Olivia Rivera
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Maternal diet influences long-term health of children well before pregnancy

Mother and infant

Maternal diet during pregnancy is thought to be one of the most influential factors on child health and development. However, dietary interventions during this period may miss a critical window to improve health during childhood, as well as adult life.

In a recent series of articles in The Lancet, researchers address the significance of nutrition in the preconception period, or the time before a woman becomes pregnant. The series of three articles challenges the current perspective of the preconception period. Currently defined as 3 months before conception, the authors suggest preconception should also include any time a woman is at child bearing age. This revision is based on an understanding of the biological events occurring during the periconceptional period, or the time immediately surrounding conception. In addition, it addresses a lack of nutritional preparedness for pregnancy in women of reproductive age and the failure of dietary interventions during pregnancy in preventing adverse health outcomes.

How does pre-pregnancy nutrition affect child health?

The periconceptional period begins before fertilization occurs, with maturation of sperm and oocytes, and extends until implantation of the fertilized egg. From the time of fertilization, this process occurs relatively quickly (up to 9 days in humans) but is characterized by drastic changes developmentally, genetically, and metabolically. The embryonic genome undergoes epigenetic modifications, or alterations to the DNA that do not change the genetic code but rather affect how a gene is expressed by turning expression on or off. These modifications are responsive to environmental conditions and nutrient availability, and likely adapt to promote optimal survival under existing conditions. However, the established gene expression pattern may be detrimental in environmental conditions outside of the uterus, promoting disease development later in life.

Although epigenetic changes can occur throughout one’s lifetime, the periconceptional period is unique in that a small number of cells are present. Full exposure to the environment allows this founder population of cells to establish the genetic program that persists throughout development.

How does this change current practice?

The influence of maternal nutrition during the periconceptional period on disease and development in offspring is not a new concept. Both maternal overnutrition and obesity, as well as undernutrition have been known to adversely affect metabolic regulation in offspring and increase the risk for metabolic disease development.

More recently, analysis from the UK National Diet and Nutrition Survey suggest that less than 10% of women of reproductive age meet the recommended daily intakes during pregnancy for several key micronutrients including zinc, vitamin A, folate, and calcium. Only 30% of women meet the daily intake recommendations for iron. A lack of success of multiple micronutrient supplementation during pregnancy in improving child health outcomes, including survival, growth, body composition, and blood pressure, indicate the importance of correcting such nutritional deficiencies well before pregnancy.

These findings suggest that preconception intervention strategies should include population targeted interventions for women of reproductive age, in addition to those targeting the 3 months before conception. This will allow adequate time to correct for nutritional deficiencies before pregnancy.

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ASN Blogger
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Submit Your Comments on the 2020-2025 Dietary Guidelines

2020-2025 Dietary Guidelines for Americans

The U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) are seeking public comments on topics and supporting scientific questions to inform the development of the 2020-2025 Dietary Guidelines for Americans. This is a new step in the development process. View the Federal Register Notice here.

Topics and questions proposed by USDA and HHS are based on four criteria: relevance, importance, potential federal impact, and avoiding duplication. The topics for 2020-2025 Dietary Guidelines are within a life stages approach, focusing on priority scientific questions from birth through older adulthood. In addition, the topics reflect a continued focus on patterns of what we eat and drink as a whole, on average and over time.

Learn more on the development of the dietary guidelines here. Submit your comments here.

Listed below are the five life stages with proposed topics and scientific questions. The guidelines will also describe current dietary patterns, including intakes of food groups and nutrients, for each stage of life.

Infants and toddlers from birth to 24 months (healthy, full-term infants)

Topic Question(s)
Recommended duration of exclusive human milk or infant formula feeding What is the relationship between the duration of exclusive human milk or infant formula consumption and 1) growth, size, and body composition; 2) food allergies and other atopic allergic diseases; and 3) long-term health outcomes?
Frequency and volume of human milk and/or infant formula feeding What is the relationship between the frequency and volume of human milk and/or infant formula consumption and 1) micronutrient status; and 2) growth, size, and body composition?
Dietary supplements (e.g., iron, vitamin D, vitamin B12) What is the relationship between specific micronutrient supplements for infants fed human milk and/or infant formula and 1) micronutrient status; and 2) growth, size, and body composition?
Complementary foods and beverages*: Timing of introduction, types, and amounts

*Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives)

 What is the relationship between complementary feeding and 1) micronutrient status; 2) growth, size, and body composition; 3) developmental milestones; 4) food allergies and other atopic allergic disease; and 5) bone health?

What is the relationship between complementary feeding, including foods and beverages, and achieving nutrient and food group recommendations of infants and toddlers?

