Healthy Food & Healthy Living by Dr. Ayala

The health and weight of the (young) nation

It has been many a pediatrician’s nightmare prediction: rising obesity rates are likely to cause an increase in type 2 diabetes in teens, in much the same way these two conditions are linked in adults.

And this fear has come to pass. Type 2 diabetes, unheard of in kids just a few decades ago (it used to be called adult-onset-diabetes for just that reason!), has become unexceptional in pediatric practice.

But what we’ve seen so far seems to be just the tip of the iceberg. A new article in Pediatrics looked at a group of about 3400 nationally representative teens (aged 12-19), and found that diabetes and pre-diabetes nearly tripled in less than 10 years, jumping from 9 percent in 1999-2000 to 23 percent in 2007-2008.

The authors, led by Ashleigh May, warn that these results should be interpreted cautiously: Diabetes and pre-diabetes were diagnosed by a single fasting blood sugar test. The true prevalence of type 2 diabetes in kids is hard to know unless blood tests are done because the disease can have little or no symptoms for a very long time. The numbers do look high, and it’s going to be interesting to see if other large-population studies corroborate them.

Teens at serious cardiovascular risk

High blood sugar wasn’t the only cardiovascular risk factor facing the teens in the study. Overweight and obesity were common – 16 percent of the kids were overweight and another 18 percent were obese.

On top of that, 14 percent of kids had pre-hypertension or hypertension, 22 percent had borderline or high LDL (bad) cholesterol, and 6 percent had low HDL (good) cholesterol.

All these above mentioned risk factors were seen much more frequently among the kids with overweight and obesity, in fact, among obese teens 61 percent had at least one cardiovascular risk factor on top of their weight status, and 8 percent of the obese teens had 3 or more of the tested risk factors. But even among normal weight teens 37 percent had a cardiovascular risk factor (the most common of which was high LDL), showing that even when teens aren’t overweight they can benefit from interventions promoting a better diet and more physical activity.

A bit of good news if I may: it seems like obesity rates have leveled off and they haven’t changed much during the 9 years covered in this study. For overweight and obesity to level off at a third of the pediatric population is of little comfort, though

Diabetes in teens carries extra burden

Kids with diabetes not only have more years to accumulate the disease’s serious complications – the longer one has diabetes the more likely heart, kidney, eye, nerve and other body systems are to suffer its consequences. Type 2 diabetes is also proving to be much harder to treat in young patients according to recent studies.

It doesn’t have to be so!

I assume that the vast majority of the kids in this study had pre-diabetes – a condition that if left unattended can, and often will, develop into diabetes (the article doesn’t differentiate between diabetic and pre-diabetic teens). But pre-diabetics can reverse their metabolic state with just modest weight loss and exercise.

And for all of us, type 2 diabetes is mostly a lifestyle disease. It is really up to us to feed kids better and help them become more active so they’re not doomed to develop totally preventable disease and disability as young adults.

What to do? HBO’s excellent Weight of the Nation looks at this complex issue in depth and with compassion. If you haven’t seen it yet, I highly recommend the Children in Crisis chapter (I actually think it’s a good idea to watch the chapters out of order – I found the first installment, Consequences, to be so depressing that I have a feeling some viewers might have just given up on both the series and on dealing with obesity before that chapter was over).

As Dr. Tom Frieden, CDC director, says: The weight of the nation is not healthy. And to get it healthy, we’re all going to have to do our part.

 

Dr. Ayala

 

Study proves school nutrition standards work

School meals are far from perfectly nutritious, even after the long awaited and very welcome changes put in place earlier this year.

The good news is that under the new guidelines kids will hopefully double their fruit and veggie intake, will be served more whole grains, all milk will be low fat, and there’ll be upper limits to salt, trans-fat and calories in the school meal. The not so great reality is that kids will continue to eat lots of highly processed foods – very few schools actually cook food from scratch – and tomato paste on pizza counts as a vegetable.

But school food isn’t just the subsidized school lunch; competing with it are the foods sold in schools -- in vending machines, school stores, and a-la-carte in the cafeteria -- which make a big part of what kids actually eat while they’re in school.

The USDA administers and regulates the school lunch program, and is developing nutrition guidelines for the foods and drinks sold at schools. (The Healthy, Hunger-Free Kids Act, passed in 2010, gives the Agriculture Department authority to set health standards for all foods sold on school property — including those in vending machines). Right now, the only existing federal restriction is that foods of “minimal nutritional values”, such as candy and soda, won’t be sold in the cafeteria during meal times. That of course doesn’t mean they can’t be sold right outside the cafeteria doors.

In the meantime some states have developed their own regulations. Studying the effects of different sets of regulations and their enforcement can teach us what’s been successful – and what doesn’t work.

Vending machines with fewer calories

California was one of the first states to implement rules for vending and selling foods in schools; these rules limit the caloric content, fat and sugar in snacks, and ban soda and sweetened beverages.

A new study in the Archives of Pediatric & Adolescent Medicine compared California high school students’ daily intake to the intake of students from 14 states without any school nutrition standards. 

California kids ate fewer calories per day at school -- 170 fewer – compared to high school students in other states. California kids also consumed less fat and sugar.

Did the kids load up the ‘lost’ calories on their way home or once they got there? It doesn’t seem so. Although California students ate more of their daily calories out of school when compared to the kids from the “no rules” states, the Golden State’s students took in 158 fewer calories a day, overall.

And a reduction of 158 calories is a big deal. We gain weight very gradually, and reducing even 100 calories a day can prevent weight gain and put a dent in the obesity crisis.

Fewer calories, perhaps no better nutrition 

California students ate fewer calories from fat and sugar, but the study found that their intake of nutrients such as vitamins and minerals was unchanged compared to the students from the other states. 

