How do I work with a caregiver of a preschooler with obesity or a preteen depressed about the way she looks?
When can I consult specialists and when can healthy lifestyle counseling remain in the primary care office?
This chapter will address the following American College of Graduate Medical Education competencies: patient care, interpersonal and communication skills, professionalism, and systems-based care.
Patient Care: It has been established that early intervention has a significant impact in establishing positive lifestyle habits.1 This chapter will help the pediatric health care provider understand the emotional, behavioral, and developmental factors impacting obesity, identify developmentally appropriate care, and practice in a culturally sensitive manner taking into consideration the availability of resources within families enabling them to deliver individualized care for their patients.
Interpersonal and Communication Skills: Effective communication with patients and caregivers is key to preventing and/or treating pediatric obesity. This chapter will help pediatric health care providers clearly address and effectively engage families around the complex issues promoting healthy habits to ensure the best patient care.2
Professionalism: This chapter will help the pediatric health care provider develop a compassionate and understanding approach to the patient with obesity and their family without judgment regarding weight.
Systems-Based Care: This chapter will increase the pediatric health care provider’s understanding of the system or context in which a patient lives which is essential to evaluating risk and accessing resources for lifestyle change.
Cognitive processes used to monitor and regulate thoughts and goal-directed behaviors (executive function) have been strongly linked with academic performance, social functioning, and emotional stability.3, 4, 5, 6, 7 A recent review has shown that children with obesity performed significantly worse on tasks requiring executive functioning such as exercising inhibitory control (suppression of inappropriate behaviors or those that interfere with goal-directed behavior) compared to healthy weight children.8 Limited studies preclude being able to determine causality,8 but this association adds to the importance of family-based interventions that support the child struggling with obesity.
In early childhood assessment, instruments and treatment recommendations are aimed primarily at adult caregivers. Specifically, managing dietary intake and creating opportunities for active play and physical activity largely depend on caregiver decision-making for younger children. For example, it is not appropriate to expect young children to make dietary choices such as what to pack for school lunch independent of adult supervision. Pediatric health care providers should educate caregivers on the cognitive limitations that make such dietary decisions difficult to achieve for younger children.
As children transition from preschool to grade school, executive functioning components, such as working memory, and other cognitive processes develop and should allow for more direct interventions to occur with grade school children. At this point, children can be given more independence to set and monitor goals that require planning, problem solving, and other cognitively complex processes. For example, school-aged children may begin to make independent food choices during lunch at school, and health care providers should actively engage older children to set specific goals around healthy lunch options. However, supervision will still be required to achieve the best outcomes.
Preschool children spend significant time with same-aged peers and may spend large portions of time outside the home environment. Surprisingly, even at these young ages, stigma and negative associations with weight have been demonstrated. For example, when young children were shown different sizes of same-aged peers, they often chose the pictures of heavier child as having more negative attributes.9 As children advance through grade school, those who become heavier tend to experience higher levels of teasing compared to healthy weight peers.10 As a result, children at higher weight status may become disengaged from social activities, making it more difficult to develop prosocial skills necessary for positive peer interactions.11 Significant isolation and poor social development may contribute to higher absenteeism or an increased risk for psychological disorders.
Pediatric health care providers should inquire about peer interactions, beginning at the preschool level, to identify potential problems. They can support the family by developing plans to address bullying via positive communication and support to the child.12 In addition, the family should be strongly encouraged to communicate with school personnel and counselors regarding bullying and teasing. Schools should have bullying policies in place that will be helpful to review and implement, if necessary. Finally, it may also be helpful to make a referral for therapy focused on social skills development.
Preschool children are learning how to use words to express their feelings though they are often quite impulsive and actively learning how to control their emotions. By school entry, children show greater abilities to manage emotions and impulse control. Eating can be an emotional experience, in which the desire to eat or not stop eating may be emotionally-based and not in response to hunger or satiety. Eating in the absence of hunger (EAH) has been utilized as an assessment strategy to measure disinhibited eating in young children and is predictive of weight status.13 Emotion-based eating behaviors may occur in early childhood and the relationship between eating and emotional states may be mediated by executive functioning.14 As children develop, the ability to regulate emotions has been considered a protective factor against obesity.15 If emotional dysfunction has been identified during clinical interviews or screening, a referral to a mental health provider may be needed.
