Kids need to move. From school-age up through young adulthood, kids should get at least 60 minutes or more of physical activity each day. Unfortunately, most kids aren’t getting the recommended amount of daily exercise. The result? According to the Centers for Disease Control and Prevention, childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years. Here are some tips and information from Mona Luke-Zeitoun, M.D., a pediatrician at the Palo Alto Medical Foundation, to help make physical activity a regular part of your child’s life for optimal good health.

Why is exercise important?

The health benefits of exercise are immense. On a physical level, exercise builds strong bones, joints and muscles. It helps prevent obesity, decreases the risk of type 2 diabetes and lowers blood pressure and cholesterol. Kids who exercise regularly sleep better and have stronger immune systems.

Equally important are the mental benefits of exercise. Kids who exercise perform better academically. They have more confidence and stronger self-esteem and are better able to handle life’s daily challenges. For kids who have trouble focusing (including  kids with Attention Deficit Hyperactivity Disorder) or who have depression, the therapeutic benefits of exercise are as effective as many medications. Exercise also helps kids release stress and maintain emotional stability.

Why are kids today so sedentary?

Kids today are far less physically active mostly because they spend so little time engaging in “free play” outdoors and so much time in front of screens. Not all screen time is bad – kids rely on phones and devices not only for entertainment, but also to interact with online information, communicate with peers, do schoolwork and create content. But it’s important to make sure that tech use, like all other activities has reasonable limits. Prioritize daily unplugged playtime, especially for the very young.

What type of exercise is best?

While strength and flexibility are important components of exercise, the greatest health benefits of exercise are associated with building endurance. Choose aerobic activities that increase your child’s heart rate and breathing.

How can I help my son get more exercise?

For younger kids, the key is keeping it fun. If kids don’t enjoy an activity, they’re not going to do it. Keep exercise simple with imaginative games that involve throwing or kicking a ball, chasing bubbles, jumping over obstacles, or going out for a walk or scavenger hunt. If one activity gets boring, move along to another.

Exercise together. Take a daily walk after dinner or start a family tradition of weekend hikes or bike rides with a healthy picnic lunch. Studies show that exercising with a parent has a meaningful and long-lasting impact on children and encourages a lifelong love of exercise.

You are also the best fitness role model for your child. If you love a sport like tennis or swimming, share that with your child. Let them see you making exercise a regular part of your day.

Children are also often motivated by their friends, so find out what activities your child’s friends are participating in. Invite friends over and host active play dates to help everyone be healthy.

My teenage daughter is really busy with school. How can I help her get more exercise?

Older kids have busier schedules, so it isn’t surprising that physical activity tends to decline in this age group. Remind your daughter that exercise can help her achieve her academic goals, feel good about herself and relieve stress. Encourage her in activities that she can share with you or with peers; a yoga or dance class, a hike with friends, a game of ultimate Frisbee or even a long walk.

If she’s having trouble finding the time to be active, help her go through her daily schedule and look for blocks of time that can be dedicated to exercise. A particularly good opportunity is right after school, when physical activity can help kids decompress and clear their heads before beginning homework assignments.

What about organized sports?

While organized sports can be a positive experience for kids of all ages, there are a few considerations to keep in mind. Younger kids may still be developing basic skills, so it’s important to find a team that emphasizes participation and fun rather than competition and winning. Before committing to a team, talk to the coach or to other parents who have kids in the program.

Additionally, while some coaches excel at helping kids and make the game fun for everyone, there can be pressure on coaches to identify talent and win. For older kids, this can mean that better players are pushed hard and play constantly, while less-skilled kids spend most of their time on the bench. Ultimately it’s not ideal for either group – kids who show early talent are often burnt out or injured by age 10 or 12. And the kids who aren’t as good don’t have the opportunity to develop their skills and often lose interest, even though sports aptitude often manifests after puberty.

The bottom line is that while organized sports can be a fun way for kids to be active, experience teamwork and gain a sense of accomplishment, parents need to be aware of the potential challenges.  Keep an eye on your child and make sure that he or she is really enjoying the sport, not just doing it to please you.

What is the most important thing I can do to help my child be active?

