Katja Rowell, M.D. joins us to discuss responsive feeding, picky eating, and how to parent without passing diet culture norms on to your kids.
We also explore the science behind a few common misperceptions from parents and doctors including: why playful or gamified tactics to change eating habits can be harmful and backfire, the problems with many “early interventions” around child BMI, and reasons to question growth charts in early childhood.
Behind the paywall, Dr. Rowell offers practical advice for parents who want to feed their children well without pressuring them, and Christy shares her experience with her daughter’s picky eating and health concerns. They also discuss how MAHA and anti-vax culture are affecting parents and offer support for relieving the pressure of tricky conversations with other adults.
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Katja Rowell, M.D. is a family doctor, author, and feeding specialist. Described as “academic, but warm and down to earth,” Rowell believes that helping children grow up to have a healthy relationship with food and their bodies is preventive medicine. Her interest in the world of feeding was sparked by her own worries as a parent, ending up with a toddler preoccupied with food. Helping her family get onto a better path inspired Rowell to learn more. Rowell expanded her knowledge; learning from and collaborating with OTs, Speech Pathologists, dietitians, psychologists, and eating disorder experts.
Rowell has particular interests in avoidant, or “extreme picky eating” including ARFID, as well as food preoccupation. She supports adoptive and fostering parents through a trauma-informed lens.
Rowell is part of an interdisciplinary group working towards defining, researching, and implementing the Responsive Feeding Therapy framework for feeding and eating challenges. Her books include, Helping Your Child When Mealtimes are Hard, Helping Your Child with Extreme Picky Eating, Love Me, Feed Me: The Foster and Adoptive Parent’s Guide to Responsive Feeding, and Conquer Picky Eating, a workbook for teens and adults. Rowell enjoys camping with her family and cooking. Learn more at thefeedingdoctor.com.
Resources and References
Contains affiliate links to Bookshop.org, where I earn a small commission for any purchases made.
Christy’s second book, The Wellness Trap: Break Free from Diet Culture, Disinformation, and Dubious Diagnoses and Find Your True Well-Being
Subscribe on Substack for extended interviews and more
Dr. Rowell’s website, The Feeding Doctor
Dr. Rowell’s Youtube channel, @TheFeedingDoctor
Dr. Rowell’s books:
Child of Mine by Ellyn Satter
Hungry for Love by Charlie Slaughter
Christy’s online course, Intuitive Eating Fundamentals
Transcript
Disclaimer: The below transcription is primarily rendered by AI, so errors may have occurred. The original audio file is available above.
Christy Harrison: Before we dive into talking about your work with kid feeding and all the specifics of that, I’m just curious to know how you came to do this work and sort of what your background is with diet and wellness culture personally as well.
Katja Rowell: Yes, I went to medical school and I certainly did not expect to be doing feeding work as a focus. I was in family medicine and I, as a family doctor, was asked all the time about growth and nutrition and feeding and picky eating and all the usual. And I really had no training in it, but somehow I thought I was qualified to give advice. And so I think that that may resonate with your audience in that I think there are a lot of people out there, from the medical providers in the establishment to the wellness folks, who are giving feeding advice and really aren’t qualified to do so. So I just want to put that right out there.
I didn’t really know what I didn’t know, and that’s hard looking back now that I may have been unhelpful as someone who wants to help. So anyway, I found my way to this work as a parent, as I think a lot of people do. I had an uncomplicated pregnancy. I had a child that was off the charts in terms of weight and length. And pretty quickly I started to really worry that she was too big. This was at the time when the childhood, I don’t like to even use the word here, but it’s appropriate, the childhood obesity panic was sort of starting 19 or so years ago, and I had worked in college health with eating disorders, and I had seen in primary care how much struggling with a relationship with food in our bodies impacts health and wellness throughout the lifespan.
So I had this child who was big and had this lovely appetite and enjoyed eating, and it scared me. And so I came to feeding her from a place of anxiety and prevention and we got in the weeds really fast. I had this idea that I could prevent certain weight outcomes or health outcomes. And so I was feeding from this mind space and I pretty quickly had a toddler who was food preoccupied and anxious and eating as quickly and seemingly out of control. And so my relationship with feeding her was really defined by anxiety and fear and trying to control things I couldn’t control.
I got really lucky to bump into a pediatric dietitian at an airport, ironically, while my toddler was inhaling her child’s snack and I was like, I don’t know what I’m doing. She said, oh, I’m a pediatric dietitian. You should read this book Child of Mine. And so I read Ellyn Satter’s book and within a few weeks, I felt much more reassured, understanding what I can and can’t control. And very quickly instituting that division of responsibility, things turned around within weeks.
