Good food, bad food and calorie counting? What kids really need to learn.

Nutrition education in schools worries me. My sentiments have been echoed

on the Academy for Eating Disorders list serve and among peers from SCAN--the Academy for Nutrition and Dietetics (AND) subgroup populated by progressive thinkers.

A very different path.

To change the direction of how kids are being taught, I've written this piece. Share this locally, in your schools, and virtually. Use it, and use it fully, including my name, please. Thanks for spreading the word and working for change.

Good food, bad food and calorie counting? What kids really need to learn.

By Lori Lieberman, RD, MPH, CDE, LDN

In an attempt to tackle the “obesity epidemic” kids, educators and parents often receive well-intentioned but potentially harmful messages to manage eating. (1)Calorie-counting apps and black and white messages about what’s healthy to eat can be problematic. Kids, parents and educators need practical, realistic strategies to add to their toolbox. Help kids learn to self-regulate their food intake utilizing current knowledge on eating behaviors and the food environment and know the damage of deprivation-based diet approaches.

One size does not fit all!

We are educating the masses—kids of all sizes and weights, including those who are sedentary and those with very high needs given their size, needs for growth and for sports—and kids with personality traits who tend to be very literal, anxious or perfectionistic. Consequentially, food messages should be presented to serve all without harm.

Good food/bad food

Nutrition messages need to shift from the ineffective ‘good’ versus ‘bad’ nutrients and foods, to factors that impact the ability to self-regulate intake. Directing individuals to restrict their fat intake can backfire. (2) Labeling sugar as ‘bad’ and setting calorie budgets fails to control weight in long term. (3) Evidence shows that perceiving a scarcity of food and deprivation from restrained eating creates greater problems (4) and contributes to eating disorder development. (5)

Calorie counting 

Calorie counting is ineffective in the long run and conflicts with utilizing hunger and fullness—essential for managing energy balance. It fails to teach kids about major obstacles to changing eating—eating behaviors and environment. Counting calories has little positive impact on improving eating habits and weight. (3,6,7)In one study kids who began dieting had a significantly higher likelihood of developing a serious eating disorder. (5)

Portions 

Portions are also not one-size fits all. Current materials (1) refer to appropriate snack sizes but for underweight kids, competitive athletes, and those simply with higher needs, these may be inadequate. Many teens require more than the current campaign’s recommended single serving of most snacks and greater than the 100 calories encouraged as ‘moderate’.

Sit, structure, separate, sense. 

Let’s shift the focus to what works—a mindfulness approach addressing simple, achievable eating behaviors. (8,9)

Address these key behaviors to improve intake and portioning of food, applicable to all children and adults.

• Sit in the kitchen or designated eating space, at a table or counter when eating.
• Structure the day to include 3 balanced meals and snacks. Include an early breakfast and be prepared—keep snacks available and give kids a chance to eat when they need to. Encourage delaying not forbidding ‘seconds’, allowing time to sense fullness. Allow eating later when hunger is present.
• Separate eating from distractions, like TV, phone, homework, computer; distracted eating increases intake. Separate food from sight; keep food off the counters to prevent triggering eating.
• Separate food from its package! 
• Plate it.
• Use your senses. 
• See, smell, feel, hear and taste your food—whether it’s a cookie or cantaloupe. You’ll be more satisfied when you really pay attention to and enjoy what you’re eating.

Encourage positive additions and messages to support a healthy diet.

• Include 3 or more cups of milk, yogurt or milk alternative (such as soy milk) for protein, calcium and vitamin D.
• Choose fruit frequently. 
• Select from fresh, frozen, canned in juice. Don’t forget dried fruit—a convenient, satisfying, nutrient and fiber rich snack.
• Vary the Vegetables: shred them, steam them, sauté them, dip them, puree them into soups or smoothies. 
• Get them in all colors. Include more than a cup a day.
• Get real! Choose more foods that are processed less, including nuts and seeds, beans, whole grains and fresh fish/meats.

Let’s spread a sensible, more sensitive message to promote health among school age kids of various sizes and needs. Advocate for diversity of foods to normalize intake for a diet rich in nutrients and adequate in calories. Let’s focus on learning to encourage portions that fit the individual’s needs by integrating both mindfulness and environmental strategies. And let’s accept that normal eating includes having foods at times simply because they taste good.

Citations

1.http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm281746.htm

2. Wansink, Brian, and Pierre Chandon. Can “low-fat” nutrition labels lead to obesity? .Journal of marketing research 43.4 (2006): 605-617.

