Interview: Eleni Koui: What can we do to prevent childhood obesity

Sync team
Sync team
May 24, 2021

This is an episode from our series of interviews with Health professionals and specialists on how people can improve their metabolic health. You can watch the episode in video on our YouTube channel.

Eleni has degrees in Nutrition from King’s College London and the University of Bristol.She worked as a Clinical dietitian for eight years in university hospitals such as Hammersmith Hospital and University College London Hospital (UCLH).She specialised in Paediatric diabetes at the University College London Hospital. She is member of the British Dietetic Association.


Daphne Karnezis (Sync): [00:00:00] Hi everyone, I'm Daphne here at the Sync team with another interview, bringing you insights into metabolic health and all its different facets and what you can do to live healthier. And today we're looking at childhood obesity and we are also going to delve into the topic of carbs a little later, which I know a lot of you are interested in and I'm delighted to say that I'm joined by Eleni Koui today. She's a pediatric dietitian. She has a degree in nutrition from King's College London and the University of Bristol. She has worked as a clinical dietitian for eight years in university hospitals, such as Hammersmith Hospital and University College London Hospital. And she specializes in pediatric diabetes and her main workload has included cases of children with food allergies, obesity or insufficient growth. And she's also a member of the British Dietetic Association and the British Pediatric Dietitian Group. Eleni thank you so much for joining me. Welcome. 


Eleni Koui: [00:01:01] Thank you for inviting me,Daphne. 


Daphne Karnezis (Sync): [00:01:04] Great! I'd like to talk about the topic of obesity first and particularly childhood obesity, which I know is one of your areas of expertise. And I'm talking here about children and adolescents aged 2 to 19 years old. I was reading earlier that the prevalence of obesity in children is around 18.5% worldwide and affects around 13.7 million children. But today I kind of want to go beyond the numbers and delve into the causes and what parents or children can do to both prevent themselves from developing obesity, but also some practical tips and strategies for managing it too. So, first of all, I guess I just wanted to ask what is obesity? And is it the same in children as it is with adults? Just, just give us a super quick overview. 


Eleni Koui: [00:01:48] Daphne, when we talk about obese or overweight children or adolescents we need first of all a proper measurement of the anthropometrics weight and height being the basic ones. That's why it's very important for each separate individual kid to assess weight and height and see whether that kid carries more weight for their height or less weight for their height. Sometimes, in some cases we assess weight and height in curves. It's not just a measurement that we write down in a piece of paper. We need to properly plot them in graphs. I assess them against their age at any specific age and then also we calculate BMI body mass index for both children and adolescents and we also use appropriate graphs or growth curves as we call them again, up until the age of 18 years old. 


Daphne Karnezis (Sync): [00:02:47] So what does it mean in practical terms? You know, what are the physical manifestations, I mean beyond the actual sort of physical appearance of someone who I guess is overweight or obese and the BMI as you mentioned, what about things like abnormal kind of excessive fat and, you know, fat accumulation and the problems I guess that this can cause because it's more than just the number of your BMI, right? It's an actual condition that presents several health risks when you're diagnosed as actually being obese.


Eleni Koui: [00:03:18] Sure. I would say that when we think about obese children, we need to think of future obese adults. We very often say it's not gonna resolve by itself. We need to take care and treat, or even prevent childhood obesity in most cases. So, I would say childhood obesity is even more severe than obesity in adulthood because it will definitely lead to future health problems in later adolescent or adult life. Unfortunately, these days we see health problems or consequences of obesity that we used to only see in adults about 20 years ago. So, we talk about kids with insulin resistance. We talk about kids with respiratory problems, with sleep apnea, sometimes like problems with difficulty with breathing during their sleep during nighttime. Some of them initial signs that even the kids themselves realize is difficulty moving or not being able to follow physical activities or PE classes at school, they feel like their knees or backs hurt, they get breathless more often. So, really obesity will affect not only growth and development and everyday routines but also future health of our kids and not to mention that obesity and body shape, body image situation have an impact in their mental health or the relations with other kids their age, or, you know, friends as they grow up. 


Daphne Karnezis (Sync): [00:05:04] Yeah. So important.  And you mentioned insulin resistance there and correct me if I'm wrong, but I was reading that children as adults as well, who have obesity or high risk of also developing things like type two diabetes, is insulin on instant levels and to extend, you know, regulating our blood sugar, making sure it's balanced, keeping our instinct in check. Is that really important when it comes to managing childhood obesity? 


