Children and Fiber: How Much is Beneficial? How Much is Safe?

Children and Fiber

Encouraging increased fiber consumption among children has long-term benefits that outweigh potential safety concerns.

Christine L. Williams, MD, MPH | Professor of Clinical Pediatrics | Columbia University, Department of Pediatrics | Morgan Stanley Children's Hospital of New York-Presbyterian | New York, NY

Dietary fiber has important health benefits in childhood, especially in promoting normal laxation. Studies also suggest it may be useful in preventing and treating obesity, and in lowering blood cholesterol levels, both of which may help reduce the risk of future cardiovascular disease. Among adults, a high-fiber, low-fat diet has been linked to reduced rates of colon and other human cancers. While it seems highly likely that this benefit would be even greater if begun in childhood, epidemiologic and experimental confirmation is presently lacking.

Current estimates of dietary fiber (DF) intake are much lower than recommended levels for a large proportion of the U.S. pediatric population. It seems common sense that parents should remedy the situation by increasing their child's consumption of a variety of fruits, vegetables, legumes, cereals and other grain products. However, although DF is associated with important health benefits, there have been concerns that very high-fiber diets could result in adverse affects, such as limiting caloric intake and reducing the bioavailability of minerals and other nutrients. 

Several guidelines recommend quantitative ranges of dietary fiber intake for children. These include recommendations by the National Academy of Sciences, the FDA food label guide, and the "Age + 5" guideline. The goal is to achieve a dietary fiber intake that is safe even for children with marginal intake of vitamins and minerals, that provides enough dietary fiber for normal laxation, and that reduces risk of future chronic diseases such as coronary artery disease.

What is Dietary Fiber?
Since the 1950's, the term "dietary fiber" has been used to describe the structural parts of plant foods that are resistant to digestion by humans. A mixture of polysaccharides and lignin, DF is usually divided into two major categories based on water solubility and viscosity. The physical properties of viscous and nonviscous DFs in food determine their physiologic effects, which in turn are related to their known and potential health benefits.1

Recently, the National Academy of Sciences proposed a new definition for fiber, one that would determine the analytical methods needed to measure it, rather than have the analytical method determine what qualified as fiber and what did not.2 The new definition proposes that: total fiber = dietary fiber + functional fiber. Under the new definition, dietary fiber consists of nondigestible carbohydrates and lignin (a non-carbohydrate substance bound to fiber) that are intrinsic and intact in plants (e.g., gums, cellulose, oat bran, wheat bran), and functional fiber consists of isolated, nondigestible carbohydrates that have beneficial physiological effects in humans. Functional fibers may be extracted or modified from plants (e.g., resistant starch from green bananas and cooked, cooled potatoes) or be derived from animal sources (e.g., chitin and chitosan found in crab and lobster shells). Functional fibers must also show a beneficial physiological effect in humans.

Modern interest in DF was stimulated by Burkitt and Painter in the 1970 s, who observed lower prevalence rates of chronic disease in Africa as compared with Western industrialized countries. They proposed a dietary fiber hypothesis, in which common gastrointestinal diseases (e.g., colon cancer, diverticulosis and appendicitis) were due in part to insufficient intake of DF.3

The known or potential health benefits of DF in childhood include promotion of normal laxation and prevention of GI disorders; prevention and treatment of childhood obesity; reduction of blood cholesterol; modulation of post-prandial hyperglycemia and glucose intolerance; and possible effects on reducing risk of future chronic diseases, such as cancer, cardiovascular disease (CVD) and adult-onset diabetes.

Laxation and Gastrointestinal (GI) Health Benefits
Constipation is a common clinical problem in childhood.4 Afflicted children often pass stools of large size as a result of chronic overdistention and insensitivity of the colon.5Incomplete rectal emptying results in chronic overdistension with retention of large fecal masses. The internal rectal sphincter is chronically held open, and overflow diarrhea (encopresis or fecal soiling) occurs. 

Treatment is aimed at re-establishing normal colonic muscular tone and instituting a plan of therapy that promotes the frequent passage of softer, more normal-size stools. The latter often includes a dietary recommendation for increased intake of DF and fluid that together promote the regular passage of softer stools and slowly allow the return of normal rectal function and tone. 

The physiologic effects of DF depend on the type of fiber ingested, the part of the GI tract involved, and other factors. In the stomach, DF tends to delay gastric emptying times whereas in the small intestine the effects are more variable. DF delays the absorption of many nutrients, thus increasing or decreasing intestinal transit time depending on the specific effects of the malabsorbed nutrients. 

In the large intestine, nonviscous DF softens and enlarges the stool by absorbing water, increasing bacterial proliferation, and increasing gas production. This results in decreased stool transit time and increased frequency of bowel movements.6 Viscous fiber in the large intestine may also increase stool volume and water content and decrease stool transit time. Viscous fibers fermented by intestinal bacteria, as well as the proliferating bacteria themselves, increase fecal mass. Fermentation also produces other byproducts that have a laxative effect. Thus, high levels of DF tend to result in more frequent, softer, and larger stools that are passed more easily.

