Ebook Bright futures nutrition (3/E): Part 1

Bright Futures Nutrition

New from the American Academy of Pediatrics and Bright Futures

THIRD EDITION

Other great resources from Bright Futures
Bright Futures Nutrition, Third Edition Pocket Guide

Bright Futures Guidelines for Health Supervision of Infants, Children,
and Adolescents, Third Edition

To order these and other pediatrics resources, visit the
American Academy of Pediatrics Online Bookstore at

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AAP



Bright
Futures
NutRItion
third edition

Editors

Katrina Holt, MPH, MS, RD
Nancy Wooldridge, MS, RD, LD
Mary Story, PhD, RD

Denise Sofka, MPH, RD

Published by

The American Academy of Pediatrics


American Academy of Pediatrics Department of Marketing and Publications Staff
Maureen DeRosa, MPA
Director, Department of Marketing and Publications
Mark Grimes
Director, Division of Product Development
Sandi King, MS
Director, Division of Publishing and Production Services
Maryjo Reynolds
Product Manager, Bright Futures
Peg Mulcahy
Manager, Graphic Design and Production
Kate Larson
Manager, Editorial Services
Kevin Tuley
Director, Division of Marketing and Sales

Bright Futures: Nutrition, 3rd Edition
Library of Congress Control Number: 2010941756
ISBN: 978-1-58110-554-4
Product Code: BF0037

The recommendations in this publication do not indicate an exclusive course of treatment or serve
as a standard of care. Variations, taking into account individual circumstances, may be appropriate.

Every effort has been made to ensure that the drug selection and dosage set forth in this text are in
accordance with the current recommendations and practice at the time of the publication. It is the
responsibility of the health care provider to check the package insert of each drug for any change in
indications or dosage and for added warnings and precautions.
The mention of product names in this publication is for informational purposes only and does not
imply endorsement by the American Academy of Pediatrics.
Copyright © 2011 American Academy of Pediatrics. All rights reserved. No part of this publication
may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior permission from the publisher.
Printed in United States of America
This publication has been produced by the American Academy of Pediatrics under its cooperative
agreement (U04MC07853) with the US Department of Health and Human Services, Health Resources
and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB).
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BRIGHT FUTURES: NUTRITION

Table of Contents
Bright Futures Children’s Health Charter..............................................................................v
Creating a Lifelong Foundation for Healthy Eating..........................................................vii
About Bright Futures: Nutrition...........................................................................................ix
Bright Futures: Nutrition Vision and Goals..........................................................................xi
How This Guide Is Organized..............................................................................................xii
How This Guide Can Be Used.............................................................................................xiii
Participants in Bright Futures: Nutrition, Third Edition..................................................... xv

INTRODUCTION............................................................................................. 1
Healthy Eating and Physical Activity.....................................................................................3
Nutrition in the Community..................................................................................................9

Cultural Awareness in Nutrition Services............................................................................13

NUTRITION SUPERVISION........................................................................... 17
Infancy..................................................................................................................................19
Early Childhood....................................................................................................................51
Middle Childhood................................................................................................................73
Adolescence..........................................................................................................................93

NUTRITION ISSUES AND CONCERNS........................................................ 113
Breastfeeding.....................................................................................................................115
Children and Adolescents With Special Health Care Needs............................................123
Diabetes Mellitus................................................................................................................131
Eating Disorders.................................................................................................................137
Food Allergy.......................................................................................................................147
Human Immunodeficiency Virus.......................................................................................153
Hyperlipidemia...................................................................................................................161
Hypertension......................................................................................................................167
Iron-Deficiency Anemia.....................................................................................................175
Nutrition in Sports..............................................................................................................183
Obesity................................................................................................................................193
Pediatric Undernutrition....................................................................................................209
Vegetarian Eating Practices...............................................................................................213

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Oral Health.........................................................................................................................201


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TABLE OF CONTENTS, CONTINUED
NUTRITION TOOLS..................................................................................... 221
Tool A: Nutrition Questionnaire for Infants.....................................................................223
Tool B: Nutrition Questionnaire for Children Ages 1 to 10.............................................227
Tool C: Nutrition Questionnaire for Adolescents Ages 11 to 21.....................................233
Tool D: Key Indicators of Nutrition Risk for Children and Adolescents..........................239
Tool E: Screening for Elevated Blood Lead Levels............................................................245
Tool F: Stages of Change—A Model for Nutrition Counseling.......................................249
Tool G: Strategies for Health Professionals to Promote Healthy Eating Behaviors.......251
Tool H: Basics for Handling Food Safely...........................................................................255
Tool I: Tips for Fostering a Positive Body Image Among Children and Adolescents......257
Tool J: Nutrition Resources................................................................................................259
Tool K: Federal Nutrition Assistance Programs................................................................265

INDEX........................................................................................................ 269

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BRIGHT FUTURES: NUTRITION

Bright Futures Children’s Health Charter
Principles developed by advocates for children have been the foundation for initiatives to
improve children’s lives. Bright Futures participants have adopted these principles in order
to guide their work and meet the unique needs of children and families in the 21st century.
Every child deserves to be born well, to be physically fit, and to achieve self-responsibility for
good health habits.

