Maya Kumar, MD, FAAP, FRCPC, a board-certified adolescent and young adult medicine pediatrician with Rady Children’s Hospital-San Diego and an assistant clinical professor with University of California San Diego School of Medicine, is on a mission. Along with nine colleagues from the Society for Adolescent Health and Medicine, for which she chairs the Nutrition Committee, Dr. Kumar is aiming to update fellow pediatric care providers’ toolkits for working with young patients on weight, exercise, nutrition and eating habits. In “Preventing Nutritional Disorders in Adolescents by Encouraging a Healthy Relationship with Food,” a new position paper published in the latest edition of the Journal of Adolescent Health, lead author Dr. Kumar and her collaborators discuss establishing positive relationships with food and physical activity and taking a whole-child approach to nutrition and exercise recommendations, using seven defined positions intended to prevent both weight problems and eating disorders. Here, Dr. Kumar gives us a look inside their research process; highlights the paper’s important messaging; and provides guidance to parents and caregivers on how to raise healthy, body-positive children and adolescents.
What was the catalyst for this position paper, and how did you and your colleagues come together to develop it?
I am the current chair of the Nutrition Committee of the Society of Adolescent Health and Medicine. Our committee consists of adolescent nutritional disorder experts from all over the world and from many different medical disciplines. In our experience, restrictive eating disorders and children being overweight are two sides of the same coin. They both stem from an unhealthy relationship with food and one’s body. But while there are a lot of guidelines for providers about how to treat obesity and eating disorders once they have already developed, we felt that providers need tools to help kids to develop a healthy relationship with food and their bodies at younger ages. This could prevent them from developing overweight or eating disorders in the future. We teamed up with colleagues from the Society of Adolescent Health and Medicine Eating Disorder Committee to outline approaches for providers to prevent both obesity and eating disorders in their patients.
What are nutritional disorders, and who do they affect?
Nutritional disorders include having an abnormal weight (too low or too high for an individual’s health); disordered eating behaviors; or a deficiency of energy, macronutrients (i.e., carbohydrates, proteins, and fats), and/or micronutrients (i.e., vitamins and minerals). Nutritional disorders can affect anyone, but adolescents are at particularly high risk. They are undergoing rapid physical, pubertal and cognitive growth, and their nutritional needs are unique from all other age groups. However, as adolescents get older and start making more of their nutritional choices independently, their eating and exercise behaviors may become less balanced and may not meet their needs. They also often become self-conscious about their bodies, and they may change the way they eat in unhealthy ways to try and cope with these emotions.
What is a “healthy relationship with food”?
In this position paper, we define it as “having eating and exercise patterns that not only meet your physical needs, but also promote positive self-image, confidence to eat and enjoy a wide variety of foods, and healthy social behaviors around eating and exercise.”
How did you and your colleagues research the paper?
We performed an extensive search of published research to provide evidence for our recommendations, but we also included opinions based on our expertise from clinical experience.
How did you and your colleagues determine your seven key positions?
We spent two years having extensive discussions amongst ourselves, and consulting with other experts in the field of adolescent nutrition, to organize our thoughts into positions that summarized what we felt was most important.
Why do you believe a child’s body mass index or weight should not be the only factor(s) for medically recommended dietary or activity changes?
BMI or weight is merely one aspect of nutritional health. Overall patterns of eating and physical activity, body composition, cardiovascular fitness, pubertal and developmental status, and previous growth trajectories are all important contributors to nutritional health. If a child has consistently been at a higher BMI percentile for their whole life, has healthy eating and physical activity patterns, has no associated metabolic or cardiovascular problems (like high blood pressure or cholesterol levels), and is healthy and happy, then that child should NOT be told that they are overweight or that they should lose weight. Telling a child they are overweight, even if they really do have a high BMI, can seriously damage body image and self-esteem. In fact, providers telling a child that they are overweight is a standalone risk factor for the child developing an eating disorder. If a provider is concerned about a child’s nutritional status after having done a comprehensive assessment, they should only recommend changes to eating and physical activity patterns; they should never tell the child to aim for a certain weight.
What is a “total diet approach,” and why is it advisable? How do popular, even “healthy,” food trends sometimes contradict it?