Note: Evidence related to dietary patterns (including beverage patterns) consumed during the complementary feeding period will be considered as part of these questions.

 

Children and adolescents, ages 2-18 years old (with data reviewed by age group)

Topic Question(s)
Dietary patterns to promote health and normal growth and meet nutrient needs What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed during childhood and adolescence and 1) growth, size, and body composition; and 2) bone health?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for children and adolescents?
Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives, caffeinated beverages) What is the relationship between beverage consumption during childhood and adolescence and achieving nutrient and food group recommendations?
Added sugars What is the relationship between added sugars consumption during childhood and adolescence and achieving nutrient and food group recommendations?

How much added sugars can be accommodated in a healthy diet during childhood and adolescence while still meeting food group and nutrient needs?

 

Adults, ages 19-64 years old (with data reviewed by age group)

Topic Question(s)
Dietary patterns to promote health, prevent disease, and meet nutrient needs What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed during adulthood and 1) body weight or obesity; 2) risk of cardiovascular disease; 3) risk of type 2 diabetes; and 4) risk of certain types of cancer?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for adults?
Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives, caffeinated beverages) What is the relationship between beverage consumption during adulthood and achieving nutrient and food group recommendations?
Added sugars What is the relationship between added sugars consumption during adulthood and achieving nutrient and food group recommendations?

How much added sugars can be accommodated in a healthy diet during adulthood while still meeting food group and nutrient needs?
Saturated fats What is the relationship between saturated fats consumption (types and amounts) during adulthood and risk of cardiovascular disease?

 

Pregnancy and lactation

Topic Question(s)
How additional calorie needs should be met during pregnancy and lactation What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed among women who are pregnant and 1) risk of gestational diabetes; 2) risk of hypertensive disorders during pregnancy; 3) gestational age at birth; and 4) birth weight standardized for gestational age and sex?

What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed among women who are lactating and human milk composition and quantity?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for women who are pregnant or lactating?
Dietary supplements (e.g., iron, folate, vitamin D) What is the relationship between micronutrient supplements consumed during pregnancy and lactation and 1) micronutrient status; 2) birth outcomes; and 3) human milk composition and quantity?
Diet during pregnancy and lactation and risk of food allergy in the infant What is the relationship between maternal diet during pregnancy and lactation and risk of infant allergies and other atopic allergic disease?
Seafood What is the relationship between seafood consumption during pregnancy and lactation and neurocognitive development of the infant?
Beverages (cow’s milk, water, 100% fruit juice, sugar-sweetened beverages, milk alternatives, caffeinated beverages) What is the relationship between beverage consumption during pregnancy and lactation and 1) achieving nutrient and food group recommendations; 2) birth outcomes; and 3) human milk composition and quantity?
Alcoholic beverages What is the relationship between maternal alcohol consumption during lactation and human milk composition and quantity?

 

Older adults, ages 65 years and older (with data reviewed by age group)

Topic Question(s)
Dietary patterns to promote health, prevent disease, and meet nutrient needs What is the relationship between specific dietary patterns (Dietary Guidelines-related, Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH), vegetarian/vegan, and low-carbohydrate diets) consumed across the lifespan and 1) body weight or obesity; 2) risk of cardiovascular disease; 3) risk of type 2 diabetes; 4) risk of certain types of cancer; and 5) risk of osteoporosis?

What modifications to dietary patterns are effective in preventing or reversing declines in muscle mass or bone density in older adults?

Are changes to the USDA Food Patterns needed based on the relationships identified? If so, how well do USDA Food Pattern variations meet nutrient recommendations for older adults, age 65-80 years and those age 81+ years?
Specific nutritional needs related to older adults What modifications to food and beverage choices promote meeting nutrient needs in older adults with impaired dentition, dry mouth, or other aspects of aging that interfere with food and beverage consumption?

Comments are accepted through March 30, 2018. If you have a new topic or question to suggest, provide a brief summary including information pertaining to the four prioritization criteria. After the review of comments and finalization of topics and supporting questions, USDA and HHS will post a public call for the Dietary Guidelines Advisory Committee nominations.

Read more about the Dietary Guidelines here.

If you have any suggestions to inform ASN’s comments please reach out to Sarah Ohlhorst, Senior Director of Advocacy and Science Policy, at sohlhorst@nutrition.org or 240-428-3647.

 

 

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Sarah Purcell
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How can we implement better health behaviors in cancer survivors?