The authors suggest that the reason lies if the food laws themselves: the laws limit sugar fat and salt, they don’t require whole grains, fruits or vegetables. Replacing full fat chips with baked low-salt ones can only do so much.

Providing truly healthy substitutes is obviously the next step, but since obesity – too many calories -- and the abundance of sugar, fat and salt in kids’ diets are the main nutrition problem facing us, I’d conclude that California kids seem to enjoy better nutrition according this study.

Does public policy impact kids’ health?

While there are plenty of studies that show policies have a positive impact on kids’ eating habits, there are definitely studies that show that they don’t. I shared a recent study that showed that in schools that banned only soda, kids bought the other vended sugary beverages instead.  In schools that banned all sugary drinks kids indeed consumed fewer sugary drinks at school, but their consumption did not decrease overall; kids were able to find sugary drinks out of school, and filled the sugar gap before and after school. In other words, school vending policies only changed the school environment, and didn’t seem to be enough to change kids’ access and behavior overall.

I’d argue that even if the regulations don’t have the immediate nutrition-improving outcome we’d hoped for, it’s still imperative to apply nutrition rules for educational reasons. It’s impossible to advocate for safe driving while holding a cellphone with one hand and the wheel with the other.

School should have a central role in nutrition education, and you can’t teach healthy nutrition while benefiting from the sale of junk food within school walls.

Kids spend half their waking hours in school and consume much of their daily calories while on campus. Changing school food should be a critical part of the effort to combat obesity.

Dr. Ayala

 

Put those fruits and veggies a little closer

Much of our eating is mindless and automatic. That’s why environmental changes can lead us to overeat. Many argue that what’s at the root of the obesity epidemic is the transformation in our environment, which gradually changed into an obesity-promoting one.

Proximity and convenience affect food choices. Food sellers know that the closest, easiest to grab, and most noticeable food items will sell more, that’s why they place the products that they want you to buy on an eye-level shelf, near the checkout and in an open case. Previous studies have shown that when candy is placed closer and is in a clear rather than an opaque bowl, people eat more of it.

Could proximity and visibility promote good-for-you foods just as well?

Gregory Privitera and Heather Creary tested how distance and visibility affect apple and carrot consumption. Their new study appears in the Environment and Behavior Journal.

The 96 healthy students in the study were not aware that eating behavior was the purpose of the experiment, and were assigned randomly to have a bowl of the fruit or the veggie in one of these four settings:

• Within arm’s reach and in a clear bowl
• Within arm’s reach and in an opaque closed bowl
• On a table about 2 yards away in a clear bowl
• On a table about 2 yards away in an opaque closed bowl

The students watched the researcher take the food out of a sealed bag (this was done to ensure the participants knew the food’s fresh and good to eat), and the researcher then excused himself for 10 minutes, with a cover story of “I’ll be right back with some questionnaires”, and an invitation to munch on the carrots or apples.

Within arm’s reach

Leaving the apples and the carrots close, within arm’s reach of where the student sat, increased intake significantly. The transparent bowl trick worked only with apples; carrot intake wasn’t significantly increased when the bowl showed though. The researchers suggest an explanation:

“apple slices may be more visually appealing than carrots in that seeing sweet-tasting apple slices (vs. bitter-tasting carrots) induces a stronger wanting to consume those foods.”

I’m here to defend the meager carrot: carrots are generally not bitter! I wonder where the researchers got their veggies, or when they last tasted a good carrot. Carrots actually have high sugar content, and are very tasty! They’re pretty, too.

Anyway, I suppose most moms knew this intuitively, but here’s some experimental proof showing that making fruits and veggies readily available can get us closer to the minimum recommended 5-a-day.

Another thing that caught my eye in this study is the background information on the study group. The students were about 19 years of age, and their average body mass index (BMI) was about 27. A BMI of above 25 puts a person in the overweight range. The study sample is a small one, and quite random, but what we see again and again is that even among young students, being overweight has become the norm. Every year of being overweight adds to the risk of chronic diseases such as type 2 diabetes and heart disease, and that’s why the overweight and obesity epidemic among kids and young people is especially worrisome.

Eating more fruits and veggies is important to health, as well as for healthy weight maintenance; so let’s think up some clever fruit and veggie placements!

Dr. Ayala

 

Preschoolers suffering nature and exercise deficits

A happy day is one in which some time is spent outdoors.

Dog owners take their dogs out daily, and pediatricians suggest we extend the same kindness to our kids.

No, seriously, kids need the outdoors quite critically. Outdoors translates to physical activity and fitness, and the more time kids spend outdoors the less likely they are to become obese. Kids don’t exercise in gyms; they have bursts of intense, vigorous, heart racing activity while playing in a large open space, when they’re chasing a friend or a squirrel, or repeatedly going up and down a slide. Playing outdoors also helps kids’ development and growth and does wonders to their vision, coordination, vitamin D levels and mood!

Experts say that free play — especially outdoors — is crucial to a kid's health, but chances to play outside have been on the decline over the past few decades. Busy lives, over anxiety about safety, screen based entertainment and lack of awareness are keeping kids indoors.

Not enough outdoors time

A new study in the Archives of Pediatrics & Adolescent Medicine looked at the frequency at which parents took their kids to play outside. The authors, led by Pooja Tandon, used a nationally representative sample of about 9,000 4-year-olds, whose parents were asked how often they took their kid out to play. 

They found that about half of the preschoolers were taken out by their parents daily.

Is another caregiver taking these kids out? Possibly — daycares are supposed to take kids out. But even among the 20 percent of children in the study who didn’t attend any day care or preschool at all, only 58 percent went outside daily with mom or dad.

Is safety the issue?  

An important barrier to spending time outdoors could be perceived or actual concern for safety. This study found that the vast majority of parents thought that their neighborhood was either very safe (58 percent) or fairly safe (35 percent), with just 5 percent assessing their area as fairly unsafe and only 2 percent as very unsafe. So dangerous neighborhoods were not the issue.

Has TV replaced playing outdoors? The researchers found that the 4-year-olds in the study spent almost 4 hours a day in front of a screen — which is a lot, and almost double the (generous) American Academy of Pediatrics’ suggested upper limit — nevertheless, screen time wasn’t correlated with how often parents took their kids out to play.

There was also no correlation with household income or mom’s marital status. 

There were, however, two interesting variables that increased the odds of getting regular fresh air: boys were taken out more often than girls, and moms who exercised regularly were more likely to the take their kids out.

It seems like active parents raise their kids to be more active, and perhaps the known statistic that boys are generally more active than girls can be partly explained by the fact that boys are given more opportunities for activity. 

Get outside!

Being active starts at home and with the parents.

Barring dangerous weather, kids — and adults — I do believe, will do themselves some good by spending some time outdoors every day. Regardless of what happened at day care or school, parents should encourage kids to go out, run around, look at trees and birds, meet some insects, get dirty and come back tired. I can’t think of a better way to take a break from work, media and chores than to leave them all behind and go out with the kids. Soon enough these young kids will be able to enjoy the outdoors without adult supervision, and if you’ve collected some great outdoor memories you’ll be rewarded with outdoor enthusiasts for life.

Dr. Ayala

“Sunshine is delicious, rain is refreshing, wind braces us up, snow is exhilarating; there is really no such thing as bad weather, only different kinds of good weather.” ~John Ruskin

 

Three healthy habits to help fight childhood obesity

I'll be taking some time off to spend time with my family and travel, and I'm be reposting a few popular posts I’ve written over the past years so that new readers have a chance to catch up. 

One in three American kids is overweight or obese. Many of our kids start accumulating extra weight—or develop the habits that will lead to weight gain later on—in very early childhood, setting them up for a lifelong struggle with both weight and a multitude of chronic diseases.

But many parents don’t pay much attention to obesity prevention advice; they don’t believe it’s relevant to their kids. They’re more focused on making sure their kids develop well, and they’re the last to notice when their kid puts on the pounds. And of course everybody hates “eat less” type of advice.

That’s why obesity-fighting tactics that aren’t directly related to what to put on kids’ plates have the potential of being successful.

A recent study in Pediatrics examined the association between childhood obesity and three household routines—regularly eating dinner as a family, getting enough sleep, and limiting TV-time—and found that 4-year-olds exposed all three routines had about a 40 percent lower prevalence of obesity than those exposed to none of these routines.

The study involved 8,550 nationally representative four-year-old American kids, and included measurements of height and weight as well as collection of background data, including ethnicity, maternal weight and education, and household income.

Eating dinner together regularly was defined as having the meal with at least some family members six or seven times a week. Adequate sleep for a four-year-old was categorized as 10.5 hours or more a night. Limited TV time was anything less than two hours a day during weekdays.

Here are the main findings:

• More than 18 percent (!) of the four-year-olds were obese.

• About half the families had a family dinner routinely.

• A little over a half of the four-year-olds got what the study considers enough sleep.

• 40 percent of four-year-olds had their TV time limited to less than two hours a day on weekdays.

• One in seven kids had all three household routines (family meals, enough sleep and limited TV time) and one in eight kids had none of these routines in place.

• Each of the routines was associated with significantly lower obesity rates. Kids who had all three routines had 40 percent less prevalence of obesity even after adjusting for maternal obesity and other socioeconomic characteristics.

Anything surprising in this data?

Unfortunately we’re getting used to seeing 18 percent obesity—yes, obesity, defined as a Body Mass Index (BMI) above the 95 percentile—not merely overweight in four-year-olds. That’s nearly one in five young kids!

Yet I still cringe whenever I see these numbers.

The finding that 60 percent of four-year-olds log more than two hours a day in front of the TV on weekdays is especially troubling to me. And I suspect these TV viewing times are an underestimate since parents tend to give socially desirable responses when asked about their habits, and only TV viewing athome and on weekdays was figured-in into this study.

Most large studies show that the more TV kids watch, the more likely they are to be overweight. How does TV contribute to obesity? Although common sense would say that TV displaces more active pursuits, that point isn’t well proven, as of yet.

What is very clear is that when our kids watch TV they are exposed to billions of dollars’ worth of well-crafted food ads, most of them for junk-foods: fast-food, sugary cereals and candy. These ads are so slick, and the marketing is so clever and entertaining that some toddlers have been known to sing the tunes and repeat the message after being exposed to some ads just once.

Most toddlers can’t tell programming and advertising apart—furry, cuddly friends and super-heroes abound in both—and it takes maturity and training to teach kids how to counteract the impact or to even notice the persuasive intent of advertising.

That’s why marketers want to get kids while they’re young; it’s like shooting fish in a barrel, and they’ll be loyal to the brand forever. That’s also why we parents should want to keep marketers away from our kids, especially when they’re very young and impressionable.

These days some food companies participate in a self-regulatory program butself-regulation doesn’t seem to be doing much to ensure responsible advertising to children. I actually don’t think there is such a thing as fair and responsible advertising to toddlers.

The American Academy of Pediatrics recommends limiting “children's total media time (with entertainment media) to no more than 1 to 2 hours of quality programming per day” and “discourage television viewing for children younger than 2 years”. TV is a babysitter every parent might want resort to every once in a while (we all need a break!) but common sense suggests that the upper limit should be lower than the Academy’s guide, and unfortunately, even quality programming is often flanked by ads. 

Should we adopt these three habits?

This study is cross-sectional and observational, meaning it looks at a population at a certain point in time and proves an association between family meals, good sleep and limited TV and lower rates of childhood obesity. It cannot prove causality, nor did the study examine the key influencers of obesity—diet and physical activity levels. It very well may be that these three habits are the habits of families who eat better and move more.