Get outside together. For young children, a backyard, park or playground is the perfect place to engage in free play where they can be creative and make up their own games. Feed their imaginations with toys that can be used in many ways, like balls, pucks and hockey sticks and playground chalk. For older kids, look for local hikes, outdoor fitness classes and neighborhood running or bike paths. Share your love of being active outdoors and your kids will make it part of their lives, too.

Dr. Mona Luke-Zeitoun is a board-certified pediatrician and pediatric pulmonologist in the Palo Alto Medical Foundation.

Although parents naturally to want to protect their children from the ups and downs of life, it’s not always possible, especially as kids get older. Accordingly, one of the most important things you can do is to help your child develop the resilience, confidence and skills they need to handle problems and setbacks successfully. In this blog post, Manisha Panchal, M.D., a pediatrician at the Palo Alto Medical Foundation, answers these common questions and offers tips to help parents teach their kids how to stay healthy and balanced even when the going gets tough.

What’s the best way to raise a confident, resilient child?

In school, encourage your child to work hard, do their best and persevere, rather than focusing on achieving a certain grade. These goals will teach your child to work towards an objective and problem solve rather than giving up or feeling bad if they don’t receive a particular grade. Remember that parents’ expectations can put enormous pressure on children, even unintentionally.

Make sure your child always feels safe and loved. A secure, supportive and nurturing home environment gives your child a solid foundation to draw from when dealing with difficult situations.

Spend time together as a family. This is an essential part of creating a nurturing, safe environment for your child. Sitting down to a meal together at the end of the day is an easy way for parents and kids to connect and share what is going on in their lives.

What else can I do to help my son deal successfully with problems?

Dealing with any potential stress or problems is easier if you are healthy. Help your son establish lifelong healthy habits by teaching him a routine that emphasizes the following:

Sufficient sleep: Well-rested children manage challenges more effectively. 10-12 hours of sleep a day (for elementary school children) is critical to let your child’s brain rest from all the learning it has done during the day and to give your child’s body time to recover as it grows and develops.

Good nutrition: Use the five food groups (fruits, vegetables, grains, protein and dairy) as your guide. Offer foods in a rainbow of colors and encourage your son to try different foods. Children should also take a daily 400 IU vitamin D supplement for best health.

Regular exercise: At least sixty minutes of vigorous physical activity every day is essential. Kids who exercise regularly have less stress, more confidence and do better in school. To help encourage activity, prioritize unplugged time. Tech use, like all other activities, should have reasonable limits.

What are some of the signs that my daughter is getting too stressed?

Too much stress can affect your child’s health. Your daughter may be suffering from stress if she:

• Complains of headaches and stomach pains
• Seems withdrawn, forgetful or overwhelmed and is not doing what she is supposed to be doing
• Has trouble falling asleep and seems tired and irritable during the day
• Is not thriving at school and has less interest than usual in attending classes and doing homework
• Seems less interested in activities that she used to enjoy
• Loses or gains weight which might also indicate an eating disorder

How can I help my son learn to manage stress or problems?

Don’t try to solve your son’s problems for him. Instead, empower him with skills that he can use throughout his life when things get difficult to manage. Follow these tips:

• Teach time management, so school projects aren’t left to the last minute.
• Make time for breaks. Tasks often expand to fit the time allowed for them. Taking time for a break or sports activity can help provide stress relief.
• Help him create a manageable schedule. If assignments are slipping through the cracks or he is missing sports practices, help him problem solve to keep things balanced. Ask him what he thinks is a reasonable load and if there are any activities he could let go to make his schedule more manageable.
• Model good stress management skills – you are your child’s best role model.
• Keep the lines of communication open. Make sure you know what’s going on in his life and check in with him often. Let him know that you are always there to talk things through.

Manisha Panchal, M.D., is a board-certified pediatrician at the Palo Alto Medical Foundation. 

Colon cancer, also called colorectal cancer, this is a cancer that  begins in the colon (large intestine) or the rectum. Colorectal cancer is the third most common cancer in the United States and the second leading cause of cancer-related deaths. Most colorectal cancers start as abnormal growths in the lining of the colon or rectum called polyps. Over time, some polyps can turn into cancer.

“Colorectal cancer is a largely a preventable type of cancer,” says Brennan Scott, M.D., Chair of Gastroenterology at the Palo Alto Medical Foundation. “We have tests that detect many different types of cancer, but colon cancer can be prevented by doing a screening test to find polyps and removing them before they have a chance to become cancerous.”

