Safeguarding The Health of America's Children: The Important Role of Nutrient-Rich Foods.

Welcome!
Safeguarding the Health of

America’s Children:
The Important Role of Nutrient-Rich Foods
Ann Marie Krautheim, MA, RD, LD

Senior Vice President, Nutrition Affairs, National Dairy Council
The Current Child Nutrition
Environment
IOM 2010 Dietary

Committees Guidelines
School
Lunch
Program
School
Breakfast WIC
Program
Program
Child Nutrition
Reauthorization
3
Kids: Overweight and
Undernourished
Fiber
Potassium Vitamin E
Nutrients of
Concern
Magnesium Calcium
Source: 2005 Dietary

Guidelines – Nutrients of
Concern for Children
4
The Need to Shift the
Dialogue
Nutrient-Rich Foods
5
Commitment to Child
Nutrition
• Decades of Research and Exciting In-

School Programs that:
– Encourage physical activity
– Reinforce dairy’s important role in child

health and wellness
– www.fueluptoplay60.com
6
The Role of Nutrient-Rich Foods
in the Diets of Children
Lynn L. Moore, DSc, MPH

Preventive Medicine & Epidemiology
Boston University School of Medicine
Primary Goals of Today’s Talk
• Explore healthy eating patterns in children and
adolescents
• Examine selected micronutrient needs among US
children and the potential contributions of nutrient-
rich foods to nutritional adequacy
• Examine effects of eating patterns on body fat in
children and adolescents
8
Adequacy of Food Group Intake as
Measured by 2005 Healthy Eating Index
9-13 yrs 5
14-18 yrs
4
Grains
Median HEI Score
3 Vegetables
Fruit
0
l
n
t
.
ta
ta
ta
ui
i
ra
le
To
To
To
Fr
G
n/
le
le
gr
ho
ho
e/
W
W
ng
ra
O
(NGHS)
9
Adequacy of Intake as Measured by 2005
Healthy Eating Index (part 2)
Meat Group
10
8 Dairy For last 2 factors, lower

scores reflect intakes
Median HEI Scores
that are too high

6
4 9-13 yrs
14-18 yrs
2
0
tal tal ils at
s
um
.O f i
To To t. d
ret S a S o
c
is
D
(NGHS)
10
Healthy Eating Pattern
(using lean beef consumption as a marker for a
healthier diet during adolescence)
11
Consumption of Lean and Non-Lean Beef
among Young Children
Girls
12
<80% lean
Girls - Mean Beef Consumption:
10
80-85% lean Preteens: 13 ounces/week
Teens: 11 ounces / week
8
>85% lean
OZ/wk
2
Boys - Mean Beef Consumption:
0 Preteens: 16 ounces/week
3-5 6-9 10-12
Age (yrs)
13-17
Teens: 22 ounces / week
12
Boys •After age 10, girls show a
10 decrease in their intake of fatty
8
beef
OZ/wk
4
•Boys show increases in beef of
2
0
all types, but especially in the
3-5 6-9
Age
10-12 13-17 intake of fatty beef
FCS
12
Eating Patterns Associated with Beef
Intake among Teens
• Most beef consumed is of a high-fat variety

• Beef consumption is not associated with intake of fruits,
vegetables, whole grains or dairy
• The apparent adverse effects of beef intake in many
epidemiologic studies may be a consequence of the overall
eating pattern rather than the beef itself
•Dietary messaging needs to focus on the incorporating
healthier eating patterns, not avoidance of selected foods
that are higher in energy or fat
13
Nutrient-Rich Foods
Dairy: milk, yogurt, cheese
(Ca, K, Mg, vit. D, phos, protein)
Fruit: melons, bananas, papaya, prunes,

oranges (Mg, K), fortified juices (Ca)
(fiber)
Vegetables: broccoli (vit. A), soy (Ca,
K), beets, mushrooms, potatoes (B6), green
leafy/spinach (vit. A, Mg, Ca), tomatoes(K,
Mg) (fiber)
14
Selected Minerals of Concern
Percent Meeting RDA

100
90
9-13 yrs
80
70
Percent
14-18 yrs
60
50
40
30
20
10
0
Ca Mg K Phos Zn
* Data from 2300 girls in the National Growth and Health Study
15
Selected Vitamins of Concern
Percent Meeting RDA

