By Whitney Crouch, RDN, CLT
​
Our children are often our greatest pride, our greatest challenge, and sometimes our greatest frustration. However, they are not small adults, and they often remind us of this around meal times when the plate full of veggies goes untouched, but the pizza is ravenously inhaled. Behaviours aside, children’s growing bodies are different from adults and require higher proportions of some nutrients.

As parents, we may know what our children should ideally be eating for breakfast, lunch, dinner, and snack times, but sometimes we just can’t seem to persuade our children to actually eat those veggies.
“Will my child be getting enough nutrition if she only eats a few bites of each meal?” “What if she relies heavily on processed, carbohydrate-rich foods?” “How can I support my picky eater in choosing a wider variety of foods?” These are valid concerns that many healthcare providers and dietitians hear from worried parents. Added to those questions is the recent government data that states, according to the 2011-2014 National Health and Nutrition Examination Survey (NHANES), many children are not meeting current nutrient recommendations.1 There are multiple factors why this is the case, and we will explore the food sources of nutrients, nutrient gaps, and strategies to help improve dietary intake of important nutrients in children.

Nutrition intake: Where are we today?The 2015–2020 Dietary Guidelines Advisory Committee (DGAC) determined that several nutrients: vitamins A, E, and C; folate; magnesium; and iron (in adolescent females) were under-consumed in children relative to the Estimated Average Requirement (EAR) or Adequate Intake (AI) levels set by the Institute of Medicine. These were characterised as “shortfall nutrients.”1 In addition to the aforementioned micro-nutrients, fiber is another nutrient that is often under-consumed. Consider these daily recommendations for fiber range based on age, sex, and calorie needs:2

• 14 g (age 1-3 years)
• 17-20 g (age 4-8 years)
• 22-25 g (age 9-13 years)
• 25-31 g (age 14-18 years)

If your child falls into the category of a “frequent processed food eater,” he or she is likely not getting enough fiber each day, which can lead to difficulty producing regular bowel movements and could possibly lead to additional nutrient deficiencies and adverse health issues.

In children 2–18 years of age, milk has been shown to be the primary source of calcium, vitamin D, and potassium.3 Dairy products, especially milk and yogurt, also provide protein, saturated fatty acids (SFA), riboflavin, vitamin B12, and phosphorus. But over the past 30 years, fluid milk consumption has declined from 247 pounds per person to 154 pounds per person, with an increase in cheese and yogurt consumption.1 The increased cheese and yogurt intake has led to increased intake of saturated fat and sodium in the diet.4 Despite the decreasing trend in cow’s milk intake, younger children appear to be consuming adequate dairy, but many will decrease consumption as they age, especially girls, despite an increased need by volume. Reasons for milk intake decreasing as children become adolescents include beliefs around dairy (females may think dairy will make them “fat”, whereas males may think it will help them grow stronger), access to milk products (sometimes limited due to parental beliefs around dairy), skipping meals that would normally contain dairy, and more.5

As recommended by the USDA, children 2-3 years old should be consuming 2-cup equivalents of dairy per day, while 4-8-year-olds need 2.5-cup equivalents, and 9-18-year-olds should be consuming around 3-cup equivalents per day.6 The American Academy of Pediatrics (AAP) adopted the American Heart Association’s (AHA) 2006 guidelines, which recommend similar intake of 2 cups/day of reduced fat or nonfat milk for ages 2-8 and 3 cups/day of reduced fat or nonfat milk for ages 9-18 years.7-8
Significantly, children 9-18 years old actually have higher calcium needs than adults, requiring 1,300 mg of calcium daily to support increased needs for skeletal development leading up to and during puberty.9
Of note, while the AAP and AHA may be aligned on low or nonfat dairy for children ages 2+ years, recent studies have shown reduced rates of obesity when higher fat dairy is consumed, and no ill effect on adult blood lipids.10

When children are meeting the recommended intake for dairy, discretion should be used to serve children low-sugar products that are nutrient-dense. To reduce sugar and improve nutrient density, parents should limit their children’s intake of flavored milks, read product labels, and avoid purchasing yogurts (and other food products) with large amounts of added sugars. Greek and Skyr type of yogurt products can be great sources of protein and often provide 9 grams or less sugar per serving and without the use of artificial sweeteners.

Nutrient needs and portionsParents usually have the best intentions at heart when it comes to their children, but if they don’t have enough information to make informed choices, can you blame them if their children aren’t meeting all of their nutrition needs?
Calorie and portion needs change as children grow. Below is a quick reference guide to better layout children’s evolving nutrition needs. Parents’ intuition and knowledge of their child’s habits are the best gauge of a child’s daily needs.

