August 2012 Issue

Healthful Beginnings — Nutritious Eating From Infancy to Toddlerhood Can Nip Obesity in the Bud
By Maura Keller
Today’s Dietitian
Vol. 14 No. 8 P. 34

Most of your clients probably already know that the rate of childhood obesity has reached a record high in this country. But what they might not know is that the steps to prevent it begin in infancy.

Today, almost 10% of infants and toddlers carry excess weight for their length, and slightly more than 20% of children between the ages of 2 and 5 are already overweight or obese.1 And while environmental factors influence a child’s risk of obesity in the first years of life, it’s the foods parents feed their children that can have the greatest impact.1

Today’s Dietitian spoke with RDs who specialize in pediatric nutrition about the dietary and caloric needs of infants and toddlers and how the foods parents introduce to them can shape their eating habits and relationship with food for a lifetime. Dietitians have a vital role in helping parents instill healthful eating habits in their children that will have long-term positive effects on their overall health and well-being.

Parents as Role Models
Joanna Dolgoff, MD, a pediatrician; child obesity specialist; author of Red Light, Green Light, Eat Right; and spokesperson for the American Academy of Pediatrics (AAP), says RDs must work with parents to teach their children healthful lifestyle and eating habits they will build on and follow for life.

“It makes sense that children are more likely to become obese when they have obese parents,” Dolgoff says. “This is linked to genetics, dietary patterns, physical activity, and parent-child relationships. Let’s face it—children often model what their parents do.” That’s why parents of children transitioning from infancy to toddlerhood should choose healthful, nutrient-dense foods and maintain an active lifestyle themselves while encouraging their kids to do the same.

“It’s difficult to change unhealthful habits as we get older, but if children learn early how to make the proper choices and become familiar with eating healthful foods, they’ll be more inclined to continue to eat in a healthful manner as they grow and become teenagers,” Dolgoff says.

Transition From Infancy to Toddlerhood
Infants more than double their birth weight and increase their length by 5 to 10 inches by the time they reach their first birthday. “To ensure this growth and development proceeds optimally, infants must obtain adequate amounts and high-quality forms of protein, essential fatty acids, vitamins, minerals, and other nutrients,” Dolgoff says. “It’s important to focus on the quality of fat consumed.”

Between 4 and 6 months of age, babies will be ready to start solid foods. However, they’ll continue to get most of their calories, proteins, vitamins, and minerals from breast milk or infant formula, says Vandana Sheth, RD, CDE, a spokesperson for the Academy of Nutrition and Dietetics (the Academy). “This is a good time to introduce iron-fortified infant cereals—rice, barley—or puréed meats to help restore diminishing iron stores,” Sheth says.

Between the ages of 6 to 8 months is a good time to introduce puréed or mashed fruits and vegetables. However, it’s best to gradually introduce one food at a time to recognize possible allergic reactions. “Babies are ready to start finger foods such as dry cereal and teething biscuits between the ages of 7 and 10 months,” Sheth says. “Between the ages of 8 and 12 months, infants are ready for soft or cooked table foods. From 1 to 2 years of age, babies start feeding themselves and enjoy most of the same foods as the rest of the family. However, food and choking hazards need to be monitored.”

Infants generally don’t consume dietary fiber for the first six months of life, but as complementary foods are introduced to the diet, fiber intake increases. “It’s recommended that from 6 to 12 months of age, parents slowly introduce whole grain cereals, fruits, vegetables, and legumes to provide 5 g of fiber per day by 1 year of age,” Dolgoff says.

Transitioning from infancy to toddlerhood means that table food starts to replace breast milk or formula, so RDs must inform parents that table food should be as nutrient dense as breast milk and formula. “Whole foods are preferred to processed foods, and a variety of food should be served so that a child meets his or her needs for protein, iron, calcium, and vitamins A and C,” says Melinda Johnson, MS, RD, a lecturer at Arizona State University and spokesperson for the Academy. “Once the intestinal tract and immune system are matured, around age 1, the child can begin to consume protein foods that might otherwise be allergenic such as cow’s milk and egg whites for example.”