According to the Centers for Disease Control and Prevention (CDC), at least 60 percent of deaths from colorectal cancer could be avoided by regular screening tests. At PAMF, the odds may be even better. New outcomes studies show that Dr. Scott and his team have surpassed national benchmarks for early tumor detection.

In this blog post, Dr. Scott answers common questions about colorectal cancer and explains how you can reduce your risk.

Who is at risk?

Colorectal cancer is most common in people over the age of 50 and the risk increases with age. Because of this, regular screening tests are recommended for average-risk people starting at age 50. People with a personal or family history of colorectal cancer or polyps, inflammatory bowel disease, or certain inherited genetic mutations may be at higher risk and should begin screening earlier. If you fit this description, talk to your doctor about when and how often to be tested, and what type of test is best for you.

What are the symptoms of colorectal cancer?

Precancerous polyps and the early stages of colorectal cancer often have no symptoms at all. This is why screening tests are so important. Signs and symptoms of later-stage colorectal cancer include:

• Altered bowel habits – including a change in stool consistency or frequency
• Blood in the stool
• Unexplained abdominal pain
• Unexplained weight loss
• Loss of appetite
• Anemia

What are the most common screening tests and how do they differ?

There are two general categories of screening tests: preventive tests that find both polyps and cancer and detection tests that primarily find cancer that has already formed.

Preventive tests include:

• Colonoscopy: The doctor uses a thin, flexible tube with a camera to examine the entire colon and remove any polyps that are detected. The procedure (which takes about 30 minutes) is usually performed under moderate sedation. Because colon must be empty so the doctor can see well, patients must “prep” by drinking a laxative before the test. The prep is generally considered the most unpleasant part of the test. However, if no polyps are found, colonoscopy typically needs to be performed only once every ten years.

• Sigmoidoscopy: Similar to a colonoscopy, but the doctor examines the only rectum and the lower third of the colon. Some bowel prep is required, and sedation is not routinely needed. It is used in conjunction with stool blood testing.

• CT Colonography: Also called a virtual colonoscopy, this a special type of CT scan. This test can detect larger polyps as well as cancer, although it may not detect smaller polyps. It is non-invasive, but a bowel prep must be still performed before the test, and the patient is exposed to some radiation.

Detection tests include:

• Stool Blood Tests: These tests look for tiny amounts of blood shed by colon tumors or large precancerous polyps. There are two types, one that uses a chemical to detect blood (FOBT or fecal occult blood test), and one that uses antibodies (FIT or fecal immunochemical test).  Both tests work on stool samples taken at home, and no prep is required. However, they need to be repeated yearly, and can miss many polyps and some cancers.

• Stool DNA Test. This test looks for genetic material shed by cancer or polyp cells. It should be repeated every three years, and also can miss many polyps and some cancers.

How do I know which screening test is right for me?

A colonoscopy is the only test that can detect and remove the abnormal growths and has been proven to prevent colon cancer. However, if you have concerns, your gastroenterologist may individualize a screening program for you that may combine several testing methods. If any of those tests indicate the presence of polyps or cancer, your doctor will schedule a colonoscopy.

Is there anything I can do to reduce my risk of colorectal cancer?

The most effective way to reduce your risk is by having regular screening tests. However, certain lifestyle factors may also help decrease your risk, such as:

• Be physically active
• Maintain a healthy weight
• Eat a diet that is high in fiber and low in fat, especially animal fat
• Avoid tobacco and limit alcohol consumption.

The CDC estimates that as many as one-third of adults age 50 or older have not been screened as recommended. Colon cancer is a cancer you can prevent. Talk to your doctor today about high quality colonoscopy screening at PAMF.

 Brennan Scott, M.D., is Chair of Gastroenterology at the Palo Alto Medical Foundation.  

According to the American Heart Association, about 5.7 million people in the United States have heart failure and that number is expected to rise to nearly 8 million in 2030. So what is heart failure and how can you avoid it?

“If you have heart failure, it means that your heart is unable to provide the support your body needs to function normally,” says Jared J. Herr, M.D., a cardiologist specializing in heart failure at the Palo Alto Medical Foundation. “It can’t keep up with pumping blood rich in nutrients and oxygen to all the organs in the body.”

