myths and realities dayle hayes, ms, rd nutrition consultant billings, montana [email protected]
TRANSCRIPT
To shape the eating habits and physical activity patterns of WIC families in ways that promote
healthy weights and reduce the risk of chronic
diseases.
MYTH #1:You have to “diet” to lose
weight and get in shape.
REALITY: DELICIOUS
NUTRITION helps your whole family enjoy good
health.
MYTH #2:Nutrition is really complicated
and expensive.
REALITY: EATING WELL
is as simple as choosing
more brightly colored foods.
MYTH #3:Good nutrition and weight
loss comes in a pill.
REALITY: WHOLE FOODS
have the nutrition power that our bodies crave.
MYTH #4:You have to exercise to lose
weight and get in shape.
REALITY:FUN ACTIVITY can help every body
move toward a healthy weight.
MYTH #5:You a need gym or fancy
equipment to physical activity.
REALITY:MOVING MORE
is as simple as putting one foot in front of the other.
MYTH #6:Getting fit is nearly
impossible in our busy lives.
REALITY:You can fit your
FITNESS into every day –
anytime, anywhere.
MYTH #7:A pregnant woman has to make a decision to breast
feed OR to bottle feed.
OR
REALITY:New moms can
choose a COMBINATION of breast and bottle
feeding.
MYTH #8:It’s very hard to keep kids from watching too much TV.
REALITY:SETTING LIMITS like on TV time – is
a very important parental job.
MYTH #9:At WIC, we only have 15 minutes to do nutrition ed.
REALITY:15 minutes of
PERSUASION can make a big
difference.
MYTH #10:If we give people enough
facts, they will change.
REALITY:Using effective tools
of INFLUENCE we can help
Keep your eye on the prize!
Research Updates
Susan L. Johnson, PhDThe Children’s Hospital of Denver
UC Health Science Center,
Denver, Colorado
Eating Uses all of our Senses• Sight• Smell• Touching• Hearing• Tasting
• Balance• Motor control• Proprioception
Frontal Lobe Smell
Parietal LobeTouch
Temporal LobesHearing
Occipital LobesVision
Complementary Foods• Sitting stably w/out help• Extrusor reflex
disappears• Palmer grasp• Pincer grasp• Lateral tongue
movement• Gag reflex moves
Innate Likes and DislikesSteiner, J (1977). Taste and Development, Ed Wiffenbach,
US Dept HEW
• We are born liking sweet
• We are born disliking bitter and sour
Innate Likes and DislikesJ.A Mennella & G. Beauchamp (1991). Pediatrics, 88, 737-44.
• Flavors from maternal diet are transferred to amniotic fluid
• Fetus swallows fluid by the 2nd trimester
• Flavors also present in breastmilk
• May ease transition to solid foods
Breastfeeding may help prevent obesity
• Somewhat controversial
–Effects of environment and genetics may be as strong or stronger
• Duration of effects?
–Some report effects through adolescence
–Others say no effect after 5 y
• Strongest predictor of child weight is maternal weight
• Breast is definitely still best
Look and Listen to the Messages
Feeding behaviors and other motor development in healthy children
Carruth and Skinner (2002). J. Amer. Coll. Nutr.
BehaviorMean Age
(Months)
Age Range
(Months)Sitting unaided 4.0 1-9Brings toy to mouth 3.3 0.1-6.5Reaches for spoon 5.5 2.5-9.5Feeds self cracker 7.7 4-14Uses fingers to rake in food 8.7 5-20Brings top lip down on spoon to remove food 7.7 3.5-9.5
Brings spoon to mouth 14.4 9-20
Do parents hear children’s messages?
• How can we help them listen?
• What are the consequences if parents delay introducing solid foods?
• What are the consequences if they start solids too early?
The Tasks of Early Childhood
Age StageInfancy Trust vs. Mistrust
Reliance on consistency and security
Toddler Autonomy vs. Shame and DoubtSense that they are separate human beings.“Look at ME!” “NO!”
Early Childhood
Initiative vs. GuiltTaking risks within safe environments.“I will try.”
