Tanuja Gandhi, MD (Host): Welcome back to Mind Cast Healthy Mind Healthy Child, a podcast from the mental health experts from Bradley Hospital.

I'm one of your hosts, Tanuja Gandhi.

Greg Fritz, MD (Host): And I'm Greg Fritz, your other co-host. Today we have Kristen Abatecola here joining with us, and she is a senior clinical dietician here at Bradley. Today, she's going to be discussing families and meal times with us. And we are looking forward to this. Welcome, Kristen. Glad to have you aboard.

Kristen Abatecola, MS, RD, CNSC, LDN: Thank you very much for having me. I am one of three dieticians here and we work with children and families, to try to help encourage, healthy lifestyle with, not only nutrition, but how that's going to interact with sleep and, how they feel about their bodies and things like that. So we do a lot of education.

Tanuja Gandhi, MD (Host): Kristen, thank you so much for joining us. This is such an important topic. In our work together, I've seen the passion you have for the topic, and many times I've reached out to you for support when families are asking questions about their children being selective or picky eaters.

Kristen Abatecola, MS, RD, CNSC, LDN: Yes. So we do have some children that are what we call selective eaters. What this kind of looks like is it's more than just a typical food jag.

So when children are young, usually it starts around two years of age. They might be stuck on a certain food, maybe it's peanut butter and jelly sandwich, and they want that breakfast, lunch, and dinner. And that will end in a week or two. And again, that's just like a food jag, but, when it tends to be more where kids are very restrictive on what they're eating; like say they'll only be open to eating five or six things. As you can imagine, that can end up leading to different nutrient deficiencies. Lots of times they're, excluding a food group or two food groups. So we look at something like that. Oftentimes it's fruits and vegetables that end up falling by the wayside.

Some children also have just only been exposed to certain foods, so maybe life is really hectic and it's eating at fast food restaurants and chicken tenders and things like that. And then the kids just really get stuck on these certain types of foods. And then when you want to expose a well-balanced, homemade family meal, they're like, whoa, I like this high fat, high salt meal that you were giving.

So sometimes it can just be resistance and then sometimes it really is that they'll get stuck. And we see that oftentimes with our autistic population. We'll call it like the tan diet and it will be french fries, potatoes, chicken nuggets or chicken tenders, bread. And it's limiting of so many different nutrients that they'll be missing.

Tanuja Gandhi, MD (Host): But why is picky eating bad, or why is it such a big concern? And how do you differentiate whether it's kind of a phase that the child is going to grow out of, or if it's something to get worried about.

Kristen Abatecola, MS, RD, CNSC, LDN: Yeah, so I think the concern is a lot of times the parents will say, wow, I just made this whole beautiful meal and no one's eating it, and now I'm stuck giving them the bowl of cereal that they want, or things like that. So I think that sometimes parents feel very badly about it themselves or question their parenting with it. But what can happen is, as I had alluded to, if we have a very limited diet, we could be missing out on all these different vitamins and minerals and we can have deficiencies with that.

We do know that food can impact your mood. Just like sleep will impact your mood and exercise will impact your mood and food will too. So that's why, it's important that we have a good overall diet and when it does become really problematic, I would say is when this is going on week after week and you're going out to eat and the kids are still stuck on the same food or the lunch is coming back and it's untouched. Sometimes it can be problematic if the child isn't gaining weight or they're gaining weight too quickly, because of the types of foods that they're eating. So things of that nature.

Greg Fritz, MD (Host): So in some families, there's already a lot going on in there. There's families that are, the child's are having mental health problems, ADHD, anxiety, trauma, something like that. So there's already a lot that's being dealt with. There's two things I wonder. One, is where do you have to pick your battles somewhere?

And we can't address everything all the time. But the other side of it is that those problems, those mental health challenges impact what goes on at the meals. So what can you tell us about how mental health issues intersect with mealtime challenges for the selective eaters?

