Your child's nutrition questions, answered

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Another school year, another year of packing lunches. Out of ideas?

Registered dietitian Helen Yeung took your questions on how to keep school lunches tasty and interesting, plus broader questions on child nutrition: how do you deal with a picky eater, how do you make sure your child is getting what they need, how do you keep dinner time healthy and delicious.

Ms. Yeung is a registered dietitian with Vancouver Coastal Health. She specializes in supporting families and caregivers of young children. She speaks frequently on the topic of "raising healthy and happy eaters," covering the "what, how, and how much" of feeding children. She has worked in public health and private practice covering the areas of: healthy meal planning and shopping; how to feed picky eaters; and promoting healthy attitudes and behaviours around food and eating. She has two school-aged children and a husband who help pack their own lunches every day.

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My youngest who will be four in December, is starting JK in a few weeks. She is still very little. How can I pack nutritious lunches for her that not only will she eat without the usual parental prodding but also be able to manage without much trouble? Even inserting straws into full juice boxes can be challenging for her at times. Thank you for your suggestions, - Nina

Helen Yeung writes: Junior Kindergarten will provide set times for learning, active playing, eating, and other activities. The routine that the school sets will help your four-year-old adjust to the activity at hand--in this case, eating.

Each day, if you pack say three food items from different food groups, your daughter will eat as much as she needs at that time, to last until the next eating time. The school staff are aware of the developmental stages of four-year-olds and will probably help your child if she needs help with her food items (e.g., opening a container, inserting straws into a juice box). After your daughter has gone to JK for a few days, you can evaluate the snacks/lunches she has eaten and adjust as needed. Vary the menu, and offer choices from "Eating Well With Canada's Food Guide" (found at www.healthcanada.gc.ca/foodguide ). A handy sheet that gives lunch ideas is Lunches to Go .

If you have concerns about your daughter's eating, the staff should be able to discuss this with you. Some parents have told me that their children eat better once they are in a child care or school setting because of the structured, social setting around eating times and the expectations set by the staff.

[Instead of juice, I would recommend packing a water bottle and some real fruit. Canada's Food Guide recommends satisfying thirst with water, and the fruit will have more fibre and nutrients. If you want to pack juice, you could pack a smaller amount in a re-usable container.]

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My daughter gets an upset stomach and rash when she drinks or eats dairy. She will eat soy yogurt and drink rice milk. I worry that the rice milk has caused weight gain. She is off the growth charts (28 months old and weighs 51 lbs). Her siblings don't have a problem with dairy and are both average weights for their ages. Could rice milk contribute to weight gain? Are there any other alternatives? What is the difference between cow's milk and goat's milk? Any advice would be much appreciated. - Pam

Helen Yeung writes: Dear Pam,

I would suggest bringing your two-year-old to a physician 1) to diagnose whether your daughter has an allergy or lactose intolerance or something else causing the symptoms you mention; and 2) to assess growth. It is beneficial to find out whether foods need to be avoided (if true allergies exist) or whether her condition is lactose intolerance (which causes stomach upset and bloating but not a rash) that can be managed with small amounts of milk products.

Rice milk is not a common cause of excessive weight gain, unless she is drinking excessive amounts (e.g., more than 500 ml or 16 oz a day). Weight gain can be caused by other factors including physical activity levels, other dietary factors, and certain medical conditions. Does your 28-month-old eat differently than her siblings, other than the dairy intake? Has your daughter always been larger than average (since birth?) or has she suddenly accelerated in weight gain? From the information you have given, I would need to ask more questions, and it may be beneficial for your daughter to see a medical practitioner to find some answers to her individual case. You may also want to speak with a dietitian in a public health unit, hospital, or private practice.

Regarding your question about the differences between cow's milk and goat's milk, they contain different proteins but some individuals who are allergic to cow's milk protein are also allergic to goat milk protein.

Note that the values in the above table came from the Canadian Nutrient File (2007). However, different brands and flavours of beverages will contain different levels of calcium, vitamin D, protein, fat, and therefore calories. Generally speaking, animal milks are higher in saturated fat (unless you get skim or fat-reduced milk), and rice drinks are much lower in protein and calories than cow's milk or goat's milk. Fortified soy beverages are included in "Eating Well with Canada's Food Guide" as Milk Alternatives. For children aged 2 through 8 years, Canada's Food Guide recommends 500 ml daily of fluid milk or milk alternatives for adequate vitamin D.

