Obesity: It’s not just the sugar

The Pediatric Insider

© 2017 Roy Benaroch, MD

For a while, fat was the culprit – eating too much fat was making us fat. We were swamped by low-fat products, like cheese and salad dressings and even low-fat potato chips. Briefly, Burger King even offered low-fat French fries (Those quickly disappeared from the menu. Don’t mess with the fries.) Yet, with or without the low-fat foods, obesity rates continued to climb.

More-recently, sugar has emerged as the “deadly villain” in the obesity epidemic. Forget the fat – it’s the sugar, or the refined high fructose corn syrup, that’s messing with our metabolism and expanding waistlines. Just cut back—or eliminate—added sugar, and our weight problems will be over.

But a recent study from Australia shows that maybe it’s not so simple as blaming the sugar, either. Researchers there found that, on a population level, reduced sugar consumption was associated with an increasing rate of obesity. It’s funny how real-world data seems to clash with our little pet theories sometimes.

The authors used data about food consumption from several different academic and government sources, creating graphs of overall per capita sugar consumption among Australian adults and children from 1980 and 2011. Although the exact numbers vary by demographic groups, there was a clear overall trend towards less sugar intake over those years. They then looked at obesity rates, based on national surveys.

The combined data is in the graph below. Sugar consumption is in blue, and though it goes up and down some years, the overall trend is downwards. In red you can see the Australian obesity rates. There’s more data in the paper about specific groups (men versus women, children versus adults), but overall the trend is clear: less sugar consumption is associated with more obesity.

The authors conclude, “There may be unintended consequences of a singular focus on refined sugars…”

So if it’s not the sugars, and it’s not the fat, what is it? I think it’s unlikely that there is a single boogeyman, or a “one thing” we can point our fingers at as the culprit. Obesity has many contributors, including decreasing physical activity, eating bigger portions, and eating more frequently. Low-quality “fast food” is quick and convenient, but it’s certainly not cheap in the long run. A ton of extra sugar can’t be good for your teeth, and is one source of extra calories you don’t need. But it’s not just the sugar that we’re eating too much.

Can having a sibling help protect against overweight?

The Pediatric Insider

© 2016 Roy Benaroch, MD

An interesting new study published in the April, 2016 edition of Pediatrics shows that the birth of a younger sibling is associated with a dramatic decrease in the risk of obesity. I don’t think this ought to sway people towards having more children, but it might offer some insight into other ways to help children keep a healthy weight.

The study recruited families from 1991-1998 (yes, it’s old data. I’m not sure why it took so long to get this written and published.) About 700 children ended up participating. Through in-person visits and phone interviews, the study children were followed from birth through about first grade, tracking who ended up having younger siblings born. The authors then compared children who had younger siblings versus those who remained the only child in the household.

The numbers look strong. Having a younger sibling born between ages 2 to 4 (and especially between 2 to 3 years of age) led to a robust decrease in the upwards trajectory of a child’s BMI. In fact, children who didn’t have a younger child born while they were in preschool had three times the risk of obesity.

Crazy, huh? Three times the risk? Statistically speaking, that’s a big change. This study was unable to show why the birth of a younger sibling helped children keep a more-healthy weight. The authors suggest two possible mechanisms, or ways that having a younger sibling could be protective. Perhaps it changes the way parents feed their children. Other research has shown that ‘restrictive’ feeding practices, like limiting portions or different kinds of foods, are associated with an increased risk of obesity – and maybe having a younger child to look after leaves parents unable to monitor feedings as closely. Allowing young children more control over their food choices does lead to healthier eating and healthier weight gain.

Another idea: children who get younger siblings may themselves become more active, by playing with their little brothers and sisters. They might also become “food leaders”, trying to show their siblings how to eat healthy.

There may be other mechanisms at work here. I’m certainly not convinced I know why the study worked out this way. I do know that healthy weights aren’t about counting calories, only eating “healthy foods”, or buying organic. Hopefully further insights along these lines of this study can help with counseling even single-child families about mealtime and lifestyle routines that can best keep families healthy.

More water means slightly less weight in New York schools

The Pediatric Insider

© 2016 Roy Benaroch, MD

A simple, safe, and cheap intervention looks like a good way to help fight obesity in our schools. But not by very much.

A study published January 2016 in JAMA Pediatrics, “Effect of a school-cased water intervention on child body mass index and obesity”, looked at the effects of installing new water dispensers in New York City school cafeterias. 1227 schools, including 1 065  562 students,  participated in the observational study, which tracked student weights and BMIs, comparing trends before and after the new equipment was installed.

