Fit not Fat --Childhood Obesity and the

Environment

Helen J. Binns, MD, MPH Ann & Robert H. Lurie Children’s Hospital of ChicagoFeinberg School of Medicine, Northwestern UniversitySponsored by Region 5, Pediatric Environmental Health

Specialty Unit

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Disclosure Information

• This material was supported by the Association of Occupational and Environmental Clinics (AOEC) and funded under the cooperative agreement award number 1U61TS000118-03 from the Agency for Toxic Substances and Disease Registry (ATSDR).

• Acknowledgement: The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing funds to ATSDR under Inter-Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications.

• Dr. Binns has no conflicts of interest to disclose.

Growing Up Healthy

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Parental Modeling

Modeling

Health Habits Dietary Choices Exercise Verbal prompts to child

Parenting Skills Parental leadership Parent-child communication Problem-solving skills

Parent Behaviors

Support for Eating ChoicesSupport for Activity & Inactivity

Home Environment

Child Health Behaviors

Child Weight Status

Adapted from Golan & Weizman JNE 2001

Parents Create a Healthy Home Environment!

Be ActiveLimit ScreensHave RoutinesHealthy FoodsSafe Products

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Physical Activity Fun

Recommended activity for children is 1 hour daily Study of children surveyed twice (1 year apart)

For those who increased their activity by 7 hours per week:

Healthy weight children achieved BMI maintenance OBESE children had BMI fall of -0.2 kg/m2 (gained about 1

less lb than expected)

Berkey CS, et al. Pediatrics 2003;111:836-843

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Physical Activity Fun screen time physical activity Screen time contingent upon physical activity

8 weeks intervention Reward for activity: 1 hr activity = 1 token =1 hr TV

Follow-up at 16 weeks Intervention group compared to controls

activity by 30 minutes/day sedentary behaviors by 2 hrs/day snacking while watching TV BMI -0.6 kg/m2 vs. +0.3 kg/m2 controls

Goldfield GS, et al. Pediatrics 2006;118;e157-e166

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COUNSELING TIPS: Family Activity

Incorporate activity into your family events Young children need play partners – that is the

parent! Support your child’s activities Plan to be active yourself (30 minutes of jogging = 1 soda)

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Home Exercise Program

www.chicagochildrensresearch.org/pprg/resources/obesity/

Lisón JF Acad Pediatr 2012; 12:319-325.

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Regulation of Eating

Sensory factors: TasteSmell

Texture Sight

Effects of:Variety

Sensory-specific satietyPalatability

Food concentrationReady availability

Brain mechanisms:Modulate sensory factors by

satiety signals to produce reward value and appetite

Eating

from Rolls ET. Obes Rev 2007;8(suppl 1):67-72

Satiety/hunger signals:Adipose tissue signals

Gut hormonesGastric distension

Cognitive factors: Conscious rational control

Beliefs about the foodAdvertising

Family & Social Influences

Weight Status Food Content

Increase Intake of Fruits and Vegetables

Fruits and Vegetables

Low in calories High in fiber – fill you up! Sensory appeal

Taste, texture, color Rich in vitamins and minerals,

which are needed to fight oxidative stress

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Fight Oxidative Stress 20% of oxygen breaks down to Free Radicals &

Reactive Oxygen Species Stressors can increase that to 80%

UV light Poor nutrition Inflammation Air Pollution Tobacco Radiation

http://www.smokersrx.com/images/why2.jpg

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Fruits and Vegetables

1/2 cup = 1 serving Needs for children:

<15% of US children get 5 daily servings! Adult on a 2000 calorie /day diet

NEED 9 servings/day

Age Group

Servings of

Fruits/day

Servings of

Vegetables/day

Toddlers 2+ 2+

Older children/adolescents 2+ 3+

The million dollar question…

How do you get kids to eat more vegetables?

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First thing:

How are the parents interacting with vegetables? Are the parents buying vegetables? Are the parents serving vegetables? Are the parents eating vegetables?

