YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise. Here Odysseas Androutsos, Associate Professor at the Department of Nutrition and Dietetics at the University of Thessaly, speaks about his work on the dietary guidelines for children.

Can you introduce yourself?

I’m an Associate Professor at the Department of Nutrition and Dietetics at the University of Thessaly and Director of the Lab of Clinical Nutrition and Dietetics.

You just gave your presentation at the ECO 2024. What should our readers know about your work?

Based on recent findings, it is evident that childhood obesity has significantly increased over the past decade. The prevalence of obesity in adolescence has quadrupled since the 1990s. According to the latest figures provided by the World Health Organization (WHO), 37 million children under the age of 5 and 390 million children and adolescents worldwide are overweight, with 160 million of them living with obesity.

The severity of this issue requires urgent attention. To address these rising trends, my colleagues and I at the European Specialist Dietetic Network (ESDN) Obesity, under the European Federation of the Associations of Dietitians (EFAD), in collaboration with the European Association for the Study of Obesity (EASO), have developed the latest guidelines for treating obesity in childhood and adolescence.

Could you outline the key principles recommended in these guidelines?

First and foremost, it is essential to recognize obesity as a disease. Therefore, healthcare professionals need to focus on intensive and long-term strategies to optimize treatment for young individuals. Instead of solely concentrating on weight loss or the maintenance of weight loss, we must consider patient-centered health outcomes. This holistic approach aims to achieve results that impact overall health and disease management.

Furthermore, through the implementation of these long-term and regular interventions, we emphasize medical nutrition therapy to maintain an energy deficit and sustain the weight loss achieved. Concurrently, our optimized approach ensures the provision of essential nutrients to develop healthy diet plans. These plans will not only lead to initial weight loss but also help in maintaining a healthy weight over time.

What are the key considerations and strategies for developing effective obesity treatment plans for children and adolescents?

While focusing on weight management, it is equally important to ensure that children and adolescents receive optimal nutritional intake to meet their requirements. This is crucial from our perspective. We must promote and incorporate low-energy, nutrient-dense foods, such as yogurt, fruits and vegetables, into their diet plans. Replacing energy-dense foods like salty snacks and sweets with healthier options is essential, not only during main meals but also in intermediate meals and breakfast.

Evidence from literature and our recommendations shows, for example, that increasing fruit intake by 0.5 servings and vegetable intake by 1.5 servings per day can be sustained over a long period. Our treatment approach must be personalized, as a one-size-fits-all strategy is ineffective. Specific, measurable, and time-related goals should be set for each patient to meet their unique needs and expectations.

Working in multidisciplinary teams is vital. Collaboration among pediatricians, dietitians, nutritionists, physical education experts, psychologists, and other professionals ensures optimal results. This team approach addresses psychological, social, and physical health aspects of obesity.

Role modeling is another crucial aspect. It extends beyond healthcare professionals to include families, parents, caregivers, teachers, and others in the child’s social environment. Promoting healthy role models is essential. Additionally, using non-stigmatizing, person-first language is important. We must respect and work individually with each person to optimize our efforts.

The care environment must be safe and welcoming, making children and adolescents feel comfortable and happy. These are the main pillars of creating a healthy environment for providing care. Overall, these are the core goals of the medical nutrition therapy described in our recommendations.

What is the place of dairy products in the guidelines, and more specifically yogurt?

Dairy products are an integral part of a healthy dietary pattern and should certainly be included when prescribing healthy diets for children. Their inclusion is not solely for the treatment of overweight or obesity; rather, dairy should be a regular component of the diet plan for all children and adolescents.

In the context of obesity treatment, dairy products provide essential nutrients crucial for growth in children and adolescents, such as proteins and calcium. Additionally, yogurt offers beneficial ferments that positively affect gut microbiota, which play a significant role in maintaining a healthy diet. Incorporating these microbial benefits is an important aspect of effective obesity treatment.

Do you have a message for dietitians on how they can effectively utilize these guidelines?