Kristen Abatecola, MS, RD, CNSC, LDN: That is definitely of concern. Many of us, even if there isn't mental health issues in the family, we're running around and we've got this soccer practice and I've gotta get out of work and I've gotta make dinner, and we have all of these things going on. When we have children with anxiety or depression, a lot of what will happen is we have some kids that will end up eating their feelings, so, they're sad and food makes us feel better. It could be their comfort, especially with some children dealing with trauma. So food is their comfort and then sometimes you will have people that when they get anxious they're very uncomfortable, like if I put food in my belly right now, I am going to feel nauseous, I'm going to be uncomfortable, and things of that nature. So it really is definitely can be anxiety provoking in and of itself when this happens. What I would recommend is that we try to encourage our children, we try to encourage them with certain foods, but I like to tell parents, and you know, I didn't come up with this theory myself, but parents are responsible for providing the food, and the kids are responsible for how much they're going to be eating of it. So we shouldn't be forcing, we don't want to get into battles at mealtimes. Food is supposed to be enjoyable. It's a time to connect. So we just want to encourage the kids to eat, without forcing.

And, you sometimes you need help from a professional in, one-on-one working with the kids. I find a lot of this anxiety happens if kids have trouble going to school, maybe they're afraid to go to school and then they're anxious about it and they're nauseous.

 So we try to develop different strategies for that. But yeah, it can be very difficult.

Tanuja Gandhi, MD (Host): What we know from our work with children who have ADHD or in general are struggling with depression or anxiety or other mental health challenges is that structure works. And I think it's a challenge for all homes to become perfectly structured, but there seems to be benefit to having structured times, including meal times, for when you're doing certain activities. What do you think would be helpful in terms of like having structured meal times and how do you set that up? Or is it okay to kind of graze and snack every now and then? What would be helpful, especially if the child is a selective eater.

Kristen Abatecola, MS, RD, CNSC, LDN: Yeah. So, you hit the nail on the head. Structure is key just for so many different behaviors, but the way that we have been taught to eat is all based off of structure. It's like, okay, even when, our children were infants, it was, they wake up, we give a bottle, we're going to play a little bit, we're going to sleep. It's a structure. We develop these patterns. Patterns are predictable. So with a child with anxiety or depression or ADHD, I think it's definitely even more so important that they understand and know what is going to happen next.

So for meals. Okay. Like we have a breakfast. We have to allow enough time before school starts. I hear all the time that, kids will be like, well, I didn't have time to eat. We have time. We just have to make it. So putting aside the electronics, having a little bit of something to eat before school, getting the kids involved in the packing of the meals so that that way they have something that they might be interested in.

Okay, you come home from school, we have a snack. Here's some ideas of what snacks might look like. And then we go on and we have dinner. We have dinner as a family at 5:30, 6 o'clock and we can't be so rigid that we can't deviate from it. Because that will always come up. But I find that kids do better if they know what to expect.

And that also applies to meal times themselves. Grazing is definitely an issue, especially with kids, I find with ADHD they have difficulty just sitting still. So to be able to sit for a meal can be challenging. And they like to just pick up something and move around and do something. But what will happen is all this grazing throughout the day, our little bellies don't have a chance to get hungry for a meal.

And then mealtime comes around and we're not hungry for the meal. And then, there's all the anxiety around the meal again. Like I may just made it the meal and nobody's eating, and things of that nature. So the more consistent we can be, and I like to tell parents we have breakfast depending upon the age of the child.

We have an AM snack. Then we're going to have lunch, and then we only have water in between until we have our afternoon snack and then we have a dinner. So it's all these times we allow ourself to get hungry and, I find that it seems to help.

Greg Fritz, MD (Host): What about milk? It seems like parents sometimes are, when they're worried about the kids getting enough nutrition, say, drink your milk, you know, and drink, more milk.

