The Kidfixer Newsletter

A quarterly newsletter from Doctors Mesibov, Altman, Jacobs & Neustein            Spring 2019


New doc in da house!

As many of you know, Dr. Marcia Rubinos has moved her family to North Carolina. Marcia is a great doc, and we will all miss her.

Here’s the good news: Dr. Sherrie Neustein, a wonderful Board Certified Pediatrician, will be joining us as of February 11th!

For the past several years Dr. Neustein has been practicing in West Islip. She is a graduate of Brandeis University and an honors graduate of Tufts University Medical School. Dr. Sherrie did her residency at Cohen’s Children’s Hospital of LIJ.

Dr. Neustein’s interests include breastfeeding, preventative medicine and safety, pediatric nutrition, and obesity management. She completed a research fellowship at the New York Obesity Research Center of Columbia University, and has been published in the Contemporary Pediatrics Journal.

We know you will all join us in welcoming Dr. Sherrie to our Kidfixer family.

Fish: Why (and How) to Choose this Healthful Protein

From the Tufts Nutrition Newsletter

Fish are a great addition to a healthy diet, but decisions at the seafood counter can scare some consumers off. Choosing doesn’t have to be confusing. Make a variety of fish and other seafood a regular part of a healthy dietary pattern.

Dietary guidelines from governments and health organizations around the world agree: a healthy dietary pattern includes around two servings of fish a week. Most Americans get less than the recommended eight ounces per week. What makes fish such an important part of a healthy diet, and what are the best choices for health and the environment?

Fish and Health: A versatile, high-quality protein source that is relatively quick and easy to cook, fish have been studied in connection with numerous health benefits. Eating fish has been associated with lower blood pressure and lower risk of stroke and heart attack, and has also been studied for lowering risk of depression, cognitive decline, and other chronic conditions. In fact, eating approximately one to two three-ounce servings of fatty fish a week could reduce the risk of dying from heart disease by 36 percent.

Fish provide protein and a variety of vitamins and minerals, but they are best known for their fat profile: fish have less saturated fat and more health-promoting polyunsaturated fat than other animal protein sources and are the top dietary source of long-chain omega-3 fatty acids, which   are known to be important to normal growth and development and have been studied for their potential to lower triglycerides, reduce risk of blood clots, lower blood pressure, reduce inflammation, and decrease risk of stroke.

Fattier fish like salmon and mackerel naturally contain more omega-3 fatty acids than leaner fish, but all fish have some omega-3s. For top sources, see starred choices in the “Choosing Fish” box.

Common Concerns: The news about fish is not always positive. In recent years, concerns have been raised about contaminants and sustainability, and a seafood counter offering a variety of both farmed and wild-caught fish from around the world can be a confusing place.

  - Contaminants. Pesticides, industrial chemicals, and other contaminants in waterways can become incorporated into the tissue of fish and other seafood. Results of regular testing of commercial seafood samples by the FDA generally find levels of pesticides and industrial chemicals that do not raise human health concerns.

One contaminant that has gotten a lot of attention is mercury. Some mercury occurs naturally, but it is also released into the environment through many types of human activity, and can collect in streams, lakes, and oceans. Larger and longer-lived fish tend to have higher levels of mercury contamination because it accumulates as the fish grow. Although current mercury levels are not thought to be dangerous to most people, mercury can be harmful to the brain and nervous system if a person is exposed to too much of it over time, and can particularly negatively affect the brain of a developing fetus. Since omega-3s are important in fetal development, it is recommended that pregnant women eat low-mercury fish regularly. (see the “Choosing Fish” box below).

   - Sustainability. “Sustainability, from an environmental perspective, is about leaving enough fish in the water to make sure the resource can renew itself in the future,” says Kyle Foley, sustainable seafood program manager at the Gulf of Maine Research Institute and a Friedman School alum. Nationally, there are fisheries regulations in place that can govern how much, when, where, and how fish can be harvested. “The U.S. today has arguably the strongest fisheries management in the world,” says Foley, “so people can feel pretty good about buying domestic fish. Plus, many grocery store chains work with organizations like ours to help them determine whether they are buying responsibly harvested seafood for their customers.”

