Vegetarian Diet in Pregnancy: Insulin Resistance in Children

For many years now there has been a push in the United States to convince the public they need to consume less animal foods and more plant-based foods. Earlier this year I reviewed our dietary habits based on consumption patterns in the US as documented by the Food and Agriculture Organization (FAO) and the Economic Research Service (ERS) of the USDA and was really shocked by the level of intake for added sugars, cereal grains and vegetable oils.

The most recent assault on common sense came this week when Newsweek featured The Fertility Diet on its cover, promoting it and the findings from epidemiological data that was the basis of the book as a proven way to eat to enhance fertility. As I noted in my review of the book and study earlier this week, the study findings and book "do not make a proven strategy or evidence-based approach to prevent or reverse ovulatory dysfunction."

I didn't write much about the potential effects on babies born to women consuming such a diet because the post was already very long. However, it needs to be discussed considering new data published this week. For all intents and purposes, The Fertility Diet is recommending a predominently vegetarian diet - limit red meat and animal foods, strictly limit saturated fat, favor protein from beans and include full-fat dairy. This is almost identical to how the population in India eats!

A study published in the January 2008 issue of Diabetologia, Vitamin B12 and folate concentrations during pregnancy and insulin resistance in the offspring: the Pune Maternal Nutrition Study, highlights the profound effect on the offspring of women consuming an habitual vegetarian diet. [link opens to full-text of paper]

In the abstract we learn the researchers set out to understand how elevated total plasma homocysteine concentrations predict birth weight and risk factors for type II diabetes - "We studied the association between maternal vitamin B12, folate and tHcy status during pregnancy, and offspring adiposity and insulin resistance at 6 years."

To do this they followed 700 pregnant women in six villages (and their children) over six years; "We measured maternal nutritional intake and circulating concentrations of folate, vitamin B12, tHcy and methylmalonic acid (MMA) at 18 and 28 weeks of gestation. These were correlated with offspring anthropometry, body composition (dual-energy X-ray absorptiometry scan) and insulin resistance (homeostatic model assessment of insulin resistance [HOMA-R]) at 6 years."

What the researchers found was not only disturbing, but may have long-term implications not considered critical to long-term health of children previously.

In the table presenting the maternal nutrition data during pregnancy, we learn the women consumed adequate calories - the majority did not consume meat, poultry or fish, but did consume dairy (milk, yougurt, cheese, etc.).

At week 18 of pregnancy, the majority of calories in the diet came from carbohydrate - 70%, fat contributed 17% of energy and protein 13%; at 28 weeks of pregnancy the dietary macronutrient ratios were similar - carbohydrate 72%, fat 16%, protein 12%. The women (without folic acid supplementation) consumed a diet righ with foods high in folate, as evidenced by the finding that only one woman in the whole group was deficient for folate - all others exceeded levels desired in pregnancy.

Alarming however was the finding that the majority were deficient for vitamin B-12 - 60% of the women had blood levels of B-12 less than 150pmol/l. While the finding was alarming, it was not unexpected since the women were not consuming meaningful intakes of animal foods from which we find vitamin B-12 in our diet - the majority of the women were vegetarian, consuming a high carbohydrate, low-fat diet - the type of diet, in fact, promoted in The Fertility Diet book.

The women in the study seem to have done well in their pregnancies and gave birth to healthy babies, some were low birth weight, but as I said, they were overall "healthy."

So why then am I writing about this study?

Well, the effect on their children, over the next six years was telling and speaks volumes about how diet and micronutrient intakes during pregnancy may effect offspring.

When the researchers followed up on the children six years later, they found a seemingly healthy bunch of kids - "At 6 years, the children were light, short and had a low BMI compared with an international (UK) reference; none were overweight or obese as defined by International Obesity Task Force criteria."

You would think that was good news, wouldn't you?

Well, it wasn't their outward appearance or their normal BMI that was problematic, it was their fatness and insulin resistance at age six that shocked the researchers!

"...skinfold thickness measurements showed that the children were relatively truncally adipose; the mean SD score for subscapular skinfold thickness was -0.42 compared with the UK growth standards, in contrast with -2.23 for weight and -1.86 for BMI. Higher fat mass and higher body fat per cent were associated with higher fasting insulin concentrations, higher HOMA-R and higher 120 min plasma glucose concentrations (p = less than 0.05 for all)."

