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Laura Taylor Pridemore JD MD FAAP

Laura Taylor Pridemore JD MD FAAP

1. Pediatric Trends and Statistics

2. Evidence–Based Medicine for Common Problems

3. Recommendations for Every Day Practice

2/3 children eat < 1 full serving of fruit or veggie daily

most common veggie—French fries

1/4 teenagers drink soda daily

1/3 children eat fast food daily

59% calories eaten daily are ultra-processed foods -- fat, sugar or salt + colors, flavors, emulsifiers & additives

Foods included --

breads, salty/sweet snacks, ice cream, frozen meals, pizza, sugary drinks, breakfast cereals, sandwiches, burgers, fries

Source: Martinez-Steele E et al. Ultra-processed foods and added sugars in the US diet. BMJ Open 2016;6:e009892

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Children 2-19 on average consume 80 gm sugar daily

American Heart Association recommendations

<2 yrs no added sugar

2-19 yrs max 25 gm daily

Sweetened drinks increase risk of obesity at all ages

Increase in snacking since 1970s

Choice foods for snacking –- ultra-processed foods

especially sweet

calorie dense and nutrient poor

Source: Piernas C, Popkin B. Trends in Snacking Among U.S. Children. Health Affairs 2010;29(3);398-404.

SAD

Relationship of height vs weight Age and gender

BMI = kg/m2

Obese > 95th percentile

Overweight 85th to 95th percentile

Normal 5th to 85th percentile

Underweight <5th percentile

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BMI 22

9 year old -- obese

14 year old -- normal

1919 lb 1 1

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Quote from my patient

Weight stabilization alone results in dramatic decrease in BMI of a

growing child.

Source: Prevalence of Overweight and Obesity Among Children and Adolescents: United States, 1963-1965 Through 2011-2011. CDC Health E Stat Sept 2014

Source: Prevalence of Obesity and Severe Obesity in US Children 1999-2014 Obesity 2016;24(5):1116-1123

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Overweight kindergarten child —

4 x more likely to be obese by high school

Obese 6 year old child —

>50% chance of being obese adult

Overweight or Obese adolescent —

70% chance of obesity as adult

10% children worldwide are obese

42 million children <5 years old are overweight/obese

70 million by 2025 if trend continues

Countries with highest meat intake show highest obesity

Poor eating and sleep habits

Less physical activity

More screen time

Average 7-1/2 hrs per day

Advertising targeted directly to children

Genetic predisposition

African Americans & Hispanics

Epidemiological studies

vegan/vegetarian children have lower BMIs

More poverty, less parental education & single parent families

Food deserts in rural, minority or low income areas

Parent factors

Choice of infant feeding

Less supervision

Parents responsible for food brought into home

New areas of research/evidence

relationship between one’s own microbiota and its effects on body weight, metabolic rate and digestion

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In US ≈ 1/2 newly diagnosed adolescent cases are type 2

In US -- genetic predisposition

Pima Indians, African Americans, Hispanic & Asian/Pacific Islanders

Saudi Arabia has highest rates world wide

Historically DM was classified as juvenile or adult onset

Now type 1 and type 2

Children w/ type 2 DM have risk of long term CV disease

Diagnosed more commonly during puberty

Pubertal hormones cause insulin resistance

Compounded with insulin resistance of obesity

Source: American Diabetes Association Consensus Statement Type 2 Diabetes in Children and Adolescents. Diabetes Care 2000;23(3)381-389

Source: Bellis MA, Downing J, Ashton JR. “Adults at 12? Trends in puberty and their public consequences. J Epidemiol Community Health 2006;60:910-911.

