food and behaviour: putting caterers at the front …...food and behaviour: putting caterers at the...

Food and Behaviour:Putting Caterers at the Front

of the Health Agenda

Dr Alex RichardsonSenior Research Fellow, Centre for Evidence

Based Intervention. University of Oxford

Founder Director of the UK Charity, Food and Behaviour (FAB) Research

16 Apr 2004 - Times Educational SupplementBy Stephanie Northern

“The physical risks to children from a nutritionally poor diet are now acknowledged, but the damage being done to their behaviour, learning abilities and mood is not.”

“A Rotten Way to Feed the Children”

• The UK Government has been forced to pump £342 million into school behaviour improvement programmes. • The WHO predicts a 50 per cent rise in child mental disorders by 2020.• Dyslexia, hyperactivity, autism and related conditions all appear to be on the increase.

© A.J.Richardson, Food And Behaviour Research 2012


Childhood Behavioural and Learning Difficulties – The Overlap

Dyslexia

Autistic SpectrumDyspraxia

ADHD

• These diagnoses are descriptions – they are not explanations. • Difficulties are dimensional, affecting > 20% of UK school children


The role of Nutrition?• Appropriate nutrition is essential for:

– The growth and development of brains and bodies – Building, maintaining, fuelling and repairing every cell in

every part of the brain and body

• At least 39 essential nutrients must be provided by our food– These include vitamins and minerals, essential amino acids,

and omega 3 and omega 6 fatty acids

• Many of these are lacking from modern diets• Individual differences affect dietary requirements

– Specific nutrients may be needed in unusually high quantities– There may be allergies or intolerances to certain foods


Nutrition in Young Offenders(Gesch et al, 2002 Brit,J,Psychiat)

• Randomised controlled trial of dietary treatment

• 231 young offenders imprisoned at a high-security unit in the UK took part

• Each received either a multivitamin + fatty acid supplement, or a matched placebo

Could diet help to reduce violence and cut crime?


Gesch et al 2002: RESULTSAll Disciplinary Incidents - Intent to treat (ITT) =231.

1133 offences: Active vs Placebo: -26.3 % (p ‹ 0.027)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Rat

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Dis

cipl

inar

y In

cide

nts

Sup

plem

enta

tion/

Bas

elin

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ActivePlacebo

Active 1 0.737

Placebo 1 0.993

Before Supplementation During Supplementation

Error bars drawn at two standard errors to indicate the 95% confidence interval

Supplementation for at least 2 weeks: Active vs Placebo: -34.0%And for violent offences only: “ -37.0%


The unbalanced diet…


‘Poor Food Choices’1983 - 1997 64 % ↑ in consumption of

high-sugar drinks by children1998 - 2002 68 % ↑ in spending on crisps, chocolate, gum and cigarettes on the way

to school (£433m in 2002)

Most commonly eaten foods: Crisps, chips and chocolate barsLeast commonly eaten foods: Fruit and vegetables

Consumers’ Association report 2003. Food diaries for 246 primary and secondary pupils: diets were • High in saturated fat, sugar and salt• Low in many vital nutrients – including zinc, iron, protein,

calcium, folate and vitamins A and C.

Many children’s diets fail to provide adequate intakes of

essential micronutrients

(vitamins, minerals and essential fatty acids)


Typical for UK Children

Fruit & Veg

Starchy foods

Calcium rich dairy

Fatty/ Sugaryfoods

Protein

Many nutritional features of modern western-type diets are

evolutionarily novel and pathological• High Glycaemic Load• Altered Fatty Acid Composition• Altered Macronutrient Composition• Reduced Micronutrient Density • Acid-Alkaline Balance• Sodium-Potassium Ratio• Dietary Fibre


Sugar

Cordain et al. (2005) Origins and evolution of the western diet: health implications for the 21st century. Am J Clin Nutr, 81:341-54.


Sugar and ‘Refined Carbs’

Blood glucose metabolism


Sugary foods and drinks cause rapid swings in blood sugar (affecting mood, behaviour and

cognition)

Optimal range for brain function


‘Slow-release’ foods at breakfast help to keep blood sugar levels stable (minimising fluctuations

in mood, behaviour and cognition)

Optimal range for brain function


Sugar addiction?

• Evidence that intermittent, excessive sugar intake causes endogenous opioid dependence.Colantuoni C, et al (2002) Obesity Research,10(6):478-88.

