Lesson 12: Child and Adolescent – Nutritional Considerations

Table of Contents

Introduction

Thus far I have discussed various health implications, both physiological and psychological, of obesity and its treatment, considerations and caveats regarding how it is defined, and informative aspects of monitoring growth over time. I have sprinkled in various tips for preventing and managing obesity in the lessons presented thus far. Here I will discuss more concretely various aspects of nutritional considerations for weight management.

I discuss overall nutrition in a significant amount of detail in the Nutrition and Weight Management course. That course discusses calories, macronutrients, micronutrients, food groups & beverages, the timing of food & drink consumption, various diets, and other considerations. Much of the information there is appropriate for children and adults, but some is more pertinent specifically for adults. Rather than rehash all of the components of healthy eating here, I will emphasize points that are pertinent to childhood weight management.

Tip: In additional to the Nutrition and Weight Management course, you can find lots of detailed advice regarding nutrition in children and adolescents in Chapter 3 of the 2020-2025 Dietary Guidelines for Americans as well as the associated appendices. The guidelines give more concrete recommendations regarding recommended food intake types and amounts for general health.

Calories

In general it is not recommended for children and adolescents to track calories rigorously without the guidance of a health professional, primarily due to concerns of increasing the risk of developing an eating disorder. Nonetheless, it can be helpful for troubleshooting purposes when weight loss is not occurring despite making significant lifestyle changes to track all food & drink intake for 3 days and to consider the associated calorie content to help determine what the next steps should be.

If food intake is going to be tracked, it is important to realize that many children & families do this incorrectly, and underreporting of dietary intake is more common in children with obesity and in children who have worse cardometabolic health markers.(Suissa, 2019) Incorrect reporting also applies to various nutrients, with correlations between reported values and accurate values in a 2020 systematic review and meta-analysis (“SR/MA”) being generally 0.33-0.56, and in particularly 0.44-0.48 for calorie intake.(Saravia, 2020) Thus, if you do consider the calorie content of the reported food intake and it does not match what you would expect based on the child’s age, current weight, and recent trend in weight change, it is worth examining further to clarify if the reported food & drink intake may be inaccurate.

This brings up the question of how many calories per day should a child eat and how many calories would a child need to consume to maintain an elevated body weight? General recommendations for caloric consumption per day based on age, gender, and activity levels are listed in Appendix 2 of the 2020-2025 Dietary Guidelines for Americans. These recommendations are for obtaining and maintaining a healthy body weight. I have reproduced this table below.

Reproduced from Appendix A2-2 of the 2020-2025 Dietary Guidelines for Americans, sourced from the USDA and HHS. Moderately Active means a lifestyle incorporating walking 1.5-3 miles daily at a pace of 3-4 miles per hour, while Sedentary would be less than this and Active would be more than this.

A 2023 analysis including 63 studies determined the typical daily energy expenditure of children of all ages, and as you can see in the following graphs calorie expenditure is typically higher in males than female and is typically higher in children with overweight or obesity compared to normal weight(Kim, 2023):

Reproduced from: Kim N, Park J. Total energy expenditure measured by doubly labeled water method in children and adolescents: a systematic review. Clin Exp Pediatr. 2023 Feb;66(2):54-65. doi: 10.3345/cep.2022.00472. Epub 2022 Oct 17. PMID: 36265521; PMCID: PMC9899554. You can read the full caption of the images here.

Not only do children with overweight and obesity typically have higher total daily energy expenditure, but the generally do not have a low resting metabolism, with one study finding only 14% of children with obesity had a resting metabolism more than 10% lower than predicted.(Tamini, 2023) Thus, while many people think a slow metabolism may cause obesity, this data shows in children this is not typically the case.

