We check in with the Packard Program

Juliana and I visited with the staff from the Packard Program yesterday.  They are doing great good in the world trying to help obese kids achieve a healthy weight, and they have good success.  Nonetheless, I believe that the calories in/calories out model that underlies the program is wrong.  So why does it work as well it as it does?

The Packard Program teaches kids to substitute lower-calorie yellow or green foods for higher-calorie red foods.  In many cases, those substitutions are from super-high-carb foods to less-high-carb foods.

From a glass of apple juice, for example, to an apple.  8 ounces of apple juice has about 29 grams of carbs; one medium apple has about 16 grams of carbs and it also has 4 grams of fiber, for only 12 grams of “net carbs.”  (When counting carbs, you subtract the fiber grams from the total carbohydrate grams, because fiber does not provoke the same insulin response).

Or from a high-sugar cereal to a low-sugar cereal.   Changing from raisin bran (36 grams of net carbs per cup) to cheerios (19 grams of net carbs per cup) cuts the carb load almost in half.

Both those substitutions are lower calorie changes, but they are also lower-carb changes.  So is it the carbs, or the calories?   I think it’s the carbs.  See chapters 19 and 20 of Gary Taubes‘ “Good Calories, Bad Calories” for a full discussion of this point.

The real power of the realization that carbohydrate restriction is the most important part of the eating plan is that your child will not be constantly hungry on a low carb plan, as they will be on a low calorie “balanced” plan.  At Packard yesterday I really emphasized this point:  Juliana complied perfectly with the program and did lose 6 pounds in 10 weeks.  But she was hungry all the time and I didn’t see how she could possibly keep it up.

A low carb eating plan doesn’t require superhuman restraint to follow.  That makes it a lot easier to coach your child on a low carb eating plan than a low calorie eating plan.

After losing a lot of weight in the beginning, Juliana’s weight loss rate has slowed on the low carb eating plan.  But even if she only loses an average of a 1/2 pound a week, as she did on the Packard Program, she will eventually get to her goal weight WITHOUT suffering constant hunger.  And in the meanwhile, her energy level is high, she has a completely new level of physical stamina, and her mood is consistently good.

We enroll in a kids weight control program

After Juliana hit 168 pounds at a height of 5′ 4″, I went looking for a kids weight control program. I found one at Lucile Packard Children’s Hospital at Stanford University. It was near my house, and started at the end of January. It was expensive and not covered by insurance, but I wanted help. Juliana was in the habit of asking my permission to eat things–usually sweets or seconds. I never said no, but would try to guide her choices–“I wouldnt have the cookie because we are going to a party later and you’ll probably want something there.” I wanted to cut myself out as the middleman. I wanted her to be in charge and empowered to control her own intake. The Packard program is designed to do that. Juliana met with the Packard staff, learned about the program, and we both agreed to try it together.

The Packard program is based on the standard calories in/ calories out model.  Kids are taught to switch to lower calorie foods, control their portion sizes, and increase their physical activity level.  Children are thereby supposed to burn more calories than they consume and lose weight.  The Packard program first ramps down on higher calorie foods. Then it ramps up on physical activity.

Foods are evaluated for their caloric density, that is calories over grams of weight: c/g. Foods with caloric density over a certain threshold are red. Below a lower threshold are yellow, and below the lowest threshold are green.

Green foods are things you may eat in virtually unlimited quantities. It’s a short list, and includes things like broccoli, romaine lettuce, and spinach. Yellow foods are go-slow foods–usually still healthy, but watch your portion size. Whole wheat bread, pasta, chicken, starchy vegetables like sweet potatoes, eggs. Red foods are junk foods, like soda or candy, or fast food, but also meats if they aren’t low in fat, full fat cheese, and nut butters.

Eating more than two servings per meal of a yellow food also makes the third portion into a red, to try to control for meal size. The kids were taught the visual cue of a serving being equal to what would fit in the palm your hand.

Some of the kids started out eating 100 or more red foods per week. They had fast food, soda, and juice regularly. Juliana topped out at 35, the week she was on a trip with her school and had no control over her food. Even so, we reduced the number of reds she ate. We eliminated maple syrup on her whole wheat French toast, substituting applesauce. She cut out the 100 calorie fudge bars she liked for dessert. I started cooking with almost no oil–a teaspoon for six servings was a “yellow”, more than that a red. I started making mostly vegetarian bean soups and stews, carefully using my teaspoon of oil to sauté garlic and onion. In a few weeks, she was down to eating only 4 or 5 reds a week.  (The Packard program didn’t recommend even trying to go below 18 reds per week, because they wanted goals to be challenging but doable—they didn’t think 18 reds or fewer was doable enough).

