Pediatric Nutrition – Virginia Academy of Nutrition & Dietetics

The Learning Connection by Dr. Robert Murray, The Ohio State University

Posted on April 20, 2016 by

Dr. Robert Murray, a professor in the Department of Pediatrics at the Ohio State University School of Medicine, kicked off the last day of the VAND annual meeting on April 12, 2016 in Fairfax, VA. He presented an engaging talk on epigenetics and the importance of nutrition in early childhood development. He opened his talk by discussing the Carolina Abecedarian Study, a study conducted in North Carolina in 1977 to study the benefits of early childhood education for impoverished children. Two groups of children were randomized to receive either quality preschool education, or the healthcare and education available to them by the government. The intervention, or quality preschool group, was provided with 8 hours of child care daily from birth to 5 years of age, health care, nutrition provisions including 2 meals and one snack, and cognitive and social stimulation. Children in the control group were set up with Medicaid, WIC, food stamps, and did not receive child care.

Their findings from this study were ground-breaking and have set the stage for public health interventions: as adolescents, children in the intervention group were less likely to fail or repeat a grade, 4x more likely to graduate from college, 4.4x more likely to hold a skilled job, had stronger social and emotional skills, were more physically active, drank less alcohol and had fewer run-ins with the law when compared to the control group. At age 40, these same children had much lower blood pressure, lower blood cholesterol, less obesity, lower type 2 diabetes risk and much lower heart disease risk than the children in the control group. Dr. Murray discussed this great impact from early childhood interventions focused on emotional, social and cognitive stimulation, as well as proper health care and nutrition, on neurological (brain) development and future health outcomes.

From there, Dr. Murray went on to discuss the role epigenetics have to play on future health and well-being. Epigenetics is the study of modified gene expression; in other words, the people we become is not entirely dictated by our DNA. Environmental factors humans are exposed to throughout their lives can change how their genes are expressed, despite not changing the genes themselves — changing how our body works and how we behave, ultimately altering who we become. A mother’s diet is a “powerful epigenetic force” during fetal growth and development. How a mother eats during pregnancy, independent of genetics, can impact how that infant’s genes are expressed, in addition to affecting overall adequacy of growth and proper development. He noted some of the common nutritional intake issues associated with many women of child-bearing age today, including high saturated fat and sodium intake, low fiber, vitamin E, calcium, magnesium and potassium intake with inadequate intake of other essential vitamins and minerals, and common deficiencies in iron and vitamin D. Mom’s nutrition status entering pregnancy influences her growing fetus, and maternal and child nutrition continue to play a vital role in the postnatal period, particularly regarding brain development in the first two years of a child’s life.

In the first year of life, a baby’s brain will double in size, and by the third year of life its size has tripled. During this time, the brain is forming 700 synaptic (communication) connections per second as the baby continues to explore and analyze every last detail of its seemingly simple life. If synapses are formed but not used regularly, they are forever lost, which is another reason cognitive and social stimulation is so important in a child’s first years. In addition, diet quality and stable health were two of four necessary things Dr. Murray highlighted to optimize brain development (social and emotional support as well as sensory-motor exploration were the remaining two contributors). Stress, a reaction controlled by the “middle brain”, is also a contributor to overall neurological development. Though brief stress can be a good thing, prolonged stress can be detrimental to a child’s overall development, potentially leading to disease, disability, social and emotional issues, and even early death. Since adequate nutrition and intake of vitamins and minerals fuel proper brain development and positively impact overall health, prolonged hunger and inadequate nutrient intake are both considered prolonged stressors on the body that can result in adverse outcomes.

According to Dr. Murray, research has confirmed that diet quality and regular activity make people healthier, regardless of size, age, or risk factors. This includes risk of heart disease, diabetes, stroke, obesity, hypertension, cancer, and other chronic diseases. The Dietary Guidelines for Americans can help adults establish a healthy eating plan that works for them. With the new recommendations for 2015-2020, Americans are especially encouraged to limit sodium, saturated fat and added sugar intake, while making sure to get enough calcium, vitamin D, iron and fiber in their diet by focusing on eating whole foods from the five food groups (whole grains, fruits, vegetables, protein and dairy). It is in part due to the most recent dietary guidelines that people started to analyze the impact of too much dietary sugar on the body, and how to reduce added sugar consumption.

When we think about a child’s diet, certain foods such as flavored yogurt, flavored milks, sugar-sweetened cereals and fruit juice may come to mind as a few of the major contributors to a child’s added sugar intake. Dr. Murray pointed out that, though these foods and drinks certainly contribute to overall added sugar intake, the largest contributors by far are sugar-sweetened beverages (not milk or 100% fruit juice) and sugary snacks, thus the focus should be on limiting these. This applies to adults as well; Dr. Murray stated health will never be the number one reason people choose to eat certain foods – taste, value and convenience are the current reigning champions. He noted a French study discovered substituting better food choices within the same food category (i.e. white vs. brown rice, carrot cake vs. chocolate cake, etc.) improved long-term dietary patterns better than simply consuming lower fat versions of the same foods.

