an ounce of prevention is worth a pound

An Ounce of Prevention An Ounce of Prevention is worth a poundis worth a pound

Shaping Habits

That Shape

Obesity

Ohio Chapter, American Academy of PediatricsOhio Department of HealthOhio Dietetics Association

Prevalence of Obesity U.S. Adults: 2001-2

• Obese 1/3Obese 1/3 (30.6%)

• Overweight 2/3Overweight 2/3 (65.7%)

• Extreme obesity Extreme obesity (5.1%)

All agesBoth sexesAll ethnic groupsAll socioeconomic levels

Source: Hedley et al. 2004; Freedman et al. 2002

Prevalence of Overweight in U.S. Children: 2002

At Risk (> 85%)(%)

22.631.230.931.0

* Overweight among non-Hispanic Black (20.5%) and Mexican-American (22.2%) increased much more rapidly than among whites between NHANES in ‘88-94 and 2002

Source: Hedley et al. 2004

Age, yrs

2-5 6-11 12-19 All 6-19

Overweight (> 95%)(%)

10.315.816.116.0

Obesity Among African-American Adults:

2002

Source: Hedley et al. 2004.

Age, yrs

Males20-3940-59

Females20-3940-59

OverweightBMI > 25

%

55.465.0

70.381.5

ObeseBMI > 30

%

24.729.7

46.650.6

ExtremeBMI > 40

%

4.12.9

11.815.1

Overweight Status of African-American Children: 2002

Source: Hedley et al. 2004.

Percentile

Males8595

Females8595

All Ages%

31.017.9

40.123.2

2-5 yrs%

23.28.0

25.69.6

6-11 yrs%

20.917.0

37.922.8

12-19 yrs%

32.118.7

41.923.6

Class 3 Obesity in the U.S.1990 through 2000

• Class 3 = BMI > 40BMI > 40

• 2-fold higher risk of mortality than BMI 30

• High likelihood of bariatric surgery

• Those over age 20 yrs

– In population 4.9%

– In black females 13.5%Prevalence increased 3-fold in only a decade and continues to rise

Pre

vale

nce

, %

Year1990 1992 1994 1996 1998 2000

50

10

5

1

BMI

<25

25-29.9

30-34.9

35-39.9

>40

Medical Consequences of Obesity

• Psychosocial

• Cardiovascular

– Lipidemia

– Diabetes mellitus

– Hypertension

– Respiratory

– Cardiac

• Medical

– Polycystic ovary disease

– Gall bladder disease

– Osteoarthritis

– Cancer

• Pregnancy and postpartum ???

• Mortality

Diseases that begin in childhood amplify morbidity – and costs

Source: Krebs & Jacobson 2003; Dietz 1998a; Dietz 1998b; Must 2003.

And how many overweight adults and kids have pre-diabetes?

Prevalence of Diabetes in US Has Risen Dramatically –1990 to 2001

Source: Narayan et al. 2003; Sinha et al. 2002; Weiss et al. 2003.

Life-Years Lost from Diabetes in the US

• If diagnosed at age 40 years

– White

• male: 1.01 yrs

• female: 13.5 yrs

– Hispanic

• male: 11.5 yrs


– Black

• male: 13.0 yrs


• If diagnosed at age 10 years

– White

• male: 16.5 yrs


– Hispanic

• male: 19.0 yrs


– Black

• male: 22.0 yrs


Source: Narayan et al. 2003

“Because of the increasing rates of obesity,

unhealthy eating habits, and physical

inactivity,we may see the first generation

that will be less healthy and

have a shorter life expectancy than their

parents”

Richard H. Carmona, MD, MPH, FACSSurgeon General

U.S. Dept of Health and Human Services, 2004

Obesity Risk Increases with the Age of the Child

• Obese at 6 years

– 50% risk of obesity at 35 yrs

• Obese at 10 years

– 70 - 80% risk

Obesity is a pediatric disorder with adult consequences Source: Bray 2002, Dietz 1998a, Dietzs 1998b,

Guo et al. 2002; Kvaavik et al. 2003; `Must 2003, Whitaker et al. 1997;

