Nutritional needs in early childhood: How to ensure optimum growth and prevent obesity

Nutritional needs in early childhood: How to ensure optimum growth and prevent obesity Yannis Manios Associate Professor Department of Nutrition and Dietetics Harokopio University, Athens, Greece e-mail: manios@hua.gr

Contents 1. Prevalence of childhood obesity & determinants 2. Food and nutrient intake recommendations 3. Are toddlers and preschool children in Greece meeting these recommendations? 4. The double burden of obesity: Can obesity influence children s nutritional status? 5. Conclusions

Prevalence of overweight and obesity among school-children in Europe 45 40 35 10,3 30 25 20 2,9 5,8 5 Obese Overweight 15 30,9 2,9 3,7 1,4 10 21,6 21,1 19,9 5 12,5 12,6 12,8 0 Greece Spain Slovenia Hungary Belgium Netherlands Norway Brug J, v et al. (2012) Differences in weight status and energy-balance related behaviours according to ethnic background among adolescents in seven countries in Europe: the ENERGY-project. Pediatr Obes 7: 399-411.

Prevalence of: -overweight/obesityamong preschool-children Manios Y. High level Group; 23-24 February 2015; Riga

Prevalence of: -overweight/obesity and -screen time > 2 h/day Manios Y. High level Group; 23-24 February 2015; Riga

Prevalence of: -overweight/obesity, -screen time > 2 h/dayand -meeting recommendations for daily steps Manios Y. High level Group; 23-24 February 2015; Riga

Factors influencing children s dietary and physical activity habits sedentary time PA levels healthy eating healthy drinking behaviors Moschonis et al. Expert Rev Cardiovasc Ther, 2015. 13(6): p. 673-92.

% parents reported that: It is a habit to organize my family so that we can see programs we like at TV P < 0.001 South (Greece, Spain) East (Bulgaria, Poland) Central/North (Belgium, Germany) Manios Y. High level Group; 23-24 February 2015; Riga

% parents reported that: I try to be physically active together with my child regularly P < 0.05 South (Greece, Spain) East (Bulgaria, Poland) Central/North (Belgium, Germany) Manios Y. High level Group; 23-24 February 2015; Riga

Physical environment Gent, Belgium Athens, Greece

Prevalence of parents with obese pre-school children underestimating their child s weight status P < 0.05 South (Greece, Spain) East (Bulgaria, Poland) Central/North (Belgium, Germany) Manios Y. High level Group; 23-24 February 2015; Riga

Prevalence of parents with overweight/obese pre-school children underestimating their child s weight status (1-5 years of age GENESIS-study ) Overweight children (n=743) Normal weight children (n=1431) 25,3 1,9 72,9 Underweight children (n=59) 2,3 15,4 57,1 4,1 38,8 82,3 Χαµηλότερο Lower Φυσιολογικό Normal Αυξηµένο Increased Manios Y, et al. (2010) Determinants of childhood obesity and association with maternal perceptions of their children's weight status: the "GENESIS" study. J Am Diet Assoc 110: 1527-1531.

Nutritional recommendations for infancy and pre-school age (1-6 years) Nutritional recommendations (portions/day) Milk (1 cup) Fruit (1 medium fruit) Vegetables (1 cup) Cereals and starch (30 g) Meat, fish, egg, legumes (30 g) Fats (1 tsp) Age group 1-2 yrs 2-4 yrs 4-6 yrs 3 2 2,5 1-2 1 1,5 1-2 1 1,5 3-5 3 5 2 2 4 3 3 4 Institute: United States Department of Agriculture (USDA) (2016) www.choosemyplate.gov

Nutritional recommendations for infancy and pre-school age (1-6 years) Nutritional recommendations (portions/day) Milk (1 cup) Age group 1-2 yrs 2-4 yrs 4-6 yrs 3 (450 kcal) 2 (240 kcal) 2.5 (300 kcal) Fruit (1 medium fruit) 1-2 (60-120 kcal) 1 (60 kcal) Vegetables 1-2 1 1.5 (1 cup) (25-50 kcal) (25 kcal) Cereals and starch 3-5 3 (30 g) (240-400 kcal) (240 kcal) Meat, fish, egg, legumes 2 2 (30 g) (110 kcal) (110 kcal) Fats 3 3 (1 tsp) (135 kcal) (135 kcal) 1.5 (90 kcal) (47 kcal) 5 (400 kcal) 4 (220 kcal) 4 (180 kcal) Institute: United States Department of Agriculture (USDA) (2016) www.choosemyplate.gov

Energy intake in infants and preschool children in Greece compared to the recommended ( GENESIS-study ) Recommended energy intake (kcal) Mean recommended energy intake: 1100kcal Frequ uency Manios Y, et al. (2008) Nutrient intakes of toddlers and preschoolers in Greece: the GENESIS study. Journal of the American Dietetic Association 108 (2):357-361.