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My 13 year old daughter has been a vegetarian for three years. She does eat fish and eggs and is open to new food such as quinoa. I am concerned about giving her tofu based "fake meat" substitutes such as deli slices & chicken cutlets.

Our background is Indian, and she also likes Italian and Mexican. - Surinder

Helen Yeung writes: Dear Surinder, The vegetarian diet can be very healthy and nutritionally adequate when it contains a variety of foods from the four food groups-Vegetables and Fruit, Grain Products, Milk and Alternatives, and Meat Alternatives.

Fish and eggs are excellent choices if these foods are acceptable to her. Whenever a food is eliminated from the diet, it is important to find alternate sources of nutrients found in the eliminated foods. You didn't mention whether your daughter takes dairy products, which are important sources of calcium and vitamin D. The imitation meats, or meat analogues, are fine to include along with whole, unprocessed foods. These foods are often made from soy or textured vegetable protein and contain the healthy oils and less saturated fat than real meat. For teens and young people who are becoming vegetarian, the "fake" meats are an easy way to substitute vegetarian options for everyday foods, such as spaghetti sauce with Veggie ground "meat," "deli slices," and veggie burgers. Meat analogues often are fortified with vitamin B12. Sometimes these meat analogues are high in sodium, so read labels and choose more often beans, lentils, nut butters, and the other foods found in Italian, Mexican, and Indian cuisines. There are many vegetarian choices found in traditional foods: pita bread and hummus; chickpea salad with couscous; lentil curry; daal and roti; veggie sushi; tofu stir-fries; bean and corn salad; pesto sauce over pasta; tacos and burritos with beans or imitation meat; rice and black bean dishes.

For additional suggestions, click on "Resource Centre" at the Dietitians of Canada web site www.dietitians.ca , and search the Resource Inventory using "vegetarian" keyword.

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How do you know how much salt is in a meal, and how do you stay within the recommended daily intake? - Ian D.

Helen Yeung writes: Dear Ian,

Sodium is a nutrient found in table salt and many other foods.

On packaged food, Sodium is one of the core nutrients listed in the Nutrition Facts Table. For sodium intake, 2300 mg per day is the Tolerable Upper Intake Level (UL) for those 14 years old and over (the upper limit is lower for children under 14 years). Rather than trying to add up the number of milligrams of sodium from all the foods you eat in a day, here are some general tips to stay within the recommended amounts of sodium:

• Cook whole foods from scratch;
• Use fewer processed and canned foods, sauces, spreads, and take-out foods;
• Emphasize more fresh or frozen (no salt added) vegetables and fruits, which are naturally low in sodium;
• Add flavour to your meals with onions, garlic, fresh herbs, pepper, lemon juice, and other seasonings instead of salt. In place of a salt shaker on your table, try Mrs. Dash, or a blend of dried herbs and salt-free seasonings.

Check out Low Sodium Eating and Cooking, at www.dialadietitian.org

There is a good fact sheet on sodium in our diets, at this Health Canada link.

[You may be interested in knowing that Health Canada is chairing a Working Group on Dietary Sodium Reduction which includes representatives from food manufacturing and food service industry groups, health-focused non-governmental organizations, the scientific community, consumer advocacy groups, health professional organizations and government representatives. The Working Group is mandated to develop and oversee the implementation of a strategy for reducing dietary sodium intake among Canadians. http://www.hc-sc.gc.ca/fn-an/nutrition/sodium/index-eng.php]

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Our 17-month old toddler enjoys a variety of foods but the quantity of food he can eat at any meal is limited. I think that sometimes he gets overwhelmed by meals that include all the food groups, even in small servings, and he starts to play with food or throw it on the floor rather than eat. it. He is very lean already and uses a lot of energy each day so I want to be sure he is taking in enough nutrients and calories.Do you have any tips for ensuring that toddlers eat a balanced diet generally, and for making meals and snacks as appetizing as possible?

