the HAES® files: Health, Not Weight Focus. What a Relief!

by Health At Every Size® Blog

by Katja Rowell, MD

Upon waking, three year-old Amalia cried for buttered toast. She’d gobble her half piece while sliced cucumbers and apples were urged on her. At the local park, she didn’t play but wandered from mom to mom asking for snacks or taking food from other children. Amalia’s mother called, desperate for a different way to address Amalia’s “weight problem,” since life was reduced to controlling Amalia’s intake. Mom was afraid Amalia was headed for an eating disorder or “obesity,” since she was still overweight according to the growth charts (growing steadily between 85th and 90th percentile, down a little from infancy).

As a family doctor turned childhood feeding specialist, about a third of my clients are children like Amalia.* As the war on obesity takes aim at our very youngest, I believe behaviors we used to see in tweens and teens are showing up in younger and younger children. Most children I see with ‘food obsession’ are preschoolers.

be a mom... copyAmalia wasn’t born ravenous. She was born larger than average, growing steadily, and was exclusively breast-fed. Both parents are naturally slender, enjoyed a variety of home-cooked foods as well as an active life-style. Looking back, mom realized that Amalia’s problems started when a pediatrician labeled Amalia as “obese” at 4 ½ months. With dire warnings of diabetes, heart disease and early death, he recommended cutting out nighttime feeds and having mom wait to feed for thirty minutes after Amalia signaled hunger. That’s how you put a breastfed infant on a diet, and Amalia is not the only one I’ve seen.

The doctor’s misunderstanding of growth and self-regulation, and ignorance of the harm of restriction (with Mom now worried and carrying out his advice) caused Amalia’s problems. With the disruption of a responsive feeding relationship, Amalia soon seemed insatiable at feedings. When Amalia didn’t move into the “normal” weight range fast enough, her parents saw a dietitian who recommended strict calorie and fat limits and red-light/green-light rules (limit high fat/sugar/calorie or “red-light” foods).

Most of the children I see with food obsession were growing steadily, healthy, albeit larger than average. Misguided fears from doctors or family led parents to worry about weight and health, who, motivated by love and fear, tried to get the child to eat less to weigh less. Just as adult dieting research shows that trying to eat less to weigh less tends to lead to more disordered behaviors and higher weight, research in children increasingly shows us that trying to get kids to eat less to lose weight also backfires. The same holds true for “underweight” children: the harder we pressure them to eat, the less well they tend to eat and grow. (Journal of Nutrition Symposium on Responsive Feeding 2011.)

The insistence by much of the medical establishment that any weight falling outside one standard deviation from the mean (15-85%) is pathological hurts children. I believe that interventions based on the faulty bedrock that weight defines health increase disordered eating and weight dysregulation at both extremes.

Not What I Learned in Med School

But I didn’t learn any of this in medical school, during my residency, from the journals I read or at the conferences I attended. When I was treating “childhood obesity” in the standard approach in primary care, I probably would have told Amalia’s mom to try harder (I’m sorry).  I might have spent half an hour brainstorming different ways to get Amalia to eat less and move more: get a dog to walk, serve fat-free cheese (I’m sorry), and pick out fruits and veggies for the lunch box… Maybe some decent advice was in there, and I sincerely wanted to help, but with the focus on weight loss, it was doomed to fail. I dreaded those visits where the children and mothers sat with downcast eyes.

I hate to admit that it wasn’t until I had my own daughter that I felt compelled to follow my discomfort, and rather than chalk it up to noncompliance, actually explore the research and seek out alternatives. It took a few years of reading the literature and the work of pioneers like Linda Bacon, Ellyn Satter and Evelyn Tribole, as well as seeing how internally regulated eating and activity in my personal and professional capacities truly transform lives and support health, before I could accept that it’s not just calories in, calories out, and reject the narrow definition of “healthy” weight. I am now a grateful Health at Every Size®-grounded practitioner, mother and activist, fighting to help parents and doctors understand that healthy children come in a range of sizes.

Tuning In to How It Feels

I ask parents to tune in to how it feels to enforce feeding-therapy rules that leave children sobbing and gagging. How does it feel to bring a child to a weigh-in who just discovered she loves the swim team but quits because she hasn’t lost weight? How does it feel to share smiles, Rice Krispies treats, milk and bananas with a once sweets-obsessed child? Similarly, in outreach to clinicians, I ask them how it feels: are they burnt out on nagging, or frustrated with poor outcomes and uncomfortable patient interactions? I ask them to sit with that discomfort and use it as a guide for learning more.

