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

Myths and Facts: Evidenced-Based Anticipatory Guidance for Childhood Eating Annual Review in Family Medicine December 11, 2015

Support and Disclosure • 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

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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, placebocontrolled, 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, HunterGatherer) • 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 antiestrogenic effects – Study done in China, where soy is cultured 7

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) 9

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” 1. 2. 3. 4. 5.

Apples Celery Cherry tomatoes Cucumbers 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 Environmental Working Group 2015

“Clean 15” 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Asparagus Avocados Cabbage Cantaloupe Cauliflower Eggplant Grapefruit Kiwi Mango Onions Papayas Pineapples Sweet corn Sweet peas (frozen) Sweet potatoes 12

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Organic dairy • 60% cost • 25% less Omega 6 fats, more omega 3 fats (62%) (may be important to look only 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 19

“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 ADA and Diabetes UK website

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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 25

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 28

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 36

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 41

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 – 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 offered as kid: http://national.deseretnews.com/article/3478/ser ving-kids-fruits-and-vegetables-is-not-a-wasteof-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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Clean plate club? • 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

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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 American Family Physician November 2015

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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

Valtin, 2002

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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 or 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 77

Arsenic in rice

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• Also AAP Pediatric Nutrition • www.HealthyFamilies.org American Family Physician May 2015

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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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