Transcript Fruits, Vegetables, Fiber - University of Illinois at Chicago

Fit not Fat -Childhood Obesity and the
Environment
Helen J. Binns, MD, MPH
Ann & Robert H. Lurie Children’s Hospital of Chicago
Feinberg School of Medicine, Northwestern University
Sponsored by Region 5, Pediatric Environmental Health
Specialty Unit
Disclosure Information
• This material was supported by the Association of
Occupational and Environmental Clinics (AOEC) and funded
under the cooperative agreement award number
1U61TS000118-03 from the Agency for Toxic Substances and
Disease Registry (ATSDR).
• Acknowledgement: The U.S. Environmental Protection Agency
(EPA) supports the PEHSU by providing funds to ATSDR under
Inter-Agency Agreement number DW-75-92301301-0. Neither
EPA nor ATSDR endorse the purchase of any commercial
products or services mentioned in PEHSU publications.
• Dr. Binns has no conflicts of interest to disclose.
2
Growing Up Healthy
Energy Balance
4
http://www.precisionnutrition.com/expert-tip-make-it-simple
Physical Activity Fun


Recommended activity for children is 1 hour daily
Study of children surveyed twice (1 year apart)
 For
those who increased their activity by 7 hours per
week:


Healthy weight children achieved BMI maintenance
OBESE children had BMI fall of -0.2 kg/m2 (gained about 1
less lb than expected)
Berkey CS, et al. Pediatrics 2003;111:836-843
5
Physical Activity Fun


 screen time   physical activity
Screen time contingent upon physical activity
8
weeks intervention

Reward for activity: 1 hr activity = 1 token =1 hr TV
 Follow-up
at 16 weeks
 Intervention group compared to controls


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 activity by 30 minutes/day
 sedentary behaviors by 2 hrs/day
 snacking while watching TV
BMI -0.6 kg/m2 vs.  +0.3 kg/m2 controls
Goldfield GS, et al. Pediatrics 2006;118;e157-e166
6
Parents and Children have Similar
Inactivity Levels



Correlations between Parent-Child
Inactivity Activity
271 children
7-12 years
Mother - Daughter
3-day activity diary
0.33**
0.28**
Father - Daughter
0.29**
0.39**
0.20**
0.24**
Father - Son
0.38**
0.08
Mother - Son
** p<.01
7
Fisher J et al. J Am Dietetic Assoc 2002;102:58-64
Children’s Activity and
Their PERCEPTION of
Parental Physical Activity



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2379 girls
Followed from ages 9-18 yrs
Evaluated how well child perceptions
predicted child activity 2 years later
Girls reporting that their parents exercised
≥3x /week were:



Age: 11-12
13-14
15-16
17-18 18-19
Age: 11-12
13-14
15-16
17-18 18-19
~ 50% more active than girls perceiving
sedentary parents
Relationship to parent measured activity
not nearly as strong
Social support by parents for activity is
very important for adolescent activity
8
Madsen KA, et al. J Pediatr 2009;154:278-83
COUNSELING TIPS: Family Activity





Incorporate activity into your family events
Young children need play partners – that is the
parent!
Support your child’s activities
Plan to be active yourself
(30 minutes of jogging = 1 soda)
9
Home
Exercise
Program
www.chicagochildrensresearch
.org/pprg/resources/obesity/
Lisón JF Acad Pediatr 2012; 12:319-325.
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Regulation of Eating
Family & Social
Influences
Sensory factors:
Taste
Smell
Texture
Sight
Effects of:
Variety
Sensory-specific satiety
Palatability
Food concentration
Ready availability
Cognitive factors:
Conscious rational control
Beliefs about the food
Advertising
Brain mechanisms:
Modulate sensory factors by
satiety signals to produce
reward value and appetite
Satiety/hunger signals:
Adipose tissue signals
Gut hormones
Gastric distension
11
Weight
Status
from Rolls ET. Obes Rev 2007;8(suppl 1):67-72
Food Content
Eating
Child Factors Associated with Higher Weight

