The Trust Model: A Different Feeding Paradigm for Managing Childhood Obesity

A common assumption is that small portion sizes, fat restriction, and calorie awareness are necessary in controlling weight gain for overweight children and will lead to weight loss if these behaviors are pursued rigorously. However, dietary restriction has been shown to backfire, as it is associated with preoccupation with food, eating in the absence of hunger, poorer self-esteem, and further weight gain (1,2,3,4). The efficacy of current dietary treatments, particularly for long-term weight maintenance, is doubtful. Most of these interventions rely on dietary restriction as their primary strategy. Hence, there is a compelling need to investigate pediatric obesity intervention paradigms without a core focus on dietary restriction. One such paradigm is the trust model proposed by Satter, a dietitian and social worker with experience in child-caregiver feeding dynamics (5). This paper will review the model constructs and examine its applicability as a dietary intervention for preventing and managing childhood obesity. The trust model emphasizes the division of feeding responsibility between caregivers and children and trust in the child's ability to self-regulate food intake by recognizing hunger, appetite, and satiety cues within the context of regular eating patterns (i.e., pleasant and structured meals and snacks) (Figure 1). The model deemphasizes portion sizes, the food pyramid, calorie or carbohydrate counting, eliminating certain foods, or overreliance on low-fat or low-calorie food options. No type of food is restricted; the trust model posits that dietary restriction creates feelings of deprivation, which lead children to crave and overindulge in the restricted food when an opportunity arises. Pressuring children to eat also is strictly discouraged because it can disconnect children from their hunger, satiety, and appetite cues. Specifically, caregivers are responsible for selecting foods to present at meals and snacks, the timing for meals and snacks, choosing the place to eat, sitting and eating with children, and keeping the atmosphere pleasant. Children are responsible for what to eat and how much (or even whether) to eat from the food provided. Food selection is emphasized only within the scope of creating meals and snacks of increasing variety and balance within the context of the family's abilities and preferences. Caregivers are taught to plan and serve a balanced meal with protein, carbohydrates, fruits and/or vegetables, dairy/calcium, and fat. Schematic representation of the trust model. The trust model is implemented within an environmental context of recognizing children's physical and emotional stages of development, children's natural growth patterns, food choices and availability, the medical and psychosocial characteristics of the caregiver and the child, and shared responsibility for physical activity (Figure 1). Satter (5) stresses that caregivers not misinterpret children's natural growth pattern as a manifestation of a feeding problem per se, as children will be of different sizes and shapes due to their genetic constitution. Four behaviors interfere with caregivers' ability to guide (nurture and preserve) the development of children's trust in their internal hunger, appetite, and satiety cues: misinterpretation of normal weight, restriction of food intake, pressures to eat when children refuse food, and using food as a calming agent (5). Satter contends that some caregivers overcontrol children's intake because of underlying conscious or subconscious anxieties about weight, body image, appearance, nutritional quality of the diet, specific food group or nutrient consumption, or inconsistent food supply. Others undersupport children's feeding by not providing regular feeding opportunities or appropriate modeling for eating, which leads to a chaotic food environment. Satter believes overcontrol and undersupport are the core of nonorganic child weight and growth problems and must be addressed in order to treat or prevent these problems (5). The difference between the trust model and traditional dietary methods is not external vs. internal control, but rather caregivers taking leadership by structuring feeding opportunities and giving their children autonomy within that structure (Table 1). In the trust model, the caregiver takes responsibility for the feeding environment, yet honors children's self-regulatory processes, thus building trust. It postulates that children who are not permitted to control their food intake learn self-doubt, ambivalence, and dependency with regard to eating and regulating their food intake. Children who are trusted to regulate how much to eat develop positive self-esteem, learn responsibility and self-care skills, appreciate their bodies, and do not become preoccupied with food (6). In summary, the trust model emphasizes feeding dynamics (i.e., appropriate division of responsibility between caregivers and children) and shuns any coercive feeding strategies (i.e., food restriction, pressures to eat). Satter's model proposes that, for prevention and treatment of child eating and growth problems, the primary focus of change must be altering caregivers' maladaptive feeding behaviors. The change desired in children's eating will emerge from (i) their innate drive to eat, self-regulate their intake, and grow in a predictable manner and (ii) the degree to which caregivers can optimize feeding (5). Although proposed in 1986 (7), the trust model has not been tested with methodological rigor in an experimental setting for either childhood obesity prevention or treatment. Most research that has supported its constructs has focused on preschoolers, feeding behaviors, or obesity prevention (8,9,10,11,12,13). Extant data have not revealed a consistent association between parental feeding behaviors and children's overweight across age (14,15), gender (14,16), socioeconomic status (SES) (17), maternal characteristics (e.g., obesity) (10,18,19,20), or within families (16,21,22). These variables (in addition to others such as ethnicity, culture, parental dieting history, parental eating behaviors, and perceived self and response efficacy for changing feeding behaviors) need to be examined in a testable model using latent variable structural equation modeling. Depending on the exposure and outcome of interest within the feeding relationship, the same variable may act as a mediator, moderator, or confounder. Reports of the efficacy of the trust model are largely anecdotal. None of the studies cited in three comprehensive reviews on interventions for preventing or treating overweight children focused on feeding dynamics, which is at the core of the trust model (23,24,25). A recent study used some of the trust model constructs as an intervention for overweight children aged 6–11 years (26). Its objective was to compare outcomes when the intervention was directed at parents-only vs. parents and their obese children. Parents were taught to be responsible for controlling where, when, and what food was offered to children. Family meals and pleasant mealtimes were emphasized. Children lost more weight in the parent-only group compared to the parent-and-child group. Because children's feeding responsibility, as described in the trust model, was not taught to either group, these results do not fully address or lend support for the trust model. How or whether external characteristics (e.g., palatability, accessibility, availability, cultural