Much of pediatric care focuses on prevention. Pediatricians generally understand how to prevent communicable diseases (by vaccinating) and injuries (periodic guidance around safety). But current pediatric practice also demands prevention of more chronic diseases. Some, like asthma, have good prevention guidelines. But one chronic disease that seems hard to prevent is obesity.
Childhood obesity is a multi-factorial disease that is poorly understood and has different etiologies in different children. Seen through another lens, however, obesity prevention is a matter of understanding how a person takes in energy (eats) and uses up energy (exercise and activity) and running a household that promotes healthy “energy” habits. Obviously, if that were easy to do, we would all do it. So, as pediatricians we must strive to help families create homes that promote healthy eating and exercise.
But, how can a pediatrician help a parent prevent childhood obesity? I have struggled with this question for many years and my solutions are a work in progress. However you go about it, it’s important to set all families up for success by promoting weight-healthy behaviors from the very beginning. Here are some of the approaches I have come upon as this health crisis has become more and more widespread.
A few years ago I realized that I needed to educate parents of young children about snacks, especially as they continue to fill up more and more of a child’s daily nutritional intake.
But when is the right time to bring this up? One of the early toddler visits? The six month visit? And would parents feel I was being judgmental of the choices they’ve made up to that point about their child’s nutrition?
I recently decided to go earlier, not later, and to start snack education at the prenatal visit. In the same way we use that visit discuss the benefits of breastfeeding or the current vaccine schedule, why not discuss the benefits of nutritionally balanced dinners, the healthy plate and portion size? And introduce the age-old advice that it’s the parents’ job is to provide nutritious, properly sized meals and a relaxed mealtime environment, and the child’s job to decide whether and how much to eat?
Discussing this at the prenatal visit can be quite easy since parents-to-be are eager to take in new information and are very committed to making the best decisions they can. This also sets the stage for this discussion at all subsequent check-ups and gives parents a framework for an important part of parenting — running the household.
When I began practicing pediatrics 20 years ago, I didn’t specifically ask about exercise. The assumption was that kids generally like to move their bodies and would be active enough without any deliberate monitoring.
But times have changed. While many children play on sports teams, there seems to be a decrease in just general movement exercise, such as walking and running around. Also, with the allure of digital activities, all families many are now forced to consciously develop lifestyles that include a lot of movement.
It’s not that parents are opposed to these lifestyles. It’s more that we all have gotten used to a more sedentary society. So I now offer “movement” suggestions for every day life, such as:
- encouraging families to walk to school when feasible or safe
- reminding them that while it might take more time, there are benefits to walking to get errands done on the weekends
- advocating for indoor movement, such as jumping rope or dancing with a dance video
The good news is the body doesn’t care about the environment in which you are active. The bad news is we all have to work harder at cultivating daily lives that value moving around more than we are. Emphasizing this at well visits sends the message that being active is important for health.
At some point in our relationships with our patients we start to talk more with the children than their parents. This shift probably varies with each of us, but I have come to be on the lookout for these conversational opportunities, even with children as young as 2 1/2. It can be empowering to a child to ask directly “Do you drink milk? Do you eat vegetables? Do you walk and run around?”
Asking children directly conveys to all family members in the exam room that nutrition and exercise are important to a child’s overall health. And as the child gets older it will be easier to revisit these ideas. It also serves as a template for how parents might talk to their children.
Many parents feel frustrated with a child who has very picky food preferences, and understandably end up making two different meals — one for the child, one for themselves. We can’t force a child to like a food, but we can certainly promote an expectation of eating at least one green vegetable and one orange vegetable, even if we don’t love it. Solutions like, “I know you hate peas, but if you swallow them whole out of the freezer you can’t taste them and they’re still good for you,” suggest, “I hear you, so let’s come up with a compromise.”
But what do you do when, despite all the preventive measures, a child comes in with a recent jump in BMI? Discussing this can be one of the most delicate conversations we have with our families, and it’s something I’ll address in my next post.
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).
To learn more about obesity prevention, contact the New Balance Foundation Obesity Prevention Center Boston Children’s Hospital.