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Supporting Healthy Eating and Growth What can we do for kids? Ellyn Satter, MS, RD, MSSW

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Raise a capable eater Follow the division of responsibility in feeding Ellyn Satters Feeding with Love and Good Sense II DVD Parent: What, when, where of feeding Child: How much, whether of eating

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Haley 10 years Parents: Gained a huge amount of weightshot off the scale. Sneaks food, eats from lunch counter even after she has finished her bag lunch from home Parents deny food restriction W/A 2 - 10 yr

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W/A 1 wk 33 mo Haley W/A history

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Decipher the story told by the growth chart

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10 months 12 months 16 months Haley W/A 10 months: MD says weighs too much 12 months: MD says tendency toward obesity 15 months: Error? 16 months: Mom says voracious appetite. 19 months: Moved. New MD doesnt question weight 19 months 15 months

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1 -6.5 years. New MD doesnt question weight 3-6.5 yr: Mother in school; father casually feeding 6.5 yr: Moved. Haley sad; mother rigidly feeding 8.5 yr: MD dont diet but eat F&V, low fat 10.25 yr: RDFood Guide Pyramid; smart snack choices 3-years 6.5 years 8.5 years 10.25 years Haley W/A

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Why do children gain too much weight? a)Misinterpretation of normal growth: A growth agenda

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10 months 12 months 16 months Haley W/A 10 months: MD says weighs too much 12 months: MD says tendency toward obesity 19 months 15 months

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Normal growth can be consistently at the mean 50 th %tile w/a Weight for Length Weight for age 0-36 months

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Low consistent W/A High consistent W/A Normal growth can be at the extremes

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BELL CURVE From Your Childs Weight: Helping Without Harming

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Abrupt, rapid divergence likely to be problematic

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Why do children gain too much weight? a)Misinterpretation of normal growth b)Restrained feeding and circumstances that mimic restrained feeding

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10 months 12 months 16 months Haley W/A 10 months: MD says weighs too much 12 months: MD says tendency toward obesity 15 months: Error? 16 months: Mom says voracious appetite. 19 months 15 months

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FOOD RESTRICTION BACKFIRES Children become afraid of going hungry and overeat when they get the chance Getting children to eat certain foods Getting children to eat more or less Depriving children of certain foods Not letting children eat as much as they are hungry for

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WHAT DOES THIS HAVE TO DO WITH CHILD OBESITY? Hunger Appetite Satiety Children who get the message they are too fat feel flawed in every waynot smart, not physically capable, and not worthy. Davison & Birch Pediatrics 2001 Girls 5 yr say they try to eat only a little bit on purpose so they dont get fat. They tend to overeat, and gain more weight than girls who do not restrict. Shunk & Birch JADA 2004: 1120.

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AUTHORITARIAN PARENTING: Restricting amounts undermines food regulation ELLYN SATTERS FEEDING WITH LOVE AND GOOD SENSE: Video and Teachers Guide The Older Baby

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Children whose food intake is restricted become food-preoccupied and are prone to overeat when the get the chance Secrets of Feeding a Healthy Family, Appendix I, Children and food regulation: the research Ellyn Satters Feeding with Love and Good Sense II DVD

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Why do children gain too much weight? a)Misinterpretation of normal growth b)Restrained feeding c)Poor feeding practices

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10 months 12 months 16 months Haley W/A 19 months: Moved. New MD doesnt question weight 19 months 15 months

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1 -6.5 years. New MD doesnt question weight 3-6.5 yr: Mother in school; father casually feeding 3-years 6.5 years 8.5 years 10.25 years Haley W/A

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POOR FEEDING PRACTICES Too little support Interference

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Children who are coerced to eat certain foods get turned off to them and avoid them when they can Secrets of Feeding a Healthy Family, Appendix J, Children and food acceptance: the research Ellyn Satters Feeding with Love and Good Sense II DVD

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FEEDING PRESSURE BACKFIRES Forcing, bribing, coercing, nudging, applauding, rewarding, explaining, teaching, restricting Getting children to eat certain foods Getting children to eat more or less Getting children to avoid certain foods

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FEEDING PRESSURE BACKFIRES Forcing, bribing, coercing, nudging, applauding, rewarding, explaining, teaching, restricting Getting children eat certain foods Getting children to eat more or less Getting children to avoid certain foods 90% of parents pressure children to eat Sherry JADA 2004:215 50% of children have feeding problems Linscheid, Handbook of Pediatric Psycholgoy, 2003: 481

