The picky eater guide: Part 3. The Rule

The Pediatric Insider

© 2012 Roy Benaroch, MD

As we’ve seen, the problem isn’t the picky eating, per se. Kids are getting enough calories, and they’re certainly growing big enough. Even the skinniest kids in today’s world are far healthier and have far better nutrition than most of the kids from previous generations. And I certainly haven’t seen health problems in the slender kids in my practice. What I see very commonly, though, are health problems from overweight: diabetes, high blood pressure, depression, and social isolation.

So, no matter what else, the first principle of healthy family eating should be to help foster a child’s own normal sense of appetite and hunger. This is The Rule of mealtimes. It’s The Truth, and The One Ring to rule them all:

  • If you’re hungry, eat.
  • If you’re not hungry, don’t eat.

(OK, so it’s two rules. Close enough.)

Humans have a built-in mechanism to control food intake, and it works well at every age. It’s called “hunger.” Often, though, we unintentionally raise our kids in ways that teach them to ignore their appetite cues and eat for all sorts of other reasons.

Think about it. In American culture we don’t just eat when we’re hungry. We eat to celebrate. We eat when we watch a movie, we eat when we’re on the phone. We eat when we’re upset, and we eat when we’re bored. We eat when we’re happy and we eat when we’re sad. Often, we eat because others encourage us to eat. Family and friends ply us with food, and mom loads up our plate. We also have to contend with an ever-present marketing effort to get us to eat even more. Most two-year-olds already recognize “The Golden Arches”, and TV and computer banner ads are a near-constant barrage encouraging us to eat. And eat. And eat.

In a way, I’m surprised obesity isn’t more common.

Let’s not make matters worse. From a very early age, encourage your children to manage their own appetite. This means that a nine-month-old who becomes less interested in nursing should be allowed to wean. And a two-year-old who wants to explore instead of cleaning his plate should be allowed to leave the table. When a child doesn’t have an appetite to eat more, do not try to trick or fool or guilt or otherwise “get him” to continue eating. Lacking hunger means the child has eaten enough. Meals shouldn’t end when mom or dad thinks Junior has had enough; meals should end when Junior thinks he’s had enough.

In fact, from The Rule flows two other rules which guide the roles of children and parents at mealtimes:

  • Parents should offer healthful foods in an appropriate manner.
  • Children decide which foods to eat, and how much to eat.

Simple! Or at least simple to say, and simple to understand. That doesn’t necessarily mean it’s always easy to do!

Next up: more about the job that parents and kids have at mealtimes.

 

The picky eater guide: The whole enchilada:

Part 1. What’s the problem?

Part 2. The “Don’ts”

Part 3. The Rule

Part 4. The jobs of parents and kids

Part 5. Special circumstances, vitamins, and a muffin bonus

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23 Comments on “The picky eater guide: Part 3. The Rule”

  1. Jess Says:

    I have 2 year old identical twin girls and struggle a bit with the interplay between the two of them and food.

    Since babyhood, one (L) has always been a heartier eater. The other (E) has always been more indifferent. They are both around the 90-95th percentile for height, and L has fluctuated between 50-75th for weight and E has fluctuated between 30th-50th.

    E is virtually always done eating first and wants down for her highchair. If I get her out of her highchair, L will insist on getting down as well although she is clearly still eating and interested in eating. I have, probably more than I should, encouraged E to stay in her highchair and continue to eat until L is done. I will also play distraction games (singing, this little piggy, etc.) for E to keep her patient until L is done.

    Wondering if you might suggest a better way forward with this?

    We are also having issues with “favorite” foods (bunny crackers, particularly) where I have a set amount for each of them, but L eats them up much more quickly than E, resulting in a meltdown from L when E has some left but L is all done. I know when they are older the fact that I can show them that they start out with equal amounts will help, but not sure what to do at this age other than cut the items out entirely.

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  2. Jess Says:

    Also — we are fortunate that the girls love peas and broccoli. However, I see that we may be setting up an unhealthy dynamic where we are using them as rewards to finish another part of the meal (usually meat).

    They will start with an amount of peas or broccoli on their plates but getting more is usually contingent on eating some of the rest of their meal — otherwise they might have meals made up exclusively of peas.

    Should I just let them have as much as they want and not care about the chicken or roast beef or whatever?

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  3. fiftyfifty Says:

    Yeah, this is the advice I gave out to patients too, until I had kids of my own. One has pronounced underweight (well below the chart) the other has tendency to overweight (BMI in overweight range despite small frame until we intervened). It ain’t as simple as you make it out to be! My underweight child really does need to be encouraged to eat. Even now, he seldom ever “feels” hungy. He will have ketone breath and behavioral melt down but won’t always want food. My daughter right from birth had a big appetite and has always favored high calorie foods and shunned produce. We didn’t play the brocolli/brownie game; she knew herself which one she wanted. Try to feed both at the same table, I dare you! My advice to parents has really changed due to by experience. I know longer believe in “Golden Rules”. Now I work with parents as a team. We put ours heads together to find a way that works for their situation. Even if it is unconventional or breaks “the rules”.