100
90 9-13 yrs
80
70 14-18 yrs
60
50
40
30
20
10
0
Vit A B6 B12 Vit C Vit D Vit E
* Data from 2300 girls in the National Growth and Health Study
16
Adolescent Protein Intake
Beef 16.9 % Meeting Protein RDA according to Weekly Beef
Intake
Poultry 13.5 100
Milk 7.5 80 Beef
Percent
Yeast bread 7.3 60 <6
6-<12
Cheese 6.5 40 12-<18
18-42
Fish etc 3.5 20
Pork 3.0
% Contribution to 0
Eggs 3.0 Total Protein Intake 9-13 yrs 14-18 yrs 19-20 yrs
Ham 2.4
0 2 4 6 8 10 12 14 16 18 20 % Meeting Protein RDA by Dairy Intake
100
• Beef & poultry are primary sources of 80
protein among adult Americans 60
Percent
<1.25
40
•Milk is #3 source, cheese is #5 1.25-<2.5
2.5-<6
20
• Adolescents consuming more beef or 0

9-11 12-13 14-15 16-18 19-20
dairy are more likely to meet protein DRI Age (yrs)
Food Data Source from: Cotton, PA. J Am Diet Assoc. 2004; 104:921-930 (Data from 1994-1996 CSFII) NGHS
17
Conceptualizing Obesity
Simple Obesity Complicated Obesity
• Excess weight for height • Excess central body fat
• High body mass index • Rates of central obesity

(BMI) rising faster than simple
obesity
• Not associated with other
abnormalities (e.g., BP, • Clusters with other risk
lipids, glucose) factors (lipids, BP,
glucose/insulin,
inflammatory markers)
• Rising rates for past few
decades
• Now recognize emerging
epidemic of complicated
obesity
18
Eating Patterns & Obesity
Can we identify eating patterns that are
associated with the acquisition of different
amounts of body fat during childhood?
19
New Data from NHANES III
Large, representative sample, cross-sectional

- Includes all ages but we looked at children & adolescents
- Dietary data based on single 24-hour recall
20
Adjusted Mean Intake of Dairy, Fruit & Vegetables
by Quartile of Central Body Fat
Adolescent Females Quartile 1
Quartile 2
Girls with most central body fat
Servings / day
4
Quartile 3
3
Quartile 4 consumed the least dairy
1 Quartile 1
Adolescent Males Quartile 2
0 4 Quartile 3
Quartile 4
Servings / day
Dairy Fruit Vegetables
3
2
Boys with most central body fat
consume less dairy and fewer 1
fruits & vegetables 0
Dairy Fruit Vegetables
Bradlee ML et al. IJPO 2009

21
Adjusted Mean Intake of Grains & Meats by
Quartile of Central Body Fat
Adolescent Females
10
Quartile 1
Girls with higher levels of body fat
Servings / day
8 Quartile 2 consumed less grains

Quartile 3
6
Quartile 4
4
2
Adolescent Males
0
Grains Meat/Protein 10 Quartile 1
Food Group Quartile 2
8 Quartile 3
Servings / day
Quartile 4
6
Boys consumed substantially more

4
grains & meats than girls
2
Boys with more central body fat 0

consumed few grains Grains Meat/Protein
Food Group

22
Food Intake among Adolescents
with/without Central Obesity
Intake in Major USDA Food Groups Milk & Fruit Subgroup Servings
8 1.4
<85th %ile
7 <85th %ile 1.2
Servings / day
≥ 85th %ile
6 ≥ 85th %ile 1.0
5 0.8
4 0.6
3 0.4
2 0.2
1 0.0
0 Milk Cheese Citrus, melon, Other fruit
berries
Dairy F&V Fruit Veg. Grains Meats
Vegetable Subgroups & Whole Grains Meats/Other Protein Subgroup Servings

2.5
2.0
<85th %ile
<85th %ile 2.0
1.6 ≥ 85th %ile
≥ 85th %ile
1.5
1.2
1.0
0.8
0.5
0.4
0.0
0.0 Red meat Processed Poultry, fish Eggs, nuts,
Dark grn, orange Potatoes, etc Other nonstarchy Whole Grains seeds, soy

