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 child’s 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

7. 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 Don’t 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

11. 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!

12. 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

13. 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 – don’t use food, money, or expensive items

14. 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!

16. 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

17. 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.

18. 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!

19. 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 – Don’t skip meals, as that encourages overeating later Less fast food – better choices Increase fruit and vegetables

21. 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 – >4 hours/day associated with obesity Have some real suggestions for other activities in your community – not just organized sports Don’t’ “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

24. 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?

25. End of the visit Family has committed to two or three changes Agrees to keep a behavioral monitoring notebook Don’t talk about it! – Focus should be praising activity and working on the changes, not weight.

26. 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