Myths and Facts: Evidenced-Based Anticipatory Guidance for - - PowerPoint PPT Presentation

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

2

• 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

Objectives

• To review the science on:

– Diets

• Gluten-free
• Mediterranean
• Paleo
• Vegetarian/vegan

– Organic food – Free range – Juicing – GMOs – Food additives – Alternate sweeteners – Seeds (Chia/Flax/Hemp) – Probiotics – What foods to start with? When?

• Pros and Cons of different information sources
• Unlikely health foods

Gluten-free—Celiac “lite”?

• Nonceliac gluten sensitivity
• Nutritional composition

– Often less fortified

• 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”

“Dirty Dozen” “Clean 15”

1. Apples 2. Celery 3. Cherry tomatoes 4. Cucumbers 5. Grapes (especially imported) 6. Nectarines 7. Peaches 8. Potatoes 9. Snap peas

• 10. Spinach
• 11. Strawberries
• 12. Bell peppers

+ Hot peppers and Kale/collard greens 1. Asparagus 2. Avocados 3. Cabbage 4. Cantaloupe 5. Cauliflower 6. Eggplant 7. Grapefruit 8. Kiwi 9. Mango

• 10. Onions
• 11. Papayas
• 12. Pineapples
• 13. Sweet corn
• 14. Sweet peas (frozen)
• 15. Sweet potatoes

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Environmental Working Group 2015

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From “The Dirty Dozen”

Organic dairy

• 60% cost
• 25% less Omega 6 fats, more omega 3

fats (62%) (may be important to look

• nly at amount of omega-3, not ratio)
• More likely from grass fed cows
• No antibiotics

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Free Range/Antibiotic Free Meat, Fish, and Eggs

• + evidence of antibiotic resistance because of use in

animals

• No difference in salmonella in free range chickens
• Free range eggs (chickens allowed outdoors) versus

cage free

– free-range egg cost 2.6 cents more to produce than a battery egg, and a barn egg cost 1.3 cents more to produce than a battery egg – Mixed data on nutritional advantage

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Juicing/Fasting (to “cleanse toxins”)

• No data but not advised for children
• A lot of sugar, but no fiber
• Fasting

– No physiological mechanism – Job of kidneys and liver

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Genetically engineered/genetically modified organisms (GMOs)

• A small proportion of US sweet corn, papaya,

and summer squash

• Pros

– Golden Rice (vitamin A) – Pest resistant

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Food additives

• Nitrates and nitrites

– React with amines to form nitrosamines, in the food itself or in the digestive tract

• Known cancer-causing compounds

– Stomach (IARC 2010) – Possibly the esophagus, brain, and thyroid

– No links from high consumption of spinach/leafy vegetables, which are naturally high in nitrates

• Potassium bromate

– Added to flour; strengthens bread and crackers dough, and helps them rise – Causes tumors at multiple sites in animals, is toxic to the kidneys and can cause DNA damage (IARC 1999) – Banned in other countries

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“GRAS” (generally recognized as safe)

• Flavors in e-cigarettes

– GRAS in foods, but not as volatile compounds

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Alternative sweeteners

• Saccharin (Sweet’N Low)
• Aspartame (Equal, NutraSweet)
• Sucralose (Splenda)
• Stevia
• Xylitol
• Erythritrol (Sun Crystals)
• Honey
• Agave
• Coconut sugar/“flour”/Oil
• Vs Sucrose (table sugar)

– 50% fructose and 50% glucose

Saccharin

– 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

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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 glucose tolerance – Also, lower Blood glucose and blood pressure, others

• 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

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Coconut

• Claims

– Diabetes, heart disease, chronic fatigue, Crohn's 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 milk

• Soy products

– Miso, tempeh, soy sauce/soy drinks

• Kimchi, sauerkraut, pickles…

“lactofermentation”

• Whey

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Kombucha

• “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

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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

– Propyl paraben (preservative, endocrine disruptor) – Butylated hydroxytoluene (preservative, ?cancer) – Propyl gallate (preservative in foods with edible fats) – BPA

• 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
• ffered as kid:

http://national.deseretnews.com/article/3478/ser ving-kids-fruits-and-vegetables-is-not-a-waste-

• f-time.html

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Trainers

• Warning: steroids, creatinine, GHB

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Teens and supplements

• Caffeine
• Proteins/AA
• Creatine
• HMB
• Chromium
• Against NCAA, IOC, etc…

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Pregnant Women

• Diet
• Sushi

J Kumar, 2006; Lombazo 2015; Hennig 2014

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Toddlers

• Balanced months not balanced plates

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Myths?

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Milk

• ?Not fat free (gum, fillers)
• CALCIUM--Oranges, leafy greens, tofu, and

almonds

• Not all dairy alternatives have calcium

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“BRAT” diet

• Composition

– Bananas – Rice – Applesauce – Toast

• Cons

– Binders, so if infectious diarrhea, keeps it in longer – Restrictive – Not nutritionally balanced – No evidence that it works

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• Toddlers grow in spurts and kids diets should

be allowed to wax/wane too. Help them learn to recognize and respond to internal satiety clues

Clean plate club?

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Eating “Rules”

• Divide responsibilities

– Parents

• Purchase
• Prepare
• Provide positive setting
• Allow child to feed him/herself

– Child chooses

• What to eat
• How much
• Eat when hungry, stop when full
• No “clean-plate club”
• Eat together

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American Family Physician November 2015

Water

• Eight glasses a day?

– 2.5 L—TOTAL

• From estimate for 1 ML water/calorie of food
• Most water from food consumption

– Can be sick from too much--hyponatremia

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Valtin, 2002

Alkaline water

• Claims

– works as antioxidant and balance – improves digestion – Slows aging – Boosts the body’s mineral content – Prevents bone loss

• No research
• Body balances pH

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Thanksgiving nap

• Turkey is not exceptionally high in tryptophan

(equivalent to chicken and beef; less than pork

• r cheese)
• When eaten with other items, absorption is

slowed

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“Don’t Swallow Your Gum”

• Gum (blockage if more than 40 pieces)
• Cheese rind (not wax)
• Past date (voluntary and everything except baby

formula and food)

• Apple Core (although many adept to cyanide))
• Vegetable skins
• Eggs (fresh and store-bought)
• Raw flour

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“Fat is bad”

• Important for children (up to 2 years, 50% of

calories should be from fat)

• Monounsaturated—nuts, avocados, oils
• Polyunsaturated

– 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)

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More chocolate

• Cons

– Calories

• Myths

– Does not cause acne

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Unhealthy choices

• Microwave popcorn with “butter”
• Reduced fat peanut butter (sugar)
• “Fruit sugar sweetened”
• Diet drinks—+/- increase cravings

– Evidence against:

• Rats
• Framingham—increased metabolic syndrome
• Acid on teeth
• “Sweet tooth”

– Evidence for:

• + weight loss if part of a calorie-restricted diet
• Eating in front of TV

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Arsenic in rice

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• Also AAP Pediatric Nutrition
• www.HealthyFamilies.org

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American Family Physician May 2015

Thank you!

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Questions?

• Susan.Fisher-Owens at ucsf.edu

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Polyphenols

• Phytochemicals
• Polyphenols

– Phenolic acids – Flavenoids – Stilbenes – Lignans

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