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

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. 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 selfcare skills, appreciate their bodies, and do not become preoccupied with food (6). 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 (1–4). 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 the trust Model: A Different Feeding Paradigm for Managing Childhood obesity