Restrictive Dieting Beyond the Key Messages

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Restrictive Dieting - Beyond the Key Messages -

• Alicia Dixon Docter, MS, RD, CD
• Clinical Nutritionist
• Childrens Hospital and Regional Medical Center,
  Adolescent Medicine
• Lecturer, UW School of Nursing

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COAT PhilosophyChildrens Obesity Action Team
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Genetics / BiologyEvolutionary Biology Theory

• Increased energy stores (fat stores)
• increased survival
• reproductive capacity
• increased breast feeding potential
• Those who survive
• genes for energy storage
• minimize energy expenditure
• Metabolism speeds up or slows down to keep weight
  at a steady state (set point theory)

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Oversimplification of a complex problem

• Its much more than
• energy in energy out

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Family / Culture / Environment

• Activity is more sedentary TV, videos,
  computers
• American Academy of Pediatrics. Pediatrics 2003
  112 424-430.
• Soda intake has increased by 500 over past 50
  years USDA
• Ludwig, et al. The Lancet 2001 357505-508.
• Portion sizes have increased
• Young, et al. Amer Journal of Public Health
  2002 92246-249.
• Food consumed outside of the home
• 34 of food budget in 1970 vs 47 in 1990s
• Gillman M, et al. Arch Family Medicine
  20009235-240.

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Core Regulatory Skills/Genetics/BiologyParental
Feeding Practices

• Children can respond to the energy density
• Each meal may be erratic, but 24-hour intake is
  well regulated
• Pediatrics 199494653-661.
• Pediatrics 1998101539-549.

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Effects of Parental Control

• Does maternal restriction promote overeating in
  the absence of hunger (EAH)?
• Higher levels of restriction at age 5 y.
  predicted higher EAH at age 7 y. and age 9 y.
• Girls who were overweight at age 5 y. and who
  received higher levels of restriction had the
  highest EAH scores at 9 y.
• 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. 78 215-20, 2003.
• Rhee, KE, et al. Parenting Styles and Overweight
  Status in First Grade, Pediatrics, 117 2047-54,
  2006.

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Family/Culture/EnvironmentParental Feeding
Practices

• Encouraging eating past satiety
• Clean-plate Club
• Eat 3 bites of vegetables and finish your milk
  before you can be excused from the table.
• Portraying some foods as something to rebel
  against others as a prize
• You may have dessert, but first pick up your
  toys.
• Eat your carrots so that you can have dessert.

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Parenting Style

• How parents vary on the dimensions of warmth and
  nurturance versus control.
• Authoritative - appropriately demanding and
  controlling, warm and responsive
• Authoritarian - highly demanding and
  over-controlling, emotionally cold and
  unresponsive
• Permissive impose little control, either overly
  indulgent (warm) or neglectful (cold)

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Parenting Style

• Children of authoritarian and permissive mothers
  - more likely to be overweight than children of
  mothers with an authoritative style.
• Permissive parenting style
• related to lower monitoring of childrens
  unhealthy food intake
• associated with greater use of restrictive
  feeding practices in mothers
• greater application of pressure to eat in fathers
• may ultimately impede a childs development of
  appropriate self-regulation of food intake
• Blissett, J., and Baycroft, E. Are parenting
  style and controlling feeding practices related?
  Appetite (2007)

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Emotional Eating

• Individuals who eat in response to emotions and
  stress are more likely to be overweight
• Emotions play a role in how much one eats
• Important to identify other factors that are
  contributing to weight gain to facilitate and
  maintain behavioral change
• Ozier et al. Overweight and obesity are
  associated with emotion- and stress-related
  eating as measured by the Eating and Appraisal
  Due to Emotions and Stress Questionnaire. Journal
  of the American Dietetic Association (2008)

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Disordered Eating

• Any style of eating that is getting in the way of
  functioning?
• Binge eating is common in obese adolescents
  seeking treatment for weight management
• Parental history of an eating disorder impacts
  the feeding relationship

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Nutrition Assessment

• Diet history
• From infancy to present
• Preferred / disliked foods
• Dietary restrictions / food allergies
• Review of typical day
• Schedule/Activities
• Beverages
• Medications

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Environmental AssessmentHome

• Family composition
• Family schedules
• Child care arrangements
• Food availability
• Location of meals snacks
• Free time
• Rules around food

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Environmental AssessmentSchool

• Involvement in school feeding programs
• Snack times
• Food rewards in classroom
• School functions
• Involvement in activities

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Environmental AssessmentCommunity

• Food purchasing options
• Supermarkets, convenience stores, farmers
  markets
• Safety of community
• Parks, playgrounds, traffic
• Transportation options
• Walkable?, Bikeable?, Busable?