To ensure adequate calcium and vitamin D intake, milk should be an important part of a toddler’s diet. According to Dolgoff, the AAP recommends vitamin D supplementation of 400 IU per day if a child is drinking less than 1 L (about 4 cups) of milk per day. In general, kids aged 12 to 24 months should drink whole milk to help provide the dietary fats they need for normal growth and brain development. After age 2, most kids can switch to 1% or nonfat milk.

It’s important to tell parents that after the rapid development experienced in the first year of life, the growth rate slows during toddlerhood. That’s why it’s imperative for parents to minimize the intake of sweet drinks, snack foods, and desserts because children’s stomachs can fill up quickly, limiting room for the more important nutrient-rich foods.

According to a study published in the January 2004 issue of the Journal of the American Dietetic Association, 30% of children between 19 and 24 months of age consume candy, pizza, chicken nuggets, soda, chips, and hot dogs.

“At the one-year mark, when parents are making the transition to more table foods, they need to understand that fruits, vegetables, whole grains, lean meats, and dairy should still be the mainstay of food choices,” says Christine Wood, MD, FAACP, a USANA Scientific Advisory Council member and the author of How to Get Kids to Eat Great & Love It. “The processed and packaged choices that are so well marketed to families should be limited or avoided. Once you go down that path, it’s difficult to turn back.”

The Critical First Year
The first year of life is when an infant’s palate is trained. “If a parent only introduces whole, natural foods to their little one during this time, the child will grow to love and appreciate their flavors,” says Tina Ruggiero, MS, RD, LD, author of The Best Homemade Baby Food on the Planet. “After 20 years of practice, I’ve seen parents successfully shape a child’s tastes and preferences, positively influencing his food choices later in life.”

That’s why it’s critical for RDs to discuss with clients the importance of introducing healthful foods from infancy to toddlerhood, focusing on the lifelong benefits. “Besides addressing various nutrient needs and how to go about achieving the right mix of foods at various stages of life with parents, it’s important to highlight the benefits of nurturing a healthful relationship with food,” Sheth says. “Clients need to be shown age-appropriate food choices and servings. Parents need to pay attention to their child’s cues and not overfeed them when their child is showing signs of being done, such as turning his or her head away. This will allow the child to naturally recognize signs of hunger or fullness.”

Johnson agrees: “It might seem hard for some parents because they may be eating an overly processed diet themselves and have lost touch with preparing and serving simple, whole foods. In reality, it isn’t that hard to feed young toddlers nutrient-dense foods. At this age, their worldview is extremely limited, and they’ll form their opinions based on the food served to them. If they’re served simple, fresh, whole foods, they’ll be much more likely to eat these foods. However, if they’re given processed foods right from the start, they’re more likely to balk when served the less processed foods.”

Feeding toddlers table food is simple, Johnson adds. They don’t need elaborate cooking methods or added flavor. Mashed beans, boiled eggs, yogurt, ripe whole fruits, and cooked veggies will suffice. “The problem is [children] like to imitate, so if they see their family eating French fries, they too will want a French fry,” Johnson says.

An Acquired Taste
Some children start out as picky eaters. But being a picky eater often is part of what it means to be a toddler. “We’ve learned that there are developmental reasons why kids between 1 and 3 years of age peck and poke at their food,” Dolgoff says. “After a year of rapid growth—the average 1-year-old is triple her birth weight—toddlers gain weight more slowly. So of course they need less food. The fact these little ones are always on the go also affects their eating patterns. They don’t sit still for anything, even food. Snacking their way through the day is more compatible with these busy explorers’ lifestyle than sitting down to a full-fledged feast. Toddlers from 1 to 3 years need between 1,000 and 1,300 kcal a day, yet they may not eat this amount every day.”

That’s why RDs should help parents establish a nutritionally balanced week for their toddlers, not necessarily a balanced day. Parents also should keep in mind that introducing their children to new foods for five to 14 days is an effective way to help a child overcome his dislikes.

