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Family
I like to listen to patients and families when they come in to the clinic. I think many times they haven’t had an opportunity to discuss just how it feels to be overweight in our society. I like to give them the opportunity to vent a little bit about that, if they want to, and to talk about the reasons they want to lose some weight and what differences it would make in their lives. Some kids want to be able to be more active; some kids are motivated to lose weight because teasing upsets them so much. Other kids would like to have more choice in clothes, or be able to make the football team, or have something like a prom coming up. So I like to hear why it is that they’re here. Whose idea was it? Are they here because someone made them come, or because they really want to lose some weight, and if so, why? So that’s the first thing. Then, because I’m a health care provider, I like to talk about the complications of being overweight, particularly later in life. We’re seeing so much diabetes now in kids who are overweight. I want to make sure that families know that in addition to feeling better about themselves and increasing their self-esteem, there really are some serious health consequences if they don’t take weight loss seriously. Colleen Kochman, RN, MSN, PNP
A lack of family support is sometimes a problem. Maybe one parent is really committed to helping the child, but another parent doesn’t feel so strongly and doesn’t follow our recommendations. We also see a lot of kids who are depressed, so we have to really deal with that underlying depression before we can make much headway with nutrition or activity recommendations. Sometimes we don’t know which came first; did the overweight make the child depressed, or did the depression make the child overeat and become overweight? That is always something we look at. Colleen Kochman, RN, MSN, PNP
Sometimes parents are frustrated by how long it takes for a child to lose weight. In general, the child didn’t put the weight on overnight, so it’s not going to come off overnight, and actually a slow, steady weight loss is much healthier than a dramatic one. Also it depends on the age of the child; with really little kids, we’re just hoping to maintain the weight rather than have them lose weight, because they have so much growing to do. Kids will ask, “What do I do about parties and Halloween?” We like to help them through those types of things, and to be helpful and supportive. I also like to see myself as a cheerleader; when they come in, I’ll say, “Great job staying on track.” If they haven’t lost weight or they’ve gained weight, I let them know that it’s okay; we’re not expecting perfection, and we need to take it one step at a time. Colleen Kochman, RN, MSN, PNP
I generally like to say that it’s the parents’ role to make sure that the right kinds of foods are in the house. They are the ones who really need to understand the concepts of our prescribed dietary plan and have the right foods available. It’s the child’s role to eat the right kinds of foods. Of course, in the case of a younger child, the parent is going to do everything for them, and be largely in control. On the other hand, an adolescent can be perfect at home under the watchful eye of their parents, but then go out and do whatever they want to, so they have to own wanting to lose the weight. However, the most successful kids are those who have very supportive families, in which the whole family eats the way we’re asking the child who goes through the clinic to eat. You can’t separate that child out and make them feel different if you want them to be successful. In fact, some parents have been amazing, and have gone above and beyond what you would expect them to do. I know of a nursery school mom who makes sugar-free snacks and sneaks them in so her child has them but never knows she is getting anything different from the rest of the kids. The parents who are supportive of their children are the most successful. On the other hand, particularly for teenagers, it doesn’t work very well if the parents are the “food police,” saying, “That’s not on your list; you shouldn’t be eating that.” That’s not going to work, because there are enough conflicts in adolescence as it is. So I really feel that adolescents have to own what they want to eat; they have to want to do it. If their parents drag them in here, it’s very unlikely that they are going to be successful. They really have to make some lifestyle changes, so they have to be committed to change. Colleen Kochman, RN, MSN, PNP
We ask parents, “Is there a family history of people who have been obese or struggled with their weight?” Parents will generally tell you if they’ve struggled with weight as a child, and sometimes it’s obvious by looking at them that they have a weight problem themselves. We also ask for a history of the parents’ weights and heights. This can be instructive if you see a parent who looks overweight and they say that there isn’t any history of overweight; we can see where they’re coming from in that thinking process. They might have a different set of values than we do in terms of what they consider overweight. I think it’s common for a parent to say, “I went through this as a child, and I don’t want my child to go through the same thing." I hear that a lot. Colleen Kochman, RN, MSN, PNP
I think you can be empathetic and sympathetic by saying that some people have different metabolisms, and it’s not fair. It’s not fair that you can’t eat what your really skinny sister or your really thin friend does. It’s quite reasonable to say that it’s not fair that this is the body type you have, but that you have to deal with it. Parents can be empathetic by being role models, and certainly not eating differently than they’re asking the child to eat. Parents can also get out and be role models in terms of exercise, so that they’re not asking the child to do things they’re not doing. If they’re sedentary and eating potato chips but then asking their child not to, that’s not going to fly. Colleen Kochman, RN, MSN, PNP
