Posted tagged ‘overweight’

Obesity: It’s not just the sugar

April 18, 2017

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?

March 28, 2016

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.

Cute siblings

More water means slightly less weight in New York schools

February 1, 2016

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.

What should we do with all of this yellow paint?

An overweight infant: Time to worry?

July 20, 2015

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

April 10, 2014

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?

December 20, 2011

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 50th percentile. If he gains 3 pounds, that takes him to the 60th 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 25-75th 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

September 28, 2011

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 5th 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.