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A Primer for Pediatricians

A Primer for Pediatricians

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  • 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
  • Appetitive traits
  • 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?

Transcript

  • 1. NUTRITION FACTSA Primer for Pediatricians Bonnie Y. Modugno, MS, RD www.muchmorethanfood.com
  • 2. 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
  • 3. 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”
  • 4. Nutrition Science ▪ Nutrients in food ▪ Macronutrients: The energy nutrients ▪ Carbohydrate ▪ Protein ▪ Fat ▪ Micronutrients ▪ Vitamins ▪ Minerals
  • 5. 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
  • 6. 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.
  • 7. Macronutrients Matter: Effects of Meal High in Carbohydrate on Satiety in Pre-pubertal Children NW Obese Lomenick J P et al. JCEM 2009;94:4463-4471©2009 by Endocrine Society
  • 8. Macronutrients Matter: Effects of Meal High in Protein on Satiety in Pre-pubertal Children NW Obese NW Pre-adol. Obese Pre-adol. Lomenick J P et al. JCEM 2009;94:4463-4471©2009 by Endocrine Society
  • 9. 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
  • 10. 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).
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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.
  • 16. 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)
  • 17. 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)
  • 18. Energy Metabolism Food supply Endocrine Physical activity Disruptors Pharmaceutical Gut Microbes Iatrogenesis Sleep Maternal debt/chronic Metabolic Health stress
  • 19. Our Current Food Supply
  • 20. Are Supermarkets the Answer?
  • 21. Current Food Supply?▪ Weekly food costs▪ N. Carolina, USA▪ $341.98 Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005.
  • 22. Our Current Food Supply▪ Weekly food costs▪ California, USA▪ $159.18 Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005
  • 23. Current Food Supply▪ Weekly food costs▪ Mexico▪ $189.09 Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005
  • 24. Current Food Supply▪ Weekly food costs▪ Guatemala▪ $76.70 Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005
  • 25. USDA Food Disappearance Data
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. Proposed model of fetal programming of offspring of women with abnormal metabolic environment (increased insulin resistance). Catalano P M Reproduction 2010;140:365-371© 2010 Society for Reproduction and Fertility
  • 36. Infections micro- infections antibiotics biome
  • 37. Intestinal microbiota during infancy ▪ Factors that shape microbiota ▪ maternal stress ▪ mode of delivery ▪ feeding method ▪ introduction of solid foods ▪ antibiotic exposureChristoph Reinhardt, Christopher S. Reigstad, and Fredrik Ba¨ckhed. Journal of PediatricGastroenterology and Nutrition. 48:249–256 © 2009
  • 38. 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
  • 39. Influencing gut microbiota Favor bacteroidetes Favor firmicutes (obesity) (leanness) ▪ Maternal well being ▪ Maternal stress ▪ Vaginal delivery ▪ C-section ▪ Breastfeeding ▪ Formula feeding ▪ Greater resistant starch ▪ More refined carbohydrates ▪ Less exposure to antibiotics ▪ High fat diet (?) ▪ Greater exposure to antibioticsChristoph Reinhardt, Christopher S. Reigstad, and Fredrik Ba¨ckhed. Journal of PediatricGastroenterology and Nutrition. 48:249–256 © 2009
  • 40. 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
  • 41. 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.
  • 42. 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)
  • 43. 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
  • 44. 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.
  • 45. What about psychiatric conditions?ICAN, Volume 4, Number 5, October, 2012
  • 46. 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.
  • 47. Pharmaceutical Iatrogenesis1.81.61.41.2 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
  • 48. 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
  • 49. 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)
  • 50. Food System–Related Environmental Chemicals Detectable In Pregnant Women In The United States, 2003–04. Sutton P et al. Health Aff 2011;30:888-897©2011 by Project HOPE - The People-to-People Health Foundation, Inc.
  • 51. Endocrine Disruptors, POP’s Impaired neurological growth and function  Learning disabilities  Autism Impaired glucose tolerance  Obesity, Diabetes  Cardio -Metabolic Syndrome  Cancer Impaired thyroid function  Obesity  Cancer Impaired fertility; reproduction  PCOS  Low Testosterone (males)
  • 52. Nutrition and Metabolic Health: Where do we start? Pregnancy Pre- Infancy pregnancy Adolescence Childhood True prevention addresses food, nutrition, lifestyle throughout the life cycle
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. 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)
  • 57. 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
  • 58. Dietary Guidelines for Fit Kids▪ Avoid getting over hungry▪ Eat regular meals, snacks through the dayStarving Just Enough Full Stuffed Still Hungry Satisfied Overfull
  • 59. 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