Thanks! - Jennifer

Helen Yeung writes: Dear Jennifer, Toddlers between 1 and 2 years of age are energetic, and often more interested in exploring and playing than eating. Some tips to make meals and snacks as appetizing as possible:

1. Set a routine for meals/snacks, and other activities. When awake, toddlers need to eat about every 3 hours or so (e.g., breakfast, lunch, afternoon snack, dinner, evening snack).
2. Offer your toddler the same types of food that you are serving the rest of your family, but possibly modify some foods (e.g., cut up, chop, or cook well rather than serve hard foods like carrots). Allow your son to feed himself. Some toddlers prefer finger foods (eating with their hands) because they are becoming independent and they are exploring their world of food with all their senses (taste, touch, smell, sight and sound!). By feeding themselves, they can control how much and how fast they eat.
3. Plan about three different food groups at each meal, so that your son has the opportunity to eat foods from the four food groups each day. Start with just a couple tablespoons of each food at a time, and offer more if he finishes that food. Developmentally, toddlers are erratic in their eating, eating only certain foods on some days and other foods on another day.
4. Eat together and enjoy each other's company at meal and snack times, without the TV and other distractions.
5. If your child is not hungry at meal times, determine whether he is filling up on calorie-containing beverages like juice (limit to 125 mL per day) or milk (limit to 500 mL per day for children up to 8 years of age). Instead, offer water for thirst, especially within an hour of scheduled meal times.

In summary, it is the parents/caregivers' jobs to decide What, When, Where, and How food is served; and it is the child's job to decide How Much, and Whether to Eat from what is offered. By following this division of responsibility in the feeding relationship (described by Ellyn Satter), you can avoid feeding struggles and promote healthy eating. Sometimes a toddler's picky eating is a way for them to assert control, as they know that refusing to eat gets them lots of attention.

Two handouts I use often with parents can be found at this link:

Meal and Snack Ideas for Your Toddler (1-3 years)

Helping Your Toddler to Eat Well -Sharing the Responsibility with Your One- to Three-Year-Old

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Help! Even if I pack a healthy lunch for my 10-year-old daughter with her assistance, once she gets to school she trades for junk food with other kids. What can I do? Thanks, Maryann

Helen Yeung writes: Dear Maryann, You describe a common situation of trading foods at school. Discuss nutrition with your daughter while also listening to her perspective on what happens at school (vis-à-vis food). Involve your 10-year-old in packing her own lunch. Include her in making the shopping list (post on the fridge, so anyone in the household can add items to the shopping list), doing the shopping, and putting items into her bag for school lunch.

Speak with the school about developing a school food policy, which includes guidelines for packing healthy food choices for school. Having some guidelines for all families will create a supportive environment, making it easier for you to pack healthy choices and for your daughter to eat what she has packed from home.

This Lunches to Go handout could be given out by school staff to all parents, as suggestions for appropriate lunch items.

You may also find useful information at this web site http://www.healthyeatingatschool.ca/

Recognize that some of the factors that influence food choices, and what parents pack for their children's lunches include: cost, convenience, taste, food accessibility and availability, environmental considerations, and portability. Finally, rather than labeling food choices as "healthy" or "junk" foods, think of foods as "everyday foods" or "sometime foods". We don't want our children to feel badly if they are eating "bad" foods, which can be OK once in a while if their usual diets are healthy overall.

A fun activity to do with school-aged children is to go to Health Canada's main page for Canada's Food Guide, and design "My Food Guide." Print out this one-page colour guide, with the foods that you like to eat or want to try, and put it on your fridge to give reminders of foods to buy and pack for school.

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Hi I have a 2 year old daughter who unfortunately is a picky eater. Me and my husband like to try different foods and because of this I now have to make a separate meal for her. She won't eat food when it is separate on her plate. For example if I bbq chicken breast and have it with rice and broccoli she won't pick-up chunks of it, if it in separate piles on her plate. But she will eat it if I make it into a 'soup'. By soup I mean if I chop the pieces up finely (not blend them) and combine with a thickening agent (water or stock & corn starch or flour) into a stew consistency she will eat it. I'm wondering how to get her off needing her meal like that. Because it adds more work and increases my stress level when we go somewhere to eat. Thank you, Valerie

Helen Yeung writes: Thank you, Valerie

A two-year-old typically is "picky" and erratic in eating. The good news is that most toddlers outgrow this stage if we follow the division of responsibility in the feeding relationship (described above in the toddler feeding question). Rather than catering to a toddler's demands, it is best to include one favourite or acceptable food in each meal (e.g., bread, fruit) while also offering newer foods at the same time. For example, soup is a great choice for one meal per day because the whole family can enjoy soup. At other eating times, offer healthy choices you enjoy from the four food groups. Rice, chicken, and vegetables, along with a beverage like milk, is a healthy balanced meal. Your daughter has the choice to eat this or not, but do not be a short order cook and make something special for her otherwise she will learn that she can control the menu (she learns that if she refuses lunch you might make her something better to eat). Her choice is to eat a small amount from what you have offered, or be hungry and wait 2 more hours until the next scheduled eating time. I often tell parents that there is not a right or wrong way to feed children, but there are consequences to different actions. Think about your goals (to help your daughter eat a variety of foods and to feel good about eating times) and how to reach those goals. Also, eat together, to role model eating regular foods. Toddlers are developmentally cautious about new foods but this will improve as they become more familiar with that food. Young children may need to be offered a food 20 times (on different days or weeks) before they start eating it.

