Children and Adolescents

A healthy lifestyle for children and adolescents can be achieved by: • Choosing a variety of foods from Canada’s Food Guide every day. • Eating at least 3 regular meals per day, including breakfast, and 2 to 3 healthy snacks. • Aiming to include food from all four food groups at meals. • Choosing snacks that are based on Canada’s Food Guide. Snacks should include foods that might be missed during meals. • Ensuring adequate intake of specific nutrients such as iron, calcium and vitamin D, fluoride and fibre. • Drinking adequate amounts of fluid for proper hydration; choosing water and milk most often. Limiting juice to 100% juice, maximum 1⁄2 cup (125 mL) a day. Fluid requirements for children vary with age. • Limiting intake of added sugars found in food, sugar-sweetened drinks, and juices. • Choosing high fibre foods, such as vegetables, fruits and whole grain breads and cereals, more often • Limiting intake of salt. • Avoiding caffeinated beverages. • Preparing and serving healthy portions to meet the recommendations from Canada’s Food Guide. • Being physically active on a daily basis.


What is a healthy eating pattern for a child?
Canada's Food Guide promotes a pattern of eating which meets the nutritional needs of Canadians two years and over.The number of servings per day of each food group depends on the child's age, gender, body size and activity level. 15Younger children who eat small amounts of food at any one time, and growing children and adolescents, may need to eat frequently throughout the day to meet their nutrient and energy needs.This need is most commonly met by having three meals and 2 to 3 nutritious snacks between meals. 16,17healthy eating pattern includes, but is not limited to: • Choosing a variety of foods from Canada's Food Guide every day.
• Choosing whole grain and enriched breads and cereals, vegetables and fruits, most often.

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Preparing and serving healthy portions to meet the recommended daily number of Food Guide servings.
• Limiting foods that are high in fat, sugar or salt, such as cookies, chips, sugar-sweetened drinks, and candy.These types of foods can be considered occasionally but should not replace foods that contain the nutrients and energy that children and adolescents need. 18fer to Guidelines: General Healthy Eating For Children and Adults; Planning Healthy Meals and Snacks What are the four food groups of Canada's Food Guide?
Canada's Food Guide recommends choosing a variety of foods from the four food groups every day. 1

What does a healthy meal look like?
For a healthy meal, aim to include food from all four food groups in Canada's Food Guide.
To build a healthy meal: • fill ½ of the plate with Vegetables • have fruit on the side A healthy meal will help with portion control and meeting recommended servings from the four food groups.

What does a healthy snack look like?
Snacks should be planned based on Canada's Food Guide and should include foods that might be missed during meals.Offer snacks 2 hours before a meal to avoid affecting appetite at mealtime.Some healthy snack choices are: • Fresh vegetables and fruit (spice things up by giving yogurt as dip) • Canned fruit in its own juice

What are the key nutrients of concern for children and adolescents?
The key nutrients of concern for children and adolescents are: iron, calcium, vitamin D, fluoride and fibre.For more information on each of these nutrients, see the questions below.

Why is iron important for children and adolescents?
Iron deficiency is the most common nutritional deficiency in the world. 20In children, fast growth is considered the main reason for inadequate iron status, thus it is important to ensure iron is an essential part of children's diets. 20Iron is vital for the normal cognitive and psychomotor development in children and is needed to make hemoglobin, the oxygen-carrying component of red blood cells (RBCs).The daily recommended intake of iron for children and adolescents varies depending on age and stage of life.
The recommended intakes (RDA) and associated Tolerable Upper Intake Levels (UL) for iron in children and adolescents are:  Following the tips below can increase the iron in a child's diet: • Choose the following sources of iron more often: beef, clams, enriched cold or hot cereals, fish, liver, mussels, chicken, pork, shrimp, turkey and lamb.

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Eating vitamin C rich vegetables and fruits or juice at each meal helps the body absorb more iron.Good sources of vitamin C include: oranges, lemons, grapefruit and their juices, cantaloupe, honeydew, kiwi fruit, berries, juices fortified with vitamin C, broccoli, cabbage, cauliflower, kale, peppers, potatoes, and tomatoes.