Industrialized countries before 3rd world countries

Meat/dairy eaters earlier than vegan/vegetarians

Meat/dairy increase IGF-1 androgen effect

Plant protein (including soy) associated with later onset

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Endocrine disrupting chemicals

meat, dairy, fish – dioxins, PBDE

environment – BPA in plastics

tea tree oil

phthalates

parabens

placenta extract

Longer estrogen effect over a life time -- increases risk of

CV disease

Metabolic syndrome

Estrogen dependent cancers (i.e. breast cancer)

Earlier likelihood of sexual activity, STDs, pregnancy

Emotional immaturity

Psychological problems -- especially depression

Quote from my husband

Acute vs chronic

Must rule out organic causes

Easily can become chronic with conscious withholding

Children can poop every day but still be constipated

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Flabby dilated colon/rectum -- full of hard poop

Must have full cleanout over a 24-48 hr period w/ glycolax or magnesium citrate

Then stool softener + dietary measures for several months to allow dilated gut to regain normal muscle tone and peristaltic action

Easy or hard to come out? Straining?

Stool stains in underwear -- think leaking problem,

not wiping problem

Does the poop clog the toilet? Size matters.

Small balls or larger in diameter than size of quarter = constipation

Urinary frequency? Day or night wetting accidents?

UTI or Recurrent UTI

The perfect opportunity ………

To ask:

Did you know that dairy elimination can improve and even cure constipation?

To emphasize:

The importance of fiber rich whole plant foods over dairy, meat and refined processed foods.

½ cow milk and ½ soy milk, then groups reversed

2/3 children had resolution of constipation with cow milk elimination

In group who drank soy milk 1st, constipation resolved and then returned when cow milk was reintroduced

Allergy mediated

Source: Iacono G et.al. Intolerance of Cow’s Milk and Chronic Constipation in Children. N Eng J Med 1998;339:1100-1104

½ cow milk/dairy products and ½ soy milk 2 week challenge, 2 week wash out, then groups reversed 100% resolution of constipation when dairy was eliminated

Source: Crowley ET et.al. Does Milk Cause Constipation? A Crossover Dietary Trial. Nutrients 2013;5:253-266

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Optimal ratio of Omega 6 fats to Omega 3 fats

2: 1 or 3:1

With Standard American Diet

up to 40:1

Key point:

Excess of Omega 6 relative deficiency of Omega 3

104 preschool & elementary children with history of either

recurrent ear infections or persistent middle ear fluid

Skin prick testing identified food allergies

4 mo food allergy elimination

ear infections/persistent middle ear fluid cleared

Allergic foods were reintroduced

94% developed ear infection within 1 mo

Source: Nsouli TM et.al. Role of food allergy in serous otitis media. Ann Allergy. 1994;73(30):215-219

Retrospective Finnish study

National registry maintained

Children with cow milk identified

Increased incidence of ear infections in cow milk allergic children

Source: Junttti H et.al. Cow’s Milk Allergy is Associated with Recurrent Otitis Media During Childhood. Acta Otolaryngol 1999;119:867-873

Most common chronic disease of childhood

2 components

Bronchospasm

Inflammation

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13 children underwent dairy & egg elimination

9 children in control group

Physician conducting testing was blinded

After 8 weeks, asthma symptoms decreased & pulmonary function studies improved

Source: Yusoff NAM et.al. The effects of exclusion of dietary egg and milk in the management of asthmatic children: a pilot study. JRSH 2004;124(2):74-80

Rash that itches

Dairy & Egg elimination

helpful

Epidemiological studies –- acne rare in

Kitivan Islander of Papua New Guineas

Ache Hunter Gatherers of Paraguay

Acne after adopting Western diet

Northern Canadian Inuits

Okinawans

Source: Spencer EH et.al. Diet and acne: a review of the evidence. International Journal of Dermatology 2009;49:339-347

Prospective Harvard study

10,000 girls & boys 9-15 yrs old

followed for 3 years

Increased acne with all types of milk

Source: Adebamowo CA et.al. High school dietary intake and teenage acne. J Am Acad Dermatol 2005;52:207-14

High glycemic foods & dairy associated with acne

Increased androgenic effect

Dairy increases IGF-1

High glycemic foods suppress SHBG

Source: Spencer EH et.al. Diet and acne: a review of the evidence. International Journal of Dermatology 2009;49:339-347

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Adventist students in US and Australia

Vegetarian students

Leaner

Lower lipid levels

Source: Sabate J, Wien M. Vegetarian diets and childhood obesity prevention. Am J Clin Nutr 2010;91(suppl):1525S-9S

Prospective randomized from Cleveland Clinic

2 groups – each had 14 obese adolescents and 14 parents

WFPB group improved in 9 measurements

AHA group improved in 5 measurements

Source: Macknin M et.al. Plant-Based, No-Added-Fat or American Heart Association Diet: Impact on Cardiovascular Risk in Obese Children with Hypercholesterolemia and Their Parents. J Pediatr 2015;166:953-959

Well-planned vegetarian diets are appropriate for individuals during all stages

of the life cycle, including pregnancy, lactation, infancy, childhood, and

adolescence, and for athletes.

