The Traffic Light Diet Can Lower Risk for Obesity and Diabetes

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152
NASN Sc hool Nurse | May 2011
Diabetes
The Traffic Light Diet
Can Lower Risk for Obesity
and Diabetes
Ryan D. Brown, MD, Oklahoma
Brought to you by the National Diabetes Education Program
Keywords: body mass index; diabe-
tes management; National Diabetes
Education Program; NDEP; obesity
G
REEN LIGHT! RED LIGHT! This is
the sound that you may hear as chil-
dren busily play an interactive game
that promotes physical activity. Little did
we suspect years ago that now those
same words would be used in another
way to help our youth eat healthy food.
Childhood obesity has been on the rise
over the past couple of decades and is
a risk factor for the development of dia-
betes (“An Update,” 2004; Ogden et
al., 2006). One way to combat child-
hood obesity is to help families learn
to eat healthy foods. Although nutri-
tion alone cannot turn the tide against
obesity, proper diet is key to support
a child’s healthy growth and develop-
ment. Because obesity is a family issue,
the whole family needs to be involved
in changing food habits. Parents need to
be role models for their children and not
expect their children to eat broccoli and
salad if they themselves are eating pizza.
Families need to be positive in the pro-
cess of obesity management and celebrate
successes. Children will be more respon-
sive to changes if they feel good about
what they are doing. School nurses can
promote this positive process to students
at school and to their families via counsel-
ing sessions and newsletter articles.
A popular and easy-to-use dietary
education tool is the Traffic Light Diet
(Collins, Warren, Neve, McCoy, & Stokes,
2006). It may also be called the Stop
Light Diet, Red Light Diet, or other vari-
ations of the concept. Simply put, all
foods are categorized into one of three
groups: RED, YELLOW, or GREEN. When
it comes to food choices, GREEN means
“GO,” YELLOW means “SLOW,” and
RED means “WHOA.” The classifica-
tion of foods into the three groups varies
slightly between the programs that devel-
oped or expanded this concept.
GREEN, or GO, foods should be the first
choice when deciding what to eat. These
foods contain less than 2 grams of fat and
are full of nutrients and/or fiber. Most fruit
and vegetables are GREEN foods, as are
whole wheat bread, oatmeal, fat free or 1%
low-fat milk, grilled fish and shellfish, and
skinless chicken or turkey.
YELLOW, or SLOW, foods need to be
the second choice when deciding what
to eat. These foods contain 2 to 5 grams
of fat. Common examples include 2%
milk, 100% fruit juice, sports drinks,
white grains (bread, rice, and pasta), gra-
nola, ham, and peanut butter.
RED, or WHOA, foods need to be
eaten sparingly. They have very
little nutritional value and are high in
fat, sugar, and calories. These foods con-
tain 5 or more grams of fat. Examples of
common foods include whole milk, reg-
ular hot dogs, french fries, butter, choco-
lates, cream cheese, sugary cereals, muf-
fins, and soft drinks.
For a more comprehensive list of
foods, see the chart of GO, SLOW, and
WHOA Foods (Table 1).
Several books have been published
about this diet. Red Light, Green Light,
Eat Right is by Joanna Dolgoff, MD
(2009), a pediatrician and childhood
obesity specialist. The Traffic Light Diet
is by Judith Willis (2004), one of the
leading health experts in the United
Kingdom.
The originator of the Traffic Light Diet
is Leonard Epstein, PhD, and his team
from the State University of New York
in Buffalo. Dr. Epstein developed his
method as a family-based approach to
childhood obesity. The Stoplight Diet for
Children: An Eight-Week Program for
Parents and Children was authored by
Epstein and Sally Squires (1988). His ver-
sion of the tool is the most commonly
used. The Epstein version of the Traffic
Light Diet is also the most studied. Two
main goals of the diet are to limit calo-
ries and encourage the consumption of
nutrient rich foods as opposed to calorie
DOI: 10.1177/1942602X11403491
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May 2011 | NASN Sch ool Nurse
dense foods. Foods are divided into five
categories (fruits and vegetables, grains,
milk and dairy, protein, and other). RED
foods are those with high fat and/or cal-
orie content. All sweets and sugared bev-
erages also belong to this group. GREEN
foods are those that contain low fat and/
or calories per serving. YELLOW foods
fit in between the two categories (see
Table 1).