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Cooking high iron foods with good sources of vitamin C also increases the amount of iron the body absorbs.

Refer to Guideline: Iron
Why is calcium important for children and adolescents?
Children and adolescents need calcium to ensure proper growth and maintenance of healthy bones and teeth and to reduce their risk of osteoporosis later in life. 22Therefore, it is essential that children's and adolescents' dietary practices incorporate a variety of calcium-rich foods.Children's and adolescents' calcium requirements vary throughout their stages of life.Their greatest need for calcium occurs during

Nutrition Guideline Children and Adolescents
Applicable to: Nurses, Physicians and Health Professionals

For Professional Reference Only
February 2013 Page 4.2.1.7 Nutrition Guideline Children and Adolescents growth spurts, where bone mineral deposition is the highest. 22,23By the age of 18 years for girls, and 20 years for boys, attainment of peak bone mass has occurred. 23e recommended intake (RDA) of calcium and associated Tolerable Upper Intake Levels (UL) in children and adolescents are:

Why is vitamin D important for children and adolescents?
Vitamin D is essential for the growth and maintenance of healthy bones and teeth in children and adolescents.Vitamin D aids in calcium absorption, thereby reducing children's and adolescents' risk of developing rickets, and in later life, osteoporosis. 25tamin D has been studied in relation to cancer (including colon and prostate cancer), cardiovascular disease, hypertension, diabetes, metabolic syndrome, weight management, falls and physical performance, immune function, autoimmune disorders, infections, neuropsychological function, and preeclampsia.Currently there is not enough evidence to clearly establish the effects of vitamin D on these health conditions, or to make recommendations about requirements to prevent or manage these conditions. 26,27e recommended intake (RDA) of vitamin D and associated Tolerable Upper Intake Levels (UL) in children and adolescents are: 24

Nutrition Guideline Children and Adolescents
Applicable to: Nurses, Physicians and Health Professionals

Nutrition Guideline Children and Adolescents
There is evidence that vitamin D deficiency exists in some Canadians, partly because of low levels of sun exposure. 28,29As well, it is widely agreed that consuming adequate amounts of vitamin D from dietary sources is difficult. 29,30n view of low levels of vitamin D intake from food and probable low levels from sun exposure, Nutrition Services, Alberta Health Services recommends that healthy children and adolescents include food sources of vitamin D in their diet, and supplement their intake as follows:

Every healthy child (1-18 years) should take 400 IU vitamin D per day as a supplement
Examples of foods that contain vitamin D are: • Fatty fish, such as salmon, halibut, and herring What if a child or adolescent doesn't eat milk products? 31ildren and adolescents may avoid milk products due to allergy, intolerance, because they dislike them, or because they follow a vegetarian or vegan lifestyle.When milk products are removed from the diet, calcium and vitamin D are decreased and must be replaced through other sources.A Registered Dietitian can assess if children and adolescents are meeting their nutrient requirements and can suggest ways to adjust dietary intake.
Children and adolescents who are allergic to cow's milk protein must avoid fluid milk, all products made from cow's milk, and all foods containing ingredients derived from cow's milk, for safety reasons.The protein in goat's milk is very similar to that in cow's milk.Consequently, most cow's milk allergic individuals will also react to goat's milk. 31,32The majority of children will outgrow a cow's milk allergy by school-age. 33dividuals intolerant to lactose, a sugar found in milk and milk products, can usually tolerate limited amounts of Milk and Alternatives at a time. 34Lactose-reduced Milk and Alternatives may be better tolerated.Enzyme preparations which reduce the lactose content of dairy products before or after consumption may be used by individuals planning to consume larger portions of dairy products in one sitting.These enzyme preparations can be purchased at most pharmacies.

