Patients often want to make big changes to improve their health. However, there often is a disconnect between wanting to make a change and the ability to carry the change through and make it a habit.
Patients often want to make big changes to improve their health. However, there often is a disconnect between wanting to make a change and the ability to carry the change through and make it a habit. Rather, the patients that are successful in improving their nutrition are those who make small but sustainable changes and maintain those changes over time.
The difficulty in change often frustrates clinicians and discourages them from making interventions at all. Physicians sometimes lack self-efficacy to deliver behavioral interventions, or they may not have significant experience with delivering nutritional counseling in their practice. This article seeks to give the pediatrician a number of focused, specific, and brief strategies that can be implemented in a busy office practice to achieve sustainable, long-term nutritional change and help patients make better day-to-day decisions by empowering them to take control of their eating.
Here are 5 small strategies that will make significant nutritional improvements for the pediatric patient.
1. Switch from soft drinks to water. Sugar-sweetened beverages are a main source of extra calories for the pediatric population. These beverages include not only soft drinks, but also specialty coffee drinks, fruit juices, sports drinks, energy drinks, and vitamin water drinks. Although soda consumption has decreased over the last 10 years, consumption of the other drinks has been on the rise. These drinks add a significant amount of calories to the average American diet.1
Consumption of sugar-sweetened drinks places children at risk for a number of poor outcomes including elevated blood glucose levels, diabetes mellitus, overweight or obesity, metabolic syndrome, and cardiovascular disease as an adult.1
Sugary drinks have very few dietary or other benefits for the pediatric patient, and they are associated with the aforementioned impacts on overall health. As a result, the pediatrician should consider recommending that caregivers eliminate sugar-sweetened beverages as much as possible from their childrenâs diet. Instead, children and adolescents should be encouraged to drink water. Developing this habit at an early age will significantly reduce wasted calories for the pediatric patient over his or her lifetime. If parents do not offer these drinks in their home, their children will have significantly reduced access to these extra, empty calories.
When beverages other than water are consumed, zero-calorie drinks, low-calorie drinks, or skim milk are good recommendations. Additionally, children should eat fruit rather than drink fruit juice or other fruit beverages. If fruit juice is to be consumed, it is recommended that children aged 1 to 6 years limit their intake to 4 oz. to 6 oz. per day, and for children aged 7 to 18 years, 8 oz. to 12 oz. (2 servings) per day.2
2.Choose whole grains. Increased intake of whole grains is inversely associated with a number of different parameters associated with obesity such as body mass index, waist-to-hip ratio, and waist circumference. Lower abdominal fat has been associated with increased intake of whole grains in a dose-dependent manner. The Physiciansâ Health Study and the Nursesâ Health Study both demonstrated that consumption of more whole grain foods was associated with lower weight compared with those who consumed fewer whole-grain foods at all follow-up points.3 Increased intake of whole grains additionally has been associated with decreased risk of high cholesterol, diabetes, heart disease, and cancer.
The US Department of Health and Human Services recommends that whole grains make up at least half of all grains consumed.4 However, fewer than half of all American meet this goal.
Pediatric patients can increase intake of whole grains by eating more brown rice, oatmeal, whole oats, bulgur (cracked wheat), popcorn, whole rye, graham flour, pearl barley, whole wheat, and whole grain corn.
Also, referral to a nutritionist is another strategy for the pediatrician to improve consumption of whole grains and other dietary interventions. Physicians generally underrefer to ancillary services, but many physicians also do not feel skilled in dietary counseling.
Some simple substitutions to recommend to parents are to buy whole-wheat bread, pasta, and crackers instead of the versions made with white flour. Whole-wheat products retain vitamins and other nutrients that are lost during the bleaching process to make white flour. Additionally, the whole-wheat versions contain more fiber. Although some patients complain that the taste, texture, and feel of whole-grain products are different, many patients come to like them over time, especially if parents do not offer the white-flour versions.
Encourage parents to experiment with different grains. There is a plethora of commercially available products that allow increased intake of grains without a lot of sacrifice. However, parents need to be mindful of words on labels such as wheat, stoned wheat, enriched wheat, or 7-grain. These may not be whole grains although they give the appearance of being so.
