Nutrition Cognition Health Robert Murray MD FAAP The

Nutrition, Cognition & Health Robert Murray MD FAAP The Ohio State University

Robert Murray MD: Disclosures Advising Speaking Writing Education National Dairy Council Abbott Nutrition Dannon Co. Cargill Inc. Sabra Dipping Co. Hass Avocado

The Carolina Abecedarian Study Campbell et al, Science 343: 1478. 2014 1972 -77: 111 Impoverished Children Randomized 57 Children Quality Preschool 8 hrs/ day birth to 5 years Health care Nutrition: 2 meals, 1 snack Cognitive & Social stimulation 54 Children Controls Medicaid, WIC, Food Stamps No child care • Survey: children, parents, teachers • Demographics • Health evaluation • Lab tests • Personality & Behavior • Cognition & Achievement Follow-up years: 12, 15, 21, 30 and mid-30 s

Every $1 Spent at least a $7 Return • • • Less likely to fail or repeat a grade 4 x more likely to graduate from college 4. 4 x more likely to hold a skilled job Stronger social and emotional skills Less drinking, run-ins with the law More physically active Campbell et al, Science 343: 1478. 2014 Campbell et al, Early Child Res Q, 23: 452, 2008

Abecedarian Kids at 40 years: Health • Much lower blood pressure • Lower blood cholesterol • Less obesity • Lower sugar diabetes risk • Much lower heart disease risk than kids without child care Physical Health at 40 Campbell et al, Science 343: 1478. 2014 Campbell et al, Science 343: 1478.

Human Brain/Behavior Development T Pivik MD Andersen, 2003 Social orientation Modulation of affect, arousal, attention; early memory Separation distress; working memory; acoustic highlighting of words Maturation of sensory and motor functions; early speech; joint attention

Building Strong Connections Brain doubles in size in first year Triples in size by the third year Synaptic connections @ 700 per second Stronger with use. Lost if unused. Birth 12 months 3 years Adult Carpenter’s Human Neuroanatomy, 1995; Ch 1 Campbell et al. Dev Psychol, 2012; 48: 1033 -43

The New Science “EPIGENETICS” Social experience changes How our genes work, which changes How our body works, which changes How we behave, which changes who we become

The Middle Brain Develops First & Fast Emotional Outbursts Fear Anxiety Impulsive Stress First Reactions

The Front Brain The Frontal Cortex Develops Slowly With Practice Calculates Plans Ahead Thinks First Multi-tasks Logical Organized Calm

NUTRIENTS AND BRAIN DEVELOPMENT Myelinated fibers Neurons and Networks The Scientist, 2013 Myelin Cell proliferation, synaptogenesis Iron LC-PUFAs Choline Protein Iron LC-PUFAs Glucose Georgieff et al. , 2015; Wullschleger et al. , 2006

Many Nutrients Contribute • Vit B 1 – utilize glucose, modulate cognition • Vit B 6, B 12 – synthesis of neurotransmitters • Vit B 12 – cognition, language • Vit C – concentrated in nerve endings • Vit D – prevents neurodegenerative disease • Vit E – membrane protection • Flavonoids – protect, enhance neuronal function • Iron – oxygenation, synthesis of myelin & neurotransmitters, brain development, IQ • Magnesium – energy and ion regulation • Zinc – taste perception, attention • Iodine – (via thyroid) cellular energy metabolism • Omega 3 PUFA – cognition, visual development Bourre. J Nutr Health Aging, 2006: 377

Neurotransmitters Require Constant Nutrient Flow Personality and Mood

Diet Quality & Regular Activity = Health • Heart Disease • Stroke • Diabetes • Obesity • Hypertension • Metabolic syndrome • Osteoporosis • Cancers • Alzheimer’s

5 Food Groups • Fruits • Vegetables • (Whole) Grains • Milk & Diary • Quality proteins Dietary Guidelines for Americans 2015 -2020 Promote Diet Quality • Nutrient Rich Foods • Nutrients of Concern: Calcium, Vit D, potassium, fiber http: //health. gov/dietaryguidelines/2015/guidelines/ While Limiting • Excess calories • Saturated fats to < 10% of kcals • Added sugars to < 10% of kcals • Sodium

Two Competing Paths to “Healthy” Avoidance … Dietary Pattern …

The Sugar Question

Where are Added Sugars? Yogurt Flavored milk Sweetened cereal Fruit juices

Controversy: Flavored Milk in School

Dairy Products Promote Health • • • Osteoporosis Hypertension Cardiovascular disease Stroke Type II diabetes Cancers – breast, colon, prostate • Obesity • Metabolic syndrome Calcium Potassium Phosphorus Protein Vitamin A Vitamin D Vitamin B 12 Riboflavin Niacin (30% DV*) (11% DV*) (20% DV) (16% DV) (10% DV) (25% DV*) (13% DV) (24% DV) (10% DV) Astrup, Amer J Clin Nutr 2014; 99: 1235 s Moreno, et al, Nutr Rev 2015; 73: 8 s-14 s

What would happen if we banned all flavored yogurt to cut sugar consumption among adults?

