Eat Your Vegetables!
Healthy Eating in Youth
Deanna M. Hoelscher, PhD, RD, LD
Youth-Nex Conference
October 10, 2013
Presentation
• Why do children need a healthy
diet?
• What are the recommendations for
a healthy diet in youth?
• What do ...
Definitions
• Nutrition is the science of food, the nutrients, and
other substances within food; their
action, interaction...
Why is Dietary Intake
Important?
• Critical determinant of several of
the major causes of death &
disability
– CVD, Cancer...
Recommendations for Healthy Diets
• U.S. Dietary Guidelines (revised in 2015)
• Dietary Reference Intakes
• Healthy People...
Dietary Issues for Children
• Obesity (HFSS)
– Sugary Beverages
– Snack consumption

• Fruit and vegetable consumption
• C...
Weight Difference (lb)

Weight Gain for Children at the 95th
Percentile from Age 6.5 to 18.5

OW/OW

18
16
14
12
10
8
6
4
...
Trends in Weight Status among US
Adolescents
80
70

70.1
66.6

60

Underweight
Normal
Overweigt
Obese

50
40
30
20
10
0

6...
Children in Texas Have High Rates of
Obesity
Obesity is > 95th Percentile for BMI by Age/Sex

40
35
30
25

20

25.6 23.5 2...
Trends in consumption of
fruits, vegetables, sweets and sweetened soft
drinks
5
4.91

4.85

4.8

4.7

4.71
4.61

4.6
4.4
4...
Trends in Student Food Choices by
Grade, SPAN 2000-2002
Question: Yesterday, did you eat..

ORadj

Grade
4th
8th
11th

p-v...
Trends in Student Food Choices by
Grade, SPAN, 2000-2002
Question: Yesterday did you eat..
Yogurt or cottage cheese or dri...
Trends in Student Food Choices by
Grade, SPAN, 2000-2002
Question: Yesterday did you eat..

Grade

ORadj

p-value

Beans s...
SSB Consumption in Children and
Overweight/Obesity
• 2 recent studies:
– Ebbeling et al., 2012, NEJM
• RCT with 224 overwe...
Vegetables & fruit in the home

Source: Chen et al., Lunch is in the Bag, unpublished data
Vegetables & fruit in
lunches
Top 5 veg. items =
51% of veg. items packed

Top 5 fruit items =
54% of fruit items packed

...
Grain ratio: home vs. lunch
Home

Lunches (overall)

0.30

0.29
0.71

WG only: 22% (n=127) of homes

0.70

WG only: 10% (n...
Total body bone gain cm/yr

Total Body Bone Mineral Content Velocity
Curves in Peripubertal Boys and Girls
450
400
350
300...
Calcium Supplementation during
Adolescence Increases BMD

% increase/year

10

*

8

*

6

*

*

4
2
0

Lee '94

Lee '95

...
Trends in Student Meal Consumption
by Grade, SPAN, 2000-2002
Question: Yesterday, did you...
Eat breakfast?

Have more tha...
Our Environment is ‘Obesogenic”

2005
2002
How Much Nutrition Education is
Enough?

7600 food ads/year
153 F&N/ year

• Briggs, M., et. al, (2010). Position of the A...
GO-SLOW-WHOA
WHOA
Highest fat and
sugar

SLOW
Higher in fat and sugar,
More processed foods
GO
Lowest in fat, no
added
sug...
Final Thoughts
• Nutritional recommendations for school-aged
children are relatively well-established; less so for
prescho...
The test of the morality of a society is what
it does for its children.
Dietrich Bonhoeffer
THANK YOU
Deanna M. Hoelscher, PhD, RD, LD
Deanna.M.Hoelscher@uth.tmc.edu
UTHealth | The University of Texas Health Scienc...
Acknowledgements and Supporters
Acknowledgements: Deanna M. Hoelscher, PhD; Steven H.
Kelder, PhD, Andrew Springer, DrPH; ...
Vision & Mission
Vision
Healthy Children in a
Healthy World