Source: Position of the American Dietetic Association: Vegetarian Diets. J Am Diet Assoc 2009;109:1266-1282.

WFPB diet can supply all nutrients except

Vit B12 and in some cases Vit D3

Calcium –- broccoli, dark green leafy veggies, nuts, beans, tofu, fortified plant milks

Protein – beans, peas, dark green leafy veggies, nuts, seeds

Fat – whole avocados, raw nuts & seeds

Hever J. Plant-Based Diets: A Physician’s Guide. Perm J 2016 Summer;20(3):15-082

Mangels AR, Messina V. Considerations in planning vegan diets: Infants. J Am Diet Assoc 2001;101:670-677

Messina V, Mangels AR. Considerations in planning vegan diets: Children. J Am Diet Assoc. 2001;101:661-669

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How do we translate our evidenced-based knowledge into simple easy actionable steps that our families and

patients can take?

Healthy food tastes bad.

Junk food tastes good.

Source: Werle CO et.al. Unhealthy Food is Not Tastier for Everybody: The “Healthy = Tasty” French Intuition. Food Quality and Preference 2013;28:116-121. Source: Raghunathan R et.al. The Unhealthy = Tasty Intuition and Its Effects on Taste Inferences, Enjoyment, and Choice of Food Products. Journal of Marketing. 2006;70:170-184

Ellen Sattyr MS RDN MSSW

Dina Rose PhD

For children with

food allergies

medical conditions

developmental needs

Find like-minded

nutritionists/dieticians

integrative or functional medicine experts

health coaches

feeding therapists

Parent’s Job What

When

Where

Child’s Job Whether to Eat

How much

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Consistent feeding schedule with water in between

3 meals + 1-3 mini-meals

Loving and firm structure – not deprivation

Works for all children whether underweight, normal weight or overweight

“Teach children HOW to eat and give them the skills they need for a lifetime of health and vitality.”

“Change the conversation from nutrition to habits.”

Excessive restriction causes increased preference and overeating when readily available

Highly restricted children show poorer self regulation

Pressure to eat F/V associated with lower intake of F/V

Source: Birch L, Savage JS, Ventura A. Influences on the Development of Children’s Eating Behaviors: From Infancy to Adolescence. Can J Diet Pract Res 2007;68(1):s1-s56.

See-food

Variety

Proportion

Moderation

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Babies 1st exposed in utero and through breast milk

Pureed baby foods – best to mash fresh

Finger foods – Forget the puffs!!! Soft veggies/fruits

Key Goal – wide variety early!

Growing Foods

Fun Foods

Treat Foods

Growing Foods

Fun Foods

Treat Foods

Growing Foods

Fun Foods

Treat Foods

“The habit of eating the right amount of food –

not too much and not too little”

“Eating when you are hungry and stopping when you are full”

Rose D. It’s Not About the Broccoli. New York: A Perigee Book 2014.

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Dessert bribe decreases preference for healthy foods

Respond to external cues for how much to eat

Exponential growth 1st year of life

Birth weight doubled by 4-6 mo

Tripled by 12 mo

Toddler/Preschool years

Average weight gain 4-6 lbs per year

Erratic eating is normal. No pressure to eat! Must trust child’s innate ability to self-regulate.

Conversation about health & environmental benefits

Parent homework – Forks Over Knives

Evidence-based medicine for problem at hand

www.NutritionFacts.org

Meatless Mondays

Getting kids involved—gardening, planning and preparation

First, do no harm

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Let food be thy medicine and medicine be thy food