Eleni Koui: [00:05:30] That's also very important. I would say when I was a student at King’s, we didn't use to talk about type 2 diabetes in kids and adolescents, but it's actually becoming everyday practice at the moment. Yes, there's a huge risk of developing type 2 diabetes, even in adolescent stages. And the other thing that affects obesity or overweight affects is their growth of development. We need to mention and make it clear that if I have a child prepubertal ages, if I have a child, girl or boy that carries more weight than they can actually afford for their height, that extra weight, that extra body, body fat accumulation will trigger puberty process earlier than we want to. And that's a problem because we face the risk of that kid never achieving the optimal height that they would have achieved if they carried a better relation of  weight to their height. And also, with our girls, we see puberty starting much earlier than we used to a few years ago. That's a problem that affects both their optimal, as I said, final height that the child can achieve up to the age depending on the genetics, but up to the age of about 16, between 16 to 18 years old, but also more body fat accumulation that especially with women with girls the moment they go into puberty with the extra fat accumulation it's becoming even more difficult to get rid of that fat in later life. So really we have kids that they get programmed to carry extra weight and fat, if we don't intervene and if we don't help them on time for the rest of their lives. 


Daphne Karnezis (Sync): [00:07:30] Really interesting. Before we go into some of the specific strategies that you recommend that maybe parents listening to this could try, what is the overall sort of goal that we should be aiming towards when it comes to both preventing but also managing obesity? What's kind of the overarching goal? Is it balanced blood sugar? Is it keeping insulin in check? How should we be thinking about it? 


Eleni Koui: [00:07:55] I would say, first of all, keep our health checks regular either without pediatricians or a pediatric endocrine doctor is the most appropriate suitable health professional to initially assess the overall health, including blood sugar levels and, you know, probably insulin resistance or overproduction with regular blood tests, that's one thing. The other thing is to be honest and be aware, I very often say if there's a family history of type 2 diabetes or obesity we need to keep an eye, a closer eye to what the kid is consuming, what sort of dietary habits are developing and make it as part of that child's education to actually develop better, healthier lifestyle. The other thing is that there's a technology these days that offers tools. More opportunities to actually either monitor blood sugars or monitor dietary habits, monitor reports, those habits and results, and actually go with those results and data to our doctors. Our pediatric dieticians and actually helping them  with the ready data to interpret and put together a plan, which is more individualized and more sort of matched to their family needs or the child's needs.


Daphne Karnezis (Sync): [00:09:24] Definitely. So when you talk about those habits and lifestyle, I mean, diet is presumably a really big one, right? What should we be keeping in mind? What should children be avoiding or getting more of? What, what are your top thoughts on that? 


Eleni Koui: [00:09:39] Sure. When we talk about practical advice cause I hope we have families and parents listening to us today. I would start with, suggesting having an organized meal routine during the day. Half of the time, this is enough to actually prevent high blood sugar fluctuations during the day, organize better sort of satiety, food portions and cravings, avoid cravings during the day. So, first of all, we need to sit down and have a plan, even with specific times if needed of what, of when that kid needs to be consuming food. And then we need to have a conversation with the family. 

Daphne Karnezis (Sync): [00:10:21] Cause that's all to avoid things like overeating, sorry to interrupt you. 


Eleni Koui: [00:10:25] Exactly. And then we need to make sure that every meal during the day doesn't have the same importance. And what I mean by that is  I meet families that are very fixated in terms of the number of meals that need to be consuming during the day. Some families that come to me, they say they need to be four, they need to be five or, you know, do we have to consume six meals a day? But we don't have the time for those six meals. And I say there isn't a magical number of meals during the day that will improve your kids' health, nutrition, and overall growth. I explained that we have three main meals, sort of form the backbone of that kid's diet and that's breakfast, lunch, and dinner, and any opportunities over the three hour interval. To make it more clear every two and a half to three hours if there is an interval between those main meals, we need to think about snacks, but healthy snacks that they are there to actually meet extra needs of that kid in terms of nutrients, such as calcium, iron dietary fiber and vitamins snacks are not there to actually, spike our blood sugars or create more cravings for the rest of the day. So when we talk about snacks, whenever they're necessary, we'll talk about it. 


Daphne Karnezis (Sync): [00:11:49] Does that mean selecting foods that don't spike our blood sugar.  So what kind of foods do we mean here? 


Eleni Koui: [00:11:56] Ideally in my mind, snacks are there to actually keep our blood sugars stable between main meals, not to actually spike blood sugars in between meals. So anything with low glycemic index fruits or combination of fruit and good fats from nuts, for example, like peanut butter or tahini sesame paste that we have here in Greece or any combination of nuts, for example with our fruits, anything that will keep blood sugar stable by actually giving a little bit of carbohydrates, we'll talk about that later, but not letting that carbohydrate quantity cause a high blood sugar. So, snacks are there to actually maintain blood sugar levels and give extra calcium iron nutrients to the kid that is actually growing one extra comment I want to make about snacking, Daphne, for older kids in adolescent years, if they don't ask for snacks, don't offer them. There's this principle that we follow mostly with adults when it comes to controlling those blood sugar fluctuations or weight overall if you're not hungry, you don't have to eat in between the main meals. And sometimes I use a principle for adolescents as well. If they don't feel the need, if they don't feel that craving or, you know, need to snack on something, especially later in the day, I wouldn't ask the adolescent to actually go and eat something before dinner. 


