Lifestyle Medicine in Children

A lot of attention and resources are spent on lifestyle medicine (LM) in adults, but its application in children receives significantly less attention. However, children, at increasingly younger ages, are experiencing many of the same lifestyle-related chronic conditions as adults. Due to the fact these at-risk youth are the adults of the future, this presents a unique opportunity for LM. Therefore, we took this occasion to interview Paula Gustafson, MD, MBA, a board-certified pediatrician who practices LM in Shelbyville, Indiana. Here, Dr Gustafson shares why and how LM can be applied to children.

DS: Do lifestyle medicine principles apply to children?

PG: Absolutely! As parents, we all want our children to grow up happy and healthy and be successful in life. Embracing four of the levers of LM (diet, exercise, sleep, and social engagement) from infancy is the first step in developing healthy lifestyle routines. Everyday routines are full of opportunities to establish healthy lifestyles for young children.

Children who adopt healthy lifestyle routines are more effective in making our population healthier and reducing the total cost of health care. Smoking rates in the United States decreased over the past 2 decades in large part because younger generations did not start the smoking habit. We need to adopt a similar pattern with LM and prevent unhealthy habits from starting. Continuing to spend health care dollars on trying to convince adults to adopt a healthy lifestyle is analogous to spending warranty dollars—fixing something that is already broken. There is an opportunity to lower our chronic disease risk by 80% if we start in infancy and raise our children on the principles of LM.

DS: What is unique about children that lifestyle medicine can impact?

PG: The growing and developing child represents an opportunity for LM to have the greatest impact. If we want to optimize long-term health, getting the best “initial design” is fundamental to raising healthy children.

An example of 2 areas that LM can impact that have long-term life and health consequences are brain development and immune system development.

The cultivating and nurturing of the intestinal biome of a newborn is a key factor in the support and development of the immune system.¹ The intestinal biome and its interaction with the metabolism of food is vital to getting all the vitamins, minerals, and micronutrients necessary to support the development of the immune system in growing children.

These nutrients are equally important for brain growth and development. For example, we know iron deficiency anemia in infancy or toddlerhood, whether from poor absorption or lack of dietary intake, results in lower IQs. Childhood zinc deficiency can affect immune system function and development as well as linear growth. Research from the National Scientific Council on the Developing Child confirms early experiences affect the development of brain architecture, which provides the foundation for all future learning, behavior, and health.

DS: Let us discuss the four levers of lifestyle medicine. Starting with diet, how do you encourage a child to follow a healthy lifestyle diet?

PG: Establishing routines and modeling healthy eating are the most important steps in getting children to eat healthy.

Data collected by the American Academy of Pediatrics demonstrate how nearly 1 in 3 children in America is overweight or obese. Many parents are still confused about what children should eat. How much does my child need to eat? Is he/she getting enough calcium? Enough iron? Too much fat? Parents understand their role in providing food for their children, but not necessarily the role in shaping their children’s eating habits.

The bottom line is a child will adopt the eating habits of the parents. If the parents embrace a whole food, plant-based (WFPB) diet, the child will grow to love a WFPB diet. It seems to be a misguided belief that children will eat only child-friendly foods such as chicken nuggets and french fries. If children were raised eating black bean burgers and sweet potatoes, they would enjoy them just as much. Trying to encourage a child to follow a WFPB diet while the parents eat a standard American diet will not work. Children want to emulate their parents. They are their child’s first and most important role models. By creating a positive eating environment and being a good role model, parents can help their children develop healthy eating habits that will have a lasting positive impact on their health.

DS: Are there any dietary concerns for children eating a WFPB diet?

PG: Iron, zinc, and vitamin B₁₂ are the main areas of concern. Because children are increasing their blood volume as they experience linear growth, they need to eat foods that are a good source of iron. Again, preventing iron deficiency anemia is critical for the early years when the brain is rapidly growing. Pediatricians will check a child’s hemoglobin during the infant/toddler years for this very reason. Getting adequate iron is also important for young ladies when they start menstruating due to monthly blood loss. Meanwhile, in our practice, which serves a predominantly rural population, I am starting to see children with inadequate levels of zinc, even those eating the standard American diet. Climate change scientists are predicting more widespread iron and zinc deficiencies in children due to agricultural practices and global warming effects on plant and soil nutrients. If children follow a strict vegetarian or vegan diet, getting adequate vitamin B₁₂ could be an issue. Pediatricians and family physicians need to be mindful of these potential concerns.

DS: How to you make sure children are being given adequate nutrition if they are consuming a WFPB diet?

PG: I recommend parents follow the My Plate program, sponsored by the US Department of Agriculture,² and fill the quadrants with the appropriate food groups. Children have an instinct to eat what their bodies need, but they must be offered proper food choices. My Plate is a valuable instrument for parents in that it reminds them to be sure to present the variety of food groups and let the child do the eating. My Plate is also the dietary program that is taught in schools, so it provides consistency for children as they grow and transition into new life experiences.