Every child and adolescent deserves ready access to coordinated and comprehensive p
­ reventive,
health-promoting, therapeutic, and rehabilitative medical, mental health, and oral health care.
Such care is best provided through a continuing relationship with a primary health professional
or team, and ready access to secondary and tertiary levels of care.
Every child and adolescent deserves a nurturing family and supportive relationships with other
s­ ignificant persons who provide security, positive role models, warmth, love, and unconditional
­acceptance. A child’s health begins with the health of his parents.
Every child and adolescent deserves to grow and develop in a physically and psychologically
safe home and school environment free of undue risk of injury, abuse, violence, and exposure
to ­environmental toxins.
Every child and adolescent deserves satisfactory housing, good nutrition, a quality education, an
­adequate family income, a supportive social network, and access to community resources.
Every child deserves quality child care when her parents are working outside the home.
Every child and adolescent deserves the opportunity to develop ways to cope with
stressful life experiences.
Every adolescent deserves the opportunity to be prepared for parenthood.
Every child and adolescent deserves the opportunity to develop positive values and
become a ­responsible citizen in his community.
Every child and adolescent deserves to experience joy, have high self-esteem, have friends,
acquire a sense of efficacy, and believe that she can succeed in life. She should help the next
generation develop the motivation and habits necessary for similar achievement.

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BRIGHT FUTURES: NUTRITION

Creating a Lifelong Foundation for Healthy Eating
To meet the challenge of developing nutrition guidelines for infants, children, and adolescents, the
Bright Futures team convened a multidisciplinary panel of health professionals, including educators,
clinicians, public health officials, and representatives from family organizations. The panel focused on
2 key issues.
1.What do families need to do to promote the nutrition status of infants, children, and adolescents?
2.What do health professionals and communities need to do to become more effective in promoting
the nutrition status of infants, children, and adolescents?
The goal was to develop nutrition guidelines for the infancy through adolescence developmental
­periods. Nutrition guidelines based on the best available scientific research, professional standards,
and expert opinions were developed and sent for review to more than 150 individuals from a variety
of health agencies and organizations.
Bright Futures: Nutrition presents the resulting nutrition guidelines and tools designed for use by
a wide array of health professionals, including dietitians, nutritionists, nurses, and physicians. The
guide can also serve as a practical, educational resource for families and communities.
Bright Futures: Nutrition emphasizes health promotion, disease prevention, and early recognition of
nutrition concerns of infants, children, and adolescents. The guide also highlights how partnerships
among health professionals, families, and communities can improve the nutrition status of infants,
children, and adolescents.
Bright Futures: Nutrition builds on the nutrition guidelines presented in Bright Futures: Guidelines
for Health Supervision of Infants, Children, and Adolescents. The nutrition guide is a practical tool
for applying concepts and principles essential to nutrition supervision. It also supports the Healthy
People objectives for the nation and can be used to develop and implement programs and policies
for the health and well-being of infants, children, and adolescents. Bright Futures: Nutrition represents a vision for the new millennium, a direction for integrating nutrition into health services in
the 21st century.
Together, health professionals, families, and communities can work to improve the nutrition s­ tatus
of our nation’s infants, children, and adolescents and build a foundation for lifelong healthy eating
behaviors—a foundation that encourages infants, children, and adolescents to enjoy eating healthy
food and encourages children and adolescents to value family meals and feel good about themselves.

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BRIGHT FUTURES: NUTRITION

About Bright Futures: Nutrition
Optimal nutrition is important for sustenance, good health, and well-being throughout life. As the
relationships among diet, health, and disease prevention have become clearer, nutrition and the
­promotion of healthy eating behaviors have received increased attention.
The nutrition status of infants, children, and adolescents affects their growth and development and
resistance to disease. Lifelong eating behaviors and physical activity patterns are often established
in early childhood. Therefore, it is important for children and adolescents to build the foundation
for good health by choosing a healthy lifestyle, including practicing healthy eating behaviors and
­participating in regular physical activity.
A DEVELOPMENTAL AND CONTEXTUAL APPROACH

