An Ounce of Prevention
is worth a pound
Shaping Habits
That Shape
Obesity
Ohio Chapter, American Academy
of Pediatrics
Ohio Department of Health
Ohio Dietetics Association
Prevalence of Obesity U.S. Adults:
2001-2
• Obese 1/3 (30.6%)
• Overweight 2/3 (65.7%)
• Extreme obesity (5.1%)
All ages
Both sexes
All ethnic groups
All socioeconomic levels
Source: Hedley et al. 2004; Freedman et al. 2002
Prevalence of Overweight in U.S.
Children: 2002
Age, yrs
At Risk (> 85%)
(%)
Overweight (> 95%)
(%)
2-5
6-11
12-19
All 6-19
22.6
31.2
30.9
31.0
10.3
15.8
16.1
16.0
* Overweight among non-Hispanic Black (20.5%) and
Mexican-American (22.2%) increased much more rapidly
than among whites between NHANES in ‘88-94 and 2002
Source: Hedley et al. 2004
Obesity Among African-American Adults:
2002
Age, yrs
Overweight
BMI > 25
%
Obese
BMI > 30
%
Extreme
BMI > 40
%
Males
20-39
40-59
55.4
65.0
24.7
29.7
4.1
2.9
Females
20-39
40-59
70.3
81.5
46.6
50.6
11.8
15.1
Source: Hedley et al. 2004.
Overweight Status of
African-American Children: 2002
Percentile All Ages
%
2-5 yrs
%
6-11 yrs
%
12-19 yrs
%
Males
85
95
31.0
17.9
23.2
8.0
20.9
17.0
32.1
18.7
Females
85
95
40.1
23.2
25.6
9.6
37.9
22.8
41.9
23.6
Source: Hedley et al. 2004.
Class 3 Obesity in the U.S.
1990 through 2000
BMI
<25
25-29.9
Prevalence, %
50
30-34.9
• Class 3 = BMI > 40
• 2-fold higher risk of
mortality than BMI 30
10
5
35-39.9
>40
1
• High likelihood of
bariatric surgery
• Those over age 20 yrs
1990 1992 1994 1996 1998 2000
Year
Prevalence increased 3-fold in only a
decade and continues to rise
– In population 4.9%
– In black females 13.5%
Medical Consequences of Obesity
• Psychosocial
• Medical
• Cardiovascular
– Polycystic ovary disease
– Lipidemia
– Gall bladder disease
– Diabetes mellitus
– Osteoarthritis
– Hypertension
– Cancer
– Respiratory
• Pregnancy and postpartum ???
– Cardiac
• Mortality
Diseases that begin in childhood amplify
morbidity – and costs
Source: Krebs & Jacobson 2003; Dietz 1998a; Dietz 1998b; Must 2003.
Prevalence of Diabetes in US
Has Risen Dramatically –1990 to 2001
And how many overweight adults and kids
have pre-diabetes?
Source: Narayan et al. 2003; Sinha et al. 2002; Weiss et al. 2003.
Life-Years Lost from Diabetes in the US
• If diagnosed at age 40 years
– White
• male:
• female:
• If diagnosed at age 10 years
– White
1.01 yrs
13.5 yrs
– Hispanic
• male:
16.5 yrs
• female:
18.0 yrs
– Hispanic
• male:
11.5 yrs
• male:
19.0 yrs
• female:
12.4 yrs
• female:
16.0 yrs
– Black
– Black
• male:
13.0 yrs
• male:
22.0 yrs
• female:
17.0 yrs
• female:
23.0 yrs
Source: Narayan et al. 2003
“Because of the increasing rates of obesity,
unhealthy eating habits, and physical
inactivity,we may see the first generation
that will be less healthy and
have a shorter life expectancy than their
parents”
Richard H. Carmona, MD, MPH, FACS
Surgeon General
U.S. Dept of Health and Human Services, 2004
Obesity Risk Increases with
the Age of the Child
• Obese at 6 years
– 50% risk of obesity
at 35 yrs
• Obese at 10 years
– 70 - 80% risk
Obesity is a pediatric disorder with
Source: Bray 2002, Dietz 1998a, Dietzs 1998b,
adult consequences
Guo et al. 2002; Kvaavik et al. 2003;
`Must 2003, Whitaker et al. 1997;
The State of Ohio’s Teens
Youth Risk Behavior Survey 2003
• 57% participate in organized after-school activities
• 68% reported participating in vigorous activity in any given week; only
41% attend PE classes
• 32% watch 3 or more hours of TV per average school day
• 14% report being overweight, up from 10% in 1999
• 30% report eating fruits one or more times per day in the past week
• 38% report eating vegetables one or more times per day in the past week
(includes potatoes)
• 20% report drinking the recommended 3 glasses per day of milk
Source: Bray 2002; Ohio Dept of Health: www.odh.state.oh.us
Nutritional Gaps in U.S. Children
% Children
Consuming
Daily
Recommended
Intake
Critical
Age
120
100
80
Iron
Phosphorus
60
Zinc
Vitamin C
40
Vitamin A
Magnesium
Folate
Calcium
20
0
6-11 Mo.
