The Impact of Early Nutrition on Health and Disease

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The Impact of Early Nutrition on Health and
Disease

• Melinda S. Sothern, PhD
• Prevention of Childhood Obesity Laboratory
• Pennington Biomedical Research Center
• Louisiana State University (LSU)

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Increasing Prevalence of Overweight Children
gt85th percentile for Body Mass Index gt95th
percentile for Body Mass Index
Source U.S. Centers for Disease Control Ogden,
et al, JAMA, 2002
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Risk Factors for Obesity and Chronic Disease

• Socioeconomic Status
• Ethnicity
• Parental Obesity - under 6 years of age
• Body Mass Index - over 6 years of age
• Critical development periods
• Birth - Low Birth Weight
• 5-9 years (adiposity rebound)
• Puberty (12-15 years of age)
• Formula versus Breastfeeding
• Poor Nutrition - Food Preferences
• Sedentary Behaviors

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As children mature, their weight condition is a
stronger predictor of adult obesity.
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80 of overweight 12 year olds will become obese
adults.
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0

Age 6
Age 12
Age 21
Parents Weight
Years
Childs Weight
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Parental Obesity

• If both parents are non-obese the child has only
  a 7 chance of developing obesity.
• If one parent is obese the risk of developing
  obesity is increased to 40.
• If both parents are obese the risk for
  developing obesity doubles to 80.

Whitaker, et al, NE J Med, 1997
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Prevalence of Obesity in Young Adulthood If
the child is overweight the risk is...
Whitaker, et al, NE J Med, 1997
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Obesigenic Families

• A recent study examined the self-reported
  physical activity and dietary intake patterns of
  parents and changes in weight status (body mass
  index and skin folds) over 2 years in offspring.
• Girls of parents with high dietary intake and low
  physical activity (obesigenic) had significantly
  greater increases in weight status.
• Family environment may explain increased weight
  status in children over and above genetic
  susceptibility.

Davison and Birch, Intl J of Ob 2002
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GENETICS PERMITS OBESITY.ENVIRONMENT CAUSES
OBESITY.
Hill Dietz
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Early Nutrition and Children

• Metabolic changes accompany excess body fat
  during critical periods of early development.
• These changes promote an increased risk for Type
  2 diabetes in adolescence and adulthood.

McGarry, 2002 Ong, 2000 Barker, 1995 Law,
1996 Neel, 1962
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Early Nutrition and Metabolic Health

• The intrauterine period is a critical period for
  the development of metabolic abnormalities later
  in life.
• A programming response is established by the
  interaction of the infant and their early
  environment.

McGarry, 2002 Ong, 2000 Barker, 1995 Law,
1996 Neel, 1962
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Birth weight and Overweight Children

• Low birth weight is associated with impaired
  insulin sensitivity, obesity and cardiovascular
  risk factors later in life.
• The relationship may be due to intrauterine
  growth retardation (IUGR)

McGarry, 2002 Ong, 2000 Barker, 1995 Law,
1996 Neel, 1962
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Birth weight and Overweight Children

• IUGR causes metabolic disorders and ultimately
  promotes diabetes mellitus.
• The impact of IUGR is exacerbated in susceptible
  populations exposed to early environments
  conducive to obesity.

McGarry, 2002 Ong, 2000 Barker, 1995 Law,
1996 Neel, 1962
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Birth weight and Overweight Children

• Law and Dietz propose that weight and adiposity
  are entrained during early life.
• Research points to nutrition-induced changes in
  the hypothalmic-pituatary-adrenal axis in the
  mother and the fetus.

McGarry, 2002 Ong, 2000 Barker, 1995 Law,
1996 Neel, 1962
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Birth weight and Overweight Children

• The local availability of nutrients during
  pregnancy, especially protein intake, has strong
  implications for future metabolic health.
• Adjustments to protect brain tissue
  preferentially over visceral and somatic growth
  result in an altered metabolic profile.