Energy intake in infants and preschool children in Greece compared to the recommended ( GENESIS-study ) Recommended Recommended energy energy intake intake (kcal) (kcal) Actual Actual energy energy intake intake (kcal) (kcal) Mean recommended energy intake: 1100kcal Frequ uency Mean energy intake: 1410 kcal Manios Y, et al. (2008) Nutrient intakes of toddlers and preschoolers in Greece: the GENESIS study. Journal of the American Dietetic Association 108 (2):357-361.

Nutritional recommendations for infancy and pre-school age (1-6 years) Institute: United States Department of Agriculture (USDA) Nutritional recommendations (portions/day) Milk (1 cup) Fruit (1 medium fruit) Vegetables (1 cup) Cereals and starch (30 g) Meat, fish, egg, legumes (30 g) Age group 1-2 yrs 2-4 yrs 4-6 yrs 3 2 2,5 1-2 1 1,5 1-2 1 1,5 3-5 3 5 2 2 4 Institute: United States Department of Agriculture (USDA) (2016) www.choosemyplate.gov

Nutritional recommendations for infancy and pre-school age (1-6 years) Institute: United States Department of Agriculture (USDA) Nutritional recommendations (portions/day) Milk (1 cup) Fruit (1 medium fruit) Vegetables (1 cup) Cereals and starch (30 g) Meat, fish, egg, legumes (30 g) Age group 1-2 yrs 2-4 yrs 4-6 yrs 3 (24g Prot) 2 (16g Prot) 2,5 (20g Prot) 1-2 1 1,5 1-2 (2-3g Prot) 3-5 (9-15g Prot) 2 (14g Prot) 1 (2g Prot) 3 (9g Prot) 2 (14g Prot) 1,5 (3g Prot) 5 (15g Prot) 4 (28g Prot) Institute: United States Department of Agriculture (USDA) (2016) www.choosemyplate.gov

Mean daily dietary protein intake compared to the recommended in infants and preschool children (1-3 years)( GENESIS-study ) 140 120 RDAs for protein 1-3 yrs: 13 g/day 100 80 60 Frequency 40 20 0 55.0 50.0 45.0 40.0 35.0 30.0 25.0 105.0 100.0 95.0 90.0 85.0 80.0 75.0 70.0 65.0 60.0 Std. Dev = 12.48 Mean = 57.0 N = 1523.00 Manios Y, et al. (2008) Nutrient intakes of toddlers and preschoolers in Greece: the GENESIS study. Journal of the American Dietetic Association 108 (2):357-361.

Mean daily dietary protein intake compared to the recommended in infants and preschool children (4-5 years)( GENESIS-study ) 120 100 RDAs for protein 4-5 yrs: 19 g/day 80 60 Frequency 40 20 0 50.0 45.0 40.0 35.0 30.0 25.0 20.0 110.0 105.0 100.0 95.0 90.0 85.0 80.0 75.0 70.0 65.0 60.0 55.0 Std. Dev = 14.54 Mean = 59.2 N = 684.00 Manios Y, et al. (2008) Nutrient intakes of toddlers and preschoolers in Greece: the GENESIS study. Journal of the American Dietetic Association 108 (2):357-361.

Mean daily dietary protein intake compared to the recommended in infants and preschool children (4-5 years)( GENESIS-study ) g protein/100 g Meat/ Poultry 24,2 31,0 120 Cheese 15,0 30,0 Yogurt 3,6 5,8 Milk 1002,5 3,5 RDAs for protein 4-5 yrs: 19 g/day 80 60 Frequency 40 20 0 50.0 45.0 40.0 35.0 30.0 25.0 20.0 110.0 105.0 100.0 95.0 90.0 85.0 80.0 75.0 70.0 65.0 60.0 55.0 Std. Dev = 14.54 Mean = 59.2 N = 684.00 Manios Y, et al. (2008) Nutrient intakes of toddlers and preschoolers in Greece: the GENESIS study. Journal of the American Dietetic Association 108 (2):357-361.

Mean daily dietary fat intake (% EI) compared to the recommended in infants and preschool children (1-5 years)( GENESIS-study ) 100 Dietary Reference Intakes(Macronutrients), 2002 90 80 70 60 50 40 30 20 10 0 1-2 years 2-3 years 3-4 years 4-5 years below recommendation within recommendations above recommendations Manios Y, et al. (2008) Nutrient intakes of toddlers and preschoolers in Greece: the GENESIS study. Journal of the American Dietetic Association 108 (2):357-361.

