Staying Healthy with O.I. Pediatric Nutrition

oif.org

Staying Healthy with O.I. Pediatric Nutrition

Staying Healthy with O.I.

Pediatric Nutrition

Sharon Werner RD CDE CD-N

Registered Dietitian

Certified Diabetes Educator

Mother of best kid in world

OI Parent

July 2012


Disclosures

‣ Connecitcut Children’s Medical Center:

Endocrinology

• Dietitian – Diabetes Educator

‣ Animas / LifeScan

• Insulin pump trainer

‣ Medical Nutrition Therapy Associates:

• Director

• Private practice nutrition counseling and

weight management: In person and Skype


Nutrition Related Health Issues

‣ Constipation

‣ Swollowing difficulties

‣ Failure to Thrive

‣ Small appetites, big energy needs

‣ Weight Management

‣ General good nutrition

‣ Vitamin D and Calcium

‣ Getting Active


Preventing Constipation

‣ An ounce of prevention is better than a pound of cure!

‣ Causes reduced appetite and vomiting

‣ Constipation vs encopresis (incontinence of feces not due to organic

defect or illness)

‣ Causes:

• Medications (anti-seizure, pain meds – especially opiods,

antidepressants, antihistamines)

• Low fiber diet

• Inadequate fluid (not thirsty / avoiding bathroom)

• Nerve damage, pelvic shape, hypotonia, obesity

• Stress, ignoring the urge

• Calcium and iron supplements, diet changes

• Inactivity


How much fiber?

‣ Old Way: Age plus 5g, or 0.5g/Kg per day, or 14g /

1000 calories

‣ Adequate Intake (per NIH)

‣ 0-6 months

None set

‣ 7-12 months None set

‣ 1-3 years

19 g/day

‣ 4-8 years

25 g/day

‣ Boys 9-13 years 31 g/day

‣ Boys 14-18 years 38 g/day

‣ Girls 9-13 years 26 g/day

‣ Girls 14-18 years 26 g/day


How much fluid?

‣ For infants and children:

• 1-10 kg 100-150 mL/kg

• 11-20 kg Add 50 mL/kg over 10 kg

• >21 kg Add 25 mL/kg over 20 kg

‣ Adolescents:

• 40-60 mL/kg


Resolving constipation

‣ Increase fiber, especially soluble fiber

‣ Drink plenty of water to avoid obstructions

‣ Physical activity

‣ Avoid laxatives: they reduce vitamin D

absorption and cause dependence

‣ Love that Miralax (Polyethylene Glycol): start the

same day you start pain meds

‣ Colace (stool softener)

‣ Initiate bowel retraining program


Fiber Sources

‣ Start slooowly (too much = > constipation and <

calories)

‣ Fruits and vegetables = best choices

‣ Beans, peas and lentils

‣ Nuts and Seeds (choking hazard < 3 years /

lying down)

‣ Whole Grains and Oatmeal

‣ Strive for Five (5 g fiber per serving)

‣ Supplements and mineral oil (last resort – can

cause nutrient deficiencies)


Swallowing Difficulties

‣ Aspiration

‣ Gastroesophageal reflux (GER)

‣ Frequent pneumonia may result from

silent aspirations (no cough)

‣ Needs to be assessed by a Speech

Therapist

‣ May need a barium swallow test


Signs of swallowing difficulties

‣ Facial weakness, decreased sensation

‣ Congestion, noisy “wet” sounds

‣ Coughing/choking/gagging before, during

or after a swallow

‣ Food refusal

‣ History of upper respiratory infections

‣ Poor intake

‣ Inefficient and lengthy mealtimes

‣ Inappropriate progression of feeding skills


Modified Consistency Meals

‣ Thickened liquids

• rice cereal or commercial thickeners

‣ Liquid

‣ Blenderized (broken jaw)

‣ Pureed (developmental disorders)

‣ Mechanical soft (dental surgery /

transition)

• Chopped, ground or mashed


Failure to Thrive (FTT)

‣ Growth failure under 3 years old

• Altered infant-caregiver interaction

• Delayed development

• Abnormal behavior

• Oromotor or sensory disorders

• Multifactorial

• Secondary due to chronic disease

• inadequate energy intake, inadequate absorption,

excess metabolic demand, or defective nutrient

utilization


FTT Contributors

‣ Too many simple carbs

‣ Over-restricting fat

‣ Excess fluids

• Limit milk to 24 oz per day for 1 and 5 years to promote

adequate intake of other nutrient-dense foods and to prevent

iron-deficiency anemia

• apple juice may induce fructose and sorbitol malabsorption

‣ Iron deficiency

• suboptimal intake or inadequate nutrient absorption, leads to

poor appetite

‣ Vitamin D deficiency: supplement when breast feeding

‣ Vitamin B12 deficiency: Strict vegetarians and Vegans are at risk

‣ Zinc deficiency

• Growth failure, skin lesions, alopecia, irritability, poor appetite


Small appetite – big energy

needs

‣ Children with OI may have a higher

metabolic rate

‣ Scoliosis may reduce stomach volume

‣ Pain reduces appetite

‣ Trauma increases energy needs

‣ Control issues

‣ Bathroom issues


Energy dense foods

‣ Heathly fats

• Olive oil, Canola oil

• Nut butters (over 2 years old)

• Nuts (over 3 years old)

• Avocado

• Wheat germ, ground flax seed meal

‣ Saturated fats

• Butter, cream, cream cheese, cheese

‣ Others

• Dried fruits (great for constipation too)


Weight Management

• Underweight:

• Due to: poor appetite (pain), scoliosis (organ

compression), high metabolic rate

• Problems: reduced immunity, hormonal

imbalance, nutrient deficiency, growth stunting

• Overweight:

• Due to: lack of physical activity, excessive calories,

hormonal imbalance

• Problems: musculoskeletal stress, fractures,

diabetes, heart disease


Ideal Body Weight

‣ BMI: (pounds / (inches * inches) * 703

• E.g. Weight 50 lb. Height 42 inches

• BMI is 19.9

Ideal adult BMI is 19 – 25. 27 or 28 is closer to

the norm for adults with OI.

Waist circumference: not a valid measure for

people with OI

How do you feel about yourself?


Healthier Food Choices

‣ The basics:

• Eat lots of non-starchy vegetables (1/2 your plate)

• Choose whole grains

• Include dried beans and lentils

• Include fish 2-3 times per week (Omega 3s)

• Choose lean meats

• Non-fat dairy

• Don’t “drink your calories”

• Small quantities of liquid fats

• Watch out for “snack attacks”

• Beware of “portion distortion” - even with “health foods”


Wise Choices

‣ Subway vs MacDonalds

‣ Salad Bar vs Pizza

‣ Mustard or hummas vs Mayonaise

‣ Water vs Soda or Juice

‣ Grilled vs fried

‣ Lemon juice + herbs vs butter + salt

‣ Whole wheat vs refined or white

‣ Fish vs Spare Ribs or Rib-Eye

‣ Fruit vs Candy


Look familiar?


General Good Nutrition

‣ Aim for a healthy weight by choosing sensible portions

and being physically active every day

‣ Eat at least 5 servings of vegetables and fruits every day

‣ Choose a variety of grain foods, especially whole grains

‣ Choose plenty of Calcium rich foods

‣ Limit saturated and trans fat, and cholesterol and

moderate total fat

‣ Limit caloric beverages (including 100% fruit juice,

“punches”, iced teas, Gatorade/vitamin water, soda)

‣ Moderate the use of salt

‣ Avoid alcoholic beverages


Plate Method


Meal Planning

• Plate Method – good starting point for

nutritionally balanced meals

• Counting Carbs – great for weight loss AND

BG control

• Helps minimize junk food

• 1 – 3 yrs 25 to 40g per meal, less than 6g snack

• 4 – 7 yrs 35 to 50g per meal

• 8 - 12 yrs 50 – 65g per meal

• 13 – 18 yrs 65 to 85g per meal


Dairy

‣ High in protein, calcium and vitamin D

‣ Fat free or 1% milk or yogurt

‣ Avoid “fruit on the bottom”

‣ Why go Greek? – Loaded with protein

‣ Lactaid or enriched soy

‣ Rice milk = very little protein

‣ Cheese – limit to 1 oz of low fat per day


Fruit

‣ All fruit has carbs

‣ NO fruit juice unless BG is low

‣ Fresh or frozen (no added sugar)

‣ Size counts!

