I have a son, now just turned 9 years old who is in need of some help to increase calorie intake. He weighs 47 lbs. now, but has only gained 4 lbs. in 4 years. Since birth he has had eating issues and has never been over the 5th percentile and most of the time is 15-20% below the growth chart for weight-age-height.
First off, he is allergic to many foods limiting his choices and secondly, he has never been able to eat more than a few bites of food at a time and honestly does not care whether he eats or not – he could go all day and not ask for anything. My problem is mainly that doctors and nutritionists are not getting us past the “just try to get him to eat more” or “try to add calories to his meals” phase.
We changed pediatricians due to a move and the new doctor was not curious enough about my queries to look into possibly prescribing something to stimulate his appetite. The doctor says “he’s just skinny.” My son has always complained about his stomach hurting when he eats. He also has developmental delays in school, and has more recently complained of tiredness, legs hurting, etc. so I am getting more concerned. I have 4 other children who have all been normal growth curves and getting them to eat is literally a piece of cake, but this one does not have the normal hunger urges… hope that makes sense. Any advice? Heather
Dr. Greene’s Answer:
As parents, we have a deep instinct to help our children grow well and achieve their potential. When our children are smaller than most others (less than the 5th percentile of weight for height, of weight for age, or of BMI) or if they are growing too slowly (inappropriately falling off their previous growth curves), it’s time to take notice.
Taking notice means first assessing whether their small size is normal for them (by definition, 5% of healthy kids are below the 5th percentile). If they are too small, the next question is to try to figure out why – and a pediatric gastroenterologist is often the one to help. There are many possibilities including undiagnosed food intolerance such as celiac disease or rare structural conditions such as Ehlers Danlos syndrome. Or it might just be that the child doesn’t feel hungry in the normal way.
In the right setting, the drug cyproheptadine, both can be a useful choice for enhancing weight gain and preventing weight loss.
What if you could increase calorie intake for your child and the intake of quality nutrients by up to 30% without drugs?
Perhaps leveraging all of the recent research on helping people lose weight using environmental triggers and resetting the body’s satiety cues could be done in reverse to help children get more nutrition and gain weight?
Ways to Increase Calorie Intake
- Plate color. In a fascinating study, 60 college reunion attendees were directed either to buffets serving pasta with Alfredo sauce or pasta with tomato sauce. Once in line, the alums were randomly handed a white plate or a red plate. Turned out, those with a plate color that matched their pasta sauce (tomato sauce and red plate or Alfredo with white plate) averaged 30% more to eat! (They also found that reducing contrast between the plate and the background (table, tablecloth, or placemat) reduced serving sizes by another 10%. So you could do the opposite of what the researchers recommend and choose plates the same color as the food, and use a placemat color or other background of high contrast to the plate.
- Plate size. Many studies (including the above study) have shown that using smaller plates results in people feeling satisfied by eating smaller portions. The converse is also true. People tend to eat more when served on larger plates, without thinking about it. This effect is so strong that it holds up even when people don’t like the food! In a famous study with fresh versus stale (14-day-old!) move-theater popcorn in medium versus large containers, those who got the popcorn in a larger container ate 45.3% more popcorn. But even when the popcorn tasted terrible, those who got the larger container ate 33.6% more popcorn that they didn’t want. Container size matters! Choose larger plates and containers..
- Portion Size. Independent of plate size, people tend to eat more when the portion size is bigger, even if they are not hungry, and even if they don’t like the food. In one study two groups were given pasta on plates of the same size, but one group got 350 gm of pasta, the other got 600 grams. Before they were served, they were both given an educational briefing about how portion size might influence how much they ate, and both groups were then asked to write about how they might avoid this. Didn’t being aware help? Nope. Those with larger portions ate 30% more pasta than those in the small portion group.
- Servings per Container. Many food manufacturers trick consumers into eating more by putting more than one serving into a container they want someone to consume in a single setting. Looking for these foods and beverages can let them do the tricking of the brain for you.
- Liquid calories. Liquid calories don’t trigger satiety the way solid calories do. Most people should avoid drinking calories – but when trying to help weight gain, look for ways to make beverages count. I suggest healthy smoothies as one way to do this, which I like far better than Pediasure, Boost, or Carnation Instant Breakfast – and far, far better than sugary sodas.
- The Milk Bet. There’s a famous bar bet that people usually win – bet you can’t drink a gallon of milk in an hour and keep it down for an hour. The protein and fat in the milk fill people up in a way that makes it nearly impossible to do (unless you use skim milk – http://www.loudermilk.org/milk/).
- When drinking milk calories, nonfat milkis much better than whole milk for gaining weight. Among other reasons, people will drink more calories this way. I first learned this from an organic dairy farmer who has a single solution whenever a calf was too skinny – switch them to skim milk to speed their weight gain.
- It’s easy to drink a gallon of beer in an hour. I’m not suggesting this for your son – but carbs are much easier to get down than fat. I’d suggest high qualityfresh-squeezed or cold-pressed juices. Not great when trying to lose weight, but can be reasonable for getting extra servings of veggies, fruits, and various good nutrients while gaining weight. If buying them in a bottle, look for those with 2 servings per bottle.