Regarding how many calories are needed to maintain excess weight, this is going to be variable based on a lot of factors (if curious, review Lesson 1 of the Nutrition and Weight Management course for a discussion of some of the relevant topics), but a 2013 study attempted to address this.(Hall, 2013) The authors proposed a model describing the dynamics of childhood growth and obesity, deriving the following formulas to estimate the excess calorie intake needed to obtain and then maintain excessive weight gain in the age range of 7-18 years, assuming the child had a healthy body composition with a weight at the 50th percentile (“%ile”) at age 5 (here kcal = kilocalories):

  • Males: kcal/kg/day = 68-2.5*age
  • Females: kcal/kg/day = 62-2.2*age

To be clear, this describes how many calories are needed to maintain a weight above the 50th %ile; as obesity is defined by having a BMI above the 95th %ile, these formulas will substantially overestimate the number of calories needed to maintain a state of obesity. See the following example for how these formulas can be applied if desired.

Example: Going along with the example in Lesson 11, we had a male child with age 10 years 3 months and a weight of 120 pounds initially. Over the subsequent 6 months he gained 4 pounds, but also an inch in height, to reach a new weight of 124 pounds with a similar BMI. Converting to kilograms, 120/2.2 = 54.5 kg, while 124/2.2 = 56.4 kg. Looking at the male growth chart (click here for a link to the various growth charts), the 50th %ile for weight at 10 years and 3 months is ~32.5 kg, while the 50th %ile for weight at 10 years and 9 months is ~35 kg.

Therefore:

  • Age 10 years 3 months:
    • 68 – 2.5*10.25 = 42.4 kcal/kg/day
    • excess weight = 54.5 kg – 32.5 kg = 22 kg.
    • 42.4 kcal/kg/day * 22 kg = 933 extra calories consumed per day
  • Age 10 years 9 months:
    • 68 – 2.5*10.75 = 41.1 kcal/kg/day
    • excess weight = 56.4 kg – 35 kg = 21.4 kg
    • 41.1 kcal/kg/day * 21.4 kg = 880 extra calories consumed per day

This shows an estimate for how many extra calories are consumed per day to maintain the elevated weight relative to the 50th %ile.

While it is not mathematically or conceptually appropriate to linearly adjust the model to determine the extra calories for maintaining a BMI above the 95th %ile (because weight gain from ~50% to 95% is different than weight gain beyond 95% with respect to the impact on body composition, and because the model is designed for weight and not BMI), for fun we can do a quick correction for this “just to see” what happens. Remember, the model itself generates an average estimate; it can already be off to a significant degree for any individual person.

Using the BMI calculator linked above, and using the height in the prior example for age 10 years and 3 months:

  • 10 years and 3 months, height = 55″
    • The weight needed for a BMI in the overweight category is 84 pounds, which = 38.2 kg.
      • Thus, if we consider 38.2 kg to be the target weight, then 54.5 – 38.2 = 16.3 kg
      • Finally, using the above formula: 42.4 * 16.3 = 691 extra calories consumed per day.
    • The weight needed for a BMI in the obesity category is 96 pounds, which = 43.6 kg.
      • Thus, if we consider 43.6 kg to be the target weight, then 54.5 – 43.6 = 10.9 kg.
      • Finally, using the above formula: 42.4 * 10.9 = 462 extra calories consumed per day.

So in summary, the model, which generates an estimate from average values of large data sets, indicates that the child at the age of 10 years and 3 months is consuming 933 extra calories per day compared to what he would need to consume to maintain a body weight at the 50th %ile. By making an admittedly inaccurate adjustment, he may need to decrease his caloric consumption by ~462 calories daily to get out of the obesity range by BMI and ~691 calories daily to get out of the overweight range by BMI. The primary points are that he is consuming substantially more calories than is necessary for his age, but cutting back on the calories by 933 daily would potentially be excessive and lead to weight loss faster than the guidelines recommended in Lesson 11.

Macronutrients

The three primary nutritional macronutrients include protein, fat, and carbohydrate discussed in detail at the associated links in the Nutrition and Weight Management course.