3. Lowe MR, Doshi SD, Katterman SN, Feig EH. Dieting and restrained eating as prospective predictors of weight gain. Frontiers in Psychology 2013;4:577.

4. Mullainathan, S, Shafir, E. Scarcity.New York::Times Books, 20135. Lowe, M. R., Thomas, J. G., Safer, D. L. and Butryn, M. L. (2007), The relationship of weight suppression and dietary restraint to binge eating in bulimia nervosa. Int. J. Eat. Disord., 40: 640–644. doi: 10.1002/eat.204056.

6. Downs, Julie S., et al. "Supplementing menu labeling with calorie recommendations to test for facilitation effects." American journal of public health 103.9 (2013): 1604-1609.

7. Ely, Alice V., et al. "Differential reward response to palatable food cues in past and current dieters: A fMRI study." Obesity 22.5 (2014): E38-E45.

8. Beshara, Monica, Amanda D.Hutchinson, and Carlene Wilson. "Does mindfulness matter? Everyday mindfulness, mindful eating and self-reported serving size of energy dense foods among a sample of South Australian adults." Appetite 67 (2013): 25-29

9. http://www.nutritionj.com/content/10/1/9  Supporting Intuitive eating section, Linda Bacon

Fat and Always Hungry? No, cutting the carbs won't cure your weight struggle.

It’s 10 AM Sunday and quite frankly, I’d much prefer to be leisurely finishing my coffee after my blueberry pancakes-topped with a dollop of vanilla yogurt and heated real maple syrup. But Ludwig and Friedman’s Always Hungry? Here’s Why piece in the NY Times  today compelled me away from my plate.

To start, let’s get a title change, please, let’s say Here’s What We Think based on virtually no research at all. This is an opinion piece stating two doctors’ theories about why we get fat and what we should do about it. Period. But with the sensational image and title you, like most people, will be drawn into more myths about weight management.

Here’s where we agree—and disagree

Do you just eat bread for your meal?

Agree: There are factors outside of your control that may contribute to your size. Genetics and the presence of fat cells exert their influence. Once you have gained to a higher weight with an increase in fat cells, you will be fighting an uphill battle to lose that weight and keep it off—without disordered behaviors.  And it’s not your fault. For more on this see Professor Lowe’s work on weight suppression and bulimia. 

Agree: Metabolic rate slows down with food restriction—that’s indisputable from the research. Obese individuals who have undergone extreme low calorie diets will have a lower metabolic rate as a result of the decrease in muscle mass that results, compared to same weight controls who had not dieted. Less aggressive approaches to dietary activity change tend to spare the muscle loss and help maintain metabolic rate.

Before dieting...

But the authors state that metabolic rate also decreases with weight increase:  “…factors in the environment have triggered fat cells in our bodies to take in and store excessive amounts of glucose and other calorie-rich compounds. Since fewer calories are available to fuel metabolism, the brain tells the body to increase calorie intake (we feel hungry) and save energy (our metabolism slows down).” Yet there appears to be few examples of this cited in the scientific literature, with the exception of a possible rare genetic mutation, not likely the cause of obesity in the greater population.

And the temporary slowed metabolic rate seen with weight loss has been demonstrated to be reversed with weight restoration in the obese (albeit a small sample size studied) and more dramatically in those who are underweight with anorexia, summarized well by Carrie Arnold in ED Bites.  In practice we see dramatic increases in metabolic rate—calories burned and required each day—with weight gain in anorexic individuals at least until they have restored to their healthy state.

Agree: Insulin increases nutrient uptake and in excess causes weight gain. And carbohydrate results in an increase in insulin secretion.

Disagree: Ludwig and Friedman’s leap that foods that increase insulin secretion should therefore be reduced or avoided for weight management is faulty reasoning—unless there is a documented underlying metabolic abnormality. A relatively small percentage of the total population has PCOS or hyperinsulinemia—a faulty regulation of insulin. For these individuals, addressing carbohydrate amount or glycemic load (impact of a food on raising blood sugar) has a positive impact. But there’s no evidence that a low carbohydrate diet is any better at long-term weight management than any other dietary intervention. 

In addition, while individual foods and their glycemic index—the amount they raise blood sugar (and therefore subsequent insulin levels) may seem valuable, practically speaking they have less impact.  You see, we generally don’t eat single nutrients like carbohydrate. Rather, we eat mixed meals, containing protein, fat and carbohydrate. And in this combination, the impact on insulin levels that even the white potato might have if eaten solo is minimized with that piece of chicken and the added olive oil or nuts in the salad.