To encourage weight loss, participants
are instructed to follow three mandates:
1. Eat a core of 900 calories per day.
2. Do not exceed 1200 to 1500 calories
per day.
3. Do not eat more than four RED foods
per week.
During the program, a family learns
about the definition of calories and the
basics of healthy nutrition, is given a
food reference guide listing foods accord-
ing to their color code and group, and is
strongly encouraged to remove all RED
foods from their home.
In addition to the diet, participants in
Epstein’s family-based research program
may be provided with a number of other
supports to help them manage their eat-
ing behaviors, food selection, and food
preparation. These supports include
self-monitoring training that empha-
sizes independent control of food intake
by the participants. Families are taught
how to use a food diary, how to chart
their weight, and, if appropriate, how
to record their physical activity. Parents
are encouraged to review their children’s
records with their children and to praise
them for accurately completing their
records.
Parents and children are taught the
importance of serving as models for other
family members as well as the impor-
tance of praise for family members who
make progress toward their goals. Family
members also may have weekly to
monthly contact with a behavioral ther-
apist. The therapist is appointed to the
family by the research staff to aid the
family in self-monitoring, to get feedback
on progress, and to answer questions. In
some cases, parents may engage in phys-
ical activity with the therapist.
Table 1
GO, SLOW, and WHOA Foods
Food Group GO (Almost Anytime Foods) SLOW (Sometimes Foods) WHOA (Once in a While Foods)
Nutrient-Dense Calorie-Dense
Vegetables Almost all fresh, frozen, and canned
vegetables without added fat and
sauces
All vegetables with added fat and
sauces; oven-baked French fries;
avocado
Fried potatoes, like French fries
or hash browns; other deep-fried
vegetables
Fruits All fresh, frozen, canned in juice 100 percent fruit juice; fruits canned
in light syrup; dried fruits
Fruits canned in heavy syrup
Breads and Cereals Whole-grain breads, including pita
bread; tortillas and whole-grain pasta;
brown rice; hot and cold unsweetened
whole-grain breakfast cereals
White refined flour bread, rice, and
pasta. French toast; taco shells;
cornbread; biscuits; granola; waffles
and pancakes
Croissants; muffins; doughnuts;
sweet rolls; crackers made with
trans fats; sweetened breakfast
cereals
Milk and Milk
Products
Fat-free or 1 percent low-fat milk; fat-
free or low-fat yogurt; part-skim,
reduced fat, and fat-free cheese; low-
fat or fat-free cottage cheese
2 percent low-fat milk; processed
cheese spread
Whole milk; full-fat American,
cheddar, Colby, Swiss, cream
cheese; whole-milk yogurt
Meats, Poultry, Fish,
Eggs, Beans, and
Nuts
Trimmed beef and pork; extra lean
ground beef; chicken and turkey with-
out skin; tuna canned in water; baked,
broiled, steamed, grilled fish and
shellfish; beans, split peas, lentils,
tofu; egg whites and egg substitutes
Lean ground beef, broiled hamburg-
ers; ham, Canadian bacon; chicken
and turkey with skin; low-fat hot
dogs; tuna canned in oil; peanut
butter; nuts; whole eggs cooked
without added fat
Untrimmed beef and pork; regular
ground beef; fried hamburgers;
ribs; bacon; fried chicken, chicken
nuggets; hot dogs, lunch meats,
pepperoni, sausage; fried fish and
shellfish; whole eggs cooked
with fat
Sweets and Snacks* Ice milk bars; frozen fruit juice bars;
low-fat or fat-free frozen yogurt and
ice cream; fig bars, ginger snaps,
baked chips; low-fat microwave pop-
corn; pretzels
Cookies and cakes; pies; cheese
cake; ice cream; chocolate;
candy; chips; buttered
microwave popcorn
Fats/Condiments Vinegar; ketchup; mustard; fat-free
creamy salad dressing; fat-free may-
onnaise; fat-free sour cream
Vegetable oil, olive oil, and oil-based
salad dressing; soft margarine;
low-fat creamy salad dressing; low-
fat mayonnaise; low-fat sour cream**
Butter, stick margarine; lard; salt
pork; gravy; regular creamy salad
dressing; mayonnaise; tartar
sauce; sour cream; cheese sauce;
cream sauce; cream cheese dips
Beverages Water, fat-free milk, or 1 percent low-
fat milk; diet soda; unsweetened ice
tea or diet iced tea and lemonade
2 percent low-fat milk; 100 percent
fruit juice; sports drinks
Whole milk; regular soda; calori-
cally sweetened iced teas and
lemonade; fruit drinks with less
than 100 percent fruit juice
*Not all snacks are poor in nutritional value.