The State of Ohio’s TeensYouth Risk Behavior Survey 2003

• 57% participate in organized after-school activities

• 68% reported participating in vigorous activity in any given week; only 41% attend PE classes

• 32% watch 3 or more hours of TV per average school day

• 14% report being overweight, up from 10% in 1999

• 30% report eating fruits one or more times per day in the past week

• 38% report eating vegetables one or more times per day in the past week (includes potatoes)

• 20% report drinking the recommended 3 glasses per day of milk

Source: Bray 2002; Ohio Dept of Health: www.odh.state.oh.us

Nutritional Gaps in U.S. Children

0

20

40

60

80

100

120

6-11 Mo. 1 Yr. 1-4 Yrs. 5-8 Yrs. 9-14 Yrs. 15-19 Yrs.

CalciumFolate

% Children Consuming

Daily Recommende

d Intake

Magnesium

Vitamin A

Vitamin CZinc

Iron

Phosphorus

Critical Age

NHANES, CFSII data compiled by Dr. John Lasekan, Ross Labs

HOME

COMMUNITY

SCHOOL

Children grow upIn 3 environments

The issue of obesity

Is multifactorial

but parents,

especially mothers,

have an opportunity

to create a healthful

home environment

Babies are Getting Bigger

Year N BW (g) Z score % SGA %LGA

1978-9 5626 3419 -0.91 11.1 8.0

80-81 5659 3426 -0.046 10.3 8.4

82-83 6333 3453 0.013 8.9 9.9

84-85 6222 3449 0.050 8.2 10.0

86-87 6192 3465 0.102 7.8 11.2

88-89 6482 3462 0.078 7.5 10.6

90-91 6985 3456 0.077 7.5 10.7

92-93 6621 3471 0.098 8.1 11.7

94-96 7079 3476 0.128 7.2 11.5

P value <0.001 <0.001 <0.001 <0.001

Source: Kramer 2002Births > 37 wks GA

Babies Are Getting BiggerAnd Moms Are the Reason

• McGill University database 1978-1996

• Mean birth weight and z-score increased

over two decades (p < 0.0001)

• No trends in premie birth weights

– Prepregnancy obesity: from 4.7 to 10.6%

– Gestational diabetes: a 20-fold increase

Prenatal

• Maternal weight gain

– An important predictor of later obesity in the child

• Breastfeeding

– Encourage breastfeeding

– Lower incidence of obesity in breastfed infants

Is Breastfeeding Protective against Obesity Later in Life?

• Von Kries, 1999 German 5-6 yr olds

• Hediger, 2001 US 3-5 yr olds

• Gillman, 2001 US 9-14 yr old

• Liese, 2001 German 9-10 yr old

• Armstrong, 2003 Scottish 3-4 yr olds

• Bergman, 2003 German 6 yr olds

• Toschke, 2003 Czech 6-14 yr old

Healthy People 2010 Breastfeeding Recommendations

• Increase the proportion of mothers who breastfeed to 75% in the postpartum period

• Increase rates to 50% at 6 mos

• Increase rates to 25% at 12 mos

0%

10%

20%

30%

40%

50%

60%

70%

80%

'65 '67 '69 '71 '73 '75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01

Any BF Exclusive BF

24.7%

21.7%

61.9%

55.0%

51.5%

43.5%

69.5%

46.3%

In-Hospital Breastfeeding Rates1965-2001

0%

10%

20%

30%

40%

50%

'71 '73 '75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01

Any BF Exclusive BF

19.8%

27.1%

10.4%

17.6%

32.5%

17.2%

Breastfeeding Rates at 6 Months1971-2001

Source: Ryan 2002

Largest Increases in In-Hospital Breastfeeding

1996-2001

Demographic

African American

< 20 yrs of age

WIC participant

20-24 yrs of age

High school education

National

1996

37.1

43.3

46.6

52.7

49.2

59.2

2001

52.9

57.2

58.2

65.9

61.1

69.5

% Change

42.6

32.1

24.9

24.5

24.2

17.4

Obesity (Pre- or In-Pregnancy Weight) Threatens Breast-feeding

(BF) • Pediatric & Pregnancy Nutrition Surveillance

Surveys

– 51,329 women and babies

– Pregnant and gestational weight gain + BF

– Both pre- and in-pregnancy obesity resulted in:

• Less initiation of BF

• Shorter duration of BF

• Increasing obesity may threaten recent gains in breast-feeding

Source: Li 2003

Train parents in how and what to feed their baby

Where Do Parents Look for Nutrition Information?

