Eating well in the early stages of life brings a double gain, because we ensure the strength that is needed for the body and mind so that children and young people can overcome all the challenges of the day, while at the same time we are laying the foundations of correct nutrition, making their bodies, flavours, digestive and immune systems empathise with a quality diet.
We are creatures of habit, and getting children used to eating in a balanced way, always alternating quality foods, is to provide them with a tool that will be their ally for life. They will be better able to avoid illnesses and the risk of concentrations of fat or sugars that can compromise their health at some point in their lives.
In this article, three health professionals help to identify the positive keys to a healthy diet recommended for childhood and adolescence, and to clarify doubts about certain information. They are: Dámaris Martínez, dietician-nutritionist of the Nutriplato Programme (Dietetic and nutritional education for children aged 3 to 12), of the Gastroenterology, Hepatology and Paediatric Nutrition Service of the Hospital de Sant Joan de Déu (Barcelona); María Gotor, paediatrician at Althaia, and one of the authors of its informative space, Blogosfera; and Aida Vásquez, dietician and nutritionist at the AD Dietistas centre.
The Harvard plate
To nourish is to provide a living being with the substances it needs to live. These substances are found in different foods, which is why it is important to ensure the variety and alternation of foods in the daily intake, so as not to overlook any nutrient. With a healthy general population in mind, specialists in nutrition in childhood and adolescence have reached a consensus on a formula developed at Harvard Medical School and implemented in the distribution of everything included in a balanced healthy diet explained on a plate.
It is the Healthy Plate, or Harvard Plate, which establishes, very simply, that foods of vegetable origin, fruit and vegetables, fill half of the plate. One quarter of the plate would be occupied by healthy protein, whether vegetable or animal, and the other quarter of the plate would be filled with cereals.
Dámaris Martínez, a specialist in nutrition and dietetics at the Hospital de Sant Joan de Déu, says that “the most important thing is that all meals should be made up of healthy foods, that fresh fruit, vegetables, nuts (always natural or roasted and never whole in children under 4 years of age), fish, pulses, meat (mainly white meat), eggs and dairy products, wholemeal foods and virgin olive oil should be introduced during the day’s meals”.
In this sense, Althaia’s paediatrician, María Gotor, believes that we should do away with the idea of classifying foods according to the meals at which we eat them. “There is no one food for breakfast, snack, lunch or dinner, there is no one food for all. Eggs can be much healthier than certain cereals – not wholemeal and with added sugars – for breakfast. And why not a plate of lentils? The English eat their beans well. In short, it’s not the order of the day that matters, nor changing according to the day, but the quality of what you eat,” he says.
For fruit, Gotor advises eating at least three times a day, “but there is no limit”, he says. “Until the age of 3 or 4, in portions that fit in the child’s little hand,” he says. “If at the end of lunch or dinner they choose to eat a yoghurt, fruit should be placed at another time of the day, but don’t forget it,” adds the paediatrician.
Like the pieces of a set, fruit, vegetables, meat, fish, dairy products and their derivatives, and cereals – if possible wholemeal – should be fitted into the different meals of the day, without leaving any piece out. As the specialists explain, healthy eating implies a day-to-day scenario, a fridge and a pantry where these foods are always present.
On the difference between the diets of children and adolescents, according to dietician and nutritionist Aida Vásquez, “the main difference is the energy required. Given that adolescents undergo more physiological and growth changes, they require more energy through food. It should also be noted that adolescents show changes in terms of behaviour, their relationship with food and physical activity, so they tend to require more attention in establishing a healthy lifestyle.
As for quantities, Vasquez explains that this will depend on age. There are tables of weight guidelines depending on the age group, but it is important to remember that this should also be adapted to the physical activity and hunger sensation of each child or young person.
How many meals should children and adolescents have throughout the day?
“There is no one number of meals that is healthiest,” says dietician Aida Vásquez, arguing that this will always depend on the habits and activities of each individual, but it is recommended that not too much time passes between meals, and that they provide the necessary energy and nutrients. A good distribution is usually 5 meals a day: three main meals (breakfast, lunch and dinner) and two complementary meals (mid-morning and mid-afternoon).
