Obesity 2015 - How Early Can We Start? Early Childhood Feeding Practices &...

Um, so, as Chris, uh, so kindly introduced me. Thank you very much, Chris, for that. Um, I am, um, on the AAP Section on Obesity Executive Committee as well, and my interest and expertise is really in nutrition as well as physical activity. I do have some training as a registered dietitian, uh, prior to going through my medical training. And to have really kept that going um throughout. And today I'm going to present a little bit on the nutrition perspective, starting from the very beginning. So you could see a lot of the recommendations and guidelines that we have that exist start at age 2, and we don't have a lot that tells us what we should be doing or what we should. Think about prior to age 2, but it's pretty clear from a lot of evidence that children's habits and their nutrition, especially, uh, starts very, very early, and there are things that we can do to intervene from the get-go that can make a big difference on helping to, uh, prevent obesity from happening in the first place. So with that, my presentation is how early can we start, um, and some early childhood feeding practices to discuss and somehow to implement them in your office. So we've talked a bit about uh the recommendations and have referenced my plate and some of the super tracker resources. So here's, here's what they say, you know, we should eat smart to play hard. Kids should eat about 25% of their, um, plate or a typical meal should be grains, preferably whole grains, about 25% protein, preferably high quality protein. And about half their plate, uh, filled with fruits and vegetables. And while these are great recommendations, and it would be fantastic if our kids followed these and they got an hour of physical activity every day, and they didn't have a lot of sugary snacks and drinks, the reality, as we know, is this is not, um, not the case. In fact, um, on any given day, studies show us that. About 40%, this is just a sampling, by the way, of a few studies. There's a lot more that make the same point. But about 40% of 2nd and fifth graders had zero vegetables and, uh, one study, about 1 out of 5 kids and teenagers eat our recommended uh 5 servings a day of vegetables and fruits, and they're counting french fries in that 5, and that's about a quarter of them. Uh, about a third of our toddlers don't eat any fruit each day, but they're eating baked desserts and candy and sweetened beverages, and we know that our kids are not really meeting the, uh, physical activity guidelines. So, our, our gut reaction to all this bad news, uh, might be to, you know, to just hunker down and tell our parents more and more that the, you know, 5210 and really have their kids do this and follow this. But kids we know, um, are little human beings with minds of their own, and they aren't necessarily gonna just listen to us when we tell them that they should be eating vegetables and fruits because it's so good for them. Uh, so we have to have different strategies and a different approach, which I'm gonna go through a little bit about some ideas of how we might help coach our parents to, um, developing healthy habits from the get-go. Because unfortunately, while many of our interventions for children, uh, especially as it comes to nutrition, uh, occur in the school-age child or later, even once we've identified that there's issues, uh, the truth is that by the time a child enters elementary school, food preferences are already very well established. And I think we saw a little bit of this play out over the past few years, uh, when there was the improved, uh, school nutrition, uh, legislation and the schools really had to have more fruits and vegetables. And there was lots of media attention and lots of hoopla about all the kids throwing away all the vegetables and they're not eating any of the food, and oh my gosh, are the children going to starve now at lunch because they won't eat any of the healthy stuff that's being offered. That's a consequence of their habits, being ones that necessarily don't include all that stuff, uh, typically. And we've seen over time that actually, um, real life experiment, natural experiment, kids come around to eating. The stuff and learning to like the stuff after they've been exposed a while, but it's a lot harder to change habits and to try to go backwards from a child who already has, uh, food preferences that are not so healthy to establishing healthy habits. We'd be a lot better off if we were able to help parents to have these, uh, habits be part of the child's life from the get-go. So I'm gonna talk a little bit more about how we do that. We want a practice full of healthy eaters, then, just as they used to say in Chicago, to vote early and vote often. In this case, we want to intervene early and often. The more we can intervene from the very beginning and have these conversations in a sensitive way with uh children and their families, the more successful we're gonna be in the long run of helping to prevent childhood obesity and as a result of that, decrease the rates of obesity, um, in our country as the children grow up to be healthy adults. So I'm gonna talk a little bit about what the evidence suggests would be things that we could do in, in our office and talk to our families um at the pregnancy stage, so prenatal before the child is born, early infancy for 6 months, late infancy, 6 to 12 months, for toddlers and for preschoolers. But again, intervene early and intervene often. So when we say how early can we start, we