Rapid rate of eating
High food-cue responsiveness
More focused on food
More impulsive when making food choices
More motivated for immediate rewards, such as good taste
Low satiety responsiveness

WHY? Obese children…

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
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Differ in response to types of food – gut hormones work differently
Fat cells are sending out signals to the brain
Brain becomes insensitive to signals of satiety
Sugary foods decrease taste preference for less sugary foods –
addictive patterns
Carnell S, Wardle J. Am J Clin Nutr. 2008;88:22-9; Epstein LH et al. Learn Motiv. 2008;39:243-44
Temple JL, et al. Am J Clin Nutr 2008;87:1121-7;
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Llewellyn CH, et al. Am J Clin Nutr 2008;88:1560-1566 Epstein LH, et al. Eat Behav 2008;9:319-27
Parental Modeling
Parent Behaviors
Home Environment
Health Habits
Dietary Choices
Exercise
Verbal prompts to child
Parenting Skills
Support for Eating Choices
Support for Activity & Inactivity
Parental leadership
Parent-child communication
Problem-solving skills
Modeling
Child
Health Behaviors
Adapted from Golan & Weizman JNE 2001
Child
Weight Status
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Increase Intake of Fruits and
Vegetables
Fruits and Vegetables



Low in calories
High in fiber – fill you up!
Sensory appeal


Taste, texture, color
Rich in vitamins and minerals,
which are needed to fight
oxidative stress
Fight Oxidative Stress


20% of oxygen breaks down to Free Radicals &
Reactive Oxygen Species
Stressors can increase that to 80%






UV light
Poor nutrition
Inflammation
Air Pollution
Tobacco
Radiation
16
http://www.smokersrx.com/images/why2.jpg
Nutritional Imbalance
High glycemic load
Insulin
Resistance
Excess caloric intake
 Glycemia
 Fat
 FFA
Reactive O Species
(O2-; H2O2; others )
Oxidative Stress
Reactive N Species
(NO + O2-)
Activation of
inflammatory
response
(in liver and fat cells)
 Cytokines
Nitrosative Stress
 Insulin Action &
Impaired  Cell
Function
Low grade
inflammation
Cell
damage or
death 17
Reactive O Species
(O2- ; H2O2; others )
Oxidative Stress
Antioxidants
Vitamins
Antioxidants
Vitamin C
Vitamin E
Carotenoids
(Vitamin A)
Other less direct effects by
Food sources
Citrus fruits; other fruits &
leafy vegetables
Vegetable oils, nuts, whole
grains, green leafy, avocado
Selenium
Vitamin B6
Zinc
Riboflavin
(B2)
Copper
Iron
orange foods, greens, green
veggies, tomatoes
18
Fruits and Vegetables


1/2 cup = 1 serving
Needs for children:
Servings of
Fruits/day
Servings of
Vegetables/day
Toddlers
2+
2+
Older children/adolescents
2+
3+
Age Group

<15% of US children get 5 daily servings!

Adult on a 2000 calorie /day diet
 NEED 9 servings/day
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The million dollar question…

How do you get kids to eat more vegetables?
20
First thing:

How are the parents interacting with
vegetables?


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Are the parents buying vegetables?
Are the parents serving vegetables?
Are the parents eating vegetables?
Children pattern their behavior after their
parents
21
Parental Modeling and Pressure to
Eat
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191 families; Girls age 5 yrs
Measures:

F&V servings/day




had girls with higher levels of F&V intake (about 1 more/day)
Parents with lower F&V intake


Parental pressure to eat scale
Parents with high F&V intake


Girls: 3/day
Parents 2/day
had higher levels of pressure to eat
High pressure decreased F&V intake

about 1 less/day, after controlling for parental intake
22
Fisher J et al. J Am Dietetic Assoc 2002;102:58-64
Changing Food Preferences