Farmed vs. Wild. Both farmed and wild-caught fish are healthy choices. “There is a misconception that farmed fish are lower in omega-3 fatty acids than wild-caught,” says Lichtenstein. “In most cases farmed are actually the same or a bit higher.”

Like wild-caught varieties, farmed fish can be sustainable or unsustainable. “When it is done responsibly, farming fish is a really efficient, environmentally responsible way to provide healthy protein,” says Foley. “Stores are increasingly looking for farmed fish that is certified, so check with your purveyor.”

Much busting: hydration

From the Tufts Nutrition Newsletter

Water is involved in many critical bodily functions, from maintaining blood pressure and transporting nutrients to lubricating joints, digesting foods, removing waste from the body, and regulating body temperature. “The human body loses fluids through sweating and urination, and, if sick, also potentially through vomiting, diarrhea, or blood loss,” says Roger A. Fielding, PhD, director of the Nutrition, Exercise Physiology, and Sarcopenia Laboratory and a professor at the Friedman School of Nutrition Science and Policy. Diuretics (medications that increase urine output) can also play a role. “If we lose significantly more fluids than we take in, the result is dehydration,” says Fielding. Chronic dehydration can contribute to fatigue, low blood pressure, constipation, urinary tract infections, and kidney stones, as well as reduced mental activity and physical coordination. Dehydration can also place stress on the cardiovascular system, and emerging evidence suggests it may increase the risk of damage from inflammation, which in turn elevates risk for chronic disease. Let’s take a look at some common myths and misconceptions regarding staying hydrated.

Myth #1: Everyone should drink eight 8-ounce cups of water every day.

Although this is not a bad rule of thumb, it’s not strictly true. How much fluid a given individual needs depends on a number of factors including body size, physical activity level, ambient temperature, humidity, and even the altitude. If you are sweating on a hot day, for example, you will need more water than if you are watching TV in an air-conditioned room. According to the National Academy of Science, 15.5 cups of water intake for most men and 11.5 cups for most women per day is adequate (more for women who are pregnant or lactating). This is much higher than the eight 8-ounce cup baseline, but foods (such as fruits, vegetables, soup, and even fish, eggs, meat, and cooked grains) supply a significant part of our needs. Beverages like coffee, tea, and milk are composed mostly of water.

Myth-busting advice: Individual needs are more important than numbers. Set a baseline, but, drink more when you’re thirsty, when it’s hot, or during exercise.

Myth #2: It doesn’t matter what I drink, as long as I stay hydrated.

It is true that any beverage or fluid-rich food will help to keep the body hydrated, but there is more to staying healthy than avoiding dehydration. Beverages with lots of added sugars, like soda, energy drinks, sports drinks, and sweetened ice teas, coffee drinks, and fruit drinks may quench your thirst, but there is plenty of evidence that they are bad for your health. Even 100 percent fruit juice provides a dose of natural sugar that could add unneeded calories without the fiber naturally present in fruit. (Most guidelines recommend no more than one 8-ounce serving of fruit juice each day.) Health effects of low-calorie or zero calorie drinks that use artificial or naturally low-calorie sweeteners remain controversial. While there is no strong evidence of harm, growing signals from animal studies and some research in humans suggest these may not be as safe as water. Finally, alcohol should not be used for hydration. “Alcoholic beverages have a significant diuretic effect, and thus contribute to dehydration,” says Fielding.

Myth-busting advice: Water (plain, sparkling, and unsweetened flavored) is the best choice for hydration. Unsweetened tea and coffee are also good choices (see Myth #3). Milk also quenches thirst while providing protein and bone-maintaining calcium and vitamin D.

Myth #3: Caffeinated beverages don’t count toward fluid intake.