Source: U.S. Department of Health & Human Services (n.d.).
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NASN Sc hool Nurse | May 2011
Studies of the Epstein program report
significant weight loss and mainte-
nance of weight loss. In one of the most
extensive studies, there was a 25.5%
decrease in overweight at the end of
treatment across groups. At 24 months,
the percentage overweight decrease was
12.9% (Epstein, Paluch, Gordy, & Dorn,
2000).
The National Institutes of Health have
also joined the colorful diet parade
with the We Can!® campaign. We Can!
(Ways to Enhance Children’s Activity
& Nutrition) is a national movement
designed to give parents, caregivers, and
entire communities a way to help chil-
dren 8 to 13 years old stay at a healthy
weight. The We Can! campaign’s GO,
SLOW, and WHOA Foods chart is listed
in Table 1. For more information, includ-
ing lesson plans and handouts, visit the
We Can! website (http://www.nhlbi.nih.
gov/health/public/heart/obesity/wecan/
eat-right/choosing-foods.htm).
Whatever the name, the Stoplight/
Traffic Light Diet has shown benefits.
The Traffic Light Diet has not been stud-
ied or implemented in the school setting.
However, school nurses may find that
the simple introduction of the GREEN,
YELLOW, and RED food concept along
with food selection lists may help
families make better food choices. Using
innovative ways to help children and
their families change eating habits and
food selection practices will contribute to
lowering the risk for childhood obesity
and diabetes.
■
Resources
Body mass index (BMI) gender-appropriate
graphs for children can be downloaded from
the Centers for Disease Control and Prevention
website at http://www.cdc.gov/growthcharts.
All books mentioned in this article can be pur-
chased from Amazon (http://www.Amazon.
com).
The Weight-control Information Network pro-
vides the general public and health care pro-
fessionals with information on weight con-
trol, obesity, physical activity, and nutrition
(http://www.win.niddk.nih.gov/, http://www
.nhlbi.nih.gov/health/public/heart/obesity/
wecan/downloads/go-slowwhoa.pdf).
References
An update on type 2 diabetes from the National
Diabetes Education Program. (2004).
Pediatrics, 114, 239-263.
Collins, C. E., Warren, J., Neve, M., McCoy, P.,
& Stokes, B. J. (2006). Measuring effective-
ness of dietetic interventions in child obesity.
Archives of Pediatrics & Adolescent Medicine,
160, 906-922.
Dolgoff, J. (2009). Red light, green light, eat
right: The food solution that lets kids be kids.
New York, NY: Rodale Books.
Epstein, L. H., Paluch, R. A., Gordy, C. C., &
Dorn, J. (2000). Decreasing sedentary behav-
iors in treating pediatric obesity. Archives
of Pediatrics & Adolescent Medicine, 154,
220-226.
Epstein, L. H., & Squires, S. (1988). The stoplight
diet for children: An eight-week program for
parents and children. New York, NY: Little,
Brown.
Ogden, C. L., Carroll, M. D., Curtin, L. R.,
McDowell, M. A., Tabak, C. J., & Flegal, K. M.
(2006). Prevalence of overweight and obesity
in the United States, 1999-2004. The Journal
of the American Medical Association, 295,
1549-1555.
U.S. Department of Health & Human Services.
(n.d.). Choosing foods for your family: GO,
SLOW, and WHOA foods. Chart available at
http://www.nhlbi.nih.gov/health/public/heart/
obesity/wecan/downloads/go-slow-whoa.pdf
Willis, J. (2004). The traffic light diet. London:
Orion.
Ryan D. Brown, MD
Clinical Associate Professor
University of Oklahoma
College of Medicine
Oklahoma City, OK
Dr. Brown is a clinical associate
professor at the University of
Oklahoma College of Medicine,
Department of Pediatrics,
Section on Pediatric Diabetes
and Endocrinology. His clinical
interests are obesity and type
2 diabetes.
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