Preventive Nutrition

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Preventive Nutrition

• Center for Health Promotion
• Edition 4/04

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Folic Acid and Birth Defects

• About 4000 neural tube defects per year
• Occur at 26-28 days post-conception
• 95 are spontaneous with no family history
• 1991 UK study showed 71 risk reduction
  
  in recurrences (4mg dose)
• In 1999 (Nov NEJM) 85 reduction in risk for
  primary
  prevention (0.4mg dose) with Cis, 70 protection

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Folic Acid and Birth Defects Knowledge

• 2003 MOD/Gallup poll (138831)
• 79 of women have heard of the relationship of
  folate and birth defects (52 in 1995)
• 21 knew folate prevents birth defects (vs 4,
  1995), 10 knew that was required before before
  conception (vs 2 in 1995)
• 32 took a daily vitamin supplement (vs 28in
  1995)
• 71 who were counseled vs 17 not counseled
  (separate study in Canadian Family Physician)
• Lowest among young and poorly educated

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Folic Acid Dietary Sources

• Dark, leafy vegetables, citrus fruits, liver and
  organ meats, fortified cereals and legumes.
• 8oz of OJ and bowl of fortified cereal
  200-400mcg of folic acid
• Cant rely on diet for pregnancy

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Folic Acid-

• Birth defects http//www.folicacid.net/login.asp
• Cardiovascular effects
• Cancer prevention
• ? Dementia

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Folic acid-ASCVD

• Folic acid (1mg), pyridoxine (10mg) and B12
  (400mcg)
• Used in controlled study with angioplasty
  patients
• Dropped homocysteine from 11 to 7µmol/l
• Reduced rate of restenosis from 38 to 20 at six
  mths follow-up
• Schnyder G et al. NEJM 3451593, 2001

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Childhood ALL

• Australian case/control study
• 83 study/166 controls
• Odds risk of 0.4 for folate supplementation at
  any time during pregnancy
• Thompson JR et al Lancet 358 1935-40
• Weak study due to numbers, but supports other
  data in which folate has impact on cancer effect
  of MTHFR gene deletion and protective effect on
  leukemia
• David Grant-UK Childhood Cancer Study

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Homocysteine and Dementia

• Framingham study group (begun in 1948)
• 8 year prospective study
• 1092 subjects, average age 76 (61 women)
• Homocysteine levels at 0 and 8 years
• For levels greater than 14µM, risk of Alzheimers
  doubled
• N Engl J Med 2002 346476-83

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Low birth weight/cardiovascular disease

• Hypertension
• Obesity
• Lipid disorders
• Diabetes

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Breast Feeding

• Impact on obesity
• Atopic diseases
• Calcium
• Impact on immunity
• Colic
• EtOH, caffeine, medications, spices

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Breast Feeding and Atopy

• BMJ- 6 year follow-up study (2000 subjects)
• Exclusive Breast feeding gt4mths
• RR of asthma 1.25, of wheezing 1.31, positive
  skin tests 1.30
• BMJ 1999319815-9

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Atopic diseases

• Identify high risk kids by family hx
• No impact of pre-natal diet
• Breast feed for at least 6 months
• Maternal diet avoidance of milk, egg and peanuts
• Delay solid foods for 6mths
• Add milk, wheat, corn, citrus and soy at 1 year
  eggs and tree nuts at 2 years shellfish, peanuts
  and fish at 3 years

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Breast Milk-infection

• Strongest test 3rd world
• During and after lactation
• Diarrhea
• Respiratory tract infections (HiB and RSV)
• Otitis media
• UTI
• Vaccine responses
• Immune cell functions

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Formula feeding

• Overfeeding
• Reflux
• Obesity
• Calcium (soy diets)
• Iron
• Fluoride (0.8-1.0ppm)
• Safety

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Table Foods

• Overfeeding (fats, carbohydrates)
• New Portion Distortion Quiz
• http//hin.nhlbi.nih.gov/portion/
• Calcium (osteoporosis)
• Iron (pica)
• Fruits and vegetables
• 5 a day (cancer, GI)
• Grains and the pyramid
• Sodas and sugar (dental and bone)
• Fluoride

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Pediatric obesity-adult obesity

• One third of obese school children will become
  obese adults
• One half of obese adolescents will become obese
  adults
• 50 year follow up in adults shows childhood
  obesity associated with adult CV mortality
• Some data that morbidity occurs even if as adults
  obesity is reduced
• Nutritional programing
• J Pediatri Gastroenterol 30345, 2000

