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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
• female: 12.4 yrs
– Black
• male: 13.0 yrs
• female: 17.0 yrs
• If diagnosed at age 10 years
– White
• male: 16.5 yrs
• female: 18.0 yrs
– Hispanic
• male: 19.0 yrs
• female: 16.0 yrs
– Black
• male: 22.0 yrs
• female: 23.0 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
Source: Fox et al. 2004
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
Source: Fox et al. 2004
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
Source: Fox et al. 2004
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
Source: Fox et al. 2004
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