Erik Erikson’s Psychosocial Stages. www.internetmediator.com/divres/pg72.cfm
Experience and Food Preference
• Sullivan and Birch demonstrated that children come to prefer foods after they have a number of experiences with them
• It takes around 8-10 tries of a new food before children come to accept it
• We decided to repeat this study looking at some different foods
Natural History of Trying New Foods
1 23 4
56
78
9 10
Smell
Ignore
PlaySpit
Swallow0
2
4
6
8
10
12
14
16
18
Smell
Ignore
Play
Spit
Swallow# C
hild
ren
Time (wk)
Children learn about new foods by gradual experience
How do we support children and parents to try new foods?
• Offer many chances to try foods.
• Don’t force children to take a bite.
• Allow children to serve themselves.
• Avoid bribing or scolding children.
• Don’t be disappointed if they don’t like it right away. Hang in there! It changes.
• Encourage learning with all senses.
A Word about Self-regulation
• Infants can self-regulate the “how much” of eating
• Toddlers and young children must learn skills to learn to self-regulate their eating
• Motor
• Behavioral
• Emotional
• Cognitive
Self-regulation of Eating is Supported by the Feeding Relationship
• Parent knowledge
• Support of child’s development & mastery
• Dynamic exchange
Age Parent Job Child Abilities(Normally developing)
InfantsBirth – 9 mo
• Attend to cues• Offer appropriate food• Feed child• Child centered routine
• Knows hunger/ fullness
Toddlers9 – 24 mo
• Routines for eating• Variety and experience• Utensils & physical
structure• Opportunities for
mastery
• Knows hunger/ fullness
• Self-feeding begins
• Verbal communication
Early childhood2 – 5 y
• Routines for eating• Variety and experience• Utensils • Opportunities for
mastery• Eating with child
• Knows hunger/ fullness
• Self-feed• Self-serve• Conversation
Beverages & Self-Regulation
Issues & ConcernsInadequate vs. excess intakes
• Calories (or lack of)• Nutrients (Ca, Fe, Pro)• GI function (diarrhea)• Appetite / Satiety
Grazing • Dental caries• Habits (grazing)
9 oz 6 oz 4 oz
Infant Cues
Interested
Needs to eat
Past due!
Relationship btwn. formula concentration & rate of growth of normal infants
Fomon, et al. Journal of Nutrition. 98(2):241-54, 1969
• Varied formula concentration – High and low concentrations
• Infants given the concentrated formula consumed less volume
• High and low groups had essentially equal caloric intake
Children can self-regulate in response to juice drinks
• Children who are given juice drinks before the meal eat less at mealtime
• The nutrient density of their diets tends to decrease since juice drinks are low in vitamins and minerals
It’s not a perfect system…it can get off track
Adults can help put it back on track
• Focus on internal cues of hunger and fullness
• Make internal cues a regular part of eating
• Attend when children say they are hungry
• Listen when children say they are full
Optimal Environments
• Healthy emotional mealtimes
• Trust children’s abilities
• Repeated experience
• Variety and modeling
• Physical setup
• Consistent mealtime routines
• Recognize hunger and fullness
Success!
Help parents provide environments to support mastering the moment!
Working with Overweight Children
and their Families: Hard Lessons
LearnedSusan L. Johnson, PhD
The GoodLIFE Clinic
The Children’s Hospital of Denver Denver, Colorado
Learning the Story
ElicitElicit ProvideProvide
LISTENLISTEN
Essential Principle—Being all EARS
Express empathyAvoid argumentationRoll with resistanceSupport self-efficacy
Develop discrepancy: where the client is vs. where they want to be
Tips for Learning the Story• Ask about a typical day• Include major events of day
– Waking– Eating– Daycare/preschool?– Activity – Sedentary pastimes– Bedtime
• Ask the parent about their concerns
• Use words like “falling behind” and “getting ahead”
• Be clear, concrete and focus on client needs and desires—not only your agenda
• Offer concrete strategies--have tools that teach good child-feeding practices
Communicating Concerns to Parents
Avoid assigning blame
• If a client feels that you are blaming them they will become more resistant to change
• Ask them for their views on why their child is “getting ahead of himself”
Identify areas for change
• If possible, have the client identify what they would like to change– Nutrition
– Activity
• Make the changes small and achievable
• Provide a method so that the client can keep track of what they are changing
Avoid asking for too much change
• Examine the barriers and the benefits to change
• Have the client determine how much they think they can do
• Be ready to accept no change—as this may open the door for future change
What’s our job?• Providing “nothing but the facts”
• Letting the clients choose all, some or none
• It is NOT your burden to GET the client to change
Creating a referral network
• Pediatric endocrinologists
• Psychologists—family and pediatric
• Social workers
• Pulmonologists
Helping clients come back for more
• RESPECT
• EMPOWER
• VISION
The Feeding Relationship
Jane Peacock, MS, RDFamily Health Bureau Chief, New
Mexico Department of Health.
