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CPJXXX10.1177/0009922814533404Clinical PediatricsFalciglia et al
Article
Longitudinal Study of Nutrient Intakes
in Infants Aged 12 to 18 Months
Clinical Pediatrics
1­–7
© The Author(s) 2014
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DOI: 10.1177/0009922814533404
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Grace Falciglia, PhD, RD1, Seung Yeon Lee, PhD1,
Kaitlyn Paxton, MS1, Christina Reinerman, BBA1,
and Libbey Spiess, MD2
Abstract
Objective. To examine the nutrient intakes in young children and to compare their intakes with the dietary reference
intakes (DRIs). Design. Longitudinal study observing the child’s food and beverage intakes as he or she grows from
12 to 18 months. Methods. Three interviewer-administered 24-hour dietary recalls over 1 week were collected
from the mother to assess the child’s intakes at 12 and 18 months of age. Intakes were calculated at the 10th,
25th, 50th, 75th, and 90th percentiles and compared with the DRIs to determine the proportions below and above
cutoff values. Results. Nutrient intakes met or exceeded energy and nutrient requirements, with some exceptions.
Diets were deficient in healthy fats, iron, fiber, and potassium and excessive in calories, synthetic folate, preformed
vitamin A, zinc, and sodium. Conclusions. Health professionals should emphasize foods that are nutrient dense while
decreasing highly processed foods for children.
Keywords
child nutrition, feeding the child, dietary reference intakes for children
Introduction
Childhood obesity in the United States is a significant
public health concern.1 Not only do children struggle
with obesity, but older infants and toddlers are now
experiencing similar problems.2 Although the causes of
childhood obesity are multifactorial, diet plays an
important role. The time when parents begin introducing table food to their children is challenging because
there are minimal guidelines to support the feeding
transition. Findings from the Feeding Infants and
Toddlers Study (FITS) show that in general, older
infants and toddlers in the United States have diets that
are excessive in calories, saturated fat, sugar, and some
nutrients (eg, sodium, vitamin A, and zinc) and deficient in iron, fiber, potassium, and healthy fats.3,4
Specifically, the data show that a substantial proportion
of infants and toddlers (22% for older infants and 28%
for toddlers) exceed their daily energy requirement.
Although these calculations may be the result of overreporting of food intake by the caregivers, it can be concluded that at least some parents are overfeeding their
children. In addition, nearly half of older infants consumed some kind of dessert, sweet, or sweetened beverage on the day of recall, and this number increased to
74% in toddlers. Also, 15% of toddlers consumed a
salty snack on the day of recall. One of the most startling findings is that among toddlers, 25% did not consume fruits, and 30% did not consume vegetables on
the day of the recall. By 15 to 18 months, one of the
most frequently consumed vegetables was found to be
white potatoes. Therefore, the FITS data show that the
transition from infancy to toddlerhood is characterized
by dietary changes that predispose children to not meet
the recommended intake levels for specific nutrients
and increase the risk of diet-related diseases.
To assess whether diets provide the nutrients needed
to meet requirements without being excessive, the
dietary reference intakes (DRIs), a set of nutrient
reference standards developed by the Institute of
­
Medicine can be used.5-10 The DRIs include Estimated
Energy Requirement (EER), Acceptable Macronutrient
Distribution Range (AMDR), Estimated Average
Requirement (EAR), Recommended Dietary Allowance
1
The University of Cincinnati, Department of Nutritional Sciences,
Cincinnati, OH, USA
2
Queen City Physicians, Cincinnati, OH, USA
Corresponding Author:
Grace Falciglia, The University of Cincinnati, 364 French East, 3202
Eden Avenue, Cincinnati, OH 45267, USA.
Email: [email protected]
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Clinical Pediatrics
(RDA), Adequate Intake (AI), and Tolerable Upper
Intake Level (UL).