can start before the baby is even born. Um, So when we have parents come to our office who um are expecting the next child or who may be coming for a prenatal visit, there are some things that we should at least be thinking about. And if the opportunity is right, you know, bringing up or having discussions about to help support healthy uh children from the get-go and healthy eating habits, um, from the get-go. So we're all very familiar about um weight gain in pregnancy and that women who gain a lot of extra weight in pregnancy are more likely to develop gestational diabetes. And we know that children who are born to a mom who had gestational diabetes are more likely to um suffer from obesity and uh complications later on. So if we can help um moms to know what the recommendations are, at least for appropriate weight gain, or partner with our OBGYN colleagues who are really the ones who have the greatest opportunity to make a significant impact on childhood obesity during that prenatal phase. And I just included some of the guidelines here for reference for about how much weight um uh is recommended for a pregnant woman to gain based on her baseline uh BMI. With that and kind of segueing from that is this notion um during pregnancy where we say or we think, you know, we're eating for two. Well, true, two lives, but not really eating for two. it's pretty clear that nutritional needs, especially calorie needs, don't actually increase all that much during pregnancy and In fact, uh, no extra calories are needed in the first trimester of a pregnancy, and then about 350 extra in the second trimester and about 450 extra in the third trimester. So when we're talking, you know, one, frappuccino a day extra, of course, we wouldn't recommend that. We'd want there to be more nutrient-dense extra calories. But the idea being that pregnant women don't really need a lot of extra. Calories even though commonly we felt that way or, you know, we've talked that way. So if we help our um patients, parents, friends, colleagues, ourselves um during pregnancies to really think about that and trying to have those high nutrient density choices um during pregnancy and not overeating, um, because we can. Natalie, that, yes, that's an amazing point because we actually are, we're starting to do some work with pregnant moms and looking at that. And really the understanding of how much those 350 calories are is shocking. So even if you just had some way to help your families or your moms know this is what this looks like, right? It's this much, you know, a half a glass of milk, some almonds, and a banana, you know, that kind of stuff would be really valuable because what we found is when we've been talking to moms is they'll say, oh, it's like a salad at a fast food restaurant. Knowing full well that salad is really more like 750 or 800 calories. So that bit of information I think could be so important and helpful to moms if you can offer it in your office when you see them. Absolutely. And in fact, um, some of the resources that Chris mentioned in the previous presentation, especially, uh, for example, if you go to Super Tracker, you go to Choose My Plate, they have, um, for pregnancy and for pregnant moms, and you can get resources and information there to share with, uh, moms so they can see just like Stephanie's mentioning, what it looks like to have that extra calorie needs and kind of how that adds up in real life. Because numbers don't mean a whole lot, uh, to a lot of people. If they can really see it and experience it, it makes, um, a pretty big impact. So again, um, chooseMyPlate.gov, they have resources there for pregnant moms, which may be really helpful to hand out or even just have available in the office. So parents, you know, moms can, can grab it, uh, when they see it, if they're interested. It's actually a really great time to seize the opportunity, a lot to um make an impact when parents and moms are very highly motivated. Most pregnant moms wanna do everything they can to provide the greatest environment for their growing child as possible, and that's, that's a period of development where there's a lot of interest in education and learning more. So it's a great time for us to be available right there to be able to provide that, um, when they're, you know, ready to receive it. Additionally, um, And what I would consider to be in the top 5 for sure in, in thinking about pregnancy is helping moms to prepare for a successful breastfeeding experience long before the baby's even born. Uh, we know that a lot of women struggle with breastfeeding, or they've heard of their friends who have struggled with breastfeeding, so they may have anxiety about it, or they may not be sure. So if we're able to have that conversation about breastfeeding when expecting moms come in and be able to help support them as they're thinking about that and, and what that will mean to them. We may be more successful in helping them to have a successful early experience with breastfeeding and keep it going. And there's some evidence, as we know, that, um, breastfeeding's helpful for the child, for their weight, a lot of other benefits. And it's also helpful, as I'll talk about in a little bit, on exposing, um, children to lots of different flavors from the very beginning, which makes them more likely to appreciate and like those flavors later, which is a way to intervene early, um, to prevent picky eating. The recommendation recommendation suggests that pregnant women should get um at least 150 minutes of exercise per week, same as the