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Resource 1: Children’s dietary intakes
Christine Williams, MD, MPH,
Member, Energy Balance Subcommittee of the 2010 Dietary Guidelines Advisory Committee^1
Recommendations for a Healthy Diet in Childhood and Adolescence
Ideally, children and adolescents should consume a diet that provides an adequate intake of all essential nutrients needed for normal growth and development, metabolism, immunity and cognitive function; and an intake of total energy (caloric) that is balanced with energy expenditure in order to maintain body weight within a healthy range. In addition to consuming a variety of nutrient-rich foods and beverages from all of the major food groups, the total diet should not only promote health in childhood, but also reduce risk for future chronic disease, e.g. cardiovascular disease, certain types of cancer, type 2 diabetes, and obesity. At the present time, however, there is concern that the majority of US children are not consuming a diet that meets these goals. This is especially true with respect to maintaining energy balance and preventing obesity.
Energy Balance in Childhood: Key to a Healthy Weight
The most significant adverse health trend among US children in the past 40 years has been the dramatic increase in overweight and obesity. Since the early 1970s, the prevalence of overweight and obesity has approximately doubled among 2-5 and 6-11 year-olds, and tripled among 12-19 year old adolescents. Among children surveyed in NHANES 2003-2006, 16.3 % of 2-19 year old children and teens were obese^2 , with BMI levels at or above the age- and gender-specific 95th percentile, and almost one-third, (31.9%) were overweight or obese, with BMI levels ≥ 85th percentile (Ogden, 2008). This is a serious public health concern since obesity is associated with adverse health effects during childhood, and increases risk of future chronic disease in adult life.
There is general agreement that childhood obesity results from long term, poorly regulated energy balance, with gradual increases in body fat, as stored energy, resulting from energy intake that exceeds energy expenditure. In other words, many children have increasingly been consuming more energy (calories) than they expend in physical activity, or need for metabolism and growth. On
(^1) This document was prepared as supplemental information related to the Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, which can be found at www.dietaryguidelines.gov.
(^2) In this document, obesity in children, 2-18 years of age, is defined as a BMI level equal to or above the age- and gender-specific 95th percentile, and overweight is defined as a BMI level between the 85th and 94th percentile relative to gender and age on the Centers for Disease Control and Prevention (CDC) growth charts (http://www.cdc.gov/growthcharts/).
average, the youth of America currently have energy intakes that fall on the high end of their respective energy ranges.
Evidence Linking Dietary Intake with Childhood Obesity
The 2010 Dietary Guidelines Advisory Committee (DGAC) examined evidence linking specific dietary and dietary behaviors with adiposity and risk of obesity in childhood. Conclusions based on the evidence reviews on energy balance are summarized below, since they provide a framework for dietary changes that may improve energy balance in childhood. Evidence supporting these associations is discussed in detail in the 2010 DGAC Report in Part D. Section 1: Energy Balance and Weight Management.
The dietary intake and diet-related behaviors associated with increased adiposity in children include: increased total energy intake; higher energy density of the diet; higher total fat intake; higher intake of sugar-sweetened beverages; low intake of fruits and vegetables; large amounts of fruit juice, especially for overweight children; large portions of food and beverages; frequent consumption of “fast foods”; less frequent consumption of breakfast; and more hours of “screen-time” (television, computer, video games, etc). Alternately, the dietary intake and diet-related behaviors associated with decreased adiposity in children include: lower total energy intake; lower energy density of the diet; lower total fat intake; lower intake of sugar-sweetened beverages; higher intakes of fruits and vegetables; smaller amounts of fruit juice; smaller portions of food and beverages; less frequent consumption of “fast foods”; frequent consumption of breakfast; and fewer hours of “screen-time”.
In addition to the items listed above for which evidence reviews led to conclusions that to some degree they played a role in either promoting or protecting against increased body weight, evidence for several other dietary intakes was inconclusive, either because little research had been conducted, as in the case of dietary fiber and childhood adiposity; or because results were inconclusive, as in the case of dairy (milk and milk products). It is important to emphasize, however, that despite the lack of evidence linking dietary fiber and dairy with adiposity in childhood; they are both important components of a healthy diet in childhood and currently are under-consumed by US children.