She was saying no to food and playing where she was previously focused on other kids snacks. So it was just totally transformative in my own home. And so I had to learn more. I actually went and trained with Ellyn Satter. I joined her clinical faculty, I took her courses.
You asked about my journey. I was raised in a very fatphobic home. I had my weight centric training and seeing my daughter’s capability, like hold up, she can turn down ice cream because she’s full, not that that’s the goal, but she could eat some ice cream and be like I’m full. And we’d put it in the freezer for later. And then learning more from people like you and others online and doing so much more research and reading that I wasn’t even exposed to in my training, I started to learn about internally driven guided eating, like intuitive eating and eating competence ideas.
I’m just so grateful for this journey, that I have a 19 year old now who is really able to feed herself well and relates really well to food in her body and the mind space that has been freed for me from my own eating and family and worries. I’m just forever grateful for this whole journey.
Christy Harrison: Thank you for sharing all that and I really appreciate you acknowledging your areas of inexpertise as a medical provider because I think so many doctors will give advice just based on what they know or what sort of diet culture stuff that they’ve absorbed maybe without having a lot of training around feeding and eating and nutrition in general. And so it’s just helpful to hear someone acknowledge that, for sure.
Katja Rowell: Absolutely. And I just want to point out too, I do a lot of collaborating now with childhood feeding specialists, speech pathologists, occupational therapists, psychologists, and the sad thing is even the pediatric feeding folks sometimes don’t get a lot of training. So you might take your child to a feeding therapist and then the reality is is that they’ve had a three day course on a sensory program and then they’re doing feeding therapy.
So really, really I have so much empathy for parents because it’s really confusing when there is so much different advice and you think, well, this is a feeding therapist and, and I didn’t know it either but at the time, SLPs and OTs, they don’t necessarily learn this. It’s not part of their curriculum and there’s not a licensing. And so you can do a three day training in one modality and then put your shingle out. So there are a lot of “experts” that lack a really broad understanding of all the different things that could go into that piece of raising children to feel good about food and their bodies and with all the different scenarios and challenges or differences that can come up.
Christy Harrison: Yeah, thank you for sharing that. I appreciate that. And I’ll share more later about my personal experience with feeding. But as a general dietitian, and now specialized in eating disorders, I didn’t get training on pediatric feeding really at all either. And you know, so feeding my own child, I’ve relied on resources like yours and Ellyn Satter’s and just sort of applications of what I’ve learned through intuitive eating, trying to apply that through the lens of responsive feeding, your work, and Ellyn Satter’s work to my own feeding relationship.
Still, we’ve had some challenges and we are just starting to seek out some help because our daughter has some medical issues that have been challenging and sort of intersecting in interesting ways with picky eating and selective eating at this age. She’s three and a half so it’s kind of the height of the picky eating time and it has been really challenging to sort of find like, who do I trust in this space?
Who can I be sure is not going to lead us astray in this really authoritarian sort of direction around food or getting overly involved in the child’s food choices when really I want to be able to trust her and communicate that we trust her with food and have a more responsive feeding relationship? So it’s just helpful to think through those things and think about who has the credentials that I’m really looking for, who has the training in the background and can really help with these things.
Katja Rowell: It’s really tough and I think parents know their kids best. My book and on our website we have a list of questions you can ask your therapist and I think that’s really helpful. But I think also if, especially if you’re in it, my kind of litmus test is if what you’re doing or being asked to do increases your child’s anxiety or yours–resistance, pushback, power struggles, for some gagging and vomiting, sorry to bring that up, I suppose we should do just a warning, we might talk about some of those things–trust that and if what you’re being asked to do is increasing those power struggles and your child is getting dysregulated and having 45 minute meltdown because of a therapy task at home, trust that and look for second opinion or other resources.
Christy Harrison: Yeah, that’s hugely helpful, thank you. I want to get into some of the details and I guess the background really first about what a responsive feeding approach is, how your approach differs from some of the traditional models of feeding and eating that you might see with pediatric dietitians or speech language pathologists and what the different outcomes might be.
Katja Rowell: Are we talking here where there might be feeding challenges or just in general?
Christy Harrison: Let’s start with in general, sort of a responsive feeding approach to generally feeding kids who maybe don’t have anything else going on.
Katja Rowell: Absolutely. So responsive feeding is really, I mean, there are a couple different definitions and different ways of thinking about it, but to me it’s a focus on a warm, attuned relationship between the caregiver, the parent and the child. We are feeding a child in ways that support their internal drives to eat, that intrinsic motivation. So it’s authoritative, it’s parents leading and then kids deciding. And we are grounding this, or a good way to think of it is in that division of responsibility which I know you’ve talked about. So that’s really foundational. And I’ve heard some say it’s parents provide, child decides.