Children pattern their behavior after their parents

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Parental Modeling and Pressure to Eat 191 families; Girls age 5 yrs Measures:

F&V servings/day Girls: 3/day Parents 2/day

Parental pressure to eat scale

Parents with high F&V intake had girls with higher levels of F&V intake (about 1 more/day)

Parents with lower F&V intake had higher levels of pressure to eat

High pressure decreased F&V intake about 1 less/day, after controlling for parental intake

Fisher J et al. J Am Dietetic Assoc 2002;102:58-64

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Changing Food Preferences

Intervention study Children 2-6 yrs

“Tasting” method: Taste vegetable for 14 consecutive days

Parent taste & provide positive verbal cues

No forcing

Significant increase in liking and consumption after using the method (compared to controls)

Repeated “tasting” can transform dislike into likeWardle J et al. Appetite 2003;40:155-62Birch LL. Annu Rev Nutr 1999;19:41–62

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Positive Messages: Increasing Healthy Eating vs. Reducing High Energy-Dense Foods

Family-based obesity intervention 13 groups sessions over

5 months 2 groups

Healthy Eating = more fruit, vegetables, and low-fat dairy

Reducing High Energy-Dense Foods = less high-fat, high-sugar foods

BMI reduction sustained only in Healthy Eating group BMI of parents in

Healthy Eating group improved more, too!

Epstein LH, et al. Obesity 2008;16:318-26

Parents set an example!

Buy, cook, serve, and eat more vegetables To start, double what you’re currently doing Put vegetables in everything you’re cooking Bring fruit and vegetable snacks with you

Eat a fruit at every meal and two vegetables at dinner

Learn to like new vegetables

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Increase Intake of Whole Grains and Fiber

What are Whole Grains?

Whole grain foods contain all the grain layers, including:

Bran (outer layer, contains seed fiber)

Endosperm or Kernel

(contains vitamins and minerals)

Germ

(concentrated source of nutrients)

What is Fiber?A group of compounds including lignin (plant cell walls) and complex carbohydrates that cannot be digested by human enzymes in the small intestine

Sources of Fiber Fiber/serving

Legumes (beans, peas) (cooked) 6-8 grams/ 1/2 cup

Fruits and Vegetables (cooked) 2-6 grams/ 1/2 cup

Whole Grains and Cereals 2-5 grams/ serving

Nuts and Seeds 2-4 grams/ ounce

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Fiber: Health benefits Increases satiety (the feeling of fullness) Helps prevent constipation (increases fecal bulk) Lower cholesterol absorption and LDL synthesis

5-10 g/day reduces LDL cholesterol by about 5% ↓ serum triglycerides ↓ cholesterol synthesis

May decrease insulin resistance Additional 5 g fiber/day→ 10% ↓ in belly fat deposition*

May help reduce weight gain Higher fiber inversely associated with BMI in major observational

studies Role of fiber in weight control is not yet clear

*Ventura E, et al. Arch Pediatr Adolesc Med 2009;163:320–7

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Dietary Fiber: HOW MUCH?

Ages 1-3 years 19 g/day

Ages 4 – 8 years 25 g/day

Ages 9 – 13 yearsMale

Female31 g/day26 g/day

Ages 14 -50 yearsMale

Female38 g/day29 g/day

US adults typically get 14-15 g fiber/day

Children:

How many grams of fiber do children need?

024

68

10

1214

16

gm

s fi

ber/

day

2-5 yr 6-11 yr Girls 12-18 yr

Boys 12-18 yr

Mean Fiber I ntake, US Children by Age

Saldanha et al, Pediatrics 1995;96:994-7

Note: 14 g fiber / 1000 calories

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Dietary Fiber: Contrasting Foods

High Fiber Low Fiber

Potato with skin (one) 2 g Potato w/out skin (one) 1 g

Dry beans (cooked)(1/2 cup)

6 g Potato chips (1 serving)

1 g

Broccoli (1 cup) 5 g Lettuce (1 cup) 1 g

Whole wheat bread (1 slice) 3 g White bread (1 slice) 1 g

Cereal: oat circles(1 cup)

3 g Cereal: corn flakes

(1 cup)0.5 g

Brown rice (cooked) (1/2 cup) 2 g White rice (1/2 cup) 0 g

Orange (one) 3 g Orange juice (1/2 cup) 0 g

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Read It Before You Eat It!