Why is fluoride important for children and adolescents?
Fluoride makes tooth enamel stronger, thereby preventing tooth caries and decay.It is naturally found in food sources (shrimp, meat and dairy products) and is added to most municipal drinking water and tooth pastes. 1 A deficiency in fluoride is rare and, therefore, it is not recommended to provide supplemental fluoride to children and adolescents. 1However, in areas where drinking water contains low levels of fluoride, or when a child is at high risk for dental caries, a fluoride supplement may be prescribed by a physician. 35,36at can be done to prevent tooth problems in children and adolescents? 19l foods, even nutritious ones, can cause cavities.Therefore, brushing and flossing after meals and snacks is very important.
Since there are times when brushing and flossing after each snack and meal is not possible, a few other ways to help lower the risk of cavities are: • Have children and adolescents rinse their mouths with water if brushing teeth is not possible.
• Offer children and adolescents water if they are thirsty.
• Ensure teeth and gums are brushed twice a day with fluoride toothpaste.
• Avoid serving sweet, sugary and sticky foods as a snack; rather serve these foods with a meal.

Why is fibre important for children and adolescents?
Dietary fibre is the part of plant foods that our bodies cannot fully digest or absorb.Providing adequate dietary fibre in children's and adolescent's diets guards against constipation by increasing fecal bulk, and may lower risk of colon cancer and heart disease later in life. 1,4Furthermore, high-fibre foods promote satiety and, therefore, may discourage overeating. 1 Good sources of fibre include vegetables, fruits, and whole-grain bread and cereals.The amount of dietary fibre in a food can be found in the Nutrition Facts

What should be done if a child is experiencing constipation?
Healthy bowel patterns differ among children and adolescents. 38Children or teens could have bowel movements after each meal or days apart; each pattern can be healthy.Concern arises when a child is experiencing hard and dry stools associated with painful bowel movements.This may cause the child to hold in stool, leading to abdominal distention.
To prevent constipation in children and adolescents, it is important to keep the bowels healthy by following these tips: • Offer a balanced diet following Canada's Food Guide.Encourage children and adolescents to eat a variety of foods high in fibre, such as vegetables, fruits, and whole-grains. 38,39Ensure fluid intake is adequate.Provide children and adolescents with their recommended intake of water and milk. 39Maintain regular toilet habits, including unhurried time on the toilet and, perhaps, diaries of stool frequency. 39Teach children and adolescents not to ignore the urge to have a bowel movement.
• Physical activity may help with maintenance of regular bowel habits.

Is a vegetarian diet appropriate for all stages of the life cycle?
Yes, a well-planned vegetarian diet is appropriate for all stages of the life cycle, including childhood and adolescence. 40Parents and/or caregivers who intend to exclude all animal products from a child's diet should consult a Registered Dietitian to ensure nutrient requirements are met.

What are the Alberta Nutrition Guidelines for Children and Youth?
The Alberta Nutrition Guidelines for Children and Youth are designed to assist facilities and organizations in creating an environment which provides healthy food choices and promotes healthy eating habits. 18These guidelines can be used wherever food is offered to children and youth; in childcare facilities, schools and recreation or community centres, at special events, and in the community at large.The guidelines use a food rating system as a simple way to separate healthy foods from the less healthy foods.This rating system puts all foods into three categories based on specific nutritional criteria.The criterion includes guidelines for total fibre, sugar, unhealthy fat, and sodium (salt) content per individual portion.The guidelines use the recommendations in Eating Well with Canada's Food Guide to help identify which foods should be placed into the following three categories:  What are Chose Most Often foods in the Alberta Nutrition Guidelines for Children and Youth? 18oose Most Often foods are high nutrient foods which should be consumed daily in amounts and appropriate portion sizes based on age category.These foods are all recommended as healthy choices in Eating Well with Canada's Food Guide.For children in childcare and elementary school, their food and beverage choices should come from foods in the Choose Most Often category Examples include: • fresh, frozen, canned or dried vegetables or fruits with no added sugar; • 100% pure vegetable or fruit juice; • low fat and low sodium whole grains; • low fat milk, meats and alternatives.
What are Chose Sometimes foods in the Alberta Nutrition Guidelines for Children and Youth? 18oose Sometimes foods provide some beneficial nutrients, but they tend to be higher in added sugar, fat and sodium (salt).For children and youth in junior and senior high school no more than three choices from the Choose Sometimes category are recommended per week.

