Ask the Pediatrician: Dr. Molly

Category: Weight

Handling the prepuberty bulge in kids

Everybody goes through puberty whether they want to or not and most kids weather the changes and adjustments quite well. One of the changes has to do with weight.

In the year or so before puberty kicks in, many kids get a little roun, especially their faces and bellies. This can cause worry for parents and children alike. Most often I encounter this concern as I am pulled aside in the hallway as I am about to enter the exam room to see an 11- or 12-year-old when the parents whisper to me they are concerned their child is getting fat. Most of the time I can reassure these parents after looking at the growth curve and the child that this round look is nothing more than the body's prelude to puberty.

Most parents remain somewhat concerned, though, because most middle school-aged kids aren't known for their love of healthy eating. Most kids will eat candy and chips with abandon even if they are somewhat concerned about their bodies, and this worries parents. With obesity rates so much higher, nipping things in the bud is increasingly important. The challenge is that this is a fine line to walk. Parents understand that everything we say and do can have one of two effects at this age: no effect at all or profound and devastating effects. OK, I understand this is a wild exaggeration but it is the way things seem, isn't it? If we say too much about our child's round appearance and eating habits, we worry we will make her so self-conscious she'll stop eating and become anorexic, but if we don't say enough she will end up obese! Quite a conundrum. Here's my advice on how to approach kids this age:

Start by weighing and measuring the height of your child and then plotting that data on the CDC growth curves based on your child's gender or age. If the height percentile and weight percentiles match (or are pretty close) you can be even more sure that this is not concerning and strictly cosmetic. Even if the height percentile is 50th and the weight is 70th, there is little need for concern. Only when the percentiles are significantly off (50th for height and more than 90th for weight for example) do you need to be concerned that issues of true overweight are present. If that is the case, see your pediatrician to talk about this issue.

It helps a lot if leading up to this time your family already has well-established, good eating habits in place. These include scheduled meal and snack times and limited unplanned snacking. In other words, have breakfast, lunch and dinner as regular parts of your day (even if they can't all be shared together as a family) and have scheduled snack time(s). If your kids get used to being able to go to the pantry and grab a snack whenever they feel like it, controlling it later is tough. In addition, have certain foods available for snacks and others available only on special occasions. For example, if your family pattern is to have an afterschool snack, offering fruits, yogurt or peanut butter crackers as the choices will make life easier later than routinely offering cookies, ice cream and chips. These other foods can of course be a part of life, but on special occasions rather than whenever the child chooses. If you haven't scheduled snack times and exerted some control over the choices, now is the time to do this. Put aside a basket in the pantry with the snack choices and put the junky food out of sight. That way no matter what your child chooses, you won't need to comment or criticize.

Another suggestion, with Halloween fast approaching, is to let your child eat several pieces of candy when first received (some parents even let the child eat as much as they want at that one time) and then give the rest away. Another alternative is to have the child put aside enough candy to have a piece every day for a specific time frame and give the rest away. This allows the child some control and pleasure but limits the total amount consumed. It is important to apply these guidelines to everyone in the family, not just the child in question.

Don't point out the fact that you think your child is gaining too much weight or looks chubby. Believe it or not, many kids who are just about to enter puberty are blissfully unaware and if you can gently encourage good snack choices and regular meal times (along with good portion sizes) you can achieve what you are trying to do without encouraging your child to focus on his appearance in this way. If your child brings up the subject of his weight with you, this can be a time to talk about controlling portion sizes and snacks and come up with a plan together. Make sure you communicate that you love your child no matter what and that we all have things we need to work on at times. If your child is significantly overweight and brings it up with you, ask him if he wants to talk to his pediatrician about strategies to get healthier.

Lastly, remember most kids will adjust their eating patterns on their own as they progress through puberty and after as a result of peer pressure or self image. The less you do to focus on the specifics of what your child is eating, the less apt he or she will be to see food as a method of power and control in the relationship between the two of you and use eating (or not eating) as a method of passive rebellion. Most children who are normal weight for height all through grade school who appear to bulk up before puberty will use that extra bulk for the huge growth spurt to come and will end up just as well balanced as they were before puberty started.

