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:
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.
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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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center, and the families of my medical practice.
I hope you find this site useful and encourage any comments.
- Dr. Howard King, M.D.