Pediatric Growth Chart Examples (Part 2)

image

“Boy Sleeping On Bull”

Parents have been bringing their overweight children to me for well over 10 years now – desperate for answers. Over that period of time, the number of children that come into my office with an unhealthy BMI has steadily risen – ask any pediatrician and they will tell you the same thing. In the beginning of my career, I can remember repeating the same old dietary rhetoric. “It’s just a matter of calories in vs. calories out,” I would say, or “You need to decrease the fat in your diet” As I think about that today, I cringe. The results were never very good – the parents would stop asking me or they would search for an answer elsewhere. I would continue treating their kids for other basic pediatric issues.

As physicians and dieticians, it is not uncommon when you are faced with such failure, to blame the patient. Rather than question the approach, it is much easier to question patient compliance. “They didn’t follow my instructions regarding diet and/or exercise.” Move on to the next patient. As the “monday morning quarterback,” it is easy for me now to look at the failed “Low Fat, Calories In Calories Out” approach and see the inherent problems from both a physiological and behavioral perspective. Indeed, not only did I experience this frustration as a physician, but as a patient too! Then I started talking to successful LCHF adult patients and I started reading anything that I could put my hands on regarding nutritional research – either in the bookstores or on the internet. Once I switched to an LCHF diet, the success was almost immediate. At that point I realized the vast majority of my overweight patients were NOT ignoring my advice and this was not a purely motivational issue – I was giving them the wrong information. It became obvious to me right away that parents and kids (particularly my overweight teens) would try ANYTHING to beat this problem and I needed to offer them Low Carb. So I started teaching the Low Carb (LCHF) diet to my patients about 3 years ago.

At the annual checkup appointments, parents will often ask about their child’s weight as a primary concern. Sometimes, I have to broach the subject. I will show the parent/teen the BMI chart and point out the problem. “Does this worry you at all?” I might ask. “I noticed that the BMI is starting to rise a little bit” is another lead in statement that I use. From there I can better gauge the level of concern. If there appears to be no real interest, which does not happen as often as you might think, I always finish by saying “You can always let me know if you want more information on nutrition and diet.”

If I am working with my patient at the checkup, I often hand them a printed version of my “Food Choices” page and I include the “Quick Low Carb/Paleo Snacks” page. I send them to my blog and direct them to those pages as starting points. We will run through a few details and I advise them to follow up if they have further questions. In addition to the checkup visit, I make myself available for more intensive, detail-oriented nutritional sessions. We call these “nutritional consults” and we block off an hour for these kids/families – particularly the kids who are well over the 97th percentile for BMI. In these sessions, I can spend more time targeting specific nutritional problem areas for the child. Are the breakfasts or lunches a bigger problem? What happens when the child is at mom’s house vs. dad’s house? Are there other medical issues that could be contributing (i.e. sleep apnea, thyroid issues)? We spend time discussing how normal saturated dietary fat is NOT the problem and is, in fact, quite healthy. I often discuss basic physiological principles such as glycemic index, the role of insulin as a fat storage hormone, and the liver’s infinite ability to convert excess blood sugar into fat. We go through the cookbooks and look at recipes. I emphasize that feeling hungry is NOT part of the program. We routinely run screening labs that look at, among other things, triglyceride/hdl ratios and diabetic risk factors. I ask the families to keep food diaries – an essential tool in fine-tuning problem areas in the diet. Finally, depending on the parental/patient level of comfort and also depending on BMI itself – we decide on followup intervals. Sometimes, I see the patients monthly (the appointments are shorter in duration). Sometimes, 3-6 months is appropriate (but I always make sure to let the family know they can come back sooner).

What I don’t do: I do not tell my patients to count calories or consciously control portions. I point out that if they follow my suggestions regarding foods that they should eat and foods they should not eat, portions will naturally control themselves through hormonal feedback.

My patients and their families have inspired me by their eagerness to embrace the latest in nutritional science. They energize me with their enthusiasm. They take the information and they go to work! When I recently asked a few if I could share their BMI chart on my blog, they wholeheartedly agreed! THEY want YOU to see what is possible!

An Important Study and The Null Hypothesis

image

Exciting growth chart examples are forthcoming, but this is an important scientific study which we should discuss.