Kristen Abatecola, MS, RD, CNSC, LDN: Milk is, it's a wonderful drink. It is packed with nutrition, it has protein, it has calcium and vitamin D, riboflavin, vitamin K. It's wonderful. But we really only need for kids to grow for the amount of calcium that they need, we only need three eight ounce servings a day. So I like to think about that as they can have a glass of milk with their meal. If they prefer to have a glass of milk with their snack, that's okay. I'm a big fan of milk at meals, water in between. But what will happen is too much milk, although it does have a lot of nutrition, too much can end up filling your belly.

So if we're drinking 16 ounces of milk and then expecting the child to sit and eat a little piece of meatloaf and a scoop of mashed potatoes and a vegetable, they're going to be getting full off of the drink. So I would limit to three eight ounce servings a day.

And it could also be, instead of milk, if they wanted to have a eight ounce portion of yogurt or something like that. It's very similar as far as calcium goes. The other thing to keep in mind too is that calcium, which is the main reason why milk is pushed so much, it also blocks iron absorption.

So if we're drinking lots and lots of milk, then we can be decreasing the amount of iron that's absorbed, and then we know that iron is going to impact our ability to sleep if our iron stores are low, in addition to other things.

Tanuja Gandhi, MD (Host): We've seen families trying to respond to increased hunger in kids on certain meds with snacks and chips or cookies, because that's what the child probably wants to eat. So I'm wondering if you have some advice on smart strategies for families to manage the extra appetite that kids could be gaining due to medications or medical conditions. And making those choices, healthy choices. And let me make that a little more complicated and choices that the kids are going to like.

Kristen Abatecola, MS, RD, CNSC, LDN: Hmm. Oh, that last part definitely did make it more difficult. So yeah, I mean, we've all experienced hunger and how uncomfortable that feeling is. We don't want to feel that way. A lot of times, what happens is the foods that we're eating are not fiber dense, or there might not be enough protein. So what can happen is we have a meal and then we get hungrier quicker because we're not really satiated, which leads to snacking. Or it could just be a snack time. So what we want to think about is the same thing. We want to be able to have protein and fiber together is what's going to make the best snack. So things like that would be it could be a yogurt with some granola and some fruit. It could be an apple with peanut butter or banana with peanut butter. It could be a string cheese with some fruit, things like that.

It could be vegetables with some dip, and a little bit of cheese, like a, you know, say it sounds silly, but I mean, you can just take a paper plate, put out a few crackers, maybe some whole grain crackers, a few slices of cheese, couple of vegetable sticks, a little bit of fruit. It's like a mini charcuterie board that's really fun.

 So sometimes just making things fun like that. It could be something as easy as like guacamole with like some tortilla chips. So I think the key part of this is we want something that's going to be filling so then we're not hungry immediately after. And that fiber and protein is definitely the balance to go.

We also want to think about making sure that we stay hydrated throughout the day, because a lot of times we're going to feel hungry if we're not hydrated. So making sure that we're drinking water throughout the day. And then the other part is I really mention water a lot, but we want to limit these sugary drinks.

We become thirstier when we have all the sugar that we're drinking. Right. It's not good for our teeth and things of that nature. So, definitely limiting soda, juice as well. Four ounces of juice a day is enough. Punch, drinks of that nature and definitelye staying away from those caffeinated or energy boosting drinks. I hear lots of kids talking about those.

Tanuja Gandhi, MD (Host): These are excellent points. One more question. How can families serve one meal for everyone when kids are selective? I've heard families say, we cook what the kid likes, and that seems to be three different meals for the entire family. It seems like a big hurdle.

Kristen Abatecola, MS, RD, CNSC, LDN: Yeah, it can be really challenging. I know, my kids are grown now, but one of my biggest challenges was always, what am I going to make for dinner? And I think every family is thinking about that. One thing that I like to emphasize is something that can be fun, like a taco bar or a pasta bar.

So you're making pasta and maybe you have, keep some pasta that's plain. And there's butter and cheese to put on it, or you have a little bowl with some sauce or meat sauce. It doesn't have to be very complicated. It could have some beans. I personally put beans on my pasta.

