Family Meals Focus
The Ellyn Satter Institute Newsletter
Doctors and weight: Help without harming
by Ellyn Satter, Registered Dietitian and Family Therapist
To prevent child overweight, teach parents to follow the division of responsibility in feeding. Parents do the what, when, and where of feeding; the child does the how much and whether of eating. You do not have to persuade parents of a child obesity or overweight diagnosis. Instead, regularly evaluate children’s weight-for-age growth charts to detect abnormal and rapid weight acceleration. Even if the child’s BMI doesn’t exceed the 85th or 95th percentile cutoff points, address weight acceleration by doing trouble-shooting with the division of responsibility in feeding.
- Are parents being consistent about maintaining the structure of pleasant family meals and snacks?
- Are parents avoiding interfering with the child’s prerogatives of determining what and how much to eat of what parents provide?
The handout, Your Child’s Weight: Helping without Harming, summarizes a division-of-responsibility-based child weight intervention. It is also available in Spanish.
Obesity intervention doesn’t work
Even if you are able to launch ambitious, multidisciplinary, behavioral and even family-based approaches, that data shows that you can expect to produce only “small and highly variable” weight loss. According to the 2016 US Preventive Services Task Force review,1 behavioral interventions of 26 hours or more produce weight losses of roughly 0.2 zBMI. For 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. These recommendations are all theoretical. There is no evidence that getting kids to eat the “right” food and not eat the “wrong” food works. Moreover, fewer than 10% of adults can follow this drab and negative advice for themselves, let alone for their children, and they feel bad about it. Here is the advice and where it comes from:
- Limit sugar-sweetened beverages.1,2,3,4,5
- Encourage fruits and vegetables.1,2,3,4,5
- Encourage low-fat dairy foods and whole grains.4
- Limit portion sizes.1,2,3,5
Parents don’t want to be food cops
Parents are reluctant to accept an obesity diagnosis for their child,6 and no wonder! Parents want to nurture, and they know that what comes after the obesity diagnosis is their being food cops: No more relaxed and enjoyable family meals, holidays, and birthday parties; Lots of struggles to get their child to eat vegetables, to eat less, to stay away from high-fat, high-sugar food. They become food cops 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.” At the next appointment, the parent doesn’t meet your eyes and the child’s weight gain has accelerated. Or parents and children simply don’t show up.
Some parents refuse to be made into food cops. They tell you: just-don’t-mention-weight! Their intuitive unwillingness to become controlling with feeding 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 ( ≥85th 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. Children who are perceived as being overweight, by parents and/or themselves, are fatter in later life.
Don’t do nothing at all
In the midst of its food advice, the American Academy of Pediatrics (AAP) essentially recommends the division of responsibility in feeding: “Empower parents to promote children’s ability to self-regulate energy intake while providing appropriate structure and boundaries around eating.”
You can do what the policy-makers say, just do it so it helps. In the midst of its own right-and-wrong-food advice, the American Academy of Pediatrics (AAP) puts forth Satter’s Division of Responsibility in Feeding (sDOR), although not by that name: “Empower parents to promote children’s ability to self-regulate energy intake while providing appropriate structure and boundaries around eating.”4 sDOR encourages parents to manage the what, when, and where of feeding, and to let children do the how much and whether of eating. 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 encouraged 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 beverage, rather than one to be carried around, 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 get afraid of going hungry 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: they eat as much as they want, then stop, even in the middle of a bowl of ice cream.
- Forget about encouraging “slimming” foods. The evidence doesn’t support recommending low-fat dairy foods.9 Whole grains and fruits and vegetables are nutritious, but they aren’t slimming.
Focus on the parents’ feeding, not the child’s eating
Particularly unsuccessful Interventions teach children to restrict their food intake. Instead, encourage parents to do a good job with feeding. 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.
- 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.
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.”
- Avoid diagnosing. Instead, identify weight acceleration or faltering early. 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: Helping without Harming.
- 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 (6th grade reading level) and staff.
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.
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.
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.
Satter E. Family Meals Focus #98. Should you put your child on skim milk? 2016.
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.
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.
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.
For more about applying sDOR to preventing child obesity, birth through adolescence, read Ellyn Satter’s Your Child’s Weight: Helping Without Harming .
- Feeding with Love and Good Sense: The First Two Years
- Feeding with Love and Good Sense: 18 Months through 6 Years
- Ellyn Satter’s Feeding With Love and Good Sense II Waiting Room DVD English also available in English and Spanish.
Address weight wisely and well
- Avoid restriction
- Children know how much they need to eat
- Follow Satter’s Division of Responsibility in Feeding (sDOR)
- Raise a healthy child who is a joy to feed
- Trouble-shooting with the division of responsibility
- Your Child’s Weight: Helping without Harming also available in Spanish