Transcript Feeding Picky Eaters , Ages 8-18

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 611 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
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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
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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
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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
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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
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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
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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
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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:
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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
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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
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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
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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
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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!