Nutrition and Health in

children and infants:

Childhood obesity

Paediatric module teaching 2016

Dr. Sophie Leung
MBBS, MD, MRCP, FRCP, IBCLC
FHKCPaed, FHKAM(Paed)
Honorary Clinical Associate Professor, CUHK
 Health related illness
Obesity is just one of the manifestations of
unhealthy diet and lifestyle

Others are DM, CHD, Cancer, Fatty Liver, Gall stone,

Constipation, Gastro-oesophageal Reflux,
Osteoporosis, Arthritis, Cataract, Macular
Degeneration, Allergic illnesses, Depression, etc.
For children: allergy diseases, recurrent URI,
constipation, hyperactivity, sleep problems, etc
 Non-communicable diseases
• Getting more prevalent than communicable
diseases in many countries

• Life expectancy will be much lower in the new

generations

• Medical costs for chronic illnesses will be

much higher
 Part I
• How does a child get obese?
• What is the risk of a child being obese?
• Why is childhood obesity on a rising trend?
• How to prevent and manage obesity?
 Early nutrition and
childhood obesity
The important first 1000 days ( or 3 months)

Foetal stage 10m 280d

From birth to 2 years 24m 730d

----------

~ 1000d
5
 First 1000 days
• Over-eating in pregnant mothers produce big babies
and with big appetite after birth
• Too rapid weight gain in first 2 months predispose to
later obesity
• Breast feeding reduce 20% adult obesity in next
generation
• Higher protein in infant formula predispose to obesity
• High energy dense solid foods during weaning
predispose to obesity

6
 Overweight /obesity in women
• Australia (BMI >25) 50%

• Hong Kong (BMI >23) 40%

• Tend to have big foetus and big babies

• Weight gain of ＞ 25lbs during pregnancy also tend

to have big babies

7
 HK Adult dietary survey, 1995
Daily protein intake was too high
Male mean 120 gm, sd 40 gm
Female mean 86 gm, sd 35 gm

Protein requirement is only 0.6-0.8 gm per kg

of desirable body weight (30-40 gm for 50
kg)
 High protein intake (g/d) in HK women
Woman Hong Kong United Japan RDA
Kingdom
3m 98 81 80
post-partum
1m 133 - -
Post-partum
35-44yrs 89 - - 0.8mg/kg/d

Pregnancy 100 1.1g/kg/d

(80)

9
High protein intake encourage
faster growth and obesity in future

Data in 1984-6

10
 Early infant Infant Milk
Milk formula
per Human formula formula Formula
No. 4
100 ml milk No.1 No. 2 No.3
4-7 yr
0-6 m 6-12 m 3yr

Energy,
67 68 71 81-100 105
kcal

Protein, g 1.5 1.55 2.8 3.1 3.9

CHO, g 7.0 7.7 8 10-14 12 - 14

Fat, g 3.8 3.5 3.1 3.3 3.3 4.2

Sodium,
18 16 34 38 55
mg

Ca:P 28 : 14 42 : 24 103 : 70 123 : 88 142 : 107

 Nutritional programming

• CVD, DM are related to nutritional status in

the first 1000 days
• David Barker, UK 1991
• Underweight at birth or at 1 year , more likely
to suffer CVD
• Body function primed to adapt to adverse
environment

12
 Programming by over-nutrition
• Obese pregnant mothers produce big babies
• Weight gain > 11 kg (25 lbs) produce big babies
• Offsprings of mothers with GDM more at risk of
obesity, DM, CVS
• Rapid weight gain in first 2 months more likely to
result in obese children
• Overweight children are at risk of obese adults

13
 Note the diet in pregnancy
• Avoidance of environmental pollutants ( pesticides,
heavy metals like mercury, lead, cadmium)for better
immunological and neurological system
• Adequate folic acid to prevent congenital
abnormality
• Adequate iron, iodine, vitamin C and vitamin D

14
Diet of obese children
1. previously bottle fed,
2. eat very little vegetables,
3. prefer refine carbohydrate—white rice, noodle,
cakes, soft drinks, ice-cream,
4. prefer meat--- sausages, chicken wing, pork chop,
5. similar to parents’ diet
6. very difficult to change their diet by the time of
consultation
HK Children’s diet, study in 2010
• Like cow milk, meat

• Like bread, cake

• Do not like vegetables

• Lack of dietary fibre

HK obese children had a 3 – 6 fold
increase in metabolic syndrome
hyper- insulinaemia,
low HDL-C,
high LDL-C,
high TG,
high BP

( 9 – 12 yrs, 300 subjects)

Sung RY et al . Diabetic Care 2002,26:250-1
 Atherosclerotic risk in
HK obese children
Overweight in children is associated with
arterial endothelial dysfunction and intima-
media thickening

Degree of endothelial dysfunction correlated

with BMI.

