healthier children living longer through better …...healthier children living longer through...
TRANSCRIPT
Healthier Children Living Longer Through Better Nutrition: Strategies to Promote and Support Healthy Diets
Prepared By:
Prof. Daniel Sellen, Jane Francis, Jim OldfieldJoannah & Brian Lawson Centre for Child Nutrition
November 21, 2017Public Health Ontario Grand Rounds
Learning Objectives
1. Identify strategic priorities and promising practices that aim to address needs and challenges in childhood nutrition
2. Highlight needs and opportunities for solutions-oriented engagement to address and improve nutrition throughout childhood
3. Discuss key considerations for enhancing provincial public health partnerships to promote, protect and support healthy diets for all children
Approach: Discussion of ongoing activities at the University of Toronto’s Joannah & Brian Lawson Centre for Child Nutrition
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Outline1. Current challenges in childhood nutrition
q Ontario and beyond
2. Joannah & Brian Lawson Centre for Child Nutritionq visionq missionq contextq priorities
3. Ongoing child nutrition projects activities by Centre scientists specifically related to
q Ontario provincial prioritiesq Lawson Centre priorities 3
Child Nutrition Challenges (1) Achieving appropriate nutrition for all in early life:
- foundational for long life + health + wellbeing (+ human capital….)
• Pre-conception, gestation, infancy, early childhood (“first 1,000 days”)
• Preschoolers, school age and adolescence
• Gender, equity and healthy aging
• Malnutrition: development biology/genetics + nutrients + “omics”
Mainstreaming nutrition knowledge:• A global effort based on rationale of “human capital formation”
• e.g. the Scaling Up Nutrition initiative (SUN)
• Nutrition-specific vs nutrition-sensitive
• Knowledge translation and engagement (KTE)• Health practitioners, child caregivers, multi-sectoral stakeholders 4
Child Nutrition Challenges (2)
Narrowing continuing gaps in research, knowledge, education, equity
• Preterm births and low birth weight
• Growth faltering
• Common nutrient deficiencies
• Child overweight, obesity and diabetes
• Drivers of choice vs drivers of poverty
• Purchasing power, food and nutrition security
• Nutritional health literacy vs. message fatigue & confusion
• Loss of trust in experts
• Nutrition “education”: need for “how-to-shop, prep, serve” vs “what to feed”
What? vs How?5
Canadian ChallengesOverweight and Obesity• 1.6 million children (31% children aged 5-17)
Poverty• 1.2 million children (17% children <18 years)• Among large urban centres in Canada, Windsor, Ontario had highest rate of
children living in low-income households (24%)
Food insecurity• 1.15 million children (17% children <18 years)• 15% of Ontario children lived in food insecure households
Changing policy and legislative landscapes• Canada Child Benefit, Ontario menu labelling, Healthy eating strategy, Basic
income pilot
6Rao DP et al. Health Promote Chronic Dis Prev Can (2016); Roberts KC et al. Health Rep (2012);
Zhang X. Statistics Canada (2017); Tarasuk et al. Household Food Insecurity in Canada, 2012. PROOF Report (2014)
Global Challenges
From the 2017 Global Nutrition Report:
• 88% of countries face a serious burden of either 2 or 3 forms of malnutrition
• 2 billion people lack key micronutrients like iron and vitamin A
• 155 million children are stunted• 52 million children are wasted
• 41 million children are overweight• 2 billion adults are overweight or obese
• “Nourishing the SDGs”?
7www.globalnutritionreport.org @GNReport #NourishtheSDGs #NutritionReport
Joannah and Brian Lawson Centre for Child Nutrition
VisionHealthier children living longer through better nutrition
MissionSupport research, education and policy to improve nutrition in children,
families and communities, in Canada and around the world. 8
http://www.childnutrition.utoronto.ca/
Strategies
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Overweight
Obesity
Malnutrition
Food Insecurity
Translate Knowledge
Ensure Food
Security
Develop Talent
CreateHealthier
Food
Partnerships
Faculty of Medicine
Lawson Centre• Nutritional Sciences• Family and Community Medicine• Paediatrics
Potential for impact and reach• The leading Faculty of Medicine in Canada• 2,663 graduate education trainees• 3,659 post-MD education trainees• 8,243 faculty• 36 full, associate, community and clinical affiliations across Ontario
• Includes City of Toronto Public Health and Public Health Ontario
10University of Toronto Faculty of Medicine Dean’s Report (2017)
Faculty of Medicine
By the numbers…
• Research • 9,312 Total Awards• $859 million Total Funding
• Contributions to Physician Supply and Distribution• 35% of family physician who trained in Ontario did so at U of T• 55% of specialists who trained in Ontario did so at U of T• 55% of family physicians and 70% of specialists in the GTA are U of T
graduates (excluding Toronto LHIN)(Source: 2015 Ontario Physician Human Resources Data Centre)
11University of Toronto Faculty of Medicine Dean’s Report (2017)
Internal CollaborationsExperts
• Social Determinants of Health• Behavioural science• Anthropology• Health policy• Knowledge translation• Nutrition• Family and community medicine• Paediatrics
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U of T• Dalla Lana School of Public Health• Banting and Best Diabetes Centre• Departments of Obstetrics &
Gynaecology, Physiology, Psychology• Lawrence S. Bloomberg Faculty of
Nursing• Rotman School, Munk School,
engineering, and more…….
