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Institute of Medicine Childhood obesity recommendations: closer, but is “portion control” the final holdout?

Posted by on Jul 11, 2011 in Blog Posts | 37 comments

Institute of Medicine recommendations on prevention of obesity in children just came out. I dreaded reading this PDF, but was pleasantly surprised- for the most part. They got closer than any other document of its kind that I have seen. (Note, I only read the summary recommendations. And, another “note.” I wish that the focus was on wellness, not weight. I wish they would recognize that most adults who struggle with weight were “normal” or “underweight” as children. Most of the recommendations are in fact, appropriate for all children. I do also have a problem with their risk definitions, with BMI >85%, and a parent with a BMI >30, but won’t rehash that here… They at least do mention weight acceleration.) With that big caveat…

I agreed with  the recommendations to increase PE and active-play opportunities for kids (though I thought the enforced “tummy-time” was kind of funny since M hated tummy-time more than anything and it was just one more thing to feel guilty about.But perhaps in a regulated childcare opportunity it is helpful to spell out that the opportunity should be provided…) I agree with limiting screen time to 2 hours a day and removing TVs from bedrooms.

I was intrigued and pleased to see some attention to the HOW of feeding in this piece. Most of the time it is totally missing, so this was a significant step in the right direction. They mention structure, adults eating with children (though arguably an adult with a control agenda can do more harm than good. Like today, M casually mentions they can’t wear hats during lunch so the teachers can see that “you don’t gobble up your candy first…” Oy. )

Read the excerpt below, and tell me what you think. What is missing? How do you read it? Perhaps I am being too sensitive?

“For toddlers/preschoolers—providing  meals and snacks as part of a daily routine; requiring adults to sit with and eat the same foods as the children; when serving children from common bowls (family-style service) allowing them to serve themselves; when offering foods that are served in units (e.g., sandwiches) providing age- appropriate portions and allowing children to determine how much they eat; and reinforcing children’s internal cues of hunger and fullness.”

What interested me, was the apparent emphasis on supporting the child’s internal regulation. I loved that they said to let the children serve themselves, that adults should eat with the kids (I wish they had gone further and said, “and then shut up. Don’t lecture them about healthy eating, your thighs or getting fat”.) But what was curious to me  is they seem to advocate portion control, mentioning “appropriate” portions a few times (in the infant section, they mention putting an “appropriate” amount in the bottle) and then “letting the child decide how much.” To me, it implies  (by omitting explicit permission) that the child should not have another portion if they are still hungry. What if the baby finishes her “serving” but is still showing signs of hunger? Or the toddler in a growth spurt who suddenly can’t seem to eat enough- can he have another “child-sized” sandwich unit, or maybe even two?  If the child is “at risk,” can he still be trusted?

Yes, the child with a smaller appetite or who just isn’t hungry that day or that meal shouldn’t be forced or even encouraged to finish a portion- this they seem perfectly comfortable with and advocate for- as do I. But– what about the child who wants MORE than an “appropriate” portion that day? Shouldn’t their internal cues of hunger and fullness be trusted as well? This seems o be the crux of where folks get stuck. Where people say they believe in the Trust Model and the Division of Responsibility, but can’t quite do it. They can let kids not finish a portion, but can’t seem to let go of portion control, can’t quite trust that we can self-regulate, that bigger kids can be trusted too…

What do you think? Reading the above, am I overreacting?

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  1. Natasha

    I’m curious if any of these recommendations have considered sleep. It may sound unrelated, but I remember in college, when pulling all-nighters, eating more food was one of the ways the body would compensate to enable me to keep going. And generally, I’ve found appetite gets all out of whack when sleep patterns get disrupted. I’ve read that Americans (adults and kids) do not get enough sleep. This could have an unhealthy effect on eating. Even more directly, this could be something that makes people less likely to get active – if you feel tired all the time, sure all you want to do is lounge and relax – it’s not surprising at all. Books on eating don’t really mention this, but I am curious if this has been something that you’ve come across in your experience or if there is any research you’re aware of.

    • katja

      They are starting to consider sleep. We are seeing increasing indications that poor sleep, not enough etc are linked to increased rates of obesity. There could be many reasons. Chaotic homes that tend to be lax on bed-time routine also tend to be lax on meal structure, i.e might see more grazing. There are also hormonal mediators in terms of growth hormones, IGF, cortisol that are likely affected by poor sleep habits. Poor sleep, less energy, less active, makes sense too. So, yes I try to address routines, sleep etc in the families I work with, and I am starting to see sleep come up more in the discussions… Great points!