Lifestyle interventions targeted at obtaining/maintaining a healthy body weight and/or incorporating physical activity and healthy eating habits have great potential in improving outcomes in cancer survivors. Cancer diagnosis is a “teachable moment” wherein many patients are highly motivated to make changes (1). Furthermore, a balanced diet and moderate exercise can improve prognosis, quality of life, physical function, and survival across the cancer continuum. As such, groups such as the Amercian Cancer Society, National Comprehensive Cancer Network and the American College of Sports Medicine have released lifestyle guidelines for cancer survivors.

However, implementing changes in individuals and healthcare systems is challenging, to say the least. This is a recent topic covered by Karen Basen-Engquist and a number of colleagues as part of a special Issue of Obesity (Transdisciplinary Research on Energetics and Cancer)(2). Their article provides a 6-point agenda for translating research into clinical and community action, as follows:

  1. Increase the availability of different types of activities for weight management, nutrition counseling, and physical activity. One size will never fit all when it comes to improving health. Individual goals/preference, resources, and logistics all come into play, and cancer-specific programs may be needed.
  2. Improve screening and referral to lifestyle interventions. A system for evaluating and triaging patients for health programs should be developed. Importantly, an individual’s physical status, health needs, and goals should be considered.
  3. Improve the health care provider’s ability to screen, assess, and refer survivors for lifestyle programs. Oncology providers have a powerful role in helping cancer survivors; however, they often do not feel confident in screening, giving advice, or administering recommendations for lifestyle-related constructs. Implementation of processes such as the 5As (Ask, Advise, Assess, Assist, Arrange), which has been successful in tobacco cessation (3) and obesity management (4) might prove beneficial.
  4. Expand the support of oncology-specific professional training and certification. Professional organizations of dietitians, exercise professionals, psychiatrists, and physical therapists have additional certification programs for oncology or are working on developing one for its members. However, professionals with specific expertise in oncology are still greatly needed to address the unique needs of this population.
  5. Expand dissemination and implementation research. Many research programs do not address how a program could be implemented in a real-world setting (external validity). Dissemination of research findings with consideration of the sustainability and generalizability of programs is essential for broader impact.
  6. Advocate for health care policies that support lifestyle services for cancer survivors. Coverage for health programs is highly variable and often has barriers such as large co-payments, no coverage in grandfathered plans, and cost sharing. A potential solution could be incentivizing nutrition and exercise services, although more research is needed to determine the effectiveness of such actions.

As the authors eloquently articulate, the time has come to enable research into action for optimal healthcare in all cancer survivors.

References:

  1. Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005;23:5814–30.
  2. Basen-Engquist K, Alfano CM, Maitin-Shepard M, Thomas CA, Schmitz KH, Pinto BM, et al. Agenda for Translating Physical Activity, Nutrition,and Weight Management Interventions for Cancer Survivors into Clinical and Community Practice. Obesity 2017; 25, S9-S22.
  3. Siu AL, Force USPST. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015;163:622-634.
  4. Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM. Effect of implementing the 5As of Obesity Management framework on provider-patient interactions in primary care. Clin Obes 2013; 4, 39-44.

 

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Mary Latimer
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I eat what you eat: Maternal Nutrition and Epigenetics

Potential mothers, new mothers and mothers of multiples often worry about how their nutrition will affect their children. With the high rates of childhood obesity, some mothers worry more than ever about what they are putting in their bodies. Although this could be a discussion that includes pesticides on food, chemicals in cleaners and even air pollution, let’s just focus on nutrition.

 

It has been shown that a strong predictor of a child’s future BMI is the mother’s pre-pregnancy BMI (Schou-Anderson et al, 2012). This prediction comes from two sources, environment (how parents eat directly influences how children eat) and genetics (especially epigenetics). Epigenetics is how our cells control gene expression without changing the core DNA sequence and can include both DNA methylation and histone modification. It is consistently reported that maternal diet can directly alter DNA binding sites (Aagaard-Tillery et al, 2008) and DNA methylation (Dudley et al, 2011) in the offspring of mothers fed high fat diets. High fat diets contain energy dense foods consisting of >45% of total calories from fat, essentially mirroring the typical Western diet, which is full of highly palatable, highly processed energy dense foods. While this is certainly not a comprehensive list of publications on this topic, it is safe to say that maternal diet can influence an offspring’s risk of developing obesity through epigenetics (a nice review here). Hence the idea that whatever you eat, your baby also experiences.

 

While this may not be a novel concept, it is more important than ever to educate mothers (and fathers!) about the influence their diet could have on their future children’s body composition and their overall risk for obesity-associated diseases. While this information may initially leave parents anxiously asking questions like “Is there anything I can do?!”; “Is the damage already done?”; or “What could I have done differently?”, our goal is to provide information that is both reassuring and accurate knowing that with the right nutritional decisions, your child will be just fine!

