Nutrition, Preventive Healthcare, Public Health

8. Maintaining a Healthy Weight in Childhood and Beyond

Aside from the common cold, the most common medical issue that I encounter in my office is pediatric obesity. It’s a huge problem, on multiple levels. The prevalence of obesity is currently about 9% among 2-5-year-olds, 17.5% for 6-11-year-olds, and 20.5% for 12-19-year-olds (and that’s just obesity, never mind simply being overweight, which is even more common!). Overall, the prevalence of pediatric obesity is about 17%, affecting 12.7 million children and adolescents. As children (and adults) get older, it becomes more difficult to lose weight, so the best strategy for dealing with obesity is avoiding it in the first place. Fortunately, concrete steps can be taken by parents to avoid this pervasive, potentially lifelong problem.

  1. “Eat food, mostly plants, not too much.” These sage words of advice were offered by Michael Pollen in his book, The Omnivore’s Dilemma. When Pollen uses the term “food,” he’s referring to unprocessed, “real” food—as opposed to the highly processed, food-like substances that are so prevalent in American diets.

Consider, for a moment, your average supermarket. The first aisle contains fruits and vegetables, the last aisle has meat and dairy, and almost everything in between is junk (ie. sugar cereals, pop tarts/granola bars, cookies, crackers, pasta, spaghetti sauce, soda, juice, etc.). Products in the middle aisles tend to fall into the category of highly processed, food-like substances. What do I mean by “processed?” Processed foods are generally made from a combination of finely ground white flour, which is calorie dense (think pizza, pasta, cake, cookies) and numerous unhealthy additives, like simple sugars which are poorly metabolized.

Years ago, before I saw the movie “Fed Up” on Netflix (which every American parent and teenager ought to watch), I didn’t fully understand why processed foods were so unhealthy, and I’m still learning. But a major point made by this movie is, “a calorie is NOT a calorie!” What do I mean by this? In the old days, I used to tell people that the science of dieting was simple—3500 excess calories equaled one pound of weight gain, so eat fewer calories and lose weight; but this turned out to be wrong. Not only does it matter how many calories you eat, but it also matters where those calories come from. Calories obtained from healthy, single ingredient foods that are picked from the ground (like fruits, vegetables, and complex starches like potatoes) are metabolized more efficiently than calories obtained from highly processed foods. In other words, junk food tends to stick to our thighs (and other body parts where fat accumulates), whereas healthy food tends not to cause weight gain.

Like fruits and vegetables, unprocessed whole grains (such as whole oats, barley, quinoa, bulgur, and brown rice) are healthy choices because they’re both filling and efficiently metabolized. A general rule of thumb is that if an item at the supermarket has only one ingredient, then it’s probably healthy; whereas food that comes in a box and has a boatload of ingredients is likely unhealthy.

  1. Another important observation in the movie Fed Up is that foods labeled “low fat” may not be healthy because they’re “high sugar.” Over the past 20 to 30 years, the food industry has been pushing low fat foods as healthy choices, but the advertising is very misleading. Yogurt, spaghetti sauce, and cereals are all examples of foods that seem healthy, but may contain tons of added sugar, much more than you might imagine. One Danimals yogurt smoothie, for example, contains 10 grams of added sugar (equivalent to 2.4 tspns). One cup of Ragu Old World Traditional Spaghetti Sauce harbors 12 grams of sugar, and Frosted Flakes Cereal contains a whopping 11 grams of sugar in just ¾ of a cup. The numbers might not sound like much, but they add up quickly over the course of a day.

How much sugar should kids be eating every day? Guidelines published by the AHA state that children under two years of age should be eating NO added sugar daily. That’s right, NONE. Children over age two should have no more than 6 tspns of added sugar/day (25 grams). Thus an eight-year-old child who drinks one Danimals yogurt smoothie has consumed 40% of her RDA for sugar. I hate to admit this, but my eight-year-old has consumed four of those smoothies in the span of 20 minutes, and she fits right in with other American kids. On average, kids in the US consume 19 tspns of added sugar daily!

When buying food for your children, check nutrition labels carefully. Look for simple sugars like fructose, high fructose corn syrup, honey, and sucrose. An excess of simple carbs is killing the average American diet, contributing to the obesity epidemic, and leading to diabetes and other health problems down the road.