The National Health and Nutrition Examination
Surveys (NHANES) monitor the dietary intake of the US
population and provide a valuable reference for dietary
trends over time; however, samples for young children are
limited, and findings are based on cross-sectional data.11
FITS strives to fill the gap by collecting dietary information in a national sample of infants and toddlers, using
phone interviews to obtain data. However, FITS findings
are also based on cross-sectional data.12 Therefore, there is
a need for longitudinal studies that can capture the changes
that occur at the challenging transition in dietary patterns
from infancy to toddlerhood.
The purpose of this study is to examine the changes
in nutrient intake in a young child as he or she grows
from 12 months to 18 months of age, with a focus on
nutrient intakes from food and beverages (not including
supplements). Specifically, nutrient deficiencies and
excesses will be identified by comparing the child’s
nutrient intakes against the DRIs.
Method
Dietary Recall. Three unscheduled, randomized,
­interviewer-administered 24-hour dietary recalls over
a 1-week span were collected from the mother to assess
the child’s dietary intake at 12 and 18 months of age.
The recalls were completed over the phone by trained
and certified interviewers from the Cincinnati Center
for Nutritional Research and Analysis at the Cincinnati
Children’s Hospital Medical Center using the Nutrition
Data System for Research (NDSR) developed by the
Nutrition Coordinating Center at the University of
Minnesota (versions 2009, 2010, and 2011; University
of Minnesota, Minneapolis, MN). The interview
method used multiple passes to aid with memory
retrieval. To maintain consistency in portion size
description, mothers used a 2-dimensional portion size
poster to determine the quantity of all foods and beverages consumed by the child.13 The data on the consumption of foods and beverages (not including
supplements) were based on the daily average of 3
days of food recalls. All foods and beverages consumed
were analyzed for total energy and macronutrient and
micronutrient composition. Data collection occurred
between the years 2009 and 2011.
Study Design and Participants
Data Analysis
This longitudinal study utilized partial data from a randomized controlled dietary intervention evaluating the
efficacy of an obesity prevention program targeting the
diet of mother-and-child dyads. Participants (n = 118
dyads) were recruited from a large obstetrics clinic in
the Cincinnati metropolitan area. Eligible children were
single-birth, full-term infants, free from known chronic
disease that could affect growth and development, and
eligible mothers were women who had a BMI ≥25, with
no other comorbidities; were 21 to 35 years of age; had
full medical clearance from a physician to participate;
and were not on special diets. In the primary study, the
diets of the mother-and-child dyads were longitudinally
evaluated at baseline when the child was 6 weeks old
and again at 6, 12, and 18 months of age. This study
analyzed dietary data from the child at 12 and 18 months
of age, with informed consent provided by the mother of
the child. The primary study procedures were approved
by the institutional review board at the university where
this research was conducted.
The nutrient data files were exported to Excel files from
NDSR, and then, they were imported into IBM Statistical
Program for Social Sciences version 22 (SPSS, Armonk,
NY). Descriptive statistics were conducted for demographic data. Group mean, standard deviation, and percentiles were calculated for energy, macronutrients, and
micronutrients. The percentage of children who did not
meet or exceeded the DRI recommendations was calculated. Specifically, energy intake was compared with the
EER; the distributions of fat, carbohydrate, and protein
intake were compared with AMDR when available; and
intake of vitamins and minerals was compared with
EAR and UL. EARs were employed as opposed to
RDAs because they are preferred for group assessment.
EARs meet the needs of 50% of individuals. The usual
intakes were not compared with the AI because AIs are
only estimates of needs.
Results
Sample Characteristics
Measures
Demographics. Sociodemographic data, including maternal age, race, education level, occupation, and marital
status were collected along with the child’s sex and firstborn status.
Table 1 shows demographic data of the study sample
and the respective child’s mother. The proportion of
male and female children was the same. Approximately
the same proportion of children were either the first born
or non–first born. The majority of the mothers were
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Falciglia et al
Table 1. Sample Characteristics for Child and Mother
(n = 60).
