Calories In, Calories Out? — May Not Always Be the Simple Equation to Weight Loss

By Jessica Brown, RD, CSP, CNSC, clinical dietitian at CHOC Children’s

The appreciation for bacteria living in our gut, and how it affects our health, is quickly gaining traction. Studies have shown that the 100 trillion microbes that live in and on the human body, called the microbiome, play an important role in overall health, including diabetes, celiac disease, allergy and autism.

Growing evidence over the past 10 years has even linked the gut microbiome to obesity. A study published in Science, a leading scientific journal, in 2013 contributed to this association. Researchers transplanted germ-free mice with fecal microbiota from obese and lean adult twins. They found that those mice transplanted with the obese gut microbiota had an increase in body mass and fat accumulation compared to those transplanted with lean gut microbes. One of the proposed theories is that obese microbiomes can harvest or release more energy from dietary components, such as non-digestible fiber, which contributes to weight gain. Further, this study showed that a lean gut microbiome can displace an obese one, preventing weight gain, if they consumed a healthy diet.

There are multiple influences to our microbiome at an early age, including what type of birth, (C-section versus natural birth), what type of feeding (formula versus breastmilk), and early exposure to antibiotics. Other influences include our environment and diet.

Eating a high-fiber diet, rich in fruits and vegetables and low in meats, refined carbohydrates, and artificial sweeteners has been shown to increase the beneficial bacteria in our gut.

Prebiotic foods such as asparagus, artichokes, garlic, leeks, onions, oats and lentils have been shown to keep our microbiome healthy. Fermented foods such as sauerkraut, kimchi and kefir are also beneficial.

A recent report published in the Diabetes and Metabolism Journal summarized multiple studies that demonstrate the potential benefits of probiotics – live bacteria and yeasts that are good for your digestive system — on the prevention and treatment of obesity and inflammation. It is important to realize that there are multiple strains of probiotics, and each strain has different effects. The effects of probiotics and obesity deserves further attention before specific recommendations can be made in the health care setting.

With the increasing prevalence in obesity, it is exciting that the manipulation of gut flora may be an integral part of weight loss and disease prevention in the future. So, it may not be just about how many calories you eat and how much you exercise that determines your weight, but what you eat and the health of your gut bacteria.

Learn more about CHOC Children’s Clinical Nutrition and Lactation Services.

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Back to School Nutrition

By Janelle Sanchez, RD, CLEC, clinical dietitian at CHOC Children’s

Nutrition can improve your child’s academic performance, as well as provide the energy needed for an entire school day. Check out these helpful tips in planning for back to school lunches, or any meal!

  • Consider choosing the least busy day of the week to organize your menu for school lunches. This can help with dinner prepping too!
  • Shop together — choose a few healthy options for each food group. This is helpful to get picky eaters to try new foods, and actually eat the meals that you both picked together.
  • Prep ahead and give your child an age-appropriate task, such as washing and cutting up fruits and vegetables. Portion out items into baggies for easy grab and go items. Consider freezing some of the items the night before to act as an ice pack.

Here are some good examples of foods from each food group:


Turkey roll ups, chicken, eggs (try hard boiled), tuna salad, peanut or nut butters, beans, lentils, hummus, tofu and string cheese.

Protein is important for growing children as it is a building block for bones, muscle, cartilage, skin and blood.


100 percent whole grain bread/bagel/bun, tortilla, English muffin, rice, pasta, crackers, cereal, granola bars, rice cakes, pretzels and pita.

Compare food labels — Choose whole grains, items higher in fiber and lower in sugar for better nutrition and to keep your kids fuller longer, to prevent over eating.


Fresh fruit (strawberries, watermelon, apple slices, orange wedges, peaches, grapes, pineapple squares, and kiwi), fruit leathers, packaged fruits in 100 percent juice, and 100 percent fruit juice boxes.

Fruit are important sources of many nutrients, including potassium, fiber, vitamin C, folate (folic acid) and phytochemicals. Choose whole fruits more often, and juice occasionally.

A good rule of thumb: Follow the MyPlate recommendations, selecting from all the food groups. Mix it up from day to day so lunch, or any meal, doesn’t get boring.
A good rule of thumb: Follow the MyPlate recommendations, selecting from all the food groups. Mix it up from day to day so lunch doesn’t get boring.


Carrot sticks, broccoli, sweet potato slices, beets, spinach, peas, bell peppers, cucumber, tomato and celery.

