Cathy Winters, her nine-year-old son Evan and her three-year-old daughter Amy are visiting their family physician, Dr. Anderson, for the children’s annual well-child visits. The children’s physical exams show them both to be healthy and within normal range for height and weight. When Dr. Anderson asks about the family’s eating habits, Mrs. Winters says she and her husband need tips on persuading Evan to eat better.
Mrs. Winters: We never used to have to fight with Evan about eating, but now that he’s in school, it’s a constant battle. Evan is always starving when he comes home. Sometimes he tells me he didn’t eat all of his lunch because he didn’t like what they served in the cafeteria. When I pack his lunch, he complains about what I give him. He says his friends’ lunches are “better” and that he’s embarrassed by what I send in his lunchbox. The fights usually continue at the dinner table. I swear, the only thing he’ll eat anymore is chicken strips. Will you tell him it’s important to start eating better?
Dr. Anderson: Well, it is important to eat healthy. It’s also pretty normal for him to be hungry after school, so it’s a good idea to have some healthy options for him to choose from when he gets home. But let’s talk about lunch. Evan, what do you wish your parents would put in your lunch?
Evan: My lunches are boring, just sandwiches and stuff. My friends get bags of chips and desserts in their lunches, but Mom never puts that stuff in mine.
Mrs. Winters: Evan, you know we only have dessert after dinner, and that’s only if you clean your plate.
Dr. Anderson: Sounds like your mom is trying hard to help you eat healthy, Evan. Sometimes you see stuff on TV or at school that looks cool, but if that food isn’t very good for you, it’s better if you don’t eat it too often. What if you start helping your mom with your lunches? My kids like turkey roll-ups, string cheese, peanut butter and crackers, and fruit with yogurt dip—stuff that’s fun to eat. And now you can get crackers and other yummy, healthy foods in small bags, too. Does any of that sound good?
Evan: Yogurt dip sounds kind of gross, but string cheese is cool. And I like peanut butter, too.
Dr. Anderson: Maybe next time your mom goes to the grocery store, you can help her pick out some healthy foods that would be fun to take for lunch. What do you think?
Evan: Yeah, I guess so.
Dr. Anderson: Now, what about soda?
Mrs. Winters: He asks for it all the time!
Dr. Anderson: Don’t give in to the pressure. Evan, soda has lots and lots of sugar in it but nothing that’s healthy for you, so it’s best if you only have it once or twice a week. Water and milk are much healthier choices.
Mrs. Winters: OK then, soda only on special occasions.
Dr. Anderson: Well, I’d encourage you not to look at it that way. When you tell your kids they can only have certain foods “on special occasions,” those foods have a kind of special importance in the kids’ minds. It’s confusing if you tell Evan that some foods are “good” and some are “bad” because, to him, it probably seems like all his favorite foods are in the “bad” category.
Mrs. Winters: Well, all of Evan’s favorite foods are pretty bad for him.
Dr. Anderson: I’m not surprised. Most nine-year-olds prefer candy to broccoli. But try to use words like “healthy” and “not so healthy” instead of “good” and “bad.” Evan, what’s your favorite kind of candy?
Evan: Um, M&Ms. No! Skittles.
Dr. Anderson: Yeah, I like Skittles, too. What are your favorite fruits?
Evan: Hmm. Grapes and apples and bananas.
Dr. Anderson: Hey, grapes and apples and bananas are really healthy and nutritious. Good for you! When you eat nutritious foods every day you’ll be healthy and strong. Evan, should we ask your mom to make sure there are always grapes and apples and bananas and other nutritious foods around for you to eat when you’re hungry?
Mrs. Winters: Evan, you can help me pick out your favorites at the store.
Evan: OK.
Dr. Anderson: And what about Amy? Are you having some of the same problems with her?
Mrs. Winters: Not really. Amy’s always been such a good eater and eats everything I put in front of her. But, of course, I always try to fix her favorite foods because I want to make sure she eats something.
Dr. Anderson: Well, let’s talk a little about family meals, then, because you also mentioned that you battle Evan at the dinner table sometimes, too. First, I want to applaud you for making an effort to eat together. It is a crucial time for you and Mike to model healthy eating habits for the kids. It’s also an important time for connecting with each other. In other words, let’s try to keep the power struggles out of it. Choose a mealtime when everyone is likely to be hungry. Then, do your best to have tasty, healthy options for the kids to choose from, but let them decide if and how much they are going to eat. Over time, when they realize that what you serve is what they get, they’ll be more likely to eat it if they’re hungry. This way there is less drama. Don’t worry, they won’t starve themselves. Is this making sense?
