Appendix I Children and Food Regulation: The Research

Children know how much they need to eat fat—when their calorie needs are particularly and, virtually from birth, they are resilient high.5 Colorado Public Health studies that fol- and resourceful regulators. University of Iowa lowed children from year to year found that the research shows that when infants over age 6 amounts they eat as well as the composition of weeks are fed overly concentrated formula or their food intake varies considerably. Some years, overly dilute formula, they simply eat less of the for instance, they eat far less fat, and other years concentrated formula or more of the dilute for- they eat far more.6 mula and grow consistently. Until age 6 weeks, You can’t predict how much a child needs to children compensate for variations in formula eat. As with adults, calorie needs vary widely concentration, but not completely. After 6 from child to child. Children of all ages who weeks, they compensate completely.1 From age look alike and act alike may vary from one 1 week to 9 months, Houston anthropologist another in their calorie requirement by as Linda Adair followed the formula and solid- much as 40 percent.7 This is a result of chil- food intake of a little boy being fed on demand. dren’s constitutional endowment, not because Although the infant ate three times as much of poor patterns of food consumption or activ- some days as other days, and even though his ity. Any assumptions you make about chil- food intake was lower than 90 percent of other dren’s calorie intake based on looking at them babies, his growth was consistent and his are likely to be wrong. Studies of young infants weight was average. When he started eating by Harvard nutritionist Jean Mayer show that solid foods, he took less formula and continued the fattest babies tend to eat the least and are to regulate well.2 least active, and the leanest babies eat the most Even premature babies can regulate. A study and are most active.8 conducted by newborn intensive care unit nurses shows that medically stable infants who weigh between 1,800 and 2,500 grams at birth Distortions in Energy are able to give signs to their care providers Regulation indicating when they are hungry and when they are full. The demand-fed babies grow bet- Children’s considerable food regulation capabil- ter on fewer calories than schedule-fed babies.3 ity depends on their being supported with the The amount children eat varies throughout the division of responsibility in feeding throughout day. Children are able to compensate for varia- their growing-up years. Both over-control of the tions in the amounts they eat at mealtimes and child’s prerogative in eating and under-support snack times.4 Children automatically seek out of the child’s access to food can cause disrup- high-calorie foods—those containing sugar and tions in food regulation and growth. Children

