Myths and Facts: Evidenced-Based Anticipatory Guidance for Childhood Eating Annual Review in Family Medicine December 11, 2015 Susan Fisher-Owens, MD, MPH Associate Professor Of Pediatrics Associate Clinical Professor of Preventive and Restorative Dental Sciences Department of Pediatrics San Francisco General Hospital Children’s Health Center
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Myths and Facts: Evidenced-Based Anticipatory Guidance for Childhood Eating Annual Review in Family Medicine December 11, 2015
Susan Fisher-Owens, MD, MPH Associate Professor Of Pediatrics
Associate Clinical Professor of Preventive and Restorative
Dental Sciences Department of Pediatrics
San Francisco General Hospital Children’s Health Center
Support and Disclosure
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• Neither I nor anyone in my family have any financial relationships relevant to this topic to disclose
• This is the best scientific knowledge in the literature as of November/December 2015
• Autism (if also eliminate casein) – No discernible effects in double-blind, placebo-
controlled, four-month study of 14 preschoolers with autism
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Mediterranean diet
• Strong evidence of positive healthy outcomes • Includes
– Nuts, legumes, seeds – Olives/olive oil – Whole grains – Fruits and vegetables – Fish 1-2x/wk – (Red wine)
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Paleo (aka, Caveman, Hunter-Gatherer) • Contains
– High-protein, high fiber – Lean meat and fish, fruits and vegetables, and
healthier fats – No processed food – No grains – Not much research to support
• Short-term consumption of a paleolithic type diet improves BP and glucose tolerance, decreases insulin secretion, increases insulin sensitivity and improves lipid profiles without weight loss in healthy sedentary humans. (Frassetto, Nature, 2009)
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Vegetarianism
• Subgroups – Ovo—egg – Lacto—milk – Pesco—fish
• Safe for children – Be mindful of protein, zinc, iron, B12 – Can be a form of restricted eating for teenagers
• Research shows less high blood pressure, cholesterol, cancer, and constipation
• Soy safe if history of breast cancer? – Isoflavones may act like estrogen, or have anti-
estrogenic effects – Study done in China, where soy
is cultured
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Vegan
• No animal derived products (honey, sometimes yeast)
• Be mindful of protein, zinc, iron, B12, Vit D, +/- Calcium
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Raw food
• Yes, food has enzymes • No lifetime limits on enzymes in body
• Some foods need to be cooked:
– Parsnips – Rhubarb
• Longer you cook the food, loss of heat and water sensitive nutrients, particularly vitamin C and thiamin
• Extreme—blackened foods and HCAs (heterocyclic amines)
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Zen macrobiotic diet
• Limits animal products, vegetables, and fruits • Not recommended by the AAP
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Organic
• No definitive health benefits (?environmental?)
• Definite financial issue – Consumer Reports: huge range on costs
• 47% more initially
• Research on children and farm workers • “Dirty Dozen” (EWG) • “Clean 15”
– Discovered (by accident) 1878 – First safety concerns in 1970—FDA was going to ban
it, but public protested • Bladder cancer in rats, not humans
– Pros • 200-700 times sweeter than sugar • Releases insulin • Longer half-life
– Cons • Sulfonamide
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Aspartame
– Pros • 200 times sweeter than sugar • Short half-life (but longer lasting sweetness) • Carb-free (no impact on BS)
– Cons • Unstable in heat • Does provide calories when metabolized • Phenylketonuria • Concerns for neurotoxicity, although not enough
science for FDA to take off market – Also European Food Safety Authority
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Sucralose
– Discovered 1976; product of sugar – Approved in 1998 – Twice the shelf life of aspartame – Retains sweetness after being heated – Splenda—partially sucralose
• Pros – 1/3 calories of sugar – No aftertaste – Heat stable – Does not affect BS
• Cons – At higher doses, does cause weight gain – Less known on safety – ?Affect bioflora
24 ADA and Diabetes UK website
Stevia
• 250-300x sucrose – Bitter aftertaste, so often blended
• Approved for sale in 2012 • Pros
– “Natural” – Heat stable – If taken regularly (6 hr intervals), can improve
• Cons – Lower BG too much – Data on cancer nonconclusive
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Xylitol
– “Natural” – Used ~40 years – Pros
• 1/3 fewer calories • Sweet taste • Good for teeth/bad for microbiotia (decreases caries
formation, reduces plaque formation, stimulates saliva) • Does not raise BS or insulin levels
– Cons • Toxic to dogs (hypoglycemia) • May cause loose stools in excess
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Erythritrol (Sun Crystals)
– Sugar alcohol found naturally in certain fruits – Less sweet than sugar; no calories, no additives, and
a zero GI (glycaemic index). – Also has no significant laxative effect on the body.