Intervention study

Children 2-6 yrs

“Tasting” method:
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Taste vegetable for 14 consecutive days

Parent taste & provide positive verbal cues
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No forcing
Significant increase in liking and consumption after
using the method (compared to controls)
Repeated “tasting” can transform dislike into like
23
Wardle J et al. Appetite 2003;40:155-62
Birch LL. Annu Rev Nutr 1999;19:41–62
Positive Messages: Increasing Healthy
Eating vs. Reducing High Energy-Dense Foods

Family-based obesity
intervention

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13 groups sessions over
5 months
2 groups

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
Healthy Eating = more fruit,
vegetables, and low-fat
dairy
Reducing High EnergyDense Foods = less highfat, high-sugar foods
BMI reduction sustained
only in Healthy Eating
group

BMI of parents in
Healthy Eating group
improved more, too!
24
Epstein LH, et al. Obesity 2008;16:318-26
Parents set an example!

Buy, cook, serve, and eat more vegetables


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To start, double what you’re currently doing
Put vegetables in everything you’re cooking
Bring fruit and vegetable snacks with you
Eat a fruit at every meal and two vegetables
at dinner
Learn to like new vegetables
25
COUNSELING TIPS:
Fruits and Vegetables


Infants / Toddlers / Preschoolers:

Put vegetables in everything. Give vegetables as snacks.

Offer whole fruits rather than fruit juice. Juice only from a cup &
limit to 4 oz/day (or not at all).
School Age/Teens:

Learn to like new fruits and vegetables.

Lots of fresh fruits and vegetables fill you up and help your body
work well.

Eat a fruit at every meal.
26
Increase Intake of Whole Grains
and Fiber
Whole Grains and Fiber

What are Whole Grains?

Whole grain foods contain all the grain
layers, including:



Bran (outer layer, contains seed fiber)
Endosperm or Kernel (contains vitamins
and minerals)
Germ (concentrated source of nutrients)
Source: Linus Pauling Institute
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Compared to Refined Grains–
Whole Grains are--
Rich in folate, vitamin E, selenium, potassium, and
magnesium


Contain Phytosterols (cholesterol-like molecules in plants)


Lower risk for cardiovascular disease
Interferes with the intestinal absorption of cholesterol
Health benefits are not entirely explained by the
individual contributions of the nutrients & phytochemicals
they contain
Whole grains are a unique package of energy,
micronutrients, and phytochemicals that work
synergistically to promote health and prevent
disease.
29
Why Fiber? Actions

Lowers glycemic load


Slower absorption rate of other nutrients (eg, glucose)
Modifies nutrient absorption



Bulk contribution impedes diffusion to the luminal
surface
↓ bile acid effects on absorption & therefore loss of fats
in stool
Fiber favors formation of short-chain FAs in the gut
lumen


short-chain FAs inhibit HMG-CoA reductase* activity in the liver →
↓ cholesterol synthesis
This is same action as a statin drug
30
*Hydroxy-methyl-glutaryl-CoA reductase
Fiber: Health benefits



Increases satiety (the feeling of fullness)
Helps prevent constipation (increases fecal bulk)
Lower cholesterol absorption and LDL synthesis

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 5-10 g/day reduces LDL cholesterol by about 5%
↓ serum TG

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
↓ cholesterol synthesis
May decrease insulin resistance


Due to same mechanisms as above
Additional 5 g fiber/day→ 10% ↓ in visceral adipose tissue deposition*
May help reduce weight gain


Higher fiber inversely associated with BMI in major observational
studies
Role of fiber in weight control is not yet clear
31
*Ventura E, et al. Arch Pediatr Adolesc Med 2009;163:320–7
What are Whole Grains?
Whole grain foods contain all the grain layers,
including:
Bran (outer layer, contains seed fiber)
Endosperm or Kernel
(contains vitamins and minerals)
Germ
(concentrated source of nutrients)
What is Fiber?
A group of compounds including lignin (plant cell walls) and
complex carbohydrates that cannot be digested by human
enzymes in the small intestine
Sources of Fiber
Fiber/serving
Legumes (beans, peas) (cooked)
6-8 grams/ 1/2 cup
Fruits and Vegetables (cooked)
2-6 grams/ 1/2 cup
Whole Grains and Cereals
2-5 grams/ serving
Nuts and Seeds
2-4 grams/ ounce
Why Fiber? Actions