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  4. Dr. Roy Says:

    Jess, your children are both in an entirely healthy weight range, and I suspect if you stopped efforts to encourage more eating they would remain in a perfectly healthy weight range and would continue to grow well. Remember, the goal here is healthy eating habits for a lifetime. Getting a certain proportion or amount of foodstuff into them at certain meals is not the goal of a healthy meal style.

    Fiftyfifty says that these rules preclude working as a team with parents. I don’t believe that is true, nor do my kids, nor do my patients. I do have a very long-range horizon which may be different from what people expect. More about that as this series of posts continues. Thanks for your interest.

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  5. fiftyfifty Says:

    Yes, I do think that sticking to a “Rule” rather than treating the individual is a problem when it comes to food. The assertion you make regarding humans having a healthy inborn sense of how much to eat at any age is just that- an assertion. You have no proof to back this theory. And there is a lot of evidence to the contrary: just look at our nation’s dogs and cats. No one forces them to clean their plates and yet there is an epidemic of obesity there as well. And I would have agreed that “underweight” was not something to worry about either…until I had my own Failure To Thrive child. Your advice is the standard pediatric advice given. It is certainly what I was taught to teach. And I have families who are fed up with it. It works for some but NOT for others.

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  6. Dr. Roy Says:

    Fiftyfifty, there’s been a tremendous amount of research on feeding, eating, and parental influences on intake. There’s certainly much more to learn, but the science supports the concept that an overly controlling feeding style contributes to underweight, overweight, and eating disorders. The current generation of often-obese adults was raised to clean their plates, and they’re now raising their own children. That doesn’t seem to be working out so well.

    Some supportive studies/sources:

    http://www.ncbi.nlm.nih.gov/pubmed/21757773
    http://www.child-encyclopedia.com/documents/Black-HurleyANGxp_rev-Nutrition.pdf
    http://journals.cambridge.org/download.php?file=%2FBJN%2FBJN96_06%2FS0007114507250457a.pdf&code=d7ce353f7aa6f0dd67d2aaa56a4c8e16
    http://her.oxfordjournals.org/content/21/6/862.long
    http://pediatrics.aappublications.org/content/121/1/e164.full.pdf

    In the interest of full disclosure, I’m a trained/certified Strong4Life provider, and I try to incorporate obesity prevention and management at every visit:
    http://strong4life.com/

    I’ve also touched on feeding/eating issues many times in this blog. You might want to see:

    https://pediatricinsider.wordpress.com/2008/10/15/the-anti-clean-plate-club/
    https://pediatricinsider.wordpress.com/2008/06/10/food-fights-fixed-how-to-have-a-successful-family-meal/
    https://pediatricinsider.wordpress.com/2011/02/02/diets-for-babies-part-1-a-perfectly-wrong-approach/

    As always, I welcome contrasting points of view! Feel free to comment anywhere you’d like.

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  7. Jess Says:

    “Jess, your children are both in an entirely healthy weight range, and I suspect if you stopped efforts to encourage more eating they would remain in a perfectly healthy weight range and would continue to grow well. Remember, the goal here is healthy eating habits for a lifetime. Getting a certain proportion or amount of foodstuff into them at certain meals is not the goal of a healthy meal style.”

    I am concerned, however, that this is the path to constant snacking. Or is that not problematic? I must admit that I hate the idea of the girls just snacking all the time while playing.

    However, I have heard of parents making a shelf with healthy snacks available and out for their kids at all times to eat as they choose. What is your opinion of something like that?

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  8. Dr. Roy Says:

    My problem with snacks isn’t the idea of eating “in between meals”, per se, it’s the concept of “snack food”– that’s become synonymous with, well, crap food. Salty, processed junk. If the snacks are the same wholesome foods that get eaten at mealtime, I don’t really have a problem with it. But, again, parents should be the ones in charge of the setting and the choices (more about that in next post!)

    There is some evidence that more frequent, smaller meals may be less likely to contribute to obesity, as long as net calories don’t increase, though that’s not completely settled.