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Honey – Pros
• Natural – Each bee makes ½ tsp of honey in lifetime
• Research shows treats cough (dark, local, buckwheat honey)
• Fructose and glucose, so lower GI than sucrose – Minerals (iron, calcium, potassium and magnesium)
• Uses: – Cough – Allergies – Antiseptic
– Cons • Sweeter than sugar, but not low calorie • High carb (GI=55) • Colony collapse
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Agave
• Fructose and glucose, so lower GI than sucrose • Can be cooked
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HFCS
• Fructose and glucose from processed corn syrup • Cheaper than sucrose • Gives products a longer shelf life • No data to show it is worse than sucrose
disease, irritable bowel syndrome (IBS), Alzheimer’s disease, thyroid conditions, energy, boosting the immune system, weight loss and lower cholesterol
– Skin/moisturizer
• Research – Saturated fat is medium chain triglycerides – Only preliminary research
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Coconut, continued
• Oil—LOTS of claims, little research • Water
– 61 mg potassium, low calories, not high fat – Not enough sodium to be only source of replacement – Expensive, not much research to support claims, not
needed for the average athlete
• Flour – Acceptable to GF and paleo diets – 5 grams of fiber with only 8 grams of carbs. – Iron, Zinc, Calcium and Potassium, along with some
short chain fatty acids, polyphenols and antioxidants
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Coconut sugar
– Same calories as sucrose – Iron, Zinc, Calcium and Potassium, along with some
short chain fatty acids, polyphenols and antioxidants – Inulin – NOT fructose free
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Neotame
• Newest artificial sugar • 7000-13,000 times sweeter than sucrose • Not used much • Seal of approval from CSPI
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Sugar is sugar
• US consumes more than 20 teaspoons of sugar a day
– Too much – Sets sweet point
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Seeds
• Chia (3T serving) – Protein (7g) – Fiber 14 gm (and volume [3/4 c]) – Has fat (12 gm, including 1 saturated) – but no cholesterol – More omega-3 fatty acids than salmon – Not low cal (190 cal) – Calcium (249 mg [25% RDV)) – Iron (3 mg [16% RDV]) – Niacin (20 mg [20% RDV]
• Flax • Hemp
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Seeds
• Flax (1 ounce serving) – Protein (5g) – Fiber (6 g) – Has fat (12 gm, including 1 saturated)
• But no cholesterol
– Not low cal (150 cal) – Calcium (7% RDV) – Iron (9% RDV)
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Seeds
• Hemp (2T serving) – Comes as seed, oil (does not have high smoke
point), or protein – Contains all 9 essential amino acids (+11) – Protein (10 g) – Fiber (2 gm) – Has fat (9 gm, including saturated); no cholesterol – High omega-3 fatty acids : Ω6 – Not low cal (100 cal) – Magnesium – Lacks leucine
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Probiotics
• Prebiotics—food for probiotics • Probiotics—“good” bacteria
– (good data) Lactobacillus for rotavirus diarrhea (studied with 10b CFU during 1st 48 hours)
– (reasonable data) probiotics to protect against allergies, in high risk infants after C-section
• 2 lactobacilli, bifidobacteria, and propionibacteria • “Gauze in the mouth” –1 hour preop, then swab after birth
– (mixed data) Diarrhea from antibiotics, travelling, chemo, other G.I. problems, BV, and H. pylori ulcers
– Insufficient data:
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Probiotic foods
• Dairy – Kefir, yogurt, buttermilk, some cheese, fermented
• “Mushroom tea” (for the SCOBY [symbiotic colonies of bacteria and yeast] the growth on top of tea
• High in acid and contain sugar, vinegar, B vitamins, antioxidants (from the tea), trace amounts of alcohol (a natural consequence of fermentation), and other chemical compounds
• Can cause metabolic acidosis (used intentionally by teens with eating disorders to fill full/sick)
• Probiotic benefits are undermined if pasteurized, but, if not pasteurized, higher contamination risk
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Beverages • Green juice
