International Conference ARVI on the Future of Fishing: The Benefits of Fish Consumption

1. Conferencia Internacional ARVI sobre el futuro de la pesca. Los beneficios del consumo de pescado Vigo, a 22 de Junio de 2018 “The consumption of fish in healty food: Atlantic Diet/NAOS Strategy” Rosaura Leis Vicepresidenta de la Fundación de la Dieta Atlántica de la USC. Profesora Titular de Pediatría. Directora del GI Nutrición Pediátrica del IDIS-ISCiii. Coordinadora de la Unidad de Gastroenterología, Hepatología y Nutrición Pediátrica del Hospital Clínico de Santiago-Xerencia de Xestión Integrada de Santiago. Universidad de Santiago de Compostela

2. Current diet. Interaction between genome and environment The "Western diet" (USA, Europe) is characterized by: • Predominance of manufactured foods rich in calories, saturated fats, trans and omega-6, sugars and sodium and low in fiber, omega-3 and functional components. • This diet increases the growing prevalence of obesity, cardiovascular diseases, type 2 diabetes, metabolic syndrome, neurodegenerative diseases, osteoporosis and certain types of cancer. • These "diseases of civilization" are due more to rapid environmental changes than to the genome. Aranceta J. Serra LL. Mataix J. Tojo R. Dieta y riesgo cardiovascular en España (Estudio DORICA III). Ed. Medica Panamericana. 2007; pp 121-162. Soli F. BMJ 2008. Iqbal R. Circulation 2008; 114:1299-37. Cordain L. AJCN 2005; 81: 341-54 Tojo R, Leis R. La obesidad en la infancia y adolescencia. Estrategia NAOS.MSC-AESAN. EM Panamericana 2007 Environmental factors and epigenetic mechanisms will influence 80%. Hanson M & Gluckman P. Am J Clin Nutr 2011; 94.

3. Cardiovascular mortality in Europe. Males • Mortality due to ischemic heart disease in men • Spain: low risk • Mortality from cerebrovascular disease in men • Extremadura and Andalucía: high risk, Comunidad Valenciana, País Vasco, Asturias, Baleares and Canarias: moderated risk 0<51 51<62 62<74 74<161 161<844 0<140 140<190 190<268 268<367 367<1.051 • In Spain • 32,5% CV mortality • 28,6% males • 36.8% females • Ischemic heart disease + Cerebrovascular disease: 57,9% CV mortality Eur Heart J. 2008; Feb 6, Bertomeu V. Situación de la enfermedad cardiovascular en España. Del riesgo a la enfermedad. Rev Esp Cardiol. 2008;8E:2-9

4. Cardiovascular mortality in Europe. Females • Mortality from cerebrovascular disease in women Andalucía, Extremadura, Comunidad Valenciana, Castilla-La Mancha, Canarias and Baleares: moderated risk • Mortality due to ischemic heart disease in women 0<28 28<37 37<50 50<92 92<307 0<37 37<60 60<84 84<135 135<324 • In Spain • 32,5% CV mortality • 28,6% males • 36.8% females • Ischemic heart disease + Cerebrovascular disease: 57,9% CV mortality Eur Heart J. 2008; Feb 6, Bertomeu V. Situación de la enfermedad cardiovascular en España. Del riesgo a la enfermedad. Rev Esp Cardiol. 2008;8E:2-9

5. Obesity:The global epidemic, the new global syndrome Nutritional and metabolic disorder most prevalent in the pediatric age. + + In Europe, the prevalence of childhood obesity presents a North-South gradient Risk of an obese child becoming an obese adult: 3-5 years: 60-70%; 17 years: ~ 95% Fussenegger D. Obesity Rev 2008; 9: 76-81 Public Health Approach Preventing Obesity (PHAPO) Working Group. International Obesity Task Force (IOTF). Kumanyika S. Int J Obes 2002; 26:429-36 Dietz WH. Obesity in childhood. Nestle Nutr Ser. Vol 49. 2002

