Joanne Kouba, MS, RD, LD

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Concepts for Nourishing Children and Adolescents

• Joanne Kouba, MS, RD, LD
• Loyola University Chicago
• School of Nursing

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Goals of Nutrition in Childhood and
Adolescence

• Adequate nutrients for optimal growth and
  development
• Development of dietary patterns that promote
  healthy life
• Limitation of dietary constituents that are risk
  factors for disease development
• Respect for environmental issues related to food
  production and consumption

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Basic Concepts related toChild/Adolescent
Nutrition

• Eating behaviors influences health
• Eating behaviors in childhood sets patterns for
  adolescence and adulthood
• long latency of chronic diseases mean that
  optimal preventive dietary patterns need to be
  established early
• Nutrition needs still high due to continued
  growth and development during childhood and into
  adolescence

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Healthy Children are Better in

• Mental Function
• Physical Function
• Physical Appearance
• Energy Levels
• Positive Outlook
• Positive Social Interactions

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Concerns Related to Diet, Nutrition and Children

• Childhood Overweight
• Eating Habits
• Heart Health
• Bone Health
• School Foods
• Type 2 Diabetes
• Food Security and Access---Hunger

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Normal Growth in Childhood

• On average, 6-10 year olds should
• --gain 5 pounds/year
• --gain 2-3 inches/year

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Key Nutrient Needs in Childhood

• Energy
• 70 kcal/kg or 2000 kcal/day
• Fine line between too little and too much
• Protein
• 1 gm/kg or 28 g/day
• Calcium
• 4-8 yo 800 mg/day 9-13 yo 1300 mg/day
• Iron
• 4-8 yo 10 mg/day 9-13 yo 8 mg/day
• Based on median weight of children.
• Food and Nutrition Board. Recommended Dietary
  Allowances. 10th ed. Washington, DC. National
  Academy Press. 1989.

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Normal Growth in Adolescence

• On average,
• Boys
• Grow 8 inches during puberty gain 45
• Growth spurt starts 12-13 yo, peaks about 14 yo,
  lasts 2 years
• Gains in lean body mass, bone mass
• Girls
• Grow 6 inches during puberty, gain 35
• Growth spurt starts 10-11 yo, peaks about 12 yo,
  lasts 2 years
• Gains in adipose tissue, bone mass

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Key Nutrient Needs in Adolescence

• Energy
• 11-14 boys
• 55 kcal/kg or 2500 kcal/day girls 47
  kcal/kg or 2200 kcal/day
• 15-18 boys
• 45 kcal/kg or 3000 kcal/day girls 40
  kcal/kg or 2200 kcal/day
• Protein
• 11-14 boys 1 g/kg or 45 g/day girls 1 g/kg or
  46g/day
• 15-18 boys .9 g/kg or 59 g/day girls .8g/kg or
  44g/day
• Based on median weight of children.
• Food and Nutrition Board. Recommended Dietary
  Allowances. 10th ed. Washington, DC. National
  Academy Press. 1989.

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Key Nutrient Needs in Adolescence

• Calcium
• 1300 mg/day
• Iron
• Boys 11 mg/day Girls 15
  mg/day
• Adequacy possible IF adequate energy is obtained
  from a variety of foods
• Inadequacy possible IF inadequate energy or
  limited intake in terms of variety/food groups
  too much junk foods
• Based on median weight of children.
• Food and Nutrition Board. Recommended Dietary
  Allowances. 10th ed. Washington, DC. National
  Academy Press. 1989.

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Surgeon Generals Call to Action to Prevent and
Decrease Obesity

• Issued December 2001
• BMI for Age (BMIA) in 2-20 year olds
• BMIA 95thile
• for age and gender overweight
• Note obesity not used for
• www.surgeongeneral.gov/topics/lbesity/calltoaction
  /CalltoAction.pdf

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Trends in Childhood Overweight

• Overweight
• 6-11 year olds
• Whites 11.9 boys 12 girls
• African Americans 17.6 boys 22.1 girls
• MexicanAmericans 17.3 boys 19.6 girls
• Increased
• from 4.2 in 1963-5 to 15.3 in 1999-2000 NHANES
• increase10 in African American youth

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Trends in Childhood Overweight

