Research

Clinical Strategies for preventing obesity and eating disorders

eating-disorders

Clinicians and parents may be reluctant to address obesity in children because of concerns for promoting eating disorders. A new clinical report from the American Academy of Pediatrics outlines strategies that can be used to address obesity without promoting disordered eating. These include counseling parents to avoid “weight talk” (comments that focus on weight or weight-related appearance, even if they are not directed at the child) and focusing goals on healthy food choices and healthy eating behaviors rather than dieting (which is distinguished by caloric restriction with a goal of weight loss).

 In most modern cultures of the developed world there is some bias against individuals with obesity, which presumes that obesity is a character flaw. Despite progress in understanding the complex origins of obesity, which include genetic, epigenetic, cultural, and environmental factors, this bias remains widespread. The bias is also present within the medical community, where it often causes providers to take a blaming approach to individuals with obesity. Such an approach is rarely effective and often jeopardizes the therapeutic alliance. Individuals with obesity have often absorbed the bias themselves, leading to self-criticism, low self-esteem, and hopelessness; these feelings are often barriers to behavior change.

Because of this widespread cultural bias, many families with obesity are sensitive about discussing the issue. To form a therapeutic alliance and engage the family in addressing weight-related behaviors, the provider must carefully avoid a blaming approach. For these reasons, it is important for providers to understand and acknowledge the role of genetics and epigenetics in the development of obesity, even though their assessment and intervention will emphasize modifiable environmental factors. The genetic and epigenetic mechanisms help to explain why families of similar education and capabilities may have very different predispositions to obesity and different success in weight management. This perspective helps the provider take a supportive rather than blaming approach and also reduces provider frustration in the challenging endeavor of weight management.

Behavioral strategies — Simply providing patients with education on obesity related health risks, nutrition, and physical activity is insufficient to induce behavior change. Instead, nutrition and physical activity should be thought of as habitual behaviors. The best-established counseling techniques used for pediatric obesity treatment use a behavioral change model, which includes the following elements [7,19-24]:

Self-monitoring of target behaviors (logs of food, activity, or other behaviors, recorded by patient or family). This process allows the patient and family to recognize which behaviors may be contributing to their weight gain. Clinician feedback throughout the self-monitoring process is essential to behavior change. A patient’s food log may also identify other contributors to eating behaviors, such as meal-time environment, boredom, and level of hunger, all of which can be valuable in the evaluation of stimulus control.

Stimulus control to reduce environmental cues that contribute to unhealthy behaviors. This includes reducing access to unhealthy behaviors (eg, removing some categories of food from the house or removing a television from the bedroom) and also efforts to establish new, healthier daily routines (such as making fruits and vegetables more accessible).

Goal-setting for healthy behaviors rather than weight goals. Goal-setting is widely used for prompting behavior change. However, the process can be detrimental if goals are not realistic and maintainable. Appropriate goals are identified by the acronym “SMART,” where goals should be should Specific, Measurable, Attainable, Realistic, and Timely.

Contracting for selected nutrition or activity goals. Contracting is the explicit agreement to give a reward for the achievement of a specific goal. This helps children focus on specific behaviors and provides structure and incentives to their goal-setting process.

Positive reinforcement of target behaviors. Positive reinforcement can be in the form of praise for healthy behaviors or in the form of rewards for achieving specific goals. The reward should be negotiated by the parent and the child, ideally facilitated by the provider to ensure that the rewards are appropriate. Rewards should be small activities or privileges that the child can participate in frequently, rather than monetary incentives or toys; food should not be used as a reward.

Experts have devised the following recommendations:

Obesity during childhood is associated with long-term health consequences and is influenced by genetic, epigenetic, behavioral, and environmental factors. Among these, only behavioral and environmental factors are modifiable during childhood, so these are the focus of clinical interventions.

We suggest the following practices among providers of primary care to children. These suggestions are based primarily on expert opinion; some are supported by clinical studies, usually with short-term outcomes.

Universal measurement of body mass index (BMI) and plotting of results on a BMI chart to track changes over time.

Routine assessment of all children for obesity-related risk factors, to allow for early intervention. This includes recording the obesity status (BMI) of the biological parents and assessing key nutritional and physical activity habits.

For children with obesity, weight-related comorbidities should be assessed through a focused review of systems, physical examination, and laboratory screening.

For all children and their families, routine health care should include obesity-focused education. Key goals to address are the common diet-related problems encountered in children, set firm limits on television and other media early in the child’s life, and establish habits of frequent physical activity.

For children who are overweight or obese, we suggest a series of clinical counseling interventions in the primary care setting. Each session can be brief (3 to 15 minutes); this brief format is most practical for the primary care setting and is supported by limited clinical evidence. Additional contact time is valuable if time permits or if an allied health care provider (eg, dietitian or registered nurse) is available to provide counseling.

Educational materials are available from a variety of sources to facilitate the counseling. These materials have much in common and have not been directly compared; it is reasonable for providers to select materials with messaging that is best suited to their community. Options include a Healthcare toolkit and an outline for a brief clinical intervention, which is based on the principles of motivational interviewing.

For patients who do not respond to a brief clinical intervention or for those with severe obesity, higher-intensity approaches are needed. These interventions are implemented in stages and usually require referral to specialized weight management programs or tertiary care centers.

To establish a therapeutic relationship and enhance effectiveness, the communication and interventions should be supportive rather than blaming, and focused on the entire family, rather than on the child alone. Long-term changes in behaviors that are related to obesity risk should be emphasized, rather than diets and exercise prescriptions, which tend to set short-term goals. When implemented in a supportive fashion, with a focus on healthy eating behaviors rather than rigid or highly restrictive dieting, interventions to support weight loss do not predispose to eating disorders.

To be effective in managing populations with obesity, primary care offices should develop an efficient office system for calculating and tracking BMI at each visit and have a wide range of blood pressure cuffs (including a “large adult” size) and high-capacity scales (ideally up to 500 or 1000 lbs). It is also helpful to have office furniture that is appropriate for large patients and their families, including sturdy armless chairs and low examination tables.

November 2, 2016

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