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7


DraOed by the ScienAfic Advisory Board

§  Prof. Berthold Koletzko (Chair), Munich, German Society of Paediatrics and Adolescent Medicine

§  Prof. Carl-‐Peter Bauer, Gaissach §  Prof. Manfred Cierpka, Heidelberg* §  Prof. Chris,ne Graf, German Sport University Cologne §  Prof. Ines Heindl, Flensburg*

§  Prof. Claudia Hellmers, Osnabrück, German Society of Midwifery Science §  Prof. Mathilde Kers,ng, Dortmund, Research InsAtute of Child NutriAon §  Prof. Michael Krawinkel, Giessen, German NutriAon Society §  Prof. Hildegard Przyrembel, Berlin §  Prof. Klaus Vecer, Berlin, NaAonal Breas0eeding CommiRee at the Federal Ins,tute

for Risk Assessment §  Dr Anke Weissenborn, Berlin, Federal InsAtute for Risk Assessment §  Prof. Achim Wöckel, Würzburg, German Society of Gynaecology and Obstetrics

*No longer a member of the Scien,fic Advisory Board

8


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Worded in the characterisAc style of guidelines

1.  Should = strong recommendaAon

2.  Ought to = moderate recommendaAon

3.  Can = open recommendaAon

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14


Breas0eeding: the best thing for the mother and child

§  Breasaeeding is the natural and preferred form of feeding an infant

§  Mother's milk provides the baby with the important macro and micro-‐nutrients it needs for growth and healthy development (Ballard, Morrow 2013; Valen,n, Wagner 2013; Hassiotou et al 2013)

§  Breasaeeding has posi,ve short and long-‐term effects on the health of the mother and child

(Ip et al 2009; Horta, Victora 2013, Horta et al 2015; Chowdhury et al 2015)

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(Sankar, M.J.; Sinha, B.; Chowdhury, R.; Bhandari, N.; Taneja, S.; Mar,nes, J.; Bahl, R. (2015): Op,mal breasaeeding prac,ces and infant and child mortality: a systema,c review and meta-‐analysis. Acta paediatrica, 104, 3-‐13)

Type of breas0eeding RelaAve risk (95% CI) Number of

studies

Overall mortality; breas0eeding for 0–5 months

Exclusively 1.0

Predominantly 1.48 (1.13–1.92) 3

Par,ally 2.84 (1.63–4.97) 3

No breasaeeding 14.4 (6.13–33.9) 2

InfecAon-‐related mortality; breas0eeding for 0-‐5 months

Exclusively 1.0

Predominantly 1.7 (1.18–2.45) 3

Par,ally 4.56 (2.93–7.11) 3

No breasaeeding 8.66 (3.19-‐23.5) 2

Breas0eeding and mortality – a systemaAc review and meta-‐analysis

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Special formulae

§  Legally speaking, they are 'dietary foods for par,cular medical purposes'

§  They are frequently adver,sed for indica,ons such as 'spixng', 'suscep,bility to flatulence' or 'colic'

§  'Spixng' is oTen harmless and does not require any special diet

§  But spixng, flatulence and colic may be symptoms of a serious illness requiring medical acen,on

à Parents ought only to give their child special formulae on the advice of a doctor

30


ProbioAcs = bacteria that produce lac,c acid PrebioAcs = indiges,ble carbohydrates §  There is currently no certain evidence of their benefits §  Contradictory results concerning the posi,ve effects*

on the child's health *As a protec,on against allergies and infec,ons

Pro and prebioAcs in infant formula

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35


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36

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37


Introducing complementary food – when? The recommenda,ons consider: §  The child's increasing nutrient requirements (no longer

guaranteed by exclusive breasaeeding in the second six months)*

§  Short-‐ and long-‐term effects on health (e.g. allergy preven,on, obesity, cardiovascular diseases, diabetes)**

§  Development of motor, cogni,ve and social skills: individually different

§  Promo,on of sensory acceptance for new foods *Dewey. Pediatr Clin North Am 2001; 48:8–104 **Kramer, Kakuma. Cochrane Database Syst Rev .2012; 8:CD003517; Leitlinie Allergiepräven,on – Update 2014; EFSA NDA Panel. EFSA J 2009; 7:1423