Morais et al.7 evaluated the intake of DF in 52 children (mean age: 6 yrs) with chronic constipation—age and gender matched with children who had normal intestinal habits. Children who were constipated consumed significantly less DF than controls (9.7 vs. 12.6 g/d). Only 25% of the constipated group met the Age + 5 g/d DF guideline,8 compared with 57.5% of controls. With respect to treatment of constipation in childhood, increasing DF appears to be one component of successful therapy for many children.9-11

Dietary Fiber and Childhood Obesity
In the past two decades, overweight in children and adolescents has dramatically increased worldwide.12 About 10% of children and adolescents in the United States were overweight based on data from NHANES III, 1988-94. However, the most recent 1999-2000 NHANES data indicate an estimated 15% of children and adolescents 6-19 years are overweight, a 50% increase in overweight prevalence from previous estimates.13

An inverse relationship between DF intake and obesity has been suggested from observations that obesity is rare in developing countries where a high proportion of calories come from complex carbohydrates rich in DF.14 In Western countries, where less DF is consumed, obesity is more prevalent.15 DF may influence the development of obesity through effects on food intake, digestion and absorption of nutrients (especially energy), and carbohydrate metabolism.16 An inverse relationship between intake of dietary fiber and dietary fat has been observed in children, as well as adults, so that fiber-rich diets tend to be less energy dense compared with fiber-poor diets. 

Dietary fiber also appears to affect satiety.17 The stomach fills sooner with fiber-rich, bulkier foods, and satiety is reached with lower energy intake. Foods rich in DF require more chewing which also increases satiety. In addition, some DF slows gastric emptying, which tends to reduce hunger and prolong a feeling of fullness.

High DF diets may also have a negative effect on metabolized energy since the digestibility of protein and carbohydrate (but not fat) is reduced with a high-fiber diet.18 Increased bulk also shortens transit time allowing less time for digestion and absorption. Increased loss of fecal energy due to high intake of DF has also been reported.19-20 Foods rich in viscous fiber modulate the insulin response to carbohydrate, resulting in a blunted postprandial glucose and insulin response.21 This may influence satiety, since insulin is an appetite stimulant. 

In a recent analysis of NHANES II data by Samuel et al.,22compared to oatmeal users, almost twice as many 2-18-year-old non-oatmeal users were "at risk" of being overweight, with BMI between the 85th and 95th percentile (24.6 vs. 13.3%). This was especially significant among girls and 2-5 year olds. Samuel et al. conclude that high fiber foods including oatmeal may be beneficial in helping children and adolescents maintain a healthy weight.

Dietary fiber has also been used in the treatment of obesity, and studies suggest a beneficial effect on weight reduction, resulting in about 2 kg added weight loss with fiber supplementation.23 In one cross-over study with obese children, 6-12 years of age, 15 g/d of DF added to a reduced calorie diet resulted in greater mean weight loss compared with the non-fiber treatment period.24 Thus, although there arerelatively few studies, some evidence suggests that DF may be beneficial in the prevention and treatment of childhood obesity.

Dietary Fiber and Blood Cholesterol in Childhood
Treatment of hypercholesterolemia in childhood is primarily through dietary modification, with drug therapy reserved for very high-risk children over 10 years of age who have LDL cholesterol levels of 190 mg/dL by itself, or lower levels of LDLC in conjunction with multiple other CHD risk factors.25 Therecommended diet emphasizes decreased consumption of saturated fat and cholesterol, and increased intake of complex carbohydrates, many of which are often rich in DF. 

The addition of viscous DF to the diet has been shown to lower LDL cholesterol further in children, without the use of drug therapy. Overall, these studies suggest that adding about 6 grams per day of viscous fiber (such as oat bran or psyllium) is effective in achieving approximately anadded 6% lowering of LDL-cholesterol, above and beyond that achieved by a low saturated fat, low cholesterol diet alone.26-30 Though many other studies showed similar positive benefits, one study showed no effect.31

In the Healthy-Start preschool study of cardiovascular disease risk factors and diet, Williams et al.32 followed a cohort of preschool children who were 3.9 yrs of age at baseline and age 8.2 years at follow-up. Lipid profiles, BMI, blood pressure and dietary intake were assessed at each point in time. Results showed that increasing BMI significantly and adversely affected blood cholesterol levels. An increase inBMI from age 3-4 to 7-10 years was a significant predictor of total cholesterol at 7-10 years. Intake of DF and of monounsaturated fatty acids had a beneficial effect on blood lipids however, and was negatively associated with total cholesterol levels at 7-10 years of age.

Current Dietary Fiber Intake
Prior to the 1990's, information on DF intake in the U.S. population was very limited, and available primarily for adults.33-36 In addition, estimates were based on analyses using a variety of different measurement protocols and methods of food analysis. Until 1991, the USDA food composition tablesprovided values only for crude fiber, which underestimated total DF due to the analytical procedure used.37 In 1991, the USDA released version 4 of their nutrient database which included DF values of foods which could then be used in other nutrient databases and dietary analyses.

Analysis of data from the 1976-80 National Health and Nutrition Examination Survey (NHANES II) estimated average DF intake of 4-19-year-old children at about 12 g/d or 6 g/1000 Kcal.38 Nicklas et al.39 also reported an average DF intake of 12 g/d for children (10-17 years of age) in Louisiana. Saldanha et al.40 examined trends in DF intake among U.S. children (2-18 years) from 1977-78 to1987-88 using USDA's Nationwide Food Consumption Survey (NFCS) data and reported significant decreases in DF consumption during this decade. Primary sources of DF shifted away from fruits and vegetables to bread, cereal and combination foods. Children who regularly ate breakfast tended to consume 1-3 g/d more DF than skippers.

Nicklas et al. reported that total DF intake remained unchanged from 1976-88 among Louisiana children (10-17 years of age), even after adjusting for energy intake (mean 12 g/d or 5 g/1000 Kcal). Blacks had higher DF intakes/1000 Kcal than whites from ages 10-17 years. Dinner contributed the greatest percentof total daily DF (34-44%), followed by lunch (26-33%), snacks (24-29%), and breakfast (12-19%). NHANES II data was similar with 1/3 of DF derived from snacks and 13% from breakfast.

