- Email: [email protected]
Children and restrained eating
practice applications
LETTERS TO THE EDITOR
Obesity Crisis Comprised of Danger and Opportunity To the Editors: Marianne Smith Edge (1) described obesity as a national crisis. As US Department of Health and Human Services Secretary Tommy Thompson said recently, obesity has become the second leading cause of preventable death in the United States, trailing only fatalities from cigarette smoking. Obesity is not only a national but also an international crisis. In a country like China, where one of every four human beings on this planet lives and where leanness used to be the norm (2), things have recently changed. China is also fighting obesity, especially childhood obesity, which is as high as 28% (2). By the end of 2000, the obesity rate in male students in Beijing, China, reached 15%, doubling the rate seen in 1990 (2,3), and surpassing that of developed countries as cited by Edge (1). Excessive caloric intake from fast food, insufficient exercise from increased mechanization, and the popularization of television are the principal causes of weight gain in China (2). In China, overweight children were 2.8 times as likely as all other children to become overweight adolescents (4); and overweight adolescents tend to grow up to be overweight adults (2,4). Coronary heart disease used to be rare in China, but it is on the rise at the present time. The prevalence of coronary heart disease has risen from the fifth most common form of heart disease in the 1950s to the most common form of heart disease in the 1980s and 1990s (2). The fact that diet plays a major role is evidenced by the progressive rise of “normal” plasma cholesterol levels in free-living Chinese men from 155 mg/dL in 1958 to 191 mg/dL in 1981, 200 mg/dL in 1997, and 232 mg/dL in 2003 (5). As Edge concluded, “Obesity is a crisis, but it is a crisis opportunity for dietetics professionals” (1). I should add that obesity is indeed a crisis for
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everybody, including the obese individuals themselves and the health care providers who treat them. In Chinese, the expression for crisis (wei-ji) is made of two Chinese characters: (wei) and (ji). The first character (wei) means danger, and the second character (ji) means opportunity. Therefore, this international crisis is comprised of both danger and opportunities. On one hand, obesity is a danger to health, but on the other hand it provides opportunities for all of us to do something about it. Tsung O. Cheng, MD Professor of Medicine George Washington University Medical Center Washington, DC References 1. Edge MS. Obesity: An opportunity to help resolve a national crisis. J Am Diet Assoc. 2004;104:331. 2. Cheng TO. The current state of cardiology in China. Int J Cardiol. 2004;96:425-439. 3. Cheng TO. Physical activity in young children [letter]. Lancet. 2004;363:1164. 4. Cheng TO. Childhood obesity in China. Health & Place. In press. 5. Cheng TO. Low cholesterol values are no longer common in China. Eur Heart J. 2004;25:184. doi: 10.1016/j.jada.2004.08.020
Children and Restrained Eating To the Editors: In the July 2004 article, “Girls at Risk for Overweight at Age 5 Are at Risk for Dietary Restraint, Disinhibited Overeating, Weight Concerns, and Greater Weight Gain from 5 to 9 Years,” Shunk and Birch identified a serious and pervasive iatrogenic condition. Directly or indirectly, it appears that young girls respond to the at risk of overweight label by being
Journal of the AMERICAN DIETETIC ASSOCIATION
dissatisfied with their bodies, using a variety of means to restrict food intake, undermining their food regulation abilities, and gaining weight. The majority of girls as young as 5 years responded “yes” when asked questions like, “Do you try to eat a little bit on purpose so you don’t get fat?” The design and data of the study are excellent, but the conclusions are unwarranted. Rather than recommending avoidance of food restriction, the authors recommended restriction by the parents. The solution to restrained eating is not restrained feeding. Clinically, I have consistently found that even moderately restrained feeding makes children foodpreoccupied and prone to overeating. This correlates with Birch’s research findings that parental overcontrol undermines children’s regulatory capabilities (1). Certainly the authors’ recommendation that parents take responsibility for feeding is appropriate. However, they emphasize not only feeding, but also restricting portion sizes, avoidance of high-caloric– density foods, and emphasizing fruits and vegetables. The