March 2018 Issue

Children's Nutrition: Raising Intuitive Eaters
By Carrie Dennett, MPH, RDN, CD
Today's Dietitian
Vol. 20, No. 3, P. 14

Parents want the best for their children — here's how to help them achieve it.

Most parents want to raise happy, healthy children. Unfortunately, this can lead parents to take a controlling hand—in the name of nutrition or weight management—when feeding them, undermining both physical health and emotional well-being.

Numerous organizations, including the World Health Organization and the American Academy of Pediatrics, include advice in their child feeding guidelines to recognize and respect children's signals of hunger and satiety, one of the core principles of intuitive eating.1

Intuitive eating is a flexible eating style that focuses on trusting—and usually following—physical hunger and satiety cues to guide when, what, and how much to eat.2,3 It's associated with positive physical and psychological outcomes.4 Intuitive eating is similar to Ellyn Satter's Feeding Dynamics Model, first published in the early 1980s, in which the parent or caregiver provides structure by choosing what food to serve at regular meal and snack times, while the child decides how much to eat of the foods offered. This model is based on trust and allows children to build autonomy.5

We're all born intuitive eaters. Consider how a hungry baby will cry until fed and then turn his or her head away when satiated. When children are fully aware of physical sensations of hunger and fullness, yet receive messages that they can't possibly be hungry or that they have to eat everything on their plates before being excused from the table, it erodes trust of their bodies and autonomy.6

"Allowing kids to eat intuitively gives children a greater sense of self-esteem, understanding of boundaries, [and] connection to family and caregivers during meals, and typically they will enjoy a wider variety of foods," says Brandi Olden, RDN, CSP, CD, owner of Creating Peace with Food in Bellevue, Washington. She points out that while strategies such as encouraging, bribing, or tricking may be well intentioned, they end up increasing picky eating and escalating power struggles at the table.

Impact of Parent Feeding Practices
Strict parental controls on eating can contribute to preferences for energy-dense foods, limit acceptance of other foods, and alter sensitivity to internal hunger and satiety cues, ultimately disrupting the child's ability to self-regulate energy intake and the amount of food eaten.6 This may result in problematic eating behaviors that persist into adulthood.4,7 The following examples illustrate how this occurs:

• Pressuring to eat can lead to restrained and emotional eating7,8 and may erode the ability to stop eating when no longer hungry.6 Encouraging children to eat more of a certain food can increase their dislike for that food.6

• Offering palatable foods as rewards or pairing them with positive attention (such as making a big deal out of going to get ice cream) increases liking of those foods.8,9

• Restricting food or types of food, or even labeling foods as "good" or "bad," can lead to an increased desire to obtain and eat "forbidden" foods, resulting in excessive consumption when food is available, eating in the absence of hunger, and emotional eating, especially when highly palatable foods are restricted.3,8-11

"I have often seen well-intentioned parents or caregivers control food choices and intake hoping to promote health, flexibility, and growth," says Katie Holder, RD, LDN, of Birdhouse Nutrition Therapy in Greensboro, North Carolina. This often backfires, leading to mealtime struggles. "If the struggle continues, no matter what the underlying cause is, the more likely it is to lead to disordered eating down the road."

Evelyn Tribole, MS, RD, coauthor of Intuitive Eating: A Revolutionary Program That Works, says that the risk of restrictive feeding practices leading to eating disorders is of particular concern in today's nutrition climate. "I've never seen such a time where there's so much pathology and neuroticism around eating, fueled by the 'obesity epidemic.' We need to teach body trust."

Obstacles to Intuitive Eating
Media coverage of the "obesogenic" food environment may prompt parents to restrict children's access to highly palatable foods.12 Parents are more likely to restrict a child's food intake if they perceive their child as overweight or at risk of becoming so, or if they themselves have a history of dieting or emotional eating. This is especially true for mothers and daughters.3,6,13

"Parents' worst fear is that their child will never stop eating," Tribole says. "Especially foods they perceive as unhealthy."

Restriction in order to promote moderation has been shown to have the opposite effect,10 promoting overeating in response to the presence of palatable, previously restricted foods without improving dietary intake.12,14 In one 2003 study that followed 182 girls from ages 5 to 9, girls who experienced high levels of food restriction by their mothers were more likely to eat when not hungry than girls who had low levels of restriction. This was true regardless of whether the girls were "overweight" or not.12

Tribole tells the story of a patient who had a home-based candy business. She chose to allow her sons free access to the candy, and while at first they ate a lot, soon they ate very little—they could take it or leave it. When her sons' friends came over, however, they couldn't stay away from the candy—because it was restricted in their own homes.

Holder says when formerly forbidden food becomes permitted, heightened cravings and consumption is a normal response. She explains to parents that if they don't intervene, the cravings—and weight—tend to stabilize all on their own. "I have never in my years of practice had a client, either child or adult, consistently gain weight while practicing the principles of intuitive eating."

On the flip side, Olden says many parents worry their children won't eat enough to grow and develop well. "The greatest challenge parents must overcome is not holding themselves responsible for what the child eats," she says. "They are only responsible for meal timing, serving a variety of nutritious foods—with at least one choice they know the child will enjoy—and ensuring the mealtime is pleasant."