Daphne Karnezis (Sync): [00:13:41] I think that's so important because I think the dogma for so many years has been the, you know, we should have lots of small snacks throughout the day. Shouldn't sit on an empty stomach because it might not be good for might slow down our metabolism and all these things. So I think it's great to kind of I guess pass that myth in a way because you're saying that that sort of promotes unwanted and unneeded really glucose fluctuations, which as you said earlier, can do things like increase our cravings, things like that.


Eleni Koui: [00:14:12] I would say that the other thing that we want to avoid by avoiding spikes in our blood sugars has to do with concentration and it's academic scores or overall behavior. And when it comes to children, adolescents, I think it's very important. We can't expect an adolescent or a younger child to actually be able to focus and be well-behaved or bring back good grades and exams. When blood sugars are all over the place and diet definitely plays a role in those situations very often I discuss this with families that they need, for some reason to control blood sugars before exams and planning the meals, the days before the exams or during the the day of the exam is very important for those kids.


Daphne Karnezis (Sync): [00:15:06] I know. I was just about to say that you reminded me that when I was younger, I always remember my dad used to tell me don't have, you know, a lot of the kids around me would have, let's say a chocolate bar or something sweet before the exam to sort of give them energy and my dad would always say, don't have chocolate because you'll go up on a high for, let's say the first half an hour or whatever but these are exams that, you know, might be two hours long, even an hour and a half long.  Have something that will give you sustained energy and won't make you peak and then crash.  Unfortunately  I always wanted the chocolate, but I did learn to listen to him at some point. 


Eleni Koui: [00:15:41] Yeah, it was well said, coming from your dad. Now, the other thing I would say in terms of practical advice for parents having a good breakfast can make a huge difference starting off our day with I would say a portion of calcium for the kids that they definitely needed to support bone health. So a portion of calcium paired with a source of good carbohydrates and we'll explain that in a minute we'll definitely start off the day in a better way. There's a golden rule, I very often say that to the kids I work with, in terms of the breakfast meal we avoid anything sweet even if it's homemade cause sometimes moms are very proud of the cake or the cookies they made but I'd say we avoid anything sugary even homemade. Cookies, cakes or confectionery and anything that comes in liquid form even freshly squeezed orange juice or smoothies. The reason for that Daphne is because everybody, all of us have a slide built in insulin resistance the early hours of the day. The insulin resistance becomes more prominent during the adolescent years and especially important for our girls during the adolescent years. So It's an excellent sort of tip I'd say,  it will start off the day, much better and it will make it easier to control the blood sugar fluctuations for the rest of the day. If you start off your day, let's say you start off your day with a nice fasting blood glucose value, and then you feed you start your day with chocolate milk or, you know, milk and a piece of cake or pancake with chocolate spread for example, that nice fasting blood sugar level, you woke up with, it will spike, it will go very high, then it will just crash very quickly, very low. And those fluctuations will follow you for the rest of the day. 


Daphne Karnezis (Sync): [00:17:55] What you said was really interesting and  I just made note of a couple of things that I want to ask you. I mean what you said about insulin resistance, having a kind of inbuilt, slightly higher insulin resistance earlier in the day. Is that something that we carry on into our adult lives as well? I mean, I've seen it definitely when I'm wearing my continuous glucose monitor my CGM if I don't eat the right kind of breakfast, it does feel like it can more easily bounce around and kind of get off the optimal levels than if I was to maybe eat the same thing slightly later in the day. I mean, how is that explained? 


Eleni Koui: [00:18:28] That's a characteristic, that's a physiology for us. We can't really manipulate that, but we need to make sure that we know of it. We are aware of the sort of phenomenon during the early hours of the day and especially for female metabolism, that insulin resistance Daphne becomes more prominent during adolescent years and during pregnancy. So even for women that's why I said that even for girls in puberty it is more important for them to know and take care of that characteristic.


Daphne Karnezis (Sync): [00:19:03] Definitely. And also what you said about fruits and I guess juice as well cause that's something that, again, I only found out recently. I mean, I still remember my mom almost every day would make me, you know, a big, you know, glass of freshly squeezed orange juice. And then  when I tried it out wearing this continuous glucose monitor, I see that it spikes me more than if I'm having, you know, a couple of biscuits with sugar in them. I think it's also, I mean, you explain a bit better, but it's also because we're having the pure juice without the fiber in it which, you know, obviously means faster absorption as well. Right?


