When a previously healthy-weight child comes in with a high body mass index (BMI) — especially above the 85 percentile — the ensuing discussion can be one of the most delicate conversations we have with our families. We need to open a dialog in a way that won’t alienate the parent or child so they will feel comfortable returning for this problem.
If this is the first conversation about a BMI problem, my main goal is to identify why the child’s weight has increased (Change in diet? Change in exercise?) and suggest changes in ways that encourage the patient to return in a month. I try to balance the conversation with information, understanding and hope, pointing out that making some changes over the next month may make a difference.
But how do you find an opening to get the conversation started? In our practice, we give the families an opportunity to provide it, in the form of a questionnaire that patients fill out at every well visit. Starting at 11 years old, it includes a question about concerns regarding nutrition/body image. If the answer is yes, it’s a very natural step to regroup about nutrition and exercise, especially if the BMI increase is recent.
Ours is only one approach or many, of course. One pediatrician I know asks permission to discuss nutrition and weight with the parents (“Are you comfortable if I bring up your child’s weight?”). This question thoughtfully sends the message that the conversation is not easy for everyone.
Some children truly struggle with high BMI and families can’t make enough changes to create progress. I find that they fall into 3 categories:
- Families who don’t perceive the patient’s BMI as a medical issue and are not interested in next step.
The most important thing is to motivate the whole family to make changes in household nutrition and activity.With these families I try to take on the role of observer, information gatherer and monitor. I point out the patient’s increased risk for lifelong problems, offer to recommend a specialist and note the need to track the patient’s metabolism labs. I used to hesitate to order labs because I thought the incidence of abnormalities was so low that is almost seemed punitive. But over the years, the rate of abnormal lab results seems to have grown, so now I am more comfortable citing guidelines and recommending monitoring.
- Families who feel they are doing all they can on their own.
This is a frustrating situation that usually requires a family to understand that they’re on the right track but have to make more lifestyle changes. I usually explain that each of us is an energy equation (more on this in a moment) and explain that this balance is different for each of us. I also offer a referral to a nutritionist. The most important thing is to motivate the whole family to make changes in household nutrition and activity.
- Families where the parent sees the problem but the patient isn’t motivated to change.
This is the most challenging situation, and is often a matter of educating and getting buy-in from the patient as much as, if not more than, the parents. Depending on the age of the child, analogies can help, such as:
- Energy equation — Each day we need to take in a certain amount of energy and use up a certain amount of energy.
- Sports car — Really fancy cars require the better fuel, so take care of yourself, consider yourself a fancy car, and only fuel up with food that’s good for you.
- Speed limits — While it’s true that cars can go 100 miles/hour, drivers make sure that we don’t go over the speed limit, which is the same with daily food intake.
- Budgets — Eating is essentially an energy intake budget. If you have cookies after school, you have spent your dessert budget for the day.
So can helping children begin to internalize their own concept of what constitutes healthy food and meals. I really promote the idea of snacks as mini-meals, and often point out to both parent and child that if you are opening a wrapper for your snack, it’s probably not the healthiest.
Making sure all the food is healthy food
Change still has to start with the parents, however. If the patient’s isn’t motivated to change, I sometimes encourage parents to do a “clean sweep”: throw out food in the house that isn’t healthy. Many parents worry that this is too drastic, but I try to help them see that this can be as medically important as if their child had a food allergy.
I also try to help families reinforce the advice from the prenatal visit about parents’ and child’s roles when it comes to food in the house, adding that if:
- all the food choices in the house are healthy
- meals are well balanced
- food is plated before it gets to the table in reasonable portion sizes
- seconds are limited to protein or fruits and veggies
then parents doesn’t have to worry about how much the child is eating. These steps can take families a long time to accomplish, but they are both very important steps towards a conflict-free home around food.
And a third step is to set up non-negotiable rules around electronics (e.g., no devices in the bedroom, exercise before video games, only 2 hours or screen time per day) to help families reclaim some device-free time.
Finally, I tell all families that one of the easiest things about improving a child’s high BMI is that it doesn’t take huge lifestyle changes to bring a child’s BMI into a healthier range. Usually one small healthy change naturally leads to others, which together can help enhance the whole family’s health.
Susan Laster, MD, is a primary care provider in private practice in Brookline, Mass., and a member of the Pediatric Physicians Organization at Boston Children’s Hospital (PPOC). Her most recent post on Notes discussed obesity prevention in primary care.