by
Howard S. King, MD with Alison Hoppin, MD, Associate Director for
Pediatric Services, MGH Weight Center, Linda S. Nikolakopoulos, MS, RD,
LDN, Consultant Dietician in Private Practice, and Melinda Strauss,
LICSW
“The Centers for Disease Control and Prevention estimates 500,000
people will die next year because of poor diet and physical inactivity.” (Bill Rodgers, in
The Boston Globe, April 19, 2004)
Childhood obesity has increased considerably in recent years. About
15% of American children are obese, and an additional 15% are
overweight. (1) “US teens are more likely than those in other
countries to eat fast food, snacks and sugary sodas and are more likely
to be driven to school and other activities, contributing to a more
sedentary lifestyle,” according to the U.S. Maternal and Child Health
Bureau.
It should be stated that heredity and biochemical processes such as
metabolism play a major role in the development of obesity. While these
factors are usually (2) beyond an individual's control, managing daily
food consumption presents both choice and challenge for parents and
children.
The American Academy of Child Psychiatry recommends changes in
eating habits, increased physical activity, diminished television
viewing, and addressing family and peer problems and issues of low
self-esteem.
Given the epidemic occurrence of obesity and the difficulty in
changing habits, what else can pediatricians do to reduce children's
vulnerability to this problem, beyond recommending dietary changes and
encouraging children to become more active? Are there attitudinal
changes we can encourage in the family-child relationship, which might
reduce a preoccupation with food?
The focus of this article is to explore the role of the family's
relationship with food and its impact on the development of obesity. It
is intended to support the pediatrician's efforts to reduce the
likelihood of a child developing a lifelong propensity to become
overweight.
Family history of weight problems
Parents often ask the pediatrician, “What ‘percentile' is he/she
in?” When parents ask that question, it may suggest they're
anticipating the likelihood of their child becoming overweight.
Pediatricians can be sensitive to that underlying parental fear and use
that opportunity to open a discussion. When we help parents put their
concerns into words, hopefully, it may diminish the likelihood of parents finding ways, unconsciously, of transforming that fear into a reality.
When parents worry about their child's weight, pediatricians need to
take an appropriate, psychologically attuned history. A family history
of being overweight, particularly in one or both parents, could be
a major contributing factor in children becoming overweight. The
history should also include the nutritional status of parents' siblings
and grandparents.
It would be helpful to gain some understanding of the etiology of a
parent's (or other family member's) weight problem, past or present. If
parents are currently overweight or had such a problem in their past,
it would be useful to ask them, if they're willing to share such
information, what they think might have contributed to this tendency?
How old were they when the problem began? Was there any investigation
of medical causes for the weight problem? Were there cultural factors,
how did being overweight affect their self-esteem, what did they or
their parents, in turn, do about it?
Every question, every comment a parent makes about his or her child
might possess a deeper meaning. For example, “Could my child be
becoming overweight?” may suggest that the parent anticipates, if the
child becomes so, that he or she will experience shame because of the
stigma of being overweight in our society. In addition, parents may
have memories of “shame” in connection with their own development or
because becoming overweight emerged in the context of a shameful
experience, e.g. the sexual abuse of the parent, at an earlier time in
his or her life. These could be “teachable moments” for pediatricians,
if they could gain the trust of parents in terms of sharing such
memories.
Can we reduce the repetition of obesity from one generation to another?
How do we help parents reduce the possibility of their child
inheriting their “weight problem?” How do we help parents establish
good boundaries between them and their children, i.e. viewing their
children as separate people, able to control their own destiny? If
pediatricians provide parents with opportunities to share their
personal stories about how and why they, themselves, became overweight,
in their own development, parents might more easily assess assumptions
they make about their children inheriting weight problems.
Is becoming overweight inherited through genes or could it be “psychogenetic” in origin, i.e. the child becoming aware of how family members approach the process of eating, around the dinner table and, perhaps , gradually internalizing
those habits? Genetics plays an important role. However, the family
eating environment and the larger cultural environment are influences
that are superimposed on any genetic susceptibility for weight gain.
Family customs , the family's attitude toward food, and parental expectations are very relevant.
For most people, being overweight is a highly conflicted personal
attribute. Most people wish they weren't overweight. But something else
is at work if only one person in twenty maintains weight loss from
dieting for more than five years.
Despite this discouraging data and the physiological and
psychological influences contributing to weight gain, strong
motivations to control weight persist . These include concerns about
current or long-term health, personal preferences and strong social
norms encouraging a thin body habitus, difficulty accomplishing the
activities of living, as well as the powerful societal discrimination
against individuals with obesity.