Vegetables, soups, breads, and cereals accounted for 50-75% of total DF consumed by 10-13 year olds. For adults,41 vegetables are the leading source of fiber (27%), followed by breads (19%). For 10-year-old Louisiana children, milk and fruit contributed about 25% of total DF intake. Milk was a major source of DF due to addition of chocolate flavoring containing carrageenan, a thickener containing DF. (For 10 year olds, the milk group contributed approximately 12% of the total dietary fiber, since more than a third of children this age consumed chocolate milk, milk shakes and ice milk. DF intake from milk sources decreased to only 5% by age 13.)

Children in the highest quartile of fiber intake consumed significantly less fat compared with children in the lowest fiber quartile (34 vs. 40% of calories from fat).42 Children with high DF intakes consumed more fruit, fruit juice, vegetables, soup, bread and grains, while children with low DF intakes consumed more high-fat foods like cheese, pork, beef, eggs and oils. Mean DF intake of 12 g/d, or 5 g/1000 Kcal reported by Nicklas et al., is similar to the NHANES II DF intake for children reported by Fulgoni. 

Among preschool children, the Healthy-Start Project—a three-year cardiovascular risk-reduction program for 3-5 year old preschool children begun in 1995—reported a mean baseline DF intake of almost 11 grams per day.43 Data from the CATCH (Child and Adolescent Trial for Cardiovascular Health) study—a school- and family-based intervention study to reduce the risk of cardiovascular disease in a group of 3rd-5th grade students—reported that children in this study met the Age + 5 recommendation for dietary fiber.44

Overall, DF intake for U.S. children has remained fairly steady over time. (See chart, "Dietary Fiber Intake Among U.S. Children in Selected National Surveys.") When dietary fiber intake in the CSFII-95 and NHANES III surveys is compared with recommended intake based on the Age + 5 guideline, fiber intake is minimally adequate in both boys and girls up through age 11 years (based on mean intake in the 6-11-year-old category).45-46This is consistent with previous data on fiber intake in young children as well as data from the Healthy-Start Project and the CATCH studies. After age 11, however, fiber goals based on either the Age + 5 formula or the 0.5g/kg/d AAP guideline are not met, despite the modest increase in fiber intake in the 16-18-year-old category for both boys and girls reported in the NHANES III survey.47-48

Hampl et al.49 reported on the DF intake of children and found that less than half (45%) of 4-6 year olds, and less than 1/3 (32%) of 7-10 yr olds met the Age + 5 fiber guideline. Children with low fiber intakes had significantly higher energy-adjusted intakes of fat and cholesterol. Children who met the Age + 5 guideline consumed more breads and cereals, fruits, vegetables, legumes, nuts, and seeds; and had significantly higher energy-adjusted intakes of DF, iron, magnesium, and Vitamins A, E, and folate.

The Safety of High Dietary Fiber Intakes in Childhood
Dietary fiber is associated with important health benefits in childhood, but there have been concerns that very high-fiber diets could result in adverse health effects, including limiting caloric intake and reducing the bioavailability of minerals and other nutrients. Some have urged caution in the use of high-fiber foods for children, although a prudent diet emphasizing increased consumption of complex carbohydrates rich in DF has been recommended by American Academy of Pediatrics (AAP) since 1986.50

In 1991, National Cholesterol Education Program's Expert Panel on Cholesterol in Children and Adolescents, in collaboration with the AAP, recommended a fat modified Step-One diet for all children over 2 years of age.51 Although this diet recommends that 50-60% of calories be derived from carbohydrate, no specific levels of DF intake are specified.52-54

Caloric Intake 
High-fiber diets could reduce caloric intake in small children since they have smaller stomach capacities than adults, and high-fiber foods are bulkier and lower in caloric density than low fiber foods. Thus, a high-fiber diet could result in inadequate caloric intake for normal growth. Food fiber may displace available nutrients in the diet, slow down the intake of food by requiring more chewing, and reduce the absorptive efficiency of the small intestine.55 Refined products, stripped of DF, are easier to digest, more completely absorbed, and have a higher energy to satiety ratio. While providing a ready source of energy for children, such refined products may promote obesity. On the other hand, reverting to more natural, higher-fiber products could result in decreased caloric intake. The question is, how much of a reduction in energy intake occurs when DF is increased, and is this decrease likely to be beneficial or harmful with respect to the present nutritional status of U.S. children?

Studies among adults have reported some loss of energy as DF is increased. Southgate56fed young British women 23 g/d DF for 7 days, and observed an increase in fecal loss of energy (4%). Levine57 reported a 10% decrease in calories consumed during breakfast and lunch after adults consumed a very high-fiber (20g DF per serving) breakfast cereal.