Try offering the following suggestions during meals or snacks to increase the amount of different grains over time and slowly introduce as snacks or pastas. Here are some suggestions of whole grains for each part of the day:
3.Always eat breakfast. Eating breakfast has been associated with decreased risk of overweight and obesity.5 Breakfast eaters have a higher consumption of fiber, calcium, vitamins A and C, and other nutrients as well as being more likely to meet general nutrition recommendations compared with breakfast skippers.6 Eating breakfast is also associated with better school attendance, grades, performance, and test scores.7,8
As children get older, they are more likely to skip breakfast. More than 95% of children aged 5 years and younger eat breakfast daily, although this number decreases to 87% among 6- to 11-year-olds and 69% in children aged 12 years and older.9 Encourage parents to be good role models for their children and not skip breakfast. If children are already overweight or obese, eating a good breakfast is an invaluable asset in helping patients control weight gain.
Healthy breakfast options that are quick for parents include:
4.Avoid processed foods. Although patients will never be totally able to avoid processed foods, they should be encouraged to choose unprocessed foods when available.
Processed foods are energy dense with a high calorie per unit weight. They are often high in added sugars, sodium, and fat, and low in fiber and whole grains as well. A better choice is a natural food with a higher content of water. For example, a fresh apple is a better choice than applesauce or some sort of apple snack that comes in a bag.
Some common foods that patients think are healthy and often do not consider processed can turn what seems to be a healthy food choice into a poorer, unhealthy one.
For example, the cereal industry spends a lot of time, effort, and money convincing parents that their products are a great way for kids to start their day. However, examining the label of many popular cereal boxes reveals ingredients such as artificial sugars, artificial dyes, sodium, partially hydrogenated oils, trans fats, and butylated hydroxyanisole (BHA), a product in embalming fluid. Mixing rolled oats, sunflower seeds, sliced almonds, chopped pecans, and raisins or a dried fruit of choice is a much healthier option. Mixing granola, steel cut oats, and millet is another homemade cereal that is much healthier than the more processed off-the-shelf versions.
Salad dressing can easily turn a healthy meal idea into a processed calorie feast that is not so healthy. A quick glance at salad dressing labels marketed as âall naturalâ and âliteâ reveals ingredients such as maltodextrin, sodium benzoate, calcium disodium ethylenediaminetetraacetic acid (EDTA), modified food starches, monosodium glutamate, corn syrup, autolyzed yeast extract, sodium chloride, and xanthum gum. Instead, suggest trying oil and vinegar with a little Dijon mustard and garlic mixed in. Another healthier option is to mix Greek yogurt, yellow mustard, raw honey, and lemon juice.
Ketchup, tortilla chips, pasta sauce, soup, flavored yogurt, granola bars, and energy bars are just a few of the other foods that may suggest one is eating healthy, but the label may reveal something different. However, all these items, with a quick Internet search, can be made from more natural and healthy ingredients easily at home. These unprocessed versions are much healthier and contain significantly fewer processed ingredients. Patients can be instructed to read a label and if they have trouble pronouncing or do not recognize a large number of the ingredients, there is a good chance the product is highly processed, and the parent might be better advised to consider an alternative option.
5.Avoid junk food. If parents choose not to buy junk food, children simply will have significantly fewer opportunities to eat these calorie-rich, low-nutritional-quality foods. Although efforts to ban junk food from the Supplemental Nutrition Assistance Program (SNAP), as was successful for alcohol and cigarettes, have failed, it is estimated that changes in the program could significantly improve diets of the 1 in 7 Americans that receive food assistance. One pilot project that has yet to be implemented found that fruit and vegetable consumption increased by 25% when SNAP recipients were incentivized with 30 cents for every dollar used to purchase fruits and vegetables.10
In addition to providing patient education on these topics, pediatricians can advocate for policies that improve the likelihood that patients will make better food choices. Because so many people in the United States receive food assistance, most grocery chains and convenience stores want to participate. Few stores opt out of programs such as SNAP or Women, Infants, and Children (WIC). In 2009, the WIC program increased the types of foods stores were required to stock in order to participate. Nearly all stores participated, and milk, whole grain, and fruit consumption increased.11
Similarly, studies have demonstrated that simply doubling shelf space for fruits and vegetables increased consumption by 30% to 60%.12,13 The SNAP or WIC mandates for certain amounts of shelf space for fruits, vegetables, and other healthy, nutritionally desirable foods will likely improve consumption of these items for people beyond participants in food assistance programs.11
Finally, there is a saying in business that âYou cannot change what you do not measure.â Whether measuring eating habits, calorie intake, or exercise, self-tracking demonstrates benefits across a wide range of desired activities. When patients record both what and how much they eat, they generally eat less and lose more weight compared with those who do not self-track the activity.14 With some activities such as exercise, patients tend not only to perform the desired activity more, but they also seem to get greater enjoyment from that activity.