38


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39


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40


Sequence of complementary food and acceptance of new tastes

Maier et al. Clinc Nutr 2008; 27: 849–57

Zucchini-tomato and peas = newly introduced foods; C0: previously no variety; C4: previously moderate variety; C10: previously frequent variety

41


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Breastfeeding is

not influential

42


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43


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44


Ready-‐made complementary food

Convenience products §  Sa,sfy strict statutory requirements §  Save ,me and work

SelecAon recommendaAons §  Welcome: Products with ingredients that sa,sfy the

recommenda,ons for home-‐made baby food §  Unwelcome: The addi,on of salt or a strong sweet taste

45


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46


Vegetarian or vegan infant nutriAon?

Vegetarian complementary food is possible

§  Vegetable-‐potato-‐cereal baby food instead of vegetable-‐potato-‐meat baby food

Parents are advised against giving their babies a vegan diet

§  The risk of nutrient deficiency is substan,al, and the health of the child is therefore endangered

§  If parents decide to give their infant a vegan diet nevertheless: meaningful advice, medical support and con,nuous dietary supplements are necessary*

*Also applies to vegans who choose to breasaeed their babies

47


Baby-‐led weaning instead of complementary (baby) food?

Baby-‐led weaning §  Offer of bite-‐sized pieces §  The infant decides autonomously what it wants to eat §  Safety is not proven §  Sufficient nutrient intake is not always guaranteed

§  Benefits not proven (e.g. in regard to strengthening of self-‐regulatory skills, preven,on of obesity)

à Nutri,onal plan based on baby food à The infant can pick up and eat suitable foods addi,onally

Hilbig, Lentze, Kers,ng. Monatschr Kinderheilkd 2012; 160: 1089–95

48


Cow's milk during the complementary food period

ObservaAonal and controlled studies show: §  High protein intake (especially in cow's milk) –

greater risk of obesity

Possible effect: §  S,mula,on of IGF-‐1 and insulin secre,on by milk protein à Promotes greater weight increase and facy deposits à Promotes higher risk of obesity later in life

Koletzko et al. Am J Clin Nutr 2016; 103: 303–304; Gunther et al. Am J Clin Nutr 2007; 86: 1765–1772; Pearce et al. Int J Obes 2013; 37: 477–485

49


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66


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models. Heterogeneity was determined by Cochrane’sQ statistic and I2 values. For interpretation, I2 values of 25,

50 and 75 were considered to indicate low, moderate and

high heterogeneity, respectively [45]. Publication bias wasanalysed using Rosenthal’s classic fail-safe N [46] and

Duval and Tweedie’s trim and fill procedure [47]. Corre-

lations between variables were interpreted as follows:0–0.19 (no correlation), 0.2–0.39 (low correlation),

0.4–0.59 (moderate correlation), 0.6–0.79 (moderately high

correlation) and C0.8 (high correlation) [48].

3 Results

3.1 Overview of Studies

The systematic search yielded 2,666 potentially relevant

articles following the removal of duplicates (Fig. 1). After

full-text screening and checking the reference lists ofincluded studies and previous reviews for additional rele-

vant articles, a total of 110 studies were included. Of the

included studies, 86 were cross-sectional, 20 were longi-tudinal and 4 were experimental. The number of study

participants ranged from 20 [49] to 1,142,599 [30]. Further

details on study characteristics are presented in Table S1 ofthe electronic supplementary material (ESM).

3.2 Overview of Study Quality

There was 95 % agreement between raters for risk of bias,and consensus was achieved on all included studies fol-

lowing discussion. Inter-rater agreement was found to be

high (j = 0.86, p \ 0.001). The results of the risk of biasassessment can be found in Table S2 of the ESM. Overall,

one study (1 %) was considered to have a high risk of bias,

34 studies (31 %) were considered to have a moderate riskof bias, and 75 studies (68 %) were considered to have a

low risk of bias. ‘Random selection of study sites or par-

ticipants was the most poorly satisfied criterion with 54studies (49 %) scoring zero. The most consistently satisfied

criterion was ‘adequate description of the study sample’

with only four studies (4 %) scoring zero.

