Download Plate Clearers and Picky Eaters: Differences in responses to food

Plate Clearers and Picky Eaters:
differences in responses to food
and how to deal
with them.
Dr Gillian Harris
University of Birmingham
Birmingham Food Refusal Service
The speaker had sole editorial control over the content
in this slide deck. Any views, opinions or
recommendations expressed in the slides are solely
those of the speaker and do not necessarily represent
those of Nutricia
To understand children’s eating
behaviour we need to understand our
own.
We eat according to appetite – or perhaps
not!
We eat a wide range of foods – or perhaps
not!
There are differences in: responsiveness to internal appetite cues
 responsiveness to foods cues
 the extent to which we can tolerate texture, smell and
taste
 the extent to which we are likely to try new foods
These are subject to individual difference,
developmental stage and sensitive or critical periods,
- however, these issues are still present in adulthood.
Inherited traits
Sensory hypersensitivity affects reactivity to taste, smell and
touch - and therefore willingness to try new foods – this trait
is related to food fussiness and food refusal. It particularly
affects texture acceptance.
(Coulthard &Thakker, (2015)JAND:DOI 10:1016/j.jand.2015.02.020; Harris (2009). Paediatrics and Child Health.; 19 (9): 435-6; Breen,
Plomin , & Wardle. Heritability of food preferences in young children. Physiology & Behaviour 2006; 88:443-447; Coulthard &
Blissett. Appetite 52 (2009) 410-415)
Food responsiveness/food fussiness affects food acceptance
in infancy and early childhood – these traits relate to food
enjoyment but could also be linked to weight gain. The
components are awareness of satiety, responsiveness to
food cues, food selectivity.
(Ashcroft et al (2007) Eur J Clin Nutr, 62,985-909; Blissett et al., BJN)
Sensory hypersensitivity predicts texture rejection
Meat
Fish
Fruit
Vegetables
Not fatty foods of smooth texture
such as yoghurts
(Breen, Plomin , & Wardle ,. Physiology & Behaviour 2006; 88:443-447; Harris,G. (2009). Paediatrics and Child Health.; 19 (9): 435-6. )
As adults :-
Regulation
 We all regulate our intake of foods, according to the energy the food
would provide us with (kilocalories), to take roughly the same
number of calories in a day.
Our appetite changes according to: Metabolic rate/ exercise
 Mood (Stress, anxiety, depression, boredom)
 Gut function
Ideally we keep our weight around our ‘set point’
Infants can begin to regulate their intake
and energy needs from birth
This regulation is only partial until about
six weeks of age, after this infants can
take the number of calories that they
need to meet growth and energy
requirements
Fomon, (1976)
There is no mechanism which directs a child
to maintaining a healthy dietary balance.
However, sensory specific satiety does mean
that we can get bored if we keep eating the
same food repeatedly.
We lose our appetite for it.....
Regulation according to internal cues
should mean that we take only the
calories that we need and up until 4 or 5
years children’s appetite is determined
mainly by their energy and growth
needs, after this time they, like adults:  begin to modify their eating according
to social rules and will learn to :-
 Finish what is on the plate
 Eat when others are eating, even if they are not
hungry – and when prompted or rewarded
 Imitate other’s eating habits
 Comfort eat
(Lumeng JC, Burke LM. Journal of Pediatrics 2006; 149:330-335.)
We can all eat in the absence of hunger at some point e.g.in response to social cues;
and we can all overeat in response to mood changes especially stress.
These are not necessarily genetically determined traits
However, some children are more likely to eat in response to
social cues or even just to the presence or thought of food.
 These children are more Food Responsive,
 and/or Eat in the Absence of Hunger,
 they also eat to control emotional states; Emotional Over Eaters.
And :Food-responsiveness is positively
associated with emotional eating an eating behaviour linked with increased :snacking,
eating energy-dense foods,
higher total caloric intake and
overweight.