• Overweight
• 12-19 year olds
• Whites 13 boys 12.2 girls
  
• African Americans 20.5 boys 25.7 girls
• MexicanAmericans 27.5 boys 19.4 girls
• Increased
• from 4.6 in 1963-5 to 15.5 in 1999-2000
• Note With increasing age, increased prevalence
  of overweight

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Trends in Childrens Weight

• Increased in the last 30 years for
• both genders
• all age groups
• pre-school
• children
• adolescents
• all ethnic and racial groups

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National CO Prevalence Data

• NHANES IV
• 2000
• n4073 children
• 2-19 yo
• Boys and Girls
• CLOCC. 2004. Prevlaence of Childhood Overweight.
  CLOCC.net
• ROW Risk of Overweight
• OW Overweight

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Illinois CO Prevalence Data

• NHANES III
• 1988-94
• n 4500
• Boys and Girls
• CLOCC. 2004. Prevlaence of Childhood Overweight.
  CLOCC.net

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Chicago CO Prevalence Data

• Hip Hop to Health Junior
• 2003
• n 778
• Boys and Girls
• CLOCC. 2004. Prevlaence of Childhood Overweight.
  CLOCC.net

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Chicago CO Prevalence Data

• Chicago Public Schools
• 2003
• n 1208
• 25 schools
• Boys and Girls
• CLOCC. 2004. Prevlaence of Childhood Overweight.
  CLOCC.net

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Chicago CO Prevalence Data

• Sinai Health System Community Health Survey
• 2003
• n 542
• Parental report
• 2-12 years old
• Boys and Girls
• CLOCC. 2004. Prevlaence of Childhood Overweight.
  CLOCC.net

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Childhood Overweight in Chicago
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Conclusions?

• Chicagos children experience the phenomenon of
  the obesity crisis
• earlier and greater extent
• Health disparities are confirmed by the community
  level data of the Sinai Health Systems report.
• Community leaders, clinicians and policy makers
  need to mobilize and collaborate to deal with
  this issue.

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How is CO defined?

• Childhood Overweight is
• Body Mass Index 95th ile for age
• Using CDC Growth Charts, 2000
• Notes
• Per the CDC criteria, childhood obesity does
  not , exist

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Body Mass Index

• Assess weight relative to height
• Simple, non-invasive, indirect measure of body
  composition
• Correlates with body fat and disease risk
• Formula
• weight (kg)/height (meters)2
• weight (lbs) x 703/ height (in)/ height (in)
• need accurate height and weight

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How to determine BMI for Age

• 1. Measure height and weight
• Stadiometer, remove shoes, coats, etc
• 2. Calculate BMI
• 3. Plot on CDC growth charts for age
• 2000 updates www.cdc.gov/growthcharts
• 4. Determine weight status

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CDC Growth Charts

• Birth-36 mos
• weight for age
• length for age
• weight for length
• head circumference
• 2-20 yo
• stature for age
• weight for age
• BMI for age
• weight for stature
• Gender specific

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Consequences of CO

• Premature Cardiovascular Risk Factors
• Hypertension (OR 4.5 CO with NW)
• Hyperlipidemias (OR 7.1 CO with NW)
• 
  Freedman. 1999.
  Pediatrics 103 1175-82
• 60 of overwt children have at least one CV risk
  factor, 20 have 2
• Type 2 Diabetes Mellitus
• (OR 12.6 for hyperinsulinemia in CO with NW)
• Increased risk of adult obesity
• 70 chance of an OW teen becoming an OW adult
• 80 change if one parent is OW as well
• 
  
  Whitaker. 1998. Pediatrics 101(5)

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Social Stigma of CO

• Overweight children
• rated their quality of life comparable to
  children with cancer
• are 4 times more likely to have problems with
  school functions
• 
  Schwimmer JB. 2003. JAMA
  2981813-19
• are described by peers as ugly, selfish,
  lazy, stupid compared to average wt peers
  
  
  Wardle J.
  1995. Int J. Obesity 19 157746-52

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Risk Factors for CO

• Genetics
• 25-50
• Parental Obesity
• Strong correlation nature or nurture?
• Odds Ratio for obesity in as adult 3.6
  comparing a
• a 5 yo children with and without one obese parent
• most powerful predictor for pre-schoolers
• lesson include parents, importance of role
  models
• Whitaker RC. 1997. NEJM 337-869-73.
• Socioeconomic Status 30 shared environment
• Conflicts in findings among demographic groups