  2. Jess

    I think there is still some room to give guidelines re: appropriate portions to parents. I’m just introducing solids to my six month old. Although I’ve done this once before, my memories of baby feeding were skewed toward the 8-10 month old spectrum… the first few days, I made so much food (several tablespoons of several fruits and veg)! Then I went and checked on the internets and was reminded that a six month old may only eat a couple of TEAspoons at a time. Of course, duh, this phase is just about learning and tasting, not really about consuming a lot. I just needed the reality check regarding what is average for my kid’s age– that doesn’t mean I’ll force her to eat at least two teaspoons or not allow her to eat more, it’s just a guideline to manage my own expectations. Also, I think that, as someone pointed out, once you’ve made a lot of food (or put a large amount in a bottle), most of us just hate to see it go to waste and that can add pressure to the situation. I love the solution that one parent suggested with subdividing everything into smaller portions (e.g. sandwiches in four pieces) so that one can always get more but there is less waste.

    In the best case, any guidelines about “appropriate” portions would help parents see that whatever their child is taking is within a normal range– so many kids are pressured to eat more or less when in fact their eating is perfectly appropriate for their age, size, growth, etc. I didn’t read the full report, so I don’t know if that’s what they are doing, but sometimes giving people info about age appropriate intake/behavior/development reassures them that everything is fine, you know?

    • katja

      I always caution about “normal” or “approrpriate.” The info must be given carefully, precisely as you say to reassure, and not to worry unnecessarily. For example, M often ate several times a “normal” portion. If worded correctly, something like, “children this age often eat around X range. However, some children eat more, some eat less. What a child eats at any given sitting appears erratic, but it evens out.” Much better to me than, “Your child should eat 1 Tbspn of X per year of age” kind of thing…

      • Jess

        Agreed! That would be much more helpful, for people at every age. The way things tend to be phrased can make a world of difference in their impact on parents expectations feeding their kids (don’t even get me started about sleep books and their draconian so called guidelines: “if your baby does not take two 1-3 hour naps every single day their brain will be fried, forever!”… I of course had a baby that refused to ever take a nap longer than 45 minutes for his entire first year of life; but I digress).

        Also, I find it weird that this report says nothing about poverty, which is a major correlate of obesity. It’s the elephant in the room on just about every social issue from education to crime to drugs, to yes, obesity. To tell an unemployed parent wondering how they’re going to pay rent, “Hey, your kid is fat. Have you thought about less Fritos and more heirloom tomatoes?” does not only seem ineffective, it seems insensitive and clueless. To me, if you want to talk about addressing morbid obesity you have to talk about changing the food environment, changing the physical environment and changing the culture, which is the work of generations; advice to individuals would have to be about lifestyle and wellness, not about counting calories.

  3. Alexa

    Age-appropriate seems like a good idea to me. I think that just as there are parents who restrict their kids’ food intake, there are probably also lots of parents who think it’s the right thing to do to practically force-feed their kids.

    My parents would regularly serve me the same amount of food as they served themselves, and expect me to “clean my plate”. When I protested being made to eat it all despite being much smaller than an adult, they insisted that it was an appropriate amount of food for me because I was growing and they were not. At the age of 5 I was not yet able to see any of the many flaws in that reasoning, and was subjected to various guilt tripping for “being bad” since I could not manage to consume more food than what my stomach would fit, and to being punished by being made to stay sitting at the table in front of my plate until I managed to eat enough for their liking. This went on at most mealtimes for many years.
    The “think of the poor starving children in _______” guilt trip was also regularly used….

    • katja

      Alexa, your experience is alas too typical. You were taught over years to ignore your hunger cues and overeat. This feeding style is still too common. 85-90 % of parents push and pressure kids to eat (in a US study) and don’t believe their kids when they say they are “full.” Kids are erratic eaters, lots one meal, little the next. I think if parents understood that they would pressure less (we’ve all heard the “two more bites then you can have dessert.”) BTW, that’s why I recommend eating dessert with the meal, at least until your child has firmly figured out her cues. Making a child finish a meal to earn dessert means possibly overeating twice if the child is not hungry, but wants the dessert. I am glad that the commission mentions not making kids overeat, this is a huge problem, I just worry that the few kids who do want more, or need more for those meals will be restricted and that has harmful consequences for internal regulation as well…

      • Alexa

        If I were a parent, I would interpret “allowing children to determine how much they eat” as not suggesting setting any limitation for the kids who want to eat more. But everyone interprets the things they read differently according to what they think is right. I think the main reason my parents overfed me is because in their eyes I was a skinny, sickly child who would not eat anything but sweets if left to her own devices. Likewise, a parent who thinks their child is too chubby would be more likely to restrict their food and think that’s appropriate and in line with whatever recommendation they read, unless the recommendation was extremely specific and referred to exactly the situation they’re in.