The “total diet approach,” endorsed by the Academy of Nutrition and Dietetics, states that there are no good or bad foods; rather, your overall pattern of eating is more important than the individual foods you consume on a given day or at a given meal. People should combine food groups together in appropriate portions to provide enough variety for nutritional needs to be met and for eating to be satisfying and enjoyable. In other words, it is a mistake to say that broccoli is a “good” food and pizza is a “bad” food; it’s not a good idea to eat pizza for every meal, but it’s not healthy to eat broccoli for every meal, either! No foods should be off-limits, although you need more of some foods than others. It is perfectly okay to enjoy all foods, even chips and soda, as long as you recognize that most of your nutrition should come from real food groups. The total diet approach is recommended by many professional organizations because it optimizes both physical and emotional aspects of nutritional health.
Unfortunately, almost every food trend and popular diet goes directly against the total diet approach by stating that certain foods are “good” and other foods are “bad.” Any food trend that advises eliminating a food or food group is not to be trusted and is actually a recipe for developing a nutritional disorder. Children and adolescents need help from their caregivers and providers to fact-check the messages they hear from peers and the media about nutrition.
What types of questions should parents ask about their children’s food consumption, nutrition and activities at health care appointments?
Parents should not allow their child to adopt any type of restrictive diet — including veganism, dairy-free, gluten-free, paleo, intermittent fasting, keto, etc. — without first consulting with their pediatrician about possible nutritional risks, especially when a child or adolescent is growing. Parents should ask whether their children are following their normal growth curves for both height and BMI percentile, and (once they reach the appropriate age) if they are going through puberty normally. Parents should discuss their child’s degree of screen time to determine whether it is appropriate. For children who participate in sports and athletics, parents should ask whether the child’s nutritional intake is sufficient to support their physical activity. Your primary care provider is the best person to talk to first if you are concerned that your child has poor body image; has changed their nutritional or physical activity patterns; or is engaging in disordered eating behaviors like binging, emotional eating or dietary restriction.
What can parents watch for that might indicate their child has a negative self-image, or is engaging in potentially risky food and exercise behaviors?
Behaviors that should cause concern include the following:
- Skipping meals or eating notably smaller portion sizes
- Avoiding foods that were previously enjoyed
- Hiding or throwing away food
- Eating in secret or hoarding food
- Adopting diets of any kinds, whether it is for the purpose of weight loss or not
- Eating large quantities of food at a single sitting and feeling a loss of control over eating
- Unusual behaviors while eating, like taking very small bites, eating very slowly, pushing food around on a dish while not really eating it or spitting out food
- Fasting
- Eating differently when sad, stressed or bored
- Counting calories or paying a lot of attention to nutrition labels
- Wearing clothes to hide or camouflage one’s body (e.g., baggy or oversized clothes)
- Looking in the mirror excessively
- Pinching one’s body to feel whether there is fat
- Weighing oneself frequently
- Weighing or measuring food
- No longer wanting to eat meals with the family, wanting to eat different foods than what the rest of the family eats or insisting on cooking their own food
- Excessive exercise or weight training, especially done after dark, in secret or at the expense of participating in other activities
- Use of supplements, herbs or products (including “natural” products)that decrease appetite, reduce weight or increase muscle
- Excessive use of stool softeners or laxatives
- Excessive use of protein powders, shakes and bars or other meal replacement products
- Overuse of nutritional supplements or vitamins
- Failure to grow taller or go through puberty as expected, even if there is no obvious weight loss
How can parents build and support a child’s healthy relationship with food?
Parents are the most important role models for their children when it comes to nutritional health, and need to create a family culture of balanced meals that includes a wide variety of foods, no “good” or “bad” foods, flexibility around eating, and positive social experiences around eating and physical activity. Parents should be careful not to talk a lot about weight or shape (whether it is their child’s, their own or anyone else’s) as this is a significant risk factor for children developing a poor relationship with food and their bodies.
To learn more about Dr. Kumar and her work at Rady Children’s Adolescent and Young Adult Clinic, visit www.rchsd.org/programs-services/adolescent-and-young-adult-medicine/.