September 16, 2011 ISMA Annual Meeting The Picky Eater: Pediatric conditions with adult consequences Theresa Rohr-Kirchgraber, MD, FACP

September 16, 2011 ISMA Annual Meeting

The Picky Eater: Pediatric conditions with adult

consequences

Theresa Rohr-Kirchgraber, MD, FACP

Dietary Guidelines 2010http://www.choosemyplate.gov/foodgroups/downloads/MyPlate/selectedmessages.pdf

Balancing CaloriesEnjoy your food, but eat lessAvoid oversized protions

Foods to IncreaseMake ½ plate fruits and vegetablesMake ½ grains whole grainsSwitch to fat-free or low-fat milk

Foods to ReduceCompare sodium in foods like soup, bread, and frozen meals and choose the foods with lower numbersDrink water in stead of sugary drinks.

April 18, 2023Customize footer: View menu/Header and Footer

Food Avoidance Emotional Disorder

Picky Eating

Selective Eating

Eating Disorder

Anorexia Nervosa

Bulimia Nervosa

Binge Eating Disorder

Eating Disorder Not otherwise specified

Picky Eating

• Common during early childhood

• Food Neophobia (avoidance of novel foods)

• Rejection of Food• Transient• Severe


Picky Eating/Selective Eating

8-12 yoa

• 13-22%• Not underweight• Not associated with

maternal or child symptoms of eating disorders

• 47% having enduring problems

<6 years of age

• 18-45%• Transient minor to life

threatening• Wt loss• Failure to Thrive/Poor

growth• Longer feeding time• Predict Anorexia• Boys > Girls


Childhood

Normal eating

• Age 2 erratic eatingFrequent food shifts

• Express independence• Outgrow PE

Selective Eating

• More severe/persistent• Mealtime disruptive

behaviorsPlaying with food

Excessive slow eating

Gagging/resist self feeding

Spitting out food

• Preferences for carbohydrates

• Anxiety with meals/foodApril 18, 2023Customize footer: View menu/Header and Footer

Selective Eating

• Physical Complications

Poor growth• Non-food-related symptoms

Anxious

Obsessional ruminations

Seperation anxiety

Stomach pain

HeadachesApril 18, 2023Customize footer: View menu/Header and Footer

Avoidant/Restrictive Food Intake Disorder (ARFID)• Feeding Disorder of Infancy or Early

Childhood• Data in adults not well defined


Picky Eaters in Adults

• Extremely limited range of foods• Avoidance of unfamiliar foods• Rejection of foods based on sensory

characteristics.• Stable trait• Anxiety in eating-related situations• Disordered Eating


Characteristics

High Pathology

• OCD 25%• Eating Disorders• Social Anxiety related to

eating• Impairment in social

functioning

Low Pathology

• Picky Eating alone• Low comorbidities• OCD 8%


Picky Eating Not Weight Related?


Binge Eating

Adult picky eaters co-occurs with symptoms of Eating Disorders it appears to be characterized by binge eating problems and obesity rather than sustained strict dietary restrictions.


2/3 lb. Monster Thickburger ®

Two 1/3 lb. charbroiled 100% Black Angus beef patties, 4 strips of bacon, 3 slices of American cheese and mayonnaise on a sesame seed bun.


Picky Eating-balanced diet?

Preference for

carbohydrates

breads

sweets

Avoidance of

fruits

vegetablesApril 18, 2023Customize footer: View menu/Header and Footer

Multiple Food Allergies

34 yo♂ allergies

Bluish nodules on both legs, sensitive to touch

Spontaneous ecchymosis

Asthenia, dyspnea and palpitations


Petechia and gingivitis

Anemia



20 yo ♀, BMI 21, presents with fatigue. Anemic-hct 21, MCV 112 w/ bizarre appearing cells.

B12 deficiency presenting as Leukemia


Pathogenesis

• Autism Spectrum Disorder• Anxiety Disorder• Food preferences inheritable• Biological• Exacerbated by family and social

consequences of the problem• Family Conflict• Avoidance of situations associated with

eatingApril 18, 2023Customize footer: View menu/Header and Footer

Parental Characteristics

• ↑Anxiety about child’s eating• Lost confidence in their parenting ability• Tried multiple tactics that failed

• Bribing, coaxing, threatening, withholding

• Unable to set limits• Depression• Selective Eating


Provider

• Ask 24 hour diet history• Ask about soda, “juice”, all drinks• Give advice and education


Diet History

1.) Are you comfortable with your body size?

2.)What have you done to change your body size in the last year?

3.) Tell me what you had to eat in the last 24 hours?


24 hour diet history

Tell me what you had to eat yesterday.

How many servings of dairy?

How many sodas? Gatorade? PowerAde?

