Ellyn Satter, Registered Dietitian and well-known authority on child feeding states in her “Division of Responsibility in Feeding” that parents are responsible for the “what, where and when” of feeding. They are responsible for choosing what foods are offered, when they are offered and where the food is eaten. Children are responsible for how much of the food is eaten and whether the food is eaten.1 As children grow up, they learn to be responsible for choosing what to eat. A common issue in the adult I/DD community is balancing an individual’s food preferences with food choices that are best for their health needs, which may not coincide. Fortunately, we do not have to choose between healthy foods a person is unhappy with or conceding to ice cream for dinner.
Providing nutrition education for people with I/DD that is easily communicated, memorable and most important, fun, are keys to effective learning. Nutrition activities can be done at home with family or in congregate settings. Replacing wordy handouts with colorful picture references, keeping nutrition messages brief, revisiting topics often and building on prior concepts make nutrition information easier to remember. Rather than providing guidance from a distance, nutrition education becomes exciting with hands-on activities like cooking and games that motivate individuals to take care of themselves and reinforces nutrition recommendations. These types of activities should be tailored for the age level and modified for any specialized diets and feeding instructions given to you by your health professional.
Research has shown that adding pictures to written or spoken health education materials increases the students’ attention, comprehension, recall and adherence to health recommendations. Pictures are especially helpful for those with differing literacy.2
Creating handouts with pictures of healthy foods from a favorite local convenience store, restaurant or grocery can help individuals recognize healthy options available in their familiar environment. Handouts highlighting food choices from local stores allow choices to be made ahead of time and can prevent frustration or challenging behaviors as new foods and eating habits are introduced. If someone has difficulty incorporating fruits or vegetables into their diet, a pictorial handout can help encourage them to work toward the recommended amount per day.
Enjoyable participatory exercises relying on pictures include slide show grocery store tours, displaying pictures of local restaurants and menus, and watching the evolution of a food starting with where it is grown, then packaged and cooked. Group discussions can be held on healthy food choices in different sections of the grocery store, what the best menu items are from local restaurants and the different ways certain food ingredients are packed and utilized. These more complicated activities may be suggestions for a day program or may inspire similar home activities. Many grocery stores now have on staff dietitians that are available to do free nutrition presentations for programs in their area.
Keeping nutrition messaging simple is a key to retention and adherence in all populations. Using Myplate or the “plate method” helps individuals understand a balanced diet to provide themselves proper proportions of fruits, vegetables, grains, dairy and protein throughout the day”. Myplate, the current food guide published by USDA’s Center for Nutrition Policy and Promotion, provides a printable graphic demonstrating a balanced plate comprised of approximately 20% protein, 30% grain, 20% fruit and 30% vegetables with a serving of dairy (or fortified non-dairy alternative) on the side. Myplate.gov includes nutrition recommendations for every stage of life, making it a rich resource for all age groups. Browsing the food group gallery, individuals can learn which foods fit in the main food groups. Using blank Myplate templates, individuals can draw, write or paste pictures of the foods they like in the correct area of the plate for each food group. When an individual favors or avoids certain food groups on their exercise sheets, that can be noted and can help guide nutrition goals toward a balanced diet.3
Additional resources that have been very useful in this setting are Myplate catch phrases such as “Make Half your Plate Fruits and Vegetables”, “Think About Your Drink” or “Try Whole Grains.” These sayings help individuals remember to avoid sugary beverages or to try whole-grain bread or pasta instead of the white flour varieties. 3
For individuals that have specific and sometimes limited diets due to sensory preferences or anxiety with changes in routine, exposure to a new food in a fun way can help increase the likelihood of trying new foods. Myplate.gov offers Grocery Store Bingo Cards where a player can search the aisles looking for specific healthy foods.3 Additionally, online templates allow for creating custom bingo cards using individualized bingo squares with nutrition goals such as “Had a Fruit for Snack” or “No Sweets Today”. Filling out the bingo card throughout the week can get a Healthy Eating Bingo! In areas with accessible farms, individuals might develop a connection to foods from a visit to a nearby farmers’ market to see the varieties of fruits and vegetables or to a pick-your-own farm. Outings and trips can increase exposure and help build positive associations to new and healthy foods. For someone who has never before tried a strawberry, a trip to see where the food grows and handling that food is the first step toward trying it.