Taking a Family Approach
Parents who want their children to eat healthfully can benefit by focusing on being good role models. A 2005 study found that mothers consuming more fruits and vegetables weren't only less likely to pressure their daughters to eat, but their daughters also ate more fruits and vegetables and were less likely to be picky eaters.15 Along those lines, Tribole says it's important for parents to look at their own behaviors about food. "What a parent does behaviorally is more powerful than anything they can ever say—parent, heal thyself."

Do parents need to become competent intuitive eaters before raising an intuitive eater? Tribole says no. "The parent can be there intellectually before they're there behaviorally. When a parent says something like, 'I don't want to break my kid,' sometimes having a goal based on another person is very powerful." Because her patients already know all the anxiety involved in chronic dieting, she tells them, "You get to stop the legacy; you get to stop the insanity."

Holder likes to use the oxygen mask analogy with parents: when on a plane, put on your own mask before helping others. "I strongly feel that any work parents can do to calm their own relationship with food, body, and self, causes a ripple effect that benefits the entire family," she says. "Also, in my experience, kids often adapt to intuitive eating habits quicker than adults."

Other than disbanding the "clean plate club" and not making eating vegetables a prerequisite for eating dessert, what are some immediate changes parents can make to preserve or build their child's intuitive eating skills?

"The number one change parents can make when feeding their children is to not say anything," Olden says. "Once the food is in front of the child, it's no longer the parent or anyone else's business how much or whether the child eats. That part is solely the child's responsibility, and they need to own it."

Holder suggests offering nutritionally complete snacks in between meals that provide at least two of the three macronutrients. This helps promote stable moods and blood sugar, helping kids and parents hone in on true hunger and fullness. She also recommends eating as a family at the table—without devices or other distractions. "It's really hard to engage in listening to your body if you're distracted."

Tribole says it's critical for both parents to buy into the intuitive eating model, or there's a risk that they'll send their child mixed messages. "How often are they using foods to reward kids for their behavior? I'd also be looking at food talk around the table, and avoid using words of morality," she says. "We have to remember that parents are doing the best they can, but we have to also remember that there's a consequence to good intentions."

— Carrie Dennett, MPH, RDN, CD, is the nutrition columnist for The Seattle Times and speaks frequently on nutrition-related topics. She also provides nutrition counseling via the Menu for Change program in Seattle.

References
1. Engle PL, Pelto GH. Responsive feeding: implications for policy and program implementation. J Nutr. 2011;141(3):508-511.

2. Tribole E, Resch E. Intuitive Eating: A Revolutionary Program That Works. 3rd edition. New York: St. Martin's Griffin; 2012.

3. Tylka TL, Lumeng JC, Eneli IU. Maternal intuitive eating as a moderator of the association between concern about child weight and restrictive child feeding. Appetite. 2015;95:158-165.

4. Dockendorff SA, Petrie TA, Greenleaf CA, Martin S. Intuitive eating scale: an examination among early adolescents. J Couns Psychol. 2012;59(4):604-611.

5. Satter EM. The feeding relationship. J Am Diet Assoc. 1986;86(3):352-356.

6. Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. Pediatrics. 1998;101(3 Pt 2):539-549.

7. Galloway AT, Farrow CV, Martz DM. Retrospective reports of child feeding practices, current eating behaviors, and BMI in college students. Obesity. 2010;18(7):1330-1335.

8. Farrow CV, Haycraft E, Blissett JM. Teaching our children when to eat: how parental feeding practices inform the development of emotional eating—a longitudinal experimental design. Am J Clin Nutr. 2015;101(5):908-913.

9. Stoeckel LE, Birch LL, Heatherton T, et al. Psychological and neural contributions to appetite self-regulation. Obesity (Silver Spring). 2017;25(Suppl 1):S17-S25.

10. Fisher JO, Birch LL. Restricting access to palatable foods affects children's behavioral response, food selection and intake. Am J Clin Nutr. 1999;69(6):1264-1272.

11. Lansigan RK, Emond JA, Gilbert-Diamond D. Understanding eating in the absence of hunger among young children: a systematic review of existing studies. Appetite. 2015;85:36-47.

12. Birch LL, Fisher JO, Davison KK. Learning to overeat: maternal use of restrictive feeding practices promotes girls' eating in the absence of hunger. Am J Clin Nutr. 2003;78(2):215-220.

13. Birch LL, Fisher JO. Mothers' child-feeding practices influence daughters' eating and weight. Am J Clin Nutr. 2000;71(5):1054-1061.

14. Loth KA, Friend S, Horning ML, Neumark-Sztainer D, Fulkerson JA. Directive and non-directive food-related parenting practices: associations between an expanded conceptualization of food-related parenting practices and child dietary intake and weight outcomes. Appetite. 2016;107:188-195.

15. Galloway AT, Fiorito L, Lee Y, Birch LL. Parental pressure, dietary patterns, and weight status among girls who are "picky eaters." J Am Diet Assoc. 2005;105(4):541-548.