What are Children Eating in America? Highlights of Current Intake, Trends and Food Sources
Similar to adults, the “total diet” of children and adolescents consists of the combined intake of foods, energy, and nutrients that constitute their complete dietary intake, on average, over time.
- Mean Intake of Energy and Mean Contribution (kcal) of Various Foods Among US Children and Adolescents, by Race/Ethnicity and Family Incomes, NHANES 2005– 06: http://riskfactor.cancer.gov/diet/foodsources/energy/table5b.html
- Distribution of Intake (calories) across Beverage Types, US children & adolescents (2-18 years), 2005–06:
http://riskfactor.cancer.gov/diet/foodsources/beverages/table1.html Total energy needs in childhood and adolescence vary significantly with age, gender, and physical activity level (see Table B2.1 in Part B. Section 2: The Total Diet: Combining Nutrients, Consuming Food ). The recommendations are for healthy children and adolescents, 2-18 years of age, and regardless of weight status. However, most children over age 2 years, and especially those who are gaining weight at a disproportionately greater rate than height, or who are already overweight or obese, would benefit from moving toward consuming a total diet that is nutrient-rich but lower in energy density. For children, as for adults, reducing the current high consumption of solid fats and added sugars (SoFAS) may be the most critically needed change for better energy balance in childhood.
Survey data from NHANES 2003-04 shows that nearly 40% of total calories consumed ( kcal/day of 2027 kcal) by 2-18 year olds in the US are in the form of empty calories (433 kcal from solid fat and 365 kcal from added sugars) with empty calories representing the sum of calories from solid fat and added sugars. This contrasts markedly with discretionary calorie allowances, which range from 8% to 20% of total calories (Reedy, 2010). Currently, intake of empty calories far exceeds the discretionary calorie allowance for all sex-age groups.
Among 2-18 year olds, about half of all empty calories come from six specific foods and beverages: soda, fruit drinks, dairy desserts, grain desserts, pizza, and whole milk (Reedy, 2010). Sugar-sweetened beverages are the largest contributor, providing 22% of empty calories. In fact, among both males and females 9-13 and 14-18 years old, the empty calories consumed from soda and fruit drinks alone effectively “use up” or exceed the discretionary calorie allowance.
Dietary Intake of Solid Fats: US Children, NHANES 2003-
Among US children and adolescents, 2-18 years of age, the average daily intake of energy from solid fat is 433 kcal (NCI, 2010c). The top sources of solid fat are pizza (50 kcal/day from solid fat), grain desserts (43 kcal), whole milk (35 kcal), regular cheese (34 kcal), and fatty meats ( kcal). This list varies by age, with younger children obtaining a greater share of their solid fat from both whole and reduced-fat milk and 14-18 year olds getting more from fried potatoes. Major contributors of solid fat also include fried potatoes among non-Hispanic Black children and youth; reduced-fat milk among non-Hispanic Whites; and Mexican dishes among Mexican-Americans.
- Mean Intake of Solid Fats & Mean Contribution (kcal) of Various Foods Among US Children & Adolescents, by Race/Ethnicity & Family Income, NHANES 2005–06:
http://riskfactor.cancer.gov/diet/foodsources/solid_fats/table4b.html
Dietary Intake of Added Sugars: US Children, NHANES 2005-
Among 2-18 year old children and adolescents in the US, the average daily intake of energy from added sugars is 365 kcal (NCI, 2010d). The major sources of added sugars are soda ( kcal/day from added sugars), fruit drinks (55 kcal), grain desserts (40 kcal), dairy desserts (29 kcal), and candy (25 kcal). There is some variation with respect to age and demographic groups, for example, cold cereals are among the top sources of added sugars for 2-8 year old children, Non- Hispanic Whites, and low-income groups.
Sugar-sweetened beverages (soda, energy and sports drinks and fruit drinks) are the top two sources of calories from added sugars among nearly all age and demographic groups. Adolescents, 14-18 years of age, consume on average 260 kcal/day of added sugars from sugar-sweetened beverages; 9-13 year olds consume 168 kcal/day; 4-8 year olds consume 121 kcal/day; and for 2- year olds, 60 kcal/day. Among all racial/ethnic and income groups, sugar-sweetened beverages contributed almost half (45-50%) of the daily energy intake from added sugars. For non-Hispanic Blacks, more added sugars are consumed from fruit drinks than soda, however, a notable difference from other groups.