Examples include:
• unbleached or white flour breads, grains, pasta, or crackers; • cereals made from refined grains or with added flavourings; • grains with added fat and salt.
What are Chose Least Often foods in the Alberta Nutrition Guidelines for Children and Youth? 18oose Least Often foods are low nutrient foods, higher in calories, fat, sugar and salt.Foods in the Choose Least Often category should not be offered in the childcare or school environment.These foods should be eaten less frequently, preferably in the home environment; one serving per week, in small portion sizes Examples include: • chips and crackers high in fat and salt; • sugary cereals, cookies, granola bars and candy; • high fat and sugar bakery items and frozen desserts; • sugary drinks like pop and fruit-flavoured beverages.

How do the Alberta Nutrition Guidelines food categories work?
The Guidelines provide charts for all three food categories, using Canada's Food Guide food groups, to help individuals determine which category foods belong in. 18ch chart outlines the food nutrient criteria, based on one Canada's Food Guide serving, that a particular food must meet in order to fit into one particular category. 18The specified serving size shown on the Nutrition Facts table on pre-packaged foods must be noted, as it may be different than that in Canada's Food Guide.A food must meet all criteria in the chart to fit into a specific category.For example: 18 • Low fat milk (skim, 1%, 2%) and fortified soy beverage meet the nutrient criteria per serving for total fat, saturated fat, trans fat, sugar, fibre and sodium.This is why they are classified as Choose Most Often.

Nutrition Guideline Children and Adolescents
• If chocolate syrup is added for flavour, the fat(s) and sugar content is now higher.This is why chocolate milk belongs in the Choose Sometimes category.
When preparing meals and snacks foods from Canada's Food Guide should be chosen with limited fat, sugar or salt, to help fit the dish in the Choose Most Often category.

Should children and adolescents eat fish?
Children 2 years and older should be encouraged to consume at least two Food Guide servings each week of a variety of fish and shellfish which are low in mercury and high in omega-3 fatty acids. 2,41Fish and shellfish are a good source of protein, are low in saturated fats, and provide benefits from their omega-3 fat content.
Fish and shellfish which are lower in mercury content are better choices. 42Health Canada advises limiting consumption of some varieties of fish: fresh and frozen tuna, canned albacore (white) tuna, shark, swordfish, escolar, marlin and orange roughy.

How much fluid to children and adolescents need per day?
Fluid requirements will vary depending on individual differences, outside temperature and participation in physical activity.Satiating thirst and consuming beverages at meals generally provides adequate fluids for individuals to maintain hydration. 43 general, the required daily fluid intake for different age groups is as follows:

What is a healthy drink for children and adolescents?
The Alberta Nutrition Guidelines for Children and Youth encourage facilities and organizations to consider the following when choosing beverages: 18 • Promote the consumption of water to quench thirst and provide adequate hydration.
• Provide access to refrigerated milk, fortified soy beverages and 100% vegetable and/or fruit juices.
• Limit 100% pure vegetable or fruit juice to ½ cup (125 mL) per day.

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To help meet calcium and vitamin D daily requirements, low fat milk (skim, 1%, 2%) or fortified soy beverages are recommended in the following amounts: 2 o 2 to 8 years = 2 cups (500 mL) daily.o 9 to18 years = at least 2 cups (500 mL) daily.
• Avoid caffeinated beverages, such as tea, coffee, and pop.

Is it okay for children and adolescents to drink chocolate milk?
Chocolate milk provides the same bone-building nutrients as regular milk and contains less sugar than 100% pure fruit juice.However, chocolate milk and other flavoured milk beverages contain enough added sugars to put them in the Choose Sometimes food category in the Alberta Nutrition Guidelines for Children and Youth; therefore, flavoured milk beverages should be consumed no more than 3 times per week. 18

