Tufts UniversityStudy of high insulin secretors vs. low insulin secretors [hi secretors >66 mU/l< low secretors]N= 32 (24-42 years old)BMI 25-29.9FBG <100 mg/dl24 week trial – 30% calorie restriction compared to individual baseline energy needs (2017 vs. 1972 calories)60:20:20 15 g fiber/1000 kcal GL116g/1000kcal mean GI 8640:30:30 15 g fiber/1000 kcal GL 45g/1000 kcal meanGI 53
The extreme changes in soil treatment from 1950 – 1999 show how the dramatic effect conventional farming practices are having on nutrient content. Vitamin C content
Average supermarket items in 1970-- 12,000Average supermarket items today – 48,000
Land of immigrantsPeople come to America looking for opportunityHow many of us are predisposed genetically and epigenetically to survive abundance?
How does farm policy play out in the grocery store? Fresh fruits and vegetables cost more
DDT. PCB. Bisphenyl A, Pthalates. PBDE, Perfluorocatonic acid (PFOA)Some other examples of putative EDCs are polychlorinated dibenzo-dioxins (PCDDs) and -furans (PCDFs), polycyclic aromatic hydrocarbons (PAHs), phenol derivatives and a number of pesticides (most prominent being organochlorine insecticides like endosulfan and DDT and its derivatives, the herbicide atrazine, and the fungicide vinclozolin), the contraceptive 17-alpha ethinylestradiol, as well as naturally occurring phytoestrogens such as genistein and mycoestrogens such as zearalenone.
Is your hunger gone?
Nutrition Facts aap district 4 2012
NUTRITION FACTSA Primer for Pediatricians Bonnie Y. Modugno, MS, RD www.muchmorethanfood.com
Full Disclosure Statement Slide▪ Bonnie Y. Modugno, MS, RD▪ has no financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CME activity
Nutrition Facts: A Primer for Pediatricians▪ GOALS▪ Review a range of food and nutrition factors influencing energy metabolism▪ Discuss the benefits of a whole foods based diet▪ Develop key strategies that help families develop the skills and capacity to eat “close to the earth”
Nutrition Science ▪ Nutrients in food ▪ Macronutrients: The energy nutrients ▪ Carbohydrate ▪ Protein ▪ Fat ▪ Micronutrients ▪ Vitamins ▪ Minerals
Food Composition Matters * * 0 -1 Weight change (kg) -2 -3 -4 -5 -6 High CHO Low CHO -7 -8 -9 -10 Low InsulinHigh Insulin Secretor SecretorPittas, A. et al. Diabetes Care 28 (12): December 2005
Food Composition MattersoConventionalDieto1700 KcaloCHO 55-60%oFAT 25-30%•ExperimentalDiet•Low Glycemic•CHO 45-50%•FAT 30-35%•Ad libitum Ebbeling, C. B. et al. Arch Pediatr Adolesc Med 2003;157:773-779. Copyright restrictions may apply.
How Food Is Produced Matters: Omega 3 Fatty Acids g/100 g lipid201816141210 Grass fed crossbred steers8 Grain fed crossbred steers6420 omega 6 FA Omega 3 FA Ratio 6:3 CLA Daley, et al. Nutrition Journal 9:10:2010
Vitamins and Minerals Matter Is this the impact of conventional farming?▪ Vitamin C Content in Food (mg/100g) 120 100 80 60 1950 40 1999 20 0 Asparagus Collard Grns Mustard Broccoli Grns Wunderlich, S. M., Feldman, C., Kane, S., & Hazhin, T. (2008).
Vitamins:Does how we grow our fruits and vegetables matter? Matched pairs = 67 Organically grown higher = 41 Conventionally grown higher = 26Courtesy of Charles Benbrook, www.organic-center.org ADA
Minerals:Does how we grow our fruits and vegetables matter? Matched pairs = 65 Organically grown higher = 34 Conventionally grown higher = 29 Courtesy of Charles Benbrook, www.organic-center.org ADA presentation , 2008
Nutrition Science ▪ macronutrients: carbohydrate, protein and fat ▪ vitamins and minerals ▪ fiber, resistant starch, omega 3 fatty acids, phytochemicals, antioxidants, gut microbes ▪ trans fats, high fructose corn syrup, artificial colors, artificial flavors, genetic engineering ▪ antibiotic resistant bacteria, bee colony collapse disorder, dead zones, pesticides, persistent organic pollutants , body burden, mercury
Nutrition Science:▪ More than essential Ecosyste ms nutrients Soil Ecology Water▪ More than food Quality Air Quality▪ More than the Pesticides human Fertilizers Hormones experience Antibiotics Nutrients
CHILD OBESITY: State of the Nation 70 ▪ Change in incidence of 60 obesity / overweight between 1970 and 2000 50 40 1970s 30 2000 20 10 0 Adult CH ADUS Dept of Health and Human Services, NCHS, Prevalence of overweight and obesity among adults and adolescents, 1999-2000.
