Fit not Fat -- Childhood Obesity and the Environment

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Fit not Fat --Childhood Obesity and the
Environment

• Helen J. Binns, MD, MPH
• Ann Robert H. Lurie Childrens Hospital of
  Chicago
• Feinberg School of Medicine, Northwestern
  University
• Sponsored by Region 5, Pediatric Environmental
  Health Specialty Unit

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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.

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Growing Up Healthy
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Energy Balance
http//www.precisionnutrition.com/expert-tip-make-
it-simple
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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 2003111836-843
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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
• ? 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 2006118e157-e166
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Parents and Children have Similar Inactivity
Levels
Correlations between Parent-Child Correlations between Parent-Child Correlations between Parent-Child
Inactivity Activity
Mother - Daughter 0.33 0.28
Mother - Son 0.29 0.20
Father - Daughter 0.39 0.24
Father - Son 0.38 0.08
plt.01 plt.01 plt.01

• 271 children
• 7-12 years
• 3-day activity diary

Fisher J et al. J Am Dietetic Assoc
200210258-64
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Childrens Activity and Their PERCEPTION of
Parental Physical Activity

• 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
• 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

Madsen KA, et al. J Pediatr 2009154278-83
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COUNSELING TIPS Family Activity

• Incorporate activity into your family events
• Young children need play partners that is the
  parent!
• Support your childs activities
• Plan to be active yourself
• (30 minutes of jogging 1 soda)

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Home Exercise Program
www.chicagochildrensresearch.org/pprg/resources/ob
esity/
Lisón JF Acad Pediatr 2012 12319-325.
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Regulation of Eating
Sensory factors Taste Smell Texture
Sight Effects of Variety Sensory-specific
satiety Palatability Food concentration Ready
availability
Brain mechanisms Modulate sensory factors by
satiety signals to produce reward value and
appetite
Eating
from Rolls ET. Obes Rev 20078(suppl 1)67-72
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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
• 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.
20088822-9 Epstein LH et al. Learn Motiv.
200839243-44 Temple JL, et al. Am J Clin Nutr
2008871121-7 Llewellyn CH, et al. Am J Clin
Nutr 2008881560-1566 Epstein LH, et al. Eat
Behav 20089319-27
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Parental Modeling
Modeling
Child Health Behaviors
Adapted from Golan Weizman JNE 2001
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Increase Intake of Fruits and Vegetables
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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

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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

http//www.smokersrx.com/images/why2.jpg
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Nutritional Imbalance
Insulin Resistance
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Antioxidants
Vitamins Vitamins
Antioxidants Food sources
Vitamin C Citrus fruits other fruits leafy vegetables
Vitamin E Vegetable oils, nuts, whole grains, green leafy, avocado
Carotenoids (Vitamin A) orange foods, greens, green veggies, tomatoes
Other less direct effects by Other less direct effects by

Selenium Vitamin B6
Zinc Riboflavin (B2)
Copper Iron
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Fruits and Vegetables

• 1/2 cup 1 serving
• Needs for children
• lt15 of US children get 5 daily servings!
• Adult on a 2000 calorie /day diet
• NEED 9 servings/day

Age Group Servings of Fruits/day Servings of Vegetables/day
Toddlers 2 2
Older children/adolescents 2 3
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The million dollar question

• How do you get kids to eat more vegetables?

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First thing

• How are the parents interacting with vegetables?
• Are the parents buying vegetables?
• Are the parents serving vegetables?
• Are the parents eating vegetables?
• Children pattern their behavior after their
  parents

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Parental Modeling and Pressure to Eat

• 191 families Girls age 5 yrs
• Measures
• FV servings/day
• Girls 3/day
• Parents 2/day
• Parental pressure to eat scale
• Parents with high FV intake
• had girls with higher levels of FV intake (about
  1 more/day)
• Parents with lower FV intake
• had higher levels of pressure to eat
• High pressure decreased FV intake
• about 1 less/day, after controlling for parental
  intake

Fisher J et al. J Am Dietetic Assoc
200210258-64
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Changing Food Preferences

• Intervention study
• Children 2-6 yrs
• Tasting method
• Taste vegetable for 14 consecutive days
• Parent taste provide positive verbal cues
• No forcing
• Significant increase in liking and consumption
  after using the method (compared to controls)
• Repeated tasting can transform dislike into like

Wardle J et al. Appetite 200340155-62 Birch LL.
Annu Rev Nutr 1999194162
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Positive Messages Increasing Healthy Eating vs.
Reducing High Energy-Dense Foods

• Family-based obesity intervention
• 13 groups sessions over 5 months
• 2 groups
• Healthy Eating more fruit, vegetables, and
  low-fat dairy
• Reducing High Energy-Dense Foods less high-fat,
  high-sugar foods
• BMI reduction sustained only in Healthy Eating
  group
• BMI of parents in Healthy Eating group improved
  more, too!

