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Pediatric practitioners should approach the discussion of childhood obesity with sensitivity and a nonjudgmental tone toward parents and patients. Practitioners must minimize embarrassment, harm to self-esteem, and stigmatization, and, instead, be supportive when discussing the issue with patients. Even though the clinical terms "overweight" and "obese" are recommended for documentation and clinical risk assessment, the use of different words should be considered in the dialogue with patients and families. Words such as "fatness," "excessive fat," and "obesity" may be derogatory, so pediatric practitioners should discuss overweight and obesity by using neutral terms such as "weight," "excess weight," "body mass index," and "healthier weight." Another neutral alternative is "risk for diabetes and heart disease."(1)
Successful treatment of overweight children depends on the cooperation of not only the child but also the child’s family. The importance of a family-based management strategy cannot be overemphasized. Thus, before initiating therapy, it is important to determine the family’s therapeutic readiness. The clinician should assess parental perceptions about their child’s weight. Specific questions to measure the family's knowledge, culture, and readiness for change are included in the Family Readiness Questionnaire. Behavior modification requires commitment by the family as well as the older patient. Providers can consider using motivational interviewing or other behavioral techniques for families that currently do not express an interest in lifestyle modifications to change their attitude. For families interested in changing dietary, physical activity, and sedentary behaviors, several behavioral intervention techniques are currently used in treatment programs. Cognitive behavioral therapy (described here) and motivational interviewing (described here) have been studied in child and family interventions. Principles of these behavioral methods can be incorporated in the pediatric primary care setting.
If parents do not feel that their child’s weight is a problem or if they feel that it cannot be changed, then therapy should be delayed. Instead, the clinician should focus on parental counseling and education, hoping to improve parental motivation. Issues that should be addressed in such counseling, according to the AAP Pediatric Nutrition Handbook, include the following:
• The risk of persistence of obesity into adulthood increases with the child’s age.
• Obesity is associated with many potential medical complications, some of which may already be evident in family members.
• The cooperation of the entire family (including all caregivers) in any therapeutic regimen is essential.
• Adopting a healthier lifestyle benefits the entire family, regardless of whether any individual family member is obese.
• The major goal is long-term maintenance of reduced body fatness, not just short-term weight reduction.
• Good health habits (diet and exercise) that are started early will likely persist into adulthood (2).
Decreased morbidity and mortality risk should be the principle aim of any treatment regimen for overweight children. Too often, an overweight child and/or his or her parents may be looking only to achieve a certain accepted body weight (3). If morbidity is not evident, then initial therapy should focus on maintaining weight while height increases. Ideally, the child will reach an appropriate height for his or her weight within a couple of years. Twenty percent of excess weight for height can be corrected in this manner within one or two years. In cases of severe obesity in which a child is already obese by adult criteria, weight loss is indicated. Click here for appropriate weight loss rates for children by age and BMI percentile to achieve deflection in BMI percentile. Children with weight loss greater than these recommended rates should be monitored for causes of excessive weight loss (4). The need for pharmacologic or surgical intervention for weight loss is best evaluated by referring these children to pediatric specialty-trained multidisciplinary programs with clinical protocols in place to carefully monitor children and adolescents.
Before recommending dietary, lifestyle, or behavior modifications, the clinician should assess the current behaviors of the child and his or her family. Standardized instruments, such as WAVE and REAP, can be used to assess diet and activity behaviors, although none of the instruments assess all the recommended areas for intervention.
Dietary changes are often viewed in a negative light by children. The clinician should keep this in mind when making recommendations to parents. Parents must understand that the presentation of dietary changes is as important as the dietary changes themselves. To effectively modify a child’s eating habits, the child must not see the changes as punishment. The importance of participation by the entire family is a crucial factor for success. Such participation will eliminate feelings of isolation that the child may experience. All caregivers should be counseled about the important role they play in the development of healthy eating habits, and they should be educated about how children’s eating habits mimic those of their parents. Rather than encouraging dangerous short-term diets promoting rapid weight loss, the clinician and parents should focus on long-term dietary modifications that will lead to a nutritionally balanced diet. For specific recommendations, see the Nutrition Guidelines. Additionally, USDA provides portion size and calorie recommendations.
Sedentary Behavior Modifications
The sedentary nature of today’s society has contributed to the increase in childhood obesity. Much of children’s free time is spent watching television, playing video games, and working on the computer or surfing the Internet. Such activities reduce the amount of time spent on physical, calorie-burning activities, and, with television, the harm is compounded by the widespread prevalence of food advertisements included in today’s programming. It is necessary to limit these sedentary activities and encourage children to participate in more active pastimes.
Physical Activity Modifications
Typically, schools and communities provide many opportunities for children to participate in various team and individual sports. Parental participation should be encouraged and considered integral to successful lifestyle changes. The health care provider, however, should keep the safety of the child’s home environment in mind when making recommendations and may need to lobby for improved school- and community-run activity programs. For specific recommendations, see the Lifestyle Guidelines.
The process for making dietary, physical activity, and sedentary behavior changes is often refered to as behavior modifications. Behavioral changes for children and their families can encourage more healthy eating patterns, leading to less overeating and increased recognition of satiety; decreased sedentary behaviors, which may affect the child’s dietary intake or physical activity; and greater use of physical activities in a child’s normal activities. For specific recommendations, see the Behavior Guidelines.
1. Barlow SE; Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: summary report. Pediatrics. 2007;120(suppl):S168.