Toddler Nutrition and Impact on Obesity and Non-communicable Diseases. Atul Singhal

Transcription

1 Toddler Nutrition and Impact on Obesity and Non-communicable Diseases Atul Singhal

2 Great Ormond Street Hospital Professor of Paediatric Nutrition UCL Institute of Child Health, London

3 Paediatrician at Great- Ormond Street Hospital

4 Early Nutrition Future Health

5 Infant nutrition has a role beyond that of meeting nutrition requirements..

6 Programming Stimulus in critical window Permanent effect on structure & function (Lucas, 1982)

7 A Global Problem >2.1 billion are overweight (WHO; McKinsey 2014)

8 % population with BMI > 30

9 Outline What are the nutritional challenges? Why education is critical? What can we do?

10 Professor Sally Davies (CMO report October 24 th 2013)

11 12.5% of UK toddlers are obese (CMO report October 24 th 2013)

12 Increase in Childhood Obesity 43 million children < 5 affected (DeOnis 2010; WHO 2011)

13 What are the main challenges in toddler nutrition?

14 Vitamin D Deficiency Prevalence increasing (12.5%) up to 40% have low levels (CMO report October 24 th 2013)

15 What are the causes of childhood obesity?

16 Development Obesity = Energy intake > expenditure Genes Environment

17 Genetic factors: Twins Studies Account for 40-85% variability in BMI between individuals (Maes 1997; Wardle 2008)

18 Adoption studies BMI more strongly related to biological parents (Silventoinen 2010)

19 Family History Increased risk if one or both parents obese (Whitaker, NEJM 1997)

20 Genome wide studies have identified >97 genetic loci associated with BMI (eg. FTO, MC4R) (Loos 2012; Speliotes 2010; Locke 2015)

21 Genes may act by affecting appetite even in young children (Llewellyn 2012)

22 On average each gene increased BMI by 0.1 (FTO by 0.5) and obesity risk by 10%

23 Cumulative Increase in Obesity risk BMI Genetic Risk (Loos 2010)

24 Mendelian FTO gene Randomisation BMI 0.4 units 17% MI risk 35% diabetes (Ingelsson 2013)

25 Genes only explain 5% of BMI variation & increased prediction of BMI by 1% (above age and sex) Environment is the Key!

26 Environmental Factors Diet Physical Activity TV Early weight gain

27 What factors in the toddler diet may increase the risk of obesity?

28 Fruit and Vegetable Intake 5% no fruit or veg 25% minimal intake (ALSPAC Study)

29 Toddler Diet: Compared to the 50 s Energy Bread, Potatoes 25x 34x Sweets Soft drinks and juices

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31 Too much! Third of Daily Calories From Sugar (5% recommended) 25% 5 yr olds

32 Role of Sugary Drinks (Bray GA 2013; Keller 2015)

33 Systematic Reviews Sugar and fat reduction small but meaningful reductions in body weight (Morenga 2013; Hooper 2013)

34 Population average intake of free sugars should not exceed 5% of total dietary energy

35 October 22 th 2015

36 Does Portion Size Matter?

37 Downsizing: policy options to reduce portion sizes to help tackle obesity (Marteau, Hollands, Shemilt & Jebb., 2015)

38 Does Portion Size Matter? Energy density and portion size affect energy intake and body size in children (Rolls 2000; Fisher 2003 Leahy 2008, Mathias 2012, Syrad 2016)

39 Does Portion Size Matter? US Surveys: Little secular change form most foods but increasing in milk, bread, cereal, juice (McConably 2002)

40 Does Portion Size Matter? Portion size affects energy intake in 5 year olds but not 3 year olds (Rolls 2000)

41 Why is nutrition in toddlers particularly important for prevention?

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43 Dietary Pattern Analysis (Northstone, 2005) Junk food

44 Dietary Pattern Analysis Traditional British

45 Dietary Pattern Analysis Health Conscious

46 Dietary patterns: established by 4 years of age & tend to be stable (Northstone, 2005)

47 Junk pattern associated with: Low maternal education Poor school attainment at age 7 Hyperactivity (Northstone 2005, Wiles 2009, Feinstein 2009)