But roughly the child is in charge of their own hunger and how much to eat from what is provided. And adults are providing enough food that tastes good or is accepted by the child, ideally offering variety and then at regular intervals. So to me, the division of responsibility is really foundational. That’s that core is that the adults are providing that supportive environment so that even if there are challenges, it is responsive and we can help the child do their best and tune in to those hunger cues.
I’ve moved towards the responsive language. I just love the word responsive. It to me really puts that dance between the parent and the child, I’m responding in the moment, I’m responding, if my child has sensory differences, I’m responding where I might be offering extra snack. There’s a little bit more flexibility than the division of responsibility model where I was trained in, where sort of a classic thing from DOR was like, oh, the kitchen’s closed between meal and snack time. And that may work really well for a lot of families, but for other children and in other scenarios, we may need more flexibility.
And so to me, that’s one of kind of the foundational differences is, is having that flexibility both for the child and the parent. What is the parent able to do? How well are they supported or unsupported? What are their challenges? So it builds in a little bit more flexibility. It’s a little squirrely because there’s overlap and different ways of defining it. But we know that division of responsibility and responsive feeding are both endorsed by the Academy of Pediatrics, World Health Organization. UNICEF endorses responsive feeding, for example.
And I think one of the really important foundational pieces under all of this is trusting that pretty much across the board we are born with the ability to regulate our intake. And children have these capabilities and feeding them in this responsive way supports those ingrown capabilities. And there may be differences and challenges where we have to again, be flexible or extra supportive.
Melanie Loomer is this amazing psychologist who ran the pediatric feeding clinic in Calgary and they treat 700 children a year with medically complex issues and all of these things. And she, she just said it’s exceedingly, exceedingly rare to find a child who actually can’t access hunger cues. So again, there may be maybe stumbling blocks or challenges but generally we are born with these capabilities and so responsive feeding supports that.
So you ask, like, how is this different? For example, when I took a sensory and behavioral based feeding therapy program, they said things like, well, we have to teach children portion control or kids don’t like vegetables. So what I see over and over again in kind of the behavioral or therapy world is this assumption that eating is really hard and for most kids it’s not. There can be challenges but, “We have to micromanage, we have to teach, we have to do portion control, we have to control.”
So I think that I see a lot of right now over pathologizing and micromanaging and over controlling with the best of intentions and often in really playful ways and with the smile. But I think we’ve gone down that sort of micromanaging and needing to take over from children where that can actually make things worse.
Christy Harrison: Yeah, that’s a really helpful explanation. Thank you. And I want to dig into that micromanaging approach because I think it’s so subtle and it’s so common. I think a lot of people don’t necessarily think of themselves as pressuring kids to eat or as interfering in their relationship with food in any way. It’s like, I’m just trying to teach them to be healthy. I’m just trying to model good nutrition or I’m just encouraging them to eat, but I’m not forcing them to stay and clean their plate the way my parents did. So it can be on a real spectrum. What does some of that pressure look like or some of that sort of low level restriction look like and why doesn’t it work to engage in those things?
Katja Rowell: So the low level pressure and restriction, I like that you call it that. I sometimes call it negative pressure and restriction. And most of us have realized you don’t want to yell at your kid or scream at them or shame them, which still unfortunately happens because it can be really scary if a child is having problems with growth or nutrition. So we kind of have moved away from, you sit there and you eat it or I’m going to spank you, what our parents did.
Now it’s more sort of playful. And there’s so many like TikTok and social media accounts that say to make it a game and who can crunch the fastest and who can eat this banana with three bites or whatever it is or let’s make art, we’re going to stamp with the blueberries or, let’s do food science experiments or food play. I’ve had families of avoidant eaters where like the only books that they’re reading at bedtime are the dinosaur eating the broccoli trees or the very hungry caterpillar or whatever, Green Eggs and Ham. Even the time that’s supposed to be about connection and winding down before bed has turned into this agenda of, I need them to eat and so even story time gets pulled into this anxiety.
We even have research. There was a study that came out in 2023 that said games and playful stories, they wrote “unexpectedly” increased avoidant eating. And I was like, not unexpected for me, I’ve seen this for decades where there’s so much attention and it’s so hard. I had a parent write to me and say I hated sitting and eating with my child because no matter how fun I was trying to make it, I knew I was pressuring them to eat.