Albuquerque, New Mexico
One way to prevent overweight is to
establish and maintaining a positive feeding relationship
from birth.
Leane W/A O-30 months
Leane W/H 2-6 years
Leane BMI
Leane weight for age
The early intervention:
Teach positive feeding from birth
OPTIMUM FEEDING: INFANTS
• Time care and feeding for quiet alert state
• Feed in response to baby’s cuesEllyn Satter’s CHILD OF MINE, Ch 4, Understanding your newborn; Ch 5, Breastfeeding your baby; Ch 6, Formula-feeding your baby
OPTIMUM FEEDING: INFANTS
• Feed baby as much or little as she wants
• Accept baby’s own growth inclinations
• Understand impact of temperamental differences on feeding
Ellyn Satter’s CHILD OF MINE, Ch 4, Understanding your newborn; Ch 5, Breastfeeding your baby; Ch 6, Formula-feeding your baby
© 2003 From ELLYN SATTER’S FEEDING IN PRIMARY CARE PREGNANCY THROUGH PRESCHOOL: Easy-to-read Reproducible Masters. In press.
© 2003 From ELLYN SATTER’S FEEDING IN PRIMARY CARE PREGNANCY THROUGH PRESCHOOL: Easy-to-read Reproducible Masters. In press.
Optimum stage-related feeding: Birth to preschool
DIVISION OF RESPONSIBILITY INFANT
• Parent: What
• Child: How much
Satter, E. How to Get Your Kid to Eat…But Not Too Much
DIVISION OF RESPONSIBILITYTODDLER AND OLDER
• Parent: What, when, where
• Child: How much, whether
Satter, E. How to Get Your Kid to Eat…But Not Too Much
FOR CHILDREN TO EAT WELL, ADULTS MUST FEED WELL
• Choose and prepare food
• Have regular meals and snacks
• Make eating time pleasant
• Provide mastery expectations
• Let children grow up to get bodies that are right for them
FEEDING WELL MANDATES TRUSTING CHILDREN TO DO THEIR
JOBS WITH EATING
• Children will eat• They know how much to eat • They will grow predictably• They will eat a variety• They will mature with eating
DIVISION OF RESPONSIBILITY IS EVIDENCE-BASED
Satter, Ellyn, Child of Mine; Feeding with Love and Good Sense, Bull Publishing 2000
• Supports food acceptance – Appendix I (10 Ref)
• Supports food regulation – Appendix J (16 Ref)
• Supports healthy growth – Chapter 2 (17 Ref)
Key question:
What is interfering?
Leane W/A 0-36 months
9 months
ASK FEEDING QUESTIONS
• How is feeding going?
• How do you feel about feeding?
• How do you feel about your child’s size and shape? Growth?
• Is there anything about feeding you would like to be different?
CROSSING DIVISION OF RESPONSIBILITY:
Food restriction scares children and makes them overeat when they can
ELLYN SATTER’S FEEDING WITH LOVE AND GOOD SENSE Video and Teacher’s Guide “Older Baby”
ACCEPT CHILD’S DRIVE TO “DO IT MYSELF”
• Include child at family meals
• Choose “safe” food to pick up, chew, swallow
• Give many chances to experiment, learn to like food
• Time snacks so child can be hungry, not too hungry, at meals
• Let child eat much or little
Ellyn Satter’s CHILD OF MINE, Chapter 7, Feeding your older baby
© 2003 From ELLYN SATTER’S FEEDING IN PRIMARY CARE PREGNANCY THROUGH PRESCHOOL: Easy-to-read Reproducible Masters. In press.