Multiple reviews indicate that the current recommended amounts of protein intake in children may underestimate the optimal amounts for whole-body protein balance, particularly when exercising regularly.(Moore, 2019; Hudson, 2021) Importantly, while as previously discussed excess protein intake in infancy seems to lead to excess weight gain later on, there is no indication that this is the case in children >2 years old. Thus, as protein generally increases satiety and may assist in skeletal muscle mass retention while losing body fat, ensuring adequate protein intake to help prevent excessive hunger is a good strategy to assist in achieving weight management goals.(Mittall, 2021)

Other than obtaining sufficient protein, the macronutrient distribution does not seem to matter for childhood weight loss efforts.(Cardel, 2020; Koletzko, 2020; Jakobsen, 2022) Thus, other than ensuring you consume sufficient healthy food groups and nutrients there is no reason to prioritize fats vs. carbohydrates or vice versa.

Regarding fiber intake, as discussed in the Nutrition and Weight Management course a general recommendation is 14 grams per 1,000 kilocalories of intake. Some people suggest children only need their age + 5 in grams (ie, a 4 year old would need 4 + 5 = 9 grams of fiber daily), but I have not come across any literature to support this. Based on the estimated calorie needs shown in the table above, most children should aim for at least 14 grams of fiber daily, and some may benefit from ≥30 grams.

Tip: It may be particularly helpful to preferentially consume extra protein at breakfast. A 2021 SR/MA found in trials of youth (mostly adolescents) that higher protein intake during breakfast (the range was 12.2-58 grams of protein) lead to increased fullness, decreased hunger, and decreased subsequent energy intake.(Qiu, 2021) It is unclear if these changes would persist over time and to what degree this may impact total daily energy intake, and there were no comments in this analysis on individual variability. Nonetheless, some individuals may find it particularly helpful to eat more protein at breakfast to help prevent excessive food consumption later in the day.

Note: While not a macronutrient, it is possible to replace some carbohydrates with nonnutritive sweeteners (“NNS”) A 2019 review of NNS use in youth found that these can aid weight stabilization or weight loss in children and adolescents with obesity.(Baker-Smith, 2019) However, a 2020 review of SRs found conflicting evidence regarding benefits of low-calorie sweetener consumption in children; of note, the prior 2019 review considers more recent research than this overview of SRs.(Andrade, 2020) A separate 2020 SR/MA found in general NNS did not lead to weight loss in pediatric subjects, but 78% of the pediatric subjects in the studies were of normal weight status and there was no indication of weight gain.(Laviada-Molina, 2020) Overall, it seems that NNS can be used in moderation to potentially good effect without significant risk of harm.

Micronutrients

There are no specific micronutrient considerations to aid weight loss directly. In general it is a good idea to consume sufficient quantities to benefit general health. Importantly, when people decrease food intake to lose weight they consume fewer nutrients overall; if they are not careful to consume sufficient amounts of variable nutrient-dense options then they run the risk of developing deficiencies. This may be particularly true for children who are generally at greater risk of insufficient intake of certain food groups.(Motevalli, 2021) If this is a concern you can consider supplementing with a multivitamin/multimineral supplement, or any other specific nutrients where you are concerned for deficiencies.

Food groups

In general, prioritizing low-energy-dense food options that have protein and fiber can be helpful when attempting to lose weight as these options will help induce satiation/satiety and curb hunger. These will include fruits, vegetables, whole grains, and lean meats. I discuss general aspects of food groups in the Nutrition and Weight Management course (here for the groups that are more universally considered healthy and here for the groups that are more controversial).

The only food group I will discuss in detail here is dairy, as there has been substantial literature and debate regarding the implication of dairy intake, and the fat content of the dairy, with childhood weight management.