FOOD GROUP                  2 year olds           3 year olds               4-5 year olds
Fruits                                 1 cup                      1-1 ½ cups                 1-1 ½ cups
Vegetables                       1 cup                      1-1 ½ cups                 1 ½-2 cups
Grains                                3 ounces               3-5 ounces                 4-5 ounces
Proteins                            2 ounces               2-4 ounces                  3-5 ounces
Dairy                                  2 cups                   2-2 ½ cups                   2 ½ cups

(www.choosemyplate.gov, 2018)
*Older children’s needs are higher and based on age, sex, height, weight, and activity level.6
Portions:11

• ½ cup of fruit: ½ cup mashed, sliced, or chopped fresh fruit; ½ cup of 100% fruit juice (try watering it down 50% with ½ cup flat or sparkling water); ½ small banana, 4-5 large strawberries
• ½ cup vegetables: ½ cup mashed, sliced, or chopped vegetables; 1 cup raw, leafy greens; ½ cup vegetable juice (choose low-sodium versions); 1 small ear of corn
• 1 ounce grains: 1 slice bread; ½ cup cooked oatmeal, rice, or pasta; 1 6” tortilla
• 1 ounce protein: 1 ounce cooked meat, poultry, or seafood; 1 whole egg; 1 tablespoon peanut butter; ¼ cup cooked legumes (pinto, kidney, black beans; lentils; peas)
• ½ cup dairy: ½ cup low-fat or nonfat milk; 4 ounces low-fat, low-sugar yogurt; ¾ ounce cheese

In the second part of this two-part series, we’ll discuss filling the nutrient gaps and provide helpful ideas to get picky eaters the nutrients they need.

References

1. O’Neil CE et al. Food Sources of Energy and Nutrients of Public Health Concern and Nutrients to Limit with a Focus on Milk and other Dairy Foods in Children 2 to 18 Years of Age: National Health and Nutrition Examination Survey, 2011-2014. Nutrients. 2018;10(8):1050.
2. Office of Disease Prevention and Health Promotion. Dietary Guidelines 2015-2020. Appendix 7. Nutritional goals for age-sex groups based on dietary reference intakes and dietary guidelines recommendations. ​https://health.gov/dietaryguidelines/2015/guidelines/appendix-7/ Accessed December 5, 2018. 
3. Keast DR et al. Food sources of energy and nutrients among children in the United States: National Health and Nutrition Examination Survey 2003–2006. Nutrients. 2013;5:283–301.
4. Thorning TK et al. Whole dairy matrix or single nutrients in assessment of health effects: Current evidence and knowledge gaps. Am J Clin Nutr. 2017;105:1033–1045.
5. Racey M et al. Barriers and Facilitators to Intake of Dairy Products in Adolescent Males and Females With Different Levels of Habitual Intake. Glob Pediatr Health. 2017;4:2333794X17694227. Published March 21, 2017.
6. United States Department of Agriculture. Choose MyPlate. https://www.choosemyplate.gov. Accessed December 5, 2018.
7. Gidding SS et al and endorsed by the American Academy of Pediatrics. Dietary Recommendations for Children and Adolescents: A Guide for Practitioners. Circulation. 2005;112:2061–2075.
8. Dietary Recommendations for Healthy Children. American Heart Association. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/dietary-recommendations-for-healthy-children. Reviewed April 16, 2018. Accessed January 6, 2019.
9. Calcium. National Institutes of Health, Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/. Published 2018. Accessed December 10, 2018.
10. Beck AL et al. Full fat milk consumption protects against severe childhood obesity in Latinos. Prev Med Rep. 2017;8:1-5.
11. Fulgoni VL et al. Foods, fortificants, and supplements: Where do Americans get their nutrients? J Nutr. 2011;141(10):1847-1854.

Whitney Crouch, RDN, CLT Whitney Crouch is a Registered Dietitian who received her undergraduate degree in Clinical Nutrition from the University of California, Davis. She has over 10 years of experience across multiple areas of dietetics, specializing in integrative and functional nutrition and food sensitivities. When she’s not creating educational programs or writing about nutrition, she’s spending time with her husband and young son. She’s often found running around the bay near her home with the family’s dog or in the kitchen cooking up new ideas to help her picky eater expand his palate.Whitney Crouch is a paid consultant and guest writer for Metagenics.

