Diet and Nutrition

Diet and Nutrition

Healthy body. Healthy Bones

Nutrition is important to the growth and success of all children. There are certain nutritional guidelines that can be helpful during the course of Perthes disease. A balanced diet is essential for bone health, additionally there are specific supplements recommended for bone health and development. A cornerstone of Perthes treatment is weight bearing restriction which changes the activity level for many children, causing weight gain. There are proven strategies to over come this and they’re easy! We’ll address these common concerns

  • Bone health
  • Obesity in Perthes
  • Strategies for healthy eating
  • Ellyn Satter’s “Division of Responsibility”
  • Diet and ADHD

Peak Bone Mass is defined as the amount of bony tissue present at the end of the skeletal maturation and it can be an important predictor of osteoporosis and fracture risk in adulthood. During childhood bone is deposited at a more rapid rate than it is resorbed causing the bone to grow in both size and density until skeletal maturity. Bone mass is determined genetics, hormones, and extrinsic factors such as diet, weight, lifestyle, and medications. What a child does to promote healthy bones during childhood can impact adult bones! We can’t change our genes, so let’s focus on extrinsic factors. And we’ll start with Vitamins and Minerals.

Vitamins and Minerals

Vitamin D is a powerhouse for your bones. Sufficient vitamin D intake enhances Calcium absorption by 30-40%, Phosphorus absorption by 70-80%, and improves musculoskeletal function. Vitamin D combats soft, thin, brittle bones. You can find vitamin D in foods such as liver, eggs, butter, margarine, fatty fish, and vitamin D fortified milk or other fortified products. However we only get about 10% of the vitamin D needed from food. Your body produces vitamin D when it’s exposed to the UVB rays of sunlight! There are also supplements such as D2-Ergocalciferol and D3-Cholecalciferol. D3 is the most effective. According to the National Institutes of Health, 600 IU/day is the recommended intake of vitamin D.

Calcium is important during growth phase. Calcium and Phosphorus comprise 80% of the mineral content of bone. During periods of calcium supplementation, bone mineral density in cortical bone increases, but stops when supplementation ends. We know that calcium supplementation supports whole body bone mineral density and increased calcium intake reduces bone turnover. However extra calcium will not improve bone mass. The recommended daily dose of calcium for a child 1-3 years of age is 700 mg/day; 4-8 years of age 1000 mg/day; 9-18 years of age 1300 mg/day.

Phosphorus is integral to bone development. 85% of the body’s phosphorus is bound to the skeleton. However, excess phosphorus can increase bone resorption. Phosphorus can be found in fish, meat, poultry, eggs, dairy, legumes, nuts, grains, cereal, and even soda. But before you add soda to your child’s “healthy diet” it’s important to note that in addition to the added calories and sugar, soda (diet or regular) has been linked to an increased risk of hip fractures in adults!

Vitamin K is involved in bone formation and reduces urinary calcium excretion. Vitamin K is synthesized by intestinal bacteria and found in food sources such as dark leafy vegetables and fermented dairy/soy products, fish, meat, liver, and eggs. Many other vitamins and minerals aid in bone formation too: Magnesium, Fluoride, Zinc, Iron, Copper, Manganese, Silicon, Boron, Vitamin D, Vitamin B12.

A common concern when dealing with Perthes is obesity. Often treatment for Perthes disease alters a child’s activity level, creating a more sedentary lifestyle. When activity is modified, dietary habits should also be modified.

Obesity in Perthes

In a 2016 study, Neal et al. report of 148 Perthes patients 16% were categorized as overweight, 32% were obese, statistically presented in a later stage of disease process. These patients were also found less likely to receive surgical intervention and noted to have a lower household income and an increased use of government-funded health insurance.   What’s more striking is increased weight correlates with an increased of higher preoperative morbidity and complications, poor wound healing, higher risk of infection, and delayed bone healing among other medical complications. Obesity is also linked to higher incidence of bilateral Perthes disease. The solution is to look at food choices in a healthier way by employing Satter’s Division of Responsibility. This model is a balance of caregiver decisions and child decisions and encourages a dialogue about nutrition rather than an approach of consequences and rewards (clean your plate or no dessert).  To simplify Satter’s model, a caregiver may choose what, when, and where a child eats, leaving the child to decide whether he or she eats and how much. Weight itself should not be stipulated, instead it should be approached as a process of learning “eating competence.” It is a process-it takes awhile to initiate structure and let go of control, as well for children to show eating capability and become relaxed and comfortable around eating. Some tips include

  • Have structured, sit down meals
  • Have sit-down snacks at specific times between meals
  • Let the child eat what and how much they want from what the parents make available
  • Don’t let the child have food or drink (except water) between meal/snack times
  • Portion sizes; limits on food
  • Limiting amounts and types of food, increasing fruit, vegetables, and fiber

Things to avoid include fast food, rigidly controlling foods, second guessing “are you sure you want that?” and using food as a consequence-reward mechanism. Some ways to combat that instead are discussions with your child to educate him or her on nutrition thus offering guidance rather than restrictions. Help your child learn to recognize what his or her body really needs. If the message or tactic encourages you to eat less, to avoid foods you like, or to lose weight, it is controlling and therefore negative. Consider normal growth, normal calorie variation-consistent growth is only reliable sign that child eats the right amount, evaluate structure

Children who get the message that they are too fat feel flawed in every way, not smart, not physically capable, not worthy.  They tend to diet, gain weight, and weigh more than they would otherwise. – Ellyn Satter

  • Provide structure to family life
  • Eat meals together as a family
  • Be active 30-60 minutes every day
  • Set limits on screen time
  • Encourage and model healthy choices
  • Division of Responsibility

Many questions arise regarding nutrition and ADHD. Studies offer conflicting information regarding the restriction of sugar, additives, salicylates, and other dietary components. This may be in part due to compliance with the diet, differing parental reports, and confounding variables such as impulsiveness and emotional distress potentially leading to self medicating with food.

Nutrition in ADHD

Despite conflicting reports regarding sugar and other additives, experts do not recommend giving caffeine to children, especially if they are taking prescription medication for ADHD. One area of study showing promising results is regarding Omega-3 and Omega-6 fatty acid, zinc, and iron supplementation. There has been a small, but beneficial link in one study. Moving from a “Western Diet” high in saturated fat and refined sugar, toward a “Mediterranean Diet rich in fruits, vegetables, fish, and whole grains is also a healthy choice that may provide added benefits.

  • “Western Diet”
  • High in saturated fat, refined sugar, processed food, caffeine
  • Low in protein, fruits/vegetables, fatty fish
  • Skip meals, eat fast foods
  • Mediterranean diet
  • rich in fish, vegetables, fruit, legumes, whole grains

Content adapted from: Perthes Parent Conference, Texas Scottish Rite Hospital for Children, 2017.

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