An additional point in your case is that some toddlers prefer moist foods, and find dry foods hard to eat (e.g., chicken breast, steak, rice). Dark meat of chicken often is more moist (cook with the skin on and remove skin before eating), serve meat finely cut up, use more water in cooking rice, serve pasta with sauce.

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The recent Canada Food Guides seem to have dumped the potato as a staple of our diet, replacing it with pasta. It now seems to be treated as another vegetable. What is the value of the potato compared to pasta, bread and rice, in our diet? - Connie

Helen Yeung writes: Potatoes are a root vegetable, in the Vegetable and Fruit group in Canada's Food Guide. The pasta, rice, and bread are in the Grain Products group. What all these foods have in common is that they contain complex carbohydrates and dietary fibre (whole grain products are recommended over refined versions because of whole grains' higher fibre content). For individuals with diabetes, they may need to "count" carbohydrates, and be more careful to distribute evenly throughout the day the carbohydrate content found in grains and starchy vegetables such as potato and corn. It is best to include a variety of plant foods, including the above foods.

Different foods will have varying levels and types of fibre and nutrients. By choosing a variety, you have the best chance of getting all the different nutrients your body needs, while also balancing out the sodium, fat, and carbohydrate content in different foods.

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I would appreciate lunch ideas for a teenager who is anaphylactic to all nuts, and all seafood, and doesn't like eggs because he is allergic to them if they are not cooked well (so he doesn't really want to eat them).

I am trying to limit salamis & preserved meats with nitrates. I try not to use processed foods. So we usually do WW buns, with chicken or turkey / ham cold cuts, sliced cheese, lettuce. Sometimes I do chicken salad. He also doesn't like tomatoes because it makes sandwiches soggy.

Sometimes we do "bits & bites" -- yop or yogurt or cheese sticks, cut veggies, fruit, crackers or goldfish, cheese breadsticks, but I think this isn't really enough. My son doesn't like to bring "leftovers" -- not cool.

I would do wraps, but I don't think they are enough carbs, plus he doesn't really like the taste of the tortillas.

We can't do pea butter (smells like peanut butter), or tuna snacks etc, or hard-boiled eggs, etc.

Any suggestions would be welcome (even if you have one or 2 ideas)!! Thanks, Selina

Helen Yeung writes: It sounds like the challenge for your son is getting enough choices from the Meat and Alternates group, as he avoids nuts, eggs, and seafood. I would suggest involving your son in packing his lunch, including the shopping, to increase acceptance of "vegetarian" choices. Does your son like veggie burgers, bean dips like hummus which can be served in a sandwich, or with bread and raw veggies? Try a variety of different breads like pitas and kaiser buns. Greek salad, chicken salad with celery and grapes, cheese scones with lettuce and avocado, and sliced turkey sandwiches are good choices for lunches. Complement the protein choice with more fruits, veggies, yogurt and milk (flavoured milks or soy beverages are OK).

This Lunches to Go handout has more ideas that may work.

You mentioned wraps and tortillas, which may not be enough food for a teenager, but if you fill it with deli meat, cheese, sliced peppers, cucumbers and lettuce, it can be satisfying when served with other foods. Perhaps adding some milk, chocolate milk, or a yogurt smoothie would help satisfy a teen's appetite. Aim to pack three of the four food groups in a school lunch. Offer more from the Meat and Alternatives group after school and at dinner. For more ideas for you and your son, check out www.dietitians.ca/eatwell

Finally, see a physician to re-evaluate your son's allergies, and to pinpoint which foods specifically he is allergic to, and which foods are safe. Some allergists recommend re-testing for allergies every other year, but this can only be determined by your medical practitioner. Being able to eat a greater variety of foods makes meal planning and shopping easier, so you want to ensure that your son avoids the foods he must avoid, but also include foods which are safe to eat.

For BC and Ontario residents, there are free nutrition hotlines staffed by registered dietitians. These tele-health services are convenient and helpful. For those living in other provinces, you may be able to access a dietitian at the outpatient department of a hospital, or a health unit community nutritionist. Dietitians and other useful nutrition resources can also be found at the Dietitians of Canada web site, www.dietitians.ca