• Opiate-like effects of sugar on gene expression in reward areas of the rat brain.

• Spangler R, et al (2004) Brain Research and Molelcular Brain Research, 19;124(2):134-42.

Sugar – the new poison?Robert Lustig Prof of Pediatrics at UCSF: Interview with New Scientist, 2011 on his Youtube lecture,

"Sugar: The bitter truth“

Q: Why Do We Consume so much Sugar?


• One reason is that it's addictive. The food industry knows that when they add fructose we buy more. That's why it's in everything.

• There are five tastes on your tongue: sweet, salty, sour, bitter and umami. Sugar covers up the other four, so you can't taste the negative aspects of foods.

• You can make dog poop taste good with enough sugar. In essence, that is what the food industry has done

Glucose vs Fructose• Glucose

– Used by all living cells as a source of energy– Absorbed directly into the bloodstream


• Fructose– Requires processing by the liver before its energy

can be used (technically – a ‘toxin’)– NO PROBLEM if consumed via eating fruits and

sweet vegetables (nature provides the antidote..)– NOT HEALTHY if consumed as a ‘white powder’

– i.e table sugar or High-Fructose Corn Syrup (both approx 50% glucose, 50% fructose.


All Calories are NOT equal(Lustig 2006 Nature Endocrinology)

• ‘Energy in, energy out’– Consuming more calories than are burned for energy leads to fat

storage. Yes, BUT:

• Conventional advice to ‘Eat Less, Exercise more’ does not work – because:– Consuming excess sugar can increase appetite and reduce energy

• Excessive calories from sugar (fructose) affect the balance of key hormones that regulate energy metabolism and appetite• Insulin resistanc, leptin resistance, increased ghrelin etc


Artificial Food Colourings and HyperactivitySchwab, D.W., Trinh, N.H. (2004) J Dev Behav Pediatr 25(6) 423-434


Food Additives also affect Behaviour in Children from the General Population

Two randomised controlled trials commissioned by the UK Food Standards Agency

• Bateman et al 2004 - Arch Dis Childhood; 89: 506-11 The effects of a double blind, placebo-controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children.

• McCann et al 2007 - Lancet; 370 (9598): 1560-67 Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial


Diets high in refined, packaged & processed foods lack many essential nutrients (& fibre)

• Fruit and vegetables are lacking– the ‘5-a-day’ message still isn’t working… – and vitamin and mineral content has fallen

• Whole, unrefined foods are lacking– these should provide fibre, and key micronutrients

• Omega-3 fatty acids are lacking– found in fish and seafood, green vegetables, some nuts &

seeds (…not children’s favourite foods…)

What’s missing from our diets ?

Many nutritional features of modern western-type diets are

evolutionarily novel and pathological• High Glycaemic Load• Altered Fatty Acid Composition• Altered Macronutrient Composition• Reduced Micronutrient Density • Acid-Alkaline Balance• Sodium-Potassium Ratio• Dietary Fibre


Cordain et al. (2005) Origins and evolution of the western diet: health implications for the 21st century. Am J Clin Nutr, 81:341-54.

Fat


Food and mood

Depression shows strong associations with diet

Omega-3 fatty acids(found in fish and seafood)

seem to be a protective factor


r =-0.84 p <0.005

Fish Consumption and Major DepressionAnnual Prevalence by Country

W. Germany

Korea

0

1%

2%

3%

4%

5%

6%

20 40 60 80 100 120 140 160Apparent Fish Consumption (lbs./ person/year)

Maj

or D

epre

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n,

Ann

ual p

reva

lenc

e, (r

ate

/100

per

sons

)

Japan (0.12%)

New Zealand (5.8%)

United States (3.0%)

Puerto Rico (3.0%)

Taiwan (0.8%)

(2.3%)

Canada (5.2%)

France (4.5%)

(5.0%)

Hibbeln, The Lancet 1998; 351-1213


The paradigm governing human nutrition last century was

wrong

The main emphasis has been on physical growth (and dietary protein)


Human development is about the growth of the BRAIN, not the body –

and Nutrition is simply Critical


The human brain is 60% FAT

and it matters what kind

Dietary advice has not been taking this into account


Getting the Fats WrongMargarines and commercially baked or fried foods usually contain high levels of hydrogenated and trans fats

These are artificially saturatedand ‘twisted’ fats, which have• no known nutritional benefits• many health risks.

