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What Not to Do: Talking to Children About Weight

Weight Loss Is a Sensitive Topic

Awkward conversations are a part of life but conversations about weight seem to be in their own category of awful! No one seems to “say the right thing” and this feeling is much worse when the conversation involves children. As parents, we are constantly hearing about the increasing rates of childhood obesity in children on one hand and the perils of eating disorders and unhealthy eating practices on the other. Let’s not forget that grandma at home is asking us why we care so much about what our kids are eating anyway – “they are just kids!”. In this blog, our goal is to discuss the basics of childhood obesity, eating disorders and strategies we can use to help our children have a healthy relationship with food.

The Common Risks of Obesity in Children

Obesity is defined as a weight 20% above the ideal weight for a particular height and age. Since children are always growing, BMI or body mass index is a helpful way to assess whether their weight is in the healthy range for their height. Generally, BMI between 85-95 percentile indicates that a child is overweight and a BMI greater than 95% indicates obesity. Children who are obese or overweight have been proven to be at greater risk of medical issues – some of which are listed below:

1. High blood pressure

2. Type 2 diabetes

3. High cholesterol and lipid levels

4. Sleep apnea

5. Pain in joints and back pain

6. Diseases of vital organs like the liver and gall bladder

Obesity and Self-Esteem

Children who are obese may also suffer from low self esteem, school bullying and feelings of isolation that set them up for emotional eating and eventually depression. On the other end of the spectrum, 10 million females and 1 million males are estimated to be suffering from eating disorders in the US. They are most commonly diagnosed between the ages of 14 and 17. The constant glamorization of thin bodies habitus in our media is hard for most of us to deal with but for those that have risk factors that predispose them to the development of an eating disorder, it can be catastrophic. Risk factors include the following:

1. Family history of obesity or eating disorder

2. Substance abuse

3. “Visual sports” like dance, gymnastics or modeling

4. A perfectionist

5. Low self-esteem

6. Hx of compulsive exercise, excessive food rules or frequently skipped meals

Types of Eating Disorders

The most common eating disorders are anorexia nervosa and bulimia nervosa.  Anorexia affects 0.5%-1% of women in the US and involves self-starving. This very low intake of calories will lead to a very low metabolic rate that will present itself with low body temperatures, low blood pressure and severe constipation. Bulimia describes the cycle of binge eating followed by “purging” of the calories by induced vomiting or stooling through laxative abuse. Unlike anorexia, bulimic children generally have an average weight number but may have physical signs that include dramatic fluctuations in weight, burst blood vessels in the face. Over time, they become more isolative and secretive and may hoard food and store it in unusual places like under their beds.

Strategies for Dealing With Unhealthy Relationships Towards Food

In the above paragraphs, it becomes evident that both extremes of the spectrum involve an unhealthy relationship to food. A clinical report by the American Academy of Pediatrics in August of 2016 published data related to common factors associated with both obesity and eating disorders. I was surprised to learn how many “time-tested “ strategies that our society employs daily actually contribute to a negative relationship with food. Some of these strategies as well as findings in the report are summarized below – the full report is linked at the end of this article:

1. Dieting – all studies indicated that caloric restriction was a factor in the development of obesity and binge eating. One study indicated that non-obese girls who restricted calories were 3 times more likely to be overweight by 12th grade compared to girls that did not diet. Another study indicated that 14  to 15-year-olds that moderately restricted their diet had a 5 fold increase in the risk of eating disorder development.

2. Weight talk – several studies indicate that talking about weight in relation to dieting contributes to a higher risk of becoming overweight – even if a parent is talking about themselves! Conversations that focus on weight loss tend to have a negative impact on children, especially adolescents and may lead to more negative behaviors like binge eating than instilling positive eating patterns.

3. Weight teasing – Multiple studies indicate that teasing comments made by peers and family have a negative impact on children (no surprise there!). These comments often continue into young adulthood and lead to a higher incidence of unhealthy weight control behaviors and binge eating. On the bright side, a higher frequency of family meals was associated with increased consumption of fruits and veggies, grains and calcium-rich foods and decreased carbonated beverages.

How Our Office Approaches Weight Issues

Soooo… what do we as physicians say when we find an unhealthy BMI during a well check or as a parent when we know in our hearts that our family can do better with overall healthy choices and food management? How do we talk about this delicate topic without making things worse? One of the answers seems to lie in how we ask about the topic of weight in the first place. If the data from the above study is to be believed, telling a patient they have a high body mass index or listing what not to eat does not seem to be decreasing the obesity or eating disorder rate in our country. The concept of Motivational Interviewing is gaining traction in the pediatric world and may provide us with a more effective way talk about weight-related issues both in the office and at home.

Motivational Interviewing involves a 4 step process to discuss a certain topic. This method has been used extensively with addiction and in adults but is fairly new to the pediatric world. The goals seem pretty simple:

1. Establish a working relationship with our children

2. Identify how change is being discussed

3. Encourage our children to explore and discuss the need for change

4. Planning for the change

Preliminary results indicate that pediatricians who are trained in this style of interviewing are more successful in reducing BMI in obese children and decreasing the incidence of eating disorders by promoting healthy conversations and relationships with food.

In our office, this interviewing process has translated to using the Strong for Life Healthy Habits Assessment form and additional training for our providers.. The form is meant to be filled out by children with their parents to identify general health-related behaviors in a non-judgemental manner. Every family has very healthy habits and every family has things they can do better. By looking at these behaviors together as a family and then with the pediatrician, the goal is to identify a doable small change that will make the family healthier. One to 2 changes over a period of several weeks are easier to stick to than drastic changes all at once. By implementing this technique, I have been pleasantly surprised at how engaged my patients are and how excited they are to identify what they want to work on when they do not feel like they are “wrong” or “ in trouble”.

We ask about things like fruit and veggie intake, sweet drink intake, screen time and eating out. As a provider, I have been floored by my patients’ honesty and willingness to change. They are very clear on behaviors they are willing to change (ie increasing 1 fruit serving a day) and things that are just too difficult (ie. decreasing screen time by ½ an hour). By engaging them in the plan, we are increasing our chances of success.

At home, keeping the focus on healthy choices is most important. By modeling healthy eating behaviors most of the time, our children understand the importance of choosing the apple instead of the pop-tart without it becoming a control issue. By discussing our lapses in healthy choices, our children understand that no one is perfect and we should not be discouraged to try again. Cooking and eating together at home and planning active family outings go a long way in creating a positive relationship with food and exercise. All of the above help us keep the lines of communication open and hopefully increase our chances of creating more positive relationships with weight and food in our country.


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