Mission
To serve as the state,
national, and international
le...
msdcenter.org
Center Social Media Sites
msdcenter
GO – SLOW – WHOA (GSW) List
• A tool to guide children and families toward
making healthy food choices
• Overall message: ...
Deanna Hoelscher, Ph.D, R.D., L.D. - "Eat Your Vegetables! Benefits of Healthy Eating in Youth"
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  • 204-263 kcal/day is Energy gapNormal weight children gained about 9 pounds per year, while overweight gained a mean of 16; Normal to overweight gained 15 pounds
  • Grades 6-10 – self-reported weights and heightsNationally representative sample.
  • Talking Points: Children aged 2-19, HP 2020 goal is 14.6%School Physical Activity and Nutrition (SPAN) is a surveillance study documenting child obesity rates in Texas at the state and regional levels. Obesity rates in Texas school-aged children are higher than average and therefore there was an immediate need for intervention
  • Scale:3: 1 day/week4: 2-4 days/week5: 5-6 days/week6: once/day7:>once/daySurveys done in 2001-2002, 2005-2006, 2009-2010
  • 224 adolescents, 85th percentile or greater, grades 9-10, drank at least one 12-oz beverage/day – home-basedn average by 0.02 SD units in the sugar- free group and by 0.15 SD units in the sugar group; Weight increased by 6.35 kg in the sugar-free group as compared with 7.37 kg in the sugar group (95% CI for the difference, −1.54 to −0.48). The skinfold-thickness measurements, waist-to-height ratio, and fat mass also increased significantly less in the sugar-free group. Adverse events were minor.
  • Text box: mean, SD availability; accessibilityThere was large variety of fruits and vegetables available in homes: (means and SD, out of possible range)So it seems that in this sample, parents have home food environment where families can “eat the rainbow”—or in other words, follow dietary recommendations to eat a large variety of different types of produce. Superimpose text box: mean +/- SD vegetable and fruit availability484 lunches
  • Need to add list of top 5 veg, top 5 fruit, with n’s to show steep drop-offMaybe add mean servings packedHowever, the variety of vegetables and fruits packed in lunch boxes was much more limited. These were the handful of most frequently packed vegetables and fruits. Lunch packed—limited variety—”monochromatic”
  • Reaffirmed by a recent systematic review: Uusi-Rasi et al., Food & Nutrition Research, 2013Calcium needed, as well as vitamin D
  • Scheer FA et al., Obesity, 2013; March 21 (3): Katz. Childhood Obesity October 2013
  • NOTE: the mission may change depending on feedback, finalization of priorities.
  • Deanna Hoelscher, Ph.D, R.D., L.D. - "Eat Your Vegetables! Benefits of Healthy Eating in Youth"

