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Skim or whole? Milk and weight mythbusting and recommendations

Posted by on Nov 10, 2010 in Blog Posts | 37 comments

A client recently called to check in about weaning her one-year-old onto milk. (Her child’s pediatrician gave what she felt was inadequate and confusing advice about weaning from formula to milk, nor did the doctor address her nutrition and feeding questions. Remember docs often don’t have the time or training…)Her pediatrician recommended skim milk. The child’s BMI was 70% (stable, steady growth).

Another friend who’s child is at the 25% was also advised to start on skim mil at 12 months.

Both pediatricians stated that skim milk would lessen the chance of developing obesity. Both were wrong, and with possibly dangerous consequences. (Neither asked follow-up questions about intake and feeding otherwise.) Both are following new recommendations to recommend skim milk to children “at risk” for overweight, which some groups include having one overweight parent, regardless of the weight status and health of the child. Seems like some assume that everyone is now “at risk” for getting overweight and are recommending skim milk for all.  Skim milk is not to be recommended willy-nilly. Here’s why.

  • toddlers need 30-40% calories from fat (Kostyak , National Academy of Science)
  • low-fat diets, with skim milk being a primary means to an end, fail nutritionally for small children (Skinner 1997 ADA and Satter 2007)

Little ones are growing. Fat is critical for certain vitamin absorption, brain and nerve development and more…

More data on milk and weight: (Hint, the assumption that putting young children on skim milk for BMI reduction doesn’t hold up.)

  • NHANES: 2006: Cross-sectional analysis of 2-5 yo children reported that neither quantity nor type of milk consumed was associated with BMI.

So, what to do? What did I recommend for my client? Start with whole milk unless there is a VERY compelling reason not to. Then, after about age two, assuming the child has stable growth, a pretty varied intake including sources of fats and protein, let the child transition to drinking the milk you like to drink as a family. I recommend at least 1% milk to include some fat for satiety and nutrient absorption. And remember to include milk into the regular schedule of meals and snacks and water in between. (I liked the milk-boxes for snacks away from home. At 2% fat, they were nice when M wouldn’t eat much which was more likely to happen when distracted away from home.)

What have you heard from your child’s doctor on this?

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37 Comments

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  1. Lisa

    Hi – coming late to the party with my take on skim/whole milk. We all drink whole milk at home (organic, low-temp pasteurized, grass fed) because it is DELICIOUS. All our dairy is full fat, actually. I was a chronic, low-fat dieter for years and years and I notice that when I eat fat, I actually enjoy the food more AND eat less of it. We also take the “1900” approach with our food choices, so lots of whole non-messed-with foods.

    When my Chinese daughter first came home at 18 mos, she was underweight. I demand-fed her for the first year and we could not get enough fat into her during her first two months home. She would literally eat big chunks of butter at the dinner table! She put on 5 lbs during the first few weeks we had her. That kind of eating has disappeared, and we’ve transitioned successfully in the DOV with eating, but I shudder to think of how a less savvy and more weight anxious parent might have handled her completely healthy cravings for fat.

    • katja

      Lisa,
      I am totally in love with that story about your daughter. Would you be willing to email me privately and share some of your experiences? I think that adoptive parents need SO much more support and education about feeding. With the very complex feeding and nutrition histories many children come with, it can be a very scary and confusing thing, and so essential to attachment. Did you have a resource you used? Thanks! I love how you trusted her and helped her best. I met a colleague who is a therapist and she talked about how we need to support our kids, and then get out of the way and let their natural drives, talents etc emerge. This is so true with feeding. Support, provide, love nurture and then stop messing it up…

  2. Bri

    Katja-

    I have been reading for awhile now and I am eating up your entire philosophy. I refer people to your site regularly and I love what you have to say. I was watching the news last night and I was floored when this news story came on my TV.

    http://www.abc15.com/dpp/news/region_northern_az/flagstaff/flagstaff-schools-warn-parents-of-overweight-kids