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Risk Factors for CO

• Adiposity Rebound
• Typical BMI curve
• increases in first year, declines to age 4-8,
  increases through adolescence
• adiposity rebound second increase in BMI
• early adiposity rebound
• associated with higher BMI as teen and adult
• Dietz WH. 1998. J Nutrition 128(2) 411S-414S
• Family Size
• Larger familiesless childhood CO
• Activity
• Inverse relationship with screen time

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Surgeon Generals Report

• Key concepts to prevent/decrease obesity
• school based nutrition
• health care
• media
• worksites (NA for children)

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Surgeon GeneralsRecommendations to Prevent CO

• Prevention
• Appropriate body weight
• Evaluate BMI for age using current CDC standards
• Focus on small, achievable, lasting behavioral
  changes
• reducing fat in daily patterns
• avoid highly restrictive eating patterns tend to
  fail
• Role Models parents, teachers
• Increasing physical activity
• foster environment that does this

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How are our School-Aged Children Eating?
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Report Card on the Diet
Quality of Children

• Diet quality of children and adolescents
  steadily declines as they get older
• USDA
• Center for Nutrition Policy and Promotion Oct
  1998
• Continuing Survey of Food Intakes by Individuals
• 5000 children surveyed

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Healthy Eating Index

• Overall picture of type and quantity of foods
  people eat
• Compliance with Dietary Guidelines
• Ideal Score100
• Declines linked to F/V, milk consumption
• Limitation
• overconsumption of kcal not judged

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What is the

• HEI for US Children?
• HEI for US Teens?

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Room for Improvement

• HEI
• Children 66
• 7-10 YEAR OLDS

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Continuing Survey of Food Intakes for Individuals

• Intake of US Children compared to Food Guide
  Pyramid
• 2 of school-aged children met guidelines
• of children with adequate intakes of foods
• 14 for fruits
• 20 for veggies
• 23 for grains
• 30 for milk

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More on Childrens Diets

• 80 do not consume adequate calcium
• 66 consume too much total fat
• 84 consume too much saturated fat
• 
  Satcher D. 2003. Am School Board Journal.
  March.

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Skipped Meals Common

• 57 breakfast
• 41 lunch
• 17 dinner
• Why
• disliked foods, no time, forgot to eat

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Sugar in Childrens Diets

• Too high--
• Sugars contribute an average of 20 of energy
  intake
• Average intake 25 t/day
• 56-85 of children consume soda daily
• Teens heavy soda users
• 30 of teens have 3 sodas/day
• USDA/ERS. www.ers.usda.gov/Data/Food
  Consumption/Spreadsheet/Beverages on 4/16/02

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Soda in Childrens Diets

• Soda
• consumption by children increased by 40 from
  1989-1996 from 1-1.4 servings/day
• intake doubled in last 30 years.
• For each additional serving of soda, odds that a
  child will become OW increased by 60
• consumption increases calorie intake by
  55-190/day comparing those who do and do not
  drink soda regularly
• USDA/ERS. www.ers.usda.gov/Data/Food
  Consumption/Spreadsheet/Beverages on 4/16/02

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Nutrition and Adolescents

• 80 Million
• Teens in US

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Key Concepts with Adolescents

• Growth Demands
• stature, bone density, muscles, internal organs
• Social Change
• autonomy, identify self, experimental behaviors
• Diet Patterns characterized by MORE
• eat away from home targets of ads
• fast foods
• skipping meals

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The Healthy Eating Index

• For Teens
• Females
• 11-14 yo 61.4
• 15-18 yo 61.7
• Lowest component for teen girls?
• Males
• 11-14 yo 60.8
• 15-18 yo 59.9--lowest of all groups/ages
• Lowest component for teen boys?

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So how well do adolescents eat?

• Continuing Survey of Food Intake by Individuals
  (CSFII) 1991
• fat 35 for all groups
• sat fat 13 for all groups
• F/V servings 3.1, 2.3, 2.3
• Na 3695, 3258, 2806 mg for each group
• lower BMI with consistent meal patterns

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So how well do adolescents eat?

• Continuing Survey of Food Intake by Individuals
  (CSFII) 1991
• 3 meals/day 57
• 2 meals/day 41
• 1 meal/day 3.5
• inconsistent intake
• associated with being AA, older, single parent
  house
• protective school lunch

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So how well do adolescents eat?

