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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