Extended Interview with
Ellyn Satter, MS, RD, LCSW, BCD

How big a problem is childhood obesity?

You know I just hate that question, but I’ll answer it straight and then I’ll get to why I hate it. Statistically, if you look at the number of children who are above a certain cut off point, which according to the Center of Disease Control is the ninety-fifth percentile, then the number of children in that category is increasing. It seems that something is going on that is making children heavier than nature intended them to be.

The reason I hate the question is that so much is made of the obesity epidemic, and we hear so much in so many different places about children of all ages, “Oh dear, oh dear you have to be careful or your child is going to get fat.” And in fact the intensity around the issue has gotten to the point where people are even afraid to have fat babies. And if you have a big baby who eats a lot, parents are actually frightened to let that baby eat as much as he’s hungry for for fear he is going to be fat in later life. All of this focus around childhood overweight has an enormous destructive potential. Clinically, I work with the casualties, the parents who come in.

The last four days I’ve been doing intensive training with the Childhood Feeding Collaborative in Santa Clara country. It’s a group of health professionals who are focusing on child feeding issues in general and child obesity as part of those eating issues. The case study that we worked with was a little girl who was six years old, whose weight was just going up and up and up. She was really a chubby child. As part of the assessment of this child, I tracked down to find out what had happened in earlier life, and come to find out she was a big baby who ate a lot, scared her parents, and they started restricting her. They forced her weight down for the first month, so they were really restricting her. She grew pretty well, until she got to be a toddler. And then she got the upper hand with feeding. A very strong willed kid, who kept after her parents to feed her, “I want more, more.” She kept whining and crying for food. They’d hold out and try not to feed her, but then they’d have to give in. She was sneaking into the cupboard and into the refrigerator. In fact, she looked like what some people call an impulsive eater: totally food preoccupied. This kept up until I had the opportunity to do the assessment when she was six years old. The thing that had caused the problem was this over preoccupation with her weight, misinterpreting which was essentially a normal weight pattern, and this food restriction that went on for years and years.

Give me an example of what you’re talking about.

A child I worked with clinically was above the ninety-fifth percentile when she was born. [She] frightened her parents, especially because she seemed like she was a pretty enthusiastic eater. They were afraid to feed as much as she was hungry for so they restricted her, kept on restricting her over the first fifteen months. Finally when she got to be a toddler they couldn’t restrict her anymore because she was too strong willed. She started getting more food and because she was worried that she wasn’t going to get enough to eat she was over eating. During that time she gained a lot of weight and she became heavier than she would have been other wise if they simply had trusted her from the very first and let her eat as much as she was hungry for.

Are all kids getting fatter, or just the fat ones getting fatter, or are normal kids moving up? Tell me about the demographics, who is gaining weight? And maybe even the demographics in terms of what segments of the population are gaining weight?

Well it seems that lower income people, their kids are gaining weight at a faster rate. That is, food insecure people, not all lower income people are food insecure. But food insecurity appears to have a big impact on children’s and adults’ weight regulation, and it’s the same thing as I talked about with the little girl. If people don’t know that they’re going to have enough to eat then they become food preoccupied and tend to over eat when they get the chance. The important baseline that we have to think about is how do you reassure children that they really are going to get fed, that they are going to get enough to eat so they can in turn regulate normally and grow normally.

So is this a real of a perceived food shortage on the part of most of these kids you’re talking about?

Oh it’s real, it’s real. If parents are food insecure they just plain don’t have enough money to provide food for the children. For parents who restrict food intake for fear the kid will get fat, for the child, it’s real. Parents have enough money to buy food, but they’re not allowing the child to eat it. So for the child, it’s real. In those cases it’s voluntary on behalf of the parents. It is intensely frightening for the child.

What about the concept of being fit and fat?

Not everybody is going to be thin. Not everybody is going to be average weight. A certain percentage of children are going to be relatively heavy normally. If those children are allowed to regulate their food intake, eat as much as they’re hungry for, and if they are given the support of regular meals and snacks, those children are going to grow consistently, even at a higher level, and those children are healthier than children whose weight diverges up or down. The kids whose weight diverges up and down are many times the ones who have feeding problems, which goes back to struggles about feeding.

So inconsistency is a bigger red flag than being over weight?

Absolutely yes that inconsistency is a bigger flag, and in fact, I work from what I call the feeding dynamics model, which states that the fundamental principle of feeding children is that parents do the “what” “when” and “where” of feeding, and the child does the “how much” and the “whether” of eating. The parent takes leadership with eating and then gives the child autonomy with eating. If a child is raised in the fashion with eating throughout their growing up years, there is very great likelihood that that child’s weight will proceed on a predictable path that is desirable for him or her in terms of the child’s own genetics.

