by Leslia Gonzalez (’22)
reviewed by Celeste Corcoran (Pediatric Primary Care and HEALTH clinic)
Childhood obesity has been a growing problem for many years. The COVID pandemic has unfortunately exacerbated this. A study published in JAMA that utilized the Kaiser Permanente Southern California population found an increase in childhood obesity across all ages, with the largest being within the age group of 5-11 yo. There was an increase of approximately 9%. We have seen this trend amongst our patient population as well.
The implications of childhood obesity include comorbidities such as nonalcoholic fatty liver disease, type 2 diabetes, high blood pressure, dyslipidemia, and mortality. As one would expect, the longer these comorbidities are present, the worse the outcomes. This is why intervention and education at an early age are essential.
In general, the approach to obesity management can be broken down into three different categories: prevention, structured weight management, and comprehensive multidisciplinary intervention. For this blog, the focus will be on prevention which encompasses the counseling and techniques that we can utilize in a primary care visit.
Counseling is a big part of any prevention. Building healthy habits such as nutrition and physical activity should be considered as changes that patients will incorporate for the remainder of their lives. The idea is to be healthy for as long as possible, not a short period which is how people often view weight loss and diet. Some strategies to help patients form these habits include self-monitoring, stimulus control, goal-setting, contracting, and positive reinforcement.
Self-monitoring: As implied by the name, the idea is to keep track of eating. The patient and family can do this with a food log or diary. This offers the provider data that can be reviewed with the patient, and feedback and suggestions can be provided.
Stimulus control: There is only so much willpower we have. Think about the number of decisions we make a day and the harder it is to make those decisions as the day goes on. This concept applies with temptation, but children have less brain development and cannot exhibit self-control. It would make it easier to remove temptation from the equation. Have the family remove sugary snacks and beverages from the home as these are not healthy for anyone. Doing so can be difficult for families as some members might want to indulge in these. Remind them that we want everyone in the household to be healthy, not just our patients.
Goal-setting: As with any goal, help your patients make a SMART one. It should be specific, measurable, attainable, realistic, and timely. For example, a patient can decide that their goal will be to reduce sugary beverage intake from every day to once a week. Have them choose the day they would like to have juice, such as Sunday morning with breakfast. Finally, set a day for when the patient can achieve this goal. Every week, the number of juice-drinking days can decrease until the patient is down to drinking juice to once a week. The goal should take approximately six weeks.
Contracting: This is having an agreement with the patient to reward them for achieving a goal. I use this with my patients to help keep them motivated. They get to choose the prize within a price range, and the terms of the award are that it must be something that does not promote an unhealthy lifestyle. Prizes range from basketball to art supplies. Having a reward system is a potent motivator for children.
Positive Reinforcement: This can mean praise or some form of reward for healthy behaviors. The rewards here can be small activities or privileges that the child can frequently participate in. An example would be, doing arts and crafts with a parent. Food should not be used as a reward.
Remember that these are a collaboration with the patient and the family. It would be difficult for the patient to make changes without the help of the family. Listen to the concerns and the barriers to change and provide understanding and support. As many of you I’m sure have experienced, not all families are educated on how to talk about unhealthy behaviors. Instead, the child is shamed and criticized, resulting in subsequent weight gain, low self-esteem, and eating disorders. Please advise families to avoid terms such as “obese” and “fat,” which can be stigmatizing.
Finally, we should be providing education around healthy eating and active living at every visit. There are many educational materials you could utilize with your patients. A major one is the 5210 method, which was designed in partnership with the U.S. Department of Health and Human Services, the American Academy of Pediatrics, the U.S. Department of Agriculture, and the National Association for Sport and Physical Activity. To review, 5210 represents the daily goals for healthy habits, 5 servings or more of fruits and vegetables, 2 hours or less of non-academic screen time, 1 hour or more of physical activity, and 0 sugary beverages. This method was research-based and proven to be effective in reducing obesity in children. It is also important to educate families on portion control. Doing so will help to dispel the notion that more food equates to bigger and healthier children. Oftentimes, this starts at a young age when parents are feeding infants 6-8 oz every 3 hours up until they are a year old. At that point, it becomes harder for parents to reduce the quantity of milk that the child wants and by then their BMI is elevated. It is important to help parents establish a healthy feeding regimen during their first few visits as this will help prevent unnecessary calorie intake.
Cook Children’s. 5210 Every Day. The Center for Children’s Health. https://centerforchildrenshealth.org/healthy-lifestyles/5210/Pages/default.aspx
Reily, Lauren (2021, September 2). Obesity among children ages 5 to 11 rises during the pandemic. The Washington Post. https://www.washingtonpost.com/business/2021/08/31/pandemic-childhood-obesity/
Skeleton A, Joseph (2021, September 10). Prevention and management of childhood obesity in the primary care setting. UpToDate, Post TW (Ed), UpToDate. https://www.uptodate.com/contents/prevention-and-management-of-childhood-obesity-in-the-primary-care-setting?source=autocomplete&index=0~2#H3863068527
Woolford SJ, Sidell M, Li X, et al. Changes in Body Mass Index Among Children and Adolescents During the COVID-19 Pandemic. JAMA. 2021;326(14):1434–1436. doi:10.1001/jama.2021.15036 https://jamanetwork.com/journals/jama/fullarticle/2783690?&utm_source=BulletinHealthCare&utm_medium=email&utm_term=090121&utm_content=NON-MEMBER&utm_campaign=article_alert-morning_rounds_daily&utm_uid=9622392&utm_effort=MRNRD0