Choose red/orange vegetables containing Vitamin C. Green vegetables will boost your Fe intake. Blue/purple vegetables provide antioxidants that may protect against cancer and heart disease. Try adding a lower calorie dip (using yogurt, hummus, etc.) to pair with the veggies.

Dairy/dairy alternatives

Milk, soy milk, almond milk, cheese, yogurt, drinkable yogurt.

These are excellent sources of calcium and Vitamin D, important for building and maintaining healthy bones. Choose low fat or non-fat sources.


Avocado, olives, nuts, oils (olive oil, canola, vegetable, peanut), butter, margarine, mayonnaise, sour cream and salad dressing.

Be mindful on the portions of fat in the meals, as they are high in calories compared to protein and carbohydrates. Choose healthy fats (unsaturated fat- plant sources) instead of unhealthy fats (saturated- animal sources).

Extras/condiments: Help children learn to season foods without adding salt. Instead, try adding fresh garlic, or garlic powder, onion, cinnamon, basil, nutmeg, parsley, etc. Choose light mayo instead of regular.

Treats: Occasionally a cookie or brownie can fit in as well.

Lastly, although school nutrition programs are evolving, there is still some room for improvement. There can be a place for school meals however. Consider reviewing the meal options for the week with your children and pick the best options together.

We know that eating patterns and preferences can be influenced early in life and extend into adulthood. Let’s teach our kids what healthy meals look like to set them up for success. Visit to learn more.

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Quick Tips to Help Children Maintain a Healthy Weight

In a recent report, the American Academy of Pediatrics (AAP) updated recommendations on childhood obesity prevention. Along with diet modifications and reducing screen time, the AAP encourages pediatricians to work with families to identify opportunities for physical activity. Parents are also encouraged to model healthy behaviors for their children.

More importantly, healthy eating and physical activity should be tailored to the child’s developmental stage and family characteristics.

Here are a few reminders to help your family maintain a healthy weight:

  • Buy fewer sugar-sweetened beverages, high-calorie snacks and sweets. If you want to have these foods for a special celebration, buy them shortly before the event and remove them immediately afterward.
  • Healthy foods and beverages (water, fruits, vegetables and other low-calorie snacks) should be readily available and in plain sight on the kitchen table, counter or in the front of a shelf.
  • High-calorie foods should be less visible – wrapped in foil rather than clear wrap, and placed in the back of the fridge or pantry.
  • Encourage children to eat five or more servings of fruits and vegetables each day.
  • Increase physical activities together to meet the recommended 60 minutes of activity a day. Examples of activities, include: team sports, dog walking, bowling, using the stairs, going to a park, playground, or walking/bicycle trail.
  • Reduce sedentary behaviors. One way to achieve this is to remove the TV and other media from the bedroom and the kitchen.
  • Children who sleep less than 9 hours a night are more likely to be overweight or obese; focusing on bedtime and understanding how much sleep children need at various ages can help improve a child’s overall health and well-being.

For more health and nutrition tips, visit

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July is National Ice Cream Month

Summer is the peak season for ice cream consumption. In 1984, July was declared national ice cream month. Historically, ice cream as we know it first emerged in the 17th century in France. In the 13th century, Marco Polo brought back from China descriptions of a sherbet-like desert. Today, we have so many flavors and types to choose from!

CHOC Children's Clinical Nutrition and Lactation Services

Here are a few more fun facts about this refreshing treat:

– Next to cookies, ice cream stands as the best-selling treat in America!

– The top five ice cream consuming countries in the world are: New Zealand, United States, Australia, Finland and Sweden

– It takes about 50 licks to finish a single ice cream cone.

– It takes 3 gallons of milk to make 1 gallon of ice cream.

So what about the sugar content and the overall calories in each ice cream serving? Always read the product label to get the cold truth.

According to the U.S. Food and Drug Administration (FDA) standards for fat content for ice cream include:
•”ice cream” contains at least 10 percent milkfat
•”Low-fat” ice cream contains a maximum of 3 grams of total fat per ½ cup serving.
•”Non-fat” ice cream contains less than 0.5 grams of total fat per ½ cup serving.

When it comes to ice cream toppings, choose wisely. Instead of whipped cream, hot fudge or chocolate sauce, try cut up fresh fruits, such as blueberries, which are in season, or a small sprinkle of chopped nuts. To go leaner, skip the ice cream cone and eat your scoop in a cup.

So this summer, enjoy your ice cream in moderation and be sure to top it with a fresh berry!

