Our food hang ups hurt kids. Here’s how to flip the script.

When parents seek help from Crystal Karges, the stories they tell her are often similar: A young child has become wholly preoccupied with food, especially sugary treats. At birthday parties, the child hovers near the dessert table, riveted by the cake instead of playing with friends. The parents are afraid that the behavior they’re seeing might be a warning sign of a bigger problem.

Karges, a registered dietitian who specializes in child feeding, says accounts like these have become more common in her San Diego-based practice since the pandemic began — an observation supported by recent research that shows how pervasive disordered eating has become among children in the United States and around the world. In December, the American Academy of Pediatrics reported that the number of children admitted to hospital emergency rooms for eating disorders soared during the pandemic, and has not returned to pre-pandemic levels. Last month, a meta-analysis in the journal JAMA Pediatrics found that 1 in 5 children worldwide showed signs of disordered eating, meaning they exhibited behaviors that are characteristic of eating disorders (such as calorie counting, food restriction or overexercising) but did not meet the threshold for clinical diagnosis. The meta-analysis, which spanned 32 studies from 16 countries, found that these behaviors were more prevalent among girls, older adolescents and also among children with a higher body mass index, or BMI.

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American children and teenagers also experienced significant weight gain during the pandemic, and the AAP recently issued its first clinical practice guideline for the evaluation and treatment of children and adolescents who are deemed overweight or obese. The guidance was met with criticism by some pediatric dietitians and eating disorder treatment specialists who say that the guideline’s focus on BMI — as well as the inclusion of aggressive treatments such as weight loss medications and bariatric surgery for adolescent patients — could increase the likelihood of developing eating disorders.

By focusing less on a child’s weight and BMI, and more on the way a family approaches feeding practices at home, some child feeding experts believe parents can help protect their children from developing disordered eating behaviors. Karges is among a growing field of pediatric and family nutritionists who aim to establish internally self-regulated eating habits and foster a positive relationship with food, while rejecting the principles of diet culture — food restriction, a fixation on the scale, a strict adherence to dietary guidelines.

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When families come to Karges for guidance, she explains that the root of their child’s eating behavior does not lie with the child. “Usually it stems from a parent’s fear of the child’s body size or appetite,” she says. “So one of the main things I do is coach parents to see that their child’s appetite and their child’s body size is not wrong, and to create some structure that helps them relinquish that role of being the food police or micromanaging what the child is eating.”

Some parents are rattled because they have been told by a pediatrician that their child’s body size is a concern, Karges says.

“I’ve had kids as young as 2 where parents are being told, ‘Your child is eating too much,’ or ‘Their weight is trending in a way that looks kind of unhealthy, so you really need to pull the reins,’” she says. “And unfortunately, that has very negative consequences, where parents try to control things — but perceived restriction to food, or limited access to food, that directly results in food preoccupation in the child.”

Jennifer Harris, a registered dietitian and a faculty member with the Ellyn Satter Institute, notes that one way for parents to create a healthier feeding environment and develop eating competence in their kids is to implement the “Division of Responsibility in Feeding” framework established by registered dietitian, family therapist and feeding expert Ellyn Satter. The division of responsibility model specifies that parents are in charge of the “what, where and when” of feeding, and children are in charge of “whether” and “how much” to eat.

“Parents are often asked: ‘Does your child eat five fruits and vegetables a day?’” Harris says. “But to make that consistent with the Satter model, the question would be more like: ‘Are you able to offer your child fruits or vegetables every day?’”

Satter’s approach also centers on the idea that all foods can be part of a nutritionally sound diet — birthday cake included — and a serving of dessert can be offered alongside dinner, with no requirements that vegetables be eaten first. “The whole goal is to not create an environment where certain foods are so novel that the minute I get them, I eat them all up,” Harris says, which is a reaction kids might have if there is fear that a particular food won’t be offered again, or they won’t be allowed to have their fill. “That’s the purpose of serving one serving of dessert within a meal, to be eaten at any time during the meal. It’s important, because if you’re following the guideline of ‘eat your meal, then you can have dessert,’ the child may finish their meal, feel kind of full and satisfied, but they’re still going to eat dessert because it’s a treat and it’s special. Now we’ve taught the child to overeat.”

It might feel counterintuitive to offer a plate of cookies at snack time and let the child eat as many as they’d like, Harris says — “and in the beginning, the child will eat more. But if you continue with this very neutral offering of food, you take the power away from it, and kids will be able to walk away from it just as easily because it’s not as special.” The structure of this kind of feeding allows children to develop internal regulation skills, she says, and offering foods they enjoy encourages a positive eating attitude: “These are the two areas of eating competence that are consistently affected in folks struggling with an eating disorder.”

Some parents might struggle at first to adjust to this way of thinking about food, likely a big shift from their own childhood feeding experiences, says Anna Lutz, a registered dietitian in North Carolina who specializes in eating disorders.

“Everywhere we look, we’re told we should be controlling our child’s eating, that it’s the parents’ responsibility to control their child’s weight in some way, that that’s somehow a reflection on the parent,” Lutz says. “And if a parent is themselves struggling with restrictive eating, or has their own history of disordered eating, that can also be challenging.”

Parents should not feel like they are to blame for the challenges their child might be facing, Lutz emphasizes. “We know there are many, many risk factors of eating disorders, including genetics, trauma, temperament, mental health, being exposed to media, any kind of dieting,” she says. A family’s feeding practices alone will not guarantee a healthy outcome, she says, “but thinking about how to feed your child is a protective factor, no matter what your child’s body size is.”

It is important to remember that healthy children come in different sizes, she says, and focusing solely on weight or BMI can have dangerous repercussions. “If we start telling a young child that there is something inherently wrong with them just based on their body size, we might be setting up this child for not only lots of medical concerns from weight stigma or weight cycling or eating disorders, but also the effect that has on their self esteem, who they see themselves to be, their mental health.”

Karges says she is continually gratified to see how quickly an alarming eating behavior can correct itself when parents pivot to an approach that centers the child’s autonomy.

“It is the best part of my job to have families reach out and say, ‘You won’t believe it, we went to a birthday party and my daughter was excited about cake but she had a piece and moved on and played with the kids,’ and they feel like they have their child back,” she says. “A lot of this is helping parents see that if you’re stressing over food and your child is feeling anxious because they’re not getting enough access to the foods that they need — the stress of that is more harmful to them than literally anything they could eat.”

The resulting freedom is life-changing for parents, too, she says. “To be able to remove this pressure of feeling like you have to be a gatekeeper of everything your child is eating — it also improves the relationship between a parent and their child.”