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

What the heck are percentiles, anyway?

The Pediatric Insider

© 2011 Roy Benaroch, MD

In pediatrics, our patients are growing targets. There’s no “best” weight or “correct” blood pressure—there’s averages and ranges that depend on things like a child’s age and sex. Since there’s no way we could possibly memorize all of the normals at every age, we rely on “percentiles.”

Talking in percentiles doesn’t always make sense to parents. I blame number grades in school, where the closer to 100% your child gets, the better the grade. “I scored a 97!” is great. Having a BMI (body mass index) percentile of 97%– that’s not so great.

A percentile is a way of comparing your child to kids of similar age and sex. If your son’s height percentile is 40%, that means he’d be number 40 in a line of boys of his exact age if they were lined up in height order. A percentile at or near 50% is about average, and anything between about 25-75 percentile is close enough to be considered average.

In most areas of health, average equals good. It’s the outliers, the ones with the highest blood pressure or the lowest blood counts, that we worry about.

Percentiles are especially useful when we look at growth and weight. Most children grow along about the same percentile range from age 2 through puberty—so if after two the percentile is changing much, something might be going wrong with growth (before two, there is a lot of percentile shifting as children move towards their expected growth pattern.)

A person’s overall “chubbiness” is usually expressed numerically as a BMI, or body mass index. In adults, a BMI of 25 is usually considered overweight; over 30 is obese. In kids, we rely on the BMI percentile—over 85% is overweight, over 95% is obese. From year to year, the BMI number will change, but the percentile should not vary very much.

Another thing about percentiles: in the middle of the pack, a very small change in a number will lead to an exaggerated change the percentile number that really isn’t very meaningful. For instance, a  9 year old boy who weighs 79 pounds is at the 50^th percentile. If he gains 3 pounds, that takes him to the 60^th percentile. But a change from 85 percentile to 95 percentile in the same boy would mean he’s gained 15 extra pounds. Percentile changes in the 25-75^th percentile range usually don’t mean there’s been a big change in absolute numbers, but percentile changes of only a few points way at the top of bottom of the percentile range can mean a big shift has occurred.

If you’re concerned about your child’s growth or weight, ask your pediatrician to review the growth chart and show you how the percentiles have trended over the years. For most kids, a nice stable percentile curve means that their overall health is good—even if the percentile isn’t right the middle. But a child who’s percentile is very far from average (especially those with BMIs higher than 85-95 percentile), may have significant health risks that ought to be addressed.

I hate juice

The Pediatric Insider

© 2011 Roy Benaroch, MD

“Why do pediatricians hate juice so much? It’s not completely junk like soda. I think kids should have some juice, but my pediatrician says it’s no good for them.”

You’re right: I’ll bet if you survey pediatricians, 4 out of 5 will say “No!” to juice. (There’s always that 5^th one, the weirdo who doesn’t prefer sugarless gum and thinks car seats are for sissies. Ignore him.) Why has juice gotten such a bad rap?

Let’s look at the cold facts, comparing fruit juice to Coca-cola:

The main ingredient in both is water.

The second ingredient in both is sugar. Sugar from juice is almost all fructose, and sugar from soda is….all fructose (from high fructose corn syrup.) It’s the same. Fructose is fructose, whether from juice or from an extract from corn syrup.

12 oz of Coca-cola has 140 calories, all of which are from fructose. It has no other nutritional value.

12 oz of orange juice has 170 calories, all of which are from fructose– in fact, there is more fructose sugar in OJ than in soda, as reflected in the higher calories. 12 ounces of apple juice has about 160 calories. All, again, fructose.

OJ does contain plenty of vitamin C, well over a day’s worth in one serving. But vitamin C deficiency is not seen in the USA, ever, except perhaps in cases of mental illness and neglect. There is also a bit of vitamin A in OJ, probably 10% of the RDA in one serving. OJ and other juices provide some folate, an important B vitamin, that’s also available from many other sources, including all fortified grains.

So: juice has more calories, more sugar, and some vitamins C, A, and folate that your child is probably getting from other sources. Nutritionally, it’s similar enough to soda that you might as well think of it as soda. I do.

Some OJ is fortified with Calcium and Vitamin D, and those nutrients are deficient in many children. There are more-healthful sources (like skim milk—it has protein, potassium, phosphorus, vit A, vit D, and calcium in a very bioavailable form.) But if Junior is anti-milk, OJ w/ Calcium to me seems like one reasonable alternative.