23
Food Intake and Risk of Abdominal Obesity
in Adolescents
Food Ref
Group Group O.R. (95% CI) O.R. (95% CI)
Dairy <2/day 2-<3/day 3+/day
1.0 0.89 (0.60, 1.3) 0.48 (0.30, 0.76)
Fruit 0/day >0 - <2/day 2+/day
1.0 0.93 (0.66, 1.3) 0.74 (0.46, 1.2)
Veg. <3/day 3-<5/day 5+/day
1.0 0.67 (0.45, 1.0) 0.76 (0.50, 1.2)

(NHANES III)
24 Adjusted for age, gender, race, SES, height and TV hours/day
DASH Eating Pattern and BMI in
Adolescent Girls
28
26
BMI (kg/m )
2
24
22 DA<2.5 & FV<3 svgs/day

DA<2.5 & FV>=3 svgs/day
20 DA>=2.5 & FV<3 svgs/day
DA>=2.5 & FV>=3 svgs/day
18
9-10 11-12 13-14 15-16 17-18 19-20
Age (years)
NGHS
25 Adjusted for age, height, SES, race, activity, & TV watching

DASH & Waist Size in Adolescent Girls
80
Adolescent Girls
78
Waist Circumference (cm)
76
74
72
DA<2.5 & FV<3 svgs/day

70
DA<2.5 & FV>=3 svgs/day
68 DA>=2.5 & FV<3 svgs/day
DA>=2.5 & FV>=3 svgs/day
66
9-10 11-12 13-14 15-16 17-18 19-20
26 Adjusted for age, height, SES, race, activity, & TV watching

Summary – Nutrient Rich Foods for Children
• In general, most children and adolescents consume too

few whole grains (and too little fiber)
• They also consume too few fruits & vegetables,
particularly nutrient-rich vegetables
• Most children and adolescents consume too little dairy
• The intake of lean meat is generally low in children and
adolescents (predominant meat source is higher fat
ground beef)
27
Summary – Nutrient Rich Food Patterns
• Need to focus on entire eating patterns in children and

adolescents
• Fatty meat is often consumed as a part of less healthy
eating patterns: higher intakes of fatty meats are
consumed with more starchy vegetables and refined
grains and less dairy
• Dairy, when consumed with higher intakes of fruits &
vegetables is similar to a DASH eating pattern
28
Foods that are Part of a Healthy Dietary
Patterns among Children
• Higher intakes of dairy

• Consumption of fruits & vegetables, particularly dark
green, yellow-orange vegetables, tomatoes
• Higher intakes of lean meats plus other protein sources
such as eggs, nuts, seeds, soy
• Focus on consumption of whole grains
29
Consequences of such a Healthy Dietary
Pattern among Children and Adolescents
• Will be more likely to meet the DRI for nutrients such

as calcium, magnesium, potassium, phosphorus, vit. A
• Will have higher intakes of protein (particularly
complete proteins) and fiber
• Will gain less body fat, particularly central body fat
during childhood
30
Thank You!
Nutrition in Schools
Karen Rafferty, RD, LMNT

Senior Research Dietitian
Osteoporosis Research Center – Creighton University
Omaha, NE
Creighton University Osteoporosis Research Center

New opportunity to improve
children’s milk consumption
Milk enhancements improve milk consumption and

increase meal participation in the
National School Lunch Program:
The School Milk Pilot Test
Journal of Child Nutrition and Management 2009; 34(fall)

Karen Rafferty, Diane Zipay, Camellia Patey, Jennifer Meyer

33
New opportunity to improve
 The School Milk Pilot Test (SMPT) 2001-2002

School Nutrition Association (ASFSA)
National Dairy Council
 The Westside School Milk Pilot Study (W-SMPS) 2006

Westside Community Schools
Children’s Hospital
MeadowGold Dairy
American Dairy Association/Dairy Council of Nebraska
(Omaha, NE)

34
 Background
 Objectives and design
 Outcomes
 Projected impact
 Opportunities
 Conclusion
35
Need for new innovations for
DGA Food Groups to Encourage
Low-fat and fat-free