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Bite Into a Healthy Slice of Watermelon

CHOC Clinical Nutrition and Lactation ServicesBy Leah Blalock MS, RD, CSP, CDE, clinical dietitian at CHOC Children’s

Nothing says summer like a thick slice of watermelon, complete with juice running down your arms and dripping off your elbows. Not only is it fun to eat, it’s packed with health benefits.

Watermelon is a vine-like flowering plant thought to originate in Kalahari Desert in southern Africa. Today, Georgia, Florida, Texas, California and Arizona are the United States largest watermelon producers. According to Guinness World Records, the heaviest watermelon was grown in Arkansas in 2005, and weighed 268.8 pounds.

This sweet refreshing fruit, made up of mostly water, is packed with nutrients. Each juicy bite has significant levels of vitamins A, B6 and C, lots of lycopene, antioxidants and amino acids. Lycopene has been linked with heart health, bone health, and prostate cancer prevention. To maximize your lycopene intake, let your watermelon fully ripen. The redder your watermelon gets, the higher concentration of lycopene.

Another phytonutrient found in watermelon is the amino acid citrulline, which converts to the amino acid arginine. These amino acids improve blood flow, leading to cardiovascular health and improved circulation.  Cucurbitacin E is another unique anti-inflammatory phytonutrient found in this popular summer fruit.

Waist line watchers also benefit from watermelon. It is considered a good source of fluid and fiber which slow digestion and promote satiety.

There are many great ways your family can enjoy watermelon.

  • Try combining diced watermelon with fresh mint, feta cheese and fresh arugula for a savory salad.
  • Make a summery gazpacho by pureeing watermelon with fresh tomatoes and cucumber.
  • Watermelon popsicles are also a refreshing treat –puree watermelon until it’s smooth. Pour the puree into frozen popsicle molds and freeze until firm.
  • Or, try this yummy recipe:

Watermelon Salsa Recipe


1 1/2 teaspoons lime zest (from about 1 lime)

1/4 cup fresh lime juice (from about 3 limes)

1 tablespoon sugar

Freshly ground pepper

3 cups seeded and finely chopped watermelon

1 cucumber, peeled, seeded and diced

1 mango, peeled and diced

1 jalapeño pepper, seeded and minced

1 small red onion, finely chopped

8 fresh basil leaves, finely chopped

1/2 teaspoon garlic salt

Tortilla or pita chips, for serving


Stir together the lime zest, lime juice, sugar and 3/4 teaspoon pepper in a bowl. Add the watermelon, cucumber, mango, jalapeño, onion and basil and toss gently. Chill the salsa until ready to serve. Add the garlic salt just before serving. Serve with chips.

Source: Food Network Magazine

Learn more about clinical nutrition and lactation services at CHOC.

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Food Safety Practices and Tips for Your Summer Outings

By Jan Skaar, RD, CSP, CNSC, CLE, clinical dietitian at CHOC Children’s CHOC Clinical Nutrition and Lactation Services

Are you planning your next weekend getaway or summer vacation and thinking about enjoying the outdoors? Food always tastes better outside, especially after a fun activity! With a little extra effort, you can make safe and mouth-watering meals that will add to the memories you make with your friends and families.

  1. Make a plan. Depending on the activity, determine how many meals and how much drinking water will be needed. Food and water needs will be higher in warmer weather and with increased activity. If you will not have access to running water, make sure you include water needs for cooking in addition to drinking. If hiking is on your agenda, make sure you plan for 2 cups of water or sports drink per person per hour. Use disposable wipes or towelettes for personal hygiene and hand washing. If you are preparing meals for camping, make a list of all the ingredients and tools needed. Decide what you will pack ahead of time and what you will buy fresh near your campsite. Don’t forget to include pre-measured packets of seasonings and spices for your recipes. Cooking outside does not mean you have to skimp on flavor!
  2. Pack ready to eat or non-perishable foods. There are plenty of healthy foods for meals and snacking that do not require refrigeration. Leave the chips and soda at home. Dried fruits, dried or freeze-dried vegetables or veggie chips are great meal additions and snacks for trekking. Trail mix, granola or energy bars work great for throwing in your day pack. Individual kits of tuna or chicken salad can be mixed up easily and eaten with whole wheat crackers or tortillas. Whole grain pasta, rice mix, pancake mix and oatmeal are quick options that only require water for mixing or cooking. Don’t forget your favorite tea, coffee or cocoa for sipping around the campfire!
  3. Bring appropriate food servings, storage and disposal items. Whether you decide to “go green” or use disposable plates and serving ware, decide which will work best for your trip. If you will have access to running water, reusable dishes and cooking equipment can be washed with biodegradable soap. You may want to consider disposable items if access to water is limited. Bring plenty of large zip lock bags and compostable trash bags. Remember, when you and your family are enjoying the natural environment, “pack it in and pack it out” to leave no trace.
  4. Make sure to follow food safety practices. Plan appropriately for food safety depending on the weather, environment and the length of time you stay. Non-perishables cannot be kept out in hot weather (over 90F) for more than one hour, no more than two hours in cooler temperatures. Food temperature danger zones are between 40 and 140F. Cold foods that need refrigeration should be transported and kept in a well-insulated cooler with plenty of ice. An ice block combined with bagged ice will be longer lasting. Keep the cooler in a shaded location. Cook and grill meats to proper internal temperatures; be safe and use a thermometer. Wash hands or use moist towelettes frequently before and after eating or preparing foods. Keep raw meats and ready to eat foods separate.