Those new dispensers are called “water jets” in the study, and I *think* they’re just those typical water cooler things that offices use, with a big jug of water on top and a little flappy valve to get cooled water into a cup below. The study description says they both chill and oxygenate the water “to keep it tasting fresh”, and cost about $1000 bucks each. Furthermore, they “are relatively easy to use” (pretty clever, those New York kids.) The authors pointed out that participants were weighed and measured by PE coaches, whose scale-using skills have “previously been found reliable” (pretty clever, those New York coaches.)

The results: after these water jets became available, there was a statistically significant drop in BMI of about 0.025 points (it was just a touch more effective in boys than girls), and the percentage of children in the schools who were overweight dropped by .6-.9%. (from about 39% to about 38%).

I know, not very impressive. The statistics are solid—whether the authors looked at trends over entire schools, or at trends among individual students before and after water jet availability, these weight parameters did drop. And the drop is, technically, statistically valid and real. That’s how it’s been reported in the media. The New York Daily News said “Water machines available in schools can help kids lose weight.”

But the drop really wasn’t very much. Going from 39% to 38% overweight is good, but I think we ought to try to do better. You can lead a student to water, but studies like this show it’s hard to make them actually lose weight.

An overweight infant: Time to worry?

The Pediatric Insider

© 2015 Roy Benaroch, MD

Megan wrote in: “My son is 6 months old, weighs 10.1 kg and 70 cm long. I am concerned about his weight as he doesn’t seem to eat and drink excessively. He can’t roll over and my GP said this is probably due to his weight. What do I do? Cut back on protein and replace with extra veggies? Could he have a health issue?”

For those of you more used to traditional units, that’s about 22 pounds and 27 ½ inches. For comparison, the average for a 6 month old boy is about 17-18 pounds and 26 ½ inches.

Megan wants to know, first, if there’s really a problem here. My definitive answer is:  Maybe. Or, more accurately, no… but there might be later. Having a few extra pounds, now, isn’t hurting Megan’s baby. If he’s otherwise healthy and his development is normal and he’s being fed appropriately, I think it would be very reasonable to wait and see.

But if there are some habits starting now that in the long run might increase his risk for obesity, now would be a good time to address those. Megan said he doesn’t seem to eat and drink excessively, but I’d want to take a better history of his intake over a few days to see exactly what’s meant by that. Is he getting excessive calories? Is he drinking an excessive amount of mother’s milk or formula? Does he get cereal added to his formula, adding calories he doesn’t need? Megan asked about cutting back on protein and increasing vegetables, but is a good idea—though I wonder where he’s getting extra protein from. I’d try to use mostly veggies as complementary foods at mealtimes.

Another thing to ask about, and this can be a difficult question: has eating become the main pacifier or soothing activity? Some babies are temperamentally more difficult to soothe, and sometimes parents fall into a rut of always soothing with food—which can sometimes contribute to a lifetime habit. Many adults eat when they’re worried or upset, and sometimes we get our babies used to doing this, too. I’d ask Megan, what do you do when your son is upset or worked up?

Megan also said he cannot roll over, which to me is unexpected. I see plenty of chunky babies, but almost all of them roll by 6 months. I’d want to do a careful physical exam and developmental assessment, here, before blaming the lack of rolling over on his size.

The question was also asked, “Could he have a health issue?”—meaning, could he have some kind of medical condition be causing his excessive weight. There are some conditions that can do this, but they’re fabulously rare. Incredibly rare. Incredibly as in most-doctors-will-never-ever-see-a-case-of-this rare. So without other history or physical exam findings to suggest something like this, I don’t think it’s very likely.

The most important steps when I evaluate a baby whose growth is not as expected—too big or too small—starts with a careful history and physical exam, and then continues with following the baby closely. Watch those numbers over the next few months to see if they level out. Though there are no immediate dangers here, overweight babies are more likely to become overweight children who are more likely to become overweight adults. Now may be the time to make a few dietary adjustments to prevent a whole lot of trouble later. It’s not time to panic, but it is time to pay attention.

High BMI in children

The Pediatric Insider

© 2014 Roy Benaroch, MD

Stephanie wrote in about a very common problem:

 My daughter is 4 years old. She isn’t the tallest cat in town (she is about the 15th-25th percentile for height), and her BMI always ends up being in the high range (like over 85%). I worry about it. I am very health conscious for myself and my family. We live by all of the ‘rules.’ And yet.