A few paragraphs later we learn, "The highest HOMA-R was in children whose mothers had the lowest vitamin B12 and highest folate concentrations."

What this means is that the children born to women consuming the highest levels of folate rich foods - green leafy vegetables and beans - and the least (or none) animal foods, had children with the highest risk of insulin resistance!

The researchers opened their discussion section bluntly, "We have demonstrated for the first time in a purposeful, community-based prospective study an association between maternal nutritional measurements in pregnancy and two major risk factors for type 2 diabetes in the offspring," and didn't stop there, "higher maternal folate concentrations predicted greater adiposity (fat mass and body fat per cent) and higher insulin resistance, and lower vitamin B12 concentrations predicted higher insulin resistance. Children born to mothers with low vitamin B12 concentrations but high folate concentrations were the most insulin resistant."

They concluded with "...our data raise the important possibility that high folate intakes in vitamin B12-deficient mothers could increase the risk of type 2 diabetes in the offspring. This is the first report in humans to suggest that defects in one-carbon metabolism might be at the heart of intra-uterine programming of adult disease."

If you are pregnant or planning to conceive, you may want to think twice before shunning foods that provide vitamin B-12 - meats, eggs, poultry, fish and dairy!

Only the Finest Propaganda will Solve Childhood Obesity

Yes, life sometimes gets in the way of my blog posts; rather than keep you waiting for a fully referenced article I was hoping to post as follow up to the new recommendations to address childhood obesity, issued jointly from the AMA, CDC and HHRS, I'm going to keep this short and point first to a massive, 400+ page, document - Preventing Childhood Obesity: Health in the Balance - published in 2005 by the Food & Nutrition Board (FNB) of the Institute of Medicine (IOM) that painstakingly reviewed the evidence published regarding childhood obesity.

When you take some time to read it, you'll notice some critically important statements thoughout:

"Empirical data is lacking..."

"...problem exists, causes less clear..."

"...little clarity about the relative importance of possible causitive factors..."

"...a robust evidence base is not yet available."

"In reviewing the available evidence to inform this report, there was an abundance of scientific studies on the causes and correlates of obesity, but few studies testing potential solutions with diverse and complex social and environmental contexts, and no proven effective population-based solutions."

But that's okay, let's press forward without hard data; the latest AMA recommendations seem to have ignored the above lack of data and even ignored that the IOM document specifically states that within their publication there is "limited literature upon which to base these recommendations..." and chose instead to concentrate on "...parallel evidence from other public health issues..." to side-step empirical data and move forward to modify public opinion anyway.

"Now that the nation has begun to realize the significant health, psychological and societal costs of an unhealthy weight, it is time to re-examine its way of thinking and revise the social norms that are now accepted."

"In the absence of precise understanding of the eitology of the problem, it may be useful to look at the lessons learned from other public health campaigns and to try and determine if these lessons have any relevance for the prevention of childhood obesity."

Their playbook to resolve childhood obesity? Lessons learned from tobacco control, seat belt enforcement, underage drinking, childhood vaccination, and regulation of speed limits; with the most notable precedent examples throughout the section on Lessons Learned from Public Health Efforts and their Relevance to Preventing Childhood Obesity being the stunning success of tobacco control initiatives, that now leave smoking, in the minds of the majority of society, "nearly considered, if not deviant behavior, at least one in private;" and they note the magnitude of the change in public perception of smoking over the years of gradual change, from a time when smoking was viewed as a private matter, to now when smoking is viewed as a moral failing and deviant behavior.

They note, "Culture is not a static set of values and practices," and that programs to prevent and reverse obesity need to balance "the role of coersion versus the individual."

Coersion?

How they fail to see the under-current of shame and moralizing a behavior like smoking is scary. We're going to now do this with children, kids who happen to weigh too much for their age and height? Have we lost our minds?

Oh, it just gets better though.

