1. ASSESSMENT OF DIET AND BEHAVIOR
___________________________________________________________________
Elizabeth Shepard, MD
Lucile Packard Children’s Hospital at Stanford
Stanford University School of Medicine
Robert Karp, MD
State University of New York, Downstate
___________________________________________________________________
Pre-Test Questions (detail explanations at the bottom):
Q1. Assessment of feeding behavior must take into account:
a. Child’s age
b. Child’s medical condition
c. Child’s relationship with food providers
d. All of the above
Q2. An example of a macrosocial element that is important in the assessment of a child’s diet is:
a. The wealth of the community in their geographic locale
b. How food is prepared
c. Availability of a microwave oven in the home
d. Who cooks the food
Q3. True or False. Parental income is an example of a microsocial element which is important in the assessment of a child’s diet.
Q4. Food jags are:
a. Uncommon
b. Occur only in infancy
c. Ups and downs in food likes and dislikes
d. Abnormal at any age
e. Seen only in certain cultures
OBJECTIVES
This introduction to assessment of diet and behavior will prepare users to:
1. Appreciate the importance of the “macrosocial” environment in the assessment of the diet - those elements “distal” to the life of the child and family related to economic and cultural influences.
2. Similarly, appreciate the importance of the “microsocial” or “proximal” elements of the environment easily recognized by the family such as their income and access to resources.
3. Identify four characteristics of culture affecting food consumption.
4. Assess the composition of the family diet for quality and safety.
5. Recognize the behavioral characteristics affecting food choices at different ages.
6. Provide a checklist for Taking a Diet History and Assessing effectiveness of breast and bottle-feeding.
INTRODUCTION
Dietary intake and feeding behavior are critical components of normal growth and development. At each developmental stage, diet and behavior affect nutritional status through an interaction with social and environmental factors in the lives of children and their families. The true impact of diet on a child’s growth and development can only be determined by assessment over several periods of time from the immediate to the long term.
This section of the Teacher's Guide will provide the reader with a framework for assessing diet and behavior in both the macrosocial and microsocial environments. The microsocial environment refers to those aspects of the child’s environment which immediately affect food consumption, such as who purchases and who cooks the food for the home. The macrosocial environment refers to phenomena with which the family may be only vaguely aware including ways in which wealth and services are distributed. We will consider the process of evaluating diet and behavior recognizing that these are overlapping, multi-faceted phenomena heavily influenced by each other.
ASSESSMENT OF DIET
Assessment of diet can range anywhere from a simple question about food intake to a complex detailed history examining sources of food and daily patterns of eating. The macro social elements of a dietary assessment are listed in Table 1.
Table 1: Macrosocial elements in dietary assessment
1. Influence of geographic locale on food availability
2. Daily/weekly/monthly/seasonal variations in income for food
3. Who is available to feed children and when
4. Social and cultural factors affecting food choice and preparation
5. Economic factors affecting food choice and storage
TEACHING CAPTION: The actual diet history is highly influenced by factors not necessarily obvious or even known to parent or provider. The macrosocial elements are not observable by the child in the distal environment.
Availability and Acquisition of Food
Geographic Locale is a primary consideration. Food variety varies greatly according to location and time of the year. The variety of foods available in Minnesota in the wintertime, for example, differs substantially from the foods available in California in the summertime. Nowadays food is shipped all over the world, but fresh local produce tends to be the most available and most tasty. Apart from fresh food, frozen, canned, packaged, and dried foods are other options.
Point of Purchase also affects dietary intake. Often this is influenced by socioeconomic status. In poor neighborhoods, for example, there may not be a supermarket in close proximity, and the corner liquor market may be the most available source of food. On the other hand, “mega-stores” may offer the best bargains on food leading to the purchase of excessive amounts of calorically-dense nutrient-poor food. Farmer’s markets have sprouted up around the country, but again may not be within reach of some families either geographically or economically. Ready to eat food whether from grocery stores, fast food restaurants, or other sources has become more and more a fixture of the American lifestyle.
Americans now eat out more than 40% of the time. Eating out can encompass restaurants, movie theaters, sports events, and social events. Food eaten out of the home tends to be more expensive. Alternatively, food costs can be kept low by obtaining food from high fat, high starch, and high sugar fast foods obtained at various establishments. As discussed in the section on Nutritional Assessment, high food costs lead to selection of inexpensive, nutritionally deficient foods – the “Engels’ phenomenon”. Malnutrition, in whatever form, follows.