Dietitians looking to utilize these guidelines can easily access them. The guidelines are uploaded and freely available on the websites of EASO and EFAD. Anyone interested can simply click on the links to access the information. Our committee is also open to any questions and future networking opportunities to optimize the implementation of these recommendations.

Additionally, it is important to note that we are actively working with healthcare professionals to gather their feedback. Through qualitative research methods, such as interviews and focus groups, we are collecting their views and suggestions on how to enhance the implementation of these guidelines. While we have compiled the best available evidence, another crucial step is optimizing the guidelines’ uptake and integration into health systems across Europe, ensuring they are effectively implemented in daily practice.

References:

• European Association for the Study of Obesity Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Adults Developed in Collaboration with the European Federation of the Associations of Dietitians
• EASO and EFAD Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Children and Adolescents

YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise. Here Maria Hassapidou, Professor of Nutrition and Dietetics at the Alexander Technological Educational Institution of Thessaloniki (Greece) tells us about her work on the dietary guidelines for Obesity in Europe.

Can you introduce yourself?

I am a Professor of Nutrition and Dietetics at the International Hellenic University in Thessaloniki, Greece, and I chair the ESDN Obesity of EFAD, the specialized dietetic group on obesity of the European Federation of the Association of Dietitians. Additionally, I co-chair the Nutrition Working Group of the European Association for the Study of Obesity (EASO).

For the past decade, our collaboration between dietitians and obesity experts has been immensely beneficial. This synergy between the two groups was instrumental in the joint publication of the guidelines.

During the Congress, we observed that a multidisciplinary approach is crucial for managing obesity. Can you share the method used to develop the dietary guidelines?

As I mentioned during my presentation, our journey began with an EU umbrella project, providing an opportunity to develop dietary guidelines for obesity, particularly focusing on medical nutrition therapy. We conducted surveys across Europe to assess the existing guidelines and published comparative studies to identify similarities and differences. This process highlighted the need for unified European guidelines, which was strongly supported by scientists and healthcare professionals across various countries.

To address this, we collaborated between EFAD and EASO, forming working and writing groups. We conducted a systematic literature review, drawing heavily on the comprehensive Canadian guidelines for obesity treatment. By extending their methodology up to 2023 and sharing our findings with our Canadian colleagues, we benefited greatly from this collaboration. Simultaneously, we developed guidelines for children with obesity, incorporating significant contributions from Australian researchers and maintaining the same rigorous methodology.

Our guidelines categorize the strength of evidence into various grades and levels based on the methods used. I hope, as I mentioned, that we have produced a well-received consensus document. Initial feedback from dietitians and the European Federation Association has been positive, but it will take time to evaluate the practical implementation and effectiveness of these guidelines.

What are according to you the main highlights from these dietary guidelines?

As I mentioned during my presentation, the key point of these guidelines for both adults and children is the emphasis on treating comorbidities. These guidelines are not solely focused on weight loss or reducing BMI: their primary goal is to improve overall health. Medical nutrition therapy aims to reduce comorbidities, making health improvement the main objective. Different diets are graded based on evidence, demonstrating their effectiveness in reducing factors like cholesterol or blood pressure. While losing weight is important, maintaining overall health is paramount.

Another important aspect is the grading of different diets. We have gathered extensive information, including evidence on specific food groups. Common questions often revolve around the effects of particular foods, such as nuts or vegetables. For example, there is strong evidence that increasing vegetable intake can help reduce body weight. A significant focus of the guidelines is dedicated to food groups, with particular interest in dairy products.

Regarding dairy, we have a specific recommendation based on evidence. There was a substantial number of studies showing positive results for certain health parameters related to dairy consumption. Overall, the inclusion of dairy, and specifically yogurt, is supported by evidence in our guidelines.

In March 2024, the FDA accepted a qualified health claim on the preventive role of yogurt in type 2 diabetes. Is it something that could lead to an update of dietary guidelines?

There are European guidelines for diabetes that are updated every few years, managed by specialists in that field. Our focus is on obesity, so I can’t provide specific data on diabetes. However, as a nutritionist, I can say that yogurt plays a significant role in the microbiota, which is related to both obesity and diabetes. The type of yogurt matters, and there is substantial evidence supporting its benefits through physiological mechanisms.