McGarry, 2002 Ong, 2000 Barker, 1995 Law,
1996 Neel, 1962
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Developmental Plasticity

• A critical period when a system is plastic and
  sensitive to the environment.
• Followed by a los of plasticity and a fixed
  functional capacity.

West-Eberhard, 1989
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Developmental Plasticity

• One genotype can give rise to a range of
  different physiological or morphological states
  in response to different environmental conditions
  during development.

West-Eberhard, 1989
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Fetal Origins Hypothesis

• Chronic diseases originate in developmental
  plasticity, in response to under-nutrition during
  fetal life and infancy.

Barker, 1995 Barker, 2002
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Fetal Origins Hypothesis

• Three processes explain why individuals born with
  low birth weight are more vulnerable to later
  chronic disease
• Reduced number of nephrons
• Setting of hormones and metabolism
• Increased vulnerability to adverse environmental
  influences in later life.

Brenner, 1993 Keller, 2003 Phillips, 1996
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Fetal Origins Hypothesis

• Reduced number of nephrons
• Leads to increased blood flow through each
  glomerulus (kydney)
• Eventually leads to glomeruli-sclerosis
• High blood pressure

Brenner, 1993 Keller, 2003 Phillips, 1996
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Fetal Origins Hypothesis

• Setting of hormones and metabolism
• Undernourished infant establishes a thrifty way
  of handling food
• Persistence of a fetal response to maintain blood
  glucose concentrations to the brain.

Brenner, 1993 Keller, 2003 Phillips, 1996
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Fetal Origins Hypothesis

• Setting of hormones and metabolism
• High blood glucose concentrations negatively
  impact glucose transportinto the muscles.
• Decreased muscle growth

Brenner, 1993 Keller, 2003 Phillips, 1996
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Fetal Origins Hypothesis

• Increased vulnerability to adverse environmental
  influences in later life.
• Low SES and poverty
• Psychosocial consequences associated with low
  social class.

Brenner, 1993 Keller, 2003 Phillips, 1996
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The Four Birth Phenotypes

• Thin
• Short
• Short and Fat
• Large Placenta

Barker, 1999
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The Four Birth Phenotypes

• Thin
• Insulin resistance during childhood
• Metabolic syndrome
• Adaption to undernutrition though endocrine and
  metabolic changes.

Barker, 1999
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Four Birth Phenotypes

• Short
• Short stature in relation to head circumference
• Reduced abdominal circumference
• Liver dysfunction
• Elevated LDL cholesterol
• Elevated plasma fibrinogen
• Brain sparing circulating adaptations
• Cardiac output is diverted to the brain at the
  expense of the trunk

Brenner, 1993 Keller, 2003 Phillips, 1996
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The Four Birth Phenotypes

• Short and Fat
• Insulin deficient
• High rates of non-insulin dependent diabetes
• Maternal hyperglycemia
• Imbalance in the supply of glucose and other
  nutrients to the fetus.

Brenner, 1993 Keller, 2003 Phillips, 1996
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The Four Birth Phenotypes

• Large Placenta
• Disproportionately large in relation to the
  babys weight
• Increased blood pressure
• Adaptive response to extract more nutrients from
  the mother.

Brenner, 1993 Keller, 2003 Phillips, 1996
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Pre-Pregnancy BMI

• Genetic and nutritional components
• Low BMI is a marker for low tissue nutrient
  reserves
• High BMI is a marker for elevated glucose and
  fatty acide concerntrations

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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Pre-Pregnancy BMI

• Results of study of 6690 women
• Normal weight and below the Institute of Medicine
  (IOM) recommendations an increased risk of
  small-for-gestational-age infants.
• Higher than the IOM increased incidence of
  Cesarean Delivery

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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Weight Gain during Pregnancy

• Results of study of 6690 women
• Women gaining 11.5-16 kg moderately high risk
  for macrosomia (fetal obesity, with excessive
  adipose tissue development)
• Women gaining gt16 kg were at greatest risk for
  macrosomia

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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Gestational Diabetes

• Common in gestational diabetes
• Abnormally high plasma glucose and fatty acid
  concentrations produce high fetal levels.
• High levels lead to excessive insulin production

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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Gestational Diabetes

• Produces excessive fetal adiposity
  characteristics
• Infants remain obese into childhood.
• Adolescents develop early signs of insulin
  resistance
• Propagation of the diabetic condition has been
  passed on for five generations in animal studies.