Whole milk and milk products
Grains
Fruits
Vegetables

36
 Children age 2-8: 2 cups
 Individuals age 9+: 3 cups

37
Mean daily
intake of
selected
beverage
categories by
age groups
Rampersaud et al JADA 2003;103:97

38
Mean daily
intake of
selected
beverage
categories by
age groups
Rampersaud et al JADA 2003;103:97

39
20 oz.
sweetened
carbonated beverages
5 oz.
milk

40
Achieving nutrient adequacy

Studies show that diets
3 cups 1% milk
low in calcium and dairy
% of DRI (age 9-18)
foods tend to be low in
multiple nutrients. . . 69% Ca
. . . and that individuals 56% P
who obtain their calcium
from non-dairy sources fail 54% Pro
to meet the nutrient 25% K
profile of those who
consume dairy foods. 23% Mg
41
Percentage of school age children reporting usual

calcium intakes below the AI
100
90 Males
80 Females
70
Percentage
60
50
40
30
20
10
0
4–8 (800 mg) 9–13 (1300 mg) 14–18 (1300 mg)
What We Eat in American Age Group (AI)

NHANES 2005-2006

42

phosphorus intakes below the EAR
100 Males
90
Females
80
70
Percentage
60
50
40
30
20
10
0
4–8 (405 mg) 9–13 (1055 mg) 14–18 (1055 mg)
What We Eat in American Age Group (EAR)

NHANES 2005-2006

43

magnesium intakes below the EAR
100 Males
90
Females
80
70
Percentage
60
50
40
30
20
10
0
4–8 (110 mg) 9–13 (200 mg) 14–18 (340/300
mg)
What We Eat in American
NHANES 2005-2006
Age Group (EAR)

44
National survey of student beverage preferences –

reported reasons for not drinking milk at school
 Availability of competitive beverages
 Poor temperature control (milk served warm)
 Limited milk varieties/flavors available
 Inferior product quality
 Unattractive/juvenile packaging (paper-board cartons)
 Milk containers hard to open/drink from
Nicklas TA. JACN 2003; 22:340-356

45
A school based strategy designed to measure the effect of a

variety of milk enhancements on:
 Overall participation in the reimbursable school meal
programs
 Milk sales
 Milk consumption
To project the impact of national implementation on:

 Diet quality
 Student health and wellness

46
Test Markets:
SMPT
 Nine test markets in the Northeast, Southeast,
Mountain and West Coast regions
 Over 100,000 students from 146 schools
(99 secondary, 47 elementary)
W-SMPT
 Midwestern, urban school district
 4 elementary schools

47
Milk Enhancements tested:
Promotional milk marketing activities

Milk packaged in plastic resealable bottles (PRB)
Coolers to maintain chilled milk at 35-37º
3 milk flavors offered (plain, chocolate, + one)
Chocolate milk upgraded to retail quality
8 oz milk (PRB) offered on meal line
10 oz milk (PBR) offered on meal line
10 and 16 oz milk (PBR) available a la carte
16 oz milk (PBR) available in vending machines

48
Change in School Lunch ADP

Test vs. Control
8%
6% + 4.8%
4%
+ 1.5% + 480,000
2%
0%
Elementary School Seconday School
(NS) (p < 0.05)

49
Impact of increased participation in the NSLP on

NUTRIENT DENSITY:
 Protein
NSLP participants  Vitamin A
consume more  Vitamin B12
nutrients at lunch  Riboflavin
 Calcium
than nonparticipants.  Phosphorus
 Potassium
Gordon A and Fox MK, 2007

School Nutrition Dietary Assessment Study–III:
USDA Food and Nutrition Service

50
Impact of increased participation in the NSLP on

DIET QUALITY:
NSLP participants were more likely to have

adequate usual daily intakes of key nutrients. . .
. . . and were less likely than non-participants

to consume competitive foods in school.
Gordon A and Fox MK, 2007

School Nutrition Dietary Assessment Study–III:
USDA Food and Nutrition Service

51
Change in Milk Sales

Test vs. Control
30%
+ 22%
25%
+ 15%
20%
15%
10%
+ 9%
5% W-SMPS
0%
Elementary Schools Seconday Schools
(p < 0.05) (p < 0.05)

52
Change in Milk Consumption per serving unit sold

Test vs. Control
30% + 26%
25%
+ 18%
20%
15%
10% + 13%
W-SMPS
5%
0%
(p < 0.05) (p < 0.05)