– Pros: • (Store bought) about 36% of potassium, 20% of vitamin
A, 12 grams of natural sugar and 4 grams of protein (less fiber)
• Home juiced (more vitamins and fiber)
– Cons • Oxalates (if kidney disorders) • Always better to eat than drink one’s nutrition
• Kefir • Other energy drinks have no intrinsic value,
except caffeine – Chocolate milk
• Kombucha 42
Vitamins
• AAP: not needed after 1st year in pt with normal diet
– Only , those with chronic diseases, eating disorders, malabsorption, and liver disease and obese children in weight loss programs.(Kleinman 2004)
• Exception: vitamin D in newborns, obesity, chronic disease, anemia
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Fluoride
• “New realm” of antivaccinationists • In water, tea, shrimp, grapes • Safe
Toxins—why such a worry with children? • Lower to the ground
– Different air – Crawling on the ground and putting hands and mouth
• Higher surface area to volume • Higher respiratory rate
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When to start feeding?
• Ideally between four and six months – Higher rates of allergies if before or after
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How to start feeding a baby
• LaLeche League: meat • Dr. Sears (Sr): salmon • Common American convention: rice cereal
– Good that cheap, has iron, but constipating
• Grandma: vegetables
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Don’t feed
• Whole nuts • Raw carrots/celery • Whole hot dog rounds • Before 9 months of age, home-processed
Spinach/roots (methemoglobinemia, oxalates)
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What about shrimp, peanuts, eggs??
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Where do you/your patients get your nutritional advice? • WIC • Grandma • Trainers • Dietitians • Conferences • School • Internet
WIC
• Overall, good education • Caveats:
– Includes juice – Does not give low-fat milk in 1st year
“Grandma” Standard
• Breakfast really is the most important meal of the day
• Eat food with ingredients that Grandma would recognize the name (e.x. wheat, flour, milk, fruits and vegetables), (or at least 2 items she wouldn’t recognize) NOT
• In lining of cans, microwaved plastics, etc • Concern for brain, behavior and prostate gland of
fetuses, infants and children
Grandma advice to take with a (small) grain of salt • Exception
– No need to give veggies before fruits – No need to avoid foods except chocking hazards – Rice cereal does not make a baby sleep through the
night
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• Kids more likely to adopt foods as adults if offered as kid: http://national.deseretnews.com/article/3478/serving-kids-fruits-and-vegetables-is-not-a-waste-of-time.html
– Omega 3 FA (salmon, mackeral, sardines, flaxseeds – Omega 6 FA (corn oil, soybean oil, safflower oil,
walnuts)
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Beans and rice
• Do not have to be at the same meal
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Fresh fruits are always more healthy
• Exception: Canned Tomatoes
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Cravings?
• When your diet is boring or restricted—except: – Iron (pica)
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Food allergies
• Now NO recommendation to withhold foods (Strawberries, mushrooms, eggs, and peanuts)
• Peanuts—boiled vs. roasted
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Formaldehyde
• One of the most common indoor air pollutants • Naturally occuring in some foods • More in food, esp when frozen • Water-soluble, so can be washed off with water
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Unlikely health foods
• Chocolate
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Chocolate (if dark) • Benefits
– Theobromine • Cough relief
– Flavenoids, antioxidant compounds that increase the flexibility of veins and arteries.
• 5 times the flavenoids of apples • square of dark chocolate a day lowered blood pressure
and reduced risk of heart attack and stroke by 39% – More filling than milk chocolate – Happier babies – Dropped insulin resistance – Decreases anxiety – Sun protection – Increased brain blood flow – Decreased Diarrhea (binds in small intestine)