Mrs. Winters: Yes, it is. Although it’s tempting to fill them up on what they will eat rather than what they should eat just to avoid a scene…
Dr. Anderson: Focus on each other and enjoying the meal rather than finishing every bite. And try to let your kids recognize the feeling of being full. If Evan has to clean his plate to earn dessert he might keep eating even though he’s already had enough. A lot of us are in the habit of doing that, and that’s a problem that can start when we’re very young. Don’t make dessert the prize, just an occasional part of the meal.
Mrs. Winters: OK.
Dr. Anderson: You mentioned that Amy finishes all the food you put in front of her. That’s great, but you don’t want to train her to eat too much by praising her for it. She’s old enough to tell you when she wants more, so try giving her smaller portions. If she’s still hungry when she finishes what’s on her plate, she can ask for seconds. Make sense?
Mrs. Winters: Yes, it does. My husband and I should probably try the same thing! I know I sometimes feel stuffed after I eat. I’m just afraid they won’t be willing to eat healthy foods.
Dr. Anderson: Well, good habits start with Mom and Dad. Everyone can practice eating a variety of foods, making healthy choices and stopping when they’ve had enough.
Eat Smart
Case #2: The Winters Family
Balance, Variety and Moderation
Advice about nutrition should emphasize balance, variety and moderation. In general, children’s diets should be balanced across food groups and include a wide variety of nutrient-dense foods to provide adequate amounts and proportions of macronutrients (protein, fat and carbohydrates), essential micronutrients (vitamins, minerals) and dietary fiber, and to provide appropriate energy to meet the needs of maintenance, growth and development.12 Less nutrient-dense foods should be consumed in moderation. Specific recommendations on caloric and nutrient intake by age and activity level are available in the Dietary Guidelines for Americans 2005.
Self-Regulation
Children need to heed their body’s hunger and satiety cues in order to consume an appropriate quantity of food. Numerous experiments have shown that infants and children are able to regulate their intake based on the energy content of the food they consume.13 When they require additional energy, babies and toddlers exhibit signs of hunger such as crying, fussiness and irritability, while older children may verbalize that they are hungry and request or seek out food. Children who maintain this instinctive ability to regulate their energy balance may do better in a food surplus environment than children who base their eating primarily on external cues or emotional triggers.14
Family Influence
In addition to their genetic influence, parents shape their children’s eating habits in a variety of important ways. These include: their choice of infant feeding method (i.e., breast or bottle); how they interact with their children in the context of eating; what foods they make available and accessible to their children; the eating behaviors they model; and other factors, such as the amount of media exposure in the home.
Breastfeeding
Breastfeeding provides the best nutrition and supports optimal growth and development for the first six months of life. (See the AAFP policy statement on breastfeeding) An additional benefit is that breastfeeding appears to allow the infant to take an active role in controlling his or her food intake.15 This may foster appropriate self-regulation of energy intake as the child grows up. Further, breastfeeding infants of mothers who eat a variety of healthy foods are exposed to those flavors in the breast milk, which may lead to improved acceptance of healthy foods after weaning.16
In addition to the physiologic, emotional and economic benefits of breastfeeding, several studies have demonstrated a link between the initiation and duration of breastfeeding and a reduced risk of becoming overweight later.17-20 Although some studies have shown no relationship between breastfeeding and later obesity,21 the numerous known benefits warrant the encouragement of breastfeeding.
In order to maintain their child’s ability to self-regulate their energy intake, parents who bottlefeed their infants should be encouraged to let the child control when he or she eats and how much formula he or she consumes.
Feeding Practices
Parental feeding practices that encourage eating based on external factors can result in the loss of the child’s ability to self-regulate according to cues of hunger and satiety. This can, in turn, lead to increased food intake.22 A parent may urge an infant to finish off a bottle to avoid wasting the formula or to increase time between feedings. In the toddler years, parents may give nonverbal reinforcement such as smiling or clapping when the child eats certain foods or eats every bite on his or her plate. In order to get their child to eat, parents may also give verbal praise (e.g., “What a good eater!”) and give the child additional attention in the form of games like “airplane.” Some parents may exhibit excessive concern about how little the child is eating.