Trans fats compete with the essential fatty acids (omega-3 and omega-6) needed for brain and body health


Getting the Fats RightQuality, not Quantity

Some Fats are EssentialOmega-3 and Omega-6

Polyunsaturates


Changes in Dietary Fat Intake Dramatic increase in Omega-6 / Omega-3 Ratio


Dietary Sources of Omega-6omega-6

LA (Linoleic) 18:2

GLA 18:3

DGLA 20:3 *

AA (Arachidonic) 20:4 *

Adrenic 22:4

DPA(n-6) 22:5

Vegetable oils, nuts, seeds, grains

Meat, eggs, dairy products (milk cheese, butter, yogurt etc)

Evening primrose

oil

EFA

HUFA


Dietary Sources of Omega-3omega-3

ALA (α-linolenic) 18:3

18:4

20:4

EPA 20:5 *

DPA(n-3) 22:5

DHA 22:6

Green leafy vegetables, seaweed, & some nut & seed oils (flax, walnut, canola)

Fish and seafood

Shorter-Chain

Long-Chain (LC-PUFA)


What are omega-3 essential for?1. The structure of all cell membranes

– Omega-3 (and omega-6) LC-PUFA increase membrane fluidity, essential for optimal cell signalling

– 6-10% of the dry mass of the brain should be DHA

– DHA is particularly concentrated in nerve terminals, where chemical signals between cells are exchanged

– Concentrations of dopamine, serotonin, noradrenalin etc are influenced by omega-3 status


What are omega-3 essential for?1. The structure of all cell membranes

– Omega-3 (and omega-6) LC-PUFA increase membrane fluidity, essential for optimal cell signalling

2. Brain development– Omega-3 and Omega-6 LC-PUFA make up around 20% of dry

brain mass, and affect brain growth and connectivity– Supplementing infant formula with LC-PUFA (found naturally

in breastmilk) can improve visual and cognitive development

Growth of Brain Cells Enhanced by DHA

Total Neurite Length/Neuron (m)

Freq

uenc

y(N

umbe

r of N

euro

ns)

0

5

10

15

20

25Control

+ DHA

B

Control + DHA

Chow Diet Neurite measure-ments and fattyacid analysis

E2 E18 6 DIV

±1.5 µM DHA

Culture andfatty acidanalysis

Calderon and Kim, J. Neurochem. 2004Number of Branches/Neuron

Freq

uenc

y(N

umbe

r of N

euro

ns)

0

5

10

15

20


Omega-3 and VisionOmega-3 fatty acids from fish oils are absolutely essential to

the visual system

• 30-50% of the retina should be made of the omega-3 DHA

• At the earliest stages of visual processing, DHA deficiency can reduce retinal signalling by more than a thousand-fold

• Omega-3 deficiency is associated with poor night vision and other problems with visual, spatial and attentional processing.


What are fatty acids essential for?1. The structure of all cell membranes

– Omega-3 (and omega-6) increase membrane fluidity, essential for optimal cell signalling

2. Brain development– Fatty acids make up around 20% of dry brain mass, and affect

brain growth and connectivity– Supplementing infant formula with HUFA (found naturally in

breastmilk) can improve visual and cognitive development3. Maintenance of optimal brain function throughout life

– Cell signalling depends on membrane fluidity– Omega-3 and omega-6 fatty acids and their derivatives have

very powerful effects on most brain signalling systems– The substances we make from them can profoundly affect

hormone balance, blood flow and immune system function


Omega 6 and Omega-3 ‘functional fats’ – a matter of balance

A few simple dietary changes can make a big difference• Eat more: fish and seafood, green vegetables, nuts, seeds• Eat less: meat, dairy products, refined vegetable oils

The omega-6 AA(from meat, eggs and dairy products – or converted from LA in vegetable oils) gives rise to substances that• promote inflammation• promote blood clotting• narrow blood vessels

The omega-3 EPA(from fish and seafood – or converted from ALA in green leafy vegetables, flax seed etc) gives rise to substances that• reduce inflammation• reduce blood clotting• relax blood vessels


If dietary intake of omega-3 is increased,

will it help?