There are two main reasons for heart failure. Either the heart muscle has stiffened (diastolic heart failure) or it has weakened (systolic heart failure).

Heart Failure Symptoms

“Some people may not experience any symptoms initially,” explains Dr. Herr. “Others will experience symptoms when the heart’s mechanisms to compensate for not being able to do its job properly begin to fail. For example, the heart may become enlarged, pump faster or your blood pressure may fall. Blood vessels respond by constricting to raise blood pressure. Then, because of this, the body shunts blood to the most important organs such as the heart and brain, neglecting the kidneys or liver.”

This results in symptoms including:

• Shortness of breath
• An irregular heart beat
• Feeling dizzy and light-headed
• Weight increase, swollen feet, ankles and legs and feeling bloated
• Tiredness and inability to do activities you used to be able to do

Causes of Heart Failure

People are most at risk of heart failure if they have a disease that damages the heart, including:

• Coronary heart disease (the most common type of heart disease)
• High blood pressure
• Diabetes
• Cardiomyopathy (diseases of the heart muscle)
• Valve diseases
• Kidney failure

“If you have any of these conditions, it’s very important to make healthy lifestyle changes and get treated now to prevent getting heart failure,” recommends Dr. Herr. “Quit smoking, follow a healthy diet, exercise and lose weight if you are overweight.”

Although there is no cure for heart failure there are many steps you can take to slow the disease’s progression and live a healthy life.

“Treatment options usually include taking medication, following a low-sodium diet, restricting fluids and getting daily exercise,” says Dr. Herr. “Patients may also need surgery to unblock arteries or a defibrillator or pacemaker placed in the chest to help control abnormal heart rhythms. Tracking your symptoms every day and working closely with your care team is also critical to managing the disease in the best possible way.”

Learn more about heart disease and preventing heart attacks on our blog:

The Truth About Heart Health

Heart Disease: What to Know

New Guidelines for Preventing Heart Attacks: What They Mean for You

 Jared J. Herr, M.D., is a board-certified cardiologist at the Palo Alto Medical Foundation.

Nap: these three letters together sound very sweet to most parents. “These daytime shut-eye sessions let your child process the learning and growth he or she is experiencing during the day and provide an important opportunity to rest and recuperate,” says Audrey Hall, M.D., a pediatrician at the Palo Alto Medical Foundation. Naps also ensure that your child doesn’t get overtired and cranky, and give parents chance to recharge their batteries, too. To determine your child’s optimal nap schedule, Dr. Hall offers these helpful tips.

What does a child’s typical nap schedule look like?

While each child is unique, here are some general guidelines by age.

• Newborn babies sleep 16 to 20 hours a day, in two to three hour spurts. Around four months, sleep patterns become more established, which is when parents can generally start sleep training.
• From four months to a year, babies typically sleep 14 to 15 hours with three naps a day. By age six to nine months, most babies drop the third nap and settle into a routine of one morning and one afternoon nap. Each nap can last anywhere from 45 minutes to two hours.
• Somewhere between 15 months and two years your toddler will usually give up the morning nap. He will sleep about 14 hours a night with a one to two hour nap in the afternoon.
• Around age three or four, your child will sleep about 10 to 12 hours a night and start transitioning out of needing an afternoon nap.
• School-age children require about 10 to 12 hours of night-time sleep.

How can I tell if my child is ready for a nap and what’s the best way to help him take one?

Look for cues from your child. Young babies will start fussing, rubbing their eyes and yawning. Toddlers will be more cranky and may keep zoning out. Follow these tips for successful naps:

• Have a consistent schedule: whenever possible, stick to naps at the same time of day, in the same place and duration. Young children do best when they have a familiar routine.
• Don’t wait until your child is overtired: put your child down for a nap when he is drowsy but still awake so he learns how to fall asleep by himself. If he is overtired, he will have a much harder time settling down.
• Create the right environment: dim the lights, sing a soothing song or read a quiet book together.
• Let him settle: If your child is making some noise, don’t immediately rush into his room. Many children chatter or talk a little as they are settling themselves down to sleep.
• Don’t make it a battle: It can be challenge to get a busy toddler to settle down for a nap and you can’t force your child to sleep. Instead, establish some quiet time where your child can look at books or play quietly in his room. He will benefit from the downtime – and may even fall asleep!