In addition to restaurants, day care centers and schools must always be considered as sources of food. Poor families additionally might receive food from food banks, shelters, or churches. Food stamps and/or WIC vouchers provide some assistance to needy families.
Social Context
Within families, patterns of food intake differ considerably. Social context can have a huge influence on what and how much children eat.
Important variables include who purchases food for the home, who cooks the food, how food is prepared, and where it Is consumed. Does the family sit down together at a table to eat, or does each person eat separately based on work and school schedules? Does the child consume meals and/or snacks in front of the television? Can the child go into the kitchen and take food on his own either from the refrigerator or cabinets? Is there a microwave oven? Does an ice cream truck drive by on the street?
These items are listed in the table below.
Table 2: Macrosocial elements in dietary assessment
1. Who purchases food for the home
2. Where food is stored and its accessibility to the child
3. Who cooks the food
4. How food is prepared
5. Where food is consumed
6. Who eats with whom
7. Neighborhood sources of food (e.g. ice cream truck)
TEACHING CAPTION: The elements of assessing diet and behavior include the microsocial – that which is observable by the child in the proximal environment.
The following mini-case history illustrates the potential strengths and weaknesses within a family:
Case 1: Mary is an obese 5-year old girl who lives with her parents and her paternal grandparents. Her parents, neither of which is overweight, are health conscious and encourage Mary to eat a varied diet with minimal junk food. However, both parents work full-time and Mary’s obese grandmother prepares her meals. The grandmother does not think Mary is overweight. She encourages Mary to eat extra portions and she does not limit Mary’s consumption of junk food. Similarly, Mary’s grandmother enjoys eating extra portions during her own meals and she consumes a considerable amount of junk food daily.
As Case 1 illustrates, the number and composition of people in the household are important determinants of how children get food and what models they have for eating behavior. Conflict within the family as to what should be presented as food may confuse the child. Perhaps there is one parent who demands that soda be purchased while the other parent wants to cut back on sugary foods. Perhaps there is a grandparent who bakes cookies every day for an afternoon snack. Sometimes if more than one family lives in the home, the child will eat with both the primary and secondary families, especially if the two share a kitchen. Health issues are another important component of the family history. An aunt with diabetes, for example, might need to monitor carbohydrates and fat. Cultural issues, as well, affect food intake.
The next mini-case history illustrates potential cultural conflicts affecting diet. The next mini-case history illustrates potential cultural conflicts affecting diet.
Case 2: Anne and Paul are 10 years old and 12 years old, respectively. They have been raised in Manhattan (NYC) by their parents, both university professors. The parents purchase mostly fresh fruits, dairy products, vegetables, lean meats, and whole grains to feed the family, but Anne and Paul prefer hamburgers, french fries, pizza, and tacos over the meals their parents cook for them. Their school friends have similar food predilections and Anne and Paul’s parents have difficulty persuading them to eat anything else.
Food Culture
As Case 2 illustrates, food consumption is not a rational phenomenon. Food selection is often based on the food culture in which children are born. Food flavor preferences learned in childhood often last a lifetime.
The food anthropologists, Elsbeth and Paul Rozin, describe a universal pattern for assessing food culture. The Rozins’ four elements of a food culture are listed in Table 3. The food anthropologists, Elsbeth and Paul Rozin, describe a universal pattern for assessing food culture. The Rozins’ four elements of a food culture are listed in Table 3.
Table 3: Elements of a food culture
1. The basic substances used
2. The method of preparation
3. The food flavorings used
4. The social setting for eating
TEACHING CAPTION: Food cultures distinguish themselves by all of the above elements, but it is the food flavoring systems that label a food culture.
Fig 1: Manicotti (southern Italian) and Blintz (European Jewish)
Manicotti Blintz
TEACHING CAPTION: As the late Jean Mayer once said “Trade the tomato sauce for sour cream, and one man’s manicotti becomes another man’s blintz.”
