News of vitamin D deficiency in children are popular in the media these days. Like all concerned parents, I am sure you have paused to pay attention to these news and wondered if you should get a vitamin D supplement for your toddler. The only way you can be sure whether your child has a vitamin D deficiency is by getting a blood test which screens for a particular form of vitamin D called 25-hydroxyvitamin D. Unfortunately, there are no early warning symptoms which can help you determine if you should take a corrective action.

You don’t need to go rushing for a blood test right away though! By paying attention to your child’s general level of outdoor activity and eating patterns, you can get a few clues. Here are 5 questions you can ask to figure out if there might be a need to get a definitive answer on vitamin D deficiency in your specific situation. However, you should not jump to a conclusion too soon just by observing over a few days. Rather you should try to look for a general pattern over a period of time.

Does he get enough time to play in the sun?

Your child’s body (and yours) is programmed to make its own vitamin D simply by being out in the sun. Even 10-15 minutes of play with arms and legs exposed to the sun can be enough. And best of all, the body is able to self-regulate the amount of vitamin D by storing the excess in fat cells.

The problem is that you may not get enough sunshine during the day, especially during the fall and winter months simply because of where you live. Children with darker skins are also at a disadvantage because of the pigment in their skin which absorbs the UVB rays which would otherwise be used to make vitamin D.

The good news is that the effect of sun is cumulative - that is, it adds up over time. Take advantage of every sunny day, even in the middle of winter to let your child play outside. Getting fresh air and physical exercise is good not only from the point of vitamin D, but also for overall physical and emotional health.

Does she drink at least 4 cups of milk every day?

Milk, by far, is the best source of vitamin D because all milk in the US is now fortified with vitamin D. However you need at least 4 cups to reach the recommended level of daily vitamin D (400 IU for children).

The problem could be milk allergies and just a natural dislike of milk. Also 4 cups is a lot, and even adults don’t usually get to drink that much on a daily basis. Try to mix with vitamin D fortified cereals, most of them generally are these days. You can also get vitamin D fortified orange juice, but be sure to watch out for added sugar.

One good way of increasing milk consumption is to add it to a smoothie. This way you can also get your child to eat some fruits!

Does he eat fish as part of a balanced diet?

Eating fish such as salmon is almost like buying insurance as far as vitamin D is concerned. You don’t have to eat it everyday – even once a week can work its magic. One serving of 3.5 oz (about 100g) or the size of a deck of cards can provide as much 2 times or even higher than the daily recommended level of vitamin D. Other fishes like tuna, mackerel and sardines are also good sources of vitamin D. Mercury contamination is a risk but should not be too much of a concern if you eat them occasionally as part of a varied diet.

The problem again could be allergies. Also your child may not like the taste or smell of fish. Trying new recipes and offering in small portions in combination with some of his other favorites can help you to build a taste for fish.

Does she seem overweight for her age?

Childhood obesity is on the rise and if your child is overweight or obese, you have a challenge in terms of vitamin D as well. That is because the body is not able to pull the vitamin D stored in the fat cells when needed.

Keep a close eye on her Body Mass Index by looking at the age specific growth charts. They are available on the CDC website or you can ask your pediatrician. Again, it is important to look at the trend and not a single point on these charts. If you see a trend creeping over the 85th percentile, you need to take action right away and improve the overall nutrition and eating habits of your child. Unless there is an underlying medical condition, nutrition and lifestyle changes can show good results.

Does he have special medical conditions?

In the most unfortunate situation, your child may have a medical condition such as Crohn’s disease, celiac disease or cystic fibrosis. These diseases cause poor absorption. Since vitamin D is a fat soluble vitamin, its availability is severely reduced in people suffering from these problems.

If this is the case, you are probably already talking to your pediatrician. Discuss the matter of vitamin D deficiency if you have not already done so.

After considering your specific situation, you can consult with your pediatrician about supplements. While I am not a fan of jumping on the vitamin supplements bandwagon, I think it is important to be informed about them. I plan to write about vitamin D supplements in future once I have had a chance to do some research on them.

What do you think? Are you concerned about your child’s vitamin D levels? Are you considering supplements? I would love to hear your comments.

Photo Source: Leo Reynolds on Flickr
©2009 Littlestomaks.com

In this post, I want to highlight some of the comments from readers of this blog. These comments provide useful advice and information and I do not want them to stay “buried” in the blog archives. I am constantly inspired by your comments and I learn a lot from them. I want to say thanks to those who spend time reading my posts – some on a very regular basis – and leave a comment behind with some advice, helpful tips or a question for further research. Some of them have their own blogs, which I highly recommend you to visit whenever you get a chance. I will be highlighting more comments in future posts; for now, enjoy these 5 insightful comments from my earlier posts. If I did not pick your comment, just hang in there and look out for another post in future. And of course, feel free to share your opinions in a comment!

