Helping preschoolers become healthy eaters

Introduction 

Good nutrition is important from birth to fuel healthy growth and development. Feeding and eating experiences early in life also shape dietary preferences and, ultimately, the quality of nutrition throughout childhood (Fox et al. 2004, Lederman, et al. 2004). The recent Feeding Infants and Toddlers Study (FITS) found that parents give infants as young as 7 months of age soft drinks and French fries, contributing to development of a lifelong preference for sweet and salty foods (Fox et al., 2004). Parents often look to practitioners for guidance in establishing and reinforcing healthy eating habits throughout childhood that will help children avoid overweight and its comorbidities.

Because children develop food- and nutrition-related attitudes during the preschool years, it is important for practitioners to help parents take advantage of the preschooler's readiness to learn and potential to change (Young, Anderson, Beckstrom, Bellows, & Johnson, 2003). The benefits of healthy eating habits are many, including prevention of chronic under-nutrition and growth retardation as well as iron-deficiency anemia, dental caries, and overweight (American Dietetic Association [ADA], 2004). Parents and other child caregivers can provide opportunities for children to learn to like a variety of nutritious foods by repeatedly exposing them to these foods, overcoming their tendency to reject unfamiliar foods (ADA, 2004).

Who are the picky eaters? 

Common eating problems among toddlers and preschoolers are picky eating and neophobia. Young children often do not like to try new or unusual foods. Children often go on “food jags,” where they tend to eat just one type of food frequently over a period of several days or weeks (Story, Holt, & Sofka, 2002). Carruth, Ziegler, Gordon, and Barr (2004) conducted a large survey of families with young children from 4 months of age to 24 months of age to determine the prevalence of picky eating, based on parental perceptions. As expected, the prevalence of picky eaters increased as the children's age approached 24 months. By 24 months of age, caregivers perceived that 47% of males and 54% of females were picky eaters. Interestingly, the prevalence of picky eaters did not differ with gender, ethnicity, or socio-economic status. A 24-hour diet recall indicated that children in both the picky and nonpicky eating groups consumed the recommended daily intake of energy and nutrients. However, picky eaters were less likely to consume vegetables and fruits and more likely to eat sugared cereals and French fries (Carruth et al., 2004).

In addition, the survey indicated that caregivers typically offered a food only three to five times before deciding their child disliked it. Other researchers have found that a food must be presented between eight to fifteen times before a child will accept it (Birch, et al. 1980, Loewen & Pliner 1999, Skinner, et al. 2002). This research indicates that picky eating is a common problem for many children and that caregivers must be educated about methods for dealing with picky eating.

Jacobi, Agras, Bryson, and Hammer (Weckerly, 2002 2003) conducted a study to determine the characteristics of picky eaters and their parents. Using laboratory-based measures, researchers determined that picky eaters consumed fewer foods with less variety, specifically avoiding vegetables. Parents of picky eaters reported more negative food interactions than did parents of nonpicky eaters. Specifically, parents of picky eaters reported struggling around meal times and more frequently offering food concessions to their children. In addition, pickiness in children was associated with a more negative parent affect. Once again, researchers noted that parents limited exposure to new foods and foods children disliked (Jacobi et al., 2003).

Research by Birch and associates with largely Caucasian samples has consistently found a positive relationship between food controlling strategies by parents and child overeating; that is, the more the parent withholds access to high calorie snacks and foods, the more likely it is that the child will desire them and overeat them when finally allowed access (Birch, et al. 1987, Fisher & Birch 1999, Orlet-Fisher, et al. 2003). This is particularly true for girls. The same effect is seen when foods are used as rewards, removing the association between hunger and eating (Birch, 1981).

What is happening and can we make a difference with educational interventions? 

Researchers have found a correlation between child weight problems and the attitudes and knowledge of caregivers about nutrition. Gable and Lutz (2001) observed Head Start teachers during mealtimes. These observations showed that opportunities, such as nutrition teaching and encouraging children to taste different foods during mealtime, were often missed. While all teachers sat with the children and many encouraged the children to classify the food into groups, some teachers also hurried eating or directed students to “clean their plate.” Educating teachers, child care providers and parents about ways to model and teach nutrition during natural daily routines can help promote positive nutrition socialization experiences for young children (Gable & Lutz, 2001).