 

Multiple studies have shown interventions in eating patterns and exercise work for reducing obesity and risk for associated diseases (reviewed here, here, here, here, here etc.).

 

The trick? Implementing these changes in your families diet and exercise routines to change the trajectory that epigenetics may have imposed when your little one was no larger than a grain of rice.

 

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Mary Latimer
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Breastmilk from a Bottle and Obesity Risk

As a new parent you can go no longer than 24 hours without hearing the phrase “Breast is Best.” I know this to be true because I became a parent in June of this year. In the hospital we were offered consults with lactation and had no less than six posters in our room touting the benefits of breastfeeding. As a PhD student I was intrigued by the literature behind these recommendations and eagerly spent multiple late night nursing sessions on my iPad reading the latest research. What I found were some studies finding associations with reduced risk of obesity, and others failing to find this same association (literature). Overall, it was concluded in the previous review that breastfeeding was associated with a reduced risk of obesity.

While this was great news, I could not help but question; was this association because of breastmilk or mode of delivery? Bottle feeding is typically associated with formula feeding but a growing number of women have begun pumping their breastmilk after returning to work or in cases of pre-term birth and latch issues.

Could bottle feeding breastmilk still ameliorate the risk of obesity later in life?

I was not the first person to raise this question which has been addressed here, here, here, and here. Overall the consensus seems to be that early bottle feeding, of breastmilk or formula, is associated with an increased risk for excess weight gain and poor self regulation. Exclusively feeding expressed milk is also associated with early cessation of breast-milk feeding.

So this leads to the inevitable question; what is a mother to do?

While the literature is still unclear if bottled breastmilk can fight obesity risk, it is clear the breastmilk has multiple other benefits according to the American Academy of Pediatrics and should be offered when possible. So to those mothers who pump a little, a lot, or all the time, I say pump on ladies!

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Chris Radlicz

Supplemental Nutrition Assistance Program Reforms

The Supplemental Nutrition Assistance Program, known as food stamps until 2008, has its roots in President Franklin D. Roosevelt’s New Deal as a part of the Agriculture Adjustment Act of 1933. This act was an effort to reduce the supply-side surplus of agricultural products, which resulted from the demand for increased exports during World War I. The federal government stepped in to restore the purchasing power of agricultural commodities to the levels seen prior to the war, primarily through the taxation of intermediary processers.

In 1939, the “Food Stamps Plan” was passed and began to resemble the current-day SNAP program. The Food Stamps Plan allowed those with low incomes to purchase food stamps with the benefit of a 50% tax-funded match in additional stamps for restricted use on foods designated to be in a surplus. The special stamps for surplus foods were eliminated in 1961.1

Fast forward to 2016 and SNAP has more than 44 million beneficiaries receiving a monthly payment of $125.50 per individual.2 About two-thirds of SNAP recipients are vulnerable individuals such as children, the elderly, and the disabled.  Of those served, 42% earn incomes below 50% of the poverty line, and 40% earn incomes between 51-100% of the poverty line.3 In general, to qualify for SNAP, the individual can’t make over 130% of the federal poverty line in gross monthly income and no more than 100% of the federal poverty line in net monthly income.4  67% of the SNAP recipients are in the aforementioned category of vulnerable individuals and are not expected to work. Of the remaining 33%, about 14% were employed, and 19% were unemployed.3

In a 2015 report by the United States Census Bureau, SNAP was shown to have kept 4.6 million Americans out of poverty, lowering the overall poverty rate by 1.4%.5 The virtues of injecting SNAP monies into the economy have been touted by many Keynesian economists for the theoretical multiplier benefit of consumption spending on the economy. It has been estimated that every $1 spent in the SNAP program generates $1.79 in economic activity.6 Though this point is debated, framing a safety-net program such as SNAP in terms of its downstream effects on the general economy is removed from the intent of the program, which is to provide aid to individuals in need of sustenance. The SNAP program continues to garner much public support as shown by a recent study, which found that 80% of individuals agreed that SNAP benefits should be raised by 19-43% depending on the scenario.7

The current presidential budget proposal for fiscal year (FY) 2018 entitled A New Foundation For American Greatness suggests cutting the SNAP program by 29% over the next ten years. The proposed budget seems to lament that the typical ebb and flow of this public safety-net program has been replaced in recent years by continual spending increases. SNAP participation usually decreases when the economy is strong and increases when the economy is weak. SNAP reached a historic high during the recession, but even with the improved employment numbers since then, “SNAP participation remains persistently high.” Furthermore, the proposed budget states that the reforms to SNAP will “close eligibility loopholes, target benefits to the neediest households, and encourage work.” Loopholes and safeguards against fraud are important steps to take, especially with the knowledge that the amount of SNAP benefits paid in error totaled $2.2 billion in 2009.8 Prominent forms of SNAP fraud include benefits that are exchanged for cash, embellishment on applications to receive more benefits, and disqualified retailers who continued to accept SNAP.9

The budget proposal also suggests a major structural change to the financing of SNAP. Previously, SNAP was fully funded through the federal government with the states covering the administrative costs, but the new budget proposes a state-federal partnership that will phase in and shift 25% of SNAP costs to the states by 2023.10 The presumable intent of this change in financing is to incentivize states to control costs and put more resources into helping recipients seek employment.

