A Primer for Pediatricians

1. NUTRITION FACTS
A Primer for Pediatricians Bonnie Y. Modugno, MS, RD
www.muchmorethanfood.com

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

5. Food Composition Matters
-10
-9
-8
-7
-6
-5
-4
-3
-2
-1
0
Low Insulin
Secretor
High Insulin
Secretor
High CHO Low CHO
Pittas, A. et al. Diabetes Care 28 (12): December 2005
*
*
Weight
change
(kg)

6. Copyright restrictions may apply.
Ebbeling, C. B. et al. Arch Pediatr Adolesc Med 2003;157:773-779.
oConventional
Diet
o1700 Kcal
oCHO 55-60%
oFAT 25-30%
•Experimental
Diet
•Low Glycemic
•CHO 45-50%
•FAT 30-35%
•Ad libitum
Food Composition Matters

7. Lomenick J P et al. JCEM 2009;94:4463-4471
©2009 by Endocrine Society
Macronutrients Matter:
Effects of Meal High in Carbohydrate on Satiety in Pre-pubertal Children
NW
Obese

8. Lomenick J P et al. JCEM 2009;94:4463-4471
©2009 by Endocrine Society
Macronutrients Matter:
Effects of Meal High in Protein on Satiety in Pre-pubertal
Children
NW Pre-adol.
Obese Pre-adol.
NW
Obese

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

19. Our Current Food Supply

20. Are Supermarkets the Answer?

21. Current Food Supply?
▪ Weekly food costs
▪ N. Carolina, USA
▪ $341.98
Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005.

22. Our Current Food Supply
▪ Weekly food costs
▪ California, USA
▪ $159.18
Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005

23. Current Food Supply
▪ Weekly food costs
▪ Mexico
▪ $189.09
Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005

24. Current Food Supply
▪ Weekly food costs
▪ Guatemala
▪ $76.70
Menzel and DiAluisio. Hungry Planet: What the World Eats. C 2005

25. USDA Food Disappearance Data

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

35. Proposed model of fetal programming of offspring of women with abnormal metabolic environment (increased
insulin resistance).
Catalano P M Reproduction 2010;140:365-371
© 2010 Society for Reproduction and Fertility

36. Infections
infections antibiotics
micro-
biome

37. Intestinal microbiota during infancy
▪ Factors that shape
microbiota
▪ maternal stress
▪ mode of delivery
▪ feeding method
▪ introduction of solid foods
▪ antibiotic exposure
Christoph Reinhardt, Christopher S. Reigstad, and Fredrik Ba¨ckhed. Journal of Pediatric
Gastroenterology and Nutrition. 48:249–256 © 2009

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

39. Influencing gut microbiota
Favor bacteroidetes
(leanness)
▪ Maternal well being
▪ Vaginal delivery
▪ Breastfeeding
▪ Greater resistant starch
▪ Less exposure to antibiotics
Favor firmicutes (obesity)
▪ Maternal stress
▪ C-section
▪ Formula feeding
▪ More refined carbohydrates
▪ High fat diet (?)
▪ Greater exposure to
antibiotics
Christoph Reinhardt, Christopher S. Reigstad, and Fredrik Ba¨ckhed. Journal of Pediatric
Gastroenterology and Nutrition. 48:249–256 © 2009

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.

45. What about psychiatric conditions?
ICAN, Volume 4, Number 5, October, 2012

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

47. Pharmaceutical Iatrogenesis
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
ADD/ADHD
no meds
ADD/ADHD
meds
ADD/ADHD
no meds
(adj)
ADD/ADHD
meds (adj)
Underweight OR
At Risk for Overweight
OR
Overweight OR
Pediatrics July 2008 vol. 122 no. 1 e1-e6 doi: 10.1542/peds.2007-1955

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)

50. Food System–Related Environmental Chemicals Detectable In
Pregnant Women In The United States, 2003–04.
Sutton P et al. Health Aff 2011;30:888-897
©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

51. Endocrine Disruptors, POP’s
 Impaired neurological growth and function
Learning disabilities
Autism
 Impaired glucose tolerance
Obesity, Diabetes
Cardio -Metabolic Syndrome
Cancer
 Impaired thyroid function
 Obesity
 Cancer
 Impaired fertility; reproduction
 PCOS
 Low Testosterone (males)

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