Feeding Picky Eaters

Ruth Carey, RD, CSSD, LD

June 24th, 2008

Nebraska School Food Service Association

Objectives

• Identify problems/situations within families that lead to development of picky eaters.

• Effectively counsel families who have difficulty with children’s food choices and eating behaviors.

• Learn to strategize with children and parents to solve mealtime struggles and grocery store choices for picky eaters.

Children’s Nutrition

• ADA Position Paper: Dietary Guidance for a Healthy Children ages 2 to 11 Years, 2004, JADA

Prevalence of Overweight

• Overweight has more than doubled among 2-5 yo since 1970’s

• Overweight has more than tripled among 6-11 yo since 1970’s

• Overweight is now more prevalent than under weight or growth retardation

Children’s Nutrition

• Energy intake has increased over the last quarter century

• Overall decline in milk, vegetables, soups, grains, and eggs

• Increase in intake of fruits, fruit juices, sweetened beverages, poultry and cheese

Children’s Nutrition

• Increased restaurant food consumption– 1997 - half food expenditures were spent

outside the home, one third on fast foods

• larger portion sizes, super sizing

Shifts in beverage consumption

– 1945 Americans drank 4 times more milk than soda

– 1997 Americans drank 2.5 times more soda than milk

Shifts in meal patterns

• Breakfast consumption is down among children and adolescents from 1965 to 1991.

• Snacking has increased significantly in the U.S.

• 50 % of children ages 6-18 report 5 eating occasions or more daily

Impact of school meals

• Children in School Lunch programs have higher intake of vegetables, milk, and meat

• Children in School Breakfast program have higher intakes of many vitamin and minerals

• School foods many times look like fast foods,i.e.: burgers, fries, pizza, nuggets

• Competitive foods in high schools and middle schools offer FMNV

Family Trends

• Fewer families eat meals together

• More families with both parents working outside home

• Increased child care by providers other than parents

Family influence

• availability and accessibility of foods

• meal structure

• adult food modeling

• food socialization practices

• food related parenting style

Situations that may encourage a picky eater

• Parents may not realize that there is a natural tendency for children to reject a new food: taste or texture issues

• Parents give in to children’s demands– fear child won’t eat– don’t want to deal with bad behavior– each child has different likes or dislikes

• Child has special needs

It may take up to 15 tries for a child to accept a new food

Division of Responsibility

• Ellyn Satter, MS, RD, LSW

• www.EllynSatter.com

Division of Responsibility

• Parent provides nutritious meals and snacks

• Parent provides regular meal and snack time

• Child decides how much to eat

• Child decides whether to eat

Common parenting mistakes

• Giving up on offering healthful foods after one refusal

• Giving in to child’s demands for food choices

• Letting a child eat while watching TV

• Letting a child eat alone

Parenting mistakes

• Giving child different meal from adult meal

• Making personal food aversions known to child

• Restricting amount or certain foods

• Dieting/restriction of own diet

Counseling children

• Cognitive development (Spear)• Early childhood: concrete operational

thought– black and white, straight forward messages– family based, multi-component education best

• Adolescence :formal operational thought– ability to think hypothetically and abstractly– Family and school based education effective

Early Adolescence

• respect for adult authority

• simple instructions

• encouragement of family involvement and direction

Middle Adolescence

• recurrent challenges to family or parental authority

• reliance on peers for standards of appearance and behavior

• simplified problem-solving techniques

• role playing

Late Adolescence

• greater reliance on internalized values

• fewer challenges to adult authority

• less reliance on peers for standards

• increased capacity to solve life problems

Counseling Parents or Caregiver

• Set a good example– healthful foods, table manners, family meals

• Model variety, moderation and balance

• Involve child in meal planning, and shopping when age appropriate

• Encourage help with meal preparation (age appropriate)

Parents and/or caregiver

• Allow child to express hunger and fullness and encourage listening to internal cues

• Allow child sufficient time to finish meal without distraction from T. V. etc.

• Avoid using dessert as reward or punishment

• Remove child from table for disruptive behaviors

Tips for increasing vegetables, dairy, variety and moderation

• Sneak vegetables into favorite food– mac and cheese

• Allow children to put favorite sauces on foods, let them dip

• Involve children in growing, picking and age appropriate preparation of meals

• Don’t provide soft drinks or sugared beverages

Tips (cont.)

• Provide a variety of vegetables and fruits often

• Use Food Guide Pyramid for meal planning

• Don’t bribe, reward or punish for eating/not eating foods

• Don’t label foods as “good or bad” or child as good or bad based on food choices

Case Study

• Daniel

• 14 yo

• 64” 87.8 lbs

• BMI 6th percentile for age

• medication : concerta

• track and Tai Kwan Do competitor

Diet Recall

• Breakfast: Multigrain Cherrios, nonfat milk,– recently added instant breakfast

• Lunch: white roll and milk (school)

• Snack: cereal, milk, ice cream

• Dinner: white bread and jelly sandwich or French bread ham and cheese, milk

• Dessert: milkshake

Other findings

• MI scale of 7 on motivation to change

• Has never eaten family meals at dinner

• Does not eat fruit or vegetables

Assessment

• underweight for height

• inadequate protein and calories for growth, sport

• diet low in fiber

• diet low in fruits and vegetables

• diet lacks variety

• extremely picky eater going back to toddler days

Recommendations

• 2500 calorie exchange plan

• planned 3 sample days menus

• increase fruits and vegetables

• eat dinner with family some nights per week

• eat more protein

• add whole grains

• take multivitamin with iron

Goals

• to eat dinner with family 3 nights per week

• to include protein in most meals

• to try eating fruits and vegetables

• to journal food intake

• return in one month

Case Study II

• Kathy

• 11 yo girl

• 5’6” 180lbs.