  • A 2016 SR/MA of 10 studies found that higher dairy intake in childhood associated with a decreased risk of overweight and obesity.(Lu, 2016)
  • A 2017 SR of randomized controlled trials found that increased dairy consumption in youth was beneficial for bone development (8/11 studies with benefit) without having a significant impact on body size or body composition (only 2/14 studies found an impact on body size and only 1/11 studies found an impact on body composition).(Kouvelioti, 2017)
  • A 2020 SR including 29 articles found that most of the evidence suggested no association of adiposity (a medical term for “body fat”) with whole or reduced-fat dairy, but as only 2 randomized controlled trials were included the authors suggested we need more trial evidence.(O’Sullivan, 2020)
  • A 2020 SR/MA of 28 studies (20 cross-sectional, 8 prospective cohort) found that whole-milk consumption was associated with a decreased risk of overweight & obesity compared to reduced-fat milk (odds ratio = 0.61 in the MA that included 14 of the studies).(Vanderhout, 2020) Considering only the studies that adjusted for the volume of cow’s milk intake the findings were similar.
  • A 2021 prospective cohort study evaluating the impact of cow’s milk fat on the risk of overweight & obesity in children up to age 8 years found that those who consumed whole milk had an odds ratio of ~0.83 for overweight and obesity after adjusting for various confounders.(Vanderhout, 2021)
  • A 2021 SR/MA found that the collective cross-sectional evidence indicates an inverse association of total dairy intake with obesity but not with overweight or overweight + obesity, while there was only 1 prospective study that found a decreased risk of obesity with increased total dairy intake. Four studies prospectively assessing total milk intake found an increased risk of overweight.(Babio, 2021)
  • A 2022 SR/MA found that higher intake of dairy foods leads to at most a small increase in lean body mass (0.34 kg) and a small decrease in body fat percentage (-0.47%).(Jakobsen, 2022)

Thus, the data overall is mostly observational and somewhat conflicting, but most studies indicate there is no significant advantage of using reduced-fat vs. whole-fat dairy products, and there does not seem to be a very meaningful impact on overweight and obesity risk if consuming 2-3 servings of dairy daily as recommended in the Dietary Guidelines.

Beverages

Dairy, which includes milk, was discussed above. Drinking sufficient water is helpful as at times increased thirst can manifest with signals of hunger.

Regarding 100% fruit juice, a 2019 review indicated that evidence regarding how to increase fruit & vegetable consumption in children is sparse and that if this is difficult then allowing 100% fruit juice consumption in lieu of actual fruit may be beneficial as many of the healthy nutrients are retained in fruit juice (and some may even be more bioavailable).(Benton, 2019) The authors indicate prior reviews have shown that fruit juice consumption under age 5 is associated with mild weight gain and consumption beyond this age may have no impact on weight gain. These thoughts are echoed in a 2021 review of fruit juice intake.(Ruxton, 2021) If consuming fruit juice it would likely be more beneficial to consume less filtered type (generally more cloudy in appearance).(Vallée Marcotte, 2022) The American Academy of Pediatrics recommends no fruit juice in the first year of life, up to 4 ounces daily when aged 1-3 years, up to 4-6 ounces daily when aged 4-6 years, and up to 1 cup daily thereafter. Of note, one of the detrimental aspects of fruit juice consumption is that many people do not find it very filling; while it may have some health benefits this can still lead to excessive caloric consumption and weight gain when consumed in higher quantities.

As for sugar-sweetened beverages, a 2016 SR/MA evaluating the methodology of 32 studies assessing the relationship between sugar-sweetened beverage consumption and overweight/obesity in children found that the studies with stronger methodology revealed a significantly positive association.(Bucher Della Torre 2016) A 2022 SR/MA similarly found that higher sugar-sweetened beverage consumption associates with a higher BMI, body fat percentage, and waist circumference.(Abbasalizad Farhangi, 2022) while another 2022 SR/MA found decreasing sugar-sweetened beverage intake leads to a relative decrease in BMI.(Nguyen, 2022)

Thus, for weight management and general health the majority of liquid intake should come from water, milk intake as a subset of 2-3 servings of dairy daily is also beneficial, 100% fruit/vegetable juice in moderation when fruits and vegetables are not otherwise consumed may have health benefits (though fruits and vegetables intake is preferable), and other drinks with calories are likely detrimental from a weight management standpoint with no significant health benefits.

Timing of nutrition intake

A 2021 review of the association between later eating times and adiposity in youth included >40 studies and found that(Zou, 2021):

  • The act of eating late at night did not make a significant difference on outcomes.
  • However, consuming greater energy intake late at night was associated with a small increased risk of higher adiposity.
  • In particular, skipping an evening meal for adolescents was associated with increased adiposity, potentially due to an increase in energy intake around bedtime.

