, carbohydrates must be counted. Typically, carbohydrates are not restricted in an otherwise healthy child. Consuming simple sugars alone is discouraged, as they can cause rapid increases in blood sugar. Since the use of insulin involves blood testing and needles, an individualized Diabetes Health Care Plan is typically started by the family and the child’s diabetes care team, which outlines the medical needs of the child and the responsibilities of those involved in the child’s care during the school day (American Diabetes Association, 2004).

In Type 2 diabetes mellitus, diet and lifestyle factors lead to overweight and insulin resis- tance. To treat Type 2 diabetes, the causes must be addressed with diet management and activity. Weight decrease and, in some cases, medication can be used to reverse the course of Type 2 diabetes. In this disease, carbohydrates may seem restricted because the child may have to consume less than he did previously, however, the amounts are normal within a healthy balanced diet that promotes normal body weight. Along with the rising rates of obe- sity in children, there is an increasing prevalence of childhood Type 2 diabetes (Bloomgarden, 2004). Adult-onset diabetes, the old name for Type 2 diabetes, is no longer an appropriate term because the condition is not limited to adults. Due to the potentially devastating long- term complications of this disease, prevention is as important as treatment of Type 2 diabetes. Encouraging nutritional balance and physical activity is extremely important for all children, not just those at risk for developing Type 2 diabetes.

Many families choose to eat a vegetarian, plant-based diet. With care, this can be a perfectly healthy way to nourish a child. There are different types of plant-based diets. Attention must be paid to those nutrients that are predominantly found in animal foods (iron, calcium, vita- min D, zinc, B12, vitamin A, omega-3 fatty acids), and complementary proteins should be provided.

Dental health is extremely important and is partially addressed with the use of supplements and the inclu- sion of fluoride in the water supply of many com- munities. The continuous consumption of high-sugar foods will increase the amount of carbohydrates and allow bacteria to proliferate in the mouth. Snacks are not inappropriate for children as long as they are part of a balanced diet that does not provide excess calories. Frequent snacking or grazing (such as con- suming foods and sugar-containing drinks, includ- ing juice) in between meals should be discouraged, because it tends to compete with nutritional balance and because it increases the chance of dental caries. Good dental hygiene should be encouraged.

Food Allergies

Food allergies are a result of the immune system recognizing a food protein as something to be attacked. Food allergy reactions include a range of symptoms, such as hives, vomiting, diarrhea, difficulty breathing, swelling, and life-threatening anaphylaxis (a quickly develop- ing allergic reaction). The most common food allergens are peanuts, tree nuts, milk, eggs, wheat, soy, finfish, and shellfish. Food allergies should be diagnosed and followed by a health care provider. Allergies to milk, soy, egg, and wheat may be outgrown, so follow up with the health care provider to assess continued allergy.

▲ Make half a plate containing fruit or vegetables, a quarter of the plate grains, and a quarter of the plate lean proteins. © iStockphoto/Thinkstock

Summary Chapter 2

Labeling for food allergies has become more precise with the Food Allergen Labeling and Consumer Protection Act of 2004 (FALCPA) (USDA, 2006). The major food allergens and any corresponding food derivatives must be clearly labeled in plain language. An example of this is casein, which is one of the major milk proteins. Many products use casein in food process- ing. On a food label, it must be indicated as “casein (milk).” Additionally, the allergy informa- tion for the entire food product must be listed in one place at the bottom of the food label. A food label that has gluten (a wheat protein) and casein would read “CONTAINS: WHEAT and MILK.”

Unlike for diabetes, a care plan for allergies may not be in place when a child enters a child care or school setting. The Food Allergy and Anaphylaxis Network (FAAN) provides a number of resources (e.g., online course for educators about food allergies, a food allergy action plan, school guidelines, and a teacher checklist; see http://www.foodallergy.org/section/back-to- school-tool-kit) that can help early childhood educators.

Summary • Infancy and childhood are periods of rapid growth, making babies and children vulner-

able to nutritional imbalances if the proper diet is not in place.

– A diet should provide adequate protein and calories in the form of carbohydrates and fat in order to promote normal growth and nutrition of the child.

– Vitamins, minerals, and phytonutrients are important cofactors and structural com- ponents that are vital to proper growth and function.

• Many tools exist to aid those involved in child care, from making appropriate food choices to building a healthy nutritional foundation. These tools cultivate the health of the child’s body and mind.

– Acceptable Macronutrient Distribution Ranges give an idea of how much of the macronutrients are needed for normal growth or maintenance.