    Just wanted to share…

    • katja

      Oh Boy, Bri, Thanks for sharing. Folks, be aware that the comments are extremely vile and triggering. Do not read them unless you want to get seriously mad. Alas, Bri, this is where most schools are headed. The USPSTF (US preventive services task force) denounced the AAP and AAFP for endorsing school BMI measuring. They felt there was no credible evidence that it helped, and plenty to suggest that it harmed. This stuff makes me CRAZY. I google alert ‘childhood obesity’ and have dozens of similar stories around the country daily. These folks are uninformed, and it is dangerous. I used to try to write letters and emails, but it felt like a huge drain of my energy, and I got nowhere. I fear we will have to hit rock bottom with all of this before we realize it is a huge waste of money, time and a huge creator of pain, suffering, added pounds and disordered eating. If you live locally, perhaps you can contact someone. If you make contact, I will be happy to pen a quick note. Ellyn satter online has some position statements about BMI in schools etc, that might help. I just can’t fight it all every day. So sad… Also, their stat on diabetes is so misleading. A US child is 2000 times more likely to have an eating disorder than diabetes in childhood.

  3. Camilla

    Do you feel strongly either way about the timing of the formula to whole milk transition? Our pediatrician doesn’t, and we’re lagging a bit, because at the rate of three bottles a week for the sitter, a can of formula lasts a long time (the child is 13 months, healthy, small for his age, and breastfed at home).

    Last time he took a swig from his brother’s sippy cup, he spat it in disgust, but I’m sure we could overcome that by mixing them.

    • katja

      I always have to preface this with “I’m not a nutritionist and I don’t know your specifics of your family,” But, here’s what I’d say…
      I only feel strongly that it is not done before 12 months.For some, I do recommend continuing formula if starting solids is slow or development is delayed, or initial nutrition wasn’t ideal. Finish up the can of formula, no problem, particularly if small for age. I would try to transition to the pattern of eating every 2-3 hours. (Meaning you don’t have bottles anytime…) I would consider offering finger and family foods first with formula in a cup. Be careful that he is not filling up only on bottles and missing his chance to be exposed to lots of flavors and textures. I would also recommend at “mealtime” putting the formula into a cup (if you use a sippy cup, I don’t like the ones in general with the strong spout where they really have to suck to get at it.) Ideally you will notice over the next few months that he is more and more interested in family foods and less interested in formula. Good instinct to mix with whole milk over a week or so when the time comes… So, be sure not to run out of the formula completely so you don’t have to buy a whole new can :) I also do recommend breastfeeding at meal and snacktime. You can do an exclusive breastfeed for a snack if that works for you. Hope that helps! Remember try not to react to their initial reactions to new tastes. Sometimes they pull a face, but it’s more out of confusion or being startled. try not to read too much into it, and certainly don’t verbalize anything like. “Oh, you don’t like that, do you?” Maybe say, “Oh, that was a new taste. It’s your brother’s milk” with a pleasant smile and move on…

  4. Heather

    Our pediatrician recommended whole milk when my son was one. After he turned 2, she said 2% was okay, since that’s what my husband and I drink. I still buy him whole-milk yogurt.

  5. The WellRounded Mama

    I have four kids. All were breastfed till well past two so they had “full fat” milk for a long time, but the fat in breastmilk is healthier (has more lipase to break it down and has more “healthy fats” like DHA) so it’s not a worry.

    However, there’s nothing wrong with the fat in cow’s milk in reasonable consumption once baby is old enough to drink cow’s milk too. We fed our kids 2% or whole milk till they were at least 2-3 years old.

    We generally buy 1-2% now because I think skim tastes horrible (that’s all I was given as a kid but I hate it) and I think a little bit of fat does help in nutrient absorption, esp Vit D which is fat soluble and for which a primary source is milk.

    Things got complicated when my boys developed cow-milk allergies as toddlers/preschoolers. They got rice milk or soy milk. I don’t know what the saturated fat content is of those and frankly I didn’t worry about it, but my guess is that it’s probably much lower than cow’s milk.

    My three oldest kids tend to be higher on the BMI charts but our pediatrician is totally fine with their builds because she knows their growth curves have been consistent and she knows we provide healthy foods for them and plenty of exercise.