The 'best practices' to be employed in a national campaign to address childhood obesity:

• Community-wide campaigns
• School-based initiatives
• Mass media strategies
• Laws and regulations
• Provider reminder systems
• Reduce costs to patients
• Home visits

The list includes elements of both formal planned interventions and recognized cultural and social factors. Detailed too are the necessary elements to convince the population at large there is a problem that requires drastic measures:

• A persuasive science base documenting a socially and scientifically credible threat
• A supportive partnership with the media
• Strategic leadership and a prominent champion
• A diverse constituency of highly effective advocates
• Enabling and reinforcing laws, regulations and policies

Notice above, the critically important factors are not solid evidence, but persuation, packaging the message for the media to propogate to the public, repeat the message through advocates and champions, and regulating laws and policies to conform to the pursuasive messages.

That's not science, that's carefully orchestrated propaganda.

"Propaganda is the deliberate, systematic attempt to shape perceptions, manipulate cognitions, and direct behavior to achieve a response that furthers the desired intent of the propagandist." Source: Garth S. Jowett and Victoria O'Donnell, Propaganda And Persuasion, 4th edition, 2006

This is what public health experts intend to do to our children.

In stunning clarity, the document provides insights into what we can expect in the coming years:

"Tough choices will have to be made at all levels of society. There will be trade-offs in convenience, in cost, in what's 'easy', in pushing oneself and one's organization, in choosing between priorities, in devising new laws and regulations, and in setting limits on individuals and industries."

The second document I'd like to direct your attention to is from the US Preventative Task Force, published in 2006, Screening and Interventions for Overweight in Children and Adolescents: Recommendation Statement.

It states, "There is insufficient evidence to ascertain the magnitude of the potential harms of screening or prevention and treatment interventions. The USPSTF was, therefore, unable to determine the balance between potential benefits and harms for the routine screening of children and adolescents for overweight."

Now, in 2007 - with no new science and still no compelling evidence, no empirical data, absolutely nothing more than "hope" this will work, the AMA, CDC, and HHRS is jumping in with both feet, and expects all of us to do the same; expects we'll all get on board, full steam ahead with little more than our fear that if we do nothing, our kids are going to die prematurely; anything is better than nothing.

Except that anything is may wind up destroying our children in the long-term.

But hey, they won't be fat, right?

The direction we're now heading in stubbornly and without evidence, reminds me of something Aldous Huxley said in a speech at the California Medical School in San Francisco, 1961:

"There will be in the next generation or so a pharmacological method of making people love their servitude and producing dictatorship without tears, so to speak, producing a kind of painless concentration camp for entire societies so that people will in fact have their liberties taken away from them but will rather enjoy it ... [through] brainwashing enhanced by pharmacological methods."

In the 1953 publication of The Impact of Science on Society, Bertrand Russel penned the following:

"Scientific societies are as yet in their infancy. . . . It is to be expected that advances in physiology and psychology will give governments much more control over individual mentality than they now have even in totalitarian countries. Fitche laid it down that education should aim at destroying free will, so that, after pupils have left school, they shall be incapable, throughout the rest of their lives, of thinking or acting otherwise than as their schoolmasters would have wished." "Diet, injections, and injunctions will combine, from a very early age, to produce the sort of character and the sort of beliefs that the authorities consider desirable, and any serious criticism of the powers that be will become psychologically impossible."

Oh, Yeah, That'll Work

An article in Sunday's Independent (UK) paints an ominous picture of what may be coming down the pike as a way to solve the epidemic of childhood obesity; simply take these children from their families and place them in care of the state.

"Doctors are calling for the parents of obese children under the age of 12 to be targeted under child protection laws and for their offspring to be taken into care."

Next month a motion will be presented at the British Medical Association (BMA) conference that will include provision for social workers to "treat childhood obesity as neglect" and allow state intervention, including removal from the home.

"Dr Matt Capehorn, who will present the motion on obesity in Torquay, said: "No healthcare professional would want to break up a family unit but this has to be considered if the child's health is being put at risk." Dr Capehorn, a GP, runs an obesity clinic in Rotherham, South Yorkshire."

The motion comes on the heels of our own American Medical Association releasing its latest Expert Committee Recommendations on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity document on June 6, 2007. Noticably absent - media coverage to highlight its release!

Take some time to read it, I'll be writing more in depth about what appears to be in the works for us here in the United States! I'll note where the evidence stands for the recommendations in the document and point out data that's obviously being ignored in the efforts to reduce the prevalence of obesity in children.

Keep in mind as you read the document, this is from the same organization led by Dr. William Plested III, president of the American Medical Association, who was quoted as saying at a recent Rotary Club meeting in Jacksonville, Florida, “We’re going to pay for this with a generation of ‘fatsos’ with every disease you can imagine.”