How will I know if my child is ready to give up her nap?

If you put your child down for a nap and she stays awake playing happily, she may no longer need that nap. If your child is cranky and irritable without a nap, she probably still needs one.

My child’s nap is now very late in the day. Should I still let her nap at this time?

A nap very late in the day may interfere with getting your child to settle down at bedtime. If your child is sleeping longer than two hours, try waking her up sooner, or gradually moving her naptime to an earlier time. Once your child is no longer napping during the day, she may need an earlier bedtime to ensure she gets the sleep she needs.

Audrey Hall, M.D. is a board-certified pediatrician at the Palo Alto Medical Foundation. 

Many of us rush through the day with only a vague awareness of gulping down breakfast, the autopilot commute and the non-stop blur of meetings and projects. The result: stress, burnout, anxiety and depression. But you don’t need to feel powerless. Practicing mindfulness can help.

“Mindfulness is about paying attention to what you are experiencing right now with genuine interest and a willingness to accept that experience, says Kaveri S. Patel, D.O., a family medicine doctor at the Palo Alto Medical Foundation. “The health benefits are many. Studies show that mindfulness reduces stress and anxiety, and provides us with a sense of well-being and the ability to notice the joyful moments in life. It also helps us relate to each other from a kinder place, making work a more positive experience and giving us tools to better cope with challenges.”

Ready to improve your work experience through practicing mindfulness? Dr. Patel offers these simple tips:

Choose how to start your day. Before you get out of bed, take a few moments to breathe and notice your breath. Set an intention for your day, for example, to be kind to yourself and others.

Use transitions well. Don’t catch up on texts or emails on your phone while walking from your car to the office or between meetings. Instead, notice the sensation of your feet walking on the floor and the connection with the ground. Notice and greet colleagues you pass.

Enjoy meals. Take time away from your computer or desk to enjoy lunch – notice the colors, taste and smell of the food.

Use prompts as reminders. Whether it’s a simple sticky note with the word “Breathe” on it, or a photo of a peaceful nature scene – use these visual cues to help you take a few conscious breaths at regular intervals.

Pause before reacting. Before reacting to a challenging situation at work, take a breath to help give yourself time to feel more grounded and react calmly and thoughtfully.

Make mindfulness part of your commute. Choose some days to drive without listening to music or the radio. Instead, breathe deeply. Send well wishes to yourself and others. Observe your feelings and thoughts with compassion and without judging.

Breathe. Throughout your day, take time to inhale deeply and exhale completely. This can help you become fully aware of your senses, how you are feeling and help you relax. Learn more about mindful breathing and how to get started in this PAMF blog post.

Learn More About Mindfulness

PAMF offers several Mindfulness-Based Stress Reduction programs for adults and teenagers. Dr. Patel teaches a Meditation and Reflective Journaling class in Fremont and Palo Alto.

 Kaveri S. Patel, D.O., is a family medicine doctor at the Palo Alto Medical Foundation.

Puberty – it’s a time of many changes for your child. While kids often struggle with the timing of physical changes as compared to their peers, parents may find the emotional changes to be the most challenging. “One minute your child is yearning for independence, the next he or she wants to be close to you. It’s a time of constant rebalancing,” says Robin Drucker, M.D., a pediatrician at the Palo Alto Medical Foundation. In this blog post, Dr. Drucker answers common questions parents have about puberty. 

When does puberty start and what are the signs?

Girls typically enter puberty between 8 and 13 years old. Early signs include breast development, body odor, darkening hair color and the appearance of pubic and underarm hair, with a first period following in about two years. Girls grow the fastest during the six months before their first period, then continue to grow slowly for the next two or three years.

Boys usually enter puberty around age 11 or 12. The first sign is most often body odor, followed by testicular growth, body hair and voice changes. There is no set time for the end of puberty for boys – they may continue to grow all the way through college.

What’s the best way to talk to my child about puberty?

During fourth and fifth grade, puberty and sex education are usually part of the curriculum at school. This can be a good opportunity to speak to your child about this topic. Some medical and community organizations offer puberty classes that boys and girls attend with a parent, which can also be a good conversation starter. Either way, make sure your child hears this important information from you first, and knows that he or she can always come to you with questions.

