Be assertive in broaching topic of pediatric obesity

Providers want guidance in discussing weight

When faced with a pediatric patient who has a heart condition that could lead to chronic health problems later in life, a physician rarely would hesitate to bring the condition to the attention of the child's parents and discuss ways to address it.

But when faced with a child who is obese, and perhaps has obese parents, physicians find it sometimes difficult to broach the subject with the parents, despite everything now known about the long-term effects of childhood obesity.

The American Medical Association recently engaged in debate over whether physicians should even use the word "obese" when talking to children and their parents.

"There's a huge social stigma attached to being overweight, and [having an overweight child] can have an effect on the parents' self-esteem, as well," according to Kelley Meade, MD, co-director of the Healthy Eating, Active Living (HEAL) program at Children's Hospital & Research Center in Oakland, CA.

"If you tell the parents that their child is obese and that he or she could suffer chronic health problems as a result, they can perceive that as being told they are not being good parents. Because what is one of a parent's earliest jobs? Making sure that their child is fed."

But to ignore such a serious health threat is harmful to these young patients, and doctors say they need to learn how to bring the subject up with parents.

In a statewide survey conducted of 240 health care providers in California, almost all — more than 90% — said they need training in strategies and skills for communicating with parents about children's weight problems.

Weight management starts with parents

According to HEAL's co-director, Lydia Tinajero-Deck, MD, the program at Children's is geared toward parents, not children.

"Weight management and obesity prevention begin with parents," she asserts. "We have an innovative program that combines obesity treatment, prevention, research, and community outreach to help parents understand their child's weight issues and give children the help they need to maintain a healthy weight and lifestyle."

The key to successfully enlisting parents in managing their child's weight and health, Tinajero-Deck says, is communicating the message with "hope and not condemnation."

Physicians should keep in mind that there is more at stake than extra weight when a child is obese, Meade says.

"Studies show that kids who are overweight have self-esteem issues akin to children who have lost a limb," she explains. "Their external presence in the world is very much affected."

Thus, a psychological component is part of the HEAL program. HEAL consists of six visits, and a psychological assessment is conducted midway through.

"That's an important part for the multidisciplinary team, because we're working on self-esteem, distress, anxiety, and family stress," Meade says.

Healthy choices have to involve whole family

One thing that is not a component of the HEAL approach is a weight-loss diet, Meade explains.

"Healthy eating, active living — the name describes our approach. We're not asking families to diet, or to enter a weight management program," she explains. "We believe in making good choices and teaching people to make healthy choices, and we pass that along like we would any other health recommendation."

Importantly, Meade says, HEAL is looking to change the entire family's perspective on healthy eating and activity; to focus only on the child would mean far less chance of success. A child's risk of obesity is 13 times greater than normal if both parents are struggling with their weight.

"In terms of ethical issues, I think the No. 1 thing is to ask permission, to say, 'May we take a few minutes to talk about weight?'" Meade suggests. "Because based on the patient's age, you have to determine who actually is the patient."

When the patient is younger than six, efforts are almost entirely directed at the parents, who will be the ones to make any changes in their child's lifestyle. When the child is between six and 12, both the child and parents are involved in food and activity choices; after age 12, the child might be making all his or her own food choices, and might even be making food choices for the whole family.

While most physicians polled in the California survey said they could use help in knowing how to broach the topic of being overweight in their pediatric patients, Meade says the subject is becoming less sensitive than it was.

"One of the things that has taken some of the sensitivity off of bringing up these issues is that all parents are interested in preventing the diseases we see in older adults, and when we can offer ways of preventing these diseases, families are a lot more receptive," she says.

By asking families how ready they are for change you can get an indication of the likelihood of success. Meade says if families indicate they are not receptive to the idea of changes in their life and food habits, "we'll wait a while, and then ask them again at a later date."