– RDA and AI provide insight into how much of a nutrient is needed.

– UL of Intake delineate the amount of a nutrient that is known to increase the risk of adverse health events.

– The Dietary Guidelines for Americans are updated every five years to help Americans make food choices that promote good health and prevent disease.

– These have been translated into a food guide currently known as MyPlate.

• Attention to individual needs of those with special considerations for feeding and nutrition should be paid by those involved in a child’s care or education.

• Knowing the resources that exist through government and community agencies can help children avoid nutrition problems that come with food insecurity.

• On the other end of the spectrum, encouraging healthy portions, a variety of nutrient- dense foods, and daily regular physical activity can help those children at risk for over- nutrition and obesity.

• The needs of children change as they grow and develop.

– During infancy, they will start out with an entirely liquid diet of breast milk or for- mula, which evolves as they start including solid foods.

– Complementary feedings help infants develop feeding skills and provide nutrients that their growing bodies need in greater amounts.

Case Study Chapter 2

– As they move into toddlerhood, their reliance on solid foods will grow, which should be fostered by providing a variety of foods from a variety of food groups in textures that are age-appropriate. During this stage and into preschooler age, chil- dren will develop more self-feeding skills and a greater sense of independence.

• Positive feeding environments that take into account children’s developmental tenden- cies will help encourage them to grow into well-balanced healthy eaters. An educator is a key participant in building and fostering a strong foundation in nutrition and nutri- tion knowledge as an important part of childhood.

Chapter Review 1. Describe the meaning of each of the key�terms.

2. Name and explain the three major macronutrients.

3. Discuss the benefits of micronutrients from dietary sources versus supplements.

4. Define the role of water in our bodies.

5. Explain the principal messages of MyPlate.

6. Identify three contributors to caloric imbalance that encourage an unhealthy weight.

7. Describe feeding development and age-appropriate foods throughout infancy.

8. Elaborate on the concept of division of responsibility in feeding.

9. Distinguish between Type 1 and Type 2 diabetes mellitus.

10. Name the major food allergens.

11. Find a Nutrition Facts label for a food. Identify the serving size, added sugars (if any), and major potential food allergens.

Case Study Ms. Brady is picking up cereal for a breakfast activity for her toddler room. She is comparing two cereals in the grocery store: Oatie-Oh’s and Frostie-Frooty-Flakes.

1. Compare the two cereals for the following components:

a. sugars

b. dietary fiber

c. protein

2. Compare the ingredients panels of the two cereals:

a. What is the most prevalent ingredient for each?

b. How can you tell what is the most prevalent ingredient?

c. Which is a better source of iron?

3. Why are there fewer added vitamins to the Oatie-Oh’s, though it has the same and/or bet- ter amounts of micronutrients (as well as protein and fiber) as the Frostie-Frooty-Flakes?

4. Do the cereals contain any of the major allergens? If so, which?

5. Do you notice anything when comparing serving sizes?

Case Study Chapter 2

6. Ms. Brady plans to serve ¾ cup.

a. Compare calories, fiber, protein, and sugars. Which one would be more nutrient- dense and which one would be more calorically dense? Why?

b. What makes the more calorically dense option higher?

7. Based on the above analysis, which cereal should Ms. Brady choose?

f02.01

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full width— 36p x 36p6

Nutrition Facts Serving Size 1 CUP Servings Per Container 14

Total Fat 2g Saturated Fat 0g Trans Fat 0g

3% 0%

Cholesterol 0 mg Sodium 155mg Potassium 165mg Total Carbohydrate 20g Dietary Fiber 3g Sugars 1g Other Carbohydrate 17g Protein 3g

0% 7% 5% 7% 11%

Amount Per Serving Calories 100 Calories from Fat

% Daily Value

Total Fat 0g Saturated Fat 0g Trans Fat 0g

0% 0% 0%

Vitamin A 10% Calcium 10%

Percent daily value reflects “as packaged” food. Product is marked with a Kosher symbol.

Vitamin C 10% Iron 45%

Vitamin A 10% Calcium 0%

Percent daily value reflects “as packaged” food. Product is marked with a Kosher symbol.