Amalia’s Healthy Changes

Amalia’s mom expressed profound relief with this new approach, based on HAES® principles and the Division of Responsibility in feeding, described in 2011 as responsive feeding “operationalized.” Parents feel grateful to leave the role of ‘food cop’ behind and are amazed to see how quickly young children can tune in again to internal cues of hunger, fullness and appetite.

Amalia’s mom got rid of portion control and stopped pushing low calorie foods. She continued to cook and serve a variety of foods. She included sweets and treats so they were no longer the forbidden food; they enjoyed family meals and moving in fun ways. Within a few months, Mom reported that meals were more fun, and while Amalia continued to enjoy food and large portions at times, she also had meals where she ate less, was allowed to stop eating on her own, said “I’m full” for the first time, and played at the park rather than scavenging for food.

Supporting Amalia and her mother felt great. It feels right to focus on providing and nurturing, rather than on deprivation and power struggles, and Amalia and her family are healthier and happier today because of it. Helping children grow up feeling good about food and their bodies is the best preventive medicine I can think of.

*This brief essay shares the experience of one family. I do not want to minimize the impact on health of food insecurity, poverty, chaos, lack of sleep, trauma, illness, lack of access to a variety of foods, lack of the means and skills to prepare meals, lack of safe places to be active in daily life and play…

Katja RowellKatja Rowell MD is a family doctor turned childhood feeding specialist, supporting parents with feeding and weight worries. She is a sought-after speaker, author, mother and family cook. Her first book, Love Me, Feed Me, is available on Amazon.com.

35 Responses to “the HAES® files: Health, Not Weight Focus. What a Relief!”

  1. I was always a thin child. My mother regulated everything I ate. She would tell me when I was full or had had enough to eat. My eating disorders started when I was 9, I am 55 now and still struggle every day.

    • Pat, I’m so sorry this happened to you. Alas, managing portions and intake is often seen as “good” parenting. I have many clients share that friends are appalled when they allow their children to eat two peanut butter sandwiches for example… (“I wouldn’t let her ride a bike without a helmet, and I wouldn’t let her eat too much either…”) The fear of a big appetite is very real and causing great damage. Thank you for sharing. I have learned so much about how to help children when adults share what they went through as children and how it impacts their eating as adults. I wish you the best with your continued recovery. I have had many adults without children comment on my blog posts over the years. Always insightful!

  2. Thank you. I was that “overweight” child from day one, although in those days chubby babies were considered a good thing. But when I didn’t “slim down” by the age of 2 or 3 I officially became the “overweight” child who needed some kind of intervention. Calorie counting was around in the 1950s, and I learned how to count calories as soon as I learned how to count. I learned “long” addition by adding up the calories in my calorie journal at the age of about 6 or 7. I was terrified of sweets, and on my 3rd birthday (when my Mom provided cake) I sat there and cried through the whole birthday party because I was devastated that my Mom would want to “celebrate” my birthday by almost forcing me to “be bad” (i.e., eat cake). I already knew that other people could eat sweets but that if I did I was “being bad.” I could go on and on. Let’s just say that I am over 60 now, and I still struggle daily with disordered eating symptoms (such as: every time I feel hungry, my brain launches into a devastating tirade of self-hatred — the very FEELING of FEELING hungry causes automatic self-torture over what a “bad” person I am … whether or not I even DO anything in response to that feeling such as Eat.

    Thank you thank you for this article. PLEASE don’t do this to a whole generation of children.

    • rg, My heart aches. So sad. I think that’s why I feel so strongly about this issue. As a physician particularly, with the “first do no harm” oath, I see what my colleagues are doing and it causes lots and lots of harm— needless suffering and heartache, and takes often a life-time to undo. Alas, parents today are as terrified of fat (or more so) than ever, and I see truly dedicated and loving parents convinced they are helping their children by dieting them or counting calories, weighing out 1/4 of rice or 1/2 slice of bread while the child cries and begs for more. Parents tell me they always felt awful and knew it was wrong, but didn’t know there was any other way to address what they perceived as the child’s limitless appetite. (post on Huffington blog about trust and following your gut as a parent http://www.huffingtonpost.com/katja-rowell-md/parents-of-picky-or-selec_b_3562613.html) This is happening to a generation of children, and it seems that it starts earlier and earlier. I’ve had many clients labeled as “obese” as infants, many of whom were exclusively breast fed. Sigh. So much work to do. I’m thrilled there is a HAES community, and hope that we can continue to think and talk about bringing HAES to pediatricians and family docs. The schools also need help. I write a lot on my blog about messages kids get in schools like, “cake is bad” which came from one of my child’s teachers in first grade, and fellow kindergartners told her that “1% milk will make you fat because it has fat in it.” Again, sigh…

  3. Delightful Katja! – thanks – I will get this out to those who really need it!!!

    • Thank you Jon. The word needs to get out! I had three new clients this week who were in the same boat as Amalia! (Well, last week, I’m on vacation this week. Back to self-care!)