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FOOD REGULATION HINGES ON THE FAMILY MEAL (AND STRUCTURED SNACKS) Meals give a context for parental support without coercion Allows going to table hungry but not famished, eating until satisfied Keeps food from being a constant issue between times Toddlers are too busy to eat on demand

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Why do children gain too much weight? a)Misinterpretation of normal growth b)Restrained feeding and circumstances that mimic restrained feeding c)Poor feeding practices d)Stress

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3-6.5 yr: Mother in school; father casually feeding 6.5 yr: Moved. Mother begins rigidly feeding 8.5 yr: MD dont diet but eat F&V, low fat 10.25 yr: RDFood Guide Pyramid; smart snack choices 3-years 6.5 years 8.5 years 10.25 years Haley W/A

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7 yr: Moved. Haley sad; mother feeding 8 yr: MD dont diet but eat F&V, low fat 9 yr: RD dont diet but follow Food Guide Pyramid 3-7 years 7 years 9 years 8 years

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MOTHER IS RESOLUTE IN ATTEMPTS TO CONTROL HALEYS EATING Drab, low-fat food that Haley detested One pork chop each, ran out of rice Use your fork (over and over) The seeds are for the salad (repeatedly) Get your elbows off the table Eat something else before you take seconds on bread Remember she showed us a portion size (broccoli) Hand on wrist and smile (Sadie eating too fast) Handing her the napkin Use your napkin

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HALEY IS EQUALLY RESOLUTE IN HER AVOIDANCE OF CONTROL Puts down her fork to pick up the pieces of salad Takes the tiniest amount of salad possible then puts the seeds in her palm Looks disgusted at lentil soup Hunches over with her whole forearm on the table Eats her bread when she wants to Goes back to eating fast Leaves her napkin on the table

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Stress undermines food regulation Ellyn Satters Feeding with Love and Good Sense II DVD

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Stress and energy dysregulation How it works Children who are poorly fed (e.g., restricted, forced to eat, not given structure) do not get their emotional needs met Childrens unmet food and emotional needs teach children to conflate eating with emotional arousal Based on such learning, children respond to life stress by eating too much or too little

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Causes of Haleys weight acceleration Misinterpretation of normal growth: High infant weight branded obesity Restrained feeding: Food restriction initiated age 10 months Poor feeding practices: Struggles around feeding exacerbated age 12 months. Lack of structure ages 3-7. Restraint ages 7 plus. Stress: Taught to use food for emotional reasons. Inconsistent parenting: Mother rigid & controlling, father neglectful. Parental conflict routed through Haley.

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CHILDHOOD FEEDING DISORDER Distorted eating/feeding attitudes/behavior Failure to regulate growth Profound finickiness Vehement struggles about eating Unconcern about serious problems Overconcern about minor problems Emotional/social problems

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fdSatter and child overweight Your Childs Weight: Helping without Harming, Kelcy Press Satter E. The Satter Feeding Dynamics Model of child overweight definition, prevention and intervention. In: O'Donahue W, Moore BA, Scott B, eds. Pediatric and Adolescent Obesity Treatment: A Comprehensive Handbook. New York: Taylor and Francis; 2007:287-314. Satter EM. Internal regulation and the evolution of normal growth as the basis for prevention of obesity in childhood. J Am Diet Assoc. 1996;96:860-864.

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TRIANGULATED CHILD: PARENTS ROUTE CONFLICT THROUGH CHILD

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TREATMENT: BLOCK TRIANGULATION, IMPROVE PARENT RELATIONSHIP

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TREATMENT OF FEEDING DISORDERS Eating management Psychotherapy or case management with the whole family Psychotherapy does not resolve eating problems

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HALEY - TREATMENT PLAN Parents Jobs Get family therapy to deal with control issues Initiate eating management after family therapy has begun Establish and maintain division of responsibility Identify and D/C restraint tactics Plan good-tasting enjoyable menus Provide appealing sit-down snacks at set times Expect and enforce positive mealtime behavior

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HALEY - TREATMENT PLAN Haleys Jobs Go to the table hungry and eat until satisfied Pay attention while you eat Ask parents to include forbidden foods at meals and snacks Sneak up on new food and learn to like it Let parents know when they slip up, but be patient

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Haley: Once more with sDOR Satter E. Prevention and Treatment of Child Overweight and Obesity. 2015

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To prevent child overweight and obesity, support parents in following sDOR from birth. To treat child overweight and obesity, restore sDOR and trust the childs own homeostasis to restore appropriate growth.