This banana chocolate pastry has plenty of fat to lower its glycemic load!
(From Tartine Bakery, San Francisco)

And did you know that many of the villainized desserts have a minimal impact on insulin levels? Peanut M&Ms aren’t much different than lentils (see glycemic load—the best measure of blood sugar impact which considers portion) and cheesecake made in it’s full fat recipe will no doubt come in quite low as well.

I don’t share this to promote a diet full of low nutrient, processed foods. Rather, to make a point. Viewing foods as good and bad will do nothing to help you manage your weight—nor your mental health. In fact, there’s plenty of evidence that feeling deprived by denying yourself foods you enjoy leads to rebound overeating.

The authors also state “what if it’s not overeating that causes us to get fat but the process of getting fatter that causes us to overeat? Unfortunately, I think they have oversimplified their hypothesis.

Sure, having more fat cells may contribute to our struggle if attempting to lose weight. But it’s not simply a macronutrient issue. Being larger presents more challenges for being active; larger individuals report being subjected to fat shaming while exercising—presenting its own challenges.

Rebound binge eating following starvation—think dieting—has been well documented as well. All or nothing thinking—what I call the “what the heck effect” results in overeating when you believe you’ve already blown it.

After...

Our over-scheduled lives with multiple competing needs don’t help us either. Multitasking while eating makes us less aware of what we are consuming and contributes to overeating. And the larger the containers or plates we are eating from, the more we will over-consume (see Prof.Wansink's extensive work on this).

Time and money constraints add flames to the fire—we take little time to plan, shop and eat mindfully. In fact, our cognitive ability is compromised by these stressors and worsened when we diet. Perceiving that we won’t have enough food to meet our wants or needs, referred to as scarcity creates a range of secondary effects. Poor decision making, impaired ability to organize and follow through and hyper-focusing on the immediate benefits without considering the long term consequences of food choices are well researched and described in the fascinating new book, Scarcity.

Unrealistic goals set by national organizations  and by ourselves adds to the problem. If 150 minutes per week plus 2 days of muscle strengthening/wk is unattainable, why bother?

Further, the food industry isn’t all bad. (And no, I am not a paid consultant to any food company!) They are the ones who bring us the convenience of precut and cleaned vegetables and canned, high fiber, low glycemic legumes. They allow us the convenience of reheating frozen brown rice and quick cook barley. And they have given us a range of milks in every fat percentage we could ask for, and yogurts of every style—Greek and higher protein, sweetened, full fat, real sugar, artificial sugar and no added sugar. But many of the choices remain ours.

So what’s the solution to our climbing weights beyond a healthy range?

• Move away from dieting and that sense of scarcity.
• Set realistic goals for change—be it frequency of a home-cooked meal or a visit to the gym.
• Begin to work on behaviors; separate eating from distractions, and delay seconds (see older posts on this blog for help)
• Include a range of foods and nutrients. Include high fiber, whole grains and legumes, fruits and vegetables, nuts and healthy oils; protein-rich foods such as poultry and fish, and less frequently red meat; low fat milk and yogurt and modest amounts of cheese.
• As part of a balanced meal, by all means enjoy your rice, breads and pasta, too. And you know my stand on baked goods! All or nothing approaches to dietary change will get you nowhere.

Thanks for reading and for passing this on via FB, Pinterest, Twitter...

Putting a Squeeze on a Family Ritual: Starting Bad Habits Early

Sure, it was messy but it was so good!

How sweet! Cute little pouches of pureed food—not for infants but for toddlers to slurp up. Designed for eating on the run, they also help to appease the difficult feeder. You know, when you fear your picky eater might starve by not eating her peas. 

And, they’re convenient for the challenged parent, juggling work and the demands of raising kids. Perfect for soothing the fussy little one while watching TV or simply while riding in the car. Allows for hands-free feeding so you can easily be typing on your ipad or dealing with work issues by phone while productively feeding your little one, too!

Professor Brian Wansink, the fabulous researcher known for his work on environment and eating behaviors may be ambivalent about these, but my opinions are solid. I would never feed these newly popular foods in a pouch (described in the NY Times article Putting a Squeeze on a Family Ritual) to my kids. Never mind that my sons are in their twenties (years, not months, that is). Still, if I did have toddlers, these would be the last things I'd purchase to feed my children.

Now before you leave this page thinking this is irrelevant to you—that you, too, have no young kids to feed, nor care to learn about approaches to feeding toddlers—let me make a point: this has everything to do with you and with managing your weight. You’ll likely learn as much about feeding yourself and self-regulating your own intake as you might your kids.