  4. That’s fascinating to me because my daughter had the opposite problem as a toddler: ‘Infantile anorexia’ as they called it then. She simply wouldn’t eat and as she fell off the growth charts, social services started asking questions about whether I was actually feeding her or if it was a case of neglect.
    Thankfully, I got the help we needed and we went to a specialist ‘Feeding clinic’ for babies and toddlers who had trouble eating. Interestingly enough, their advice was pretty much identical to the advice Amelia’s parents were given! We had to stop pushing the high fat snacks and build-up drinks and just offer a variety of food, including low calorie foods. We were warned that such children often don’t eat properly, even with treatment until about 6 years old, which was pretty much true almost to the day.
    These days, she is a slim, fit young woman who eats well. However, she has been diagnosed with a gut disorder, which was apparently the cause of her ‘anorexia’ as a tot. Thankfully, because we were taught to allow her to eat intuitively, she is very good at moderating her choices and portion size according to how well her tummy is feeling. Recently, we had a nutrition screen for her, to check her wellbeing, and we discovered that despite her restrictions, including dairy and fatty foods, her iron, calcium and vitamin levels were all perfect 🙂
    I dread to think what the story would have been if we had continued to be the food police.

  5. Wow! As a nutritionist who works with eating disorders and teaches mindful eating I am pretty shocked. Maybe because my own children are in their 30s and I do not get referrals from pediatricians I am out of the baby loop right now. Or maybe it is because i was a La Leche Leader for many years and I cannot fathom ever telling a mother to restrict a babies nursing! This is the first I have ever heard of this. When did a plump baby become a problem?
    I remember my own babies so round and plump everyone asking what on earth do you feed your baby? (They were breast fed until baby led weaning at ~ 2 years old and solid food (table food) added at ~ 6 months with mashed veggies and fruits as starters to their own satisfaction.)
    My children are lean and healthy and have no issues with weight and do this without exercise regimes or restrictive or punitive diets.

    I have always taught my adult clients, with no idea of what to eat or when. to eat again as they did as babies….feeling for the hunger cues and to stop as a breast fed baby would– stopping when they are full (no way to force feed a breast fed baby).
    Where are these docs getting this information? Do these docs not understand the brain and the detriment of low fat nutrition?

    Katja I am thrilled you have posted this and I applaud you for being involved in the HAES way of living and treating patients. I trust this pendulum will eventually swing the other way but I am saddened at the numbers of innocent children who will be horribly harmed by disordered eating being inflicted on them. The numbers of people suffering with ED is staggering as it is –with a multitude of paths to entry, now with this medical model being the latest.

    Are we really that afraid of fat? Why do clinicians and politicians keep digging the hole deeper? I often wonder where we can begin true change

    Perhaps it is time we get to the bottom of this fear of fat and who says what we can or cannot weigh. Thanks to HAES we have a resource to refer to and platform to spring from.

    • Gina, thank you for sharing! I have done some outreach with ED professionals which has been most interesting. I have also had many share that they are shocked that this is all going on. It is, and ED professionals can be part of the army of professionals that will be needed to stop the pendulum and get it moving back to a more good sense approach to growth and feeding. Early feeding impacts eating for a life-time. I fear that many children like Amalia end up in ED clinics as older children, tweens and teens with a diagnosis of binge eating disorder. (I get calls from parents of children as young as 8 who are found binging in the bathroom at a friend’s house and then they are referred to the ED clinic.) ED professionals need to understand, and explore early feeding. Perhaps the child was restricted since infancy or early toddler years? Treatment needs to be tailored to the clinical history. You might enjoy my blogs at Huffington Post. I also see children with severe food anxieties and aversions that I believe will end up in the ED treatment realm. I’d love to find more ways to open a dialogue with ED professionals around early feeding and the consequences of feeding children with pressure to influence weight down or up. What I am grateful for is the HAES principle that weight doesn’t define health. Many smaller than average but healthy children are pushed to eat more, and some will be taught to eat beyond fullness, while others will be turned off and grow less well. Fascinating stuff, and I believe it is imperative that we address counterproductive feeding practices as early as possible, and support parents with responsive feeding and parenting help.