• Continuing Survey of Food Intake by Individuals
  (CSFII) 1991
• 2-3 meals on a regular basis
• adequate intake of kcalories
• greater intakes of
• calcium (89, 71, 65 for 3, 2, 1 meals/day)
• iron (11.3, 10.3, 8.7)
• fiber
• fruit
• compared to inconsistent intakers

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Heart Health and Adolescents

• Bogalus Heart Study
• 16,000 young people in Louisiana
• found coronary lesion in children as young as 5-8
  yo (autopsy)

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Heart Health and Adolescents

• American Heart Association
• compelling evidence that the atherosclerotic
  process begins in childhood and progresses slowly
  to adulthood....then coronary heart disease
  becomes evident .
• National Heart, Lung, and Blood Institute,
  American Academy of Pediatrics and AHA
• support efforts to encourage lower fat, saturated
  fat and cholesterol intakes in children 3

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Heart Health and Adolescents

• American Academy of Peds
• 1998
• clear epidemiological and experimental evidence
  indicates that the risk of coronary heart disease
  is significant with elevated cholesterol levels.
  Diet changes that lower fat, sat fat and chol
  intake in children and adolescents can be applied
  safety and acceptably to improve lipid levels and
  have potential to reduce atheroslcerotic vascular
  disease

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Fat Intake in Children

• Average Total Fat Intakes
• 35-36 of total calorie intake
• Recommended Total Fat Intake
• 30 of total calorie intake
• NIH, AHA, NCI, ADA, ADA
• High cholesterol diet 25

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Bone Health

• Two ways to protect bone mass
• reduce rate of bone loss post-menopause
• increase peak bone mass
• 40-60 of bone mass is accrued during
  adolescence!
• PA important too
• soda consumption of teens dangerous --Harvard SPH

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Milk and Dairy Intake

• of those consuming adequate milk
• 49 of 7-10 yo
• 15 of 11-14 yo girls
• 27 of 11-14 yo boys
• No milk consumption
• 20 teen boys and 40 teen girls
• Average calcium intake of girls 700 mg/d
• about 1/2 of recommended 1300 mg/d

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Access to high quality, nutritious food is the
key to

• proper growth and development
• health in later life
• Hunger
• 5.5 million experience hunger
• at risk
• low SES problems
• growth/development, fatigue,
• cognitive development

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CDC School Health Program
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CATCH Programwww. Sph.uth. Edu/catch

• Goals
• Healthy children and Healthy school environments
• Components
• Food Services
• Nutrition Ed/Class
• Physical Activity
• Home

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• Food Services
• Materials
• recipes
• staff training

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CATCH Materials

• Classroom materials

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• Illinois initiative
• Healthy Environment
• Foods and Nutrition
• Lead, Asthma
• Policy and Practice
• Farm to Schools
• getting local produce into schools

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Ways for schools to support healthy dietary habits

• Strengthen nutrition education and physical
  education for optimal knowledge, attitudes,
  skills and behaviors related to diet and health
• Oppose exclusive soft drink contracts
• Closed vs open campuses for lunch
• Minimize brand-name fast foods in cafeteria

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Nutrition Recs for Competitive Foods

• Center for Science in the Public Interest
• Beverages
• fruit drinks at least 50 fruit juice
• no added sweeteners
• Not Allowed
• soda, sports drinks, punches, iced teas
• fruit drinks with
• caffeine containing drinks (except lowfat choc
  milk)
• Snacks, Sweets, Side Dishes sold

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Nutrition Recs for Competitive Foods

• Center for Science in the Public Interest
• Snacks, Sweets, Side Dishes sold
• excluding naturally occurring in fruits, veg,
  dairy
• Fruits and Vegetables shall be offered for sale
  at any location where other foods are sold

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Portion Size Limits

• Per CPSI recommendations
• 1.25 oz for chips, crackers, popcorn, cereal,
  trail mix, nuts, seeds, dried fruit
• 2 oz for cookies and cereal bars
• 3 oz for bakery items such as pastries, muffins,
  donuts, frozen desserts
• 8 oz for non-frozen yogurt
• 12 oz for beverages, excluding water

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The Illinois NET Program

• www.kidseatwell.org
• 1-800-466-7998
• Loan Library with curricula

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Findings of Media Influence

• Prevalence of CO increased 1.9 for every hour of
  TV watching in 12-19 yo
• OR for CO 4.6
• for those watching 5 hours/day compared to
• NHANES II and III data
• Dietz, 1985

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How does TV influence food choices?

