1. Eat Your Vegetables!
Healthy Eating in Youth
Deanna M. Hoelscher, PhD, RD, LD
Youth-Nex Conference
October 10, 2013

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. 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. 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. 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. Dietary Issues for Children
• Obesity (HFSS)
– Sugary Beverages
– Snack consumption
• Fruit and vegetable consumption
• Calcium consumption
• Meal patterns/timing of foods

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. 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. 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. 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. 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. 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. 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. 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. Vegetables & fruit in the home
Source: Chen et al., Lunch is in the Bag, unpublished data

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. 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. 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. 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. 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. Our Environment is ‘Obesogenic”
2005
2002

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. 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. 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. The test of the morality of a society is what
it does for its children.
Dietrich Bonhoeffer

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. 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. 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. msdcenter.org

30. Center Social Media Sites
msdcenter

32. 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