Characteristics
Gender of infant
Male
Female
First-born child
Yes
No
Mother’s age (years)
21-25
26-30
31-35
Mother’s race
White, non-Hispanic
White, Hispanic
African American, non-Hispanic
African American, Hispanic
Asian
Mother’s education
Eleventh grade or less
High school diploma
Some college
Completed college
Mother’s occupational status
Employed
Not Employed
Mother’s marital status
Married
Single/Divorced
Percentage of Sample
50
50
46.7
53.3
27
40
33
83.3
3.3
11.7
0
1.7
0
1.7
11.7
86.7
71.7
28.3
90.0
10.0
between the ages of 26 and 30 years and white, had completed college, and were employed and married.
Dietary Intake
Toddlers 12 Months of Age. The usual energy and nutrient intake distributions of 12-month-olds are displayed
in Table 2. The mean energy intake was 916 kcal/d for
boys and girls combined. Those values were higher
(60% for boys and 66% for girls) than the EER for
12-month-olds of 844 kcal/d for boys and 768 kcal/d for
girls (data points are not included in the table). AMDR
values are not available for carbohydrates, fat, and fiber.
The mean value for protein intake was 35 g/d as compared with the EAR of 1.1 g/kg/d, which is equivalent to
9.9 g/d for the reference 9-kg older infants. For micronutrients, EARs are available only for iron and zinc. The
mean iron intake of 8.1 mg/d was adequate; however,
48% did not meet the EAR (6.9 mg/d). The mean zinc
intake was 5.6 mg/d, with 63% exceeding the UL
(5 mg/d). Also, the mean preformed vitamin A intake
was 605 µg/d. Preformed vitamin A intake exceeded the
UL (600 µg/d) in 20% of 12-month-olds.
Toddlers 18 Months of Age. The usual energy and nutrient
intake distributions of 18-month-olds are displayed in
Table 3. The mean energy intake was 1089 kcal/d for
boys and girls combined. Those values were higher (66%
for boys and 70% for girls) than the EER for 18-montholds: 961 kcal/d for boys and 899 kcal/d for girls (data
points are not included in table). The majority of diets of
18-month-olds fell within the AMDR for fat, carbohydrate, and protein, except for 18% and 16% of diets that
were below the AMDR for fat and carbohydrate, respectively, and for 15% and 11% of diets that were above the
UL for fat and protein, respectively. Although there are
no EARs for fiber, the mean usual fiber intake of 9 g/d as
well as the 90th percentile was well below the AI of
19 g/d. The mean intake of micronutrients was adequate,
with some exceptions. The mean vitamin C intake was
45 mg/d (EAR = 13 mg/d); however, 10% of the children
did not meet the recommendation. The mean vitamin E
intake was 3 mg/d, and 83% did not meet the recommendations (5 mg/d). The mean vitamin D intake was 6 µg/d,
and 95% of 18-month-olds were below the EAR
(10 µg/d). The usual intake of preformed vitamin A
(565 µg/d), zinc (6.2 mg/d), and sodium (1637 mg/d)
exceeded the ULs in 6%, 31%, and 51%, respectively.
Although there are no EARs for potassium, the mean
potassium intake of 1651 mg/d as well as the 90th percentile was well below the AI of 3000 mg/d.
Discussion
Assessment of Energy and Macronutrient
Intakes
This study revealed that children 12 to 18 months old
had nutrient-adequate diets with a few exceptions. A
large percentage of 12-month-olds had energy intakes
above the EER, and this pattern continued as the child
reached 18 months of age. This discrepancy between the
usual energy intake and the EER may reflect true overconsumption of calories or overreporting of food intake
by the mothers. In terms of macronutrients, a noticeable
fat intake for some children was below the recommendations. The recommended use of low-fat dairy products
for the general population and underreporting of hidden
fat may explain the low dietary fat values. The American
Academy of Pediatrics recommends a gradual lowering
to about 30% of fat intake with an emphasis on healthy
fats during toddler years.14 The majority of 18-monthold children did not meet the recommendation for fiber
intake. The AI was based on studies that found an
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Table 2. Usual Nutrient Intake Distribution from Food Sources Only for Older Infants Aged 12 Months (n = 60).
