7/1/2016
A Child’s Weight:
Helping without Harming
Dana Sturtevant, MS, RD
Obesity:
An Iatrogenic Condition?
• It is caused by the cure
“In their efforts to do what they had been told
was the right thing for their child, parents and I – were inadvertently contributing to the
children’s weight problems by restricting food
intake.” - Ellyn Satter
Satter Feeding Dynamics Model
“Provide, don’t deprive, then trust your
child to grow up to be the size and shape
that is right for him or her.”
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Perspective
Children have ability to maintain energy
balance and grow in predictable fashion,
provided feeding relationship is
appropriate.
Satter Feeding Dynamics Model
Obesity epidemic?
Is this really the first generation of
children that may have a shorter life
expectancy than their parents?
“Citation is an opinion paper published in
the NEJM, which offers no statistical
evidence to support the claim.”
- Weight Science, Bacon and Aphamor, Nutr Journal 2011
Definition of
Child Overweight
• Weight acceleration v high weight
– Abnormal weight divergence for individual
child
• Child compared only to himself, not to
statistical cut off points for population
wide evaluation
Satter Feeding Dynamics Model
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Exploring Causation
• What is happening in this child’s
environment to undermine his
considerable ability to regulate energy
balance and grow predictably?
• Not – how do we get this child to lose wt?
Satter Feeding Dynamics Model
Four Typical Causes
• Misinterpretation of normal growth
• Restrained feeding
• Poor feeding practices
• Stress
Satter Feeding Dynamics Model
Prevention
• Optimize feeding from birth by maintaining
division of responsibility (DOR)
• Maintaining a DOR in activity
• Supporting parents in accepting consistent
weight, even if weight is at or above levels
defined as ‘overweight’ or ‘at risk’
Satter Feeding Dynamics Model
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Treatment
• Assess individual child to identify causes
of weight acceleration
– Treatment plan to correct those causes
• Support parents in optimizing feeding and
activity
• Let child’s weight establish its own level
in response to above
Satter Feeding Dynamics Model
Division of Responsibility
DOR for Feeding:
• PARENT is responsible for what, when, & where
• CHILD is responsible for how much & whether
DOR for Activity:
• PARENT is responsible for structure, safety, &
opportunities
• CHILD is responsible for how much & whether
Satter Feeding Dynamics Model
Competent Eaters
• Feel good about eating
• Eat based on cues of hunger and fullness
• Learn to like unfamiliar food
• Enjoy family meals
- Ellyn Satter
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An Issue of Trust
• Children will eat
• They know how much to eat
• They will eat a variety
• They will grow predictably
• They will mature with eating
- Ellyn Satter
What is normal eating?
Restrained Feeding
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Portion sizes: arbitrary limits on food
Limiting fat: amounts and types of food
Pushing low calorie, healthy food: f&v, high fiber
Rigidly controlling “treat” foods
Eat this (low calorie) before that (high calorie)
Restricting menu to drab, uninspiring foods
“Are you sure you really want that?”
The look
Your method?
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Avoid Food Restriction
• Are your decisions about food selection
intended to make your child eat less and
weigh less?
• If the answer is yes, it is restrained
feeding and it is making the child fatter,
not thinner. - Ellyn Satter
Circumstances that mimic
restrained feeding
• Erratic and inconsistent feeding
• Food insecurity
Poor feeding practices
• Too little support
• Too much interference
Structure is the bottom line!
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Follow the DOR in feeding
• Have structured, sit-down meals
• Have sit-down snacks at specific times between
meals
• Let the child eat what and how much
s/he
wants from what the parents make available
• Don’t let the child have food or drinks (except
water) between times
Parenting Tips
• Provide structure to family life
• Eat meals together as a family
• Be active 30-60 minutes every day
• Set limits on screen time
• Consider the division of responsibilities for
activity and feeding
• Encourage and model healthy choices
Do Not Embellish DOR
• Increase fruit, vegetables and fiber
• Decrease fat
• “My plate”, etc
• Stipulating ‘healthy’ foods in DOR
• No fast food, no restaurants
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Do not tweak child’s eating
• Portion sizes
• Asking: What is your tummy telling you?
• Have ‘no thank you’ bite
• Rewards, praise, ‘the look’
• Talking with child about being “healthy”
• Reasoning, teaching nutrition
“Children who get the message that they are
too fat feel flawed in every way, not smart,
not physically capable, not worthy. They tend
to diet, gain weight, and weigh more than they
would otherwise.”
- Ellyn Satter
Conversation
Strategies
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Paradox of Change
When a person feels accepted for who they
are and what they do
– no matter how unhealthy –
it allows them the freedom to consider
change rather than needing to defend
against it.
OPEN EARS
Open-ended questions
Permission first
Elicit “change talk”
Nurture confidence
Encourage; empathize
Affirm
Reflectively listen
Summarize
Invest in the beginning
“I’d like to spend a few minutes talking about
his growth charts. The purpose of this
conversation isn’t to make you feel judged or
pressured to do anything differently. I’d just
like to better understand your thoughts about
how he is growing and see if there is anything
we could talk about that might be helpful. Is
this okay?”
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Provide neutral feedback
• Be clear, succinct, and non-judgmental
• Avoid using words of judgment
• Talk about growth patterns, not weight
“too big”
“too much”
“overweight”
Example of neutral feedback
“This graph shows how your child has been
growing since we’ve been seeing you. Kids
typically pick a curve to follow and grow
predictably over time, just like he has until
recently. When we see a kid jump up (or down)
like this, we start to wonder if something
might be going on to make his growth pattern
change. What do you think might be going on?”
Draw out the parent’s
perspective
• What do you think might be going on?
• What concerns, if any, do you have about
your child’s growth (health)?
• If there was one thing you could change
about your child’s (family’s) eating
habits, what would it be?
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Offer information
1. Get permission to provide
2. Ask the parent what information would
be helpful
3. Provide information in a neutral, nonjudgmental tone (Some parents…others…)
4. Ask the parent what they think about
the information shared
Practice Activity
• How would you open the conversation with a
parent of a child whose weight is
accelerating?
– Practice saying it to your partner
• Based on this presentation, what openended questions might you ask?
• How might you incorporate the principles of
Health at Every Size into your conversation?
Resources
• Your Child’s Weight: Helping without
harming by E. Satter
• Health at Every Size by L. Bacon
• Yale Rudd Center – yaleruddcenter.org
• Ellyn Satter – ellynsatter.com
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THANK YOU!
Motivational Interviewing:
The Art & Science of Behavior Change Counseling
September 25-28, 2016
Kripalu Center for Yoga and Health
Stockbridge, MA
www.benourished.org
503-288-4104
[email protected]
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