Transcript The Learning Connection – Childhood Nutrition

Robert Murray MD FAAP
The Ohio State University
Robert Murray MD: Disclosures
Advising
Speaking
Writing
Education
National Dairy Council
Abbott Nutrition
Dannon Co.
Cargill Inc.
Sabra Dipping Co.
Hass Avocado
The Carolina Abecedarian Study
Campbell et al, Science 343:1478. 2014
1972-77: 111 Impoverished Children Randomized
57 Children
Quality Preschool
8 hrs/ day birth to 5 years
Health care
Nutrition: 2 meals, 1 snack
Cognitive & Social stimulation
54 Children
Controls
Medicaid, WIC, Food Stamps
No child care
•Survey: children, parents, teachers
•Demographics
•Health evaluation
•Lab tests
•Personality & Behavior
•Cognition & Achievement
Follow-up years:
12, 15, 21, 30 and mid-30s
Every $1 Spent at least a $7 Return
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Less likely to fail or repeat a grade
4 x more likely to graduate from college
4.4 x more likely to hold a skilled job
Stronger social and emotional skills
Less drinking, run-ins with the law
More physically active
Campbell et al, Science 343:1478. 2014
Campbell et al, Early Child Res Q, 23:452, 2008
Abecedarian Kids at 40 years: Health
• Much lower blood
pressure
• Lower blood cholesterol
• Less obesity
• Lower sugar diabetes risk
• Much lower heart
disease risk
than kids without child care
Physical Health at 40
Campbell et al,
Science
343:1478.
2014 2014
Campbell
et al,
Science 343:1478.
Human Brain/Behavior Development
T Pivik MD
Andersen, 2003
Social orientation
Modulation of affect,
arousal, attention; early
memory
Separation distress;
working memory; acoustic
highlighting of words
Maturation of sensory and
motor functions; early
speech; joint attention
Building Strong Connections
Brain doubles in size in first year
Triples in size by the third year
Synaptic connections @ 700 per second
Stronger with use. Lost if unused.
Birth
12 months
3 years
Adult
Carpenter’s Human Neuroanatomy, 1995; Ch 1
Campbell et al. Dev Psychol, 2012; 48:1033-43
The New Science
“EPIGENETICS”
Social experience changes
How our genes work,
which changes
How our body works,
which changes
How we behave,
which changes
who we become
The Middle
Brain
Develops
First & Fast
Emotional Outbursts
Fear Anxiety
Impulsive
Stress
First Reactions
The Front Brain
The Frontal Cortex
Develops
Slowly
With
Practice
Calculates
Plans Ahead
Thinks First
Multi-tasks
Logical
Organized
Calm
NUTRIENTS AND BRAIN DEVELOPMENT
Myelinated fibers
Neurons and Networks
The Scientist, 2013
Myelin
Cell proliferation, synaptogenesis
Iron
LC-PUFAs
Choline
Protein
Iron
LC-PUFAs
Glucose
Georgieff et al., 2015; Wullschleger et al., 2006
Many Nutrients Contribute
• Vit B1 – utilize glucose, modulate
cognition
• Vit B6, B12 – synthesis of
neurotransmitters
• Vit B12 – cognition, language
• Vit C – concentrated in nerve
endings
• Vit D – prevents
neurodegenerative disease
• Vit E – membrane protection
• Flavonoids – protect, enhance
neuronal function
• Iron – oxygenation, synthesis of
myelin & neurotransmitters,
brain development, IQ
• Magnesium – energy and ion
regulation
• Zinc – taste perception,
attention
• Iodine – (via thyroid) cellular
energy metabolism
• Omega 3 PUFA – cognition,
visual development
Bourre. J Nutr Health Aging, 2006: 377
Neurotransmitters
Require
Constant
Nutrient Flow
Personality and Mood
Diet Quality &
Regular Activity = Health
•Heart Disease
•Stroke
•Diabetes
•Obesity
•Hypertension
•Metabolic syndrome
•Osteoporosis
•Cancers
•Alzheimer’s
Dietary Guidelines
for Americans 2015-2020
5 Food Groups
• Fruits
• Vegetables
• (Whole) Grains
• Milk & Diary
• Quality proteins
Promote Diet Quality
• Nutrient Rich Foods
• Nutrients of Concern:
Calcium, Vit D, potassium, fiber
http://health.gov/dietaryguidelines/2015/guidelines/
While Limiting
• Excess calories
• Saturated fats to < 10% of kcals
• Added sugars to < 10% of kcals
• Sodium
Two Competing Paths to “Healthy”
Avoidance …
Dietary Pattern …
The Sugar Question
Where are Added Sugars?
Yogurt
Flavored milk
Sweetened cereal
Fruit juices
Controversy: Flavored Milk in School
Dairy Products Promote Health
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Osteoporosis
Hypertension
Cardiovascular disease
Stroke
Type II diabetes
Cancers
– breast, colon, prostate
• Obesity
• Metabolic syndrome
Calcium
Potassium
Phosphorus
Protein
DV)
Vitamin A
Vitamin D
Vitamin B12
Riboflavin
Niacin
(30% DV*)
(11% DV*)
(20% DV)
(16%
(10% DV)
(25% DV*)
(13% DV)
(24% DV)
(10% DV)
Astrup, Amer J Clin Nutr 2014; 99:1235s
Moreno, et al, Nutr Rev 2015; 73:8s-14s
What would happen
if we banned
all flavored yogurt
to cut sugar consumption
among adults?
