Should You Put Your Teenager on a Diet?

stock-photo-74105099-unhappy-teenage-girl-sitting-on-floor-looking-at-bathroom-scalesI still remember that day I was sitting around a long conference table in the Endocrinology department at the children’s hospital where I was just hired to help develop a weight management program for teens and children. There were several nurses, a few endocrinologists, myself, another dietitian and my manager. They had decided the children would keep food logs as well as track their calories. I was so glad I was there to enlighten them about that! I explained that counting calories was a very bad idea as this would not only lead to more focus on food, they would likely gain weight, not lose, and even worse could develop an eating disorder. I explained that even the thousands of adults I had worked with over the past 2 decades were never successful with counting calories, and the only ones who were good at it had eating disorders. Phew, now we can move on (I thought).

No luck. They basically ignored all I said, and my manager was fuming. I was flabbergasted.  So the other dietitian and I decided we would gather the research articles refuting this approach, and share it at the next meeting. We did just that but again, no luck. Although I was floored, I had faith they would learn their lesson when it all unfolded.

I was right. When it came time to teach the classes (parents would come as well as the child and siblings if they wanted), the first step was to share their notebooks. These were also brought to individual sessions with the nurses and dietitians. Lo and behold, almost none of the participants did it! Or if they did they were so obviously inaccurate, it was almost funny. Guess what? It took at least 2 years if my memory is correct but eventually they eliminated the calorie counting (Thank God!). The great news is they eventually hired a full time psychologist who had lots of experience with eating disorders and weight issues, and who went on to change the entire program to be more evidenced-based, and focus on health (and not dieting).

Anyway, I picked this topic to write about this week after getting my monthly newsletter from the weight management “practice group” I belong to in the Academy of Nutrition and Dietetics (AND). It included an article entitled “Alternatives to Calorie Counting: Consideration for Pediatric Weight Management”. The article mentioned the AND Position Paper’s recommendations that “treatment plans for managing pediatric overweight should emphasize multi-component, family based programs, which combine nutrition education, physical activity, and behavioral strategies….alternative approaches to calorie counting should be implemented for this population as a means of self-monitoring nutrition decisions”. The article summarized exactly what these “alternative approaches” were.

The author (Giselle Willeford, MS, RDN) does a great job of summarizing the research describing the detrimental affects of having kids or teens count calories (increased focus on food and eating, increased risk of eating disorders or further weight gain). Here is a brief summary of the “alternative to calorie counting” that were described:

  1. Traffic Light Approach: this method (originally developed by Leonard H. Epstein) calls for dividing foods into 3 categories, Red, Yellow and Green. Green foods are things like vegetables and fruits that you can help yourself to (low calorie and low fat). Yellow foods are those foods that have more calories and that you need to be careful with portion sizes (chicken, rice, etc) but are still healthy. Red foods include sweets, fried foods etc. that you should try to limit and/or decrease in your diet. I am NOT A FAN of the “Stoplight Diet”. Although it sounds simple enough, I have seen first hand the damage it can do. I have had several very young children (age 8, 9) that took this diet to heart. They were those really “good” students who got all A’s and did not want to disappoint their teachers, so when they got the message that red foods should be decreased, they stopped eating them altogether. The patients I saw lost weight when they should have gained, stopped gaining in height, with great repercussions to their family relationships (“she won’t come out for pizza with us anymore”, or “he only will eat the “green” foods so we can’t go out to eat anymore, it is driving us crazy!”  These children were on the verge of developing serious eating disorders and actually were at risk for stunting their growth if they kept it up. The good news if I have been successful with helping these kids because they just needed to hear another authority figure (“The Dietitian”) tell them all the reasons it was ok to drink milk and eat cheese and even pizza again. My recommendations: skip the traffic light approach. Traffic lights are for cars.
  2. Plate Visuals: this is an easy tool to use for those who can’t read or write, so it makes sense to use it with children and teens. You might be familiar with the colorful diagram, and if not see the website: My Plate The visual shows half of the plate with “colors” and this means half your plate should be fruits and vegetables. A quarter of the plate is for “meats” or protein food and a quarter of the plate is for “grains”. The dairy is on the side and that is your serving of milk. There are some things I really like about “My Plate” for education. It is simple and the message is about adding in and not as much focused on taking away. I have used to demonstrate how much fruits and vegetables we need if we want to be healthy. The downside is that some kids, especially picky eating teenagers, really struggle with vegetables because they don’t like the texture or the taste, and so through most of their life refused them. Parents in turn, sometimes just stop making them with the unfortunate outcome being nobody in the family has been exposed over time to vegetables and so nobody eats them. When you show a teen that plate, they tend to feel bad, and like a failure because there is no way they are going to get to that amount of colors on their plate (unless you count brown or yellow, you know, french fries, macaroni and cheese, Doritos). I don’t like making teenagers or even adults feel guilty, so instead we work on increasing exposure and sometimes start with more fruits. Check out the website for more information.
  3.  Portion Sizes: this method uses your own hand to estimate portion sizes. So a “fist” might be a serving of rice. I am not especially irritated by this method, however what if you want 2 fists of rice? I guess the awareness that you are having 2 servings is ok, but then again, will it trigger guilt and overeating? This method traditionally has been used with diabetics, who really do need to follow a special diet with balanced amounts of carbohydrates, so for these folks, it could be very helpful.
  4. Hunger and Satiety Cues: this of course, being the “non-diet” approach for kids and teens, is my favorite! It teaches strategies to help individuals pay attention to their body signals. For younger children, it is called the “Trust Model” promoted by Ellyn Satter (see Ellyn Satter Institute for specifics). This model describes the “Division of Responsibility” with a focus on the parent’s role of buying healthy foods, determining structured meal times, not catering to kids but allowing them to eat as much or as little as they want at a meal. This teaches children to trust their hunger and fullness mechanisms and promotes a healthier relationship with food and eating. With teens, it becomes tricky because sometimes, after over 10 years of being restricted by parents, an abnormal focus on food (such as sneaking food) has developed (survival!). It may require some counseling for some teens who have a significant “disconnect” between their hunger and fullness related to parental restriction. If your teenager sneaks food or binge eats, or restricts and alternates with binge eating, don’t ignore it. Get help by a therapist who specializes in eating issues.