- Mean Intake of Added Sugar & Mean Contribution (kcal) of Various Foods Among US Children & Adolescents, by Race/Ethnicity & Family Income, NHANES 2005– 06:
http://riskfactor.cancer.gov/diet/foodsources/added_sugars/table4b.html
children and teens between the 1977-78 and 2001-02 surveys. As a percentage of total beverage intake, intake of soda by children 6-11 years increased from 15% to 33% during this 25 year time period. At the same time, milk decreased from 61% of total beverage intake to 33%. Among teens, soda replaced milk as the beverage of choice. In 1977-78, soda accounted for 29% and milk 51% of all beverages consumed by teens on a per gram basis. In 2001-02, these percentages were virtually reversed with soda making up 50% and milk 23% of this total. Ninety-five percent of soda consumed by both age groups was regular (sugar-sweetened) soda. Consumption of fruit drinks and fruitades changed slightly, increasing as a percentage of total beverages from 14% to 20% for children and 11% to 17% for teens. Intake of 100% fruit juice as a percentage of total beverages increased from 10% to 14% for children and remained relatively constant for teens (9% in 1977-78, 10% in 2001-02). In addition to changes in the type of beverage consumed, significant changes also occurred in the amount of various beverages consumed by children. Children and teens who consumed fruit juice, fruit drinks and fruitades, and soda in 1977-78 were drinking more per day of these products in 2001-02, while amounts of milk consumed by milk drinkers declined. For the 6- year olds, significant differences (p<0.001) were observed in consumption of milk, soda, and 100% fruit juice. For adolescents, significant differences in intake were found for all beverages examined except milk. In 2001-02, soda was consumed in the largest amount of any beverage. To translate into common measures, mean soda intake by children who drank soda was about 15 ounces per day for 6-11 year olds and 25 ounces for teenagers.
Dietary Intake of Fruits, Vegetables and 100% Fruit Juice: US Children, NHANES 2001-
Although evidence suggests that increased consumption of fruits and vegetables confers some protection against increased adiposity in children, at present, current intake by US children does not meet recommendations, either with respect to numbers of daily servings or variety of types consumed. Recently, the National Cancer Institute (NCI) used data from NHANES 2003-04 to determine the distribution of intake (cup equivalents) of vegetables, whole fruit and fruit juice within the MyPyramid Vegetable and Fruit Groups, for US Children and Adolescents (2-18 years). In this analysis, the weighted population contribution of each subgroup to its MyPyramid food group and the contribution of specific foods to intakes of whole fruit, fruit juice, dark green vegetables, orange vegetables, legumes, starchy vegetables, other and vegetables were determined.
Vegetables : US children and adolescents do not consume vegetables in the proportions that are recommended. Rather they eat more starchy vegetables, and other vegetables, and less dark green and orange vegetables and legumes than recommended. Mean intake of total vegetables in NHANES 2001-04 among 1-8 yr old children was only 0.8 to 1.0 servings/day, and for older children, 1.2 to 1.5 servings/day (NCI, 2010e). For older children however, especially teens, a
significant proportion of total vegetable intake is from white potatoes, often consumed as french fries. On the other hand, children consume too few servings of dark green and orange vegetables. In 2003-04, consumption of these nutrient-rich vegetables represented only 7% of total vegetable consumption by children and adolescents, 2-19 years, compared with 31% for potatoes (NHANES 2003-04).
Within the MyPyramid Vegetable Group, starchy vegetables contributed 36% of daily vegetable intake (cup equivalents), legumes contributed 7%, while dark green and orange vegetables each contributed 3%. The largest source was from “other vegetables,” a category that includes vegetable components of pizza, pasta and pasta dishes, condiments, lettuce, tomatoes, vegetable medleys, burgers, rice and mixed rice dishes, string beans, soups, Mexican mixed dishes, chicken and chicken mixed dishes, and tomato sauces.
Fried white potatoes accounted for one-third (33%) of intake from starchy vegetables, followed by potato/corn/other chips (26%); other white potatoes (23%); and corn (7%). Carrots were the top vegetable consumed in the orange vegetable subgroup, comprising 62% of children’s intake, with sweet potatoes accounting for only 5%. For dark green vegetables, broccoli accounted for 43% of intake, followed by spinach (19%), and lettuce (14%). Almost two-thirds (65%) of legumes consumed were beans, followed by legumes contained in Mexican mixed dishes (20%), rice and rice mixed dishes (7%), chili (4%), and soup (3%).