    1. 1. Eat Your Vegetables! Healthy Eating in Youth Deanna M. Hoelscher, PhD, RD, LD Youth-Nex Conference October 10, 2013
    2. 2. Presentation • Why do children need a healthy diet? • What are the recommendations for a healthy diet in youth? • What do current youth diets look like? • What can we do to improve them?
    3. 3. Definitions • Nutrition is the science of food, the nutrients, and other substances within food; their action, interaction, & balance in relation to health & disease; and the processes by which the organism ingests, absorbs, transports, uses & excretes food substances. Guthrie & Picciano, 1995 • Nutrition is needed for – Energy – Maintenance of biologic processes – Growth & development (infants/children/adolescents) • Nutrients include macronutrients (lipid, protein, carbohydrate), water, vitamins, miner
    4. 4. Why is Dietary Intake Important? • Critical determinant of several of the major causes of death & disability – CVD, Cancer, Type 2 Diabetes, Obesity • Modifiable behavior • “Universal & indispensable human exposure” Kumanyika, 2000
    5. 5. Recommendations for Healthy Diets • U.S. Dietary Guidelines (revised in 2015) • Dietary Reference Intakes • Healthy People 2020 Goals – Example: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=2 9 • Leading Health Indicators – Health Indicators Warehouse: http://www.healthindicators.gov/ • Others
    6. 6. Dietary Issues for Children • Obesity (HFSS) – Sugary Beverages – Snack consumption • Fruit and vegetable consumption • Calcium consumption • Meal patterns/timing of foods
    7. 7. Weight Difference (lb) Weight Gain for Children at the 95th Percentile from Age 6.5 to 18.5 OW/OW 18 16 14 12 10 8 6 4 2 0 N/OW N/N Boys Girls 6 to 7 7 to 8 8 to 9 9 to 10 to 11 to 12 to 13 to 14 to 15 to 16 to 17 to 10 11 12 13 14 15 16 17 18 Age in Years Source: CDC weight charts, Butte & Ellis, 2003 OW = overweight, N = normal wt
    8. 8. Trends in Weight Status among US Adolescents 80 70 70.1 66.6 60 Underweight Normal Overweigt Obese 50 40 30 20 10 0 66.5 14.9 10.3 4.7 2001 17 16.6 12.7 12.7 3.7 2005 4.2 2009 Source: Iannotti RJ & Wang J. Trends in physical activity, sedentary behavior, diet, and BMI among US adolescents, 2001-2009. Pediatrics.2013;132(4):606-614
    9. 9. Children in Texas Have High Rates of Obesity Obesity is > 95th Percentile for BMI by Age/Sex 40 35 30 25 20 25.6 23.5 23.8 23 18 18.8 17.5 21.6 18.4 17.3 18.4 14.5 15 10 5 0 4th grade 2000-02 8th grade 2004-05 2009-11 11th grade NHANES 2009-2010 Sources: Hoelscher et al., 2004; Hoelscher et al., SPAN; Ogden et al., 2012 Healthy People 2020 Goal, 1 4.5%
    10. 10. Trends in consumption of fruits, vegetables, sweets and sweetened soft drinks 5 4.91 4.85 4.8 4.7 4.71 4.61 4.6 4.4 4.2 4 4.29 4.31 4.46 4.46 4.36 Eat fruits (1 never-7>once/day) 4.18 4.1 Eat vegetables (1 never-7>once/day) 3.8 Eat sweets (1 never-7>once/day) Drink soft drinks (1 never-7>once/day) 3.6 2001 2005 2009 Source: Iannotti RJ & Wang J. Trends in physical activity, sedentary behavior, diet, and BMI among US adolescents, 2001-2009. Pediatrics.2013;132(4):606-614
    11. 11. Trends in Student Food Choices by Grade, SPAN 2000-2002 Question: Yesterday, did you eat.. ORadj Grade 4th 8th 11th p-value 1 1.97 2.16 (1.45;2.69) (1.66;2.81) 0.000 0.026 * † 8 11th 1 0.88 1.14 (0.64;1.21) (0.81;1.60) 0.465 0.162 * † Gravy (either on a food or by itself)? 4th 8th 11th 1 1.12 1.58 (0.76;1.64) (1.04;2.41) 0.032 0.514 * † Peanuts or peanut butter? 4th 8th 11th 1 0.67 0.73 (0.52;.85) (0.55;.98) 0.036 0.058 * † Cheese by itself or on your food? 4th 8th 11th 1 2.49 1.86 (1.75;2.73) (1.31;2.65) 0.001 0.000 * † Drink any kind of milk? 4th 8th 11th 1 0.45 0.27 (0.37;0.55) (0.21;0.35) 0.000 0.113 * † Hamburger meat, hot dogs, sausage (chorizo), steak, bacon, or ribs? Any fried meat with a crust, like fried chicken, chicken nuggets, chicken fried steak, fried pork chops, or fried fish? 4th th + Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007
    12. 12. Trends in Student Food Choices by Grade, SPAN, 2000-2002 Question: Yesterday did you eat.. Yogurt or cottage cheese or drink a yogurt drink? Rice, macaroni, spaghetti or pasta noodles? Any bread, bun, bagel, tortilla or roll? Any hot or cold cereal? French fries or chips? Any vegetables? Grade 4 th 8 th 11 th 4 th 8 th 11 th 4 th 8 th 11 th 4 th 8 th 11 th 4 th 8 th 11 th 4 th 8 th 11 th OR adj 1 0.5 0.52 1 0.81 0.99 1 2.06 2.46 1 0.65 0.48 1 1.98 1.38 1 0.76 0.94 p-value (0.31;0.80) (0.30;0.90) 0.019 0.105 * † (0.66;.99) (0.78;1.27) 0.958 0.032 * † (1.61;2.61) (1.75;3.47) 0.000 0.021 * † (0.53;.80) (0.35;.64) 0.000 0.604 * † (1.46;2.69) (0.70;2.73) 0.354 0.004 * † (0.57;1.01) (0.73;1.21) 0.614 0.083 * † + Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007
    13. 13. Trends in Student Food Choices by Grade, SPAN, 2000-2002 Question: Yesterday did you eat.. Grade ORadj p-value Beans such as pinto beans, baked beans, kidney beans, refried beans or pork and beans? 4th 8th 11th 1 1.26 1.48 (0.96;1.67) (1.04;2.09) 0.030 * 0.738 † Fruit? 4th 8th 11th 1 0.41 0.33 (0.32;0.53) (0.23;0.48) 0.000 * 0.007 † Drink fruit juice? 4th 8th 11th 1 0.73 0.68 (0.52;1.02) (0.43;1.06) 0.088 * 0.467 † A frozen dessert? 4th 8th 11th 1 0.88 0.54 (0.73;1.08) (0.40;0.72) 0.000 * 0.049 † Sweet rolls, doughnuts, cookies, brownies, pies, or cake? 4th 8th 11th 1 1.87 1.92 (1.46;2.40) (1.49;2.48) 0.000 * 0.007 † Any chocolate candy? 4th 8th 11th 1 1.37 1.17 (0.98;1.91) (0.91;1.51) 0.242 * 0.111 † + Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007
    14. 14. SSB Consumption in Children and Overweight/Obesity • 2 recent studies: – Ebbeling et al., 2012, NEJM • RCT with 224 overweight/obese adolescents • Intervention was displacement of SSB with non-caloric beverages, MI • At Year 1 and Year 2,  SSB, E in Intervention group • Change in BMI at 1 year, but not 2 years – Did see changes in Hispanic adolescents at 1 and 2 years – deRuyter et al., 2012, NEJM • 18 month RCT with 641 normal weight 4-11 year olds • 8 oz of SSB or artificially sweetened beverage • Mean BMI z-score  by 0.02 SD units in Intervention compared to 0.15 SD in control • Weight gain, fat mass  significantly less
    15. 15. Vegetables & fruit in the home Source: Chen et al., Lunch is in the Bag, unpublished data
    16. 16. Vegetables & fruit in lunches Top 5 veg. items = 51% of veg. items packed Top 5 fruit items = 54% of fruit items packed Carrots (29%) Tomato sauce (13%) Raw tomatoes (8%) Cucumber (5%) Corn (4%) Grapes (12%) Applesauce (12%) Strawberries (11%) Apples (10%) 100% juice (9%) Source: Chen et al., Lunch is in the Bag, unpublished data
    17. 17. Grain ratio: home vs. lunch Home Lunches (overall) 0.30 0.29 0.71 WG only: 22% (n=127) of homes 0.70 WG only: 10% (n=55) of lunches Source: Chen et al., Lunch is in the Bag, unpublished data
    18. 18. Total body bone gain cm/yr Total Body Bone Mineral Content Velocity Curves in Peripubertal Boys and Girls 450 400 350 300 250 200 150 100 50 0 boys girls 9 10 11 12 13 14 15 16 17 18 19 Age in Years Bailey, D.A., et al. J. Bone Min. Res. 14:711-715, 1999
    19. 19. Calcium Supplementation during Adolescence Increases BMD % increase/year 10 * 8 * 6 * * 4 2 0 Lee '94 Lee '95 Placebo *p<0.05 Bonjour Johnson Ca Supplement Adapted from Weaver, 2002 Dibba Cadogan
    20. 20. Trends in Student Meal Consumption by Grade, SPAN, 2000-2002 Question: Yesterday, did you... Eat breakfast? Have more than one meal? Have a snack? Take a vitamin pill? ORadj Grade 4th 8th 11th 4th 8th 11th 4th 8th 11th 4th 8th 11th 1 1.05 p-value (0.80;1.36) 0.795 * 1.05 1 1.13 (0.74;1.49) 0.859 † (0.79;1.61) 0.296 * 1.18 1 1.61 (0.87;1.60) 0.801 † (1.24;2.11) 0.001 * 2.07 1 1.01 (1.37;3.12) 0.286 † (0.77;1.33) 0.287 * 0.88 (0.68;1.12) 0.455 † + Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007
    21. 21. Our Environment is ‘Obesogenic” 2005 2002
    22. 22. How Much Nutrition Education is Enough? 7600 food ads/year 153 F&N/ year • Briggs, M., et. al, (2010). Position of the American Dietetic Association, School Nutrition Association, and Society for Nutrition Education: comprehensive school nutrition services. Journal of nutrition education and behavior, 42(6), 36071. Society for Nutrition Education. • Kann, L., et. al, (2007). Health Education: Results from the School Health Policies and Programs Study 2006. The Journal of school health, 77(8), 408-34. doi:10.1111/j.1746-1561.2007.00228.
    23. 23. GO-SLOW-WHOA WHOA Highest fat and sugar SLOW Higher in fat and sugar, More processed foods GO Lowest in fat, no added sugar, WG, V, F, lean meats
    24. 24. Final Thoughts • Nutritional recommendations for school-aged children are relatively well-established; less so for preschool children – Issues: sugary beverages, snacks, F & V, calcium • Children do not consume adequate diets: what can we do to ensure this? – Behaviorally based nutrition education – Parenting practices – Environmental changes (marketing) • New directions – Do we need „kid foods‟? – How can we use natural biologic variations in appetite to our advantage? – Decreasing food availability – periods of „not eating‟
    25. 25. The test of the morality of a society is what it does for its children. Dietrich Bonhoeffer
    26. 26. THANK YOU Deanna M. Hoelscher, PhD, RD, LD Deanna.M.Hoelscher@uth.tmc.edu UTHealth | The University of Texas Health Science Center at Houston School of Public Health Austin Regional Campus Michael & Susan Dell Center for Healthy Living 1616 Guadalupe | Suite 6.300 | Austin, TX 78701 www.msdcenter.org Twitter: @DeannaHoelscher @DrSteveKelder @msdcenter facebook.com/msdcent er msdcenter.blogspot.c om
    27. 27. Acknowledgements and Supporters Acknowledgements: Deanna M. Hoelscher, PhD; Steven H. Kelder, PhD, Andrew Springer, DrPH; Guy Parcel, PhD; Cheryl Perry, PhD; Sandra Evans, PhD; Nalini Ranjit, PhD; Cristina Barroso, DrPH; Roy Allen, MA; Brooks Ballard, MPH; Courtney Byrd-Williams, PhD; Sherman Chow, MPH; Megan Conklin, MPH; Peter Cribb, MEd; Joanne Delk, MS; Lupe Garcia, MS; Pam Greer; Alejandra Gonzalez; Kacey Hanson, MPH; Tiffni Menendez, MPH; Carolyn Smith; Joey Walker, MPH; Jerri Ward, MA, RD CATCH Supporters: • National Heart Lung and Blood Institute • Centers for Disease Control and Prevention • Texas Department of State Health Services • Robert Wood Johnson Foundation • Paso del Norte Health Foundation • Houston Endowment • Michael & Susan Dell Foundation • RGK Foundation
    28. 28. Vision & Mission Vision Healthy Children in a Healthy World Mission To serve as the state, national, and international leader in the promotion of healthy living for children and their families.
    29. 29. msdcenter.org
    30. 30. Center Social Media Sites msdcenter
    31. 31. GO – SLOW – WHOA (GSW) List • A tool to guide children and families toward making healthy food choices • Overall message: foods can fit into a healthy diet and that a healthy diet consists of GO foods > SLOW foods > WHOA foods • Provides RDA by age for each of the food categories: – 4-8 years old – 9-13 years old Note: The GSW list does not contain combination foods such as sandwiches or pizza

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