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of authoritative parents—those who are par- Chatoor found that disorders of homeostasis, ented well—grow appropriately, whereas chil- attachment, and separation/individuation can dren of permissive, neglectful, or overly strict contribute to NOFTT and that toddler NOFTT is parents are at increased risk of .9 related to mother-child interaction.15 Both mothers and fathers who are concerned Clinical observations indicate that letting about child overweight or have anti-fat attitudes children graze for food can make them either are likely to restrict children’s food intake and eat too much and grow too rapidly, or eat too raise fatter children.10 Being overcontrolling little and grow too slowly. Psychologist Kay with feeding—trying to get children to eat more Toomey found in her clinical work with poorly or less than they want—interferes with chil- eating toddlers that toddlers fed in a structured dren’s knowing when they are hungry and fashion eat 50 percent more than when they when they are full and contributes to undereat- are allowed to graze for food.16 Texas A&M ing as well as to overeating.4 anthropologist Katherine Dettwyler observed Sugary and fatty foods are often blamed for New Guinea toddlers roaming the village in making children overeat. But children and groups and eating only if they happened to be other people who have structure and support present in a home when food was available. for eating and whose internal regulators are Adults did not, in any systematic way, see to it intact can get full without overeating when they that toddlers got fed. Growth rates of children are offered sugary and fatty foods, the same as in New Guinea were very slow.17 they do when they are offered other foods. But Parents’ concerns about their own weight as if sugary and fatty foods are forbidden and well as their children’s contribute to distortions purged from the family food supply, children in feeding. Mothers report using more restric- overeat on them when they get a chance and are tive feeding practices when they are invested in fatter than children whose parents are more weight and eating issues overall, when they matter-of-fact about including them in meals perceive daughters as overweight, when they and snacks.11 Restricting a child’s food intake are concerned about daughters’ weight, and tells the child that his weight is unsatisfactory. when daughters are heavier. Mothers also A child who gets idea that he is overweight report using more pressure in child feeding feels bad in all ways: not smart, not physically when daughters are thinner, and when mothers capable, and not worthwhile.12 perceive daughters as .18 This Distortions in feeding dynamics can start at interference with feeding has been demon- birth. An Edinburgh, Scotland study with nor- strated to be counterproductive.4,19 mal, well-born infants shows that parents of Children whose food intake is restricted tend smaller-than-average babies tend to be more to become food-preoccupied and overeat when active in feeding than parents of average sized they get a chance. Children who are urged and babies. The more active the parents, the less coerced to eat more than they want frequently well the babies grow. Since it is easier to get become resistant to eating and undereat when pushy with bottle-feeding than with breast- they get a chance. However, whether a child feeding, the tendency to be overactive shows up eats too much or too little in response to paren- more with bottle-feeding parents than with tal pressure with feeding depends on who gets those who breastfeed.13 the upper hand with feeding. The submissive A few children suffer from growth problems child of a controlling parent may be underfed serious enough to be diagnosed as Nonorganic or overfed in accordance with the parent’s (NOFTT). In many if not most wishes. On the other hand, a more aggressive cases, disruptions in the feeding relationship child may resist the parent’s feeding efforts and are at the root of the problem. Clinicians in a eat in the very way that the parent is trying to Buffalo, New York, hospital found that half of prevent. infants hospitalized with growth failure had The tactics parents use to control their own feeding problems.14 Disruption in the achieve- food intake rub off on children, for good or ill. ment of developmental tasks can undermine a Parents who overcontrol their own eating, with child’s ability to eat and grow normally. In her either amount or type of food, tend to throw work with infants and toddlers, Washington, away all controls from time to time and be fatter DC, Children’s Hospital psychiatrist Irene than if they ate consistently. In the Framingham

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children’s study, parents who display high levels much they eat of what parents provide, chil- of disinhibited eating, especially when coupled dren experience so much static and interfer- with high dietary restraint, appear to foster ence from the outside that they can’t tune in on excess weight gain in their children.20 Children their sensations of hunger, , and sati- of parents who restrain and disinhibit also tend ety. Sometimes children go along with pres- to disinhibit and are relatively fat.19 Associa- sure from the outside and eat more or less than tions between parents’ restrictiveness with they really want. Sometimes they fight against respect to their own eating behavior and adoles- that pressure, and, again, eat more or less than cent eating attitudes and behaviors have not they really want. Either way, they lose sight of been examined. However, parental attitudes how much they need and make errors in regu- and behaviors undoubtedly play a role in pre- lation. They eat too much or too little, and they cipitating adolescent characteristics that do cor- get too fat or too thin. relate with eating disorders: high incidence of dieting behavior, pressure to be thin, modeling of eating disturbances, appearance overvalua- tion, and body dissatisfaction.21 References On the other hand, adolescents who report 1. Fomon SJ, Filer LJJr., Thomas LN, parental meal management behaviors that Anderson TA, Nelson SE. Influence of involve taking leadership and giving autonomy formula concentration on caloric intake and are less likely to engage in disordered eating. growth of normal infants. Acta Paediatrica Adolescents do better with eating when parents Scandanavica. 1975;64:172-181. assign a high priority to family meals, provide 2. Adair LS. The infant’s ability to self-regulate family meals more frequently, and maintain a caloric intake: a case study. J Ame Diet Assoc. 22 positive atmosphere at mealtimes. Regardless 1984;84:543-546. of their weight to begin with, 13- to 16-year-olds 3. Collinge JM, Bradley K, Perks C, Rezny A, using both healthful and unhealthful weight- Topping P. Demand vs. scheduled feedings control behaviors are four or five times more for premature infants. JOGN Nurs. likely to have gained too much weight 5 years 1982;11:362-367. later than adolescents not using any weight- 4. Birch LL, Davison KK. Family control behaviors. “Healthful” behaviors environmental factors influencing the include exercising more and eating more fruits developing behavioral controls of food and vegetables and less fat and sweets. intake and childhood overweight. Pediatr Unhealthful behaviors include fasting or eating Clin North Am. 2001;48:893-907. very little food; using a food substitute such as 5. Kern DL, McPhee L, Fisher JO, Johnson S, a powder or a special drink; skipping meals; Birch LL. The postingestive consequences using diuretics, laxatives, or diet pills; and vom- of fat condition preferences for flavors iting. Teenagers who don’t diet don’t gain too associated with high dietary fat. Physiol 23 much weight. Behav. 1993;54:71-76. 6. Beal VA. Dietary intake of individuals The point? Children know how much they followed through infancy and childhood. need to eat, but they need help from adults if Am J Public Health. 1961;51(8):1107-1117. they are to act on and retain that capability. 7. National Research Council (NRC). Children need to be able to tune in on what Recommended Dietary Allowances, 10th Ed. goes on inside of them and be aware of how Washington, DC: National Academy Press; hungry or how full they are. If adults give them 1989. insufficient support—if they don’t offer food 8. Rose HE, Mayer J. Activity, calorie intake, regularly or if they fail to offer appropriate sit- fat storage, and the energy balance of uational and emotional support at feeding infants. Pediatrics. 1968;41:18-29. times—children can have trouble knowing 9. Rhee KE, Lumeng JC, Appugliese DP, how hungry or how full they are and can eat Kaciroti N, Bradley RH. Parenting styles too little or too much. If adults are too active and overweight status in first grade. and controlling in feeding and interfere with Pediatrics. 2006;117:2047-2054. the children’s prerogatives of whether and how