“Taste Tests” are another way to increase exposure to foods and allow individuals to describe their experience of the food. Taste tests can be set up for different types of apples or pears picked from an orchard or from a grocery-store trip. Individuals can be asked to describe the difference in taste (tart, sweet, bitter), texture (crunchy, smooth, mushy) and take notes next to each type. Originally intended for children, the USDA offers a “Kids Food Critic” handout that can be adapted for all ages and groups where they can draw a food they are tasting, rate it by visual appeal, smell, taste and texture, and then give it a total score.3 For those with sensory preferences, strategizing with a feeding therapist first is beneficial.
When there are no contraindications, including an individual in meal preparation is fundamental. Among youths, helping to prepare meals is associated with healthier eating behaviors, and helping at home with meal preparation has been demonstrated to be associated with improved overall diet quality, eating more fruits and vegetables and potentially with consuming more grains, meat and meat alternatives and milk and milk alternatives.4 For individuals where a hot oven or handling a knife is not feasible, they might choose recipes, gather ingredients and kitchen tools, wash vegetables, measure and stir ingredients and help set the table. Introducing an individual to a kitchen starts with safety and sanitation, where hand washing and the dangers of knives and kitchen equipment are reinforced.
Finding healthy recipes to prepare and sharing why the recipes were chosen will help fortify nutrition concepts. There may be stories or books related to a major ingredient in the recipe to read aloud or share beforehand. Along with meal preparation, being involved with meal planning can help individuals develop self-efficacy and confidence in making healthy food choices. Individuals can plan a dinner and make sure the meal is balanced with a protein, vegetable, fruit, and grain or starchy vegetable. They can aid in planning the grocery shopping list and by making sure there are enough vegetables to serve for the week’s dinners. Lastly, tending to a small vegetable garden or growing some herbs on the windowsill to use in home-cooked recipes can be fulfilling for a family or housemates living in a group residence. As they become acclimated to inclusion, there are endless ways individuals can participate in food related activities.
Trying and handling different foods can be very difficult for some children with I/DD or autism, especially for those that have Sensory Processing Disorder. While an individual may grow out of limited eating, some individuals maintain a restricted palate through adulthood. Individuals may favor certain textures or temperatures over others, so introducing new foods or recipes within those parameters can increase acceptance (ex. crunchy, creamy, cold, etc). Avoiding too many new textures at once and loud kitchen equipment can also be helpful.
Given the heavy load shouldered by caregivers, finding time for nutrition activities can be difficult, but even planning one nutrition activity per month around one important and practical nutrition goal can make a difference. Seek advice and resources from your healthcare team, including a Registered Dietitian. When time is limited and accessing visual and print resources is not an option, you may still request them from a Registered Dietitian or Feeding Therapist. Teaching an individual basic nutrition information will decrease their risk of chronic illness and help them feel their best. With clear nutrition messages imparted through enjoyable activities appropriate for one’s age and individual needs, we can respectfully provide those in the I/DD community the knowledge to make healthy choices for themselves.
ABOUT THE AUTHOR:
Jenny Torino is a Registered Dietitian with over 15 years experience in the field. She is currently working with individuals with I/DD at the ARC in Sussex County, NJ. She has also held positions as an outpatient dietitian at the VA Medical Center and a private nutrition practice in Providence, Rhode Island. She initially started her career at GMHC, the nation’s first HIV/AIDS service organization in New York City. She holds her Masters Degree in Clinical Nutrition from New York University.
1. “Raise a Child Who is a Joy to Feed: Follow the Ellyn Satter Division of Responsibility in Feeding” Ellyn Satter: https://www.ellynsatterinstitute.org/how-to-feed/the-division-of-responsibility-in-feeding/, Accessed 1/20/22.
2. Houts, P.S., C.C. Doak, L.G. Doak, and M.J. Loscalzo 2006. “The role of pictures in improving health communication: A review of research on attention, comprehension, recall and adherence.” Patient Education and Counseling 61:173-190.
3. U.S. Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC. https://www.myplate.gov. Accessed January 27, 2022.
4. Quelly, S.B. PhD, RN, CNE, “Helping with Meal Preparation and Children’s Dietary Intake: A Literature Review,” The Journal of School Nursing, 2019, Vol. 35(I) 51-60.9
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