“Five meals is considered adequate to provide the right amount of vegetables, fruit, protein and cereals in a convenient way. All occasions are valid for including those foods that define a healthy diet”, explains Dàmaris Martínez. However, “lunch and dinner would have to maintain the structure of the Harvard dish, with the required presence of vegetables, and the onion in the spaghetti stir-fry, for example, would not count as a vegetable, but as a more conscious preparation of the pasta dish”.
Breakfast, getting up, a mid-morning meal and a mid-afternoon meal will depend on one’s life and schedule. “If you don’t feel like breakfast when you get up, it is better to have nothing than something quick and perhaps more superfluous such as biscuits or sugary cereals. If we have to lose nutritional quality, it is better to eliminate that meal,” they recommend, as long as the child does not lose quality in attention and energy to attend to his or her activities, be they physical or intellectual.
“At lunch you can eat any healthy food, which is lactic or derived, carbohydrates, such as cereals without added sugars or bread, fruit or protein, such as canned tuna or nuts. You can have scrambled eggs with bread and avocado, yoghurt with nuts and oat flakes; a tortilla sandwich, a sliced tomato, peanut butter with no added sugars, milk, yoghurt, bread with oil and fruit. The ideal structure is for there to be some lactic acid or derivative, carbohydrates and fruit,” suggests Dàmaris Martínez. However, she recommends that lunch should be eaten in a calm, seated way. Some healthy snack ideas could be: a cheese or tuna sandwich; sticks with natural yoghurt; dried fruit or a glass of milk.
“We in paediatrics can provide training, but there are very established habits, such as ColaCao and biscuits as a regular and quick breakfast formula”, says the paediatrician, pointing out that food should be adapted to each family, its culture and economic possibilities.
As for timetables, the experts advocate a certain flexibility, depending on the lifestyle of each person. The ideal is to have dinner before resting, but if a training session ends very late at night, it may be better to have a good snack-dinner before the activity, and before going to bed to have something light, such as a glass of milk. More important than schedules is that meals are healthy, they insist. “You should not force yourself to eat or starve yourself. You should only go hungry and only at the beginning, because of the body’s need to purge the extra appetite, in case you have to lose weight, and always on medical advice,” says Dr María Gotor.
Avoid processed foods
When we talk about food quality, we are talking about foods low in sugars and saturated fats, and the less processed they are, the higher the quality. In pastries, for example,” says Gotor, “there are practically no healthy options. Even homemade pastries don’t have to be, it depends on the quality of the ingredients used. The same cake made with yoghurt, if we use refined wheat flour, does not provide us with the nutritional quality that would be desirable”.
Another clear comparison between quality and processed foods is Serrano ham, which should be prioritised over sweet ham because the latter has been processed and the amount of protein it contains should be checked along with the preservatives, additives and other components that may be involved in its processing, whereas Serrano ham is just meat and salt. As for turkey and other types of sausage, the amount of protein they contain should be checked on the label and priority should be given to extra ranges that retain as much natural food as possible. “The ideal would be foods without a nutritional label, so that the content is 100% of whatever it is: for example, fresh chicken, which is 100% chicken, fresh apples or fish,” says the Althaia paediatrician.
But reality tells us that at first glance when entering a supermarket and in strategic areas of large shopping centres, industrially processed food products are lurking in front of the customer. This is why we must “promote the importance of natural foods among children and adolescents, especially among adolescents, who tend to have many more external influences, through social outlets and, therefore, more tendency, are more prone to move away from healthy eating, and consume products with more additives, salts, sugars and unhealthy fats. It is important that the concepts of healthy eating are well established in them”, recommends Dámaris Martínez.
At friends’ houses
When sons and daughters are invited to friends’ houses, or to birthday parties, and the food is not in line with what they eat at home, then we talk about exceptions. But how do we set limits on these unhealthy or unhealthy food intakes, such as industrial pastries, over-saturated with sugar, sweets, sugary and fizzy drinks?
Consumption of these foods is discouraged, even when eating out. However, given that the reality is different, the recommendation is that, if they are consumed, it should be on a very occasional basis, always opting for healthy options when inviting friends over or going out to a restaurant.
One day at a time, but not on a special day
As the nutritionist at Sant Joan de Déu Hospital suggests, “we should not establish a positive association between a special day and unhealthy food, but take advantage of these exceptional occasions to make way for healthy food. For example, on Friday night you can prepare a homemade pizza and add vegetables or pieces of salmon, or make a mushroom, tuna, cabbage or carrot quiche, or a vegetable lasagne with courgette or aubergine. And for anniversaries, you can make fruit kebabs with dark chocolate, crepes with banana, or milk and fruit smoothies.
One thing is clear: if you don’t want to eat badly, don’t keep processed products in the house. “Nor should we be concerned all day long, a whole part of our lives, about what we eat, or suffer for it, or experience it as a punishment. Once you learn to eat well, you integrate it forever,” says paediatrician María Gotor, who explains that as a result of confinement, she has seen increases of up to 20 kgs, because there has been very poor metabolic control of overweight and obesity by eating at home without going out to exercise.
In any case, if any dietary pathology is suspected in children or young people, it should be brought to the attention of their doctors, and they will establish specific diets or recommendations in each case. They will say whether it is appropriate to count quantities, but not kilocalories. Sometimes it will be a matter of reducing carbohydrate intake and introducing more fibre, not dieting, but adjusting the diet. Aida Vásquez adds that, “in the case of overweight children, as with other children, meals will have to be composed according to the structure of the Harvard plate method, but it is important in these cases to analyse not only the structure of the meals, but also all the child’s eating habits and physical activity”.
Children who don’t want vegetables and fish
Aware of the daily realities in every home, and in particular the difficulties many parents have in getting their children to eat everything, nutritionists offer ideas. Vegetables are difficult for some children, but it helps a lot to vary the cooking and preparation, making them more attractive. Aubergines stuffed with Parmesan cheese, cauliflower with béchamel, or creams, for example, can be prepared. If adolescents have already integrated vegetables, there is no need to vary the presentations so much.
Plan weekly meals
Improvising is not healthy; being hungry and not having anything prepared often leads to fast food such as pasta or sandwiches, and not, on the other hand, to taking the time to prepare a varied salad or a plate of pulses, dishes which, if we already have them ready, avoid falling into the quick fix of carbohydrates.
Another recommendation linked to healthy eating is to go shopping without hunger and having foreseen everything you will need during the week so as not to buy what is not convenient. In this way, we will also avoid wasting food. Buying the healthiest food, says Dr Gotor, “can be a little more expensive, because refined sugars and flours are cheaper and make the taste much stronger, but if you can’t buy as much meat or fish, then pulses are a very affordable source of protein”.
Red meat – why limit consumption?
Red meat has a bad reputation because the WHO published that it can affect the cardiovascular system and the intestine, and even have a carcinogenic effect, in particular colon cancer. “But this does not detract from the nutritional quality of red meat, because of its benefit in protein and iron. There is no other food in which they are more absorbable,” argues Dr María Gotor. You can live without eating red meat, but it has its benefits, another thing is what you accompany it with, whether it is chips, sauces… We must also distinguish between processed red meat, and especially industrially prepared meat, because if you buy a fillet of beef, chop it up and make meatballs, it is just as healthy as a grilled steak,” says the paediatrician. Processed meat should be limited to once or twice a week, because of its unhealthy components such as flavour and colour enhancers.
Sausages, hot dogs and sausages such as fuet or chorizo should be limited to very occasional consumption due to their high salt and unhealthy fat content and additives. The nutritionist at Sant Joan de Déu Hospital recommends eating red meat no more than twice a week. Meat in general, including poultry and rabbit, she recommends 3 or 4 times a week. And fish, 3 to 4 times a week, both white and blue fish. “Of oily fish, however, small and medium-sized fish should be prioritised and at least once a week. While large oily fish, such as tuna or swordfish, shark or pike, the Spanish Agency for Food Safety and Nutrition recommends avoiding their consumption in children under 10 years of age, and between 10 and 14 years of age, limiting consumption to 120 grams per month, due to their mercury content,” he argues.
How many eggs per week?
“The consumption of one egg a day would not be related to negative effects on health, but such a high consumption of eggs could lead to the consumption of other interesting foods such as fish or pulses, which is why we are talking about consuming eggs 3 or 4 times a week,” says Dámaris.