53
Change in Milk Consumption per 100 in attendance

Test vs. Control
45% + 39%
40%
+ 35%
35%
30%
25%
20%
+ 21%
15% W-SMPS
10%
5%
0%
(p < 0.05) (p < 0.05)

54
Flavored milk opportunities
Over 90% is
low-fat and
fat-free
Annual School Milk Survey, 2009

Milk Pep, SNA, NDC

55
Impact of FLAVORED milk consumption on nutrient

density:
1% 1%
Per 8 oz serving: Plain Chocolate Soda Fruit
Milk Milk Drink
Calcium (mg) 290 290 0 0
Vitamin D (IU) 130 130 0 0
Vitamin A (IU) 480 490 0 0
Potassium (mg) 366 425 0 25
Protein (g) 8 8 0 0
Fat (g) 2.5 2.5 0 0
Sugar (g) includes lactose 12 24 27
68 29
73
Added Sugar (g) 0 12 68
27 73
29
USDA Nutrient Database for Standard Reference
56
RCT, secondary analysis Nutrient Densities

Calcium intervention Calcium (mg)
n = 149 adolescent girls Phosphorus (mg)
Age 14-16 yr
Potassium (mg)
36 months
Vitamin D (IU) Low-Fat Chocolate Milk
High Calcium intake
Magnesium (mg) Calcium-Fortified Composite
 1494 mg Ca
Dairy foods Sodium (mg)
 1014 mg Ca Energy
Calcium-fortified foods 0 50 100 150 200 250 300 350 400 450
 304 mg Ca
Protein (g)
 Orange juice
Carbohydrate (g)
 RTE breakfast cereal
 Snack bars Sugars added (g)
 Breads Total Fat (g)
0 5 10 15 20 25 30 35 40 45
Rafferty, unpublished data 2009
57
Impact of FLAVORED milk consumption on diet quality

and health outcomes:
 drink more milk and get more calcium
 do not have higher intakes of added sugars or

total fat
 not associated with adverse effects on BMI
Murphy et al, JADA 2008; 108:631

1999-2002 National Health and Nutrition Examination Surveys
7,557 children and adolescents aged 2 to 18 years

58
Impact of FLAVORED milk consumption on diet quality

and health outcomes:
 participate in school lunch more often
Annual School Milk Assessment, 2005-06.
Milk Processor Education Program and SNA
 drink less soda and fruit drinks

The Bogalusa Heart Study
Ranganathan et al, JADA 2005;105:1391
 sweetened beverage intake at age 5, but

not flavored milk intake … was positively
associated with adiposity from age 5-15.
Fiorito et al, AJCN 2009;90:935

59
“…small amounts of sugars added to

nutrient dense foods, such as reduced-fat
milk products, may increase a person’s
intake of such foods by enhancing the Dietary Guidelines for Americans
appeal of these products, thus improving
nutrient intake without contributing
excessive calories.” “When sugars are added to
otherwise nutrient-rich foods,
such as dairy products, the
American Heart Association quality of children’s and
adolescents’ diets improves.”
“… replacing sweetened drinks in

school vending machines with 100% The American Academy of Pediatrics
fruit juices, water, and lowfat plain or
flavored milk.”
60
Implementing milk enhancements
Impact of milk consumption on HEALTH & WELLNESS:

 Development and maintenance of a strong skeleton
 Improved bone strength at all stages of life
 Reduced incidence of fractures
 Maintenance of bone and muscle as a recovery
beverage
 Not associated with increased weight, BMI, or obesity
Moore et al, J Pediatr 2008;153:667
Goulding et al, JADA 2004;104:250
Thorpe et al, J Nutr 2008;138:1096
Fiorito et al, AJCN 2009;90:935
Murphy et al, JADA 2008;108:631

61
Over 10,700 schools have implemented the

piloted milk enhancements now known collectively
as the New Look of School Milk.