(Ashcroft et al., 2008; Steinsbekk, Belsky, & Wichstrom, 2016; Sleddens, Kremers, De Vries, & Thijs,
2010; Nguyen-Michel, Unger, & Spruijt-Metz, 2007; Braet & VanStrien, 1997; Braet et al., 2008;
Croker, Cooke, & Wardle, 2011)
Characteristics of food responsive children
include:particularly enjoying food
eating very quickly
eating when they are not hungry
asking for food outside of their meals and planned snacks
and so eating more frequently
eating all the food they are given (‘plate clearers’)
eating whenever they see accessible food
They don’t necessarily eat more unhealthy
food they just eat more food!
(Syrad, Johnson, Wardle& Llewellyn AJCN 2016)
Developmental stages
At Birth
There are inherited factors that determine which foods might be rejected or accepted.
There is certainly one, and possibly two, innate taste preferences that will endure
throughout life –
Sweet
Fat
And certain innately disliked tastes – a dislike that continues through to adulthood:-
Bitter
Geosmin (beetroot)
Coriander
(Schwartz,C, Issanchou,S, & Nicklaus,S . 2009 British Journal
of Nutrition 102,1375-1385; Bell KI, Tepper BJ. 2006 Am J Clin Nutr; 84:245–251).
4-6 months -Learning about tastes.
Window of acceptance for new tastes
(complementary foods)
 Food acceptance learning is a function of: exposure
 variety
 taste and smell
(Maier, A, Chabenet, C. Schall, B. Leathwood, P. & Issanchou, S. (2008). Clinical Nutrition, 27, 849-857.
Schwartz,C. et al (2011) Physiol & Behav.104:646-52. Remy, E et al. (2013) Journal Nutr. 143 (7) 1154-61.
Caton,S.J.et al (2014) Plos One:9(5) e97609. Nicklaus,S.(2014) Appetite 81(0),60-66.)
However, it is easier to get some tastes accepted
rather than others.
 Sweet tastes are innately preferred
 Salt and sour taste acceptance is easier than bitter
 Bitter tastes are usually associated with toxicity in the
plant world, and are therefore more often rejected –
unless there is early exposure.
NB. There is no evidence to suggest that a bland
tasting food should be introduced as a first food.
6-12 months – Learning about textures
Critical period for the introduction
of solid textures.
Oral motor skills are learned from food
texture experience.
Texture acceptance from the age of 6 months.
The infant learns the tongue movements
needed for processing textured foods around
the mouth.
Infants’ chewing skills develop most markedly
between the ages of 6 to 10 months, but only if
the infant has experience of food in the mouth,
after this time infants become more orallydefensive to texture
(Gisel EG.. Dev Med Child Neurol. (1991) Jan;33(1):69–75; Mason SJ, Harris G, Blissett J.
Dysphagia.( 2005);20(1):46–61).
Northstone et al (2001) looked at the effect of the
timing of the introduction of lumpy solid foods on
subsequent feeding difficulties.
Age of introduction.
<6mths
6-9mths
>10mths.
Feeding difficulties
at 15 months
29.1%
38.6%
52.3%
This effect was still evident at 7 years, and predicted
fruit and vegetable acceptance .
( Northstone K1, Emmett P, Nethersole F;. J Hum Nutr Diet. 2001 Feb;14(1):43-54; Coulthard, Harris, Emmett & Northstone,
2009)
The end of the first year
Foods introduced in the first year are recognised by
their: taste
 texture
And then by the way that they look
Food acceptance is a function of exposure:I see the food
I see others eat the food
I recognise the food as safe to eat
I learn to like the food and anticipate eating it with
pleasure
Vegetables have bitter taste, a stringy texture
and very few calories – we have been designed
to avoid them!
And children don’t like food with bits in !
Smooth, high fat,
sweet foods win!
Nederkoorn C, Jansen A, Havermans RC. Appetite.2015; 84: 7–10
The start of the neophobic response –
at around 20 months
A developmental stage when new foods,and some previously accepted foodswill be rejected.
Children at this stage:Refuse new foods on sight, without tasting
Refuse food that has mark on it or is the ‘wrong colour’
Refuse foods that they had before – if they differ on subsequent presentations
This is though to be of evolutionary benefit –
to avoid poisoning
( Brown, S. & Harris, G. (2012)International Journal of Child Health and Nutrition,1, 72-81; Pliner P,Loewen,E. . Appetite
1997;28:239-254.)