What are the biggest causes of an increase in pediatric obesity?

From the feeding dynamic’s perspective and from my own clinical practice and from my reading of the research, the biggest cause is restrained feeding, is restricting the child’s food intake. Many times restrained feeding is based on a misinterpretation of a child’s normal growth. Like the little girl I told you about, she was fine but her parents were frightened and they thought she was too fat so they restricted her. When you restrict a child’s food intake they’re going to become food preoccupied and prone to overeat when they get the chance.

So you are suggesting that among all the things in our environment; television, fast foods, less exercise, all of those are dwarfed by parents inadvertently doing the wrong thing?

Right, and failing for what ever reason to do the right thing which is to establish and maintain a division of responsibility in feeding. In order to do a good job of regulating food intake, children have to know they are going to be fed, have to know that they are going to get enough to eat, and have to know that they can depend on food being provided for them at certain reliable times, and they have to not be allowed to graze at will in between times.

So you’re actually saying the number one cause is the parents.

The number one cause is the parents’ misunderstanding of what is optimum feeding, what is a good way to raise children so they can grow up to get bodies that are right for them.

And why would that have changed so dramatically over the last few years?

The focus on feeding ourselves, and having meals and having snacks and just doing what’s necessary in order to see to it that we are getting fed, that focus has diminished and we have become less eating competency focused and more nutrient focused. I was talking with a friend this morning and he said, “Oh sheep who have a high glycemic index diet get fatter, they have fatter babies.” And this is an example of the kind of preoccupation we have with specific nutrients. Oh is it high fructose corn syrup in the soda? Well, maybe, but who is the child who drinks soda all the time? He’s the one who is not being parented very well with food. The child who has regular meals and regular snacks might drink soda, and he might drink soda at more than one of those daily meals and snacks, but he’s not going to drink buckets of soda, he’s not going to drink liters of soda, and so the soda intake gets to be totally disproportionate.

And why is there a guarantee he won’t drink buckets of soda?

Because there’ll be other things to eat. Who are these kids that hall around the liter bottles of soda; they’re the ones who don’t have any lunch. They go down to the corner store and they get a liter of soda. If you put any of these negative nutritional habits into context of structured meals and snacks where people have access to a variety of good tasting food, food that they enjoy, the likelihood that any of these dietary components will go out of proportion goes way down.

So what are the biggest risk factors and who is most at risk?

From a Feeding Dynamics perspective, and I keep saying that because this is quite different from the conventional model, this is quite different from what you hear in the news and what you’re going to hear in some of your other interviews, the biggest risk is a child’s being seen as being vulnerable. Sometimes that child I told you about was vulnerable because she was relatively big, others are relatively small, or they are ill to begin with, they’re born prematurely or parents worry about them for some reason that they’re not going to make it. And the reason they’re vulnerable is that attracts a lot of parent concern about feeding and the parents start to put pressure on them to eat or in case of the big kid they start to restrict their food intake. That undermines the child’s intuitive natural powerful ability to regulate food intake. Kids are great about knowing how much they need to eat, and they are born with that. In order to retain that, they have to have supportive feeding by the parents.

It sounds like you are suggesting that the biggest risk factors are not a particular ethnic group, or genetic component, but the biggest risk factor is a child who for any reason garners the concern or unnecessary worry of the parents. Is that right?

That’s right, he scares the parents, or he’s unusually large or unusually small. He eats a lot, or he doesn’t eat very much. Parents kind of automatically compensate if their kid seems to be functioning at the extreme. And so they’ll try to unconsciously get the large child to eat a little less or the small child to eat a little more or the cautious child to eat a bigger variety of food. When parents move in and overwhelm the child’s internal regulators, it sets that child up to have difficulty growing appropriately.

What would you most want parents to know?

That feeding demands a division of responsibility. That the parent does the “what” “when” and “where” and the child does the “how much” and “whether.” Embedded in that is that family meals are absolutely essential. They are critical in all ways.

What do you think is most misunderstood by parents?

I think what the parents misunderstand most is the child’s capability, that the child brings a lot of competence to the feeding situation. They don’t have to get the child to eat certain amounts or certain types of food. What they need to do is their own job: having the meals, being there themselves, having a pleasant time. If they do that, the children are going to do a good job of eating and growing. They’ll want to grow up to eat the foods their parents eat. The kids will be fine.