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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Nutrient Intake during Pregnancy

• Fatty acid intake contributes to growth of lipid
  tissues in the fetus.
• Essential fatty acid nutrition is correlated with
  reduced fetal growth and head circumference.
• Fish oil supplementation in the third trimester
  improves neonatal neurodevelopment.

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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30 Minute Rule

• Research indicates that after 30 minutes of
  mental work the ability to concentrate begins to
  decline.
• Sitting burns only 33-50 calories per
  hour.

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Anything is Better than Sitting!

• Flex at Your Desk
• Hot Seat (chair squats)
• Raise the Roof (overhead press)
• Stand and stretch
• Off the Wall (wall push-ups)
• Tippy Toes (calf raise)
• Music break (dance to one song)
• Stand like a tree and balance
• Reward positive behavior with indoor or outdoor
  play periods

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Childhood Growth and Chronic Disease

• Rates of disease is predicted more strongly by
  rates of weight gain than by the measure of
  childhood BMI.
• Compensatory growth when under-nutrition is
  followed by improved nutrition

Huxley, 2002 Barker, 2002 Middowson, 1972
Metcalfe, 2001
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Childhood Growth and Chronic Disease

• Compensatory growth reduces life-span.
• Rapid growth is associated with persisting
  hormonal changes that promote large body size.

Huxley, 2002 Barker, 2002 Middowson, 1972
Metcalfe, 2001
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Childhood Growth and Chronic Disease

• Small and thin babies lack muscle.
• Muscle deficiency persists because the critical
  period for development is before birth.
• Rapid, weight gain leads to high fat to muscle
  ratio and eventual insulin resistance.

Huxley, 2002 Barker, 2002 Middowson, 1972
Metcalfe, 2001 Erikkson, 2002
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Feeding during Catch-Up Growth

• Infants with a slower rate of intrauterine growth
  are unlikely to ever grow normally.
• Low nutrient intake and reduced growth in SGA
  infants is associated with improved insulin
  sensitivity.

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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Feeding during Catch-Up Growth

• Getting bigger faster is detrimental
• Optimal neurodevelopmental outcome is achieved
  with
• Slower growth rate of pre term infants
• Breastfeeding

Hay, 2003 Neggers, 2003 Catalano, 2003
Gershwin, 2000
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Catch-up Growth Hypothesis.

• Aggressive feeding to induce catch-up growth,
  especially high fat intake, is strongly
  associated with
• Obesity
• Insulin resistance
• Diabetes in later life.

Cianfarani, 1999 Erikson, 2003 Eriksson, 2002
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Low Pre-pregnancy BMI
• Pre-gestational Diabetes
• Malnourishment
• Smoking
• Caffeine
• Compromised Immune System
• Maternal stress response
• Short Inter-pregnancy Intervals
• Early Pregnancy
• Multi Fetal Pregnancy

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Low Pre-pregnancy BMI
• Strongest predictors of pre-term birth and fetal
  growth retardation
• Interacts with smoking and stress.

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Pre-gestational Diabetes
• Increased risk of fetal growth restriction
• Related to the increased incidence of chronic
  hypertension and diabetic nephropathy.

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Malnourishment
• Deficient or excessive consumption and/or
  absorption of select nutrients
• Disease, diet-nutrient interactions,
  drug-nutrient interactions and lifestyle habits
  (alcohol and tobacco) affect absorption.

