Healthy, Happy

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Healthy, Happy Fit Kids Eating Smarter

• Robert Murray MD
• Center for Healthy Weight Nutrition
• Nationwide Childrens Hospital
• The Ohio State University

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Childhood Obesity Now
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where does the problem start?
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HOME
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From 12-24 months the child assumes the eating
habits of the family The Feeding Infants And
Toddlers Study J Amer Diet Assoc,supplement Jan
2004
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CerealsInfants Toddlers
Fox et al JADA, Jan 2004
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What Infants Toddlers Drink
Skinner et al 2004, 104s45
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Desserts and Sweets
Fox et al JADA, Jan 2004
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We Dont Promote Vegetables

• Dark Green Vegetables are consumed by fewer than
  10 of toddlers
• Deep yellow vegetables
• actually decrease from 39 at 9 mos
• to 14 at 18 mos

• Potatoes consume daily
• 4-6 mos 3.6
• 7-8 mos 12.4
• 9-11 mos 24.1
• 12-14 mos 33.2
• 15-18 mos 42.0
• 19-24 mos 40.6
• By 24 mos 25 of toddlers consume fried potatoes
  on any day

Source Fox et al. 2004
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The TV Habit Starts Early, Too
Percent of children watching gt 2 hrs/ day at age
2 yrs were more Likely to watch gt 2 hrs/ day at 6
yrs, also
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The Child is Father to the Man and the
Woman, too
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The 12 Well Child Visits
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6
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2
5
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An Ounce of Prevention www.NationwideChildrens.
org/HealthyWeight
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School
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A Paradox how can this be the shape of hunger?
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Poverty Hunger Obesity

• Inadequate access
• Abundance of convenience stores
• Cheap snack foods
• Expensive fruits, veggies, dairy and quality
  proteins
• Few selections

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Poverty in OhioBelow the Poverty Line

• 10 of Ohio families
• 18 families with kids lt 18 yrs
• 20 families with children lt 5yrs
• 23 of all children lt 5 yrs

Childrens Hunger Alliance
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Food Insecuritya sensitive measure of hunger

• Households (13.5 million) 11.9
• Households with children 17.6
• Black households 23.7
• Hispanic households 21.7
• Households below poverty level 36.8

Associated with lower nutrient intake, lower
physical mental health status and lower
quality of life
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Childhood Hunger Psychosocial Function

• Community Childhood Hunger Identification Project
  (CCHIP)
• 8 kids lt 12 yrs report food insufficiency
• 20 are at risk
• Low income predicts hunger
• Even periodic, persistent food insufficiency is
  tied to objective measures of psychosocial and
  academic dysfunction

Food Research and Action Center
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USDA Nutrition Programsthe nutritional safety
net

• National School Lunch Program (74 of eligible)
• School Breakfast Program (31)
• Summer Food Service Program (10)
• Child and Adult Care Food Program
• Women, Infants and Children (WIC)
• Food Stamp Program

How can we optimize these programs?
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The Promise of School Food

• Improve nutrition
• Lower obesity risk
• Improve attention
• Improve behavior
• Potentially, improve academics

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35-40 of Daily Calories are consumed at school
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The School Breakfast Program

• 86 Free or Reduced Price
• 1/3 African American
• 1/3 Hispanic
• Low Income
• 14-18 yo female only 4
• Up to 1/3 eat no breakfast
• Fewer skip if a quality BF is served (10 REA)

We need better BF quality
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Nutritional Contributions ofSchool Breakfast
Program

• Greater energy/ day
• Vit C
• Phosphorus
• Calcium
• Magnesium
• Riboflavin
• Fiber

Energy and micronutrients not consumed in SBP
are not made up over 24 hrs in non-participants
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Breakfast Body Weight

• Several studies in children and adolescents
• show an association between regular breakfast
• consumption and lower BMI
• 30 lower odds of obesity with BF consumption
• Skippers 2x more likely to be overweight
• Overweight kids more likely to skip BF than
  peers
• Similar to data on adult men women
• Paradox BF eaters consume more energy per day
  yet
• are less likely to be overweight.