1 Yr.
1-4 Yrs.
5-8 Yrs.
9-14 Yrs.
15-19 Yrs.
NHANES, CFSII data compiled by Dr. John Lasekan, Ross Labs
Children grow up
In 3 environments
HOME
COMMUNITY
SCHOOL
The issue of obesity
Is multifactorial
but parents,
especially mothers,
have an opportunity
to create a healthful
home environment
Babies are Getting Bigger
Year
N
BW (g)
Z score
% SGA
%LGA
1978-9
5626
3419
-0.91
11.1
8.0
80-81
5659
3426
-0.046
10.3
8.4
82-83
6333
3453
0.013
8.9
9.9
84-85
6222
3449
0.050
8.2
10.0
86-87
6192
3465
0.102
7.8
11.2
88-89
6482
3462
0.078
7.5
10.6
90-91
6985
3456
0.077
7.5
10.7
92-93
6621
3471
0.098
8.1
11.7
94-96
7079
3476
0.128
7.2
11.5
<0.001
<0.001
<0.001
<0.001
P value
Births > 37 wks GA
Source: Kramer 2002
Babies Are Getting Bigger
And Moms Are the Reason
• McGill University database 1978-1996
• Mean birth weight and z-score increased
over two decades (p < 0.0001)
• No trends in premie birth weights
– Prepregnancy obesity: from 4.7 to 10.6%
– Gestational diabetes: a 20-fold increase
Prenatal
• Maternal weight gain
– An important predictor of later
obesity in the child
• Breastfeeding
– Encourage breastfeeding
– Lower incidence of obesity in
breastfed infants
Is Breastfeeding Protective against
Obesity Later in Life?
• Von Kries, 1999
German
• Hediger, 2001
US
3-5 yr olds
• Gillman, 2001
US
9-14 yr old
• Liese, 2001
German
9-10 yr old
• Armstrong, 2003
Scottish
3-4 yr olds
• Bergman, 2003
German
6 yr olds
• Toschke, 2003
Czech
6-14 yr old
5-6 yr olds
Healthy People 2010
Breastfeeding Recommendations
• Increase the proportion of mothers
who breastfeed to 75% in the
postpartum period
• Increase rates to 50% at 6 mos
• Increase rates to 25% at 12 mos
In-Hospital Breastfeeding Rates
1965-2001
80%
69.5%
61.9%
70%
51.5%
60%
50%
55.0%
40%
43.5%
24.7%
46.3%
30%
20%
21.7%
10%
0%
'65 '67 '69 '71 '73 '75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01
Any BF
Exclusive BF
Breastfeeding Rates at 6 Months
1971-2001
50%
40%
30%
32.5%
27.1%
17.6%
20%
10%
19.8%
17.2%
10.4%
0%
'71 '73 '75 '77 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 '99 '01
Any BF
Exclusive BF
Largest Increases in In-Hospital Breastfeeding
1996-2001
Demographic
1996
2001
% Change
African American
37.1
52.9
42.6
< 20 yrs of age
43.3
57.2
32.1
WIC participant
46.6
58.2
24.9
20-24 yrs of age
52.7
65.9
24.5
High school education
49.2
61.1
24.2
National
59.2
69.5
17.4
Source: Ryan 2002
Obesity (Pre- or In-Pregnancy Weight)
Threatens Breast-feeding (BF)
• Pediatric & Pregnancy Nutrition Surveillance
Surveys
– 51,329 women and babies
– Pregnant and gestational weight gain + BF
– Both pre- and in-pregnancy obesity resulted in:
• Less initiation of BF
• Shorter duration of BF
• Increasing obesity may threaten recent gains in breast-feeding
Source: Li 2003
Train parents in how
and what to feed their baby
Where Do Parents Look
for Nutrition Information?