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ChildDevelopmental Tasks

• Toddlers
• Messy eaters
• Finger foods
• Say No to new foods
• Learn words at meals
• Preschoolers
• Curious and ask why
• Help mix stir food
• Make sandwiches

• School Age
• Eat well
• Carry on a conversation
• Want foods they see on TV
• Enjoy cooking eating food they make

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AdolescentDevelopmental Tasks

• Early adolescence autonomy focus on peers and
  learning to make it in a teenage world
• Later adolescence intimacy and identity
• Sexual identity and finding themselves
• Move into formal operations ability to think in
  the abstract as well as concrete terms

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Family InvolvementakaDivision of Responsibility

• Ellyn Satter, MSW, RD
• Role of parents/caregiver
• Provide meals and snacks at regular intervals
• Provide a wide variety of food
• Role of child
• Listen to internal regulation and eat according
  to hunger and satiety

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Counseling Strategies
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Why this Topic?

• Clinical experience
• Providers note restriction when families and
  teens are talking about managing overweight are
  uncertain as to how to work with it.
• In practice with overweight and eating disorders,
  note various forms of restriction in kids, teens
  and parents

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Red Flags in Office or Home

• I dont know why Johnny is gaining weight, we
  only eat healthy or good foods.
• If you eat that, you are going to have to
  exercise it off.
• They said I am big boned so I just have to live
  with my weight and take care not to eat too
  much.
• Drink water before your meal so you eat less.
• Caregivers or providers restrict carbs or fat
  or the current magic bullet if we could just
  get rid of all the sugared cereal in their house,
  Jenny would lose the weight.

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Nutrition Counseling and Education

• Themes development and maintenance of rapport
  coordination between teen and parents/caregivers
• Return Visit 1 Physiology of metabolism and
  semi-starvation
• Return visit 2 Meal patterns
• Return Visit 3 Food, nutrients, and how they
  work
• Return Visit 4 Energy use during activities of
  daily living
• Return Visit 5-8
• Nutrition for an active or sports-involved person
• Why restrictive diets dont help meet goals of
  fat loss
• Body image
• Review meal pattern changes and suggest new goals
• Monitor and review body comps (AMA) on on-going
  basis

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Set the Stage for Success

• Allow adequate time for an initial visit (60-90
  min.)
• Allow for regular follow-up visits
• Who sees whom
• 2 - 5 Years Old
• Communicate with parent
• Arrange for childcare
• 6 - 11 Years Old
• Communicate with parent or both
• The first encounter is with the parent only
• Follow up with parent and/or child
• Over 12 Years Old
• Communicate with parent and teen, ask parent to
  leave and then bring back into room at end of
  session.

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Relationship Building via Motivational
Interviewing

• Develop rapport and trust by focusing on what
  they are doing well.
• The goal - facilitate fully informed, deeply
  contemplated, and internally motivated choices,
  not necessarily to change behavior
• Keep education conversational open-ended
  questions and reflective listening
• Take time to choose what you say
• See patient or family on an on-going basis
• Deliver one message at a time

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Motivational Interviewing in Healthcare,
Rollnick, Miller and Butler, 2008

• Guiding more than directing
• Dancing more than wrestling
• Listening at least as much as telling
• Overall spirit of MI
• Collaborative
• Evocative
• Honors patient autonomy
• RULE
• Resist the righting reflex
• Understand your patients motivations
• Listen to your patient
• Empower your patient

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Goals for Nutrition Sessions

• Promote self-regulation so that a child grows and
  attains his/her genetically determined body type.
• Help with self-regulation to normalize weight and
  body composition.
• Enjoy food! eat when hungry and stop when
  satisfied most of the time (Ellyn Satter, 2005).

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Message 1 Restriction Doesnt Work

• Diminishes self-regulation
• Cant tell when hungry or satisfied
• Restriction of a meal leads to binging/grazing
  eating in the absence of hunger, shame
• Not very pleasurable

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Effects of Semi-starvationBiology of Human
Starvation, Ancel Keyes (1950)

• Physiological
• RMR decreased by 40
• Lost 25 body weight
• Suppressed vitals
• Psychological
• Crave food and focus on this one need
• Toying with and hoarding food
• Anxiety, fatigue, depression

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Patterns of Restriction Leading to Overeating

• B L S D S
• ---- X xxxxxx X ----
• XXX xxxxx
• XXX XXX x XXX xxx
• Oprah!

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Grazing vs. Structured Meals and Snacks

• Food intake increases the release of insulin
  leptin - causes increased storage of fat and
  glucose to be used during times of fasting
• With constant snacking during the day, insulin
  levels remain elevated resulting in prolonged
  episodes of storage increasing risk for
  becoming overweight
• Structured meals and snacks (approx. every 3
  hours) allows time for the blood sugar to return
  to basal levels resulting in hunger.
• Children who snack all day never experience the
  internal cues of hunger or fullness and thus tend
  to overeat.

Corinne Marmonier, et al. Am J Clin Nutrition,
September 2002.
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Effects of Restrictive Eating (Dieting) on Weight
Change Among Preadolescents and Adolescents

• Teens who dieted more likely to gain excessive
  weight than non-dieters. Dieters more likely to
  binge than non-dieters. (Field, et al, Ped, 112
  900, 2003)
• Girls who dieted in ninth grade were more than
  three times as likely to be overweight in twelfth
  grade, as compared with girls who did not diet in
  9th grade. (Stice, et al, J. Cons. And Clin.
  Psych. 67 967, 1999)

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Adolescent Dieters 5 Years Later How do they
fare?