• #1 Pediatrician/ Family MD

• Social environment

• Magazines

• Internet

• Dietitian

• TV

• Nutrition Center

• Food labels

• MediaSource: Van Dillen 2003

The 12 Well-Child Visits

221212

33

4

55 6677

88

9910

1111

Anticipate problem feeding and activity practices

Newborn/First Visit

• For Breastfed and Formula Fed Infants

– Help sustain breastfeeding by building skills and offering resources for support

– Iron-based formulas only

– Hunger and satiety cues

– Babies should regulate their own intake

– Crying does not always represent hunger

• It is normal for 1-3 month old babies to cry up to 3 hours per day

How are Infants Fed? Milk Feeding 2000

Human Milk

Human Milk & Formula

Formula

Cow's Milk

0

10

20

30

40

50

60

70

80

90

100

In Hospital 1 to 3 4 to 6 7 to 9 10 to 12

Months

% o

f M

ilk

Fee

din

g

Source: Ryan et al. 2002

Infants Adjust Their Calories

By 6 weeks, the baby regulates its own energy intake

Source: Fomon 2004.

Vo

lum

e o

f In

tak

e (

mL

/kg

/da

y)

Ca

lori

e I

nta

ke

(k

al/

kg

/da

y)

Age (days)

200

180

160

140

120

100

130

120

110

100

90

814 28 42 56 84 112

53 kcal/100ml

67 kcal/100 ml

100 kcal/100 ml

From birth to 24 months, the

child assumes the eating

habits of the family

The Feeding Infants And Toddlers Study (FITS)

Source:Dwyer, 2004

FITS Study Methodology

• Adds critical information to augment NHANES, CFSII, Ross Mother’s Survey information

• 5 Gerber sponsored FITS surveys over 30 yrs

• Snapshot of eating habits in first 2 years (2002)

• Random sample of 3022 (Experian database)

– Recruitment and household review

– 24-hr dietary recall and subject information

– Second dietary recall for subset (n=703)

– Response rate for recalls 94%

Source: Devaney et al. 2004a

FITS: Nutrient Intakes 0-24 months of age

• Examined transitional times for feeding

– 4-6 months

– 7-11 months

– 12-24 months

• Diets found to vary widely day-to-day

• Nutrition is good over the first 24 months

• Exceeds adequate intake for all nutrients, 0-12 months and almost all nutrients, 12-24 mos

• Vitamin E low 12-24 mos

• Fiber low in toddlers

• But energy intake exceeds Estimated Energy Requirement (EER) at all ages

Source: Devaney et al. 2004 b

Energy Intake Infants and Toddlers

• Energy intake exceeds EER

– 4-6 mo 10%

– 7-11 mo 23%

– 12-24 mo31%

• Feeding

– Breast < EER

– BF/ formula = EER

– Formula > ERR

– Solids and cereals add to energy intakes, especially when coupled with formula

Two-Month Visit

• Infant Feeding

– Set expectations:

• the baby will increase to 24-28 oz/day over the next 2 months

– Provide 4 oz four to six times per day

– No cereal, no baby food, no juices

– Nothing added in the bottle

Not all Crying Needs FoodTwo Months

• Learn to interpret the infant’s cries

• Parents eager to “empty the bottle” encourage overeating

• Satiety cues between 4-12 weeks:

– Turns head away or releases nipple

– Falls asleep

• Comfort the baby

– Rocking, massaging, cuddling, or listening to music

Recommendations for Iron

• Healthy People 2010: “…reduce iron-deficiency

among children aged one to two years to 5%”

• AAP Committee on Nutrition

– Supplement breastfed infants with iron

– Iron-fortified formula is the appropriate substitute for

breastfeeding in the first 12 months

– Iron fortified infant cereals and grains, as well as meats

are important sources of iron, especially for infants who

continue to breastfeed beyond 6 months of age

Physical ActivitiesTwo Months

• Minimize stationary devices

• Use crib mobiles

• Encourage reaching, kicking, stretching, and belly play time

• No T.V.