Yogurt Promotes Health • Yogurt is a marker for diet quality • Lowers risk of hypertension, type II diabetes, CVD, metabolic syndrome, osteoporosis and fractures • Easy to digest in lactose intolerance • Promotes gut flora • Rank #1: quality protein source (PDCAAS) • Calcium, Vit D, potassium • Fosters satiety Hess and Slavin. Nutrients, 2014; 6: 4750 -59 Added sugars cut by 25% in the U. S.

Special Supplemental Nutrition Program for Women Infants & Children WIC • Revised WIC Packages: Final Rule March 4, 2014 – Increased access to low- and no-fat milks – Access to lactose-free milk, soy beverages – Cheese as a dairy allowance – Yogurt may swap quart-for-quart with milk • Unsweetened or • < 40 grams total sugar/ 8 oz serving http: //www. fns. usda. gov/wic/final-rule-revisions-wic-food-packages

RTE Cereals & Nutrition • Improves nutrients, milk, and fruit intake in children and adolescents • Better diet quality • Less body fat • Consumers: more calcium, Vit D, iron, magnesium, Vit A, phosphorus, and zinc • Fortified: folic acid, iron Michels et al. Eur J Nutr 2016; 55: 771 -9 Michels et al. Eur J Nutr 2015; 54: 653 -64 Barr et al, Br J Nutr 2014; 112: 1373 -83 De la Hunty et al. Obes Facts, 2013; 6: 70 -85

100% Fruit Juice Improves Diet Quality Cross-sectional study of 100% fruit juice in 2 to 18 year olds by consumption levels: • Nutrient intake higher • Diet quality higher • Weight status no difference NHANES 2007 -2010 Nicklas TA, et al. Int J Child Health Nutr. 2015. 4: 112 -121. 25

100% Fruit Juice is a Fruit Serving • Among <2 year olds: – 1/2 of fruit consumed as 100% FJ – Primary contributor folate, magnesium, thiamin, riboflavin, and niacin; top sources vitamin C, potassium • Among 2 -18 year olds: – 1/3 of fruit consumed as 100% FJ – Potassium (#2), vitamin D* (#5) and calcium* (#7), but not total energy (#17) Clemens R, et al. Adv Nutr. 2015; 6: 236 S-243 S. Fox MK, et al. J Am Diet Assoc. 2006. 106: S 28 -42 Keast DR, et al. Nutrients. 2013. 5: 283 -301

Sweetened Beverages • • Flavored water Soft drinks Fruit-flavored drinks Energy drinks Rehydration drinks Alcoholic drinks Flavored milk* 100% fruit juices* These do Not belong with this group

What’s Your Advice?

“A positive emphasis on nutritional value, variety, appropriate portion, and encouragement for a steady improvement in quality will be a more effective approach for improving nutrition and health than simply advocating for the elimination of added sugars. ” Snacks, Sweetened Beverages, Added Sugars, and Schools Murray R, Bhatia J and the COUNCIL ON SCHOOL HEALTH, COMMITTEE ON NUTRITION Pediatrics 2015; 135: 3 575 -583

Use modest added sugars, saturated fats, and sodium WISELY to promote nutrient rich foods

A Healthful Diet Pattern • • • Plant oils Fish & seafood Lean meats Legumes Nuts & seeds Vegetables Fruits Dairy & yogurt Whole grains Wine Dietary Patterns are personal Preferences, experiences, culture Improvements are incremental

The Holy Trinity of Food Choice TASTE VALUE CONVENIEN CE

Look for “Nutrient Density” • Dairy – Protein, calcium, Vits D, A, potassium, B vits, phosphorous, magnesium, zinc, niacin • Sweet Potatoes/ Squash – Carotenoids, Vit C, potassium, fiber • Spinach, kale, watercress – Vit A, C, K, folate, potassium, mag. , iron, phytochemicals • Tomatoes, avocados – Vit A, C, fiber, phytochemicals Ratio: Nutrients per Kcal • Broccoli, green beans – Vit C, folate, carotenoids • Rye, wheat, oat grain products – Whole grain, fiber, B Vitamins • Citrus fruits – Vit C, fiber, folate, phytochemicals • Blueberries, blackberries – Vit C, fiber, folate, potassium • Salmon & fatty fish – Omega-3 fatty acids, protein • Nuts, seeds – Fiber, protein, MUFA/ PUFA, omega-3 FA (walnuts), vit E (almonds), folate (peanuts) Drewnowski, Fulgoni; Am J Clin Nutr; 1223 s, 2014 Verger EO et al, J. Nutr. 144: 929– 936, 2014

