Eat Your Vegetables!  Healthy Eating in Youth

Deanna M. Hoelscher, PhD, RD, LDYouth-Nex Conference

October 10, 2013

• Why do children need a healthy diet?

• What are the recommendations for a healthy diet in youth?

• What do current youth diets look like?

• What can we do to improve them?

Presentation

Definitions

• Nutrition is the science of food, the nutrients, and other substances within food; their action, interaction, & balance in relation to health & disease; and the processes by which the organism ingests, absorbs, transports, uses & excretes food substances.Guthrie & Picciano, 1995

• Nutrition is needed for – Energy– Maintenance of biologic processes– Growth & development

(infants/children/adolescents)

• Nutrients include macronutrients (lipid, protein, carbohydrate), water, vitamins, minerals

• Critical determinant of several of the major causes of death & disability– CVD, Cancer, Type 2 Diabetes,

Obesity

• Modifiable behavior

• “Universal & indispensable human exposure” Kumanyika, 2000

Why is Dietary Intake Important?

Recommendations for Healthy Diets

• U.S. Dietary Guidelines (revised in 2015)• Dietary Reference Intakes• Healthy People 2020 Goals

– Example: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=29

• Leading Health Indicators– Health Indicators Warehouse:

http://www.healthindicators.gov/

• Others

Dietary Issues for Children

• Obesity (HFSS)– Sugary Beverages– Snack consumption

• Fruit and vegetable consumption• Calcium consumption• Meal patterns/timing of foods

Weight Gain for Children at the 95th Percentile from Age 6.5 to 18.5

6 to 7 7 to 8 8 to 9 9 to 10 10 to 11 11 to 12 12 to 13 13 to 14 14 to 15 15 to 16 16 to 17 17 to 1802468

1012141618

BoysGirls

Age in Years

Wei

gh

t D

iffe

ren

ce (

lb)

Source: CDC weight charts, Butte & Ellis, 2003 OW = overweight, N = normal wt

OW/OW

N/OW

N/N

Trends in Weight Status among US Adolescents

Source: Iannotti RJ & Wang J. Trends in physical activity, sedentary behavior, diet, and BMI among US adolescents, 2001-2009. Pediatrics.2013;132(4):606-614

4th grade 8th grade 11th grade0

5

10

15

20

25

30

35

40

25.6

18.8

14.5

23.5

17.5 17.3

23.823

21.6

18 18.4 18.4

2000-02 2004-05 2009-11

Children in Texas Have High Rates of Obesity

Healthy People 2020 Goal, 14.5%

Obesity is > 95th Percentile for BMI by Age/Sex

Sources: Hoelscher et al., 2004; Hoelscher et al., SPAN; Ogden et al., 2012

2001 2005 20093.6

3.8

4

4.2

4.4

4.6

4.8

5

4.29

4.71

4.91

4.31

4.464.61

4.7

4.46

4.1

4.85

4.364.18

Eat fruits (1 never-7>once/day)Eat vegetables (1 never-7>once/day)Eat sweets (1 never-7>once/day)Drink soft drinks (1 never-7>once/day)

Trends in consumption of fruits, vegetables, sweets and sweetened soft drinks

Source: Iannotti RJ & Wang J. Trends in physical activity, sedentary behavior, diet, and BMI among US adolescents, 2001-2009. Pediatrics.2013;132(4):606-614

Trends in Student Food Choices by Grade, SPAN 2000-2002

Question: Yesterday, did you eat.. Grade

4th 1

8th 1.97 (1.45;2.69) 0.000 *

11th2.16 (1.66;2.81) 0.026 †

4th

1

8th 0.88 (0.64;1.21) 0.465 *

11th1.14 (0.81;1.60) 0.162 †

4th 1

8th 1.12 (0.76;1.64) 0.032 *

11th1.58 (1.04;2.41) 0.514 †

4th 1

8th 0.67 (0.52;.85) 0.036 *

11th0.73 (0.55;.98) 0.058 †

4th 1

8th 2.49 (1.75;2.73) 0.001 *

11th1.86 (1.31;2.65) 0.000 †

4th 1

8th 0.45 (0.37;0.55) 0.000 *

11th0.27 (0.21;0.35) 0.113 †

Gravy (either on a food or by itself)?