distinction is in the intent. It is restrained feeding when the intent is to control what and how much children eat. Children cannot be fooled. They react to even subtle and indirect restriction by becoming food-preoccupied and are prone to overeat when they get the chance. This iatrogenic condition appeared to exacerbate the very problem the designation of at risk of overweight is intended to solve (2). Up to age 9 years, children with a high body mass index are more likely to slim down than remain heavy (3). Instead of conforming to that natural tendency, these food-restricted girls gained excessive weight. To accurately regulate food intake, the school-age child depends on parents to establish and maintain a division of responsibility in feeding. Parents manage the what, when, and where of feeding; children manage the whether and how much of eating (4). To preserve the effectiveness of the division of responsibility in feeding, it is essential to respect children’s
© 2004 by the American Dietetic Association
LETTERS TO THE EDITOR prerogatives with respect to food regulation and food acceptance. Properly enacted in a stage-appropriate fashion, the division of responsibility provides children with both structure and support for eating. When adults do their jobs with feeding, children are effective about doing their jobs with eating. Ellyn Satter, MS, RD CEO Ellyn Satter Associates Madison, WI References 1. Birch LL, Fisher JA. Appetite and eating behavior in children. Pediatr Clin North Am. 1995;42:931953. 2. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert committee recommendations. Pediatrics. 1998;102:E29. 3. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22: 167-177. 4. Satter EM. The feeding relationship. J Am Diet Assoc. 1986;86: 352-356. doi: 10.1016/j.jada.2004.08.010 Author’s Response: I have great respect for Ellyn Satter and have been a great admirer of her work for years. Satter’s contributions are among the very best in providing excellent guidance to parents on feeding children, especially in today’s very challenging food environment. However, I disagree with her concerns regarding our recent paper (1). First, Satter suggests that girls’ negative evaluations and attempts at restricting intake were a response to our labeling girls as “at risk for overweight.” However, we did not give girls or their parents this information. In our research, we did use the National Center for Health Statistics’ cutoffs to categorize girls as at risk for overweight (ⱖ85th percentile) for purposes of our analyses. However, we never told girls or their parents about this categorization, so their behavior could not have been a response
to our labeling them as at risk for overweight. Second, Satter argues that we are advocating restricting children’s intake when we suggest (a) providing children and parents with guidance and information about portion size, and (b) encouraging intake of foods high in nutrient density and lower in energy density, such as fruits and vegetables. I disagree. In the discussion and conclusion we made some suggestions regarding how to ameliorate or prevent the problematic behaviors and negative self-evaluations we observed in these girls. Our suggestions focused on providing alternatives to restrictive tactics, not promoting them. Providing parents with guidance about what children should be offered is consistent with Satter’s division of responsibility. Satter has said, “parents are responsible for the what, when, and where of feeding.” Following Satter’s lead, we suggest that parental responsibility for what children eat includes offering an array of healthy alternatives, including foods high in nutrient density and lower in energy density, especially fruits and vegetables. Prior research has shown that if we offer such foods frequently, in positive contexts, children are likely to learn to like and accept some of them (2-4). With respect to providing parents and children with information about portion size, our previous findings have shown that by age 5, children are already responding to larger portions by eating more; our previous research has shown that as the size of the portion offered increases, children eat significantly more (5,6). These findings support the view that parents and children do need guidance about portion sizes in the current food environment, where large portions are promoting overeating among adults and children. Given all our findings showing that restrictive feeding can also promote overeating and reduced responsiveness to internal cues of hunger and satiety (7-10), I would never recommend restrictive feeding approaches, and did not intend to send a message that could be interpreted in that way. However, the results of the research showing that large portions can increase children’s intake (5,6) has led me to conclude that, given the super-sized portions available these days, we do need to provide children and parents with guidance about appropriate portion sizes that are of-