Research Community• St. Michael’s Hospital• Alliance for Human Development• SickKids• TARGet Kids! Courtesy of: Gustavo Toledo Photography
25 Clinician Scientists / Researchers
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Lawson Centre
Nutritional Sciences
Paediatrics
Family & Community Medicine
Harvey Anderson
Richard Bazinet
Zulfiqar Bhutta
Elena Comelli
Anthony Hanley
David Jenkins
Mary L'Abbé
Deborah O’Connor
Daniel Sellen
John Sievenpiper
Valerie Tarasuk
Christopher Tomlinson
Robert Bandsma
Catherine Birken
Jill Hamilton
Jonathon Maguire
Shaun Morris
Patricia Parkin
Daniel Roth
Onil Bhattacharyya
Michael Coons
Eva Grunfeld
Nav Persaud
Karen Tu
Daniel Moore
Kinesiology & Physical Education
Provincial Child Health InitiativesNUTRITION-SENSITIVE
• Ontario Healthy Kids Strategy & Healthy Kids Community Challenge
• Healthy Babies Healthy Children
• Healthy Schools: Daily Physical Activity Policy
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NUTRITION-SPECIFIC
• Ontario Food and Nutrition Strategy & Basic Income Pilot
• NutriSTEP®
• Ontario Student Nutrition Program
• EatRight Ontario
Provincial Child Health InitiativesNUTRITION-SENSITIVE
• Ontario Healthy Kids Strategy & Healthy Kids Community Challenge• Dr. Mary L’abbé
• One Sweet App• Dr. Patricia Parkin
• TARGet Kids!• ‘Thought Leader’• Iron deficiency risk tool
• Dr. Catherine Birken• Scientific reference committee• TARGet Kids!• Obesity and health care utilization• Obesity management app
• Healthy Babies Healthy Children• Dr. Deborah O’Connor
• Preterm infant human milk fortifier• OptiMoM research program• Rogers Hixon Ontario Human Milk Bank• PINSTEP (w/ Prof. Dan Sellen)
• Healthy Schools: Daily Physical Activity Policy 15
NUTRITION-SPECIFIC
• Ontario Food and Nutrition Strategy & Basic Income Pilot• Dr. Valerie Tarasuk
• Food insecurity and health care and data integrity
• NutriSTEP®• Drs. Patricia Parkin & Catherine Birken
• TARGet Kids! data collection
• Ontario Student Nutrition Program
• EatRight Ontario
Dr. Mary L’AbbéNutrition facts tables in Canada do not identify Free Sugar, only Total Sugar
Free Sugar• Sugar no longer in its naturally occurring state (i.e. whole fruits, vegetables,
unsweetened dairy, grains)• Consumed as is, or incorporated into other foods
• Table sugar, syrup, honey, fruit juice and nectar• 63.5% Canadian prepackaged foods contain free sugar ingredients
One Sweet App• Smartphone app to identify total and free sugar in packaged foods
• Scan barcodes or search database• Track teaspoons of sugar consumed
16WHO. Guideline: Sugars Intake for Adults and Children (2015); Bernstein et al. Nutrients (2016)
Dr. Patricia ParkinThe Applied Research Group for Kids (TARGet Kids!) investigator• Lead investigator
• OptEC: Optimizing Early Child Development in the Primary Care Setting: Pragmatic Randomized Trial of Iron Treatment for Young Children with Non-Anemic Iron Deficiency
One of 19 ‘thought leaders’ asked by the Healthy Kids Panel to provide advice on the provincial Healthy Kids Strategy in 2012• Chaired the Working Group on Child Obesity Prevention and Screening
Guideline, Canadian Task Force on Preventive Health Care
Co-investigator on Lawson Centre grant to develop and validate an early childhood (ages 1-3 y) iron deficiency risk stratification tool for primary care doctors
17Parkin P et al. Recommendations for growth monitoring, and prevention and management of overweight and obesity
in children and youth in primary care. Canadian Medical Association Journal;187(6):411-21. (2015)
Dr. Catherine BirkenScientific Reference Committee for Healthy Kids Community Challenge: Co-PI and Co-I on two evaluation effectiveness studies
TARGet Kids!• Lead investigator
• PROMOTE: Preschoolers at Risk – Obesity and Cardiometabolic Risk Factors: Towards Early Identification
• Fit for school, fit for life: Child health and school readiness• PARENT trial: Parenting and public health home visits towards obesity
prevention in early childhood
PI on study of severe obesity in children 0-18 years in Ontario and its impact on health care utilization through Electronic Medical Records
Co-I to develop a smartphone app for personalized management of obesity by adolescents with and without disabilities
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Dr. Deborah O’Connor
Co-invented a human milk fortifier • Used globally to improve preterm infants’ development and growth