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Breakfast Weight in Teens

• Project Eating Among Teens
• 5 year study
• BF associated with
• Carb, fiber, calories/ day
• Higher SES, white race
• Physical activity
• BF inversely related to
• BMI (dose-dependent relationship)
• Smoking, alcohol, dieting

Timlin et al, Pediatrics, 2008 121e638
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Breakfast Improves Performance

• Improves matching familiar figures, math, word
  recall, short term memory tests, spatial memory
• Improves mood, anxiety, and irritability
• Strong subjective sense of physical and mental
  well-being

A Smith, Physiol Behav 2000 68228
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Grab Go Breakfast in the Classroom
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Eating a School Lunch Promotes Better Nutrition

• Twice the servings of fruits and vegetables.
• Higher intake of milk
• and dairy.
• Larger amounts of meat.
• Greater amount of grains.
• More vitamins and minerals.
• NSLP impact holds true for lunch
• and for 24-hour intake.

USDA Food and Nutrition Report No. CN-01-CD1
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How School Lunch is Balanced

• Must meet Dietary Guidelines for Americans
• No more than 30 fat / 10 saturated fat
• Provide 1/3 RDA for
• Protein
• Iron
• Calories
• Calcium
• Vits A C
• Local school decides the menu and how to prepare,
  they purchase foods, then balance the meals over
  the week

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School may be the Only Place a Child
LearnsPortion Proportion
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Naturally Nutrient Rich US Dietary Guidelines
Focus on fruits.
Vary your veggies.
Get calcium-rich foods.
Make half your grains whole.
Go lean with protein.
Know the limits on fats, salt, and sugars.
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What Might Improve the NSLP?

• Adapt the new US Dietary Guidelines
• Ease total fat restriction to 35 of calories
• Restrict saturated and trans fats
• Use more beneficial fats (MUFA/ PUFA)
• Emphasize whole grains and fiber
• Encourage more fruits, vegetables and dairy
• Increase reimbursement
• Adjust commodities to aid the food service
• Create national standards for competitive foods

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IOM Recommendations

• Tier 1 all students
• Fruits, vegs, whole grains, non- or low-fat dairy
  and
• lt 200 cals
• 35 fat
• 10 sat fat
• Zero trans fats
• 35 sugars except yogurt (lt 30 g sugars)
• Sodium lt 200 mg
• Beverages
• Water
• Low- non-fat milk 8 oz (soy and lactose free
  also)
• 100 fruit juice 4 oz
• Caffeine free

• Tier 2 HS After Hours
• lt 200 calories as pkgd
• 35 cals from fat
• 10 cals from sat fat
• Zero trans fats
• 35 cals from sugars
• 200 mg or less sodium
• Beverages
• Non-caffeinated, non-fortified, lt 5 cals/ portion

Institute of Medicine Report, April 2007
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the competition
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Competitive Foods
A la Carte Sales School Parties Fundraisers School
Stores Vending Boosters Athletics Student Clubs
Versus
The Federally Regulated School Meal Program
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Energy-Dense, Nutrient-Poor Foods

• EDNP foods gt30 of daily energy
• Total daily calories increased
• Energy from carbohydrates increased
• Energy from fat increased
• Displace Protein, fiber, vitamins, folate,
  calcium, magnesium, iron, zinc

Kant Arch Ped Adol Med 2003 157789
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Overweight, Unfit Undernourished
Children Consuming Daily Recommended Intake
Critical Age
Iron
Phosphorus
Zinc
Vitamin C
Vitamin A
Magnesium
Folate
Calcium
Data compiled by Dr. John Lasekan, Ross Labs from
NHANES 1999-2000 and the Continuing Food Survey
1994-96, 1998
Data compiled by Dr. John Lasekan, Ross Labs from
NHANES 1999-2000 and the Continuing Food Survey
1994-96, 1998 NHANES, CFSII data compiled by Dr.
John Lasekan, Ross Labs
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Foods of Minimal Nutritional Value

• Defined lt 5 of RDA per serving of any of 8
  nutrients
• 4 categories of prohibited foods
• Soda
• Water ices
• Chewing gum
• Certain candies
• Hard candy
• Marshmallow
• Jellies gums
• Taffy
• Licorice
• Spun candy
• Candy-coated popcorn
• Cannot be sold in school food service areas
  during the meal

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Top 10 Foods in High SchoolA la Carte Lines