Far less data are available for children. In Hummel's classic 1943 study, 18 preadolescent children consumed diets containing 4-6 g/d of crude fiber for 1-6 months. Good health and normal bowel function was reported with no evidence of adverse effects on absorption of nitrogen or mineral balance. He also noted an age-dependent increase in ability to ferment DF.58

In summary, DF tends to increase dietary bulk, decrease caloric density, and reduce caloric intake. Fecal energy loss may increase as intestinal transit time decreases leaving less time for digestion and absorption of nutrients.59 These effects may be beneficial for most U.S. children who usually consume a calorically dense, highly refined, high-fat diet. On the other hand, increasing DF in malnourished children from underdeveloped countries with inadequate nutrient intake could further reduce available energy.60-64

Vitamin and Mineral Bioavailability
A second safety concern has been that high fiber diets in childhood may reduce the bioavailability of minerals. This reflects the fact that some foods high in DF contain phytate (inositol hexaphosphate), which may form insoluble compounds with minerals, rendering them unavailable for normal absorption and metabolism. Other plant foods contain oxalic acid, which can also interfere with iron absorption.65

Studies of the effects of DF on mineral balance have generally been acute, short duration, high-dose feeding studies. A gradual dietary increase in DF containing added phytate—which binds minerals and decreases bioavailability—would trigger a compensatory physiologic response to increase intestinal absorption.66-67 Thus, decreased bioavailability of minerals is likely to be a chronic problem only when the mineral intake is inadequate, and absorption cannot be increased.68-70 In the U.S. and other industrialized countries, vitamin/mineral intake is generally adequate, and DF intake is moderately low.

There are special segments of the population where caution is prudent, such as in preschool children, adolescents with mineral-deficient diets, impoverished children with inadequate nutritional support, and some children who are vegetarians with nutritionally inadequate diets. Although DF intake may be very high (2-4 times recommended intake) and be accompanied by poor growth, the high DF may not be the cause of the latter.71 The growth stunting has been linked to lack of essential nutrients, low energy intake, and underutilization of health care services.

In reviewing studies of DF and mineral deficiencies in childhood, it is important to compare the actual concentration of DF and phytate in the study population with levels of intake among U.S. children. Cooking and baking processes must also be considered. Phytate is destroyed by leavening, thus mineral deficiencies due to phytate binding are rare in countries where leavened bread is consumed.

In the 1970's, poor physical growth was reported for rural Iranian children, for whom unleavened whole-grain pita bread provided 75% of energy intake and was the main dietary source of zinc.72 For U.S. children, however, only about 20% of zinc intake comes from bread and cereal, intake of animal protein is high, and the majority of bread consumed is leavened. Phytate intake in Iran was 2 g/d, compared to an estimated intake of 0.4 g/day in the U.S.73 One-third of the rural Iranian children had iron-deficiency anemia compared with about 5% of U.S. children.74 Bioavailability of iron is significantly enhanced by calcium and magnesium in the U.S. diet, which competitively form salts with phytic acid and neutralize the phosphate in phytic acid. U.S. children also consume more animal foods, which are a source of highly bioavailable heme iron. Vitamin C also increases iron absorption, and is generally abundant in U.S. diets.

More recent studies have evaluated the effects of DF on mineral balance. Drews75 fed 14 g/d of DF to adolescent males for 4 days, and although fecal zinc, copper and magnesium increased, serum levels were unchanged. Kawatra76 found that 25 g/d of psyllium increased fecal excretion and decreased serum levels of zinc, copper, and manganese in adolescent Indian girls. However, anemia was not present. Dennison77 found that children's (5-17 years of age) growth, serum vitamin (A,D,E and folic acid) and mineral (iron, zinc and calcium) levels were not affected when 12 g/d DF was added to their usual diet for 1-2 months, suggesting that a doubling of usual DF intake for U.S. children with adequate intake of essential vitamins and minerals may not adversely affect growth, serum vitamin, or mineral levels.

McClung78 treated constipated children (2-12 years of age) with a doubling of DF to 0.6 g/kg (about 18 g/d) and found no decrease in serum vitamin, mineral, or hemoglobin levels during 6 months of treatment. Kelsay79 reviewed the effects of DF on mineral bioavailability and concluded that up to 32 g/d DF and 2 g/d phytic acid had no adverse effect on mineral balance. Even among U.S. vegetarian children with very high DF intake, anemia is not common, perhaps because higher vitamin C intake enhances iron absorption.80-81

In summary, studies suggest that although a small loss of energy may occur with a high intake of DF, this small decrease is unlikely to be significant for children with adequate nutrient intake. Increases in DF up to a doubling of current intake are not likely to adversely effect growth or serum vitamin and mineral levels in healthy U.S. children on adequate diets. Thus, for U.S. children, a moderate increase in DF would be more healthy than harmful.

Conclusions
U.S. children, on average, currently consume amounts of DF that appear to be inadequate for healthy gastrointestinal function, and for disease prevention. It is recommended therefore, that children over 1 year of age increase DF intake by increasing consumption of a variety of fruits, vegetables, legumes, cereals and other whole grain products. A moderate and safe range of dietary fiber intake for children and adolescents may be between Age + 5 and Age + 10 grams per day. This range of DF intake is felt to be safe even for children and adolescents with marginal intake of some vitamins and minerals; should provide enough DF for normal laxation; and may provide enough added DF to help prevent future chronic disease. The recent NAS recommended AI for DF is significantly higher than the Age + 5 guideline, and there is a paucity of pediatric research data which would help pediatricians determine if this level of intake is appropriate or excessive, especially for younger children.

Although there are some safety concerns for a very high fiber intake in childhood, the potential health benefits of a moderate increase in dietary fiber for children probably outweigh the potential risks, especially in highly industrialized countries such as the United States where constipation, high blood cholesterol levels, and obesity are common among children, and where coronary heart disease is the leading cause of death for adults.