Caffeine can modestly increase water loss through urination, but not enough to cause dehydration. This effect may also be less prominent in people who habitually drink caffeinated drinks like coffee or tea. Coffee and tea have been associated in some studies with health benefits, such as lower risk of diabetes. The health benefits of decaffeinated coffee appear to be similar to those of regular coffee.

Myth-busting advice: Caffeinated beverages can count toward fluid intake—but be mindful what you add to your coffee and tea, particularly if you drink them multiple times per day.

Myth #4: People only need to drink when they are thirsty.

Thirst is triggered by the brain in response to low fluid balance in the body. In generally healthy people, thirst and consumption of foods and drinks at meals and snacks are typically enough to maintain hydration. But, with aging the body’s ability to sense hydration and thirst may be less sensitive. Several studies suggest that older adults drink less water than younger adults, although they need just as much in general. In some people, the loss of as little as two to three percent of body fluid can cause physical and cognitive impairment, so it’s important to keep an eye on your fluid intake if you tend to not feel or not notice thirst. The color of your urine can be a clue to hydration status: If it is deep yellow it could indicate you are not drinking enough.

Myth-busting advice: While most people respond normally to their thirst cues, remember to consciously drink water if you’re over age 65, on hot days, or when you’re exercising.

Keep your kids active and healthy

A publication

Regular physical activity in children and adolescents promotes health and fitness. Compared to those who are inactive, physically active youth have higher levels of cardiorespiratory fitness and stronger muscles. They also typically have lower body fatness. Their bones are stronger, and they may have reduced symptoms of anxiety and depression.

Youth who are regularly active also have a better chance of a healthy adulthood. Children and adolescents don't usually develop chronic diseases, such as heart disease, hypertension, type 2 diabetes, or osteoporosis. However, risk factors for these diseases can begin to develop early in life. Regular physical activity makes it less likely that these risk factors will develop and more likely that children will remain healthy as adults.

Youth can achieve substantial health benefits by doing moderate- and vigorous-intensity physical activity for periods of time that add up to 60 minutes (1 hour) or more each day. This activity should include aerobic activity as well as age-appropriate muscle- and bone–strengthening activities. Although current science is not complete, it appears that, as with adults, the total amount of physical activity is more important for achieving health benefits than is any one component (frequency, intensity, or duration) or specific mix of activities (aerobic, muscle-strengthening, bone strengthening). Even so, bone-strengthening activities remain especially important for children and young adolescents because the greatest gains in bone mass occur during the years just before and during puberty. In addition, the majority of peak bone mass is obtained by the end of adolescence.

This chapter provides physical activity guidance for children and adolescents aged 6 to 17, and focuses on physical activity beyond baseline activity.

Parents and other adults who work with or care for youth should be familiar with the Guidelines in this chapter. These adults should be aware that, as children become adolescents, they typically reduce their physical activity. Adults play an important role in providing age-appropriate opportunities for physical activity. In doing so, they help lay an important foundation for life-long, health-promoting physical activity. Adults need to encourage active play in children and encourage sustained and structured activity as children grow older.

Key Guidelines for Children and Adolescents

  1. Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily.

    1. Aerobic: Most of the 60 or more minutes a day should be either moderate- or vigorous-intensity aerobic physical activity, and should include vigorous-intensity physical activity at least 3 days a week.

    2. Muscle-strengthening: As part of their 60 or more minutes of daily physical activity, children and adolescents should include muscle-strengthening physical activity on at least 3 days of the week.

    3. Bone-strengthening: As part of their 60 or more minutes of daily physical activity, children and adolescents should include bone-strengthening physical activity on at least 3 days of the week.

  2. It is important to encourage young people to participate in physical activities that are appropriate for their age, that are enjoyable, and that offer variety.

Types of Activity: The Guidelines for children and adolescents focus on three types of activity: aerobic, muscle-strengthening, and bone-strengthening. Each type has important health benefits.