Co-chairs the Rogers Hixon Ontario Human Milk Bank advisory board• The milk bank provides a safe supply of human donor milk for low birth weight
infants in Ontario
Principal author of the Society of Obstetricians and Gynaecologists of Canada Clinical Practice Guidelines• “Canadian Consensus on Female Nutrition: Adolescence, Reproduction,
Menopause, and Beyond”
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Dr. Deborah O’Connor
Co-leads multiple research programs with Dr. Sharon Unger to improve the health of preterm infants through nutrition and the use of human milk
• MaxiMoM (Maximizing Mothers’ Milk for Preterm Infants)
• OptiMoM (Optimizing Mothers’ Milk for Preterm Infants)
• DoMINO (Donor Milk for Improved Neurodevelopmental Outcomes)
• microDoMINO (Impact of feeding type and nutrient fortification on the gut
microbiome of very low birth weight infants)
• Parkdale Infant Nutrition Security Targeted Evaluation Project (PINSTEP) co-principal investigator with Prof. Daniel Sellen
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Dr. Valerie Tarasuk
PROOF research program principal investigator• Purpose: to identify policy approaches to reduce household food insecurity
Over 4 million Canadians experience food insecurity• “inadequate access to food due to financial constraints”• Associated with:
• Poor physical, mental and social health among children & adults• Increased health care costs
• Households with children <18 y at greater risk than households without children• Most vulnerable are lone-parent families headed by women
• Households relying on social assistance are another highly vulnerable group
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Tarasuk V et al. CMAJ (2015); Melchior M et al. PLoS One (2012);Kirkpatrick SI et al. Arch Pediat Adol Med (2010);McIntyre L et al. J Affect Disorders (2013); Vozoris NT & Tarasuk V. J Nutr (2003) ;
Tarasuk V et al. Household Food Insecurity in Canada, 2014. PROOF Report (2016)
Dr. Valerie TarasukFood insecurity and data integrity• Dr. Tarasuk and colleagues are making the scientific case for mandatory
data collection• Public service announcements• Journal commentary• Media outreach• In-person presentations provincially
• Data is used to produce reports and guide public health strategies
• In 2015/16, Ontario, Newfoundland & Labrador, and Yukon did not collect food insecurity data
• Canadian Community Health Survey (CCHS) will include mandatory food insecurity module in 2017/18, but Statistics Canada has not committed to making it required thereafter 22
Lawson Centre Priorities
• “Discovery” Science(Applied + Basic Research)
• Implementation Science
• Knowledge Translation
• Policy Impact
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Courtesy of: Yobro10, Dreamstime
Discovery Science Dr. Elena Comelli
Lawson Family Chair in Microbiome Nutrition Research
Microbiome patterns associated with specific growth trajectories in school age children: Interactive effects of diet and social determinants of health• 2016 Microbiome and Nutrition Collaborative Grant• Co-PI Dr. Robert Bandsma
Purpose• Aims to study children into adulthood to determine role of microorganisms,
diet, and socio-economic environment on their growth patterns• Little is known about how various microorganisms in children’s guts impact
nutrient absorption and long-term health 24
Discovery Science Dr. Elena Comelli
Methods• 5-year study on groups of pre-adolescent children in Toronto + Pelotas, Brazil• Collaboration with TARGet Kids! and the Federal University of Pelotas• 2004 Pelotas birth cohort
Impact• Multi-disciplinary study of growth and the microbiome• First data on gut microbiome composition of adolescents in Canada and Brazil
Additional area of study• Nutritional programming - how the mother’s diet during pregnancy and
breastfeeding impacts the offspring’s microbiome and long-term health?
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Discovery Science Dr. Jonathon Maguire
HOLD IT: Health Outcomes from low Vitamin D in Toddlers
Purpose is to determine whether
• low vitamin D in children is associated with development of fractures, asthma, viral upper respiratory tract infections, lower respiratory tract infections, obesity or hypertension
• there is a vitamin D dose response relationship with adverse health outcomes
Methods• Longitudinal cohort study to assess vitamin D level and health outcomes
annually during regularly scheduled primary healthcare visits for 4 years in the previously established cohort of healthy children 1-5 years old.