Composition of the Diet
What a child actually eats consists of both liquid and solid components. For a very young child, that liquid component is milk, preferably breast milk. Solid intake typically starts at 4 to 6 months of age, and weaning to a semi-adult diet by one year of age. Some children become abnormally dependent on liquids, taking largely milk, juice, or soup in the diet. This pattern can lead to both caloric deprivation, i.e. failure to thrive, and to nutrient deprivation such as iron deficiency. In other cases excess liquids, especially juice, lead to obesity. Children with developmental problems may be chronically dependent on liquids, soft foods, or pureed foods due to inability to chew and swallow regular foods. Others may not be able to tolerate thin liquids due to the risk of aspiration from a poorly coordinated swallowing mechanism.
Food Allergies and Intolerances
Apart from food texture, food allergies and intolerances are another restrictive factor in terms of food intake. Symptoms of allergies may be gastrointestinal, respiratory, or dermatologic. Cow’s milk and peanut allergies are among the most common. The former tends to resolve between one and two years of age while the latter tends to persist throughout childhood and beyond. Lactose intolerance can have an impact later in childhood starting around the preschool years. Celiac disease has become more and more recognized in recent years as a cause of GI upset and growth abnormalities, and if present necessitates lifelong restriction of wheat and other gluten-containing products. In rare cases, inborn errors of metabolism necessitate restriction of protein or sugars in the diet.
Macronutrient Components of the Diet
The nutrient content of the diet can be divided into two major categories: macronutrients and micronutrients. The macronutrients are protein, carbohydrate, and fat. These can be further subdivided into animal and vegetable proteins, simple and complex carbohydrates, and saturated, polyunsaturated, and monounsaturated fats. Animal protein containing heme is the most easily absorbed form of iron. Dietary fiber is contained within complex carbohydrates. Too much insoluble fiber in young children can cause diarrhea, bloating, and failure to thrive. Essential fatty acids are long chain polyunsaturated fats. It is helpful to obtain at least an overview of dietary macronutrient composition to determine adequacy of the diet for growth, and balance of the diet in terms of chronic disease prevention. Excessive saturated fat or trans fatty acids, for example, might predispose to later heart disease. These issues are discussed in more detail in the Nutrition Notes.
Can We Count Calories In Childhood?
It is difficult to obtain an exact calorie count from dietary recall or even recording of the diet, but estimates are helpful in looking at diet in relationship to growth. One very basic framework for calorie needs is to project 1000 calories per day for age one and an additional 100 calories per day per year of age up until adolescence. Within this framework the parent and health care provider can discuss how many calories come from certain common foods and beverages. A glass of whole milk for example provides about 160 calories in 8 ounces. A standard piece of bread has around 80 calories. A 24-hour recall is the simplest tool for dietary assessment in the office. Self-monitoring through keeping a food diary is an excellent learning tool for older children who are overweight. Three to seven-day diet records for younger children with failure to thrive can help to determine calorie and nutrient intake.
Monthly cycles of income and intake are critical among the poor in the United States with families who are dependent on outside support. In many developing countries, seasonal famine affects nutritional status adversely (Food Costs and Cultures).
Micronutrient Components of the Diet
Micronutrients are divided into two primary categories: vitamins and minerals. The more newly recognized phytochemicals and antioxidants might also be considered as micronutrients. Vitamins are subdivided into fat-soluble and water-soluble vitamins. Minerals are subdivided into major minerals and trace minerals. Geographic locale, including particularly soil quality, is a major determinant of the nutritional adequacy of the diet. Certain parts of the world, for example, contain soil that is deficient in selenium. Within the US, the soil in some areas has been stripped of nutrients yielding a lower quality food supply. In general, the greater the variety of colors in the diet, the greater the array of vitamins and minerals. Iron and zinc are particularly important micronutrients for growth in the first year of life. Calcium is important throughout childhood and especially in adolescence to build up adequate bone stores.
An awareness of the basic sources of the micronutrients is helpful. For iron, primary sources are fortified formula, fortified cereals, red meat, and beans. For zinc, sources include seafood, red meat, and eggs. For calcium milk products are the major source for most children, but other foods such as almonds also provide calcium. Dietary supplements, usually in the form of multivitamins for children, can add to the nutrient balance, but sometimes cause interference with absorption of other nutrients. A history of supplement use should always be part of the dietary assessment.
