Treating overweight in children

1
Treating overweight in children

• Current views

2
Two models for treatment

• Behavioral Management
• Outpatient Nutrition Clinic
• Summarized from Building Block for Life vol.
  25(3)2002

3
Behavioral Management

• Three person team MD, RD Psychologist
• First step assess readiness to change
• Family has to be the unit of change not just the
  child.
• Defer treatment if not ready to change because of
  possible impact of failure on childs self esteem
  and negative effects on future treatment.
• Note from Dr. K, think about stage of change
  theory family centered care. You want to be
  perceived as a helper.

4
Goals of therapy

• If deferring treatment RD provides information
  on health consequences and offers to help in the
  future.
• Goal in uncomplicated obesity
• Change eating and physical activity behaviors
  Not a change in weight

5
Skills to teach families

• How to assess current eating and physical
  activity behavior to determine where changes need
  to be made.
• Identify problem behaviors
• eating high calorie/high fat foods
• barriers to physical activity
• Focus on a few small permanent changes at a time
• Monitor the behavior and learn how to problem
  solve

6
Dietary Intervention

• Assess eating behavior to identify BOTH foods and
  patterns of eating that lead to excessive intake
• occasions of eating
• preferred or disliked foods, dietary
  restrictions, allergies
• frequency of eating outside of home
• 24 hr recall and 3 day record

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Dietary intervention

• Reduce and stabilize caloric intake
• Reduce fat
• Follow dietary guidelines
• If necessary, add restrictions for complicating
  conditions
• Refer to pediatric obesity center for intensive
  treatment
• Weight control information network
• Http//www.niddk.nih.gov/NutritionDocs.html

8
Dietary interventions

• Dont count calories, but teach to rely on
  internal cues of hunger and satiety.
• Teach low calorie, low fat choices
• Traffic light diet all foods can fit!
• green nutrient dense and unlimited
• yellow average value
• red low nutrient density and high calorie

9
Dietary interventions

• Teach how to make food choices away from home
• school, stores and vending machines
• restaurants teach to be assertive and ask for
  modifications.
• portion sizes
• what is a healthy portion?
• discuss how to modify
• small hamburger or cheese burger not a Big Mac

10
Physical activity

• Kids find periods of set physical activities
  boring.
• Individualize recommendations to activities child
  can accomplish and enjoy.
• Suggestions
• limit amount to TV or video games
• Play outside every day
• Walk after dinner
• Bright Futures in Practice Physical Education
• www.bright futures.org also nutrition info

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Parenting skills

• Psychologist, with your assistance
• Find reasons to praise child related to behavior
  not appearance
• Never use food as a reward!
• Establish daily times for meals and snacks
• Choose the type of food and the time, let the
  child decide how much
• Be observant so you can praise appropriate
  behavior
• Model appropriate behavior, even how to deal with
  set backs!

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Goal setting

• Focus on behavior change NOT weight!
• Specific, achievable and measurable
• switch from whole to 1 milk
• drink only 2, 12 oz pops a week
• ONLY ONE OR TWO PHYSICAL OR EATING BEHAVIOR GOALS
  IN TOTAL AT ONE TIME!
• Add additional goals when first set is achieved

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Self monitoring

• Key component
• Record daily eating and physical activity in
  notebook.
• Habit books reviewed by parents daily and at
  treatment team visits
• REINFORCEMENT
• praise and point system
• dont use food, money , or expensive items

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Self monitoring

• STIMULUS CONTROL
• change the environment to reduce cues and
  opportunities associated with eating
• Alter access remove food from house, meal
  times
• Establish new routines family walks, housework,
  after school activities

15
Duration of treatment

• Weekly or bi-weekly until eating an appropriate
  diet
• 3-6 month follow up
• Long term commitment by health care team and
  family!

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Part 2 Hints from a Nutrition Clinic

• Medical history
• collect as much as possible ahead of time
• Have the family state the problem in their own
  words
• Ask Why are you here? What do you think we are
  going to do today?
• You will get lots of emotion seize the moment
  to redefine the problem and offer hope

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Redefine the problem

• Define the problem as one of balance
• 1. Children need energy to grow in height and
  weight.
• 2. More energy has been coming in than is
  needed.
• 3. Today, we will look for ways to increase
  energy going out and decrease some of the energy
  coming in.

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Assess food and activity

• Bring 3 day record
• Ask child to go through a typical day s food,
  schedule and activities.
• 24 hr recall
• Be sure to ask about spending money, as this is
  usually spent on food!

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Keep it simple!

• Focus on 1 or 2 changes that will make the most
  difference!
• Beverages are easiest first change to make
• Have list with caloric value of juice, soda and
  milk
• Snacks not just junk
• list of good snacks
• plan timing
• are part of healthy eating

20
Keep it simple!

• Bring lunch from home?
• Make night before
• Not just sandwiches
• Dont skip meals, as that encourages overeating
  later
• Less fast food
• better choices
• Increase fruit and vegetables

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What about calories?

• Not the focus of the intervention
• Some basic information is OK
• 3500 kcal 1 lb
• Often weight gain can be explained by 80-150
  kcal/day, or an extra soda, or more TV time.

22
Decrease sitting around time

• Limit TV, computer and video came time
• gt4 hours/day associated with obesity
• Have some real suggestions for other activities
  in your community
• not just organized sports
• Dont exercise, dance or do an exercise tape
  with a parent or friend

23
Plan for difficulties

• Hunger
• limit choice of foods
• encourage activity
• Food as distraction
• have a basket of games and crafts to bring out
  when bored and want to eat.
• Keep away from temptation. Alter routines

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• Kids spend all day trying to get attentions and
  maintain their territory.
• Could it be that hunger is really a need to
  slow down and be filled up with some special
  attention?

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End of the visit

• Family has committed to two or three changes
• Agrees to keep a behavioral monitoring notebook
• Dont talk about it!
• Focus should be praising activity and working on
  the changes, not weight.

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Long term goals

• For young child maintain weight
• For older child 1 lb per month
• No fast fixes!
• Follow up as possible. If not identify community
  resources for families to use.
• Think about a group class using a purchased
  program