Which brings us back to the original question: Why are pediatricians so down on juice? We have to look at The Big Picture. There really is only one nutritional problem in the United States, one problem that is much more common than all other nutritional problems combined. It’s not vitamin C deficiency, or folate deficiency, or any other deficiency. It’s an excess. An excess of calories. When you think about it, the only nutritional problem we commonly see is obesity. Kids getting too many calories are far, far more common than any sort of lack of vitamins. So when a pediatrician thinks about the best advice to give families about feeding their children, we’re first and foremost trying to think of ways to prevent and treat obesity. Sure, there are plenty of slender kids out there, and for those kids some juice (or some soda) really wouldn’t hurt. But many of them have overweight siblings, and many of them will end up fighting with overweight when they’re older. So it really is better for most families to not encourage any kind of extra calories from soda or juice.

To put it another way: I struggle to try to help families with overweight kids every single day. I’ve yet to see a single child with health problems from juice deficiency. So I’m sticking to my guns. Stay away from juice.

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.

Diets for babies, part 1: A perfectly wrong approach

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.

Plenty of people are overweight—that’s not news. So if you’re a worried parent, why not start early. Could putting an infant or baby on a diet be a good way to prevent obesity?

No. The answer is no. It is the wrong thing to do.

Dieting is never, under any circumstances, an effective way to reach or maintain a healthy weight. The very idea of “going on a diet” implies that someday you’ll “go off the diet”. Even the most successful diet is a temporary step, a brief “holiday” of well-meaning improved eating to lose weight. Inevitably, dieting ends with a return of old habits, yo-yoing weight right back up to and often past where the victim started. Trying to be a healthful eater by dieting is like trying to drive safely by keeping your eyes open—but only for the next 10 weeks.

Dieting is especially a bad idea for the youngest people. Their bodies need nutrition, and plenty of it, to grow. Fat is essential for the developing brain. Healthy babies can seem quite chubby, especially before the baby fat melts away as crawling and exploring replaces eating as their main hobby.

Unfortunately, the very babies at the most risk for eventual weight problems are the ones most likely to be targeted for the unhealthy habits of dieting. Parents who themselves are weight-worried, or have suffered from psychological and physical harm from overweight, may be very motivated to prevent obesity in their children. But by restricting intake, parents dramatically  increase their children’s risk of obesity and eating disorders. The evidence is overwhelming that an overly restrictive feeding style is just about the best way to ensure that children will grow up without the ability to make healthful food choices of their own. Dieting is the wrong idea for all babies, but especially those at the most risk for overweight.

Parents who wish to prevent obesity in their children may look to diets as an effective approach—this despite the fact that dieting probably never helped themselves! Media hype about the latest diet and the latest celebrity stringbean model only adds to the pressure.

Fortunately, there are effective, simple steps during early childhood that parents can take to help ensure a lifetime of healthy eating for their children. The goal isn’t a specific weight at a specific age, but a healthy attitude about food that children can enjoy for the rest of their lives. Doesn’t that sound better than a diet?

Coming soon: Diets for babies, part 2: A better alternative

Calories on the menu

The Pediatric Insider

© 2010 Roy Benaroch, MD

Sometimes a simple study can reveal unexpected truths.

In this month’s Pediatrics, researchers asked 99 parents to choose meals for themselves and their children from one of two ordinary fast food menus from McDonalds. (Don’t ask me why they didn’t get one more to reach an even hundred. Sometimes the intricacies of research elude me.) One of the two menus had calorie content information next to each item; otherwise, they were identical.

Do you need to guess what happened?

Parents who saw just how many calories were in each item (hamburgers-250 cals, Big Macs-540 cals; yogurt parfait-160 cals, McFlurry-550 cals) ordered less food with fewer calories for their children, on average about 100 calories fewer. That may not sound like a lot, but over the course of a year an extra 100 calories a day adds up to gaining about an extra five pounds of fat each year.

And none of the meals ordered by any of the parents with calorie-count menus ordered a meal that was too small. All of the meals chosen were plenty big and provided all of the calories their growing children needed.

There was one other big truth– and maybe we should have expected this as well.

For parents ordering meals for themselves, having calorie counts made no difference whatsoever. Whether or not their menus had calorie counts, adults tended to order the same enormous meals. More information on menus may encourage parents to order more-reasonably sized meals for their kids, but not for themselves.

Junior, you get a munchkin; and while you’re at it, pass me another donut.