- Glass shape. It turns out the shape of a glass can have as large an impact on how much someone drinks as the size of the glass. Short wide glassesencourage people to drink much more than the same volume glass that is tall and skinny. In fact, even when the glasses are the same volume, people tend to drink about 30% more (29.75%) from short wide glasses. Also, people tend to drink faster and more if the side of the glass is curved or slanted.
- Color works here too. A cup or mug that matches the color of the liquidtends to increase consumption.
- Some people will drink more of a beverage if they are holding the cupwhen it is filled.
- And bigger glassesor mugs help, independent of shape.
- Stand up. People tend to eat or drink more, without noticing, when they eat or drink standing up, or not at a table.
- Eating speed. One of my favorite series of studies looked at eating speed and found that eating speed correlated with weight gain more closely than all other factors. The difference in outcome between 2.3 bites per minute and 3.2 bites per minute was dramatic. Slowing down from 19 seconds per bite to 26 seconds per bite results in eating significantly less. To gain weight, then, pick up the tempo. Eating tempo is unconsciously increased by several environmental factors (in addition to several factors above). People eat more slowly with soft music, dim lights, muted colors, and a clean environment. They become aware of feeling full sooner. Several cues have been shown to pick up the pace (and amount people eat):
- Music with a lively beat
- Bright light
- Bright colors – especially red and yellow – in the dining area.
- A cluttered dining area.
- Pictures of Food. People eat more of a cake if there is a picture of cake on the box. Casually leave cookbooks or websites with gorgeous pictures open. In homes with cereal boxes stored on the counter, people eat more. Watch Food Network shows.
- Kids tend to eat more when they cook (the same goes for Food Network viewers who make the recipes). Perhaps a cooking class? A knife class or a baking class?
- Calories per Volume. The volume of food is a big determinant of when people stop eating – and perhaps especially for kids who complain of their stomach hurting when they eat. To increase the calories per volume, either remove volume (think dried fruit– someone can eat many more dried apricots than normal apricots, and get all the great nutrients) or increase calories in the same volume (add butter, oil, or avocado – something you’ve probably already done, since it is usually the first thing suggested). Choose calorie dense foods, not bulky ones. For instance, Granola has more calories per ounce than corn flakes. A panini press can help take the air out of bread.
- People eat more Blue Lake green beans than the same green beans if they are just called green beans. They eat more of the same blueberries when they are called hand-picked blueberries. And drink more of the same wine if it’s called California wine instead of North Dakota wine. Not only that – people eat more of the accompanying food if the same wine has won an award or is introduced with positive descriptors. Tell your son what’s for dinner, and subtly add appetizing adjectives.
- The right aromas. Fresh-baking bread or sizzling appetiters can signal the brain to increase hunger.
- Choose Binge-worthy Foods. Healthy, but binge-worthy. The idea is not for him to binge, at all, but to choose foods that are easy to eat even when not that hungry. People tend to go through an entire bag or box of cookies or chips, but not apples. More healthful options that people might eat a lot of include Triscuit or Wheat Thins style crackers, cherries, or pizza (made with healthy ingredient, not the fast-food, low quality version). There are many others. Think either (whole-grain) carbs, bite-sized, or flat foods as a good place to start.
- Mindless Eating. This goes along with eating while not at the table. Many studies have shown that kids eat significantly more while watching TV, going to a movie or sporting event, or are engaged in other activities. Take him out to a ball game. Popcorn can be a healthful whole grain snack. Consider a big tub of fresh popcorn with butter or a big bowl of hummus with things to dip when watching TV.
- All-You-Can Eat. People tend to eat more at buffets and with all-you-can-eat deals. Consider looking for these when out with your son.
- Celebrate with Food. People tend to eat more on special occasions. Think of lots of reasons to celebrate with healthy food.
One key to all of this is subtlety. Kids tend to unconsciously resist eating more when we are trying to get them to eat more. You don’t need to mention that the plates are bigger or you’ve changed the shape of your glassware. Let the aroma of baking bread call to him – but don’t ask him if he smells the bread.
I wouldn’t make all of these changes at once, but spread them out over the next year or so – they are more likely to have additive effects that way. And choose the ones that work the best for your family. Some of these are easily reversible when children are at an ideal weight (dinnerware size, shape, and color). Others are tougher to reverse (binge-worthy foods). All of these can be worth the effort of habit changing at the other end.
There’s little that’s more important than what kids eat and how wonderful that you are paying attention to this, even if others around you aren’t.
Koert Van Ittersum and Brian Wansink, Plate Size and Color Suggestibility: The Delboeuf Illusion’s Bias on Serving and Eating Behavior, Journal of Consumer Research, The University of Chicago Press
Bad Popcorn in Big Buckets: Portion Size Can Influence Intake as Much as Taste, Journal of Nutrition Education and Behavior, Elsevier
Karen Cavanagh and Lenny Vartanian, The Effect of Portion Size on Food Intake is Robust to Brief Education and Mindfulness Exercises, Journal of Health Psychology, Sage journals
Fast Food Restaurant Lighting and Music can Reduce Calorie Intake and Increase Satisfaction, Psychological Reports, AmSci
Brian Wansink, Collin Payne, and Jill North, Fine as North Dakota Wine: Sensory Expectations and the Intake of Companion Foods