practices, maternal weight) influence response to the trust model has not been investigated. Indeed, children of mothers who engage in disinhibited eating are less able to self-regulate food intake (27,28). Further studies need to examine how modifying feeding behavior or eating patterns can be effective as a dietary intervention. Accordingly, the first step is an in-depth review of extant literature of the trust model (or individual components of the model) as a dietary intervention. Child feeding behaviors, obesity, and the trust model. Oftentimes, caregivers use one of two types of controlling feeding behaviors when attempting to encourage good nutritional habits in their children (9,10,18,22,29,30). The first, restrictive behavior, reflects caregivers controlling their children's intake of foods, especially those deemed unhealthy (e.g., high-fat, high-sugar foods). The second, pressure-to-eat behavior, describes excessive pressure placed on children to eat foods that are considered healthy (e.g., fruits, vegetables). For both controlling behaviors, caregivers excessively monitor children's food choices and intake. These practices may disrupt children's awareness of and response to physiological cues of hunger, appetite, and satiety, thereby increasing their risk of dysfunctional eating. Researchers have shown that mothers who adopt controlling feeding behaviors are more likely to have children with poor self-regulation of energy intake (13,27,29,31) and higher body mass (9,10,27,28). More than two decades ago, Costanzo and Woody (32) provided a basis for this link between caregiver feeding behaviors and obesity. In their model, caregiver feeding style is influenced if caregivers (i) are obese, (ii) observe the child to be overweight, (iii) perceive the child is at risk for overweight and associated problems, and (iv) express concern about the child's capability to control his/her weight. Francis et al. (19) supported elements of the model, reporting maternal body mass, maternal dietary restraint, and maternal perception of child overweight as significant predictors of controlling feeding behaviors. Caregivers may use these behaviors because they do not believe that children can regulate their food intake appropriately. In a laboratory study of 77 children and their mothers, Drucker et al. (31) noted that a majority of mothers used some form of prompting or restraint to guide their children's intake. This lack of faith in children's ability to self-regulate food intake can backfire. A study of 196 white girls (assessed at ages 5 and 7 years) found when mothers restricted their daughters' intake, the daughters were twice as likely to eat in the absence of hunger (33). Girls who ate in the absence of hunger were also five times more likely to be overweight at age 5 and 7 years (34). The protective effect of breastfeeding on subsequent obesity in the child has been partially explained by decreased maternal restriction (35), linking restrictive feeding practices to overweight, even as early as infancy. The associations between poor eating regulation, controlling feeding behaviors, and increased body mass has been inconsistent across age (14,15), gender (14,16), SES (17), maternal characteristics (e.g., obesity) (10,18,19,20), and families (16,21,22) suggesting that other variables may moderate the association between controlling feeding behaviors and weight. Perhaps controlling feeding behaviors, as currently measured, is not a single construct. Ogden et al. argue that control of food intake can be overt or covert based on how children perceive their caregivers' behavior (12). If the child perceives the caregiver as controlling, the behavior is overt; it is covert when the perception of control is absent. The trust model counters that the intent behind the specific feeding behavior is what distinguishes between controlling and noncontrolling feeding behaviors. In division of responsibility, caregivers are responsible for what is served; thus, they can provide healthy options and direct children's intake of less nutritious foods, exhibiting covert rather than overt control. Studies are needed to investigate pathways through which controlling behaviors are risk factors for childhood obesity. For instance, what child, maternal, cultural, developmental, and environmental factors in the presence of controlling feeding behaviors adversely affect children's weight? Also, which of these factors in the presence of division of responsibility are likely to help stabilize/normalize children's weight while honoring their natural body size? Data gleaned from these studies will determine whether the trust model's division of responsibility is viable for preventing or treating childhood obesity. Can children self-regulate or relearn to self-regulate food intake? In the trust model, the children's role in division of responsibility is predicated on their ability to recognize hunger, appetite, and satiety cues, or self-regulate their food intake. Most experts agree that if children are unable to internally self-regulate, their weight and subsequent food relationships are adversely affected (10,29). Studies have demonstrated that young children have an inborn ability to self-regulate caloric intake, with some individual variation (13,36). For instance, in the Feeding Infants and Toddler Study, toddlers consumed larger-than-average portion sizes at low-energy-density meals compared to smaller-than-average portion sizes at high-energy-density meals (37). The ability to self-regulate weakens as children and become more to external pressures to eat or intake the to eat, what to eat, and how much to eat are by and by (e.g., and appetite and satiety by the of of the in the the and of the food, to the about its The at which there is a in appetite for a meal based on food cues from and is to as of satiety the in appetite that early on in a the of satiety can help with are especially in the presence of hunger, which is that the The trust model's to not between structured meals and snacks may help children appreciate dietary fat as a to the for satiety, the of the effect The trust model's lack of restriction of dietary fat may it be effective for obesity prevention and treatment. can overweight recognize hunger cues and eating when a intervention of and overweight hunger were by but for overweight In when were hunger in the and they higher satiety with support is that overweight both eat and food intake more than which lead to hunger and satiety cues overindulge in food that they have dietary or have a food In the study when obese of hunger or satiety cues on their food were to focus on their hunger and satiety they that they were able to these and their food intake A of the trust model is that it not any intervention that children to recognize hunger or satiety cues. it that caregivers or feeding practices, children will to Satter internal takes for young children. the children may eat a of food, If caregivers to the trust model, children learn to trust that they will be to eat when and as much as they and to are studies as of yet this the trust model stresses in division of responsibility for self-regulation to develop and the if the trust model's are not any behavior as the behavior is and is a of any behavior change The model that to restrictive or pressure-to-eat behaviors, even for a may the efficacy and any Can children learn to self-regulate their food intake? 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