Be sure to talk to your daughter about periods well before they might start, and make sure she’s prepared with a starter kit of sanitary supplies that she can keep in her backpack or locker at school.

Can puberty come too early or too late?

There is a wide range of what’s considered normal when it comes to puberty. Speak to your child’s doctor if your child has signs of puberty before age 8, or has no signs by age 14.  Also speak to your doctor if your daughter has not started her period by age 16.

What can I do to support my child’s health during this time?

• Ensure Ample Sleep: Growing is hard work. At least nine to 10 hours of sleep at night is recommended to give your child’s brain and body sufficient time to rest and restore energy.
• Encourage Good Nutrition: Healthy foods fuel healthy growth. Make sure your child has plenty of healthy food options and doesn’t skip meals. Inadequate nutrition can intensify hormonal mood swings.
• Top Up Calcium and Iron: Our bodies build the most bone mass during these years, so it’s vital that your child gets the recommended 1,300 mg of calcium a day. (Four 8-ounce servings of calcium-rich products such as milk or yogurt). Once your daughter gets her period, make sure she is getting the recommended 8 mg per day of iron. The richest sources of iron are lean meat and seafood followed by nuts, beans and vegetables. A daily multivitamin can help cover any potential deficiencies.
• Hydrate: Remind your rapidly-growing preteen or teen to drink enough fluids – preferably water – throughout the day.
• Monitor Social Media Involvement: Although it’s not always easy, try and stay on top of what your child is looking at online, and who he or she is connected with on social media. Talk to your child regularly about his or her social media involvement so you can provide guidance.

Robin Drucker, M.D., is a board-certified pediatrician at the Palo Alto Medical Foundation’s Palo Alto Center.

How much sleep does my child need?

Although there is no one-size-fits-all number, in general toddlers and preschoolers need 11 to 12 hours of sleep, school-age children at least 10 hours and teens about nine to 10 hours per day.

What’s the best way to establish a good sleep routine?

Every child can benefit from a bedtime routine that encourages good sleep habits. Use these tips as a guide to help your child fall asleep more easily:

• Stick to a regular bedtime and give your child a heads-up when bedtime is approaching.
• Create a calming, familiar bedtime routine. Dim the lights, sing a lullaby and read a book together.
• Let your baby or young child learn to settle and soothe him or herself to sleep. This is one of the best gifts you can give your child to help encourage lifelong good sleep.
• Turn off all screens (TVs, tablets, phones and laptops) before you start your wind-down routine, and keep screens and chargers out of the bedroom. Studies have shown that the bright light from screens suppresses melatonin, the hormone that our bodies make to help us sleep.
• Encourage teens to set and maintain a bedtime.

How do I know if my daughter is getting enough sleep?

Children need a fairly predictable amount of sleep to be happy and function well. You’ll be able to tell if your daughter is getting enough sleep based on how she behaves during the day. Although she won’t necessarily appear sleepy, if it seems like she is on an emotional roller coaster – happy and wound-up one moment, then upset and cranky the next – try making sure she gets more sleep.

Are there any sleep disorders that might stop my son from sleeping well?

There are a number of things that can disrupt a child’s sleep.

• Nightmares and night terrors both disrupt sleep, although they are actually very different. If your son is experiencing a nightmare, you will be able to gently wake him up and comfort him. Providing a nightlight or leaving his bedroom door open can be reassuring and help him get back to sleep. Night terrors, on the other hand, take place during the deepest stage of your child’s sleep. A child experiencing a night terror cannot be woken – the only thing to do is to wait it out.
• Sleepwalking. If your child sleepwalks, make sure his surroundings are safe, doors and windows are secured and there are no sharp edges or obstacles nearby. If you find your son sleepwalking, gently guide him back to bed.
• Obstructive sleep apnea. A cold may cause your son to snore but if he doesn’t have a cold and is snoring a lot, he might have sleep apnea. Daytime symptoms may include sluggishness, irritability and difficulty getting up in the morning.
• Bedwetting. This is still quite common for children under five and can disrupt their sleep. If your son is over five and still wetting the bed, check in with his doctor.

How do I handle my daughter’s sleep schedule during summer or other vacations?

