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A Roadmap for Raising Healthy Eaters

As a pediatrician and nutritionist, many parents come to me frustrated that their kids won’t eat vegetables. They’ve tried everything. Bribe the kids. Hide the vegetables in the food. Blend greens into a smoothie. Some days it works. Other days it doesn’t. But most days mealtimes are a struggle. I’ve been there, too. It’s frustrating when a child won’t just eat the nutritious food that is placed in front of him. But the key to getting kids to ‘eat their vegetables’ and choose healthy foods because they want to, when there is no adult looking over their shoulder making them, isn’t in the day-to-day forcing them to eat vegetables. Rather, it is in the daily repetition of honoring an approach to feeding kids that I’m calling family-centered feeding.

1. Learn to recognize your child’s cues of hunger and fullness – and listen to them! Infants show hunger through increased alertness, rooting and lip smacking, and opening their mouths. Crying and irritability are later signs. They show fullness by falling asleep and pulling or turning away from the nipple, bottle, or spoon. Older kids are better able to tell you when they are hungry but also may show signs of hunger by becoming more grumpy or irritable. Recognize these signs in your kids. Even more importantly, teach older children to recognize these signs in themselves, and listen to them. Stomach growling? Hungry. Stressed? Bored? Sad? Not hungry? Don't eat.

2. Recognize your child’s developmental feeding stage. Through each stage of development, infants and children become increasingly able to feed themselves. In fact, as they develop the fine motor skills, they will demand to play a bigger role in self feeding. While it can sometimes be frustrating for parents, overall this is good, as practicing self-feeding skills also helps your child develop and refine fine motor skills. On average, you can expect a 4-6-month-old to be able to eat soft foods and purees from a spoon but fed by caregiver; a 6-9-month old wants to self-feed and can sometimes get finger foods to his mouth; a 9-12-month old is better able to self feed with finger foods and can dip a spoon into food, but the food might not make it to his mouth. A 15-18-month old can successfully feed himself with a spoon and a 2-year-old may become adept with using a fork.

3. Develop a feeding routine (when, where, and what) and stick to it as closely as you can. While it is important to use your child’s cues to guide food intake, you can count on the fact that infants and children tend to become hungry about every 2-3 hours or so. To be sure that your children are hungry at mealtimes (and thus more likely to eat the healthful foods you are offering them), try to develop a feeding routine that includes meals and snacks at about the same time every day (note: some of these “meals” and “snacks” for an infant just learning to eat will be breastmilk and/or formula). Plan for about 3 meals and 1-2 snacks per day, with 2 to 3 hours between each feeding event. Help toddlers avoid ‘grazing’. Also help get them used to eating only in a high chair at table or at a toddler table next to the grown-up table. For instance, a routine might be: 7am breakfast, 10am snack, 12pm lunch, 3:00pm snack, 6:00pm dinner.

Of course, it is not always possible to stick to your routine and I highly encourage taking children on adventures and exploring new opportunities, which are great learning experiences, though they admittedly can heavily interrupt daily routines. My advice is to have fun and explore and do the best you can to maintain your routine while you are out and about, and then once you are home return to your usual routine as soon as you can.

4. You decide what food is offered, when, and where, but let your child decide what to eat and how much. This is an expansion of the classic “division of responsibility” advised by the dietitian/social worker Ellyn Satter that has become widely-accepted advice by health and nutrition professionals and which research supports is an effective approach to raise healthy eaters without mealtime battles. The idea is that parents create a healthy home environment, full of plenty of healthful foods. Parents control a child’s access to these foods by having a routine (the timing) and control over the meal plan (what foods are offered) and the meal or snack place (at the table). The child has control over what foods they will eat of those that are offered and how much. It may feel counterintuitive, but what this says is don’t force your children to eat everything that you serve or offer them. You may wonder, how then your child will come around to eating those foods (or will they starve in the meantime if you stick to this plan and they refuse to eat)? You may also wonder how much food you will have to waste to teach your child to eat healthfully if you continue to offer foods that they continue to refuse to eat? We get it. These are legitimate concerns. We will address them by age and stage throughout the following chapters. At the end of the day, we think you will find this to be an effective strategy that maintains harmony around mealtimes, nudges your child towards healthy eating, and minimizes food waste.

5. Let your child’s hunger be their guide. In other words, don’t force a clean plate. This is an extension of strategies #1 and #4 but it is so important it deserves its own mention. Despite the urge (and we all feel it sometimes!), don’t pressure or force your children to eat. When a child eats despite not being hungry, it overrides the body’s own internal cues and makes it more difficult for a child to recognize and respond to hunger cues later. Some studies have shown that kids as young as 3 years old have lost the ability to listen to their body’s cues, and much of this is likely due to force feeding as well as the offering of foods rewards (see principle #6). When kids don’t listen to hunger cues, they eat more than their body needs, setting them up for later weight and health concerns. Instead of forcing a child to eat, or “clean your plate”, offer small portions with the option for more rather than larger portions. Be familiar with a typical portion size for your child’s age (we discuss this more by age and stage in later chapters). For a child reluctant to eat or try new foods, it is ok to praise eating but resist attention for not eating (i.e. pressure/coercion/bribing/begging a child to “try just one bite” or “clean your plate!”)