Nice, huh?

Study: Pediatricians Failing our Kids!

Earlier this week the Buffalo News carried Pediatricians slow to treat childhood obesity; an article critical of pediatricians - they were found in a survey to be "failing in large numbers to take Step 1 in the manual of fat prevention — calculating a child’s body mass index, or BMI." [emphasis mine]

Here readers are led to believe that Americas pediatricians are negligent in their basic duties of standard care for children - they're not calculating out BMI to "prevent" obesity in children.

Never mind the fact that the large majority are indeed weighing and measuring children at their routine well-child visits; ignore they have eyes to see and recognize a child who is too heavy; and heck, let's just forget they have experience, experience, experience, with years of taking care of kids to recognize the difference between an obese child and a normal child in their care.

Nope, let's just chastise them for exercising clinical judgement in their practice of medicine because they're not in lock-step with the additional recommendation to now calculate and chart BMI to "prevent obesity."

**sigh**

Some days I'm just tired of the misinformation and misleading of the public.

Calculating a BMI is data collection - nothing more; nothing less - and like any data collection, its usefullness is only as good as what one does with the data in hand.

Data such as a calculated BMI does not prevent disease (obesity); it is only a piece of a larger picture, and is a piece of data that is considered by many to be highly unreliable as a predictor of health.

Imagine for a moment you're a doctor, a pediatrician, and you've just weighed and measured this child:




















He's five, stands 3'10" tall and you've determined he weighs 54-pounds, thanks to the nurse who weighed and measured him then added those figures to his chart before you entered the exam room.

You give him the once over and note he's lean and healthy; his mother tells you he's very active, quite a little monkey outside climbing, running and jumping whenever he has a chance - and you note too that he is itching to get out of your office as quickly as possible, laughing gleefully as you continue along with your physical of him.

Do you calculate his BMI at this point in time?

No? No you say?

Why, you've missed this healthy and active kid is at the 95th percentile according to the BMI - in children, that's "overweight," the politically correct way of classifying a child who registers obese on the BMI chart.

In this example, this child is one of the roughly 15% in our nation classified as "overweight" for age.

So much for your clinical judgement - you failed to recognize the fat kid in need of intervention to improve their diet and activity levels before they develop other diseases correlated with obesity!

**sigh**

So what are we to make of the survey?

How about some context.

The researchers reviewed the charts of 400 children and found pediatricians calculated BMI in roughly 1 in 20 children; while 91% did actually weigh and measure height in kids.

Somehow the researchers failed to ask or look at those who were calculated to compare to those not calculated - perhaps these pediatricians fail not in their care, but rather fail to see the usefulness of calculating each and every child, especially those obviously a healthy weight.

Let's do math!

According to the IOM, it's estimated that roughly 15% of children this age are at or above the 85th percentile for BMI. A closer look defines an estimated 10% are at or above the 95th percentile for BMI.

Children who hit the 85th percentile for BMI are said to be "at risk for overweight" and those who reach the 95th or higher are said to be "overweight."

Stated another way, 85% of kids are well within normal weight, and some are underweight (as problematic potentially as obesity) with BMI calculated below the 85th percetile; another 5% may be "at risk" for becoming overweight/obese because they fall between the 85th and 94.9th percentile for BMI.

Simply put - 90% of children today are not obese; 85% are not obese or at risk for overweight.

But we don't hear or see that much in the media, do we?

The media and authorities, it seems, are working really hard to scare the beejeebers out of parents these days.

Yes, the prevalence of children who are calculated as having a BMI at or above the 85th percentile has indeed increased. Where in the 70's roughly 5% of children were at or above the 85th percentile, today roughly 15% are.

But we're communicating the increased prevalence in terms designed to make the increase an issue for every parent to not only worry about, but do everything in their power to change, when the fact is that 85% of children are normal weight (or underweight).

We're not just targeting adults with the message we have a problem in the United States - today every child is being targeted - with messages about diet, exercise, risks to future health, and even the potential of premature death; hearing, repeatedly, they'll die at an earlier age than their parents because kids today are too fat.

We really need to ask ourselves, must we target all children in our attempts to reduce obesity in some children, or are our resources and time better spent when they're directed and focused on the children who really do need some help?

