Primary Care Physicians and Childhood Obesity Issues

Issuing Behavioral Prescriptions

Challenges Primary Care Physicians Face with Parents of Obese Children

1. Parents May Not Believe Their Child Is Overweight.
   Health care professionals have pointed out that many mothers who had overweight children didn't feel that their children were overweight. This was identified as a major obstacle to successful counseling about the prevention and treatment of obesity. If the subject of being overweight was raised, the mother became offended. Some possible explanations for this maternal reaction include the mother's sense that the child is 'plump,' and thus healthier or more attractive, especially at younger ages. Many also believe that their child will 'outgrow' the weight problem.
2. Parents Have Difficulty Setting Food Limits For Their Child.
   Parents may lack the knowledge or ability to effectively discipline their child, giving in to their child's demands more often than not. The child - often by default - is thus given too much decision-making power over food issues. This problem can have a serious impact on the child's nutrition and weight.
3. Parents May Use Food As A Parental Tool or Coping Mechanism.
   Parents may use food as a coping mechanism to deal with high levels of stress. Food is used to calm, reward, and even emotionally nurture their child. Food is thus used as a control tool for the child's behavior and also as a way to indulge the child and express affection.
4. Parents Lack Knowledge About Normal Child Development and Eating Behaviors.
   The lack of knowledge about child development, as with the lack of knowledge mentioned above, effects the parent-child feeding interaction. Health care professionals have noted the common practice of mothers to give children food types and portion sizes that were inappropriate. Parents were frequently unable to tell when the mood or behavior of their child was the result of hunger or a sign of other distress, such as loneliness, anxiety, or fatigue.
5. Parents May Lack Motivation or Commitment to Modify Behavior.
   Even when parents receive counseling regarding childhood obesity, many have shown a lack of motivation or commitment to modify their own or their child's eating habits. Many parents will be interested only in immediate results and express scant interest in diet-modifying nutritional counseling.

1. Be sensitive.
   Any health condition will be sensitive for parents to discuss if it is stigmatized, involves a genetic predisposition, and is shaped by the household environment. You can expect parents to feel guilty or defensive if your concern about their child's risk is based on the parent also having the condition. Guilt isn't a constructive emotion from which parents can initiate and sustain action to prevent or treat their child's obesity.
2. Understand the family history.
   If obesity runs in the family, it greatly influences parents' and grandparents' ideas about the causes and cures for it and can produce feelings of guilt, shame, or vulnerability. The family, as both "seed and soil" for obesity and mental health conditions, may develop its own way of dealing with it that needs to be understood. For example, families can maintain an informal code of silence about these conditions that isn't comfortable for you to penetrate. Obtaining a detailed family history of any health conditions may be the best entry point for beginning these difficult discussions.
3. Focus on function more than labels.
   The degree and nature of a child's functional impairment-physical, social, and emotional-is likely to be more important than the diagnostic label. Although your training and experience as a health care provider may compel you to categorize children as either "diseased" or "nondiseased." you should carefully consider whether the child's function would actually be improved by labeling these brain-centered conditions for which the stigma is high. Try instead to view obesity along a spectrum. In this way you may be able to help children and their parents who have significant functional impairment at symptom levels below a diagnostic threshold while avoiding labels for those who are above the threshold but unimpaired.
4. Learn the context.
   The pathways leading to obesity and mental health conditions are highly varied. Your clinical approach must take into account many contextual factors, including past emotional trauma, the family's current social support and household composition, and the child's household, day care, school, and neighborhood environments. These factors can alter the expression of inherited susceptibility to obesity and also affect the level of functional impairment associated with it. Asking open-ended questions can help you get a better understanding of the context in which the obesity is occurring.³

1. Limiting Screen Time.
   When television-watching behavior is altered, it affects weight gain. Even though the size of the association between t.v. viewing and obesity is small, it's still an important behavior to target because children's exposure to it is enormous: the average U.S. child age 2-17 spends more than three years of life watching t.v. Moreover, about 57% of U.S. children ages 8 to 16 have televisions in their bedroom.⁵ Children spend more time now than ever in front of computers and electronic games. When it's joined with the consumption of soft drinks (see number four below) its effects are especially deleterious.
2. Encourage Outdoor Activities.
   Limiting t.v. by itself won't always mean a child becomes more active, but when coupled with increased activity outdoors - the strongest correlate of physical activity in young children - the potential to promote healthy weight in children is promising.⁶ Spending time outdoors also has the potential to promote a child's social and cognitive development through participation in unstructured play with other children and through the exploration of the physical environment.
3. Encourage Breastfeeding for New Mothers.
   Although it isn't absolutely clear whether there is some factor related to breastfeeding, and not breastfeeding itself, there is enough evidence to support the contention that the prevention of childhood obesity is one of the many benefits of breastfeeding.⁷ When encouraging breastfeeding, remember not to be overzealous about it. Most bottle-fed infants won't become obese children, and many mothers choose not to breastfeed because there may be inadequate breastfeeding accommodations in the workplace or too little support at home. Nevertheless, this is another behavior with which to deal with childhood obesity, especially if there is a family history of obesity.
4. Limit the Intake of Sugar-Sweetened Drinks.
   Especially when coupled with too much time in front of the t.v., the number of soft drinks consumed is significantly associated with childhood obesity.⁸ Aside from being low in nutrients, this type of beverage contributes an enormous amount of calories to a child's diet: the average U.S. teenager gets about 8% of daily calories from soft drinks.⁹ Soft drinks also may promote tooth decay and lead to sub-optimal bone mineralization.¹⁰