48 Dietary intake: tracks from infancy through complementary feeding and toddlerhood Energy dense, nutrient poor diets or nutrient rich diets including fruit and veg, dairy, eggs, fish tracked between 9 and 18 months of age (Lioret et al, 2013)

49 Breast-feeding Reduces Obesity Risk Systematic Reviews Arenz 2004 Owen 2005 Owen 2005 Harder 2005 Quigley 2006 Weng 2012 Gale 2012

50 Breast-feeding & Obesity Risk Non-exclusive 0.89 Exclusive Up to 20% reduction 0.76 (Owen 2005) OR

51 Dose-response effect Each month of breastfeeding associated with 4% lower risk of obesity (Harder 2005)

52 Systematic Review (11 studies) Breast-feeding is associated with lower fat mass from 1 year (Gale AJCN 2012)

53 Unifying Growth Acceleration Hypothesis Benefits of breast-milk related to slower growth and undernutrition (Singhal & Lucas, Lancet 2004)

54 Growth Acceleration (Faster weight & length gain)

55 Systematic Reviews Faster growth in infancy Later obesity (Baird, Monteiro, Ong, Weng, Brisbois, Druet)

56 Systematic Review Faster growth in infancy Effect on Obesity: 20% to 6X (Baird, 2005)

57 Faster Infant Weight gain Increases Visceral fat (Ibanez, 2007) (Demerath, 2009) (Rolfe, 2010)

58 Infants Age (yrs) at FU Outcome Preterm BP, insulin, LDL (Singhal 2001, 2003, 2004) SGA <10 th 6-8 BP, Fat mass (Singhal 2007, 2010) Term 6 BMI (Weber 2014) SGA<20 th 4-6 Fat mass (Singhal 2010) Term 2 BMI (Inostroza 2014)

59 Infants Intervention (mths) Outcome Preterm BP, insulin, LDL (Singhal 2001, 2003, 2004) SGA <10 th 6-8 BP, Fat mass (Singhal 2007, 2010) Term 2-12 BMI (Koletzko 2009) SGA<20 th 6 Fat mass (Singhal 2010) Term 3-12 BMI (Inostroza 2012 Abstract)

60 Infants given solids < 4 months 6X more likely to be overweight at 3 years of age (Huh 2011; Systematic reviews: Weng 2012; Pearce 2013)

61 High protein intake at 21 months 10% later overweight / obesity (Pimpin et al 2015)

62 Cow s milk at age 8 months (Hopkins et al 2015) BMI at age 9 years

63 Meta-analysis 16 Studies Pooled effect size 0.28 SDS

64 19 / 24 studies protein intake in preschool children aged 6 36 months associated with greater risk of obesity (Lanigan et al, unpublished)

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66 Early Protein & Long-term Health 0-6 months 6-12 months

67 Protein intake in the first year: 3 X greater than physiological requirements (Michaelsen & Greer 2014)

68 Cows Milk Iron Protein Not recommended < 12 months (ESPGHAN Guidelines 2008)

69 Cows Milk < 500 ml day in Toddlers (ESPGHAN Guidelines Domellof 2014)

70 Avoid over-nutrition in infants Nutrient intake = Nutrient concentration (protein) X Volume of milk Behaviour

71 Responsive Feeding (DiSantis 2011) awareness interpretation response Discordance hunger / satiety cues Increased frequency or amount Impaired appetite regulation Accelerated weight gain / obesity

72 Responsive Feeding Mothers need to be aware of feeding cues (WHO Guidelines)

73 Summary of Risk Factors Energy balance >8 hrs TV per week Parental obesity Rapid weight gain in first year <10 hrs sleep at 3 years (Reilly J 2005)

74 What are the consequences of childhood obesity?

75 CHILDHOOD OBESITY Complications: (Reilly 2003) Orthopaedic Sleep apnoea Liver disease Hyperlipidaemia Respiratory disease Psychological

76 Childhood obesity increases risk of later obesity and CVD (Freedman 2005)

77 Toddler Obesity 1 in 3 obese 3-5 year olds will become obese adults (Serdula, 1993)

78 Early Origins of Vascular Disease Atherosclerosis Is Common in the Young (Enos et al, 1955)

79 Early Origins of Vascular Disease Begins in childhood Risk factors correlate with pathology (Berenson 1998) Metabolic syndrome is common