So the answer is: NO do not ask your teenager to count calories. If they are using some app on their phone to track their food intake, pay attention. Instead, work together to find healthy recipes and meals, go grocery shopping to pick fruits and vegetables your children will eat, have taste tests with new ones. Shut off that TV during meals, sit at the table, don’t allow kids to nibble all day, and instead plan for snacks where kids sit down and enjoy it (not in their rooms, nibbling for hours in front of a computer…..who is going to want to try squash when dinner time rolls around?). Consult with a dietitian regarding strategies to make your environment healthier as well as ideas for healthy but yummy meals. But don’t focus on calories or dieting in your home. Instead, focus on EVERYONE being as healthy as they can be. Enjoy eating out, ordering pizza once in awhile, going out for an ice cream cone. Set an example by living the kind of life you want your child or teenager to live. Remember, kids do as you do, not what you say. If you count calories and diet, your teenager will too. If it hasn’t worked for you, it won’t work for them.

5 Things You Should Never Do if Your Doctor Tells You Your Child is Overweight

We all have heard it a thousand times. We have an obesity epidemic among our children and we need to do something. Back in July of 2013 when the American Medical Association declared obesity a “disease”, pediatricians took action. If a child’s Body Mass Index (BMI) was equal to or greater than the 95th percentile on a growth chart the child would be labeled “obese”. If the BMI was equal to or greater than the 85th percentile then they were “overweight”. Parents needed to be informed so they could do something about it.

There is lots of controversy about using BMI as a criteria to determine health. To calculate BMI all you need is a height and weight. Unfortunately, although this is what pediatricians use to diagnose and label “obesity”, BMI has little to do with health. Check out this BMI article for some great scientific background on why BMI is not a useful tool.  Anyway, if you are a parent, and you take your child for a yearly check up, you may be informed of your child’s BMI (especially if your child is out of range according to the Center for Disease Control (CDC) growth charts) See CDC Growth Charts.

What should you do if your pediatrician tells you your child is overweight or obese? Here is my advice on what you should NOT do:

