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
9. How Food Is Produced Matters:
Omega 3 Fatty Acids
g/100 g lipid
0
2
4
6
8
10
12
14
16
18
20
omega 6 FA Omega 3 FA Ratio 6:3 CLA
Grass fed crossbred steers
Grain fed crossbred steers
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)
0
20
40
60
80
100
120
Asparagus Collard Grns Mustard
Grns
Broccoli
1950
1999
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 = 26
Courtesy 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
nutrients
▪ More than food
▪ More than the
human
experience
Ecosyste
ms
Soil Ecology
Water
Quality
Air Quality
Pesticides
Fertilizers
Hormones
Antibiotics
Nutrients
15. CHILD OBESITY: State of the Nation
▪ Change in incidence of
obesity / overweight
between 1970 and 2000
0
10
20
30
40
50
60
70
Adult CH AD
1970's
2000
US Dept of Health and Human Services, NCHS, Prevalence of overweight and obesity among adults and adolescents, 1999-
2000.
16. Ten Putative Contributors to the Obesity
Epidemic
▪ Food marketing practices
▪ Physical activity
▪ Infections
▪ Perinatal epigenetic factors
▪ maternal obesity
▪ over/undernutrition
▪ hyperinsulinemia
▪ Maternal age
▪ Assortative mating
▪ Sleep debt
▪ Endocrine disruptors
▪ Pharmaceutical iatrogenesis
▪ Ambient temperature
Critical Reviews in Food Science and Nutrition 49(10) 868-913 (2009)
17. Contributors to the Obesity Epidemic
▪ Current food supply marketing
practices
▪ Cost of whole foods
▪ USDA farm policy
▪ Physical activity
▪ Perinatal epigenetic factors
▪ maternal metabolic health obesity
▪ over/undernutrition
▪ Hyperinsulinemia
▪ Infections
▪ Gut Microbiota
▪ Assortative mating
▪ Sleep debt
▪ Endocrine disruptors
▪ Pharmaceutical iatrogenesis
Adapted from Critical Reviews in Food Science and Nutrition 49(10) 868-913 (2009)
18. Energy Metabolism
Food supply
Physical activity
Gut Microbes
Maternal
Metabolic Health
Sleep
debt/chronic
stress
Pharmaceutical
Iatrogenesis
Endocrine
Disruptors
26. Cost of Food
0 50 100 150
% Increase
Soft Drinks
Fats/Oils
Eggs
Sugar/Sweets
Poultry
Red Meat
Dairy
Cereal/Bakery
Fish
Fr and Veg
Fr. Fruit and Veg
2002 USDA
27. How Much Does 100 Calories Cost?
▪ Cost in cents
▪ Vegetables and fruits cost more per
calorie
▪ Food costs surveyed Sept/2011
0
10
20
30
40
50
60
70
80
90
100 Calories
Soda
Bread
Potato chips
Cookies
Licorice
Orange
Apple
Carrots
28. Obesity is really an economic issue
▪ 2010 Adam Drewnowsky
(UW) study
▪ Funded by NIH grant
▪ 2001 Seattle shoppers in
low cost vs. high priced
grocery stores 0
5
10
15
20
25
30
35
40
45
Total Whole
Foods
Albertson's
> 30 BMI
> 30 BMI
http://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 resistance
syndrome in obese children
0
0.2
0.4
0.6
0.8
1
1.2
1.4
MONTH 0 MONTH 4 MONTH 8
EX/ No EX
No EX/ EX
• Body Fat %
Ferguson MA, et al. International Journal of Obesity (1999) 22, 889±895
31. Exercise training and insulin resistance
syndrome in obese children
0
0.2
0.4
0.6
0.8
1
1.2
1.4
MONTH 0 MONTH 4 MONTH 8
EX/ No EX
No EX/ EX
• Triglycerides
(mmol.l -1)
Ferguson MA, et al. International Journal of Obesity (1999) 22, 889±895
32. Exercise training and insulin resistance
syndrome in obese children
0
20
40
60
80
100
120
140
160
180
200
MONTH 0 MONTH 4 MONTH 8
EX/ No EX
No EX/ EX
• Insulin levels
(pmol.l -1)
Ferguson MA, et al. International Journal of Obesity (1999) 22, 889±895
33. Exercise training and insulin resistance
syndrome in obese children
4
4.2
4.4
4.6
4.8
5
5.2
5.4
MONTH 0 MONTH 4 MONTH 8
EX/ No EX
No EX/ EX
• Glucose (mmol.l -
1)
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
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
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
average
Xiaoli Chen, May A. Beydoun, Youfa Wang. Is Sleep Duration Associated With Childhood Obesity? A
Systematic 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?
Hyposensitive
.
Hypersensitive
Touch/pressure
Taste
Smell
Light/visual stimuli
Auditory stimuli
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 antecedent
Stang 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.
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 with
developmental disabilities.
ICAN, Volume 4, Number 4, August, 2012
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. SOURCES
TRANSPORT DEPOSITION FOOD SUPPLY
Runoff
Erosion
Combustion
Industrial
Processes
Direct
Discharge
Endocrine Disruptors (POPs):
Sources & Pathways to Human Exposures
Courtesy of Dr. Linda Birnbaum, PhD, Director of Toxicology, EPA (adapt)
52. Nutrition and Metabolic Health:
Where do we start?
Pregnancy
Infancy
Childhood
Adolescence
Pre-
pregnancy
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
physicians
ICAN, Wilhelm et al. Vol 4, No. 5, Oct, 2012
54. Cultivating an approach to food that works
▪ Improve metabolic
health
▪ Measure true
biomarkers
▪ Focus on behaviors,
not body size
Organic/Local
Foods
MORE WHOLE
FOODS,
Less refined
sugar/starch/fat
Better balance
of
CHO/PRO/FAT
Move
ICAN, 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
Eat balanced
meals and
snacks
•Enough protein
•Carbohydrates
from whole
foods, mostly
produce
•Enough healthy
fats
CHO PRO /CHO PRO +CHO w/
FAT
0 1 2 3 4 5
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 day
Starving 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
Notas do Editor
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.