GREAT ARTICLE

Feeding Lessons
By Susan Okie
Special to The Washington Post
Tuesday, March 22, 2005; Page F01

Eleven-year-old Adam Barnett has learned a new way to eat. For breakfast on a recent morning, he had a bowl of high-fiber cereal with milk and mixed fruit. The lunch he carries to school typically includes a peanut butter sandwich, fruit, yogurt and skim milk. He often snacks on high-fiber, low-fat health bars or cucumber pickles — and he drinks plenty of water. Fried potato chips and French fries have been banished from his home in Newton, Mass. Pizza, when it’s served, is often homemade on small loaves of whole wheat pita bread.

Adam does not consider his new pattern of food choices a “diet.” He calls it an eating plan, or a healthier way to eat, and he’s been following it for almost three years. “I’ve been doing really well on it, and I’m going to keep it up,” he said.

Adam learned about the eating plan at Optimum Weight for Life (OWL), a research and treatment program for overweight children directed by David Ludwig, a Harvard pediatrician and obesity researcher at Boston’s Children’s Hospital. OWL is based on a growing body of research suggesting that a diet rich in fruits and vegetables but low in refined starches and sugars, and which also contains protein, unprocessed whole grains, some dairy products and a moderate amount of fat, may be healthy for the heart and least conducive to weight gain and diabetes. In the medical literature, such an eating plan is called a low-glycemic-index diet.

Adam’s mother, Laura, knew by the time her son was 8 that he would need to learn to manage his weight. As adults, she and Adam’s father had struggled intermittently with their own weight problems. At 8, Adam weighed enough to qualify as obese, and he seemed to be hungry all the time. The family’s pediatrician, concerned that the boy was unhealthily heavy, referred Adam to OWL, which treats overweight kids 4 and older. After Adam underwent an initial medical evaluation, he and his parents attended group sessions to learn about the new eating plan.

Adam watched a slide show to get the basics of the plan, while his parents learned how it is thought to work. Starchy foods like potatoes or bread made from white flour are rapidly broken down to sugar by the body, tending to raise blood sugar levels rapidly and trigger a corresponding surge in insulin. A few fruits — bananas and watermelon, for instance — also cause a quick surge in blood sugar (glucose).

Such foods are said to have a high glycemic index. (“Glycemic” is a medical term that means “putting sugar into the blood.”) On the other hand, protein and fat, as well as most fruits and vegetables, which are high in fiber, take longer to digest, so they raise blood sugar more gradually and do not provoke such a large or sudden insulin surge. Hence, they have a low glycemic index.

Whole grains that have not undergone much grinding or processing are also digested slowly. In addition, including some fat as part of a meal slows the emptying of the stomach, so that nutrients are not delivered too rapidly to the intestines, where digestion and absorption into the bloodstream take place. Studies by Ludwig and his research team have found that children who were given a breakfast containing foods with a low glycemic index were less hungry during the day and consumed fewer calories than those who ate a breakfast containing an equal number of calories but composed of high-glycemic-index foods.

To Adam’s mom, part of the appeal of the OWL program was that Adam would be less eager for snacks between meals — although healthy snacks are permitted in moderation. Laura also liked the plan’s flexibility. “What I think works about it is, it doesn’t say ‘You can’t have’ and ‘You can have,’ ” she observes. “It tries to say ‘More of this, less of that.’ You keep foods in proportion.”

Following the plan required big changes in Adam’s eating habits.

“At the start, it was just so hard for me,” Adam recalls. At one point “I said, ‘I can’t do this,’ and I almost stopped. But my mom and dad encouraged me to go back [to the plan] again.”

A year into the plan, a leaner, trimmer, more muscular Adam — weighing 34 pounds less than he did the previous year, despite his growth — said he had gotten used to it and no longer found it hard to follow. “It’s one of the easiest things I do,” he said. “It’s just part of my regular schedule. I don’t sneak treats at school or anything.”

New Parental Burden

Following a low-glycemic-index eating plan like Adam’s is not the single “right” way for a child or a family to eat healthfully. In fact, despite the popularity of weight-loss regimens such as the South Beach Diet that are founded on similar concepts, most nutrition experts concur that diets based on foods’ glycemic index still need additional study, especially in large clinical trials designed to test their long-term effects on body weight and overall health.