Part of me wants to just give permission to listeners to be like, yeah, this isn’t working. The sticker chart or the rainbow, whatever. It’s not helping my child to feel better. Our meals are not any more connected or calm. There’s still tears. We’re still wrestling over this stuff. Just permission that these tactics, these things we try to get kids to eat more or less or different foods, even if they’re playful or with a smile, they can backfire.
Christy Harrison: That really resonates with my experience. We were so hands off with my daughter and just very relaxed, division of responsibility, responsive feeding approach. We would provide and give lots of variety, and she would decide, and it wasn’t a thing when she was young and eating really “well,” like eating a lot of the foods and having a lot of variety and experimenting. And then as she started getting pickier, we started getting a little more nervous, I think.
And then she developed a medical issue. And then it was like, okay, the pressure’s on and it was this unintentional shift, but I think we all felt it. And I’m now reflecting on how it has change the feeding relationship and it can be so subtle, and it can be engaging in those little games, like, let’s see who can crunch the loudest or whatever. And it doesn’t seem like pressure on the surface, but actually it’s making the meal about the food and how much the child is eating and not just sort of focusing on keeping it relaxed and letting them do their job with food and maybe having conversations about things other than the food, other than maybe to say, ooh, look, this is really delicious, or would you like to try some of this? Or whatever it might be.
Katja Rowell: It’s very tricky and it’s very subtle. And again, I’m grateful I came to this as a parent who was in that cycle of, I’m trying this and it’s not working and things are getting worse. And what it seems to do when you’re in that cycle is prove that your child can’t be trusted. For me, it was, oh, my child can’t stop eating, I have to control this. I have to clamp down. For kids on the opposite side of this eating continuum of, like, kids with avoidant or anxious eating where, where they may not be or might not seem to be eating enough or enough variety, the more we try to get them to eat, often the worse they do. And then it seems to be like, oh, see, they can’t do it and I have to.
What I think is so damaging right now is with so much more attention to interoception, this idea of being able to feel what’s going inside your body in terms of hunger, fullness, emotions, thirst, etc. Many children and parents are being told, well, your child has sensory differences or your child is on this spectrum or they have interoceptive differences so they can’t sense hunger. And that’s terrifying because if my child can’t do it, I have to make them or they’ll die, right? This is really an existential anxiety and then you really get stuck.
I tell this story all the time in training and in my book is, a 4 year old who has never initiated eating, never reached for food. And the parents were told, oh, they’re underweight at birth, right? 10th, 15th percentile. So we can certainly talk about that whole issue too as these misperceptions around growth at play. And they were told you have to get them to eat. So right from the start they were pushing and pushing food and pushing food. So a child who’d never asked for or initiated food and two years of feeding therapy and they’ve been told they can’t sense hunger.
When we actually looked and saw that, wow, seven hours a day they’re at the table or being followed around with sips of supplements or crackers and earning stickers and the whole life of the family was around trying to get this child to eat. And I mean really simple intervention of just let’s limit eating time to 30 minutes every two to four hours, two to three hours, whatever and no more following them around. We moved a bottle of milk to breakfast. I mean really simple things that within three or four days I got an email where the parent said, my child just said I’m hungry and asked for seconds on pancakes, which they had never done.
This is that point of like, how do we set up the environment around the child to support appetite? How do we trust that they have these capabilities? Did this child need two years of feeding therapy? I don’t know, but they certainly were able to very quickly access hunger cues and begin to access those cues and show some capabilities. And again, I just feel for these parents, and I’ve had this scenario happening often enough that I just wanted to put that out there, that I think we need to be really cautious before we say a child can’t sense hunger. How can we optimize the environment so they can do their best is, I think, a good way to focus things.
Christy Harrison: Yeah, thank you. That’s really helpful. I want to explore the idea of weight a little bit more because I think on all sides of the spectrum of weight, there can be concerns that are maybe unwarranted and there’s undue pressure placed on parents and kids and families to do something about their child’s weight when the reality, I think, is much different.
So can you talk about what that looks like to have both, like this child you gave the example of who was in like the 10th or 15th percentile being told they were underweight and then kids at the higher end of the spectrum as well, like your daughter maybe when she was younger, the sort of pressure and the diet culture, weight stigma expectations that come down on parents, I think, when they have a kid at the higher end of the weight spectrum as well. What does it do to focus on kids weight like that to the feeding relationship?
Katja Rowell: It can absolutely destroy it. And again, as a doctor, I had zero training in how to interpret growth charts. And I think this is such an important point because the worry about weight is one of the top three reasons why families get into dysfunctional feeding patterns. It a hundred percent was for me and I see this so, so often. And I think that it’s such a shame because I think parents and doctors don’t understand how kids grow. And I did a lot of reading and looking into this and looking into growth charts and when I was in training in my early years, and I’m in my mid-50s, I’m not that old, we did not check BMI for children.
