4/23/2015 Collaborate Cultivate Educate PENS 2015 National Conference Nutritional Strategies for Overweight/Obese Pediatric Patients PENS Conference May 9th, 2015 Jennifer Willoughby, RD, LD Cleveland Clinic Children’s Conflict of Interest Disclosure Conflicts of Interest None Jennifer Willoughby A conflict of interest exists when an individual is in a position to profit directly or indirectly through application of authority, influence, or knowledge in relation to the affairs of PENS. A conflict of interest also exists if a relative benefits or when the organization is adversely affected in any way. 1 4/23/2015 Objectives • Audience will be able to describe the prevalence of pediatric obesity and related risks • Identify the methods and results of traditional weight loss approaches • Identify the methods and results of emerging mainstream diets in America • Identify the methods and results of non‐traditional Medical Nutrition Therapy • Decode the new FDA proposed food labels Prevalence and Trends of Obesity • 1/3 of children and adolescents in the US are either overweight or obese • Body Mass Index (BMI) is the accepted standard measure for children 2 and older o Adults: BMI 25‐30 kg/m2 overweight; BMI ≥30 kg/m2 obese o Children: growing in height as well as weight. Body fat and muscle mass changes • Gold standard for assessment –growth charts o Clinical definition of overweight: BMI between 85‐95th%ile on CDC growth charts o Clinic definition of obesity: BMI >95th%ile on CDC growth charts o Severe obesity –BMI ≥120 % of the 95th percentile values, or a BMI ≥35 kg/m2 (whichever is lower) o 5% of children and adolescents in US Nutritional Strategies l May, 9th 2015 l 5 Etiology of Obesity Epidemic • Environmental factors • Genetic Factors o Food sources particularly sugar o Responsible for 30 to 50 percent of the sweetened beverages variation in adiposity o Screen time o Sleep • Endocrine Disease o Medications o Identified in less than 1% of children and o Virus adolescents with obesity o Gut microbiota o Toxins • Metabolic Programming o Maternal nutrition and endocrine profile 2 4/23/2015 Comorbidities Associated with Childhood Obesity • Abnormalities in the endocrine, cardiovascular, gastrointestinal, pulmonary, orthopedic, neurologic, dermatologic, and psychosocial systems • Persistence into adulthood • Lower health related quality of life o Psychological and behavioral factors Nutritional Strategies l May, 9th 2015 l 7 Presentation Title l April 23, 2015 l 8 Traditional Diets Emerging Diets Medical Nutrition Therapy USDA MyPlate Gluten Free diet PSMF diet Mediterranean Diet Paleo diet Multidisciplinary DASH Diet Intermittent Fasting Caloric Restriction Detox diets Low Carbohydrate Liquid Shake diets Low Fat Vegetarian Diet Vegan/Plant Based Diet Expectations: Explanation of Diet Advantages/Disadvantages Utilization in practice Presentation Title l April 23, 2015 l 9 3 4/23/2015 Traditional Weight Loss Approaches USDA MyPlate • Replaced food pyramid in 2011 • Created as a new generation icon with the intent to prompt consumers to think about building a healthy plate at meal times • Consistent with 2010 Dietary Guidelines for Americans • Illustrates the 5 food groups as a building block for healthy lifestyle Traditional Weight Loss Approaches Mediterranean Diet Heart‐healthy eating plan based on typical foods and recipes of Mediterranean‐style cooking o Eating primarily plant‐based foods, such as fruits and vegetables, whole grains, legumes and nuts –eat these multiple times every day! o Eat fish and poultry at least twice a week o Limit red meat to no more than a few times a month o Replacing butter with healthy fats, primarily olive oil o Using herbs and spices instead of salt to flavor foods o Diet also promotes being physically active and enjoying meals with family Traditional Weight Loss Approaches Mediterranean Diet • Reduce risk of metabolic syndrome and reduce metabolic syndrome parameters • Associated with a significant decrease in BMI, lean body mass, fat mass, glucose, insulin resistance, TG and LDL‐C • Superior in reducing dyslipidemias, plasma glucose, CRP and markers of oxidative stress when compared to low fat • Diet compliance increased consumption of omega 9 fatty acids, zinc, vitamin E, selenium, and decreased consumption of saturated fatty acids 4 4/23/2015 Traditional Weight Loss Approaches DASH Diet (Dietary Approach to Stop Hypertension) • Emphasizes increased intakes of low‐fat dairy products; fish, chicken and lean meats; nuts, fruits, whole grains, vegetables and legumes • Low in fat and sodium; high in calcium, potassium, magnesium and dietary fiber • Has been shown to prevent excess weight gain during adolescence • Cardiovascular benefits • May be beneficial for patients with