So what’s my problem, you’re thinking? Let me highlight a few of my concerns.

Distracted eating

Yes, that's a grapefruit he's eating. With a spoon. Not pureed.

Mindful eating enables us to fully appreciate our food with all our senses. And it slows us down. In doing so, we can better appreciate when we’ve had enough, helping to prevent overeating. Distracted eating—eating while on the phone, while watching TV, or even while jumping on the trampoline (an example pulled from this NY Times article) is anything but mindful.  Eating while distracted may lead to overeating. (Although, for those anorexic patients I see, it may enable eating food that wasn’t intended—and that could be a good thing). It is challenging enough to change behaviors in adulthood that perhaps only started recently. I could only imagine what it would be like to shift these behaviors in adults raised mindlessly sucking down pureed food goo.

Regulation of juices, sodas and mush? Not so easy.

It’s well established that we don’t do a very good job regulating our intake of caloric beverages such as juices and sodas. It’s challenging for our body to recognize when it has had enough calories from such beverages, so we certainly need to be aware of our portions. Again, for some needing to increase their intake, this form of nourishment is quite helpful. Less has been explored about the impact on feeding a less-than-solid but greater than liquid calorie diet, such as the slush-from-a-pouch.

Mealtime a thing of the past? Are we really too busy to parent? To nourish our kids with attention, with positive interaction, and with calories and other nutrients?

Even when camping, there's time for meals.

Maybe I’m an idealist, but I cherished the family dinner with my young family. It was a time to connect, to hear about their day, to be present. Sure, when the little ones would toss their food off their tray it would come to an abrupt end. But it was good while it lasted. And it established a tradition that lasted throughout the years (the family eating, not the throwing of food!) It was a time we were all theirs—we were not blogging, texting or talking on the phone. We were simply present—if only just for the mealtime.

If we don’t have time for what may be our most important job—parenting—it’s really a sad state we’re in. An acquaintance recently stated that he had no time to deal with exploring college options for his daughter with special needs—he had some very important business deals that needed his full-time attention! Seems like parents choosing feeding pouches may feel similarly.

Gone is the motivation for change.

Feeding our kids is often what motivates parents to shape up their own diet and eating behaviors. They want their children’s experiences to be positive—to feel good about their body, to be healthy and fit. They care about their little ones’ intake, but had previously not given much thought to their own eating. Having kids can change that, unless of course, family meals are eliminated. Gone is the need for role modeling and healthier eating for parents.

What’s normal and appropriate anyway?

Perhaps because we view smoothies and meal replacement shakes as eating, pouches fit the bill for our little ones. But what about the experience of eating? It’s enough that movies go with popcorn, and we need hot dogs at baseball games. Must we solidify the link from the youngest age, between eating and other activities? Must riding in a car be accompanied by fueling your body? Will they not expect to be eating, mindlessly, once they start to drive? I mean, isn’t that what they’ll have learned to associate with doing whenever they’re in the car?

Neil Grimmer, chief executive of Plum Organics, sees it as empowering children. “It’s on-the-go snacking, on-the-go nourishment,” he said. “It moves with kids and puts the control in their hands.” Seems to me that these days kids have more control in their hands than they need or want—perhaps limit setting would be a more appropriate parenting approach.

He further endorses feeding in response to hunger, and I’m all for that! In my mind, that necessitates parents connecting with their children and being aware of their cues. You know, taking note of when they start pushing their food away, when they have had enough. Or providing them with an additional few bites of cheese when they have finished what you served—just to see how much they truly need.  When they’re done, they will make it clear! This is quite different than serving a predetermined 100-calorie portioned food pouch. But the convenience of these foods and their inappropriate use in so many situations far from tunes in to a child’s hunger. See how this might be relevant for you, too?

Grimmer also states “Regular mealtimes just add one more item to the schedule”. Bummer. Now you have to deal with those kids you decided to have! Hain Celestial Group, the company that makes Earth’s Best baby food, sees it as the solution for the child who wants to be independent and self-feed. How about teaching them to use a fork or starting them on finger foods? Toddlers are developmentally ready for more than slush from a pouch!

This old momma thinks it’s time to shift our thoughts about feeding—our kids, and ourselves.

The Halo Effect. Your Thoughts About Healthy Foods Can Make or Break Your Weight Struggle.

Convinced of the health merits of such calorie-dense items as almonds, peanut butter and olive oil? You may feel more relaxed, more permissive about eating them as they’re nutrient rich and heart-healthy. After all, they’re good for you, right? So what’s the harm of eating them freely?

But then there’s the frustrated cry I hear most days, by seemingly educated dieters.