Summary
Assessment of diet in children is a multifaceted process. The simplest questions pertinent to every well child visit are to ask about types of liquids and solids in the diet and usual daily pattern of intake. Occasionally a 24-hour recall or a three to seven-day diet record is indicated to give a better overview of nutrient intake. It is always important to keep in mind social factors and their influence on the type and availability of food for children. Lastly the impact of the micronutrient supplements needs to be considered.
ASSESMENT OF BEHAVIOR
Food intake is one of the most basic processes of human life. It begins at birth and must continue throughout life. Early interactions between children and their caretakers surrounding food can have a profound impact on the development of feeding behavior. Assessing the behavior of both parent and child around feeding is an essential element in supporting good nutrition.
Young Infants
Normal feeding behavior starts with suckling at birth. Sick or premature infants may not have even this most basic reflex, and may need intravenous or tube feeding until they can learn to suckle. In the absence of oral feeding, the infant must still receive enough oral stimulation to promote the development of suckling and avoid future feeding refusal.
For healthy infants who can breastfeed, early frequent feedings are critical to establish the process. To assess the effectiveness of breast-feeding the health care provider must at a minimum inquire about the number of feedings over 24 hours, interval between feedings, time spent on each breast, and stool and urine output. It is preferable not to introduce the bottle within the first two weeks of life to avoid nipple confusion. Thus it becomes important to explore the use of bottle as a substitute for the breast or the use of formula as a supplement to breast-feeding in mothers who are insecure about whether the infant is getting enough breast milk.
Older Infants
One year of age is an appropriate time for weaning from the breast or bottle. Exclusively breast-fed infants often avoid the bottle entirely and progress directly to cup drinking by the latter half of the first year of life. Some mothers choose to continue breastfeeding beyond one year of age, but in terms of nutrition and development children are ready to wean by one year. Occasionally, prolonged breastfeeding becomes a problem leading to failure to thrive, when the child spends excessive time on the breast just for comfort at a time when the breast milk is no longer providing much nutrition. This is a phenomenon called non-nutritive suckling.
A Role-Playing Exercise:
Role 1 – Mrs. M
Role 2 – The Pediatrician or Pediatric Resident
Mrs. M brings in her healthy twelve-month old child for evaluation of chronic constipation. Upon assessment of the infant’s diet, you, the physician, learn that the infant mostly drinks formula (about 64 ounces per day). He refuses to eat, and Mrs. M is very concerned.
1. What should the doctor advise Mrs. M in regard to the infant’s diet?
2. What are the risks of a liquid only diet?
3. What responses do you expect from Mrs. M?
4. Will she be responsive, resistant, passive-aggressive, offended, too fearful to tell you about issues/problems in the family?
Supplemental Foods
The appropriate time for introduction of supplemental foods is between four and six months of age for healthy infants. At this stage the gut is sufficiently mature to allow a wider diversity of proteins and the infant’s development has progressed to the point of being able to hold up the head and accept a bolus of food on the tongue. Introducing solids either too early or too late can have ill effects on health and nutrition. Early introduction of solids, for example, might predispose to obesity or food allergies. If, however, solids are not introduced by six to eight months, the so-called critical period for the development of feeding skills, there can be long-term difficulty for the child in learning how to eat.
Gradually throughout the first year of life the parent should be able to increase the texture and complexity of the diet. Beyond the first year, children can consume essentially the same diet as adults with the exception of small tough pieces of food or excessively viscous foods such as gel candies, and extremely spicy foods such as peppered foods. All of these foods can lead to choking.
Taste and Flavor Perceptions
Taste is another important component of food acceptance. Sweet taste is innate. Salty preferences come later by about four months of age. Bitter and sour are the last tastes to develop, continuing to progress through the first few years of life. Taste preferences, however, are modifiable based on experience. For example a child who learns to prefer very salty foods can be retrained to like a less salty diet.
Initial rejection of new foods is a normal developmental process termed neophobia. Up to ten tries of tasting may be necessary before a child begins to accept a new food. Ups and downs in likes and dislikes, known as food jags, are a common occurrence in the toddler years. Culturally appropriate and socially acceptable patterns of food intake develop over about the first five years of age. Before that time children are more willing to accept novel combinations of foods and to consider non-food items as edible.