Nutrition needs to be approached from 2 perspectives: (1) the development of infants, children, and
adolescents and (2) the context of their daily lives and environment. The guidelines in Bright Futures:
Nutrition represent a developmental and contextual approach for helping children and adolescents
develop positive attitudes toward food and practice healthy eating behaviors.
The developmental approach, which is based on the unique social and psychological characteristics
of each developmental period, is critical for understanding infants’, children’s, and adolescents’ attitudes toward food and for encouraging healthy eating behaviors.
The contextual approach emphasizes the promotion of positive attitudes toward food and healthy
­eating behaviors by providing infants, children, adolescents, and their families with consistent nutrition messages. Consistency, combined with flexibility, is essential for handling the challenges of
infancy and early ­childhood. During middle childhood and adolescence, it is important for parents to
encourage their children and adolescents to become more responsible for their own health and to help

them develop the skills they need to practice healthy eating behaviors.
Bright Futures: Nutrition recommends that food and eating be viewed as both health-enhancing and
pleasurable. Food provides more than just energy and sustenance. It holds innumerable symbolic,
emotional, social, and personal meanings. Food is connected with nurturing, family, culture, tradition,
and celebration. Promoting positive attitudes toward food and healthy eating behaviors in i­ nfants,
children, and adolescents involves recognizing the multiple meanings of food and creating an environment that encourages the enjoyment of food. Family meals are emphasized because they help build on
family strengths and promote unity, social bonds, and good communication.
PARTNERSHIPS AMONG HEALTH PROFESSIONALS, FAMILIES, AND COMMUNITIES

Encouraging healthy eating behaviors in infants, children, and adolescents is a shared responsibility.
One of the principles of Bright Futures: Nutrition is that together health professionals, families, and
communities can make a difference in the nutrition status of infants, children, and adolescents.
Today many families face the challenges of balancing work and home life and dealing with hectic
schedules. Health professionals can help families learn how to fit nutritious meals and snacks into
their busy lives. To be most effective, strategies need to be tailored to the family’s individual needs.
The family is the predominant influence on infants’, children’s, and adolescents’ attitudes toward food
and their adoption of healthy eating behaviors. The family exerts this influence by
■■
■■

Providing food
Transmitting attitudes, preferences, and values about food, which affect lifetime eating behaviors
Establishing the social environment in which food is shared

Parents want to know how they can contribute to their infants’, children’s, and adolescents’ health and
are looking for guidance; however, they are faced with contradictory nutrition information. Dietary
recommendations can be misunderstood or misinterpreted, especially when adult guidelines are
applied to infants, children, and adolescents.

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■■


BRIGHT FUTURES: NUTRITION

Bright Futures: Nutrition will help health professionals revise standards of practice, promote the
­development of new nutrition programs, and provide the information children and adolescents
need to develop positive attitudes toward food and practice healthy eating behaviors. The guide can
serve as a resource for training health professionals and students. Sections of the guide—­particularly
the Frequently Asked Questions at the end of the Infancy, Early Childhood, Middle Childhood,
and Adolescence chapters and the tools on nutrition risk, food safety, body image, and federal food
­assistance programs—can serve as a resource for educating families.
Throughout the nutrition guide, we use the term “parent” to refer to the adult or adults responsible
for the care of the infant, child, or adolescent. In some situations this person could be an aunt, uncle,
grandparent, custodian, or legal guardian.
The community can be invaluable in helping children and adolescents develop positive attitudes about
food and practice healthy eating behaviors. Bright Futures: Nutrition can be used in a variety of community settings (eg, clinics, health and child care centers, hospitals, schools, colleges, and universities).
Community settings and events that provide a variety of healthy, affordable, and enjoyable foods can
be instrumental in communicating positive nutrition messages.
WHERE WE GO FROM HERE

There are many opportunities to promote the nutrition status of infants, children, and adolescents.
It is our sincere hope that Bright Futures: Nutrition will be useful to health professionals, families,
and communities as they strive to ensure the health and well-being of the current generation and of
­generations to come.

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BRIGHT FUTURES: NUTRITION

Bright Futures: Nutrition Vision and Goals
The vision and goals of Bright Futures: Nutrition are to
■■ Improve the nutrition status of infants, children, and adolescents.
■■ Identify desired health and nutrition outcomes that result from positive nutrition status.
■■ Set guidelines to help health professionals promote the nutrition status of infants, children,
and  adolescents.
■■ Encourage partnerships among health professionals, families, and communities to promote the
nutrition status of infants, children, and adolescents.
■■ Describe the roles of health professionals in delivering nutrition services within the community.
■■ Identify opportunities for coordination and collaboration between health professionals and
the community.