The family doctor doesn’t worry – been shrugging it off since day one. Maybe because both Dad and I are very lean. Maybe because, as patients of hers, she knows we are a very healthy family (regular exercise, healthy diet, no smoking, healthy pregnancy with aforementioned child). Family doc knows we have never fed our kid a drop of juice, no fast food, homemade meals, limiting screen time, healthy choices…

So I’m stumped. Why the high BMI for my daughter? I would love to hear some solid, scientific data about why this could be, as opposed to: ‘Meh, she’ll be fine.’

We know that obesity, in the long run, isn’t good—but we can’t even agree on what “obesity” is. BMI, or Body Mass Index, is a single number that basically reflects weight-for-height. We figure that the more someone weighs for their height, the more likely they are to weigh “too much.” What we really need is a measure that tells us when someone’s weight is unhealthy, or likely to lead to ill health. Instead, we use that BMI number, a very poor predictor of individual health outcomes.

There are several reasons why BMI is not a great way to discriminate between healthy and unhealthy weights:

A BMI doesn’t reflect the difference between lean muscle mass and fat mass. What’s unhealthy is excess body fat, not excess body muscle. A muscular, lean individual with little body fat may have a “high” measured BMI because muscle has weight.

BMI doesn’t distinguish between kinds of body fat. We know that visceral fat—the kind in your belly, or the kind that contributes to an “apple” shape—has far more long term negative consequences for health than fat distributed in the lower body.

Criteria for “healthy” versus “unhealthy” BMI are based only on statistics, not on individual health outcomes. We’ve decided that anyone above the 85 percentile for BMI (down to age 2) is overweight, and anyone above the 95 percentile for BMI is obese. This compares a child or adult’s BMI against historical data, which assumes that people thirty years ago had a BMI distribution healthier than today. While that’s generally true for the population (obesity-related health problems are genuinely much more common now), that doesn’t mean it’s specifically true for each individual or child. In other words, relying on statistics forces us to oversimplify and generalize instead of focusing on ways to individualize our approach to maximize health.

Finally, improved diet and exercise habits improve health outcomes, even if the BMI doesn’t change. Over-focusing on BMI can lead to discouragement, preventing steps that can really improve well-being in children and adults.

So what should Stephanie’s mom do? Forget the BMI and keep up those good healthy life habits. Stay active. Turn off the TV. Eat moderate-sized portions, slowly, eating mostly plants and whole-grains. Eat as a family, and share cooking and cleaning chores together. Avoid eating out or doing take-out too often, and stay away from sweet drinks (soda and juice are equally unhealthy). Enjoy eating and playing, together as a family, and don’t worry about the numbers on the scale. The BMI is one thing, maybe a starting point to remind us to keep up healthy habits. But it’s a terrible target to use as a goal for your child’s body.

Children discover: Adults just fattening them up to eat them

Babies know when they’re hungry

The Pediatric Insider

© 2012 Roy Benaroch, MD

There seem to be two styles of baby-feeding: scheduled versus on-demand. Strict schedulists stress that babies need regularity, and that parents know best what and when and how much their babies ought to eat. In the opposite corner are the on-demand feeders, sometimes thought of as a bit more Earthy-crunchy, the hippie tie-dye, anything-goes crowd. Who’s right?

If preventing obesity is your goal, here’s one more point for the hippies.

A recent study from 2011 presented inAustralia looked at about 300 babies, comparing those fed on-demand to those who were strictly scheduled. The scheduled babies weighed more, on average, at 14 months of age. We know from a good body of prior research that overweight toddlers are much more likely to become overweight children and overweight adults, so that weight difference at 14 months does have important predictive powers.

The results, to me, make sense. An ongoing struggle I have with counseling families trying to control weight is to stress the simple concept: Eat when you’re hungry, but stop eating when you’re not hungry. Unfortunately, many of us eat for too many reasons. We’re bored, we’re upset, we’re anxious, we’ve been taught we need to clean our plates. It is crucial, even from a very early age, to allow babies to develop their own, internal sense of appetite, and to develop the ability to decide themselves how much to eat. After all, it’s the baby himself how knows if he’s hungry, or how hungry he is.

Efforts to over-schedule meals and intake prevent this normal development of a child’s internal hunger-meter. If mom and dad are the ones deciding when and how much to eat, Junior may just eat whatever’s put in front of him, hungry or not.