Mean daily dietary fat intake (% EI) compared to the recommended in infants and preschool children (1-5 years)( GENESIS-study ) Saturated Fatty Acid s intake (% EI) 20 15 Children AAP AHA 10 5 1-2 ετών 2-3 ετών 3-4 ετών 4-5 ετών American Academy of Pediatrics (1998) Pediatrics; 101(1): 141-147 AHA (2000) Circulation; 2296 2311 De Backer et al. (2003) EurHeartJ; 24(17):1601-10 National Cholesterol Education Program (2002) http://www.nhlbi.nih.gov/guidelines/cholesterol

Mean daily dietary fat intake (% EI) compared to the recommended in infants and preschool children (1-5 years)( GENESIS-study ) Poly-Unsaturated Fatty Acid s intake (% EI) 20 15 10 Children AHA 5 0 1-2 years 2-3 years 3-4 years 4-5 years American Heart Association (2002) Cardiovascularhealthinchildhood: Circulation;106(1):143-60 National Cholesterol Education Program (2002) http://www.nhlbi.nih.gov/guidelines/cholesterol

Mean daily dietary fat intake (% EI) compared to the recommended in infants and preschool children (1-5 years)( GENESIS-study ) n-3/100 g Salmon: 1.8g Anchovy: 1.7g Sardine: 1.4g Herring: 1.2g20 Mackerel: 1.0g Trout: 1.0g Tuna fish: 0.7g15 n-3/100 g Σολομός: 1.8g Γαύρος: 1.7g Σαρδέλα: 1.4g Ρέγγα: 1.2g Σκουμπρί: 1.0g Πέστροφα:1.0g Τόνος: 0.7g 10 5 0 Poly-Unsaturated Fatty Acid s intake (% EI) 1-2 years 2-3 years 3-4 years 4-5 years A.I. for n-3 fatty acids 1-3 years: 0.7 g/day 4-8 years: 0.9 g/day Children AHA American Heart Association (2002) Cardiovascularhealthinchildhood: Circulation;106(1):143-60 National Cholesterol Education Program (2002) http://www.nhlbi.nih.gov/guidelines/cholesterol

% of preschool children in Greece with dietary intakes of selected micronutrients below EAR * ( GENESIS-study ) Micronutrients % < EAR * Vitamins Vitamin D (μg) 100 Vitamin E (μg) 22.2 Vitamin Β1 (Thiamin) (mg) 1.3 Vitamin Β2(Riboflavin) (mg) 6.3 Vitamin Β3 (Niacin) (mg) 14.5 Folate(μg) 19.7 Vitamin C (mg) 0 Minerals Calcium (mg) 0 Iron (mg) 0 Zinc (mg) 0 Magnesium(mg) 0 * EAR: Estimated Average Requirements Manios Y, et al. (2008) Nutrient intakes of toddlers and preschoolers in Greece: the GENESIS study. Journal of the American Dietetic Association 108 (2):357-361.

Prevalence of vitamin B2 deficiency in children in Greece (9-12 years old) Manios, Y., et al. (2015) EurJ Nutr. Epubahead of print

Prevalence of vitamin B2 deficiency in children in Greece (9-12 years old) Percent contributions of individual food items and food groups in the dietary intakeof vitamin B2 Contribution of Dietary vitamin B2 (%) Milk 26.6 Cheese 12.2 Red meat 6.2 Fruits 5.5 Manios, Y., et al. (2015) EurJ Nutr. Epubahead of print

Prevalence of vitamin B2 deficiency in children in Greece (9-12 years old) Percent contributions of individual food items and food groups in the dietary intakeof vitamin B2 Contribution of Dietary vitamin B2 (%) Milk 26.6 Cheese 12.2 Red meat 6.2 Fruits 5.5 Positive linear associations of vitamin B2 derived from milk and fruits with plasma vitamin B2 levels Manios, Y., et al. (2015) EurJ Nutr. Epubahead of print

Prevalence (%) of iron deficiency among school-children by weight 25 20 15 10 5 0 group ( Healthy Growth-study ) Male p<0.001 23.3 17.4 14.1 6.9 7 5.3 2.8 2.3 1.4 Normal weight Overweight Obese 25 20 15 10 5 0 20.6 15 12.4 Iron deficiency (TS<16%) Female p=0.001 2 3.3 8.2 Iron deficiency anemia (TS<16% and Hgb<12g/dl) 5.8 7.5 7.2 Non-iron deficiency Anemia (Hgb<12g/dl) Normal weight Overweight Obese Manios, Y., et al., The double burden of obesity and iron deficiency on children and adolescents in Greece: the Healthy Growth Study. J HumNutrDiet, 2013. 26(5): p. 470-8.