  1. Never assume your pediatrician is correct to have any concerns about your child’s health due to his or her BMI. Instead, ask to see your child’s growth chart. Typically, children tend to follow along a curve. So, if your child has always plotted around the 50th percentile for weight, that is their “norm”. If they have always plotted along the 95th percentile for weight, then that is their “norm”. If their length or height has always plotted along a certain curve, the same holds true. Therefore, if a child happens to genetically be on the lower side for height and on the higher side for weight, their BMI may fall into a range that is above normal for BMI. Does that mean something is wrong? No! In fact, I have had several children come to see me who were referred for “overweight” who were actually very healthy and growing normally. One case I clearly remember is a little boy, about 10 years old I will call Johnny. Poor Johnny looked terrified when he came into my office. When I asked what brought them here, he blurted out “The doctor said I am overweight! Am I going to die? Am I too fat?” It was sad to me how frightened he appeared. When I looked at his growth chart, it was clear he was one of those kids who was a bit shorter and a bit higher on the weight chart. He was an athlete who played several sports and appeared very muscular and was definitely very fit and healthy. I had to tell him “your doctor made a mistake! He forgot to look at your growth chart! You are growing perfectly! But let’s go over what you eat anyway so I can be sure you are getting everything you need, ok?” He showed a visual sign of relief as he let out a big breath and sighed. I thought, this is so wrong. This athletic young boy should never have to worry about his weight. The doctor should have looked at the growth chart and known that this kid will probably never have a BMI that falls in the “normal” range and that his healthy lifestyle was what mattered. So the bottom line is be sure to ask your doctor to see your child’s growth chart. If, on the other hand, your child has veered off of his or her normal growth that may be a different story. Sometimes when there are big changes in lifestyle (that are not conducive to health, such as getting a new video game and discontinuing playing outside everyday to sit on the couch and play videos), well, weight can increase in a way that is not normal for the child. In that case, working on decreasing screen time and going back to healthy outdoor play is what is important. Again, working on having a healthy lifestyle is what matters, not the number on the scale, and certainly not a child’s BMI.
  2. Putting your child on a diet. Yes, after getting the news your child is overweight, a good parent wants to fix it. Often, a parent will come to me and ask for a “diet” for the child. Because of all of the cultural emphasis on dieting to lose weight, parents fail to stop and think that these are children, not adults we are talking about. And, the ironic thing is that research has proven that even adults are not able to diet successfully. Dieting leads to binge eating. Why would we think children can do it?Don’t you think if an adult ends up sneak eating and binge eating after restricting that the same thing will happen to children? It will.  Diets don’t work, not for adults and definitely not for children.
  3. Expecting your child to do something you can’t or don’t do. Do you expect your child to eat vegetables and fruits and salad, yet you don’t eat them? Do you drink soda yet expect your child to just drink water? Do you sit for hours in front of the TV yet expect your child to go exercise on the treadmill? Children do as we do. You can talk until you are blue in the face about the benefits of eating fruits and vegetables, and about how good exercise if for your body, but if you have an unhealthy lifestyle, glued to the TV, bringing home fast food every day, then your child is likely to be just like you. If, on the other hand, you have a healthy approach to eating and moving, with a focus on being healthy, then your child will likely adopt the same healthy attitude and lifestyle. This does not mean living on health food and driving yourself into the ground with exercise. It means using a healthy guide such as My Plate to help make your meals healthier. It means taking your child to the park to run around and have fun instead of handing them a video game to sit in front of a screen for 4 hours. It means planning some outdoor play and limiting the use of screens (TV, cell phones, video games) to less than 2 hours a day (yes, it is easier when they are occupied in front of a screen, but not healthy for their bodies if it is excessive). So work on this instead of thinking your child is going to be able to diet.
  4. Treating children differently when it comes to food depending on their body size. This is a pet peeve of mine. When a family says they have cookies in the house, or chips, or soda, because “her brother is skinny, he needs it”, this drives me crazy! What typically happens is the child who is overweight sits there in my office looking guilty. Their head is down, no eye contact. The mom goes on to say how little Cindy is sneaking her brother’s cookies. Mom also caught her sneaking some of her brother’s Doritos. Could I please tell her that she does not need them? Maybe she will listen to the dietitian! So what do you imagine my response is? I whisper (loudly), and look straight at the sneaky little criminal “you know what? I would be sneaking those chips too!” Now at this point, the mom usually looks at me like I am crazy, until I explain. How would you feel if your very favorite food were in the home and yet you were the only one who could not have it? It simply is not fair. Instead, I believe in trying to have a healthy food environment. This means having healthy snacks in the home, not having soda around (since most kids might fill up on it and say heck with the milk). Have soda when you go to parties, don’t restrict it, however be smart about it. The same goes for chips. Make them a part of a meal with other healthy foods (like a tuna sandwich, you really do need a few chips with that). Just because brother Johnny is skinny does not mean he does not deserve to be healthy too. He should also be eating fruit and vegetables and not filling up on soda. Everyone needs to care about health. It has nothing to do with body size. So stop treating children differently depending on their weight. It does not help anyone and it only serves to make the labeled child feel bad. It also usually increases a focus on food and sneaking. This is not a way to move toward healthy eating.
  5. Talk about weight at all. Your child’s weight, your weight, your friends weight. Just stop talking about it. In fact, I would also recommend you have a talk with your pediatrician to request he or she avoid commenting about BMI or weight at all in front of your child. If there are any concerns, ask that they talk to you privately. You do not need your child worrying about weight. This is not a good thing at all and only serves to make them feel bad. Instead, get the details about their growth chart (ask to see it, ask them to explain it and why they are concerned). If your child truly has gone way off of the chart then don’t talk about it. Instead, look at your entire family and the habits you have fallen into. Work on getting more physical activity for the entire family. Look into healthier cooking and less eating out, and other strategies to promote a healthy lifestyle. Seek the help of a registered dietitian by going to Eatright and finding a dietitian in your area. Or check out the My Plate link above and work on it yourself. But don’t talk about weight in front of your child. It is not helpful and will most likely be harmful. Think about it. How would you feel if everyone was watching every morsel that you ate, and pushing you to exercise when everyone else in the family was sitting on their butts playing video games? It is simply not fair.

So there you have it. There are also many things you definitely should do to promote the healthiest body possible for your child. Stay tuned for that. In the meantime, give your child a hug and accept them for the beautiful blessing that they are in your life.