In a Miami Herald op-ed, Mick Mulvaney, director of the U.S. Office of Management and Budget has defended the proposed budget cuts to the SNAP program as a means of making the government more efficient, decreasing the deficit, and allowing individuals to keep more money in their pockets through decreased taxation.11

In the budget proposal, the SNAP program takes the largest cut relative to other public programs. The widespread public support and historical bipartisan support of SNAP makes it hard to foresee the budget passing as proposed without a revision to this particular suggested cut to SNAP. Though the presidential budget is just a recommendation, there are senators on both sides of the aisle who have expressed the sentiment that the budget in its current form is “dead on arrival.”12 House and Senate Appropriations Committees will be considering the FY 2018 spending bills in July after the Independence Day recess so we will soon find out the depth of cuts to the SNAP program.

References

  1. The History of SNAP. SNAP to Health. https://www.snaptohealth.org/snap/the-history-of-snap/. Accessed June 26, 2017.
  2. Supplemental Nutrition Assistance Program (SNAP) Participation and Costs, 1969-2016.; 2017. https://www.fns.usda.gov/pd/supplemental-nutrition-assistance-program-snap. Accessed June 24, 2017.
  3. Chart Book: SNAP Helps Struggling Families Put Food on the Table. Washington, DC; 2017. http://www.cbpp.org/research/food-assistance/chart-book-snap-helps-struggling-families-put-food-on-the-table#part4. Accessed June 25, 2017.
  4. Supplemental Nutrition Assistance Program – Fact Sheet on Resources, Income, and Benefits. https://www.fns.usda.gov/snap/fact-sheet-resources-income-and-benefits. Published 2017. Accessed June 25, 2017.
  5. Renwick T, Fox L. The Supplemental Poverty Measure: 2015. Washington, DC; 2016. https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-258.pdf. Accessed June 24, 2017.
  6. Hanson K. The Food Assistance National Input-Output Multiplier (FANIOM) Model and Stimulus Effects of SNAP.; 2010. https://www.ers.usda.gov/publications/pub-details/?pubid=44749. Accessed June 25, 2017.
  7. Kull S, Ramsay C, Lewis E, Williams A. Americans on SNAP Benefits.; 2017. http://vop.org/wp-content/uploads/2017/04/SNAP_Report.pdf. Accessed June 24, 2017.
  8. Brown K. Supplemental Nutrition Assistance Program: Payment Errors and Trafficking Have Declined, but Challenges Remain.; 2010. http://www.gao.gov/products/GAO-10-956T. Accessed June 24, 2017.
  9. What is SNAP Fraud? https://www.fns.usda.gov/fraud/what-snap-fraud. Published 2017. Accessed June 25, 2017.
  10. A New Foundation For American Greatness – Fiscal Year 2018. Washington, DC; 2017. https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget.pdf. Accessed June 24, 2017.
  11. Mulvaney M. Mulvaney: The federal budget released today puts taxpayers first. Miami Herald. http://www.miamiherald.com/opinion/op-ed/article152074727.html. Published May 22, 2017. Accessed June 24, 2017.
  12. Gambino L. Republicans voice opposition to Trump’s budget: “Dead on arrival.” The Guardian. https://www.theguardian.com/us-news/2017/may/23/republicans-opposition-trump-budget-medicaid-spending. Published May 23, 2017. Accessed June 25, 2017.
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Chris Radlicz

The Future of the National School Lunch Program

The former First Lady Michelle Obama revealed her “Let’s Move!” campaign in February of 2010 with the intent of curbing the childhood obesity epidemic. The initiative included a modification to the nutrition standards of the U.S Department of Agriculture’s (USDA) National School Lunch and School Breakfast Programs which provide 32 million meals to children daily. The principle legislation effecting these standards is the Healthy Hunger-Free Kids Act (HHFKA) of 2010 which has been touted as the first major reform to school lunch and breakfast in nearly 30 years.