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BRIGHT FUTURES: NUTRITION

How This Guide Is Organized
The guide is divided into the following sections.
INTRODUCTION

This section provides information on promoting good nutrition and physical activity as essential
­components of a healthy lifestyle; establishing a framework for understanding how culture affects

food choices and nutrition; and building partnerships among health professionals, families, and
­communities to improve the nutrition status of infants, children, and adolescents.
NUTRITION SUPERVISION

This section outlines critical nutrition issues in infancy, early childhood, middle childhood, and
­adolescence. Each chapter contains an overview of the developmental period; nutrition s­ upervision
information (including interview questions, screening and assessment, and anticipatory guidance);
desired health and nutrition outcomes; and a list of frequently asked questions with answers that can
be used as a handout for families.
NUTRITION ISSUES AND CONCERNS

This section provides an overview of common nutrition issues and concerns that affect infants,
­children, and adolescents.
NUTRITION TOOLS

This section provides nutrition screening tools, strategies, and resources to help health professionals,
families, and communities promote the nutrition status of infants, children, and adolescents.
INDEX

This section contains a subject index of the guide.

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How This Guide Can Be Used
Bright Futures: Nutrition is designed to complement Bright Futures: Guidelines for Health Supervision

for Infants, Children, and Adolescents1 by providing in-depth coverage of nutrition issues.
Bright Futures: Nutrition can be used in many settings, such as university- or community-based
­training programs, community health clinics, school-based health centers, and community programs
(eg, Special Supplemental Nutrition Program for Women, Infants and Children [WIC]; Head Start;
child care; home visiting). Many health professionals, such as dietitians, nutritionists, nurse practi­
tioners, nurses, physicians, physician assistants, dental hygienists, health educators, and students, will
find the guide useful. Potential uses of the information fall into 4 main areas: clinical, community,
­policy, and education and training.
CLINICAL

Uses
Augment nutrition information as outlined in Bright Futures: Guidelines for Health Supervision of
Infants, Children, and Adolescents.1
Develop and evaluate nutrition programs.
Implement standards of practice and protocol.
Educate children, adolescents, and their families.
Refer families to nutrition resources.
Support studies to determine the efficacy of Bright Futures nutrition guidelines.
Examples
Develop nutrition standards of care for Early and Periodic Screening, Diagnostic, and
Treatment services.
Incorporate nutrition screening, assessment, and counseling information into health encounter forms.
Incorporate desired outcomes (eg, “gradually increases variety of foods eaten”) from the nutrition
supervision chapters to track developmental milestones on health encounter forms.
Implement recommendations for screening, assessment, and treatment of hypertension.
Develop protocol for iron-deficiency anemia screening.
COMMUNITY

Uses
Provide anticipatory guidance to families on healthy eating behaviors.

Provide information to program staff to educate families about nutrition.
Develop and evaluate nutrition education programs.
Refer families to nutrition resources.
Help schools incorporate nutrition education into their curricula.
Implement standards of practice and protocol.
Examples
Develop a resource guide for parents with infants or children participating in WIC to promote a
healthy feeding relationship between parents and their children.
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Promote partnerships among health professionals and members of the community interested in food
safety (eg, food service workers, school nurses, child care providers, restaurant owners).


BRIGHT FUTURES: NUTRITION

Develop recommendations for sports and physical activity participation to prevent dehydration and
heat-related illness among children and adolescents. Dietitians and other health professionals, physical
education teachers, coaches, and parents could use information from the nutrition guide to develop
fact sheets for distribution throughout the community.
Help children and adolescents in group homes and juvenile justice facilities obtain access to a wider
range of healthy food choices; access to physical activity opportunities; and knowledge of the relationships among body weight, fitness, body image, and substance use.
Promote partnerships among health professionals, families, and the community (eg, parent-teacher
association members, principals, teachers, food service personnel, coaches) interested in promoting
healthy nutrition in schools.
POLICY

Uses
Provide information to policymakers, program administrators, and community leaders on nutrition

issues and concerns.
Obtain support for nutrition policies and programs.
Develop standards of practice and protocol for nutrition programs.
Examples
Incorporate recommendations into state nutrition education guidelines and regulations.
Revise health care guidelines for managed care settings to cover nutrition screening, assessment, and
counseling for infants, children, and adolescents.
Focus advocacy efforts on preventing early childhood caries and promoting community water
fluoridation.
Support studies to determine the cost-effectiveness of Bright Futures nutrition guidelines.
Develop coverage and care appropriate for infants, children, and adolescents provided by the
Children’s Health Insurance Program.
EDUCATION AND TRAINING

Uses
Educate and train health professionals and paraprofessionals.
Provide in-service education and training to staff.
Use the nutrition guide as a textbook or reference.
Examples
Add a cultural awareness component to nutrition counseling training, using Keys to Good CrossCultural Communication (page 16).
Plan monthly nutrition case conferences in clinical training programs, using the nutrition supervision
chapters and Tool D: Key Indicators of Nutrition Risk for Children and Adolescents to evaluate nutrition risk. Use desired outcomes from the nutrition supervision chapters to evaluate developmental
milestones and formulate nutrition care plans.
REFERENCE

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1. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.