I love it. Not for everybody, but some people might want, some meatballs with it. So having some different things out. Same thing with the taco bar. There's some meat, there's some beans. Here's our shells, here's our cheese. And then, the kids are assembling it themselves, pulling out the things that they really like.

But at least it allows for everybody to have something that they might enjoy. And it's also important, to keep in mind that if your child is only eating 6, 7, 8 things, maybe you put one of those things out. So you have a few different things. Maybe there's chicken and you know, you're making grilled chicken and you know that they really like mashed potatoes.

So you have mashed potatoes. Make sure that that's available. And then you're having different components. So there's always something there that's familiar and comfortable. And it also takes 10 to 15 times of trying something, being exposed to it before you might actually like it. I try to always remind people that we need to be role modeling in having these good behaviors ourselves as adults.

So if we're role modeling, like, wow, this is really good and trying out things and our body language is in check, lots of times kids might be interested in trying something, the more we can get them involved with it. So saying, you know, that's something you would like at dinner.

Greg Fritz, MD (Host): Does that approach go for helping kids try new foods? I mean, oftentimes that isn't, that's a hurdle and it can get into a headbutting struggle.

Kristen Abatecola, MS, RD, CNSC, LDN: Yes, absolutely. I think that it's important for families just to encourage, again, it's that encourage and not force. One of my colleagues, I'm going to throw it out there because she's going to listen and love this.

She always says to the kids here, don't ick someone else's yum. So I try to let the kids know when I meet with them and provide a snack during my classes we just say, you know what? I didn't care for this, or it's not my favorite. Because what somebody else loves, somebody else might not like.

I think that the more kids have maybe an active role in meal preparation or selecting some things is important too. Grocery shopping has to happen, so maybe alternate if you have multiple children bring one child with you to the grocery store and we pick a new food. I used to do that when my kids were little.

They were the helper of the day and they got to pick out a new fruit or vegetable to try and they felt very empowered. It was very exciting. And also the other thing that I like to point out with this is we want things to be prepared in a variety of ways. One of the classes that I do with the kids that is a favorite is we do an apple taste test, and I will give them fresh apple slices, apple sauce, and then dried apple. All taste very differently.

And then what I do is I have a big post-it sticker sheet on the wall, and I tally how many kids love it, how many kids say it's okay. And how many kids say it's not my favorite. And then they have a nice visual to say, wow, I loved the apple slices and I loved the apple sauce, but I didn't like the dried apple.

And then what I say from there is, if you were exposed only to dried apple, you would say, I don't like apple at all. And you're missing out on all these other things. So we just want to try to do things a little bit differently. And then, like I had mentioned before, multiple exposures. It's going to take quite a bit of time before kids will really, turn onto it.

Greg Fritz, MD (Host): Yeah. One shot learning doesn't happen.

Kristen Abatecola, MS, RD, CNSC, LDN: Absolutely.

Tanuja Gandhi, MD (Host): So to change gears a bit, many of our patients in the hospital or in general, patients who are in treatment for ADHD or in our clinics can be on medications, in particular stimulant medications. And it is well known that they can affect appetite. Not necessarily, but it's a big possibility. What's your advice for families who have kids on stimulant medications and they don't want to eat?

Kristen Abatecola, MS, RD, CNSC, LDN: Yeah, this can be challenging. We always tell people to listen to their bodies for when they're hungry, which is great, but when we have a medication that's affecting our appetite, it is very challenging.

 I have a few ideas, one that I feel is very important is definitely getting a good breakfast in before the medication is taken. So we know that the medication is only going to last for a certain span of time, and it kicks in very shortly after it's taken. So getting that breakfast in is important.

Trying to pack something for lunch, that the kids might like. And even if it turns out that they're just having a couple of snacks. Ideally we'd love them to have a sandwich and a fruit and a little starch and a drink and all of that. But with these types of kids where they're just not hungry, maybe just like some chips and salsa. If that's what they want. It can be a snack food, it can be a yogurt. That's enough. When the kids come home from school, they're usually famished by then because the stimulant is wearing off. And then they didn't really have a lot for lunch. So what we want to do is go back to that, the talk about snacks that we had.