If you have been following health news lately, you have seen press releases on the “Look Ahead Trial.” This is a fairly well designed study. It looks at diet, weight loss and followup health benefits in Type 2 Diabetics. The patients were followed for as long as 11 years before the NIH halted the study because they noted there was NO difference between the treatment group and the control group with regards to cardiovascular (CV) events such as heart attacks and strokes. The treatment group was given a specific dietary/exercise plan of action. The control group was told to do whatever they wanted. The treatment group, indeed, successfully lost weight, but as mentioned above, there was no difference in CV events. We will get into the diet intervention later in the post.

After stopping the study, many news outlets screamed the headlines. “Weight loss doesn’t work!!!!.” I’m paraphrasing. Here are some examples: here, here, and here.

“Dr. Hoop, what’s the point of weight loss than?” or “Dr. Hoop, why should I even bother to eat right?”

Let’s dig a little deeper and I will tell you more about the Look Ahead study. By the way, the study cost $220 million dollars. Even though there was no significant difference between groups regarding CV Events, it still gives us valuable information.

Why? First, let’s talk about the “Null Hypothesis.” ANY SCIENTIST WHO KNOWS WHAT HE/SHE/THEY ARE DOING CAN TELL YOU ALL ABOUT THE NULL HYPOTHESIS (again, not yelling, just emphasizing). Here is the wikipedia definition for the Null Hypothesis: “The practice of science involves formulating and testing hypotheses, assertions that are capable of being proven false using a test of observed data. The null hypothesis typically corresponds to a general or default position. For example, the null hypothesis might be that there is no relationship between two measured phenomena or that a potential treatment has no effect.” In other words, the Null Hypothesis states there is no relationship between Event A and Event B. Event A does not cause Event B and Event B does not cause Event A. When a scientist goes about trying to prove a theory, HE/SHE /THEY ARE TRYING TO REJECT THE NULL HYPOTHESIS. From a mental standpoint, a good scientist will approach a given theory by trying to prove it wrong (try to support the Null Hypothesis) – “How could this be proven wrong?”

Remember what Gary Taubes says in Good Calories Bad Calories. “A sound theory,” referring to the words of the great 18th century genius Sir Francis Bacon, “gains strength over time and welcomes a challenge whereas a weak theory has to try harder and harder to find supporting data and will tend to omit, dismiss, even ignore data that contradicts it and with time becomes more and more frustrated. A clear sign of a failing theory,” says Taubes, “Is how increasingly sensitive to criticism it becomes and how easily it can regress into hypersensitive, protective dogma.” Taubes concludes that “This is exactly what has happened in diet and health science. It has betrayed the fundamental imperative – to be rigorously self-corrective.”

“Dr. Hoop, please move on to the study.” Will do.

So if you read the majority of press releases or blog posts regarding the Look Ahead study, you would come away with the impression that “weight loss, regardless of the method used” (Event A) has no bearing on “cardiovascular events such as heart attack and stroke” (Event B). It would appear that the Null Hypothesis is supported. I would agree that it is, but in what way? What exactly is “Event A”?

Let’s look at the Look Ahead study protocol (pun intended). It is located as a PDF file at the Look Ahead website. Remember, there are many ways to LOSE Weight (ex. LCHF, starvation, etc.) To find out more specifically what weight loss intervention was used, you can look at Page 35 of the PDF:

“5.4.5 Diet Restriction of caloric intake is the primary method of achieving weight loss. In order to aim for a weight loss of 10% of initial weight, the calorie goals are 1200-1500 kcal/day for individuals weighing 250 lbs (114 kg) or less at baseline and 1500-1800 kcal/day for individuals who weigh more than 250 lbs. These goals can be reduced to 1000-1200 kcal/day and 1200-1500 kcal/day, respectively, if participants do not lose weight satisfactorily. These calorie levels should promote a weight loss of approximately one to two lbs/week. The composition of the diet is structured to enhance glycemic control and to minimize cardiovascular risk factors. The recommended diet is based on guidelines of the ADA and National Cholesterol Education program and includes a maximum of 30% of total calories from total fat, a maximum of 10% of total calories from saturated fat, and a minimum of 15% of total calories from protein. During the first four weeks of the intervention, participants are encouraged to follow a portion controlled diet, given findings that this approach produces significantly larger weight losses than having participants consume a self-selected diet of conventional foods.”