In accordance with recommendations from the Institute of Medicine report “Nutrition Standards for Foods in Schools: Leading the Way toward Healthier Youth” and the 2010 Dietary Guidelines for Americans, the HHFKA informs the nutrition guidelines that schools must follow in order to be eligible for reimbursement under the National School Lunch Act and the Child Nutrition Act. Various standards resulting from the HHFKA went into effect in 2012, requiring schools to serve more fruits and vegetables, limit sodium, increase the whole grain composition of foods, and increase low-fat and non-fat options. To be more precise, all grains must be 50% whole grain by weight (or have whole grains as the first ingredient), food items can’t have more than 35% of total calories coming from fat, and only 10% of total calories can come from saturated fat. Many exceptions to these regulations exist and are enumerated in the final rule, which codifies the Act. For example, a high-fat food like peanut butter can be served if it is paired with a vegetable or fruit.

A 2014 study evaluated the initial implementation of the HHFKA in a cohort of students at four elementary schools in Washington State. The new guidelines were adhered to by 2013, and compared to the prior year, there was a decrease in average caloric intake by students across each individual macronutrient. Ingestion of key nutrients such as calcium and vitamin C decreased compared to the meals consumed under the old guidelines. Fiber was the only nutrient that was significantly increased. Despite the general dietary improvements that resulted, only about 1,000 meals in total were examined in this study. Following the implementation of these guidelines, childhood obesity rates have remained rather stable, but extrapolating the impact of this program on obesity rates over such a short time interval would not be sensible.

The new secretary of the USDA, Sonny Perdue, announced this past week that schools will be given “greater flexibility in their nutrition requirements for school meal programs in order to make food choices both healthful and appealing to students”. Schools have been facing increased financial burdens by adhering to the HHFKA regulations alongside a decline in school lunch participation, further exacerbating financial strain. Though students may be foregoing school lunches more often, the levels of food waste have not significantly changed compared to pre-implementation. Secretary Perdue acknowledged that 99% of the schools are partially compliant with the HHFKA standards, but noted that this metric is not indicative of program success. The temporary flexibility granted by Secretary Perdue includes a sodium target that is less rigorous, an exemption of the required 51% whole-grain composition, and the ability to serve 1% flavored milk rather than strictly non-fat flavored milks.

Dr. Margo Wootan of the Center for Science in the Public Interest, a consumer advocacy group, expressed disconcert with Secretary Perdue’s regulatory roll back, stating that “ninety percent of American kids eat too much sodium every day” and that “schools have been moving in the right direction, so it makes no sense to freeze that progress in its tracks.” Conversely, the School Nutrition Association, a nonprofit with 57,000 members, applauded this reform in a press release citing the HHFKA regulations as “overly prescriptive and having resulted in unintended consequences including reduced student participation, high costs, and food waste.” The new flexibility emphasizes the authority granted to localities to bolster the requirements of their own school nutrition and physical activity through the use of local “wellness policies.” The temporary deregulation of the HHFKA lowers the proverbial “floor” set by the federal government, giving the states an opportunity to have a direct impact in fighting the obesity epidemic.

References
https://www.fns.usda.gov/school-meals/healthy-hunger-free-kids-act
https://www.federalregister.gov/documents/2012/01/26/2012-1010/nutrition-standards-in-the-national-school-lunch-and-school-breakfast-programs
https://schoolnutrition.org/uploadedFiles/About_School_Meals/What_We_Do/Nutrition%20Standards%20for%20School%20Meals.pdf
https://www.cdc.gov/obesity/data/childhood.html
http://stateofobesity.org/childhood-obesity-trends
https://www.usda.gov/media/press-releases/2017/05/01/ag-secretary-perdue-moves-make-school-meals-great-again
https://schoolnutrition.org/news-publications/press-releases/sna-commends-usda-supporting-practical-flexibility-benefit-school-meal-programs/
https://www.cdc.gov/healthyschools/npao/wellness.htm
https://cspinet.org/news/trump-administration-undermining-school-meals-menu-labeling-20170501
https://www.ncbi.nlm.nih.gov/pubmed/24650841

/2 Comments/by
Mary Latimer
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Regular Bedtimes for Children May be Protective Against Obesity

For many generations parenting books and gurus alike have heralded the importance of routine. Beginning in infancy, children are scheduled to eat, sleep and play, and busy moms often follow this schedule to assure their youngest children are happy, healthy and well socialized. But, as is always the case, children grow older and become involved in more activities making it difficult to stick with rigid schedules established in infancy.

Recent evidence however has shown that regular mealtimes, bedtimes and limits on television at age 3 were all linked to children having better emotional self-regulation later in life. Self-regulation has two distinct domains, emotional and cognitive. Together, these domains help children control their attention. While these two domains have traditionally been studied together it is important to examine them independently as emotional self-regulation is tied to subcortical structures in the brain while cognitive self-regulation is based in the prefrontal cortex. The prefrontal cortex is known to mature later in development continuing its maturity until the early 20’s so outcomes based on these two domains must be distinct.