Now that you’re dreaming about your next picnic or campsite in the mountains, make your own plans for an outdoor adventure! Healthy, safe and delicious foods will add to your enjoyment.

For more health and safety tips for your family, please visit

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Carbohydrate: Premium Fuel for Sports Performance

By Shonda Brown, RD, CNSC, clinical dietitian at CHOC Children’s

Carbohydrates have received a bad rap as low carb diets gained in popularity and other fad diets advertized messages of “good” and “bad” carbs. However, carbohydrate is the preferred fuel source for exercising muscles and provides two thirds or more of the energy source during intense exercise.

CHOC Clinical Nutrition and Lactation Services

Carbohydrate rich foods include: breads, cereals, pasta, potatoes, fruit, and dairy as well as honey, jam and sweets. An athlete needs carbohydrate to store energy in preparation for exercise, to provide an exogenous fuel source during exercise and to maximize recovery after exercise. The source of carbohydrate is not as important as the amount and the time which ingestion occurs. Check out the following guidelines:


Athletes should consume 200-300 grams of carbohydrate 3-4 hours prior to exercise or competition. An example would be four pieces of French toast with berries and syrup, and 12 ounces orange juice or 1 ½ cups pasta with meat sauce, 1-2 breadsticks, 1 cup fruit salad drizzled with honey, and 16 ounces low-fat milk.


During intense exercise or activity lasting longer than 60 minutes, a sports beverage containing approximately 15 grams of carbohydrate per 8 ounces should be consumed at regular intervals. This keeps blood glucose (sugar) available for the working muscles and can delay fatigue, allowing an athlete to exercise longer and harder.


After exercise, it is important to refuel with carbohydrate within the first 30 minutes to maximize carbohydrate storage in the muscles. It can also help decrease muscle protein breakdown. Anything portable and easy will do. Some examples include chocolate milk, granola bar and fig bars.

It can be a challenge for an athlete to consume the amount of carbohydrate needed for optimum performance. Some tips to increase carbohydrate intake are drizzling honey over cereal, fruit or yogurt; spreading jam on toast or crackers; adding fruit to cereal, yogurt or pancakes; and packing dried fruit, trail mix, or pretzels as a quick snack.

For additional information on eating for performance or for an individualized meal plan, contact a CHOC Pediatric Sports Dietitian at 714-509-4572.

Learn more about CHOC Children’s Clinical Nutrition and Lactation Services.

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CHOC Patient is Succesfully Treated for Feeding Problem

CHOC Children's Multidisciplinary Feeding ProgramBefore coming to CHOC Children’s, Pacer Lybbert had never eaten a Cheerio, a piece of toast or even spoonful of yogurt. He was almost 4 and had never enjoyed birthday cake, Halloween candy or a Thanksgiving dinner with his family. Since birth, Pacer had received almost all of his nutrition through a feeding tube.

Quinn and Mekell Lybbert may never know why their son, now 7, was born unable to swallow. Everything was fine at first, but within a couple of weeks it was clear their baby was struggling to eat. Finally, there was no choice but to put a feeding tube through their infant’s nose. It was supposed to be a short-term fix, but as Pacer grew older, and efforts to help him failed, he had to have a gastric tube inserted directly into his stomach.

Quinn and Mekell had resigned themselves to the possibility that Pacer would need a feeding tube for life. Then, they met a little boy near their new home in Montana who had been successfully treated for a similar problem at the CHOC Children’s Multidisciplinary Feeding Program. Mekell immediately called CHOC.

Five weeks after coming to CHOC, Pacer’s feeding tube was removed. He left for home eating equal parts solid food and a liquid nutritional supplement. Six months later, Pacer was eating regular food with his family — and asking for seconds.