6. Resist the urge to offer food “rewards” and comforts or food punishments. Every parent has offered a food reward at some point. Whether it’s a “treat” for enduring a round of vaccines, candy for sitting on the potty during potty training, or the classic dessert after “eating your vegetables”. In fact, food rewards are so ingrained for many of us from our own childhoods that it’s near impossible to avoid. I get it. The reason that I strongly encourage you to try to minimize this practice as much as possible is that food “rewards” are usually high sugar, very sweet foods that act on the pleasure centers of the brain. Repeated exposures to these foods paired with a very positive memory or experience establishes a strong connection in the brain.

As a result, later in life when a child (or later as an adult) is feeling sadness or anxiety, he or she may seek out these same types of high-sugar foods to recreate the more positive feelings or emotions from childhood, resulting in emotional eating which can become very detrimental. We strongly advise making an effort to choose other motivators instead, such as stickers, extra praise/hugs/kisses, or experiences or outings. Using food as comfort – such as breastfeeding a 9 month-old infant when he cries in the night – teaches a child to use food to soothe. Making a child eat left-over vegetables as punishment for refusing to eat them the night before, simply causes a child to hate the vegetables even more.

7. Quench thirst with water and milk (or breastmilk or formula for infants less than 1 year). Avoid other drinks, most of the time. The greatest risk factor for the development of childhood (and adult) weight concerns is the routine consumption of sugary drinks. I consider sugary drinks to include sodas, fruit drinks, sports drinks, and other sweetened beverages and also 100% fruit juice and flavored milk such as chocolate milk. Many expert groups carve out 100% fruit juice and flavored milk and consider them not to be sugary drinks because unlike the other forms of sugary drinks they have some redeeming nutritional value. However, I strongly prefer that the redeeming nutritional value be obtained from other sources. For example, it is much more nutritious for a child to eat the whole fruit – which contains fiber, texture, and loads of nutrients, and also contributes to feelings of fullness, rather than 100% juice which is stripped of fiber and texture, and in liquid form does not contribute much to feelings of fullness. Plain milk is loaded with nutrients including protein, calcium, and vitamin D. So is chocolate or flavored milk, but it also packs on added sugars and a sweet taste. Once a child has had flavored milk, it is very difficult to go back to plain milk as we are born liking sweet taste. Many argue that flavored milks should not be considered sugary drinks since we would rather have a child drink milk or an equivalent milk substitute to obtain its nutritional benefits. And some suggest that if the alternative is chocolate milk versus no milk, we are better off with them drinking chocolate milk. If chocolate milk is not an option, a child who is repeatedly exposed to white milk will develop a taste and preference for it and will drink it. And if the child does not, we can identify other unsweetened alternative drinks or foods to obtain the same nutritional value. This is not to say that a child should never have a sugary drink. I just feel that they routinely should not. I support the American Heart Association recommendation that kids older than 2 years drink no more than 1 sugary drink per week (and children less than 2 years old should not have any added sugars at all, to the extent possible).

8. Model a positive relationship with food. Perhaps the greatest impact parents can make is not through the words they speak, but the actions they take. Kids from the youngest ages are watching what their parents are doing. A dietitian friend loves to share how she was eating a sardine and onion sandwich on rye toast (count on dietitians to put together some very interesting concoctions!) when her toddler-aged son took quite an interest to what she was eating and reached for a taste. She obliged and he loved it – eating almost half her sandwich! This surprised even her. You just never know what a child is going to like, but you can be sure if his mom was not eating it, it would probably be a long time before he would otherwise try sardines and onions. Let your kids see you eat in a balanced way, listen to your body for feelings of hunger and fullness, and incorporate a variety of foods in your diet. Let them see you eat dessert sometimes. Let them see you get off track or make a mistake and help them understand how you worked through it in a positive way to get back to your plan. Also, it can be frustrating day in and day out offering your child foods that he continues to refuse to try. Know that even when it doesn’t feel like it, when your kids see you eating a variety of healthful foods in a balanced way, they come to eating just like you eventually. Same goes for physical activity – kids raised with active parents are much more likely to become active themselves. The counter is also true – if kids hear their parents saying negative things about foods, physical activity, their bodies – the kids tend to adopt similar beliefs.

9. Prioritize family meals. The most important routine a family can adopt in raising healthy, well-balanced, happy children is regularly eating family meals together, ideally at home, at the table, free of “screens” and distractions. This may seem like an exaggeration, but countless studies have supported the value of family mealtimes. Kids who eat dinner together with their family at least 3 days per week, ideally more, not only eat more vegetables and fruits and more healthfully overall, but they also have richer vocabulary and brain development as infants and toddlers and are less likely to engage in risk-taking behaviors and report a stronger relationship with their parents as adolescents. Aim for about 20 minutes or more together. Except for younger children - limit their mealtime to about 15-20 minutes so as to avoid grazing and frustrations and trying to get them to sit down, when really that is not something young children are up to do for very long!

10. Create a positive experience around food and mealtimes. When eating family meals, or even at times when you are not all able to eat together, strive to make mealtimes enjoyable for your child (and yourself!) Focus your attention on your children and family. Ask them how their day was. At my house we love to talk about the best part of our day, and the worst part. Talk together. Focus less on the food and more on the company. If you notice a child is not eating, try to not put too much attention on it. It is ok to nudge every now and then. But we try not to force it and we don’t put too much attention on the child that is not eating in the way we would like. Instead, we put our attention towards building the relationship with our kids through a consistent routine of enjoyable, loving family meals.

Even if on the inside you are feeling very anxious about what your child is and is not eating – don’t let them see you sweat it! The investment that you make in the process will pay huge rewards, regardless of the “outcome” at any given meal. But don’t take our word for it. Find out for yourself as you practice these 10 principles of family-centered feeding.


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