Lowers glycemic load


Slower absorption rate of other nutrients (eg, glucose)
Modifies nutrient absorption



Bulk contribution impedes diffusion to the luminal
surface
↓ bile acid effects on absorption & therefore loss of
fats in stool
Fiber favors formation of short-chain FAs in the gut
lumen


short-chain FAs inhibit HMG-CoA reductase* activity in the liver →
↓ cholesterol synthesis
This is same action as a statin drug
34
*Hydroxy-methyl-glutaryl-CoA reductase
Compared to Refined Grains–
Whole Grains are--
Rich in folate, vitamin E, selenium, potassium, and
magnesium


Contain Phytosterols (cholesterol-like molecules in plants)


Lower risk for cardiovascular disease
Interferes with the intestinal absorption of cholesterol
Health benefits are not entirely explained by the
individual contributions of the nutrients & phytochemicals
they contain
Whole grains are a unique package of energy,
micronutrients, and phytochemicals that work
synergistically to promote health and prevent
disease.
35
Fiber: Health benefits



Increases satiety (the feeling of fullness)
Helps prevent constipation (increases fecal bulk)
Lower cholesterol absorption and LDL synthesis


 5-10 g/day reduces LDL cholesterol by about 5%
↓ serum TG



↓ cholesterol synthesis
May decrease insulin resistance


Due to same mechanisms as above
Additional 5 g fiber/day→ 10% ↓ in visceral adipose tissue deposition*
May help reduce weight gain


Higher fiber inversely associated with BMI in major observational
studies
Role of fiber in weight control is not yet clear
36
*Ventura E, et al. Arch Pediatr Adolesc Med 2009;163:320–7
Dietary Fiber: HOW MUCH?

How many grams of
fiber do children need?

Ages 1-3 years 19 g/day

Mean Fiber Intake, US Children by Age
Ages 14 -50 years
Male 38 g/day
Female 29 g/day
Note: 14 g fiber / 1000 calories
gms fiber/day
Ages 4 – 8 years 25 g/day
Ages 9 – 13 years
Male 31 g/day
Female 26 g/day
US adults typically get
14-15 g fiber/day
Children:
16
14
12
10
8
6
4
2
0
2-5 yr
6-11 yr
Girls
12-18 yr
Boys
12-18 yr
37
Saldanha et al, Pediatrics 1995;96:994-7
Dietary Fiber: Contrasting Foods
High Fiber
Low Fiber
Potato with skin
(one)
2 g
Potato w/out skin
(one)
1 g
Dry beans (cooked)
(1/2 cup)
6 g
Potato chips
(1 serving)
1 g
Broccoli
(1 cup)
5 g
Lettuce
(1 cup)
1 g
Whole wheat bread
(1 slice)
3 g
White bread
(1 slice)
1 g
Cereal: oat circles
(1 cup)
3 g
Cereal: corn flakes (1 cup)
Brown rice (cooked)
(1/2 cup)
2 g
White rice
(1/2 cup)
0 g
Orange
(one)
3 g
Orange juice
(1/2 cup)
0 g
0.5 g
38
Read It Before You Eat It!