Dietary Reference
Intakesa
Nutrient
EAR
Macronutrients
Energy (kcal/d)
Fat (g/d)
Carbohydrate (g/d)
Protein (g/kg/d)
1.1b
Dietary fiber (g/d)
Percentage of total energy
Fat (%)
Carbohydrate (%)
Protein (%)
Antioxidants
Vitamin C (mg/d)
Vitamin E (mg αtocopherol/d)
B vitamins
Thiamin (mg/d)
Riboflavin (mg/d)
Vitamin B6 (mg/d)
Niacin (mg niacin
equivalents/d)
Folate (µg dietary
folate equivalents/d)
Vitamin B12 (µg/d)
Bone-related nutrients
Calcium (mg/d)
Phosphorus (mg/d)
Magnesium (mg/d)
Vitamin D (µg/d)
Other micronutrients
Vitamin A (µg retinol
activity equivalents/d)
Vitamin K (µg/d)
Iron (mg/d)
6.9
Zinc (mg/d)
2.5
Sodium (mg/d)
Potassium (mg/d)
AI
UL
30
95
50
5
0.3
0.4
0.3
4
80
0.5
25th
50th
75th
90th
916 (246)
35 (10)
116 (35)
35 (13)
7 (3)
630
22
76
21
4
735
27
90
25
5
873
35
107
34
7
1011
42
137
42
9
1280
49
181
54
12
—
—
—
—
—
—
—
—
—
—
35 (5)
50 (6)
15 (3)
27
41
10
30
45
12
34
51
14
39
56
18
43
60
20
—
—
—
—
—
—
52 (33)
3 (2)
13
1
24
2
51
2
74
4
94
6
—
—
—
—
0.7 (0.2)
1 (0.5)
0.8 (0.2)
17 (6)
0.4
0.7
0.5
11
0.5
0.9
0.6
12
0.7
1.3
0.8
16
0.9
1.7
1.0
20
1.1
2.1
1.2
26
—
—
—
—
—
—
—
—
217 (88)
119
147
202
268
343
—
—
2.9 (1.2)
1.2
1.9
2.8
3.7
4.5
—
—
407
418
94
1.4
569
562
107
4.1
757
673
132
6.8
1032
926
150
8.2
1161
1127
193
9.2
—
—
—
—
0
—
—
0
335
426
557
749
923
—
20c
42 (39)
14
8.1 (5.2)
4.0
5.6 (1.4)
3.7
1079 (545) 441
1434 (394) 1029
21
5.2
4.5
690
1171
29
7.0
5.4
1031
1357
51
9.8
6.8
1389
1658
73
13.0
7.6
1908
2143
—
48
1
—
—
—
1
63
—
—
1500
38
784 (281)
733 (263)
134 (39)
6.1 (3.0)
500
600
605 (224)
40
5
370
700
Percentage Percentage
<EAR
>UL
Mean (SD) 10th
260
275
75
10
2.5
Inadequate/Excessive
Usual Intake
Usual Intake Mean and Percentiles
Abbreviations: EAR, Estimated Average Requirement; AI, adequate intake; UL, tolerable upper level; SD, standard deviation.
a
EAR is the average daily nutrient intake level estimated to meet the requirements of half of the healthy individuals in a group; AI is a value
based on estimates of nutrient intake by a group; UL is the highest nutrient intake level that is likely to pose no risk of adverse health effects to
almost all individuals. A blank space in the column indicates that no requirement has been defined. Prevalence of inadequacy was calculated for
nutrients with EAR values only using recommendations for children aged 7 to 12 months.
b
EAR for protein is set at 1.1 g/kg/d (equivalent to 9.9 g/d for the reference 9-kg older infants).
c
As preformed vitamin A only.
association between high intakes of dietary fiber and
significant reductions in cardiovascular disease risk in
adults.9 Health benefits may be gained from some
increase in fiber intake from fruits, vegetables, legumes,
and whole grains.15 All these observations align with
FITS findings.3
Prevalence of Inadequate Micronutrient
Intakes in Toddlers 12 and 18 Months of
Age
At 12 months of age, EAR are only available for iron
and zinc. A sizeable proportion of 12-month-olds had
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Falciglia et al
Table 3. Usual Nutrient Intake Distribution From Food Sources Only for Toddlers Aged 18 Months (n = 60).