4-Month Visit

• The addition of cereal

– No solids until developmentally ready to use a spoon, usually 4-6 mos of age

– Cereal only with a spoon, not in the bottle

– Start a single grain, iron-fortified cereal

– Portion: increase to 1-2 Tbsp twice daily

• First baby food: vegetables at 6 mos

Excessive Juice is a Risk for Obesity

• Both short stature and obesity are tied to excessive intake of juices

– Only 100% juice

– Only after 6 months of age

– Only from a cup, not from a bottle

– Limit to 3 oz initially with a maximum of 4-6 oz / day for 1-6 year olds

Promote Vegetables for Infants & Toddlers

• Fail to consume vegetables as a discrete food:

– 9-11 months 27 %

– 12 months 18-23%

– Dark Green Vegetables are consumed by fewer than 10% of toddlers

– Deep yellow vegetables decrease from 39% at 9 mos to 14% at 18 mos

• Potatoes – consume daily

– 4-6 mos 3.6%

– 7-8 mos 12.4%

– 9-11 mos24.1%

– 12-14 mos33.2%

– 15-18 mos42.0%

– 19-24 mos40.6%

– By 24 mos 25% of toddlers consume fried potatoes on any day

Source: Fox et al. 2004

Feeding the Baby

• Infants innately prefer sweet and salty.

• Infants may reject bitter and sour

• Infants tend to resist new foods (neophobic)

Implications…

• More than 10 exposures may be needed to establish a new food.

• Children like and eat what is familiar

• Parental eating habits influence the baby’s choices at this age

Physical ActivitiesFour Months

• Non-restrictive play

– Belly play time

– Sits with support

– Reaches and holds objects

– Play gyms

– No TV

Top 5 FruitsFITS Study, 2004

Age (mos)

#1 2 3 4 5

4-6 Applesauce Baby bananas Pears Peaches Fresh bananas

7-8 Applesauce Baby bananas Pears Peaches Fresh bananas

9-11 Bananas Applesauce Baby bananas Pears Cand applesauce

12-14 Banana Applesauce Grapes Apple Peaches

15-18 Banana Grapes Apples Strawberries Peaches

19-24 Banana Apple Grapes Raisins Strawberries


Six-Month Visit

• Start vegetables and offer first at each meal

• Add one new food every 3-4 days

• Portion sizes

– Cereal 2-4 tablespoons twice per day

– Vegetables 2 tablespoons twice per day

– Fruits 2 tablespoons twice per day

Meats & Proteins for Infants & Toddlers

Age

(mos)

Chicken,

Turkey

(%)

Hotdogs,

Sausages

(%)

Beef

(%)

Pork,

Ham

(%)

Fish,

shellfish

(%)

4-6 2.0 % 0.0 % 0.9 % 0.3 % 0.0 %

7-8 7.3 2.1 2.6 1.7 0.5

9-11 22.4 7.1 7.7 4.0 1.9

12-14 33.0 16.4 16.1 9.7 5.5

15-18 46.9 20.1 16.3 11.3 8.7

19-24 47.3 27.0 19.3 13.9 7.1


Common Early Feeding Traps

• Anticipate that daily milk intake will fall as baby’s food intake increases

• Avoid “combo dinners” and baby desserts

• The extrusion reflex is normal and does not mean that the baby doesn’t like the food

• New foods require multiple presentations

• Focus on new eating experiences and skills

Physical Activities Six Months

• Minimize stationary devices

• Sits without support

• Starting to crawl

• First signs of independent mobility

• No T.V. until after 24 months of age

Nine-Month Visit

• Offer many new foods and textures

• Introduce a cup as the diet advances

• Discuss choking hazards

• Never use food as reward or bribe

• Offer variety: finger and table foods

– New food types and textures

– Veggies & fruits at every meal

– Establish a variety of meats

Aim to DevelopSelf-feedingSkills

What Infants & Toddlers Drink

Age

(mos)