Where or how can dietitians find the guidelines?

Dietitians can access our guidelines by downloading the free papers available online. They are also accessible on the EASO and EFAD websites. To encourage their use, we are planning workshops and webinars for health professionals to ensure they are aware of these guidelines. These efforts are being made through EASO, EFAD, and national associations. While it will take some time for the guidelines to be fully integrated, initial feedback from health professionals, especially dietitians, has been very positive, and they have expressed their intention to use them.

References:

• European Association for the Study of Obesity Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Adults Developed in Collaboration with the European Federation of the Associations of Dietitians
• EASO and EFAD Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Children and Adolescents

YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise.

Here Dr Michele Sculati, Medical Doctor, Clinical Nutrition Specialist, PhD Public Health in Italy, speaks about the significance of addressing obesity with a comprehensive approach that includes newly available drugs, lifestyle changes, dietary adjustments, and the beneficial roles of prebiotics, probiotics, and fermented foods on the gut microbiota.

Can you introduce yourself?

I am a medical doctor specializing in Clinical Nutrition, with a strong focus on diet and dietotherapy, areas typically managed by dietitians. My passion lies in understanding how food and dietary habits can influence our health. Additionally, I have a deep interest in endocrinology and metabolism. This Congress, the ECO 2024, covers many of these topics extensively, making it an exciting and relevant event for me.

What do you believe are the key learnings from the ECO 2024 Congress?

There are numerous key messages to consider, given that the scientific program is an extensive 300-page document! Obesity has garnered significant interest, particularly with the advent of new treatment results. One of the most discussed topics is the efficacy of new drugs, including not only GLP-1 inhibitors but also others GP inhibitors and emerging medications. Currently, we have around 20 new molecules in development, making it possible to treat obesity with drugs, in addition to surgery.

However, prescribing drugs alone is not sufficient. When treating a patient with obesity, it’s crucial to remember that better results are achieved if the patient’s habits are changed. Therefore, a nutritionist or medical doctor treating obesity should emphasize the importance of personalized dietary prescriptions. These prescriptions should be tailored to the patient’s needs and habits, ensuring they are practical and achievable in real life. This includes considering the patient’s taste preferences, food preparation time, daily schedule, and activities such as sports or the use of lunch boxes.

Beyond the combination of drug development, clinical approaches and personalized dietary prescriptions, are there new targets in obesity research?

An area of growing interest among scientists is how dietary habits affect the microbiota, which plays a significant role in weight regulation. The microbiota aids in regulating weight through GLP-1. A diet rich in fiber and a healthy microbiota can lead to the production of short-chain fatty acids. These acids stimulate G protein on enterocytes, which in turn promotes the secretion of glucagon-like peptide-1 (GLP-1), the same target as many GLP analog drugs.

In recent years, there has been a shift towards prescribing diets that positively impact the microbiota by enhancing the fermentation of short-chain fatty acids. This can be achieved through diet, prebiotics, and probiotics. Probiotics are not limited to pills or supplements but can also be found in foods like yogurt, which naturally contain probiotics.

Many foods have potential probiotics. However, the way we cook, prepare, and store these foods affects their probiotic content. In contrast, yogurt is a standardized food with known probiotic content and substantial scientific backing.

Based on the sessions you attended here at ECO 2024, can you think of new benefits yogurt may bring to the microbiota?

Definitely! For example, I attended sessions on Metabolically Associated Steatohepatitis (MASH), previously known as Non-Alcoholic Steatohepatitis (NASH). These sessions highlighted the connection between the microbiota and the liver. Poorly differentiated microbiota, lacking healthy taxa, can lead to a thinner mucus layer in the gut, causing a condition known as leaky gut. This allows chemicals like lipopolysaccharides to pass through enterocytes into the bloodstream, reaching the liver directly.