Epstein LH, et al. Obesity 200816318-26
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Parents set an example!

• Buy, cook, serve, and eat more vegetables
• To start, double what youre currently doing
• Put vegetables in everything youre cooking
• Bring fruit and vegetable snacks with you
• Eat a fruit at every meal and two vegetables at
  dinner
• Learn to like new vegetables

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COUNSELING TIPSFruits 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.

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Increase Intake of Whole Grains and Fiber
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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
• Lower risk for cardiovascular disease
• Contain Phytosterols (cholesterol-like molecules
  in plants)
• 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.

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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

Hydroxy-methyl-glutaryl-CoA reductase
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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
• Due to same mechanisms as above
• ? cholesterol synthesis
• May decrease insulin resistance
• 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

Ventura E, et al. Arch Pediatr Adolesc Med
20091633207
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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)

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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
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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

Hydroxy-methyl-glutaryl-CoA reductase
35
Compared to Refined Grains Whole Grains are---

• Rich in folate, vitamin E, selenium, potassium,
  and magnesium
• Lower risk for cardiovascular disease
• Contain Phytosterols (cholesterol-like molecules
  in plants)
• 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.

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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
• Due to same mechanisms as above
• ? cholesterol synthesis
• May decrease insulin resistance
• 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

Ventura E, et al. Arch Pediatr Adolesc Med
20091633207
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Dietary Fiber HOW MUCH?

• US adults typically get 14-15 g fiber/day
• Children

• How many grams of fiber do children need?

Ages 1-3 years 19 g/day
Ages 4 8 years 25 g/day
Ages 9 13 years Male Female 31 g/day 26 g/day
Ages 14 -50 years Male Female 38 g/day 29 g/day
Note 14 g fiber / 1000 calories
Saldanha et al, Pediatrics 199596994-7
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Dietary Fiber Contrasting Foods
High Fiber High Fiber High Fiber Low Fiber Low 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) 0.5 g
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
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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 lt 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

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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 (gt 5 is
  preferred)

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Drink Milk, Eat Dairy

• Calcium
• Vitamin D
• Protein

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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)

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Milk and Dairy Products

• Benefits of dairy consumption
• Dietary patterns with higher dairy consumption
  may protect individuals from obesity and insulin
  resistance
• However, dairy or calcium consumption
  with/without caloric restriction does not result
  in weight loss
• 2 servings low-fat dairy/day may help lower BP
• Children at high risk for obesity
• 2 milk _at_ 12 months
• skim milk _at_ 24 months
• Vitamin D Needs
• lt1 year, 400 IU daily
• 1 years, 600 IU daily

Hirschler V, et al. J Pediatr 2009154101-105
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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 (American) 1.5 oz (2 slices) 160 13 200
Yogurt (vanilla low-fat) 8 oz 208 3 420
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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.

Daniels, Greer, et al. Pediatrics
2008122198-208 Boot AM, et al. Bone 2010 (in
press)
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Reduce/Avoid Sugar-Sweetened Beverages and Foods
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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)

Age Kcal/day (among consuming) Kcal/day (among 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
Vartanian, et al. Am J Pub Health.
200797667-75 NHANES 1999-2004
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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

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Sugar-Sweetened Beverages

• Sugar types
• Sucrose (cane/beet sugar glucose fructose)
• High fructose corn syrup (55 fructose 45
  glucose)
• Fructose has more negative health effects
  (compared to 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

Stanhope et al, J Clin Invest 20091191322-34 Wan
g et al, Pediatrics 2008121e1604-14
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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

Fiorito et al, Am J Clin Nutr 200990935-42
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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
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Sugary Drinks Impact

• Subjects
• 224 overweight / obese adolescents
• 21 Hispanic
• Intervention
• Monthly motivational phone calls and 3 20-minute
  clinic visits over 1 year
• 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

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Diet Beverages (Non-nutritive sweetened beverages)

• Typically sugar-free, artificially sweetened,
  non-alcoholic, 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.

Raben et al. Am J Clin Nutr 200276721-9
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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/son
ic-bacon-cheddar-sheeses.jpg
Mattes et al. Am J Clin Nutr 2009891-14
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Diet Beverages
Oh yeah a diet soda too.

• No benefits for weight loss or slowing weight
  gain, UNLESS accompanied by total energy
  restriction and improved energy balance

http//www.cartoonstock.com/directory/d/diet_drink
s.asp
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Counseling Tips Sugar-Sweetened 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 (gt60 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 sweetand can increase your intake of high
  calorie foods.

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Summary

• 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.