I often recommend meeting with a dietician versed in the WFPB diet to help parents identify appropriate foods and serving sizes based on the child’s age. In general, children can eat the same foods as their parents, assuming the foods are not choking hazards. I do not recommend nuts for this reason until they are at an age when they can chew their food. Also, the question of milk is frequently brought up when discussing a WFPB diet. Children can drink soy or almond milk that is fortified with calcium and vitamin D with their meals, but I would recommend only water at all other times. It is important to not let a child develop the habit of wanting a “sweetened” beverage when they are thirsty.

DS: Are there any other dietary practices important for children when considering lifestyle medicine?

PG: Not only is eating a WFPB diet important for childhood health, but equally important is how it is eaten. Children need to establish healthy eating habits by sitting at the table with family for routinely scheduled meals. Having scheduled mealtimes will prevent the “grazing” and “grab and go” patterns inherent in poor dietary patterns. In addition, scheduled mealtimes help develop children’s sense of food security and prevent the tendency to overeat associated with not knowing when the next meal will come.

The family meal is one of the best practiced cornerstones of LM—social engagement. It is one of the best times to nurture the social and emotional development of children through the sharing of daily experiences. Having an established time for the family to come together without the distraction of electronics and to dialogue face-to-face is invaluable for creating tight family bonds and the social connection needed for healthy mental development.

DS: You mentioned social connections being important for children. Can you expand further on this?

PG: We know how important social engagement is to keeping elderly people healthy, but it is critical for early childhood. Infants and toddlers must learn language and emotional regulation. They can only do this through face-to-face interactions with parents, family, and caregivers. Research conducted by the Center for the Developing Child at Harvard confirms healthy brain architecture depends on a sturdy foundation built by appropriate input from a child’s senses and stable, responsive, social relationships with caring adults. If an adult’s responses to a child are unreliable, inappropriate, or simply absent, the developing architecture of the brain may be disrupted, and subsequent physical, mental, and emotional health may be impaired. The persistent absence of what the Center calls “serve and return” interaction acts as a “double whammy” against healthy development: not only does the brain not receive the positive stimulation it needs, but the body’s stress response is activated, flooding the developing brain with potentially harmful stress hormones.

Studies are now emerging that are linking the use of electronic devices to the development of anxiety and depression in teens.³ For example, the Child Mind Institute found that in several recent studies, teenage and young adult users who spend the most time on Instagram, Facebook, and other digital, social media platforms were shown to have a substantially (from 13% to 66%) higher rate of reported depression than those who spent the least time. The American Academy of Pediatrics advises a limit of 2 hours a day of “screen time,” but even this is too much for young children. Emphasizing actual face-to-face social engagement stressed in LM is critical to reversing this ominous, looming epidemic.

DS: Exercise is one of the health “levers” of lifestyle medicine. What role does exercise play in pediatric health?

PG: Exercise is just as important to children’s health as that of adults for the same reasons: developing and maintaining cardiovascular, pulmonary, bone, and muscular health.

Exercise is fundamental in early infancy and child development. Not only does a toddler’s exercise of crawling, walking, and climbing develop their musculoskeletal/nervous system, it is also an integral part of their brain development by allowing self-exploration of their environment. Inhibiting this form of exercise in the early childhood years affects neurodevelopment.

Given that children have an innate desire to move and explore, we need to foster this throughout their childhood. A visit to the playground is more than just fun. It lets kids exercise their bodies, brains, and social skills. It also gives them a chance for unstructured, free play that is important for healthy development.

Organized sports participation for older children and teens is a great way to incorporate exercise in their daily activities.⁴ This form of exercise also ties in social engagement and development of teamwork skills, and further helps maintain mental health.

Parents are the role models for children when it comes to exercise. If parents make physical activity a priority, children will adopt this habit and be more likely to maintain an active lifestyle. I recommend families find an activity that they can enjoy as a family, such as hiking or biking. This way they can be active, socially engaged, and develop strong family bonds. If parents get their children interested in physical activity when they are young, exercise and fitness are more likely to become a habit that lasts for many decades.

DS: We have not discussed sleep. How important is sleep to pediatric health?

PG: Sleep is extremely important to the growing and developing child. The rapid growth of the brain that takes place from birth to 5 years of age needs significant rest time for healthy neuronal development. An infant may sleep up to 18 hours per day and a toddler 12 hours per day. Childhood sleep research has shown that inadequate quantity or quality of sleep can result in poor impulse control and behavior regulation.⁵ Furthermore, school performance, creativity, and social skill development are negatively affected by a sleep-deprived brain.

For a growing child, having an adequate and consistent sleep-wake cycle is vital for establishing an optimum circadian-hormonal release pattern necessary for healthy growth. Developing the habit of a set bedtime and wake time in early childhood will pay dividends in learning during the school age years.

DS: What role can the ACLM play in promoting pediatric lifestyle medicine?

PG: I would recommend the ACLM (American College of Lifestyle Medicine) push to increase the membership numbers of providers who practice pediatric and family medicine. We need to focus our efforts on the young child and their family. It is important that the messenger, the provider, understand and embrace the principles of LM so they can be effective advocates. The ACLM is an incredible learning network whose educational material is applicable to all areas of medicine. Bringing this message to a broader audience at the front lines of medicine, primary care, is necessary so the voice of “health” in health care can be heard and adopted. Now is the opportune time. We are heading into an election year and health care is one of the biggest issues. While we look at reforming the health care payment system, let us truly revolutionize health care and deliver health!