I think one of the most important things is to have [weight loss] be something that is approached by the entire family, as opposed to just saying, “This child is overweight and needs to change his or her eating habits.” I think we tend to see the most success when the whole family jumps on board and says, “These are things that would benefit all of us: eating more healthfully, getting out and walking around, and doing more physical activity.” When everyone is doing it together, I think that children feel less ostracized than when they try to make the changes completely on their own. When the whole family is involved, children often tell me that they then feel as though they are part of a team. Nicole Eldridge Marcus, PhD, Behavioral Therapist
When children are young, between five and nine years old, they really need their parents to be the ones preparing their snacks. This way, the parent knows that when a daughter opens the refrigerator and sees that her mom has already made her a fresh fruit cup, she’ll have the opportunity to make a healthy snack choice. The parents have so much responsibility at this point that they really need to become quite involved in the food preparation. But as children grow older and especially into early adolescence, I have noticed that parental involvement with food preparation and choices can sometimes start to backfire. There is a very fine balance that needs to be forged somehow: parents need to be supportive but also allow the child to realize that this is his life and he needs to be responsible for the decisions he is making. Everyone in the family should certainly be educated about food choices. However, I think that sometimes parents need to step back a little bit at this point and let the older child or adolescent know, “I trust you, and I trust that you are going to make some of these good decisions,” so that we do not have food issues becoming a source of conflict and power struggle between parent and child. I also think that this step of indicating confidence in a child’s decision-making capabilities can provide an important and empowering message for the child as well. Nicole Eldridge Marcus, PhD, Behavioral Therapist
Improving the Health of the Entire Family A dietary intervention is successful if and only if the entire family gets involved. If the child feels that everybody at home is consuming the same diet, he or she will be more willing to adhere to the dietary recommendations. It is very likely that overweight children will become defiant and argumentative or non-compliant if their parents and/or siblings are consuming a different diet than they are. The same thing applies to physical activity. We try not to stigmatize the child by making him feel different from the rest of the family. Besides, this is an excellent way to improve the health of the entire family. Diego Botero, MD, Pediatric Endocrinologist
These weight issues occur within the context of a family, so it’s very important for the family to be a part of the team. When I see patients here, I encourage whole families to come to clinic, regardless of weight. I think it works better that way, when the whole family works together and doesn’t single out the patient. Jan Hangen, Clinical Nutritionist
Setbacks and disappointments happen. I think group support is important, because children need to know that setbacks and slow progress, or lack of progress, are common themes in this population of kids trying to lose weight or manage weight. One important thing is to let children know that they’re not alone. This might be done by establishing contact between their family another family, so that they can be in contact with other children. Or it could be done by having them be part of a group, even a special exercise group. The other really important thing to remember in dealing with setbacks is that certainly a long-term goal is being in an ideal body weight range, but leading up to that goal there should be numerous small goals. Meeting small goals should be rewarded, and there are many types of rewards that don’t need to cost money. For example, a reward can be verbal praise. I used to photocopy children’s hands and then have them put the photocopies on the wall and high-five themselves when they had a great day. I also encourage parents and guardians to give verbal praise. I often encourage parents not necessarily to keep a food journal, but to keep a praise journal to celebrate short-term goals. At the end of the day, they sit down and write two things in the journal that the child thought went very well. Then parents can look at those two things and ask the child if he or she thinks that one of those two positive things could be improved a bit. The idea is to focus on praise and not on foods, but to make the foods a part of the praise. Also, we’re building on the positives; we’re not saying, “How did you mess up today?” In fact, that may come out in the conversation at the end of the day, but in general I like to keep a very positive chain of events going. Focus on the positive, and build on the positive. Jan Hangen, Clinical Nutritionist