During vacations, it’s OK to be flexible about your daughter’s usual bedtime routine and shift sleep times to enjoy those long summer days and special vacation activities. The most important thing is that your daughter gets enough sleep. As the start of school approaches, start easing back into her usual sleep routine.

 Paul Protter, M.D., is a board-certified pediatrician at the Palo Alto Medical Foundation.

What are carbohydrates and how do they affect your health? Carbohydrates include starches like bread, pasta, rice, cereal and potatoes, as well as sugars such as milk, yogurt and cookies. During digestion, all carbohydrates are converted to sugar and released into the bloodstream, where they are either used for energy or stored as fat.

But not all carbs are created equal. Or more accurately, not all carbs have the same effect on blood sugar. The measure of the effect of carbs on blood sugar is called the glycemic index (GI).

High GI carbs like white bread, instant mashed potatoes and sugary beverages digest quickly, causing blood sugar levels to surge. “In the body, these blood sugar spikes cause the release of insulin, fat storage, mood swings and brain fog,” says Darcie Ellyne, M.S., R.D., CDE, a registered dietitian and certified diabetes educator at the Palo Alto Medical Foundation (PAMF). “Then blood sugar plummets, causing the release of the stress hormone cortisol, food cravings, fatigue and more brain fog.”

Good (low GI) carbs, on the other hand, like bran cereal, fresh fruit and vegetables, are digested slowly.  As a result, your blood glucose rises slowly than falls gradually over a longer period of time, which helps control appetite and delay hunger.

“Not only do we feel better when  blood sugar levels stay steady throughout the day, but a low GI diet also reduces your risk of diabetes, cardiovascular disease, breast and colon cancer, Alzheimer’s and obesity,” says Ellyne.

Ellyne answers these commonly asked questions about good and bad carbs:

How do I know which carbohydrates have a low or high glycemic index?

• Processing – The more a food has been processed, the easier it is for the digestive enzymes to attack it quickly, and the higher the GI. To choose less processed foods, think about how that starch occurred in nature, and how much processing was required to get it to its current form.
• Particle size – If your body has to do more of the work to break large food particles down, the GI is likely to be lower. For example, steel cut oats, which are covered by a layer of fiber, have a lower GI than long cook oatmeal, and long cook oatmeal has a lower GI than instant oatmeal.
• Sugar Content – Consider both the type and amount of sugar contained in your food. Fructose has the lowest GI, then sucrose and then glucose.

What other factors affect glycemic index?

• Food combination – Combining your carbohydrates with fat and protein slows down the rate of digestion and lowers the GI. So for a healthier snack that keeps you satisfied, have a wedge of cheese with your apple, or a spoonful of peanut butter on your toast.
• Acid content – Adding acid to a food lowers the GI. This makes sourdough bread relatively low on the GI scale, and gives you another great reason (besides flavor), to add a dash of lemon or balsamic vinegar to foods.
• Cooking time – The longer you cook a food, the higher the GI. Less cooking means the body has to work harder to digest the food, so keep your pasta al dente and serve your steamed broccoli as soon as it turns bright green and you can pierce it with a fork.
• Physical entrapment – Whole grains have a fibrous coat that acts a physical barrier to slow down the digestion of the starch inside. White flour, on the other hand, has been processed and all the fiber has been removed. So instead of corn flakes, choose All Bran cereal, and instead of a bagel, choose pumpernickel bread.

What  general rules should I follow to lower the glycemic index in my diet?

• Eat starches as they are in nature. Watch portions, especially of high GI starches like potatoes and white rice. Choose intact, minimally-processed grains and legumes.
• Add an acidic fruit or condiment.
• Include a lean protein in a meal or snack.
• Include a healthy fat (olive or nut oils).
• Include produce at every meal, and avoid juicing fruits and vegetables.

Glycemic food choices: More fun facts

• Eggs and cheese are considered a protein. Fat and protein won’t increase blood sugar, but milk and regular (non-Greek) yogurt will. Greek yogurt generally has about half the carbs, and twice the protein of regular yogurt.
• To choose lower GI fruits, keep in mind the general rule that tropical fruits (bananas, mangos, etc.), have a higher GI than non-tropical fruits (apples, oranges).
• Pasta is a relatively low GI food – as long as you cook it al dente.
• Potatoes – especially white potatoes – spike blood sugar more than eating straight sugar.