Eleni Koui: [00:19:37] Sure, that's spot on. Now, what we need to avoid, it's not the fruit. If you, if you decide to eat your whole fruit for a part of your breakfast is absolutely fine and that can be a good choice paired with a little bit of carbohydrate and probably your calcium coming from your milk or yogurt. But it's the liquid form of fructose. Fructose is the natural sugar occurring in our fruits, we like fructose, but when it comes to the liquid form of fructose, especially in the early hours, it can actually, if you monitor your blood sugars in a continuous monitoring system it's just amazing, within the first half an hour, that  blood sugar levels will  sky high. And that happens to everybody. Now, when the fruits, when you squeeze your orange, you lose your fiber, you lose your dietary fiber is the element in our fruits that actually makes fructose, the sugar to get absorbed more slowly. And that's why we say, we eat our fruits and we don't drink them. That's the motto I usually use for kids. You want to eat your fruit and not to drink it cause when you drink it, then  it won't satisfy you the same. And that has to do with the fluctuations in your blood sugars. The other thing you mentioned, quantity and how your mom used to prepare like a huge glass of juice for you, my mum used to do the same,  but, while we need, in terms of consumption of orange juice or any fruit juice for our kids is maximum hundred twenty to hundred twenty fifty mils of juice for that kid. And that  equals a portion of fruit for the day. Let me just add an extra tip note to the juice subject. According to the guidelines coming from the American Diabetes Association it's not necessary to offer any fruit juice to our kids younger than the age of two years old. So basically in simple terms, you avoid fruit juices for kids younger than the age of two. And when you start introducing, if you want to, then you start with quantities that are no more than hundred and 20 mils for the day. 


Daphne Karnezis (Sync): [00:22:05] And also, as we were talking, I was curious, cause you mentioned fasting glucose. Is it different?  The ideal fasting glucose levels that children or adolescents should have versus adults or is it the same for everyone? The kind of guidelines let's say for non-diabetic children.


Eleni Koui: [00:22:22] Not much. To be honest and I would say something here very often parents come with lab results, blood results coming from all sorts of different sources, hospitals, or private laboratories and sometimes the range of the acceptable fasting blood sugar can be up to 120 milligrams per DL that's the measurements here in Greece.  But in real life we don't want the fasting blood sugar level of our kids and adolescents to be much over 90. 


Daphne Karnezis (Sync): [00:22:58] I was just gonna say that just to summarize, kind of what we've said, and move on to our next topic, which I'm really excited about, which is carbs.  You know, what are some of the main, and you'll tell me if we've left anything out in terms of what parents can be doing and what children can be doing, but what are some of the main worries or struggles or obstacles that you see and you hear from parents that you speak with of obese children.


Eleni Koui: [00:23:22] In terms of the management of that kid?


Daphne Karnezis (Sync): [00:23:24] Yeah, exactly. Like, you know, maybe you've seen, you know, people who have been struggling with that for a while. And  what would you advise those people really, if, you know, if you had to say, let's say three things and what are the worries that they come to you with mainly.


Eleni Koui: [00:23:39] I would say, make a home environment, the one environment that you can control, most of the time since the home environment. So make that one, a healthier environment by removing, all the, you know, all the distractions, but I'm looking for another word. And so it's not enough. If you have your fruits and vegetables in your kitchen. So it's not enough. If you provide fruits and vegetables, remove the cakes and the biscuits and all the sugar is staffed at the same time. If your child is already overweight or obese, that child has prove that they  can't control, their appetite or they can't control the way they consume things. So it's up to us and it's on our hands basically to help the kid by , presenting a better home environment. The other thing I would say to parents is they need to become the example if they set the pace the kids will follow, they don't need to make comments like, Oh, I hate broccoli. I never have fish. The whole family needs to change their habits so that the kids will follow their lead. The other thing, the other practical and it works, we need to make the children part of the change that I'd say, take the kids to the supermarket or the market with you, make it fun, ask them to choose a new fruit or a new vegetable that you will then incorporate to a dish or a new meal during the week. So let them explore new tastes and flavors with you and even for the older ones let them play in the kitchen and let them prepare something like a smoothie or a salad or a quick snack with you. Most of the time you'll be surprised if the kid was involved in the preparation of a healthier meal, we'll definitely have the curiosity to try that new meal. So make it fun, consistent, I over say that one good day will not make a difference, but, you want everyday to be a little better, a little healthier than the previous one. And then at the end of the month, you'll have a number of healthier days and that can make a difference. 


