CB Ebbeling, DS Ludwig. J Pediatr 2023; 255: 22-29. Open Access! Treatment for Childhood Obesity: Using a Biological Model to Inform Dietary Targets

This article describes the role of glycemic index and a carbohydrate-insulin model (CIM) in promoting obesity rather than the more conventional view of energy dense foods causing obesity.

• In the CIM, “dysregulation of hormonal control over fuel partitioning in response to a high-glycemic load diet leads to excess fat deposition, as an antecedent to positive energy balance…. Consuming a high-glycemic index food causes a sharp increase in blood glucose followed by a rapid decline, whereas consuming a low-glycemic index food causes a more gradual increase and decrease with a lower peak. Decreasing dietary glycemic load involves lowering carbohydrate amount and selecting sources of carbohydrate with a low glycemic index. In general, low-glycemic load foods include nonstarchy vegetables, most temperate (vs tropical) whole fruits, and legumes; and high-glycemic load foods include potato products, processed grains, sweets, fruit juices, and sugary beverages.²¹“
• “Fructose also increases fat deposition by upregulating enzymes of de novo lipogenesis via mechanisms independent of energy intake.^22,23 Thus, the conventional understanding of obesity pathogenesis (overeating causes increasing adiposity) is opposed in the CIM (increasing adiposity causes overeating).”

“Dietary targets for which there is general consensus are:

• Ample nonstarchy vegetables (eg, broccoli, lettuce), whole temperate fruits (eg, apple, orange, pear), and legumes
• No sugar-sweetened beverages
• Limited refined grains
• Adequate protein

Additional dietary targets of particular relevance to the CIM which differ to some extent from conventional recommendations include:

• Reduced amounts of starchy vegetables and total grains
• Increased healthful fats (eg, nuts, seeds, avocado, olive oil)”

” When counseling, we recommend home-prepared protein (eg, poultry, fish) over preprepared items with breading (eg, chicken nuggets, fish sticks). We do not specifically recommend reduced-fat (1% or nonfat) dairy. Emerging observational data indicate that consuming whole vs reduced-fat milk is associated with lower adiposity in children,⁶⁶…Regarding milk with added sugar and flavoring (eg, chocolate milk), prospective data indicate a direct association between consumption and adverse changes in body composition”

Three main goals with this diet approach:

1. Eat balanced meals  – Follow a Plate Model
2. Eat Paired Snacks When Hungry Between Meals
3. Stop and Think Before You Drink Sugary Beverages – Drink Water Instead

My take: I have favored the Mediterranean diet as a general goal for patients concerned with healthy eating. This article challenges the conventional approach of targeting energy dense foods in favor of avoiding high glycemic carbohydrates.

This article is a good resource–more information available at these links:

• Boston’s New Balance Foundation Obesity Prevention Center
• Boston Children’s Fit Kit Food Guide
• Paired Snacks