Peanuts or peanut butter?

Cheese by itself or on your food?

Drink any kind of milk?

ORadj p-value

Hamburger meat, hot dogs, sausage (chorizo), steak, bacon, or ribs?

Any fried meat with a crust, like fried chicken, chicken nuggets, chicken fried steak, fried pork chops, or fried fish?

+ Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007

Trends in Student Food Choices by Grade, SPAN, 2000-2002

+ Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007

Trends in Student Food Choices by Grade, SPAN, 2000-2002

Question: Yesterday did you eat.. Grade

4th 1

8th 1.26 (0.96;1.67) 0.030 *

11th1.48 (1.04;2.09) 0.738 †

4th 1

8th 0.41 (0.32;0.53) 0.000 *

11th0.33 (0.23;0.48) 0.007 †

4th 1

8th 0.73 (0.52;1.02) 0.088 *

11th0.68 (0.43;1.06) 0.467 †

4th 1

8th 0.88 (0.73;1.08) 0.000 *

11th0.54 (0.40;0.72) 0.049 †

4th 1

8th 1.87 (1.46;2.40) 0.000 *

11th1.92 (1.49;2.48) 0.007 †

4th 1

8th 1.37 (0.98;1.91) 0.242 *

11th1.17 (0.91;1.51) 0.111 †

ORadj p-value

Beans such as pinto beans, baked beans, kidney beans, refried beans or pork and beans?

Fruit?

Drink fruit juice?

A frozen dessert?

Sweet rolls, doughnuts, cookies, brownies, pies, or cake?

Any chocolate candy?

+ Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007

• 2 recent studies:– Ebbeling et al., 2012, NEJM

• RCT with 224 overweight/obese adolescents• Intervention was displacement of SSB with non-caloric

beverages, MI• At Year 1 and Year 2, SSB, E in Intervention group• Change in BMI at 1 year, but not 2 years

– Did see changes in Hispanic adolescents at 1 and 2 years

– deRuyter et al., 2012, NEJM• 18 month RCT with 641 normal weight 4-11 year olds• 8 oz of SSB or artificially sweetened beverage• Mean BMI z-score by 0.02 SD units in Intervention

compared to 0.15 SD in control• Weight gain, fat mass significantly less

SSB Consumption in Children and Overweight/Obesity

Availability Mean ± SD MaxVegetable, no potato 12.8 ± 3.8 21Fruit 13.0 ± 4.4 27

Accessibility Mean ± SD MaxVegetable, no potato 1.3 ± 0.9 3Fruit 2.8 ± 0.9 4

Vegetables & fruit in the home

Source: Chen et al., Lunch is in the Bag, unpublished data

Vegetables & fruit in lunches

Top 5 veg. items = 51% of veg. items packed

Carrots (29%)Tomato sauce (13%)Raw tomatoes (8%)

Cucumber (5%)Corn (4%)

Top 5 fruit items = 54% of fruit items packed

Grapes (12%)Applesauce (12%)Strawberries (11%)

Apples (10%)100% juice (9%)

Source: Chen et al., Lunch is in the Bag, unpublished data

Grain ratio: home vs. lunch

0.71

0.29

Home

0.30

0.70

Lunches (overall)

WG only: 22% (n=127) of homes WG only: 10% (n=55) of lunches

Source: Chen et al., Lunch is in the Bag, unpublished data

050

100150200250300350400450

9 10 11 12 13 14 15 16 17 18 19

Age in Years

Tota

l bo

dy b

on

e g

ain

cm

/yr

boys

Bailey, D.A., et al. J. Bone Min. Res. 14:711-715, 1999

girls

Total Body Bone Mineral Content Velocity Curves in Peripubertal Boys and Girls

0

2

4

6

8

10

% in

cre

ase/

year

Lee '94 Lee '95 Bonjour J ohnson Dibba Cadogan

Placebo Ca Supplement

Calcium Supplementation during Adolescence Increases BMD

*p<0.05 Adapted from Weaver, 2002

**

*

*

Trends in Student Meal Consumption by Grade, SPAN, 2000-2002Question: Yesterday, did you... Grade

4th 1

8th 1.05 (0.80;1.36) 0.795 *

11th 1.05 (0.74;1.49) 0.859 †

4th 1

8th 1.13 (0.79;1.61) 0.296 *

11th 1.18 (0.87;1.60) 0.801 †

4th 1

8th 1.61 (1.24;2.11) 0.001 *

11th 2.07 (1.37;3.12) 0.286 †

4th 1

8th 1.01 (0.77;1.33) 0.287 *

11th 0.88 (0.68;1.12) 0.455 †

Have a snack?