Daphne Karnezis (Sync): [00:26:04] Great. Thank you so much. Very wise words.

This is an episode from our series of interviews with Health professionals and specialists on how people can improve their metabolic health. You can watch the episode in video on our YouTube channel.

Eleni has degrees in Nutrition from King’s College London and the University of Bristol.She worked as a Clinical dietitian for eight years in university hospitals such as Hammersmith Hospital and University College London Hospital (UCLH).She specialised in Paediatric diabetes at the University College London Hospital. She is member of the British Dietetic Association.


Daphne Karnezis (Sync): [00:00:00] Hi everyone, I'm Daphne here at the Sync team with another interview, bringing you insights into metabolic health and all its different facets and what you can do to live healthier. And today we're looking at childhood obesity and we are also going to delve into the topic of carbs a little later, which I know a lot of you are interested in and I'm delighted to say that I'm joined by Eleni Koui today. She's a pediatric dietitian. She has a degree in nutrition from King's College London and the University of Bristol. She has worked as a clinical dietitian for eight years in university hospitals, such as Hammersmith Hospital and University College London Hospital. And she specializes in pediatric diabetes and her main workload has included cases of children with food allergies, obesity or insufficient growth. And she's also a member of the British Dietetic Association and the British Pediatric Dietitian Group. Eleni thank you so much for joining me. Welcome. 


Eleni Koui: [00:01:01] Thank you for inviting me,Daphne. 


Daphne Karnezis (Sync): [00:01:04] Great! I'd like to talk about the topic of obesity first and particularly childhood obesity, which I know is one of your areas of expertise. And I'm talking here about children and adolescents aged 2 to 19 years old. I was reading earlier that the prevalence of obesity in children is around 18.5% worldwide and affects around 13.7 million children. But today I kind of want to go beyond the numbers and delve into the causes and what parents or children can do to both prevent themselves from developing obesity, but also some practical tips and strategies for managing it too. So, first of all, I guess I just wanted to ask what is obesity? And is it the same in children as it is with adults? Just, just give us a super quick overview. 


Eleni Koui: [00:01:48] Daphne, when we talk about obese or overweight children or adolescents we need first of all a proper measurement of the anthropometrics weight and height being the basic ones. That's why it's very important for each separate individual kid to assess weight and height and see whether that kid carries more weight for their height or less weight for their height. Sometimes, in some cases we assess weight and height in curves. It's not just a measurement that we write down in a piece of paper. We need to properly plot them in graphs. I assess them against their age at any specific age and then also we calculate BMI body mass index for both children and adolescents and we also use appropriate graphs or growth curves as we call them again, up until the age of 18 years old. 


Daphne Karnezis (Sync): [00:02:47] So what does it mean in practical terms? You know, what are the physical manifestations, I mean beyond the actual sort of physical appearance of someone who I guess is overweight or obese and the BMI as you mentioned, what about things like abnormal kind of excessive fat and, you know, fat accumulation and the problems I guess that this can cause because it's more than just the number of your BMI, right? It's an actual condition that presents several health risks when you're diagnosed as actually being obese.


Eleni Koui: [00:03:18] Sure. I would say that when we think about obese children, we need to think of future obese adults. We very often say it's not gonna resolve by itself. We need to take care and treat, or even prevent childhood obesity in most cases. So, I would say childhood obesity is even more severe than obesity in adulthood because it will definitely lead to future health problems in later adolescent or adult life. Unfortunately, these days we see health problems or consequences of obesity that we used to only see in adults about 20 years ago. So, we talk about kids with insulin resistance. We talk about kids with respiratory problems, with sleep apnea, sometimes like problems with difficulty with breathing during their sleep during nighttime. Some of them initial signs that even the kids themselves realize is difficulty moving or not being able to follow physical activities or PE classes at school, they feel like their knees or backs hurt, they get breathless more often. So, really obesity will affect not only growth and development and everyday routines but also future health of our kids and not to mention that obesity and body shape, body image situation have an impact in their mental health or the relations with other kids their age, or, you know, friends as they grow up. 


Daphne Karnezis (Sync): [00:05:04] Yeah. So important.  And you mentioned insulin resistance there and correct me if I'm wrong, but I was reading that children as adults as well, who have obesity or high risk of also developing things like type two diabetes, is insulin on instant levels and to extend, you know, regulating our blood sugar, making sure it's balanced, keeping our instinct in check. Is that really important when it comes to managing childhood obesity? 