6. Evolución prevalencia niños/as 6 a 9 años (según tablas de Orbegozo) Principales resultadosEvolución prevalencia España es uno de los países con más alta prevalencia de obesidad infantil AESAN-NAOS-MSC, 2011 Aladino 2013: 43% Sobrepeso+Obesidad, según OMS La tendencia temporal del exceso de peso en niñas y niños de 6 a 9 años en España es en la actualidad decreciente. Aladino 2015 Desde 1999 la prevalencia de obesidad se estabilizó en 35.5% -35.8% en adultos y en 16.9% para niños y adolescentes. Livingston E. JAMA 2012; 307: 970-71 • % exceso de peso • enKid: 30,4% • Aladino 2011: 31,4% • Aladino 2013: 28,6% • Aladino 2015: Sobrepeso 23,2 % y obesidad 18,1% Base Estudio Aladino: 7.923 niños /as Base Estudio enKid: 423 niños /as

7. Evolution of weight, height and BMI in children of 10 years of Galicia. 1979-2001. GALINUT study

8. Evolution of BMI percentiles. 1979-2006. Gauss curve progressively to the right. GALINUT study. ♀ 12 years old. 1991-2005 10 years old boys 35 GALINUT(2006) GALINUT(2001) GALINUT(1991) GALINUT(1979) 30 25 BMI Waist +5.2cm 20 Obesity 1979: 5%, 2006:16% 15 10 Weight: +2.7 Kg BMI: +1.7 Kg/m2 P1 P5 P15 P50 P85 P95 P99 Percentiles R. Tojo, R. Leis. USC-HCU. Estrategia NAOS 2007

9. Quality of diet in children of Galicia. Krece Plus Test. GALINUT study. Quality of diet in males Quality of diet in females High Low High Medium Low Medium R. Leis, R. Tojo 2009.

10. The danger of extinction of traditional healthy dietsThe progressive change to the western diet Diets rich in cereals, fruits, vegetables, legumes, fish, olive oil, wine in moderation and low consumption of red meat. • The risk of morbidity and mortality decreases. • Increase the state of health and well-being. A recent FAO report shows the progressive deterioration of the Mediterranean diet in both shores of the Mediterranean sea from 1970 to the present. • Increase in obesity and comorbidities and other major pathologies that cause morbidity and mortality. Sofi F. Adherence to Mediterranean diet and Health status. BMJ 2008; 11:1337-44Sofi F. The “Florence” diet is no Mediterranean Eur J Clin Nutr 2005; 59:584-91 Scarnicas N. Mediterranean diet and cognitive impairment. Arch Neurol 2009; 66:216-25

11. ICTs in Adolescents in Galicia TV HOURS / DAY Videogames Computer R. Leis, R. Tojo. Estudio GALINUT 2008.

12. COMORBIDITIES OF CHILDREN OBESITY Psychosocial Low self-esteem, depression, insomnia Anxiety, harassment / bullying / teasing Stigmatization, social isolation Attention deficit / hyperactivity Ideation and suicide attempt Eating behaviour disorders, drug abuse Neurological Pseudotumor cerebri Skin Intertrigo Acantosis nigricans Pulmonary Sleep apnea Asthma Intolerance to exercise Pickwick syndrome Cardiovascular Dyslipidemia Hypertension Coagulopathy Chronic inflamation Endothelial dysfunction Left ventricular hypertrophy Progression atherosclerosis Gastrointestinal Colelithiasis Hepatic steatosis Pancreatitis Gastroesophageal reflux METABOLIC SYNDROME Renal Glomeruloesclerosis Endocrine Insulin resistance, glucose intolerance Type 2 diabetes Early puberty Polycystic ovarian syndrome (♀)/Dysmenorrhea Hipogonadismo (♂)/Hipercorticismo Nutrition Hypovitaminosis D Iron deficiency Calcium deficiency Muscle-eskeletal Femoral head epiphysiolysis Blount disease Increased risk of fracture Flatfoot Accidents Cancer New pandemic Tojo R, Leis R. 2008. Modified from Ebbeling CB. Lancet 2002; 360:473-82

13. LO QUE COMES EN LOS 1000 PRIMEROS DÍAS TE MARCA PARA EL RESTO DE LA VIDA What you eat the first thousand days will condition you for the rest of your life • The changes that lead to obesity and metabolic diseases of adults are mostly originated in critical periods of growth and development (pregnancy, childhood, childhood and adolescence). • The first 1000 days span the period from the moment of conception to 2 years: 270 days pregnancy + 365 days 1st year + 365 days 2nd year