Patterns of Eating
The most appropriate pattern of food intake for normal growth and optimum bodily function at any age is to consume three meals per day and one or more snacks. Continual eating throughout the day is a pattern called nibbling or grazing that can lead to either obesity or failure to thrive. Children who eat this way may never learn the cycle of hunger and satiety. Gorging, on the other hand, is excessive food intake at one time. Grazing is probably metabolically advantageous over gorging, but neither is optimal.
Other deviations from normal feeding behavior include rumination (vomiting and re-swallowing food), night feeding, infantile anorexia, and the classic eating disorders of anorexia nervosa and bulimia nervosa. Trained night feeders learn to wake up one or more times per night and demand breast milk or formula. Breaking this habit can be very difficult for parents, especially when they have concerns that the child’s crying will awaken other family members or neighbors.
Relationship with food Relationship with food
The development of an appropriate relationship with food begins in infancy and progresses through a lifetime. Parents, and particularly mothers, must learn to read the feeding cues of their infants to avoid either overfeeding or underfeeding. Obese mothers may not be able to recognize hunger and satiety cues in their babies. Sometimes a cry signals hunger. Other times it might signal fullness while the parent is still attempting to feed the child.
Older children generally eat as much food as is placed on a plate in front of them. Foods paired with unpleasant experiences become less preferred. For example if a child is always forced to eat spinach before he can have a cookie, he will learn to dislike spinach. Modeling of food intake by either adults or peers helps children learn to like new foods. Peer intake of vegetables is an important motivating factor for young children.
Within families, external experience affects how food is treated. It is well known for example, that the experience of war, famine, extreme poverty, or exposure to wasting diseases like tuberculosis make it difficult for a family to permit food to be left on the plate. Obesity may be the result when food becomes more plentiful.
When A Child Refuses To Eat
Medical problems must always be considered when a child refuses to eat. Kidney disease, for example, often causes anorexia, and heart disease can lead to excessive fatigue with feeding. Gastrointestinal problems such as gastroesophageal reflux and constipation can cause aversive reactions to food when the child learns that food intake is associated with pain. Careful questioning about symptoms, and targeted laboratory and x-ray studies, are essential to a complete evaluation of feeding.
Summary
Assessment of feeding behavior must take into account age, medical condition, and the child’s relationship with food providers. The role of adults is to provide age-appropriate, healthy, and tasty foods and allow children to make their own choices within this framework. Adults that criticize children for their feeding behaviors can create long term guilt surrounding food. Ideally a child should experience feeding as a pleasurable activity both for its social aspects and it’s sensory and physical satisfaction.
POST-TEST QUESTIONS
1. Microsocial elements of the dietary history include all of the following except
a. How food is prepared
b. Where meals are eaten
c. Seasonal variations in food availability
d. Who cooks the food
e. Types of appliances in the home
2. Macronutrient components of the diet include all of the following except
a. Fiber
b. Essential fatty acids
c. Protein
d. Total caloric intake
e. Iron
3. Normal feeding behaviors in infancy and early childhood include
a. Starting solids at 8 months of age
b. A preference for sweet tastes starting at birth
c. Weaning off the breast or bottle at 9 months of age
d. Trained night feeding
e. Eating gel candies
4. Medical and social problems that can interfere with feeding include all of the following except
a. Gastroesophageal reflux
b. Constipation
c. Poverty
d. Modeling
e. Oral aversion
ANSWERS = 1- C , 2- E, 3- B, 4- D
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Pre-Test Answers
A1. The answer is D. No single element in a child's history is more important than another. Rather one must determine how they interact with one another.
A2. The answer is A. A"macrosocial" element in the environment refers to those conditions or institutions with which the child or family has no direct interaction, yet they greatly affect the microsocial environment in which the child and family live. For example the presence of a national food policy ensuring availability of nutritious food would have a powerful but unknown impact on the likelihood of food insecurity.
A3. The answer is True. The family would be aware of the income and budget accordingly. Seasonal variation lost in the complexity of the general economy would be a macrosocial element in that the family would be unable to affect a change.
A4. the answer is C. Individuals and groups frequently experience "ups and downs" in their likes and dislikes as well as the quantities of foods they eat. It is an ubiquitous phenomenon.