• #1 Pediatrician/ Family MD
• Social environment
• Magazines
• Internet
• Dietitian
• TV
• Nutrition Center
• Food labels
• Media
Source: Van Dillen 2003
The 12 Well-Child Visits
11
12
7
5 10
9
2
8
4
3
Anticipate problem feeding and activity practices
6
Newborn/First Visit
• For Breastfed and Formula Fed Infants
– Help sustain breastfeeding by building skills
and offering resources for support
– Iron-based formulas only
– Hunger and satiety cues
– Babies should regulate their own intake
– Crying does not always represent hunger
• It is normal for 1-3 month old babies to cry up to
3 hours per day
How are Infants Fed?
Milk Feeding 2000
Cow's Milk
100
90
% of Milk Feeding
80
70
Formula
60
50
40
Human Milk
& Formula
30
20
10
0
In Hospital
Human Milk
1 to 3
4 to 6
7 to 9
10 to 12
Months
Source: Ryan et al. 2002
Calorie Intake (kal/kg/day)
Volume of Intake (mL/kg/day)
Infants Adjust Their Calories
200
53 kcal/100ml
67 kcal/100 ml
100 kcal/100 ml
180
160
140
120
100
130
By 6 weeks, the
baby regulates its
own energy intake
120
110
100
90
814
28
42
56
84
Age (days)
112
Source: Fomon 2004.
From birth to 24 months, the
child assumes the eating
habits of the family
The Feeding Infants
And Toddlers Study (FITS)
Source:Dwyer, 2004
FITS Study Methodology
• Adds critical information to augment NHANES,
CFSII, Ross Mother’s Survey information
• 5 Gerber sponsored FITS surveys over 30 yrs
• Snapshot of eating habits in first 2 years (2002)
• Random sample of 3022 (Experian database)
– Recruitment and household review
– 24-hr dietary recall and subject information
– Second dietary recall for subset (n=703)
– Response rate for recalls 94%
Source: Devaney et al. 2004a
FITS: Nutrient Intakes
0-24 months of age
• Examined transitional times
for feeding
– 4-6 months
• Exceeds adequate intake for all
nutrients, 0-12 months and
almost all nutrients, 12-24 mos
– 7-11 months
• Vitamin E low 12-24 mos
– 12-24 months
• Fiber low in toddlers
• Diets found to vary widely
day-to-day
• Nutrition is good over the
first 24 months
• But energy intake exceeds
Estimated Energy Requirement
(EER) at all ages
Source: Devaney et al. 2004 b
Energy Intake
Infants and Toddlers
• Energy intake
exceeds EER
• Feeding
– Breast
< EER
– 4-6 mo
10%
– BF/ formula = EER
– 7-11 mo
23%
– Formula
– 12-24 mo 31%
> ERR
– Solids and cereals add to
energy intakes, especially
when coupled with formula
Two-Month Visit
• Infant Feeding
– Set expectations:
• the baby will increase to 24-28 oz/day
over the next 2 months
– Provide 4 oz four to six times per
day
– No cereal, no baby food, no juices
– Nothing added in the bottle
Not all Crying Needs Food
Two Months
• Learn to interpret the infant’s cries
• Parents eager to “empty the bottle” encourage
overeating
• Satiety cues between 4-12 weeks:
– Turns head away or releases nipple
– Falls asleep
• Comfort the baby
– Rocking, massaging, cuddling, or listening to music
Recommendations for Iron
• Healthy People 2010: “…reduce iron-deficiency
among children aged one to two years to 5%”
• AAP Committee on Nutrition
– Supplement breastfed infants with iron
– Iron-fortified formula is the appropriate substitute for
breastfeeding in the first 12 months
– Iron fortified infant cereals and grains, as well as meats
are important sources of iron, especially for infants who
continue to breastfeed beyond 6 months of age
Physical Activities
Two Months
• Minimize stationary devices
• Use crib mobiles
• Encourage reaching, kicking,
stretching, and belly play time
• No T.V.
