Management of Childhood Obesity – a dietitian’s perspective.

Obesity in children is a global epidemic, and the situation locally is particularly grave. In the most recent ‘Health Behaviour in School-aged Children’ study by the World Health Organisation (2020), it was reported that Maltese children aged 11, 13 and 15 had the highest rates of obesity among all the countries surveyed (45 in total). Lifestyle was an obvious culprit and in fact Maltese children were found to have low consumption of vegetables, high consumption of sweets, and high rates of problematic social media use. The approach taken to tackle obesity in a child will vary according to age group.

Infants and Preschool Children

While it is difficult to overfeed a breastfed infant, a bottle-fed infant can indeed be persuaded to drink greater volumes than they require. It is therefore important for the parent of a bottle-fed infant to not always assume that crying signals hunger. The infant can simply be bored, tired, or uncomfortable. It is also essential that formula is made up exactly as per manufacturer’s directions, and that volumes provided are appropriate for age. Infants should be introduced to a cup from about 7 to 8 months of age and bottles should omitted completely by 1 year of age as there is a tendency to consume larger quantities of milk when feeding from a bottle.

Children under 5 who can walk on their own should partake in at least 3 hours of physical activity per day. This includes both light activity such as moving around and playing, and more energetic activity such as running and jumping.

Primary School Children

For primary school children, ownership of the issue needs to be taken by the parents/carers. The parents are the gatekeepers of the child’s food and it is up to them to ensure that the appropriate quality and quantity is being provided. The intervention will have the highest odds of success if the whole family adopts healthy eating patterns, and parents should strive to be role models for the child. The main changes recommend are for the family to reduce the intake of foods high in fat and sugar, replacing them with healthier options such as fruits and vegetables, and ensuring that age-appropriate portions are being consumed.

Goals should be set with the child and rewards for achieving these goals can be motivating. Rewards should be inexpensive non-food items such as a book or a family excursion.

It is also helpful to remove temptations that encourage unhealthy behaviours and provide more opportunities for the child to engage in the desired behaviour. Examples would include not having sugary drinks around the house, going for family walks on the weekends, and always having fruit available as a quick snack.

It is important however to avoid extreme dietary restriction or unbalanced diets, since this could impair the child’s growth and development. It should go without saying that weight-loss supplements are not appropriate in children.


Adolescents are a challenging group and the intervention will only be successful if the teenager himself/herself acknowledges the need for change and is ready to commit to it. Parents should ‘only’ play a supporting role. The main issue at this age is peer pressure for the consumption of fast foods and high calorie snack foods. Strategies used in this age group will involve negotiating acceptable food swaps, portion control, and an increase in physical activity.

Children and young people aged 5 to 18 years should aim for at least 1 hour of moderate-intensity physical activity each day, such as fast walking, playground activities, cycling, and organised sports.

Screen Time

Screen time (watching television, using computers or mobile phones) has become an increasingly insidious problem, and for a lot of children (and their parents) reducing screen time can be the most challenging change to make. According to WHO recommendations (2019), screen time should be avoided in children under 1, while children between 2 to 4 years should be allowed not more than 1 hour of screen time per day. It is recommended that parents designate media-free times for all the family (e.g. meal times) as well as media-free locations at home, such as bedrooms.

Authored by Manuel Attard, M.Sc RD – registered dietitian and nutritionist. This article was first published in the Times of Malta Child Magazine on November 20th, 2021.

7 Tips to Deal with Snacking

When it comes to snacking, we all have our little habits. Some have a sweet tooth, others prefer salty snacks. Some bring snacks to bed, others like to snack while driving. These habits are often ingrained into our routines.  Yet, we can outsmart them. Follow some of the following suggestions:

  1. If you’ve just eaten your meal and still feel peckish, distract yourself for 15 to 20 minutes. It takes some time for the brain to receive the signal that we are full. Hence, if you ate too fast, not enough time has passed for the signal to arrive yet. If you give it some time, the urge to snack might pass.
  2. Chew a gum instead of reaching for a snack.
  3. Put snacks in a walkable distance. Don’t have them handy. If you can’t see your snacks, you are less likely to habitually reach for them.
  4. Make snacks look less attractive. For example, if you have some leftovers from a birthday party, wrap the cake in an aluminium foil so you can’t see it. In contrast, your healthy snacks, such as slices of fresh fruits, should be wrapped in a clear foil so you can easily see them.
  5. If you buy things in bulk and come home with super-size packages, re-pack them. If we are given a bigger pack, we are going to eat it. However, if we are given a smaller package, we are going to eat that too, but, it will be half the calories. It’s as simple as that. And, we will still be happy.
  6. Don’t eat out of the package. Bringing a whole tub of Ben & Jerry’s in front of the TV is a bad idea. Serve yourself a portion and eat only your ration.
  7. Make sure you get enough sleep. We can often feel peckish when we are tired. Lack of sleep and stress have been linked to hormonal imbalances that can influence weight gain. Sleep deprivation has also been linked to obesity. So, get your dose of deep sleep and ensure the bedroom is an environment that facilitates good sleep (think temperature, light, noise). Also, try to go to bed at roughly the same time and build a good sleeping routine. This will help you balance out your hormones.