International J of obesity 2004,28:852-857

Growth
monitoring
is a good
tool to
monitor
nutritional
×
status
provided ×
×

they are
used in the ×
right way.

×
Genetic
smallness
and
Physiological
Downward ×
crossing of
percentiles ×

often wrongly ×

diagnosed as
×
failure to thrive, ×
resulting in ×
×
forced feeding × ×
of high energy
×
high protein
foods
×
 LHC

Early detection
of obesity by
growth monitoring

××

×
 LHC
Early detection
of obesity by
growth monitoring

×
×

×
 Comparing height of boys, cm

Age, yrs UK, 1990 USA, 1977 HK, 1996 China, 2009

2 87.1 87.6 86.2 --

11 143.2 143.3 136.0 --

18 176.4 176.8 170.0 172.7

23
 Height US vs HK

USA 1977
 Weight US vs HK

USA 1977
 WHO growth reference, published 2006
0-5 yrs, collection 1997-2003
• 0-2yrs，longitudinal data of babies who were breast fed for the
first 6 m
• 2-5 yrs, cross-sectional data

5-12 yrs, collection 1963-1974

• Cross-sectional data
• Weight for height reference up to 10 yrs
• No data for Head circumference, puberty and skinfold thickness

26
 X P50 HK growth reference

× ×

29
Diet of 6-12 m infants in USA
• High in energy
• Meat, sausage, cheese
• Low in nutrients

30
 Genetic difference in growth
Adoption of WHO reference for HK would
underestimate the prevalence and seriousness
of childhood obesity in Hong Kong, and
encourage even more over-consumption of
high energy foods.
 Summary of Part I
1. Chronic diseases of adults has origin in early life—
fetal stage, infancy, childhood

2. Overconsumption of energy dense food across

almost all age group in HK

3. Lack of awareness among the public and health

profession on the growth and nutrition assessment
in infancy and childhood
 Part II

• Why is there overeating?

• Are all CHO equally bad?
• Are all fat equally bad?
• Are all protein the same?
 Eating the wrong food
• Highly processed foods with refined wheat,
containing high sugar, salt and fat, tasty but bad for
health
• Meat from poultry and animals that are raised to
grow fast with chemicals and growth factors
• Aggressive marketing
• Fast food culture for busy lifestyle
• Many junk foods that are targeting at children
 Over eating
Excess calorie intake is a feature of
industrialisation & commercialisation

Longevity is associated with less energy intake

Energy (kcal) from food: CHO, gm x 4

Protein, gm x 4
Fat, gm x 9
 Wrong concept

• Calcium only from cow milk

• Protein only from meat, fish or egg
• Children need to eat a lot to grow
 Correct concept
• Nutrient dense ( not energy dense) foods are
good for health
• CHO of lower GI usually better
• Our body needs good fat
• Proteins are present in plants
• 80-100% plant based, whole food (whole
grain, not highly processed) is the best
 NUTRIENT – DENSITY SCORES
based on identified phytochemicals, antioxidant activities,
and total vitamin and mineral content
Highest=100 Lowest =0
100 Raw leafy green vegetables
lettuce, kale, spinach, parsley
97 Solid green vegetables
bok choy, broccoli, cabbage, celery, peas, string beans, cucumber
50 Non-green, non-starchy vegetables
Beets, eggplants, mushrooms, onions, tomatoes, water chestnuts
48 Beans/legumes
Soybeans, black eye beans, black beans, lentils, chickpeas
45 Fresh fruits

EAT TO LIVE by JOEL FUHRMAN,M.D. 2003

35 Starchy vegetables
sweet potatoes, potatoes, pumpkins ,corn, chestnuts ,turnips
22 Whole grains
brown rice, oat ,barley, buckwheat, quinoa, millet
20 Raw nuts and seeds
15 Fish
13 Fat-free dairy
11 Wild meats and fowl
11 Eggs
8 Red meat
4 Full-fat dairy
3 Cheese
2 Refined grains ( white flour)
1 Refined oil
0 Refined sweets
 Nutrients of plant and animal foods (per 500 kcal)
Nutrients Plant food* Animal food**
cholesterol - 137
Fat 4 36
protein 33 34
β carotene 29,919 17
Fibre 31 -
Vit C 293 4
Folic acid 1168 19
Vitamin E 11 0.5
Iron 20 2
Magnesium 548 51
Calcium 545 252