3.3 Physiological Benefits

A summary of the associations between MF and each of the

potential benefits can be found in Table 1.

3.3.1 Adiposity

Fifty-one studies reported on the association between MFand measures of adiposity (e.g., body mass index [BMI],

sum of skin-folds, waist circumference [WC] etc.). Forty-

two studies were cross-sectional, seven were longitudinal,and two were experimental. A number of measures were

used, both between and within studies, to measure adi-

posity. These measures can be broadly classified as mea-suring either total body fatness (e.g., BMI) or central body

fatness (e.g., WC). Of the 50 studies reporting on the

association between MF and measures of total body fat-ness, 45 (90 %) reported significant inverse associations.

These associations were generally low to moderate. Nine of

these studies however, also reported a significant positiveassociation between one measure of MF and adiposity.

Positive associations were only found for tests of MF in

which the subject was not required to support their bodyweight during movement (e.g., handgrip strength). Perfor-

mance in MF tests in which the subject was required to

either lift their body weight (e.g., curl ups, push ups) orpropel their body through space (e.g., vertical jump,

standing long jump) was consistently found to be inversely

associated with adiposity. Of the 37 studies with a low riskof bias, 33 (89 %) found a significant association, provid-

ing strong evidence of an inverse association with MF.

Fourteen studies examined the association between MFand central adiposity, which was most commonly measured

by WC. Thirteen studies were classified as having low riskof bias. Overall, ten studies (71 %) found a significant

association, including nine (69 %) studies with a low risk

of bias, suggesting strong evidence of an inverse

Records identified through database searching

(n = 3,156)

Records screened by title and abstract (n = 2,666)

Records excluded (n = 2,462)

Full-text articles assessed for eligibility (n = 204)

Full-text articles excluded with reasons (n = 151)

No analysis of association between MF and benefit (n = 69)No physiological or psychological outcome (n = 33)No MF measure (n = 16)Non-English manuscript (n = 3)Non-peer reviewed journal article (n = 10)Subjects too old/young (n = 4)Special population (n = 15)Could not locate full-text (n = 1)

Studies included in review (n = 110)

Additional relevant articles retrieved (n = 57)

Duplicates excluded (n = 490)

Fig. 1 Flow of studies through the review process. MF muscularfitness

J. J. Smith et al.

123

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Records identified through database searching database searching

(n = 3,156)

Records screened by title and abstract (n = 2,666)

Records excluded (n = 2,462)

Full-text articles assessed for eligibility (n = 204)

Full-text articles excluded with reasons (n = 151)

No analysis of association between MF and benefit (n = 69)No physiological or psychological outcome (n = 33)No MF measure (n = 16)Non-English manuscript (n = 3)Non-peer reviewed journal article (n = 10)Subjects too old/young (n = 4)Special population (n = 15)Could not locate full-text (n = 1)

Studies included in review Studies included in review (n = 110)

Additional relevant articles retrieved (n = 57) retrieved (n = 57)

(n = 10)retrieved (n = 57)

(n = 10)Subjects too old/young (n = 4)retrieved (n = 57) Subjects too old/young (n = 4)retrieved (n = 57) retrieved (n = 57)

Duplicates excluded (n = 490)

Fig. 1 Flow of studies through the review process. MF muscularmuscularfitnessfitness

67


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Imprint2016

Published by

aid infodienst Ernährung, Landwirtschaft, Verbraucherschutz e.V. Heilsbachstr. 16, 53123 Bonn, www.aid.de

Text: Prof. Berthold Koletzko, Munich; Prof. Carl-Peter Bauer, Gaissach; Prof. Manfred Cierpka, Heidelberg; Prof. Christine Graf, Cologne; Prof. Ines Heindl, Flensburg; Prof. Claudia Hellmers, Osnabrück;

Prof. Mathilde Kersting, Dortmund; Prof. Michael Krawinkel, Giessen; Prof. Hildegard Przyrembel, Berlin; Prof. Klaus Vetter, Berlin; Prof. Anke Weissenborn, Berlin; Dr"Achim Wöckel, Ulm.

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