Breastfeeding
Breastfeeding provides the best nutrition and supports optimal growth and development for the first six months of life. (See the AAFP policy statement on breastfeeding) An additional benefit is that breastfeeding appears to allow the infant to take an active role in controlling his or her food intake.15 This may foster appropriate self-regulation of energy intake as the child grows up. Further, breastfeeding infants of mothers who eat a variety of healthy foods are exposed to those flavors in the breast milk, which may lead to improved acceptance of healthy foods after weaning.16
In addition to the physiologic, emotional and economic benefits of breastfeeding, several studies have demonstrated a link between the initiation and duration of breastfeeding and a reduced risk of becoming overweight later.17-20 Although some studies have shown no relationship between breastfeeding and later obesity,21 the numerous known benefits warrant the encouragement of breastfeeding.
In order to maintain their child’s ability to self-regulate their energy intake, parents who bottlefeed their infants should be encouraged to let the child control when he or she eats and how much formula he or she consumes.
Feeding Practices
Parental feeding practices that encourage eating based on external factors can result in the loss of the child’s ability to self-regulate according to cues of hunger and satiety. This can, in turn, lead to increased food intake.22 A parent may urge an infant to finish off a bottle to avoid wasting the formula or to increase time between feedings. In the toddler years, parents may give nonverbal reinforcement such as smiling or clapping when the child eats certain foods or eats every bite on his or her plate. In order to get their child to eat, parents may also give verbal praise (e.g., “What a good eater!”) and give the child additional attention in the form of games like “airplane.” Some parents may exhibit excessive concern about how little the child is eating.
It is the parents’ responsibility to decide what food to offer and to create a supportive eating context, whereas it is the child’s responsibility to decide when and how much to eat.
Ellyn Satter, who is well known for her work in the area of child feeding, suggests a division of responsibility between parent and child. It is the parents’ responsibility to decide what food to offer and to create a supportive eating context, whereas it is the child’s responsibility to decide when and how much to eat.23 In other words, parents should provide healthful food options at consistent mealtimes and snack times and then allow the child to determine whether he or she is hungry and, if so, how much of the food to consume. This approach provides healthy choices and food security while allowing children to regulate their intake, eliminating the power struggle that can undermine family mealtime.
Food Preferences
There is no evidence that humans have an innate preference for high-fat or high-energy foods. Instead, a preference for these foods may be learned when their flavors become associated with the physiological satiety achieved from eating them or through various social influences, such as the use of food to reward or reinforce desired behaviors.24,25
The food environment created by the parents shapes a child’s food preferences because children tend to like and eat what is most familiar to them. Parents should be mindful that early exposure to particular foods, whether healthy or unhealthy, may play a key role in establishing a hierarchy of food preferences and selections.26 It is also important for parents to persist in offering a new food, even if their child initially resists trying it. In fact, parents may need to offer a new food as many as 10 times before a child will accept it.27
Parents are also important role models for their children’s eating behavior.28 For example, children whose parents eat a diet high in saturated fat are more likely to eat a diet high in saturated fat.29 Likewise, children whose parents enjoy a variety of healthful foods are more likely to enjoy those foods as well. Adoption of healthier eating habits is more likely to occur when there is positive modeling and support rather than coercion, hiding foods, bribing or threat of health consequences. Family mealtime is essential for modeling healthy eating, as well as for bonding and communication.
In addition, children are exposed to billions of dollars worth of food advertising and marketing in the media. It is estimated that the typical child sees about 40,000 television ads each year and that the majority of ads targeting kids are for candy, cereal and fast food.30 Increasingly, children are also exposed to advertising on the Internet and in their schools. Exposure to this food marketing influences children's food preferences and requests. It may also contribute to confusion among children about the relative health benefits of certain foods. For example, advertisers may use the phrase “as part of a balanced breakfast” to conceal the fact that their sugary cereal has little nutritional value.31
Dieting
Following a restrictive diet has been shown to be largely ineffective for long-term weight reduction in adults. In children, dieting may actually promote weight gain.32 When parents try to control how much their children eat by restricting their diet, the children may actually eat more when they are not hungry, choose the restricted foods more often and feel guilty about eating.33 Dieting for weight control can affect a child’s physical and emotional connections to food. For example, dietary restrictions often require children to deny their hunger cues and stop eating when they are still hungry. Further, adherence to the rules of a strict diet places undue focus on food.