Ten Putative Contributors to the ObesityEpidemic▪ Food marketing practices ▪ Maternal age▪ Physical activity ▪ Assortative mating▪ Infections ▪ Sleep debt▪ Perinatal epigenetic factors ▪ Endocrine disruptors ▪ maternal obesity ▪ over/undernutrition ▪ Pharmaceutical iatrogenesis ▪ hyperinsulinemia ▪ Ambient temperatureCritical Reviews in Food Science and Nutrition 49(10) 868-913 (2009)
Contributors to the Obesity Epidemic▪ Current food supply marketing ▪ Infections practices ▪ Gut Microbiota ▪ Cost of whole foods ▪ USDA farm policy ▪ Assortative mating▪ Physical activity ▪ Sleep debt▪ Perinatal epigenetic factors ▪ Endocrine disruptors ▪ maternal metabolic health obesity ▪ Pharmaceutical iatrogenesis ▪ over/undernutrition ▪ HyperinsulinemiaAdapted from Critical Reviews in Food Science and Nutrition 49(10) 868-913 (2009)
Energy Metabolism Food supply Endocrine Physical activity Disruptors Pharmaceutical Gut Microbes Iatrogenesis Sleep Maternal debt/chronic Metabolic Health stress
Cost of Food Soft Drinks Fats/Oils Eggs Sugar/Sweets Poultry % Increase Red Meat Dairy Cereal/Bakery Fish Fr and Veg Fr. Fruit and Veg 0 50 100 1502002 USDA
How Much Does 100 Calories Cost? 90 80▪ Cost in cents 70 Soda 60 Bread▪ Vegetables and fruits cost more per 50 Potato chips calorie Cookies 40 Licorice 30 Orange▪ Food costs surveyed Sept/2011 20 Apple Carrots 10 0 100 Calories
Obesity is really an economic issue > 30 BMI ▪ 2010 Adam Drewnowsky 45 (UW) study 40 35 30 25 ▪ Funded by NIH grant 20 15 10 > 30 BMI 5 ▪ 2001 Seattle shoppers in 0 low cost vs. high priced grocery storeshttp://www.msnbc.msn.com/id/37280972/ns/health-diet_and_nutrition/t/pricey-grocery-stores-attract-skinniest-shoppers/#.T4ioY9m8S5J
Physical Activity▪ Calories burned▪ Increased insulin sensitivity ▪ Enhanced glucose uptake ▪ Moderated insulin secretion in response to carbohydrate load ▪ Greater use of fat for fuel ▪ Greater satiety over time ▪ More effective regulation of food intake ▪ Sharper distinction between hunger and satiety▪ Excessive activity/overtraining ▪ Increased insulin resistance ▪ Can mitigate benefits
Exercise training and insulin resistancesyndrome in obese children1.4 • Body Fat %1.2 10.8 EX/ No EX0.6 No EX/ EX0.40.2 0 MONTH 0 MONTH 4 MONTH 8Ferguson MA, et al. International Journal of Obesity (1999) 22, 889±895
Exercise training and insulin resistance syndrome in obese children1.4 • Triglycerides (mmol.l -1)1.2 10.8 EX/ No EX0.6 No EX/ EX0.40.2 0 MONTH 0 MONTH 4 MONTH 8 Ferguson MA, et al. International Journal of Obesity (1999) 22, 889±895
Exercise training and insulin resistancesyndrome in obese children200 • Insulin levels180 (pmol.l -1)160140120100 EX/ No EX 80 No EX/ EX 60 40 20 0 MONTH 0 MONTH 4 MONTH 8 Ferguson MA, et al. International Journal of Obesity (1999) 22, 889±895
Exercise training and insulin resistancesyndrome in obese children5.4 • Glucose (mmol.l - 1)5.2 54.8 EX/ No EX4.6 No EX/ EX4.44.2 4 MONTH 0 MONTH 4 MONTH 8 Ferguson MA, et al. International Journal of Obesity (1999) 22, 889±895
Perinatal Epigenetic Factors▪ Before pregnancy health status ▪ Nutrient intake, calorie intake ▪ Relative insulin sensitivity ▪ Activity level, stress management▪ Perinatal nutrition status ▪ Diet & activity ▪ Glucose tolerance ▪ Total and rate of weight gain▪ Nutrition status infant ▪ Birth weight, body composition, rate of weight gain ▪ Breast v. bottle feeding
Gut Microbiome and Obesity Executive Summary ▪ At birth, humans are essentially free of bacteria and over time the body becomes a host to complex microbial communities ▪ Dietary habits are considered to be one of the main factors that contribute to gut microbiota. ▪ Microbial changes in the human gut are one of the possible causes of obesity.http://www.futuremedicine.com/doi/pdf/10.2217/fmb.11.142
Sleep Debt ▪ Children with shorter sleep duration had a 58% higher risk for overweight or obesity, ▪ Children with shortest sleep duration had an even higher risk (92%) ▪ Each hour increase in sleep, reduces the risk of overweight/obesity by 9% on averageXiaoli Chen, May A. Beydoun, Youfa Wang. Is Sleep Duration Associated With Childhood Obesity? ASystematic Review and Meta-analysis. Obesity Volume 16, Issue 2, pages 265–274. February 2008
Chronic Stress ▪ Both behavioral and biological pathways are involved in the connection between chronic stress and obesity in adults and children ▪ Emotional "comfort" eating ▪ Lack of sleep ▪ Impulsive behaviors ▪ Selection of specific foods Eat Weight Disord. 2010 September; 15(3): e166–e172.