• School aged children
• Prince Georges County, MD
• if TV on for 2 meals/day
• greater intake
• meat, pizza, fries, chips, soda, processed meats
• less intake
• fruits, veggies, grains, chicken, fish, yogurt
• pathway of influence not clear..
• 
  Coon DA. 2001. J Adol Health
  107(1) 7015

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Health Concerns ofSchool-Aged Children

• Type 2 diabetes
• 16 of all childhood diabetes in 1994
• 2 of all childhood diabetes before 1992
• Very serious aspect of overweight in youth

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Hunger

• Severe hunger was a significant predictor
• chronic illness (after controlling for housing
  status, LBW, stressful life events
• more behavioral problems
• higher anxiety
• depression

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Making Changes

• What has been successful in small doses
• Sustained, repeated messages
• Not just one-shot events
• Multi-level support to make change
• Education, availability, cost, taste, convenience
• Parental or role model involvement
• Changes made by family and parents, not just
  child
• Re-setting the norm within social group
  including friends, home, school

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Why make changes?

• Longer that one has a hx of overweight, the more
  likely that person is to continue increasing BMI
  and to continue overweight hx
• More likely to develop other health problems (CV,
  DM, etc)

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Why should schools be concerned or involved with
nutrition?

• Most children attend school
• Most children eat 1/3-2/3 of meals/day at school
• Children look to school peers and role models for
  direction
• Greater potential for program delivery and
  coverage than health care systems

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What is the effect of primary interventions to
all students?

• Knowledge
• Related to optimal diet and health
• Behavior
• Increased F/V and low fat dairy intakes
• Decreased fat intakes
• Health Measures
• Very few long enough to show changes in BMI

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What is the effect of interventions to targeted
studentsobesity focus

• Intervention Components
• nutrition
• physical activity
• behavior techniques
• parental involvement
• Intervention Effects
• those aimed at younger children more effective
• those with more components more effective
• 50 of those with parents were more
  effective---mixed
• those with heavier children were more
  effective
• Note long term follow up data not available

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Care and Caution about school-based interventions

• Careful not to label or stigmative students who
  do participate confidentiality, respect,
  sensitivity

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Broad Based Programs CV focus

• Knowledge
• Definite changes, improvement
• Behaviors
• Improved behaviors effect diminishes with time
• CATCH fat fell from 38 to 31 in school
  lunch and 33 to 31 in total intake more PA
• Health Measures
• Less increase for intervention groups
• CATCH 3 years intervention no change in
  BMI, BP, cholesterol

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Example McComb, MS

• 3000 students, low SES, single-parent fam
• 1997 only 11 of district at grade level in 2nd
  grade
• 1998 implemented coordinated health program
• Health and wellness center in each school
• Improved school breakfast and lunch offerings
• Eliminated most vending only jce/water
• Junk food not allowed in classrooms
• Nutrition education
• 45 minutes of PA daily for students

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McComb, MS Follow-UP

• After 4 years of implementation
• 82 were at grade level at end of 2nd grade
• Behavior improved
• Suspensions went from
• 4568 in 1997 to
• 2568 in 2001
• Drops outs declined from
• 52 in 1997 to
• 10 in 2001

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ExampleVenice High School, Los Angles, CA

• Students for Public Health Advocacy Club
• Health teacher concerned students
• Proposed alternatives for vending offerings
• Students advocacy work was instrumental
• in banning soda sales during school hours,
• adding salad bar, fruit and soup to cafeteria
  offerings

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School Breakfast 1966

• Subsidies and commodities used
• 1.6 billion for 2002
• 1/4 of RDAs must be met
• Full, Reduced and Free pricing available
• 50 of school districts implement with about 20
  of all children using
• Similar nutrition standards, 1/4 of RDAs

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Benefits ofSchool Breakfast

• Collaborative research by
• Kleinman/Murphy, 1998,
• Harvard School of Public Health
• Childhood Hunger Identification Project (CHIP)
• 8 of US school children
• hungry often
• children not starving like in other countries
  but hunger exists which causes subtler problems
  in learning

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• Studied children who participated in school
  breakfast and those who did not in Baltimore and
  Philadelphia children
• 15 ate SB regularly
• those who did
• better grades, attendance, behavior, psych tests,
  math grades ( 1 whole grade better)

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