Vitamin C 10% Iron 25%

*Percent daily values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs:

*Percent daily values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs:

Total Fat Sat Fat Cholesterol Sodium Total Carbohydrate Dietary Fiber

Calories Less than Less than Less than Less than

2,000 65g 20g 300mg 2400mg

300g 25g

2,500 80g 25g 300mg 2400mg

375g 30g

Total Fat Sat Fat Cholesterol Sodium Total Carbohydrate Dietary Fiber

Calories Less than Less than Less than Less than

2,000 65g 20g 300mg 2400mg

300g 25g

2,500 80g 25g 300mg 2400mg

375g 30g

Cholesterol 0 mg Sodium 135mg Potassium 15mg Total Carbohydrate 27g Dietary Fiber 1g Sugars 11g Other Carbohydrate 15g Protein 1g

0% 6% 1% 9% 3%

Amount Per Serving Calories 110 Calories from Fat

% Daily Value

Oatie-Oh’s FROSTIE-FROOTIE-FLAKES

Nutrition Facts Serving Size 0.75 CUP Servings Per Container 19

Calories per gram: Fat 9 Carbohydrate 4 Protein 4

Calories per gram: Fat 9 Carbohydrate 4 Protein 4

Ingredients Whole grain oats (includes the oat bran), Modified Corn Starch, Sugar, Salt, Tripotassium Phosphate, Wheat Starch, Vitamin E (mixed tocopherols) Added to Preserve Freshness CONTAINS WHEAT INGREDIENTS

Ingredients Sugar, Corn Flour, Wheat Flour, Malt Flavoring, High Fructose Corn Syrup, Salt, Sodium Ascorbate and Ascorbic acid (Vitamin C), Niacinamide, Iron, Pyridoxine Hydrochloride (Vitamin B6), Riboflavin (Vitamin B2), Thiamine Hydrochloride (Vitamin B1), Vitamin A Palmitate, Folic Acid, BHT (Preservative), Vitamin B12 and Vitamin D. CONTAINS WHEAT INGREDIENTS, CORN USED IN THIS PRODUCT CONTAINS TRACES OF SOYBEANS

Figure 2.1: Nutrition Labels

Concept Check Chapter 2

Activity Consider the following meal to discuss with kindergarten students:

• Half sandwich with ½ slice of ham and ½ slice of cheese on whole-grain bread

• ½ cup apple slices

• ½ cup baby carrots

• 6 oz. of low-fat 1% milk

Break the meal apart to demonstrate how it fits with the MyPlate. Then plan another meal using the principles of MyPlate.

Concept Check 1. All carbohydrates contain these three elements:

a. carbon, hydrogen, & oxygen

b. carbon, helium, & oxygen

c. nitrogen, hydrogen, & oxygen

d. nitrogen, hydrogen, & carbon dioxide

2. Another technical term for fat is .

a. limpid

b. lard

c. lipid

d. lipoprotein

3. The two categories that vitamins are separated into are .

a. multi and individual

b. water- and fat-soluble

c. generic and name brand

d. antioxidants and free radicals

4. When introducing infant cereal, it should be fed .

a. before bedtime to help with sleep

b. from a bottle mixed with breast milk

c. from a bottle mixed with formula

d. from a spoon

5. Complications of this condition include blindness, kidney failure, nerve problems, increased risk of cardiovascular disease, and stroke.

a. food allergies

b. diabetes

c. leaky gut

d. decreased physical activity

Answers:�1.�a;�2.�c;�3.�b;�4.�d;�5.�b

Key Terms Chapter 2

Key Terms amino acids Building blocks of protein.

antioxidants Substances that destroy free radicals; associated with decreasing the risk of cardiovascular disease and cancer.

body mass index (BMI) Kilograms divided by meters squared; measure that helps classify obesity.

botulism Disease that occurs from ingestion of spores of Clostridium�botulinum, can be found in honey (meaning honey should not be fed to infants), and causes muscle paralysis and can potentially lead to death.

carbohydrate Macronutrient composed of carbon, hydrogen, and oxygen that primarily serves as a source of energy for our bodies.

cholesterol Kind of fat that is found in animal foods only; can be made by the body and therefore does not need to be consumed from the diet; is associated with heart disease.

complex carbohydrates Polysaccharides; carbohydrates made up of multiple units.

complementary feeding Stage of feeding in which semisolid and solid foods are intro- duced to infants to develop feeding skills and fill nutritional gaps (particularly iron).

corrected age The chronological age that reflects when the child was born. Sometimes called gestational age.

complementary proteins Plant foods that, when combined, provide all 20 of the amino acids our bodies require to build and maintain tissue.

diabetes Disease caused by high blood sugars.