  1. Aerobic activities are those in which young people rhythmically move their large muscles. Running, hopping, skipping, jumping rope, swimming, dancing, and bicycling are all examples of aerobic activities. Aerobic activities increase cardiorespiratory fitness. Children often do activities in short bursts, which may not technically be aerobic activities. However, this document will also use the term aerobic to refer to these brief activities.For More Information

  2. Muscle-strengthening activities make muscles do more work than usual during activities of daily life. This is called "overload," and it strengthens the muscles. Muscle-strengthening activities can be unstructured and part of play, such as playing on playground equipment, climbing trees, and playing tug-of-war. Or these activities can be structured, such as lifting weights or working with resistance bands.

  1. Bone-strengthening activities produce a force on the bones that promotes bone growth and strength. This force is commonly produced by impact with the ground. Running, jumping rope, basketball, tennis, and hopscotch are all examples of bone strengthening activities. As these examples illustrate, bone-strengthening activities can also be aerobic and muscle-strengthening.

How Age Influences Physical Activity in Children and Adolescents

Children and adolescents should meet the Guidelines by doing activity that is appropriate for their age. Their natural patterns of movement differ from those of adults. For example, children are naturally active in an intermittent way, particularly when they do unstructured active play. During recess and in their free play and games, children use basic aerobic and bone-strengthening activities, such as running, hopping, skipping, and jumping, to develop movement patterns and skills. They alternate brief periods of moderate- and vigorous-intensity physical activity with brief periods of rest. Any episode of moderate- or vigorous–intensity physical activity, however brief, counts toward the Guidelines.

Children also commonly increase muscle strength through unstructured activities that involve lifting or moving their body weight or working against resistance. Children don't usually do or need formal muscle-strengthening programs, such as lifting weights.

Regular physical activity in children and adolescents promotes a healthy body weight and body composition. As children grow into adolescents, their patterns of physical activity change. They are able to play organized games and sports and are able to sustain longer periods of activity. But they still commonly do intermittent activity, and no period of moderate- or vigorous-intensity activity is too short to count toward the Guidelines.

Adolescents may meet the Guidelines by doing free play, structured programs, or both. Structured exercise programs can include aerobic activities, such as playing a sport, and muscle-strengthening activities, such as lifting weights, working with resistance bands, or using body weight for resistance (such as push-ups, pull-ups, and sit-ups). Muscle-strengthening activities count if they involve a moderate to high level of effort and work the major muscle groups of the body: legs, hips, back, abdomen, chest, shoulders, and arms.

Levels of Intensity for Aerobic Activity

Children and adolescents can meet the Guidelines by doing a combination of moderate- and vigorous intensity aerobic physical activities or by doing only vigorous-intensity aerobic physical activities. Youth should not do only moderate-intensity activity. It's important to include vigorous-intensity activities because they cause more improvement in cardiorespiratory fitness.

The intensity of aerobic physical activity can be defined on either an absolute or a relative scale. Either scale can be used to monitor the intensity of aerobic physical activity:

  1. Absolute intensity is based on the rate of energy expenditure during the activity, without taking into account a person's cardiorespiratory fitness.

  1. Relative intensity uses a person's level of cardiorespiratory fitness to assess level of effort. Relative intensity describes a person's level of effort relative to his or her fitness. As a rule of thumb, on a scale of 0 to 10, where sitting is 0 and the highest level of effort possible is 10, moderate-intensity activity is a 5 or 6. Young people doing moderate-intensity activity will notice that their hearts are beating faster than normal and they are breathing harder than normal. Vigorous-intensity activity is at a level of 7 or 8. Youth doing vigorous-intensity activity will feel their heart beating much faster than normal and they will breathe much harder than normal.

When adults supervise children, they generally can't ascertain a child's heart or breathing rate. But they can observe whether a child is doing an activity which, based on absolute energy expenditure, is considered to be either moderate or vigorous. For example, a child walking briskly to school is doing moderate-intensity activity. A child running on the playground is doing vigorous-intensity activity.