14. Association between fish intake in pregnancy and lactation and neurodevelopment in childhood. Danish National Birth Cohort • Study in 25446 newborns (1997-2002), assessment at 6 and 18 months of age. • Maternal consumption of fish during pregnancy and lactation, independently associated with greater development of the child. • High maternal ingestion of fish in pregnancy and lactation is associated with greater neurodevelopment at 18 months of age (OR:1.29, 95% Cl: 1.20% 1.38). Oken E. AJCN 2009; 88:789-96; Jacobson JL. J Pediatr 2008; 152: 356-64, Ryan AS. Prostglan. Leukotr. Essent Fatty Acids 2010; 82: 305-14

15. Prevention of cardiovascular disease from the early stages of life • Feeding the pregnant women. • Breastfeeding. • Introduction of complementay feeding.

16. Early introduction of complementary feeding and obesity Breastfeeding Adapted formula % The energy intake at 4 months is related to the early introduction of solids. Obesidad For every 420 Kj / day of energy increase at 4 months: Increased risk of overweight 3 years: OR: 1.56 5 years: OR: 1-25. Age of introduction of complementary feeding (months) The introduction of non-milk foods in the infant's diet before 4 months is associated with later obesity Huh SY et al. Pediatrics 2011; 127: e544. Ong KK. Pediatrics 2006; 117:e503-e508. Pearce J. International Journal of Obesity. 2013;37:477-485.

17. The feeding of the infant and the young child in future health     Excess of proteins / adiposity Excessive weight gain during the first 24 months is the best predictor of overweight in school age. PROTEINS Influence of macronutrients on adiposity development: a follow up study of nutrition and growth from 10 months to 8 years of age. Rolland-Cachera MF, Deheeger M, Akrout M, Bellisle F. Int J Obes Relat Metab Disord. 1995 Aug;19(8):573-8. • The only nutrient whose intake is associated with the development of an overweight pattern is protein intake at 2 years of age. • The results of this study suggest that a high protein intake in early childhood may increase the risk of obesity and other pathologies at later ages. • A correlation between high protein intake and subsequent obesity occurs mainly in populations where protein intake is greater than 16 % of total energy intake from 12 to 24 months of age ... → maximum acceptable intake: 14% of total caloric value from 12 to 24 months age Agostini et al. Int J Obes 2005; 29 (suppl 2): s8

18. The feeding of the infant and the young child in future health Excess of fats • There is evidence that a diet high in fat during childhood has no relationship with obesity in later stages. Agostoni C & Caroli M. Role of fats in the first two years of life as related to later development of NCDs. Nutr Metab Cardiovasc Dis. 2012 May;22:775-780. • An observational study suggests that a low-fat diet at 24 months may increase the risk of obesity and leptin resistance at 20 years. Rolland-Cachera MF, et al. Association of nutrition in early life with body fat and serum leptin at adult age. Int J Obes. 2013,37:1116-1122. • Perinatal exposure to high levels of omega-6 fatty acids in relation to omega-3, during the first four months of life, may contribute to the disposition of the adipose accumulation. Rudolph MC, et al. Int J Obes (Lond). 2017;41:510-517. • AGPI n-6 stimulates such proliferation and maturation (unlike n-3 PUFAs that induce lipolysis / apoptosis). Rolland-Cachera MF, et al. Association of nutrition in early life with body fat and serum leptin at adult age. Int J Obes. 2013,37:1116-1122. Rudolph MC, et al. Int J Obes (Lond). 2017;41:510-517. Michaelsen KF. Et al. Emerging issues in complementary feeding: Global aspects. Matern Child Nutr. 2017;13:e12444 The intake of lipids in the infant should not be restricted, as it may increase the risk of obesity.

