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 • • • •
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 28%in 1995): – 71% who were counseled vs 17% not counseled (separate study in Canadian Family Physician) • Lowest among young and poorly educated
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 • Can’t rely on diet for pregnancy
Folic Acid• Birth defects http://www.folicacid.net/login.asp • Cardiovascular effects • Cancer prevention • ? Dementia
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 345:1593, 2001
Childhood ALL
• Australian case/control study • 83 study/166 controls • Odd’s 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 –
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; 346:476-83
Low birth weight/cardiovascular disease
• • • • Hypertension Obesity Lipid disorders Diabetes
Breast Feeding
• • • • • • Impact on obesity Atopic diseases Calcium Impact on immunity Colic EtOH, caffeine, medications, spices
Breast Feeding and Atopy
• BMJ- 6 year follow-up study (2000 subjects) • Exclusive Breast feeding >4mths • RR of asthma 1.25, of wheezing 1.31, positive skin tests 1.30
» BMJ 1999:319:815-9
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
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
Formula feeding
• Overfeeding
– Reflux – Obesity
• • • •
Calcium (soy diets) Iron Fluoride (0.8-1.0ppm) Safety
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
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 30:345, 2000
Effect of Multiple Risk Factors on Atherosclerosis in the Aorta and Coronary Arteries in Children and Young Adults
Intimal-Surface Involvement (%)
8 6 4 2
3
2
3 0 1 2
Aorta
0
1
0
Coronary Arteries
Number of Risk Factors
Berenson et. al (NEJM 1998)
Update from Bogalusa
• 77% of overweight children became obese adults (mean follow-up=17 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 108:712, 2001
Obesity and CV physiological dyfunction
• 48 obese (>3 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
Obesity and Inflammation
• N-HANES III • 3512 kids (age 8-16) • Kids with elevated CRP (>.22mg/dL) or WBC > 10,000 • Overweight (>85%) vs < 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
Maternal perception
• Mothers blame overweight on
– Family genes – Family members
• Mothers don’t recognize their kids are overweight unless
– Teased – limited physical activity
• Jain A Pediatrics 107: 1138, 2001
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
Adolescents
• Eating disorders
– Undereating, overeating
• Fast food, drinks (fat, sugar), vending machines • Folate • Iron • Calcium • Ethanol
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 >95%tile • African-Americans and Native Americans • TV, intrauterine experience • Diet and physical activity both effective
– Ludwing and Ebbeling JAMA 286: 1427, 2001
% of High School Students Who Reported Eating Less than 5 Servings of Fruits/Vegetables on Day Preceding Survey, 1997
3
Data missing
81.3 - 78.3 75.6 - 74.2 73.3 - 68.4 68.1 - 60.5
(7) (7) (7) (8)
From Youth Risk Behavior Survey
% of High School Students Not Enrolled in Physical Education Class, 1997
8
Data missing
68.7 - 62.5 % 62.3 - 52.7 % 51.2 - 41.9 % 38.9 - 0.8 %
(8) (8) (8) (8)
From 1997 Youth Risk Behavior Survey
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; 289:1813
Controversies
• Has emphasis on fat shifted us towards carbos, obesity and type 2 DM?
– Science 291:2536, 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 286:717, 2001
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
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) • • • •
Nutrition screens
• Dietary screens in hospitalized patients • BMI/ ht and wt screens (>90%tile or 120% of med. wt/age=obese; >140%med. wt/age =super-obese • www.blubberbuster.com • Nutrition history – 24 hr recall • Family history – Obesity – HTN, ASCVD, DM, Cancer • Social hx • Exercise history
Nutrition Resources
• Direct advice
– Web based, AAP
• Referral
– – – – – ACH dieticians Breast feeding team, La Leche Commercial programs obesity clinic (GPC) State and Federal Programs
State and Federal Programs
• • • • • Food Stamp/Card programs WIC and WIC Farmer’s market Headstart School lunch and breakfast Summer Food Service
• REMEMBER TO REFER!