* tomato, spinach, peas, beans, potato ** beef, pork, chicken, milk

The Nutrition Rainbow
 Different anti-oxidants in plants of
different colour - The Nutrition Rainbow
Colors Foods Colorful Protective Substances and
Possible Actions
Red Tomatoes and tomato Lycopene: antioxidant; cuts prostate
products, watermelon, cancer risk
guava
Orange Carrots, yams, sweet Beta-carotene: supports immune
potatos, mangos, system; powerful antioxidant
pumpkins
Yellow- Oranges, lemons, Vitamin C, flavonoids: inhibit tumor
orange Grapefruits, papayas, cell growth, detoxify harmful
peaches substances
Green Spinach, kale, collards, and Folate: builds healthy cells and genetic
other greens material
 Different anti-oxidants in plants of
different colour - The Nutrition Rainbow
Colors Foods Colorful Protective Substances
and Possible Actions
Green- Broccoli, Brussels sprouts, Indoles, lutein: eliminate excess
white cabbage, cauliflower estrogen and carcinogens

White- Garlic, onions, chives, Allyl sulfides: destroy cancer cells,

green asparagus reduce cell division, support immune
systems
Blue Blueberries, purple grapes, Anthocyanins: destroy free radicals
plums
Red- Grapes, berries, plums Reservatrol: may decrease estrogen
purple production

Brown Whole grains, legumes Fiber: carcinogen removal

 Glycemic index (GI)
(H>70,M 56-69,L<55)
Foods GI Foods GI
Black beans 30 Glucose 100
Lentils 30 Honey 74
Black eye bean 30 Cane sugar 65
Corn 52 Coconut palm sugar 35
Oat 55 fructose 23
Barley 35 Agave 19
Millet 71 Orange 37
Brown rice 75 Apple 39
White rice 83 Banana 47
Whole wheat 70 Grapes 59
White bread 75 Watermelon 76
Sweet potato 61 Udon 62
potato 90 Rice noodle 61
Calcium requirement depends on lifestyle

• 1 gm animal protein ---- loss I mg calcium

• 1 gm sodium( 2.5 gm salt)---loss 15 mg calcium
• I gm potassium save 20 mg calcium
• Sugar and refine CHO create acidic environment and
encourage calcium loss
• Exercise and Sunshine ( Vit D) improve calcium
absorption
• Green leafy vegetables are a good source of calcium
 Harvard University 2005
a more scientific food guide
 Discrepancy between nations on calcium requirement

US WHO UK China Singapore

2m 210 Human milk: 300 525 300 Human milk: 300
Cow milk: 400 Cow milk: 400
4m 210 Human milk: 300 525 300 Human milk: 300
Cow milk: 400 Cow milk: 400
6m 210 Human milk: 300 525 400 Human milk: 300
Cow milk: 400 Cow milk: 400
12 m 270 400 525 600 500
24 m 500 500 350 600 500
36 m 500 500 350 600 500
48 m 800 600 450 800 600
60 m 800 600 450 800 600
 Risks of advising to drink
2/3 glasses of milk per day

• Milk allergy
• Lactose intolerance
• Saturated fat
• Extra calories leading to obesity
• Impair appetite for whole grains and
vegetables
• Unneeded hormones
• Possible increase in prostate or
ovarian cancer
Strategy to prevent obesity is the
same as that of cancer
1/11/2007
1/11/2007
 WCRF HK’s Recommendations for
Cancer Prevention
1. Be as lean as possible without becoming
underweight
2 . Be as physically active for at least 30 minutes every
day
3. Avoid sugary drinks. Limit consumption of energy-
dense foods (particularly processed foods high in
added sugar, or low in fibre, or high in fat)
4. Eat more of a variety of vegetables, fruits, whole
grains, and pulses such as beans
 WCRF HK’s Recommendations for
Cancer Prevention
5. Limit consumption of red meats (such as beef, pork
and lamb) and avoid processed meat. ie More at risk
of cancer if taking more than 2 oz (70 gm) meat /day
6. If consumed at all, limit alcohol drinks to 2 for men
and 1 for women a day
7. Limit consumption of salty foods and foods
processed with salt (sodium)
8. Don't use supplements to protect against cancer
Recommendations also good for DM, CHD and general health
 WCRF HK’s Recommendations for
Cancer Prevention

Special Population Recommendations

9. It is best for mothers to breastfeed exclusively

for up to 6 months and then add other liquids and
foods
10. After treatment, cancer survivors should follow
the Recommendations for Cancer Prevention
Hippocrates 500BC

Let food be thy Medicine and

let Medicine be thy food.