19. Evidence of the effects of sugars on health • Infants who took sugar-sweetened beverages (SSB - Sugar Sweetened Beverage) were more likely to suffer from obesity at six years than those who did not take SSB. Consuming SSB during the infant stage can be a risk factor for pediatric obesity. • An intake higher than the recommendations of "free sugars", particularly drinks with added sugars, in children and adolescents is associated with an increase in the incidence of dental caries and adiposity. • An intake higher than that recommended for "added sugars" in adolescents is positively associated with parameters of higher cardiovascular risk. Data in adolescents suggest that high fructose consumption is associated with an increased risk of cardiovascular disease and type 2 diabetes. • The sugars in the drinks do NOT promote satiety compared to the equivalent in solid foods and induce an excessive intake of energy. • Observational studies show that the intake of SSB during lactation and early childhood is associated with high intakes in childhood and adolescence, but its causality can not be demonstrated. Fidler Mis N,et al. ESPGHAN Committee on Nutrition. Sugars in infants, children and adolescents: a position paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2017;65:681-96. Pan L, et al. A Longitudinal Analysis of Sugar-Sweetened Beverage Intake in Infancy and Obesity at 6 Years. Pediatrics 2014;134:S29-S35.

20. The importance of infant and young child nutrition in future health CURRENT SITUATION (ALSALMA STUDY) 95,9% childrenbetween 7-36 monthshaveanelevateddiaryintake of proteins (4 times RDI) 95.9% PROTEIN EXCESS IN THE INGESTION Proteinexcess comes mainlyfromproteins of animal origin Animbalancedisdetected in micronutrients: iodine and vitamin D deficiency, sodium and vitamin A excess The Spanish study Alsalma describes how the child's diet is for 1-3 years. The majority of Spanish infants and young children consume an excess of proteins.

21. Food deficiencies from 1 to 3 years A significant proportion of children do not comply with dietary recommendations OMEGA 3 | DHA More than 50% do not consume 2 servings of fish per week VITAMIN D 90% of children do not cover the recommended intake of vitamin D ALSALMA study EnKid Study IRON 21% of children do not cover the recommended intake of iron PROTEINS In general, there is an excessive consumption of proteins among children ALSALMA study ALSALMA study

22. Through our results we cannot suggest a similar ideal dose of weekly seafood intake in preschoolers, but our findings indicate a dose-response relationship between WPPSI-III raw scores and amount of fish consumed. IQ scores are known to be stable measures that are not easily changed within an individual. Scatter plots of changes in the Wechsler Preschool and Primary Scale of Intelligence, 3rd edition (WPPSI-III) from pre- to post-intervention vs amount fish (blue)/meat (red) consumed in kilograms (kg) (dietary compliance). The estimated regression line from an adjusted mixed effect model including the interaction between intervention and compliance, together with regression coefficient (β) and a 95% confidence interval are presented. Panel a shows WPPSI-III Total raw score, b Verbal raw score, c Performance raw score, and d Processing speed raw score Oyen J, Kvestad I, Midtbo LK, Graff IE, Hysing M, Stormark KM, et al. Fatty fish intake and cognitive function: FINS-KIDS, a randomized controlled trial in preschool children. BMC Med 2018; 16: 41.

23. 10 objectives for greater nutritional health. Recommendations for the whole familyThe response of the Atlantic diet. Consume more whole grain Eat more fish Consume more vegetables, fruits and olive oil Consume more fat-reduced dairy products Eat lean meats and sausages Limit fast food rich in fat and sugar Limit sugary drinks, limit salt Consume more foods dense in nutrients and less dense in energy Increase the variety of foods consumed Cook steam, grill, oven and less frying AHA-AAP. Guiding SS. Pediatrics 2006; 117:544-9 Tojo, R, Leis R. E. NAOS-MSC. 2007; 69-112

24. Pyramid of the Atlantic Diet: Healthy, functional and bioactive R. Tojo, R. Leis. 2009

25. Healthy characteristics of the traditional Atlantic diet of Galicia - I Abundance of local seasonal foods, fresh and minimally processed. Abundance of plant foods: fruits, vegetables, potatoes, bread and cereals, nuts, chestnuts, honey, legumes... Abundant consumption of fish, molluscs and crustaceans, mainly from the sea but also from the river. Moderate dairy consumption. Moderate consumption of meat, mainly pork. Moderate consumption of eggs. Moderate consumption of desserts composed mainly of flour, eggs, nuts. R. Tojo. Fundación Dieta Atlántica 2007