fered to children. Yes, we need to be careful that this guidance is not interpreted as restriction. I strongly agree with Satter’s statement, “we need to respect children’s prerogatives with respect to food regulation.” However, the research evidence has indicated that very large portions can overwhelm children’s ability to self-regulate. Rather than constituting restriction, guidance about appropriate portions can provide the support parents need to create family environments that foster children’s self-regulation. Such guidance could help to limit opportunities for overeating, which can be triggered by excessively large portions. However, at this point, additional research is needed to determine how best to communicate portion size information to make sure we avoid the concerns Satter raises. Leann L. Birch, PhD Professor Department of Human Development and Family Studies The Pennsylvania State University University Park References 1. Shunk J, Birch LL. Girls at risk for overweight at age 5 are at risk for dietary restraint, disinhibited eating, weight concerns, and greater weight gain from 5-9 years. J Am Diet Assoc. 2004;104: 1120-1126. 2. Birch LL, Zimmerman S, Hind H. The influence of social-affective context on preschool children’s food preferences. Child Development. 1980;51:856-861. 3. Birch LL, Marlin DW. I don’t like it; I never tried it: Effects of exposure to food on two-year-old children’s food preferences. Appetite. 1982;4:353-360. 4. Birch LL, Gunder L, GrimmThomas K, Laing DG. Infant’s consumption of a new food enhances acceptance of similar foods. Appetite. 1998;30:283-295. 5. Rolls BJ, Engell D, Birch LL. Serving portion size influences 5-year-old but not 3-year-old children’s food intakes. J Am Diet Assoc. 2000;100:232-234. 6. Fisher JO, Rolls BJ, Birch LL. Children’s bite size and intake of an entrée are greater with large portions than with age-appropriate or self-selected portions. Am J Clin Nutr. 2003;77:1164-1170.
Journal of the AMERICAN DIETETIC ASSOCIATION
1547
LETTERS TO THE EDITOR
Obesity Crisis Comprised of Danger and Opportunity To the Editors: Marianne Smith Edge (1) described obesity as a national crisis. As US Department of Health and Human Services Secretary Tommy Thompson said recently, obesity has become the second leading cause of preventable death in the United States, trailing only fatalities from cigarette smoking. Obesity is not only a national but also an international crisis. In a country like China, where one of every four human beings on this planet lives and where leanness used to be the norm (2), things have recently changed. China is also fighting obesity, especially childhood obesity, which is as high as 28% (2). By the end of 2000, the obesity rate in male students in Beijing, China, reached 15%, doubling the rate seen in 1990 (2,3), and surpassing that of developed countries as cited by Edge (1). Excessive caloric intake from fast food, insufficient exercise from increased mechanization, and the popularization of television are the principal causes of weight gain in China (2). In China, overweight children were 2.8 times as likely as all other children to become overweight adolescents (4); and overweight adolescents tend to grow up to be overweight adults (2,4). Coronary heart disease used to be rare in China, but it is on the rise at the present time. The prevalence of coronary heart disease has risen from the fifth most common form of heart disease in the 1950s to the most common form of heart disease in the 1980s and 1990s (2). The fact that diet plays a major role is evidenced by the progressive rise of “normal” plasma cholesterol levels in free-living Chinese men from 155 mg/dL in 1958 to 191 mg/dL in 1981, 200 mg/dL in 1997, and 232 mg/dL in 2003 (5). As Edge concluded, “Obesity is a crisis, but it is a crisis opportunity for dietetics professionals” (1). I should add that obesity is indeed a crisis for
1546