Dietary Reference Intakea
Nutrient
Macronutrients
Energy (kcal/d)
Fat (g/d)
Carbohydrate (g/d)
Protein (g/kg/d)
Dietary fiber (g/d)
Percentage of total energy
Fat (%)
Carbohydrate (%)
Protein (%)
Antioxidants
Vitamin C (mg/d)
Vitamin E (mg alphatocopherol/d)
B vitamins
Thiamin (mg/d)
Riboflavin (mg/d)
Vitamin B6 (mg/d)
Niacin (mg niacin
equivalents/d)
Folate (µg dietary
folate equivalents/d)
Vitamin B12 (µg/d)
Bone-related nutrients
Calcium (mg/d)
Phosphorus (mg/d)
Magnesium (mg/d)
Vitamin D (µg/d)
Other micronutrients
Vitamin A (µg retinol
activity equivalents/d)
Vitamin K (µg/d)
Iron (mg/d)
Zinc (mg/d)
Sodium (mg/d)
Potassium (mg/d)
EAR or
AMDR
0.88b
AI
UL
100
19
30-40
45-65
5-20
Inadequate/Excessive
Usual Intake
Usual Intake Mean and Percentiles
Percentage Percentage
<EAR or
>UL or
90th
<AMDR
>AMDR
Mean (SD) 10th
25th
50th
75th
1089 (236) 815
41 (11)
28
138 (34)
96
44 (11)
30
9 (4)
5
908
34
111
35
6
1026
39
130
42
9
1240
48
160
52
11
1449
58
191
58
14
—
—
—
—
—
—
—
—
—
—
34 (5)
50 (5)
16 (3)
27
43
12
30
48
14
34
50
15
36
55
18
41
58
20
18
16
0
15
0
11
400
200
45 (29)
3 (1)
12
1
25
2
42
3
54
4
85
6
10
83
0
—c
0.4
0.4
0.4
5
30
10
0.9 (0.2)
1.6 (0.4)
1.0 (0.3)
21 (4)
0.6
1.0
0.7
15
0.7
1.3
0.8
17
0.9
1.6
0.9
20
1.1
1.9
1.1
24
1.3
2.2
1.5
29
0
0
0
0
—
—
0
NDd
120
300
270 (104) 164
193
247
312
431
0
NDd
3.5 (1.2)
2.0
2.6
3.5
4.4
5.0
3
—
13
5
0.7
500
380
65
10
2500
3000
65
63
906 (265) 598
894 (234) 611
161 (34) 120
6 (2)
3
702
721
133
4
914
862
160
6
1116
1059
184
8
1219
1206
203
9
5
0
0
95
0
0
—e
0
210
600
565 (194) 329
375
575
693
829
0
6f
41 (38)
14
40
7.8 (3.1) 4.4
7
6.2 (1.7) 4.1
1500 1637 (644) 839
1651 (347) 1201
21
5.6
4.9
1281
1345
30
6.7
6.0
1514
1657
45
10.0
7.1
1913
1927
74
12.2
8.4
2525
2077
—
1
0
—
—
—
0
31
51
—
30
3.0
2.5
1000
3000
Abbreviations: EAR, Estimated Average Requirement; AMDR, acceptable macronutrient density range; AI, adequate intake; UL, tolerable upper
level; SD, standard deviation; ND, not determined.
a
EAR is the average daily nutrient intake level estimated to meet the requirements of half of the healthy individuals in a group; AI is a value
based on estimates of nutrient intake by a group; UL is the highest nutrient intake level that is likely to pose no risk of adverse health effects to
almost all individuals. A blank space in the column indicates that no requirement has been defined. Prevalence of inadequacy was calculated for
nutrients with EAR values only using recommendations for children aged 1 to 3 years.
b
EAR for protein is set at 0.88 g/kg/d.
c
The UL for vitamin E applies only to any form of supplementary α-tocopherol.
d
The ULs for niacin and folate apply only to the synthetic form obtained from supplements and/or fortified foods. The nutrient database
includes fortified foods but does not differentiate from the nutrient content of foods, so the percentage above the UL could not be
determined.
e
The UL for magnesium is based on supplements only.
f
As preformed vitamin A only.