Yet even without further proof that these three habits curb obesity, I would absolutely recommend them to families, mainly because family meals, good sleep and limited TV-time make so much sense. There are other reasons to adopt these habits (for example, eating together is simply a good way to keep family ties strong), and there’s very little downside to embracing them.

But there are possible drawbacks. Your kids may suffer some arguments over the dinner table, have occasional bad dreams while they sleep, and miss some educational and entertaining stuff on TV.

On the other hand, they’ll be learning the pleasures and skills of dining in company rather than gulping down food, they’ll get enough sleep to sustain growth and health, and I’m pretty sure that most alternatives to TV (playing, reading or even being bored) offer better stimulation and sustenance to a child’s developing brain. If these three habits also protect young children from obesity, that’ll be a nice added bonus.

I’d take the risk.

Dr. Ayala

 

Moms oversharing their kids’ most personal stories

The mommysphere was abuzz over Dara-Lynn Weiss's Vogue article that detailed her effort to get her 7-year-old daughter to lose weight.

Criticism of Weiss spread like wildfire, especially after Katie J. M. Baker posted her scorn in Jezebel and described Weiss’ self-reported intense regimen of calorie restriction and public shaming as “abrasive, often irrational weight-loss strategies” and accused Weiss of projecting her hatred of her own body onto her child, and of writing the “worst Vogue article ever”.

Was Weiss wrong to put her daughter on a diet? Was the diet regimen inappropriate? Was its message misguided? Is being tough on your kid a parenting mistake?

There are situations in which action needs to be taken to prevent kids from further weight gain, and it’s definitely a parent’s job to educate kids about healthy eating and active lifestyle, and to provide for healthy food. There’s more than one way to obesity prevention and treatment in kids, and the discussion about what to do when a kid is diagnosed with overweight or obesity is an important one.

But here’s why I’m absolutely appalled by Dara-Lynn Weiss's piece: the Vogue article not only gave the child’s full name, it also displayed her photos.

A few days after witnessing the media party around the 7-year-old-on-a-diet, I read Elizabeth Weil’s Puberty Before Age 10: A New ‘Normal’? in the New York Times. This article opens with a story told by another mother, Tracee Sioux, whose daughter started growing pubic hair at the age of 6. Again, full name of the child, hometown and picture all included.

Outing kids

Reality TV seems to have dampened our instinct for privacy.

Adults willing to share tears and fears and humiliation with strangers are one thing, but dragging your kids exposed into the village square is an entirely different story.

Could anyone really imagine that a girl could benefit from the world knowing when her breasts budded?

So here’s an easy trick for moms with oversharing tendencies: Ask yourself this: if someone else revealed the information about your kid, would you feel comfortable? If your kid wanted to expose the information on the Internet, would you advise him to go ahead?

I’m sure most parents would be outraged if their kid's weight struggles, breast budding or pubic hair appearance were exposed by a reporter or a friend. They’d sue them!

Why did these moms do it? Weiss’ diet might have been designed to help her kid. Sioux might be thinking that she has an important story to tell.

But revealing the names and images served only mom’s interest – and was done for publicity and financial gain. Apparently, Weiss scored a book contract with Random House following her article. Sioux got to plug her “No Craptastic Ingredients” cosmetic line in the Times article as the solution to early puberty.

Every parent will make mistakes. I believe that kids are pretty resilient, and usually turn out fine despite the fact that perfect parents don’t exist. Our kids might be angry with us over what they see as our wrongdoing, but will forgive us – because most kids realize their parents do the best they can, and mean well.

I really can’t see exposing your kids’ private life for financial or any other gain as an act done in the kids’ best interest.

Dr. Ayala

 

Can fruits and veggies make your skin glow?

I used to chuckle when I heard moms urge their daughters to eat tomatoes for rosy cheeks. Old wives' tale, so, I thought, and by that logic would I turn greener with kale? I was a little less sure of my dismissiveness when my own palms turned an orangey tint when I went heavy on my carrots, and was totally humbled when I met my first pink flamingoes.

Beauty from the garden’s bounty 

A new study in the scientific journal PLoS ONE followed 35 students for 6 weeks looking at how fruit and veggie intake affects skin tone, as measured by a spectrophotometer (an instrument that measures the spectrum and photometric intensity of each wavelength present, and in this case of visible light). 

The researchers, led by Ross Whitehead, found that measured skin tone correlated with reported changes in the diet: eating more fruits and veggies increased skin redness and yellowness, and these skin color changes where achieved with a relatively modest increase of fruit and veggie intake – adding about 4 servings did the trick.

In a second part of the study, the researchers asked 24 students to rank face’s health appearance and attractiveness when these faces were manipulated to take on the hue change seen under low fruit and veggie diet as opposed to a fruit and veggie rich one.  The experiments showed that the faces with the skin color associated with high fruits and veggie intake were perceived as more appealing and vibrant.

Carotenoids and blood perfusion

This study, and others before it, show that we prefer rosy, slightly flushed, lightly yellow-toned skin -- perhaps because it sends a signal of healthfulness -- and pigments from the fruit and vegetables in our diet seem to impart just the right tone to our complexion.

Fruit and veggie pigments, such as lycopene and carotenoids, make their way into the skin and change its hue. Fruits and veggies may also change skin’s blood perfusion. 

Skeptical of this small study’s results? We are what we eat, and food affects health in a profound way. There are many reasons to eat your veggies, but if you find the beauty-from-a-tomato argument effective, I’d consider this study support to use it as needed.

Dr. Ayala

Kids aren’t getting enough sleep (and they never have)

Sleep’s a mysterious thing. We’re not sure what sleep is or why we need it, but we do know sleep is critical to our health and wellbeing. Lack of sleep has been associated with pretty much all that ails humans, and recently it has been also blamed for rising obesity rates.

Parents loose sleep worrying about sleep. Most parents believe their kids don’t get enough of it. We blame it on overscheduling, iPads, YouTube or our busy state of mind, but whatever it is, sleep’s always insufficient.

Sleep concerns are nothing new

A new study in the March issue of the journal Pediatrics finds concerns over kids’ sleep from the early 1900s were much similar to our concerns today. The researchers, led by Lisa Anne Matricciani, tracked more than a century’s worth of advice in more than 200 articles regarding children’s sleep, and compared it to data on how much kids actually slept over the years.

Kids always slept less that what health professionals thought they should -- about 37 minutes less than recommendations.

With the passing century sleep recommendations have also shrunk by a rate of about 0.71 minutes per year.

Our kids are indeed sleeping less: Sleep has declined about 0.73 minutes per year in the past century. That amounts to our kids slumbering about 20 minutes less than we did, and 40 minutes less than their grandparents. 

“Modern Living” robs kids’ dreams

Our great grandparents shared our perception of life going faster and faster, and a British Medical Journal editorial from 1894, titled “Sleeplessness”, cited in the article, states “The hurry and excitement of modern life is quite correctly held to be responsible for much of the insomnia of which we hear.” 

The novel preoccupation of the day has always been charged with keeping kids away from shuteye: first it was books, then the radio, and later TV, the Internet and social media.

How much sleep do kids need?

Despite finding 35 sets of recommendations about optimal sleep duration, the study discovers that the sleep need of kids remains a big unknown. Recommendations were based largely on opinions, which were based on, well, nothing really.  We have no scientific clue how much sleep kids need.

But in case you’re curious about current recommendations take a look here; these, too, I assume are based on observations and very little evidence. If your kid is tired and cranky, he’s not getting enough sleep. 

The kids are all right 

There was something comforting about reading this research. It suggests we’re just a link in a generational chain of worrying parents.

When my kids ask why I worry about them so much I say it’s mom’s job to worry. I guess it used to served our species well to be cautious and protective of our young. 

We may long for bygone, simpler times, but the kids never slept enough, whatever that enough might be, and nevertheless, they’re probably going to turn out just fine. 

Dr. Ayala

 

Cities Fighting Soda

Several city health departments are stepping up their anti-soda efforts in an attempt to curtail obesity and diabetes. Philly is now airing its own TV spot, which my kids had noticed and brought to my attention over the dinner table.

There's quite a wide range in the messaging tactics each city takes.  NYC's campaign certainly caused a stir, especially the "Are You Pouring On The Pounds" video, which was deemed too disgusting by some. Take a look at these different approaces.  Which works best in your opinion?

Philly:

 

New York: 

 

 

Boston:

 

See LA's media campaign here and Santa Clara's here.

Dr. Ayala

Full disclosure: I’m vice president of product development for Herbal Water, where we make organic herb-infused waters that have zero calories and no sugar or artificial ingredients. I’m also a pediatrician and have been promoting good nutrition and healthy lifestyle for many years.

Halftime in the school cafeteria

Last month Michelle Obama and Agriculture Secretary Tom Vilsack announced some very welcome and long awaited changes to the government subsidized school meals. These are the first changes made in the program -- which feeds 32 million kids each day – in 15 years. Under the new guidelines kids will be doubling their fruit and veggie intake, will be eating more whole grains, all milk will be low fat, and there’ll be upper limits to salt, trans-fat and calories in the school meal.

Yes, the program is far from perfect, kids will continue to eat lots of highly processed foods – very few schools actually cook food from scratch – and tomato paste on pizza counts as a vegetable. But it’s a laudable change in the right direction, and considering the mighty fight the food industry wages against any proposed change, and the fact that the new rules will add 3.2 billion to the yearly cost of the program it’s reason for a mini celebration.

The next critical change is yet to come 

Competing with the subsidized school lunch are the foods sold in schools, which make a big part of what kids actually eat while they’re in school. These are foods and beverages sold in the cafeteria or in a school store, from a vending machine or in fundraising events. The lunch money parents give their kids may very well be spent on these offerings rather than on the school lunch.

Kids love the vending machines and the school stores, but that’s not the only reason these outlets exist. Schools depend on the revenues that vendors bring in to fund much-needed programs. This creates an unusual and worrying conflict of interest.

The USDA administers and regulates the school lunch program, and is developing nutrition guidelines for the foods and drinks available at schools. (The Healthy, Hunger-Free Kids Act, passed in 2010, gives the Agriculture Department authority to set health standards for all foods sold on school property — including those in vending machines). Right now, the only existing federal restriction is that foods of “minimal nutritional values”, such as candy and soda, won’t be sold in the cafeteria during meal times. That of course doesn’t mean they can’t be sold right outside the cafeteria doors.

Vending junk 

A new study published in the Archives of Pediatrics & Adolescent Medicine showed that even in elementary school half of the students could buy potato chips, ice cream or similar snacks from vending machines and at snack bars during school.

Other studies show that a la carte foods sold in the cafeteria are common in all school levels. Vending machines are available in 87 percent of middle schools and virtually all high schools. Forty percent of kids consume competitive foods on any given day, eating 280 calories daily in mostly junk food (the most commonly consumed competitive foods are desserts, snacks and sweetened beverages.

The new age of vending

Getting rid of the vending machines is perhaps a fancy aspiration and a non-starter, especially during tight budget times.

Instead, states and schools have put in place policies guiding the nutritional content in schools’ vending machines, and now offer healthier vending options.  Several vending companies specialize in healthy vending. 

But the neatest idea I’ve seen yet is the LiVe vending machine Intermountain Healthcare installed at Rose Park Elementary School in Salt Lake City. The talking machine will make its rounds in Utah schools spending a few weeks at each. 

 

I want one of these in my kids’ school!