• Recruited via TARGet Kids! 26
Discovery ScienceDr. Jonathon Maguire
Impact• Provide evidence on early childhood low vitamin D levels and later adverse
health outcomes• Multiple peer reviewed publications: e.g. recent JAMA article • Policy impact
27Courtesy of: Alex Raths, Dreamstime
Discovery ScienceDr. Richard Bazinet• Neurological development linked to nutrition• Brain lipid metabolism
• Lipid requirements of infant brains
Dr. David Jenkins• Dietary portfolio
• Lower cholesterol and diabetes risk (Low Gycemic Index diet) using foods and limit reliance on drugs that may have side effects over life time
Dr. Harvey Anderson• Physiology of food intake control in children
• Age, sex, pubertal stage, body fat, macronutrient composition of food• Folate, neuronal development and fetal programming of obesity & metabolism
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Implementation Science Dr. Deborah O’Connor and Prof. Daniel Sellen
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Parkdale Infant Nutrition Security Targeted Evaluation Project (PINSTEP)• Research partnership with Parkdale Community Health Centre (PCHC)
Purpose• Phase I: comprehensive evaluation of PCHC infant feeding support program• Phase II: transfer learnings to test breastfeeding support intervention in
additional community sites in Toronto
Impact• Data on infant feeding practices and experiences of vulnerable mothers• Model to promote and support breastfeeding in vulnerable groups• Guide implementers and policy makers
Knowledge TranslationDr. John Sievenpiper
Nutrition in medical education at U of T• Lifestyle medicine program
• Culinary medicine workshop
• Endocrine and metabolism in-class learning
• Nutrition learning objectives throughout pre-clerkship
• Postgraduate medical training
• Continuing professional development
30Courtesy of: Jim Oldfield & University of Toronto
Nutritional Medical Education Coordinator
Knowledge TranslationDr. Mike Evans
Knowledge translation communications media projects• Translating complex nutrition research into engaging & simple videos for the
public, patients and physicians
Whiteboard health videos• DocMikeEvans YouTube channel• ‘Med School for the Public’• https://www.youtube.com/watch?v=9WC8A1Lrq8M
31Courtesy of: Dr. Mike Evans & Reframe Health Lab
Policy ImpactDr. Valerie Tarasuk
Implications of household food insecurity for maternal and infant health• 2016 Public Policy and Child Nutrition Collaborative Grant
Purpose• Determine how household food insecurity affects pregnancy and birth outcomes• Identify maternal characteristics and household circumstances associated with
household food insecurity at this life-stage
Impact• Develop policy recommendations to lessen the risks of food insecurity in pregnancy
and reduce food insecurity among families
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Policy ImpactDr. Mary L’Abbé
Evaluating food environment to support healthy eating among children• 2016 Public Policy and Child Nutrition Collaborative Grant
Purpose• Examine nutritional quality of foods most relevant to Canadian children • Determine impact of 3 recent policies on nutritional quality of foods and diets:
• Voluntary sodium reduction targets• Children’s Food and Beverage Advertising Initiative• Menu labelling
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Policy ImpactDr. Mary L’Abbé
Methods• Collect nutritional information on foods from the largest Canadian grocery
retailers and restaurants in 2017• Assess changes in nutrients and overall healthiness of foods before and after
policy implementation• Link information with children’s intake data from 2015 CCHS to assess how the
3 policies affected diets
Impact• Evidence to evaluate food policies on child nutrition• Inform future policy development
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Policy Impact Drs. Catherine Birken, Jonathon Maguire, Patricia Parkin
TARGet Kids!• Innovative collaboration: researchers, physicians and families• Co-ordinated by SickKids and St. Michael’s Hospital• Largest Canadian children’s cohort
• Enrolled >9,000 Ontario children• Growth, development, health, learning
Purpose• Link early life exposures to health problems including obesity,
micronutrient deficiencies, and developmental problems• Identify childhood nutrition and health problems associated with adult
conditions (literacy, mental health, cardiovascular health)• Prevent common health problems before they begin• Improve quality of children’s primary health care 35
Policy Impact Drs. Catherine Birken, Jonathon Maguire, Patricia ParkinMethods• Longitudinal cohort study with embedded clinical trials
• Data collection at annual primary heath care visits• Lifestyle questionnaires (nutrition, physical activity, screen time),
anthropometrics, blood sample• Parental height, weight, waist circumference
Impact• Disease prevention and child health promotion• Establish evidence-based recommendations for primary healthcare• Embedded knowledge translation
Mission: partner with community health care providers, families and children and create knowledge to raise healthy children 36
Acknowledgements
Thank you to
John McLaughlinMaggie CivakDeborah BrewsterDon Newton
…… and all the scientists mentioned in today’s presentation!!
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Thank you!
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