Lipopolysaccharides impact inflammation mediators in the liver, contributing to chronic inflammation associated with non-alcoholic fatty liver disease (NAFLD) and MASH. Once again, as previously stated, modulating the microbiota through dietary habits and probiotics can play a crucial role in managing these conditions.

In March, the FDA accepted a claim that yogurt can help prevent type 2 diabetes. How significant is this claim for clinicians, and will it impact their recommendation of yogurt?

This claim is the result of decades of research, marking a significant milestone. I don’t believe any other food has such a strong claim related to a globally prevalent health issue like type 2 diabetes, making this incredibly important.

It’s not just based on a few years of research; it’s the culmination of extensive studies. While the FDA doesn’t consider the evidence entirely conclusive, the claim they approved is still very strong. We know there’s a negative association between yogurt consumption and the incidence of diabetes: the more yogurt you consume, the lower your risk of developing diabetes.

The exact reasons for this observation are still under investigation. It could be due to bioactive peptides in yogurt or its influence on the microbiota. As mentioned earlier, diet can affect the endogenous secretion of GLP-1, which was initially developed as a drug for diabetes therapy. This might give us some insight into why these observations occur.

Besides diabetes, yogurt offers numerous benefits: it is a nutrient-dense food, which likely explains the negative association between yogurt consumption and BMI. Additionally, yogurt consumption is associated with overall healthy dietary habits.

What is vitamin D?

Vitamin D is a fat-soluble vitamin. It exists on 2 different forms, D2 (ergocalciferol), mainly produced by some plants and D3 (cholecalciferol). The human body synthesizes vitamin D3 in the skin, under the effect of ultraviolet rays.

Vitamin D is known for its significant role in calcium homeostasis and metabolism but it plays a multitude of effects on the body besides bones and calcium metabolism by contributing to:

• the normal function of the immune system
• inflammatory response
• muscle functions

The roles of vitamin D

Vitamin D promotes healthy bones by aiding calcium absorption through modulation of active transport absorption and maintaining a good ratio of calcium and phosphate for bone mineralisation.

It reduces inflammation, modulates cell growth, glucose metabolism, neuromuscular and immune function through the modulation of genes encoding proteins that regulate these processes.

A chronic deficiency in vitamin D leads to improper bone mineralisation, as less calcium and phosphorous are absorbed in the small intestine and can induce hypocalcaemia (low levels of calcium in the blood) and phosphaturia (phosphate in urine) causing accelerated bone demineralization. This can result in bone mineralisation diseases such as osteomalacia, osteoporosis, and rickets in children. Adequate levels of vitamin D combined with calcium can help prevent these diseases.

Vitamin D consumed in the diet is absorbed through passive diffusion in the gut and this absorption is enhanced by fat.

Diet recommendations

Vitamin D is synthesised by the skin when exposed to UV light. However, the amount synthesised depends on a multitude of factors such as where you live, weather, skin melanin levels, and wearing sunscreen.

Diet recommendations usually assume skin endogenous production of vitamin D is equal to 0 to ensure guidelines provide enough vitamin D through diet alone. The recommended daily intake is 15µg per day for adults. The ability of the body to produce and absorb vitamin D decreases with age which is why this recommendation increases to 20µg per day for people over the age of 70.

It is important not to consume too much vitamin D because excess vitamin D in the body is toxic and can lead to symptoms such as headache, nausea and vomiting, weight loss or fatigue. It is recommended to not consume more than 100µg per day. However, this happens almost only in cases of supplement overuse and it is not something the majority of the population has to worry about. In fact, most people fall short of meeting recommended intakes. In the USA, over 90% of adults do not consume enough vitamin D and this is similar in most northern hemisphere countries.

Dietary sources of vitamin D

Dietary sources of vitamin D are quite rare. Some vitamin D can be found in fatty fish, fish liver oils, beef liver, egg yolk, cheese and fortified dairy. For example, in the USA, almost all milk is fortified with vitamin D and it is compulsory in Canada.

Some mushrooms can have vitamin D if they are treated with UV light which makes the mushroom produce vitamin D.