rest of us. Uh, for a long time, it was thought, you know, oh, when you're pregnant, you should be really careful and you shouldn't, you know, do as much exercise and be cautious about starting new exercise. We know now that exercise is extremely important, um, for pregnant women. And the recommendation really is if you're doing something. Uh, already, keep doing what you're doing. Listen to your body, how you feel to determine intensity and how much to do. And if you haven't been physically active previously, it's OK to begin activity and to have a basic level of physical activity getting started. It's just not going from 0 to 100% right away. Natalie, there's a question on the, uh, chat um it looks like Stephanie answered it on the chat board, but uh there's a question you may want to answer for those I don't, I don't know if everybody's on the chat board, but those extra calories for a pregnant mom, is that on top of a 2000 calorie diet? Yeah, that's on top. Well, that's on top of what their baseline nutrient need is, um, from the beginning. So not every pregnant woman is gonna have a 2000 calorie diet recommendation. It depends on a lot of, um, factors where again, they could go to supertracker. USDA.gov, put in their age, their height, their weight, um, and get in their gender and get a recommendation for how many calories they need at baseline. And then this recommendation would be on top of what their baseline calorie needs are. Right. Any other questions for um the pregnancy, top 5 things to consider or think about when we have that opportunity to intervene with pregnant moms? I don't see any right now. OK, so I'm gonna move on then, um, to my, uh, infancy, uh, part one. So that's a 0 to 6 months top 5. So these are, um, evidence-based or evidence-informed recommendations for when we have that child come in, they're coming in for their newborn check, a 2-week check, 2 months, 4 months, 6 months. What kinds of nutrition advice or information can we provide the mom to help that child be a healthy eater, um, from the get-go? So we've talked about um the breastfeeding and ideally, as we know from the AAP recommendations, we'd like for moms to breastfeed exclusively to 6 months if they can and not introduce solids until 6 months. We know at at least not earlier than 4 months, um, there's some evidence that Children who are introduced to solid foods before that have an increased risk of developing childhood obesity later on and, and don't need the, the solids at that point. So we as pediatricians all know how to talk to parents about introducing solids and just kind of reinforcing, um, that is helpful for early eating habits, um, especially as I mentioned previously. For breastfeeding moms, it's a great opportunity. It's a great first well, actually, pregnancy is the first opportunity. Breastfeeding is the second opportunity to help. Uh, support a child to be an adventurous eater and not be a picky eater later on by eating a wide variety of, um, healthy foods that have lots of different tastes and flavors. There is evidence that shows that, um, the flavors pass in the amniotic fluid to the baby, and they also are going to pass through the breast milk to a baby. So they're getting first experiences of different flavors through that breast milk. And there's some evidence that babies who are breastfed. are more likely to try a variety of different foods later and it may be related to this, that they're getting exposed to lots of flavors um early on. We know that the more we try something, the more we come to liking it and so breastfed babies get that from the get-go. So I would say, um. Breastfeeding moms eat lots of things, especially bitter, bitter vegetables, because that's what usually our toddlers are gonna reject. So let's get them in early. And yes, some of those vegetables like the cruciferous, you know, broccoli, cauliflower, Brussels sprouts, that type of thing may cause the baby to have a little gas or something. We can deal with that if we need to. But I generally recommend moms to eat lots of, lots of really healthy foods, a wide variety, even spicy stuff and, and everything. We know this, but to really just think about, um, it regularly and helping our moms to know this is really following a baby's cues for determining, um, signs of hunger and fullness. So early on, we often as parents, you know, we often use food to comfort a crying infant. And a lot of times the baby does need to be fed. The baby's hungry. But we really want to cue in the signs of hunger, you know, the the rooting, the being alert, wide eyes, um, fist and mouth, and then also queuing into when a baby is full, starting to fall asleep, pulling away, not interested anymore, and really respecting the baby's internal cues of hunger and fullness. And uh we'll talk a little bit about this more in the next section too with a movement that's been discussed a lot and you may be familiar with, with is this idea of baby-led weaning, which is really trying to cue into that, but I'll, I'll do a little overview of that in a sec. Um, but this is especially true for babies who are bottle-fed because a lot of times we just naturally think, oh well, the baby had, you know, 3 ounces last feeding. That's how much the baby needs to have every feeding. But not necessarily. Babies will, will show us and tell us how much they need and really encouraging parents to to be OK with that. And if the baby doesn't want to drink the whole bottle, that's OK. And not trying to overfeed or not feeding. Um, because the baby is crying, necessarily, trying