Let’s hope the upcoming USDA regulations for competitive foods in schools will be sensible and have teeth. 

Dr. Ayala

 

Reposted as part of Food Renegade's Fight Back Fridays.

Should we reward kids for eating their veggies?

Many parents struggle with getting their kids to eat veggies.  A new study in the American Journal of Clinical Nutrition tests a new tactic to getting those veggies in and shows that rewarding kids for tasting a disliked veggie increased both its intake and liking.

I was surprised when I read the title of the study – prizes for healthy eating run contrary to the advice generally dispensed to concerned parents – so let’s read through the study and see what we can learn from it.

Rewards and praise for trying veggies

The study, led by Anna Remington, was conducted in North London, UK, and recruited 3-4-year-olds.

The 149 kids who completed the study were randomly divided into 3 groups:

• Tangible rewards - parents offer their kid a small piece of the target veggie for 12 days, and if the kid tastes the piece of veggie he’s rewarded with a sticker.
• Social rewards - parents offer their kid a small piece of the target veggie for 12 days, and if the kid tastes the piece of veggie he’s rewarded with praise, such as “brilliant, you’re a great vegetable taster”.
• Control group - no daily tasting and no rewards.

The target veggie was picked according to the kid’s initial reaction.  The families were presented with 6 veggie options: carrot, cucumber, white cabbage, red pepper, celery and sugar snap peas.  After the kid had a taste he ranked the veggies from 1 (most liked) to 6 (least liked).  The target veggie for the experiment was each kid’s “4”, giving this veggie an opportunity to either rise or fall in fondness.

And the result: the kids who received the prize ate more of the target veggie and reported liking it better than the controls.  This increase in intake and liking persisted over the 3 months of follow-up.  The praise group also increased its intake and liking, but less so than the reward group.

Give veggies a chance

This study, and many others, capitalizes on the well-known fact that repeated tasting works.  We are creatures of habit, and people -- especially kids -- like what they know.  The way to know a veggie is to see it often, know its name, and give it a taste – many times.  Studies show that it might take 10 taste exposures to get kids to accept a new food.

Young faces will light up with pleasure when tasting a sweet food for the first time, but foods that are out of the realm of sweet, fatty and salty can be an acquired taste, if given the chance.

To know is to like; to like is to eat.  In that respect we parents can really make a huge difference in our kids’ food preferences and habits.

Anything to get a kid eating

So how far would you go to get your kids eating healthy? The issue of rewards for eating is a controversial one, with many experts arguing that rewards -- or any kind of pressure for that matter -- are counterproductive in the long run.

This study suggests that rewards do work, at least for 3 months, and the reward was small enough to perhaps make parents deem it a non-issue.

But whether large or small, is a reward worth considering?

I personally believe that eating behavior shouldn’t be punished or rewarded.  After all, eating isn’t a good deed or an achievement.  Eating, whether healthful or not, is something one does to fulfill a basic self-interested need.

Kids, I think, are not supposed to be eating for their parent’s satisfaction or praise.

How did we even get to accept that “like” is a requirement for eating good food when hungry? Have marketers convinced us that “lovin it” is a prerequisite? 

Family dinner should be simple: Serve a healthy meal, don't serve anything that you don't want your kids to eat, no fuss, no electronics, no need to clean the plate, but a taste is much appreciated. Except it isn't, and many families struggle with how to best feed their kids peacefully and healthfully.

Regardless, the person to be thanked and praised is the provider of the meal – praise the cook, not the eater!

What do you think? Would you try prizes to get your kids eating their veggies?

Dr. Ayala 

 

Are junk-eating friends ruining your diet?

I'll be taking a few weeks off to spend time with my family and travel, and will write infrequenly during this time. Meantime, I'll be reposting some of the more popular posts I’ve written over the past years so that new readers have a chance to catch up.  Happy holidays!

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Peer pressure is a pretty powerful force that can both help and impede kids’ choices. No kid is totally immune to peer pressure and that’s why I care a lot about who my kids hang out with—I’m sure most parents do.

Peer behavior influences a wide range of health related behaviors--from smoking to alcohol intake to bike-helmet wearing--and also influences kids' eating patterns. The need to belong and the effect of peers are most pronounced in adolescence.

A study in the journal Appetite set out to see if friendship groups affect teens’ unhealthy snacking behavior. The study looked at the snacking habits of about 750 Dutch teens while mapping out who’s friends with who. It also collected data including the teens’ weight, education level and personal characteristics as well as the availability of high-caloric-density snacks (chips, candy, soda etc.) in those kids’ school canteens and vending machines.

Here are the study’s main findings:

• Teens with friends who ate snacks and drank soft drinks tended to do the same if snacks were available in schools canteens and vending machines. In fact most soft drinks were consumed by teens with friends that drank soft drinks.

• The tendency to conform to friends’ snack habits was stronger for boys and for teens with lower education levels.

• Girls ate more healthfully than boys, and seemed less susceptible to peer pressure to snack unhealthfully.

Chicken or egg?

So which came first? Do teens model their friends when it comes to snacking, or do they pick friends with similar snacking habits? This study can’t really answer that question. Other experimental studies though have shown that people model eating choices and quantities after friends’ patterns. Regardless, herd-like snacking behavior suggests new possibilities for intervention: Create a ripple of better eating within the group and it may grow into a wave that includes the entire cluster of friends.

The effect of vending machines

The presence of junk-for-sale in schools was a critical component of unhealthy snacking group-behavior in this study. In schools that had limited or no junk around, peer influence was less strong. It’s quite obvious that regardless of your friends’ habits, inability to perform the habit in school due to a missing key ingredient—the snack for purchase—gives less opportunity for the habit to spread.

Resisting unhealthy peer-pressure

Although friends affect teens quite a bit, and teens spend fewer hours with their family as they grow older, I’m quite sure that good family relationships, good role-modeling from parents and a high self-esteem are really important in enabling kids to stick to what they know is better for their health.