        As an aside, what I was taught by my experiences was mostly to dislike mealtimes with my parents, dislike my parents’ habit of trying to control everything I did, and frankly, most of all, to dislike my parents in general. I would make an effort to eat more than I wanted when they were there, but otherwise I ate when and what I liked as much as is possible for a child.

        And in an example of the total lack of common sense some families have about the way they feed their children, my mom went through periods of praising me for being thin in my tweens to telling me I needed to lose weight as soon as I finally started liking ‘regular’ food and gaining a bit more weight in my mid-teens; all while still pushing me to eat more at every meal. I’m well into my 20’s and she still doesn’t trust me to feed myself.

        • katja

          Oy. Sorry, no fair. I think, alas, yours was a common experience. So many skinny kids are pushed to eat more, then they do, some get bigger (as they might have anyway) and then parents restrict… Or still push, but make remarks. it all comes down to the DOR and loving our kids as they are, doesn’t it?

  4. jaed

    But– what about the child who wants MORE than an “appropriate” portion that day? Shouldn’t their internal cues of hunger and fullness be trusted as well?

    One thing that occurs to me is that these days, the Most Important Thing of All about food is that you not eat too much of it. What you eat is considered important too (and the subject of endless bizarre ukases), but the main thing is “Don’t eat too much!”

    (Of course, in actual biological fact, the most important thing is that you eat enough. But possibly I digress.)

    It’s just very difficult for anyone influenced by the last forty or so years of diet advice, medical advice, cultural advice, cookbooks, baby books, newspaper articles, studies, and doctor visits to give this up, to say “It’s OK not to limit portions.” It’s far easier given this background for someone to allow a child to eat less than “appropriate” than to eat “more”, and I suspect that’s what you’re seeing in these recommendations. It’s too hard to completely let go of the central idea about food that the writer has unquestionably grown up with and had reinforced innumerable times in professional and personal life: that the Most Important Thing is to Not Eat Too Much.

    Still, this is a big step forward, I think, regardless of some problems. It sounds like there’s an emphasis on a child’s own hunger cues, and on normalizing eating by having adults eat with the children and having children serve themselves.

    • katja

      Yup, the “eat what you like, but not too much” is the new motto. Blech. “Eat what you like. Some days it will be more, some days it will be less. trust your body, learn to listen to it, move your body in ways you enjoy, provide yourself with regular and rewarding meals…” Sounds better to me! (paraphrasing much of Ellyn Satter’s eating competence work.)

  5. Elizabeth

    Haven’t read the report but I did not interpret the excerpt that way. Honestly, I think serving “appropriate portions” can be important. I volunteer at my kiddo’s daycare and I see parents who way overpack food for what their 2 year old will eat, for example. These kids seems totally overwhelmed with say, 2 cups of tomatoes. I agree that people could not use this recommendation appropriately but IME with my own child and others, serving “appropriate” portions can play a role in healthy eating. Also, it can be really good for a lot of adults to see what an “appropriate” serving size is for a young child. Yes, kids don’t nec. follow this but I know with my own daughter it helped reinforce that her body did not need bigger amounts of food to be healthy like I thought she did – 1 oz of cheese is a lot for a young toddler, for example. Hope I’m making sense.

  6. The WellRounded Mama

    All my kids hated “tummy time” too. I’d encourage it a bit but if they fussed a lot I certainly wasn’t going to *make* them stay in it. How cruel would that be???

    And somehow all my kids managed to roll over, crawl, cruise, and walk on time perfectly fine, and are all fine with their motor skills now, tummy time or not. I don’t know why docs have this over-obsession with tummy time these days.

    • katja

      yup. mine too. I just wonder again, what kind of science we have on this, or if this is another one of those “it makes sense” like kids should only drink low-fat dairy and they’d be skinny, but none of the actual data supports this…

  7. Samantha C

    I’ve never really understood the connection of screen time to the Obesity Epidemic. (And this is specifically in how it relates to making kids more active, I don’t know the research for whether too much screen time is harmful in and of itself) I distinctly remember how I reacted when I had screen time limitations. When TV time was up, I didn’t get up and play outside or run around (or do the structured Exercise that my mom insisted on), I just went to my room and read. When internet came into the picture, I snuck and stole extra internet time, because I was a 12-year-old girl who needed to talk to her friends, and most of them were online.