Vitamin D in dairy

As dairy products are often fortified in vitamin D, it is a major source of this nutrient for populations. For example, in France, 25% of vitamin D intake comes from dairy products.

Dairy products were chosen to be fortified as it doesn’t change the taste and it also helps in absorbing the high content of calcium and ensure healthy bones.

Fortified dairy products are an interesting source of vitamin D as they provide a large portion of the dietary recommendation.

Data from the USA National Health Nutrition and Examination Survey (NHANES), the Canadian Community Health Survey, and the UK National Diet and Nutrition Survey show that yogurt consumers have higher daily intakes of several key nutrients including vitamin D.

Research shows that people that consume yogurt have stronger bones and lower bone resorption markers. In older adults, yogurt consumption is linked to increased bone mineral density and physical function. Therefore, encouraging older people to eat yogurt more often, particularly vitamin D- and calcium-fortified yogurt, may be a valuable public health strategy to stave off osteoporosis.

See also

• Boost your vitamin D with fortified yogurt
• Eat your way to stronger bones: fermented dairy may help

Sources

• Office of Dietary Supplements – Vitamin D.

• Sizar O, Khare S, Goyal A, Givler A. Vitamin D Deficiency. StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.

• Vitamin D: why do I need an adequate intake and how can I make sure I get it ? In: Anses – Agence nationale de sécurité sanitaire de l’alimentation, de l’environnement et du travail [Internet]. 2 Mar 2022 [cited 13 Feb 2024].

• EUFIC – Vitamin D: foods, functions, how much do you need & more.

• CIQUAL – La table de composition nutritionnelle des aliments. ANSES, France.

• Zhu Y, Jain N, Holschuh N, et al. Associations between frequency of yogurt consumption and nutrient intake and diet quality in the United Kingdom. J Nutr Sci. 2021;10:e85.

• US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th Edition. December 2020.

• Cifelli CJ, Agarwal S, Fulgoni VL. Association of yogurt consumption with nutrient intakes, nutrient adequacy, and diet quality in American children and adults. Nutrients. 2020;12:3435.

• Vatanparast H, Islam N, Prakash Patil R, et al. Consumption of yogurt in Canada and its contribution to nutrient intake and diet quality among Canadians. Nutrients. 2019;11:1203.

• He M, Yang YX, Han H, et al. Effects of yogurt supplementation on the growth of preschool children in Beijing suburbs. Biomed Environ Sci. 2005;18:192–7

• Laird E, Molloy AM, McNulty H, et al. Greater yogurt consumption is associated with increased bone mineral density and physical function in older adults. Osteoporos Int. 2017;28:2409–19.

• Bonjour JP, Benoit V, Payen F, et al. Consumption of yogurts fortified in vitamin D and calcium reduces serum parathyroid hormone and markers of bone resorption: a double-blind randomized controlled trial in institutionalized elderly women. J Clin Endocrinol Metab. 2013;98:2915–21.

• Bonjour JP, Benoit V, Atkin S, et al. Fortification of yogurts with vitamin D and calcium enhances the inhibition of serum parathyroid hormone and bone resorption markers: a double blind randomized controlled trial in women over 60 living in a community dwelling home. J Nutr Health Aging. 2015;19:563–9.

• Sahni S, Mangano KM, Kiel DP, et al. Dairy intake is protective against bone loss in older vitamin D supplement users: the Framingham study. J Nutr. 2017;147:645–52.

YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise. Here Niam Arthurs, pediatric dietitian and researcher in the area of child and adolescent obesity based in Dublin, Ireland, speaks about her research on child obesity.

Can you introduce yourself and tell us what you work on?

I’m a senior pediatric dietitian and researcher in the area of child and adolescent obesity based in Dublin, Ireland. My team works on food habits among children with obesity. Our main objective is to gather intelligence about our young patients’ habits before implementing any obesity treatment in order to maximize the effectiveness of personalized dietary approaches.

Firstly, we examine the nutritional quality of children’s reported food and fluid intakes. For this specific aspect, we use a 28-item food frequency questionnaire, conducted with the parents.