other soothing methods first to see if it's true that the baby's hungry or if it's the baby just needs to be comforted. And then, uh, number 4 here for us pediatricians, is we, we're pretty good about monitoring weight gain, I think, and really checking that weight curve every visit. I don't know if we do as great of a job in the first couple of years of looking at that weight for length, but really paying attention to weight for length from the beginning. And if we're seeing above the eighty-fifth percentile, above the ninety-fifth percentile, starting in a sensitive way to, to have that conversation if it's necessary, um, it may be that the baby's, you know, gaining fine and has really healthy, um, Feeding moms really queuing into hunger and fullness, maybe it's, it's no problem, but at least to be aware of that. And there is evidence that babies who gain weight very rapidly in the first year of life are more likely to then go on to have um troubles with weight as children later on. And then finally, I have to include the physical development in this as well, even though the main focus is on nutrition, because we know that that motor skill development and this idea of physical literacy of really being able to move the body in a confident way, starts from the beginning and helps to predict activity later, and helps to predict the child's health later. So really trying to um bring up that tummy time, which we talk about a lot, but this is baby's first early opportunity to really develop those motor skills that will be used later on. Um, so the recommendation is an hour a day or more and you can do it in spurts. A lot of babies, as we know, don't like to necessarily be on their tummy all the time, but tummy during the day as much as possible and back to sleep at night. Any questions on these ideas for the 1st 6 months or suggestions? Natalie, we did get one question from the audience and uh Alan Brown was asking, is it, is it solids per se, or is it, or does the type of solid matter? Yeah, that's a really excellent question. And there's been a lot of evolving, uh, research on this of what should we start first. You know, so we used to say, start with rice cereal and avoid things that are more likely to be allergic, like fish and eggs and that kind of thing till later. But now, you know, we don't, we're not as, we're not seeing that that probably makes much of a difference. So it really doesn't make a huge difference what is started first, although the process will be as recommended by the AAP. So as we know, you know, one thing at a time, wait the 3 to 5 days between um adding new solids to see if the baby has a reaction. Make sure it's soft enough that the baby isn't gonna have, um, You know, a choking event. And then the guidelines say, well, maybe we should not necessarily wait a long time to introduce those more allergic types of foods, but maybe start with more bland foods just to get the baby going on solids and then do the eggs and the fish, um, and the nuts later. But I don't think it's necessarily the case, and meats are fine, proteins are fine, vegetables and fruits. Really, there isn't a one right way to do this. Great. And I think you bring up a good point too about bringing all this in and how it really then relates to later on and, you know, tummy time when you're thinking about your kids playing soccer later, right? I mean, showing those correlations and bringing up the importance of the parental involvement in this, in this time of their lives, does it at a time that it's really not threatening, right? It's, it's easier once you've started these conversations and it's easier to continue them when they're 23 and 4. So I, I think it's great, the more you can educate and discuss with your family, the more they can take with them then later on and starting off these habits really early. Absolutely, Stephanie, that's a great point too, where this is a time where parents are, are, are open. They're not gonna be on the defensive like they may be later on if a child is noted to start having some issues with the weight. It's a really great time to establish the relationship. They expect you to talk about this. Stuff every time they come in so it's not a shock to them as you talk about it. So if the child does have a weight issue or something like that later on, it's just part of the conversation you've been having all along. So it's much less um threatening and it's much less of um the risk I guess of discord between the parent and the pediatrician and, and having some of these conversations. If they know when, if they know that from the very beginning you've been showing them the growth percentile and you've been talking about weight for length from the time that they came in for the child's, you know, initial visit or two month visit, it's not, it's not surprising when you're talking about that when the child's 5 or 6 and then you have to talk about how the BMI is greater than the 95th percentile and what that means should that happen. Although ideally with all this stuff that won't happen to prevent it, right? We're very idealistic here. Yeah, OK. So then, uh, let's move on to infancy, what I call infancy part two. So this is really where you're getting into a lot of, uh, the solids introduction and the child's beginning to, to develop, uh, nutrition habits. So 6 to 12 months. So we talked about this briefly already in the, uh, earlier slide, but introduced lots and lots of different types of solids, is what I would suggest. Um, and the process is advised by the AAP which I just