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  9. fiftyfifty Says:

    Dr. Roy, your linked research is not as supportive as you think. The first link simply states that mothers who believe that their children do not regulate intake well are more likely to try to influence intake. It gives no outcomes of this strategy. The second link notes that overweight and parental controlling behaviors are correlated, but states very clearly that it has not been determined whether the controlling behavior is a cause or a consequence of overweight. The third link is non-functional. The fourth link once again states that we cannot infer causation between parental attempts to control intake and overweight. It does, however, advocate *rewarding* healthy eating behavior with praise and tangible rewards such as stickers. It also endorses monitoring fat intake. The fifth link shows that mothers who attempt to control intake at one year show success in lowering overweight when measured at age 2. The authors do caution that even though this controlling behavior seems to work in the short term, that the study was only 1 year in length, but state that “In a clinical setting it would be irresponsible to suggest that a caregiver should not exert appropriate levels of control over the intake of a child who is either obese or malnourished.”

    And do you really think that the reason our current generation of adults is obese is because they were raised to clean their plates? Children have been made to clean their plates for hundreds of years (my 97 year old grandmother was, and you can find many references in old children’s literature)…and yet the obesity epidemic didn’t start until the 1980s.

    The idea that we are all born with a perfectly regulated intake mechinism (until it is ruined by our pushy parents) is nothing more than a pretty, but almost completely unsupported, theory.

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  10. Dr. Roy Says:

    Sorry on busted link… I will try to dig up the correct one later.

    Parenting, I think, is the process of helping children develop into effective, healthy, and happy adults. Doing this means encouraging and nurturing self-control and the child’s own ability to make good decisions. As tiny babies, parents make all of the decisions, and literally “feed” their children– that’s the way it has to be. Once children become adults and leave the nest, they’ll make their own decisions 100% of the time. Parents who cling to the earlier model– that is, parents who feel that they must make their children’s decisions for them– will have a hard time successfully creating adults. And some point, the balance of power tips. Exactly when and how, that’s certainly debatable. And variations on approaches based on temperament and individual children’s needs are of course necessary.

    In any case: there is no single cause of obesity– it’s not just parental meal style, no more than it’s only caused by high fructose corn syrup. Contributors include an overabundance of high-energy, poor quality food, decreased physical activity, relentless marketing, huge portion sizes, too much screen time, lack of family meals, and, yes, an often-distorted desire to eat that’s not based on hunger. There are probably other environmental factors, and certainly genetic influences too.

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  11. Jess Says:

    “The idea that we are all born with a perfectly regulated intake mechinism (until it is ruined by our pushy parents) is nothing more than a pretty, but almost completely unsupported, theory.”

    The first time I gave L a piece of cheddar cheese, she giggled and did a happy dance in her seat it gave her so much pleasure. E has never reacted like that to food — there are things she clearly likes better than others, but she has never demonstrated the level of pleasure in eating tht L has. It will be interesting to see how it pans out — my assumption is that because L really enjoys eating more that her intake will be bigger (borne out so far), but we’ll see how it is over the long run.

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  12. fiftyfifty Says:

    Also Jess, I know you asked Dr. Roy and not me, but I would urge you to take your kids to their regular doctor not an internet doctor to decide if they are in the healthy weight range if you haven’t already. A child who is 90-95% for height while only weighing 30-50% may NOT be in the “entirely healthy weight range” as Dr. Roy asserts. For example a 24 month girl who is 36″ (90-95%) and 26# (30-50%) will be at only 2%ile for BMI. This is considered underweight, not normal weight.

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  13. Jess Says:

    I didn’t think BMI could be used for toddlers? The Dr. did not seem concerned at their last appointment. E has a little belly and some adorable chubb on her thighs…

    I do think the girls are going to be tall but small boned like I am. My doctors always put my healthy weight at below the regular BMI range — 5’11” and 125 was considered healthy (sadly long behind me thanks to lack of time for exercise, stress eating and thyroid issues).

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  14. fiftyfifty Says:

    Actually, measures of height/weight proportionality (such as BMI) can and should be used for children from infancy onwards. However, many doctors neglect to do so. Is can be very inaccurate to eyeball a child and decide if he or she is at a healthy weight. Therefore, ask your children’s doctor to do a BMI measure at every well visit. It’s true that a parent’s genetic build has an influence on a child’s genetic build. But remember, in your case, you have available an even better guide as to what your child’s build “should” be: your daughter has an identical twin!

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  15. Dr. Roy Says:

    It’s recommended to calculate BMI starting at age 2; earlier than that, a weight-for-length calculation can be used. It’s a bit of a mess, with two different sets of standards: http://www.cdc.gov/growthcharts/who_charts.htm.

    The exact numbers and percentiles are far less important than the trend across time in these numbers and whether the child is healthy and thriving. Building and reinforcing healthy and independent eating habits should be the point of mealtimes rather than focusing and numbers on a scale and trying to make a child the size someone expects them to be.