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Smoking
• Pregnant smokers have poorer nutrient intakes of
  most micronutrients.
• Pregnant smokers require more micronutrients.
• Smoking combined with caffeine is negatively
  associated with birth weight

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Smoking and Caffeine
• Pregnant smokers have poorer nutrient intakes of
  most micronutrients.
• Pregnant smokers require more micronutrients.
• Smoking combined with caffeine is negatively
  associated with birth weight

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Compromised Immune System
• Disease state compromises nutrient uptake
• Poor nutrition compromises the immune system
• Chronic infection leads to maternal catabolism
  and nutrient competition between mother and
  placenta

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Stress in Early Pregnancy
• Work strain
• Poor nutrition
• Stress on neuro-endocrine-immune interactions
  increases the risk for infections
• The timing of prenatal stress is the most
  important factor

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Short Inter-pregnancy Intervals
• Closely spaced pregnancies (lt18 months)
• Insufficient time to replace nutrients used
  during the previous pregnancy

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Early Pregnancy
• Within 2 years of menarche
• Low nutrient reserves because of recent use of
  nutrients to facilitate growth.

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Nutritional Risk Factors for Fetal Growth
Restriction and Pre- Term Birth

• Multi-fetal Pregnancy
• Weight gain is positively and llinearly related
  to birth weight in twin pregnancy
• Declining weight gain late in pregnancy is
  associated with low birth weight twins.

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Summary

• Increased adiposity at both end of the birth
  weight spectrum
• 1) Higher BMI Higher Birthweight
• 2)Higher central obesity low birth weight

Naggers, 2003 Catalarc, 2003 Gershwin, 2000
Matthews, 2000, Brown, 2000 King, 2003
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Summary

• Once the fetus is programmed by either
  under-nutrition and growth restriction, or
  over-nutrition and obesity, metabolic disease is
  inevitable.
• Prevention of childhood obesity is critical and
  may have lifelong, multi-generational , impact.

Snoeck, 1990 Singhal, 2003, Hay, 1997,
Albertsson-Lwikland, 1997 Neggers, 2003
Cianfarani, 1999
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30 Minute Rule

• Research indicates that after 30 minutes of
  mental work the ability to concentrate begins to
  decline.
• Sitting burns only 33-50 calories per
  hour.

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Anything is Better than Sitting!

• Flex at Your Desk
• Hot Seat (chair squats)
• Raise the Roof (overhead press)
• Stand and stretch
• Off the Wall (wall push-ups)
• Tippy Toes (calf raise)
• Music break (dance to one song)
• Stand like a tree and balance
• Reward positive behavior with indoor or outdoor
  play periods

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Breast feeding Obesity Chronic Disease

• Recent research strongly suggests that postnatal
  nutrition is an important factor in the
  development
• obesity,
• insulin resistance
• dyslipidemia
• other chronic diseases.

Von Kries, 1999 Liese, 200 Das, 2001 Dietz,
2001
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Breast feeding Obesity Chronic Disease

• There is evidence for a significant relationship
  between breastfeeding and future obesity.
• Breastfeeding may reduce the risk for adult
  obesity and metabolic disease.

Von Kries, 1999 Liese, 200 Das, 2001 Dietz,
2001
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Breast feeding Obesity Chronic Disease

• The prevalence of obesity in 5-6 year-old
  children who were never breast fed is almost
  double that of breast fed children.
• The risk of childhood obesity declines as the
  duration of breast feeding increases.

Von Kries, 1999 Liese, 200 Das, 2001 Dietz,
2001
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Breast feeding Obesity Chronic Disease

• Breast feeding is associated with improved immune
  function.
• Obesity may be associated with inflammatory
  disease.

Von Kries, 1999 Liese, 200 Das, 2001 Dietz,
2001
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Food Attitude and Practices in Young Children

• How parents present food to their young children
  greatly impacts their food preferences.
• Providing rewards for eating nutritious foods
  initially enhances preference, but has a negative
  effect later when the reward is removed.