"But I eat so well, so healthily, I don't understand why I'm not able to lose weight”.

Thank you Jenny Wan-Chen Lee, a graduate student at Cornell University and her mentor Dr. Wansink for clarifying what’s going on here, confirming and quantifying what I’ve long experienced with my patients the past 25 years in practice. It’s called the halo effect.

What’s the Halo Effect?

Beautiful people are often attributed other positive features, simply because of their beauty. Their beauty radiates a sort of halo, influencing us to see them as smarter, more competent, and more likely to make a better president, for instance.

I enjoyed every morsel of this lavender flavored chocolate, and no,
it was not organic!

Growing evidence suggests that this halo effect may also apply to foods, ultimately influencing our eating. Research has shown that people tend to eat more calories at fast-food establishments claiming to serve "healthier" foods, versus the amount they’d have at a standard fast-food restaurant. Perceiving a food to be more nutritious, they’re less cautious and tend to overindulge. New research by Lee explored the halo effect around organic food, to see if people’s positive notions of organic items would lead them to perceive them as tastier or lower calorie.

“She tested this question by conducting a double-blind, controlled trial in which she asked 144 subjects at the local mall to compare what they thought were conventionally and organically produced chocolate sandwich cookies, plain yogurt, and potato chips. All of the products, however, were actually of the organic variety -- they were just labeled as being "regular" or "organic." Participants were then asked to rate each food for 10 different attributes (e.g., overall taste, perception of fat content) using a scale from 1 to 9. She also asked them to estimate the number of calories in each food item and how much they would be willing to pay.”

“Confirming Lee's health halo hypothesis, the subjects reported preferring almost all of the taste characteristics of the organically-labeled foods, even though they were actually identical to their conventionally-labeled counterparts. The foods labeled "organic" were also perceived to be significantly lower in calories and evoked a higher price tag. In addition, foods with the "organic" label were perceived as being lower in fat and higher in fiber. Overall, organically-labeled chips and cookies were considered to be more nutritious than their "non-organic" counterparts.”

http://www.sciencedaily.com/releases/2011/04/110410130831.htm

From my experience, this halo effect can have a positive or a negative impact on eating, depending on your eating issue.

For those struggling with overeating, the halo effect contributes to eating in

excess. Here's how it happens. If you perceive a food as healthy or good for you, and therefore acceptable to eat, you tend to be less mindful of portions of these foods. So consider that cry I hear frequently from new patients presenting for weight management. Assessing their intake makes it crystal clear—they are simply eating too much of a good thing!

And the Atkins and Zone Diets have made the situation worse, as I see it. If you were indoctrinated with the false information that protein at any cost is the answer and that carbohydrate is the culprit for your weight problems, it’s not so easy to let it go.

 And so excessive portions of protein rich foods are eaten, leading to excessive calories and therefore worsening weight struggles.

It may look attractive in the display, but... 

Trainers at the gym, are also frequently at fault, for propagating nutrition bubbe meises, or old wive’s tales. “Eat more protein to lose weight”, they convince their clients, who return to my office frustrated by their escalating weight (not, I might add, the result of increasing muscle mass).

When I started practice in the 1980s, I remember patients proudly sharing their progress. They'd declare that they had moved from Oreos to Snackwell's fat free cookies, consuming 6 or 8 at a time because they were fat free. But they missed the part that they were not calorie free. These patients were sold on the merits of Snackwells having no fat, which in that era was considered a good thing.

This very same halo effect has its benefits for those dealing with

restrictive eating disorders. It is often easier to include foods seen as healthy, even if only because of their organic label. Yes, for some people, certified organic chocolate feels safer as a means to increase calories than many other items might be. Similarly, a food attribute such as fiber content often allows people to select that food even if it is higher in calories. It's an effect I encourage taking advantage of, as it allows clients to become more comfortable with a wider range of foods.

What does this halo effect mean for you?

If you struggle with restrictive eating, you may find it easier to incorporate foods with some perceived health benefit, something you can justify as good for you. This often makes change easier. This will also lead to greater variety with less deprivation. It can then lead to transference of trust—allowing you to change items, to swap them—recognizing they are equivalent in nutritional value for weight and energy balance. Ultimately, you’ll be more likely to manage your nutritional needs, expanding your food selection and increasing your intake.

For those who believe that simply eating healthy foods without regard to physical need shouldn't result in weight gain, think again. Excessive calories relative to need is what impacts weight. Organic, high fiber, whole grain, omega 3-containing foods may all have their merits. But weight management comes down to calories in versus calories out.