May 2015 Family Meals Focus #100 Doctors and weight: Helping without harming

Ellyn Satter, Registered Dietitian and Family Therapist

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Satter’s Division of Responsibility in Feeding(sDOR) is recognized as best practice by the AAP: 7th edition, Pediatric Nutrition. sDOR: The parent is responsible for the what, when, where of feeding and the child is responsible for the how much and whether of eating. To prevent child overweight and obesity from birth, support parents in following sDOR. To treat child overweight and obesity at any age, restore sDOR and trust the child’s own homeostasis to restore appropriate growth.

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Standard food advice is negative

For the policy makers and consensus-arrivers, child obesity prevention is about eating the right food and avoiding the wrong food, with a bit of “restrict portion size” and “move more” thrown in.  

• Limit sugar-sweetened beverages^1-5
• Encourage fruits and vegetables^1-5
• Encourage low-fat dairy foods and whole grains⁴
• Limit portion sizes^1-3,5 

Negative food advice does harm

Less than 10% of adults can follow this drab and negative advice⁶ for themselves, let alone for their children, and they feel bad about it. Imposing food rules makes it harder for parents to get a meal on the table, even when you try to soft-pedal by saying  "watch what he eats," or "follow the Food Pyramid," or “follow MyPlate," or “don’t let him eat so much starch—so many sweets—so many fried foods." You know by the dread and consternation on a parent’s face. Parents want to nurture. This advice makes them food cops. No more relaxed and enjoyable family meals, holidays, and birthday parties.  Parents brace themselves to get their child to eat vegetables, to eat less, to stay away from high-fat, high-sugar food. At the next appointment, the parent won’t meet your eyes and the child’s weight gain has accelerated. Or they simply don’t show up.

Some parents tell you: just-don’t-mention-weight! Parents’ intuitive wisdom is backed by evidence: children who are labeled overweight feel flawed in every way—not smart, not physically capable, and not worthy.⁷  Five to nine year olds characterized as being at risk for overweight ( ≥85^th BMI percentile) say they eat only a little bit on purpose so they don’t get fat.⁸ That’s pretty sad, isn’t it? Children are entitled to be free from worry about eating, moving, and weight. 

Put a positive spin on the standard advice

You can do what the policy-makers say, just do it so it helps. In the midst of its own negative food selection advice, the American Academy of Pediatrics (AAP) puts forth this possibility: “Empower parents to promote children's ability to self-regulate energy intake while providing appropriate structure and boundaries around eating.”⁴  Essentially, AAP recommends sDOR. To translate, consider this advice from the handout, Your Child’s Weight: Helping without Harming and the book of the same name.

• Have regular, reliable, and rewarding sit-down family meals and sit-down snacks. This would be AAP’s “appropriate structure and boundaries around eating.” The rewarding part is important. Consistently providing family meals is a lot of work. Parents who are freed to provide food the family enjoys get intrinsic reinforcement for making meals a priority.
• Include a variety of good-tasting, wholesome foods. Families who eat regular meals get around to including fruits, vegetables, and other wholesome foods. And they eat them because they enjoy them, not because they have to.
• Include “forbidden foods” in meals and snacks. Making sugar-sweetened beverages a sit-down, rather than a carry-around beverage limits consumption. A lot. Giving a time and place to enjoy high-sugar, high-fat snack foods also limits consumption. More importantly, children come to regard high-calorie, low nutrient foods and beverages as everyday food that they consume the same as other food: sometimes a little, sometimes a lot.   
• Trust the child to decide what and how much to eat from the food parents provide. The food cops emphasize limiting portion sizes, which is, of course, a form of restriction. Children whose food intake is restricted become food preoccupied and are prone to overeat when they get the chance.  Children whose parents follow sDOR do a good job of managing their own portion sizes.
• Forget about encouraging “slimming” foods. The evidence doesn’t support recommending low-fat dairy foods.⁹  Whole grains are nutritious, but they aren’t slimming.

Focus on the parents’ feeding, not the child’s eating   

Encourage parents to do a good job with feeding, not to try to fix their child’s eating. Be persistent in your encouragement, and keep your nerve. It takes parents time to establish family meals and more time to stop interfering with what and how much their child eats.  sDOR is working when family meals are pleasant and the child is relaxed and positive about eating. Keep your nerve about weight as well. Until the middle grades, children have a greater than even chance of slimming down.^10,11  In the process of making change on behalf of their child, many parents will improve their own eating competence. Parents who are eating competent follow sDOR¹² and their children show better nutrition profiles.¹³ The Joy of Eating translates sDOR in feeding children into guidelines for adults’ feeding themselves.  

 The 15 minute intervention

• Assess weight in an sDOR consistent fashion. Support consistent growth, even if it is high or low enough to be “diagnosable.” Identify weight acceleration or faltering early and address it by restoring sDOR.
• Give the handout, Your Child’s Weight: Helping without Harming, also available in Spanish.
• Encourage parents to follow a division of responsibility in activity.
• Encourage parents who read books to read Your Child’s Weight.
• Incorporate feeding dynamics education into your anticipatory guidance handout routine. Articles on the ESI website are free. Feeding in Primary Care handout masters are in English and Spanish and cost about $.01 each.
• Show the Feeding with Love and Good Sense DVD (also in English/Spanish) in your waiting room.
• Give the Feeding with Love and Good Sense booklets to all parents (6^th grade reading level) and staff.
• Do both: Show the DVD, give the booklets. Consider buying the Office Package.

References    

1. CDC. Overweight and Obesity: Strategies and Solutions.  http://www.cdc.gov/obesity/childhood/solutions.html. Accessed March 22 2015.
2. Barlow SE, and the Expert C. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120(Supplement_4):S164-192.
3. USDA, FNS. Maximizing the message: Helping moms and kids make healthier food choices. FNS-409. 2012 http://www.fns.usda.gov/core-nutrition/maximizing-message. Accessed May 8, 2015.
4. American Academy of Pediatrics Committee on N. Prevention of pediatric overweight and obesity. Pediatrics. 2003/2007;112:424-430.
5. USDA, USHHS. Dietary Guidelines for Americans. 2010 U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans, 2010 http://www.cnpp.usda.gov/DietaryGuidelines. Accessed May 8 2015.
6. Laster LE, Lovelady CA, West DG, et al. Diet quality of overweight and obese mothers and their preschool children. Journal of the Academy of Nutrition and Dietetics. 2013;113(11):1476-1483.
7. Davison KK, Birch LL. Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics. 2001;107:46-53.
8. Shunk JA, Birch LL. Girls at risk for overweight at age 5 are at risk for dietary restraint, disinhibited overeating, weight concerns, and greater weight gain from 5 to 9 years. J Am Diet Assoc. 2004;104(7):1120-1126.
9. Satter E. Family Meals Focus #98. Should you put your child on skim milk?  . 2015; http://www.ellynsatterinstitute.org/fmf/familymealsfocus.php.
10. Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US preventive services task force. Pediatrics. 2005;116:e125-e144.
11. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Preventive Medicine. 1993;22:167-177.
12. Tylka TL, Eneli IU, Kroon Van Diest AM, Lumeng JC. Which adaptive maternal eating behaviors predict child feeding practices? An examination with mothers of 2- to 5-year-old children. Eat Behav. 2013;14:57-63.
13. Lohse B, Satter E, Arnold K. Development of a tool to assess adherence to a model of the division of responsibility in feeding young children: using response mapping to capacitate validation measures. Child Obes. 2014;10(2):153-168.

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