Category: Weight

Portion size is key to healthy weight for kids

Running a marathon was the final challenge on "The Biggest Loser." Amazingly, all four of the final contestants finished it and what an accomplishment that was! What I love about "The Biggest Loser" is that in addition to showing the contestants exercising like crazy, they also emphasize the fact that diet is at least as important to achieve weight loss.

Most adults, when faced with the need to lose weight, start exercising. Unfortunately, for most of us, this is not nearly enough. Walking 4 miles an hour for 60 minutes will only burn about 350-400 calories. Even if you do that four days a week, you will only lose a little bit each week if you don't also change your eating habits.

Most kids are already pretty active (compared to adults) and as long as you are limiting screen time (TV, video games, computer and texting time) to an hour or so a day for school-aged kids, chances are between sports, the playground and physical education at school, your child is getting the bare minimum of exercise. Teenagers who don't participate in a sport may not be getting enough physical activity. These kids need to be even more aware of their eating and should make sure they aren't consuming more calories than they need.

To calculate how many calories a typical teenager needs for weight maintenance, the USDA Web site provides a handy formula. Once you know about how many calories your child needs, you can find information about how many calories there are in specific foods using Web sites such as My Calorie Counter. Other good sites with free calorie counters and daily diet journals are FitDay, The Daily Plate and My Fitness Pal. One of the most difficult things about calorie counts and journals is making sure the appropriate portion size is chosen. This is the key to achieving and maintaining a healthy weight. The new FDA food pyramid and Web site is a great resource for meal plans, portion sizes and general info about what proportions of different foods make up a healthy diet.

Changing activity level seems much easier to parents than changing eating habits. If I had a dime for every parent of an overweight child who tells me that his child really eats only healthy foods, I would be a millionaire. The truth is, almost no matter what you eat (healthy or not), you will get overweight if you don't watch your portion size. Parents are often eager to have their child play a sport or encourage more activity as the first step to helping their overweight child, when the bigger issue is in the kitchen.

Did you know that a portion size for pasta is the size of your fist? Bowls of mac and cheese are three times the normal portion size for a child. Pasta should generally be a side dish. Did you know that an entire apple only has about 90 calories and that is the same as about two chicken nuggets (even the baked ones)? Did you know that an 8 ounce glass (or small sippy cup) of skim milk only has 90 calories and lots of protein, vitamin D and calcium but an 8 ounce glass of apple juice has between 120 and 140 calories, no protein and very few vitamins?

Children under 2 are not likely to overeat. Their bodies are programmed to eat more when they are growing and less when they are not (hence the picky eating 2 year old) but by about age 3 or 4 this automatic turn off switch can be overridden by cake, candy, fried foods, chips or whatever the favorite junk food may be. In addition, well-meaning parents will encourage (or force) a child to eat more than a quarter of a sandwich or a slice of apple even when the child indicates she's done eating. Even though these are healthy foods, overriding the child's sense of hunger and fullness will take its toll and the child will begin to become accustomed to eating larger portions. This is especially true if children eat carryout or at restaurants. Even kids menu portions are huge and almost never offer the right balance of lean protein (like chicken or black beans), carbohydrates (like bread, pasta or potatoes) and fruits or vegetables.

Parents can help keep their children on track with portion sizes in a very simple way by continuing to use kid-sized plates and small glasses until puberty. That's right, Spiderman and princess plates with the three divisions are the way to go. In the larger well goes the lean protein and in each of the smaller wells go the carbohydrate and the fruit or vegetable. Kids can have seconds of anything except the carbohydrate to encourage a healthy balance of foods in the diet. When those same amounts of food are put on a regular plate, the dish looks bare and inadequate so by using the right size plate, you will offer appropriate amounts.

I encourage you to pour water into a measuring cup until you reach the 8 ounce mark and then transfer the water to the cups or glasses you use. See how much you are offering your children to drink. I think you will be surprised. Although drinking more than 8 ounces of water isn't going to add weight, drinking larger volumes of juice or even milk can add up. Kids need no more than three 8 ounce glasses of milk a day and no more than 4 ounces of juice.

Although I certainly don't want to discourage activity and exercise, the truth of the matter is that controlling the amount you and your children eat is a more powerful way to prevent obesity and will teach your children the important lifelong lesson that they should eat when they are hungry and stop when they are full.