Read the food label
Look for High Fiber and Whole Grain


 5 g fiber/serving is HIGH for cereal and bread
Find the LOW SUGAR food

4 g sugar = 1 teaspoon sugar




Sugary circles: 12 g sugars; 3 g fiber
Sugary flakes: 11 g sugars; 1 g fiber
Look for those with < 8 g sugar per serving
Mix brands of cereals to increase fiber and lower
sugar content
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Counseling Tips:
Whole Grains and Fiber

Add fiber to foods your family already eats:


Add extra oat bran to oatmeal
Mix ground flaxseed into pancakes, cooked cereal

Add nuts and seeds to salads, yogurt

Include dried beans, lentils in soup

Eat whole fruit rather than drinking juice
Counseling Tips:
Whole Grains and Fiber

When making sandwiches:


Add vegetables
Serve peanut or almond butter on whole grain bread

Serve bean dip or hummus for snacks

Choose grains with “whole (grain)” as the first
ingredient

At least 3 grams fiber per serving (> 5 is preferred)
Drink Milk, Eat Dairy



Calcium
Vitamin D
Protein
Milk and Dairy Products

Provide protein, vitamin D, A, B-12 , phosphorus,
potassium, magnesium, riboflavin, and niacin

Daily recommended servings
Age Group


Servings per day
Calcium, mg/day
1-3 years
2
500
4-8 years
2-3
800
9-18 years
3-4
1300
Sources: milk, cheese, yogurt, ice cream
Only milk is routinely fortified with Vitamin D (100 IU/cup)
43
Milk and Dairy Products

Benefits of dairy consumption

Dietary patterns with higher dairy consumption may protect
individuals from obesity and insulin resistance



2 servings low-fat dairy/day may help lower BP
Children at high risk for obesity



However, dairy or calcium consumption with/without caloric restriction
does not result in weight loss
2% milk @ 12 months
skim milk @ 24 months
Vitamin D Needs


<1 year, 400 IU daily
1+ years, 600 IU daily
44
Hirschler V, et al. J Pediatr 2009;154:101-105
Milk and Dairy Products
Dairy Product
Serving
Calories
Fat, gm
Calcium, mg
Whole milk
8 oz
150
8
300
2% milk
8 oz
120
4
300
Skim milk
8 oz
90
0.4
300
Chocolate milk (2%)
8 oz
178
5
300
Chocolate ice cream
(premium)
½ cup
260
14
150
Cheese
1.5 oz
160
13
200
208
3
420
(American)
Yogurt
(vanilla low-fat)
(2 slices)
8 oz
45
Counseling Tips: Milk and Dairy



TODDLERS:

Stop bottles at 12 months

Offer 2 servings of dairy products/day
SCHOOL AGE:

Calcium helps you grow strong bones.

Get 3 servings of low-fat dairy products every day.
TEENS:

Bone strength peaks at about age 20, so now is the time to get
enough calcium to make strong bones.

Get 3-4 servings daily of low-fat dairy products.
46
Daniels, Greer, et al. Pediatrics 2008:122:198-208
Boot AM, et al. Bone 2010 (in press)
Reduce/Avoid Sugar-Sweetened
Beverages and Foods
Sugar-Sweetened Beverages (SSB)

What are SSBs?




Soda, fruit drinks, juice blends, lemonade, sweetened tea
Other carbonated or uncarbonated drinks (ie, sports and energy drinks)
Most consumption happens at home (55-75%)
Daily calories from juice and other SSB (among those consuming):
Kcal/day (among consuming)
Age
Juice
Other SSB
SSB & Juice
2-5 y
148
176
190
6-11 y
136
229
220
12-19 y
184
356
345
48
Vartanian, et al. Am J Pub Health. 2007;97:667-75
NHANES 1999-2004
Juices & Sugar-Sweetened Beverages

OZ
Calories
Vit C, mg
Sugar,
teaspoons
Apple Juice
12
180
12-60
10
Orange Juice
12
168
150
8
Grape Juice
12
240
0
15
Cola
12
145
0
10
Sports drink
12
75
0
6
Vitamin waters
12
75
36
5
Vanilla frappuccino
12
320
0
11
Added to the typical US diet: 1 soda/day → gain ~ 15 lb/year
49
Sugar-Sweetened Beverages

Sugar types



Fructose has more negative health effects (compared to glucose)