    My littlest one is as skinny as the day is long, despite the same food as everyone else! She has had trouble gaining weight, with a very slow growth curve. For her, we alternate between 1-2% and whole milk, just to give her a little extra fat and calories in her diet. We have an organic dairy not far from us so my husband will sometimes go there and get her some fresh (pasteurized) whole milk. She loves it and seem to be doing well, so we let go of the worry about saturated fat.

    You are not a bad parent if you feed your child cow’s milk that’s isn’t skim! Research has shown that it’s a bad idea to give children below age 2 skim milk, so it distresses me to hear that some docs are actually recommending this now. They NEED extra fat for the very rapid brain development that happens in those early years!

    • katja

      Love so much about this post. Kids are different in their make-up, appetites, builds and temperaments, which the BMI chart does not take into account.
      Sorry about the allergies. That can be a major hassle, but sounds like youa re handling it all well. I worry less and less about saturated fat. I think the evidence to recommend the low-saturated fat diet (which resulted in more carbs) is shaky. Am still working through a book called “good calories, bad calories” (horrible title) but the laying out of evidence for our current nutrition guidelines, and how high carbs, rather than fat may be more of a culprit with our weight, diabetes and CVD struggles is fascinating!

      • Datura

        I was warned by a dietitian to avoid fat free yoghurts, fat free soups etc, as they most often replace the milk fat with corn flour. I try to eat low-GI as much as possible to keep my blood sugar stable, and “hidden” carbs like those don’t help! I think a lot of people probably aren’t aware of the added corn starch in fat free dairy products.

  6. JeninCanada

    Thank you so much for putting this information out there. So many people have no idea how much fat a kid needs for brain development! We weaned Gabe from bottles of formula to whole milk for about two years then to 2%. He LOVE cheese and yogurt so even when he’s not drinking a lot of milk I know that he’s getting what he needs. He’s also a big fan of bread and butter, and peanutbutter.

    I HATE when I see pediatricians or other doctors using BMI for kids; it was never meant for anyone but full grown MEN. Using BMI as a measurement for health for kids is like looking at someone across the room and trying to accurately guess their bra size.

  7. Jennifer

    We’re sticking with the whole milk in our house. I thought about switching at one point when my oldest was younger but wasn’t comfortable with it. I think I was supposed to switch to 2%? Though, I did feel guilty ignoring health recomendations. Luckily I did though, because I just found out that my oldest is in the 3rd percentile for BMI. (I’d never seen BMI percentiles before, just height and weight percentiles.) As he has always been the larger of the two siblings percentile-wise, I think they’ll be drinking whole milk for awhile!

    • Kate

      Jennifer: How old is your oldest? BMI percentiles only apply to children 2 years and above, weight for height is used for children under 2. Perhaps that’s why this is the first time it’s been mentioned?

      Katja: What about the saturated fat in whole milk? Most dietitians I work with want children on skim as they enter grade school at the latest, presuming they can get healthier fat from other areas of their diet.

      My daughter is 2 and on 2% now, but I think within the year we’ll switch her to skim since that’s what we drink and it’s easier to just buy one kind of milk. We don’t eat much full fat dairy at home, but I suspect at school she’s getting a lot of cheese and yogurt and I cook mostly with olive oil.

      • katja

        Alas, many are using BMI for infants. I never in my own prior practice at an FP clinic, nor with referral notes I get from docs do I see them using weight for length charts. Every visit I went to from birth on at the top of the paper, there was a calculate BMI. Yuck. They almost all only use weight for age and height for age. They really need to get with the program. I’ll pass this on to my pediatric dietitian I work with. I am not a nutritionist, so I appreciate you all keeping me honest. I think there is a lot of controversy on this right now. Some say that you need fat with the milk to absorb calcium and nutrients better, some say the milk from all grass fed has a better fat profile. The RDs I work with pay so much attention to internal regulation and structure (eating competence) that they pretty much recommend drink the milk that tastes good to you. But, for most people who really struggle with eating well, are not able to eat based on internal cues, have no structure, perhaps recommending 2% or skim is best. In other words, I’m not sure there is a concensus…

      • Jennifer

        Kate

        My oldest is 6 and neither I, nor anyone else is concerned about his weight. I know virtually nothing about BMI in kids and I haven’t directed a lot of energy to figuring out what it actually means that he has a low BMI percentile.