Eleni Koui: [00:05:30] That's also very important. I would say when I was a student at King’s, we didn't use to talk about type 2 diabetes in kids and adolescents, but it's actually becoming everyday practice at the moment. Yes, there's a huge risk of developing type 2 diabetes, even in adolescent stages. And the other thing that affects obesity or overweight affects is their growth of development. We need to mention and make it clear that if I have a child prepubertal ages, if I have a child, girl or boy that carries more weight than they can actually afford for their height, that extra weight, that extra body, body fat accumulation will trigger puberty process earlier than we want to. And that's a problem because we face the risk of that kid never achieving the optimal height that they would have achieved if they carried a better relation of  weight to their height. And also, with our girls, we see puberty starting much earlier than we used to a few years ago. That's a problem that affects both their optimal, as I said, final height that the child can achieve up to the age depending on the genetics, but up to the age of about 16, between 16 to 18 years old, but also more body fat accumulation that especially with women with girls the moment they go into puberty with the extra fat accumulation it's becoming even more difficult to get rid of that fat in later life. So really we have kids that they get programmed to carry extra weight and fat, if we don't intervene and if we don't help them on time for the rest of their lives. 


Daphne Karnezis (Sync): [00:07:30] Really interesting. Before we go into some of the specific strategies that you recommend that maybe parents listening to this could try, what is the overall sort of goal that we should be aiming towards when it comes to both preventing but also managing obesity? What's kind of the overarching goal? Is it balanced blood sugar? Is it keeping insulin in check? How should we be thinking about it? 


Eleni Koui: [00:07:55] I would say, first of all, keep our health checks regular either without pediatricians or a pediatric endocrine doctor is the most appropriate suitable health professional to initially assess the overall health, including blood sugar levels and, you know, probably insulin resistance or overproduction with regular blood tests, that's one thing. The other thing is to be honest and be aware, I very often say if there's a family history of type 2 diabetes or obesity we need to keep an eye, a closer eye to what the kid is consuming, what sort of dietary habits are developing and make it as part of that child's education to actually develop better, healthier lifestyle. The other thing is that there's a technology these days that offers tools. More opportunities to actually either monitor blood sugars or monitor dietary habits, monitor reports, those habits and results, and actually go with those results and data to our doctors. Our pediatric dieticians and actually helping them  with the ready data to interpret and put together a plan, which is more individualized and more sort of matched to their family needs or the child's needs.


Daphne Karnezis (Sync): [00:09:24] Definitely. So when you talk about those habits and lifestyle, I mean, diet is presumably a really big one, right? What should we be keeping in mind? What should children be avoiding or getting more of? What, what are your top thoughts on that? 


Eleni Koui: [00:09:39] Sure. When we talk about practical advice cause I hope we have families and parents listening to us today. I would start with, suggesting having an organized meal routine during the day. Half of the time, this is enough to actually prevent high blood sugar fluctuations during the day, organize better sort of satiety, food portions and cravings, avoid cravings during the day. So, first of all, we need to sit down and have a plan, even with specific times if needed of what, of when that kid needs to be consuming food. And then we need to have a conversation with the family. 

Daphne Karnezis (Sync): [00:10:21] Cause that's all to avoid things like overeating, sorry to interrupt you. 


Eleni Koui: [00:10:25] Exactly. And then we need to make sure that every meal during the day doesn't have the same importance. And what I mean by that is  I meet families that are very fixated in terms of the number of meals that need to be consuming during the day. Some families that come to me, they say they need to be four, they need to be five or, you know, do we have to consume six meals a day? But we don't have the time for those six meals. And I say there isn't a magical number of meals during the day that will improve your kids' health, nutrition, and overall growth. I explained that we have three main meals, sort of form the backbone of that kid's diet and that's breakfast, lunch, and dinner, and any opportunities over the three hour interval. To make it more clear every two and a half to three hours if there is an interval between those main meals, we need to think about snacks, but healthy snacks that they are there to actually meet extra needs of that kid in terms of nutrients, such as calcium, iron dietary fiber and vitamins snacks are not there to actually, spike our blood sugars or create more cravings for the rest of the day. So when we talk about snacks, whenever they're necessary, we'll talk about it. 


Daphne Karnezis (Sync): [00:11:49] Does that mean selecting foods that don't spike our blood sugar.  So what kind of foods do we mean here? 


Eleni Koui: [00:11:56] Ideally in my mind, snacks are there to actually keep our blood sugars stable between main meals, not to actually spike blood sugars in between meals. So anything with low glycemic index fruits or combination of fruit and good fats from nuts, for example, like peanut butter or tahini sesame paste that we have here in Greece or any combination of nuts, for example with our fruits, anything that will keep blood sugar stable by actually giving a little bit of carbohydrates, we'll talk about that later, but not letting that carbohydrate quantity cause a high blood sugar. So, snacks are there to actually maintain blood sugar levels and give extra calcium iron nutrients to the kid that is actually growing one extra comment I want to make about snacking, Daphne, for older kids in adolescent years, if they don't ask for snacks, don't offer them. There's this principle that we follow mostly with adults when it comes to controlling those blood sugar fluctuations or weight overall if you're not hungry, you don't have to eat in between the main meals. And sometimes I use a principle for adolescents as well. If they don't feel the need, if they don't feel that craving or, you know, need to snack on something, especially later in the day, I wouldn't ask the adolescent to actually go and eat something before dinner. 