Karin Ballard, MS, RD, LDN, a pediatric dietitian at La Rabida Children’s Hospital in Chicago, says RDs can further address the issue of picky eating by incorporating Ellyn Satter’s Division of Responsibility in Feeding initiatives, which help parents provide the structure, support, and opportunities for their children to eat nutritious foods. The initiatives make children responsible for how much they want to eat and whether to eat what their parents provide. In other words, parents are in charge of feeding and the child is in charge of eating, Ballard explains. This means that parents decide what to serve (a variety of healthful foods and drinks), when to serve it (scheduled meal and snack times), and where to serve it (preferably at the kitchen or dining room table with limited distractions).

“If a variety of healthful foods are served, the child can decide which foods he or she wants to eat and how much he or she wants to eat,” Ballard says. “By forcing a child to eat certain foods, like vegetables, and offering certain foods such as desserts as a reward teaches the child that some foods are desirable and others are not. Also, forcing a child to eat more than they want, such as making them clean their plates, can cause obesity as well as an unhealthful relationship with food, which also can lead to obesity. By giving the child control of their intake and choosing which food to eat establishes a healthful relationship with food.”

RDs should encourage parents never to give up on getting their children to enjoy healthful foods, even if they don’t like them the first time around. “It may take up to 10 exposures to a new food before a child decides he or she actually likes it,” Dolgoff says. “And if they like something, they’ll eat when they’re hungry and stop when they’re full.”

“Clients greatly appreciate hearing how we feed our own children—it makes it more real,” Johnson says. “ So [as RDs], practice what you preach, and then share what works in your life with your clients.”

— Maura Keller is a Minneapolis-based writer and editor.


Benefits of Breast-Feeding
Preventing overweight and obesity starts during infancy. According to Early Childhood Obesity Prevention Policies, a report published in June 2011 by the Institute of Medicine, exclusive breast-feeding for the first six months of life and continuation of breast-feeding in conjunction with complementary foods for one year or more can prevent childhood obesity. If a parent can’t or chooses not to breast-feed, it’s important to pay close attention to infant hunger and satiety cues and avoid forcing an infant to finish a bottle.


Calorie Requirements for Toddlers
According to the Academy of Nutrition and Dietetics, most children aged 2 to 3 need approximately 1,000 kcal per day. To help parents meet their toddlers’ nutritional needs, Vandana Sheth, RD, CDE, a spokesperson for the Academy, suggests they distribute the calories daily across the following food groups:

Grains: 3 oz of grains, of which one-half should be whole grains. This is equivalent to approximately three slices of bread or 1 slice of bread plus 1/3 cup cold cereal and 1/4 cup cooked rice or pasta.

Vegetables: 1 cup raw or cooked vegetables.

Fruits: 1 cup fresh, frozen, canned, dried, and/or 100% fruit juice. Whole fruits rather than juice are recommended.

Milk: Two cups per day. For children under age 2, whole milk is recommended. Older children can switch to low-fat/nonfat milk, yogurt, and cheese.

Meat and beans: 2 oz from lean meat, chicken, eggs, fish, or beans.

Oils: 3 tsp or fewer per day.


Macaroni and Cheese With Peas

Makes about 3 cups

1 T butter or margarine
1 T all-purpose flour
1 cup 1% low-fat milk
1/2 cup (2 oz) shredded reduced-fat cheddar cheese
Pinch ground nutmeg
Salt and pepper to taste
2 cups hot cooked macaroni or pasta shells (1 cup uncooked)
3/4 cup frozen peas, thawed

In a medium saucepan, melt the butter over medium heat. Whisk in the flour. Add the milk. Cook and stir until the mixture thickens and comes to a boil.

Lower the heat, add the cheese, nutmeg, salt, and pepper. Cook and stir 2 minutes. Add the pasta and peas, and mix gently.

Nutrient Analysis per 1/2 cup: Calories: 144; Total fat: 5 g; Sat fat: 3 g; Cholesterol: 14 mg; Sodium: 116 mg; Total carbohydrate: 19 g; Dietary fiber: 1 g; Sugars: 3 g; Protein: 7 g

— Recipe courtesy of Jean Kressey, MS, BSN


1. Institute of Medicine. Early Childhood Obesity Prevention Policies. Files/2011/Early-Childhood-Obesity-Prevention-Policies/Young Child Obesity 2011 Report Brief.pdf. June 2011. Accessed June 5, 2012.