Nevertheless, the OWL plan’s emphasis on eating plenty of fresh fruits and vegetables, whole grains and nonfat or low-fat dairy products while including sources of “healthy” fats such as olive oil, nuts and fish are principles that most nutrition scientists and dietitians endorse — and they also form the basis of the federal government’s latest dietary guidelines. Most American families could probably benefit from some of the lessons about healthy eating that Adam and his family have learned.

Parents can no longer take for granted that their children will grow up knowing how to make good food choices and maintain a desirable weight. Recent decades have seen pervasive changes in our daily patterns of eating and activity — changes that make excess weight gain likely for just about everyone at some time. Teaching children to make choices that add up to a healthy lifestyle requires a degree of sophistication that simply was not necessary for parents in the past.

“If the environment were not the way it is, it probably wouldn’t matter if people had good parenting skills around food and physical activity,” notes Shiriki K. Kumanyika, a professor of epidemiology at the University of Pennsylvania School of Medicine. But today’s kids are far more sedentary than children were in past decades, and they live in an environment replete with high-calorie, tasty, heavily advertised food and drink. “We need to reeducate parents,” Kumanyika said.

Faced with an environment packed with fattening foods and resounding with cues urging us to eat more of them, what can parents and other adults do to teach children to resist these seemingly irresistible forces?

On an individual or a family level, the changes in behavior required to avoid weight gain may be less drastic than one might expect. Simply by making small changes in daily routines and in the home environment, parents have more power than they may think to improve the family diet and move their own habits and those of their children in a direction that can help everyone to achieve or maintain a healthy weight.

The University of Colorado’s James Hill estimates that the “energy gap” causing so many children and adults to gradually gain weight probably amounts to an average of 100 calories per day — that is, on average, people are likely consuming about 100 calories more than they expend in activity. That’s equivalent to about one slice of bread or two-thirds of a can of soda.

It should be possible for many people to eat 100 fewer calories a day without drastically altering their lifestyle, Hill suggests. For instance, eating three bites less of a typical fast food hamburger could reduce intake by 100 calories. Walking an extra mile each day, about 2,000 to 2,500 extra steps, would burn 100 calories. Because children do not inherently know how to make such choices, Hill writes, “as a society, we should be more willing . . . to carefully manage the food and physical activity environments of our children at home, in school and in other places.”

Consensus for Change

People often complain about what they view as conflicting dietary advice from experts and inconsistent findings from scientific studies about nutrition, yet in many broad areas there is little or no disagreement. Experts on nutrition and obesity are virtually unanimous about a number of steps parents and other adults can take to improve the chances that the children they love will grow up with healthy eating habits.

As often as possible, meals should be a family activity, a time for parents and children to be together. Starting in infancy, children should be able to see the face of the person feeding them. Just as a baby should never be put to bed with a bottle or propped in a seat with one, older children should generally not be expected to eat meals alone.

It’s also wise to limit eating and drinking to areas of the home such as the kitchen or dining room, since children become conditioned to expect food in physical settings where it is usually offered. In particular, parents should not allow children to eat — even snacks — while watching television. There is ample research evidence that television viewing contributes to the epidemic of childhood obesity, not least because kids tend to ingest excess calories almost unconsciously while watching TV.

Children generally do best with regularly scheduled meals — especially breakfast, which has been shown to improve their thinking skills as well as academic and physical performance. Recent studies in children and adults have also found that those who eat breakfast regularly are less likely to be overweight. There is nothing magic about a three-meals-a-day schedule: one study found that adults who ate frequent small meals (four or more daily) were less likely to be obese than people who ate three large ones.

In addition to regular meals, many children, especially preschoolers and fast-growing adolescents, need snacks. However, significantly more U.S. children report consuming snacks today than in the 1970s, and this increased snacking has probably contributed to the rise in kids’ calorie intake. Steering kids toward snacks that are not calorie dense, such as fresh fruits, vegetables and nonfat or low-fat dairy products, can improve their diets and help limit excessive caloric intake.