went through, and really trying to avoid sugary foods and juice. Now, some people will even say with this, you know, introduce vegetables before you introduce fruits, because if you introduce fruits first, that baby's going to prefer that flavor and isn't going to like the bitter vegetable. I don't think that's really played out as much in the research, but There's lots of different ways to do this. I try to be very open with what the family is interested in or what or what they want, and then just try to um keep a queue out for things that could be uh potentially dangerous and kind of add on to what they're doing, things that they may not have thought of that could help to even further support what they're trying to do. Uh, a good example of this is this idea of baby-led weaning. Which you may have heard about, it's, you know, I'm in the San Diego area, so I don't know if it's just that it's here or what, but it's, it's a very trendy thing that parents are starting to do now, where the idea is being, um, skipping the purees and around 6 months just kind of letting babies explore with. Real food, um, and letting them kind of decide how much, if, if much at all, that they're gonna take of that and relying mostly on the, um, breast milk or formula for the first year of life, year of life, and then just gradually kind of adding on opportunities for solids. The idea of it being that the baby gets to really um have more control over the food, uh, how much they're gonna take and having that opportunity to play and explore. The main thing that comes up is kind of the safety risk in my perspective is the choking hazard risk of it. So when I have families that come in that are talking about this and, and wanting to follow this, I, I definitely always talk about the choking hazard. Um, there's not a lot of studies or evidence either way about this other than our innate concern about choking and can six month olds really handle, eat, you know, all types of foods. Um, but I try to support parents. But if it's up to me or if they're asking my advice, uh, generally, having that soft foods early on, 6 to 9 months, is usually pretty well tolerated, and it's a great opportunity if parents can, to make some of their own foods and to use real foods, not in trying to minimize, um, processed foods as much as possible. And giving that baby exposure to lots of different tastes from the get-go and then gradually building on and adding the solids to that. So by 9 months, you know, we're doing lots of food, a variety of different, um, flavors and textures, and then by 12 months, most babies are pretty much eating the same foods and the same schedule, um, as the rest of the family, or they certainly could be doing that. And if the family's healthy eaters should be doing that. So, a little known fact, uh, perhaps to, to many people is that babies have, um, somewhat immature taste buds, which makes it so that they like everything. Um, it's hard to find a baby that is truly using, uh, new foods, although there are some, but typically babies in the first year or so of eating solid foods are pretty open to trying lots of different things. And if they're, you know, if they seem like they're spitting in. Out it may just be their extrusion, uh, reflex as they're starting out, not that they're not that they're rejecting it, but they just weren't expecting that. So I encourage all of my parents at this, at the 6 month visit and the 9 month visit and the 12 month visit to expose their child, their baby who's willing to try everything to lots of different flavors. It's a very effective approach to trying to prevent picky eating later on and helping kids to be able to like the stuff later. It's not guaranteed, but it certainly increases the odds that you will not have a picky eater. So foods that toddlers reject are the foods that we should definitely be pushing onto our infants, not pushing onto them, so you don't wanna force. We should definitely be exposing them too frequently and giving them opportunities to taste and try. So really there isn't a real role for these vegetables and cereals with added sugars. Can you say that again, Stephanie? I'm sorry. There was a question about vegetables and cereals with added sugars, and you're basically saying that they have, they actually will take the bitter without any problems, so there really isn't a role for any extra sugar. Absolutely, yeah, I certainly would not, uh, recommend adding sugar to any of this stuff for these infants. No way. There's enough added sugar later on, even though we're gonna try to minimize that. So I don't recommend adding sugar. Kids will babies, they'll try stuff. They'll go for the bitter if you want it to pair. So there is a strategy, especially for older kids, of pairing something bitter with something sweet to try to improve, um, the child's likelihood of, of accepting it. If a parent was really concerned at this stage that a child was really rejecting something bitter, which really doesn't happen that much, but it can, maybe they pair it with a fruit, so like pears or apples are things that are pretty sweet that if you pair a more bitter vegetable with that, then they might like it, but it's, it's more of a healthy sweetness and healthy sugar. Yeah, I think your point that they're making a face, but they're not necessarily rejecting it is really important because they do. If it's a new taste, they may make a funny face. It doesn't mean they don't like it. They just weren't, like you said, they weren't expecting it, so not always assuming that their funny