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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