María Gotor also believes that the consumption of eggs should not be limited, an issue that she assumes is much debated, but she also considers it right to limit them if it is so as not to displace other options, because hens are totally healthy. “I would be more concerned about how many croissants you eat per day, and yet no one asks that question, just like how many biscuits you can eat per week,” he says. As for the cholesterol associated with egg consumption, as the paediatrician explains, it should not be forgotten that cholesterol is a particle found in cell membranes and can be consumed, but it is a different matter what the egg is accompanied with, such as bacon, or the oil with which it is fried. The problem is not the egg, but the diet with which it is accompanied.
How often do you eat pulses?
Pulses are also part of a Mediterranean dietary pattern and should be eaten 3 or 4 times a week. According to the Sant Joan de Déu nutritionist, “pulses are a very interesting food because they not only provide protein, but also carbohydrates, fibre, vitamins and minerals. It is very complete and versatile and we should include it in our weekly diet. It could form part of the carbohydrate group, together with bread, potatoes, and also with the protein group, which is meat, eggs and fish.
How can we discern which sugars are best for children and adolescents?
The difference lies in whether sugars are part of the natural food or whether they are added, says Aida Vasquez. All sugars added to food (cereals, dairy products, processed and ultra-processed foods…) that are not suitable for children, adolescents or adults should be avoided. Sugars that are naturally present in food, such as those found in fruit and dairy products, can be consumed. For example, if you prepare homemade custard with natural ingredients, instead of sugar you can add fruit or dates, or at least reduce the amount of sugar and enjoy more flavours such as vanilla.
Sugar consumption in the general population is considered to be high. Therefore, getting children used to savouring the natural taste of food, reducing sugars as much as possible, is a healthy recommendation. The nutritionist at the Hospital de Sant Joan de Déu, Dámaris Martínez, invites parents to work conscientiously on the threshold of sweetness demanded by the palate. She advises the progressive elimination, if they have already been introduced, of added sugars and sweeteners or honey, for example in natural yoghurt. It is preferable, he says, to add cinnamon, fruit pieces such as bananas, sultanas, nuts or ground seeds.
It is also advisable to reduce salt as much as possible, compensating or substituting it whenever possible with spices. In processed products, it is usually too much, but in natural food, salt consumption is reduced. “Using salt in cooking is not a problem, but it is a different matter to take the salt shaker to the table and add it. It is better to incorporate spices, for example, oregano or black pepper in spaghetti, or thyme in natural tomato sauce.
To drink, water
Water should be the drink of choice in childhood and adolescence. However, there is no recommended amount of water consumption per day at these ages; drinking when you are thirsty is what paediatrician María Gotor recommends. In order to move towards healthy consumption, Dámaris Martínez points out that an adequate water intake for children would be around one and a half litres, and for adolescents between two and two and a half litres. In any case, it should be taken into account whether the child or adolescent is physically active and what their needs are, but in general it is recommended that water should be the drink of choice at main meals and that intakes should be made throughout the day. “They need to hydrate themselves and, if they can take a bottle of water with them and refill it throughout the day, so much the better”.
What all the specialists in healthy eating in the early stages of life agree on is the need to minimise the consumption of sugary drinks. Even juices should only be consumed on exceptional occasions, due to their sugar or preservative content, additives that enhance flavours or colours. On home-prepared natural juices, it is argued that it is much better to eat a whole fruit than to drink only the juice. “The interesting thing is the fibre composition of the fruit, which, together with its sugars, slows down absorption and has a better impact on the body,” says the paediatrician. When only the juice of the fruit is drunk, the sugars basically reach the body.
In the case of adolescents, drinking tea, according to Dàmaris Martínez, would not be a problem, if consumption is moderate and adapted in a natural way, without adding sugar, but always insisting on water as the main drink. Coffee, on the other hand, should be avoided or limited at this age.
As for the consumption of milk and vegetable drinks, as long as there is no contraindication of intolerance to dairy products, consumption of these should not be withdrawn, and, in the case of vegetable drinks, they should always be without added sugars and enriched with calcium and vitamin D.
With bread, it is important to be clear that it is made with flour, water and yeast. Anything that deviates from this, anything that can be added to it, such as milk, sugar, preservatives or additives, already blurs its quality. In the case of wholemeal breads, it is important to know the percentage of wholemeal flour used, both in fresh bread – ask the baker – and in toasted and sliced breads.
As for the vegetarian diet, paediatrician María Gotor recommends that until the age of two, at least, children should be omnivorous, because there are certain elements, such as a specific omega-3 present in fish, which are related to neuronal development.