All Milks

(%)

100% Juice(%)

Fruit Drinks

(%)

Soft Drinks

(%)

Water

(%)

4-6 100 21.3 1.6 0.1 33.7

7-8 100 45.6 7.1 1.1 56.1

9-11 99.7 55.3 12.4 1.7 66.9

12-14 98.2 56.2 29.1 4.5 72.2

15-18 94.2 57.8 38.6 11.2 74.0

19-24 93.4 61.6 42.6 11.9 77.0

Source: Skinner et al. 2004

Nine-Month Visit

• Continue breastmilk and/or iron-fortified formula until 12 months

• 100% fruit juice, 4-6 oz maximum and only from a cup

• Avoid all other sugary drinks

• ¼ cup (2 oz) fruits and vegetables daily

• Promote textures to improve skills

AAP Recommendations: Cow’s Milk and Fat Intake

• Delay the introduction of cow’s milk until one year of age

• Calcium intake for 1-3 year olds should be 500 mg/day

• Cow’s milk should be whole milk - not reduced-fat or non-fat - during the second 12 months of life

• Fat intake should not be restricted in the first 24 months of life

And now, a word about…TV

Age (mos)

0-1 1-2 3-4 >5 hours per day

0-11 83 11 4 3

12-23 52 27 11 11

24-35 21 38 25 16

Children watching > 2 hrs a day at age 2 yrs were more likely to watch > 2 hrs a day at 6 yrs too.

Television and Obesity Are Linked

• TV > 2 hrs/ day in 5-15 yr olds is associated with adult overweight, high cholesterol, and low fitness

• Even brief exposure to TV ads can influence a preschooler’s food choices

• Mean TV watched by 3-4 yr olds = 2.2 hrs/ day

• Maternal obesity and depression correlates with the highest TV viewing by their children

Physical ActivitiesNine Months

• Begins to hold cup

• Spoon feeds with help

• Encourage crawling

• Pulls to stand

• No T.V.

100%WHOLE

MILK

Twelve-Month Visit

• Introduce regular milk

– Whole milk - not skim or 2%

– Taper from 24 oz. to 16 oz. per day

– All fluids from a cup

– Continue to wean from the bottle

• Fluids

– Avoid sweetened drinks

– Water is best for extra fluid

CerealsInfants & Toddlers

Age

(mos)

Any Grain(%)

Infant Cereal

(%)

Non-Sweet(%)

Sweet Cereal

(%)

Cereal Bars(%)

4-6 65.8 64.8 0.5 0.0 0.0

7-8 91.5 81.2 17.0 1.8 1.1

9-11 97.5 63.8 37.0 9.0 3.4

12-14 97.8 23.9 44.5 17.7 9.8

15-18 98.6 9.2 40.6 26.4 10.0

19-24 99.2 3.1 31.9 22.7 9.7


Twelve Months

• Solid foods

– Emphasize eating skills and experiences

– 3 regular meals & 2-3 planned snacks

– Avoid “grazing” throughout the day

– Emphasize vegetables and fruits

• Appropriate serving size is 1/2 cup of fresh (or 1/3 cup canned) fruits/ vegetables per serving per meal

Parental Control Measures Usually Backfire

• Restricting “bad” (ie, palatable and enjoyable) foods encourages their consumption and raises a desire for future intake

• Avoid a mixed message that forbidden foods are “bad” except on special occasions

• Avoid food as a comfort or a reward

• Categorical thinking about “good” and “bad” foods is common and inappropriate

Physical Activities Twelve Months

• Push toys

• Walking

• Running

• Unrestrictive play

• Never inactive for more than 60 mins

• No T.V.