Daphne Karnezis (Sync): [00:13:41] I think that's so important because I think the dogma for so many years has been the, you know, we should have lots of small snacks throughout the day. Shouldn't sit on an empty stomach because it might not be good for might slow down our metabolism and all these things. So I think it's great to kind of I guess pass that myth in a way because you're saying that that sort of promotes unwanted and unneeded really glucose fluctuations, which as you said earlier, can do things like increase our cravings, things like that.


Eleni Koui: [00:14:12] I would say that the other thing that we want to avoid by avoiding spikes in our blood sugars has to do with concentration and it's academic scores or overall behavior. And when it comes to children, adolescents, I think it's very important. We can't expect an adolescent or a younger child to actually be able to focus and be well-behaved or bring back good grades and exams. When blood sugars are all over the place and diet definitely plays a role in those situations very often I discuss this with families that they need, for some reason to control blood sugars before exams and planning the meals, the days before the exams or during the the day of the exam is very important for those kids.


Daphne Karnezis (Sync): [00:15:06] I know. I was just about to say that you reminded me that when I was younger, I always remember my dad used to tell me don't have, you know, a lot of the kids around me would have, let's say a chocolate bar or something sweet before the exam to sort of give them energy and my dad would always say, don't have chocolate because you'll go up on a high for, let's say the first half an hour or whatever but these are exams that, you know, might be two hours long, even an hour and a half long.  Have something that will give you sustained energy and won't make you peak and then crash.  Unfortunately  I always wanted the chocolate, but I did learn to listen to him at some point. 


Eleni Koui: [00:15:41] Yeah, it was well said, coming from your dad. Now, the other thing I would say in terms of practical advice for parents having a good breakfast can make a huge difference starting off our day with I would say a portion of calcium for the kids that they definitely needed to support bone health. So a portion of calcium paired with a source of good carbohydrates and we'll explain that in a minute we'll definitely start off the day in a better way. There's a golden rule, I very often say that to the kids I work with, in terms of the breakfast meal we avoid anything sweet even if it's homemade cause sometimes moms are very proud of the cake or the cookies they made but I'd say we avoid anything sugary even homemade. Cookies, cakes or confectionery and anything that comes in liquid form even freshly squeezed orange juice or smoothies. The reason for that Daphne is because everybody, all of us have a slide built in insulin resistance the early hours of the day. The insulin resistance becomes more prominent during the adolescent years and especially important for our girls during the adolescent years. So It's an excellent sort of tip I'd say,  it will start off the day, much better and it will make it easier to control the blood sugar fluctuations for the rest of the day. If you start off your day, let's say you start off your day with a nice fasting blood glucose value, and then you feed you start your day with chocolate milk or, you know, milk and a piece of cake or pancake with chocolate spread for example, that nice fasting blood sugar level, you woke up with, it will spike, it will go very high, then it will just crash very quickly, very low. And those fluctuations will follow you for the rest of the day. 


Daphne Karnezis (Sync): [00:17:55] What you said was really interesting and  I just made note of a couple of things that I want to ask you. I mean what you said about insulin resistance, having a kind of inbuilt, slightly higher insulin resistance earlier in the day. Is that something that we carry on into our adult lives as well? I mean, I've seen it definitely when I'm wearing my continuous glucose monitor my CGM if I don't eat the right kind of breakfast, it does feel like it can more easily bounce around and kind of get off the optimal levels than if I was to maybe eat the same thing slightly later in the day. I mean, how is that explained? 


Eleni Koui: [00:18:28] That's a characteristic, that's a physiology for us. We can't really manipulate that, but we need to make sure that we know of it. We are aware of the sort of phenomenon during the early hours of the day and especially for female metabolism, that insulin resistance Daphne becomes more prominent during adolescent years and during pregnancy. So even for women that's why I said that even for girls in puberty it is more important for them to know and take care of that characteristic.


Daphne Karnezis (Sync): [00:19:03] Definitely. And also what you said about fruits and I guess juice as well cause that's something that, again, I only found out recently. I mean, I still remember my mom almost every day would make me, you know, a big, you know, glass of freshly squeezed orange juice. And then  when I tried it out wearing this continuous glucose monitor, I see that it spikes me more than if I'm having, you know, a couple of biscuits with sugar in them. I think it's also, I mean, you explain a bit better, but it's also because we're having the pure juice without the fiber in it which, you know, obviously means faster absorption as well. Right?