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Satter feeding dynamics model: fdSatter Parents feed based on the division of responsibility Children remain/become eating competent Children grow in the way that is right for them. Satter The feeding relationship, JADA 1986 Satter. Internal regulation & child overweight. JADA 1996 Satter. Childhood eating disorders. JADA 1996 Satter. Moderate view on fat restriction. JADA 2000 Satter. fdSatter and child overweight IN ODonahue, Pediatric and Adolescent Obesity Treatment. 2007 Danaher, Intervention. Childhood Obesity. 2011

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Parents have to be good eaters to do good feeding Further reading and references Secrets of Feeding a Healthy Family Part 1, How to eat Part 2, How to raise good eaters Appendix I, Children and food regulation: the research Appendix J, Children and food acceptance: the research

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Satter Division of Responsibility in Feeding (sDOR) Infant Parent: What Child: How much

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Transitional child Parent/feeding Still and always responsible for what Becoming responsible for when and where Child/eating How much Whether Satter Division of Responsibility in Feeding (sDOR)

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Toddler through adolescent Parent: What, when, where of feeding Child: How much, whether of eating Satter Division of Responsibility in Feeding (sDOR)

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sDOR Parents take leadership with feeding Choose and prepare healthy food Have regular meals and snacks Make eating time pleasant Provide mastery expectations Accept and support childrens growth

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sDOR Parents give children autonomy, support childrens natural ability with eating Children will eat They know how much to eat They will eat a variety They will grow predictably They will mature with eating

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10 months 12 months 16 months Haley W/A 10 months: MD says weighs too much 12 months: MD says tendency toward obesity 19 months 15 months

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The tendency is to slimming Serdula - Children slim down Infants >75% Preschoolers 59-74% School-age children 37-58% Whitlock At age 13 years, children >95th %tile W/H have a 50% probability of adult obesity (BMI >30) Serdula Preventive Medicine 1993 Whitlock Pediatrics 2005

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10 months 12 months 16 months Haley W/A 16 months: Mom says voracious appetite. 19 months 15 months

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10 months 12 months 16 months Haley W/A 19 months: Moved. New MD doesnt question weight 19 months 15 months

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1 -6.5 years. New MD doesnt question weight 3-6.5 yr: Mother in school; father casually feeding 3-years 6.5 years 8.5 years 10.25 years Haley W/A

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3-6.5 yr: Mother in school; father casually feeding 6.5 yr: Moved. Mother begins rigidly feeding 3-years 6.5 years 8.5 years 10.25 years Haley W/A

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8 yr: MD dont diet but eat F&V, low fat 9 yr: RD dont diet but follow Food Guide Pyramid 3-7 years 7 years 9 years 8 years

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Structure is the bottom line In adult EC In child nutrition and feeding In child overweight prevention and treatment.

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To be a competent feeder, the parent has to be a competent eater.

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Satter Eating Competence Model (ecSatter): Inclusive definition of eating attitudes and behaviors 1.Positive attitudes about eating and about food 2.Food acceptance skills that support eating an ever- increasing variety of the available food 3.Internal regulation skills that guide consuming enough food to give energy and stamina and to support stable body weight 4.Skills and resources for managing the food context and orchestrating family meals Satter, E. M. (2007). J Nutr Educ Behav, 39 (suppl), S142-S153.

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ecSatter tested using the validated ecSatter Inventory ecSI 2.0ecSI 2.0 Lohse, J Nutr Ed Behav 2007

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The evidence: ecSatter associated with... Superior dietary quality Greater physical activity Better weight status More positive parent food behaviors Decreased preschooler nutrition risk Fewer cardiovascular risk factors Good food management skills Higher sleep quality

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The point of the fdSatter and ecSatter research? You can achieve nutrition and wellness goals by focusing on sDOR and Eating Competence.

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For more... Satter E. The Satter Eating Competence Model for the autodidact 2015

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For more information

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