Are sports drinks recommended for children and adolescents?
For most regularly active children and youth, water is still an excellent first choice during and after physical activity. 44avoured beverages or sports drinks (which have added flavour, carbohydrate -mostly as sugars -and electrolytes, like sodium and potassium) often increase the amount of fluid voluntarily consumed, resulting in better hydration during exercise than plain water.Therefore, for children and adolescents who find it difficult to stay hydrated during intense exercise, especially during exercise in the heat, choosing beverages they find more palatable may help. 45However, sports drinks should not replace other healthy drinks in a child's or adolescent's meal pattern

What about energy drinks for children and adolescents?
Energy drinks are not the same as sports drinks.They are generally high in calories and sugar; they often also contain high levels of caffeine (50-200 mg per can), which exceed the maximum caffeine recommendations for most children and teens. 46ergy drinks are not recommended for children and adolescents due to their sugar and caffeine content. 18rovision of caffeinated beverages to children and youth should be avoided, as caffeine may cause children to become excited, restless, irritable and unable to sleep.Caffeine can also make it difficult for children to concentrate. 18fer to Guideline: Food and Drinks High in Calories, Fat, Sugar or Salt

How can children and adolescents eat healthfully at school?
Children and adolescents spend the majority of their time away from home, either at school or partaking in school related activities.Proper nutrition helps to ensure they have enough energy to participate and concentrate at school.
The ideas below will help ensure that children and adolescents are receiving a nutritious lunch: • Plan ahead and shop in advance to ensure there are a variety of nutritious choices available when making lunches.
• Involve your child in planning, preparing and making lunches.
• Be a role model.Remember children will mimic parent's and/or caregiver's behaviours.
• Do some research.Investigate the nutrition programs and food choices available to children and adolescents at their schools.
• Advocate for a healthy eating environment in schools.There are some ideas in the Alberta Guidelines for Children and Youth (http://www.healthyalberta.com/1141.htm).Some safe food handling tips for making bag lunches are: • Use thermos containers for hot soups, casseroles or cold salads.
• Sandwiches with meat, cheese, fish or poultry can be made ahead of time and frozen, for safety and convenience.
• Wash and peel enough vegetables for several days.Wrap in a damp towel, close tightly in a plastic bag and refrigerate.

How can children and adolescents eat healthfully outside the home?
As children grow older they frequently eat their meals away from home.Fast food meals may be eaten more often by children and adolescents when not at home; these are associated with a lower intake of vegetables and fruit and milk products. 1rents and/or caregivers and their children and adolescents can use the following strategies to ensure eating out is nutritious: • Plan ahead.Go online and look at the restaurant's menu and nutrition information.
• Make sure the meal offers choices from each of Canada's Food Guide's four food groups.
• Choose water or milk for a beverage, to minimize intake of high sugar beverages and foods.
• Choose items that are grilled; these are usually lower in fat and calories than food which has been deep fried.
• Add extra vegetables to the meal (for example, enjoy a salad with light dressing).

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fill ¼ of the plate with Meat and Alternatives • fill ¼ of the plate with Grain Products • have 1 serving of Milk and Alternatives

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Fortified soy, rice, almond or other plant-based beverages•

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Milk and fortified soy, rice, or almond beverages • Eggs • Margarine • Fortified cereals • Fortified yogurt or kefir (fermented milk) Refer to Guideline: Calcium and Vitamin D

For
include: calcium-fortified orange juice and soy beverages, baked beans, broccoli, almonds, tofu made with calcium, oranges, dried figs and bok choy.Vitamin D is also found in fortified soy beverages, fish, eggs, and margarine.Refer to Guideline: Calcium and Vitamin DNutrition Guideline Children and AdolescentsApplicable to: Nurses, Physicians and Health Professionals -18 Applicable to: Nurses, Physicians and Health Professionals For Professional Reference Only February 2013 Page 4.2.1.5Nutrition Guideline Children and Adolescents 21 37ble, under total carbohydrates.The recommendation for Adequate Intakes (AI) of fibre (grams per day) in children and adolescents is:37 February 2013 Page 4.2.1.10Nutrition Guideline Children and Adolescents 18 15ounts listed are the adequate intakes for fluid, less the water content in food eaten.Water content of food accounts for about 20% of total water intake.15 Note: