Nutritional strategies to prevent obesity in children and adolescents

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Nutritional strategies to prevent obesity in
children and adolescents

• Dr Saeed Bawa (PhD, Food and Nutrition Sciences)
• Department of Dietetics
• Faculty of Human Nutrition and Consumer Sciences
• Warsaw University of Life Sciences
• Nowoursynowska Street 159C
• PL-02776 Warsaw, Poland
• Tel. [phone]
• Fax [phone]
• E-mail saeed_bawa_at_sggw.pl

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Obesity
Behavioral Environmental Metabolic Complex
Causes
Obesity and weight gain are the result of choices
individuals make about the types and quantities
of foods they eat and the amount of physical
exertion they undertake within the context of
limited time and income, in the presence of goods
and activities and with objectives of multiple
outcomes or goals, only one of which is health.
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WHO classification of obesityBMI
weight(kg)/height(m)2
World Health Organization. Obesity Preventing
and Managing the Global Epidemic. Geneva WHO,
1997
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What is BMI?

• Body mass index (BMI)
• weight (kg)/height (m)2
• BMI is an effective screening tool it is not a
  diagnostic tool
• For children, BMI is age and gender specific, so
  BMI-for-age is the measure used

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Indicators of nutritional status in youth
Obesity ? 95th percentile of BMI-for-age
Overweight gt 95th percentile of BMI-for-age
Risk of overweight gt 85th to lt 95th percentile
of BMI-for-age
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Obesity rates are projected to double over the
next 30 years An alarming increase
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US
40
England
Australia
30
Brazil
BMI ?30 ()
20
10
0
1960
1970
1980
1990
2000
2010
2020
2030
Year
1Kuczmarski RJ et al. JAMA. 1994272205. 2Mokdad
AH et al. JAMA. 19992821519. 3NIH Natl Heart,
Lung, and Blood Inst. Obes Res. 19986(suppl
2)51S.
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WHO and obesity

• 1995 200 million
• 2000 Over 300 million
• BMI kg/m2

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Obesity and Mortality Risk
2.5
Digestive and pulmonary disease
Cardiovascular and gallbladder disease Diabetes
mellitus
2.0
?
?
1.5
Mortality Ratio1
?
?
?
?
?
?
?
?
1.0
?
?
?
?
VeryLow Risk
VeryHigh Risk
Moderate Risk
Moderate Risk
Low Risk
High Risk
0
20
25
30
35
40
BMI
1Adapted with permission from Gray DS. Med Clin
North Am. 1989731.
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Overweight and Obesity

• Obesity has been related to changes in our
  lifestyle, including diet and physical activity
• Efforts to lose weight have proven unsuccessful
  for many adults
• Obese children are 43.5 times more likely to have
  at least 3 cardiovascular risk factors (Nicklas,
  2001)
• As many as 45 of children newly diagnosed with
  diabetes have type 2 diabetes

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GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC
2000-2010
26.5 32.9 24
14.2 17.5 23
84.5 132.3 57
9.4 14.1 50
1.0 1.3 33
15.6 22.5 44
World 2000 151 million 2010 221
million Increase 46
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Tracking BMI-for-age from birth to 18 years with
percent of overweight children who are obese at
Age 25
Whitaker et al. NEJM 1997337869-873
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Genes are not the Answer!

• Gene pool has not changed over past 100 years
• Genetic models are limited
• Obesity phenotypes observed in highly inbred
  mouse and rat strains
• Genes may make one susceptible for obesity rather
  than actually causing obesity.
• Mutations may increase risk with regard to
• energy intake utilization
• taste preferences
• muscle fiber characteristics
• metabolic characteristics

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Obesity is an Environmental Issue

• Obesity is a relatively recent public health
  concern
• Obesity is virtually nonexistent among
  hunter-gatherers
• In non-industrial and non-western societies,
  obesity is uncommon
• Populations that transition to westernized
  lifestyles experience significant and
  predictable increases in risk for the diseases
  of civilization

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Paleolithic and modern lifestyle
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Nutrition transition
Popkin BM, 2001
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Body Fat Mass
EIn
EOut
Palatable, low-cost, easily available foods
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No simple answer to the obesity epidemic
Glycemic Index
Food Industry
TV
Sugar
Candy
Decreased PE in Schools
Genes
Energy Density
ObesityEpidemic
Soft Drinks
Decreasing Physical Activity
Pouring Contracts
Junk Food
School Feeding
Restaurants
Poor Parenting
Fast Food
Working Mothers
Computers
Poverty
Nicklas, TA, 2003
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Fat Content of Selected Foods
Whole milk (1 cup) Skim milk (1 cup)
Butter (1 tbs) Margarine (1 tbs) American
cheese (1 oz) Ice cream (1 cup) Boiled shrimp
Fried shrimp Flatfish fillet Salmon
filletChicken White, no skin
Dark, no skin Dark, friedGround
beef Ground beef, leanSirloin steak
Sirloin steak, trimmed Sponge cake (1 slice)
Chocolate cake (1 slice)Baked potato (3 oz)
French fries (3 oz) Potato chip (1 oz)
Dairy products
Meat products(3 oz servings)
Other products
Grams/unit
Adapted from Alpers et al. Manual of Nutritional
Therapeutics (4th ed) Lippincott Philadelphia,
2002.
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Energy Density of Selected Foods
Lettuce Vegetable soup Skim milk Apple Black
beans White fish Yogurt Vegetable lasagna Roast
chicken White bread Pretzels Cheddar cheese Salad
dressing Potato chips Bacon Butter
Energy Density (kcal/g)
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FAST FOODS
Food Calories Fat Pepperoni pizza - 1
slice (Pizza Hut) 422 16 Whopper
(Burger King) 640 39 Big Mac
(McDonalds) 530 28 BK Double Whopper
with Cheese 1150 76 Big Fish (Burger
King) 700 41 Chicken Nuggets
300 18 BK 32 oz. old Fashioned Shake
1200 64 Soft Drink (20 oz.) 250 0
Fruit Works (20 oz.) 275 0 30 minutes
of moderate exercise 210 calories (cycling,
swimming, walking, tennis, fast dancing)
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Early nutrition and human capital formation
Nutrition interventions during pregnancy and the
first years of life have positive effects on
human capital formation and may increase
productivity therefore, may impact socioeconomic
development
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Hypothesis about fetal and early life origins of
chronic diseases in the adult (Barker Hypothesis)

• Low birth weight newborns and those with retarded
  growth in infancy ? risk of non communicable
  chronic diseases (NCCD)
• Genes are determinants of NCCD but expression of
  genes is modified by the nutritional status in
  early life
• Undernutrition and overnutrition (obesity) are
  not separate and opposite nutrition conditions
  instead they are linked and are caused by an
  adverse nutritional environment in early life

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Emerging Understandings about Nutrition in
Pregnancy

• Fetal nutritional status is affected by the
  intrauterine and childhood nutritional
  experiences of the mother
• Maternal nutritional status at time of conception
  is an important determinant of outcomes
• Intrauterine nutritional environment affects
  health and development of the fetus throughout
  life

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Emerging Understandings about Nutrition in
Pregnancy

• Periods of critical development are key when
  considering effects of nutrition in pregnancy.
  Undernutrition has different effects at different
  times of life.
• Societies transitioning from chronic malnutrition
  to access to high calorie foods are at high risk
  of chronic disease due to lasting effects of
  early nutritional status

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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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Potential Mechanisms of Developmental
Programming
Structural Deficits ? Reduced Functional Units in
Organs
Kidney ? Nephron HTN Pancreas ? Islet Cell
? Insulin secretion ??
Glucose Muscle ? muscle mass ? Basal
met rate ? Exercise capacity Heart
? myocyte ? Risk CHF Liver ? cells
? ? lipid metabolism
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Maternal Protein Deficiency
The Thrifty Phenotype
FOOD
CATCH-UP GROWTH
BODY MASS
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Hormonal programming Ozanne 2002
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Odds ratio of Type 2 Diabetes and Impaired
Glucose Tolerance and Birth weight of men aged
59-70 y
Am J Clin Nutr 2000, 71 (suppl). 1344S-52S.
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Thrifty Phenotype Hypothesis

• Explains why T2DM very low in Sub-Saharan Africa
  where poor fetal nutrition followed by poor
  postnatal nutrition, and much higher in Western
  populations where poor fetal nutrition, (stress?
  leading to poor placental dysfunction) followed
  by over-nutrition and obesity
• Suggests why obesity has become a huge problem in
  environments with plenty of food and no need for
  physical work, where those in lower SES suffer
  more chronic stress

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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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Breastfeeding a tremendous strategy to prevent
obesity
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Children NOT exclusively breastfed for 6 months
are

• about 40 more likely to develop type 1 diabetes
• about 25 more likely to become overweight or
  obese
• about 60 more likely to suffer from recurrent
  ear infections
• about 30 more likely to suffer from leukemia
• about 100 more likely to suffer from diarrhoea
• about 250 more likely to be hospitalized for
  respiratory infections, asthma and pneumonia
• (Estimates from the USA)

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Breastfeeding and obesity

• Although, more work needs to be done,
  epidemiological evidence - 17 of the 21 studies -
  strongly suggest that breastfeeding represents an
  ideal window of opportunity for obesity
  prevention.
• Once a child becomes obese, it is quite likely
  that he or she will remain obese as an adult.
• Breastfeeding could influence the development of
  a taste receptors profile which fosters a
  preference for lower energy diets later on in
  life.

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• Artificially fed infants consume 30,000 more
  calories than breastfed infants by 8 months of
  age
• (Riordan and Aerbach Breastfeeding Human
  Lactation Jones and Bartlett 1999)
• This is equivalent to 120 Mars bars - 4 a week!

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6 months exclusive breastfeeding

• 82 out of 192 Member States of WHO have policies
  recommending 6 months exclusive breastfeeding.
• This includes 12 countries in the European
  region Azerbaijan, Belarus, Bosnia,   Bulgaria,
  Czech Republic France, Georgia, Germany,
  Luxembourg, Netherlands, Slovakia, UK

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Breastfeeding and ObesityScientific evidence

• Does breastfeeding protect against pediatric
  overweight? Analysis of longitudinal data from
  the CDC and prevention Pediatric nutrtion
  surveillance system
• Grummer-Strawn et al, Pediatrics 200411381-86
• CONCLUSION This study reinforces the rationale
  for recommendations to breastfeed for at least a
  year

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Breastfeeding and ObesityScientific evidence

• Duration of Breastfeeding and Risk of Overweight
  A Meta-Analysis.
• Harder T et al (2005). Am. J. Epidemiol
• CONCLUSION A meta-analysis of the existing
  studies on duration of breastfeeding and risk of
  overweight strongly supports a dose-dependent
  association between longer duration of
  breastfeeding and decrease in risk of overweight.

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Breastfeeding rates in Europe

• The survey on breastfeeding rates in Europe done
  by the authors of the Blueprint for Action on
  Breastfeeding in Europe (a project funded by the
  European Commission) has shown that Breastfeeding
  rates in Europe are generally lower than the
  World Health Organization (WHO) recommendations
  and the targets set by national governments.

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European breastfeeding rates
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• Even in countries where a high proportion of
  mothers choose to breastfeed from birth, numbers
  fall significantly in the first six months. The
  number of mothers exclusively breastfeeding at
  six months is low throughout Europe

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Rate of any breastfeeding at 6 months
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LIQUID CANDY - HFCS

• When people consume excessive calories in drinks,
  they do not cut back on food to make up for it
• Two recent studies
• - Relation Between Consumption of
  Sugar-sweetened Drinks and Childhood Obesity by
  Ludwig,Peterson Gortmaker, The Lancet,
  2/17/2001
• - Sugar-sweetened Beverages, Weight Gain and
  Incidence of Type II Diabetes in Young and
  Middle-aged Women by Schulze, Manson, Ludwig et
  al, JAMA, 8/25/2004

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Studies Show

• A 1998 UCLA survey of 900 children in 14 Los
  Angeles elementary schools found
• 40 were obese
• An extra soft drink per day increases a childs
  risk for obesity by 60
• 9th and 10th grade girls who drank colas were 3
  times more likely to develop bone fractures

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On Average, Adolescents Aged 12-17 Get From Soft
Drinks
Soft drinks carbonated beverages,
fruit-flavored and part juice drinks, and sports
drinks Source USDA, Continuing Survey of Food
Intake by Individuals, 1994-96
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of Adolescents, Ages 12-19, Who Consumed Milk
Carbonated Soft Drinks On Any Given Day, 1994
Source Borrud L, et al. CNI Newsletter, April
18, 1997 (analysis of USDA CSFII data).
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Limit Empty Calories
Liquid Candy
236 calories
76 calories
COLA
200420 oz. now made with high fructose corn
syrup (15 teaspoons)
Introduced in 1894 6.5 oz.made with cane
sugar (4 teaspoons)
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Summary of Calcium Metabolism and Mechanisms of
Disease

• Decreased Calcium Reserve
• Osteoporosis
• Decreased Food Residue Calcium in Chyme
• Colon cancer
• Kidney stones
• Lead Poisoning
• Adaptive Mechanisms Maintaining Extracellular Ca2
• Hypertension
• Pre-eclampsia
• Premenstrual syndrome
• Obesity
• Polycystic ovary syndrome (Hyperparathyroidism)

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Ca2
1,25-(OH)2-D
mVDR
-
-
lipolysis fat oxidation
Ca2i
?
-
Dietary calcium
FAS
RXR
nVDR
DR-3
Mitochondria
UCP2
de novo lipogenesis


Nucleus
apoptosis
Core Temperature
Other Dairy Components
Adipocyte
Fat Oxidation
Zemel, 2004
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HFCS and Obesity

• HFCS Obesity Correlates Well (Bray, 2004)
• Obesity rose slowly until 1980s
• 132/200 extra calories come from sugars
• Food Industry says its about calories and not
  HFCS.
• Fructose Sweeter than Sugar
• Lower satiety response stimulates appetite
• Increases TG
• Increases insulin resistance
• More likely to be converted into fat
• Sucrose increases lipogenesis in liver

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Adipose tissue as endocrine cells
Fructose
appetite
?
Leptin
Insulin
?
energy expenditure
?
?
Glucose
Starvation hormones - FSH, LH, T3
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The Toxic Environment

• Increased portion sizes
• USDA standard serving of meat is 3 oz.
• Many restaurants serve portions ranging from 7 to
  38 oz.
• Standard serving for soda is 12 oz.
• Soda servings as high as 44 oz.

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The Toxic Environment

• Increased portion sizes
• Standard serving size for popcorn is 3 cups
• Medium-size movie theater popcorn consists of 16
  cups
• Super sizes contain 2-3 times more calories

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The Toxic Environment

• SES and Obesity in Developed Nations
• Strong negative relationship between BMI and SES
• Low SES diets high in fat and calories
• Food deprivation rare
• Labor saving devices

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The Toxic Environment

• SES and Obesity in Developing Nations
• Strong positive relationship between BMI and SES
• Low SES individuals engage in physically
  demanding work
• High SES individuals have greater access to
  better nutrition
• Overweight viewed positively

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Rationale forPublic Policy Interventions

• ? in Obesity Prevalence Due to Genetic Factors
  ?
• ? Calories (e.g., 200 kcal/day Over 10 Years)
• ? Portion Sizes (e.g., 22 oz. Steaks and 44 oz.
  Sodas)
• Western Diets in Developing Nations ? Risk of
  Obesity

Battle and Brownell (1996)
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The seek for solution to the Toxic Environment

• Regressive Policies
• Tax high-fat foods
• Limit advertising to children
• Penalize stores for not offering low-fat foods
• Incentives
• Promoting physical activity
• Increase access recreational facilities
• Insurance reductions for healthy behaviors
  (exercise, diet)

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Provide appropriate portion sizes for foods and
beverages

• Serve portion sizes appropriate for age
• Avoid super-size meals and drinks and all-you-can
  eat buffets
• Share restaurant meals or ask for take-home
  container
• Help children learn to eat when hungry and stop
  when full

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Thank you for your attention