By Whitney Crouch, RDN, CLT

Filling nutrient gaps in kids’ diets 
A large study of 16,110 individuals aged 2 years and older, known as the National Health and Nutrition Examination Survey (NHANES) found 25-70% of those surveyed to be eating less than the EAR for vitamins A (34%), C (25%), D (70%), and E (60%); calcium (38%); and magnesium (45%).1 Enrichment and fortification within the food supply largely contributed to the levels of vitamins A, C, and D, thiamine, iron, and folate reaching levels that were attained by diet.1 These statistics shed light on both the importance of nutrient fortification of certain foods in our food system and on the importance of nurturing healthy nutrition habits early and often.

Top 5 foods to help fill the gaps:

1. Vitamin A: liver, sweet potato, carrots, pumpkin, spinach
2. Vitamin C: acerola cherry, sweet bell peppers, peaches, mustard greens, broccoli
3. Vitamin D: mushrooms (exposed to UV light), salmon, sardines, whole egg, cow’s milk
4. Vitamin E: sunflower seeds, almonds, peanuts, avocado, spinach
5. Calcium: sesame seeds, cheese, tofu, sardines, edamame
6. Magnesium: pumpkin seeds, edamame, almonds, Swiss chard, black beans

Enriched and fortified orange and apple juices are also good sources of vitamins C, D, and calcium, but watch out for sugar content. Cod liver oil is also a great source of vitamins A and D.2
You may be thinking, “Okay that’s great, but my child will not eat liver, mushrooms, or broccoli.” According to child feeding specialist Ellyn Satter, there is a division of responsibility between parent and child when it comes to meal and snack time nutrition intake.3 What does this mean?

A parent’s job is to: 

• Choose and prepare the food
• Provide regular meals and snacks
• Make eating times pleasant
• Step-by-step, show your child by example how to behave at family mealtimes
• Be considerate of your child’s lack of food experience without catering to likes and dislikes by providing one or two side dishes your child likes at each meal and include something he or she is still learning to like
• Avoid excess foods and beverages (except for water) between meals and snack times
• Let your child grow into the body that is right for him or her

Part of your feeding job is trusting that your child will:  

• Eat the amount he or she needs
• Learn to eat the food you eat

Bottom line: According to Ms. Satter, you are responsible for what, when, and where your child eats; your child is responsible for how much and whether to eat or not.8 Get creative in the kitchen, share the cooking experience, and lead by example with nutrient-dense food choices regularly. If you have a creative flair, creating “artwork” with the food on the plate, or using cookie cutters to create new shapes can be a great way to spark your child’s interest in the food and an opportunity for fresh conversation at the family table.

Nutrient-boosting ideas
​When it comes to optimal growth and development, filling nutrient gaps is an important factor. Even children with the best of diets and diverse palates can enjoy including new ways of incorporating fruits, veggies, and other nutrients into their diet. For children with more narrow palates, these ideas can be great ways to introduce flavors or nutrients using new delivery methods:

• Smoothies:

• Incorporate a high-quality children’s nutrition powder into a fruit and veggies smoothie. Try blending water, low-fat cow’s milk, or a fortified dairy alternative as a base, plus ½ frozen banana, ½ cup frozen berries, a handful of spinach, ¼ avocado, and a serving of children’s nutrition powder.

• Fruit and veggie muffins:

• Get your child involved! Pressed or chop fruits and veggies but have your child empty the ingredients into a mixing bowl while you talk about the health attributes of each ingredient and how delicious the muffins will taste.

• If you’re new to the kitchen yourself, don’t be intimidated; there are plenty of recipes out there on the Internet that are great for even newly chef-hatted parents. Look for whole wheat or gluten-free flour-based recipes with ingredients like grated carrots, steamed broccoli, shredded zucchini, and mashed banana to cook up colourful, nutrient-dense and fiber-rich treats for your family.

• Chews or gummies:

• Offer age-appropriate multivitamin chews or gummies by incorporating these nutrient gap-filling tools as a treat or a part of your child’s daily routine. You can buy premade or experiment with making your own!

• Liquid or powdered vitamins:

• Standalone vitamins, like vitamin D3, can be added to foods like yogurt, applesauce, milk, or oatmeal for an added boost of commonly fortified vitamins.

References

1. Fulgoni VL et al. Foods, fortificants, and supplements: Where do Americans get their nutrients? J Nutr. 2011;141(10):1847-1854.
2. US Department of Agriculture (USDA), Agricultural Research Service, Nutrient Data Laboratory. USDA national nutrient database for standard reference, legacy. Current version: April 2018. Internet: http://www.ars.usda.gov/nutrientdata
3. Division of responsibility in feeding. Ellyn Satter Institute. https://www.ellynsatterinstitute.org/. Accessed December 9, 2018.