80 Survival Probability Adolescent Obesity & CVD Obese Non-obese 0.2 p = (Must et al, 1992) Age (years)

81 Long-term Consequences 10% increase in fatal event (Baker, 2007; Systematic Review: Owen 2009)

82 Systemic review of 7 studies: BMI (7-18 years) increases CVD (Owen 2009) risk by 9%

83 (Olshansky 2005)

84 Toddler Diet Low maternal education more: chocolate, white bread, chips, diet drinks, and tea. (Northstone, 2005)

85 Toddler Diet Low maternal education Less: cheese, fish, breakfast cereal, fruit, fibre (Northstone, 2005)

86 Prevention Policy Individual

87 Education is key Health care professionals Families

88 Ten Steps for Healthy Toddlers

89 Ten Steps for Healthy Toddlers Eat as a family Eat the foods you want your toddler to eat

90 Ten Steps for Healthy Toddlers Reward your toddler with your attention. Never use food and drink as rewards, treats or comfort

91 Ten Steps for Healthy Toddlers Reached: 586 settings, 1.5 million families

92 Evaluation of behaviour before and 9 months after Ten steps Fussy eating: Difficult behaviour Staff confidence: 18% 8% 27%

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94 Randomised Trial of 10 steps 402 families contacted 150 children recruited Randomized 75 Control 75 intervention 6 month Follow up 75 71

95 Fruit and vegetable intake, & physical activity in intervention group higher at 6 month follow-up. (Danah Al Tarrah 2015)

96 Weight gain lower in the 10 steps group (0.2 BMI z scores; p=0.01)

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98 Can toddler nutrition influence future health?

99 Toddler Nutrition Foundation for health throughout life Toddler Diet Long-term Health

100 Institute of Medicine Parents need to understand that bigger is not always better (June 2011)

101 Don t supersize him!

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103 Prevention in the pre-school years is critical for long term health

104 We need to instil healthy eating habits one step at a time

105 More is not necessarily better

106 Investing in Human development Rate of return (Doyle 2009) Pre-school School Adult 0 2 Age

107 References De Onis M, Blossner M, Borghi E. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr 2010; 92: Reilly JJ, Methven E, McDowell ZC, et al. Health consequences of obesity. Arch Dis Child 2003; 88: Freedman DS, Khan LK, Serdula MK, et al. The relation of Childhood BMI to adult adiposity: The Bogalusa Heart study. Pediatrics 2005; 115: Berenson GS, Srinivasan SR, Bao W, et al. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. N Engl J Med. 1998; 338 (23): Must A, Jacques PF, Dallal GE, et al. Long-term morbidity and mortality of overweight adolescents: A follow-up of the Harvard Growth Study of 1922 to N Engl J Med 1992; 327: Abdullah A, Stoelwinder J, Shortreeed S, et al. The duration of obesity and the risk of type 2 diabetes. Public Health Nutrition 2009; 14: Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st Century. N Engl J Med 2005; 352: Gardner DS, Hosking J, Metcalf BS, et al. Contribution of early weight gain to childhood overweight and metabolic health: a longitudinal study (EarlyBird 36). Pediatrics Jan;123(1):e doi: /peds Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ. 2005; 330: Musaiger AO. Overweight and Obesity in Eastern Mediterranean Region: Prevalence and Possible Causes. Journal of Obesity 2011, doi: /2011/ Locke AE et al. Genetic studies of body mass index yield new insights for obesity biology. Nature Feb 12;518(7538): doi: /nature Syrad H, Johnson L, Wardle J, et al. Appetitive traits and food intake patterns in early life. Am J Clin Nutr Jan; 103: doi: /ajcn Syrad H, Llewellyn CH, Johnson L, et al. Meal size is a critical driver of weight gain in early childhood. Sci Rep Jun 20;6: doi: /srep Keller A, Bucher Della Torre S. Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews. Child Obes Aug;11(4): doi: /chi Pimpin L, Jebb S, Johnson L, et al. Dietary protein intake is associated with body mass index and weight up to 5 y of age in a prospective cohort of twins. Am J Clin Nutr. 2016; 103: