The Family Meal

One of the things that research consistently supports is the value of a family meal. The more often your children sit at the table with you and have a meal together, the better off they are.

When I read some of the early research on this topic, it seemed obvious and biased. When we examine households in which there are two parents, one full-time breadwinner who shows up every night by 6 PM, one full-time homemaker who shops and does child-care and prepares meals, we find certain unsurprising and uninformative things. Relatively low rates of juvenile delinquency, teenage drug use, legal entanglements, and similar social problems. The kids seem to eat healthier, snack less and have a lower rate of obesity.
I was and remain dismissive of this as medically relevant. In so many ways, it’s like surveying people who identify themselves as happy and then announcing that these people have a lower rate of depression than the population in general and a much lower rate of depression than those who have been hospitalized for depression. These mythical households, in which parents live unrealistic lives in unrealistic places with unrealistic children, provide little in the way of helpful insight for those who don’t fit into the constraints of these fantasy family structures. In most places, financial realities have made two incomes essential. Even when it’s not, and perhaps especially when it’s not, the idea that one partner is at home cooking dinner for several hours a day is obsolete. equally unstudied are school and work schedules. Our children, even from the happy and intact families, are busy with their own schedules that include after school sports, tutoring, or jobs. Perhaps because of where I practice, here in Berkeley (but I think this is true most places) it’s tough to make a living from a job you never take home. It’s been hard not to notice, making as many house calls as I do, how often one of the parents isn’t at home. Mostly it’s dad who is still working at 7 or 8 o’clock. But I have often seen kids who are fed and watched and put to bed by dad or grandma since mom won’t get home from work until after the child is asleep.

So I admit that this might seem like a distant dream for many families. But there are a lot of lessons in The Family Meal that go beyond nutrition. Those families from the television-reality of the 1950’s may not have much in common with yours. And it’s no surprise that in these families, teenagers are expected to be home from school before dinner and don’t go out at night. With this level of tight supervision, it is understandably difficult to imagine them getting into trouble. There’s also little opportunity for stopping for a cheeseburger on the way home instead of dinner with the family. No chance for snacking, drinking, or other unhealthy activities.
I have intentionally painted this lifestyle as repressive and restrictive. That’s the way your teenager is likely to see it. After all, their friends get to do these things. And that feeling of imprisonment is a universal one at this developmental stage. They know what they are able to do, and this doesn’t match what their parents are able to allow them to do. But I wouldn’t be doing my job if I advised ignoring some of this research.
I don’t think the research adequately explains why kids with more family meals are less likely to be obese. Maybe the reduced time outside of the house, eating fast food less often is an explanation. Maybe the increased parental supervision contributes something. Maybe it’s something deeper.

Think about the last binge you had—whatever constitutes a binge for you. Did you do it sitting down at a table of people? Maybe kids who would eat particularly badly feel this same social restraint. So if they get a family dinner every night, even if it’s hot dogs and mashed potatoes, and even if they have two helpings, they won’t be having 7 or 8 portions. Even if they could sneak out, the sense of fullness probably will short-circuit the impulse to binge, which happens more often when we miss meals.

Think about the last good dinner you had with someone else, or a group of people. What made it good? The most fabulous chef can’t make food good enough to provide satisfaction and enjoyment from time spent with bickering unfriendly people. Normal family and sibling interactions are not, realistically, going to lead to peaceful supportive conversations at every meal. But the dependability of the meal, day after day—or even week after week—will provide its own important support. Think of it this way. You are on a team. Sometimes it’s competitive, and sometimes you need to work together. Sometimes you will win and sometimes you’ll lose—and some of those times, you feel that you’ve lost very unfairly. But you keep showing up for practice, keep showing up for games. And your coach is always available, whether encouraging you or pointing out your mistakes. I think the family dinner is like this. Sometimes a child will be sulking and quiet, or quick to anger. And nobody should be forced, somehow, to do this. But the dependability of that dinner is crucial. They can invite a friend to join. That may seem easy, but it’s an impossible social step if everyone in the family eats at different times, in different places. So it’s easy for a child to ask a classmate to come over for dinner if your child knows in advance when and where that dinner will take place. If they don’t do this, when will you meet and get to know your child’s friends? This is an easy, natural way to do this important task.

Most important of all, the family meal is the place to show your children that you’re interested in them and their lives, their schoolwork, friends, and news. Please, no interrogations. Don’t go around the table as I have sometimes seen and make each child complete some checklist you have created for them. Tell me one thing that happened in school today or something like that. If the child is always saying that nothing happened and that they have no homework and nothing is new, you need to reach out in a better way. Maybe over the dinner table isn’t the ideal venue for many types of conversation. But when parents repeatedly express interest in their children and the lives of their children, it’s probably a good thing. Maybe it will convince some of those kids that their parents really care about them. Maybe it will help them care about themselves. Maybe it will help a few of them eat healthier.