26. Healthy characteristics of the traditional Atlantic diet of Galicia - II Use of sauces with low energy load and high fat quality. Abundance of water from springs, many with a healthy mineral profile. Moderate consumption of wine, usually in meals. Preferential use of olive oil for seasoning and cooking. Culinary preparation preferably steaming, cooking, oven, griddle and stewing rather than frying. Simplicity in the preparation. Originality in the food association R. Tojo. FundaciónDietaAtlántica. USC. 2007

27. Sea products • Fish, shellfish, molluscs, crustaceans, algae. Single source of long-chain omega-3 (ω-3) fatty acids, ≥ 20 carbon atoms. • Two main ω-3 fatty acids for health: • Eicosapentaenoic acid (EPA: 20:5 ω-3) • Docosahexaenoic acid (DHA: 22:6 ω-6) Fish R. Tojo. Fundación Dieta Atlántica. USC 2007 R. Tojo, R. Leis. La Dieta Atlántica, el pescado y las algas. Servicio Publicaciones USC. 2009

28. Consumption of fish in the home (K / l / person / year) in Spain, CCAA Atlantic and Mediterranean 2016 La alimentación en España (2016), Ministerio de Medio Ambiente, Medio Rural y Marino, Gobierno de España.

29. Intervention with Atlantic Diet. GALIAT 6 + 7 Preliminary Results Objetivos secundarios Maingoal. Lipidicprofile Children Females Males Cholesterol= - 4 LDL-cholesterol= -6 Cholesterol= -11 LDL-cholesterol= -7 Cholesterol= - 11 LDL-cholesterol=- 6 Children Males Females Quality of the diet: ↑ 1.1 Suprailiac fold:  1´2 mm Quality of the diet: ↑ 1.1 BMI:  0.7 kg/m2 Quality of the diet: ↑ 1.4 BMI:  0.6 kg/m2 Calvo-Malvar MM, Leis R, Benítez-Estévez AJ, Sánchez-Castro J, Gude F. A randomised, family-focused dietary intervention to evaluate the Atlantic diet: the GALIAT study protocol. BMC Public Health 2016; 16:820. doi:10.1186/s12889-016-3441-y

30. Southern European Atlantic Diet The South Atlantic Diet (SEAD) is the traditional diet in northern Portugal and Galicia, a region in northwestern Spain. • An index of adherence to the SEAD was developed with 9 key components: fresh fish excluding cod, red meats and pork products, dairy products, vegetables and legumes, vegetable soup, potatoes, whole grain bread and wine . Assigning to each food a score of 1 or 0 according to whether the consumption is higher or lower, respectively, than the sex-specific median in the controls. • Adherence to the SEAD was associated with a lower probability of non-fatal AMI. However, not all components of the SEAD can contribute to a low coronary mortality in the north of Portugal and Galicia • This study identifies possible mediators of the effect of SEAD on myocardial infarction, because SEAD is associated with a lower concentration of markers of inflammation and with the reduction of triglycerides, insulin, insulin resistance and systolic blood pressure Oliveira A, Lopes C, Rodríguez-Artalejo F. Adherence to the Southern European Atlantic Diet and occurrence of nonfatal acute myocardial infarction. Am J Clin Nutr 2010;92:211-7. Guallar-Castellón P et al. The Southern European Atlantic Diet is associated whith lower concentrations o markers of coronary risk, Atherosclerosis. 2012.

31. Longevity in Spain (2012) INE. Padrón Municipal 2012

32. Common findings in people over 100 years old. The recipes of longevity. Study in 4 regions where the largest number of centenarians are found (Sardinia, Okinawa, Lomalinda and Nicoya). In collaboration with the National Insitute on Aging USA. • None had been obese. •    No type of "diet" •    Habits and healthy routines practiced continuously. •    Stop eating before there is a feeling that the stomach is full (caloric self-restriction). •    Small bulky size of the dishes and in the glasses. •    Do not eat precooked foods, soft drinks and salty snacks. •    Eat natural foods, fresh and often own cultivation. •    Abundance of consumption of vegetables, fruits, legumes, fiber, nuts, fish and wine in moderation. •    Regular physical exercise, especially walking. •    Life of intense relationship with strong social ties: family, friends, associations. •    Find time to meditate. •    Set goals and objectives. Dan Buetter. The Blues Zones 2010.