Given that most dietary recommendations fail, might that imply that
when we manage such patients, we may be giving insufficient attention
to the family history and the family system? Parental modeling is a
critical influence on the development of a child's behavior. For
example, family-based behavioral counseling demonstrated significant
improvement in obesity in a ten-year follow up. (3)
The child as an agent for change in the family
It is difficult to manage the overweight child without seeing him or
her in the context of a family system. In that context, the child could
become an agent for change. The parent, by definition, is the primary
mediator of change, and a family-based effort is , accordingly, both
appropriate and necessary.
Discussing the overweight child with the pediatrician can provide
the parent with a unique opportunity to reflect back upon the parent's
own history of how she or he became overweight or even obese. Dr.
Vincent Felitti (of the department of preventive medicine at
Kaiser-Permanente) speculates that obesity may sometimes have a
“protective” function, when it developed as a response to some
unresolved conflict, early in life, e.g. sexual abuse. Some experts
feel that this is rare (except in morbid obesity), although it could
become a trigger for becoming overweight.
The parent's own struggle with weight or ambivalent relationship
with food can strongly influence his or her approach towards the
child's weight. That's why it's important to understand the meaning and
natural history of the parent's weight problem. The child's struggle
with weight could present parents with a wonderful opportunity for the
parents themselves to reassess their long-standing problem. The
pediatrician can help the child by helping the parent.
Weight problems or obesity in children is a family problem. Even if
the parent is no longer overweight, and it seems to be no longer an
issue for the parent, it is necessary to understand how the parent's
weight problem came to be , as well as how it was managed. This would
be not only helpful to the child, but would also promote the parent's
long-term health.
Family stressors may contribute to childhood obesity
Does a family history of alcoholism or drug abuse play a role in the
predisposition to obesity and other eating problems, e.g. anorexia? If
some anorectic children have parents or grandparents who were
alcoholic, shouldn't we also inquire about a family history of
alcoholism and drug addiction when we evaluate overweight or obese
children? Similarly, can we successfully address weight problems or
obesity in children without acknowledging the problem of nicotine
dependence in a parent or even a grandparent?
Other stressors such as family chaos or the lack of nurturing role
models could be significant factors in understanding a child's obesity.
Can parental management of some infantile “habits” predispose a child to a tendency to becoming overweight?
What are the consequences of parents' fears that they will contribute to a child's insecurity in the first year of life?
Many parents believe their mission is to prevent their children from
ever being unhappy or sad. Even in the absence of a physical illness
(e.g. infection, gastro-esophageal reflux, allergy to some food or
failure to gain weight), it is difficult for many parents to ever allow
their child to cry. Parents' self-doubts about their ability to nurture
their child can lead to difficulties setting limits.
In some populations, parents prefer their young child to be
overweight. It makes them feel like better parents because they feel it
demonstrates they have adequately fed their child. (4)
Most infants can give up 2 am feedings by two months of age and are
able to sleep, approximately from 7 pm to 6 or 7 am, by four months of
age. If parents can help children achieve such a schedule, doing so
might make it less likely that a child would be predisposed
to associate feeding as the only way to feel comforted. But that isn't
easy, if parents are currently under stress or experienced serious
deprivations in their own development. Such parents find it difficult
not to give their child that extra feeding beyond the time that it is
necessary.
The idea that the child requires the bottle, breast or pacifier “for
security,” beyond the time when most children usually give it up (by
one to one and a half years of age), could result in the child becoming
dependent upon it as a source of comfort.
A common belief that teething causes irritability and pain in young
infants can undermine a parent's resolve not to respond to a crying
child at night. But many infants appear to erupt new teeth in the
absence of obvious pain or irritability. On the other hand, other
infants seem to be irritable for which “teething” is blamed, despite no
obvious alteration in the appearance of the gums. In fact, some may
have real pathology (e.g. an earache) even though a relative or a
professional may have ascribed the symptoms to “teething.”
The pediatrician can help by checking for physiological causes of
irritability and, if none is found, by reassuring the parents that some
irritability in the sleepy infant is common and usually does not
indicate hunger. If given a little time, the child can often return to
sleep and develop more mature and independent sleep habits.
Whatever the reason for the persistent use of these transitional
objects, the challenge for pediatricians is how to encourage parental
self-efficacy along with their ability to set limits. We should
always be thinking of how we can help parents learn how to set limits
and raise a healthy growing child, without needing to overfeed, as a
way of proving their efficacy to themselves.
Barriers to following advice
Most parents, if a pediatrician suggests giving up the bottle or
discontinue getting up with a child at night, can usually follow
through with those tasks, except in the following circumstances:
• If the pediatrician suggests doing so for inappropriate reasons, at an inappropriate time, or in a controlling manner.