      • Aloha Katja! Thank you so much for your thoughtful responses to everyone here! I can feel your heart dedicated to this healing in our healthcare system. Yes I will head over to your blog and will share it with everyone on my site.Mahalo for all your efforts!

  6. Beautifully written, Katja. Thank you SO MUCH for the work you do. I want to find ways we can encourage more MDs to explore the HAES approach so their patients (grown ups and kids alike) can benefit!

  7. I can get to the bottom of the fear of fat RIGHT NOW. It makes a lot of money for a lot of people.

    This is a terrific post. It is horrifying to realize how little we respect the body’s wisdom, a symptom of our refusal to see ourselves as animals.

  8. Great post Katja and insightful comments from everyone as well. We see many patients with similar histories and continued difficulty trusting their bodies and embracing their natural hunger/fullness cues into and throughout adulthood.

    It is so difficult for parents within the context of our culture’s fear of fat, as they often want to do the right thing for their kids but they are bombarded by mixed messages about feeding/weight from the professionals they trust AND from powerful media/marketing giants who stand to benefit financially from parents’ increased anxiety about weight.

    It often feels like swimming upstream but we applaud those like you who work to educate and spread the message of HAES and Ellyn Satter’s work with early feeding practices.

    Great to hear about your forthcoming book – we will look forward to that in 2015!

    • Yep. Follow the money as they say. It is hard for parents. I get it. I have so much empathy for parents trying to feed children well in our culture where a scared parent is viewed as a money-maker. Parents are scared of fat, and food and everyone suffers.

  9. Katja, if my experience of my daughter with ‘infantile anorexia’ is useful as a case study, please contact me. It was a while ago (she’s now 19!) but I remember the experience vividly and had planned to write about it myself, but felt unqualified for the task.

    • Thank you Anna, we are beyond that stage for the book, but if you want to share your story with me, I’d be really curious, and can always learn more to help other families. Feel free to email me at katja@thefeedingdoctor.com. There is a great FB support group called Mealtime Hostage (also has a blog) that is a great resource for parents.

  10. Wonderful post! I think the book “Victorian Literature and the Anorexic Body” by Anna Krugovoy Silver is excellent. I think medical people and doctors should take a look at it. She examines literature: children’s (eg. Alice in Wonderland), Dracula, poetry (eg. Barret Browning) and scientific books in Victorian England and finds out what the views of girls, hunger, women, and sexuality was for society at large. Some writers at that time were real perverts, but had large followings.

    She’s gotten some flack in book reviews that since she’s not a doctor, why is she writing about anorexia and giving loose diagnoses? I think the purpose of the book was more to do with expanding our understanding of how those ideas affect today and how they’ve changed. I enjoyed it, and I think there is a large disjoint between doctors and historians: frequently historians of science have a better grasp of the fundamentals of – what I call – “just what the hell is going on”.

    Anna’s book starts off with a short bit about dieting in today’s culture and how they got underway in the time period she was studying. Before that, these disorders were unheard of, and it’s no surprise they’re increasing today.

    Another book you should have a look at (more like a trilogy) is “The Nature of their Bodies: Women and their Doctors in Victorian Canada” by Wendy Mitchinson, with the semi-sequel “Giving Birth in Canada 1900-1950” and the full sequel “Body Failure: Medical Views of Women 1900-1950” just published last year. I found the topics in “Nature of their Bodies” very fascinating, and illuminates some “dark age” theories that still hold sway today.

    Sorry to derail the comments, but I thought the Anna Silver book would be a good match to what you are practicing and what she studied.

    I also started dieting at 8 yrs old, but I was quite small all my childhood due to an ovarian cyst that went undiagnosed for years, and caused many illnesses for me (that we believed were stomach flu until much later), and I had next to no growth spurts in puberty, so as a result, I am the shortest person on all sides of the family. I am 4-6 inches shorter than everyone else. But I seem to have the biggest feet (size 9).

    • It’s a common myth that anorexia nervosa is a modern illness. Symptoms which sound remarkably like anorexia nervosa have been discovered going back thousands of years, but attributed to demon possession, or poisoning or other diseases. Which isn’t surprising since many wasting diseases, such as TB, were rife. Plus we now know a lot about the neuroscience behind anorexia nervosa and a big part of it appears to be genetic.

      However, I do agree our modern society has turned what is a relatively rare disease into a kind of signifier of our society. Whilst a few starve themselves, sometimes to death, many others are unhappily restricting, bingeing, obsessing or doing other behaviours which probably won’t kill them, but will kill the joy in their lives and cause longterm damage to their health. My grandmother, who was born in 1919 was almost certainly anorexic, long before the modern obsession with skinniness hit, but her’s was a rare case. But these days, it seems that everyone you meet has disordered eating and disordered body image even though they don’t meet the criteria for a serious, psychiatric eating disorder.