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Effect of Multiple Risk Factors on
Atherosclerosis in the Aorta and Coronary
Arteries in Children and Young Adults
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2
3
1
2
1
0
0
Aorta
Coronary Arteries
Number of Risk Factors
Berenson et. al (NEJM 1998)
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Update from Bogalusa

• 77 of overweight children became obese adults
  (mean follow-up17 years)
• However, risk factors such as lipid levels,
  insulin, BP did not correlate well with BMI
• Other factors?? Role of fitness?
• Freedman DS et al Pediatrics 108712, 2001

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Obesity and CV physiological dyfunction

• 48 obese (gt3 SD) and 27 normal kids, all
  normotensive
• Carotid dopler studies showed significant
  differences in elasticity/compliance in response
  to vascular stress
• Obese kids had elevated TG, insulin resistance
  and lower HDL
• Lancet 2001 358 1400-04

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Obesity and Inflammation

• N-HANES III
• 3512 kids (age 8-16)
• Kids with elevated CRP (gt.22mg/dL) or WBC gt
  10,000
• Overweight (gt85) vs lt 85
• Odds Ratio (OR) of 3.7 (M) and 3.1 for
  correlation of CRP with overweight
• Also elevated risk for WBC

M Visser et al Pediatrics e13, January 2001
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Maternal perception

• Mothers blame overweight on
• Family genes
• Family members
• Mothers dont recognize their kids are overweight
  unless
• Teased
• limited physical activity
• Jain A Pediatrics 107 1138, 2001

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Osteoporosis

• In adults, peak bone mass and rate of bone loss
  are biggest determinants of osteoporosis
• Peak bone mass achieved in childhood and
  adolescence (16yrs in girls and 18 yrs)
• Adolescent girls need 4-5 dairy servings a day to
  achieve goal of 1300mg intake
• Negative associations exercise, sunshine (10-20
  minutes/day)
• Positive associations smoking, sodas, high
  sodium diets

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Adolescents

• Eating disorders
• Undereating, overeating
• Fast food, drinks (fat, sugar), vending machines
• Folate
• Iron
• Calcium
• Ethanol

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Teens, obsesity, Type 2 DM

• New incidence is 2-50/1000 (10 fold over last 20
  years)
• Almost all childhood Type 2 DM have BMI gt95tile
• African-Americans and Native Americans
• TV, intrauterine experience
• Diet and physical activity both effective
• Ludwing and Ebbeling JAMA 286 1427, 2001

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of High School Students Who Reported Eating
Less than 5 Servings of Fruits/Vegetables on
Day Preceding Survey, 1997
Data missing
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From Youth Risk Behavior Survey
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of High School Students Not Enrolled in
Physical Education Class, 1997
Data missing
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From 1997 Youth Risk Behavior Survey
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Childhood Obesity and QOL

• Compared to healthy kids and kids with cancer,
  obese kids had equivalent physical, social and
  psychosocial scores to those who had cancer
• Sleep apnea was an even worse marker
• The BMI inversely correlated with QOL
• JB Schwimmer, JAMA 2003 2891813

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Controversies

• Has emphasis on fat shifted us towards carbos,
  obesity and type 2 DM?
• Science 2912536, 2001
• Are genes the real culprit? (MODY)
• NEJM 345, 971, 2001
• Should we move from a focus on fat to fitness?
  (Sedentry Death Syndrome)
• JAMA 286717, 2001

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Concepts in prevention

• Early childhood habits adult habits
• Adult pathology begins in childhood
• Atherosclerosis begins in childhood
• Obesity begins in childhood
• Interventions in childhood should begin in
  childhood
• Children are members of a family

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Nutrition interventions that work

• Goal grow into ideal weight
• Modified energy intake
• Decreased fat
• Increased physical activity (30m/d) with parent
• Behavior modification (self-monitoring) with
  parent (frequent rewards)

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Nutrition screens

• Dietary screens in hospitalized patients
• BMI/ ht and wt screens (gt90tile or 120 of med.
  wt/ageobese gt140med. wt/age super-obese
• www.blubberbuster.com
• Nutrition history
• 24 hr recall
• Family history
• Obesity
• HTN, ASCVD, DM, Cancer
• Social hx
• Exercise history

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Nutrition Resources

• Direct advice
• Web based, AAP
• Referral
• ACH dieticians
• Breast feeding team, La Leche
• Commercial programs
• obesity clinic (GPC)
• State and Federal Programs

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State and Federal Programs

• Food Stamp/Card programs
• WIC and WIC Farmers market
• Headstart
• School lunch and breakfast
• Summer Food Service
• REMEMBER TO REFER!