While it may seem useful to chastise pediatricians, whom are quite competent in their daily practice of medicine, for not calculating every child's BMI - maybe a better question is why are they being asked to when 85% of the kids walking into their office each day are not too heavy?

Do we really think pediatrians are so daft they'd visually miss recognizing an obese child?

Do we really want to require a doctor to spend time calculating out the BMI for all children s/he sees and chart they actually did calculate it out too, when 85% of the patients are likely to be below the 85th percentile?

Add to this, a percentage of the children falling at or above the 85th percentile are not really overweight or obese - by the simple BMI they are, but as the above picture illustrates visually, the BMI is not always an accurate measure of true fatness that should cause concern.

How useful is it really, in the long-term, to have every parent in America wondering if their pediatrician is failing their child because they're not calculating BMI at the office visit?

Impact of Community Based Diet Intervention, More than BMI

There's been a lot of fuss over the publication of the Shape Up Somerville: Eat Smart Play Hard.™, initiative results in the May issue of Obesity. (abstract)

As noted in the abstract, the objective "was to test the hypothesis that a community-based environmental change intervention could prevent weight gain in young children" as reflected in the change in BMI z-score.

In total, 1,178 children were enrolled - 385 in Somerville (the intervention group), and two control communities, one enrolling 561 children to be followed, the other 232 children to be followed. All the children were in grades 1 through 3 at the beginning of the study period, school year 2003-2004 (September to June).

The intervention was intensive, and expensive.

Overall, the researchers started with a $1.5-million dollar CDC grant. And, if that were not enough, the Tufts website notes the grant "received supplemental support from The US Potato Board, Dole Food Company, Blue Cross and Blue Shiled of MA. It is also supported through generaous donations by Whole Foods Market, WGBH, New Balance, Gaining Ground, Annie’s Homegrown, Stonyfield Farm, Organic Valley, White Wave, Earthbound Farms, Shaw’s Supermarkets, Cabot Creamery, Friendship Dairies, Newman’s Own, The Vermont Bread Company, and the Kashi Company."

The Wall Street Journal included some idea of this supplemental support in quantifiable terms...

"...the Tufts researchers helped the city win a grant from the Robert Wood Johnson Foundation for a bigger-ticket item, an extension of a bike path that will eventually go all the way to Boston. "

"...the City Council came up with its own ideas: reimbursements on gym membership for city employees and dozens of new bike racks for schools and streets."

"...Dr. Economos persuaded a Whole Foods store to donate about $35,000 in fresh produce."

"...a Department of Homeland Security grant is providing fitness equipment at fire stations and chefs to train the firefighters about nutrition and healthy meals."

"...a doctor sponsors the community fun run."

So, it's hard to add up all the additional monies and in-kind donations to know the true cost of the initative, but Somerville has secured an additional $1.5-million dollars to continue the efforts.

What exactly happened in Somerville that so much attention is focused on this small town?

Throughout the city of Somerville, the efforts to place the towns children on a diet and increase activity included:

• School lunches, classroom snacks and fundraisers revamped


• Teachers were trained to implement the new health curriculum, called The HEAT Club (Health Eating and Active Time)


• School Staff Role Modeling implemented


• After school program policies created for snacks


• After School policies for physical activity developed


• Increased time for recess, lunch, and physical education


• Annual height and weight data collected with reports for parents


• Monthly newsletter was sent to parents


• Monthly community newsletter to community members


• Parent education forums held for non-english speaking parents


• Area restaurants developed "Shape Up Approved" menu items


• Safe Routes to School maps were created


• Crosswalks were re-painted in thermoplastic material


• Bike racks installed at elementary schools


• School nurses and area Pediatricians were educated about taking weight and height of children

I don't think they missed an opportunity to intervene, do you? No Child Left Behind - heck, this was an "in your face" intervention, with no one left behind.

Throughout Somerville, it was impossible to escape the Shape Up Somerville messages.

So you'd think the results would be impressive given the media's attention the last few weeks.

The researchers trumpted "A community-based environmental change intervention decreased BMI z-score in children at high risk for obesity. These results are significant given the obesigenic environmental backdrop against which the intervention occurred. This model demonstrates promise for communities throughout the country confronted with escalating childhood obesity rates."

