Treating Children With Obesity: Developing a Plan
Here I will add to my previous postings about treating children with obesity. The earlier discussions focused mostly on principles of approach. Here we will get into the specifics of developing a workable plan.
Step one: the referral
Let us create a hypothetical patient: John is a 9 year old male child referred by his primary care physician for evaluation and treatment of excessive weight gain. The referral was agreeable to the parents and to John. In fact, it was John’s mother who expressed concern to the doctor; John had come home from school crying the week before. Apparently, he had been teased about his weight. John had been seeing the same doctor since birth and excellent growth records were available. They showed normal growth in height but excessive weight gain beginning at about 6 years of age. The present BMI was > 95% for age. John’s general health had been excellent and he was taking no regular medications.
I do encourage referrals from primary care doctors as opposed to self-referrals; in my experience it is very helpful to have each child’s primary care doctor “in the loop” and not opposed to our seeing the child.
Step two: learn all about the child and family
Before we can develop a treatment plan, we need to learn as much as possible about the child and family. We ask lots and lots of questions including whether the child and family understand the reason for the referral and what their sense is of the seriousness of the situation.
We want to know if the child has any chronic medical conditions, including any that might have been caused by the obesity (e.g., sleep apnea, limited exercise tolerance). Is the child taking any medications on a regular basis?
We want to know what the child’s growth pattern has been. Usually the primary care doctor sends us old growth records. We are interested in learning if the linear growth has been normal, basically eliminating endocrine gland disorders as possible causes for the obesity. We are also interested in learning when the excess weight gain begain and whether there were any “triggers.”
We want to know about the family structure- who lives in the home, ages of siblings, other care-givers, etc. We want to know the child and family routines- when do they eat their meals, is it a sit-down evening meal or is it in front of the TV?
We want to know what the child and family members typically eat. Does the child have breakfast at home or at school or both? Does the child buy the school lunch or bring lunch from home? What does the child eat for lunch? What about an afternoon snack; is it supervised, what does he typically eat for the snack?
We want to know about the child’s eating patterns- is he a fast eater, is he a big helping, seconds and thirds eater or a megasnacker or both? Does the child drink sugar-containing sodas, sport drinks, fruit juices and how much? Who does the cooking? Does anyone monitor the child’s portion sizes?
We want to know how often the family eats out, where do they eat, and what do they eat?
We want to know about the child’s activity pattern; does he have physical education classes at school? Is he a couch potato or always on the move? How much time does he spend watching TV and playing computer games?
We want to know how much the child and family members know about nutrition. Do they know what are high fat foods? Do they know how to read food labels?
Psychosocial issues
We need to learn about the child’s self-image and psychological impacts of the obesity. For example, many overweight children are teased over and over by children at school and even by sibs. This can be very upsetting to the child who may not even tell the parents about it. Sometimes, the child will retaliate by fighting with the teasers; this almost never results in less teasing.
Family history
We need to learn as much as possible about the family medical history- how many relatives are overweight, have diabetes, heart disease, high blood pressure, etc.? How many relatives have had premature deaths, possibly from obesity-related conditions?
Physical examination
A brief but complete physical examination is important. We measure the blood pressure, height, weight, and calculate the BMI. The skin is examined for evidence of insulin resistance (a skin condition called acanthosis nigricans). Pulmonary and cardiac status are assessed. Sexual staging is performed (i.e., is the child pubertal?). Musculoskeletal status is assessed with an emphasis on the child’s capacity for exercise.
Step four: the plan
Now that we have gathered lots of information, it’s time to put a plan together. Our first plan is usually quite simple and does not require that the family have an in-depth understanding of nutrition principles. Our program dietitian usually participates in developing the plan- depending on the child and family, we may or may not arrange a separate consultation with the dietitian shortly after the family’s initial visit to our clinic.
We give the child a three-ring binder with lined paper and begin to make specific suggestions. If the child and parents agree with the recommendations, we write them down in the notebook (the child is expected to bring the notebook to follow-up visits). A typical set of recommendations for our hypothetical 9 year old male child might look lilke the following:
1. One breakfast each day- either at home or at school, not both
2. Bring lunch from home 3 days a week
3. Afternoon snack is to be pre-prepared or supervised and limited to about 120 calories
4. The evening meal is to be a sit-down family meal without TV 5/7 days each week
5. The child should be the last family member to take their first bite of food
6. Smaller portion sizes at each meal and no seconds
7. No sugar-containing sodas
8. Limited use of sport drinks, fruit juices, etc.
9. Eat out no more than 2 times each week and follow portion size rules
10. Watch out for certain high fat foods- cheeses, spreads, salad dressings, etc.
11. More regular exercise, 1 hour TV/computer time during the schoolweek
Now what?
Now we have a list of “how to eat” that we have all “signed off on.” The child and family now have a relatively simple plan that they can start following immediately. The underlying principle is as follows: “it’s not yes or no but how much and when.” I do not favor listing foods as either good, bad, or so-so, as some weight loss programs do. I could not in good conscience tell a child pizza is a “red light food.” Who can live without pizza? So if John, our 9 year old patient likes pizza, that’s just fine. Maybe he can go for 2-3 slices not a whole pizza and maybe try Canadian bacon instead of sausage?
Calorie and weight loss goals
You may have noticed that I did not mention any specific calorie level goals (except for the afternoon snack). You may also have noticed that I did not discuss specific weight loss goals. I do not find that setting a calorie level and weight loss goals work very well. I can assure you that if the child just follows their written plan, caloric intake will be down by quite a bit and weight loss will follow. Anyway, in children success is often a slower rate of weight gain (remember they are still getting taller) than before rather than any weight loss.