“The interdisciplinary approach is what made this program so different and why it was so successful,” Mekell said. “We had so many people working together as a team trying to figure this out. Had we not gone to CHOC, Pacer would still have a feeding tube.”

See Pacer’s brave journey in this video.

Learn more about CHOC Children’s Multidisciplimary Feeding Program.


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New Nutrition Labels Coming to a Supermarket Near You

By Mary Sowa, MS, RD and Emily Barr, MS, RD, clinical dietitians at CHOC Children’s

If you are like many consumers, the Nutrition Facts label found on most food packages can sometimes be confusing.  There are now changes being proposed by the U.S. Food and Drug Administration (FDA), aimed at making it easier for consumers to understand these labels and help them make healthier food choices. The Nutrition Labeling and Education Act (NLEA) mandated that food packages come with a Nutrition Facts label starting in 1994. There has only been one change made in the last 20 years, which was the addition of trans fat to the label.

In light of National Nutrition Month, read below for the proposed label changes. If adopted, they may just affect the way you shop for food moving forward!


Proposed Changes Rationale
Food labels will have a new design The goal is to emphasize the serving sizes and calorie content.
“Added sugars” This label will appear to alert the consumer when sugar has been added to the product.
Adding potassium and vitamin D to label The nutrition facts will include both the content in mg or mcg and the % daily value. Calcium and iron content will continue as part of the label. Vitamin A and C are being removed.
Removal of calories from fat Total fat, saturated fat and trans fat will continue on the label.
Change in serving sizes By law this information is supposed to represent what Americans are “typically eating,” not necessarily what is an appropriate (healthy) serving size.
If the product has multiple servings, two labels will be required One label with include the nutrition information for the “amount per serving size” and a second label the “amount per container.”


A side-by-side comparison:

Current                                    Proposed








Once the changes have been approved, manufacturers will have two years to comply.

Other labeling news:

As part of the 2010 Patient Protection and Affordable Care Act, there will be a national requirement for restaurants (with 20 or more locations) to list the calorie information for items on their menus. This not only covers restaurants, but also includes prepared foods sold at movie theaters, grocery stores and convenience stores.

The goal for these changes is to help Americans make more informed and healthier choices, which will hopefully lead to reduced rates of obesity, diabetes and heart disease.

For more information, visit the FDA website.

For more nutrition tips, visit


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Bite Into a Healthy Lifestyle! March is National Nutrition Month

CHOC Children's Clinical Nutrition and Lactation ServicesBy Caroline Steele, MS, RD, CSP, IBCLC, director clinical nutrition and lactation services at CHOC Children’s

In honor of National Nutrition Month, join CHOC Children’s in encouraging everyone to adopt eating habits focusing on reducing excess calories from fat and sugar, reducing intake of processed foods, and making information food choices to help fight disease and promote good health.

With so much nutrition information available and so many food choices, deciding what to put on your dinner plate can feel daunting and time consuming. The United States Department of Agriculture’s MyPlate makes it easy. No matter how busy you are, one quick glance at your plate can show you if you are getting the variety you need to stay healthy.

Compare the foods on your plate with the MyPlate icon below. How does it compare? Are there food groups that you should be eating more of? Less of? All foods fit into a healthy diet — it’s just a matter of balance.

Some hints for a healthier table:

Balance Calories

  • Enjoy your food, but eat less.
  • Avoid oversized portions.

Foods to Increase

  • Make half your plate fruits and vegetables.
  • Choose whole grains whenever possible.
  • Switch to fat-free or low fat (1%) milk.
  • Choose lean sources of protein such as lean meats, chicken, fish and beans.

Foods to Reduce

  • Reduce your intake of processed foods. When choosing canned or frozen foods, choose those with lower amounts of sodium.
  • Reduce or eliminate sugary drinks—drink water instead!

Make it fun and use MyPlate as a family! Have kids draw the MyPlate icon then compare it to their own plates. Getting children involved in mealtimes and food choices can help them be healthier and make better nutrition decisions as they get older.

So, dig in! Good nutrition and healthy eating are as close as your plate.

For more information, go to for interactive tools and sample meals.

Or, go to, the website of the Academy of Nutrition & Dietetics, for a variety of topics including nutrition for life and food safety.

Learn more about CHOC Children’s Clinical Nutrition and Lactation Services.

Is there a nutrition topic you would like to know more about? Let us know in the comments section below and we may cover it in a future article.

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