Health care providers should ask caregivers of preschool- and school-aged children about EAH. Specific behaviors associated with EAH are frequent requests for food despite recent snacks or meals, and eating out of boredom or feelings of sadness or anxiety. These behaviors likely indicate poor appetite awareness and may reflect poor emotional regulation that has evolved into maladaptive eating patterns based on emotional states. Helping children identify internal states of hunger and fullness can be helpful. For example, caregivers can be instructed to ask their child how hungry he or she feels before eating. The aim is to feed the child before the child becomes very hungry. Caregivers then inquire about fullness after a serving of food with the goal of ending the meal before the child is overly full. To make their estimate more reliable, children can think of a number and assign a 1 to being “very hungry” and 10 to feeling “very full.” Children can begin to associate eating with hunger and fullness based on meal consumption and not with external cues or routines (eg, always eating a dessert after a meal).
Gross motor development during early childhood provides a framework to build increasingly active living. Motor development allows greater activity levels and affects muscle mass development and energy expenditure.16, 17, 18 Links identified between motor development and overweight or obesity have been inconsistent and primarily the findings of cross-sectional research. Recent longitudinal studies examining early motor development and later adiposity are similarly inconsistent, making it difficult to draw any definitive conclusions about an association.19, 20, 21
Health care providers are encouraged to focus on activity levels in basic terms such as time playing for younger children and time spent outside for older children. Simply spending more time outside has been associated with greater activity levels and positive health status.22 Given the cognitive and physical limitations of younger children, recommendations for play can be thought of as total amount of time engaged in active play each day, even though the time may be broken up in multiple blocks of smaller number of minutes playing. In other words, caregivers should encourage 5 to 10 minutes of active play multiple times throughout the day versus one single block of time. As preschoolers become older, opportunities for organized sports emerge and should be geared to the child’s developmental stage. Sports participation offers additional opportunities for more structured activities but requires family support to sustain long-term engagement.
Across all age groups, sleep has been related to adequate growth and development, with significant associations with risk for obesity.23,24 From preschool through childhood, short sleep duration has been associated with greater risk for having overweight or obesity.25 Children with obesity are at greater risk for sleep-disordered breathing which, in turn, may impact dietary preferences, physical activity patterns, and regulation of hormones related to hunger and satiety.25, 26, 27, 28 Overall, children are getting about 1 hour less of sleep compared to a century ago.25
During the preschool years, in a study of key parenting routines for children (family meals eaten together, sleeping ≥ 10.5 hours each night, and limited screen time) were found to be associated with a 40% reduction in prevalence of obesity.29 During early childhood, caregivers can optimize healthy sleep by setting consistent sleep or wake times, which may have a significant impact on overall sleep duration. Sleep quality may be compromised by other factors, including use of media in bedrooms, particularly at night. Caregivers who allow media use at night and lack bedtime routines may find it more difficult to change such routines, because children develop strong habits around sleep. Therefore, health care providers are encouraged to prompt early adoption of healthier sleep hygiene as a preventive approach to childhood obesity.
Significant changes in eating behaviors occur during early preschool years following transitions from breast- and bottle-feeding. Early feeding studies showed infants and toddlers were able to self-regulate eating behaviors and overall nutritional intake. However, studies also showed children’s self-regulation skills were reduced when external cues were introduced, such as overfeeding.30 As a result, children may lose the innate ability to self-regulate dietary intake. This may lead to eating behaviors which are more externally-based compared to internal states of hunger and satiety. During early preschool years, food neophobia (fear and avoidance of new foods) is at its peak, slowly declining throughout childhood.31 Food neophobia may present a challenge to families trying to achieve healthier eating patterns, but it is encouraging that studies have demonstrated that exposure to new and less preferred foods may positively impact food neophobia.32, 33, 34, 35
Similar to other developmental processes, early intervention may hold the most promise to prevent maladaptive eating habits. Specifically, frequent, positive exposures to a wide variety of foods may be most effective in limiting the effects of food neophobia or development of “picky eating” habits. Health care providers may help caregivers by explaining a child’s innate acceptance of sweet and salty foods and avoidance or fear of sour or bitter tastes, sometimes associated with vegetables.36 Parents can help their children increase acceptance of new foods by modeling healthy eating themselves, sharing their enjoyment of new foods, and involving preschoolers in preparing new foods.
