At 'age+5' rule:
Comparisons of dietary fiber intake among 4- to 10-year-old children


Author: Hampl, Jeffrey S; Betts, Nancy M Benes, Beverly A
Source: American Dietetic Association. Journal v98n12 (Dec 1998): 1418-1423
ISSN: 0002-8223
Number: 04093368
Copyright: Copyright American Dietetic Association 1998

Objective To determine children's sources of dietary fiber and to identify the food group choices made by those who met the "age+5" rule, which recommends that children daily consume an amount of fiber that is equal to their age plus an additional 5 g fiber.

Design This study used 24-hour dietary recalls and 1-day food records to assess the nutrient intake and food group choices of children who did and did not meet the recommendations of the age+5 rule.

Subjects The 1989-1991 US Department of Agriculture Continuing Survey of Food Intakes by Individuals provided the study sample of 603 children between the ages of 4 and 6 years and 782 children between the ages of 7 and 10 years.

Statistical analyses Differences in nutrient and food group intakes between age categories were determined by t tests.

Results Only 45% of 4- to 6-year-olds and 32% of 7- to 10year-olds consumed adequate fiber to meet the age+5 rule. Those who met the age+5 rule did so by consuming significantly more high-,and low-fiber breads and cereals, fruits, vegetables, legumes, nuts, and seeds. Children with low fiber intakes had significantly higher energy-adjusted intakes of fat and cholesterol, whereas those who met the age+5 rule had significantly higher energy-adjusted intakes of dietary fiber, vitamins A and E, folate, magnesium, and iron.

Applications The majority of the children had low intakes of dietary fiber, suggesting that they are at risk for future chronic disease. Parents and school foodservice personnel should strive to offer fiber-rich foods to children so their acceptance and consumption of them will be increased. JAm Diet Assoc. 18-1423.

Objective 2.6 of Healthy People 2000 (1) proposes that, by the end of the decade, American adults should be consuming at least 5 servings of vegetables and fruits daily and at least 6 servings of grains daily. The dietary fiber found in these foods is thought to protect against constipation (2), obesity (3,4), cardiovascular disease (5,6), some cancers (7), and diabetes (8). Unfortunately, because of limited data, the US Department of Health and Human Services was not able to expand this objective specifically to include children. Omitting children from the objective, although understandable, is unfortunate, because these diseases may originate during childhood (9). Because vegetables, fruits, and grains are good sources of fiber and essential and nonessential nutrients, parents should ensure that their children consume adequate amounts of these foods.

Despite the fact that a federally recognized standard for dietary fiber intake during childhood does not yet exist (10), the American Academy of Pediatrics Committee on Nutrition (11) has recommended that children consume 0.5 g dietary fiber for every 1 kg body weight (with an upper limit of 35 g/ day) . Although this amount is healthful for most children, fiber intakes for male adolescents may be too high, particularly if their intake of essential minerals (ie, calcium, iron, and zinc) is low. A second recommendation that children consume 10 g dietary fiber for every 1,000 kcal consumed may provide excessive fiber for small or young children (12). For more practical reasons, the utility of these formulas must be questioned, because most parents would find them too complex for determining their children's optimal dietary fiber intake.

In May 1994 the American Health Foundation recommended that children at least 2 years old should consume daily an amount of fiber that is equal to their age plus an additional 5 g dietary fiber (13,14). For example based on this "age+5" rule, a 3-year-old should consume at least 8 g dietary fiber daily. This recommendation holds throughout childhood and adolescence until the age of 20 years, after which intakes of 25 to 35 g dietary fiber per day are recommended for healthy adults (15).

Recognizing that a lack of data excluded children from objective 2.6 of Healthy People 2000, several studies have been conducted since then to examine dietary fiber intake during childhood; however, many of these focused on older children and adolescents (16-20), or they obtained generic values for fiber intake by averaging values over a wide range of years (21). Two studies did compare children's fiber intake to the age+5 rule, but their analyses were limited by a small sample size (21), the use of a data set possibly biased by a low response rate (22), and a limited number of food group categories that could not distinguish between low- and high-fiber foods within a category (22).

