Primary Care Physicians and Childhood Obesity Issues
Issuing Behavioral Prescriptions
|"Because of the increasing rates of obesity, unhealthy eating habits and physical activity, we may see the first generation that will be less healthy and have a shorter life expectancy than their parents." Statement made by U.S. Surgeon General Richard Carmona, March 2, 2004.
|We are all familiar with the rising statistics of childhood obesity. The statement made by the U.S. Surgeon General should give us all a reason to pause.
In fact, it is hard to read a newspaper without seeing a headline talking about the "obesity epidemic." While there are many factors contributing to the
causes of child and adolescent obesity, some factors are modifiable and some are not. Environmental factors play a significant role in obesity.
American lifestyle patterns are influenced by an overabundance of energy-dense food choices and decreased opportunities and motivation for physical
activity. Children learn from those around them and families tend to share eating and activity habits. The good news is that evidence shows it is much
easier to change a child's eating and exercise habits than it is to alter an adult's.1
We recognize it isn't easy to speak to parents about the weight or eating habits of their children. Many parents are likely to view any criticism of
their childrens' weight as a criticism of their parenting. But the fact is, while parenting may have something
to do with childhood obesity, other factors - such as physical activity or soft drinks or fast food in schools - are often harder to control.
Challenges Primary Care Physicians Face with Parents of Obese Children
|The Parent's Perspective
It isn't easy for many health care providers to address the issue of obesity with the child's parents. Aside
from the concern of many physicians that the parent will become angry at the mere mention of childhood obesity, healthcare professionals with experience
in dealing with parents and childhood obesity have noticed some common parental perceptions of which all health care providers should be aware:2
How Can Primary Care Physicians Approach the Topic of Childhood Obesity with Parents?
- 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.
- 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.
- 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.
- 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.
- 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.
In addition to the parental perceptions mentioned above that can impede dealing with childhood obesity, for many families, 'obesity' is
simply a forbidden topic. It carries many negative and emotional connotations for both the parents and the child. Obesity still carries
the stigma of afflicting only the weak-willed or lazy, when many other external factors and complex behavioral issues underlie its development.
It's important to identify the specific social context of each family that you deal with regarding childhood or adolescent obesity. In this way
it's possible to avoid doing any additional psychological or social harm to the family as the issue is addressed. Using the following guidelines
can help you address obesity in the appropriate and effective way:
Four Behaviors for the Primary Care Physician to Target
- 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.
- 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.
- 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.
- 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
A key step in dealing with obesity is understanding how it works in conjunction with physically inactive behaviors and caloric intake or dietary
issues. Focusing on four behaviors will help your patient and parents take a big step in the right direction:
Tailored messages to children and adolescents (as well as to their parents) should emphasize the importance of regular physical activity accompanied
by a properly balanced diet so that physical growth and mental development isn't impaired. To maintain a healthy weight, good dietary habits must be
coupled with physical activity, and these must become permanent lifestyle changes, not just transitory actions.
- 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.
- 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.
- 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.
- 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
|1British United Provident Association. (2004). Avoiding childhood obesity. Retrieved, August 23, 2004, from BUPA: The Personal
|2Chamberlin, L.A., Sherman, S.N., Anjali, J., Powers, S., Whitaker, R. The Challenge of Preventing and Treating Obesity In Low-Income,
Pre-School Children. Perceptions of WIC Health Care Professionals. Arch Pediatric Adolesc Med. 2002; 156:662-668.
|3These four points adapted from Mental Health and Obesity in Pediatric Primary Care, A Gap Between Importance and Action. R. Whitaker,
ed., Arch Pediatric Adolesc Med./Vol. 158, Aug. 2004.
|4Robinson, T.N. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA. 1999; 282:1561-1567.
Gortmaker, S.L., Peterson, K., Wiecha, J., et al. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatric
Adolesc Med. 1999; 153:409-418.
|5Robinson, T.N. Does television cause childhood obesity? JAMA. 1998;279:959-960. Woodard, E.H., Gridina, N. Media in the Home 2000:
the Fifth Annual Survey of Parents and Children. Philadelphia: Annenberg Public Policy Center, University of Pennsylvania; 2000.
|6Klesges, R.C., Eck, L.H., Hanson, C.L., haddock, C.K., Klesges, L.M. Effects of obesity, social interactions, and physical
environment on physical activity in preschoolers. Health Psychol. 1990;9:435-449. Baranowski, T., Thompson, W.O., DuRant, R.H., Baranowski, J., Phul, J.
Observations on physical activity in physical locations: age, gender, ethnicity, andmonth effects. Res Q Exerc Sport. 1993;64:127-133. Sallis, J.F., Nader,
P.R., Broyles, S.L., et al. Correlates of physical activity at home in Mexican-American and Anglo-American preschool children. Health Psychol. 1993;12:390-398.
|7Butte, N.F. The role of breastfeeding in obesity. Pediatr Clin North Am. 2001;48:189-198. Gilman, M.W., Rifas-Shiman, S.L.,
Camargo, C.A., et al. Risk of overweight among adolescents who were breastfed as infants. JAMA. 2001;285:2461-2467. Hediger, M.I., Overpeck, M.D.,
Kuczmarski, R.J., Ruan, W.J. Association between breastfeeding and overweight in young children. JAMA. 2001;285-2453-2460. Toschke, A.M., Vignerova,
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|8Giammattei, J., Blix, G., Marshak, H.H., Wolitzzer, A.O., Pettitt, D.J. Television Watching and Soft Drink Consumption.
Associations with obesity in 11-to-13-year-old schoolchildren. Arch Pediatr Adolesc Med. 2003;157:882-886.
|9Troiano, R.P., Briefel, R.R., Carroll, M.D., Bialostosky, K. Energy and fat intakes of children and adolescents in the United
States: data from the National health and Nutrition Examination Surveys. Am J Clin Nutr. 2000;72(5 suppl):1343S-1353S.
|10Burt, B.A., Pai, S. Sugar consumption and caries risk: a systematic review. J Dent Educ. 2001;65:1017.