Examples of Moderate- and Vigorous-Intensity Aerobic Physical Activities and Muscle- and Bone-Strengthening Activities for Children and Adolescents

Type of Physical Activity

Age Group

Age Group

Moderate–intensity aerobic

  1. Active recreation, such as hiking, skateboarding, rollerblading

  2. Bicycle riding

  3. Brisk walking

  4. Active recreation, such as canoeing, hiking, skateboarding, rollerblading

  5. Brisk walking

  6. Bicycle riding (stationary or road bike)

  7. Housework and yard work, such as sweeping or pushing a lawn mower

  8. Games that require catching and throwing, such as baseball and softball

Vigorous–intensity aerobic

  1. Active games involving running and chasing, such as tag

  2. Bicycle riding

  3. Jumping rope

  4. Martial arts, such as karate

  5. Running

  6. Sports such as soccer, ice or field hockey, basketball, swimming, tennis

  7. Cross-country skiing

  8. Active games involving running and chasing, such as flag football

  9. Bicycle riding

  10. Jumping rope

  11. Martial arts, such as karate

  12. Running

  13. Sports such as soccer, ice or field hockey, basketball, swimming, tennis

  14. Vigorous dancing

  15. Cross-country skiing


  1. Games such as tug-of-war

  2. Modified push-ups (with knees on the floor)

  3. Resistance exercises using body weight or resistance bands

  4. Rope or tree climbing

  5. Sit-ups (curl-ups or crunches)

  6. Swinging on playground equipment/bars

  7. Games such as tug-of-war

  8. Push-ups and pull-ups

  9. Resistance exercises with exercise bands, weight machines, hand-held weights

  10. Climbing wall

  11. Sit-ups (curl-ups or crunches)


  1. Games such as hopscotch

  2. Hopping, skipping, jumping

  3. Jumping rope

  4. Running

  5. Sports such as gymnastics, basketball, volleyball, tennis

  6. Hopping, skipping, jumping

  7. Jumping rope

  8. Running

  9. Sports such as gymnastics, basketball, volleyball, tennis

Note: Some activities, such as bicycling, can be moderate or vigorous intensity, depending upon level of effort

Meeting the Guidelines

American youth vary in their physical activity participation. Some don't participate at all, others participate in enough activity to meet the Guidelines, and some exceed the Guidelines. Children and adolescents can meet the Physical Activity Guidelines and become regularly physically active in many ways.

One practical strategy to promote activity in youth is to replace inactivity with activity whenever possible. For example, where appropriate and safe, young people should walk or bicycle to school instead of riding in a car. Rather than just watching sporting events on television, young people should participate in age-appropriate sports or games.

  1. Children and adolescents who do not meet the Guidelines should slowly increase their activity in small steps and in ways that they enjoy. A gradual increase in the number of days and the time spent being active will help reduce the risk of injury.

  2. Children and adolescents who meet the Guidelines should continue being active on a daily basis and, if appropriate, become even more active. Evidence suggests that even more than 60 minutes of activity every day may provide additional health benefits.

  3. Children and adolescents who exceed the Guidelines should maintain their activity level and vary the kinds of activities they do to reduce the risk of overtraining or injury.

Children and adolescents with disabilities are more likely to be inactive than those without disabilities. Youth with disabilities should work with their health-care provider to understand the types and amounts of physical activity appropriate for them. When possible, children and adolescents with disabilities should meet the Guidelines. When young people are not able to participate in appropriate physical activities to meet the Guidelines, they should be as active as possible and avoid being inactive.

Getting and Staying Active: Real-Life Examples

Children and adolescents can meet the Physical Activity Guidelines and become regularly physically active in many ways. Here are just two examples showing how a child and an adolescent can be physically active for at least 60 minutes each day over the course of a week. These examples illustrate that even though the activity patterns are different, each young person is meeting the Guidelines by getting the equivalent of at least 60 minutes or more of aerobic activity each day that is at least moderate intensity. Both are also doing vigorous-intensity, muscle-strengthening, and bone strengthening activities on at least 3 days a week.