「汝之食物即葯物，汝之葯物即食物」
 Summary of Part II
• For the same amount of energy provided in foods
with CHO, protein and fat, the food source is very
important for health reasons.
• Whole grains, beans, seeds and nuts, variety of
vegetables and fruits can provide good sources of
CHO, protein and fat.
• Animal products, processed meat and refined CHO
with chemicals should be taken in moderation with
caution.
Further information
 CHO in typical American diet

• Cake, sweet rolls, doughnuts, pastries

• Bread, rolls, buns, English muffins, bagels
• Potato chips, corn chips, popcorn
• French fries, potatoes
• Pizza
• Soft drinks, sodas, fruit-flavoured drinks
• Beer
 CHO in HK diet

• Refine rice
• Chinese foods made with rice flour– rice
noodle, sticky rice dumplings and sweets,
wheat flour noodles and dumplings, sweet
teas, varieties of Chinese sweet desserts and
snacks from all over China
• As above, effect of westernisation
 Brown rice better than white rice
• Higher satiety value with the fibre
• More nutrients, higher in vitamins,
trace minerals,
protein and fat (good fat)
• More health benefits
• No roller coaster effect on blood
sugar and prevent hyper-insulinism
 Sugar and Insulin

After digestion, simple sugar is absorbed to blood

stream, stimulating secretion of insulin which helps
to open up muscle cell membrane and other cells to
utilize or storage– excess stored as fat.
Flood of insulin can drive glucose levels too low,
causing hunger and further eating.
Such glucose-insulin roller coaster can be smoothed
out by whole grain CHO and protein.
 Insulin resistance
• A result of overconsumption of refine CHO
• Physical inactivity and too much storage fat
• Dietary fat too low in PUFA, too high in trans
fat
• Genes: more prone in Asians, Native
Americans, Pacific Islanders than Europeans
• Insulin resistance is linked to BP, TC,
DHL, CHD & some cancer
 Dietary fat
• Traditional American diet 40 % daily energy
• Traditional Chinese / Japanese diet 15 % only
• Breast milk contains fat that is 50 % of energy,
such high energy food is required for the
rapid growth of infants
• Weaning process is one to reduce dietary fat
• Dietary fat is required to provide essential
fatty acids , to carry fat soluble vitamins /
phytochemicals and to provide satiety effect
 Various dietary management in
Obesity
• Low fat diet Dr. Ornish diet 10% of
daily energy

• High fat diet Dr. Atkins diet > 50%

• Mediterranean Diet Dr. Key 30 % (8 %

saturated fat from fish and plants)

• Healthy Eating Pyramid Dr. Willett

 Bad fat
• Bad fat increase TC, TG and decrease HDL,
linked to CHD, and other health damaging
faults, like immunity disorder, and possibly
cancer
• Saturated fat from red meat, whole milk
• Trans fat in processed food, bakeries, fried
food in restaurants. Health risk is worse than
saturated fat
Content of Trans Fat before regulation
• 7 gm trans fat : 50 % more likely to develop CHD over
a 14 yr compared to those < 1 gm

• One serving of M French fries 3 gm

• One serving of Donuts 6 gm
• One serving of KFC chicken pie 8 gm
• One serving of Burger King Fish Sandwich 3 gm
• One serving of Swiss Rolls 2 gm
• One serving (3 pieces) Oreos cookies 2 gm
 Good Fat
• Monounsaturated and polyunsaturated fat
from vegetable oil, nuts and seeds, whole
grain and fish
• Good for the heart. But excessive can also
lead to obesity
• Essential fat , omega 6 and 3 , in right
proportion (4:1 instead of 20:1)
 EFA
• Omega 3 reduce obesity and ease DM
• Excess omega 6 and deficient in omega 3
leads to insulin resistance
• source of omega 3: algae, fish, walnuts, soya
bean, flaxseed
• Source of omega 6 : vegetable and seed oil
 Protein- animal vs vegetable
The more animal protein in the diet, the more
DM, heart disease and cancer
Also note the protein package
Red meat and whole milk- saturated fat, grilling
and frying cause cancer
Beans, nuts, whole grain vegetables-low in sat
fat and high in fibre
Environmental destruction and pollution: 20 lbs
of corn to make 1 lb of beef
Too much animal protein cause calcium loss
from the bones
 Fish as source of protein
• Good source of omega 3
• Beware of mercury contamination and other
pollution
• Avoid shark and shark fin, tuna and big fish
• Don’t over eat.
• Recommendation in US, Australia– for
children and pregnant women, not more
than 3 x a week.
 Fat brain Healthy mind
• Fat free diet in rats showed a failure to grow, weight
loss, scaly skin, kidney damage and premature death.
This can be reversed with omega 6
• Brain cells without sufficient quantity of omega 3 FA
in membranes cause dysfunctional behaviour in
animal studies
• Omega 3 deficiency is associated with CHD, major
depression, manic-depressive disorder, Arthritis, DM,
RA, Crohn’s, Lupus, Asthma; in pregnant mothers
associated with premature birth, ADH, postpartum
depression; in teenagers: hostility, violence; in elderly:
stroke, dementia
 Go nuts
Replace meat with nuts