We now know that calories were consciously counted and that portions were consciously controlled. If you’ve read my blog or have followed other quality low carbohydrate blogs, you know this is a failed method. You know that this (along with the low fat theory) has been the prevailing theory regarding both obesity and CV disease for decades. Regarding dietary composition, the diet was restricted in terms of total fat – 30% (there was no restriction on omega 6 polyunsaturated fatty acids or PUFA-rich vegetable oils! I have not discussed omega 6 PUFA-rich vegetable oil in detail yet but they are terrible for you – a science supported statement). In the study, calories consisting of normal dietary saturated fat (the healthy fat) were restricted to 10%. Patients were allowed a minimum of 15% protein. Although it was not explicitly stated, this means that the patients were allowed up to 55% carbohydrate – from any source.

Remember, that LCHF does not limit protein and normal dietary saturated fat. It may also help to remember that a REAL low carbohydrate diet starts at 10% carbohydrate (ideally from non-sugar and non-grain sources – such as fruits and vegetables). LCHF prohibits PUFA-rich vegetable oil. Also, remember LCHF naturally controls portions through hormonal feedback. Most notably Leptin. Finally, we know that all controlled weight-loss trials utilizing a (REAL) low carbohydrate diet conclude superior results.

So instead of saying there was no measurable benefit (or the Null Hypothesis was supported) from “weight loss in general” with regards to “CV events” as the headlines are screaming, they should be saying something different. They should be saying something along the lines of “weight loss resulting from a low-fat, omega 6 PUFA-rich vegetable oil abundant, conscious calorie restricted, conscious portion controlled diet plus exercise” appears to fail in preventing “CV events.”

Maybe we can finally put the “low fat, consciously portion/calorie controlled” theory behind us. That would certainly make this pediatrician happy :-). Our children certainly deserve it! Go science!

Pediatric Growth Chart Examples (Part 1)

image

A picture is worth a thousand words.

Before I post representative BMI growth charts which illustrate how well a Low Carb diet works with our children and teens, let’s look at what we are seeing on a daily basis. Most physicians are able to plot weight and height on growth charts. They have been doing so for decades. Although not perfect, Body Mass Index (BMI) has been used by the World Health Organization (WHO) as the standard for recording obesity statistics since the early 1980’s.

BMI = [ Weight in lbs / ((Height in inches) x (Height in inches)) ] x 703
or
BMI = [ Weight in kg / ((Height in meters) x (Height in meters)) ] x 703

As you can probably guess, prior to the advent of Electronic Medical Records, calculating and plotting the BMI for a child at every check-up visit had the potential to be time consuming for either the nurse, dietician or physician. One of the advantages of the widespread use of EMR’s in medical offices is the quick and easy BMI calculation.

Which BMI Growth Chart should we use? Most offices use the CDC Growth Chart from 2000 (either in print or digital form). In 2006, WHO released a new version of its own growth chart as well. In 2010, with the support of the American Academy of Pediatrics, the CDC now recommends that the WHO growth chart be used to measure height, weight and head circumference between ages 0 and 2. After age 2, it recommends using the CDC growth chart to measure height, weight and BMI.

Let’s look at some sample BMI growth charts. You might agree with me that in this age of childhood obesity the difference between the CDC and the WHO growth charts is probably minimal. Using and plotting BMI at every checkup visit, regardless of the growth chart used, is the most important step in tracking growth development.

First, here is a sample BMI growth chart for a 15 year old girl. Note the dots which represent the BMI measurement at each yearly checkup. Age is plotted along the x-axis and BMI is plotted on the y-axis. You can also see the lines which represent the 95th%, the 50th% (average), and the 5th% (as determined by the CDC in 2000). In other words, the BMI for this sample 15 year old girl has been tracking below “average” and above the 5th%. Most physicians would consider this completely normal:

Here is a corresponding “normal” growth chart for a sample 15 year old boy. He has been tracking slightly above “average”, but well below the 95th%:

Now let’s look at a sample BMI growth chart for a 13 year old girl who is overweight. Her BMI is above 34 – well above normal. Follow the dots and notice the increasing rate of BMI gain. The measurement tracks well above the 95th% and has been doing so since early elementary school. UNFORTUNATELY, THIS IS NOT AN UNCOMMON SCENARIO. Most pediatricians and family physicians are seeing this particular pattern on a regular basis:

Finally, let’s examine a sample “abnormal” growth chart for a 10 year old boy. Again, I see this pattern almost on a daily basis. Follow the dots. The rate of increase (the increasing slope of the line that would connect the dots) is very alarming!

Again, the above sample charts show BMI trajectory without any attempt on the part of the healthcare professional to institute a specific dietary plan of action.

Follow

Get every new post delivered to your Inbox.

Join 90 other followers