There is no evidence that humans have an innate preference for high-fat or high-energy foods. Instead, a preference for these foods may be learned when their flavors become associated with the physiological satiety achieved from eating them or through various social influences, such as the use of food to reward or reinforce desired behaviors.24,25
The food environment created by the parents shapes a child’s food preferences because children tend to like and eat what is most familiar to them. Parents should be mindful that early exposure to particular foods, whether healthy or unhealthy, may play a key role in establishing a hierarchy of food preferences and selections.26 It is also important for parents to persist in offering a new food, even if their child initially resists trying it. In fact, parents may need to offer a new food as many as 10 times before a child will accept it.27
Parents are also important role models for their children’s eating behavior.28 For example, children whose parents eat a diet high in saturated fat are more likely to eat a diet high in saturated fat.29 Likewise, children whose parents enjoy a variety of healthful foods are more likely to enjoy those foods as well. Adoption of healthier eating habits is more likely to occur when there is positive modeling and support rather than coercion, hiding foods, bribing or threat of health consequences. Family mealtime is essential for modeling healthy eating, as well as for bonding and communication.
In addition, children are exposed to billions of dollars worth of food advertising and marketing in the media. It is estimated that the typical child sees about 40,000 television ads each year and that the majority of ads targeting kids are for candy, cereal and fast food.30 Increasingly, children are also exposed to advertising on the Internet and in their schools. Exposure to this food marketing influences children's food preferences and requests. It may also contribute to confusion among children about the relative health benefits of certain foods. For example, advertisers may use the phrase “as part of a balanced breakfast” to conceal the fact that their sugary cereal has little nutritional value.31
Dieting
Following a restrictive diet has been shown to be largely ineffective for long-term weight reduction in adults. In children, dieting may actually promote weight gain.32 When parents try to control how much their children eat by restricting their diet, the children may actually eat more when they are not hungry, choose the restricted foods more often and feel guilty about eating.33 Dieting for weight control can affect a child’s physical and emotional connections to food. For example, dietary restrictions often require children to deny their hunger cues and stop eating when they are still hungry. Further, adherence to the rules of a strict diet places undue focus on food.
All Foods Fit
From a purely nutritional perspective, there is no clear definition of “good food” or “bad food” since overall energy intake and dietary quality are determined by the total amount and combination of foods consumed. A given food or beverage may have multiple nutritional quality dimensions, and its impact will depend on a person’s overall eating habits and on what other foods are eaten in a given time period. According to the American Dietetic Association, all foods can fit into a healthy diet.34
Family physicians should urge parents to teach their children simple nutrition information that emphasizes the importance of balance, variety and moderation while avoiding subtle or overt messages about “good” and “bad” foods. Parents can teach children about the health benefits of certain foods, involve them in selecting and preparing delicious examples of those foods, and model eating those foods consistently. Children should learn that less nutrient-dense foods can be eaten as part of their total energy intake but should be consumed in moderation to leave room for adequate nutrient intake. This approach allows children to learn to negotiate the current food environment by balancing eating for health with eating for pleasure in the context of hunger and satiety.
It is important to remember that children and adults consume food and beverages because it is a pleasurable and integral part of family life, celebrations, recreational events and other social occasions. Therefore, it is unrealistic to base recommended eating patterns solely on the chemical composition of foods without taking cultural, social, economic and emotional drivers of food consumption into account.
In addition to the messages in Case #2 and on the Tips for Healthy Families handout, family physicians can use the materials available in the AIM initiative’s Toolkit and can direct parents to the Food & Nutrition section of the AAFP’s consumer Web site, familydoctor.org, for detailed information on making smart nutritional choices.
Family physicians should urge parents to teach their children simple nutrition information that emphasizes the importance of balance, variety and moderation while avoiding subtle or overt messages about “good” and “bad” foods. Parents can teach children about the health benefits of certain foods, involve them in selecting and preparing delicious examples of those foods, and model eating those foods consistently. Children should learn that less nutrient-dense foods can be eaten as part of their total energy intake but should be consumed in moderation to leave room for adequate nutrient intake. This approach allows children to learn to negotiate the current food environment by balancing eating for health with eating for pleasure in the context of hunger and satiety.
It is important to remember that children and adults consume food and beverages because it is a pleasurable and integral part of family life, celebrations, recreational events and other social occasions. Therefore, it is unrealistic to base recommended eating patterns solely on the chemical composition of foods without taking cultural, social, economic and emotional drivers of food consumption into account.
In addition to the messages in Case #2 and on the Tips for Healthy Families handout, family physicians can use the materials available in the AIM initiative’s Toolkit and can direct parents to the Food & Nutrition section of the AAFP’s consumer Web site, familydoctor.org, for detailed information on making smart nutritional choices.
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