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Clinical Pediatrics
iron intakes below the EAR. Although the use of ironfortified cereals and infant-fortified formula has reduced
iron deficiency in the United States, the prevalence of
iron deficiency anemia still occurs in 6.6% to 15.2% of
young children.14
As infants grew into their second year of life, their
nutrient intakes, in particular vitamins E and D, fell
below the EAR. A high proportion of toddlers’ intakes
were less than the EAR for vitamin E. Other surveys
such as FITS, NHANES, and Continuing Survey of Food
Intakes by Individuals have shown a high prevalence of
inadequacy of vitamin E, despite the lack of evidence of
vitamin E deficiency in this population.3,11,16 This could
be a result of the fact that the EAR was extrapolated from
adults. The usual mean intakes as well as the 90th percentile values for vitamin D were below the EAR for a
high proportion of toddlers. The latest DRIs for vitamin
D (10 µg/d) were released by the Institute of Medicine in
2011 under the assumption of minimal sun exposure.
However, given that many US children appear to obtain
at least some vitamin D from inadvertent or deliberate
sun exposure, there are implications for the interpretation
of intake levels of the vitamin. The 2011 Institute of
Medicine report on applications of DRIs for vitamin D
states that whenever possible, the assessment of apparent
dietary adequacy should consider biological parameters
such as anthropometry, biochemical indices, diagnosis,
clinical status, and other factors as well as diet.10 The
totality of the evidence and not dietary data alone should
be considered when assessing and planning diets. That is,
although mean total intakes of vitamin D generally are
lower than the EAR, the available clinical measures do
not suggest widespread deficiency states. This underscores the possibility that sun exposure is contributing
generally to the maintenance of adequate serum
25-hydroxy vitamin D concentrations. The usual mean
potassium intakes as well as the 90th percentile values
were below the AI, consistent with findings from FITS.3
Because the EAR for young children for potassium was
extrapolated from adults, there is a need for reassessment
of the EAR for children.
Prevalence of Excessive Micronutrient Intakes
in Toddlers 12 and 18 Months of Age
UL values for infants have been set for only a few micronutrients. Of those, a significant proportion of 12-montholds’ diets exceeded the ULs for preformed vitamin A
and zinc. These nutrients continue to be excessive as the
child grows to 18 months of age.
More UL values are available to evaluate the diets
of 18-month-olds. Nutrients of concern at this time are
niacin, folate, preformed vitamin A, zinc, and sodium.
The UL values for niacin and folate apply only to the
synthetic form obtained from supplements and/or
fortified foods. This study did not include use of
­
­supplements, and the nutrient database used does not
differentiate fortification values from the nutrient content of foods, so the percentage above the UL could not
be determined. However, the data suggest that fortification may have contributed to the intakes above the
UL for some children. Whereas the benefits of folic
acid fortification for women capable of becoming
pregnant are well recognized, fortification programs
should protect against excessive intakes for others,
given the potentially adverse effects on neurodevelopment.17 Diets exceeding the UL for preformed vitamin
A were attributable to some foods commonly consumed by young children. In addition, some children’s
vitamin supplements contain preformed vitamin A in
amounts exceeding the UL, exposing young children to
risk of vitamin A toxicity. Zinc intakes from food and
beverages were also above the UL for a significant
number of toddlers. Zinc-fortified infant formulas,
cereals, and ready-to-eat cereals are the main sources
of dietary zinc for young children. Although zinc
homeostatic mechanisms protect against excessive
dietary intakes, monitoring zinc intake from all sources
is necessary. A considerably high proportion of toddlers have diets exceeding the UL for sodium. The consumption of highly processed foods and snacks may
account for high sodium intake. The findings for vitamin A, zinc, and sodium are consistent with FITS and
Continuing Survey of Food Intakes by Individuals
findings.3,16
In summary, food intakes met or exceeded energy
and nutrient requirements, with some exceptions. Diets
were deficient in healthy fats, iron, fiber, and potassium
and excessive in calories, synthetic folate, preformed
vitamin A, zinc, and sodium. For older infants, the critical role of iron should be emphasized. Meals for toddlers should provide foods with healthier fats, rich in
fiber and moderate in sodium. Overall, guidance should
be given on the importance of eating a variety of high
nutrient density foods such as fruits, vegetables, and
whole grains and decreasing the intake of highly processed foods. Findings also suggest caution in food fortification and nutrient supplementation of young
children.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
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Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence
of obesity and trends in body mass index among US
children and adolescents, 1999-2010. JAMA. 2012;307:
483-490.