That’s not to say there are no benefits to scheduling. Schedules help babies sleep at more regular intervals, including through the night. And schedules are essential for working families, who need to get their babies where they need to be, fed, at a certain time. Some sort of schedule is certainly a good idea, at least for the timing of meals.

But at mealtimes, it really is best—from a very young age—to allow babies to decide how long to nurse, or how much to take from the bottle. Try not to second-guess your baby, or push more intake. Trust your own baby to know when she’s hungry, and help her learn that it’s OK to stop eating when her little tummy is full.

Children discover: Adults just fattening them up to eat them

The Pediatric Insider

© 2012 Roy Benaroch, MD

Dateline –Washington,DC

In a shocking revelation, an investigative subcommittee has revealed that adults are deliberately raising fat children—intending, it is alleged, to eat them.

The allegations have been made at the annual convention of all of the nation’s children, currently underway inWashington, DC. Lead investigator Katie McMillan of Everett,Washington read stoically from her report to the estimated 60 million American children in attendance.

“We had been tasked to discover why, in the United States, the rates of obesity have increased so dramatically, especially in children. At school entry, one in three of us is already overweight. Now, we know why,” said McMillan. She went on to review her committee’s findings:

• Parents give us far more food than we need, and constantly tempt us with tasty treats between meals.
• Public media is saturated with ads and imagery promoting unhealthy eating.
• Parents encourage us only to exercise our eyeballs and thumbs with an endless variety of indoor games.

“That last point is especially important,” added committee member Molly Denise, 12. “They want our muscles tender and juicy. More exercise would make us stringy.”

Several conference attendees seemed skeptical at first. Alex Benjamin, 13, asked, “If that’s so true, then why does my mom want me to eat brussels sprouts?”

“That’s covered in appendix ‘C’ of the report,” answered Denise, referring to the 106 page section titled “Things that really aren’t food.” In later comments, it was revealed that these items were being substituted for real food to give children a tastier flavor. “We think it’s kind of like a marinade,” Denise clarified.

Other attendees questioned whether the evidence proved the committee’s conclusion.

“We looked for any other explanation, and honestly, nothing else makes sense,” answered McMillan during questioning after the presentation. “I mean, really. So much food. Restaurant portions are huge, and they even come with soda. And what, really, could be the reason we get desserts? Hello? I just ate, and then you give me more food?”

“Keep in mind,” concluded McMillan to the shudders of the crowd, “that adults are really fat, too. And they sure eat a lot. Where is all of their food going to come from? From us, that’s where!”

None of the nation’s 250 million adults could be reached for comment.

Earlier:

Children surprised, upset by new I-O-Us

Nation’s children call for general strike

Children decide “Adults suck”

The picky eater guide: Part 2. The “Don’ts”

The Pediatric Insider

© 2012 Roy Benaroch, MD

Last post, the Picky Eater Guide started with some history and perspective. The bottom line: there is a huge nutritional problem in the developed world, and it’s causing huge health problems. But it’s not that kids don’t eat their veggies, or that kids don’t eat what their parents want them to eat. It’s that kids, and adults, eat too much. Unfortunately, some things parents do to try to get their kids to “eat healthy” might in the long run be contributing to the warped sense of appetite that seems to be a major cause of the obesity epidemic. This post is about what parents shouldn’t do—the “don’t” list of things that in the long run may end up doing far more harm than good. Got a picky eater? Let’s not make things worse by creating a picky eater with a weight problem.

Do not make food contingencies. That means, don’t make the availability of one food depend on whether another food is eaten first. Think about this common scene:

Mom: “Boscoe, if you eat your broccoli, you can have a brownie.”

Boscoe eats the broccoli, then eats the brownie.

What mom thinks: Good! I got him to eat the broccoli!

What Boscoe thinks: Wow, a brownie must be extra special—it’s a reward food! And broccoli must be some kind of horror. After all, I got a brownie for eating that dreck. I’ll keep in mind that no one in their right mind would voluntarily eat broccoli. I wonder if I can make some kind of deal to get more brownies?

So, net, after this scene, Boscoe did in fact eat some broccoli. But the cost of this was to reinforce how special and wonderful brownies are, and to encourage him to continue to crave them—while at the same time teaching Boscoe how nasty and unloved broccoli must be.

Remember: the point of a meal isn’t to get a serving of broccoli inside a child. (If that were the case, we could just sedate the kids and feed them through tubes.) The point is to 1) enjoy the meal as a family and 2) help reinforce healthy social and eating habits to last a lifetime.