The New Jersey Department of Health developed the Prevention-Oriented System for Child Health (PORSCHE) Project to target high-risk families identified through community screenings (Worobey, Pisuk, & Decker, 2004). A public health nurse would meet with the family to provide the intervention strategy, which included hand washing and hygiene, increasing iron intake, increasing water consumption, eating fewer snacks that are high in fat, and eating healthier snacks such as yogurt or fresh vegetables (Worobey et al., 2004). After these interventions, they found that total caloric intake decreased over time, intakes of calcium, iron and zinc were sustained or increased, and vitamin use increased (Worobey et al., 2004).

Horodynski, Hoerr, and Coleman (2004) developed the NEAT program (Nutritional Education Aimed at Toddlers) to improve the knowledge, attitudes, mealtime practices, and dietary intake of rural, low-income caregivers with toddlers in the home. The intervention consisted of three major learning objectives: increasing knowledge of food and food safety, increasing knowledge of feeding self-regulation and the best management of family meals with toddlers, and toddler-parent interactions, as well as healthy food choices away from home and time-saving tips (Horodynski et al., 2004). The researchers believed that negative attitudes toward nutrition led to poor parental feeding practices, which, in turn, led to picky eaters (Horodynski et al., 2004). Having a picky eater for a child often leads parents to bribing them to eat, spoon-feeding them, catering to their demands, or playing games in order to increase dietary intake. Although these parents initially lacked knowledge regarding toddler eating habits, they all attended the NEAT classes, showing a desire to learn and provide better nutrition for their toddlers. This study showed a positive correlation between community nutrition education programs and healthier eating habits and mealtime practices for toddlers (Horodynski et al., 2004).

Are preschoolers too young to learn about nutritious eating? 

Children learn about food and eating behaviors through their surroundings. Children are socialized to food in the home, school, and other caregiving environments. Matheson, Spranger, and Saxe (2002) examined preschool children's perceptions of food and their interpretation of daily food experiences using open-ended interviews and play observations. Children classified foods based on concrete qualities, such as color, shape, and texture. Preschool children did not group foods based on abstract concepts, such as nutritional food groups. Play interactions indicated that children tend to mimic their daily food experiences, with realistic and detailed play scenarios. This research suggests that nutrition interventions targeting preschoolers should be play-based and take place in the child's natural environment. Matheson, Spranger, and Saxe (2002) also suggest focusing on the concrete qualities of food, rather than abstract categories such as food groups that preschoolers may not comprehend.

Children develop opinions and concepts of food based on experiences. Byrne and Nitzke (2002) examined the effect of presenting a novel vegetable (kohlrabi) through a storybook. One group was read a storybook with positive messages about kohlrabi, while another group was read a storybook with negative messages. Willingness to taste kohlrabi before and after the intervention was measured. Children who were read the positive-message storybook were significantly more likely to taste kohlrabi and to indicate that they would eat it again. This study indicates that presenting a novel vegetable in a positive, interactive manner increases the willingness of children to taste new foods.

Learning about new foods is fun! 

The following suggestions are adapted from Nutrition Explorations, an interactive nutrition education program developed by the National Dairy Council, accessed from www.nutritionexplorations.org and applied in a parent handout in the Box.

This page may be reproduced for noncommercial use by health care professionals to share with patients. Any other reproduction is subject to JPHC approval. The information and recommendations are not a substitute for seeking health care. For specific information concerning your personal health condition, JPHC suggests that you consult your health care provider.

Why educating preschoolers can work 

Preschool children fall into Erikson's (1950) early childhood developmental stage, which encompasses two- to six-year-olds. The primary conflict in the early childhood stage is initiative versus guilt. Young children are developing more skills and independence and becoming more engaged in social interactions. They are learning to balance a greater sense of responsibility with a need to control sudden impulses (Erikson, 1950). Nutrition education and food tasting experiences provide preschool children with a greater sense of initiative in making healthy food choices and tasting new foods, Rewarding and reinforcing children for trying new foods on their own. In addition, children are not forced to eat foods they do not want to eat and are not punished when they do not try a new food. This eliminates feelings of guilt and disappointment for not pleasing the parent or caregiver. In addition, the strategies suggested encourage children to use their imagination to view and describe food from a different point of view. Based on Erikson's model, it is anticipated that encouraging children to try new foods will lead to greater initiative in trying different foods in a variety of settings.

Conclusion 

Good nutrition and healthy food choices are an important component of child health and development. The nutrition choices that young children learn to make affect them throughout their lifetimes. The optimal time to teach nutrition is in the preschool years before unhealthy habits are established and while children are eager to learn. We hope you enjoy sharing these ideas with your young patients and their parents.