• 1 serving = 1 fist size (big kids get more)

• 1 banana = 2 servings

• 2 to 3 servings per day

‣ Great in salads or as a snack


Low Carb Vegetables

‣ Fresh or frozen (no sauces)

‣ The more the merrier

‣ Dipping raw veggies

• Hummus, salsa, fat free cottage cheese

‣ Let the kids grow them

‣ Sneak them on sandwiches

‣ Try new recipes www.allrecipes.com


Grains / High Carb Veg

‣ Size counts! ½ cup – 1 cup total

‣ Grains:

• Rice, pasta, couscous, barley, quinoa

‣ High Carb Vegetables:

• Potatoes, sweet potatoes, yams, peas, corn,

lima beans, winter squash, plantains


Protein

‣ Keep it Lean!

‣ Eggs, fish, chicken, turkey

‣ Meatless Mondays (great for the budget)

• Beans, lentils, tofu, tempeh

‣ Avoid: sausages, hotdogs, ribs, bacon

‣ Grill or bake – Limit fried food

‣ Avoid the breading


Also important…….

• High fructose corn syrup Fructose and

NAFLD

• Good reason to eliminate juice and soda!

• Check labels for high fructose corn syrup

• Vitamin D: RDA for teens is 600 IU per day

• Probably not enough, especially for obese teens

and teens with poor diets

• Up to 80% are deficient / insufficient

• Usually on 1,000 IU daily or Replesta 50,000 IU

weekly for 8 to 12 weeks, then maintenance.


Vitamin D and Calcium

‣ Like PB and J, they go together

‣ Calcium:

• 0-6 months 200 mg/day

• 7-12 months 260 mg/day

• 1-3 yrs 700 mg/day

• 4-8 yrs 1000 mg/day

• 9-18 yrs 1300 mg/day

• > 18 years 1000 mg/day

• Women > 51 1200 mg/day

• Men > 71 1200 mg/day

• No weight related guidelines available


Calcium

• Influenced by:

• Protein, caffeine, soda, fiber, bone turnover (urine

loss), age, obesity, medications, and fat

malabsorption

• Min. 700 mg per day Max 4000 mg (UL)

• Aim for 1000 to 1300 mg, ideally from food

• Supplements: Calcium Citrate or Calcium

Carbonate (with food)

• Small doses, twice a day (cut tablet in half)


Calcium Sources (mg)

‣ Fortified oatmeal, 1 packet 350

‣ Cheddar cheese, 1½ oz. shredded 306

‣ Milk, nonfat, 1 cup 302

‣ Yogurt, plain, low-fat, 1 cup 300

‣ Tofu, firm, with calcium, ½ cup 204

‣ Orange juice, fortified with calcium, 4 oz. 150

‣ Salmon, canned, with edible bones, 3 oz. 181

‣ Baked beans, 1 cup 142

‣ Cottage cheese, 1% milk fat, 1 cup 138

‣ Frozen yogurt, vanilla, soft-serve, ½ cup 103

‣ Cheese pizza, 1 slice 100

‣ Turnip greens, boiled, ½ cup 99

‣ Broccoli, raw, 1 cup 90


Vitamin D – A Powerful Hormone

‣ Needed for:

• Calcium absorption

• Calcium / Phosphate balance: N.B. ESRD

• Bone remodeling

• Immune function

• Control of inflammation

• Modulates many genes encoding proteins that

regulate cell proliferation, differentiation, and

apoptosis (cancer promotion or prevention?)

• Pain Management? (Shriner’s research)

• Prevention of DM, HTN, IGT, MS ?


Vitamin D Sources

‣ Produced endogenously (by our bodies)

when ultraviolet rays on the skin trigger

Vitamin D synthesis

‣ Food:

• Egg yolks, nuts, beans, salmon, tuna,

mackerel, poultry, lean meats, fortified foods

‣ Supplements

• D2 (ergocalciferol)

• D3 (cholecalciferol)

• D3 is up to 3 times more effective at raising

serum calcidiol levels (contraversial).


Vit D: Why so many names?

