By Carissa Garey-Stanton, MD, FAAP
As many pediatric healthcare providers have noticed, America has a growing problem with pediatric obesity and chronic disease. Childhood obesity has tripled from 5% to 18% in the last 30 years, and currently 1/3 of children are overweight or obese. Along with the obesity comes type II diabetes, which has increased in children 30% from 2001 to 2009. Other chronic diseases are occurring more in children. For instance, asthma has doubled since 1980. One of the reasons I chose pediatrics was to treat less chronic disease, but increasingly pediatric healthcare providers are having to treat type II diabetes, hypertension, dyslipidemia, and other chronic ailments. Per an article by JM Perrin in JAMA, the rate of rise of chronic disease in children is too quick to be genetic shift; therefore it is mostly attributable to environmental causes. One of the major contributing factors is a shift to a diet that is less in whole natural foods, and more in highly processed foods that have high calories (energy dense) but nutrient poor. Approximately 30-40% of daily energy in children’s diet is consumed as highly processed foods that have sugar and other additives added to them but nutrients taken out. This creates a diet that is not only high in calories causing overweight and obesity, but also low in essential nutrients like vitamin D, calcium, fiber and magnesium which may contribute to chronic disease.
So what can we do? Well, as a society we need to shift back to 1970 (when childhood obesity was at a baseline 5%) to a diet that was balanced with whole natural foods eaten mostly at home. America needs to modify environments (home, school, workplace, grocery stores, restaurants) to make it easier to choose healthier whole foods instead of highly processed convenience foods. What we as healthcare providers can do is educate and help families choose a diet that is higher in whole natural foods and less highly processed foods, something I term “eat closer to nature”.
Nutrition and obesity research is showing that one of the most high yield areas of focus to help families get healthier is decreasing added sugar. As a dietitian and a pediatrician, this is something I’ve stressed to my patients and families, but for numerous reasons it has not hit mainstream knowledge until the problem of obesity has worsened and more literature has developed. Now knowledge about the dangers of hidden sugars is coming out of hiding. The American Heart Association (AHA) recently released a scientific statement about added sugars and cardiovascular disease risk in children. The article reviews the current literature on the cardiovascular health effects of added sugars on children. It found the consensus of research shows excess added sugar in children’s diet leads to increased adiposity, elevated blood pressure, and has adverse effects on dyslipidemia. They also found that added sugar introduced before the age of 2 predicted future sugar consumption and taste preferences. The paper also discusses different forms of sugar, and concludes that sugar in beverages has the most proven link to cardiovascular risk factors due to metabolic effects (such as hyperinsulinemia) and decreasing satiety (children consume more calories when drinking sugar). Based on their findings, the AHA recommends children limit sugar to less than 25 grams per day, maximum 1 sugar sweetened beverage per week, and avoid added sugars in children <2 years of age. Currently the average American child eats 3-4 times that amount, around 80 grams per day! The AHA concludes: “associations between added sugars and increased cardiovascular disease risk factors among US children are present at levels far below current consumption levels.” Considering cardiovascular disease is the leading cause of death in North Americans, and atherosclerosis can start in childhood, this is a huge public health concern and decreasing added sugar should be a major target to improve the health of Americans.
So now that we know that information, how do we get families to decrease added sugar? By working with families to educate, set goals, monitor progress, and get through barriers to change habits. The first step is teaching families to find hidden sugar. This was supposed to get easier when the FDA mandated a change in food labeling that puts a percent maximum on the label (albeit with the adult recommendation of 50 grams), but with the current administration it is unsure if this change will go into effect. In any case, we can still educate families to find sugar that the food companies hide to make it taste better so consumers buy the product. For instance, flavored yogurts and chocolate milk often have around 24 grams (6 teaspoons) of sugar, which is a child’s whole days maximum allowance of sugar, and as much sugar as a Snickers candy bar. I have a kitchen scale where I have kids measure out 6 teaspoons of sugar, which weighs around 24 grams, and ask them if they would really stir that amount of sugar into their yogurt! And most sugar-sweetened beverages (Gatorade, soda, juice) have even more, up to 2 times the maximum daily amount of sugar. So the first step is to teach the family about grams of sugar, as this is another way for companies to hide sugar by using an unfamiliar measurement like grams. One way to conceptualize the amount is 4 grams = 1 teaspoon (as per the example above 24 grams=6 teaspoons). I tell families choose foods with less than 6 grams of sugar (most kids eat average of 4 added sugar foods per day, so 6×4=24 grams which would be their maximum). Most importantly, sugar sweetened beverages have been shown to be the most high yield lifestyle behavior to modify, so set goals to decrease sugar beverages to once a week per the AHA recommendations. I tell my families “drink white milk with meals and water between, anything else is a treat once a week”.