A little note Don’t deprive yourself of comfort foods entirely. Keep them, but just eat them in smaller amounts.

Hydration & Athletic Performance

During exercise, our bodies sweat to keep the temperature from rising too much. As a result, we lose water through our skin and unless this is replenished, dehydration can arise.

Dehydration is defined as a body fluid deficit of more than 2 % of bodyweight (e.g. a 2 kg loss in a person weighing 100kg, or a 1 kg loss in a person weighing 50kg). When this happens, blood volume decreases leading to a drop in blood pressure and blood flow, making exercise much harder. Performance (both physical and mental) is impacted, and fatigue will set in faster. It is therefore essential that athletes strive to avoid a loss of body fluid of more than 2%.

Signs and symptoms of dehydration in athletes include:
  • Thirst
  • Dark-coloured urine and lower urine output
  • Headache
  • Poor mental focus
  • Lethargy
  • Confusion and unconsciousness in severe dehydration
Conditions/events that increase the risk of dehydration include:
  • Warm weather and/or high humidity
  • Exercising at higher altitudes
  • Training at high intensities
  • Concomitant diarrhoea and/or gastroenteritis
Electrolyte Supplements

Electrolyte supplements or sports drinks can be used during training or competitions of long duration to help prevent dehydration and electrolyte imbalances. These contain glucose and salt that facilitate rehydration and replenish salts lost through sweat. If such drinks or supplements are not available, salty carbohydrate foods such as cereal or salted crackers can be consumed alongside water.

How much should you drink after training?

To fully rehydrate after training, you need to drink about 125 to 150mL for every 100g of body weight lost. This is because the body will keep losing fluids (sweat) even after exercise has stopped. Therefore, if you weigh yourself before and after exercise, and you find that you have lost 1kg, you should aim to drink between 1.25 to 1.5L of fluid to fully rehydrate.

How to Prevent Kidney Stone Recurrence

More than 1 in 10 people will experience kidney stones in their lifetimes, most commonly between the ages of 30 and 60. The most common type (and the focus of this article) are calcium oxalate stones, which account for about 80% of cases. Kidney stones have a high rate of recurrence, with about half of those who experience kidney stones having another attack within 5 years. Fortunately, lifestyle changes can be very effective at reducing risk of stone formation.

  • Drink more water. If you are dehydrated, there is a much higher risk of crystals forming in your urine, eventually becoming stones. It is generally recommended that persons susceptible to kidney stones aim for 3 litres of fluid daily.

  • Consume more calcium. Since they are called “calcium oxalate” stones, many people restrict calcium intake for fear of increasing the risk. In reality, the opposite is true. The problem with calcium is when there are high levels in the urine, and this is not caused by ingested dietary calcium. In fact, calcium from food binds oxalates in the intestines, and the two are then eliminated with the stools. This way, oxalates are prevented from reaching the blood and eventually urine. It is particularly important to consume calcium with oxalate-containing foods (more on this later). On the other hand, calcium supplements are generally advised against, as these may increase urine calcium levels.

  • Reduce salt intake. In order for the kidneys to remove salt from the blood (through the urine), they must also excrete calcium in the urine. And as mentioned previously, high levels of calcium in the urine is something we should avoid.

  • Limit non-dairy animal protein. Diary should be included for reasons stated previously, however, other animal proteins (meat, fish, poultry) should be limited. This is due to the fact that when the body is digesting and metabolising these proteins, it produces acid which is excreted in the urine. To balance this acid, the kidneys will excrete calcium as a buffer. In addition, very high intakes of protein can increase endogenous production of oxalate in the liver.

  • Increase fruit and vegetables. High intakes of fruits and vegetables have consistently been associated with a lower risk of stones. A possible reason is that these contain a substance called citrate, which can inhibit stone formation in the urine. Citrus fruits, in particular, contain high levels of citrate.

  • Limit added sugar. Although the reasons are not fully understood, high intakes of added sugars (e.g. from sugary beverages) have been associated with a higher risk of stones.

  • Avoid vitamin C supplements. The liver can make oxalates from vitamin C, and in fact vitamin C supplements have been shown to be a primary contributor of oxalates in the urine. Note that vitamin C from foods should not be limited because as stated earlier, higher intakes of fruits and vegetables are actually associated with lower risk.

  • Limit dietary oxalates. Oxalates are found in a range of foods, and a high intake of oxalates from the diet is known to increase oxalate levels in the urine, making stones more likely to form. There are no official cut-offs for the quantities of oxalate that should be consumed, and generally, complicated oxalate calculations are not needed. Avoiding, or greatly limiting, the foods highest in oxalate tends to be enough: these include spinach, almonds, beets, raspberries, and potatoes. Note that this recommendation is only for persons who have experienced kidney stones in the past. One needs to also be careful with supplements and nutritional powders since these may contain extracts of high oxalate vegetables.