Anderson and colleagues (2017) tackled these questions in their recent publication accepted in the Journal of Obesity. Using a prospective study they examined how both domains of self-regulation and routine can impact obesity later in childhood (although only until age 11). The Millennium Cohort Study gathered data from 19,244 families recruited in the UK from 2000-2002. Data was collected beginning at 9 months with follow-ups at ages 3, 5, 7 and 11. Child Social Behavior Questionnaires were used at age 3 to determine self-regulation, while height/weight was used at age 11 to determine BMI and obesity status. A series of logistic regressions were used to understand how self-regulation and routine related to risk for obesity at age 11.

Results showed that having a “sometimes-regular bedtime” or “inconsistent bedtimes” were both associated with elevated risk for obesity at age 11. High television/video viewing time was initially associated with higher obesity rates but the result was not significant after controlling for other routines, a result that could be explained by the imprecise measurements used to quantify time spent. Surprisingly, children with mealtimes that varied considerably were found to be less likely to be obese at age 11. While this study agrees with previous literature in terms of bedtime, the results for mealtime were unexpected and need to be considered in the context of the study which was observational and based on parent self-report. Overall, emotional self-regulation and household routines were independent predictors of obesity at age 11 and those children with regular bedtimes, mealtimes, and limits on television/video displayed enhanced emotional self-regulation.

While this study demonstrates the importance of routine, it is important to understand that many factors could not be controlled for, leaving the study with multiple limitations. Still, if putting the kids to bed at the same time could be protective, maybe those rigid schedules shouldn’t be abandoned just yet.

 

References:

Anderson, S. E., et al. “Self-regulation and household routines at age three and obesity at age eleven: Longitudinal analysis of the UK Millennium cohort study.” International journal of obesity (2005) (2017).

Sowell, Elizabeth R., et al. “Mapping cortical change across the human life span.” Nature neuroscience 6.3 (2003): 309-315.

 

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Designing interventions to achieve impact

Student Blogger for Global Nutrition Council at ASN’s Scientific Sessions and Annual Meeting at EB 2016

By: Sheela Sinharoy, MPH

A symposium titled Program Effectiveness for Addressing Undernutrition during the First 1,000 Days provided attendees with examples of programs in Bangladesh, Guatemala, and Burundi.

In Bangladesh, the Rang-Din Nutrition Study tested lipid-based nutrient supplements (LNS) in a community-based program. According to presenter Kay Dewey, the study found that giving LNS to mothers prenatally reduced the prevalence of stunting and increased the birth weight, head circumference, and body mass index (BMI) in infants at birth. LNS and multiple micronutrient powders (MNP) for children were also associated with better developmental and cognitive outcomes. Dr. Dewey noted that the impact on child anthropometry was much larger in food insecure households, so future programs may want to target based on this and other criteria.

Moving from Asia to Africa, Marie Ruel presented results from an impact evaluation of a food-assisted integrated health and nutrition program in Burundi. The program gave food rations to mothers and children and also provided behavior change communication. Interestingly, the nutrition situation in Burundi deteriorated sharply during the program period, but decreases were less severe in the treatment groups. For example, while the prevalence of stunting increased dramatically in the control group, the prevalence in the treatment group remained essentially flat. Thus, although the treatment group did not improve, the results suggest that the intervention protected families who otherwise would have been vulnerable to economic shocks.

Guatemala is another country with a very high prevalence of chronic undernutrition, and Deanna Olney presented results from a study of a similar food assistance program. The impact of the program was greatest among those who received a full family food ration plus an individual ration of corn-soy blend. In these households, mothers had significantly higher mean BMIs, children had a lower prevalence of stunting, and both mothers and children had a lower prevalence of anemia. However, there were no significant impacts on child underweight, wasting, or language or motor development.

The differing impacts of various programs was the impetus for a talk by Per Ashorn, who discussed pathways of impact for fetal growth, linear growth, and cognitive function. He explained that the pathways for linear, ponderal, and head growth are partially different, and there are possibly partially different pathways to childhood length gain and brain function. This suggests a need for multipronged interventions targeting pathways including infection, nutrition, and inflammation, as well as a variety of outcome measures to assess the interventions’ impact.