A family history of weight issues often comes up in the course of a child’s medical evaluation. But even if it doesn’t, I always bring the subject up, because it goes back to the bottom line for me in treatment, which is that these issues of overweight occur within the context of a family. There may be a genetic predisposition, but there are also numerous environmental concerns. Some of those environmental concerns are certainly related to school and society, but the bottom line is that children come home at night. So I try to use kindness and humor to bring out the fact that a family needs to do this together. I have gone so far as to suggest that a family weigh in together— that each family member get a weight, and that the families come back to the clinic together. These families, believe it or not, do beautifully. So one of the things I have been doing is having families keep a lifestyle journal, including everything they’ve done to change their lives. For example, how did they clean out the kitchen and make the kitchen cupboard and fridge conducive to healthful family eating? How did they rearrange their house and their schedule so that they could increase activity? We’ll take pictures of where they were each month- how they looked each month. We’ll also include their weights, and food, if they want to talk about food. I have families who will glue food labels into their journals, old ones next to new ones. It’s a journal of actually getting back to the root meaning of the word “nutrition,” which comes from a Greek word meaning “to cherish.” It’s a journal of how these families cherish themselves Jan Hangen, Clinical Nutritionist
A frequent problem is motivation, either on the parents’ part, or on the child’s part. It’s sad when I see a child who really wants to lose weight but whose parent isn’t motivated enough. Or the parent may not have the time at home, because they have three other children, to provide the tools and support that the child really needs to be successful. Other times, the child is here because they have been brought here by their parents or because their doctor insisted that they go, but they don’t really want to do it. That is more frequently a problem among teenagers; with a small child the parent can really control what they are going to end up eating. But when a child is nine, ten, eleven, twelve or thirteen, they are really starting to make their own decisions and really want to be more independent. If they don’t want to make changes, their parent can want them to do it a lot, but it’s not going to happen. If teenagers don’t want to do this, they have their own money, they’re out with their friends, and they’re going to make their own food choices; a parent can’t really control their food intake. So motivation is really something that some people struggle with. Kelly Sinclair, Clinical Nutritionist
I think something that I really want to emphasize to patients and their families is that the task of making lifestyle changes to become healthier is really tough work. I think that a lot of times they might be expecting it to be easier, and if so they can become really disappointed and upset by the amount of effort, work, and persistence that it can often take. I think that this is really important to emphasize, because sometimes we may forget to share this with out patients as we are going forward. This is not say that it can’t be done, because we have seen it be done very well. One of the biggest keys to being successful and making healthy lifestyle changes is having adequate support. Children need support in terms of what foods are available and having opportunity to exercise, but they also need good family and friendship support as they take on this really challenging task. Allison Lauretti, PhD, Staff Psychologist
Sometimes when you see a patient or family not coming to appointments very regularly, or not showing progress over a period of time, I think you need to present to them the questions that you’re considering, like, “Is this a good time to try and make these changes?” I think it is especially hard when you are talking about a child’s health; maybe the child is motivated to make changes and show up and they want to do this, but they may be lacking parent support and family support. So there isn’t any really specific time period after which we say, “Okay they have been here a year and they’re not showing signs of success, so we are going to suggest that they go elsewhere.” It’s not like that; it’s much more on a case-by-case basis. We have to look at a lot of factors, like where they started, what changes they have been able to make, and what kinds of support that particular family has. I think what we do is think carefully as a team about whether we need to ask the family if they are willing to do some of the small things to try and keep on the path towards a healthy weight. That is usually our biggest factor in determining whether their time here needs to be stopped. Some families will say, “You know what? No, we are not ready to do this anymore. We just can’t do it.” Then maybe we need to refer them to other things that they need to do. We invite them back too, though. I think one thing that we always do is to say, “You can come back when you feel more ready.” Allison Lauretti, PhD, Staff Psychologist
We like to see families informed about what is happening with the child in the clinic. Age, maturity level, and individual circumstances need to be considered in terms of how involved we want parents to be. Some kids do better with very involved parents, and other kids need more separation and space. Younger kids certainly need quite a bit of parental involvement. Any child younger than age twelve needs a lot of parental support in terms of meals, meal plans, supervision, and monitoring. As they start to reach adolescence, I think you have to be careful to balance involvement, intrusion and support. It’s really nice when families can communicate about what they need, and we do see cases in which there is too much parent involvement and it starts to become a little bit of a battle. I think that, as children grow, involvement needs to look different. It’s not that it’s time for parents to say, “Look, I’m done— you’re on your own!” That doesn’t seem to work. But parents can tailor their involvement from hands-on, day-to-day stuff to more emotional support as children grow older. On the other hand, we have some eighteen year-olds who would say, “I need you to remind me every day to eat breakfast,” or, “ I need you to ask me if I exercised.” It is really on a case-by-case basis. Allison Lauretti, PhD, Staff Psychologist