15- and 18-Month Visits

• No more bottle

– Whole milk from a cup in four 4-oz servings / day

– Milk limit 16 oz/day

– 100% fruit juice 6 oz/ day

– No bottle and no “sippy” cup

• Snack times

– 2-3 planned snacks per day

– Watch portion size, nutritional value

• Meal times

– 3 meals per day

– Variety of color, texture, and tastes

– New foods at the start of the meal

– 10 exposures of each new food

Caution: Choking Hazards!

• Nuts

• Grapes

• Apple chunks, slices

• Sausages

• Popcorn

• Round candies

• Hard chunks of uncooked veggies

• Hot dogs

Some foods are dangerous becausethe infant can’t chew or coordinate swallows and lacks a full set of teeth.

Safe Snacks for the Toddler

• Cheese

• Yogurt

• Saltines

• Graham crackers

• Pretzels

• Bagel, bread, toast

• Whole wheat crackers

• Fruit (watch for seeds and peels)

• Fruit smoothies

• Steamed veggies

• Puddings

• Unsweetened cereals

• Mashed/ finely cut meats or fish

Avoid the habit of snacking in the car and on the go

Desserts and Sweets Age

(mos)

Any Dessert

(%)

Baby Desserts

(%)

Cakes, Pastries, Cookies

(%)

Candy

(%)

4-6 10.4 4.2 4.3 0.0

7-8 45.8 17.7 27.0 1.1

9-11 61.1 17.0 40.9 3.2

12-14 78.8 6.0 50.5 10.2

15-18 88.8 2.3 60.2 15.2

19-24 90.5 0.0 61.6 20.0

Source: Fox et al. 2002 ???Infants Don’t Need Desserts

15- and 18-Month Visits

• Meals are social occasions

– Establish family meals

– Adults should act as role models during meals

– Milk with meals

– Limit desserts, avoid candy

– TV off during meals

National RecommendationsFiber = ‘Age plus 5’

• Fiber should equal the age of the child plus

5 grams a day

– For a 2-year old that would be 2 + 5 g = 7 g/day

– Maximum = age + 10 g/day

• Emphasize whole grains to boost fiber

Dietary Fiber Intake of 4 to 10-yr-old US Children

• Children who meet the ‘Age plus 5’ rule

– 4-6 year olds 45%

– 7-10 year olds 32%

• Children who meet this rule consume more breads, cereals, fruits, vegetables, nuts, legumes and seeds

• Low fiber intakes are associated with higher fat and cholesterol

Recommendations for Grains and Whole Grains for Children

• Healthy People 2010: “Increase the proportion of persons aged 2 and older who consume at least 6 daily servings of grain products, with at least 3 being whole grains”

• Serving is defined by the USDA Dietary Guidelines for Americans 2005: 3 or more ounce equivalents of whole grain products per day (at least ½ of grains from whole grains)

• Primary sources of whole grains for children:

– Ready-to-eat cereals Yeast breads

– Corn & other chips Popcorn

– Hot breakfast cereals crackers

Whole Grain Intakes are PoorContinuing Survey of Food Intakes by

Individuals 1994-6

Age Total Grains Whole Grains

Mean Servings/ Day

2-18 years 6.6 0.9

2-5 years 5.0 0.8

6-11 years 6.5 0.9

12-18 years 7.7 1.0

Source: Harnack et al. 2003.

The Parent’s Role

“It is the parent’s responsibility to

offer the child a healthful variety

of foods and a supportive eating

environment ...

Satter, J Am Diet Assoc. 1986; 16:355

Source: Satter 1986

The Child’s Role

…and it is the child’s responsibility to decide when

and how much to eat.”

Source: Satter 1986

Two Years• Activity:

– Only planned TV & only 1 hour per day

– Planned time outdoors every day

• Milk

– Milk at every meal

– Switch from whole milk to 2%

• Meals

– Begin to decrease the fat content of foods

– Appropriate portion sizes at home and away: 1 Tbsp per year of age

Subjects for More In-Depth Discussion with Parents

• Parents “bias” a child’s food choices

• The picky eater grows up just fine

• Food jags are normal

• Plate and glass sizes alter intake

• Food dislikes over time

• The problem of “dessert”