  1. Along with limiting excessive amounts of sugar, parents should monitor the types of fat their children are eating, and how much. All humans need fat to survive, but some fats are far healthier than others. Let’s starting by reviewing the good ones. Polyunsaturated and monounsaturated fats are found in fish and plant-based foods, such as avocados, olives, and walnuts. Liquid vegetable oils like soybean, corn, safflower, canola, olive and sunflower also contain unsaturated fats. Unsaturated fats are healthy when consumed in reasonable amounts.

Now the bad. Saturated fats are concentrated in butter, red meat, chicken skin, non-skim dairy products, and coconut oil.  The dreaded “trans” fats are partially hydrogenated oils used to cook many fried foods and baked goods such as pastries, pizza dough, pie crust, doughnuts, muffins, cookies and crackers—the stuff we Americans love to eat. Why are these fats so unhealthy? Unsaturated fats and trans fats tend to clog up arteries over time, leading to heart attacks and early death.

The USDA recommends that roughly 30% of our dietary calories come from fat, and most of it should be unsaturated. Remember, fats are more calorie-dense than carbs, so small portions can be highly caloric. When it comes to eating fats, a general rule is to eat the healthy kind (unsaturated fats), but not too much.

  1. Serving vegetables and fruit at the beginning of a meal to encourage children to fill up on the good stuff is never a bad idea. When children eat healthy food first, they are less likely to consume large amounts of unhealthy food. What if getting your toddler to eat vegetables is a challenge? In the late afternoon, when you’ve turned on Sesame Street for an hour to get dinner on the table, offer your child a bowl of vegetables. As she watches the screen with glazed eyes, she will insert healthy food into her mouth without even noticing; before you know it, the bowl will be empty!
  1. Another good rule of thumb for cultivating a healthy diet is avoiding restaurants in general, and more specifically fast food restaurants like McDonalds. In restaurants, parents have minimal control over the ingredients used in meals and zero control over portion size. Excessively large portion size is a major contributing factor to obesity in all age groups. The portions at fast food restaurants like McDonalds may be smaller, but they’re loaded with calorie-dense, unhealthy ingredients. Almost all kids love those delicious McDonalds fries and chicken McNuggets; but these “foods” are fried in partially hydrogenated vegetable oil, one of the worst ingredients for the human heart.
  1. The importance of eating regular family meals cannot be overstated. From a medical and psychosocial standpoint, one of the healthiest things a family can do is eat dinners together at home. Below I’ve listed some of the proven health benefits of eating home-cooked, family meals, as noted by the AAP, and these go far beyond issues related to weight:

If at least one parent is home and the meal is prepared at home, then eating three or more family dinners per week decreases the risk of children being overweight by 12%.

Families eat significantly healthier food when they have meals at home. Healthy eating habits learned in childhood persist into adulthood.

Talking around the dinner table improves vocabulary for young children, eventually leading to improved reading skills.

 Eating family meals at least three times weekly significantly decreases the risk of children and adolescents developing eating disorders, like anorexia and bulimia.

The social-emotional wellbeing of children is improved by having regular family dinners, leading to better peer relationships and improved school performance.

Adolescents who have regular family dinners have fewer problems with cyberbullying and are less likely to engage in substance abuse and high-risk sexual behavior. Overall, they have better mental health, including decreased risk of depression and suicidal ideation, and increased hopefulness about the future. Having regular family meals is also a powerful predictor of academic achievement in the teens.

  1. Here’s another simple rule for avoiding obesity: drink water, all the time. Soft drinks and juices are loaded with simple sugars. Remember the 25 grams of sugar per day recommendation for kids over age two? One 12-ounce can of regular Coke contains 40 grams of sugar! Juice isn’t much better; a 12-ounce glass of apple juice has 39 grams of added sugar. Because kids tend to drink a lot, they can pack on the pounds due to poor drinking habits. In 2017 the AAP released a statement recommending against drinking ANY juice in the first year of life. Regardless of age, if children are eating fruits and vegetables, there is no reason they need to drink juice. At the age of four months, children should be given water to drink with their solid meals, a pattern which should continue into adulthood.