Sucrose (cane/beet sugar = glucose + fructose)
High fructose corn syrup (55% fructose + 45% glucose)
An increase in visceral fat (in organs)
Less sensitivity to insulin
Increased fat production in the liver
Higher LDL cholesterol
Higher triglycerides
Effects on energy intake


↑ hunger & ↓ satiety
Displace appetite for nutrient-balanced foods
50
Stanhope et al, J Clin Invest 2009;119:1322-34
Wang et al, Pediatrics 2008;121:e1604-14
Sugar-Sweetened Beverages
Consumption of SSBs
promotes higher




% body fat
Waist circumference
Weight status
Compensation for the
quickly consumed added
energy from SSB is
inadequate
Body fat (%) by SSB Consumption
Pattern at Age 5 Years
37
Body fat (%)

32
27
22
17
5
7
9
11
13
15
Girls age (years)
<1 Serving/d
≥2 Serving/d
51
Fiorito et al, Am J Clin Nutr 2009;90:935-42
Sugary Drinks Impact

Subjects



641 children, ages 4-11y
Mostly normal weight
Intervention - 18 months
8 oz/day of sugar-free vs. sugary beverage (~100 calories)
Outcome
 Sugary beverage group gained about 1 kg more
 Fat mass  significantly less in the sugar-free group


de Ruyter, NEJM 2012
52
Sugary Drinks Impact

Subjects

224 overweight / obese adolescents


Intervention

Monthly motivational phone calls and 3 20-minute
clinic visits over 1 year


21% Hispanic
Experimental group also received free home delivery of
water and diet drinks
Outcomes


Experimental group gained 1.6 kg
3.5 kg gain for control group
53
Diet Beverages



(Non-nutritive sweetened beverages)
Typically sugar-free, artificially sweetened, nonalcoholic, carbonated beverages
Marketed towards:
 health-conscious people, diabetics, athletes
 people who want to lose weight or stay fit
Replacing sugar-sweetened beverages with water
and diet beverages can lower total calories
consumed.
54
Raben et al. Am J Clin Nutr 2002;76:721-9
However…

Sweet goes with fatty and
salty!

When consumed alone,
diet beverages may
increase hunger

But, no hunger change if
diet beverages are added
to energy containing
products and/or
consumed with foods
EVEN BETTER WITH A DIET COKE AND FRESH LIME
The food item alone has 710 cals
(40 grams fat, 13 grams saturated
fat) and that is without the 300-600
calories from French fries!
http://www.foodfacts.info/blog/uploaded_images/sonic-bacon-cheddar-sheeses.jpg
55
Mattes et al. Am J Clin Nutr 2009;89:1-14
Diet Beverages

No benefits for weight loss
or slowing weight gain,
UNLESS accompanied by
total energy restriction and
improved energy balance
Oh yeah…
a diet soda
too.
http://www.cartoonstock.com/directory/d/diet_drinks.asp
56
Counseling Tips: SugarSweetened beverages

INFANTS/TODDLERS:




Offer water as beverage of choice.
Limit juice to 4 ounces/day, maximum.
No juice at all is just fine! Whole fruit is healthier than fruit juice.
SCHOOL AGE/TEENS:




Theoretically, 12 oz of soda a day adds 15 pounds per year.
For a 15 year old male, it takes 30 minutes of jogging to burn off
the calories contained in 12 oz of soda.
Sports drinks are not “healthier” than water and contain lots of
sugar. Sports drinks are for long-term activity (>60 minutes).
Replace SSB with water or lower-calorie beverages.
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Counseling Tips: Beverages

Plain water is best! Drink plenty of it.

Flavor water with lemon or lime. Keep it cold in
the refrigerator.

While diet soda is preferred over regular soda, it
is sweet…and can increase your intake of high
calorie foods.
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Summary
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
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Be a role model for healthy habits!
Be positive about healthy foods.
Make changes to the home environment to
promote healthy habits.
A few changes can have a big impact.
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