Birch, Ch. Dev., 1980 and 1995 Spruijt-Metz, 2002
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The strategy of having a child eat a food in
order to obtain a reward tends to reduce the
childs liking for the food she is rewarded for
eating.
Food Preferences
Birch, Young Children, 1995
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Food Attitude and Practices in Young Children

• Pressure to eat and concern for childs weight
  are associated with increased fat in children.
• If left unattended, children will select foods
  they enjoy and leave behind foods they dislike.

Birch, Ch. Dev., 1980 and 1995 Spruijt-Metz, 2002
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Food Attitude and Practices in Young Children

• Children will eat less if served less or if
  allowed to serve themselves.
• As children mature, parental influence is reduced
  and the influence of peers may change food
  preferences.

Birch, Ch. Dev., 1980 and 1995 Spruijt-Metz, 2002
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Nutrition Tips for Kids at Risk for Obesity
Chronic Disease
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I do like vegetables Thats why I hate to see
them brutally killed and eaten!
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Nutrition and At-Risk Youth

• Let babys appetite determine what and how much
  to feed.
• Teach young children that its OK to leave food
  on the plate.

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Nutrition and At-Risk Youth

• Observe the childs eating and physical activity
  behaviors.
• Schedule frequent sessions with the pediatrician
  for advise and monitoring.

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Nutrition and At-Risk Youth

• Discourage consumption of high sugar beverages.
• Select healthy fruits and snacks as treat foods,
  i.e. grapes, raisins, etc.

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Nutrition and At-Risk Youth

• Require that all drinks and foods be consumed at
  the kitchen or dining table or other designated
  area.
• Schedule mid-morning and mid-morning healthy
  snacks - make them attractive.

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Nutrition and At-Risk Youth

• Always require children to eat a healthy
  breakfast.
• Discourage snacking after dinnertime.
• Children who eat late dinners or snacks are less
  hungry in the morning.

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Nutrition and At-Risk Youth

• Dont place a moral value on food.
• Teach children that all food is OK some is grow
  tall or big food and some is not.
• Never give food as a reward.

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Nutrition and At-Risk Youth

• Create a safe home food environment
• Gradually replace non-nutritious foods in the
  home. Involve children with shopping.
• Display and keep within reach nutritious foods
  naturally low in fat and sugar.

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Nutrition and At-Risk Youth

• Create a safe home food environment
• Allow infrequent consumption of non-
• nutritious foods away from the home.
• Downsize Place foods in serving size containers.

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The Ultimate Parent Tip
Stop nagging. Praise children who select healthy
snacks. Ignore unhealthy nutrition and
re-direct. Offer choices, Do you want
strawberries, carrots or melon for your snack.
Sothern, et al, Trim Kids, 2001
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What if the Parents say
You know, Im big, my momma was big, my grandma
was big..Were just big people.
Sothern, et al, Trim Kids, 2001
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Parent Tip
Even if your child is genetically designed to
be overweight, his or her environment can be
adjusted to combat this predisposition. Your
child may become chubby even with adjustments. He
or she does not have to be doomed to a life of
ill health. Weight management is the key.
Sothern, et al, Trim Kids, 2001
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30 Minute Rule

• Research indicates that after 30 minutes of
  mental work the ability to concentrate begins to
  decline.
• Sitting burns only 33-50 calories per
  hour.

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Anything is Better than Sitting!

• Flex at Your Desk
• Hot Seat (chair squats)
• Raise the Roof (overhead press)
• Stand and stretch
• Off the Wall (wall push-ups)
• Tippy Toes (calf raise)
• Music break (dance to one song)
• Stand like a tree and balance
• Reward positive behavior with indoor or outdoor
  play periods

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Patty Panther
Molly Monkey
Katy Kangaroo
Say Time to Play!
Any Questions?