Secondly we evaluate the level of parental knowledge about nutrition, their self-reported cooking confidence and their relationship to food consumption. Ultimately, these elements guide us in determining the relationship between parental nutritional knowledge and children’s dietary habits. That is the basis for tailoring personalized treatment.

What have you learned about personalized dietary treatment for children with obesity using this method?

Getting a baseline idea about what children and teenagers are actually eating, combined with parents’ nutrition knowledge and their ease with cooking preparations allowed us to avoid making assumptions about children’s environments. This truly helped us make the connection between gathered information and its relationship with food consumption.

Our study found that parents who reported lower levels of cooking confidence tended to have households with higher consumption of convenience meals and takeaway foods. For dietitians aiming at framing their patients’ specific needs, such elements represent key targets for designing their interventions.

Assessing levels of knowledge in nutrition also enables understanding of general food and nutrient recommendations knowledge. We observed that the consumption of dairy products was a lot lower than the recommended amounts, in all age groups. From 5- to 88-year-olds, only about over 50% of the studied population met the recommended daily intakes for dairy products.

In Ireland, dairy products are the main source of calcium in children’s and teenagers’ diets. This nutrient is of pivotal importance during this age of growth. However, none of the 9- to 16-year-olds included in the survey met the recommended daily intakes for calcium, from either dairy products or other calcium-rich foods.

Again, the study aims at identifying such key target points to let dietitians design relevant interventions.

How do these results translate in your day-to-day consultation?

Expanding on the earlier example of calcium deficiency, the study highlighted that our interventions need to focus more on dairy products. This implies addressing the myths around dairy products and exploring with the families the reasons why they do not consume enough dairy products, particularly children and teenagers.

In this instance, it appears that a lot of the parents simply do not know what the recommendations for dairy foods are – i.e. 3 portions of dairy foods per day from up to 8 years, and 5/day after 8 years old, in Ireland – nor what a serving size corresponds to.

That information is crucial for health and nutrition literacy, and we need to incorporate it more into our one-on-one consultations and group education programs to ensure that individuals are receiving adequate levels of necessary knowledge.

Do you provide them with simple ways to incorporate more dairy into their meals?

This is where tailoring comes in. It’s important to understand what children and teenagers are currently eating to make small, specific suggestions for incorporating more dairy. For example, many children begin skipping breakfast when they transition from primary to secondary school, often due to time constraints or lack of appetite. However, breakfast is an important opportunity to consume calcium-rich foods.

We can suggest alternatives such as eating something once they get to school or choosing quicker options for the morning to overcome time barriers. Additionally, they can incorporate more calcium-rich foods into their lunch. For instance, they could add cheese to their sandwiches or bring pouch yogurts, which are convenient and less likely to burst in their bags. Drinkable yogurts are also a good option. These types of recommendations are often more acceptable and practical for their routines.

In March 2024, the FDA published a qualified health claim about the role of yogurt in the prevention of type 2 diabetes. Can this have an impact on the recommendations? Do you think it can be an opportunity for patients?

It’s incredibly valuable to have strong, evidence-based claims because there’s so much misinformation surrounding dairy foods. For instance, myths about dairy contributing to acne, containing hormones, or causing inflammation are not supported by scientific evidence. Unfortunately, the science community isn’t reaching these target groups effectively. Families are increasingly getting their information from social media, so we need to be much louder in our communication. Having well-supported claims can help us do that.

Moreover, these claims are particularly significant in our world today, where we face rising rates and high prevalence of conditions like type 2 diabetes. These conditions can severely impact an individual’s quality of life and health if not properly managed. Strong, scientifically-backed claims not only help us communicate more effectively but also attract media attention. This can encourage individuals, families, and teenagers who might be avoiding calcium-rich foods, such as dairy products, to reconsider their choices.

Eating ultra-processed foods is linked to the risk of developing long-term health problems, according to the latest evidence from an umbrella study conducted by an international team of researchers (1).

But questions remain on just how much do these ready-to-eat products affect our well-being and should they all be assessed under the same umbrella.

An umbrella approach to assessing ultra-processed food effects