• >95 %ile stature for age > 95%ile wt for age

• BMI 29 >95th %ile

• no medications or other health concerns

Diet Recall

• Breakfast: sugared cereal, NF milk, banana– or white bagel with cream cheese

• Lunch: School lunch with chocolate milk, or lemonade– or turkey sandwich with mustard, 100 cal pack

of cookies or crackers

Diet recall (cont);

• Snack: Crackers, chips, or granola bar, milk

• Dinner: Grilled chicken, broccoli or – Out: Applebee’s Orange Chicken and Rice,

lemonade

• Dessert: Lite ice cream

Other findings:

• Mom “ Kathy can eat large portions”

• Constipation a problem

• No allergies

• Rarely drinks water

• Activity is PE at school only 2 days week

Assessment

• diet low in fruits and vegetables

• sugared cereals and beverages contribute empty calories

• breakfast is low in fiber and protein

• breakfast and lunch inadequate calories

• low in fluids/ water

• not enough regular activity

Recommendations

• Planned sample menu for 3 days, using Food Guide Pyramid

• Include protein at breakfast– egg or peanut butter with whole wheat toast– whole wheat English muffin with fat free cream

cheese

• Switch to high fiber cereal – Oatmeal, Bran flakes

• Drink water with all meals and snacks

Recommendations (cont)

• Drink plain milk and water at lunch

• Include fruit and vegetable at lunch in place of “100 calorie packs”

• Pack lunch 3 days per week, and buy 2 days

• Have yogurt and fruit, or cheese stick and vegetables and dip for after school snack

• Control portions at dinner (measure for a while to learn portion control)

• Increase activity to one hour per day

Recommendations (cont)

• Concrete, black and white

• First visit, set goal to work on breakfast recommendations

• Second visit, set goal to work on lunch recommendations

• Third visit, set goal to work on snack recommendations

• Keep simple food journal for 3 days each week

Results

• At one month weight is holding steady, no loss or gain

• Kathy is reading labels, sugar and fiber

• Mother realizes that this is a slow process of change

• Kathy has signed up for softball and is trying to be more active

Case Study III

• Sally

• 12 yo girl

• 5’4” 110 lbs.

• 90%ile for stature for age 75% ile wt for age

• BMI 19 54% ile

• vegetarian , lacto- ovo x 2 years

• allergic to legumes

Other

• plays competitive basketball and soccer 2 X per week

• goes to athletic club with father for pick up games and run mile

• has not started menses• Dr. concerned with recent weight loss• Mother complains Sally wants to be

vegetarian but is picky eater

Diet Recall

• Breakfast: granola with yogurt (recent change to whole milk yogurt)

• Lunch: Bagel and fruit, sometimes a cheese stick

• Snack: granola or Odwalla bar

• Dinner: Pasta with parmesan cheese, bread, broccoli

Diet Recall (cont)

• Sally wants to eat all meals downstairs in front of T.V.

• Sally states “it’s so lame to eat with your parents, none of my friends eat with their parents”

• Great deal of tension between mother and daughter

• Mother also a vegetarian, has always watched her diet

Assessment

• Diet is low in protein

• Diet is low in fruits and vegetables and variety

• Diet is low in calories for all activity

• Diet is low in calcium

• Lack of family meals

• Sally is in Middle adolescent phase

Recommendations

• 2400 calorie vegetarian exchange diet

• increase low fat dairy to 4 servings daily

• increase fruits and vegetables to 9 servings daily

• increase protein to 6 servings daily

• Sally plans 2 dinners for family per week

• Sally eats with parents with no T. V.

Recommendations

• Two goals per visit

• Concrete, specific food choices, ideas for increasing variety

• Keep food journal

• Take a multivitamin with iron

• Sally direct help from mother

Results: 3 follow up visits:• Sally has increased her protein at all meals

– edemame, sushi, dried beans and more cheese

• Sally still needs to drink more milk or eat more yogurt

Results (cont.)

• Sally has increased her fruit intake, eating more variety of vegetables

• Sally is eating tree nuts for snacks

• Increase in weight 1-2 lbs per week.

Case Study IV

• Adam

• 15 yo male

• 72” 237 lbs

• >95 %ile for weight 90% ile for height

• BMI: 32 >95%ile

• Dx: pre-diabetic, ADD

Medications

• Concerta

• Respiradal

• Selexa

Diet Recall

• Breakfast: lg bowl cereal and skim milk• Lunch: White Bagel with cream cheese and

water• After school snack: Sandwich, Lean Pocket,

Goldfish, nuts, 2 diet sodas• Dinner: Meat, chicken or fish, potatoes• Snack: Cereal with milk or dessert of

cookies and ice cream

Assessment:

• lacking in fruits and vegetables

• lacking in protein and calories at breakfast and lunch

• too large after school snack

• lacking in calcium, does not like milk

• no exercise

• medications affect appetite

Recommendations

• 2500 calories, exchange type pattern

• Weight loss

• 3 sample menus created

• Increase size of breakfast

• Add protein to breakfast and lunch

• Add fruit to breakfast

Recommendations (cont.)

• Increase intake of vegetables at dinner

• Walk 4 days per week, increasing to daily activity

• Set 2 goals per visit

• Parents both involved to help and monitor

• Help directed by Adam

Results : 6 weeks

• Weight loss of 7 lbs.

• Walking 4 days per week for 30-40 minutes

• Discontinued anti -depressant

• Oatmeal x 2 packets with protein powder most days of week

• Eating fruit at pm snack

• Eating vegetable with dinner

Conclusion

• Parents and care givers provide variety of healthy food choices

• Parents and care givers provide regular meal and snack times

• Children decide whether to eat and how much

• Involve children in growing, preparing and serving

Thank You!