Dr. Murray concluded his presentation by restating the power of nutrition in epigenetics, how hunger can be a persistent and sometimes toxic stressor, the constant nutrient requirements of the brain, particularly during early life development, and how breakfast and snacks are our best bet at improving the dietary intake of children and adolescents.

Source: “The Learning Connection”, PowerPoint presentation by Dr. Murray

Monica Hershey is currently a dietetic intern at the University of Virginia Health System in Charlottesville, VA. A Pennsylvania native, Monica earned her undergraduate degree in nutritional sciences at Penn State University. Upon graduation, Monica would like to work as a clinical RD at a large medical facility on the East Coast, with hopes of working as a renal dietitian in the near future. Her personal interests include hiking with friends, recipe-less cooking and exploring all the fun that Charlottesville has to offer!

Making Food Dollars Stretch: A Family Affair!

Posted on April 13, 2016 by

Last week I went grocery shopping at my favorite “big box” market, and once again I winced as I watched the total click higher and the printed receipt get longer. The printed tape makes it even more difficult to deny that the cost of food has skyrocketed over the past few years. My family of four, including two athletic teenage (hence HUNGRY!) boys, started to notice the price creep higher first on the foods that we regularly bought in the stores that we shopped at the most frequently, and it became a game to try to guess the final total price while we waited in line to pay. We certainly took notice of an increase of fifty cents per pound of meat, one pound of strawberries that used to cost two dollars now costing three dollars, and one pounds of grapes all of a sudden costing almost four dollars, even in the summer time! Feeding two growing adolescent boys was getting more expensive by the week. Now, we can’t get out of a grocery store for less than $300 for one week’s worth of groceries, and it seems the shopping basket is a little lighter each time.

Hard economic times can force families to consider their grocery budget a little more carefully, cutting out “extras” and skipping restaurants; the good thing is, this can often lead us to eating a healthier diet with smaller portions. Shopping with less food dollars requires more planning, including budgeting and deciding on a menu for the week, but this usually keeps the “extras” such as chips, cookies, candies, sodas, and other sweetened beverages from finding their way into the cart. As family members start to eat healthier, portion sizes may decrease, saving money on the grocery or dining out bill, and maybe even leading to weight loss.

If you need to make your food dollars stretch, involve your whole family in the process.

Take the cookbooks off the kitchen shelf, look through smartphone apps such as Food.com or the Food Network app, or browse through magazines and TV shows to get recipes and meal ideas. Invite your children to pick a new recipe to help avoid the monotony that can happen at dinnertime.
Create a monthly calendar that is printed and pinned to the refrigerator or kitchen bulletin board. Plan breakfast, lunch, and dinner for each family member a week at a time. Knowing what foods you will need for the week minimizes the number of trips to the grocery store (where it’s always tempting to buy more than you need!) and prevents after-work trips through the fast food drive through because “there’s nothing to eat at home.”
“Eat down the pantry and the refrigerator.” We often have several different ingredients already in stock at home; have your spouse help you create a meal using only the ingredients that you have already. Be sure to check the expiration dates on the foods; use the First-in First-out method when putting your groceries away in the pantry (foods already in the pantry move to the front of the shelf and the newer foods are placed behind.)
Have your school age children make a shopping list from recipes they want to try or meals they know they will like, double-checking the pantry and refrigerator for items already on-hand. Wasted food is decreased when everyone likes what’s served!
Avoid being a “short order cook.” Cooking the same meals for the whole family generates less leftovers, encourages each family member to possibly try new foods, and saves time and energy in the kitchen by the “chef.”
Choose healthy, low-cost foods that can be used in more than one dish in the same week.
“Base” ingredients include foods like whole grain bread, skim or 1% milk, chicken breasts, romaine lettuce or spinach, and frozen vegetables. These foods can be used in a variety of recipes, are generally cheaper than other foods, and don’t spoil as quickly.
At the grocery store, shop the perimeter of the store first, stocking up on fresh produce and meats while avoiding the more expensive processed items that are most often found on the interior shelves of the store. Invite the kids or your spouse to go grocery shopping with you; it might at first seem like a difficult distraction, but family members who are more engaged with the selection of groceries will likely be more willing and adventurous eaters.
Making food dollars stretch can be a learning opportunity for the kids. Kids can use their math skills to determine the price per serving of various food items to determine which package is the best value. Remember, buying in bulk is not always the best investment if some of the package goes to waste.
Copy the children when taking your lunch to work: buy yourself a cute reusable lunch box or container that makes you want to take your foods to the office refrigerator.
Have the center of focus during meals be family time, not the quantity of food. Pleasant conversation can help you eat slowly and let your body be satisfied naturally by smaller portions.
Start a conversation at work about healthy shopping or food budgets, or even just eating smaller portions. You might be able to glean a tip or two from your co-workers on how they make their own food dollars stretch!

Other tips:

Shop the supermarket weekly ads for special sales or coupon items, and build your week’s meals around what’s on sale. If you are unsure of how to cook these foods or incorporate them into your meal plan, check the Internet or cookbooks for recipes or ask the grocery store manager for hints.
Look in the “markdown” bin of your grocery store; each section of the store seems to have foods on sale that are nearing the expiration date or are on overstock clearance. Ask the store manager what day of the week these “markdowns” are usually taken. Just be sure that you will use it quickly before it expires!
Buy frozen foods on sale, as these usually keep longer and still retain their nutritional value.
When making large meals, freeze the leftovers to enjoy later in the week. Prioritize using the leftovers within a few days.
Try re-purposing leftovers: use extra meat and rice from dinner in breakfast burritos the next morning or send left over salad in your family’s lunch the next afternoon.

Remember, these are YOUR healthier habits, so make them work for you!

Janelle Walker, MBA, CLE is a lifestyle educator for Kaiser Permanente, with a special interest in helping families learn to live healthy together through nutrition, exercise, and other healthy habits.

Wendy Phillips, MS, RD, CNSC, CLE, FAND is a Division Director of Clinical Nutrition for Morrison Healthcare, with a background in pediatric nutrition and desire to help kids grow up healthy!

Nutrition Strategies for Children with ADHD – Part 2

Posted on January 20, 2016January 15, 2016 by

This week I introduced you to my son, Austin, and some nutrition interventions that do and do not work to help children with Attention Deficit Hyperactivity Disorder (ADHD). While it’s true that impulsivity, inattentiveness, and hyperactivity are each hallmarks of ADHD, so are creativity, innovation, imagination, and usually intelligence! Children with ADHD are often the best little chefs if this imagination and creativity are fostered correctly. You see, while most of us can shut out the multiple distractions that come at us each day to focus on the task at hand, individuals with ADHD are not able to shut out that stimuli. Another child tapping a pencil, someone humming a tune, or a butterfly outside the school window are each enough to pull the attention of a child with ADHD in many different directions.

This inability to maintain focus is thought to be related to a disorder of the dopamine receptors in the brain and a decrease in serotonin activity (both of these chemicals are known as neurotransmitters that help control brain activity). Therefore, it’s believed that a child with ADHD has difficulty or the inability to shut down the right brain in favor of the left brain as many of us normally do. So while this can lead the child to be impulsive and inattentive, these children are also usually the builders, creators, engineers, inventors, and chefs.

Austin underwent 6 weeks of psychological testing a few years ago to determine the cause of his nervous tics and impulsive behavior. He was diagnosed as a genius with ADHD. We weren’t surprised – at the age of 2 he was building 500 piece puzzles and massive Lego structures. We originally thought he would be an engineer when he grows up, and we still think that is a possibility. But now we’re thinking he may become a chef – he has decided he loves cooking and baking if he gets to cook from scratch rather than from a box. The science of food intrigues him; he wants to know the role that each individual ingredient plays to make the final product. Even as a Registered Dietitian who studied food science in college he sometimes stumps me with his questions!

Working with my son in the kitchen has taught me several things that are helpful for all children, and not just those with ADHD:

Children are known to ask (sometimes repeatedly) “when will dinner be done?” For children with ADHD and other behavioral diseases characterized by impulsivity, it is especially difficult for them to wait for the meal (or really anything else). But when they are helping make the food, they don’t need to ask – they will know. Preparing the ingredients, assembling the meal, and placing it in the oven while setting the timer for cook time will give them something active to do while waiting and give them control and knowledge over the time to completion.
All children are more likely to eat new foods if they help prepare them. Developmentally and age appropriate tasks should be assigned to children to help with some aspect of meal preparation, even if it is simply setting the table.
Creativity and imagination should be encouraged, even in the cooking process! I let Austin experiment with new or substituted ingredients, just so he can see what will happen. Some of these are tried and true things, like substituting applesauce for the fat source in muffins to reduce the overall calories. While it’s a well-known cooking “trick” for those of us who have been cooking for years, it is still a fun novelty for my son while sneaking some “stealth health” into our food. Other times, I let him try things that will have unexpected results (like using baking soda instead of baking powder to see for himself the difference between the two, or using different spices and seasonings). If the meal doesn’t turn out right, we always have a back-up soup or crock-pot meal that can stand in its place. But the memories created, knowledge gained, and creativity fostered are priceless in comparison.

My husband fears that my cooking career is on hiatus for the next 6 years until Austin leaves for college! In the meantime, I’m loving having a partner in the kitchen to expand my own skills and spend quality time with my son all while harnessing his ADHD in a positive manner. If you have a child with ADHD, I hope you will consider some of these tips and guidelines as a way to utilize their ADHD to their benefit while becoming more engaged in nutrition in the kitchen!

Wendy Phillips, MS, RD, CNSC, CLE, FAND is the Immediate Past President of VAND and a Division Director of Nutrition for Morrison Healthcare. She is the mom of 2 boys, ages 12 and 15.

Nutritional Strategies for Children With ADHD – Part 1

Posted on January 18, 2016January 15, 2016 by

“All we ever do as a family anymore is talk about my ADHD,” my son Austin complained, as he pushed aside the books I bought to help us learn about this new diagnosis he had been given. I sighed, because I knew he was right, but I didn’t know what else to do. Due to concerns shared by his teachers, we went through several weeks of testing for my youngest son for what we thought at the time was anxiety. Instead, he was diagnosed with Attention Deficit Hyperactive Disorder (ADHD), which in many ways is better than anxiety! Needless to say, we quickly gave ourselves and Austin an extensive education on the disorder, its treatment options and what we could do to help our son. For the first time ever, I began browsing through parenting blogs and nutrition blogs to see what others were doing to help their children cope with ADHD.

I was dismayed by the sensational information that is “published” on some of these blogs, with a complete lack of scientific evidence for what is being recommended. Many of the writers were very persuasive, and other parents seemed to be trying very hard to follow their advice even at a high monetary and peace-of-mind cost to themselves and their families. It was an overwhelming transition to begin with: finding out my child has ADHD, working towards a medication regime that was effective without horrible side effects, working with teachers for a school special education plan, changing routines at home and educating siblings, friends and ourselves. Not to mention helping your child understand his diagnosis and cope with the fact that he will be taking medication for the rest of his life, only to have him tell you he feels like “all we ever do as a family anymore is talk about his disease.” You get the point! I didn’t want to wade through pages upon pages of opinions; I wanted nutrition interventions that had at least been proven to effectively help with ADHD.

So what are those interventions that work? Here’s a quick summary of what I found!

Sugar and artificial sweeteners do not increase the impulsivity, inattentiveness, or hyperactivity of children with ADHD (or any other children). However, these substances do have other adverse effects and all children should be encouraged to reduce intake of simple carbohydrates and sugars, and be provided with education to work towards increasing whole grains and complex carbohydrates.
The research is conflicting on whether or not artificial food colorings and preservatives increase the symptoms of ADHD. It’s hard enough to help a child learn to control ADHD behaviors. Avoiding all foods with artificial colors and preservatives at home, and expecting him to do so at school and social situations is almost impossible. RDs should have conversations with parents about the pros and cons of this diet to complement other lifestyle and behavioral management components of ADHD and help the family reach their goals for their child.
Vitamin D supplementation may be beneficial for children with ADHD. Low blood levels of Vitamin D are common in people with ADHD and other disorders associated with impulsive behavior. Supplementation has been shown to improve inattention, hyperactivity, and impulsivity; individuals with confirmed deficiency may benefit from supplementing with 4,000 IU of Vitamin D per day, but specific dosage advice should be obtained from the child’s pediatrician.
Omega-3 fatty acids may help with reducing inattentiveness associated with ADHD. If a deficiency is confirmed or nutrition history suggests very limited dietary intake of Omega-3s, it may be beneficial to choose a supplement that contains both EPA and DHAs (specific types of Omega-3 fatty acids). Specific dosage advice should be obtained from the child’s pediatrician.

As for my son, he is 12 now, and we have been through a lot with medications that didn’t work, some that made him much worse than before, and have finally settled on a medication plan that we are happy with. He started middle school last year, and with many prayers and worried nights, he hit the ground running and had an amazing year – so much better than elementary school, which is surprising for a child with ADHD. He talks about his diagnosis with other children because he too wants to educate others. And, he tells other kids “eating sugar isn’t an excuse for being hyper, so calm down. I know this because my mom is a Registered Dietitian!”

While it’s true that impulsivity, inattentiveness, and hyperactivity are hallmarks of the disease, so are creativity, innovation, imagination, and usually intelligence. In a future blog post I’ll share ideas on how to harness these traits to benefit you and your child in the kitchen!

Wendy Phillips, MS, RD, CNSC, CLE, FAND is the Immediate Past President of VAND and the Professional Education Chairperson. She is a Division Director of Nutrition for Morrison Healthcare, and the mom of 2 boys, ages 12 and 15.