Read the food label Look for High Fiber and Whole Grain

5 g fiber/serving is HIGH for cereal and bread Find the LOW SUGAR food

4 g sugar = 1 teaspoon sugar Sugary circles: 12 g sugars; 3 g fiber Sugary flakes: 11 g sugars; 1 g fiber

Look for those with < 8 g sugar per serving Mix brands of cereals to increase fiber and lower

sugar content

Reduce/Avoid Sugar-Sweetened Beverages and Foods

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Sugar-Sweetened Beverages (SSB)

What are SSBs? Soda, fruit drinks, juice blends, lemonade, sweetened tea Other carbonated or uncarbonated drinks (ie, sports and

energy drinks) Most consumption happens at home (55-75%) Daily calories from juice and other SSB (among

those consuming): 2-5 yrs, 190 calories 6-11 yrs, 220 calories 12-19 yrs, 345 calories

Vartanian, et al. Am J Pub Health. 2007;97:667-75NHANES 1999-2004

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Juices & Sugar-Sweetened Beverages

Theoretically, if added to the typical US diet: 1 soda/day = 15 lb/year

Studies show switch to calorie free saves 1-3 kg/yr gain in children & lowers fat deposition

OZ Calories Vit C, mg

Sugar,

teaspoons

Apple Juice 12 180 12-60 10

Orange Juice 12 168 150 8

Grape Juice 12 240 0 15

Cola 12 145 0 10

Sports drink 12 75 0 6

Vitamin waters 12 75 36 5

Vanilla frappuccino 12 320 0 11

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Sugar-Sweetened Beverages Sugar types

Sucrose (cane/beet sugar = 50% glucose + 50% fructose) High fructose corn syrup (55% fructose + 45% glucose)

Fructose has more negative health effects (compared to glucose) An increase in visceral fat (in organs) Less sensitivity to insulin Increased fat production in the liver Higher LDL cholesterol Higher triglycerides

Effects on energy intake ↑ hunger & ↓ satiety Displace appetite for nutrient-balanced foods

Stanhope et al, J Clin Invest 2009;119:1322-34

Wang et al, Pediatrics 2008;121:e1604-14

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Diet Beverages (Non-nutritive sweetened beverages)

Typically sugar-free, artificially sweetened, non-alcoholic, carbonated beverages

Marketed towards:health-conscious people, diabetics, athletespeople who want to lose weight or stay fit

Replacing sugar-sweetened beverages with water and diet beverages can lower total calories consumed.

Raben et al. Am J Clin Nutr 2002;76:721-9

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However…

Sweet goes with fatty and salty!

When consumed alone, diet beverages may increase hunger

Mattes et al. Am J Clin Nutr 2009;89:1-14

The food item alone has 710 cals (40 grams fat, 13 grams saturated fat) and that is without the 300-600 calories from French fries!

EVEN BETTER WITH A DIET COKE AND FRESH LIME

http://www.foodfacts.info/blog/uploaded_images/sonic-bacon-cheddar-sheeses.jpg

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Diet Beverages

No benefits for weight loss or slowing weight gain, UNLESS accompanied by total energy restriction and improved energy balance

Oh yeah… a diet soda

too.

http://www.cartoonstock.com/directory/d/diet_drinks.asp

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Counseling Tips: Beverages

Plain water is best! Drink plenty of it.

Flavor water with lemon or lime. Keep it cold in the refrigerator.

While diet drinks are preferred over regular soda, the sweet taste can increase your intake of high calorie foods.

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Less & Safer Chemical Exposures

Effects Fat cell regulation -- PPAR – peroxisome proliferator-

activated receptors Endocrine disruptors

Products w/ potential for harm BPA -- 7 Phthalates – 3 Organotins – PVC - 3 PBDE (polybrominated diphenyl ethers)

Less & Safer Chemical Exposures

Choose safer plastics Avoid heating plastics Wash produce

Buy organic if you can, but Eating Fruits and Veggies is more important than eating only organic F & V

Peel – but think about fiber

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Summary

Be a role model for healthy habits! Be positive about healthy foods. Make changes to the home environment to

promote healthy habits. A few changes can have a big impact.

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