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10. Musher-Eizenman DR, Holub SC, Hauser 18. Francis LA, Hofer SM, Birch LL. Predictors JC, Young KM . The relationship between of maternal child-feeding style: maternal parents’ anti-fat attitudes and restrictive and child characteristics. Appetite. feeding. (Silver Spring). 2001;37:231-243. 2007;15:2095-2102. 19. Savage JS, Fisher JO, Birch LL. Parental 11. Fisher JO, Birch LL. Eating in the influence on eating behavior: conception absence of hunger and overweight in to adolescence. J Law Med Ethics. girls from 5 to 7 y of age. Am J Clin Nutr. 2007;35:22-34. 2002;76:226-231. 20. Hood MY, Moore LL, Sundarajan- 12. Davison KK, Birch LL. Weight status, Ramamurti A, Singer M, Cupples LA, parent reaction, and self-concept in five- Ellison RC. Parental eating attitudes and year-old girls. Pediatrics. 2001;107:46-53. the development of obesity in children. 13. Crow RA, Fawcett JN, Wright P. Maternal The Framingham Children’s Study. Int J behavior during breast- and bottle-­ Obes (Lond). 2000;24:1319-1325. feeding. J Behav Med. 1980;3(3):259-277. 21. Stice E, Presnell K, Spangler D. Risk 14. Sills RH. Failure to thrive: the role of factors for onset in adolescent ­clinical and laboratory evaluation. Am J girls: a 2-year prospective investigation. Dis Child. 1978;132:967-969. Health Psychol. 2002;21:131-138. 15. Chatoor I, Surles J, Ganiban J, Beker L, 22. Neumark-Sztainer D, Wall M, Story M, Paez LM, Kerzner B. Failure to thrive and Fulkerson JA. Are family meal patterns cognitive development in toddlers with associated with disordered eating infantile . Pediatrics. behaviors among adolescents? J Adolesc 2004;113:e440-e447. Health. 2004;35:350-359. 16. Toomey KA. Caloric intake of todders fed 23. Neumark-Sztainer D, Wall M, Guo J, structured meals and snacks versus on Story M, Haines J, Eisenberg M. Obesity, demand. Verbal Communication. 1994. disordered eating, and eating disorders in 17. Dettwyler KA. Styles of infant feeding: a longitudinal study of adolescents: how parental/caretaker control of food do dieters fare 5 years later? J Am Diet consumption in young children. American Assoc. 2006;106:559-568. Anthropologist. 1989;91:696-703.

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