by Katja Rowell, MD
Upon waking, three year-old Amalia cried for buttered toast. She’d gobble her half piece while sliced cucumbers and apples were urged on her. At the local park, she didn’t play but wandered from mom to mom asking for snacks or taking food from other children. Amalia’s mother called, desperate for a different way to address Amalia’s “weight problem,” since life was reduced to controlling Amalia’s intake. Mom was afraid Amalia was headed for an eating disorder or “obesity,” since she was still overweight according to the growth charts (growing steadily between 85th and 90th percentile, down a little from infancy).
As a family doctor turned childhood feeding specialist, about a third of my clients are children like Amalia.* As the war on obesity takes aim at our very youngest, I believe behaviors we used to see in tweens and teens are showing up in younger and younger children. Most children I see with ‘food obsession’ are preschoolers.
Amalia wasn’t born ravenous. She was born larger than average, growing steadily, and was exclusively breast-fed. Both parents are naturally slender, enjoyed a variety of home-cooked foods as well as an active life-style. Looking back, mom realized that Amalia’s problems started when a pediatrician labeled Amalia as “obese” at 4 ½ months. With dire warnings of diabetes, heart disease and early death, he recommended cutting out nighttime feeds and having mom wait to feed for thirty minutes after Amalia signaled hunger. That’s how you put a breastfed infant on a diet, and Amalia is not the only one I’ve seen.
The doctor’s misunderstanding of growth and self-regulation, and ignorance of the harm of restriction (with Mom now worried and carrying out his advice) caused Amalia’s problems. With the disruption of a responsive feeding relationship, Amalia soon seemed insatiable at feedings. When Amalia didn’t move into the “normal” weight range fast enough, her parents saw a dietitian who recommended strict calorie and fat limits and red-light/green-light rules (limit high fat/sugar/calorie or “red-light” foods).
Most of the children I see with food obsession were growing steadily, healthy, albeit larger than average. Misguided fears from doctors or family led parents to worry about weight and health, who, motivated by love and fear, tried to get the child to eat less to weigh less. Just as adult dieting research shows that trying to eat less to weigh less tends to lead to more disordered behaviors and higher weight, research in children increasingly shows us that trying to get kids to eat less to lose weight also backfires. The same holds true for “underweight” children: the harder we pressure them to eat, the less well they tend to eat and grow. (Journal of Nutrition Symposium on Responsive Feeding 2011.)
The insistence by much of the medical establishment that any weight falling outside one standard deviation from the mean (15-85%) is pathological hurts children. I believe that interventions based on the faulty bedrock that weight defines health increase disordered eating and weight dysregulation at both extremes.
Not What I Learned in Med School
But I didn’t learn any of this in medical school, during my residency, from the journals I read or at the conferences I attended. When I was treating “childhood obesity” in the standard approach in primary care, I probably would have told Amalia’s mom to try harder (I’m sorry). I might have spent half an hour brainstorming different ways to get Amalia to eat less and move more: get a dog to walk, serve fat-free cheese (I’m sorry), and pick out fruits and veggies for the lunch box… Maybe some decent advice was in there, and I sincerely wanted to help, but with the focus on weight loss, it was doomed to fail. I dreaded those visits where the children and mothers sat with downcast eyes.
I hate to admit that it wasn’t until I had my own daughter that I felt compelled to follow my discomfort, and rather than chalk it up to noncompliance, actually explore the research and seek out alternatives. It took a few years of reading the literature and the work of pioneers like Linda Bacon, Ellyn Satter and Evelyn Tribole, as well as seeing how internally regulated eating and activity in my personal and professional capacities truly transform lives and support health, before I could accept that it’s not just calories in, calories out, and reject the narrow definition of “healthy” weight. I am now a grateful Health at Every Size®-grounded practitioner, mother and activist, fighting to help parents and doctors understand that healthy children come in a range of sizes.
Tuning In to How It Feels
I ask parents to tune in to how it feels to enforce feeding-therapy rules that leave children sobbing and gagging. How does it feel to bring a child to a weigh-in who just discovered she loves the swim team but quits because she hasn’t lost weight? How does it feel to share smiles, Rice Krispies treats, milk and bananas with a once sweets-obsessed child? Similarly, in outreach to clinicians, I ask them how it feels: are they burnt out on nagging, or frustrated with poor outcomes and uncomfortable patient interactions? I ask them to sit with that discomfort and use it as a guide for learning more.
Amalia’s Healthy Changes
Amalia’s mom expressed profound relief with this new approach, based on HAES® principles and the Division of Responsibility in feeding, described in 2011 as responsive feeding “operationalized.” Parents feel grateful to leave the role of ‘food cop’ behind and are amazed to see how quickly young children can tune in again to internal cues of hunger, fullness and appetite.
Amalia’s mom got rid of portion control and stopped pushing low calorie foods. She continued to cook and serve a variety of foods. She included sweets and treats so they were no longer the forbidden food; they enjoyed family meals and moving in fun ways. Within a few months, Mom reported that meals were more fun, and while Amalia continued to enjoy food and large portions at times, she also had meals where she ate less, was allowed to stop eating on her own, said “I’m full” for the first time, and played at the park rather than scavenging for food.
Supporting Amalia and her mother felt great. It feels right to focus on providing and nurturing, rather than on deprivation and power struggles, and Amalia and her family are healthier and happier today because of it. Helping children grow up feeling good about food and their bodies is the best preventive medicine I can think of.
*This brief essay shares the experience of one family. I do not want to minimize the impact on health of food insecurity, poverty, chaos, lack of sleep, trauma, illness, lack of access to a variety of foods, lack of the means and skills to prepare meals, lack of safe places to be active in daily life and play…
Katja Rowell MD is a family doctor turned childhood feeding specialist, supporting parents with feeding and weight worries. She is a sought-after speaker, author, mother and family cook. Her first book, Love Me, Feed Me, is available on Amazon.com.