• If parents are experiencing some ongoing stress, which make it
difficult for them to help the child cope with the loss of this
transitional subject. In that case, it is important for us to ask if
they would be comfortable sharing what is currently going on,
emotionally, with the family.
• Perhaps this task has a "double meaning," e.g. parents may be
having difficulty giving up their own nicotine or food dependency and
he or she may (unconsciously) identify with the child's sense of
frustration. Or there may be a family history of an addiction, e.g.
alcohol dependency. In such cases, it would help the parent (and,
ultimately, the child) if we could inquire about such issues, in a gentle and compassionate manner.
• The parent may remember having experienced difficulty giving up a bottle, thumb, or pacifier when he or she was younger.
Parental guilt about allowing their children to cry can be another
barrier to setting healthy limits. Sometimes it may just be the lack of
awareness of what children are capable of mastering at such an age.
Assuming pediatricians have eliminated the aforementioned medical
factors (illness, allergy, failure to gain weight), pediatricians
should consider reassuring parents that their children don't require
endless support. (If parents feel otherwise, consider exploring why
they feel that way.)
But, to be successful, pediatricians must evaluate how the parents
are doing. It might mean acknowledging parents' (often mothers')
ambivalence about working during the child's first few years of life.
Parents may need help not identifying the child as mirroring their own
past or present feelings, e.g. of being abandoned. If a mother had some
degree of postpartum depression or recalls having had trouble sleeping
through the night during her own development, it could be difficult for
her to facilitate the child's mastery of this developmental stage.
What should a pediatrician's response be to these observations?
Should we just tell parents “what to do?” Wouldn't a better response
be, “Let's figure out where there is a problem and decide what you want to
do or why it might be hard for you to do so?” (This line of
patient-focused questioning draws from motivational interviewing, which
is increasingly used as a strategy for counseling in obesity.)
The challenge for pediatricians is how to discuss the issue of
weight, with parents, in a sensitive and non-judgmental way. By using
icebreaker questions, we may be able to help parents gain insight into
their own motivations and issues, as well as open up a healthy
discussion about weight:
• “Whom does he/she remind you of?” “Why do you think so?” “Tell me about that person.” “What was his/her experience?”
• How is the parent doing? Is she having, or has she ever had, a postpartum depression?
• Does the parent recall having feelings of abandonment/sleep problems as a child?
• What was the parent's relationship with food when he/she was
growing up? How did their parents' attitude affect that relationship
(e.g. “clean plate club,” the use of food as a reward, withholding food
as a punishment or for dieting)?
• What is a typical day of eating like for the family, e.g. are
there structured meals or do members of the family just ‘pick'
throughout the day?
A pediatrician's personal experience with food or weight management may affect his or her perspective
There are many management issues for pediatricians, which are
straightforward and often just need one solution. They include, for
example, the treatment of pneumonia or meningitis.
On the other hand, helping parents manage some developmental tasks
has special meaning for all pediatricians, at one time or another. It
could be something with which they, themselves, are in
conflict with in their role as parents, or something that acquired
particular significance in their own development. The consequence may
be that we'd like to help parents make the best decision, for them, but
our own feelings or our need to be in control may get in the way of
helping parents decide what is best for them.
For example, physicians who have struggled with weight may impose
their own experience on that patient. On the other hand, if they've
never struggled with their weight, they may have a distorted
perspective, silently assuming that it should be equally easy for
everyone to make healthy choices. In such situations, it may be worth
discussing our conflict or frustration with a seemingly “resistant
parent” with one of our peers and see if we, ourselves, can overcome
our difficulty helping parents master this task.
We want to avoid parents saying to us, “Doc, I tried what you suggested , but it didn't work ”
(which could be their way of saying, “I don't think you understood why
this was difficult for me”). It should be just the opposite. The goal
of client-focused counseling is to help patients identify, within
themselves , the barriers that might be inhibiting change.
There are various developmental tasks for which there is no absolute
answer. In such instances, one could say to a parent, “If it were my
child, I might do this.” Or, it might be preferable to say, “Most
parents accomplish this task by a certain age … but you may have a very
good reason for delaying the mastery of this task. Perhaps you could
share with me your thinking about this.”
It is worth remembering that children who don't seem to cooperate
with their parents' best intentions may be teaching their parents
something (about the parents' own background). Similarly, the parent
who doesn't follow through with our suggestions may be teaching us
something about how we've approached some issue with the family (and about our own background).
And a word about “exercise”
It's important for every parent and child to identify and
participate in a physical activity that they enjoy. Consider exploring
family patterns of exercise and help parents to suggest changes that
support an increase in physical activity, such as setting limits on TV
time for the whole family.