IL-6 CRP Zafon et al Obesity Reviews 2009

Prevalence of vitamin D insufficiency by weight status and season Winter(Mar-Apr) 80 70 60 50 40 30 20 10 0 33,3 39,3 45,5 47,4 45 66,7 Male Female Manios Y. Presented in 'Regional Conference on South East Asian Nutrition Surveys (SEANUTS): Current Updates on Childhood Nutrition and Development' 6th - 7th November 2012, Kuala Lumpur.

Prevalence of vitamin D insufficiency by weight status and season Winter(Mar-Apr) 80 70 60 50 40 30 20 10 0 33,3 39,3 45,5 47,4 45 66,7 Male Female 50 40 42,9 Summer(Sept-Oct) 30 20 10 0 7 14,3 8,3 15,6 10 Male Female Manios Y. Presented in 'Regional Conference on South East Asian Nutrition Surveys (SEANUTS): Current Updates on Childhood Nutrition and Development' 6th - 7th November 2012, Kuala Lumpur.

Contents 1. Prevalence of childhood obesity & determinants 2. Food and nutrient intake recommendations 3. Are toddlers and preschool children in Greece meeting these recommendations 4. The double burden of obesity: Can obesity influence children s nutritional status? 5. Conclusions

Conclusions/recommendations Educate parents to understand/ evaluate appropriately: children s weight status Manios, Y. et al. (2015) Food group and micronutrient intake adequacy. Nutrients. 11; 7 (3):1841-58.

Conclusions/recommendations Educate parents to understand/ evaluate appropriately: children s weight status the importance of covering nutrients needs not just caloric needs nutrients needs can be met by a balance diet Manios, Y. et al. (2015) Food group and micronutrient intake adequacy. Nutrients. 11; 7 (3):1841-58.

Conclusions/recommendations Educate parents to understand/ evaluate appropriately: children s weight status the importance of covering nutrients needs not just caloric needs nutrients needs can be met by a balance diet still might need to prioritize certain food items within specific food groups: - Diary ( milk, yogurt, cheese) -Protein food ( meat, fish) -Fruit (vs fruit juices) -Vegetable -Cereals and starch ( whole grain) Manios, Y. et al. (2015) Food group and micronutrient intake adequacy. Nutrients. 11; 7 (3):1841-58.

Conclusions/recommendations Educate parents to understand/ evaluate appropriately: children s weight status the importance of covering nutrients needs not just caloric needs nutrients needs can be met by a balance diet still might need to prioritize certain food items within specific food groups: - Diary ( milk, yogurt, cheese) -Protein food ( meat, fish) -Fruit (vs fruit juices) -Vegetable -Cereals and starch ( whole grain) seek for opportunities outdoor activities and sun exposure. Manios, Y. et al. (2015) Food group and micronutrient intake adequacy. Nutrients. 11; 7 (3):1841-58.

Conclusions/recommendations Educate parents to understand/ evaluate appropriately: children s weight status the importance of covering nutrients needs not just caloric needs nutrients needs can be met by a balance diet still might need to prioritize certain food items within specific food groups: -Diary ( milk, yogurt, cheese) (enriched milk) -Protein food ( meat, fish) -Fruit (vs fruit juices) -Vegetable -Cereals and starch ( whole grain) (enriched) seek for opportunities outdoor activities and sun exposure. consider enriched products with vitamin D Manios, Y. et al. (2015) Food group and micronutrient intake adequacy. Nutrients. 11; 7 (3):1841-58.

HarokopioUniversity Athens Department of Nutrition & Dietetics Yannis Manios, Associate Professor E-mail: manios@hua.gr

Back up Iron: Pro-oxidant, transition (of electrons) metal. Hepcidinis a peptide expressed predominantly in liver. Hepcidinregulates intestinal iron absorption, plasma iron concentrations, and tissue iron distribution by inducing degradation of its receptor, the cellular iron exporter ferroportin. Ferroportinexports iron into plasma from absorptive enterocytes, from macrophages that recycle the iron of senescent erythrocytes, and from hepatocytes that store iron.

Conclusions Educate parents toevaluate/understand: Their children s weight status Their children s nourishment status That increased body weight is no way a sign of good nourishment The importance of all food groups: - Diary ( enriched milk, yogurt, cheese) -Protein food ( meat, fish) -Fruit -Vegetable - Cereals and starch ( enriched whole grain) Seek for opportunities for sun exposure and outdoors activities. Alternatively, consider enriched products with vitamin D Manios, Y. et al. (2015) Food group and micronutrient intake adequacy. Nutrients. 11; 7 (3):1841-58.