Of course, cost is an important – and often challenging – issue when planning interventions. The final talk of the symposium was given by Steve Vosti, who explained that programs must balance need, acceptability, use, and both short-term and persistent demand in order to achieve impact. These and many other factors, such as the costs of manufacturing supplements in country and the proportion of locally available ingredients being used, can affect the cost of an intervention. In addition to deciding on the most appropriate intervention to meet a need, practitioners must take these factors into account when planning their programs.

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The French Brown Bag

By Emily Roberts

The American Cafeteria

The quality, cost and nutritional adequacy of school lunches have been an ongoing hot bed for debate in our country. The National School Lunch Program has been enact since 1946 and provides lunches to many children of the public school system in the United States (1). The Healthy, Hunger-Free Kids Act of 2010 called for a revision of school meals to meet new nutritional standards that adhere to the 2010 Dietary Guidelines for Americans (2). However these changes have caused some upset including increased cost and waste. As we struggle to perfect the American school lunch, it is helpful to observe how other countries are managing their school lunch programs. My current position as a primary teacher in France gives me the opportunity to witness how the French tackle lunchtime

La Cantine FranÇaise

La cantine, French for the cafeteria, is where children enjoy their lunches if they choose not to return home for the two-hour break. From 11:45am to 1:45pm public schools in France have lunchtime, a time to eat, learn and relax. If the students choose to stay at school for their meal, they often have a wide selection of foods throughout the month from mutton stew, roasted chicken and veal, always paired with a meatless option. Accompanying the main dish is a fruit, vegetable and of course cheese. Throughout the month there are regional recipes capitalizing on local favorites as well as resources.

What’s on the menu?

Montpellier, France Public Elementary Schools

Tuesday March 29th, 2016

A Regional Recipe

Pomelos au sucre grapefruit with sugar

Gardianne de taureau bull meat with onions and carrots

Riz de Camargue long grain rice

Leerdamer cheese

Chocolat de Pâques Easter chocolate

Repas sans viande: flageolets

Meatless recipe: flageolets, a type of legume

Origine de la gardianne de taureau: nÉ, ÉlevÉ et abattu en Franc

Meat Origin: Born, raised and slaughtered in France

—————–

Baltimore County, Maryland Public Elementary Schools

Wednesday March 23rd, 2016

Chicken Nuggets

Grilled Cheese Sandwich

Yogurt Box (including yogurt, string cheese, granola clusters, fruit, vegetables and milk)

Green Beans

Carrot Sticks

Peaches

Meatless option is only offered on Monday

There is no national program in France that helps provide public school lunches assuring that all meals meet certain standards. Rather the menus are developed, reviewed and prepared by each region. Montpellier, France is a general representation of the school lunches in France.

The development and review

A technical team creates the menus that are then reviewed by two certified dietitians (3). The dieticians ensure the meals provide the necessary nutrients for each corresponding age group. They also take into account specific preferences of children. The dieticians will often intervene during lunchtime as well to explain the meals and educate the students on healthy eating.

The preparation

Before preparing the food, there is a careful selection process for products by Quality Assurance. They must be tasted and closely examined to ensure all ingredients meet criteria (such as absence of GMO’s, proper nutritional content and the least additives as possible). They conduct visits to schools to verify proper adherence to the quality guidelines (3,4). Similar to the Unites States, there are strict regulations for the storage, cooking and serving of food to ensure safety.

The price

It ranges from 1€ – 5€ per child depending on the amount of children in each family and the meals consumed (4). This is comparable to the US Average of $2.18 per meal in Elementary Schools (5)

My views

My memories of school bought lunches include pizza, mozzarella sticks, fruit cups and the ice cream cart. Given the limited options I was always a packer. Needless to say I was amazed by the variety, quality and importance of school lunches in France. This local approach to school meal management allows them to utilize local resources and allocate more attention to the nutrition, quality and preference of meals.

USA A school lunch in an elementary school in Maryland with two mini cheeseburgers, applesauce, French fries, broccoli and chocolate milk.

France A school meal I ate at la cantine in a small town outside of Montpellier. A green salad with a light oil dressing, a plain egg omelet, sautÉed carrots, fresh bread, an apple and a piece of almond cake. The omelet was a little boring, but overall a satisfactory lunch.

http://www.fns.usda.gov/nslp/national-school-lunch-program-nslp

tp://www.fns.usda.gov/school-meals/nutrition-standards-school-meals

. Guide de la Restauration Scolaire, Ville de Montpellier

http://www.montpellier.fr/689-cantine-ligne-ecoles-de-montpellier.htm

https://schoolnutrition.org/AboutSchoolMeals/SchoolMealTrendsStats/#4

http://www.nejm.org/doi/full/10.1056/NEJMp1409353

Full March and April Menu

https://www.bcps.org/offices/OFNS/menus/Elementary-Lunch-Menu.pdf

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