What is Stress? ▪ How much is sensory integration a factor? ▪ At what point is the stimulus/lack of stimulus overwhelming? Touch/pressure Taste Smell Light/visual stimuliHyposensitive Auditory stimuli Hypersensitive Vestibular stimulation’ Developmental expectations Academic expectations Social expectations . Family stress (time/$/relationships)
Genetic Traits Impact Food Intake ▪ Up to 69% of eating behaviors may be genetically determined ▪ Response to internal satiety cues ▪ Response to taste or smell of food ▪ Sensitivity to rewards/reinforcement for eating preferred foods ▪ Food preferences ▪ Parental monitoring of food intake ▪ is more result of child obesity, not an antecedentStang and Loth. ADAJ:111(9) 1301-1305
Chronic Stress ▪ Four studies examined ADHD in obese adults and teens and reported higher- than-expected prevalence ranging from 13.3% to 57.7% ▪ Elevated cortisol/insulin drives refined starch and sugar intake ▪ How much of the issue is undeveloped self regulation and/or resilience? Eat Weight Disord. 2010 September; 15(3): e166–e172.
What about psychiatric conditions?ICAN, Volume 4, Number 5, October, 2012
What about neuro-developmental disabilities ? • Children with disabilities account for 9.2% of school age children (autism spectrum disorder, Down Syndrome, cerebral palsy, intellectual disability) • Obesity occurs disproportionately in children withICAN, Volume 4, Number 4, August, 2012 developmental disabilities.
Pharmaceutical Iatrogenesis220.127.116.11.2 1 Underweight OR0.8 At Risk for Overweight0.6 OR0.4 Overweight OR0.2 0 ADD/ADHD ADD/ADHD ADD/ADHD ADD/ADHD no meds meds no meds meds (adj) (adj) Pediatrics July 2008 vol. 122 no. 1 e1-e6 doi: 10.1542/peds.2007-1955
Iatrogenic Medications for Kids▪ Weight gain is possible with many medications ▪ Psychoactive meds ▪ Anti-psychotics ▪ Mood stabilizers ▪ Antidepressants ▪ Diabetes Meds ▪ Insulin, Sulfonureas ▪ Steroids ▪ Prednisone ▪ Meds for allergies, asthma ▪ Oral birth control ▪ ??? Antibiotics
Endocrine Disruptors (POPs): Sources & Pathways to Human Exposures SOURCES TRANSPORT DEPOSITION FOOD SUPPLY Industrial ProcessesCombustion Runoff Erosion Direct DischargeCourtesy of Dr. Linda Birnbaum, PhD, Director of Toxicology, EPA (adapt)
Nutrition and Metabolic Health: Where do we start? Pregnancy Pre- Infancy pregnancy Adolescence Childhood True prevention addresses food, nutrition, lifestyle throughout the life cycle
Is doing something better than nothing?▪ Nutrition counseling is not well studied in the context of primary care▪ Clinicians report only 55 seconds, on average, per visit were spent with children on nutritional counseling▪ Nutrition counseling only occurred for 33% of obese children, and 25% of all visits to family practice physiciansICAN, Wilhelm et al. Vol 4, No. 5, Oct, 2012
Cultivating an approach to food that works▪ Improve metabolic Organic/Local health Foods▪ Measure true MORE WHOLE FOODS, biomarkers Less refined sugar/starch/fat▪ Focus on Better balance behaviors, not body of size CHO/PRO/FAT MoveICAN, Wilhelm et al. Vol 4, No. 5, Oct, 2012
Stop, Start, Continue ▪ STOP ▪ Assuming ideal weight or BMI is the same as metabolic health ▪ Believing weight loss is a simple math problem ▪ Using weight or BMI to determine who needs nutrition counseling. All children and their families benefit from effective food, nutrition and lifestyle support
FOOD COMPOSITION CHO PRO /CHO PRO +CHO w/ FATEat balancedmeals andsnacks •Enough protein •Carbohydrates from whole foods, mostly produce •Enough healthy 0 1 2 3 4 5 fats SATIETY --TIME AFTER EATING (hours)
Stop, Start, Continue ▪ START ▪ Considering what approach to food is best for any one patient ▪ Mix of macronutrients ▪ Food distribution ▪ How much is enough ▪ Considering each encounter an opportunity to teach/reinforce self- regulation and resilience
Dietary Guidelines for Fit Kids▪ Avoid getting over hungry▪ Eat regular meals, snacks through the dayStarving Just Enough Full Stuffed Still Hungry Satisfied Overfull
Stop, Start, Continue CONTINUE ▪ Engaging with each child, each family, actively assessing the capacity to change ▪ Readiness ▪ Willingness ▪ Ability ▪ Focusing on the process, not just the outcome ▪ Providing appropriate referrals and resources for additional support