I don’t know how many parents-to-teen-boys (of which I am one) will appreciate this, but this study does hint that hanging out with the girls can promote better eating. I do love a study that compliments girls. Women tend to make healthier food choices at all stages of life, so having us around is usually a health promoting lifestyle.

Dr. Ayala

 

Banning soda in school isn’t enough

It took the whole village a few decades to create the obesity epidemic.  We slowly allowed the development of a food environment in which junk, fast and highly processed foods became available everywhere and anytime. Marketing and advertising of these food products permeated every real and virtual space making every moment and every deed a consumption occasion.

When we noticed that obesity rates among kids tripled and looked at what kids consumed, it was shocking to see that sugar sweetened beverages contribute about 300 (empty) calories a day to a teen’s diet, making them the single largest source of added sugar.  Indeed, sugary drinks have become a way of life, and their makers make sure fueling stations are densely spread so a kid would never have to go without.

And since so much time is spent at school, where kids are a captive and impressionable audience, school became another sugary drink fueling station.  Vended sugary drinks offered schools a source for much needed funds, and so developed the unholy union between the companies that want to imprint their brand’s image in kids’ minds and the institution that’s trusted to teach kids critical thinking and prepare them for a healthy and productive life.

Does changing the vending machine’s content change kids’ habits?

When the Institute of Medicine called for the removal of all sweetened beverages from schools and the American Academy of Pediatrics advised their elimination, some school districts and states did nothing, some opted to replace soda with lower-sugar options, such as sports drinks and vitamin water, and other cities and states went further and placed all-out bans on sweetened drinks.

A new study published in the Archives of Pediatrics and Adolescent Medicine examines the effect of different policies using data gathered from almost 7000 middle school students from 40 states; 22 of these school districts had no policy governing sales of sugary drinks in middle schools, 11 banned sales of soda only allowing all other sugary drinks, and 7 banned all sugary drinks, including sports drinks and fruit drinks (but not 100% fruit juice).

So how would you expect the kids to respond to the different vending policies?

I think no one would be surprised to hear that in schools that banned only soda, kids bought the other vended sugary beverages instead.  Banning soda did nothing to reduce sugary drink consumption in schools with a partial policy. 

But here’s an even more discouraging result: In schools that banned all sugary drinks kids indeed consumed fewer sugary drinks at school, but their consumption did not decrease overall; kids were able to find sugary drinks out of school, and filled the sugar gap before and after school.

In other words, school vending policies only changed the school environment, and didn’t seem to be enough to change kids’ access and behavior overall.

So are school policies useless?

It will take a village

The study authors, led by Daniel Taber, suggest it would take a comprehensive alteration of kids’ environment to change their sugary drink habits

“Experts have recommended broader policies, such as SSB (sugar-sweetened beverage) taxes or regulations of food marketing aimed at children. Future research should explore the effect that school-based policies have on youth diet and weight gain when implemented in conjunction with policies in other sectors.”

It would be naive to expect that changes at school can result in instant improvement when other sectors aren’t cooperating.

But there’s enormous value in creating a healthy school environment.

Giving a yellow card to kids shouting obscenities on the athletic field doesn’t guarantee the same words won’t be used when refs are out of earshot, but it still does teach kids sportsmanship – this is as much as we should expect from our schools.  Teaching kids good nutrition doesn’t guarantee they’ll eat well given the many unhealthy options all around them, but demonstrating through a school policy that chips and a sports drink aren’t food sends an educational message.   Schools should be parents’ partners in teaching healthy eating habits.  But schools can’t to do it all on their own.

At this point it will take a village to change our habits.

Dr. Ayala

 

Full disclosure: I’m vice president of product development for Herbal Water, where we make organic herb-infused waters that have zero calories and no sugar or artificial ingredients. I’m also a pediatrician and have been promoting good nutrition and healthy lifestyle for many years.

Reposted in Fight Back Fridays.

Study shows what kids eat at McDonald’s

Eating out, and especially eating at fast-food restaurants, is considered a risk factor for obesity, poor diet and chronic diseases.

Yet eating fast food is a major American habit: At least one quarter of adults eat fast food daily, as do 25 - 30 percent of kids.

Fast food meals typically serve big portions of calorically dense food, rich in fat and sugar and quite aptly labeled “fiberless food”.  The typical kids’ meal in fast food chains is no better – the main distinction of the young ones’ fare is the addition of the collectable toy.

Fast-food restaurants publicize (and are often applauded for) their move to healthier oils, and many have revamped their menu and now include a few healthier options, such as salads and apple slices (both accompanied by condiments that return guilt into the equation).  But do kids and their parents order the ‘better’ menu options?

What kids actually eat at McDonald’s

A new study in Childhood Obesity collected the receipts and interviewed 544 families with kids visiting the McDonald franchise inside the Children’s Hospital of San Diego for lunch.

Let me pause for a moment to comment on the presence of a McDonald franchise inside a children’s hospital, which feels like a great endorsement from a major medical institution.  I assure you that no reputable medical authority has ever given McDonald’s its blessing, yet San Diego’s Children’s Hospital is not alone in hosting a fast-food joint.  Children’s hospital of Philadelphia, considered by some the No 1 children’s hospital in the nation, had a McDonald’s for 34 years -- it closed a few weeks ago because the hospital needed the space -- Children’s Los Angeles has a McDonald’s on its first floor, as does Texas Children’s.

So what’s for lunch? The most frequent items bought for preschoolers (2-5 years) were French fries, soda, chicken nuggets, cheeseburgers and hamburgers.  The most frequent items for kids 6-11 years were French fries, chicken nuggets, cheeseburgers, soda and apple pie.  Adolescents’ choices centered on French fries, soda, cheeseburgers, chicken nuggets, and chocolate chip cookies.

