Raising healthy eaters: WHAT do they need?

I am often asked what to feed kids and how to get them to eat more healthful foods. Some kids are super picky eaters from the get-go, while others have just got used to having a certain set of options every night and aren’t really willing to stray beyond those. In other families, kids are fairly open to new flavors and parents simply want ideas for kid-friendly foods, while others need guidance on providing a more balanced diet. So, there’s a what and a how of feeding children, and I’ll address both. In this article I’ll start with what to feed kids to help them grow and thrive, and in the next  part I’ll talk about how.

Six types foods and nutrients are consistently lacking in kids' diets, two nutrients that you might be mindful of are usually adequate, and two more are often excessive (and hidden everywhere). Here's a quick run down!

​Often insufficient

Fruits and vegetables
A national survey in the USA found that 93% of children aren’t eating enough veggies each day. Of those the vegetables they did eat,  about 1/3 were white potatoes, most of which were in the form of French fries (1). Similarly, in the UK, a survey found that only 18% of 5-15 year olds manage to eat the recommended five servings of fruits and vegetables each day (2). Ideally, kids should get a variety of fruits and veggies totaling about 2 cups each day for toddlers (2-3 years old) and 2.5-3 cups for 4-8 year olds. Older children (9-13 years) should be aiming for 3.5 cups per day. One cup of fruit is equivalent to one apple, or eight strawberries; one cup of vegetables is around 12 baby carrots or three spears of broccoli. The reason they need all this fresh produce is because it provides fiber, vitamins and minerals that children need to grow and thrive (see below). Some kids eat plenty of fruit and not many vegetables - that’s okay, but vegetables provide a much wider range of nutrients than fruit, without the sugar, so try and shoot for 50:50 fruits and vegetables.

• Offering a fruit or a vegetable at every snack and meal will get you to five servings a day: for example, berries or banana with breakfast, carrots with morning snack, spinach in scrambled eggs for lunch or baby tomatoes with a sandwich, apple slices with afternoon snack, and a couple of veggie options at dinner
• Easy snacking veggies include: carrots, snap peas, bell peppers, cherry tomatoes, cucumbers, pickles, kale chips, seaweed snacks, olives, avocado (‘on the half shell', with a spoon) etc.
• Try keeping sliced veggies in a mason jar in the fridge that kids are free to access throughout the day
• If kids want a snack right before dinner because they’re too hungry to wait, offer salad or vegetables (consider it an appetizer!). If they're hungry they'll eat them, if not, they can wait til dinner.
• Don’t forget that beans and legumes count as vegetables too! Edamame are easy to nibble on, and hummus is great for dipping vegetables and crackers, or in a sandwich with shredded carrots and avocado.​

Fiber (fruits & veggies, whole grains, beans & legumes)
Most kids need more fiber. The average child in the US consumes less than half the adequate intake each day (3), which is 19g per day for 2-3 year olds, 25g for 4-8 year olds, 26g for girls aged 9-13 years, and 31g per day for boys aged 9-13 years. Fiber regulates bowel movements and feeds our friendly gut microbes. Constipation is a common issue in children and inadequate fiber intake is the first thing to address. The easiest way to increase fiber intake is to eat more fruits and vegetables (see above), to choose whole grains in place of refined grains (e.g. wholewheat pasta, brown rice), include more beans and legumes (e.g. refried beans in a cheese quesadilla, Chipotle-style burrito bowls), and nuts and seeds. 

One slice of whole wheat bread typically has 2 grams of fiber, 1/2 cup of brown rice has 2 grams, 1/4 cup of beans has 3-4 grams, 1/2 cup of raspberries or blackberries has 4 grams, one orange or apple has 4 grams, 1/2 cup of cauliflower or broccoli has 2.5 grams, 1/2 cup of leafy greens has 2 grams, and an ounce of almonds has 4 grams. Fiber also needs water, so make sure your child is well hydrated. If you feel the need to add supplementary fiber, opt for oat or wheat bran (12 grams per ounce) or ground flax seed (8 grams per ounce), sprinkled on hot cereal or yogurt, or incorporated into pancake, muffin or cookie recipes.

