Feeding Picky Eaters

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Feeding Picky Eaters

• Ruth Carey, RD, CSSD, LD
• June 24th, 2008
• Nebraska School Food Service Association

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Objectives

• Identify problems/situations within families that
  lead to development of picky eaters.
• Effectively counsel families who have difficulty
  with childrens food choices and eating
  behaviors.
• Learn to strategize with children and parents to
  solve mealtime struggles and grocery store
  choices for picky eaters.

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Childrens Nutrition

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

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Prevalence of Overweight

• Overweight has more than doubled among 2-5 yo
  since 1970s
• Overweight has more than tripled among 6-11 yo
  since 1970s
• Overweight is now more prevalent than under
  weight or growth retardation

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Childrens 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

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Childrens Nutrition

• Increased restaurant food consumption
• 1997 - half food expenditures were spent outside
  the home, one third on fast foods
• larger portion sizes, super sizing

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Shifts in beverage consumption

• 1945 Americans drank 4 times more milk than soda
• 1997 Americans drank 2.5 times more soda than milk

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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

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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

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Family Trends

• Fewer families eat meals together
• More families with both parents working outside
  home
• Increased child care by providers other than
  parents

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Family influence

• availability and accessibility of foods
• meal structure
• adult food modeling
• food socialization practices
• food related parenting style

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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 childrens demands
• fear child wont eat
• dont want to deal with bad behavior
• each child has different likes or dislikes
• Child has special needs

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

• Ellyn Satter, MS, RD, LSW
• www.EllynSatter.com

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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

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Common parenting mistakes

• Giving up on offering healthful foods after one
  refusal
• Giving in to childs demands for food choices
• Letting a child eat while watching TV
• Letting a child eat alone

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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

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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

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Early Adolescence

• respect for adult authority
• simple instructions
• encouragement of family involvement and direction

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Middle Adolescence

• recurrent challenges to family or parental
  authority
• reliance on peers for standards of appearance and
  behavior
• simplified problem-solving techniques
• role playing

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Late Adolescence

• greater reliance on internalized values
• fewer challenges to adult authority
• less reliance on peers for standards
• increased capacity to solve life problems

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The Counseling Setting

• who should be present?
• how many visits?
• setting goals
• techniques for success

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Children 8-13

• Both child and parent present in session
• Initial visit and several follow up visits
• Set one or two goals per visit
• Simple menu plan
• Food and activity journal

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Children 14-16

• Child alone for part of session, parent (s)
  present for part
• Initial visit and several follow-up visits
• Brainstorming with client for solutions to
  problems
• Use of role playing by client
• Use of exchanges in meal planning increasing
  choices
• Food and activity journal

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Teens 17-18

• See child alone, may drive self to sessions
• Parents involved if teen chooses
• At least one initial, one follow up visit ,
  client directed if more needed
• Exchange plans, menu planning, grocery lists and
  planning for future leaving home, college

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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)

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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

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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
• Dont provide soft drinks or sugared beverages

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Tips (cont.)

• Provide a variety of vegetables and fruits often
• Use Food Guide Pyramid for meal planning
• Dont bribe, reward or punish for eating/not
  eating foods
• Dont label foods as good or bad or child as
  good or bad based on food choices

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Motivational Interviewing

• client centered
• adolescents and parents
• readiness to change
• motivation scale
• goal setting

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Break
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Case Study

• Daniel
• 14 yo
• 64 87.8 lbs
• BMI 6th percentile for age
• medication concerta
• track and Tai Kwan Do competitor

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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

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Other findings

• MI scale of 7 on motivation to change
• Has never eaten family meals at dinner
• Does not eat fruit or vegetables

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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

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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

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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

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Case Study II

• Kathy
• 11 yo girl
• 56 180lbs.
• 95 ile stature for age 95ile wt for age
• BMI 29 95th ile
• no medications or other health concerns

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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

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Diet recall (cont)

• Snack Crackers, chips, or granola bar, milk
• Dinner Grilled chicken, broccoli or
• Out Applebees Orange Chicken and Rice,
  lemonade
• Dessert Lite ice cream

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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

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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

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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

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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

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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

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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

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Case Study III

• Sally
• 12 yo girl
• 54 110 lbs.
• 90ile for stature for age 75 ile wt for age
• BMI 19 54 ile
• vegetarian , lacto- ovo x 2 years
• allergic to legumes

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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

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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

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Diet Recall (cont)

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

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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

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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.

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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

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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

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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.

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Case Study IV

• Adam
• 15 yo male
• 72 237 lbs
• 95 ile for weight 90 ile for height
• BMI 32 95ile
• Dx pre-diabetic, ADD

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Medications

• Concerta
• Respiradal
• Selexa

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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

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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

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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

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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

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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

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Consulting opportunities

• Pediatricians offices
• individual counseling
• group talks
• Schools or group homes
• Corporate Wellness Programs
• family wellness
• feeding your kids

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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

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Thank You!