You looked at the growth chart if there was something amiss. Generally, you want to look at tracking. I’m not one of these people that says we shouldn’t weigh children. I actually think that it’s an important piece of information, but there is so much harm being done in misinterpreting that growth. So, for example, one of the diagnostic criteria for avoidant restrictive food intake disorder is faltering growth or falling off the growth chart. I want to be really clear that any weight loss in any child really needs to be investigated.
But we have research in thousands of healthy children where they looked at their growth for the first year. More than a third of them will fall down lower onto lower curves in that first year, and a similar number will raise up on the growth curves. It looks like a bell curve. Humans grow in a wide range of shapes and sizes. And what’s really, really tricky is in that first year, most kids are actually moving around on the growth curve. And yet I’ve had parents come to me and go, like, well, my doctor said my child went from 23rd to 25th percentile, and now I need to switch to skim milk. 23rd to 25th percentile is like nothing. It’s not having a bowel movement that morning or whatever it is. So there are a lot of misperceptions around growth.
You look at the growth charts, the first thing they do, they would hand me this thing and right at the top, in bright red, it was like, your daughter is 98th percentile, obese and here’s these recommendations. I’m like, she’s two. She’s not drinking soda. It’s sort of this boilerplate nonsense. And so there’s actually a paper from, I think it was 2011, that looked at growth charts and said that mislabeling children as underweight can cause feeding disorders. Mislabeling these children is so toxic.
I’ll get to the flip side in a minute but we also have parents who may have these expectations. I had one family where the older child was 80th percentile, so a little more stocky. The younger child was 30th percentile and a little more lean. And the parents were like, I can see this child’s ribs, they’re underweight. There was so much panic and anxiety because in their home, their reference point was a stockier child. They were both perfectly healthy, normal, thriving children. So we have these misperceptions. My child isn’t eating enough. They’re not big enough.
And in that second case where my child’s underweight, they actually were not problematic. But then we see, even just from that perception, parents getting into, you have to have two more bites of chicken, you have to eat your growing food first and applying pressure. So super critical point, children can be at the fifth percentile, which is labeled as underweight or failure to thrive, 3rd, 5th percentile, and be totally healthy for them. I see referrals for underweight, and parents are like, well, I’m 5’1 and my husband’s 5’4 and we’re just small.
There are so many misperceptions where we’re plotting a child, oh, we’re in the red or yellow or orange zone or whatever. And now we’ve turned the child’s body into a problem to solve. We’ve raised the parent’s anxiety, and we’ve now introduced the anxiety and the idea that parents can and should control how much their children are eating so that they weigh more or less. And it just doesn’t work that way.
I want to just real quickly say in that paper that talked, and this was from the CDC, by the way, how dangerous it is to mislabel children as underweight. They did not say how dangerous it is to mislabel them as overweight or “obese,” on the growth charts. And that’s weight bias at play. I think it’s just as dangerous to mislabel children or to label them at all. There’s so many hours of conversations we could have. But I just want to focus on this idea of labeling children.
We know that the BMI is a screening test under age 6 is not even accurate two thirds of the time to identify what the test says it’s identifying, which is fatness, percent body fat. So we’re using a screening test that I wish would go away forever and it’s especially, especially harmful on children. And we know that black and brown children, indigenous children, are harmed even more. They’re mislabeled at even higher rates. So I just want to put out there that this quest for our medical providers to label an early intervention is causing so much harm and we’re missing opportunities to help children be healthier who happen to fall in the “normal” range.
So, anyway, there’s my TED talk on child BMI, but there’s so much misperception on the role of caregivers, on the role of medical providers, that it’s really doing a lot of harm.
Christy Harrison: Thank you. I want to explore more how you can help parents get comfortable with this no pressure approach, especially when their kid is being labeled or mislabeled in many cases as having a problematic weight. So whether that’s underweight or “overweight” or “obese” now and there’s now recommendations of putting kids on GLP-1s and things like that. It’s a scary time, I think, for parents to be navigating all of this and they feel so much pressure, I think, from providers, sometimes from family members and it can feel really uncomfortable.
And especially if a kid has medical issues as well, whether it’s diabetes or low blood sugar or there’s neurodivergence going on, there can be a lot of things complicating it as well. So how do you help parents get their head around, get comfortable with this no pressure approach when they might be getting pressure themselves from so many other sources?
Katja Rowell: It is so, so hard.