‣ Vitamin D must go through 2 processes to

become active:

• The liver converts vitamin D to calcidiol, or

25 hydroxyvitamin D, written as 25 (OH)D.

This is what the blood tests measure.

• Then the kidney converts calidiol to the active

form: a hormone called calcitriol, or

1,25 – dihydroxyvitamin D,

written as 1,25 (OH) 2 D


Testing Vitamin D levels

‣ Serum concentration of 25(OH)D (calcidiol) is

the best indicator of vitamin D status due to its

long half-life of 15 days

‣ Does not reflect body stores (fat soluble)

‣ The active form, 1,25 (OH) 2 D (calcitriol) is NOT

a good indicator of vitamin D status as it has a

very short half-life of 15 hours, and is closely

regulated by parathyroid hormone, calcium and

phosphate.

‣ Calitriol levels only drop when deficiency is very

severe


Vitamin D

IOM Report 2011

Age Calcium RDA UL Vitamin D RDA UL

mg mg IU

0 to 6 mths 200 1000 400 1000

6 to 12 mths 260 1500 400 1500

1 to 3 years 700 2000 600 2500

4 to 8 years 1000 2500 600 3000

9 to 13 years 1300 3000 600 4000

14 to 18 years 1300 3000 600 4000

19 to 30 years 1000 2500 600 4000

RDA for Calcium: Meets needs of > = 97.5% of population

RDA for vitamin D: supports serum 25OHD level of 20 ng/ml


How much is too much?

‣ UL, per NIH, is 4000 IU: some prescribe more

‣ Intake level at which Vitamin D is toxic is unknown

‣ Sun exposure and food, other than cod liver oil, do not

cause toxicity.

‣ Toxicity more likely from long-term supplements

‣ Large doses for a short period increase stores, not

toxicity. E.g. 50,000 IU /week for 8 weeks

‣ Serum calcidiol:

• < 20 ng/ml = deficient

• 20 – 29 ng/ml = insufficient

• 30 ng/ml or more = adequate

• >200 ng/ml (>500 nmol/L) = potentially toxic


Risks of Overdosing Vit D

• Kidney stones (17 to 20% increase)

• Pancreatic Cancer (Finnish study)

• Birth defects

• Excessive Calcium blood levels, altered

mental status, arythmia

• Delayed sexual maturity

• Side effects: nausea, vomiting, poor appetite,

constipation, weakness, and weight loss.


Getting Active

‣ Benefits of increased physical activity

• Improved functioning of cardiovascular system

• Improved strength and physical work capacity (N.B. lungs)

• Enhanced mobility and balance (less falls - less fractures)

• Decreased risk for coronary artery disease (CAD)

• Lower LDL and triglycerides

• Higher HDL

• Lower blood pressure

• Reduced stress / improved quality of life and self-esteem

• Reduced weight

• Reduced insulin resistance / increased insulin sensitivity

• Reduced hyperinsulinemia (proposed risk factor for

atherosclerosis)

• Enhanced fibrinolysis / less risk of clotting

• Higher lean muscle: body fat ratio (burns more calories at rest)


Getting Active

‣ Medical clearance for physical activity

‣ Customizing an exercise regimen that’s right for you

• Minimize risk of injury

• Avoid boredom: Mix it up

• Make it time effective

‣ Get professional help

• Physical Therapist

• Rehabilitation Specialist

‣ Implementing

• Schedule it!

• Make it a priority

• Buddy up

• Ideas: Wii Fit, swimming, chair exercises, deep breathing


Use your health-care team

‣ Medical Nutrition Therapy (MNT) provided

by a Registered Dietitian (R.D.)

• Part of your health-care team

• Diagnose underlying nutrition issues

• Individualize plan for lifestyle changes

• Treat to goals for weight, blood glucose,

cholesterol, blood pressure

• Translate research into useable information

• Improve health and quality of life


Conclusion

‣ Get tested today: Annual physical

‣ Expand your knowledge

‣ Set achievable goals

• Measurable

• Realistic

‣ Modify lifestyle with

• Healthier food choices

• Daily physical activity

‣ Tap into local resources

You’re not alone

References: http://www.nutritioncaremanual.org/

More magazines by this user
Similar magazines