| Challenge | Counseling strategies |
| When and where food is consumed |
| Family has little or no structure to eating patterns (few family meals, meals are not eaten at the table, television on during meals, grazing, etc) | - Advice to caregivers and/or older children:
- Eat meals together as a family as often as possible.
- Schedule regular times for meals and snacks.
- Avoid skipping meals.
- Limit mealtime distractions (eg, television, smartphones, tablets).
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| Family frequently eats meals away from home | - Identify barriers that prevent the family from eating at home more often.
- Provide meal-planning resources, initially using recipes that are familiar to the family; begin the process of cooking more at home using these recipes.
- Assess the type of restaurant and usual selections, and discuss healthy alternatives.
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| Skipping meals | - Emphasize the importance of eating 3 regularly scheduled meals a day to have a healthy weight and metabolism.
- Explain that skipping meals can lead to increased hunger and excessive eating later.
- Start by establishing the goal that the child eats something (eg, just 1 food group) at the time that they would usually skip a meal.
- Increase the goal gradually by introducing other food groups as the child is ready; encourage the child to achieve a balanced meal.
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| Excessive snacking | - Set a snack schedule between meals to encourage less grazing.
- Work with the family to identify several choices for healthy snacks.
- Emphasize the importance of eating a single portion of food from 2 different food groups to encourage fullness until the next meal.
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| Food choices |
| High intake of sugar-sweetened beverages | - Explain that sugar-containing beverages (including 100% fruit juice) often cause weight gain because they have high calories but may not help the child feel full.
- Estimate the calories that the child is currently taking in from these beverages and how much of their daily energy needs are "used up."
- Recommend eliminating sugar-sweetened beverages from the home environment.
- Suggest low-sugar alternatives for the family to try.
- Substitute water or low-fat (skim or 1%) milk (unsweetened). Plant-based milks are acceptable if unsweetened; soy milks are preferred due to higher protein.
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| Lacks nutritional knowledge (no label reading, does not make shopping list, etc) | - Assess family's level of nutritional knowledge, and start by helping them set small goals, such as balancing their plates or providing a variety of foods.
- When the family is ready, increase goals gradually by discussing which foods should be eaten most often and which should be eaten sparingly.
- Teach the family to understand and interpret a food label, especially serving size and content of fat, added sugar, and fiber.
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| Poor dietary quality (lack of fruits/vegetables and whole grains, consumption of whole milk, etc) | - Provide education about food groups, discussing the importance of each food group as part of the daily diet.
- One approach is to discuss the concept of a "balanced plate," focusing on supplying ample vegetables, fruits, and fiber (approximately 1/4 plate each for vegetables, grains, fruits, and protein). Guidance is available at the MyPlate website.
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| Excessive refined grains (white bread, pasta) and simple carbohydrates (sugars) | - Emphasize the importance of including fiber in the diet as a means of decreasing hunger and feeling full after eating.
- Explain that whole grains are digested and absorbed at a slower rate than refined gains and sugars, resulting in a more stable blood sugar, which reduces hunger and is healthier.
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| High-fat dairy intake | - Compare nutritional information of high-fat dairy products with low-fat dairy products.
- Discuss types of fat: which fats are healthier and which fats should be avoided (ie, saturated fats).
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| Low fruit and vegetable intake | - Provide education regarding serving sizes of vegetables and fruits.
- Discuss the importance of fiber from vegetables and fruits.
- Have the family try new vegetables and fruits to increase variety.
- Provide quick and easy recipes or products.
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| Managing the child's food preferences |
| Picky eating | - Advice to caregivers:
- Introduce the child to new foods gradually but consistently. Encourage (but without pressure) the child to explore food appearance, feel, and smell as well as taste.
- Provide the same foods for each family member; no "special orders."
- Provide meals and snacks on a predictable schedule, without compensating if the child chooses not to eat what is offered.
- Encourage, but do not pressure, the child to eat a specific food. The caregivers should continue to offer the same food on >10 occasions even if the child declines to eat it.
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