Harold: A 7-Year-Old Child

Harold participates in many types of physical activities in many places. For example, during physical education class, he jumps rope and does gymnastics and sit-ups. During recess, he plays on the playground—often by doing activities that require running and climbing. He also likes to play soccer with his friends and family. When Harold gets home from school, he likes to engage in active play (playing tag) and ride his bicycle with his friends and family. Harold gets 60 minutes of physical activity each day that is at least moderate intensity. He participates in the following activities each day:

Monday: Walks to and from school (20 minutes), plays actively with family (20 minutes), jumps rope (10 minutes), does gymnastics (10 minutes).

Tuesday: Walks to and from school (20 minutes), plays on playground (25 minutes), climbs on playground equipment (15 minutes).

Wednesday: Walks to and from school (20 minutes), plays actively with friends (25 minutes), jumps rope (10 minutes), runs (5 minutes), does sit-ups (2 minutes).

Thursday: Plays actively with family (30 minutes), plays soccer (30 minutes).

Friday: Walks to and from school (20 minutes), plays actively with friends (25 minutes), bicycles (15 minutes).

Saturday: Plays on playground (30 minutes), climbs on playground equipment (15 minutes), bicycles (15 minutes).

Sunday: Plays on playground (10 minutes), plays soccer (40 minutes), plays tag with family (10 minutes).

Harold meets the Guidelines by doing vigorous–intensity aerobic activities, bone-strengthening activities, and muscle-strengthening activities on at least 3 days of the week:

  1. Vigorous-intensity aerobic activities 6 times during the week: jumping rope (Monday and Wednesday), running (Wednesday), soccer (Thursday and Sunday), playing tag (Sunday);

  2. Bone-strengthening activities 6 times during the week: jumping rope (Monday and Wednesday), running (Wednesday), soccer (Thursday and Sunday), playing tag (Sunday); and

  3. Muscle-strengthening activities 4 times during the week: gymnastics (Monday), climbing on playground equipment (Tuesday and Saturday), sit-ups (Wednesday).

Maria: A 16-Year-Old Adolescent

Maria participates in many types of physical activities in many places. For example, during physical education class, she plays tennis and does sit-ups and push-ups. She also likes to play basketball at the YMCA, do yoga, and go dancing with friends. Maria likes to take her dog on walks and hikes. Maria gets 60 or more minutes of daily physical activity that is at least moderate intensity. She participates in the following activities each day:

Monday: Walks dog (10 minutes), plays basketball at YMCA (50 minutes).

Tuesday: Walks dog (10 minutes), plays tennis (30 minutes), does sit-ups and push-ups (5 minutes), walks briskly with friends (15 minutes).

Wednesday: Walks dog (10 minutes), plays basketball at YMCA (50 minutes).

Thursday: Walks dog (10 minutes), plays tennis (30 minutes), does sit-ups and push-ups (5 minutes), plays with children at the park while babysitting (15 minutes).

Friday: Plays Frisbee® in park (45 minutes), mows lawn (30 minutes).

Saturday: Goes dancing with friends (60 minutes), does yoga (30 minutes).

Sunday: Hikes (60 minutes).

Maria meets the Guidelines by doing vigorous-intensity aerobic activities, bone-strengthening activities, and muscle-strengthening activities on at least 3 days of the week:

  1. Vigorous-intensity aerobic activities 4 times during the week: basketball (Monday and Wednesday), dancing (Saturday), hiking (Sunday);

  2. Bone-strengthening activities 4 times during the week: basketball (Monday and Wednesday), dancing (Saturday), hiking (Sunday); and

  3. Muscle-strengthening activities 3 times during the week: sit-ups and push-ups (Tuesday and Thursday), yoga (Saturday).