        But what seeing that percentile did for me was remind me that I need to keep making sure he has good access to fat in his diet. I find it takes effort sometimes to ignore the “low-fat diet for kids” phenomena because it is so pervasive. It seems like they are making food lower and lower in fat and sometimes I feel like I need to go out of my way to get him fatty food. Though, this is partly because he has a limited diet and doesn’t eat a lot of the common “fatty foods” in our culture’s diet.

        Milk is such an easy way to provide fat in his diet. (I’m also not totally convinced about the dangers of saturated fat, perhaps I am just contrary by nature ;))

        • katja

          This is typical, that many families need to be mindful about including fat, especially when preferred or offered foods are low in fat (often fruits or refined carbs.) It’s good to keep in mind that fat is important! See one of my other responses (to wellroundedmama) for my thoughts on the whole saturated fats hysteria. I too am no longer convinced…

    • katja

      way to listen to your intuition!

  8. Susan Hanson

    I can remember being told to give whole milk for my almost 30 lb one year old who was always off the charts. The doctor never made any mention that she was concerned with whole milk being an issue due to his size. She questioned how much juice we were giving. The doctor was not a huge fan of giving much juice. Not sure if it was due to our childs size or if she is just against giving much juice to young children regardless of their size.

    • katja

      interesting. Juice is generally looked upon as a contributor to childhood weight issues, but again, anytime I hear “just cut out juice” kind of solution, without addressing other feeding issues, I get suspisious. (Literally I consulted on a 3 yo who was rapidly gaining weight, was on steroids for asthma… the RX was to limit to 4 oz of juice a day, well the mom already was doing that…)
      I do generally recommend limiting to 4 ounces or so. I often would water down, and be sure to offer it with meals and snacks.

  9. Kate

    I thought the AAP was now recommending 2% milk for children 1-2 who were at risk for overweight. It sounds like doctors are misunderstanding when they recommend skim milk. My doctor didn’t say anything about it at the 2 year appointment. I had to specifically confirm that moving from whole to 2% was appropriate. I’m curious about the Huh article, I’ll have to take a look. I wonder if they adjusted for overall calorie intake. Perhaps the kids drinking whole milk were fuller and therefore ate less of other food?

    • katja

      I got lazy. I had hear the skim thing, tried to look up the AAP recs awhile ago. I will have to look into WIC recs too, but alas, many are recommending skim…

      • jessidehl

        My family gets WIC right now. My son cannot drink milk so he gets cheese (and it works just fine for him). My daughter gets lactose free milk but she can only get skim or 1%. As I understand it, you can get whole milk until a child is 2 then you have to switch.

        • katja

          My understanding from casual conversation and from a quick perusal of their website is that states have some leeway about the foods they offer, and the individual states and RDs do as well. I noted that they authorize all kinds of milk, from skim to whole for purchase, so I suppose the powers that be in each state can do things slightly differently. Will have to learn more though! Thanks for the input. It is interesting that your dtr can only have skim or 1% (is that moms too?) I assume that’s not price, but nutrition and weight concerns. I am curious how old she is, and if they would change a recommendation based on BMI…

          • Noreen

            Howdy, I’m a little late, but I’m a WIC Nutrition Educator in Florida, so I can at least tell you the guidelines here.

            From birth to 12 months, formula for non-breastfeeding infants.

            From 12 to 24 months, whole milk. If there is a need for soy, we can provide a soy formula at this age as well.

            From 2 years to 5 years, it’s 1% or Fat Free milk, both are on the check, and the parent can choose at the store. If your child is underweight or at risk for underweight, I can give you 2% at my discretion, but if you want whole milk at that age you will need a note from a medical doctor with an explanation of why it is needed (underweight, failure to thrive, medical condition that requires a higher fat diet). If you are between 2 and 5 and would prefer soy milk, I can provide that as long as you have a note from your doctor stating that she knows that you are providing soy and not cow milk, no medical reason necessary.