Christine L. Williams, M.D., M.P.H., is Professor of Clinical Pediatrics, and Director of the Children's Cardiovascular Health Center in the Department of Pediatrics and Institute of Human Nutrition at Columbia University, College of Physicians and Surgeons. She is Co-Director of the Columbia Institute of Human Nutrition's Food and Nutrition Council, and Principle Investigator of the NIH-funded Nutrition Academic Award program at Columbia University. Dr Williams' developed the widely acclaimed Healthy-Start preschool nutrition and health curriculum (www.Healthy-Start.com), and "Animal Trackers" a preschool motor skill and physical activity program. Dr. Williams is a member of the American Academy of Pediatrics and the American Heart Association, and served as chair of the Committee on Atherosclerosis, Hypertension and Obesity in Childhood for the AHA's Council on Cardiovascular Disease in the Young.

References 

  1. Gurr Ml and Asp N.G: Dietary Fibre. Washington D.C.: International Life Science Press; 1994.
  2. Food and Nutrition Board. Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids. The National Academy of Sciences, 2002. 
  3. Burkitt DP, Walker ARP, Painter NS: Effect of dietary fibre on stools and transit times and its role in the causation of disease. Lancet 1972;2:1408-1412.
  4. Hatch TF. Encopresis and constipation in children. Pediatr Clin North Am. 1988;35:257-280.
  5. Loening-Baucke VA. Sensitivity of the sigmoid colon and rectum in children treated for chronic constipation. J Pediatr Gastroent Nutr. 1984;3:454-459.
  6. Eastwood MA and Kay RM. An hypotheses for the action of dietary fiber along the gastrointestinal tract. Amer J Clin Nutr. 1979;32:364-367.
  7. Morais MB, Vitolo MR, Aguirre AN, Fagundes-Neto U. Measurement of low dietary fiber intake as a risk factor for chronic constipation. J Pediatr Gastroenterol Nutr 1999;29(2):132-135. 
  8. Williams CL, Bollella M, Wynder EL: A new recommendation for dietary fiber in childhood. Pediatrics 1995; 96(5)S: 985-988.
  9. McClung HJ. Constipation and dietary fiber intake in children. Pediatrics 1995;86:999-1001.
  10. Weaver LT. Bowel habits from birth to old age. J. Pediatr Gastroenterol Nutr 1988;7:637-640.
  11. Durschlag R. Dietary management of constipation in children. Sem Pediatr Gastrolenterol Nutr 1992;3:11-14.
  12. World Health Organization. Obesity; preventing and managing the global epidemic. Report of a WHO consultation. Geneva, 3-5 Jun 1997. Geneva: WHO, 1998 (WHO/NUT/98.1).
  13. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among U.S. children and adolescents, 1999-2000. JAMA 288; 1728-32: 2002.
  14. Van ltalie TB. Dietary fiber and obesity. Am J Clin Nutr l978;3lS43-S52.
  15. Ibid.
  16. Ali R, Staub H, Leveille GA, Boyle PC. Dietary fiber and obesity: A review. ln:Vahouny GV, Kritchevsky D, ed. Dietary Fiber in Health and Disease. New York:Plenum Press, 1982.
  17. Pereira MA and Ludwig DS. Dietary fiber and body weight regulation. Pediatr Clin North Am 48(4); 969-80: 2001.
  18. Southgate DAT, Durnin JUGA. Caloric conversion factors. An experimental reassessment of the factors used in the calculation of the energy value of human diets. Cr J Nutr 1970; 24: 517-535.
  19. Farrell DJ, Girliel, AJ. Effects of dietary fibre on the apparent digestibility of major food components and on blood lipids in men. Aust J Exp Biol, 1978;56:469-479.
  20. Kelsay JL, Behall KM, Pratner ES. Effect of fiber from fruits and vegetables on metabolic responses of human subjects. 1. Bowel transit time, number of defecations, fecal weight, urinary excretion of energy and nitrogen and apparent digestibilities of energy, nitrogen, and fat. Am J Clin NUTR. 1978;31:1149-1153.
  21. Jenkins DJA, Wolever TMS, Leeds AR, et al. Dietary fibres, fibre analogues and glucose tolerance, importance of viscosity. Br Med J. 1978;1: 1 392-1394.
  22. Samuel P. Keast DR, Williams CL, and Bartholmey SJ. Dietary fiber and its role in childhood obesity. FASEB J 2003; 17(4): Pg A746 (Abstract 453.5). Experimental Biology 2003, April 11-14, San Diego, CA. 
  23. Kimm SYS. Dietary fiber and childhood obesity. Pediatrics 96(5)S: 1010-1014,1995.
  24. Gropper SS, Acosta PB. The therapeutic effect of fiber in treating obesity. J Am Coll Nutr. 1987;6(6):533-5.
  25. National Cholesterol Education Program Report of the Expert Panel on Blood Cholesterol Levels in Children and adolescents. Ped 1992;89(Suppl):S1-S84.
  26. Williams, CL, Boliella M, Spark A and Puder D: Effectiveness of a Psyllium enriched Step I Diet in Hypercholesterolemic Children, JACN 14(3).251-257, 1991.