• n2,516 (diverse backgrounds)
• Project EAT surveys in 1999 and 2004
• Outcome measures weight status, binge eating,
  extreme wt. control, self-report ED
• Using wt. control practices
• 3 times greater risk for being overweight in
  2004
• BMI higher than no wt. control practices (25.1
  5.6 vs. 22.53.9 in girls)
• At increased risk of binge eating with loss of
  control and purging, etc.
• Neumark-Sztainer, D., J. American Dietetic
  Assoc.,107448-455, 2007

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M.Savoye study in JAMA, 2007

• n209 with BMI95th percentile for age, ages 8-16
  y. Required caregivers participation
• Studied BMI change, body composition, insulin
  sensitivity, bp and lipids
• Control group counseling q. 6 months (MD, RD,
  occ SW)
• Weight management group family-based program
  including exercise, nutrition and behavior
  modification. Intervention occurred biweekly the
  first 6 months and bimonthly for 6 more months.
• In second randomization, group assigned to
  structured meal plan approach (dieting) dropped
  out so this arm discontinued 6 months into study
• Groups included nutrition topics as well as
  goals, identification of high-risk situations,
  bullies, understanding relapses
• JAMA. June 27, 2007, Vol 297, No. 24. Effects of
  a Weight Management Program on Body Composition
  and Metabolic Parameters in Overweight Children

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Message 2 Food Does Work

• All foods work
• Carbohydrates provide glucose for energy most
  important nutrient in daily activities and
  exercise
• Protein building, strength, shape
• Food sources of fat cell structure, satiety,
  elimination, flavor, energy
• Your body works and uses food
• Your body needs food to grow
• Your body needs food to feel good and look good
  and so you achieve your goals
• It is normal to feel hunger signals every 3-4
  hours tells you that your metabolism is
  working!

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Satisfaction from consuming a varied meal or snack
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Breakfast

• n2216 63.1 white 9.9 black 17.1 Asian
• Time 1 age 14.9 y Time 2 age 19.4 y
• Higher BMI observed in those eating breakfast
  intermittently or never
• In both cross-sectional and prospective analyses,
  dieting and weight-control behaviors were
  inversely associated with frequency of breakfast
  consumption
• Timlin, MT, Pereira, MA, Story, M, and
  Neumark-Sztainer, D., Breakfast Eating and Weight
  Change in a 5-Year Prospective Analysis of
  Adolescents Project EAT, Pediatrics, 121 3,
  2008

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Approximate Food Intake for an Active Child and
Adolescent

• Breakfast cereal with milk, toast with spread,
  fruit or juice
• Snack (if school allows) fruit or cereal bar
• Lunch sandwich with meat or fish, (/-cheese),
  fruit, chips or cookies, milk or juice or school
  entrée, fruit and milk
• Snack granola bar and yogurt
• Dinner chicken, grain, vegetables or salad or
  fruit, milk or burrito, salad, milk
• Dessert or snack cereal and milk

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Message 3A Supportive Environment Helps

• Balance eating pattern dont restrict!
• Parents to help develop a balanced meal pattern
  by having regular meal snack times. Eat every
  3-4 hours aiming for 3 real meals and 1-3 snacks
  in a day.
• Family meals What would need to change if you
  decided to have family meals a certain number of
  times per week?
• Power of role-modeling examine your own ideas
  around food, exercise, body image, emotion
  regulation.
• If someone says they feel fat, take time to
  explore what is really going on.
• Allow for variation in an individual.
• (JADA 107 62, 2007)

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Learning from Teens

• Love me the way I am
• Dont tell me my weight is OK
• Walk the walk
• Help me out dont single me out
• Get off my back
• Let ME be in charge
• Help me be patient and realistic
• Weight Loss ConfidentialAnne Fletcher, MS, RD

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New ways to talkinstead of this, try this

• Avoid foods high in calories food gives you
  energy so you can ___________________________.
• In order to eat a cookie, you need to take a
  walk enjoy something you really like to eat
  it will be more satisfying for you in the long
  run
• Eat some carrot sticks for a snack be sure you
  have a snack that satisfies you.
• If you are feeling fat, go for a walk Feeling
  fat is not a feeling. What is the real
  feeling? Loneliness, sadness, anxietytalk about
  possible solutions.

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New ways to talkinstead of this, try this

• Its just a matter of intake and outputwith
  help, I know you can do this.
• Just eat more fruits and vegetables (or high
  fiber foods or low-glycemic foods or protein,
  etc.)I see that you are doing a great job
  eating breakfast and lunch but that you are still
  eating more than you are comfortable with at
  snack time. Have you thought about adding a
  piece of fruit to your breakfast to make it more
  of a real meal? Adding some crackers (or even
  chips) at lunch to make it a real meal? Adding
  some turkey or cheese to that bagel at lunch?
• Resource Like I am So Fat! by Dianne
  Neumark-Sztainer, PH.D., RD

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Thank you