Less than 1 percent of kids bought the yogurt parfait, and apple dippers were bought by less than 1 percent of preschoolers, 3.5 percent of 6-11 year-olds, and almost none of the teens (0.3 percent).

And now to the calorie count:  The average caloric content bought for kids’ lunch was 646-811 calories, which makes about half of the daily caloric need of a young kid.

The meals averaged 35-39 percent of calories from fat, with about 10 percent of that fat saturated. 

The sodium content of the meals averaged 866-1100 mg, which pretty much covers the daily sodium allowance of a preschooler.

The parents were asked what made them choose McDonald's for lunch, and the most common reasons for their pick were “the kids like the food” and its convenience. 

Better options at fast food restaurants – a remote option

This study confirms what we already know: Customers go to McDonalds for fries, hamburgers and soda, not for milk and salad.  A recent article by Christina Rexrode of the The Associated Press sums up the healthier options at fast food chains as just that – a remote option.  What really sells is the high calorie, high fat food, which the chains are famous for.   And the reasons are varied, but one of them is price: “Healthier foods also are usually among the most expensive menu items, which can be tough for recession-weary customers to stomach”.

Let’s face it, McDonalds isn’t renowned for its salads and apples, and as the kids in this study testify, they’re ‘lovin’ it’ for the taste they know -- it's the McDonald's fat-salt-sugar mixture they crave.

And it would have been fine, had it remained an infrequent indulgence.  Problem is, kids are eating fast food often.  Very often.

Dr. Ayala

 

The 5-a-day of good parenting

It’s always hard to say goodbye to summer.  And what a glorious end-of-summer we’ve had -- days of lazing about together, good food, wonderful books (I have to mention Ann Patchett’s remarkable “State of Wonder”, which put me in a an utter state of wonder) and a few glorious hiking days in Yosemite and Sequoia National Parks. My kids are back in schooI and I, too, feel the beginning of a New Year – time to get focused and get a lot of work done, but also time to give some thought to reflect on education and child rearing.

The 5-a-day for raising healthy young kids

I recently came across a report from the British think tank CentreForum that pulled my attention.  Drawing directly on the science of early childhood experience, the author, Chris Paterson, suggests that 5 steps are proven to be vital to kids’ optimal development:

• Read to your child for 15 minutes- being read to regularly from a young age is extremely important to language skills, fosters bonding and develops the young brain.

• Play with your child on the floor for 10 minutes - the adult and the child need to be on the same physical level, and to have fun together.

• Talk with your child for 20 minutes with the television off - switching off external distractions, such as the TV, is crucial, and we all know what distracts us, don’t we? 

• Adopt positive attitudes towards your child and praise them frequently – this speaks to the quality of the parent-child interaction, where the previous guidelines were more about quantity.  Adopting a positive parenting approach doesn’t mean the child isn’t criticized, but rather that criticism is constructive.

• Give your child a nutritious diet to aid development – kids need good food to develop and grow, but as importantly, tastes and eating habits are formed early in life, therefore emphasis on healthy nutrition in early life can lead to healthy eating habits throughout life, and to prevention of obesity and disease.

The report calls government to support high quality parenting, and implement a 5-a-day parenting campaign – in much the same way governments established and supported the ‘5-a-day’ concept in relation to fruit and vegetables.

I’m sure much of the reaction to this proposal centered on “nanny-state” type of criticism. CentreForum is a liberal think tank, and for some, any suggestion of governmental influence in the home reeks of loss of liberty, and many believe that parenting is a private matter.  But politics aside, it’s hard to argue that adopting these 5-a-day wouldn’t be a positive step, and it is so fundamentally unfair that some kids don’t experience these 5 elemental needs daily.

In many ways these 5 pieces of simple guidance are so basic that I doubt they’re news to parents, but I do think that it’s helpful to have a memorable, automatic way to remember these guidelines.  There’s something about announcing a new ‘norm’ and breaking up the big job of being a good parent into a few small manageable actions that I do like.

A healthy diet

Parents have been in charge of feeding kids from the beginning of time, but parents’ role in nutrition in our times is shifting, and we need to learn and readjust.

Parents of previous generations had to think about getting enough food, enough calories, enough nutrients to support growth and development.  In the past few decades the food landscape has changed so much, that besides providing adequate food for growth it has become imperative for parents to teach kids how to edit their food environment: How to tell food from junk, how to say no to frequent, unrelenting opportunities to snack and overeat all the wrong foods, how to resist and dismiss the marketing and advertising messages kids are bombarded with from a very young age.

Because if you just go with the flow, and don’t actively create a sanctuary of healthy eating at home and in your kid’s mind, your kid is more likely than not to eventually end up struggling with weight, and suffer from overconsumption of sugar, fat and salt.

Not just for babies and toddlers

There’s ample evidence to support the investment in early childhood – early investment pays off big time.  But I find that my parents still pretty much extend the 5-a-day gift to me every time I interact with them.  I am no longer read to, but we’ll share a good read over the phone and exchange books.  My parents really listen – no distractions – I can count on that, and their positivity lifts me up.  We still play together – whether it’s a board game or a visit to a garden, we concentrate on having fun together.  And I credit my mom with teaching me the fundamentals of how to eat healthily in a world full of junk and highly processed foods, and to this day we learn something new about food whenever we share a meal.

The 5-a-day of fruits and veggies is a huge success in that most adults and kids know what the advice behind the 5 is.  It’s an utter failure in implementation – very few Americans (only about 11 percent!) actually eat the minimum daily-recommended fruits and veggies. 

But awareness is a good start, and suggesting to us moms and dads that what parents do, every day, matters so much to our kids’ wellbeing is both empowering and humbling.

I’d love to hear your thoughts.

Dr. Ayala

 

Reposted as part of Food Renegate's Fight Back Fridays.