Baumrind originally described 3 distinct styles of parenting37 which were later expanded by Maccoby and Martin38 to 4 by combining high or low levels of control and responsiveness. Authoritative parenting is the result of high control and high responsiveness to child autonomy. Authoritarian parenting is expressed by high control and low child responsiveness. Indulgent parenting is characterized by low control and high child responsiveness, whereas neglectful parenting is low control and low child responsiveness. Authoritative parenting includes setting consistent rules and expectations, and promoting independence with warmth and nurturance. This is in contrast to an authoritarian style of parenting, which includes inflexible rule-setting and punishment with limited warmth. An indulgent parenting style includes few set limits, but nurturance and warmth, whereas a neglectful (permissive) parenting style includes a paucity of limit-setting and warmth. In general, most positive child outcomes have been associated with authoritative styles of parenting. Specifically, caregivers who use this style have children who are less likely to engage in aggressive behavior, have better emotional regulation, and greater problem- solving skills.39, 40, 41 An authoritative parenting style has been associated with children with lower body mass index (BMI), whereas a permissive parenting style has been associated with children with unhealthy eating habits42 and higher BMI.43
More recently, parenting styles have been adapted to the mealtime.44,45 Parental feeding style studies differ from traditional feeding studies which focus on the child, and focus on the role of parent feeding styles, such as restricting energy-dense foods or pressuring to eat nutrient-dense foods.44 Similar to general parenting styles, parental feeding styles vary by demandingness and responsiveness to derive 4 categories: indulgent, uninvolved, authoritarian, and authoritative. Low-income families of preschool children (regardless of race and ethnicity) were found to most likely use indulgent feeding styles, setting few boundaries around eating, and providing nondirective support.45 Though an authoritative parenting style provides children with opportunity to learn emotional self-regulation, there is also emerging evidence that authoritarian feeding styles in lower-income families are associated with healthier eating practices in children.46 This is an important area of research which has the potential to inform family-based feeding interventions.
In contrast to styles of parenting and feeding, parenting practices at mealtimes have been studied largely within a model of control.47 Specifically, parental feeding practices that utilize controlling methods, such as restriction, managing child eating behaviors with rewards or punishments, and pressuring to eat, have been associated with poorer child weight outcomes.47 This body of research has largely been limited to middle-income families with little racial or ethnic diversity. Additional research on controlling feeding practices with more diverse families remains important to consider, given controlling feeding concepts have not always been cross-culturally valid.48 To promote healthy mealtime behaviors and healthier eating habits, caregivers are encouraged to keep all food in the kitchen, provide regularly scheduled meals and snacks which are eaten in the kitchen or dining room, and provide repeated exposure to a variety of foods and model healthy eating.49
Caregivers have a significant role in helping to shape physical activity and sedentary child behaviors.50 Empirically, however, parental support and encouragement for children to be physically active has been inconsistently related to activity behaviors.22,51 Monitoring child activity was found to be associated with increased physical activity.52 A recent longitudinal investigation of over 2000 children highlighted the complexity in the relationship between parenting and child activity behaviors.53 Stimulation of physical activity was associated with higher levels of child activity behaviors while caregiver restriction of sedentary time was greater for boys compared to girls.53 Lower maternal education and higher working hours were associated with lower stimulation for child physical activity and less restriction of sedentary time. The authors concluded that parenting around physical activity and sedentary behavior rules likely needs to be tailored to the child, based on child characteristics.
Family-based activities and caregiver modeling of physical activity are recommended ways to promote children’s physical activity.49 For instance, a health care provider may recommend that caregivers set their own activity goals and include their children to promote daily activity. This could include trips to the park, walks down the sidewalk, or active play in the backyard, where possible. The health care provider can provide guidance in setting goals that increase the likelihood of success. Goals should be specific (eg, walking 30 minutes 5 times per week), not general (eg, get in shape or lose weight). Goals should be easily tracked (eg, marking days on the calendar, counting frequency or length of the activity). Goals also should be realistic. For example, if a child has not been walking or active, it would be more realistic to start out with the goal of walking 2 to 3 times per week than 7 times per week. Once the goal of twice weekly has been achieved for several weeks, then the goal can be adjusted to 3 to 4 times per week. Daily limits on the amount of time spent watching TV should be set, including the caregivers’ viewing time. Specific goals on increasing activity time and frequency could be set to monitor progress, with planned nonfood rewards based on achievement, such as a trip to the library or park or earning special caregiver time.