3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008. />and_Pocket_Guide.html


BRIGHT FUTURES: NUTRITION

Participants in Bright Futures: Nutrition, Third Edition
STEERING COMMITTEE MEMBERS

Chris DeGraw, MD, MPH
Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
Katrina Holt, MPH, MS, RD
Georgetown University, Washington, DC
Amy Pirretti, MS
American Academy of Pediatrics, Division of Developmental Pediatrics and Preventive Services,
Elk Grove Village, IL
Karyl Rickard, PhD, RD
Indiana University, School of Health and Rehabilitation Sciences, Indianapolis, IN
Madeleine Sigman-Grant, PhD, RD
University of Nevada Cooperative Extension, Las Vegas, NV
Denise Sofka, MPH, RD
Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
Bonnie A. Spear, PhD, RD, LD
University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL
Mary Story, PhD, RD
University of Minnesota, School of Public Health, Minneapolis, MN
Nancy Wooldridge, MS, RD, LD
University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL
CONTRIBUTORS

Irene Alton, MS, RD, LN

West Side Community Health Services, St Paul, MN
Sarah Barlow, MD, MPH
Baylor College of Medicine, Department of Pediatrics, Houston, TX
Sue Brady, DMSc, RD
Indiana University, School of Health and Rehabilitation Sciences, Indianapolis, IN
Paul Casamassimo, DDS, MS
Ohio State University, College of Dentistry, Children’s Hospital of Columbus, OH
Lynn Christie, MS, RD, LD
University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR
Stephen Daniels, MD, PhD, MPH
University of Colorado, School of Medicine, Department of Pediatrics, Aurora, CO
Peter Dawson, MD, MPH
Colorado Schools of Medicine and Public Health, Boulder, CO
Jennifer Graf, MS, RD
Lieutenant Commander, US Public Health Service, National Institutes of Health, Clinical Center,
Nutrition Department, Bethesda, MD
Anne Hague, PhD, MS, RD, LD, RDH
Ohio State University, College of Dentistry, Columbus, OH

Albert C. Hergenroeder, MD
Baylor College of Medicine, Adolescent Medicine and Sports Medicine, Houston, TX

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Betsy Haughton, EdD, RD, LDN
University of Tennessee, Department of Nutrition, Knoxville, TN


Bright Futures: Nutrition

Katrina Holt, MPH, MS, RD
Georgetown University, Washington, DC
Stephanie Joyce, MS, RD, LD
University of Tennessee, Department of Nutrition, Knoxville, TN
Katie Kavanagh, PhD, RD, LDN
University of Tennessee, Department of Nutrition, Knoxville, TN
Joann Kosinski, MPH, RD, CSP
Connecticut Children’s Medical Center, Hartford, CT
Ruth Lawrence, MD
University of Rochester Medical Center, Department of Pediatrics, Rochester, NY
Emily Smith Loghmani, MS, RD, LDN, CDE
Johns Hopkins Diabetes Center, Baltimore, MD
Katie Loth, RD, MPH
University of Minnesota, School of Public Health, Minneapolis, MN
Beth Reisdorf, MPH, RD, LD
University of Minnesota, School of Public Health, Minneapolis, MN
Karyl Rickard, PhD, RD
Indiana University, School of Health and Rehabilitation Sciences, Indianapolis, IN
Madeleine Sigman-Grant, PhD, RD
University of Nevada Cooperative Extension, Las Vegas, NV
Denise Sofka, MPH, RD
Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
Bonnie A. Spear, PhD, RD, LD
University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL
Jamie Stang, PhD, MPH, RD
University of Minnesota, School of Public Health, Minneapolis, MN
Mary Story, PhD, RD
University of Minnesota, School of Public Health, Minneapolis, MN
Janet Horsley Willis, MPH, RD

Virginia Commonwealth University, Partnership for People with Disabilities, Richmond, VA
Nancy Wooldridge, MS, RD, LD
University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL
content experts

Kathryn Y. McMurry, MS
Holly H. McPeak, MS
Office of Disease Prevention and Health Promotion
Office of the Assistant Secretary for Health, Washington, DC