- Usual Intake of Total Vegetables, Including Cooked Dry Beans & Peas, NHANES 2001-2004:
http://riskfactor.cancer.gov/diet/usualintakes/pop/t14.html
- Distribution of Intake (cup equivalents) among Subgroups within the MyPyramid Vegetable Group, US Children and Adolescents (2–18 years), NHANES 2003-2004: http://riskfactor.cancer.gov/diet/foodsources/food_groups/figure3.html
Fruit and Fruit Juice: US children and adolescents consume more fruit juice and less whole fruit than recommended. Mean intake of total fruit for US children in NHANES 2001-04 was only 0.8 to 1.2 servings/day for ages 4-18 years, and 1.5 servings/day for ages 1-3 years (NCI, 2010f). In addition, more than half of the fruit intake (cup equivalents) within the MyPyramid fruit group, is from juice (57%) while whole fruit accounts for just 43%. For whole fruit intake, apples and pears were the top whole fruit choice of children (38%), followed by bananas (16%), other fruit and fruit salads (8%), citrus fruits (8%), melon (8%), and grapes (7%). The leading source of juice
from 10% to 14% for 6-11 year-old children, but remained relatively constant for 12-19 year-old teens (9% to 10%). In addition, children and teens who consumed fruit juice in 1977-78 were drinking more per day of these products in 2001-02. Between the 1977-78 and 2001-02, the amount of 100% fruit juice consumed each day increased from 212 to 327 grams/day for 6-11 year-old children, and increased from 238 to 423 grams/day for 12 – 19 year-old adolescents (Sebastian, 2006).
Current Intake of Dietary Fiber: US Children, NHANES 2005-
Currently, dietary fiber is under-consumed by US children, whose intake is far less than the recommended adequate intake (AI) of 14 grams of per 1000 kcal (see Part D. Section 2: Nutrient Adequacy in the 2010 DGAC Report for more information on current dietary intake of fiber). Thus, public health strategies to increase consumption of dietary fiber are vitally important to promote the health of US children. Among 2-18 year olds surveyed in NHANES 2005-06 (NCI, 2010g), top food sources of dietary fiber intake, contributing at least 5% are yeast breads, Mexican mixed dishes, pasta and pasta dishes, pizza, ready-to-eat cereals, grain-based desserts, fried white potatoes, and potato/corn/other chips, with some variation by age, gender, race/ethnicity, and income. For example, apples and pears (6%) and bananas (5%) are major contributors for 2-3 year olds, and beans (8%) and apples and pears (5%) are major contributors for all Mexican-American children and adolescents.
- Distribution of Fiber Intake (grams) across Food Sources, US Children & Adolescents (2–18 years):
http://riskfactor.cancer.gov/diet/foodsources/fiber/figure2.html
- Mean Intake of Dietary Fiber & Percentage Contribution of Various Foods among US Children & Adolescents, by Age, NHANES 2005–06: http://riskfactor.cancer.gov/diet/foodsources/fiber/table1a.html
- Mean Intake of Dietary Fiber & Percentage Contribution of Various Foods among US Children & Adolescents, by Race/Ethnicity & Family Income, NHANES 2005– 06: http://riskfactor.cancer.gov/diet/foodsources/fiber/table4a.html
Total Fat Intake in US Children: Current Intake, Trends, and Food Sources
Trends in dietary fat intake among children are of interest with respect to increasing childhood obesity since fat is the most energy dense nutrient. Based on data from cross-sectional surveys of US children over the past several decades, percent of energy from total fat has decreased. Between 1965 and 1996, the proportion of energy from total fat consumed by US children decreased from 39% to 32%, and saturated fat from 15 to 12%. Both children, age 6 -11 years, and adolescents, age 12-19 years, in 1994-96, 1998 consumed 25-26% of calories from discretionary fat (Enns, 2002). Data from the 2001-2004 NHANES survey shows that among children, mean intake of total fat has remained at about 32-33 % of energy intake. Although mean intake falls with the Acceptable Macronutrient Distribution Range (AMDR), fully one-fourth of 2-18 yr olds consume more than 35% of energy as fat, exceeding the recommended range (available at: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/Meeting6/AdditionalResources/ NutrientsByTotalFatQuartiles-AllAges.pdf).