Eat nuts as snack

Choose non roasted ones

But don’t overeat, avoid those that got rancid

 Beans
• Most studied : soy bean

• Good source of protein and phytoestrogen–

isoflavones and lignans

• Again, don’t overeat

Dark green vegetables

• A good source of vitamins, minerals and

phytochemicals, protect the heart, the vessels,
the bones, the eyes and cancer prevention

• Children’s eating behaviour starts very early–

embryo stage, breast –fed stage, weaning stage
and then childhood. Influence from parents very
important
 Calcium nutrition, I
• There is cultural difference in dietary source of calcium

• Our Chinese ancestors had survived with strong bones

to do heavy manual work without eating high dietary
ca

• Genetically we are adapted to a habitual ca intake

much lower than the milk drinking populations

• Our ancestors’ diet was plant based. They used to work

outdoor, had plenty of physical activity and sunshine.
 Calcium nutrition, II

• Dietary calcium is important for health, not just for bone but
for nerves, muscles, blood pressure, etc

• Hypertension, insomnia, anxiety and depression

( premenstural) can be improved or prevented by taking
adequate calcium or calcium – magnesium

• It is good to pay attention to foods that is rich in calcium but

it is also important to know the other associated minerals

• That’s why high doses of calcium alone may be harmful. Ca-

Mg is better
Healthy vegetarian foods

• Whole grain
• Little cooking oil
• Little salt
• Little sugar
• Good variety
• Some in raw
• In natural form
+B12
USA 1992, did not reduce CHD in US
USA 2005, still with political and economic consideration
Poor feeding in HK infants/children

1. Too rapid wt gain in infancy

2. Predispose to future childhood obesity
and metabolic syndrome
3. Allergic disorders ( GI bleeding, regurgitation, infant
colic, eczema, allergic rhinitis, etc)
4. Constipation
5. Frequent infections ( URI, Tonsillitis)
6. Abdominal discomfort
7. Easy fatigue
8. Growing Pain and behavioural disorder
 Optimal nutrition in children
• Starts with good preparation of mother before and
during pregnancy
• Full breast feeding for 6 months
• Weaning onto a whole grain plant based solid food
with a sensible amount of meat, fish and egg
• Monitor growth-- to be within normal range, and
genetically appropriate
• Free of illness, happy relationship with parents
 Children > 2 yrs do not have to

• Drink milk (every day )

• Eat pork (every meal, every day)
• Eat fish (every meal, every day)
• Eat egg (every day)
Early detection of overweight and
obesity in infancy and childhood by
routine growth monitoring
and
prompt dietary advise can be given
 Weight control in obese children
• Exercise
• No over-eating
• 3 main meals at the right time
• Whole grain
• Good fat
• Moderate amount of protein—plant/animal
• High fibre
• Plenty of vitamins, minerals , phytochemicals and
antioxidants
Decrease in body fat can be a normal phenonmenon around 1
year and should not taken as resulting from a poor diet.
Traditional plant based diet, 3 year old child–
self feeding , 3 meals per day, no milk
 References:
• Eat, Drink and be healthy, 2005, Walter Willett, Harvard
University

• Nutrition guide for Clinicians, 2007, Physicians Committee

for Responsible Medicine

• 育兒新知--讓孩子生長得最好,2010,梁淑芳,全心出版社

• 飲食配合濕疹治療,2013,梁淑芳,香港預防醫學協進會

• 廚房醫學,2016,梁淑芳,香港預防醫學協進會