• Avoid in-car snacking

• Food rules should be shared with daycare provider, grandparents

• Eating out with a child

• Letting the child direct their own intake

The Problem of “Dessert”

• A place in a balanced meal for dessert foods

• Not a required part of meal planning though

• Not necessary at every meal

• Not a reward or bribe for eating other foods

• OK to use fruit, yogurt, cheese

• OK for celebrations away from home

Eating at Restaurants

• Split meals between kids or share yours

• Recall portion size: ¼ the adult portion

• Buffets promote overconsumption

• Drinks: ask for milk with the kids’ meals

• Pre-meal: watch out for breads & crackers

• Salad dressing: serve on the side, use as dip

2%

Two-Year Visit

• Meals: All 5 food groups daily

– Begin to decrease the fat content

– Appropriate portion sizes at home and away: 1 Tbsp per year of age or ¼ of an adult portion

– Plate and cup size matters

– Food “jags” are typical & normal

– A variety of textures, colors, flavors

– Don’t bias your child’s food choices

Top 10 Sources of Dietary Fats for Children 2-5 yrs

Total Fat Rank Sat. Fat Rank

Whole milk 11.3 1 17.8 1

Sweet grain products 8.5 2 6.5 6

Franks, sausage, meat 8.1 3 7.6 3

Mainly grain mix 7.3 4 7.4 4

Nut buttters, nuts, seeds 5.8 5 2.4 14

Natural/ processed cheese 5.2 6 8.2 2

Beef 5.1 7 5.3 8

Butter/margarine 4.9 8 4.2 9

Salty snacks 4.6 9 3.4 11

Low fat milk (1-2%) 4.6 10 7.3 5

Source: Thompson & Dennison, 1994

Milk Intake of Infants & Toddlers

Age

(mos)

Breast

(%)

Formula

(%)

Cowmilk

(%)

Low-fat

(%)

4-6 39.6 74.1 0.8 0.3

7-8 25.7 82.2 2.9 0.5

9-11 21.3 75.0 20.3 5.3

12-14 13.6 21.2 84.8 17.7

15-18 4.2 5.1 88.3 20.7

19-24 4.5 1.5 87.7 38.1


Drinks Matter Early Food Preferences Predict Future Food

Preferences

• The “displacement theory” is real

– Calcium intake falls as milk is replaced

– Vitamin C rises as juices replace milks

• Beverages are important:

– They provide >1/3 of daily calcium, Vits A, C, D, protein and zinc

• Fruit drinks are too common :

– By 2 years 40% drink them daily and 5% drink > 16 oz/d

• Soft drinks are unnecessary:

– >11% toddlers 15-24 months consume them daily

Source: Skinner et al. 2004

Physical Activites Two Years

• Encourage active play with other children

• Marching

• Jumping

• Climbing

• Limit T.V. to 1-2 hours per day

• Get outside

Three- and Four-Year Visits

• Meal times

– Planned meal & snack times

– Establish a family mealtime free of TV

– Move toward skim milk

– Variety: fruits, vegetables, whole grains

– Limit potatoes

– Avoid the TV & Food habit

– Limit TV to 1-2 hrs per day

– Help child choose what to watch

Physical ActivitiesThree / Four Years

• Throwing and bouncing balls

• Jumping

• Running

• Ride tricycle

• Unstructured play at least 30 minutes/ day

• Structured play at least 60 minutes/ day

• T.V. limited to 1-2 hours per day

Five- and Six-Year Visits

• Daily diet suggestions

– A nutritious breakfast every day

– School lunch or a quality brown bag lunch

– Milk and dairy at every meal

– Fruits and vegetables in abundance

– Plan healthful snacks for after-school time

– Limit soft drinks and fruit drinks

– Caution when eating at restaurants – share your meal with your child

Eating a School Lunch Promotes Better Nutrition

?Eating a Lunch While at School ? - or take out pic of lunch box from home

• Consume twice the servings of fruits and vegetables

• Higher intake of milk and dairy

• Larger amounts of meat

• Greater amount of grains

• More vitamins and minerals

• NSLP impact holds true for lunch and for 24-hour intake

USDA Food and Nutrition Report No. CN-01-CD1

Five Years

• Daily activity suggestions

– Plan outdoor time and reading time daily

– Limit “screens” to 1-2 hrs/ day, including

• computers

• games

• TV

• movies

Decreased TV viewing has been proven to

alter obesity

Obesity & Psychological Issues

• Victimization/ bullying

• Sense of alienation

• Depression

• Behavioral problems

• Lifelong psychological issues

• Low self-esteem

• A cycle of food, depression and inactivity

Energy-Dense Nutrient-Poor FoodsDefinition

• Tip of the Food Pyramid: fats, oils, sugars

• NHANES III 1988-94: 4,265 foods classified

– Foods are considered to be in the EDNP group if they are not part of the following food groups:

• Dairy – milk, buttermilk, cheese yogurt

• Fruit – fresh, frozen, canned, juice

• Grains – bread, cereal, pasta, rice

• Meat & Beans – meat, fish, poultry, eggs, beans, nuts, seeds

• Vegetables – raw, fresh, frozen, canned, juices

• Mixed – foods from several groups

Energy-Dense, Nutrient-Poor FoodsNHANES III

• EDNP foods = nearly 1/3 of daily energy intake

• As EDNP foods increased

– Mean daily total calories increased

– Percent energy from carbs increased

– Percent energy from fat increased

– Fiber, protein, vitamins, decreased

– carotenoids, iron, calcium, folate decreased

Source: Kant 2000

As EDNP foods increase, nutrition from other 5 food groups falls = displacement

Snacking Among Children1977 to 1996

• 3 dietary surveys in children 2-18 yrs (N = 21,236)

• “Snack” = foods grouped outside of meals

• Snacking adds 30% kcal to the diet

• Highest snack intake is among 2-5 year olds

• Energy per snack rose only 3% in 20 yrs

• Energy density is greater than meals

• Increased frequency, not size of snacks is the trend in America

Source: Jahns et al. 2001

American Dietetic Association Snack Guidelines Preschool-/ School-Age

• Continue 2-3 planned snacks for preschool age and 1-3 for school age children

• Aim for variety of texture, taste, and color

• Adjust portion size to age

• Allow the child to respond to internal cues of hunger and fullness

• Healthy snacks are whole grains (breads, cereals, crackers), fruits and veggies, lean meats, and dairy products (low-fat cheese, pudding, yogurt)

Eating Out with Your Child

• Include at least two different food groups

• Limit sweets to one per meal

• Only one fried food per meal

• Assure that all foods, especially desserts and drinks, are child-sized

Source: Satter 1986

Control Portion Sizes When Eating Out

• Share your meal or order a half-portion

• Order an appetizer as an entrée

• Take half your meal home

• Be aware and stop eating when you feel full

• Avoid super-sized sweetened drinks

• When traveling, pack nutritious snacks

Weight Control Information Network, NIDDK, Jan 2003

More Tips for Portion Control• Before eating, assess your hunger

• Eat slowly and appreciate your food

• Eat small meals more frequently to avoid hunger

• Measure your food portions to hone your portion perception

• Skip “family style” servings except for veggies

• Always serve salad dressing on the side

• Interpret labels in terms of single servings

Susan Burke, MS, RD, CDE

Menu Hints While Eating Out

• English muffin, toast, bagel NOT croissant, biscuit, pastry

• Ham NOT sausage

• Low-fat milk, fruit juice or water NOT soft drinks or shakes

• Baked, broiled or poached NOT fried

• Catsup, mustard, BBQ sauce, salsa NOT mayo and cheese on burgers

• On the side: low-fat dressing, sour cream, gravy, sauces

• With (NOT before) the meal: bread, non-water drinks, chips

American Dietetic Association, If your Child is Overweight: A Guide for Parents

Summary

• Childhood obesity can be prevented

• No one factor causes obesity and no one intervention will stop it

• Physician’s most important role will be in developing sound eating and activity habits

• At each well-child visit review the child’s BMI status and deliver core messages

• Advocate for better school & community policies that support your well-child advice

an ounce of prevention is worth a pound

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