faces are because they don't like it, it might just be that it was a different taste to them. Yup, got it. Well, welcome back, everyone. So, um, just to kind of wrap up infancy part two, so in the 6 to 12 months, my top 5, finally, just to kind of add on there is again, encouraging that gross motor skill development, really checking in on those motor milestones and encouraging parents to, you know, Provide a safe place for their child to be able to move around, explore, uh, their world, and really have an opportunity to, uh, get up and like I said, explore the world. You know, a lot of times kids are in strollers all day, or they're in car seats, they're in swings, they're kind of buckled in. We really want to try to give them an opportunity to move around and develop those skills. So then, let's move on, um, to toddlerhood and the toddler, 1 to 3 years, top 5. This is where things can sometimes get tricky, and this is where parents can get very frustrated and you start to get into these, uh, food battles and all of that, which is totally counterproductive, um, for the short haul as well as, well, for the short haul, maybe they get, you know, what they need out. Of it, I don't know, very nervous about getting kids to eat their vegetables, so forcing them, but for the long haul, it doesn't work. It's unproductive. It's not helpful. Um, so I think a top thing for pediatricians, for us who are kind of on the front lines to recognize and support our parents with is to know that neophobia, so that's the fear of wanting to try new things, is a developmental milestone. Almost every toddler goes through this. It's totally normal. If parents realize that, it takes some of the pressure off. Toddlers don't like to try new things. That's part of the reason why we want nothing to be new by the time they're a toddler. So when they're infants and they're willing to try everything, that's a great time to get first exposures. But if that didn't work out or it's not happening, For parents to know, not liking new things is, is normal. Once they know it's normal, they maybe are a little bit less invested in trying to force their kid to eat it. But you can see how they'd be kind of torn because we're telling them, you know, make sure your kid gets 5 types of vegetables and fruits a day, and then their kid is saying, I hate that. I don't want to eat that, so what do you do? Um, so one normalized neophobia. 2, is really helping parents to at least be aware of and think about adopting what is known as an authoritative approach to parenting or responsive parenting. You may have heard of this about like, division of responsibility. So, What this is, is parents really set the stage for their child to be healthy by giving their child a little bit of control, um, by setting, setting it up. So let me just explain the division of responsibility. So the idea is. Parents decide what foods are offered. So, what foods are in the house, what's gonna be the options for meals and snack time, and when they're offered. So, what time does mealtime happen? What times do snack time happen? And you could even it to saying and where they're offered. So we're going to sit at the kitchen table to eat. We're not going to eat in front of the television or, you know, walking around or all day long. So parents decide what and when and where, and they let the child decide of the food that's offered to them, what they're going to eat and how much of it they're going to eat. So, you both, the parents ultimately are kind of behind the scenes, just setting the stage. They're only creating an environment that's going to support their child making a healthy choice, but they're giving that toddler a sense of choice, a little bit of autonomy, a child who feels like they have a little bit The control in their life is going to be more likely to to own it and want to do it and kind of move forward. It's it's sort of like what we talk about in motivational interviewing and really respecting a person's autonomy. It's kind of like that with a toddler, but you're setting the stage so that you're making sure that the choice they make is going to be OK. So maybe they're getting a choice between, you know, carrot sticks or celery sticks. You don't care which one they pick because they're both good for them, but the fact that they got to choose helps them to be more likely that they'll try it. So, division of responsibility is a key facet of authoritative parenting, where the parent sets the stage for the child to make healthy choices, parent decides what foods are offered, when and where, child gets to decide of what's offered, what they're gonna eat, and how much. And that's kind of the basic approach that you can, you know, you can extend it. So you could say, well, parents will say, yeah, but what if, you know, we have, first of all, what if my kid doesn't eat anything? Or, OK, what if we have this meal and all they want to eat is the macaroni and cheese or whatever is part of the meal? There's ways that you can, um, Help parents to to navigate this, making sure to include one thing the child likes at each meal, but making sure it's something that's relatively healthy if they're kind of transitioning to um really implementing the authoritative parenting, if that's not been their approach previously. Uh, the next step is really eating the same family meals together often. So first of all, the same, that means not catering to the picky eater and making that separate meal for the toddler who only wants chicken nuggets and mac and cheese or whatever it is. Like