  27. Glassman M, Spark A, Berezin S, Schwartz S, Medow M. Treatment of type Ila hyperlipidemia in childhood by a simplified American Heart Association diet and fiber supplementation. Amer J. Dis Child l990;144:193-197.
  28. Blumenschein D, Torres E, Kushmaul E, Crawford J, Fixler D. Effect of oat bran/soy protein in hypercholesterolemic children. Ann NY Acad Sci. 1991;623:413-415.
  29. Taneja A, Bhat CM, Arora A, Kaur AP. Effect of incorporation of isabgol husk in a low fibre diet on faecal excretion and serum levels of lipids in adolescent girls. European J Clin Nutr. 1989;43:197-202.
  30. Zavoral JH, Hannan P, Fields DJ. The hyperlipidemic effect of locust bean gum food products in familial hypercholesterolemic adults and children. Am J Clin Nutr. 1983;38:285-294.
  31. Dennison BA and Levine DM. Randomized, double-blind, placebo-controlled, two-period crossover clinical trial of psyllium fiber in children with hypercholesterolemia. Pediatrics 1993;123:24-29.
  32. Bollella M, Williams CL, Strobino B, Brotanek J: Dietary predictors of cardiovascular risk factors among children in a 5-year health tracking study: Healthy-Start. Presented at the American Dietetic Association, Food & Nutrition Conference & Expo, San Antonio, TX, October 25-28, 2003. 
  33. Lanza E, Jones Y, Block G, Kessler L. Dietary fiber intake in the U.S. population. Am J Clin Nutr. 1987;46:790-797.
  34. Anderson JW, Bridges SR, Tietyen J, Gustafson NJ. Dietary fiber content of a simulated American diet and selected research diet. Am J Clin Nutr. 1989;49:352-357.
  35. Thomson FE, Sowers MF, Frongillo EA. Sources of fiber and fat in diets of U.S. women aged 19 to 50. Implications for nutrition education and policy. AJPH 1992;82:695-702.
  36. Block G, Lanza E. Dietary fiber sources in the United States by demographic group. JNCI 1987;79(l):83-91.
  37. Slann JL. Dietary fiber: Classification, chemical analyses, and food sources. J Am Diet Assoc. 1987;87(9):1164-71.
  38. Fulgoni VL, Mackey MA. Total dietary fiber in children's diets. Ann. New York Acad. Sci. 1989;623:369-379.
  39. Nicklas TA, Farris R, Myers L, and Berenson GS: Dietary fiber intake of children and young adults: The Bogalusa Heart Study. JADA 1995; 95:209-214.
  40. Saldanha LG, Yagaila MV, Keast DR: Trends in dietary intake among children 2-18 years of age: Comparison of 1977-78 versus 1987-88 Nationwide Food Consumption Surveys. Pediatrics 96(5):S884-997,1995.
  41. Block G, Lanza E. Dietary fiber sources in the United States by demographic group. JNCI 1987;79(l):83-91.
  42. Nicklas TA, Farris R, Myers L, and Berenson GS: Dietary fiber intake of children and young adults: The Bogalusa Heart Study. JADA 1995; 95:209-214.
  43. Bollella MC, Boccia LA, Nicklas TA, Lefkowitz KB, Pittman BP, Zang EA, Williams CL. Assessing dietary intake in preschool children: The Healthy-Start Project—New York, Nutrition Research 19 (1):37-48, 1999. 
  44. Lytle LA, Stone EJ, Nichaman MZ, Perry CL, Montgomery DH, Nicklas TA, Zive MM, Mitchell P, Dwyer JS, Ebzery MK, Evans MA, Galati TP. Changes in nutrient intakes in elementary school children following a school-based intervention: Results from the CATCH Study, Preventive Medicine 25:465-477 (1996).
  45. Williams CL, Bollella M, Wynder EL: A new recommendation for dietary fiber in childhood. Pediatrics 1995; 96(5)S: 985-988.
  46. Alaimo K., McDowell MA, Briefel RR, Bischof AM, Caughman CR, Loria CM, Johnson CL. Dietary intake of vitamins, minerals and fiber of persons ages 2 months and over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-91, Advance data from vital and health statistics; no 258. Hyattsville, MD: National Center for Health Statistics, (1994).
  47. Ibid.
  48. Mueller S, Keast DR, Olson BH: Intakes and food sources of dietary fiber in children. FASEB J.(1997) 1 1:Al 87 (Abstract 1083).
  49. Hampl JS et al: The Age + 5 rule: comparisons of dietary fiber intake among 4 to 10-year-old children. JADA 1998; 98 (12):1418-23.
  50. Committee on Nutrition, American Academy of Pediatrics. Cholesterol in Children. Pediatrics 1998;101:141.
  51. National Cholesterol Education Program. Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. USDHHS, PHS, NIH, 1991;USDHHS Publ.No. (NIH) 91-2732.
  52. Ibid.
  53. American Heart Association, Task Force Committee of the Nutrition Committee and Cardiovascular Diseases in the Young Council. Diet in the Healthy Child. Circ. 1986; 74: 14IIA-1414A.
  54. Wynder EL, Berenson GC, Strong WB, Williams CL: Coronary artery disease prevention: Cholesterol—a pediatric perspective. Prev Med. 1989;18(3):323-409.