Iron (red meat, shellfish, beans, whole grains)
Iron deficiency is the most common nutritional deficiency in children, with toddlers (9%) and teenage girls (9-11%) being particularly at risk (4). Toddlers aged 1-3 years need 7mg/day; in this age group excess milk consumption is a major contributor to iron deficiency (calcium blocks iron absorption), so limit milk to 16 oz per day. Beyond toddlerhood, 4-8 year olds need 10mg/day, and older kids (9-13 years) need 8mg/day. Iron is important for making red blood cells which carry oxygen around the body; signs of deficiency include fatigue, weakness, difficulty concentrating and pale skin. If it advances, iron deficiency will lead to iron deficiency anemia (IDA), which can cause delays in cognitive development and physical growth.

We all think of meat when we think of iron-rich foods, and it is a good source of easily absorbed iron (2 oz of red meat = 2 mg of iron), but other foods can also make a substantial contribution: 1/4 cup of white beans has 2mg, 1 oz of dark chocolate has 2 mg, 1/4 cup of lentils has 1.5 mg, 1/2 cup of spinach has 1.5 mg, 3 shrimp have 1 mg, 1/3 cup of oats has 1 mg, and 1/4 cup of quinoa has 0.7 mg. Fortified breakfast cereals are another supplementary source, with Cherrios having 3mg of iron in a 1/2 cup serving. It is not unusual for kids to need an iron supplement to get their daily recommended amount; talk to your doctor or health professional if you suspect a deficiency.

Calcium (dairy products, soy products, leafy greens and seeds)
Calcium is important for children’s bone growth in the younger years and for achieving peak bone mass in adolescence, yet 1 in 5 kids don’t meet the recommended intake. Per day, 1-3 year olds need 700 mg, 4-8 year olds need 1000 mg, and 9+ years need 1300 mg. Toddlers usually get adequate calcium, mostly from milk (275-300 mg per 8 oz cup), and are less likely to be deficient than older children. Older kids get close to the recommended amount, but most could use a little extra: they tend to get their calcium from other dairy products like cheese (1.5 oz of cheddar has 300 mg, 1 string cheese has ~200 mg) and yogurt (1/2 cup of plain yogurt has ~200 mg). ​

Non-dairy sources of calcium include canned salmon (with 180 mg per 3 oz), tofu (1/2 a cup has ~ 250 mg), chia seeds (1 tbsp has 75 mg) and leafy greens (1/2 cup of kale has 50 mg, 1/2 cup of boy choy has ~35 mg). Calcium supplements may be necessary if your child doesn’t eat dairy products. Needs are high in childhood and it can be hard to meet them with a restricted diet; talk to your healthcare practitioner.

---

Vitamin D (sunshine, fish, eggs, dairy, mushrooms)
Almost all children get inadequate vitamin D. It mainly comes from sun exposure and modern life sees children indoors much of the day, and covered in sunscreen when they’re not. Vitamin D plays a role in immune function as well as bone health - calcium needs vitamin D to build bones. Children aged one and over need at least 600 IU per day to maintain adequate levels; overweight children and those with darker skin tones are at greater risk of deficiency.

There aren’t many dietary sources of vitamin D: oily fish like sockeye salmon and trout have around 600 IU per 3 oz serving, but aside from that, mushrooms (175 IU per 1/4 cup) and eggs (45 IU in one large egg yolk) are the only other foods that naturally offer significant amounts. Some foods have vitamin D added, particularly cow’s milk and other alternative milks, typically around 120 IU per cup. Most fortified products use D2 (ergocalciferol) instead of D3 (cholecalciferol) - D2 is cheaper, but D3 is the best form for raising blood levels of vitamin D (5). Also, bear in mind that vitamin D is a fat-soluble vitamin, so if your fortified milk is fat-free, you’re probably not absorbing much of that vitamin D. Supplements are probably the best option for most kids - go for an oil-based suspension with D3; 400-800 IU per day to maintain levels (especially through the winter), and more if deficient, as directed by your healthcare provider.