            For pregnant and postpartum women, it is basically the same. 1% or fat free is standard, you can get 2% with weight risks at my discretion, or whole with a qualifying note from your doctor. If you want soy, I can do that with no problem, no doctor’s note is needed.

            Lactose free milk is always an option, just ask for it. However, if you would prefer to get just cheese and no milk at all, I need a note from your doctor saying that is what he recommends for lactose intolerance.

            Part of my job is dealing with “well, he just won’t drink that milk.” I provide alternate calcium sources, and ways to use the milk that don’t involve drinking it.

            Thanks,
            Noreen

    • katja

      A quick search recommends “reduced fat” milk. I can see why some just say skim. Here is a link to a very recent Q and A at AAP website which gives me hope…
      http://www.healthychildren.org/english/tips-tools/ask-the-pediatrician/pages/question.aspx?qid=659&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

  10. Gretchen

    Oh no! Something new to worry about!

    I have a 26 month old and a 13 month old. They are both lactose-intolerant. Because we live in Switzerland, our grocery options are limited. The lactose-free milk is only available with 1.7% fat. Should I do something extra to get them more fat? They also both eat a lot of cheese and yogurt, which are always full fat. (Anything else would be considered scandalous to most Europeans!) In addition, the 14 month old still gets 4 bottles of formula per day and the 26 month old gets 8 ounces of formula at bedtime. (Cannot wean him completely while his little sister still gets bottles. Too close in age!)

    • katja

      E-gads! That is the last thing I want! I want to get rid of worry and food whenever possible! If your kiddos are eating lots of yogurt and cheese with fat they are almost certainly getting enough fat. Dont worry! :) Interesting that they are lactose intolerant, but seem to do ok with cheese and yogurt. Maybe the process of turning them into yogurt and cheese makes it more digestible. I bet you get great yogurt and cheese!

      • jaed

        Interesting that they are lactose intolerant, but seem to do ok with cheese and yogurt. Maybe the process of turning them into yogurt and cheese makes it more digestible.

        It does. (The yeast beasties that make milk into cheese or yogurt eat most of the lactose in the milk in the process.) Most lactose-intolerant people can eat at least some cheese and yogurt, although not all can.

        (I think I’m also going to mention how ill I feel at the thought of a doctor putting a one-year-old baby on a diet. Bleh.)

        • katja

          try 4 month old. I’ve seen it. I have had several families reach out who’s children were put on calorie restriction as toddlers, who are not really struggling in the grade school years. (As an aside, most were larger, but growing at a steady rate, so were probably going to slim down with time as statistics say they do. More than 2/3 of “obese and overweight” toddlers based on BMI will NOT grow up to be adults in that range.)

          • Kristin

            My brother (born in 74) was put on “a diet” when he was 6 weeks old. The pediatrician thought he was gaining weight too quickly so he told mom to feed him cereal in addition to nursing him.

          • katja

            would love to know more of the story. How did that go? Did he recommend any further action? I suspect that pediatrician had a lot of miserable patients out there over his career…

      • Gretchen

        I am actually lactose intolerant as well. The active bacteria in yogurt eats the lactose, so no issues there. And cheese doesn’t contain enough lactose to be an issue for most. You’d have to eat a fair amount (or be extremely sensitive). Regular milk, on the other hand, creates a reaction within minutes!

  11. Cecile

    Hi Katja. I like your new site !
    We all drink whole milk, my pediatrician was OK with that… at least for Chiara, I don’t think I even asked for Lucas, actually. We don’t seem to be overweight, either. I always had whole milk, I switched to 2% briefly after baby 2 but switched back because I think milk just tastes better when it’s whole… as do a lot of foods !

    • katja

      I grew up on skim milk, so I actually prefer it… I guess the point is as adults and older kids, drink what tastes good and don’t worry too much about it :) (As long as you are getting other sources of fat.)