everybody, including the obese individuals themselves and the health care providers who treat them. In Chinese, the expression for crisis (wei-ji) is made of two Chinese characters: (wei) and (ji). The first character (wei) means danger, and the second character (ji) means opportunity. Therefore, this international crisis is comprised of both danger and opportunities. On one hand, obesity is a danger to health, but on the other hand it provides opportunities for all of us to do something about it. Tsung O. Cheng, MD Professor of Medicine George Washington University Medical Center Washington, DC References 1. Edge MS. Obesity: An opportunity to help resolve a national crisis. J Am Diet Assoc. 2004;104:331. 2. Cheng TO. The current state of cardiology in China. Int J Cardiol. 2004;96:425-439. 3. Cheng TO. Physical activity in young children [letter]. Lancet. 2004;363:1164. 4. Cheng TO. Childhood obesity in China. Health & Place. In press. 5. Cheng TO. Low cholesterol values are no longer common in China. Eur Heart J. 2004;25:184. doi: 10.1016/j.jada.2004.08.020
Children and Restrained Eating To the Editors: In the July 2004 article, “Girls at Risk for Overweight at Age 5 Are at Risk for Dietary Restraint, Disinhibited Overeating, Weight Concerns, and Greater Weight Gain from 5 to 9 Years,” Shunk and Birch identified a serious and pervasive iatrogenic condition. Directly or indirectly, it appears that young girls respond to the at risk of overweight label by being
Journal of the AMERICAN DIETETIC ASSOCIATION
dissatisfied with their bodies, using a variety of means to restrict food intake, undermining their food regulation abilities, and gaining weight. The majority of girls as young as 5 years responded “yes” when asked questions like, “Do you try to eat a little bit on purpose so you don’t get fat?” The design and data of the study are excellent, but the conclusions are unwarranted. Rather than recommending avoidance of food restriction, the authors recommended restriction by the parents. The solution to restrained eating is not restrained feeding. Clinically, I have consistently found that even moderately restrained feeding makes children foodpreoccupied and prone to overeating. This correlates with Birch’s research findings that parental overcontrol undermines children’s regulatory capabilities (1). Certainly the authors’ recommendation that parents take responsibility for feeding is appropriate. However, they emphasize not only feeding, but also restricting portion sizes, avoidance of high-caloric– density foods, and emphasizing fruits and vegetables. The distinction is in the intent. It is restrained feeding when the intent is to control what and how much children eat. Children cannot be fooled. They react to even subtle and indirect restriction by becoming food-preoccupied and are prone to overeat when they get the chance. This iatrogenic condition appeared to exacerbate the very problem the designation of at risk of overweight is intended to solve (2). Up to age 9 years, children with a high body mass index are more likely to slim down than remain heavy (3). Instead of conforming to that natural tendency, these food-restricted girls gained excessive weight. To accurately regulate food intake, the school-age child depends on parents to establish and maintain a division of responsibility in feeding. Parents manage the what, when, and where of feeding; children manage the whether and how much of eating (4). To preserve the effectiveness of the division of responsibility in feeding, it is essential to respect children’s
© 2004 by the American Dietetic Association
LETTERS TO THE EDITOR prerogatives with respect to food regulation and food acceptance. Properly enacted in a stage-appropriate fashion, the division of responsibility provides children with both structure and support for eating. When adults do their jobs with feeding, children are effective about doing their jobs with eating. Ellyn Satter, MS, RD CEO Ellyn Satter Associates Madison, WI References 1. Birch LL, Fisher JA. Appetite and eating behavior in children. Pediatr Clin North Am. 1995;42:931953. 2. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert committee recommendations. Pediatrics. 1998;102:E29. 3. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22: 167-177. 4. Satter EM. The feeding relationship. J Am Diet Assoc. 1986;86: 352-356. doi: 10.1016/j.jada.2004.08.010 Author’s Response: I have great respect for Ellyn Satter and have been a great admirer of her work for years. Satter’s contributions are among the very best in providing excellent guidance to parents on feeding children, especially in today’s very challenging food environment. However, I disagree with her concerns regarding our recent paper (1). First, Satter suggests that girls’ negative evaluations and attempts at restricting intake were a response to our labeling girls as “at risk for overweight.” However, we did not give girls or their parents this information. In our research, we did use the National Center for Health Statistics’ cutoffs to categorize girls as at risk for overweight (ⱖ85th percentile) for purposes of our analyses. However, we never told girls or their parents about this categorization, so their behavior could not have been a response