33. Potentialities of Galicia as a nutritional reference, cultural gastronomy and natural space and researcher. A comprehensive strategy • The natural environment • Great diversity, acceptable conservation. • The habitat • Microcities, towns, parishes, not yet sufficiently degraded. • Lifestyles • Still a certain balance between tradition and modernity. • Population longevity with quality public health service. • Culture • Excellent architectural heritage. More than 300 gastronomic festivals. • Food and gastronomy • Atlantic Diet: Perfect assembly of traditional gastronomy and modernity, nutritional and organoleptic quality.. • Investigation • Great research potential • Biomedicine, aquaculture and agribusiness in search of ideal R + D + I R. Tojo. Fundación Dieta Atlántica-USC. 2007

34. Legislation on social and national policies Organizational and commercial practices Planning of controls and regional strategies Community and cultural traditions School practices and peer influence Choices and family habits Children at risk Individual self-control

36. Development of healthy eating habits • The healthy eating habits established in the first years serve for a lifetime. • Adapt to each child the option of the baby-led weaning. • There is a tendency to reject new foods "neophobia", especially in the 2nd year of life . • Variety and repetition are effective strategies to increase the taste for vegetables. • Children who take longer to introduce new textures often become "picky eaters". • Offering foods with low energy density helps the child to balance his intake. • Restricting access to certain foods increases more than decreases preference. Benton D. Int J Obes Relat Metab Disord 2004; 28: 858-69

37. Styles of parental behavior and risk of obesity in children. (Average age: 4.5 years) Paternal cultural models influence determinantly in the alimentary habits of their children. The responsible authority, that is to say "the example", to share habits, education in lifestyles is the best strategy. The parents know the medical recommendation, but despite this their children do not follow it. Brewis A. Am J Hum Biol 2006; 18: 203-13 The unhealthy lifestyle habits of the family and the non-adherence to the nutritional advice of the pediatrician at the time of incorporation of the child to the family table (end of the first year) suppose an important nutritional risk in this critical period.

38. Objectives for the school canteen. Characteristics of the school menu. • Contribution of 30 - 35% of the total calories / day. • High nutritional quality Macronutrient content / 100 Kcal: ≥1. • Wide variety of foods preferably fresh, seasonal and adequately represented in rations of food groups during the week. • Increase in the frequency of consumption of foods underrepresented in the usual diet: • Fruit and vegetables (rotation of the five colors of life: red, yellow-orange, green, blue-violet and white). • Legumes. • Whole grains. • Blue and white fish, other sea products and fresh water. R. Tojo, R. Leis. GALINUT Study

39. THE FAILED SUBJECT Compulsory discipline with great practical content Learn to cook Know food Know how to read the labels Transmission of Good Habits Learn to make the purchase

40. SERVICIO DE PEDIATRÍA Hospital Clínico Universitario de Santiago. Xerencia de Xestión Integrada de Santiago. GI-NUTRICIÓN PEDIÁTRICA Instituto de Investigaciones Sanitarias de Santiago (IDIS). Thanks a lot!

41. Evolution of prevalence boys/girls 6 to 9 years old (according to Orbegozo) Spain is one of the countries with the highest prevalence of childhood obesity AESAN-NAOS-MSC, 2011 The temporary tendency of overweight in girls and boys from 6 to 9 years old in Spain is currently decreasing. Aladino 2015 Aladino 2013: 43% Overweight+Obesity, according OMS Main resultsEvolution of prevalence Since 1999, the prevalence of obesity has stabilized at 35.5% -35.8% in adults and in 16.9% for children and adolescents. Livingston E. JAMA 2012; 307: 970-71 % overweight • enKid: 30,4% • Aladino 2011: 31,4% • Aladino 2013: 28,6% • Aladino 2015: overweight 23,2 % and obesity 18,1% Estudio Aladino: 7.923 boys and girls Estudio enKid: 423 boys and girls