Pediatric Annals

Feature 

The CHILD 1 and DASH Diets: Rationale and Translational Applications

Linda Van Horn, PhD, RD; Eileen Vincent, MS, RD

Abstract

The National Heart, Lung, and Blood Institute convened an expert panel to develop integrated guidelines for cardiovascular health and risk reduction in children and adolescents. Because it is well documented that the roots of cardiovascular disease in adults are initiated in childhood, the expert panel sought to review the existing literature to address a broad array of questions related to prevention and translate these findings into practical, effective lifestyle guidelines.1,2 Among the many risk factors contributing to the development of disease, diet and eating behaviors are central to several of them, including dyslipidemia, hypertension, obesity, and diabetes. The panel evaluated research studies involving specific nutrients, such as dietary fatty acids, sodium, and fiber, as well as foods such as sugar-sweetened beverages and dietary patterns including the application of the Dietary Approaches to Stop Hypertension (DASH) diet.3–5 This allowed the comparison of different benefits/risks and applications of certain findings from several studies that collectively influenced the development of the Cardiovascular Health Integrated Lifestyle Diet (CHILD 1).

The CHILD 1 diet is intended to be the first stage of diet intervention when a child is identified with one or more cardiovascular risk factors or a positive family history. The diet was carefully developed to meet the nutrient needs of growing children while minimizing dietary factors that contribute to excess calories, saturated/trans-fatty acids, sodium, and sugar. The CHILD 1 diet can be fully achieved by following a DASH-style eating pattern that emphasizes fat-free/low-fat dairy products; increased intake of fruits and vegetables, fish, and fresh lean meats; and lower sodium intake. The expert panel differentiated the diet recommendations by age group, starting with strongly advocating breast-feeding for as long as possible but at least until 6 months of age. Transitions to reduced-fat (2%) milk and then fat-free milk were recommended during the 12- to 24-month period, with input and guidance from the pediatrician. A delayed introduction of solid foods until preferably 6 months of age was also recommended.

Because of the prevalence of overweight and obesity, the expert panel further recommended limited sugar and solid fat intake, only one 4-oz serving of 100% fruit juice per day, and avoidance of sugar-sweetened beverages. In addition, the panel encouraged guidance regarding eating behaviors including modest portion sizes, regular breakfast eating, family meal times, and intake of high-fiber foods.1

With minor adjustments and age-appropriate serving sizes, the translation of the CHILD 1 diet can easily fit into a modern context for busy families on the run. The adaptation of a DASH-style diet can achieve the CHILD 1 goals and likewise meet the nutrient needs of all members of the family. Also, meeting the recommended sodium intake goals can be accomplished by careful attention to lower-sodium choices to target less than 2,300 mg/d. Table 1 illustrates one such approach across three age groups. Table 2 provides the estimated nutrient needs of these age groups, and Table 3 lists the estimated nutrients provided by the menu in Table 1.

Table 1. Sample Pediatric DASH-Style Menus

Table 2. Nutrient Analysis of Pediataric DASH-Style Diets

Table 3. Recommended Pediatric DASH Dietary Goals

MyPlate ( www.choosemyplate.gov)6 (see Figure) can be used as a reference to make sure each meal plan contains adequate amounts of each food group to stay on target for a healthy lifestyle. On the site, users can calculate the daily food group target and the total percentage of target for preschool and school-aged children and adolescents. Also, Super Tracker ( www.supertracker.usda.gov)7 is easy-to-use online software that can help check energy and nutrient goals on a daily basis.

Figure. My Plate can be used as a reference to make sure…


The National Heart, Lung, and Blood Institute convened an expert panel to develop integrated guidelines for cardiovascular health and risk reduction in children and adolescents. Because it is well documented that the roots of cardiovascular disease in adults are initiated in childhood, the expert panel sought to review the existing literature to address a broad array of questions related to prevention and translate these findings into practical, effective lifestyle guidelines.1,2 Among the many risk factors contributing to the development of disease, diet and eating behaviors are central to several of them, including dyslipidemia, hypertension, obesity, and diabetes. The panel evaluated research studies involving specific nutrients, such as dietary fatty acids, sodium, and fiber, as well as foods such as sugar-sweetened beverages and dietary patterns including the application of the Dietary Approaches to Stop Hypertension (DASH) diet.3–5 This allowed the comparison of different benefits/risks and applications of certain findings from several studies that collectively influenced the development of the Cardiovascular Health Integrated Lifestyle Diet (CHILD 1).