  55. Heaton KW: Food fiber an obstacle to energy intake. Lancet 1973;ii:14181421.
  56. Southgate DAT and Durnin JVGA: Calorie conversion factors. An experimental reassessment of the factors used in the calculation of the energy value of human diets. Br J Nutr. 1970;23:517-535.
  57. Levine AS, Tallman JR, Grace MK, Parker SA, Billington CJ, Levitt MD: Effect of breakfast cereal on short-term food intake. A, J Clin Nutr. 1989;50:1303-1307.
  58. Hummel FC, Shepherd ML, Macy IG: Disappearance of cellulose and hemicellulose from the digestive tracts of children. J Nutr. 1943;25:59-70.
  59. Williams CL and Bollella M: Is a high fiber diet safe for children? Pediatrics 96(5):S 1014-1019,1995.
  60. Cummings JH, Southgate DAT, Branch W, Houston H, Jenkins DJA, James WPT: Colonic response to dietary fiber from carrot, cabbage, apple, bran and guar gum. Lancet. 1978;i:5-9.
  61. Karisson A and Svanberg U: Dietary bulk as a limiting factor for nutrient intake in preschool children. IV. Effect of digestive enzymes on the viscosity of starch-based weaning foods. J Trop Ped. 1982;28:230-234.
  62. Hellstrom A, Hermansson AM, Karisson A: Dietary bulk as a limiting factor for nutrient intake—with special reference to the feeding of pre-school children. II. Consistency as related to dietary bulk. J Trop Ped. 1981;27:127135.
  63. Brandtzaeg B, Melleshi NG, Svanberg U, Desikachar HSB, and Mellander 0. Dietary bulk as a limiting factor for nutrient intake in preschool children. 111. Studies of malted flour. J Trop Ped. 1981;27:184-189.
  64. MacDonald 1: The effects of dietary fiber: Are they all good? in, Fiber in Human Nutrition. G.Spiller and R.Amen (Eds). Plenum Press, New York, 1976.
  65. Committee on Nutrition, American Academy of Pediatrics. Plant fiber intake in the pediatric diet. Pad. 1981;67(4):572-575.
  66. Walker ARP, Fox FW, Irving JT. Studies in human mineral metabolism. 1. The effect of bread rich in phytate on the metabolism of certain mineral salts with special reference to calcium. Biochem J. 1948;42:452-462.
  67. Committee on Nutrition, American Academy of Pediatrics, Lewis A. Barness, MD,Ed, Pediatric Nutrition Handbook, Third edition, Chapter 10: Carbohydrate and dietary fiber, pg 104. American Academy of Pediatrics, Elk Grove Village, IL. 1993.
  68. Walker ARP, Fox FW, Irving JT. Studies in human mineral metabolism. 1. The effect of bread rich in phytate on the metabolism of certain mineral salts with special reference to calcium. Biochem J. 1948;42:452-462.
  69. Ekvall S. Constipation and fiber—in Pediatric nutrition in chronic diseases and developmental disorders: Prevention, and treatment. S. Ekvall (Ed) NY, Oxford University Press, 1994; 301-309.
  70. Cullumbine H, Basnayake V, Lemottee J: Mineral metabolism of rice diets. Br J Nutr. 1950;4:101-111.
  71. Dwyer J. Dietary fiber for children: How much? Pediatrics 96(5):Sl 019-1023,1995.
  72. Haghshensas M, Mahloudji M, Reinhold JG, Mahammad N: Iron- deficiency anemia associated with high intakes of iron. Amer J Clin Nutr. 1972;25:11431146.
  73. Thompson FE, Sowers MF, Frongillo EA, Parpia BJ: Sources of fiber and fat in the diets of women aged 19-50: Implications for Nutrition Education and Policy. AJPH. 1992;82:695-702.
  74. Weihang B, Dalferes ER, Srinivasan SR, Webber LS, Berenson GS: Normative distribution of complete blood count from early childhood through adolescence: The Bogalusa Heart Study. Prev Med. 1993;22:825-837.
  75. Drews LM, Kies C, Fox HM: Effect of dietary fiber on copper, zinc, and magnesium utilization by adolescent boys. Am J Clin Nutr. 1979;32:1893.
  76. Kawatra A, Bhat CM, Arora A: Effects of isobgol husk supplementation in a low-fibre diet on serum levels and calcium, phosphorus and iron balance in adolescent girls. Eur J Clin Nutr. 1993;47:297-300.
  77. Dennison BA and Levine DM. Randomized, double-blind, placebo-controlled, two-period crossover clinical trial of psyllium fiber in children with hypercholesterolemia. Pediatrics 1993;123:24-29.
  78. McClung HJ, Boyne LJ, Linsheid T, Heitlinger LA, Murray RD, Fyda J, Li Buk: Is combination therapy for encopresis nutritionally safe? Pediatrics. 1994;91(3):591-594.
  79. Kelsay JL: Effects of fiber, phytic acid, and oxalic acid in the diet on mineral bioavailability. Amer J Gastroent. 1987;82(10):893-97.
  80. Sanders TAB, Reddy S. Vegetarian diets and children. Am J Clin Nutr. 1994; 59:11 76-81.
  81. Jacobs C, Dwyer JT. Vegetarian children: appropriate and inappropriate diets. Am J Clin Nutr. 1988; 43(suppl 3):S811-818.