What about whole milk, which is recommended for toddlers from age one to two years? My feeling on whole milk is that it’s overrated and not too healthy. Fat, calcium, and vitamin D, the important nutrients in milk, can all be obtained from other, healthier sources. If kids are eating a well-balanced diet with adequate intake of these nutrients,  then there is no reason they need to drink whole milk. If a family has a toddler under the age of two who is already struggling with weight, I usually recommend switching to skim milk immediately.

For a really provocative and interesting look at the potential downsides of eating animal-based proteins, especially milk and meat, check out the movie, “Forks and Knives” on Netflix. This documentary presents the lifework of two well-respected, long-practicing physicians who have concluded that a plant-based (vegan) diet is the most essential ingredient for maintaining long-term human health. Extensive research done by these physicians has suggested that a plant-based diet dramatically reduces the development of heart disease and cancer. Furthermore, individuals suffering from coronary artery disease might be able to reverse some of the damage by switching to a plant-based diet, a truly amazing conclusion.

  1. Exercise:

Although exercise is important for maintaining a healthy weight, it isn’t nearly as important as eating a healthy diet. Why is this? A person’s caloric intake, relative to basal metabolic rate, is mainly what determines weight gain. Nonetheless, one of the best things parents can do for their children to avoid obesity is to provide them with plenty of exercise. How much exercise? The AAP recommends 60 minutes of aerobic, sweaty, out-of-breath exercise every day. When it comes to exercise, more is more. Sixty minutes is the minimum recommendation, but families should feel free to do more. Admittedly, I continually overschedule my own children with activities to keep them moving, especially during the cold New England winter months, when it’s hard to play outside. When choosing sports, I try to select activities that combine aerobic activity and muscle-building. Having adequate muscle mass is important for weight maintenance, because muscle burns plenty of calories at rest. The more muscle a person has, the greater the basal metabolic rate. Sports that combine aerobic activity and muscle-building include things like gymnastics, dance, swimming, and distance running.

  1. No discussion of pediatric obesity would be complete without mentioning screen time. While it’s initially cute to watch toddlers swiping cell phones and iPads, bad habits can develop quickly and become all-consuming. The AAP currently recommends that children under 18 months have ZERO screen time daily.

Given the structure of American society, this might be asking too much, especially from tired parents who occasionally use educational television as a babysitter. Kids can learn a lot from shows like Sesame Street and Super Why, so I never fault families for turning on the TV while they’re cooking dinner, cleaning the house, or snookering kids into eating vegetables (I did, too!). However, screen time should be monitored and limited. For kids over the age of two, the AAP recommends limiting screen time to one hour daily, maximum. This includes cell phones, iPads, computers, televisions, etc. Kids who consume more than two hours of screen time per day are at risk for numerous problems, such as social isolation and a sedentary existence leading to excess weight gain and poor cardiovascular health.

Studies have shown that simply keeping a television in a child’s bedroom is a risk factor for obesity, so avoid putting one there, and don’t allow your child to fall asleep while watching TV. Parents who want to cultivate a healthy lifestyle should monitor screen time and limit consumption from the very beginning.

  1. The best way to avoid eating unhealthy food is to not keep it in the house. There is no need to feel guilty that you’re depriving your children by not buying them junk food. Between birthday parties, special occasions, school celebrations, holidays (think Halloween, Christmas, Valentine’s Day, Easter, etc.), and visits to Grandma’s house, I guarantee they’ll be getting much more junk food than they need. Below I’ve included a list of healthy and not-too-healthy foods. Stock up on the former, and avoid buying the latter. If junk food isn’t in the house, then there’s no temptation to eat it.
  1. Healthy Foods—eat frequently

Baked chicken (serve without skin if possible)

Fish

Fruit

Nuts

Potatoes

Vegetables

Whole Grains (oatmeal, barley, brown rice, couscous, quinoa, etc.)

  1. Not-too-healthy food/pseudo-food—eat in moderation and check labels

Anything with lots of added sugar (soda, juice, candy, some yogurts, sugar cereals, granola bars, sauces)

Baked goods (cake, pie, cookies, crackers, etc.)

Deep-fried anything, especially from fast-food restaurants; most of that stuff is cooked in partially hydrogenated vegetable oil—bad for your heart!

High-fat dairy

Red meat: steak, ribs, lamb chops, and bacon

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