1. In response to my post 6 Easy Tips for Helping Your Child Choose Healthy Foods, Anne of yourfamilyviewer wrote:

I find it really interesting that, among other things, the amount of TV watching didn’t seem to affect what the children in the study chose – that what did was what the parents chose…. Hmmm. Not that I believe that TV has no effect on kids – in fact, I strongly support the American Academy Pediatrics recommendation of no screen time before the age of 2, and no more than 2 hours a day. But, as I have said before and will say again, parents have the most effect on what their kids think, do and eat.
And while I do think that having only veggies and fruit at a party is totally unfair, having several healthy alternatives along with some of the other stuff is a great idea. We call veggie trays crudite and serve them with a special dip. Gives it that “party/fun/special” effect.

2. Jenna of KidAppeal gave this advice when she read my post on the idea of Homemade OJ Ice Cream Cup:

my SIL just returned from the pediatricians office telling me the doc considers 100% juice to be in the soda category! i’m not sure i’d go that far, but i don’t know if i can condone 3 servings of juice a day either. One 4-6 oz serving a day is my limit unless we are visiting someone’s house, at a bday party where juice boxes flow freely or it’s a holiday. Home-made popsicles are a tasty treat and are a better choice than most candy or ice-cream, but it’s still a treat and once a day is plenty. Young kids lack impulse control they need to make the best food choices. My advice? Next time they beckon for “ice cream cold” let them choose which meal they’d like it with. They will probably cry when they don’t get it. You can follow up with saying ice cream is a special treat and is not grow food. Tell them lots of grow food is ok, but lots of treats are not healthy. This might be painful and tearful for a couple days, but they’ll accept it if you follow through. Let me know if this helps.

3. When I highlighted a news that some doctors were suggesting cholesterol lowering drugs for kids with high LDL (bad cholesterol)  in Noteworthy Child Nutrition News of 2008, Dr. Ayala of Herbal Water responded:

Great post!
On cholesterol meds for kids:
This paper really stirred a huge debate among pediatricians for several reasons:
1. There’s very little evidence that the use of the cholesterol-lowering drugs prevent heart attacks later in life.
2. There’s little data on the possible side effects of taking these drugs for decades
3. My main outrage: if money could be found for cholesterol screening and treatment for kids, can we not invest money in better child nutrition in schools, more exercise (gym classes are only cut back), and a plan that fights childhood obesity? Weight loss, exercise and a better diet are proven ways to lower cholesterol in children that don’t have genetic disorders of cholesterol metabolism, and suffer high cholesterol mainly due to overweight, inactivity and a poor diet.

4. Jodie of freedomdesign.usana provided this detailed information about nutritional supplements in response to my post 5 Reasons to Consider a Multivitamin Supplement:

There is still much we don’t know about the ways nutrients work together. A healthy body is an extremely complex system, and each functional area requires a diverse mix of nutrients. For many reasons, nutritional supplementation should provide nutrients that are both balanced and in adequate doses. For example, certain vitamins supplied in isolation can result in other nutritional deficiencies, and many micronutrients can be toxic at excessive or imbalanced levels. USANA painstakingly designed the Essentials to allow components to work together both safely and effectively.

To be useful, all nutrients must be of high quality and be bioavailable; in other words, in a form the body can absorb and use. USANA makes every effort to obtain the highest quality ingredients; and it tests those ingredients for quality and potency. In addition, USANA imposes rigorous quality control standards at every step of the manufacturing process. USANA Essentials are advanced daily nutritional supplements that supply optimal nutrition for every age group. To help meet the “essential” nutrient needs of children and teens during the years of development, when good nutrition is most important, USANA offers:

* Usanimals, a great-tasting formulation of vitamins, minerals, and antioxidants, in an easy-to-take chewable tablet. For children 13 months to 12 years old.
* BodyRox, a nutritional supplement containing 31 essential vitamins, minerals, antioxidants, and cofactors for adolescents 12 to 18 years old, who need optimal nutrition to support the demands of growth and active teenage lifestyles.

Disclaimer – I have not personally tried any of USANA’s products. Nor do I have any affiliations with USANA. I did recently saw a video about their products on their website, and I must say I was quite impressed.

5. In response to this question “Do you think enforcing (with lots of encouragement) the “taste one bite” rule leads to kids who avoid those foods?” on this Global Toddler Survey, Cathy of A Life Less Sweet wrote:

Good question at the end, Jenna! We’re a 2 bite rule family, and honestly, I don’t think that it leads to food avoidance. I guess I can say that from personal experience as my parents had a similar rule. Many of the foods that I didn’t like as a young child, I grew to like. Many I did not, but I do actually value having tried those foods numerous times. Perhaps I’m just weird that way.