How much juice? “Energy Drinks”?What kind of “juice”?

16 year old ♀volleyball player

April 18, 2023

Sports physical

Healthy

ROS unremarkable

6 cans of soda/day


Girls’ Early Sweetened Carbonated Beverage Intake Predicts Different Patterns of Beverage and Nutrient Intake across Childhood and Adolescence

• Soda consumption at age 5→→ ↑adolescence

• Soda→↑added sugars, ↓protein, ↓ fiber, ↓calcium,↓ vitamin D, ↓magnesium, ↓potassium

April 18, 2023Fiorito, l et al, J Amer Diet Assn, 2010;110:543-550

17 yo Myalgias

Worsening over the last few months

Physically active.

Diet: 2-3 sodas per day, fast food 2-3 x per week, milk with cereal in the morning

FHx: lactose intolerance

Exam unremarkable

Vitamin D level <12

Vitamin D

17 yo♀ Well Child Visit

• Obese• G1P1• Complicated with

spina bifida


RDA Fruits and Vegetables5 per day


April 18, 2023USDA

Folate Deficiency

• 1/3 patients with severe depression• vitamin may enhance recovery of the

mental state

April 18, 2023

Bottiglieri B, Laundy M, Crellin R, Toone BK, Carney MW, Reynolds EH. Homocysteine, folate, methylation, and monoamine metabolism in depression. J Neurol Neurosurg Psychiatry. 2000;69(2):228-232.

24 hour diet history:Breakfast40% of kids skip

Decreased reading scores

Increased iron deficiency anemia

Increased Obesity

50% of adults skip

Irritability

Restless

Tired


16 yo ♂Stomach Pain

• 3-4 months• Worsening• Nausea• Midepigastric

April 18, 2023

April 18, 2023

The Importance of Family Dinners

• 3x “excellent” relationship with their mothers and fathers.

• >2x as likely to say their parents are good listeners.

April 18, 2023News release, National Center on Addiction and Substance Abuse, Columbia University. Feinstein, E. The Importance of Family Dinners VI.WebMD Health News: “More Americans Using Illicit Drugs.” Customize footer: View menu/Header and Footer

<3 Dinner/week vs >4 dinners/wk.

• 1.5 times likelier to have friends who drink regularly and use marijuana.

• 1.5 times likelier to have friends who abuse prescription drugs in order to get high.

• 1.25 times more likely to have friends who use illegal drugs such as LSD, ecstasy, cocaine, methamphetamine, and heroin

April 18, 2023Customize footer: View

Parent

• Model good behavior• Make family meals a priority• Encourage different foods• Give choices• Limit junk food in the home• Read labels• Realistic portions• Don’t barter


“Good girls who eat their carrots get ice cream.”

“I’m entitled to this whole bag of cookies because I won the new account.”


“Let’s stop for ice cream to cheer you up.”

“I am entitled to this whole pint of ice cream, because I am sad.”


April 18, 2023http://www.eatright.org/default.aspx

American Dietetic Association Foundation Survey Finds Children Skipping Meals, Snacking FrequentlyTuesday, November 09, 2010

How do we get here?


Sneak it in!


Recommendations

Be patient

Make meal time regular, peacefull, varied

Include children in making meals

Include children in grocery shopping

Discuss with physician and refer when needed

GET TREATMENT!


THANK YOU!

Questions?

30 yo ♂physician

• Refuses all fruits/vegetables

• Wt gain when lived with a AN

• Anxiety around group meals

• Unable to talk about nutrition with patients and families

April 18, 2023This picture is a representation and not of the physicians discussed in this case

BibliographyLéger D, Scurvy: Reemergence of nutritional deficiencies Can Fam Physician. 2008 October; 54(10): 1403–1406.

Frikke-Schmidt H, Lykkesfeldt J, Role of Marginal Vitamin C Deficiency in Atherogenesis:

In Vivo Models and Clinical Studies 2009 Basic & Clinical Pharmacology & Toxicology, 104, 419–433

Des Roches*, L. Paradis, J. Paradis, S. Singer Food allergy as a new risk factor for scurvy June 2006 Allergy 2006: 61:1487–1488

http://www.choosemyplate.gov/foodgroups/downloads/MyPlate/selectedmessages.pdf

Nicholls D, Christie D, Randall L, Lask B, Selective Eating: Symptom, Disorder or Normal Variant

Clin Child Psychol Psychiatry 2001 6: 257

Watikins B, Cooper PJ, Lask B, History of eating disorders in mothers with children with early onset eating disorder or disturbance. Eur Eat Dis Review 20 (2012) 121-125


Documents

September 16, 2011 ISMA Annual Meeting The Picky Eater: Pediatric conditions with adult consequences Theresa Rohr-Kirchgraber, MD, FACP