Bill Rodgers (a four-time winner of the Boston Marathon) has written the following:
“Changing the dietary habits of children is a primary concern,
because during childhood we form eating habits that last through our
lifetime. But telling kids to eat healthy foods because staying slim
will help prevent diabetes, heart disease, or cancer later in life will
not work. For every parent who replaces candy or cookies with apples at
dessert time, there will be a contraband stockpile of candy waiting in
the child's closet when dinnertime is over …”
“The most effective way to attack obesity is to get people involved
in a sport or physical activity … that burns calories and makes them
feel good while they're doing it … “
“People change eating habits only after they start to lose weight
and feel better about themselves through running or other sports and
physical activities. They become more attuned to their bodies, and
realize it's going to be a lot harder to achieve their goal – finishing
a 5k race, winning a dance contest, or being the best player on their
soccer team – if they don't watch what they eat. Even kids who become
interested in a sport like soccer are more likely to choose an apple
over a cookie if they know it will help them excel at their chosen
physical activity …” (The Boston Globe, April 19, 2004)
Referral for nutritional education
The disease of obesity is clearly multi-factorial. Each component
must be addressed individually, by the respective team member
responsible for providing the care, in order to appropriately and most
effectively treat this disease. The pediatrician and dietitian are
integral members of this team, with a psychologist or clinical social
worker possibly becoming involved when warranted.
How does one decide upon a good dietitian? A dietitian working
primarily with obesity and obesity in children would be the primary
candidate. Advice from friends or professionals may be helpful, but the
American Dietetic Association provides a Nationwide Nutrition Network, www.eatright.org , which is a national referral service.
The following information would be useful, prior to referring a child to a dietitian:
• Current height and weight, along with a copy of the growth chart
• Lab work, including hemoglobin, total cholesterol and blood lipids
• History of chronic conditions, including diabetes, metabolic disorders, etc.
• Family history of coronary artery disease, hypertension, diabetes
mellitus, elevated cholesterol levels, eating disorders, alcohol or
substance abuse
Summary of recommendations for discussion with parents
• When parents worry about their child becoming overweight, find
out if there is a relative with whom the child might be identified –
parent, grandparent, aunt or uncle.
• If such a relative had a weight problem, how and when did it
develop, and what are the parents' perceptions of why the problem
developed?
• Is there a significant family secret that a parent would be willing to share - alcoholism, eating disorder, or addiction?
• Do the parents believe this particular child has “a weight problem?” Do they convey this to the child?
• How do they think the problem developed?
• Did the child have difficulty mastering earlier developmental
stages, e.g. sleeping through the night, giving up the bottle, breast,
and/or pacifier?
• What is the parents' “worst fear” regarding this particular child?
• Do they have other worries about this child?
• How are the parents doing – individually, in their interpersonal
relationship, with other members of their families, at work, and with
their own self-esteem?
• How is the child doing – socially (in school, friends,
activities) and emotionally, including his or her relationship with the
family?
• Do the parents believe some physical problem, e.g. thyroid
disorder, is causing the child's weight problem? If they do, check it
out early.
What observations are reassuring to me?
• The child's height and weight percentiles have been consistent over time.
• The parents don't believe a physical problem is the cause of the child's weight problem.
• The child seems to be functioning well in every other way.
• The parents, individually, and as a couple, appear to be doing well.
• The parents have developed good “boundaries” in regard to their child.
If I can help parents to be relatively open about their own past and
about other overweight family members, and also help them to be
comfortable talking about unpleasant experiences related to weight that
can be addressed by a referral to further professional help, a positive
outcome is more likely to happen.
And, if I, as a pediatrician, can make the above observations, I
would be relatively optimistic that the child would, over time, master
his or her own eating habits and gradually develop a positive
self-image. The hoped for outcome would be that the young patient
become an adult without a weight problem or serious obesity.
Footnotes
• Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and
Trends in Overweight Among US Children and Adolescents, 1999-2000. JAMA, Oct 2002; 288: 1728-1732
• There is mounting and intriguing evidence that nutrition during
gestation and early life can have a permanent effect on an individual's
predisposition to obesity (the concept of metabolic programming).
Ozanne SE, Hales CN. Lifespan: catch-up growth and obesity in male
mice. Nature, 427 (6973): 411-412
• Epstein LH. Family-based behavioral intervention for obese children. International
Journal of Obesity and Related Metabolic Disorders: Journal of the
International Association for the Study of Obesity, 20 Suppl1: 514-21,
1996
• Baughcum AE, Burklow KA, Deeks CM, Powers SW, Whitaker RC.
Maternal feeding practices and childhood obesity; a focus group study
of low-income mothers. Archives of Pediatrics & Adolescent Medicine, 152(10): 1010-4, 1998
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