17 months
Leane W/A 0-36 months
LEANE 17 MO: ANSWERS TO FEEDING QUESTIONS
• She is sneaking food
• Leanne’s food demands are constant
• Limit at meals, no snacks
• They are worn out
TODDLER: TEACH TO BE PART OF FAMILY
• Have family meals; scheduled snacks• Not let the child graze• Eat with the child• Teach the child to behave at mealtimes• Not short order cook• Let the child experiment, eat much or little
Ellyn Satter’s CHILD OF MINE, Chapter 8, Feeding your toddler
PRIMARY INTERVENTION: Education and early problem-solving
• Teach stage-related feeding
• Teach about normal growth
• Intervene at the first sign of growth disruption
• Even if treatment is called for, keep the intervention primary
LEVELS OF INTERVENTION WITH FEEDING
• Primary—Education, early problem-solving
• Secondary—Detailed evaluation and treatment
• Tertiary—Detailed evaluation and treatment of complex or entrenched problems with adjunct specialists, ie, physician, psychotherapist
WIC’s job is to get children started right
Emphasize Growth, not
WeightJane Peacock, MS, RD
Family Health Bureau Chief, New Mexico Department of Health.
Albuquerque, New Mexico
Interfering with normal growth may precipitate
weight gain.
Children are excellent regulators and tend to grow in accordance with their genetic
endowment.
Weight for age 0-24 months
Length for age
CHILDREN TEND TO GROW PREDICTABLY
NORMAL GROWTH CAN BE CONSISTENTLY
AT THE MEAN
50th %TILE W/L
Weight for Length
NORMAL GROWTH CAN BE LOW AND
SLOW
LOW CONSISTENT W/L
Weight for Length
NORMAL GROWTH CAN BE HIGH AND FAST—IF IT IS CONSISTENT
Weight for heightBMI
BMI PLOTTINGS MAY DISTORT PATTERNS
High consistent W/H…
…inconsistent on BMI curve
EVIDENCE-BASED
Satter, Ellyn, Child of Mine; Chapter 2 —Your Child Knows How to Eat and Grow
• High or low consistent growth is normal
• A single growth point tells nothing
Arbitrary growth cutoffs put pressure on feeding
and distort growth.
ERICA 10 MONTHS
Food restriction
Weight for length
© 2003 From ELLYN SATTER’S FEEDING IN PRIMARY CARE PREGNANCY THROUGH PRESCHOOL: Easy-to-read Reproducible Masters. In press.
ERICA 5 YEARS
Optimum feeding age three years
Weight/height
BMI
Optimum feeding
ERICA
PARENTS WHO CAN UTILIZE PRIMARY INTERVENTION
• Can self-evaluate
• Can accept the child's point of view
• Can set aside agendas
• Can change with advice, information
EVIDENCE-BASED Satter, Ellyn, Child of Mine; Chapter 2—Your
Child Knows How to Eat and Grow
• Food restriction likely to weight
• Parental self-restraint child obesity risk
INFORMING THE PARENT
• Child relatively large
• Certified for WIC on that basis
• Parents worry, try to feeding
• We’ll help you feed well
Growth divergence may or may not be normal.
SLOW DIVERGENCE OVER TIME IS LIKELY
TO BE NORMAL
Weight for Age 2-20 yr
RAPID GROWTH DIVERGENCE MAY NOT BE NORMAL
Leane weight for age 0-36 mo
RAPID GROWTH DIVERGENCE
MAY BE NORMAL
Adele weight for length 0-18 months
DIVERGENT WEIGHT IN WIC
• Ask feeding questions
• Optimize feeding
• Do not limit food intake—even indirectly
CHILDREN COME IN ALL SIZES
Principle of Influence: Be likable
Actions that make you likable:
· Make your client feel good about herself
· Accept and like your clients
· Make your client feel comfortable, welcome and relaxed
· Talk about things you share in common
Principle of Influence: Be likable
Actions that make you likable:
· Be positive.
· Avoid words that have harsh or negative connotations.
· Present situations as temporary.
Principle of Influence:
Give them something.
Give them something — but use emotion.
Principle of Influence:
Give them “exclusive” information, tips and messages
Principle of Influence:
Let them know what others are doing.
Formula for success:
Describe action.
Talk about the emotional benefits of taking that action.
Add a dash of facts or logic.
Tell them others are already doing it.
Principle of Influence:
The desire for consistency is a central motivator of behavior.
Ask questions like:
“What will you do first?”
“When do you plan to start?”
“How do you think it will unfold?”
Try verbal confirmations like:
· “Are you willing to give (action) a try?”
· “Can I count on you to give me feedback on (action) next time?”