to our labeling them as at risk for overweight. Second, Satter argues that we are advocating restricting children’s intake when we suggest (a) providing children and parents with guidance and information about portion size, and (b) encouraging intake of foods high in nutrient density and lower in energy density, such as fruits and vegetables. I disagree. In the discussion and conclusion we made some suggestions regarding how to ameliorate or prevent the problematic behaviors and negative self-evaluations we observed in these girls. Our suggestions focused on providing alternatives to restrictive tactics, not promoting them. Providing parents with guidance about what children should be offered is consistent with Satter’s division of responsibility. Satter has said, “parents are responsible for the what, when, and where of feeding.” Following Satter’s lead, we suggest that parental responsibility for what children eat includes offering an array of healthy alternatives, including foods high in nutrient density and lower in energy density, especially fruits and vegetables. Prior research has shown that if we offer such foods frequently, in positive contexts, children are likely to learn to like and accept some of them (2-4). With respect to providing parents and children with information about portion size, our previous findings have shown that by age 5, children are already responding to larger portions by eating more; our previous research has shown that as the size of the portion offered increases, children eat significantly more (5,6). These findings support the view that parents and children do need guidance about portion sizes in the current food environment, where large portions are promoting overeating among adults and children. Given all our findings showing that restrictive feeding can also promote overeating and reduced responsiveness to internal cues of hunger and satiety (7-10), I would never recommend restrictive feeding approaches, and did not intend to send a message that could be interpreted in that way. However, the results of the research showing that large portions can increase children’s intake (5,6) has led me to conclude that, given the super-sized portions available these days, we do need to provide children and parents with guidance about appropriate portion sizes that are of-
fered to children. Yes, we need to be careful that this guidance is not interpreted as restriction. I strongly agree with Satter’s statement, “we need to respect children’s prerogatives with respect to food regulation.” However, the research evidence has indicated that very large portions can overwhelm children’s ability to self-regulate. Rather than constituting restriction, guidance about appropriate portions can provide the support parents need to create family environments that foster children’s self-regulation. Such guidance could help to limit opportunities for overeating, which can be triggered by excessively large portions. However, at this point, additional research is needed to determine how best to communicate portion size information to make sure we avoid the concerns Satter raises. Leann L. Birch, PhD Professor Department of Human Development and Family Studies The Pennsylvania State University University Park References 1. Shunk J, Birch LL. Girls at risk for overweight at age 5 are at risk for dietary restraint, disinhibited eating, weight concerns, and greater weight gain from 5-9 years. J Am Diet Assoc. 2004;104: 1120-1126. 2. Birch LL, Zimmerman S, Hind H. The influence of social-affective context on preschool children’s food preferences. Child Development. 1980;51:856-861. 3. Birch LL, Marlin DW. I don’t like it; I never tried it: Effects of exposure to food on two-year-old children’s food preferences. Appetite. 1982;4:353-360. 4. Birch LL, Gunder L, GrimmThomas K, Laing DG. Infant’s consumption of a new food enhances acceptance of similar foods. Appetite. 1998;30:283-295. 5. Rolls BJ, Engell D, Birch LL. Serving portion size influences 5-year-old but not 3-year-old children’s food intakes. J Am Diet Assoc. 2000;100:232-234. 6. Fisher JO, Rolls BJ, Birch LL. Children’s bite size and intake of an entrée are greater with large portions than with age-appropriate or self-selected portions. Am J Clin Nutr. 2003;77:1164-1170.
Journal of the AMERICAN DIETETIC ASSOCIATION
1547