Food & Beverage Choices Verger et al. J Nutr 2014; 144 What if? One notch higher in nutrients • Soda, energy drinks, sports drinks, juices • Grain desserts • Dairy desserts • Dry cereals • Cooked cereals • Breads • Milk, cheese, yogurt • Crackers • • • Fruits Vegetables Pizza Fast food Tacos, burritos Nuts, seeds Eggs Meats Fish

Fast, Easy Diet Quality Scenario #1: Substitute a lower fat, lower sugar alternative Scenario #2: Substitute better choice within the same food category • Regular to low-fat cheese • Easy for consumer • Goals met: calories, total and sat fat, cholesterol, carbs and sugar • Almost no improvement in diet quality • White rice to long-grain rice • Easy for consumer, retains personal and cultural tastes • Goals met: for nearly all nutrients and calories • Rapid rise in diet quality Verger et al. J Nutr 2014; 144: 929

Simple Swaps… • • Cream based dips to vegetable salsas Potato chips to whole grain chips Frozen dessert to flavored yogurt Refined to whole grain cereals Cake to carrot or zucchini cake Chocolate chip to oatmeal nut cookies Veggies into soups, stocks, mixed dishes INCREMENTAL

1 in 5 Children are Food Insecure 51% of US kids qualify for free-and-reduced • Worse developmental outcomes • Psychosocial, behavioral, and attention problems • Depression and suicidal symptoms in adolescents • Lower academic performance

The USDA Food & Nutrition Service Child Safety Net • • Child and Adult Care Food Program The National School Lunch Program School Breakfast Program The Seamless Summer Meal Program After-School Snacks Special Milk Program Fresh Fruit and Vegetable Program Commodity Supplement Program

The School Nutrition Opportunity • • 55 million students 32 million lunches/day 10 million breakfasts 35 -40% kcals school vs 56% kcals at home Improves diet quality Lessens obesity risk Improves in-class behavior Boosts academic achievement

The National School Lunch Program • School Nutrition Dietary Assessment – SNDA I (1995), II (2001), III (2007) • School Health Policies and Programs Study (SHPPS) – 1994, 2000, 2006, 2012, 2015 No Correlation of Obesity with NSLP

Nutritional Contributions of School Breakfast Program • • Greater energy/ day Vit C Phosphorus Calcium Vitamin D Magnesium Riboflavin Fiber Nutrients not consumed at breakfast are not made up over 24 hrs 20% children, 31% teens skip

Breakfast Science • Nearly all showed a positive effect – Vulnerable kids got the most effect – BF at school had the best effect 45 Studies • • • Math & Memory better Memory, attention better Late morning support Better on more demanding tests High-risk children showed better – Verbal skills – Memory – Matching tests Hoyland et al. Nutr Res Rev 2009; 22: 220

Fasting vs Glucose-Rich Brain FASTING The Mid-Brain Food Seeking Mode * Distracted, irritable, Restless, anxious Glucose-rich The Front Brain Working Mode * Calm, focused, organized, thoughtful Tataranni et al: http: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 16373/

In-School Breakfast has Many Benefits What if they ate at home too?

And Yet…Only 1/3 of Eligible Kids Get Breakfast at School • Less hunger during school • More attentive, fewer behavioral problems • Increased attendance • Less tardiness • Fewer visits to school RN • Lower risk of obesity • Math scores 17. 5% higher • Higher graduation rates Share Our Strength/ Delloite Study, 2013

Make Snacks Contribute to the power of incremental change

Energy-Dense, Nutrient-Poor Snack type foods = 40% of daily energy • Added sugars (40%) • High total fats • Vital nutrients (<15%) • Displaces: Protein, fiber, vitamins, folate, calcium, magnesium, iron, zinc

Speed Snacks Foods that Pair with Other Foods Salsa Hummus Guacamole Yogurt Dips Dressings Cereals Soups Smoothies Popcorn & 100% Juice 100 kcal microwaved + 120 kcal fruit juices Whole grain, fiber, vitamins Yogurt Plus … 90 -250 kcal Calcium, Vit D Many Vits & Minerals Energy Bars 230 kcals Grains, fruit High in potassium, Vit A, Vit C, Calcium, Iron, Vit D, Vit E, fiber, Vit B 12, Magnesium, Zinc, etc. Balance: fats, carbs, protein Milk +/- Breakfast Powder 130 kcals + non-fat milk = 220 kcals High in potassium, Vit A, C, Calcium, Iron w/ milk it blends carbs, protein, fats

Summer is 3 Months Long

Nutrition is a powerful epigenetic force Hunger is a persistent stress Brain requires consistent nutrients Breakfast is crucial Snack = best opportunity Summer can be scary