With self-tracking, a patient can set smaller waypoints on the way to achieving a bigger goal. Measurement allows patients to not be overwhelmed by a larger goal, and allows them to see where they are on the path to achievement.
Small incremental changes in eating habits and purchasing decisions can make a big difference in the nutritional state of children and adolescents. The pediatrician has an opportunity to counsel in the office as well as participate in local and national advocacy related to food assistance programs and food programs in public schools. Finally, advocating for patients to measure and record aspects of their nutritional habits is likely to lead to improvements in what patients consume.
1. Wang ML, Lemon SC, Olendzki B, Rosal MC. Beverage-consumption patterns and associations with metabolic risk factors among low-income Latinos with uncontrolled type 2 diabetes. J Acad Nutr Diet. 2013;113(12):1695-1703.
2. American Academy of Pediatrics. Policy statement: The use and misuse of fruit juice in Pediatrics. Pediatrics. 2001;107(5):1210-1213. Reaffirmed in: Pediatrics. 2007:119(2):405.
3. Jonnalagadda SS, Harnack L, Liu RH, et al. Putting the whole grain puzzle together: health benefits associated with whole grainsâsummary of American Society for Nutrition 2010 Satellite Symposium. J Nutr. 2011;141(5):1011S-1122S.
4. US Department of Health and Human Services. Dietary guidelines 2015-2020. Available at: http://health.gov/dietaryguidelines/2015/guidelines/executive-summary/. Accessed May 17, 2016.
5. Blondin SA, Anzman-Frasca S, Djang HC, Economos CD. Breakfast consumption and adiposity among children and adolescents: an updated review of the literature. Pediatr Obes. February 4, 2016. Epub ahead of print.
6. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. 2005;105(5):743-760.
7. Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE. The relationship of school breakfast to psychosocial and academic functioning: cross-sectional and longitudinal observations in an inner-city school sample. Arch Pediatr Adolesc Med. 1998;152(9):899-907.
8. Meyers AF, Sampson AE, Weitzman M, Rogers BL, Kayne H. School Breakfast Program and school performance. Am J Dis Child. 1989;143(10):1234-1239.
9. US Department of Agriculture, Agricultural Research Service. What We Eat in America, NHANES, 2001-2002. Available at: http://www.ars.usda.gov/SP2UserFiles/Place/12355000/pdf/Table_5_BIA.pdf. Accessed May 17, 2016.
10. Bartlett S, Klerman J, Olsho L, et al. Evaluation of the Healthy Incentives Pilot (HIP): Final Report. Prepared by Abt Associates for US Department of Agriculture, Food and Nutrition Service. Available at:
. Published September 2014. Accessed May 17, 2016.
11. Farley TA, Sykes R. See no junk food, buy no junk food. New York Times. March 21, 2015;A19. http://www.nytimes.com/2015/03/21/opinion/see-no-junk-buy-no-junk.html?_r=0. Accessed May 17, 2016.
12. Bodor JN, Ulmer VM, Dunaway LF, Farley TA, Rose D. The rationale behind small food store interventions in low-income urban neighborhoods: insights from New Orleans. J Nutr. 2010;140(6):1185-1188.
13. Farley TA, Rice J, Bodor JN, Cohen DA, Bluthenthal RN, Rose D. Measuring the food environment: shelf space of fruits, vegetables, and snack foods in stores. J Urban Health. 2009;86(5):672-682.
14. Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc. 2011;111(1):92-102.
Dr Bass is chief medical information officer and associate professor of medicine and of pediatrics, Louisiana State University Health Sciences CenterâShreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.