“Making food choices that lower GI and boost nutrition will not only keep you focused and productive throughout the day, but can help prevent diabetes and other diseases,” says Ellyne. “So get off the sugar roller coaster and enjoy smooth sailing all day long.”

Darcie Ellyne, M.S., R.D., CDE, is a registered dietitian and certified diabetes educator at the Palo Alto Medical Foundation.

Is it healthy to snack or is this just a sure-fire way to pile on unwanted pounds?

“Snacks can be an important part of a nutritious and balanced diet,” says Valerie Spier, MPH, R.D., CDE, a registered dietitian and diabetes educator at the Palo Alto Medical Foundation. “But you do need to be thoughtful about the quality and quantity of snacks. It’s very easy to overdo it and too many snacks can easily derail efforts to maintain a healthy weight.”

Healthy snacks can benefit you in several ways, says Spier. They can:

• Help meet energy needs, especially for children and athletes
• Round out the daily nutrients you need to stay healthy
• Bridge the gap between meals (if you are allowing about six hours between meals)
• Help prevent low blood sugar and overeating

What is a healthy snack?

A healthy snack is a small amount of food or a beverage (approximately 100 to 150 calories) you have between meals. Don’t forget to include any beverages towards your daily calorie count, as many specialty coffee drinks and smoothies are laden with sugar and calories.

“To help you pick the right snacks, start by looking at your diet and what you eat every day to help you determine nutritional gaps,” suggests Spier. “Most people don’t eat enough fruits and vegetables so choosing a snack from that food group is always a good option.”

Spier offers the following healthy snack ideas (that all contain about 100 to 150 calories) from the five food groups to help you balance your nutritional needs.

Dairy (to meet calcium needs): glass of milk, kefir, almond or soy milk; flavored yogurt; cottage or ricotta cheese with fruit or veggies; one portion of low-fat string cheese; Parmesan cheese crisps (grated cheese, baked in the oven), kale chips or edamame

Fruit: fruit kebab; one small piece of whole, seasonal fruit; two tablespoons of dried fruit; unsweetened applesauce, 4 to 6 ounce fruit smoothie or dehydrated fruit crisps

Vegetables: raw or roasted vegetables; one cup of vegetable or minestrone soup; endive or lettuce wrap; veggie smoothie (limit add-ins); salad or pickled vegetables (quantities for veggie snacks: unlimited non-starchy vegetables, half a cup of starchy vegetables)

Carbohydrates/Starch: one cup of quinoa or other grain-based salad; cup of butternut or corn soup; wasabi peas or spicy garbanzo beans; half-a-cup of oatmeal; three cups of air-popped popcorn; three falafel; one serving (15 to 30 grams of carbohydrates) of whole-grain crackers

Protein: one hard-boiled egg; 1 to 2 ounces of left-over meat, fish or poultry, beef or turkey jerky, canned tuna, sardines, oysters or kippers; a handful of nuts or seeds; a cup of bean or lentil soup or marinated tofu (check serving size on package to limit to 100 to 150 calories)

For beverages, choose unsweetened options such as herbal or green iced or hot teas, sparkling water or water flavored with a slice or fruit or cucumber to help keep your calorie intake on track.

Avoid the Snack Attack

So how can you make sure you snack sensibly, not mindlessly?

The best approach, says Spier, is to think about whether you really need a snack.

“Before you just grab a snack, determine if you are really hungry,” advises Spier. “For example, you might think you want something to eat but are actually thirsty. Try drinking an unsweetened beverage first. Or you might be bored or stressed. Consider going for a quick walk outside, do a couple of stretches or deep breathing if you are at work or enjoy a chat with a friend before eating something.”

Shopping ahead for healthy snacks and stocking the fridge with cut-up, prepared fruits and vegetables for easy access is also a good plan. Make tea or fruit-flavored waters and have them ready in the fridge to drink.

“Combining a carbohydrate-containing food with a low-carb food, such as eating an apple with a piece of cheese, is a great way to enjoy a healthy snack that will help keep you feeling full longer,” says Spier. “And avoid traditional snack foods such as chips that are high in calories but low in nutritional value.”

 Valerie Spier, MPH, R.D., CDE, a registered dietitian and diabetes educator at the Palo Alto Medical Foundation.