    No part of screen being restricted ever made it more palatable to move more, and I always, always resented being given a maximum screen time over a minimum exercise time. I feel like part of the message that I got was, out of the howevermany hours I had between school and sleep, the Right Thing to Do was to spend all the rest of them on Exercise. It left me with nothing to do but feel guilty that I didn’t want to spend 4 or 5 or 6 hours every day Active and Moving when I wanted to crash and relax.

    Apparently I have enough to say about this for a post of its own….but the point being, I don’t understand why screen time regulations get brought up in discussion of nutrition recommendations

    • baconsmom

      Because fat people – and, therefore, fat kids – do nothing but lay around all day watching the TeeVee and stuffing our faces with McDonald’s, duh.

      All sarcasm aside, I feel the same way you do about arbitrary limits. I had no limits as a kid, and spent plenty of time outside – and was still fat. My daughter has no limits, and spends plenty of time outside – and is thin.

      But we’re lucky enough to live in a climate and neighborhood that allows for outdoor play. We moved here in part because of that; when we lived in a shady neighborhood in Phoenix, we did not go outside. Partly because it was just too hot, and partly because we didn’t want to get shot. What are parents in those situations supposed to do? The kids are going to be inside, screens or no; why not let the kids be entertained and learn something with a “How It’s Made” marathon or something?

      Like so many recommendations, these assume a level of parental involvement/ free time/ money that simply isn’t available in a large number of cases. Considering that “obesity” is largely correlated with poverty, telling people to turn off the TV and send their kids outside is not exactly the most well-considered advice, and I think we need to stop giving it as if it’s just that easy.

      • katja

        This one is for bacon’s mom, last one was for samantha 🙂
        Great, great points. We forget and talk from our place of privilege. I heard Anthony Bourdain complain ab out Alice Waters say (again, paraphrasing, so don’t sue me anyone please) that “poor people should buy organic grapes and just buy fewer cell phone minutes or skip the Nikes…” I think his point being that the ignorance and assumptions from a place of privilege do more harm than good. Thanks for keeping me honest. There is a DOR for activity too. I do think we should (as a society) make an effort to improve access to safe, inviting places to enjoy the out of doors, and moving our bodies, because it feels good and is fun, and promotes good health for all bodies.

    • katja

      great points. There aren’t great studies about screen time and activity. There are a few about how to help create the time for exercise and moving your body, which is good for everyone. The study found that limiting screen time was more successful than actively promoting exercise, which is the opposite of what you say you would have preferred. Interesting. I don’t think the choice has to be TV or Jumping Jacks. My sense is not that TV per se, or the “junk” food ads are an issue. I wonder if children who watch hours on end also lack safe play environments, also have less parental involvement, less structure and opportunity for after-school activity. Is the TV time getting in the way with social time, book reading, creative play, drawing etc? Are they days where M watches more than 2 hours? Sure, a few. Are they days where she watches none? A few. It seems like a reasonable goal, not for weight loss, or to take as an opportunity to make kids do lunges, but to help overall with being a kid. What do you think about all that rambly mess? PS, I have had shoddy internet so am trying to answer lots of these quickly, so please forgive my disorganization…

  8. Kris

    I didn’t read it that way. I read it as “Don’t give a whole sandwich to a kid, because they are likely not going to eat it (even if they claim to want it), and you’ll feel annoyed that you’re wasting good food when you end up throwing away most of it.”

    This is something I deal with a lot–you never know what they’ll eat, and even if they ate eight broccoli florets yesterday, they may only eat one (or none) today. So I serve up small portions at a time, reminding them they can have more if they like, and holding off on dishing myself up as much as I’d like until the kids are done.

    • katja

      I hope you’re right, but I don’t think we can assume. You might interpret it that way, but the vast majority of nutrition information child care providers give is not trust model, but control. Again, this is a step in the right direction, but without explicit permission, I worry children will be limited to certain portions. But, that’s why I’m asking my readers, albeit a totally biased, enlightened group.

      • jessidehl

        They make the point of saying “age appropriate” portions. That makes me think that we should be serving an allotment of food, which means I’m controlling the amount of food my kids get. That’s how I interpreted it, anyway.

    • Kate

      The other thing about giving a whole sandwich is that it’s sending the message that that is the amount they are “supposed” to eat and that can throw off their internal cues. They didn’t decide how big the sandwich is, so they didn’t decide their serving. We did by plopping a whole sandwich in front of them.