everybody's eating the same stuff, and they're eating it together. There's a lot of evidence that shows just by having that family meal, kids adopt healthier habits without even saying a word, especially if the parents are healthy eaters and they can model some of this behavior. Kids are watching, even when we don't think so. We all know this. Um, sometimes things come out of their mouth, we can't believe that they heard us say. Um, So, kids are watching, they know, so if parents model it and they're eating family meals together, there's lots of benefits from the health side. There's benefits later on for adolescents, for socially, lots of, lots of uh things to do. So, having the family meals early and often early, meaning starting from when they're the youngest, eating all together, and often as frequently as possible. A lot of the evidence shows at least 3 times a week is really um valuable for the family. And then offering choice between two equally acceptable options, which I discussed a little bit in talking about that division of responsibility. And then, uh, this can be so difficult and challenging for parents who are so invested in wanting their kids to eat this healthy stuff, but really trying to keep meal times relaxing and enjoyable. Trying not to, uh, pressure to eat, not making deals. If you eat everything on your plate, then you'll get a dessert at the end of the day. Counterproductive, not helpful. Just making sure that those healthy options are available. Everybody's sitting down together. Uh, trying to include at least one thing the child likes at the meal and just letting the child kind of go from there. Kids are really good if we let them at knowing how much their body needs and regulating intake, but if we don't let them, if we force them to clean their plates, if we use food as rewards, if we set up food for comfort, if we bribe them with food, they unlearn their ability to listen to. Their body in deciding hunger and fullness. And there's studies that show that this happens as young as 3 because we've been trying, we've attached so many other things, uh, to eating for our kids. If we can make it enjoyable, let them listen to their body, help them listen to their body, they'll be more likely to be healthy eaters that can self-regulate later on. Um, and a strategy that can be really helpful for a picky eater or a child who only likes certain things is what's known as food bridges. So I showed the example here in the picture of, you know, say you have a child who likes pumpkin pie. Because of that texture and the taste of pumpkin pie, you could bridge them to something like mashed sweet potatoes, which still tastes pretty sweet. It's still kind of similar texture to the pumpkin pie, but it's healthier, a little less sugary. And then once they've accepted those mashed sweet potatoes, you could bridge. Them to something like mashed carrots, which are a little bit less sweet, different type of vegetable, similar texture and consistency, so the child is more likely to try it. And if a child tries it more than a couple, you know, it can take 15 to 20 times, but repeated exposures, they'll come around to starting to like this. Uh, as adults, we can think about this. If you think about, you know, coffee or tea, or beer, you know, bitter flavors that you probably didn't like at first, and then the more you've tasted them, the more you come around to liking them. It's the same thing, uh, with eating and for toddlers. And I already mentioned this, but it's worthy of reinforcement. So trying to avoid, uh, food rewards and bribes for these toddlers. This is the most challenging stage, I think, for a lot of parents, a lot of it due to the fact that that that neophobia is going on now. But if we can just be calm, be consistent, and understand that helping to shape healthy habits is a process, then we'll be a lot more successful at the end of the day of having healthy eaters that are pretty good at making good choices and self-regulating. Any questions um for this toddler phase before we move on to the, the last bit, which is the preschoolers? I think we're good. Awesome. All right, so then I'm just gonna wrap up here, um, with the developmental considerations top 5 for that preschool age child. So preschoolers are starting to really develop their food preferences now, and, uh, modeling is extraordinarily important both from a parental level, a sibling level, and a peer level. So as much as we can show our kids rather than telling them, but showing them what healthy looks like. The more successful we'll be at helping them to have similar habits. And at the same time, if we are having habits like, uh, the clean plate club, eating everything on the plate, using food as incentives and threats, eating desserts on an everyday basis, um, kids are gonna follow in our footsteps. So it's a really great way to connect with parents of really trying to step it back and think about what their habits are. And at this age, kids are really paying attention and they're gonna model after that. Um, I've mentioned this a few times, but it's worth repeating. Uh, you, you can train the taste buds. I, I call it this with my son who's 6, who we've been in the process of training his taste buds for quite some time now. Uh, but it's finally working, and he's, he's much more willing to try things than he, he, he was as a, as a toddler, which makes sense because that's how it works. Um, but you can train the taste buds. It takes 15 to 20 tastes for a child to like it. The taste buds are on the tongue, so the child doesn't