      I think the difference is between the biological illness that some unfortunate people get, like other people get depression or others schizophrenia; and the socially constructed ‘disorder’ that so many of us have. Which isn’t to say it isn’t a problem: it is. It’s just not a psychiatric issue so much as a social one.

      The book does sound very interesting however.

      • Agreed. AN has been around for a long time, but does seem to be on the rise. I also worry about BED, which is the most common ED, and which I fear Amalia and others like her are set up for. Sigh. It is indeed rare to find folks who are eating competent and have a healthy body image. I treasure those friendships and meals when you can eat out and enjoy the company and the food without having to endure comments about fat, in the food or in our bodies…These are such complex bio-psychosocial issues with genetic pieces etc. If we can support folks from the beginning to eat in a tuned in way, that would be a great start!

    • Thanks for the recommendations!

  11. Katja, I was not familiar with your name or your work before this. I am glad to have finally come across someone who is doing the work that you do. For a long time I have been quite vexed by the totally misguided obesity prevention crusade against children. I have two website resources that you might want to check out: http://no-obesity-epidemic.org and http://recessionfoodguide.com. They contain a lot of information that is relevant to your theme.

  12. The fact that Amalia complained about not getting enough to eat, and found ways to get the food she was being denied is soo important! It shows that she had not (yet) learned to distrust and despise her body. Thanks to your wise help, she can grow up healthy in mind and body. The situation you describe–putting nursing infants on reducing diets!–is absolutely chilling. The connection between restrictive policing of children’s food intake and development of eating disorders is clear. The “cure” is the cause of the “disease”!

    • It is chilling! Also happening to bottle fed infants. One can read a bottle fed infant’s cues as well, and parents need some guidance how to do so and not to try to finish a bottle or hide a bottle to try to get a child to eat more or less… Yes, most of my clients are Kindergarten and younger because they still try to get what they want and pester, pester, pester. I think older children give up if they haven’t been successful and will get it away from home when they can. After one workshop a mom of an 11 year-old boy whom she had tried to restrict (with portion control and bullying from the child’s doctor, “You’re the parent, act like it!”) he was eating boxes of donuts at the market on his bike ride home from school…

  13. I love reading stories like this! I have completely shifted how I practice as a dietitian with regard to children and overweight. I am so grateful to have learned from masters such as Ellyn Satter (Your Child’s Weight- Helping Not Harming)…and reading your post Dr. Rowell helps to reinforce this philosophy. It makes me feel like I’m not alone in having these views even though the vast majority of the medical profession still feels as though portion control, restriction, subbing low calorie foods, weigh-ins at the clinic, etc is the best treatment method. Thank you so much!

  14. Thank you for this. My mum, genuinely worried about my weight as a small child, regulated my intake and put me on a diet around aged 5. My weight became the family obsession, with everyone, including my two brothers, turned into the food police. Inevitably, I used to sneak out to buy chocolate from a vending machine down the road, hiding it, and eating it alone in my room. I was about 8 at the time.

    I got bigger and bigger as a result of my family’s well meaning interference. I hated being the fat girl at school with the special ryvita and cottage cheese lunches that I didn’t enjoy and would never have chosen for myself. I was active – I played on the school hockey team and had plenty of interests, but I also had a serious eating disorder. I don’t think it ever goes away. I try hard now to follow a balanced approach but at 48, some habits are ingrained.

    I wish my mother hadn’t put me on a diet when I was a child – she served a wide variety of healthy food at the dinner table and my two brothers didn’t have a weight issue. I am still big – a size 20 – but I am still active, enjoying regular Nordic walking sessions. I don’t blame my mother or my family – they were doing what they thought best at the time.

    However, I DO blame doctors and politicians and dieticians and nutritionists for still perpetuating they myth that putting children on diets is tackling childhood obesity. It seems to me that obesity has risen at the same rate as dieting – so far from dieting being the answer, I wonder if it’s actually the CAUSE of a lot of weight gain.

    I am in no doubt that if I had not been pressured into dieting, body awareness, and an unnatural relationship with food from a young age that I would be slimmer now than I am – and, more importantly, I wouldn’t struggle every day with my feelings and thoughts about food. It’s a lifetime legacy.

    • Thank you for sharing your experience. Sadly I’ve heard it often. It’s why I do what I do… May I excerpt it for a blog post with a link to this original post on my blog? Thank you again. We need your voice in this fight for the health and well being of our children!

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