4-Month Visit
• The addition of cereal
– No solids until developmentally ready to
use a spoon, usually 4-6 mos of age
– Cereal only with a spoon, not in the bottle
– Start a single grain, iron-fortified cereal
– Portion: increase to 1-2 Tbsp twice daily
• First baby food: vegetables at 6 mos
Excessive Juice is a Risk for Obesity
• Both short stature and obesity
are tied to excessive intake
of juices
– Only 100% juice
– Only after 6 months of age
– Only from a cup, not from a bottle
– Limit to 3 oz initially with a maximum
of 4-6 oz / day for 1-6 year olds
Promote Vegetables for Infants & Toddlers
• Fail to consume vegetables
as a discrete food:
• Potatoes – consume daily
– 4-6 mos
3.6%
– 9-11 months
27 %
– 7-8 mos
12.4%
– 12 months
18-23%
– 9-11 mos
24.1%
– 12-14 mos
33.2%
– 15-18 mos
42.0%
– 19-24 mos
40.6%
– Dark Green Vegetables are
consumed by fewer than 10%
of toddlers
– Deep yellow vegetables
decrease from 39% at 9 mos
to 14% at 18 mos
– By 24 mos 25% of toddlers
consume fried potatoes on
any day
Source: Fox et al. 2004
Feeding the Baby
• Infants innately prefer
sweet and salty.
• Infants may reject
bitter and sour
• Infants tend to resist
new foods (neophobic)
Implications…
• More than 10 exposures
may be needed to
establish a new food.
• Children like and eat
what is familiar
• Parental eating habits
influence the baby’s
choices at this age
Physical Activities
Four Months
• Non-restrictive play
– Belly play time
– Sits with support
– Reaches and holds objects
– Play gyms
– No TV
Top 5 Fruits
FITS Study, 2004
Age
(mos)
#1
2
3
4
5
4-6
Applesauce
Baby bananas
Pears
Peaches
Fresh bananas
7-8
Applesauce
Baby bananas
Pears
Peaches
Fresh bananas
9-11
Bananas
Applesauce
Baby bananas
Pears
Cand applesauce
12-14
Banana
Applesauce
Grapes
Apple
Peaches
15-18
Banana
Grapes
Apples
Strawberries
Peaches
19-24
Banana
Apple
Grapes
Raisins
Strawberries
Source: Fox et al. 2004
Six-Month Visit
• Start vegetables and offer first at each meal
• Add one new food every 3-4 days
• Portion sizes
– Cereal
2-4 tablespoons twice per day
– Vegetables 2 tablespoons twice per day
– Fruits
2 tablespoons twice per day
Meats & Proteins for Infants & Toddlers
Age
(mos)
Chicken,
Turkey
(%)
Hotdogs,
Sausages
(%)
Beef
(%)
Pork,
Ham
(%)
Fish,
shellfish
(%)
4-6
2.0 %
0.0 %
0.9 %
0.3 %
0.0 %
7-8
7.3
2.1
2.6
1.7
0.5
9-11
22.4
7.1
7.7
4.0
1.9
12-14
33.0
16.4
16.1
9.7
5.5
15-18
46.9
20.1
16.3
11.3
8.7
19-24
47.3
27.0
19.3
13.9
7.1
Source: Fox et al. 2004
Common Early Feeding Traps
• Anticipate that daily milk intake will fall as
baby’s food intake increases
• Avoid “combo dinners” and baby desserts
• The extrusion reflex is normal and does not
mean that the baby doesn’t like the food
• New foods require multiple presentations
• Focus on new eating experiences and skills
Physical Activities
Six Months
• Minimize stationary devices
• Sits without support
• Starting to crawl
• First signs of independent mobility
• No T.V. until after 24 months of age
Nine-Month Visit
• Offer many new foods and textures
• Introduce a cup as the diet advances
• Discuss choking hazards
Aim to
Develop
Self-feeding
