According to Dr. Williams, early childhood is a time when healthful eating patterns are learned.  This sets the stage for prevention of many chronic diseases later in life.  An important part of this preventive effort centers upon dietary fiber. Although fiber's health benefits in adulthood have been known for some time, its role in childhood was not previously emphasized. Dietary fiber is key for promoting regularity in children.  In addition, research suggests that the consumption of a proper diet with recommended levels of dietary fiber by children reduces blood cholesterol, prevents excessive weight gain, and may help reduce the future risk of cancer, cardiovascular disease, and adult-onset diabetes mellitus.

The intake level of dietary fiber for children in the United States, as measured in the National Health and Nutrition Examination Survey (NHANES II; 1976 to 1980), for children ages 4-19 years was estimated at 12 grams per day or 6 grams per 1000 kcal.  Of this, 1/3 comes from snacks and 13% from breakfast.  These values fall short of the current recommendations for fiber intake and may be inadequate for optimal health promotion and disease prevention.  While at the American Health Foundation (AHF) , Dr. Williams proposed that a reasonable goal for dietary fiber intake during childhood and adolescence may be approximately equivalent to the age of the child plus 5 grams per day.  Based on the "Age + 5" formula, minimal dietary fiber intake would range from 8g/d at age 3 to 25g/d by age 20 (shown in figure 1).  Based on current levels of intake, more than half of 2-18 year old US children consume less than the AHF goal.

The "Age + 5" level of dietary fiber intake is similar to the American Academy of Pediatrics recommendation of 0.5 g/kg/d up to the age of 10.  The  "Age + 5" level of dietary fiber intake represents a level which would provide health benefits, such as normal laxation, without compromising mineral balance or caloric intake in children over 2 years of age.  In addition, the "Age + 5" recommendation is consistent with current guidelines for adult dietary fiber intake (25-35 g/d) and gradually increases the fiber recommendation to achieve the minimal adult dietary fiber intake of  25g/d by age 20.

The "Age + 5" to "Age + 10" may represent a safe and tolerable level for most children based on current knowledge. This range is thought to be safe even for children and adolescents with marginal intake of some vitamins and minerals. The "Age + 10" upper level of dietary fiber intake is similar in some respects to levels based on 10-12 g/1000 Kcal.

Dr. Williams recommends that dietary fiber intake should be increased gradually by increasing consumption of an assortment of fiber-rich fruits, vegetables, legumes, cereals, and other grain products (which provide a mixture of both soluble and insoluble fiber), along with a concomitant increase in water consumption. Since dietary fiber increases water retention in the colon, resulting in bulkier, softer stools, recommendations for water/fluid intake should be increased commensurate with increases in dietary fiber.  About 6-8 cups/d of water are needed for children to produce soft bulky stools.

The USDA Food Pyramid guide suggests five servings of fruits and vegetables and six servings of breads, cereals, and grain products per day.  Parents who feed their children according to this five a day-six a day pattern for fiber-rich foods and other Pyramid-related guidance will achieve the age plus 5 g of fiber target.  Parents can add one or more servings of fiber-rich fresh fruits (such as apples, blackberries, bananas, dried figs and dates, pears, oranges, prunes, and berries), fresh or lightly processed vegetables (such as broccoli, Brussels sprouts, carrots, corn, peas, and potatoes with skins), or plenty of salads to meals each day.  The key to acceptance of this diet is a gradual increase, rather than sudden and dramatic changes in fiber intake. Each serving of these fruits has about 3g of fiber and these vegetables listed provide about 2.5g  per serving.  Juices are low in fiber. A changeover to whole-grain breads, cereals, and rice adds about 2.5g of fiber per serving.  High fiber cereals such as bran may provide as much as 8 to 10 g per serving.  Another step is to also introduce children to legumes and serve them at least once a week.  Pinto beans, lentils, chick peas, and kidney beans are all good sources of fiber.

Increasing fiber in children's diets is an integral part of interventions geared to the reduction of coronary artery disease (CAD).  Experts recommend a dual approach to achieving this goal.  Healthy children over 2, should stick to a diet moderately reduced in total and saturated fat and cholesterol and increased in complex carbohydrates.  High risk children (based on high lipid profiles) are also put on a similar diet with the addition of food high in water-soluble fiber to further lower LDL cholesterol without the use of drugs.

Fiber's role in preventing constipation is especially important in childhood where bowel habits are developed.  Children who sometimes soil themselves are perceived as delayed in their toilet training.  In actuality, these children are so constipated that they have developed a condition called encopresis.  This is associated with retention and passage of extremely large stools, incomplete rectal emptying, and chronic overdistention of the colon.  The internal rectal sphincter is chronically held open, and overflow diarrhea (or fecal soiling) occurs. Increased intakes of dietary fiber and fluid greatly helps reverse this condition by promoting the regular passage of softer stools and slowly allowing the return of normal rectal function and tone.

According to Dr. Williams children eat one third of their total daily calories at home, another third at school, and another third out.  For this reason we all have to work as a society to implement measures that will help increase dietary fiber intake in children.  Efforts must be carried out at home, schools, restaurants, and by the media.  At home, parents need to make fiber-rich foods available.  Parents will benefit from nutrition education, and the awareness of  behavioral factors impacting on children's eating habits.  For instance, too much television viewing has negative effects, while watching adults eat in a healthful manner has positive effects.  Schools should modify their lunch programs to include fiber-rich foods. Vending machines filled with fat and sugar-loaded snacks have become readily available in schools, institutions, and public areas. The snacks in these machines should include more of the complex carbohydrate variety.  Restaurants also need to modify children's menus to include more fiber.  There is a current Massachusetts Bill requiring children's restaurant menus to include at least one item containing less than 22% fat. More of this type of legislation should be enacted, requiring fiber-rich choices for children in restaurants.  Furthermore, since children are constantly exposed to media and advertising through television, changes promoting healthy eating patterns should be considered in this industry as well.  Advertisers need to be made sensitive to this issue.

Dr. Williams is involved in a current research project at the Child Health Center of the American Health Foundation, which evaluates the effects of 5-10 grams of added dietary fiber on the stool weights and bowel habits of 2-5 year old children. In conclusion, it should be emphasized that children currently consume suboptimal amounts of dietary fiber, and the potential health benefits of increasing dietary fiber in childhood outweigh the potential risks.  Efforts should therefore be directed at enhancing intake levels.  Also, dietary fiber requirements for the first two years of life are not known, and information on intake levels for this period are sparse.  Future studies should address these issues, and elucidate just how "an apple a day" (starting early in life) can truly promote long-term health.