The CHILD 1 diet is intended to be the first stage of diet intervention when a child is identified with one or more cardiovascular risk factors or a positive family history. The diet was carefully developed to meet the nutrient needs of growing children while minimizing dietary factors that contribute to excess calories, saturated/trans-fatty acids, sodium, and sugar. The CHILD 1 diet can be fully achieved by following a DASH-style eating pattern that emphasizes fat-free/low-fat dairy products; increased intake of fruits and vegetables, fish, and fresh lean meats; and lower sodium intake. The expert panel differentiated the diet recommendations by age group, starting with strongly advocating breast-feeding for as long as possible but at least until 6 months of age. Transitions to reduced-fat (2%) milk and then fat-free milk were recommended during the 12- to 24-month period, with input and guidance from the pediatrician. A delayed introduction of solid foods until preferably 6 months of age was also recommended.

Because of the prevalence of overweight and obesity, the expert panel further recommended limited sugar and solid fat intake, only one 4-oz serving of 100% fruit juice per day, and avoidance of sugar-sweetened beverages. In addition, the panel encouraged guidance regarding eating behaviors including modest portion sizes, regular breakfast eating, family meal times, and intake of high-fiber foods.1

Child 1, Dash, and The Modern Family

With minor adjustments and age-appropriate serving sizes, the translation of the CHILD 1 diet can easily fit into a modern context for busy families on the run. The adaptation of a DASH-style diet can achieve the CHILD 1 goals and likewise meet the nutrient needs of all members of the family. Also, meeting the recommended sodium intake goals can be accomplished by careful attention to lower-sodium choices to target less than 2,300 mg/d. Table 1 illustrates one such approach across three age groups. Table 2 provides the estimated nutrient needs of these age groups, and Table 3 lists the estimated nutrients provided by the menu in Table 1.

Sample Pediatric DASH-Style Menus*

Table 1. Sample Pediatric DASH-Style Menus

Nutrient Analysis of Pediataric DASH-Style Diets*

Table 2. Nutrient Analysis of Pediataric DASH-Style Diets

Recommended Pediatric DASH Dietary Goals*

Table 3. Recommended Pediatric DASH Dietary Goals

MyPlate ( www.choosemyplate.gov)6 (see Figure) can be used as a reference to make sure each meal plan contains adequate amounts of each food group to stay on target for a healthy lifestyle. On the site, users can calculate the daily food group target and the total percentage of target for preschool and school-aged children and adolescents. Also, Super Tracker ( www.supertracker.usda.gov)7 is easy-to-use online software that can help check energy and nutrient goals on a daily basis.

My Plate can be used as a reference to make sure each meal plan contains adequate amounts of each food group to stay on target for a healthy lifestyle. For more information, go to www.choosemyplate.gov.6Photo courtesy of U.S. Department of Agriculture

Figure. My Plate can be used as a reference to make sure each meal plan contains adequate amounts of each food group to stay on target for a healthy lifestyle. For more information, go to www.choosemyplate.gov.6 Photo courtesy of U.S. Department of Agriculture

Conclusion

The CHILD 1 and DASH Diets are intended to help young families adopt a heart healthy eating pattern that can become the foundation for a lifetime of good health. By applying the recommended foods, portion sizes and variety, even the busiest families can find new and fun ways to eat healthy and enjoy meals and snacks together. Including the children in the choices and even age-appropriate preparation of favorite fruits, vegetables, whole grains and protein foods helps them feel important in the process of adopting these life giving skills.

References

  1. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(Suppl 5):S213–S256.
  2. Gidding S, Daniels S, Kavey RE. Developing the 2011 Integrated Pediatric Guidelines for Cardiovascular Risk Reduction. Pediatrics. 2012;129(5):e1311–e1319. doi:10.1542/peds.2011-2903 [CrossRef]
  3. Van Horn L, Obarzanek E, Friedman L, Gernhofer G, Barton B. Children’s adaptations to a fat-reduced diet: the Dietary Intervention Study in Children (DISC). Pediatrics. 2005;115:1723–1733. doi:10.1542/peds.2004-2392 [CrossRef]
  4. Couch S, Saelens B, Levin L, Dark K, Falcigila G, Daniels SR. The efficacy of a clinic-based behavioral nutrition intervention emphasizing a DASH-type diet for adolescents with elevated blood pressure. J Pediatr. 2008;152:494–501. doi:10.1016/j.jpeds.2007.09.022 [CrossRef]
  5. Talvia S, Rasanen L, Lagstrom H, et al. Longitudinal trends in consumption of vegetables and fruit in Finnish children in an atherosclerosis prevention study (STRIP). Eur J Clin Nutr2006;60:172–180. doi:10.1038/sj.ejcn.1602283 [CrossRef]
  6. US Department of Agriculture. MyPlate. www.choosemyplate.gov/food-groups. Accessed Aug. 13, 2013.
  7. US Department of Agriculture. Super Tracker. www.supertracker.usda.gov. Accessed Aug. 13, 2013

Sample Pediatric DASH-Style Menus*

Meals Preschooler (3–4 years old) School-Age Girl (8 years old) School-Age Boy (10 years old) Adolescent Girl (16 years old) Adolescent Boy (16 years old)
Breakfast ½ cup oatmeal with ½ cup nonfat milk 1 small banana 1 cup oatmeal made with 1 cup nonfat milk 1 cup blueberries 1 cup oatmeal made with 1 cup nonfat milk 1 cup blueberries 1 cup oatmeal made with 1 cup nonfat milk 1 cup blueberries 1 cup oatmeal made with 1 cup nonfat milk 1 cup blueberries
Lunch Sandwich: 1 sl whole wheat bread   1 oz reduced sodium turkey   1 oz lite cheese 6 baby carrots w/2 tbl lite ranch dressing 1 medium apple, sliced ½ cup nonfat milk Sandwich:   2 sl whole wheat bread   2 oz reduced sodium deli turkey   ½ Tbl lite mayo   1 Romaine lettuce leaf 1 medium apple, sliced 1 cup nonfat milk Sandwich:   2 sl whole wheat bread   2 oz reduced sodium turkey   ½ Tbl lite mayo   1 Romaine lettuce leaf 1 medium apple, sliced 1 cup nonfat milk Sandwich:   2 sl whole wheat bread   2 oz reduced sodium turkey   ½ Tbl lite mayo   1 Romaine lettuce leaf 10 baby carrots with 2 Tbl lite ranch dressing 1 oz baked potato chips 1 cup nonfat milk Sandwich:   2 sl whole wheat bread   3 oz reduced sodium turkey   ½ Tbl lite mayo   1 Romaine lettuce leaf 12 baby carrots with 2 Tbl lite ranch dressing 1 medium apple 1 oz baked potato chips 1 cup nonfat milk
Afternoon snack 1 medium celery sticks with 2 Tbl peanut butter 1 cup water 10 baby carrots with 2 Tbl lite ranch dressing 1 cup water 10 baby carrots with 2 Tbl lite ranch dressing 1 cup water 1 medium apple, sliced 1 Tbl peanut butter 1 cup water 1 medium plain bagel 2 Tbl peanut butter 1 cup water
Dinner ½ cup whole wheat pasta cooked ½ cup reduced sodium spaghetti sauce made with 2 oz extra lean ground beef & olive oil ½ cup cooked broccoli 1 teaspoon lite tube margarine 1 cup water Dessert: ½ cup low fat frozen yogurt with ¼ cup sliced strawberries 1/2 cup whole wheat pasta cooked 1 cup reduced sodium spaghetti sauce made with 2 oz extra lean ground beef & olive oil 1 cup cooked broccoli with .5 Tbl lite tube margarine 1 cup water Dessert: 1/2 cup low fat frozen yogurt with ¼ cup sliced strawberries 1 cup whole wheat pasta cooked 1 cup reduced sodium spaghetti sauce made with 2 oz extra lean ground beef & olive oil 1 cup cooked broccoli with .5 Tbl lite tube margarine 1 cup water Dessert: 1 cup lowfat frozen yogurt with ¼ cup sliced strawberries 1 cup whole wheat pasta cooked 1 cup reduced sodium spaghetti sauce made with 2 oz extra lean ground beef & olive oil 1 cup cooked broccoli with .5 Tbl lite tube margarine 1 cup water Dessert: 1 cup low fat frozen yogurt with ¼ cup sliced strawberries 2 cups whole wheat pasta cooked 1.5 cups reduced sodium spaghetti sauce made with 3 oz extra lean ground beef & olive oil 1 cup cooked broccoli with .5 Tbl lite tube margarine 1 cup waterDessert: 1 cup low fat frozen yogurt with ¼ cup sliced
Evening snack 2 graham cracker squares ½ cup nonfat milk 2 graham cracker squares with 1 Tbl peanut butter 2 graham cracker squares with 1 Tbl peanut butter 1 ounce baked unsalted tortilla chips w/ 2 Tbl salsa 1 cup water 1 ounce baked unsalted tortilla chips w/ 2 Tbl salsa 1 cup water

Nutrient Analysis of Pediataric DASH-Style Diets*

Nutrient / Food Group Preschooler (3–4 years old) School-Age Girl (8–9 years) School-Age Boy (10 years old) Adolescent Girl (16 years old) Adolescent Boy (16 years old)
Estimated daily calorie needs 1200–1600 1400–1800 1600–2200 1800–2400 2400–3200
Total calories 1433 1718 1877 2068 2880
Total fat (g) (% calories) 51 (32%) 57 (30%) 53 (25%) 57 g (25%) 85g (26%)
Total carbohydrate (g) (% calories) 185 (50.4%) 228 (57%) 271 (57%) 307 g (59%) 413 g (57%)
Total protein (g) (% calories) 70 (18%) 86 (13%) 95 (19%) 98 g (19%) 138 (19%)
Saturated fat (g) 14 10.2 11.6 12 16
Cholesterol (mg) 104 123 131 131 179
Calcium (mg) 1071 1101 1305 1321 1474
Iron (mg) 8.7 12 13 14 23
Sodium (mg) 2274 1921 2001 2335 2467
Fiber (g) 24 32 34 37 46
Fruit (cups) 2 2 2 2 2.5
Vegetables (cups) 2.5 3 3 3 3.5
Whole grains (oz) 3 5 6 6 8
Low-fat dairy (cups) 2 2.5 3 3 3

Recommended Pediatric DASH Dietary Goals*

Category Preschooler School-Age Girl School-Age Boy Adolescent Girl Adolescent Boy
Daily energy needs 1200–1600 1400–1800 1600–2200 1800–2400 2400–3200
Dietary fiber (g) 19–25 25 31 26 38
Calcium (mg) 500–800 800 1100 1100 1100
Iron (mg) 7 8 8 15 11
Fruit (cups) 1.5–2 2–3 2–3 2–3 2–3
Vegetables (cups) 2–3 3 3 3 3
Whole grains (oz) 2–4 3–6 3–6 3–6 4–8
Low-fat dairy (cups) 2–3 2–3 3 3 3
Authors

Linda Van Horn, PhD, RD, is a Professor of Preventive Medicine and Associate Dean of Faculty Development, Northwestern University, Feinberg School of Medicine. Eileen Vincent, MS, RD, is Assistant Director of Nutrition Research in the Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine.

Address correspondence to: Linda Van Horn, PhD, RD, Northwestern University, Feinberg School of Medicine, 680 North Lake Shore Drive #1400, Chicago, IL 60611. Email: lvanhorn@northwestern.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00904481-20130823-11

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