First Do No Harm: Dr. Katja Rowell

Does the standard medical approach to overweight kids, calorie restriction, do more harm than good?

by Katja Rowell

As a family doctor and childhood feeding specialist, I see a lot of families upset about their kids' weight.  I also take seriously the medical oath to “first do no harm,” which is why I've grown to care so much about this issue.  After immersing myself in research and getting past blaming parents for not doing "as they were told," I've become convinced that the standard medical approach to childhood weight concerns, from diagnosis to “treatment,”  most likely is doing more harm than good.   Many parents are trying desperately to “do as they are told,” but the problem is that much of the advice and tools we have given parents don’t work, and even make things worse.

The reasons for the rising rates of obesity in the last thirty years are complex. We know that genetics, stress, sleep, lack of activity, more eating out and grazing, food insecurity (not having reliable access to enough food either because of money or unsupportive feeding), and food choices all play a role. I think however that the most important piece is often left out of the discussion. Instead of continuing our blind focus on what we are feeding kids, we need to begin by looking at how we are feeding them.

I see three main contributors to our current crisis and the related health concerns of unhealthy weight gain, disordered eating, epidemic dieting among teens, malnutrition, and increased diagnoses of eating disorders.

Parents and health professionals often don’t understand how kids grow

Many children who are at a healthy weight but larger than their peers are being labeled as overweight or obese, which leads to dieting and tends to make matters worse.

Extremes on the growth curve can be normal. A child growing consistently at the 90% may be healthy and normal, but will be labeled as “obese” based on current guidelines. This is wrong, and verges on malpractice if you ask me. I see clients all the time for weight concerns who were started on diets due to a basic misunderstanding of normal growth, and the outcome is a child who was growing well and consistently at the 90% now is gaining weight more quickly, is obsessed with food and miserable (as are the parents.)

A healthy weight is most definitely not as simple as calories in, calories out. I see this regularly in my intake analyses with clients. Relatively fat children, for example, are often eating within the recommended amounts for calories and fat.  In other words, the problem lies not only in how many calories they are consuming, but chaos in eating patterns, i.e. periods of eating significantly less calories than recommended and then far more the next day with little planning or structure. Sound familiar?

I have talked to the parents of a four month-old baby who were told to cut back on breast feeding because the baby was “getting obese.” This based on a gross misinterpretation of the growth chart for a baby born 3 weeks early who was doing catch-up growth. Similarly, after five years of constant battles around food, a seven year-old-girl is now exhibiting disordered behaviors with food obsession, sneaking and eating large quantities. (All based on a misinterpretation of normal growth and recommended restriction starting at two.)

You should be concerned when your child’s pattern diverges. When your child who was growing well and consistently starts to cross percentiles on the growth charts. Be concerned when your child diets, loses or gains weight. Be concerned when your meals or lives seem to center around who is eating how much, when you feed to control your child’s weight. You need to ask, “Why is my child no longer able to eat and grow in a healthy way for her?” Ask, “Am I doing my job in supporting her health, her eating and growth?”

As a group, fatter children do not eat more than their leaner counterparts (see the Donald study***). This means there are lots of normal and “underweight” kids out there who eat what we would consider “atrocious” diets, and many large children who eat what we would consider an “ideal” diet and vice versa.  Look around at the school cafeteria.  Chances are that leaner and fatter kids are eating the same things.

Most “obese” adults were not “obese” children.  And leaving childhood lean is not protective.  We need to focus on how all children are being fed to provide a basis for lifetime good health. (A great resource on growth is Chapter 2 of Child of Mine, available free online at www.ellynsatter.com under the resources section.)

Parents and health care professionals often don’t understand how children eat

Young children naturally eat in an erratic way. That means large meals and snacks some days, and almost nothing at other meals. Parents find this worrisome and intervene. The large child having a large meal will be cut off and the small child will often be pushed to eat more. Over time this makes it very hard for the child to tune-in to hungry and full sensations. One of the biggest problems is that kids are grazing and eating frequently. Grazing and eating in front of the TV or with other distractions makes it harder for children to eat the right amount.