My son wouldn’t try many foods at all without that rule, and sometimes – not always, in fact not usually – he realizes that he actually likes a food. My daughter realizes that she actually likes a food through the 2 bite rule more often than not. She’ll take her required 2 bites and then take more. For my kids, it’s a way to get them to continue testing their taste buds. We do talk a lot about taking those bites with an open mind. When my son will eat with an open mind, that’s when it works!

I also feel like it’s important for my kids to be able to eat food that they don’t like without gagging and making rude comments. It’s an important social skill as they get older.

Photo source: regalzam0ra on Flickr
©2009 Littlestomaks.com

It’s another Friday!. Here is my commentary on 5 interesting nutrition related news of the week.

Water! Could it be the answer to childhood obesity?

In this very interesting study, researchers in Germany considered the effect of installing drinking water fountains and classroom lessons about benefits of water on preventing obesity among 2nd and 3rd graders in 32 elementary schools. The risk of being overweight was reduced by 31% in the group that got the water fountains and the lessons compared to those who did not. Water consumption was higher in this group, although the juice consumption in the two groups was similar. Body Mass Index (BMI) was also not different at the end of the study.

I think the idea is neat, although I do not fully agree with the conclusion that this type of intervention is effective in prevention of overweight. Encouraging children to drink more water instead of juice or other sugary drinks is definitely good idea but not the only factor in preventing obesity.

How do you get your toddler to drink more water instead of juice?

Now they will tell you what are “good” and “bad” foods

I recently discovered a great blog called Nutrition Unplugged written by a dietitian who discusses nutrition and food trends in a very simple, intelligent way. A recent post on this blog talks about a hot new trend called nutrition profiling which attempts to put foods into good and bad categories. The idea is simple – give consumers an easy-to-understand nutritional information label on the front-of-the box so they can quickly decide if they should be eating that food or not. There are already many different labels of this type becoming popular – I have written about Kellogg’s nutrition-at-a-glance label and a traffic light system of food labeling. Then there is the Nuval system which gives you a simple score between 1 and 100; higher score suggesting more healthy.

I am all for simplified food labeling. It is clear to me that the standard nutritional information label is not working for a majority of people. No one has time to read and understand the information, much less use it to compare different foods. Still, I worry about so many different types of so-called simple labeling systems getting out there without any standards or industry consensus. This will surely create a lot of confusion. Also the possibility of manipulating consumer choice by clever marketing is quite real. I am not suggesting more regulation by the government, but the food processing industry should quickly come to a common consensus. They should present data in a simple, objective way and stay away from implying “good” or “bad” by other subliminal messages on the box. Consumers are smart enough to make their own decisions!

First peanuts, now pistachios – when will this stop?

Even though the media has forgotten about it, I hope you still remember the recent Salmonella outbreak from the peanut factory in Georgia. Now there is news that a California company is recalling over a million pounds of pistachios due to a possible Salmonella contamination. Of course, this is much preferred to contaminated product going on the shelves and making people sick. But the question is how come our so-called modern food processing plants cannot keep Salmonella out! Turns out that the companies are not even required to inform the FDA in case of a suspected contamination. It is only after the fact when people get sick that the FDA launches an investigation. Wouldn’t it be nice if we all tried to prevent these incidents from happening in the first place? Will more regulation or oversight by the FDA solve this problem? What do you think?

Consumers are taking the fizz out of soda sales

In an encouraging trend,  a lot of people are opting out of regular soda in favor of diet or other non-carbonated drinks. According to this story, number of people choosing regular soda fell by 15.6 million in 2008 compared to the 2003 number. I am pleased to realize that I am one of those 15.6 million! I would love to see a similar trend in potato chips and fries. Bottled water and energy drinks are increasingly the beverages of choice. This data is based on a survey of adults; it would be interesting to see if the same holds true for teens too.

Tropicana introduces Trop50 – Don’t fall for the hype

Fooducate, another favorite blog of mine, has an interesting commentary on a new “innovation” from Tropicana called Trop50. It is based on stevia and claims to provide the “orange juice goodness with 50% less sugar and calories”. In simple terms, it is diluted orange juice with a new sweetner; so I am not impressed by this so called breakthrough innovation!

Don’t get me wrong – we do like Tropicana, and use their vitamin D and calcium fortified orange juice regularly. It does contain sugar (fructose from the fruit) so we do watch the total amount our twins drink each day. We even came up with this idea of frozen OJ “ice cream” that the twins were crazy about for quite some time. But this new product seems a gimmick with a new marketing twist. If I were you, I would not pay a “100% price for 42% juice”. What do you think?

Enjoy your weekend!

Image source: Gregoire on Flickr
©2009 Littlestomaks.com

Disclaimer – this is not a commercial product; just something we made up to solve a nutritional problem with our twins!