Eleni Koui: [00:19:37] Sure, that's spot on. Now, what we need to avoid, it's not the fruit. If you, if you decide to eat your whole fruit for a part of your breakfast is absolutely fine and that can be a good choice paired with a little bit of carbohydrate and probably your calcium coming from your milk or yogurt. But it's the liquid form of fructose. Fructose is the natural sugar occurring in our fruits, we like fructose, but when it comes to the liquid form of fructose, especially in the early hours, it can actually, if you monitor your blood sugars in a continuous monitoring system it's just amazing, within the first half an hour, that  blood sugar levels will  sky high. And that happens to everybody. Now, when the fruits, when you squeeze your orange, you lose your fiber, you lose your dietary fiber is the element in our fruits that actually makes fructose, the sugar to get absorbed more slowly. And that's why we say, we eat our fruits and we don't drink them. That's the motto I usually use for kids. You want to eat your fruit and not to drink it cause when you drink it, then  it won't satisfy you the same. And that has to do with the fluctuations in your blood sugars. The other thing you mentioned, quantity and how your mom used to prepare like a huge glass of juice for you, my mum used to do the same,  but, while we need, in terms of consumption of orange juice or any fruit juice for our kids is maximum hundred twenty to hundred twenty fifty mils of juice for that kid. And that  equals a portion of fruit for the day. Let me just add an extra tip note to the juice subject. According to the guidelines coming from the American Diabetes Association it's not necessary to offer any fruit juice to our kids younger than the age of two years old. So basically in simple terms, you avoid fruit juices for kids younger than the age of two. And when you start introducing, if you want to, then you start with quantities that are no more than hundred and 20 mils for the day. 


Daphne Karnezis (Sync): [00:22:05] And also, as we were talking, I was curious, cause you mentioned fasting glucose. Is it different?  The ideal fasting glucose levels that children or adolescents should have versus adults or is it the same for everyone? The kind of guidelines let's say for non-diabetic children.


Eleni Koui: [00:22:22] Not much. To be honest and I would say something here very often parents come with lab results, blood results coming from all sorts of different sources, hospitals, or private laboratories and sometimes the range of the acceptable fasting blood sugar can be up to 120 milligrams per DL that's the measurements here in Greece.  But in real life we don't want the fasting blood sugar level of our kids and adolescents to be much over 90. 


Daphne Karnezis (Sync): [00:22:58] I was just gonna say that just to summarize, kind of what we've said, and move on to our next topic, which I'm really excited about, which is carbs.  You know, what are some of the main, and you'll tell me if we've left anything out in terms of what parents can be doing and what children can be doing, but what are some of the main worries or struggles or obstacles that you see and you hear from parents that you speak with of obese children.


Eleni Koui: [00:23:22] In terms of the management of that kid?


Daphne Karnezis (Sync): [00:23:24] Yeah, exactly. Like, you know, maybe you've seen, you know, people who have been struggling with that for a while. And  what would you advise those people really, if, you know, if you had to say, let's say three things and what are the worries that they come to you with mainly.


Eleni Koui: [00:23:39] I would say, make a home environment, the one environment that you can control, most of the time since the home environment. So make that one, a healthier environment by removing, all the, you know, all the distractions, but I'm looking for another word. And so it's not enough. If you have your fruits and vegetables in your kitchen. So it's not enough. If you provide fruits and vegetables, remove the cakes and the biscuits and all the sugar is staffed at the same time. If your child is already overweight or obese, that child has prove that they  can't control, their appetite or they can't control the way they consume things. So it's up to us and it's on our hands basically to help the kid by , presenting a better home environment. The other thing I would say to parents is they need to become the example if they set the pace the kids will follow, they don't need to make comments like, Oh, I hate broccoli. I never have fish. The whole family needs to change their habits so that the kids will follow their lead. The other thing, the other practical and it works, we need to make the children part of the change that I'd say, take the kids to the supermarket or the market with you, make it fun, ask them to choose a new fruit or a new vegetable that you will then incorporate to a dish or a new meal during the week. So let them explore new tastes and flavors with you and even for the older ones let them play in the kitchen and let them prepare something like a smoothie or a salad or a quick snack with you. Most of the time you'll be surprised if the kid was involved in the preparation of a healthier meal, we'll definitely have the curiosity to try that new meal. So make it fun, consistent, I over say that one good day will not make a difference, but, you want everyday to be a little better, a little healthier than the previous one. And then at the end of the month, you'll have a number of healthier days and that can make a difference. 


Daphne Karnezis (Sync): [00:26:04] Great. Thank you so much. Very wise words.