· “Will Annie get to try (action) this month?”
End the encounter on a high note.
TV Time: Helping WIC
Families Make Better ChoicesCarolyn Dunn, PhD.
NC Cooperative Extension Service
NC State University,
Raleigh, North Carolina
TV Time…Helping WIC families make
better choices
•98% of all US homes have at least one TV
•TV is the #1 source of news and understanding about current events for the nation’s children.
eleVT ision
You Know You May Be
Watching Too Much TV
When…
• The first thing you do when you enter the room is turn on the TV.
• You eat all your meals in front of the TV.
• There are as many TVs in your home as people.
You Know You May Be Watching Too Much TV When…
• You’re watching a show you don’t like when you realize it’s a repeat and you didn’t like it the FIRST time either.
• You know the theme songs to all the shows in prime time.
You Know You May Be Watching Too Much TV When…
• The number of shows you absolutely cannot miss is equal to or greater than the number of days in the week.
• The clerk at the video store knows you on a first name basis.
You Know You May Be Watching Too Much TV When…
• Your cable goes out and you have the cable company on speed dial.
• The hall closet is dedicated not to coats and hats but to DVDs, videotapes and video games.
• The last thing you do at night before closing your eyes is turn off the TV.
You Know You May Be Watching Too Much TV When…
How Much?
•On average, children 2-11 watch 23 hours/week (teens 22 hours). This does not include videos and playing video games.
•Average more than 4 hours/day.
How Much?
•American children 2-17 spend up to 1/3 of their waking hours in front of the television.
•20% of 9 year olds watch 6 hours per day!
1984 1990
AAP suggested that TV has potential to increase violent behavior and may contribute to obesity. Cautions parents to limit the time watching TV and monitor viewing choices.
AAP reaches same conclusion about TV viewing in children and makes similar suggestions to parents.
Television Over The Years
1993 1998
Most children in the US spend more time watching TV than any other activity besides sleeping.
Children spend an average of 900 hours per year in school and an average of 1500 hours watching TV (21-23 hours per week).
Television Over The Years
Current Recommendations From The American
Academy of Pediatrics
< 2 years old – none
> 2 years old – no more than 2 hours per day
What TV Does To Our Brains…
• TV viewing slows the brains alpha waves so you feel relaxed and passive – which explains why the longer you watch, the harder it is to stop.
• The longer a child watches the more difficult they are to distract.
What TV Does To Our Brains…
• TV viewing is negatively related to children’s academic achievement (less homework/reading).
• Amount of time spent in front of the TV relates to how well children do on standardized tests.
What TV Does To Our Brains…
• Children’s reading skills are not developed while watching TV.
• Children who don’t play with friends don’t learn the social skills needed for classroom interaction.
What TV Does To Family Time…
What TV Does To Our Bodies…
Overweight in children has
almost doubled in the past decade.
Link between overweight in children
and TV viewing.
What TV Does To Our Bodies…
Study at Johns Hopkins - children who watched TV 4+ hours were significantly heavier than children who watched 2 or less.
Stanford study – children who were involved in a one-year curriculum to decrease TV viewing gained significantly less body fat than control (did not suggest other activities just decrease video games, videos and TV viewing).
What TV Does To Our Bodies…
What Are Our Children Watching?
90% of viewing by children is of
programs that are not designed for
children.
What Are Our Children Watching?
Children learn behavior by
mimicking what’s on TV
What Are Our Children Watching?
24% increase between 1991 and
1998 of commercials and promotions aired
by broadcast networks
Food producers and the fast food industry
if they are successful…
we all eat more
Advertisers for video/film industries
if the are successful…
we all buy more
Television industry
if they are successful…
we all watch more
Simple Solutions To Turn
Off The
1Get The TV Out Of The Bedroom
Simple Solutions To Turn
Off The
2Agree On A
Media Budget
Simple Solutions To Turn
Off The
3Set Clear Limits
Simple Solutions To Turn
Off The
4Make lists of things
you want to do – involve children in talking about other things they can do.
Simple Solutions To Turn
Off The
5Don’t keep the TV on
all the time – tune into specific shows
Simple Solutions To Turn
Off The
6Don’t watch TV during meals.
Simple Solutions To Turn
Off The
7Watch with
children
TV Time…Helping WIC families make
better choices