Promoting “Healthy” Food in the Context of Internal Regulation of Eating: Comment on Slusser et al.

Dear Editor:

This letter is in reference to the discussion between Inés Anchondo, DrPH, RD, LD, CSP, ¹ and Wendy Slusser, MD, MS, ² about Dr. Slusser's article, “Pediatric Overweight Prevention through a Parent Training Program for 2–4 Year Old Latino Children,” ³ published in Childhood Obesity, February 2012. It appears that Dr. Slusser does not take Dr. Anchondo's point, which is that it is contradictory and counterproductive to teach the philosophy of internal regulation of eating based on Satter's Division of Responsibility in Feeding (sDOR) ⁴ at the same time as emphasizing the usage of “healthy” food. Supporting the child's internal regulation of food intake requires that parents follow sDOR: parents do the what, when, and where of feeding and children do the how much and whether of eating.^5,6 Following sDOR is consistent with children's eating healthy food. However, it is inconsistent to promote healthy food in the context of sDOR. The distinction is enjoyment. The Satter Eating Competence Model (ecSatter), ⁷ tested by a validated instrument, ⁸ demonstrates that parents do best in feeding ⁹ when they, themselves, are eating competent (EC): They feel positive about eating foods they enjoy, internally regulate food intake, and maintain structure with eating. ⁷ Although ecSatter says nothing about eating “healthy” or any other food, ¹⁰ EC adults do better nutritionally,^8,11,12 have lower BMI,^8,12,13 and more positive health indicators.^12,13 Parenthetically, first-generation Hispanic parents ¹⁴ are, by tradition, EC and consistently have high-quality diets. This is despite the fact that their food selection does not conform to healthy food guidelines. ¹⁵

Emphasizing healthy food grows out of the conviction that eating the “right” food and avoiding the “wrong” food is the critical element in child weight management. From the perspective of sDOR, the critical element is preserving or restoring the child's ability to regulate food intake and grow in a genetically appropriate fashion. Healthy food, of course, is a value-laden term that currently refers to predominantly low-caloric density foods, such as fruits, vegetables, and whole grains, and few, if any, high-calorie foods, such as fats, sweets, and foods made with a high proportion of sugar and/or fat. Children's eating a variety of food and achieving a nutritionally adequate diet is desirable and naturally grows out of EC parents following sDOR. In contrast, emphasizing healthy food contradicts the food acceptance and internal regulation principles of ecSatter ⁷ and sDOR^4–6 by imposing indirect calorie restriction through prescribed food selection. Bright Futures ¹⁶ and the American Academy of Pediatrics Childhood Obesity Prevention Expert Committee ¹⁷ set up the same contradiction by recommending sDOR, then emphasizing healthy food. The Stoplight Diet for Children ¹⁸ and its spinoffs systematize good-food/bad-food distinctions.

Structured meals, sit-down snacks, and no grazing for foods or caloric beverages between meal times are the backbones of ecSatter and sDOR, a structure that parents maintain day after day, year after year, throughout the child's growing-up years. Parents sustain that enormous effort because the process is intrinsically rewarding: Their food is enjoyable for them to prepare, provide, and eat. Children's eating a nutritionally adequate diet is also intrinsically rewarding: They see their parents enjoying a variety of food, and they push themselves along to do the same. As their parents do, children gradually learn and grow with respect to dietary variety when they have a sense of self-direction with respect to choosing what to eat (from what parents make available at meals and snacks) and a sense of agency—of inner capability—with respect to learning to eat unfamiliar food at family eating times.

In contrast, stipulating healthy food sets up dissonant relationships with food and with feeding children. Expecting parents and children to eat certain foods whether or not they enjoy them, undermines both self-direction and agency, complicates planning enjoyable family meals, reinforces the concept of good-food/bad-food, and may give parents agendas with respect to what the child shall eat. Such agendas precipitate and exacerbate picky eating and produce parent/child feeding struggles that undermine meals. Preschoolers, who are developmentally eager to please, feel overwhelmed or rebellious when they are expected to eat certain foods. Even well-intended and “motivated” older children lose interest in healthy food, gain interest in “unhealthy” food, and sneak, hide, and defy to get it. Parents get pulled in to be enforcers, siblings tattle, and family quality of life erodes.

In contrast, EC and sDOR are about quality of life: parents' harmonious relationships with food and with feeding their children. These positive relationships support the child's ability to eat and grow well.