So we want to have a good hearty snack after school, something with protein and fiber. But the key is that we don't want to make it too big because then it's going to interfere with dinner. So then we'll have a kid not wanting lunch and not wanting dinner. So we want to keep the snack reasonable, again, protein and fiber.

It could be something like a nice yogurt parfait after school if they like that, having yogurt, add some granola, add some fruit, things like that. And then dinner could be two, three hours later, but that way hopefully they'll be more inclined to eat.

Tanuja Gandhi, MD (Host): Right and just an extra point to children who are losing appetite due to medication, especially stimulants, this is for our listeners is that if it gets really concerning, make sure to follow up with the pediatrician or the doctor prescribing the medication because not always is the stimulant responsible, but if it is, there are other things that you need to follow up on. Well, on that topic, do you have some ideas, Kristen, on healthy snacks?

Kristen Abatecola, MS, RD, CNSC, LDN: Yeah, I mean, ones that I think are great, cheese sticks. They're nice and convenient. They're easy. Kids, love peeling them. Peanut butter and crackers, guacamole with tortillas, yogurt and fruit, or add a little granola in there. We want to have good food readily available. I know when I am hungry, I get hangry.

I am not nice to be around. So, if I'm really at that point coming home from work, just like a child would come from school and I'm famished, I need to have something that I can eat very quickly. So if I have to be cutting stuff up and things of that nature, I'm not going to want to do it. I'm going to want to go for something that's quick and easy, and it might not always be the great choice.

So, just for everybody, not only kids like this, we want to have things readily available. So it might be spending a little bit of time, with cutting up some pepper strips, cutting up some fruit. There are apple slices that won't brown, guacamole. You can buy little cups of that and just peel off the top.

So there's lots of things that we can do ahead of time, that really don't take a lot of time just to make it accessible. So that it's easy to grab when we get home.

Greg Fritz, MD (Host): Wow. This has been really helpful and we appreciate it, Kristen. Thanks a lot.

Kristen Abatecola, MS, RD, CNSC, LDN: You are so welcome.

Greg Fritz, MD (Host): You, you break this down in such a, uh, reasonable way and always have a good, kind, approach to it that, uh. I think is very helpful. Before we go, maybe you could tell us what's, if you had one take home message for parents who are having kids with mental health challenges and one thing that would help mealtime, what would that be?

Kristen Abatecola, MS, RD, CNSC, LDN: Hmm. Oh, this is a tricky one. I've got so many up my sleeve. But, I would have to say one of the biggest things is just to have a little grace. Dinnertime is not going to be perfect every day. We don't want it to be in anxiety provoking for parents, for kids. We want it to be an enjoyable time. So have a little grace. We're doing the best we can. Maybe have a visual calendar on the fridge so people know what to expect for dinners.

You can reinforce with certain things, it's just, it's not always going to be perfect. And then the other little thing, you're going to give me two things that I think are great takeaways. Yes. I'm not to say two things. Two things, two things. I can't emphasize enough that structure is key. It really, really is.

We need to be able to expect what's coming. And I don't want to be blindsided at work. I want to know how my day is going to be going. And if all of a sudden I'm putting out all these fires or things start springing up on me, my routine changes, it's not going to go well. And I think that that's the same thing for kids.

Greg Fritz, MD (Host): Absolutely.

Kristen Abatecola, MS, RD, CNSC, LDN: So having good structure. Yep.

Tanuja Gandhi, MD (Host): Well, Kristen, this has been a pleasure. I haven't met someone else who has this enthusiasm to talk about food. I mean, I love my food. Mm-hmm. But not talking about it. So thank you. For all our listeners, thank you for tuning in. For more informative podcasts from the experts at Bradley Hospital, please visit www.bradleyhospital.org/podcast.

Until the next time.