Skills
• Never use food as reward or bribe
• Offer variety: finger and table foods
– New food types and textures
– Veggies & fruits at every meal
– Establish a variety of meats
What Infants & Toddlers Drink
Age
All Milks
(mos)
(%)
100%
Juice
(%)
Fruit
Drinks
(%)
Soft
Drinks
(%)
Water
4-6
100
21.3
1.6
0.1
33.7
7-8
100
45.6
7.1
1.1
56.1
9-11
99.7
55.3
12.4
1.7
66.9
12-14
98.2
56.2
29.1
4.5
72.2
15-18
94.2
57.8
38.6
11.2
74.0
19-24
93.4
61.6
42.6
11.9
77.0
(%)
Source: Skinner et al. 2004
Nine-Month Visit
• Continue breastmilk and/or ironfortified formula until 12 months
• 100% fruit juice, 4-6 oz maximum
and only from a cup
• Avoid all other sugary drinks
• ¼ cup (2 oz) fruits and vegetables
daily
• Promote textures to improve skills
AAP Recommendations:
Cow’s Milk and Fat Intake
• Delay the introduction of cow’s milk until
one year of age
• Calcium intake for 1-3 year olds should be
500 mg/day
• Cow’s milk should be whole milk - not
reduced-fat or non-fat - during the second
12 months of life
• Fat intake should not be restricted in the
first 24 months of life
And now, a word about…TV
Age
(mos)
0-1
1-2
3-4
>5 hours
per day
0-11
83
11
4
3
12-23
52
27
11
11
24-35
21
38
25
16
Children watching > 2 hrs a day at age 2 yrs were more likely
to watch > 2 hrs a day at 6 yrs too.
Television and Obesity Are Linked
• TV > 2 hrs/ day in 5-15 yr olds is associated with
adult overweight, high cholesterol, and low fitness
• Even brief exposure to TV ads can influence a
preschooler’s food choices
• Mean TV watched by 3-4 yr olds = 2.2 hrs/ day
• Maternal obesity and depression correlates with
the highest TV viewing by their children
Physical Activities
Nine Months
• Begins to hold cup
• Spoon feeds with help
• Encourage crawling
• Pulls to stand
• No T.V.
Twelve-Month Visit
• Introduce regular milk
– Whole milk - not skim or 2%
– Taper from 24 oz. to 16 oz. per day
– All fluids from a cup
– Continue to wean from the bottle
• Fluids
– Avoid sweetened drinks
– Water is best for extra fluid
Cereals
Infants & Toddlers
Age
(mos)
Any
Grain
(%)
Infant
Cereal
(%)
NonSweet
(%)
Sweet
Cereal
(%)
Cereal
Bars
(%)
4-6
65.8
64.8
0.5
0.0
0.0
7-8
91.5
81.2
17.0
1.8
1.1
9-11
97.5
63.8
37.0
9.0
3.4
12-14
97.8
23.9
44.5
17.7
9.8
15-18
98.6
9.2
40.6
26.4
10.0
19-24
99.2
3.1
31.9
22.7
9.7
Source: Fox et al. 2004
Twelve Months
• Solid foods
– Emphasize eating skills
and experiences
– 3 regular meals & 2-3 planned snacks
– Avoid “grazing” throughout the day
– Emphasize vegetables and fruits
• Appropriate serving size is 1/2 cup of
fresh (or 1/3 cup canned) fruits/
vegetables per serving per meal
Parental Control Measures Usually Backfire
• Restricting “bad” (ie, palatable and enjoyable)
foods encourages their consumption and raises a
desire for future intake
• Avoid a mixed message that forbidden foods are
“bad” except on special occasions
• Avoid food as a comfort or
a reward
• Categorical thinking about
“good” and “bad” foods is
common and inappropriate
Physical Activities
Twelve Months
• Push toys
• Walking
• Running
• Unrestrictive play
• Never inactive for more than 60 mins
• No T.V.