Milk Pep, SNA, NDC
62
Schools using PRB for 8 oz. milk

Milk Pep, SNA, NDC
63
Conclusions
1. School children drink more milk when it is offered

well chilled
in plastic re-sealable bottles
in a variety of sizes and flavors
at diverse points of sale within school
2. Increases were measured in
average daily participation in the NSLP
volume of milk sold
quantity of milk consumed
3. Implementing similar milk enhancements in schools
nation-wide could be projected to
improve the nutritional intake
diet quality
health & wellness
64
Solutions for schools
and beyond
1. Improve opportunities for school children to enjoy

cold milk in plastic re-sealable bottles, in low-fat
flavors that appeal
2. Use Nutrient Density as the basis for dietary

recommendations and the foundation for School
Wellness nutrition policies
3. Educate the public, parents, and children with the

positive approach that emphasizes total nutrient
content of Food Groups to Encourage

65
NDC’s Commitment to Child
Nutrition
Commitment to Child Nutrition
• NDC’s Long History of Commitment to Child Health
• Child Nutrition Health Education Kit

– Child Nutrition white paper
– Fact sheets on lactose-free milk, cheese and
flavored milk
– More
• Fuel Up to Play 60 Program

– ENGAGE youth to invest in their own health by
arming them with nutrition and physical activity
know-how
– INVITE collaboration between youth and adult
mentors to build a customized plan
– Help them ACTIVATE their program with
supporting materials and grants
67
Get Up & Play Fuel Up

60 Minutes/Day Nutrient Rich Foods
68
• Continuing to emphasize the consumption of nutrient-rich

foods in child nutrition programs helps to ensure overall diet
quality consistent with the Dietary Guidelines.
• NDC Resources:
o www.nationaldairycouncil.org
o www.thedairyreport.com
o www.fueluptoplay60.com
69
Questions?
A Few Quick Reminders…
• CPEU
• Survey
• Slides posted on The Dairy Report

Thank you!

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Welcome!

Safeguarding the Health of

Ann Marie Krautheim, MA, RD, LD

IOM 2010 Dietary

Source: 2005 Dietary

• Decades of Research and Exciting In-

– Encourage physical activity

– Reinforce dairy’s important role in child

Lynn L. Moore, DSc, MPH

8 Dairy For last 2 factors, lower

that are too high

• Most beef consumed is of a high-fat variety

Fruit: melons, bananas, papaya, prunes,

Percent Meeting RDA

Percent Meeting RDA

0 2 4 6 8 10 12 14 16 18 20 % Meeting Protein RDA by Dairy Intake

• Beef & poultry are primary sources of 80

protein among adult Americans 60

• Adolescents consuming more beef or 0

• High body mass index • Rates of central obesity

Large, representative sample, cross-sectional

fruits & vegetables 0

Dairy Fruit Vegetables

Bradlee ML et al. IJPO 2009

8 Quartile 2 consumed less grains

Boys consumed substantially more

Boys with more central body fat 0

Bradlee ML et al. IJPO 2009

Vegetable Subgroups & Whole Grains Meats/Other Protein Subgroup Servings

Bradlee ML et al. IJPO 2009

Dairy <2/day 2-<3/day 3+/day

1.0 0.89 (0.60, 1.3) 0.48 (0.30, 0.76)

Fruit 0/day >0 - <2/day 2+/day

1.0 0.93 (0.66, 1.3) 0.74 (0.46, 1.2)

Veg. <3/day 3-<5/day 5+/day

1.0 0.67 (0.45, 1.0) 0.76 (0.50, 1.2)

22 DA<2.5 & FV<3 svgs/day

25 Adjusted for age, height, SES, race, activity, & TV watching

DA<2.5 & FV<3 svgs/day

26 Adjusted for age, height, SES, race, activity, & TV watching

• In general, most children and adolescents consume too

• Need to focus on entire eating patterns in children and

• Higher intakes of dairy

• Will be more likely to meet the DRI for nutrients such

Karen Rafferty, RD, LMNT

Creighton University Osteoporosis Research Center

Milk enhancements improve milk consumption and

Journal of Child Nutrition and Management 2009; 34(fall)

Creighton University Osteoporosis Research Center

 The School Milk Pilot Test (SMPT) 2001-2002

 The Westside School Milk Pilot Study (W-SMPS) 2006

Creighton University Osteoporosis Research Center

 Objectives and design

DGA Food Groups to Encourage

Low-fat and fat-free

Creighton University Osteoporosis Research Center

 Children age 2-8: 2 cups

 Individuals age 9+: 3 cups

Creighton University Osteoporosis Research Center

Rampersaud et al JADA 2003;103:97

Creighton University Osteoporosis Research Center

Rampersaud et al JADA 2003;103:97

Creighton University Osteoporosis Research Center