Yogurt Promotes Health
• Yogurt is a marker for diet quality
• Lowers risk of hypertension, type II
diabetes, CVD, metabolic syndrome,
osteoporosis and fractures
• Easy to digest in lactose intolerance
• Promotes gut flora
• Rank #1: quality protein source
(PDCAAS)
• Calcium, Vit D, potassium
• Fosters satiety
Hess and Slavin. Nutrients, 2014; 6:4750-59
Added sugars
cut by 25%
in the U.S.
Special Supplemental Nutrition Program
for Women Infants & Children WIC
• Revised WIC Packages: Final Rule March 4, 2014
– Increased access to low- and no-fat milks
– Access to lactose-free milk, soy beverages
– Cheese as a dairy allowance
– Yogurt may swap quart-for-quart with milk
• Unsweetened or
• < 40 grams total sugar/ 8 oz serving
http://www.fns.usda.gov/wic/final-rule-revisions-wic-food-packages
RTE Cereals & Nutrition
• Improves nutrients, milk,
and fruit intake in
children and adolescents
• Better diet quality
• Less body fat
• Consumers: more
calcium, Vit D, iron,
magnesium, Vit A,
phosphorus, and zinc
• Fortified: folic acid, iron
Michels et al. Eur J Nutr 2016; 55:771-9
Michels et al. Eur J Nutr 2015; 54: 653-64
Barr et al, Br J Nutr 2014; 112:1373-83
De la Hunty et al. Obes Facts, 2013;6:70-85
100% Fruit Juice
Improves Diet Quality
Cross-sectional study of 100% fruit
juice in 2 to 18 year olds by
consumption levels:
• Nutrient intake higher
• Diet quality higher
• Weight status no difference
NHANES 2007-2010
Nicklas TA, et al. Int J Child Health Nutr. 2015. 4:112-121.
25
100% Fruit Juice
• Among <2 year olds:
– 1/2 of fruit consumed as 100% FJ
– Primary contributor for folate, magnesium, thiamin,
riboflavin, and niacin; top sources vitamin C, potassium
• Among 2-18 year olds:
– 1/3 of fruit consumed as 100% FJ
– Potassium (#2), vitamin D* (#5) and calcium* (#7), but
not total energy (#17)
Clemens R, et al. Adv Nutr. 2015;6:236S-243S.
Fox MK, et al. J Am Diet Assoc. 2006. 106:S28-42
Keast DR, et al. Nutrients. 2013. 5:283-301
Sweetened Beverages
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Flavored water
Soft drinks
Fruit-flavored drinks
Energy drinks
Rehydration drinks
Alcoholic drinks
Flavored milk*
100% fruit juices*
These
do
Not
belong
with this
group
What’s Your Advice?
“A positive emphasis on nutritional
value,
variety, appropriate portion, and
encouragement for a steady
improvement in quality
will be a more effective approach
for improving nutrition and health
than simply advocating for
the elimination of added sugars.”
Snacks, Sweetened Beverages, Added Sugars, and Schools
Murray R, Bhatia J and the
COUNCIL ON SCHOOL HEALTH, COMMITTEE ON NUTRITION
Pediatrics 2015; 135:3 575-583
Use modest
added sugars, saturated fats, and sodium
WISELY
to promote nutrient rich foods
A Healthful Diet Pattern
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Plant oils
Fish & seafood
Lean meats
Legumes
Nuts & seeds
Vegetables
Fruits
Dairy & yogurt
Whole grains
Wine
Dietary Patterns are personal
Preferences, experiences, culture
Improvements are incremental
The Holy Trinity of Food Choice
VALUE
CONVENIEN
CE
Look for “Nutrient Density”
• Dairy
– Protein, calcium, Vits D, A,
potassium, B vits, phosphorous,
magnesium, zinc, niacin
• Sweet Potatoes/ Squash
– Carotenoids, Vit C, potassium,
fiber
• Spinach, kale, watercress
– Vit A,C,K, folate, potassium,
mag., iron, phytochemicals
• Tomatoes, avocados
– Vit A,C, fiber, phytochemicals
Ratio: Nutrients per Kcal
• Broccoli, green beans
– Vit C, folate, carotenoids
• Rye, wheat, oat grain products
– Whole grain, fiber, B Vitamins
• Citrus fruits
– Vit C, fiber, folate,
phytochemicals
• Blueberries, blackberries
– Vit C, fiber, folate, potassium
• Salmon & fatty fish
– Omega-3 fatty acids, protein
• Nuts, seeds
– Fiber, protein, MUFA/ PUFA,
omega-3 FA (walnuts), vit E
(almonds), folate (peanuts)
Drewnowski, Fulgoni; Am J Clin Nutr; 1223s, 2014
Verger EO et al, J. Nutr. 144: 929–936, 2014
Food & Beverage Choices
Verger et al. J Nutr 2014; 144
What if?