Overall, there was very low certainty in the evidence, but this implies it may be beneficial to prioritize intake earlier in the day and avoid eating significant amounts late at night.

Regarding other timing aspects, such as intermittent energy restriction or intermittent fasting, there are some studies including adolescents with obesity that do show health benefits, and in these studies most of the adolescents do enjoy this eating strategy.(Athanasian, 2021) However, these interventions have all been supervised by health professionals, and it is unclear if encouraging youth to engage in these practices in a non-supervised fashion may increase the risk of harmful outcomes in some way.

Tip: As recently reviewed, studies typically show that when youth are in structured environments (ie, in school compared to out of school) they generally engage in healthier behaviors regarding nutrition, sleep, and physical activity, and this may be one reason why children and adolescents tend to gain more weight in the summer.(Zosel, 2022) Finding ways to promote greater lifestyle structure, particularly on non-school days, which can include the timing of food intake with mealtime structure, will possibly assist in achieving healthier lifestyle and weight management goals. This will particularly apply to nutrition; without structure some children will sit around the home and eat all day long if allowed to do so.

Various diets

There are lots of named diets or dieting patterns. In adolescents the Mediterranean diet and vegetarian diets have been associated with lower odds of developing overweight and obesity while ketogenic diets and vegan diets have proven effective to aid weight loss.(Athanasian, 2021) No specific diet should be necessary, though; following generally healthy eating principles with regular exercise will be sufficient to improve health and body composition for the vast majority of people.

Regarding vegetarian and vegan diets, as some families follow these for moral/ethical reasons regardless of weight management considerations, in 2019 advice was published regarding how to plan out vegetarian and to some degree vegan diets (with the VegPlate Junior) in youth populations.(Baroni, 2019) It is important to watch for adequate intake of protein, essential fatty acids, iron, zinc, calcium, vitamin B12, and vitamin D. Importantly, vegetarian and vegan diets do not seem to increase the risk of eating disorders in childhood though individuals with disordered eating may prefer them; this applies to other mental health considerations such as anxiety and depression as well.(Melina, 2016; Sergentanis, 2020; Athanasian, 2021) Most of the studies finding these relationships are cross-sectional; it seems people with these various mental health conditions are drawn towards starting vegetarian or vegan diets rather than developing these conditions as a result of adopting these diets.

Conclusion

In this lesson I have discussed practical advice regarding nutrition for weight management. In summary:

  • Much of the advice in the Nutrition and Weight Management course applies to children, you can review that course for advice on healthy nutrition practices as a whole and then refer back to the above sections for additional modifications for children.
    • One big difference is that while for adults I do recommend tracking calories at least for a brief period of time as either an educational or troubleshooting tool, I generally would advise not doing this with children without first discussing with a healthcare professional. Additionally, I would only advocate tracking calories in children for short periods of time and only after initially utilizing other nutritional and lifestyle strategies to treat obesity.
  • Calorie guidelines are listed above; if progress is not being made then it may be worth tracking food intake for 1-3 days and then determining what is leading someone to consuming an excessive amount of calories. However, keep in mind the calorie guidelines are estimates based on group averages and individuals may need more or less.
  • Consuming meals with protein and fiber will aid satiety and decrease hunger.
  • The amount of carbohydates and fats consumed is not very relevant for weight management as long as sufficient amounts for general health are obtained.
  • Avoiding sugar-sweetened beverages is generally advisable.
  • Prioritizing nutritious options will aid in micronutrient acquisition, particularly if one is decreasing their overall food intake in an attempt to lose weight.
  • Many will find having consistent meal times and avoiding late-night eating to be beneficial.
  • There are no specific sustainable diets that need to be followed when it comes to weight management in children and adolescents; sticking to generally healthy eating principles tailored to one’s own preferences will generally be a perfectly viable strategy.

If this advice does not seem sufficient for a specific child then I recommend discussing with the child’s healthcare provider to determine if more specific dietary strategies or other interventions are warranted.

In the next lesson I will discuss considerations of feeding behaviors, sleep, and exercise in children and adolescents.

Click here to proceed to Lesson 13

References

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