This leads to the second most common barrier: once you find the sugar, it is hard to change habits to reduce the sugar because kids are accustomed to excess sugar. The preference for sweet taste and the sugar “high” (dopamine release) make the kids literally addicted to sugar. I have had patients throw tantrums for their sugar habits! But I have equated it to things like kids resisting when getting into car seat, the parent has to do what is healthy for them. Same with the sugar, do not give into them, adults have insight and know better, and the kids will thank you when they are healthy adults! So it takes time for to change habits, for instance for a kid to change from chocolate milk to plain milk. Now I want to point out there is sometimes conflicting results when it comes to nutritional research. For instance, the AHA article does point out there is some conflicting literature on added sugar in food with some nutrient value, like milk. One study showed switching from flavored to unflavored milk decreased caloric intake. Another study showed BMI scores were comparable in flavored milk, unflavored milk, and non-milk drinkers. Interestingly, the 1st study was funded by Robert Wood Johnson Foundation obesity grant, while the National Dairy Council funded the 2nd study with the lead author disclosing a role as the Vice President of the National Dairy Council’s research. Nutrition and environmental research is tricky to interpret, not only do you need to take into consideration funding and bias, but there are lots of factors that make it difficult to show cause and effect of one factor on a second factor. There are rarely randomized control trials that can be done on diet due to numerous factors involved with diet and environment. Therefore it can be hard to tease out cause and effect as easily with nutrition/environmental research as with medication/treatment trials. This is where we need to interpret it and add some common sense. For instance, plain milk without added sugar is healthiest, and anecdotally I have seen patients decrease their BMI just by changing flavored added sugar milk to plain milk (the closer to nature the better!). Therefore I have recommended to some families who are trying to get healthier, that if the child won’t drink plain milk, than a calcium and vitamin D supplement is better than added sugar with calcium and vitamin D. And with time I have seen children’s palates get used to less sugar and they accept plain milk, especially if there is no option of flavored sweet milk. And this is where Ellyn Satter’s Division of responsibility comes in handy: “parent’s job is to offer a variety of healthy food, the child chooses how much”. I tell parents if there was a famine, and all the PB&J sandwiches and chocolate milk were gone, and the only thing available was broccoli and white milk, they would eat and drink it and not let themselves starve!
Lastly, I would like to point out that we have updated the KAAP website sections Chapter Focus: Obesity and Parent info: Healthy eating & lifestyle. There are many resources available to help healthcare providers and families address the childhood obesity epidemic, and we have compiled many of these resources in one handy location, and included handouts and my presentation from the KAAP spring meeting 2016. Feel free to contact me at firstname.lastname@example.org if you have any suggestions or would like to communicate.
Perrin JM, Bloom SR, Gortmaker SL. The increase of childhood chronic conditions in the United States. JAMA 2007;297:2755-9
Vos MB, et al. Added Sugars and Cardiovascular Disease Risk in Children. Circulation. 2016;134:1-18
Briefel RR, Wilson A, Cabili C, Hedley DA. Reducing calories and added sugars by improving children’s beverage choices. J Acad Nutr Diet. 2013;113:269-275
Murphy MM, Douglas JS, Johnson RK, Spence LA. Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in US children and adolescents. J Am Diet Assoc. 2008;108:631-639