Evidence from Randomised Controlled Trials


Dysfunctions of Body and Mind that Omega-3 from Fish and Seafood can help

to prevent or ameliorate• Cardiovascular Disease

– Heart Disease and Stroke

• Inflammatory / Auto-immune Disorders– e.g. Rheumatoid Arthritis

• Visual Problems– ‘Retinopathies’ of Prematurity, Diabetes, Old Age

• Disorders of Behaviour, Learning and Mood?– Depression and other mental health problems– ADHD / Dyspraxia / Dyslexia etc


In Adults• Five recent ‘meta-analyses’ show:

– Significant benefits for depression (+ bipolar disorder) • American Psychiatric Association recommends >1g/day

EPA+DHA as an add-on treatment for mood disorders(Freeman et al, J. Clin Psychiat. 2006)

– Mixed results from studies including more varied populations and treatments (Appleton et al 2006, Rogers et al 2008)

In Children• One pilot RCT to date, showing significant benefits for

children with depression (Nemets et al, Am.J.Psychiat. 2006)

Omega-3 for Mood Disorders


EPA alone vs Prozac alone vs Both for major depression

Jazayeri et al (2008) Australian and NZ J Psychiat, (Epub ahead of print)


Omega-3 for Depression - EPA vs DHA?Sublette et al (2011) J Clin Psychiat

Omega-3 for Child Behaviour and Learning

Evidence from RCTs

Omega-3 from fish oils are effective in reducing ADHD symptoms


Bloch and Qawasmi 2011, JAACAP

• All showed specific difficulties in motor coordination (DSM-IV DCD)

• 40% were behind expected achievement in reading and spelling

• Over 30% scored in the clinical range for ADHD-type symptoms(>2SD above population means)

THE OXFORD-DURHAM STUDY:A randomised controlled trial of dietary supplementation with

fatty acids in children with developmental coordination disorder.

Richardson AJ & Montgomery P. Pediatrics, 2005, 115:1360-6

117 underachieving children aged 5-12 years from mainstream schools

Reduction in ADHD-related Symptoms

-0.10 0.00 0.10 0.20 0.30 0.40 0.50 0.60

Opposition

Cognitive Problems

Hyperactivity

AnxietyPerfectionism

Social Problems

Conners Index

CG Restless-Impulsive

CG Emotional LabilityConners Global Index

DSM Inattention

DSM Hyperactivity

DSM Combined-type

Treatment Effect Size (Mean change 0-3m / Pooled Baseline SD)

Placebo (N=52)Active (N=50)

Behaviour RatingsRichardson AJ & Montgomery P. Pediatrics, 2005, 115:1360-6


Reading and Spelling

Active treatment• Compared with expected

progress for normal children, gains were > 3 x normal rate for reading, > 2 x for spelling

Placebo• Gains were 1 x normal rate for

reading, < 0.5 x for spelling

Group Differences• Reading p < 0.004• Spelling p < 0.001

Improvements in Literacy Skills

0

3

6

9

12

Active (N=55) Placebo (N=57)R

eadi

ng /

Spel

ling

gain

(mon

ths)

Mea

n +/

- 1SE

Reading Age Gain 0-3mSpelling Age Gain 0-3m

Richardson AJ & Montgomery P. Pediatrics, 2005, 115:1360-6


The DHA (Docosahexaenoic Acid) Oxford Learning And Behaviour

(DOLAB) Study


DOLAB Study – Basic Design• RCT: 16 weeks of supplementation with DHA

(600mg/day) or placeboPopulation:

• 360 healthy children aged 7-9 years from mainstream schools

• Normal ability range, but reading < 20th 33rd centilePrimary outcomes:

• Reading• Behaviour (ADHD-type symptoms)• Working Memory

– All children invited to provide a finger-stick blood sample for Fatty Acid analysis (Martek Biosciences Inc, USA)


Reading

Implications / Practical Relevance

Reading Age changes• Improvements for Active treatment over Placebo

during the 4-month treatment period

33rd centile (n=362) - 0 months

20th centile (n=224) - 0.8 months (≈20% improvement)

10th centile (n=105) - 1.9 months (≈ 50% improvement)

Parent-Rated Behaviour – Sub-Scales

Parent-Rated Behaviour – Global Scales


Dietary need for Omega-3 (EPA/DHA)**Available evidence does not show similar health benefits from shorter-chain omega-3 (ALA), derived from plant sources