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  16. princessleia Says:

    Obviously Jess should be consulting with her children’s doctor rather than taking advice from anyone on the internet, whether a blogger or some random person commenting on a blog. The doctor should be looking at a number of factors, including history and the size of the parents. (I am unsure, however as to why fiftyfifty is so sure that the other twin has the model build. Why is that the standard of what this twin “should” be?)

    Fiftyfifty, I notice that you are very quick to criticize all of Dr. Roy’s advice. So what DO you tell parents? I am anxious to hear all the wisdom you have to impart. You’ve made some assumptions about Dr. Roy’s experience; let’s hear yours.

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  17. fiftyfifty Says:

    “Why is that the standard of what this twin “should” be?)”. Because the thinner twin meets criteria for prompting a failure to thrive workup, the larger twin (while still quite slender) does not. Being in the failure to thrive range does come with health risks. Of course not all underweight children will go on to develop problems (just as not all obese individuals have problems) but to ignore this increased risk just because we want to keep sticking to the Magic Rule is foolhardy.

    I’m not criticizing all Dr. Roy’s advice, just that which is unsupported or frankly wrong (like telling the mom her child is at a normal weight when she isn’t, without bothering to calculate BMI).

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  18. Dr. Roy Says:

    fiftyfifty, as you know there wasn’t enough information to calculate a BMI. You did, based on made-up numbers that fit within the information provided; but whether those numbers are right, who knows?

    In any case: I don’t know what you had in mind for a “failure to thrive” workup, but a BMI of 2%ile should prompt a review of the history and physical exam, with particular emphasis on mealtimes. If there are no red flags and no history that suggests maladaptive feeding behaviors (such as coercion) continued routine monitoring would be all that’s appropriate. With tall stature as described, malnutrition is phenomenally unlikely. Giving Jess the impression that her children need more calories is a great example of missing the forest for the trees.

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  19. fiftyfifty Says:

    “fiftyfifty, as you know there wasn’t enough information to calculate a BMI. ” No, you are right, there is not, it is an estimate based on the numbers she gave. But there is also not enough info to tell a mother who presents with worries that her child is in “the entirely healthy weight range” as you did.

    Failure to thrive, as I’m sure you know, goes in 3 stages. A lack of sufficient calories first causes only underweight. At first height is preserved…until it is not. Then head size is preserved…until it is not.

    This is my concern about the unquestioned philosophy of “trusting appetite”. Appetite usually works…unless it doesn’t. Failure to thrive can and does happen. Overweight can and does happen. If we believe too strongly that appetite is perfect, we may overlook problems. And if problems are finally discovered, the philosophy is very mother-blaming. It reminds me of the flawed philosophy at the center of the Natural Chilbirth movement: “Trust Birth”.

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  20. Dr. Roy Says:

    The point of this series of posts is to develop a lifetime of healthy eating habits. That means fostering a child’s ability to choose and regulate intake (assuming you want your child to grow into an adult.) The Rules suggested in this post are a goal, not a bludgeon. The idea is to encourage a child’s own ability to know when he or she is hungry, and respond appropriately to those cues. You won’t do that by micromanaging intake, coercion, contingent feeding, or other trickery.

    fiftyfifty, I’m sure you’ll be happy to know I’m a supporter of Dr. Amy Tuteur and her eye-opening, healthy-childbirth site Skeptical OB (we’re actually in each other’s blogrolls.)

    Tomorrow, the next post in this series. I’m not too sure what fiftyfifty will think of it, but I suspect we’ll find out!

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  21. fiftyfifty Says:

    “assuming you want your child to grow into an adult”

    What are you trying to imply Dr. Roy? That those who challenge you don’t have their patients’ best interests at heart?

    And yes, I got to your site as a link from Dr. Tuteur.

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  22. Dr. Roy Says:

    This is getting kind of silly. Parents (and anyone else) are of course free to challenge me, or free to choose another doctor, or choose to not read this blog or these scintillating comments. They can listen to my advice, or they can ignore it. That doesn’t make them good, bad, or indifferent, and doesn’t reflect positively or negatively upon, well, anything.

    Can we move on now?

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  23. mabl77 Says:

    fiftyfifty vs. Dr. Roy:
    This is the first time i have visited this site and found the information very helpful for my 15 month daughter who isn’t a veggie eater since she moved from pureed food to solids. However, I found it tacky and in poor taste for fiftyfifty to junk up the post feed with the constant barrage comments about the accuracy, consistency, etc. of Dr. Roy’s advice. If you don’t agree with his comments or blog, don’t read it. Or at the very least, address Dr. Roy through his “Contact Me” link on the homepage. fiftyfifty if you were trying to help a fellow reader, it was lost by your lack of tact and rudeness.

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