Parents and health professionals often believe that feeding with pressure works

Most parents pressure with feeding.  But approaches like bribing or bargaining (i.e. “two-more-bites and then you can have dessert”) or enforcing arbitrary portions don’t help children and often backfire.  Let children stop when they are full, even if they leave food on their plates; allow them to have seconds and thirds if they are still hungry.  Using food to soothe, discipline, or control the weight of your child can sabotage their natural ability to eat what they need.

*  Children pressured to eat more tend to eat less and grow less well
*  Children pressured to eat less tend to eat more
*  Children pressured to eat more fruits and vegetables tend to eat fewer

Early feeding problems are common and correlate with adolescent weight gain, even more than breastfeeding is considered protective. It’s why I spend so much time talking to parents of small children. One mom said dinner was like “forty-five minutes of hostage negotiations,” and most parents struggle with picky eating and fighting over how much or what their children eat. One out of three parents will ask a health care provider for help with feeding.

OK, so what can we do?

Children are born with the ability to self-regulate, to know how much to eat. Our job with feeding is to support, not extinguish that ability.  Our ancestors seemed to do this naturally, but in our changing culture and food climate we have lost our way and need assistance.  Happily, Ellyn Satter, a therapist and dietitian with over 40 years of experience, pioneered the “division of responsibility in feeding” for parents and kids, an approach advocated by the American Dietetic Association. Ellyn’s approach sounds simple but it is almost revolutionary in our current feeding climate. Basically the division of responsibility is that the parent decides when, where and what to feed and the child decides if and how much.  It trusts that if parents do their job with feeding and let the children do theirs, children will eat a variety of foods in the right amounts, and grow to have healthy bodies that are right for them.

Once you have an older child or teen who has been restricted or dieted  (not allowed to do their job of deciding how much to eat), it can take time and a lot of patience to turn things around. But teens and adults can learn to trust themselves and tune in to hungry and full signals again, with the right support.

So here’s a list of ten things parents can do that are likely to help and not harm (this applies to all kids, not just those labeled as “overweight.”):

1.  Get TVs out of bedrooms
2.  Encourage and support children to find ways to move their bodies that feel good to them.
3.  Limit screen time to 2 hours a day.
4.  Encourage children not to focus on weight, not to diet, and not to skip meals.
5.  Love them whatever size they are.
6.  Encourage them to get enough sleep and learn to deal with stress and emotions in a healthy way.
7.  Make family meals a habit. Encourage children to eat breakfast, and to eat about every 3-4 hours after that.
8.  Discourage grazing or eating between meals (a regular snack time is ok).  One of the biggest problems is that kids are grazing and eating too frequently (that is the child taking over the parent’s job of when to offer food.) Grazing, or eating when distracted  (i.e watching TV) can make it harder for your child to eat the right amount.
9.  Offer snacks and meals that include carbs, protein and fat so children are satisfied until the next meal.
10.  Model a healthy attitude to eating yourself.  Enjoy your food, move your body, and feel good about whatever size or shape your body is.  Fake it at first if you have to. Get help for yourself if you need to.

As a culture we need to reshape how we feed and raise our children. The feeding model I work with is known as the Trust Model.  It is not a pill, a quick fix, a diet, or a way of sneaking or tricking kids into eating "healthy."  It's not a soundbite or a money-maker.  It is the framework for nurturing and feeding healthy children – planning, providing, prioritizing, and spending joyful and reliable time with your family around food.  It may even feel "wrong" or counter-cultural at first.  But I feel lucky to practice the most powerful preventive medicine I can imagine— helping families give children the gift of a healthy relationship to food and their bodies.

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Learn more about Katja Rowell, MD, at her website, www.familyfeedingdynamics.com.

***Note:  The DONALD study followed thousands of children in Germany for seventeen years and their food intake in terms of calories, fiber, fat, processed foods, sugars etc.  Some kids ate lots of sugar, processed foods, and fat. Others did not. But, try as they might, researchers could not find any association with intake and BMI. That means that based on what a kid is eating, you can't predict what size they will be. Conversely you cannot guess what a child eats just by looking at them.

  Published May 4, 2010