15- and 18-Month Visits
• No more bottle
– Whole milk from a cup in four 4-oz servings / day
– Milk limit 16 oz/day
– 100% fruit juice 6 oz/ day
– No bottle and no “sippy” cup
• Snack times
– 2-3 planned snacks per day
– Watch portion size, nutritional value
• Meal times
– 3 meals per day
– Variety of color, texture, and tastes
– New foods at the start of the meal
– 10 exposures of each new food
Caution: Choking Hazards!
• Nuts
• Popcorn
• Grapes
• Round candies
• Apple chunks, slices
• Hard chunks of
uncooked veggies
• Sausages
• Hot dogs
Some foods are dangerous because
the infant can’t chew or coordinate swallows
and lacks a full set of teeth.
Safe Snacks for the Toddler
• Cheese
• Yogurt
• Fruit (watch for seeds and
peels)
• Saltines
• Fruit smoothies
• Graham crackers
• Steamed veggies
• Pretzels
• Puddings
• Bagel, bread, toast
• Unsweetened cereals
• Whole wheat crackers
• Mashed/ finely cut meats
or fish
Avoid the habit of snacking in the car and
on the go
Desserts and Sweets
Age
Any
Dessert
(%)
10.4
Baby
Desserts
(%)
4.2
Cakes, Pastries,
Cookies
(%)
4.3
Candy
7-8
45.8
17.7
27.0
1.1
9-11
61.1
17.0
40.9
3.2
12-14
78.8
6.0
50.5
10.2
15-18
88.8
2.3
60.2
15.2
19-24
90.5
0.0
61.6
20.0
(mos)
4-6
Infants Don’t Need Desserts
(%)
0.0
Source: Fox et al. 2002 ???
15- and 18-Month Visits
• Meals are social occasions
– Establish family meals
– Adults should act as role
models during meals
– Milk with meals
– Limit desserts, avoid candy
– TV off during meals
National Recommendations
Fiber = ‘Age plus 5’
• Fiber should equal the age of the child plus
5 grams a day
– For a 2-year old that would be 2 + 5 g = 7 g/day
– Maximum = age + 10 g/day
• Emphasize whole grains to boost fiber
Dietary Fiber Intake of 4 to 10-yr-old US Children
• Children who meet the ‘Age plus 5’ rule
– 4-6 year olds
45%
– 7-10 year olds
32%
• Children who meet this rule consume more
breads, cereals, fruits, vegetables, nuts,
legumes and seeds
• Low fiber intakes are associated with higher
fat and cholesterol
Recommendations for Grains and
Whole Grains for Children
• Healthy People 2010: “Increase the proportion of persons
aged 2 and older who consume at least 6 daily servings of
grain products, with at least 3 being whole grains”
• Serving is defined by the USDA Dietary Guidelines for
Americans 2005: 3 or more ounce equivalents of whole
grain products per day (at least ½ of grains from whole
grains)
• Primary sources of whole grains for children:
– Ready-to-eat cereals
Yeast breads
– Corn & other chips
Popcorn
– Hot breakfast cereals
crackers
Whole Grain Intakes are Poor
Continuing Survey of Food Intakes by
Individuals 1994-6
Age
Total Grains
Whole Grains
Mean Servings/ Day
2-18 years
6.6
0.9
2-5 years
5.0
0.8
6-11 years
6.5
0.9
12-18 years
7.7
1.0
Source: Harnack et al. 2003.
The Parent’s Role
“It is the parent’s responsibility to
offer the child a healthful variety
of foods and a supportive eating
environment ...
Satter, J Am Diet Assoc. 1986; 16:355
Source: Satter 1986
The Child’s Role
…and it is the child’s
responsibility to decide when
and how much to eat.”
