“One can of soda per day can result in 15 pounds of weight gain in one year,” I distinctly remember my attending saying when I was a pediatric resident.
It was applicable then and even more so today as we struggle with a severe and worsening obesity problem among our nation’s children.
We are all affected by obesity – either personally or professionally – so knowing a straightforward approach to management has value for all of us regardless of our medical specialty. Overall, one in five teenagers is obese, and the prevalence has quadrupled since 1980.
With the dramatic increase in the prevalence of childhood obesity over the last several decades, what is perhaps most troubling is the emergence of youth-onset obesity complications, which had previously been traditionally adult-onset problems. Hypertension, dyslipidemia, metabolic syndrome, hepatic steatosis, obstructive sleep apnea and type II diabetes have become relatively common obesity-related complications requiring treatment by pediatric providers. Pediatric subspecialists in a variety of disciplines now can receive additional training in these areas as there has been an increased need for specialized expertise in the treatment of the sequalae of obesity in young people.
There are numerous, at times fairly complicated, published recommendations for lifestyle improvements that can be difficult to implement and maintain. Attention to some basic principles and initiation of small but permanent improvements may help improve the likelihood of success.
With the rising prevalence of obesity in our youth has come increased emphasis from the medical community on the importance of prevention of obesity and related complications. In 2012, the National Institutes of Health released the “Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents.” Following review of numerous sources, a group of experts from multiple disciplines convened to develop recommendations to guide prevention of acquired cardiovascular disease in young people.
The guidelines provide a comprehensive review of various modifiable risk factors and conditions and what interventions might be useful. The panel provided a basic review of issues including dyslipidemia, hypertension and obesity, among others, and included recommendations on evaluation and treatment.
This reference provides both subspecialists and generalists alike the ability to practice a consistent and thorough approach to prevention of cardiovascular disease and provides the basis for what many of use use in our recommendations to referring providers as well as patients and their families. In particular, the panel advocated for universal screening of children and adolescents for dyslipidemia, which has allowed us to capture patients with potentially serious familial hypercholesterolemia.
More recently, and much anticipated, the American Academy of Pediatrics released the “Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents.” It was the first update since the 2004 release of hypertension guidelines. It, too, provided an in-depth overview of the issues to consider in the recognition, evaluation and treatment of pediatric hypertension. These sources provide the basis for our recommendations in pediatric preventive cardiology.
Guidelines
The guidelines provide a detailed series of recommendations for preventive of cardiovascular disease. While the details are useful to us as providers, we often extrapolate from the details to provide more basic and straight forward suggestions to patients and their families. While some are able to count calories, cholesterol content and sodium levels in foods, many would struggle with that degree of detail. For this reason, we tend to provide some simple strategies for improvements – ones that we can also use ourselves in our homes and with our friends and families.
Some of our recommendations are, of course, disease-specific, for example limiting carbohydrates and sugars in the setting of hypertriglyceridemia or limiting salt in patients with hypertension, while others are more general and likely to benefit all patients seeking to improve. In general, we recommend the following:
1. Elimination of sugary drinks. In particular, sugary drinks not only include sodas and sweet tea but also sports drinks and juice. Educating families that juice is an unnecessary component of a child’s diet is often part of our discussion. We also discuss that sports drinks are generally for times when we are highly active and sweating. Otherwise, there are few reasons for sedentary children needing to lose weight to drink them.
2. Appropriate carbohydrate portions. American portion sizes of carbohydrates are excessive. Having a family start reading the labels of common carbohydrates can be eye-opening for them. Portion sizes at restaurants may be three or four times a reasonable portion, but it has become so common that families are often unaware. We also promote using carbohydrates as the carrier for healthy foods – a small portion of whole grain pasta to carry some baked chicken and steamed fresh vegetables, for example. Of course, we recommend whole grains as much as possible.
3. Minimal sugary foods/sweets/treats. Treats should be for special occasions, infrequent, and of appropriate portion size.Although consistent attention to healthy eating habits is wise, it is important to avoid being overly restrictive. In most cases, kids should be able to have the cake at the birthday party!
4. Minimal fast and fried food. Even so-called healthy options at fast-food restaurants can be problematic. It can be difficult for families to pick the right options when eating out. Eating a salad with a large portion of ranch dressing may be worse than other available options, for example.
5. Portion out less healthy/snack foods. If we do indulge in something less healthy, we should look at what a reasonable portion size is, take that amount out of the package and put the rest away without returning for more. This avoids sitting and eating an entire bag of chips without realizing it.
6. Changing to 1% or skim milk (if over the age of 2). Eliminating unnecessary fat is wise. Kids often don’t care that much about milk, so cutting fat out here could be preferable than limiting other sources that are more important to them.
7. Drink mostly water. Young people drink way too little water in general. Orthostatic intolerance is common in adolescents and is a frequent reason for referral to pediatric cardiology. Even competitive athletes I see in my practice may drink only 1 to 2 small bottles of water per day. Increasing water intake to a reasonable level can prevent a lot of problems and can improve energy and activity stamina. Drinking water before and during meals can also help prevent overeating.
Lifestyle Habits
We also recommend to parents that the entire family participate in the improvements. Children will be most successful if everyone in the family has the same lifestyle habits.
Ideally, children would participate in vigorous physical activity for at least an hour every day. Some children get none and many sit in front of phones or video games whenever they are not in school.
Sedentary lifestyles have become sadly common for our society. Recommending to a child who sits all day that they follow the aforementioned recommendations for activity may not be terribly realistic. For them, we recommend that at first they simply sit less. Often the first way to achieve this is by limiting screen time, which is recommended by the American Academy of Pediatrics.
For other children, we try to find something they like to do and find a way to do it more. If they have a dog, we try to get them to go for walks. Keeping up with chores at home is another way families help their children sit less. The hope is that with small increases in activity, they will tolerate well and be able to further increase their stamina without getting discouraged.
For those who do exercise but who feel they are making inadequate progress toward their goals, we talk about varying the physical activity and using different muscle groups as well as the need to push ourselves sequentially so that we can continue to make progress as we become more fit.
Although the process of lifestyle change can be daunting, following some simple recommendations can help us, our families and our patients make the kind of improvements that will help decrease our cardiovascular risk over time. With increasing obesity in our youth, pediatric medical providers have become more knowledgeable about the evaluation and treatment of these problems.
So if you know of someone who has a need for expert evaluation and intervention, there are experts here in Georgia to help. It is possible to make measurable improvements that will improve the health of children for decades to come.
References:
The State of Obesity: Better policies for a healthy America, 2018. The Robert Wood Johnson Foundation and the Trust for America’s Health. September, 2018.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128 Suppl 5:S213-56.
Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904.