      The way we handle things like that is to cut the sandwich (or whatever) up into halves/fourths/etc. and let the kiddo decide how many to take.

      • katja

        It’s interesting that a 3 year old eats until full in studies and stops (if they haven’t been restricted or pushed) while a 5 year old will eat the entire serving. I propose that what has changed is the effort to please, the constant pressure to finish or be good that they have internalized in the meantime. With that said, I totally agree with your point 🙂 Start with smaller amounts and take more if you need it. Works on so many levels 🙂

  9. jessidehl

    Here’s how my shorties get “child-sized” portions of sandwiches in my house: I make a couple of sandwiches and cut each one in four pieces. I pile the pieces on a plate and put it on the table. When/if they are gone, I make another sandwich and cut it up. Sometimes I make another one, usually the dog eats sandwich pieces for lunch. Then they go outside to play or we take a walk/bike ride to the park.

  10. Twistie

    I’m curious, what is ‘Tummy Time?’ I’m afraid I’m not familiar with that term.

    My guess is that you’re not overreacting, simply because this world has become so fat-phobic that the idea of not controlling portions is terrifying to many people, and pretty much a foreign language to nearly everyone else. That means that if not specifically told that it’s okay, they won’t make the intuitive leap from ‘it’s okay to trust your child not to want everything on the plate’ to ‘it’s okay to trust your child to stop asking for more when full.’

    • katja

      ugh the tyranny of tummy-time. it is a prescribed time that infants are supposed to spend prone (on their tummies) to strengthen their muscles, improve development etc. My kid didn’t like it, and never made the recommended 20 minutes stints multiple times a day… I stopped trying and stopped worrying about it…

      • Twistie

        Thanks for the info! The things I miss not being a mommy.

        • Elizabeth

          Tummy time is only an issue because of our culture of leaving babies in car seat, bouncy seats, plus the Back to Sleep Campaign (which I support, but it does affect infant muscle and head development). With all these things babies can spend a huge amount of time with pressure on the back of their skulls, developing flat heads, and not free to move and develop their muscles.

          • Ashley

            Also I think tummy time issues are largely due to personality. My baby LOVED it and got hours of tummy time a day. If she wasn’t in my arms or in a bouncer seat, she was on her tummy. I put her down at all and it was on the tummy. It was about the only way I could get her out of my arms as she was pretty much made of velcro.

          • katja

            elizabeth, you seem to know lots about this. Is their research on baby carrying? Is being carried in a sling more active vs passive? I see lots of babies in slings now which seems marvelous, but just curious. Can it also be “too much of a good thing?” I’ve heard moms say they only put the babies down for diaper changes or when they go to bed at the end of the day.

          • Heidi

            Not sure why this won’t let me “reply” to Katja – according to Dr. Sears and general AP thought, babywearing actually serves as tummy time because it requires a certain amount of strength/balance work on the part of the baby also, particularly as they get older. I don’t know if it’s actually true and never had to worry about it, as my son LOVED tummy time (the day he mastered the commando crawl at six months was a sad, sad day!)

      • Michellers

        Interestingly, at my daughter’s RIE daycare they believed that babies should not have any “tummy time” until the baby could roll over themselves. This is the same daycare that did not believe in feeding babies, they put the food out and let even the really young babies feed themselves. It was kind of awesome and it definitely helped my daughter be an independent eater.

        • katja

          I love this. See, I think it’s one of those things we just don’t know, and yet we make these sweeping recommendations and condemnations. Good sense should prevail, but rarely does. I am so intrigued by the RIE philosophy and would love to consult with them on their feeding curricula!

  11. Ines

    I am glad you are focusing in what is positive about this report. And, also about what is confusing and not straight forward. I read this report too. I think it reflects the ‘paradigm’ straddler that Dr. Birch is. What is ‘interesting’ is that her own research has proven that the opposite of portion control rules work, especially for children.
    Now, my take on the report is, what are these women talking about? Have they never been with small children? Small children ARE movement. They don’t need to be encouraged, quite the opposite. Although, parents do need to reminded that children need opportunities (space, time, a patient grown-up, etc.) for movement.

    • katja

      Thsnka Ines,
      I did like that they make a point of giving the kids time… So often playtime is lost to testing etc. I also think a reminder of DOR anc activity is in order. Many times M would go to the park and just swing, or her other friend would sit in the sand and just watch. Other times they raced around, wiggled etc. We can trust kids!