Omega-3s DHA & EPA (fish & seafood, nuts & seeds)
Children who don’t eat fish probably don’t get enough omega-3 fats in their diet. There are plant sources of omega-3s (ALAs), but these need to be converted into DHA and EPA in the body, and this conversion rate is fairly low. These essential fatty acids are important for brain development and building new cells, and lower levels have been linked to ADHD and other neurodevelopmental disorders (6). Recommended amounts are set for ALA (the precursor), but not EPA and DHA. For ALA, toddlers 1-3 years old need 0.7 grams per day, 4-8 year olds need 0.9 grams per day; for tweens, 9-13 year old girls need 1 gram and boys need 1.2 grams per day. Good sources of ALA include chia seeds (1 oz has 5 g), walnuts  (1 oz has 2.5 g), and flaxseed oil (1 tsp has 2.4 g). For DHA and EPA, 500-1000 mg per day (altogether) is probably ideal. Aim to get omega-3s from food first: 3 oz of wild salmon has ~1,500 mg, 3 oz of rainbow trout has ~850 mg, and 3 oz of shrimp has 240 mg. If your child doesn’t eat much fish, a supplement would be beneficial. Look for fish oil supplements with at least 300 mg of EPA and DHA; they come as gummies for younger kids, easy to swallow soft gels for older kids, and liquid formulations, all flavored to be more palatable to children.

---

Restricted diets
Certain subgroups will be at risk for nutritional deficiencies beyond the ones mentioned above. Some picky eaters might be also be deficient in potassium, zinc, and vitamins A or E. If your child follows a vegan or vegetarian diet they may be at higher risk of all the main deficiencies (except perhaps fiber), as well as zinc and B12. If you have your child on a gluten-free diet, they are at higher risk of the above deficiencies as well as inadequate B vitamins, and magnesium (7); most grain products are enriched with these but gluten-free ones are not. If your child has multiple food allergies they are also at increased risk for various nutrient deficiencies; consult with your healthcare provider for personalized support.

​Almost Always Adequate

Protein
Many parents pay close attention to their child’s protein intake - this is generally not something to worry about. While children’s protein needs are higher than adults per pound of body weight, the overall amount needed is easily covered by all but the most limited diets. Kids need approximately 1 gram of protein for every 2 lbs of body weight, so a 40 lb child needs around 20 grams per day (divide their weight in pounds in half). Considering that 3 oz of beef or poultry has 25-28 grams of protein, 3 oz of fish has 22 grams, half a cup of beans has 7-10 grams, one egg has 6 grams, and 1 oz of mozzarella has 7 grams, kids can easily meet their minimums.

The majority of children I’ve worked with are getting double the minimum needed, and some whose families are on protein-heavy diets (e.g. paleo) can actually be getting too much, which can compromise kidney function, so don’t overdo it. Kids need carbohydrates for energy and fats for brain and hormone heath, so make sure they get an age-appropriate balance.

Vitamins
In the US, most children meet the recommended daily amounts of the majority of vitamins and minerals (8) from foods, with the main exceptions discussed above. On top of this, around 1/3 of children nationwide take a multivitamin as well (9), and most children I work with are taking one. To be honest, I don’t really recommend multivitamins, for a couple of reasons: Firstly, most kids don’t need one, as mentioned, so it’s just unnecessary expense and sugar (~ 2-4 grams per serving), and the children that need them most aren’t likely to be the ones taking them. Secondly, most don’t contain the commonly lacking nutrients discussed above, like iron, calcium and omega-3s - calcium is too bulky for manufacturers to include, fish oil can't be easily blended into a multi, and iron has a strong flavor. Many of them do contain vitamin D, but it isn’t always D3 (cholecalciferol), so look out for that. Multis often have synthetic forms of B vitamins like folate too, which aren’t well absorbed by a large chunk of the population. Another reason I’m not a fan is that they can provide a false sense of security in terms of making up for a limited diet: they really can’t replace the nutrients from food, in terms of the range offered or the quantities of those nutrients that they do include.

​I’m not against multivitamins entirely - some kids do need all the support they can get while working on dietary improvements, and some children with restricted diets may need one on an ongoing basis. Personally (and professionally) I prefer supplements to be targeted the individual child’s needs (for example, a stand alone zinc, iron or calcium supplement where needed). Stand alone supplements are often higher quality and offer therapeutic quantities of the needed nutrient.