One notch higher in nutrients
• Soda, energy drinks,
sports drinks, juices
• Grain desserts
• Dairy desserts
• Dry cereals
• Cooked cereals
• Breads
• Milk, cheese, yogurt
• Crackers
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Fruits
Vegetables
Pizza
Fast food
Tacos, burritos
Nuts, seeds
Eggs
Meats
Fish
Fast, Easy Diet Quality
Scenario #1:
Substitute a lower fat, lower
sugar alternative
Scenario #2:
Substitute better choice within
the same food category
• Regular to low-fat cheese
• Easy for consumer
• Goals met: calories, total
and sat fat, cholesterol,
carbs and sugar
• Almost no improvement in
diet quality
• White rice to long-grain rice
• Easy for consumer, retains
personal and cultural tastes
• Goals met: for nearly all
nutrients and calories
• Rapid rise in diet quality
Verger et al. J Nutr 2014; 144:929
Simple Swaps…
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Cream based dips to vegetable salsas
Potato chips to whole grain chips
Frozen dessert to flavored yogurt
Refined to whole grain cereals
Cake to carrot or zucchini cake
Chocolate chip to oatmeal nut cookies
Veggies into soups, stocks, mixed dishes
INCREMENTAL
1 in 5 Children are Food Insecure
51% of US kids qualify for
free-and-reduced
• Worse developmental
outcomes
• Psychosocial,
behavioral, and
attention problems
• Depression and
suicidal symptoms in
adolescents
• Lower academic
performance
The USDA Food & Nutrition Service
Child Safety Net
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Child and Adult Care Food Program
The National School Lunch Program
School Breakfast Program
The Seamless Summer Meal Program
After-School Snacks
Special Milk Program
Fresh Fruit and Vegetable Program
Commodity Supplement Program
The School Nutrition Opportunity
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55 million students
32 million lunches/day
10 million breakfasts
35-40% kcals school vs 56%
kcals at home
Improves diet quality
Lessens obesity risk
Improves in-class behavior
Boosts academic
achievement
The National School Lunch Program
• School Nutrition Dietary Assessment
– SNDA I (1995), II (2001), III (2007)
• School Health Policies and Programs Study
(SHPPS)
– 1994, 2000, 2006, 2012, 2015
No Correlation of Obesity with NSLP
Nutritional Contributions of
School Breakfast Program
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Greater energy/ day
Vit C
Phosphorus
Calcium
Vitamin D
Magnesium
Riboflavin
Fiber
Nutrients not consumed at breakfast
are not made up over 24 hrs
20% children,
31% teens
skip
Breakfast Science
• Nearly all showed a positive effect
– Vulnerable kids got the most effect
– BF at school had the best effect
45 Studies
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Math & Memory better
Memory, attention better
Late morning support
Better on more demanding tests
High-risk children showed better
– Verbal skills
– Memory
– Matching tests
Hoyland et al. Nutr Res Rev 2009; 22:220
Fasting vs Glucose-Rich Brain
FASTING
The Mid-Brain
Food Seeking Mode
* Distracted,
irritable, Restless,
anxious
Glucose-rich
The Front Brain
Working Mode
* Calm, focused,
organized,
thoughtful
Tataranni et al: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC16373/
In-School Breakfast has Many Benefits
What if they ate at home too?
And Yet…Only 1/3 of Eligible Kids
Get Breakfast at School
• Less hunger during school
• More attentive, fewer
behavioral problems
• Increased attendance
• Less tardiness
• Fewer visits to school RN
• Lower risk of obesity
• Math scores 17.5% higher
• Higher graduation rates
Share Our Strength/ Delloite Study, 2013
Make Snacks Contribute
to the power
of
incremental change
Energy-Dense, Nutrient-Poor
Snack type foods = 40% of daily energy
• Added sugars (40%)
• High total fats
• Vital nutrients (<15%)
• Displaces: Protein, fiber, vitamins,
folate, calcium, magnesium, iron, zinc
Yogurt Plus …
90-250 kcal
Calcium, Vit D
Many Vits & Minerals
Speed Snacks
Foods that Pair with Other Foods
Salsa
Hummus
Guacamole
Yogurt
Dips
Dressings
Cereals
Soups
Smoothies
Popcorn & 100% Juice
100 kcal microwaved +
120 kcal fruit juices
Whole grain, fiber, vitamins
Energy Bars
230 kcals
Grains, fruit
High in potassium, Vit A, Vit C,
Calcium, Iron, Vit D, Vit E, fiber,
Vit B12, Magnesium, Zinc, etc.
Balance: fats, carbs, protein
Milk +/- Breakfast Powder
130 kcals + non-fat milk = 220 kcals
High in potassium, Vit A, C, Calcium, Iron
w/ milk it blends carbs, protein, fats
Summer is 3 Months Long
Nutrition is a powerful epigenetic force
Hunger is a persistent stress
Brain requires consistent nutrients
Breakfast is crucial
Snack = best opportunity
Summer can be scary