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Introduction

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BRIGHT FUTURES: NUTRITION

Healthy Eating and
­P hysical ­Activity

Healthy Eating and
Physical Activity
Healthy, age-appropriate eating and physical activity are essential for good health at every
age. Both are especially important for the growth and development of infants, children,
and adolescents. Healthy eating can help prevent health problems such as iron-deficiency
anemia, eating disorders, undernutrition, dental caries (tooth decay), overweight and
­obesity, and osteoporosis. Healthy eating along with physical activity can help prevent
overweight and obesity and osteoporosis. Over the long term, healthy eating and physical
activity can help lower the risk of developing chronic diseases (eg, heart disease, certain
cancers, type 2 diabetes mellitus, stroke, osteoporosis) or reduce risk factors for diseases
(eg, overweight and obesity, high blood pressure, high blood cholesterol levels).1 Physical
activity in children and adolescents also improves strength and endurance, builds healthy
bones and lean muscles, develops motor skills and coordination, reduces fat, reduces
feelings of depression and anxiety, and promotes psychological well-being.2 Many children and adolescents like physical activity because it is fun; they can do it with friends
and ­family; and it helps them learn skills, stay in shape, and feel good. By making healthy
food choices and finding a balance between the amount of food they consume and the
level of physical activity they engage in, they can feel good and stay healthy.1,2
Unfortunately, there are barriers to both healthy eating and being physically active. Highcalorie, low-nutrient foods are widely available, and portion sizes are often large. These
foods, which require little or no preparation and are frequently inexpensive, are attractive
to families facing time and money pressures. In addition, many media messages encourage unhealthy eating, thereby negatively influencing children’s and adolescents’ eating
behaviors. Too often, “healthy eating” connotes expensive food that is tasteless, timeconsuming to prepare, and part of a regimented “diet” that is inconsistent with usual
eating habits.
Similarly, negative images create barriers to being physically active. Physical activity is
sometimes viewed as time-consuming, painful, boring, or expensive. Some people feel
they can’t be physically active on a regular basis, so they don’t try to be physically active at
all. Children and adolescents who are sedentary often feel that physical activity goals are
beyond their reach, and others feel intimidated about joining activities with those who are
more fit or athletic. Furthermore, some families have difficulty finding safe, inexpensive
places where they can enjoy physical activity.

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Health professionals, families, and communities can work together to improve the wellbeing of children and adolescents by creating opportunities for healthy eating and physical activity. Multifaceted, community efforts can combat negative images and demonstrate
that healthy foods can be tasty, quick to prepare, and affordable and that physical activity can be fun. Using settings such as community centers, athletic facilities, libraries,


Healthy Eating and
­P hysical ­Activity

BRIGHT FUTURES: NUTRITION

restaurants, and grocery stores to deliver innovative nutrition-education programs should
be explored. Environments that make it easier to be physically active should be provided.
Examples of such environments include parks
with play areas, walking and biking paths, and
school and other community recreational facilities that are open during nonschool hours (eg,
after school, on weekends, during the summer).
Providing families with healthy food choices
that are appealing and affordable, as well as with
options for becoming more physically active,
can empower all family members to develop
healthy lifestyles.

be adopted by the public. Taken together, the
Dietary Guidelines recommendations encompass
2 over-arching concepts1:
■■ Maintain calorie balance over time to achieve
and sustain a healthy weight.
■■ Focus on consuming nutrient-rich foods

and beverages.

People’s lifestyle choices are based on their nutrition needs and on their cultures, access to food,
environment, friends and family, and enjoyment
of certain foods or activities. A variety of factors
play roles in how people select foods, plan meals,
and decide where to eat and with whom. A variety of factors also influence what physical activities people engage in and how long they spend
on physical activity each day.

The Dietary Guidelines, which are jointly issued
by the US Department of Agriculture and the US
Department of Health and Human Services, are
updated every 5 years. New communication tools
based on the Dietary Guidelines are available at
/>
The Dietary Guidelines for Americans and the
Physical Activity Guidelines for Americans are
the foundation for nutrition and physical activity principles that form the basis for government
nutrition policy and education.1,2
DIETARY GUIDELINES FOR
AMERICANS
The Dietary Guidelines for Americans 2010
­comprise core principles to help people, ages
2 years and older, develop healthy lifestyles
based on individual needs, likes, and dislikes
related to both eating and physical activity. The
Dietary Guidelines focus on choosing from a
variety of nutritious foods, reading food labels,
and being more physically active to meet nutrition requirements, promote health, and reduce
risk of chronic disease. The Dietary Guidelines

emphasize that individuals and families can
make choices today that will help them feel
good and be healthy in the future.1

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The Dietary Guidelines summarize and synthesize knowledge about individual nutrients and
food components into an interrelated set of
recommendations for healthy eating that can

Box 1 lists the Dietary Guidelines for Americans
2010 key recommendations, which are the
most important for improving public health.
To get the full benefit, individuals should carry
out the Dietary Guidelines recommendations
in their entirety as part of an overall healthy
eating pattern.