So you have a great deal of confidence in the child’s innate ability to regulate?

Yes I do, provided he gets appropriate support from the parents. Parents miss understanding and supporting the child’s competence, but they also miss knowing how important they are. They’re providing that structure for the child. Their being there with the child is a very critical part of the child being able to do well with eating.

I’m sure people come to you and say, “Obesity is on the rise, what’s the solution?”

And I always say, “This is not an easy thing.” But if I had to choose one thing, I would say the family meal. Structure, structure, structure. Within that structure, let the child have as much as he wants and what he wants from what the parent has put before him.

Could you give me some more detail on the division of responsibility and what the parents do?

The parent gets to decide what food comes into the house. They’re the gatekeepers. They plan the meals or do the cooking, or see that somebody does the cooking. Kids can cook along that’s fine. They put the food on the table, they round up the family and they sit down and have pleasant social time.

What foods do they put out? What foods do they not put out?

What they like.

So I love See’s Chocolate, do I put that out?

It can be part of the meal, but in your mind is that a mealtime food? What is your concept of a meal?

Well I think for some people it might very well be something that’s incredibly high in fat and calories and sugar.

Well I asked you what your concept was of a meal.

Well I tend to eat fairly healthily so I may not be a good example.

Aright well what goes on the table? Main dish, maybe fruit or vegetable, probably some bread, might be milk or something else to drink. Some bread, some rice, some noodles. Almost everybody has an idea of what a meal is, what goes on a table for a meal. In working with a family, I start with their definition of a meal. For families to continue to have meals it has to be food that they find richly rewarding to plan, prepare, provide and eat.

What should the parents offer and what should they not offer?

What they should offer is what they enjoy. Almost everybody has some concept of what a meal is. You’ve got to have your protein, your starch, your vegetables, your bread. Depending on what ethnic group you’re coming from, there’s sort of a standard idea of what a meal should be.

Suppose that standard ideal is pizza.

I think that’s great; it’s a marvelous meal. In fact many times, often I suggest to parents when they are just getting started having meals, when they haven’t ever had them before, I say, “Eat what you’re eating now, just have it at regular meal times.” So if they’re in the habit of ordering out a pizza or baking a pizza and sticking it on the counter and everybody comes along and sort of munches it, have it at meal time, have everybody sit down together, enjoy it. Fist you work with the “how” and then you work with the “what.”

The “how” versus the “what,” tell me about that.

Don’t get me wrong, I’m a dietitian, and once you are that you don’t get over it, because nutrition is important to me too. However I do find that if people get caught up on the rules of what they should or shouldn’t eat, it really gets in the way of having a meal on the table. They feel that, “Oh we’ve got to have this, we shouldn’t have that.” It gets very quickly to the point where meals are for duty and everything you sneak around in between times is for fun. You want the family meal to be rewarding. The twelve year old isn’t going to show up if he’s got to eat canned green beans or the foods that he enjoys are not there and it’s all foods that somebody thinks are healthy and he ought to be eating whether he likes it or not. It has to be rewarding, but that doesn’t meal that you are going to cater. Well I guess you start out that way because that’s what everybody likes.

Interesting enough, when people get used to having these meals, when they get the meal habit, and the kids will like it because they like to have access to their parents as long as they’re not being bullied into eating, you know, okra (laughs). They do like it, and then the family starts to get bored, because you’re sitting down and paying attention, you know, “Pizza again, what else is there?” Then they start to experiment and think about some different things they can have for meals. The variety starts to come in, and ever so gradually, even some vegetables.
Once you finally get everybody to the table, what’s the next step? It sounds as though you have a great deal of confidence that an evolution will just take place and healthful foods will appear.

That’s right, I do have that confidence that people’s natural tendencies is to learn and grow. They do it in all things. With food, we’ve become so rule-bound as if we won’t learn and grow unless somebody hits us on the head.

Is there an addictive quality to foods that are high in sugar and fat and salt? So that going down to broccoli just won’t cut it?

Well you wouldn’t go down to broccoli overnight, and if you went down to broccoli you would have it with cheese sauce, or butter and salt. Broccoli has a agent in it that tastes bitter to some people…so putting a little butter and salt on it will help cut that bitter taste.

But is there an addictive quality so that it’s kind of hard to pull back from these foods?

The only people I have seen who act addicted with foods are the ones who are trying not to eat particular foods. They’re trying to stay away from candy all together, particularly if they’re trying to under eat altogether. Then these high caloric density foods, high fat high sugar foods, are going to be extremely appealing because if you consume them it helps take away the hunger. It takes it away in a hurry.