2. Ogden CL, Carroll MD, Curtin LH, Lamb MM, Flegal
KM. Prevalence of high body mass index in US children
and adolescents, 2007-2008. JAMA. 2010;303:242-249.
3. Butte NF, Fox MK, Briefel RR, et al. Nutrient intakes
of US infants, toddlers, and preschoolers meet or exceed
dietary reference intakes. J Am Diet Assoc. 2010;110:
S27-S37.
4.Siega-Riz AM, Deming DM, Reidy KC, Fox MK,
Condon E, Briefel RR. Food consumption patterns of
infants and toddlers: where are we now? J Am Diet Assoc.
2010;110:S38-S51.
5. Institute of Medicine, Food and Nutrition Board. Dietary
Reference Intakes for Phosphorus, Magnesium, Vitamin
D, and Fluoride. Washington, DC: National Academies
Press; 1997.
6. Institute of Medicine, Food and Nutrition Board. Dietary
Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin
B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and
Choline. Washington, DC: National Academies Press;
1998.
7. Institute of Medicine, Food and Nutrition Board. Dietary
Reference Intakes for Vitamin C, Vitamin E, Selenium,
and Carotenoids. Washington, DC: National Academies
Press; 2000.
8. Institute of Medicine, Food and Nutrition Board. Dietary
Reference Intakes for Vitamin A, Vitamin K, Arsenic,
Boron, Chromium, Copper, Iodine, Iron, Manganese,
Molybdenum, Nickel, Silicon, Vanadium, and Zinc.
Washington, DC: National Academies Press; 2001.
9. Institute of Medicine, Panel on Macronutrients, Food and
Nutrition Board. Dietary Reference Intakes for Energy,
Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,
Protein, and Amino Acids. Washington, DC: National
Academies Press; 2005.
10.Institute of Medicine, Food and Nutrition Board.
Dietary Reference Intakes for Calcium and Vitamin D.
Washington, DC: National Academies Press; 2011.
11. US Department of Agriculture. What we eat in America.
http://www.ars.usda.gov/Services/docs.htm?docid=18349.
Accessed January 10, 2014.
12.Briefel RR, Kalb LM, Condon E, et al. The Feeding
Infants and Toddlers Study 2008: study design and methods. J Am Diet Assoc. 2010;110:S16-S26.
13.Millen B, Morgan JL. The 2D Food Portion Visual.
Framingham, MA: Nutrition and Consulting Enterprises;
1996.
14.American Academy of Pediatrics. Pediatric Nutrition
Handbook. 7th ed. Elk Grove Village, IL: American
Academy of Pediatrics; 2014.
15. Kranz S, Mitchell DC, Siega-Riz AM, Smiciklas-Wright
H. Dietary fiber intake by American preschoolers is associated with more nutrient-dense diets. J Am Diet Assoc.
2005;105:221-225.
16.US Department of Agriculture. Continuing Survey of
Food Intakes by Individuals, 1994-1996. Beltsville, MD:
US Department of Agriculture; 1998.
17. Smith AD. Folic acid nutrition: what about the little children? Am J Clin Nutr. 2010;91:1408-1409.
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on March 5, 2016