Sidebar References
S1. Food and Nutrition Board. Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids. The National Academy of Sciences, 2002.
S2. Roberfroid MB. (2005) Inulin-Type Fructans: Functional Food Ingredients, CRC Series in Modern Nutrition, Edited by Ira Wolinsky and James F. Hickson Jr, CRC Press, Boca Raton/London/New York/Washington D.C.
S3. Ghisolfi J. Dietary fibre and prebiotics in infant formulas. Proceedings of the Nutrition Society 2003; 62:183-185.
S4. Goulet O, Thibaut H, Gontier C, Blareau JP. Less severe diarrheic episodes with consumption of a new fermented infant formula FFC50: a double-blind randomised study in 968 French infants. Annals of Nutr and Metab 45, Suppl 1, 558A.
S5. Moro G, Minoli I, Mosca M, Fananro S, Jelineek C, Stahl B, Boehm G. Dosage-related bifidogenic effects of galacto and fructooligosaccharides in formula-fed term infants. J Pediatr Gastroent and Nutr 2002; 34, 291-295.
S6. Saavedra J, Tschernia A, Moore N, Abi-Hanna A, Coletta F, Emenhiser C, Yolken R. Gastrointestinal function in infants consuming a weaning food supplemented with oligofructose. J Pediatr Gastroent and Nutr 1999; 29, 513A.
S7. Yazourh A, Mullie C, Leroux, Romond MB. Reproduction par effet prebiotique de la flore intestinale du nourison au sein (Probiotic effect on reproduction of intestinal flora of the infant). Archives Francaises de Pediatrie 17, Suppl 2, 244s-246s.
S8. Roberfroid MB. (2005) Inulin-Type Fructans: Functional Food Ingredients, CRC Series in Modern Nutrition, Edited by Ira Wolinsky and James F. Hickson Jr, CRC Press, Boca Raton/London/New York/Washington D.C.
S9. Rumessen JJ, Bode S, Hamberg O, Gudmand-Hoyer E. Intestinal handling of fructans and their influence on blood glucose and insulin release. Scand J Gastroenterol 1990; 25: 38-41.
S10. Belcazar-Munoz B, Martinez-Abundis E, Ganzales-Ortiz M. Effecto de la administracion oral de inulina el partil de lipidos y la sensibilidad a la insulina en indeviduos con obesidad y dyslipidemia. Rev Med Chile. 2003; 131:597-604.
S11.Jackson KG, Taylor GRJ, Clohessy AM, Williams CM. The effect of the daily intake of inulin on fasting lipid, insulin and glucose concentrations in middle aged men and women. Brit J Nutr 1999; 82:23-30.
S12. Department of Agriculture, Food and Nutrient Intakes by Individuals in the United States, I Day, 1989-91. Riverdale, Maryland, Agricultural Research Service; NFS Report N. 91-2 (NTIS Accession No. PB95-272746) (1995).
S13. Wright HS., Guthrie HA, Wang MQ, Bernardo V. The 1987-88 Nationwide Food Consumption Survey: An update on the nutrient intake of respondents, Nutrition Today, 25:21-27 (1991).
S14. Alaimo K., McDowell MA, Briefel RR, Bischof AM, Caughman CR, Loria CM, Johnson CL. Dietary intake of vitamins, minerals and fiber of persons ages 2 months and over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-91, Advance data from vital and health statistics; no 258. Hyattsville, MD: National Center for Health Statistics, (1994).
S15. National Center for Health Statistics, Dietary Source Data: United States 1976-1980. Vital and Health Statistics, Hyattsvillie, MD: U.S. Department of Health and Human Services; NCHS publication (PHS) 83-1681, series 11, No. 231 (1983).
S16. http://www.health.gov/cnpp/pyramid.html (USDA Food Guide Pyramid).
S17. National Cholesterol Education Program Report of the Expert Panel on Blood Cholesterol Levels in Children and adolescents. Ped 1992;89(Suppl):S1-S84.
S18. Hendricks K, Walker A: Manual of Pediatric Nutrition, 2nd Ed. BC Decker, Publ, Philadelphia, PA, 1990.
S19. Agostoni C. Dietary fiber in weaning foods of young children. Pediatrics 96(5):Sl 002-1005, 1995.
S20. Committee on Nutrition, American Academy of Pediatrics, Lewis A. Barness, MD,Ed, Pediatric Nutrition Handbook, Third edition, Chapter 10: Carbohydrate and dietary fiber, pg 104. American Academy of Pediatrics, Elk Grove Village, IL. 1993.
S21. Dwyer J. Dietary fiber for children: How much? Pediatrics 96(5):Sl 019-1023,1995.
S22. Food and Drug Administration. Focus on Food Labeling. An FDA Consumer Special Report. Washington D.C.: Govt. Printing Office. May 1993. Publication FDA 93-2262.
S23. Williams CL, Bollella M, Wynder EL: A new recommendation for dietary fiber in childhood. Pediatrics 1995; 96(5)S: 985-988.
S24. Williams CL and Bollella M: Is a high fiber diet safe for children? Pediatrics 96(5):S 1014-1019,1995.
S25. Food and Nutrition Board. Dietary reference intakes for energy, carbohydrates, fiber, fat, protein and amino acids. The National Academy of Sciences, 2002.
S26. Rimm EB, Ascherio A, Giovannucci E, Spiegelman D, Stampfer MJ, Willett WC. Vegetable, fruit and cereal fiber intake and risk of coronary heart disease among men. JAMA 1996; 275:447-451.
S27. Wolk A, Mason JE, Stampfer MJ, Colditz GA, Hu FB, Speizer FE, Hennekens CH, Willett WC. Long term intake of dietary fiber and decreased risk of coronoary heart disease among women. JAMA 1999; 281:1998-2000.
S28. Pietinen P, Rimm EB, Korhonen P, Hartman AM, Willett WC, Albanes D, Virtano J. Intake of dietary fiber and risk of coronary heart disease in a cohort of Finnish men. Circulation 1996; 94:2720-2727
S29. Life Sciences Research OfFice FASEB: Physiologic effects and health consequences of dietary fiber. Center for food safely, DA, DHHS. Pilch SM (ed). Washington, DC 20204,1987.
S30. Agostoni C. Dietary fiber in weaning foods of young children. Pediatrics 96(5):Sl 002-1005, 1995.
S31. Constipation and fiber, in pediatric nutrition in chronic diseases and developmental disorders: Prevention, Assessment and Treatment. NY:Oxford University Press, 1993;301-309.
S32. Hendricks K, Walker A: Manual of Pediatric Nutrition, 2nd Ed. BC Decker, Publ, Philadelphia, PA, 1990. 

 
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