Source: Satter 1986
Two Years
• Activity:
– Only planned TV & only 1 hour per day
– Planned time outdoors every day
• Milk
– Milk at every meal
– Switch from whole milk to 2%
• Meals
– Begin to decrease the fat content of foods
– Appropriate portion sizes at home and away: 1 Tbsp per
year of age
Subjects for More In-Depth Discussion with Parents
• Parents “bias” a child’s food choices
• The picky eater grows up just fine
• Food jags are normal
• Plate and glass sizes alter intake
• Food dislikes over time
• The problem of “dessert”
• Avoid in-car snacking
• Food rules should be shared with daycare
provider, grandparents
• Eating out with a child
• Letting the child direct their own intake
The Problem of “Dessert”
• A place in a balanced meal for dessert foods
• Not a required part of meal planning though
• Not necessary at every meal
• Not a reward or bribe for eating other foods
• OK to use fruit, yogurt, cheese
• OK for celebrations away from home
Eating at Restaurants
• Split meals between kids or share yours
• Recall portion size: ¼ the adult portion
• Buffets promote overconsumption
• Drinks: ask for milk with the kids’ meals
• Pre-meal: watch out for breads & crackers
• Salad dressing: serve on the side, use as dip
Two-Year Visit
• Meals: All 5 food groups daily
– Begin to decrease the fat content
– Appropriate portion sizes at home
and away: 1 Tbsp per year of age or
¼ of an adult portion
– Plate and cup size matters
– Food “jags” are typical & normal
– A variety of textures, colors, flavors
– Don’t bias your child’s food choices
Top 10 Sources of Dietary Fats for
Children 2-5 yrs
Total Fat
Rank
Sat. Fat
Rank
Whole milk
11.3
1
17.8
1
Sweet grain products
8.5
2
6.5
6
Franks, sausage, meat
8.1
3
7.6
3
Mainly grain mix
7.3
4
7.4
4
Nut buttters, nuts, seeds
5.8
5
2.4
14
Natural/ processed cheese
5.2
6
8.2
2
Beef
5.1
7
5.3
8
Butter/margarine
4.9
8
4.2
9
Salty snacks
4.6
9
3.4
11
Low fat milk (1-2%)
4.6
10
7.3
5
Source: Thompson & Dennison, 1994
Milk Intake of Infants & Toddlers
Age
Breast
Formula Cowmilk Low-fat
(mos)
(%)
(%)
(%)
(%)
4-6
39.6
74.1
0.8
0.3
7-8
25.7
82.2
2.9
0.5
9-11
21.3
75.0
20.3
5.3
12-14
13.6
21.2
84.8
17.7
15-18
4.2
5.1
88.3
20.7
19-24
4.5
1.5
87.7
38.1
Source: Fox et al. 2004
Drinks Matter
Early Food Preferences Predict Future Food
Preferences
• The “displacement theory” is real
– Calcium intake falls as milk is replaced
– Vitamin C rises as juices replace milks
• Beverages are important:
– They provide >1/3 of daily calcium, Vits A, C, D, protein and zinc
• Fruit drinks are too common :
– By 2 years 40% drink them daily and 5% drink > 16 oz/d
• Soft drinks are unnecessary:
– >11% toddlers 15-24 months consume them daily
Source: Skinner et al. 2004
Physical Activites
Two Years
• Encourage active play with other children
• Marching
• Jumping
• Climbing
• Limit T.V. to 1-2 hours per day
• Get outside
Three- and Four-Year Visits
• Meal times
– Planned meal & snack times
– Establish a family mealtime
free of TV
– Move toward skim milk
– Variety: fruits, vegetables, whole grains
– Limit potatoes
– Avoid the TV & Food habit
– Limit TV to 1-2 hrs per day
– Help child choose what to watch
Physical Activities
Three / Four Years
• Throwing and bouncing balls
• Jumping
• Running
• Ride tricycle
• Unstructured play at least 30 minutes/ day
• Structured play at least 60 minutes/ day
• T.V. limited to 1-2 hours per day
Five- and Six-Year Visits
• Daily diet suggestions
– A nutritious breakfast every day
– School lunch or a quality brown bag lunch
– Milk and dairy at every meal
– Fruits and vegetables in abundance
– Plan healthful snacks for after-school time
– Limit soft drinks and fruit drinks
– Caution when eating at restaurants – share your
meal with your child
Eating a School Lunch Promotes Better Nutrition
?Eating a Lunch While at School ? - or take out pic of
lunch box from home
• Consume twice the servings of fruits and
vegetables
• Higher intake of milk and dairy
• Larger amounts of meat
• Greater amount of grains
• More vitamins and minerals