■■ NUTRITION FACTS FOOD LABEL
The Nutrition Facts food label appears on most
packaged foods. The label helps people select
foods that meet Dietary Guidelines recommendations. Key nutrients (including the amount
of nutrients per serving) that the food provides are listed on the label. The Nutrition Facts
food label provides a mechanism for comparing the calories and nutrients in different foods.
Consumers can also use the label to choose foods
rich in polyunsaturated and monounsaturated
fat and low in saturated fat, trans fat, and cholesterol, or to choose foods with less sugar and salt.3
See Figure 1 on page 6 for a sample nutrition

facts label.
PHYSICAL ACTIVITY GUIDELINES
FOR AMERICANS
The Physical Activity Guidelines for Americans
describe the types and amounts of physical
activity that offer substantial health benefits
for children and adolescents ages 6 and older
and adults.2 The Physical Activity Guidelines for
Americans complement the Dietary Guidelines for
Americans, and together the 2 documents provide
guidance on the importance of being physically


BRIGHT FUTURES: NUTRITION

BOX 1. DIETARY GUIDELINES FOR AMERICANS 2010 KEY RECOMMENDATIONS

Foods and Food Components to Reduce
Reduce daily sodium intake to less than 2,300 mg and further reduce intake to 1,500 mg
among persons who are 51 and older and those of any age who are African American or
have hypertension, diabetes, or chronic kidney disease. The 1,500 mg recommendation
applies to about half of the US population, including children and the majority of adults.
Consume less than 10% of calories from saturated fatty acids by replacing them with
monounsaturated and polyunsaturated fatty acids.
Consume less than 300 mg per day of dietary cholesterol.
Keep trans fatty acid consumption as low as possible by limiting foods that contain synthetic
sources of trans fats, such as partially hydrogenated oils, and by limiting other solid fats.
Reduce the intake of calories from solid fats and added sugars.
Limit the consumption of foods that contain refined grains, especially refined grain foods that
contain solid fats, added sugars, and sodium.

If alcohol is consumed, it should be consumed in moderation—up to 1 drink per day for
women and 2 drinks per day for men—and only by adults of legal drinking age.

Healthy Eating and
­P hysical ­Activity

Balancing Calories to Manage Weight
Prevent and/or reduce overweight and obesity through improved eating and physical
activity behaviors.
Control total calorie intake to manage body weight. For people who are overweight or
obese, this will mean consuming fewer calories from foods and beverages.
Increase physical activity and reduce time spent in sedentary behaviors.
Maintain appropriate calorie balance during each stage of life—childhood, adolescence,
adulthood, pregnancy and breastfeeding, and older age.

Foods and Nutrients to Increase
Individuals should meet the following recommendations as part of a healthy eating pattern
while staying within their calorie needs.
Increase vegetable and fruit intake.
Eat a variety of vegetables, especially dark-green and red and orange vegetables and beans
and peas.
Consume at least half of all grains as whole grains. Increase whole-grain intake by replacing
refined grains with whole grains.
Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or
fortified soy beverages.
Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans
and peas, soy products, and unsalted nuts and seeds.
Increase the amount and variety of seafood consumed by choosing seafood in place of some
meat and poultry.
Replace protein foods that are higher in solid fats with choices that are lower in solid fats and

calories and/or are sources of oils.
Use oils to replace solid fats where possible.
Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are
nutrients of concern in American diets. These foods include vegetables, fruits, whole grains,
and milk and milk products.
Building Healthy Eating Patterns
Select an eating pattern that meets nutrient needs over time at an appropriate calorie level.
Account for all foods and beverages consumed and assess how they fit within a total healthy
eating pattern.
Follow food safety recommendations when preparing and eating foods to reduce the risk of
foodborne illnesses.
Source: US Department of Agriculture, US Department of Health and Human Services.1

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BRIGHT FUTURES: NUTRITION

FIGURE 1. NUTRITION FACTS

Healthy Eating and
­P hysical ­Activity

Nutrition Facts
Serving Size 1 cup (228g)
Servings Per Container 2
Amount Per Serving

Calories 250

Calories from Fat 110

Total Fat 12g
Saturated Fat 3g
Trans Fat 1.5g
Cholesterol 30mg
Sodium 470mg
Total Carbohydrate 31g
Dietary Fiber 0g
Sugars 5g
Protein 5g
Vitamin A
Vitamin C
Calcium
Iron

% Daily Value*
18%
15%
10%
20%
10%
0%

4%
2%
20%
4%

* Percent Daily Values are based on a 2,000 calorie diet.
Your Daily Values may be higher or lower depending on
your calorie needs:
Calories:
2,000
2,500
Total Fat
Less than
65g
80g
Sat Fat
Less than
20g
25g
Cholesterol
Less than
300mg
300mg
Sodium
Less than
2,400mg
2,400mg
Total Carbohydrate
300g
375g
Dietary Fiber
25g
30g

Source: US Department of Health and Human Services,
Food and Drug Administration.3

active and eating healthy foods to promote health
and reduce the risk of chronic diseases.
Children and adolescents can achieve substantial health benefits by doing moderate- and
­vigorous-intensity physical activity for a total of
60 minutes or more each day. This should include
aerobic activity as well as age-appropriate muscle- and bone-strengthening activities. It appears
that the total amount of physical activity is more
important for achieving health benefits than any
one component (frequency, intensity, or duration) or the specific mix of activities (aerobic,
muscle strengthening, or bone strengthening).
Even so, bone-strengthening activities remain
especially important for children and adolescents
because the greatest gains in bone mass occur
during the years just before and during puberty,
and most peak bone mass is obtained by the end
of adolescence.2
Just as children and adolescents can get in
the habit of being physically active on a regular basis, they can also learn to be inactive if
they are not given opportunities to be active.
Children and adolescents who are inactive are
much more likely to be sedentary as adults.
Children and adolescents learn by example—if
parents, grandparents, and other family members
enjoy and engage in physical activity on a regular
basis, they will too.

BOX 2. KEY PHYSICAL GUIDELINES FOR CHILDREN AND ADOLESCENTS .

AGES 6 AND OLDER
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6

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Children and adolescents should engage in 60 or more minutes of physical activity each day.
—— Aerobic: Most of the 60 or more minutes a day should be either moderate- or vigorousintensity aerobic physical activity and should include vigorous-intensity physical activity
at least 3 days a week. Moderate-intensity activities include hiking, skateboarding,
rollerblading, bicycling, and brisk walking. Vigorous-intensity activities include jumping
rope; running; bicycling; swimming; or playing basketball, soccer, tennis, and hockey.
—— Muscle-strengthening: As part of the 60 or more minutes of daily physical activity,
children and adolescents should include muscle-strengthening physical activity at least
3 days a week. Muscle-strengthening activities can be unstructured and part of play,
such as playing on playground equipment, playing tug-of-war, and climbing trees. These
activities can also be structured, such as lifting weights, doing sit-ups, or working with
resistance bands.
—— Bone-strengthening (weight-bearing): As part of their 60 or more minutes of daily physical
activity, children should include bone-strengthening physical activity at least 3 days a
week. Bone-strengthening activities include jumping rope; running; or playing basketball,
soccer, volleyball, and tennis.
It is important to encourage children and adolescents to engage in physical activities that
are appropriate for their age, that are enjoyable, and that offer variety.

Source: US Department of Health and Human Services.2

BRIGHT FUTURES: NUTRITION

US Department of Agriculture, Food and Nutrition Service.
Eat Smart. Play Hard. />Resources/eatsmartmaterials.html
US Department of Agriculture, Food and Nutrition Service.
Empowering Youth with Nutrition and Physical Activity.
/>US Department of Agriculture, Food and Nutrition
Service. Grow It, Try It, Like It! Preschool Fun with Fruits
and Vegetables. Washington, DC: US Department of
Agriculture, Food and Nutrition Service; 2010
US Department of Agriculture, Food and Nutrition Service.
Loving Your Family, Feeding Their Future. .
usda.gov/nal_display/index.php?info_center=15&tax_
level=5&tax_subject=261&topic_id=1941&level3_
id=6322&level4_id=10692&level5_id=20039
US Department of Agriculture, Food and Nutrition Service.
Nibbles for Health: Newsletter for Parents of Young Children.
Washington, DC: US Department of Agriculture, Food and
Nutrition Service; 2008
US Department of Agriculture, Food and Nutrition Service.
Team Nutrition. />US Department of Agriculture, Food and Nutrition Service.
The Two Bite Club. Washington, DC: US Department of
Agriculture, Food and Nutrition Service; 2009
US Department of Health and Human Services, Food and
Drug Administration; US Department of Agriculture,
Food and Nutrition Service. The Power of Choice:
Helping Youth Make Healthy Eating and Fitness Decisions.
Washington, DC: US Department of Health and Human
Services, Food and Drug Administration; US Department
of Agriculture, Food and Nutrition Service; 2008

Healthy Eating and
­P hysical ­Activity

1. US Department of Agriculture, US Department of Health
and Human Services. Dietary Guidelines for Americans
2010. 7th ed. Washington, DC: US Government Printing
Office; 2010
2. US Department of Health and Human Services. 2008
Physical Activity Guidelines for Americans. Washington,
DC: US Department of Health and Human Services; 2008
3. US Department of Health and Human Services, Food
and Drug Administration. Nutrition Facts. Washington,
DC: US Department of Health and Human Services,
Food and Drug Administration; 2006

■■ RESOURCES FOR FAMILIES

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■■ REFERENCES