Ever since my son discovered the Breyers Pure Fruit All Natural frozen bars in the store, he just doesn’t want to give it up. “Ice cream cold! Ice cream cold!”, as he calls them, is all he wants to eat for breakfast, lunch and dinner. For a while, we didn’t think it was that big a problem; after all, the Breyer’s product claimed to be “pure fruit”. And it had vitamin C, no added sugar and only 40 calories. After a few attempts, we gave in to his demands because we noticed that he would eat the rest of his otherwise healthy dinner if he had a frozen fruit bar in his other hand.

Except that he was eating 3 of these frozen bars throughout the day. So the “empty” calories just continued to add up. He was not getting any other nutritional value from these frozen bars. And to make it worse, his twin sister also joined in the fun and started demanding the same at each meal. So, we decided that something needed to be done about this problem.

I should admit that we got real lucky because this idea happen to come to us purely by chance.

Our twins like to eat a lot of yogurt. One day, as I was about to throw the empty yogurt cup in the trash bin, I wondered if we could just freeze some orange juice in it to offer it to my son instead of the “pure fruit” bars. The OJ we buy is packed with vitamins, calcium, folic acid, magnesium and potassium. It is low in sugar and calories. As it turns out, the yogurt cup holds about the same amount as one of the frozen pure fruit bars, so the nutritional comparison is easy:

%Daily value based on 2000 cal diet

It was, as you can imagine, very easy to make. Even if my son eats 3 or 4 of these in a day, it is like drinking a cup of healthy, nutritious OJ. And judging by these photos, both my son and daughter can’t tell a difference!

We are thinking of trying cranberry juice (my daughter’s favorite) and frozen yogurt too.

What do you think? Have you had a similar problem? How did you solve it? Do you have other ideas to try?

If you are giving your toddler a couple of cups of milk, vitamin D fortified orange juice, yogurt and cereal, and you take him out to play in the sun for 5 – 30 minutes each day, then there is no reason to worry. And if he has a taste for salmon and tuna, you are in really good shape. There is absolutely no need to grab that fancy multivitamin nutritional supplement on your next shopping trip. Balanced diet and an active, healthy lifestyle works like a charm!

There has been a recent buzz in the media about vitamin D deficiency among infants and toddlers. “Kids Aren’t Getting Enough Vitamin D” screams one headline, while “Vitamin D Deficiency Puts 40% of U.S. Infants and Toddlers at Risk” cries another. It is quite natural to be alarmed by such news; even I paid attention to it and started researching the topic to figure out if our twins were getting enough vitamin D each day.

It is worthwhile to get a little better understanding of why vitamin D deficiency is such a big deal. It is known to cause rickets (softening and twisting of bones in children). Vitamin D is important of absorption of calcium and phosphorus in bones to maintain their strength and proper development. Recent research is also showing that vitamin D plays an important role in prevention of diabetes, multiple sclerosis and certain cancers. It can also cause weakness in muscles if deficient. It seems to influence over 200 genes, including those that regulate cellular proliferation of both normal and cancer cells.

As I read more, I found myself fascinated by the incredible biochemistry that goes on in the body while processing vitamin D from various sources. Sunlight converts cholesterol from skin into vitamin D₃, which is converted inside the liver into another form (25-hydroxyvitamin D) and released into the circulating blood stream. Vitamin D fortified foods can contain D₃ and another form D₂, both of which end up in the liver for conversion to 25-hydroxyvitamin D. By the way, it is the level of this 25-hydroxyvitamin D that tells you if you have a vitamin D deficiency. If this level is between 30 – 60 ng/mL, you have no reason to worry! 25-hydroxyvitamin D now finds its way to the kidneys, where it is converted to the active form 1,25-dihydroxyvitamin D under the influence of hormones from the parathyroid gland. This active form of vitamin D increases calcium absorption in the small intestine. Calcium and phosphorus absorbed in the small intestine are released in the blood, from where they are picked up by the bone cells for bone growth. 1,25-dihydroxyvitamin also regulates the growth and maturity of bone cells, which in turn release back the calcium and phosphorus in the blood to maintain their levels in the circulation system. The whole system works in harmony, promoting controlled bone growth!

You can continue to be vigilant by paying attention to what you buy. Remember that unless the label says Vitamin D fortified, orange juice, yogurt, cheese and cereals do not contain this vitamin. If you have a choice, go for Vitamin D₃ because it is three times more effective than Vitamin D₂ in conversion to 25-hydroxyvitamin D. If the label simply says Vitamin D, then most likely it is Vitamin D₂.

Here are some of the products we use regularly. Looking at them, and how much our twins are getting overall each day, I am not worried about Vitamin D deficiency.

Are you still worried?

If so, discuss with your pediatrician. Depending upon your specific case, you may be able to get advice about a nutritional supplement.

Here are some links for more information:

1. A very technical article in the New England Journal of Medicine
2. Dietary supplement fact sheet on Vitamin D from NIH