even necessarily need to swallow the food to be able to get that benefit. So just having a willingness to give it a try or presenting things in a way that makes it, uh, encouraging for a child to want to try. So things like, uh, cooking meals together, having a Garden or having even just herbs in a windowsill that you're growing together, bringing kids along to the grocery store, let them pick out a vegetable or a fruit, really engaging children in the process can help make them more willing to try something. And even if they don't eat a lot of it, but they just try it, you've already moved a step along in the way for getting them to accept it down the road. Um, so as I mentioned, engaging children in food preparation, it does work. There's studies that show it does work. So, we do more with what we can show and do with a child than what we say to them. So trying to step back from that coercive approach of making them do something, and really trying to make it a fun process and letting them have some control is pretty effective. Um. And we know that the environment makes a big difference on what kids eat. So something parents can do again without saying anything is just decreasing access and exposure to those less healthy options. So creating a healthy home environment, not to say to never have the stuff that's not healthy, but have it be limited, not storing it in the house. If dessert happens, not keeping leftover desserts in the house to be eaten, you know, whenever, but just really making it, um. Something that occurs, but it's short-lived and there's not a lot of access to the junk in the house. Hungry kids will eat. So if you put in front of them something healthy when they're hungry, they will eat it. And if you put something in front of them, something unhealthy, then they will eat that too. So really, it's about what they've got access to. And then, um, taking advantage of the power of peers. So peer influence is really powerful. Uh, so a child who's unwilling to try anything, who has a friend who's a very adventurous eater, could be benefited maybe by a play date and having a meal together. And even if that other friend is eating everything, and the picky eater doesn't want to try so much, they might be more willing to try something because their friend did, even if they taste it and they decide they don't like it. So taking advantage of peer influence. And every step further along on the path, peers become even more important, and the parental role, um, goes down a little bit, although obviously still important all along the way. Let me back up. Um, any questions at all for the preschool, uh, strategies or or recommendations here? OK, so I'll move to the next. I know I'm a little over here, so we'll, we'll wrap it up. Um, just as a framework to think about putting all this together when we're coaching our parents or, or having these conversations, uh, this is recommended by the US Preventive Services Task Force and some of the, uh, Medicare obesity counseling, uh, recommendations for adults is to use the five A's, and that's really, um, Ask, assess, advise, assist, agree, and arrange. So really a coaching approach to work together in a partnership with our families and our parents to explore areas that we may be able to help them with, work with them to uh establish goals and then have a process for accountability and following up. And then finally, um, just to add a couple of resources on to what Chris already did a great job in lots of detail for lots of resources. Um, the Alliance for a Healthier Generation has in parts of the country, what's known as a Healthier Generation benefit that the AAP is part of, um, helping to connect pediatricians with registered dietitians and providing obesity counseling and treatment with insurance, um, covering the payment for that. So something worth, uh, looking into and seeing if it's in your area, and Healthier Generation.org is the place to start for that. Um, there's increasingly more pediatrician registered dietitian collaborations and interest in that. And Eatr.org has a tool there where you can find an RD in your area, if you're interested in that. Uh, there's some parent coaching programs that have been studied. For example, UCLA has a pretty interesting parent coaching program, where it's, um, partnering with, uh, parents, pediatrician. And, uh, I don't, I can't remember if it's an RD or social worker that worked together and help with actually parenting strategies that end up having a positive impact on food preferences. And that's available to Wendy Schlusser as the lead for that. You can look that up. Um, and then social media, Chris talked about this a lot, but lots of opportunities to engage, connect, and make a difference, um, on social media and so, and to counter some of the misinformation, um, or hype that's out there. And then just quickly here's some references that I cited in the presentation, as well as a couple of other resources that may be of interest and useful. Um, so for pregnancy, the Academy of Nutrition and Dietetics has a nice position paper that you can get, uh, from Eatr.org as well on, um, nutrition and pregnancy. They also have a really nice one on nutrition guidance for kids 2 to 11, if you're interested, and then it's come up a million times, but motivational interviewing in the book, um, is now in its 3rd edition by Miller and Wolnick. It's fantastic, um, to learn more about that. Great, thanks so much, Natalie. Absolutely, and there's a few resources to just kinda have available and um that's it. Thank you.