• Fresh fruit 100
• Cookies 98
• Skim milk 98
• Whole/ 2 milk 96
• Chips 87
• Pizza 77
• Juice drinks 75
• Doughnuts 72
• Sandwiches 72
• Snack cakes 64

Story et al, JADA 1996 96123
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A la carte Foods Hamper Nutrition

• Consume 3x more sugars (21 vs 64)
• Top sellers pizza, chips, soda, French fries,
  candy and ice cream
• Lower fruit, vegetable and milk higher sweetened
  beverages and fried veggies

Cullen, Am J Pub Health 2004 94463
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Snacks Sold in Middle School School Stores

• Candy 80
• Fruit 0
• High fat, sugar 88.5
• Averaged 8.7g fat, 23g sugar
• Sold during lunch 50

Journal of American Dietetic Association, 2000,
Fat and Sugar Levels are High in Snacks Purchased
from Student Stores in Middle Schools
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Top 10 Foods in High School Vending Machines

• Juice drinks 88
• Soda 81
• Fruit juice 77
• Candy bars 60
• Cookies 58
• Candy 56
• Cheese puffs 54
• Chips 54
• Snack mix 40
• Sport drinks 35
• Milk? only 6

Story et al, JADA 1996 96123
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the question
Can snack foods contribute to nutritional
quality?
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Avoidance Standards

• Based solely on what a food should not contain
• Has created a public misperception
• fewer bad nutrients a nutritious food

calories
fat, saturated fat, trans fat
cholesterol, sodium
sugars
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Less fat, fewer calories, but not more nutrients
Does it merit this?
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The Baby with the Bathwater?
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National Nutrition Standards

• Traditional cut sugar, fat, trans fat, sodium,
  cholesterol, calories
• New nutrient density
• Contribute to daily nutrition
• Portion size
• US Dietary Guidelines
• Discretionary calories, sugars and fats drive
  nutrients

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Nutrient Density

• Nutrient density nutrients-to-calories ratio
• Nutrient-dense foods are those foods that
  provide substantial amounts of vitamins and
  minerals (micronutrients) and relatively few
  calories.
• US Dietary Guidelines for Americans 2005

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How do we make nutrient density work with snack
foods?
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Snack Foods are Simple

• Vended foods tend to be
• Processed
• High in energy per unit weight (kcal/ 100 g)
• Fortified, not naturally nutrient-rich
• High in sodium
• Substantial contribution to daily energy
• Minimal contribution to daily nutrients

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Application
Create a simple, usable Nutrition Rating
System Use the whole nutrition facts label Act
as an educational tool
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US Dietary Guidelines
PROBLEM NUTRIENTS

• Children and Adolescents
• Calcium
• Potassium
• Fiber
• Magnesium
• Vitamin E
• Iron

• Adults
• Calcium
• Potassium
• Fiber
• Magnesium
• Vitamin A
• Vitamin C
• Vitamin E

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Parameters lt 150 200 35 of total calories lt
35 of total calories gt 10 of total calories
230 mg 5 g gt 35 of total calories 3 g
10 10 10 10
Snackwise PARAMETERS
Energy Total Fat (Saturated Trans
Fat) Sodium Protein Sugar Fiber Vitamin A Vitamin
C Iron Calcium
Align With the US Dietary Guidelines 2005
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Snackwise vs Dietitian Ratings
points
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Least nutritious Moderately nutritious Most
nutritious
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6
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Points vs RD r 0.78
2
0
-2
New Points System (Higher numbers are healthy)
-4
1
2
3
4
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Dietitian Ratings (interobserver r 0.78)
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(No Transcript)
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Use the Whole Label
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• Simple --
• Fun --
• Educational
• and FREE

www.Snackwise.org
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Who Uses Snackwise

• Parents
• Schools
• Colleges Universities
• Community Recreation Centers
• Government Health Care
• Business and Industry
• Vending companies

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School Nutrition Policy
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Application
Columbus Public Schools

• Phase out all red foods
• from vending machines
• and a la carte lines
• Eliminate all sweetened drinks
• and offer
• only water and milk

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Columbus Public Schools
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• Quality Nutrition Improves
• academics
• test scores
• grades
• tardiness
• absenteeism
• mood

We cannot improve IQ -- But we can put a better
student in the chair
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Children grow up In 3 environments
HOME
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