​Whitney Crouch, RDN, CLT Whitney Crouch is a Registered Dietitian who received her undergraduate degree in Clinical Nutrition from the University of California, Davis. She has over 10 years of experience across multiple areas of dietetics, specialising in integrative and functional nutrition and food sensitivities. When she’s not creating educational programs or writing about nutrition, she’s spending time with her husband and young son. She’s often found running around the bay near her home with the family’s dog or in the kitchen cooking up new ideas to help her picky eater expand his palate.Whitney Crouch is a paid consultant and guest writer for Metagenics. Whitney Crouch is a paid consultant and guest writer for Metagenics.

By Whitney Crouch, RDN, CLT

Collagen: It’s the most abundant structural protein in the body, and it’s more than just a hip, new trend popularised by different lifestyle personalities and brands. It takes the shape of a triple helix composed of the continuous repetitive motif, Gly-X-Y, where Gly is glycine, X is proline (Pro), and Y is hydroxyproline (Hyp).1 The latter two amino acids are specific to collagen structures. These protein building blocks make up the structure in skin, tendons, bones, and teeth and are integral in the health and maintenance of these structures over our lifetime.

Collagen is found naturally in the connective tissue of land animals such as humans, cows, and chickens, as well as some marine life, including fish. It makes up about 25% of our bodies’ protein content and is helpful in soft-tissue repair.2-3

People who consume animal protein regularly in their diet are consuming some collagen; however, muscle-meat proteins largely lack the rich proteins found in connective tissue. Individuals who routinely sip traditionally prepared bone broth benefit from the collagen extracted from the cartilaginous tissue used in the broth’s preparation. Furthermore, studies show that easily digested and absorbed forms of collagen, like those found in quality dietary supplements, can have an even greater rate of absorption than traditionally prepared foods.

Different types of collagen
Whether from animal or marine sources, all collagen comes from amino acids, the building blocks of protein in the body. Animal and marine collagens are constitutionally the same—that is, they’re made up of the same amino acids—however, animal sources have a larger quantity of some amino acids (proline and hydroxyproline, specifically).4

Research shows there are more than 28 different types of collagen, but the three most abundant are Types I, II, and III. These collagen types form the structural fibrils of tissues, while the others take part in the association of these fibrils with other tissues.2

• Type I: This is the most abundant form of collagen and is found in tendons and throughout the body. It is a key building block for hair, skin, nail, blood vessel, and teeth health.5
• Type II: This type of collagen structure is found most often in joint cartilage.6
• Type III: This is the second most abundant form of collagen and is always found in association with Type I collagen.5

What is the difference among hydrolyzed collagen, collagen peptides, and gelatin?

• Gelatin is the denatured form of collagen, but it is packaged in a different structure from other forms of collagen. It’s created by partial hydrolysis (breaking apart) of the full-length protein, and depending on the extraction process used, gelatin may vary in functional properties, despite having the same amino acids content as collagen. Gelatin, also considered the cooked form of collagen, usually undergoes extensive processing which decreases its bioavailability.7 Gelatin mixes well with hot water and becomes a gummy solid when cooled.
• Hydrolyzed collagen (also called collagen hydrolysate) is the result of the enzymatic breakdown (or hydrolysis) of the full-length collagen protein, extracted and dehydrated (into a white powder). It contains a mixture of different types and combinations of collagen peptides. Because of its smaller size, hydrolyzed collagen is easier to digest and use. The absorption rate of hydrolyzed collagen is said to be over 90% compared to only 27% or less in food.1
• Collagen peptides (another name for hydrolyzed collagen and collagen hydrolysate) involve the breaking down of the molecular bonds between individual collagen strands to peptides. These are specific peptides fragments, usually 2 to 20 amino acid residues in length, which have biological activity. Due to their smaller size, these peptides show higher bioavailability and are better absorbed into the bloodstream.1 Collagen peptides mix well with hot or cold liquids, and these mixtures remain liquid when at room temperature and when cold.