After six weeks, the Packard program starts to ramp up on exercise. Different activities have different point values, and you try to increase your exercise points while you decrease your red foods. Juliana had always exercised, but she began to do even more.

Did she lose weight? Yes, she lost 6 pounds in 10 weeks.   I didn’t find that rate of weight loss very impressive, considering how few reds she was eating and how much she exercised.  Then she stalled, gaining back half a pound at the weekly weigh-in. And meanwhile, she was almost always hungry, despite eating every few hours. I would pick her up from school, and before she said hello, she would gasp, “do you have a snack?”

The Packard program confirmed for me what I had been saying to anyone I thought could help–compared to the other overweight and obese kids in the program, her eating habits had been super healthy, and now were even healthier, and she exercised. If the Packard program was going to work for her, shouldn’t she be steadily dropping weight eating only 4 reds a week and exercising a minimum of 30 minutes a day at a medium intensity? But she wasn’t. She was also having a hard time because she was frequently hungry.   I went looking for something better.

She won’t grow into it.

Wait for them to “grow into their weight.” This is one of the more misleading ideas out there. As Juliana grew older, I kept hoping this magic was starting to happen, or looked like it was going to start happening. I had been a bit pudgy as a child, and had a growth spurt and slimmed down when I was about eleven. I thought it was worth waiting to see if Juliana had a slimming growth spurt before trying something else, because I was worried about creating an eating disorder.  

As a result, we spent years on the wrong track. I only went looking for a structured weight loss program when Juliana’s weight at age 13 exceeded even a healthy adult weight. I realized that even if she grew to my height, she would still be overweight. Looking back, I realized that I had probably never been overweight, and certainly not obese as a child, as Juliana has been.

We tried exercise…and tried…and tried…

Juliana was lethargic from a young age. I wasn’t sure why parents were always taking their kids to the park–even before she became obese, Juliana didn’t run around, she sat in the sand. I expanded my efforts to get her to move. She did gymnastics, swimming lessons, and soccer. She played basketball and indoor soccer in the winter. She joined a swim team in the summer. We tried softball because it was one of the few sports available in the spring, but it had a terrible driving to exercise ratio–lots of driving, very little exercise, so we stopped.

When she was in third grade, I started the first Girls on the Run program in our town. She ran her first 5k. Then she ran more races. Then she joined a kids triathlon team, and did triathlons too. When she was 12, she ran a 10k race by herself. We did kids’ weight training at home, since muscle mass is supposed to boost metabolism, and is also good for reducing sports related injuries.

Although exercise seemed to help her mood, a lot, it did not help her achieve a healthy weight.  It did not even seem to slow her weight gain.

Maybe if I cook healthier food?

I went to elaborate lengths to prepare healthy food. I cooked breakfast every morning–no cold cereal. Whole wheat French toast, whole wheat pancakes, oatmeal, broccoli omelets. I packed healthy lunches every day. Juliana’s staple lunch was whole wheat pasta with carrots and chicken sausage. She would have a sweet potato, or a banana or beets for a snack. Sometimes with popcorn or applesauce. I tried the Jessica Seinfeld method of reducing calories by mixing starches like whole wheat couscous or quinoa with puréed yellow squash or cauliflower. I made pizza from scratch, with whole wheat dough and minimal cheese.

I packed, and packed, and packed, food on the go.  We have a busy life, and the kids have lots of activities.  My kids regularly eat in the car.  Packing food is a lot of work, and I would have loved to have “healthy” choices to pick up on the road–but there weren’t any.  Nonetheless, Juliana remained overweight.

My daughter’s weight explosion

My daughter went from a low normal Body Mass Index of 25th percentile to above the 95th percentile (considered clinically obese) in about one year from the age of 3 and a half to 4 and a half.  I spent more and more time and energy over the next eight and a half years trying to help her slim down, ultimately enrolling us both in a pediatric weight control program at the Lucile Packard Children’s Hospital at Stanford.  Our experience in that program convinced me there had to be something else going on with Juliana than just that she ate more calories than she burned.  And I was right.

Maybe she’ll grow into it?

I hoped she would “grow into her weight.” I had been a bit pudgy as a child and suddenly grew and slimmed out at age eleven–I thought the same growth spurt might happen to her.

But the signs weren’t good. Juliana seemed to have no internal satiety control. If she were eating pasta (whole wheat) she could not get enough. At the end of her kindergarten year, I learned that she had been routinely eating her entire lunch (healthy, packed by me), and then consuming one of the leftover school hot lunches of a child who was absent that day (unhealthy, from a pizza place). She would often be hungry again just a few hours after a large meal.