Typically Too Much

Sugar
The vast majority of children get too much added sugar, even if they never eat candy. The US government recommends that added sugar comprises no more than 15% of daily energy intake, while the World Health Organization suggests half this, just 5-10% of daily calories. The US guidelines translate to 16 grams per day for 2-5 year olds (4 tsp), 12 grams per day for 6-11 year olds (3 tsp), and 20 grams per day for middle schoolers (5 tsp). The actual average sugar intake for US children is at least triple this: 2-5 year olds average 52 grams (13 tsp) per day, 6-11 year olds average 80 grams (20 tsp), and 12-19 year olds average 96 grams (24 tsp) (10). For British readers, these numbers are a little lower in the UK, but still exceed the recommended amounts (11).

This might surprise you, but sugar is hidden in almost all children’s foods, even the apparently healthy ones. The average kids’ cereal, the most popular yogurt tubes, and the average granola bar all have around 10 grams of sugar per serving. Then there’s the hidden sugar added to bread, pasta sauces, dressings, ketchup, peanut butter and yogurts (12), before we even touch on obvious sources like juice drinks, sodas, sweet snacks and desserts. While there is a socioeconomic disparity between adults’ added sugar intake, there is not between children - children in higher income families consume just as much sugar as those in lower income families (13). Too much sugar spikes blood sugar levels and can lead to energy crashes; over time, this blood sugar rollercoaster ride can lead to type 2 diabetes, as well as increased triglycerides and lowered HDL cholesterol. Rates of type 2 diabetes (previous called ‘adult onset’ diabetes) in children are steadily rising (14), and 13% of children has low HDL cholesterol (15). Added sugars are also the leading cause of tooth decay in children, and contribute to both obesity (excess calories) and malnutrition (crowding out more nutritious foods).

To reduce sugar intake, avoid packaged and processed foods in favor of fresh foods where possible. If you are buying packaged snacks and cereals for your kids, look for less than 7 grams of sugar per serving, and stick to the serving size. If your children are used to sweetened yogurts, buy plain and add your own sweetness with a teaspoon of jam (3 grams of sugar) or honey (6 grams of sugar) - even two teaspoons will be less added sugar than a store-bought sweetened yogurt, and you can slowly reduce as your child’s palate adjusts. If they like to drink juices, try diluting 50:50 with water and scaling back from there, if they like to drink sodas, try flavored sparkling water or kombucha for less sugar. When doing your grocery shopping, look out for added sugars in staples like sauces, condiments, bread, etc, and opt for brands with lower or no added sugars when available. Your kids are sweet enough already!

---

Sodium
Around 90% of US children eat too much sodium daily (16), mostly from processed and store-bought foods. It is recommended that toddlers get no more than 1500 mg per day (most eat more than 2000 mg), and older children should get less than 2300 mg per day (average intake is more than 3300mg) (17). Although we all think of the salt shaker when we think about sodium, packaged and prepared foods are the most significant contributor, with pizza, breads, processed meats, cheese, savory snacks and chicken nuggets topping the list. 

Too much sodium can raise blood pressure, leading to hypertension: one in six school-aged children in the US has elevated blood pressure. Eating more fresh foods in place of packaged foods will reduce sodium intake; additionally, fruits and vegetables are loaded with potassium, which acts as a counterbalance to sodium. There is emerging evidence that eating more potassium-rich foods, even with minimal reduction in sodium intake, can lower blood pressure and reduce risk of hypertension and stroke (18). One note on sodium: it is an essential electrolyte, so the goal is not to eliminate it entirely, and if you have low blood pressure to start with, don’t worry too much about getting excess sodium. ​

---

So, there you have it! You now know what most kids need to eat more of, and less of, and have some idea which foods provide those nutrients. Obviously nobody’s child is the statistical average, they are each unique, as are their nutritional needs; if you want personalized nutrition recommendations for your child, particularly if they have a restricted diet, please feel free to reach out to me for a consult. ​

Part two will talk about how to get kids to eat more of these nutritious foods, without tears, tantrums, or bribery!