Because of the attention paid to the age+5 rule by consumers, health educators, and food manufacturers (23), we used a large national data set to determine what percentage of children were meeting the American Health Foundation's age+5 recommendation and what the leading contributors to total dietary fiber intake were. Because of the frequently cited risk that a very-high-fiber diet can satiate a child before an adequate amount of nutrients is ingested or absorbed (9,12-14), intakes of food and nutrients between those who did and did not meet the age+5 rule were also compared.

METHODS

Data were obtained from the 1989-1991 Continuing Survey of Food Intakes by Individuals (CSFII). These surveys included men, women, and children who resided in the 48 contiguous states. Methods used to conduct these multistage, stratified-- area, probability surveys have been previously documented (24,25). Our study included data from 603 children between the ages of 4 and 6 years and 782 children between the ages of 7 and 10 years. These age categories were chosen because they matched those of the Recommended Dietary Allowances (RDAs) (26). All 1,385 of the children had one 24-hour food recall and two 1-day food records completed for them by a knowledgeable adult, generally the child's primary caregiver.

The US Department of Agriculture (USDA) released each of the CSFII data sets separately; however, because they were released with labels and a fixed format, all 3 surveys were combined for data processing into 1 large data set. The USDA assigned each food and beverage item a 7-digit code number and provided food groups to categorize them. However, these food groups were found to be too broad for the purposes of this investigation because low- and high-fiber foods in a category could not be distinguished adequately. Instead, food and beverage items reported as consumed were recoded and recategorized into 41 major food groups using previous research as a guide (27,28). Food groups were created to identify dietary sources of fiber and to differentiate between fiber-rich and fiber-poor foods in a category. For example, high-fiber breads and cereals were defined as foods made from whole grains that provided at least 2 g dietary fiber per serving. Mixed dishes were classified according to their primary ingredient (eg, macaroni and cheese was placed into the pasta category). Data involving the nutrient content of each food and beverage item were included in the CSFII database when released by USDA.

Data from the 4- to 10-year-olds in the CSFII were used in these analyses, and the sample was stratified by age so that the 4- to 6-year-olds could be examined separately from the 7- to 10-year-olds. The sample was not stratified by sex because boys and girls in this age range have similar dietary intakes and because the RDAs for young children do not differ by sex (26). The contribution to total dietary fiber by each food group was determined using the following formula (27): (total grams of dietary fiber from all foods in a group)+ (total grams of dietary fiber from all foods).

t Tests were used to compare food group intakes between those who consumed adequate dietary fiber according to the age+5 rule and those who did not. Because the consumption of nutrients is at least partially dependent on total energy intake, and because the nutrient density of the diet is, in this instance, more relevant than actual gross intake, we adjusted for energy intake by computing nutrient intakes per 1,000 kcal. t Tests determined significant differences in energy intake and energy-adjusted macronutrient intakes between the age+5 fiber groups; additionally, energy-adjusted intakes of cholesterol, sodium, and all nutrients that have an RDA (with the exceptions of selenium, iodine, and vitamins D and K, which were not included in the CSFII database) were compared between groups. The Statistical Package for the Social Sciences (SPSS-X, version 3, 1988, SPSS, Inc, Chicago, Ill) was used for all analyses.

RESULTS

Among the 4- to 6-year-olds, 274 (45%) children met the age+5 rule, and 329 did not. In comparison, the proportion of 7- to 10year-olds who met the age+5 rule was even lower. Only 252 (32%) children consumed adequate fiber according to the age+5 rule; 530 did not.

Contributors to total dietary fiber intake are presented in Tables 1 and 2. For 4- to 6-year-olds, low-fiber breads and vegetables led the food groups as the primary sources of dietary fiber, with each food group providing 12% of the total. Other notable sources of dietary fiber included fruit (10%), low-fiber cereals (9%), and potatoes (8%). High-fiber breads provided 4%, and high-fiber cereals provided 2%, of total dietary fiber. For 7- to 10-year-olds, vegetables provided 12% of total dietary fiber, whereas low-fiber breads provided 11% of the total. Additional sources of dietary fiber were fruit (10%), potatoes (9%)o), and low-fiber cereals (8%). High-fiber breads and high-fiber cereals provided 4% and 2%, respectively, of total dietary fiber intake.

(Table Omitted)

Captioned as: Table 1

(Table Omitted)

Captioned as: Table 2

Because our study was designed to compare fiber intakes among children, the food group intakes that differed significantly between the groups were the predominant contributors to total fiber intake, and children who consumed adequate fiber consumed greater amounts of all of these foods. Children in both age categories who met the age+5 rule consumed significantly (P<=.02) more low-fat milk, legumes, nuts, seeds, low- and high-fiber breads, cereals, pasta, fruit, vegetables, condiments, and potatoes. Among the 4- to 6-year-olds, children who met the age+5 rule consumed greater amounts of salty snacks, fruit juice, and pizza (P<=.022). In contrast, 7-to 10-yearolds with adequate fiber intakes consumed greater amounts of whole milk, table fats, and pancakes or waffles (P<=.045).

Initial analyses showed that the mean unadjusted intake of each vitamin and mineral exceeded two thirds of its respective RDA, and consistently, the children who met the age+5 rule consumed significantly (P<.05) greater amounts of each nutrient. To better describe the children's diets, Table 3 presents intakes of total energy, unadjusted dietary fiber, and energy-- adjusted nutrients that significantly differed between the fiber-intake groups. For both age groups, the energy intake of children who met the age+5 rule was about 400 kcal greater than the energy intake of the children who consumed low-fiber diets. Consequently, the mean unadjusted fiber intakes of the children who met the age+5 rule were significantly greater for both 4- to 6-year-olds (14 g vs 7 g; P<.0001) and 7- to 10-yearolds (18 g vs 10 g; P<.0001); however, after adjusting for total energy intake, children who met the age+5 rule still consumed significantly greater amounts (mean=3 g/day) of dietary fiber, indicating that their diets were more nutrient-dense.

Additional evidence that those who met the age+5 rule made better food choices comes from their intake of other nutrients. Mean energy-adjusted intakes of vitamins A and E, folate, magnesium, and iron were significantly (P<=.01) greater among those with an adequate fiber intake. In contrast, energy--adjusted intakes of fat and cholesterol were significantly (P<=.001) higher among the children with fiber-poor diets; furthermore, 7- to 10-year-olds who did not consume adequate fiber had significantly higher energy-adjusted intakes of protein (P=.03), although the difference between the fiber-intake groups was small.

DISCUSSION

As noted by Nicklas et al (19), American children eat the typical Western diet that their parents do. That is, children on average consume 33% of their energy as fat and have low dietary fiber intakes (29,30). Reported fiber intakes among children have ranged from 8 to 11 g/day for 2- to 5-year-olds to 11 to 13 g/day for 6- to 11-year-olds (10,22). These results reflect our findings that 4- to 6-year-olds consumed about 10 g dietary fiber per day and 7- to 10-year-olds consumed about 13 g dietary fiber per day. These averages provide little information, however, without reference to a dietary guideline. By making comparisons to the age+5 rule, our results make clear that most of the children in our sample consumed inadequate dietary fiber.

We found that only 45% of the 4- to 6-year-olds and 32% of the 7- to 10-year-olds consumed enough fiber to meet the age+5 rule. These results support earlier, preliminary comparisons made with the age+5 rule. With a self-selected group of 45 health-conscious families, McClung et al (21) found that almost half of the 2- to 12-year-olds in their sample did not meet the age+5 rule. Results similar to our own were shown by Saldanha (22), who found that more than 60% of the 2- to 11year-olds in her sample did not consume adequate fiber.

Although one might assume that foods with high fiber content would lead as the contributors to total fiber intake, our results do not confirm this supposition. Collectively, low-fiber breads and cereals provided 21% and 19% of total dietary fiber for 4- to 6-year-olds and 7- to 10-year-olds, respectively; in contrast, high-fiber breads and cereals provided just 6% of total dietary fiber for both age groups. These results reflect the general eating patterns found in the United States. Even though the Food Guide Pyramid (31) recommends several daily servings of whole-grain foods, these foods are not popularly consumed by American children or adults. Using 14-day dietary intake data from 2,000 households, Albertson and Tobelmann (32) found that 22% of their sample did not consume any whole-grain products during that period, and 55% did not consume any whole-grain ready-to-eat cereals. Among those who did consume whole-grain products, the majority (62%) averaged less than 1 serving per day.

(Table Omitted)

Captioned as: Table 3

Our results showed that vegetables led fruits as a contributor to fiber intake, and the children's intake of vegetables and fruits was similar. In contrast, Krebs-Smith et al (33) showed that children ate vegetables much more frequently than fruits. For several reasons, differences exist between these studies. First, our sample comprised 4- to 10-year-olds, whereas the sample of Krebs-Smith et al included 2- to 18-year-olds. Furthermore, dietary fiber was the focus of our study, but Krebs-- Smith et al looked specifically at fruit and vegetable intake. To do so, they carefully included "camouflaged" vegetables, such as tomato sauce on pizza and lettuce and tomato on hamburgers. These foods are popular, particularly among adolescents, so the higher intake of vegetables by their sample members is not surprising.

Domel et al (34) showed that the children in their sample reported that they preferred fruit to vegetables. The effect of food perceptions on children's diets is still not fully understood. Although food preferences consistently predict vegetable and fruit consumption, they actually explain little of the variability involved in children's vegetable and fruit intake (r sup 2 <=. 10) (35). Children generally describe vegetables as "dill, bland, and nasty" whereas fruits are seen as "sweet, juicy, and fun" (36). Perhaps if vegetables were characterized as fruits are, their contribution to fiber intake could be even greater, allowing more children to meet the age+5 rule.

Although they are good sources of fiber, vegetable and fruit intakes among children fall short of the recommended 5 servings per day (37). Actual intakes average around 2 servings per day (38), and only 20% of children consume at least 5 servings of vegetables and fruits daily (33). French fries, in particular, are popular among children and constitute nearly 25% of all vegetables consumed (33). Because they were frequently consumed, potato products were an important contributor to total dietary fiber intake among the children in our sample, providing more dietary fiber than did legumes and high-fiber breads and cereals.

For all children, those who met the age+5 rule consumed greater amounts of condiments, and 7- to 10-year-olds who met the rule had greater intakes of table fats. Although these results appear to contradict the healthfulness of the children's diets, those who met the age+5 rule did have significantly (P<=.001) lower energy-adjusted intakes of fat and cholesterol. Indeed, the greater intake of condiments and table fats may have been partly responsible for the children meeting the age+5 rule. About one third of the vegetables consumed by children are prepared or served with fat (eg, salad dressing, butter) (33), and children tend to prefer their vegetables either raw served with dip or cooked served with cheese sauce or butter (39). Children typically will not choose to consume a food based on its nutrient density (36); consequently, parents may feel the need to add condiments or table fats to make fiber-- rich foods more attractive to their children.

Although fruit juice is not an important source of dietary fiber, the 4- to 6-year-olds who met the age+5 rule did consume significantly (P=.022) more fruit juice than those who did not meet the rule. Since the late 1940s, consumers have developed a reliance on fruit juice as a convenient source of nutrients. Because fruit juice is perceived as being healthful, fat free, and nutritious, more than 50% of fruit intake among children is in the form of juice, and children younger than 5 years consume about 9 gallons of juice per year (40). Despite its popularity, parents should monitor their children's intake of fruit juice, providing no more than 12 fluid oz per day. Excessive fruit juice consumption among children has been associated with nonorganic failure to thrive, obesity, and kidney stones (40,41). Rather than offering juice, parents should encourage children to eat whole vegetables and fruits so that they can obtain dietary fiber and other important phytonutrients.

A second reason to monitor juice consumption is the association between juice and milk; the recent increase in drinking fruit juice has been coupled with a decrease in milk consumption. Between 1978 and 1988, fluid milk consumption among 7to 10-year-olds decreased by 7% (42). In general, juice competes with milk when these beverages are placed together on children's menus. Thomas et al (43) showed that when fruit juice and milk were served at a meal, children's consumption of milk decreased. Our results show that all children who met the age+5 rule consumed significantly (P<=.0001) more low-fat milk than those who did not meet the age+5 rule. The 7- to 10year-olds who met the age+5 rule did not consume significantly more fruit juice than the children with low fiber intakes, but they did drink more whole milk (P=.01). Our categories of whole milk and low-fat milk subsumed chocolate milk; future analyses assessing children's fiber intake should consider having a separate category for chocolate milk. Carrageenan, which is added to chocolate milk as a thickener, is usually cited as being an important source of dietary fiber for children (13); however, carrageenan actually provides a small amount of dietary fiber compared with the amount contributed by the cocoa powder itself.

The children who met the age+5 rule did have greater intakes of energy and, consequently, many nutrients than those who did not meet the rule. So that the greater energy intake would not mask the quality of the children's diets, we looked at nutrients per 1,000 kcal. Even after controlling for total energy intake, children who met the age+5 rule still consumed significantly more dietary fiber, indicating a greater nutrient density in their diet. Besides fiber, children who met the age+5 rule consumed significantly more energy-adjusted amounts of iron, magnesium, folate, and vitamins A and E. Consumers generally associate iron with animal products (eg, beef and oysters) because the iron in these foods is in the heme form and has greater bioavailability. Iron can also be found in fiber-rich foods, but certain plant constituents may modify how well it is absorbed (44). Nevertheless, plant foods can provide ample iron for most people. In the United States, wheat products are fortified with iron. Broccoli, potatoes, and green peas are notable examples of iron-rich vegetables.

Vitamin E, folate, magnesium, and vitamin A (in the form of beta carotene) are all plant-based nutrients, so it is not surprising that the children who met the age+5 rule consumed significantly greater energy-adjusted amounts of these nutrients. Conversely, protein, fat, and cholesterol are associated with animal products and were consumed in significantly greater energy-adjusted amounts by the children with low fiber intakes. The fact that the intake of these 3 nutrients was associated with low-fiber diets prompts some concern for the long-term health of these children. The current leading causes of death in the United States are cardiovascular disease and cancer ( 1 ); both of these have been linked to dietary intake and may have their origin during childhood. Because food preferences and eating habits may be established during childhood (45), parents should ensure that their children follow the recommendations of the Food Guide Pyramid to promote healthy lifestyles, even in childhood.

The updated Dietary Guidelines for Americans (46), released at the end of 1995, emphasizes the role of fiber-rich foods in the US diet. The 1990 guideline, "Choose a diet with plenty of vegetables, fruits, and grain products," was reworded for the 1995 edition so that grain products would be listed before vegetables and fruits. This guideline was also changed in priority from fourth to third place, because the Dietary Guidelines Advisory Committee wanted the guidelines to be consistent with the Food Guide Pyramid, emphasizing that grains, vegetables, and fruits (ie, fiber-containing foods) are the foundation of a healthful diet.

APPLICATIONS

To promote future health and longevity, nutritionists who work with children should be sure to emphasize the importance of dietary fiber, noting that the use of fiber supplements for otherwise healthy children is inappropriate (12). Because it was frequently consumed, low-fiber bread was a large source of dietary fiber for all of the children in our study. Substituting high-fiber breads would go a long way toward improving children's dietary fiber intakes and, with the wide variety available, should be relatively easy to accomplish.

Perhaps a slightly more difficult change, but one worth recommending, would be to substitute high-fiber cereals for the low-fiber cereals commonly advertised to children. Eating breakfast and including fiber-rich foods as part of that meal are important steps children can take to meet the age+5 rule. Children who skip breakfast tend to have lower fiber intakes throughout the entire day (22); among the children who do eat breakfast, most do not consume vegetables and fruits at that time (38). Because cereals vary widely in their fiber content, reviewing food labels with parents and children offers opportunities for nutrition education that reinforce knowledge about food contents and recommended dietary intakes (47). Additionally, foodservice personnel who work with children's breakfast and lunch programs could make an important impact on children's health by serving high-fiber breads and cereals along with other fiber-rich foods.

Reference:

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Author Affiliation:

J. S. Hampl is an assistant professor of nutrition in the Department of Family Resources and Human Development at Arizona State University, Tempe. N. M Betts is a professor and B. A. Benes is a senior lecturer with the Department of Nutritional Sciences and Dietetics at the University of Nebraska, Lincoln.

Address correspondence to: Jeffrey S Hampl, Department of Family Resources and Human Development, Arizona State University, PO Box 872502, Tempe, AZ 85287-2502.