• NSLP impact holds true for lunch and for 24-hour
intake
USDA Food and Nutrition Report No. CN-01-CD1
Five Years
• Daily activity suggestions
– Plan outdoor time and
reading time daily
– Limit “screens” to 1-2 hrs/
day, including
• computers
• games
• TV
• movies
Decreased TV viewing
has been proven to
alter obesity
Obesity & Psychological Issues
• Victimization/ bullying
• Sense of alienation
• Depression
• Behavioral problems
• Lifelong psychological issues
• Low self-esteem
• A cycle of food, depression and inactivity
Energy-Dense Nutrient-Poor Foods
Definition
• Tip of the Food Pyramid: fats, oils, sugars
• NHANES III 1988-94: 4,265 foods classified
– Foods are considered to be in the EDNP group if they are
not part of the following food groups:
• Dairy – milk, buttermilk, cheese yogurt
• Fruit – fresh, frozen, canned, juice
• Grains – bread, cereal, pasta, rice
• Meat & Beans – meat, fish, poultry, eggs, beans, nuts, seeds
• Vegetables – raw, fresh, frozen, canned, juices
• Mixed – foods from several groups
Energy-Dense, Nutrient-Poor Foods
NHANES III
• EDNP foods = nearly 1/3 of daily energy intake
• As EDNP foods increased
– Mean daily total calories
increased
– Percent energy from carbs
increased
– Percent energy from fat
increased
– Fiber, protein, vitamins,
decreased
– carotenoids, iron, calcium, folate
decreased
As EDNP foods increase, nutrition from other
5 food groups falls = displacement
Source: Kant 2000
Snacking Among Children
1977 to 1996
• 3 dietary surveys in children 2-18 yrs (N = 21,236)
• “Snack” = foods grouped outside of meals
• Snacking adds 30% kcal to the diet
• Highest snack intake is among 2-5 year olds
• Energy per snack rose only 3% in 20 yrs
• Energy density is greater than meals
• Increased frequency, not size of snacks is the trend
in America
Source: Jahns et al. 2001
American Dietetic Association Snack Guidelines
Preschool-/ School-Age
• Continue 2-3 planned snacks for preschool age
and 1-3 for school age children
• Aim for variety of texture, taste, and color
• Adjust portion size to age
• Allow the child to respond to internal cues of
hunger and fullness
• Healthy snacks are whole grains (breads, cereals,
crackers), fruits and veggies, lean meats, and dairy
products (low-fat cheese, pudding, yogurt)
Eating Out with Your Child
• Include at least two different food
groups
• Limit sweets to one per meal
• Only one fried food per meal
• Assure that all foods, especially
desserts and drinks, are child-sized
Source: Satter 1986
Control Portion Sizes When Eating Out
• Share your meal or order a half-portion
• Order an appetizer as an entrée
• Take half your meal home
• Be aware and stop eating when you feel full
• Avoid super-sized sweetened drinks
• When traveling, pack nutritious snacks
Weight Control Information Network, NIDDK, Jan 2003
More Tips for Portion Control
• Before eating, assess your hunger
• Eat slowly and appreciate your food
• Eat small meals more frequently to avoid hunger
• Measure your food portions to hone your portion
perception
• Skip “family style” servings except for veggies
• Always serve salad dressing on the side
• Interpret labels in terms of single servings
Susan Burke, MS, RD, CDE
Menu Hints While Eating Out
• English muffin, toast, bagel NOT croissant, biscuit, pastry
• Ham NOT sausage
• Low-fat milk, fruit juice or water NOT soft drinks or
shakes
• Baked, broiled or poached NOT fried
• Catsup, mustard, BBQ sauce, salsa NOT mayo and cheese
on burgers
• On the side: low-fat dressing, sour cream, gravy, sauces
• With (NOT before) the meal: bread, non-water drinks,
chips
American Dietetic Association,
If your Child is Overweight: A Guide for Parents
Summary
• Childhood obesity can be prevented
• No one factor causes obesity and no one
intervention will stop it
• Physician’s most important role will be in
developing sound eating and activity habits
• At each well-child visit review the child’s BMI
status and deliver core messages
• Advocate for better school & community policies
that support your well-child advice