In contrast, comparing dietary intake in 1977-78 with intake in 2001-02 shows that higher fat food choices among US children have increased (Sebastian, 2006). Consumption of pizza, tacos, and snack foods increased dramatically among children and teens over this 25 year period. The following food groups showed large increases in mean intake: savory grain snacks including corn chips, tortilla chips, popcorn, pretzels, and non-sweet crackers (+320% in both groups); pizza (+413% for children, +208% for teens); Mexican dishes (+367% for children, +567% for teens); and candy (+180%, +220%). Overall, vegetables not consumed as part of a mixed dish exhibited a decrease in consumption despite a sizable increase in fried potatoes intake. All reported differences in food group intake were significant (p<0.001).
Further analysis of data from NHANES 2001-2004 reveals that as total fat intake increases, so also does intake of saturated fat, cholesterol and sodium (available at: http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/Meeting6/AdditionalResources/ NutrientsByTotalFatQuartiles-AllAges.pdf). Thus from the perspective of promoting cardiovascular health in children and adolescents, keeping total fat, saturated fat and cholesterol intakes within recommended intake levels is very important. Although it is theoretically possible for children with high total fat intakes to maintain energy balance with careful attention to calorie intake and expenditure; and to substitute monounsaturated fat for saturated fat to promote healthy a healthy lipid profile, the reality of achieving this, in view of the top sources of energy among US children and adolescents, is unlikely without drastic changes in the foods and beverages currently consumed.
Current recommended levels of fat intake for children were proposed by the National Academy of Sciences (NAS) in their 2005 Macronutrient Report (IOM, 2005). Acceptable
The Special TURKU Risk Factor Intervention Project (STRIP): In this unique randomized controlled dietary intervention trial in Finland, children have now been followed prospectively for more than 15 years, beginning in infancy. To date, more than 100 scientific reports from the STRIP study have been published on methodology, as well as outcomes. Overall, findings from the STRIP study suggest that a dietary pattern begun early in life, characterized by low saturated fat and low cholesterol, with total fat intake at about 30% of energy intake, may translate into significant long-term reductions in risk factors for cardiovascular disease, including healthier lipid profiles, lower blood pressure levels, less metabolic syndrome, and in some children, less obesity.
In the STRIP trial, a low-saturated-fat, low-cholesterol diet was introduced to intervention infants (n=540) at 7 months of age, and control children (n=522) received an unrestricted diet. Children’s dietary intake, serum cholesterol values, somatic growth, and development were subsequently monitored through childhood and adolescence. Breastfeeding was encouraged until weaning. At 12 months of age, dietary counseling included skim milk for intervention children versus reduced fat milk (2% fat by weight) for the usual care group. Intervention children were also encouraged to consume 2 tsp (10g) soft margarine or vegetable oil daily during the second year of life to maintain adequate fat intake and increase the ratio of unsaturated to saturated fatty acids. No advice to lower sodium given until age 8 yrs, and even then – not strongly emphasized. An extensive list of outcome measures were obtained on subjects, parents and siblings during from childhood through adolescence; however key outcomes variables included measures of dietary intake, blood lipids, blood pressure, growth and development, and cognitive and psychosocial status.
Improved Lipid Profiles: Niinikoski et al. (2007) evaluated the effect of the STRIP intervention on fat intakes, growth, serum cholesterol values, and pubertal development in participating children. Results showed that saturated fat intakes, serum total cholesterol, and low- density lipoprotein cholesterol values were lower (p<0.001) in the intervention than in control children during the 14 years of follow-up, whereas HDL-cholesterol values in the 2 study groups showed no difference. Boys had lower total and low-density lipoprotein cholesterol concentrations than girls throughout childhood (p<0.001), and the intervention effect on serum cholesterol concentration was larger in boys than girls. The 2 study groups showed no difference in growth, body mass index, pubertal development, or age at menarche (median, 13.0 and 12.8 years in the intervention and control girls, respectively; p=0.52). The cholesterol values decreased as puberty progressed. Mean concentrations of total and HDL-cholesterol decreased from ≈ 4.5 and ≈1. mmol/L, respectively, in Tanner stage 1 (prepubertal) boys to ≈3.9 and ≈1.1 mmol/L in Tanner stage 4 (late pubertal) boys. The authors concluded that repeated dietary counseling remains effective in decreasing saturated fat and cholesterol intake and serum cholesterol values at least until 14 years of age. Puberty markedly influences serum cholesterol concentrations.
Lower Blood Pressure: Niinikoski et al. (2009) measured blood pressure annually among the 1,062 children followed in the STRIP study from 7 months to 15 years of age. At age 15 years, systolic and diastolic blood pressures were 1.0 mm Hg lower (95% CI for SBP: -1.7 to – 0.2 mm Hg; 95% CI for DBP: -1.5 to – 0.4 mm Hg) in children receiving low-saturated fat counseling through childhood than in control children. Intakes of saturated fat were lower; and intakes of polyunsaturated fat were higher in the intervention versus control group. Dietary intakes of sodium (p=0.76) and calcium (p=0.08) did not differ between the study groups, but intakes of potassium (p=0.002) and magnesium (p<0.0001) were significantly higher in children in the intervention group compared with controls.
Reduced Prevalence of Metabolic Syndrome : Hakanen et al. (2010) evaluated the impact of the STRIP dietary and lifestyle intervention on the clustering of overweight-related metabolic syndrome risk factors among subjects in the trial. A cluster was defined as having high BMI and ≥ 2 other risk factors. Results showed that at age 15 years, 13.0% of girls and 10.8% of boys in the intervention group, and 17.5% of girls and 18.8% of boys in the control group had the risk factor cluster (p=0.046 for main effect of the study group). Having even one risk factor at the age of 5 years predicted the clustering of risk factors at the age of 15 years (OR: 3.8, p < 0.001). They concluded that repeated, individualized dietary and lifestyle counseling may reduce the clustering of cardiometabolic risk factors in adolescents even if the counseling is not intense enough to prevent overweight.
Lower Indices of Insulin Resistance: Kaitosaari et al. (2006) assessed insulin resistance (HOMA-IR) index, serum lipids, blood pressure, and weight for height in a random subgroup of 78 STRIP intervention children and 89 control children at 9 years of age. Intervention children consumed less total and saturated fat than the control children (p=0.002 and 0.0001, respectively). Results showed that the HOMA-IR index was lower in intervention children than in control children (p=0.020). There was a significant association between saturated fat intake and HOMA-IR. In multivariate analyses including saturated fat intake, study group, and other determinants of HOMA-IR (serum triglyceride concentration, weight for height, and systolic blood pressure), study group was, whereas saturated fat intake was not, significantly associated with HOMA-IR. This suggests that the beneficial effect of intervention on insulin sensitivity was largely, but not fully, explained by the decrease in saturated fat intake. The authors concluded that long-term biannual dietary intervention decreases the intake of total and saturated fat and has a positive effect on insulin resistance index in 9-year-old children.
Less Overweight and Obesity in Girls at Age 10 years; but not at Age 13 in Males or Females: Hakanen et al. (2006) evaluated the impact of individualized dietary and lifestyle counseling on the prevalence of overweight during the first 10 years of life in children participating
(2008) found that subjects assigned to the DASH diet pattern for 3 months had a significantly greater decrease in systolic blood pressure and diastolic blood pressure z-scores compared with subjects in the usual care group. In this study, the DASH group had a greater increase in intake of fruits (p<0.001), low-fat dairy products (p<0.001), potassium and magnesium (both (p<0.001), and decreased intake of total fat (p<0.05) compared with controls. Sodium intake did not differ significantly between treatment groups.
Thus in summary, there is a small but growing body of scientific literature that links health benefits in childhood, especially lower blood pressure and reduced risk of cardiovascular disease, with specific dietary patterns in well-designed cohort studies and clinical trials. Evidence from these studies suggest that children and adolescents are likely to accrue health benefits from diets that emphasize plant-based foods, especially vegetables and fruits, and an intake of total fat that is in the lower range of the AMDR (<30% energy) and is low in saturated fat (<10% energy). In addition, health benefits are linked to carbohydrate intake that is primarily from complex carbohydrates, especially from high fiber and whole grain products; low-fat and non-fat dairy; and lean sources of high quality protein. These findings are of public health importance, since cardiovascular diseases are the leading cause of death in the US and atherosclerosis begins in childhood.
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