Another big don’t: don’t force feed anything. You’ll create food aversions and a warped sense of anxiety and power struggles at meal time. If you’re forcing anything, you’re causing problems. Stop it. You also shouldn’t distract and fool children into eating, by, say, leaving a television on while you shovel the food in. Junior might continue to eat (kind of like a little bird, just opening up that mouth), but that’s not a way to teach children how to choose foods and modulate their own food intake. It’s also, well, creepy.

Next: how to reinforce The Rule, a Universal Truth and simple philosophy that should be the guiding principle of mealtime. When you’re hungry, eat. When you’re not hungry, don’t eat.

 

The picky eater guide: The whole enchilada:

Part 1. What’s the problem?

Part 2. The “Don’ts”

Part 3. The Rule

Part 4. The jobs of parents and kids

Part 5. Special circumstances, vitamins, and a muffin bonus

An evil in your home

The Pediatric Insider

© 2011 Roy Benaroch, MD

What if there were one sinister thing in the bedrooms of your home—an evil, odious thing that not only contributes to childhood obesity, but also to school failure, depression, and social isolation? Its wickedness not only damages your children, but affects you as well: it interferes with marital intimacy, promotes divorce, and by interfering with sleep can make it difficult to drive safely and perform well at work.

Ready to get out the torches and pitchforks? Ready to get rid of this hideous monstrosity, this malevolent, hateful force that sickens children and their parents, ruining health, marriage, and careers?

The sad irony: there’s nothing good on, anyway.

Get those things out of your bedrooms, and your children’s bedrooms. You’ll be glad you did.

Diets for babies, part 2: A better alternative

The Pediatric Insider

© 2011 Roy Benaroch, MD

Part 1 and part 2 of this article originally appeared on WebMD.com, as a response to this somewhat nauseating story.

Dieting is a terrible idea for everyone—everyone, that is, who’s trying to reach or maintain a healthy weight. It’s especially a bad idea for babies, because it interferes with the most important, fundamental skill that babies need in order to keep a healthy weight throughout their lives.

Ready for the secret to a lifetime of no-dieting, eating enjoyment, and keeping a healthy weight?

The Hungry Rule: Eat when you’re hungry. Don’t eat when you’re not.

It’s simple enough, and in fact every human baby is born with this wonderful skill. But dieting short-circuits the mechanism, leading to food cravings and stress and a distorted view of what and when one ought to eat. Instead of dieting, families should do everything they can to reinforce “the hungry rule.”

Start by breastfeeding. A mother and her baby follow cues from each other about how much milk to supply and when to eat. Bottlefeeding is just guesswork—guess how much your baby can eat, guess how often, and guess when she’s done.

Though feeding is one way to soothe a fussy baby, it isn’t the only way—parents need to be taught other soothing skills besides the bottle or breast, so that babies can learn to soothe themselves without eating.

Introduce appropriate solids between 4-6 months, and allow your baby to decide how much to eat at every meal. Is he turning away? The meal is over. Parents can never know better than their baby when he is full. Bottle or breast-fed babies often start to wean themselves by 9 months or so, as they become more interested in exploring. They’re pulling away? Put them down, the meal is over.

Quickly move towards a family-style meal, including soft table foods that a baby can feed herself at nine months. Set a good example by eating slowly, drinking water, and talking and laughing during enjoyable meals. Don’t chide each other about how much or how little anyone is eating. Provide healthy choices, mostly plant-based, and then allow your baby to decide how much to eat (or even whether or not to eat certain dishes at all.)

Keep sugary drinks out of the house. Juice is no better than soda. However, don’t make any foods forbidden—that just makes them more desirable. Sure, Junior can have juice when he’s at a friend’s birthday party.

Don’t be in any hurry to start “fast food.” The marketing of these products is pervasive and effective—more toddlers recognize “The Golden Arches” than just about any other trademark. McBurgWendfil-a would love to get your child hooked early, and hooked often. Sometimes you’ll be busy, but the fast food “Unhappy Meal” ought to be avoided when your kids are young. Remember: eating is something to do when you’re hungry—not something to do because you get a cool toy or get to go to the restaurant that looks so special on TV.

Diets seem appealing because they promise success, but they’re not going to help you or help your baby. Effective ways of raising a child with a healthy attitude about food always reinforce “The Hunger Rule”—only the child can decide if he’s hungry, so only the child can decide how much to eat. Parents who try to control their child’s appetite and intake from a very early age may deprive their children of the nutrition they need while increasing their risk of obesity. Dieting is no good for anyone, and an especially bad idea for babies.