Satiety and Problems with Obesity Research

There's plenty of research on obesity. When push comes to shove, however, we already know the answer. When we consume fewer calories than we use, we gain weight and vice versa.


There's much less research on what drives obesity: satiety. This is the feeling of being satisfied that you've had enough. So all the useless research on portion control, what a 4 ounce piece of steak looks like, on how to measure 100 grams of pasta, is of little applicable value. A patient put it perfectly, "I'm just not satisfied with a yogurt for lunch." We don't have a problem with metabolism, with not getting enough exercise, with fast food chains. If we could go to McDonald's and order one single hamburger and leave, we might be happy with the quality, taste, and value of the food. We don't do that for the same reasons we can't push away from the table after our 4 ounces of chicken breast.


For decades, stomach ulcers were thought to be caused by 'Type A' personalities, emotional instability, and so on. A whole medical-industrial industry had been created to get these high-strung, quick-tempered, hotheads to relax. It wasn't true. The ulcers are caused by a bacterial infection that is treatable. What everybody talks about as 'willpower' is a code word for blaming the patient in the same way that people with ulcers were blamed for their own ulcers. I have met people whose iron discipline is helpful in some circumstances; a surprising number of these folks, in my professional opinion, probably could be comfortable placed somewhere on the autistic spectrum. (You've met these people. Their diets aren't generally the only things they are completely rigid about. They often have difficulty imagining or accepting alternative ways of getting even simple tasks accomplished. Does this sound like people with easy-going personalities and excellent social skills?) For most of us, however, I think what we dismissively think of as a lack of willpower is, in fact, representative of deficiencies in our scientific knowledge about satiety. Many of us insist that our metabolisms run differently, and that others we see eating the same meals don't seem to have our difficulty with weight. I strongly suspect that what is unstudied is not differences of metabolic rate (sorry, most studies suggest that it's all about eating more calories than we burn). It's individual differences in satiety that determines if we need that extra piece of pizza.

When I lived in New York, I was taken to a screening of movies recently completed by film-school students, one of whom was the roommate of my girlfriend at the time. It seemed oddly curious to me that all the films had same maudlin themes of dark introspection. No humor, no irony, no twists, no surprises, no action, no sex. The roommate asked me what I thought. After saying that I thought it was really deep (she smiled proudly), I asked what kinds of movies she liked. She bragged, 'I've seen every European film produced in the last year that I could get my hands on.' I named a couple of blockbuster American hit movies and asked if she had seen any of these. 'Why would I?' she scoffed, and went back to a group of her classmates and professors in black turtlenecks.


It's not that the popular movies were better. But the fact that they were popular strongly suggests that there was some universal, shared appeal about them. So while I would never argue that one should eat more Big Macs, we miss something really important by ignoring how popular they are and why so many people really like them. This is the research that hasn't been done yet.



Back to the lousy student films. I would never argue that popular is equivalent to good. But only in figuring out why some things are popular can we find out our universal drives. Why isn't there more research about what makes fast food so good or so popular? Why do we like it so much, why do we eat too much of it, why do we want to get the larger size for just 50 cents more? Maybe there are great lessons to be learned there about the issues that the majority of us face every day in our eating decisions. This, I believe, is an important reason so many struggle with overweight.



This is also a reason why people on stimulant drugs lose weight. It's not that they no longer like cheeseburgers, or that the stimulant speeds up their metabolism. These medications reduce hunger and increase satiety.


Our bodies have no trouble losing weight. It's our brains that can't do it so easily.


So it has saddened me over the years to read so much research concentrating on the body, which was never the problem. Here are titles of 3 research studies in the April 2010 issue of Obesity, a leading medical research journal in this field:

• Long-term Successful Weight Loss Improves Vascular Endothelial Function in Severely Obese Individuals

• In Central Obesity, Weight Loss Restores Platelet Sensitivity to Nitric Oxide and Prostacyclin

• Exercise Training Prevents Regain of Visceral Fat for 1 Year Following Weight Loss

So, based on these studies, weight loss is a good thing for the obese, especially if they start exercising. Imagine being sent a colorful postcard from a paradise-like exotic resort. It says that your friends are having a wonderful time, will probably never leave, and wish you were there. There's no mention about how to get there, how to afford it, or where, exactly, the place is.


With all of the above contributing to a comfortable amount of cynicism about this, I went to a lecture on childhood obesity. The content was an unexpected surprise. They didn't say that we're winning the war, not even winning the battle. But I think they've come up with some reasonable rudimentary tools. That's the next post.

The Committee: Problems with Obesity Researchers

A couple of years ago, I was on a committee of the American Academy of Pediatrics that focused on child nutrition and problems of overweight. We all agreed there was a problem. Maybe most adults, even those who don't work with children, have seen a generational change.

When I was a child, there was often one kid--if that--who was thought of as fat. I wasn't that child, and that child, at school at least, must have had a tough time. Honestly, I don't remember if there was such a child in the elementary schools I went to. There was a single classmate in grades 7-12, but at the school we shared, it would have been considered rude to make fun of anyone. (Though some were more competitive than others, I don't think anyone would have wanted to appear mean. I never got the impression he was anything but as happy as any of us were as teenagers.)