Take a vitamin pill?

ORadj p-value

Eat breakfast?

Have more than one meal?

+ Adjusted odds ratio by gender, race/ethnicity and body mass index; Source: Perez et al., 2007

Our Environment is ‘Obesogenic”

20022005

How Much Nutrition Education is Enough?

• Briggs, M., et. al, (2010). Position of the American Dietetic Association, School Nutrition Association, and Society for Nutrition Education: comprehensive school nutrition services. Journal of nutrition education and behavior, 42(6), 360-71. Society for Nutrition Education.

• Kann, L., et. al, (2007). Health Education: Results from the School Health Policies and Programs Study 2006. The Journal of school health, 77(8), 408-34. doi:10.1111/j.1746-1561.2007.00228.

7600 food ads/year153 F&N/ year

WHOA Highest fat and sugar

SLOW Higher in fat and sugar, More processed foods

GO Lowest in fat, no added sugar, WG, V, F, lean meats

GO-SLOW-WHOA

• Nutritional recommendations for school-aged children are relatively well-established; less so for preschool children– Issues: sugary beverages, snacks, F & V, calcium

• Children do not consume adequate diets: what can we do to ensure this?– Behaviorally based nutrition education– Parenting practices– Environmental changes (marketing)

• New directions– Do we need ‘kid foods’?– How can we use natural biologic variations in appetite

to our advantage?– Decreasing food availability – periods of ‘not eating’

Final Thoughts

The test of the morality of a society is what it does for its children.

Dietrich Bonhoeffer

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@msdcenter

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THANK YOU

Deanna M. Hoelscher, PhD, RD, LDDeanna.M.Hoelscher@uth.tmc.edu

UTHealth | The University of Texas Health Science Center at Houston 

School of Public Health Austin Regional CampusMichael & Susan Dell Center for Healthy Living1616 Guadalupe | Suite 6.300 | Austin, TX 78701www.msdcenter.orgTwitter: @DeannaHoelscher @DrSteveKelder

Acknowledgements: Deanna M. Hoelscher, PhD; Steven H. Kelder, PhD, Andrew

Springer, DrPH; Guy Parcel, PhD; Cheryl Perry, PhD; Sandra Evans, PhD; Nalini

Ranjit, PhD; Cristina Barroso, DrPH; Roy Allen, MA; Brooks Ballard, MPH; Courtney

Byrd-Williams, PhD; Sherman Chow, MPH; Megan Conklin, MPH; Peter Cribb, MEd;

Joanne Delk, MS; Lupe Garcia, MS; Pam Greer; Alejandra Gonzalez; Kacey Hanson,

MPH; Tiffni Menendez, MPH; Carolyn Smith; Joey Walker, MPH; Jerri Ward, MA, RD

CATCH Supporters: • National Heart Lung and Blood Institute• Centers for Disease Control and Prevention • Texas Department of State Health Services• Robert Wood Johnson Foundation• Paso del Norte Health Foundation• Houston Endowment• Michael & Susan Dell Foundation• RGK Foundation

Acknowledgements and Supporters

VisionHealthy Children in a Healthy World

Mission To serve as the state, national, and international leader in the promotion of healthy living for children and their families.

Vision & Mission

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Center Social Media Sites

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• A tool to guide children and families toward making healthy food choices

• Overall message: foods can fit into a healthy diet and that a healthy diet consists of

GO foods > SLOW foods > WHOA foods• Provides RDA by age for each of the food

categories:– 4-8 years old– 9-13 years old

Note: The GSW list does not contain combination foods such as sandwiches or pizza

GO – SLOW – WHOA (GSW) List