Recommendations from international scientific & health organisations

• General population - cardiovascular health: – ≥ 500mg / day EPA+DHA (ISSFAL Statements 2004, 2009, 15 other

International authorities 1989-2009)

• Depression or other mental health conditions: – ≥ 1000mg (1g) / day EPA+DHA (APA Freeman et al 2006, Hibbeln & Davis

2009)

• In the UK, US, Australia and Canada, most people consume less than 150mg/day


Fish and seafood provide other essential nutrients that few other foods contain

In addition to providing long-chain Omega-3 (EPA and DHA), fish is also an important dietary source of other nutrients important for brain function, including:

• Vitamin D• Iodine• Selenium


Nutrition in disorders of mood, behaviour and cognition

– key issues1. Blood sugar regulation problems

2. Fatty Acid deficiencies / imbalances

3. Micronutrient deficiencies or imbalances

4. ‘Anti-nutrients’ and toxicity issues

5. Food allergies / intolerances

6. Gut dysbiosis / digestion & malabsorption issues


The Modern, Western-Type Diet

• Modern, ‘junk food’ diets are seriously damaging our physical health – leading to increased rates of:– Obesity– Type-II Diabetes– Heart Disease– Cancer– Allergies / Immune Disorders

• Diet also affects our brains and behaviour

• Low income groups are most at risk


Learning is easier when your brain is well fed!

The challenge!

Psychology of the child

Child Food preferences in

context

Parenting style

Family food culture

Financial resources

Advertising & marketing

School /nursery food policy

Peer food culture

Shops

Catering outlets

Peer pressureLocal catering outlets

School/nursery food policy

Family food culture Local shops Child psychology

Financial resources Advertising & marketingParenting style

School food and younger children

• Model healthy eating

• Expose children to a variety of healthy foods

• Remove the unhealthy options

• Decouple unhealthy food and rewards

School food and older children• EDUCATION

– Give young people the opportunity to think and learn about what makes “good” food

• Taste?• Image?• Health impact?• Environmental impact?• Fair trade?• Local?• Animal welfare?

• SCHOOL MEAL ENVIRONMENT ?– Eating should be a SOCIAL activity

The Importance of Education

• Young people (and older people!) who can– Taste– Grow– Cook– Critically assess advertising, marketing and

packaging– Apply the concept of balance to their diet

.... are much more likely to make good decisions about food

Farr (Sutherland)

Inverness High School “REAL” project

Resilience• Children and Young people need to be resilient.

• For food, resilience is needed against viral marketing

and peer pressure.

• They need not just ‘food literacy’, but confidence and

self esteem.

• Food literacy creates a virtuous circle: good mental

health – good food choices – good mental health.

What can parents, caterers and school / LA staff do to promote a healthy food culture?

• Do– Set a good example– Expose children (and staff!) to the right foods– Encourage self-service– ‘Play’ / be creative with your food– Cook with children– Reward with healthy food

• Avoid– Buying the wrong food– Nagging / Pressure– Bribery / Threats– Inconsistency– Reward with high fat / sugar foods


The take-home message (1)• Nutrition matters

– To brains as well as bodies – This is not an ‘alternative’ approach – it is fundamental

• Controlled trials show benefits for mood, behaviour and cognition from some dietary interventions, such as:– Supplementation with Long-chain Omega-3 fatty acids– Withdrawal of Artificial Food Colourings

• Modern, western-type diets are not healthy, and are affecting the way our brains develop and function– The issues are not just about obesity and poor physical health– Nutrition affects mental health and performance throughout life, so

it’s worth getting the basics right.


The take-home message (2)• School Food Matters

– Free School Meals benefit all children – but particularly those from low income groups

– Breakfast Clubs can improve learning and social skills– After School Clubs can foster stronger, healthier communities

(involve parents? teach cookery skills? school gardening club?)

• Local Authorities will have an unrivalled opportunity to cater to the ‘bigger picture’ in future– ‘Cheap’ food is very often a false economy– ‘Cost-benefit’ analysis: i.e. Taking into account the broader costs

and benefits of good (or bad) nutrition


Further InformationFor details of this and related research see

Food And Behaviour (FAB) Researchwww.fabresearch.org

and the bookThey Are What You Feed Them

food and behaviour: putting caterers at the front …...food and behaviour: putting caterers at the...

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