Things are clearly different now. Not just every school but every class has several overweight children, in every grade. Among these, some are dramatically overweight. Research confirms that though many kids get leaner when they grow into adolescents, many don't really recover from this early obesity. 

Given the lack of easy fixes for this problem, and the obviousness of the extent of the problem, it is a hot topic for research. I've been frustrated, however, by the work that's been done and the people who do it.

In general, I think people should go into fields they're interested in. This is not only important for their own happiness and job satisfaction, but also for their motivation and creativity. I was shocked, for example, to have met in my pediatric career more than a handful of people who don't particularly like children. That's OK, I suppose, but it implies a suboptimal career choice for both doctor and patient.

So, in this statistically-unsupported argumentum ad hominem, let me tell you about the people I've met in the obesity-science world. First, who do you think chooses to go into the field? The professor in medical school who lectured on the topic, and has published quite a bit on this topic since, had nothing in common with me. Rail thin, his lectures were, to my sensitive ears, fire-and-brimstone evangelical sermons on people being their own worst enemies, fast or prepared food of any kind being a narcotic-like poison that eats like a parasite at the very fiber of civilized society. He taught, at least this is what I recall, that eating is like smoking, and should be heavily regulated if not banned altogether. He could be seen in the cafeteria eating a salad without any dressing. I didn't sit at his cafeteria table. He actually said, and I remember this vividly, that doctors need to be models for their patients. I interpreted this to mean that doctors who struggle with their weight or smoking or personality flaws are pretty much equivalent to permitting an alcoholic counsel other alcoholics.

Uh, that actually works. In study after study, though by no means always successful, the Alcoholics Anonymous model--in which recovering addicts share their experience and hard-earned wisdom--has been about the most consistently worthwhile intervention. It has been copied for addictive behaviors of many kinds.

But the obesity research establishment hasn't gotten this message. They haven't even opened the mailbox to see that there might be a message waiting. It's because their aren't looking for this or some other message. They think, like that anorexic professor at Yale whose personal diet is uneconomic and unsustainable for even patients with the most driven eating disorders and who thinks that his obsessive neurosis is the only appropriate prescription for the millions of people with whom he has neither anything in common nor empathy, that they really know how to fix the problem.

So the research they do doesn't, ultimately, tell us much that's actually helpful. Studies that show that if you watch TV 6 hours a day you tend to be fatter than those whose varsity sports team practices 3 hours a day after school. The title is usually something like, 'Varsity sports participation is a protective factor for excessive body-mass-index in adolescents.' Or, 'Proportion of daily calories from fruit predicts lean body mass.'

Knowing the abysmal failure rate when doctors tell their patients they need to lose weight, and the worthless nature of this kind of research for any practical purpose except the resumé-building of the authors, I had assumed that the grind of inevitable progress would, by now, have brought us out of this dark cave. So I looked forward to joining this committee, in which I presumed to be kept at the very cutting edge of child obesity research. I wanted to find out what actually works, what has been tried, and what can I tell my patients and their families that will genuinely help them.

The committee met at a lovely upscale restaurant in San Francisco. I was one of 3 men. There were about 40 women on the committee, but not every member came to every meeting. Though their ages spanned from mid 20's to mid 40's, I feel comfortable, since this whole post is about judging books by covers, saying that they all could have been sisters. A pair of waiters came around to take our orders. You know the rest already, I suppose. Salad with no dressing--not even on the side. Fish grilled without butter or oil, no potatoes, no bread, no dessert. Even so, most didn't eat at the table, and just pushed the food around the plate. At the time, I felt humiliated and ashamed, as if they were all staring at me conspiratorially and silently agreeing that He's the reason we're here.

I thought the committee might address pediatric patients who have a nascent weight problem that needs to be addressed for their health. This group, as a subset of the obesity-research elite seeing to affirm their own dysfunctional relationship with food, was really just an excuse for these doctors to get together and affirm each other's neurosis. The consensus was that

McDonald's = Blackwater. 

More than one of the members of this committee proudly boasted that she had never, not once, eaten or even been inside a McDonald's.

I'm no apologist for McDonald's. But I think there's deep truth about patient care that these starvation-junkies have missed.

On a personal note, by the third meeting or so, I looked forward to the dinners. I would ask for extra butter on my mashed potatoes, ranch on the salad. At one point, about 25 people indicated that they didn't want dessert. I asked for an extra crème brûlée. It wasn't passive aggressive, it was just aggressive. The committee disbanded when the American Academy of Pediatrics realized, I suppose, that it would be cheaper to pay for these doctors to stand around outside of the restaurant rather than go inside and order food they didn't eat. And that it would not be possible for even less to get accomplished.

Next: what's missing from obesity research.
After that: some hope, or at least some reality, from recent research