Based on their results that found over eight months, "At baseline, 44% (n = 385), 36% (n = 561), and 43% (n = 232) of children were above the 85th percentile for BMI z-score in the intervention and the two control communities, respectively. In the intervention community, BMI z-score decreased by –0.1005 (p = 0.001, 95% confidence interval, –0.1151 to –0.0859) compared with children in the control communities after controlling for baseline covariates."

Simply put, the kids in the intervention group gained about 1-pound less than the kids in the two control towns who received no intervention.

They didn't lose weight, they just gained less, which is expected - growing children gain weight each year (or are supposed to).

Within the full-text we find a curious table designed to highlight the effect of this intervention, Estimated intervention effect over 8 months on a child at the 75th percentile BMI z-score, which seems contrary to the objective of reducing the incidence of overweight and obesity, which is defined as a BMI that places a child in the 85th percentile or higher.

Nonetheless, the researchers included it to show how the intervention would effect children at the 75th percentile - children, it should be noted, already within the definition of a "healthy weight" for age.

It seems to have escaped many that with or without intervention such a child would remain within "normal, healthy" weight, as evidenced in the table data included.

Case in point - highlighted in the table - a boy, at baseline 8-years old has a BMI of 17 and is in the 75th percentile. Eight months later, without intervention (it's hypothesized) he might grow about an inch-and-a-half and gain 5.07 pounds; with intervention, just 4.25-pounds (a difference of 0.82-pounds, or about 12-ounces).

Without intervention the child's BMI is now 17.4; with intervention it is now 17.17 - in both instances the BMI increased, right?

But in both instances the child in this scenario fell on the charts, going from the 75th percentile to the 73.9 percentile without any intervention and the 71.1 with intervention, and at a cost of $1.5-million to keep this hypothetical child well within "normal" when he would have remained there anyway?

I wondered, what happened to the kids who were overweight or obese to start - the 170 of 385 children in the intervention.

As I combed through the data, another curiosity - no data was provided to show the intervention was effective for this particular subset of children within the intervention group.

Why was that data not provided?

I would think that would be the icing on the cake for the researchers to highlight the benefit of such an intense intervention, wouldn't you?

So, I got to thinking, what changes, based on the data provided, might happen for a child within this group?

The researchers neatly summed up the hypothetical child within normal, so how about we create the same table for a child who was at the 95th percentile at baseline to see what might happen.

Johnny is 8-years old, he stands 4' 2.25" and weighs 72-pounds - BMI 20.1, 95th percentile.

In eight months, like the scenario presented by researchers, he now stands 4' 3.75" (growing 1.5") and without intervention is likely to weigh 77-pounds (gained five pounds); with intervention he'd weigh about 76-pounds (gained four pounds).

Without intervention he's fallen to the 93.8 percentile; with it he's fallen to the 93rd percentile.

Yes - with or without intervention this hypothetical child went from "overweight" to "at risk for overweight" - which begins to explain the absence of data on the subject of where the children were on the charts at the end of the study period.

I'm not trying to say we shouldn't try to help children engage in more activity or eat a healthier diet, but quite frankly, these results are not as impressive as we're being led to believe.

We have no data to look to in our understanding of how this type of aggressive community-based intervention impacted children already underweight or at the bottom of "normal, healthy" weight; we have no clue as to how this type of intervention impacted those children who were well within "normal, healthy" weight; and without the hard data we don't know that any of this helped those children at risk for or already overweight!

I'd like to see the data and also see someone investigate impacts in other areas of life, like reading and math scores. Sandy Szwarc, over at Junkfood Science, pointed out that "While the school year was absorbed in diet and exercise, (after the Shape Up program was completed in 2005) the average reading test scores among Somerville kids are 15.4% below state average, and their math test scores are a whopping 26% below those of kids in the rest of the state."

I did some poking around and found the Somerville MCAS testing stats online; in the 2003/04 school year, third grade reading scores indicated that 44% needed improvement or were failing; in the 2004/05 school year - these same students, now 4th graders, tested in ELA (english language arts) showed 63% now needing improvement or failing, and 73% needed improvement or were failing math (not tested in 3rd grade).

Just some food for thought, and a hat tip to Sandy for the educational impacts that may be part of the intiatives overall impact not recorded in the results that are focused on BMI z-scores.