Hiding and disguising food is not successful in
getting a child to eat new foods, unless the
‘hidden’ food is chopped into very, very small
pieces.
Even then a sensory hypersensitive child will
find the hidden food and reject the whole
meal.
Brown & Harris (2012) also found that
children show a disgust and contamination
response as early as 20 months.
Some children will reject a liked
food that has been touched by a
disliked food.
Interventions
Responsive children
Are some children more susceptible to the
effects of the use of food to control mood?
Do parents use mood control more with
responsive children than with non-responsive
children?
Parents are likely to find it easier to use food to
control the mood of children who are
responsive to food and who eat in the absence of
hunger
They will use to food when the child is: upset
 cross
 bored
 anxious
(Sleddens, Kremers et al. 2008,). (Jansen & Rosa, 2012) (Farrow, Haycraft et al. 2015)
If parents get into a pattern of using food in this
way – then the child will also use food to control
mood into later life
 Maternal ‘emotional’ feeding predicts increases
in emotional eating over the course of one year
in toddlers and preschoolers.
 and in overweight 8-12 year olds, emotional
feeding was the factor most strongly associated
with emotional eating.
(Rodgers et al. 2013; Blissett, Haycraft, & Farrow, 2010; Braden et al., 2014).
Points for parents
Think - are they really hungry?
Just because food responsive children ask
for food it doesn’t always mean that they
need it.
The only way in which you can know if
they are likely to still be hungry is by
monitoring weight/ height.
Do they look overweight or slightly
chubby? Then they don’t need more food.
Model good eating
Eat with the child and eat a wide range of foods
Social interactive mealtimes tend to be slower
than meals eaten alone.
Don’t allow food in front of the TV etc., when the
child is distracted from what they are eating.
Remember modelling can also have a negative
effect – peers with poor eating habits, foods with
characters on the label, TV adverts for high calorie
foods.
.
Plan ahead and tell the child
Plan meals and snacks for the day meals and three
snacks) and tell your child what they can expect.
Stick to your plan and carry healthy snacks with you
when you go out.
Remind your child of the food that they have already
eaten that day.
If our child asks for more food at the end of a
meal, prompt them to wait a while, to see if
they really do feel hungry.
Covert restriction
Do not have high calorie desirable foods in
the house where children can see or access
them.
But do not withhold foods if the child knows
they are available (overt restriction)
Fussy ... and responsive children
We know which strategies increase the
intake of new foods with young children:-




Exposure
Modelling
Prompting (possibly)
Attention for eating (possibly)
We also know that:-
Pressure to eat
Hiding and disguising
Will decrease intake of foods
Other strategies often recommended....
Force feeding
Sitting in front of new foods
Leaving the child to go hungry
Rewarding with other foods
Also don’t work
The role of reward.
We reward away from
mealtimes :-
to control boredom
or
unacceptable behaviour
Do not Reward With Food!
 No rewarding /coaxing or coercing a child for finishing or
clearing the plate.
 No rewarding the child with pudding for eating first course
 Calorie dense food should not be deemed ‘naughty but
nice’/overtly withheld /used as a reward.
CDFs should instead be given at set times as part of routine
during the week without too much comment - plan in these
foods; for example, an ice cream when at the park on
Sunday, some chocolate after swimming on Friday, or cake at
a birthday party.
(Newman & Taylor J.Exp Pysch. 1992)
•
.......However reward with non- food does
sometimes work with all children
Young children in a nursery setting were
more likely to try a food
if offered a sticker
(Cooke et al, Appetite 57, 2011)
Always .... new food should be given : on a separate plate away from accepted food
 away from mealtimes
 in very small portions
.....and it needs more than one taste to establish a
preference – it might take up to ten tastes
Desensitize
In a young child:Encourage and promote general
desensitization, such as messy play,
and specific oral desensitization, textured
spoon, allowing fingers
in at side of mouth.
If all else fails......