Dietary Reference Intake Targets of daily intake of nutrients that should help maintain good health and prevent diseases.

disaccharide A simple carbohydrate made up of two units.

division of responsibility of feeding Concept of feeding pioneered by Ellyn Satter where the adult is responsible for providing the what, when, and where of feeding and the child determines whether and how much of the food is eaten.

electrolytes Minerals that play a part in the regulation of fluid balance and participate in nerve transmission.

essential fatty acids Fats that must be consumed from the diet and cannot be converted from other fat sources in our bodies.

fat Nutrient that serves as a concentrated source of energy; also referred to as a lipid.

fat-soluble vitamins Vitamins A, D, E, and K, which require fat to be absorbed into our bodies.

Key Terms Chapter 2

fiber Indigestible complex carbohydrates.

food allergies Condition that results from the immune system recognizing a food pro- tein as something to be attacked, prompting it to launch an immune reaction; symptoms may include hives, vomiting, diarrhea, difficulty breathing, swelling, and life-threatening anaphylaxis.

food insecurity Situation in which a household is unable to access sufficient nutritious and safe food due to a lack of resources.

food jags Phases of eating common in toddlers when foods are refused, sometimes even former favorites.

food rituals Phases of eating common in toddlers that occur when a child may have very particular food patterns, such as the way food is cut or whether foods touch on the plate.

fortified foods Foods that have nutrients added to them.

free radicals Compounds that combine with oxygen and can cause bodily damage.

glycogen Animal storage form of carbohydrate.

growth failure Growth pattern that is abnormal and is the result of taking in too few calories; also referred to as failure to thrive.

gut permeable Description of molecules that can penetrate the still-developing infant intestines; sometimes called leaky gut.

high-density lipoprotein Healthy cholesterol that takes fats to the liver to be used in the body or excreted.

hyponatremia A condition in which there is not enough sodium (salt) in the bodily fluids outside the cells and is caused by too much water.

incomplete proteins Proteins that do not provide the necessary amino acids when eaten in isolation.

infancy First 12 months of life.

insoluble fibers Complex carbohydrate that does not dissolve in our guts or get digested by the good bacteria, but provides bulk for our stool that helps with gut regularity.

kilocalorie Unit that describes the energy in food, also referred to as calorie; amount of energy necessary to raise the temperature of 1 liter of water by 1° Celsius at sea level.

leaky gut See gut�permeable.

lipid See fat.

low-density lipoprotein Unhealthy cholesterol that is deposited into artery walls and increases the risk of heart disease.

macronutrients Nutrients needed in large supply (grams) daily.

Key Terms Chapter 2

macrovascular Large blood vessels; in the context of diabetes, those that are associated with cardiovascular disease and stroke.

malnutrition A state of nutritional imbalance that describes a deviation from normal nutri- tion and can describe both undernutrition and overnutrition.

micronutrients Nutrients needed in smaller supply (micrograms to milligrams) daily.

microvascular Small blood vessels; in the context of diabetes, those that are associated with blindness, kidney failure, and nerve problems.

minerals Inorganic substances that yield no energy and are required by the body in small amounts to serve as structural components and facilitators of body processes.

monosaccharide A simple carbohydrate made up of one unit.

nutrient Any component of food that our bodies require for biological functions.

phytochemicals Chemicals that are found in plants and have properties that offer health benefits or prevent disease.

polypeptides Long chains of amino acids.

polysaccharides Complex carbohydrates that are longer chains of individual sugar units.

protein Nutrient composed of amino acids whose primary function in our bodies is to build and maintain tissues.

saturated fats Fats that are solid at room temperature and are associated with heart disease.

simple carbohydrate Monosaccharides or disaccharides, carbohydrates made up of one or two units; often referred to as sugars or simple sugars.

solubility Description of how molecules react with water; soluble molecules attract water, insoluble repel water.

soluble fibers Complex carbohydrates that slow digestion, help with satiety, and provide nutrition for good bacteria in our colons.

starch Plant storage form of carbohydrate.

trans fats Oils that have been hydrogenated to become solid fat; increase the risk of heart disease.

Type 1 diabetes mellitus Disease that results from autoimmune destruction of the pan- creas, leading to the inability to produce sufficient insulin and causing high blood sugars; primary treatment is with insulin.

Type 2 diabetes mellitus Disease that results from diet and lifestyle factors that lead to overweight and insulin resistance; primary treatment is with diet and activity, although some individuals may progress to needing insulin.

Key Terms Chapter 2

unsaturated fats Fats that are liquid at room temperature; when consumed in modera- tion, provide health benefits.

vitamins Organic compounds required in small amounts to facilitate body processes such as cofactors for enzymes.

whole foods Foods that have been minimally processed.