metabolic syndrome o Improved glycemic control and liver enzymes in type 2 diabetic patients • Meets all nutritional requirements ‐ no need for supplements Presentation Title l April 23, 2015 l 13 Traditional Weight Loss Approaches Caloric Restriction • Hypo‐caloric diet defined as 500 calories/day from baseline o No fewer than 900 kcal/day for children aged 6 to 12 years and 1,200 kcal/day for adolescents aged 13 to 18 years • Caloric deficit, different for variety of weight loss o Weight loss guidelines to be set by RD, based on age and linear growth expectations • All diets that work include some version of caloric restriction • Balanced macronutrient intake Presentation Title l April 23, 2015 l 14 Traditional Weight Loss Approaches Low Carbohydrate Diet • Diet limits carbohydrates found in grains, fruit, dairy and starchy vegetables; emphasizes foods high in protein and fat • Complex v simple carbs • Premise: decreasing carbs lowers insulin levels, which causes the body to burn stored fat for energy and ultimately leads to weight loss • Various definitions o 60‐130 grams/day typical definition o <60 grams/day or 20% of total calories o <20 grams/day to enter ketosis = medically supervised diet Presentation Title l April 23, 2015 l 15 5 4/23/2015 Traditional Weight Loss Approaches Low Carbohydrate Diet • Limitation of carbs typically leads to lower calorie, higher protein intake • Whole grain intake promotes greater decrease in waist circumference and CRP as opposed to refined grain group • Low carb diets may improve HDL cholesterol and triglyceride levels more than moderate carbohydrate intake o Shown to be more effective in reducing triglycerides than caloric restriction in subjects with NAFLD o Depends on quality of other foods consumed • Carbohydrate restricted diet superior for short term weight loss o Follow‐up at 2 years showed no difference as compared to low‐fat Presentation Title l April 23, 2015 l 16 Traditional Weight Loss Approaches Low‐Fat Diet • Guidelines first published in 1977 • USDA Dietary Guidelines for Americans 2005. 2010 o Consume <30% of total calories from fat o <10% of calories from saturated fatty acids o Avoid trans fats o Promotes fat free dairy products and lean meats o Limit eggs and cholesterol intake o Use oils to replace solid fats • All fats are not created equal Presentation Title l April 23, 2015 l 17 Traditional Weight Loss Approaches Low‐Fat Diet • Adverse events more often in • Globally less effective at decreasing low‐carb diet than low‐fat biomarkers for metabolic syndrome when compared to low carb diet or • Fat is calorically dense Mediterranean diet • Evidence in adult trials that lower • Difficult to maintain fat intake leads to small, but statistically significant reductions • Dietary fat and cholesterol intake no in body weight when baseline fat longer associated with increased risk intakes were 28‐43% of cardiovascular disease o Evidence less strong in children • Dietary fat = body fat directly 6 4/23/2015 Traditional Weight Loss Approaches Vegetarian Diet • Types of vegetarians o Lacto‐ovo: still consume milk and eggs o Pescatarian: include fish o Flexitarian: flexible version of vegetarian diet, consuming meat on occasion. Research shows high weight loss success o Vegan: full animal product restriction • Diets low in energy density and high in complex carbs, fiber and water • Epidemiological studies consistently show that vegetarians are leaner than comparable non‐vegetarians • Consider type of vegetarian diet and execution • Results in weight loss… if following diet correctly Presentation Title l April 23, 2015 l 19 Traditional Weight Loss Approaches Vegan/Plant Based Diet • “Vegan” –full animal product restriction‐ primary intake from grains, beans, legumes, vegetables and fruits • “Whole food‐plant based” – whole, unrefined or minimally refined plants o Excludes meat, dairy, eggs, highly refined foods like bleached flour, sugar and oil o Starch based foods and fruit form the basis; vegetables are complementary foods o Contains all essential nutrients, B12 exception Presentation Title l April 23, 2015 l 20 Traditional Diets • USDA MyPlate USDA MyPlate appropriate tool for generalization, appropriate Mediterranean Diet for children DASH Diet • Mediterranean and DASH have proven to be effective Caloric Restriction • Caloric restriction has merits, Low Carbohydrate multitude of factors to consider Low Fat • Low carb superior to low fat Vegetarian Diet • Vegetarian/Vegan Vegan/Plant Based Diet Presentation Title l April 23, 2015 l 21 7 4/23/2015 Emerging Weight Loss Trends Presentation Title l April 23, 2015 l 22 Emerging Dietary Approaches Gluten Free Diet • Gluten is a protein composite consisting of gliadins and glutenins o Wheat, rye, barley • In 2010 the US