Outward appearance
In addition to improving structural integrity and elasticity of the skin, the consumption of Types I and III collagen also improves skin’s ability to retain moisture and may fight UVB photodamage, which in turn promotes healthier and younger looking skin, according to studies.8-10
There is also mounting clinical evidence of collagen’s benefits in strengthening the collagenous structures of hair and nails. A study in the Journal of Investigative Dermatology reveals that collagen is strongly deposited in hair follicles, and the lack of collagen delays hair cycling and growth, suggesting that collagen could be a potential area warranting further investigation.11
In a six-month study looking at brittle nails, researchers found that daily supplementation with collagen resulted in increased nail growth and improved brittle nails in conjunction with a notable decrease in the frequency of broken nails.12

Inner strength and resilience 
Additional evidence shows that supplementing with oral collagen stimulates collagenic tissue regeneration by increasing not only collagen synthesis, but minor components (glycosaminoglycans and hyaluronic acid) synthesis, as well. One such study used validated self-perception questionnaires to measure joint comfort and overall joint health in study subjects. After 90 days of intervention, 78% of subjects in the test group reported to have less joint discomfort, and more than 60% of the subjects agreed their joint health improved by increasing joint flexibility, mobility, and reducing joint stiffness. There were no statistically significant changes in the control group.13

As if the benefits of adequate dietary collagen seen in hair, skin, nails, and joints aren’t enough, there is also evidence to support collagen and gelatin’s role in bone health. In bone, approximately 95% is Type I collagen, providing viscoelastic strength, torsional stiffness, and load-bearing capacity. Type II collagen is also involved in bone formation, even though it is mainly found in cartilage.14
While the body of evidence around collagen supplementation continues to grow, the benefits of daily supplementation with collagen peptides (hydrolyzed collagen) can already be seen. There are uses for both gelatin and collagen peptides in cooking, baking, smoothies, and other means; however, the higher rate of digestion and bioavailability of the peptide form makes this supplement a great addition to anyone’s health routine.

References

1. Fu Y et al. Exploration of collagen recovered from animal by-products as a precursor of bioactive peptides: Successes and challenges. Crit Rev Food Sci and Nutr. 2018;2:1-17.
2. Rodriguez MIA et al. Collagen: A review on its sources and potential cosmetic applications. J Cosmet Dermatol. 2018;17:20-26.
3. Eastoe JE. The amino acid composition of mammalian collagen and gelatin. Biochem J. 1955; 61(4):589-600.
4. Fazli S et al. Marine collagen: an emerging player in biomedical applications. J Food Sci Technol. 2015;52(8):4703–4707.
5. Lodish H et al. Molecular Cell Biology. 4th edition. New York: W. H. Freeman; 2000. Section 22.3, Collagen: The Fibrous Proteins of the Matrix. https://www.ncbi.nlm.nih.gov/books/NBK21582/
6. Buckley MR et al. Distributions of types I, II and III collagen by region in the human supraspinatus tendon. Connect tissue res. 2013;54(6): 374–379.
7. Eastoe JE. The amino acid composition of mammalian collagen and gelatin. Biochem J 1955; 61(4):589-600.
8. Shimizu J et al. Oral collagen-derived dipeptides, prolyl-hydroxyproline and hydroxyprolyl-glycine, ameliorate skin barrier dysfunction and alter gene expression profiles in the skin. Biochem Biophys Res Commun. 2015;456(2):626-30.
9. Nozomi J et al. Optimization of dose of collagen hydrolysate to prevent UVB-irradiated skin damage. Biosci Biotechnol Biochem. 2016;80(2):356-9.
10. Proksch E et al. Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study. Skin Pharmacol Physiol. 2014;27(1):47-55.
11. Chen P et al. Lack of collagen VI promotes wound-induced hair growth. J Invest Dermatol. 2015;135(10):2358-2367.
12. Hexsel D et al. Oral supplementation with specific bioactive collagen peptides improves nail growth and reduces symptoms of brittle nails. J Cosmet Dermatol. 2017;16(4):520-526.
13. Clark KL et al. 24-week study on the use of collagen hydrolysate as a dietary supplement in athletes with activity-related joint pain. Curr Med Res Opin. 2008;24(5):1485-96.
14. Czajka A et al. Daily oral supplementation with collagen peptides combined with vitamins and other bioactive compounds improves skin elasticity and has a beneficial effect on joint and general wellbeing. Nutr Res. 2018;57:97-108.

​Whitney Crouch, RDN, CLT

Whitney Crouch is a Registered Dietitian who received her undergraduate degree in Clinical Nutrition from the University of California, Davis. She has over 10 years of experience across multiple areas of dietetics, specializing in integrative and functional nutrition and food sensitivities. When she’s not creating educational programs or writing about nutrition, she’s spending time with her husband and young son. She’s often found running around the bay near her home with the family’s dog or in the kitchen cooking up new ideas to help her picky eater expand his palate.
Whitney Crouch is a paid consultant and guest writer for Metagenics.