Parents and others concerned about preventing obesity should resist the societal trend toward relying ever more heavily on restaurant or carryout food. A study of children and older adolescents found that those who ate dinner at home with their families consumed fewer fried foods (both at home and elsewhere) and less soda, and ate more fruits and vegetables, than those who did not. Preparing a meal at home allows those who cook it to control the kinds of fats used, the sugar and salt content, and whether foods are steamed, baked, boiled, grilled or fried. It is difficult and sometimes impossible for consumers to influence what goes into a meal cooked in a restaurant or into a frozen entree or heat-and-serve item from the deli or supermarket. Sharing meal preparation with children also teaches them lifelong lessons about how to choose healthy foods and how to handle food safely, as well as imparting cooking skills and family and cultural traditions.

Although eating with the family is good for kids, highly charged emotional struggles focusing on food are not. Research has shown that absolute bans on certain foods are likely, paradoxically, to make children crave them more: Telling a child “no French fries” is a surefire strategy for making them a favorite.

Conversely, insisting that a child eat broccoli may trigger a fixed opposition to that vegetable. Parents can have a more positive impact by letting the child see them eating and enjoying the food they wish to promote (such as a cooked vegetable) and by encouraging the child to try a taste, even a tiny one, each time it is served. It’s normal and expected for young children to distrust or reject an unfamiliar food, and research has shown that it may take 5 to 10 experiences with a new item before some children accept it.

Urging children to finish every last morsel on their plate can interfere with their developing ability to sense satiation, the feeling that makes a person end a meal. In one study comparing two groups of children, those who were taught to focus on noticing the sensation of fullness in their stomachs did better at adjusting their intake in response to foods’ calorie density than the group rewarded for cleaning their plates.

Children’s bodies have their own well-regulated systems for determining their caloric needs. Those needs may vary from day to day — much to the distress of parents who want to see a child eat three “good” meals daily — but research has shown that even picky toddlers eat an appropriate and consistent number of calories for their size when their intake is averaged over two or three days. When a baby refuses to eat another spoonful or when a child says he is full, parents should respect the child’s internal satiety signals. As soon as they are old enough to do so, children should be encouraged to determine their own portion sizes and serve themselves.

Family Rules

How else can parents and other adults best encourage healthy eating habits while avoiding battles over food? They can start by ensuring that the entire family is committed to having healthy foods in the home. The available choices, the menu at meals, and family policies about eating should be the same for everybody. Parents should not set a bad example by eating junk food or following a fad diet while expecting their children to follow a different set of rules.

Conversely, parents or other caregivers should not give in to the temptation to feed kids unhealthy items just because they are easy to prepare or because they know children will eat every bite. “It’s essential” that the whole family commit to following a healthy eating plan, said Harvard’s Ludwig. “With overwhelming environmental influences to eat junk food and not get enough exercise, one has only the family. The family is the last bastion of defense against the toxic environment.”

Children need to be able to control how much they eat and whether or not they will eat specific foods, but adults should determine what the range of choices will be, as well as what products will not be on the home menu. That strategy will help prevent battles over whether a child can or cannot have a particular food. It also encourages kids to develop healthy tastes that will persist as they get older. “Parents should be in charge of what children are offered and when, and children should be responsible for the decision to consume what is offered or not,” write William Dietz of the Centers for Disease Control and Prevention and Steven Gortmaker of the Harvard School of Public Health.

Parents whose child refuses to eat dinner may worry that the child will go to bed hungry.

“I’d say, that’s just the point,” Dietz said. “Your child needs to learn the logical consequences of not eating. That’s a lesson that many children never learn.”

Dietz believes that working parents who have limited time to spend with their kids may be tempted to give in to food demands because they think that having quality time with their children means avoiding an argument at any cost. “I think parents accede to their children’s wishes about food when children are not in a position to make responsible decisions about food,” he said, adding that, while there is no formal scientific evidence that the approach he advocates can reduce obesity, “it clearly reduces conflicts around feeding.”

Susan Okie, a family physician and a former Washington Post staff writer, is a contributing editor for the New England Journal of Medicine. This piece is adapted from her book, “Fed Up! Winning the War Against Childhood Obesity” (Joseph Henry Press), published this month.