Parental weight history comes up initially when families meet with the medical providers; they have to determine whether there is a familial history of obesity, so the issue is inherently involved in the OWL clinic. But it is also interesting to talk to kids about their parents’ weights and the expectations that they have. Many of these parents have opted for some surgical intervention to lose weight, and in those cases I think it’s important to assess what kids’ understanding is of their parent’s weight management and when they lost weight. We sometimes hear from kids, “Well, I’m just going to do what my mom or dad did, because they had surgery to lose weight.” We don’t rule that out or anything, but children need to talk about their parents’ weights, because it is important to determine what their thoughts are, particularly when their parents have been overweight. On the other hand, if their parents are very lean, we talk with the child about what’s it’s like to be a little bit different from their parents Allison Lauretti, PhD, Staff Psychologist
I think it is useful to ask about family history, because you hear the family’s story about being overweight. This can be important in making changes, because some kids think, “I’m going to be overweight because my parents are overweight; it’s just the way things are.” It may also be a way for children to be connected to their parents. Allison Lauretti, PhD, Staff Psychologist
Teasing is probably the biggest challenge we face in helping and supporting the children who come through the program. Age and maturity level are really important factors in addressing it. If it is a young child who is being teased or bullied, there are many limitations on what the child can do in that situation, so it really requires a lot more direct involvement from the parent. The parent needs to both support their child and validate how upsetting those experiences can be, and try and have open communication about the teasing. If it is happening at school, they must bring it to the school’s attention. It is just not healthy for a child to be teased or bullied at school. If parents are willing to address it with the school we recommend that, and there are also times when we talk to the school, to try to educate them about the environment that the child has been reporting to us. I think parents of older kids should think about what it is like emotionally to be teased and to cope with all of those feelings that come up. But they should also try to figure out how to respond. At certain ages, it may not feel appropriate to go to the school, and the child may not want that to happen, for fear of more teasing or bullying. So we talk with parents and kids about how the kids themselves can respond. If they react back or lash out, that tends to reinforce kids teasing them again. Some kids are even teased for eating salad, but most are teased for their size and shape. I think it is really important for parents to emotionally support their kids. I think another thing we do is to encourage parents to help the child enlist the support of positive peers and get the child involved in positive experiences in which they won’t be subjected to a lot of ridicule and teasing. So if you know that a child is going to be exposed to a great amount of teasing in a certain environment, you might steer him or her away towards another environment that is more supportive. I think another thing that comes up a lot is teasing at home— teasing by siblings or sometimes even parents. This kind of teasing can really sabotage our patients as they try to make healthier choices. We say to the parents that it is up to them to respond to teasing from their other child appropriately, through discipline, limit-setting, and really explaining how that behavior is sabotaging their brother or sister’s efforts. We really encourage parents to get involved. Allison Lauretti, PhD, Staff Psychologist
Balance Between Empathy and Encouragement There is such a thing as being overly empathetic. Some parents find it hard to believe that at times you can become so empathetic with a child that they start to think, “ I am okay where I am; I don’t have to make changes.” We try to help parents see that there is a balance to be struck, so that they can empathize with their child’s feelings, yet also express concern about their need to make changes. In empathizing we really encourage parents to reflect back what the child is saying about their feelings. Allison Lauretti, PhD, Staff Psychologist
For countless generations, children have learned what, how and when to eat from the people who have their best interests at heart: their parents. The main classroom for these lessons was the family dinner. Unfortunately, the family meal has become an endangered species. Meals away from home are the norm, and children spend countless hours in front of the TV. Today, many children learn more about food from TV commercials than from anywhere else, and of course, the main goal of food ads is to sell products, not promote the health of children. A typical child in the US sees 10,000 food commercials each year, overwhelmingly for high calorie, poor quality products such as fast food, soft drinks and sugary breakfast cereals. So it shouldn’t be surprising that TV viewing is strongly linked to childhood obesity. Some food companies and media outlets have recently announced campaigns to address the childhood obesity epidemic. However, the most effective way to deal with the unhealthful effects of advertising is for parents to turn off the TV and spend more time with their kids, both at the dinner table and physically active outdoors. My advice for parents is:
David Ludwig, MD, PhD
I often talk with parents and children about who is in charge of what within the family: Who is in charge of buying your food? Who is in charge of cooking? How can you help your mom? How can you help your dad? We really define clearly which are the grown-ups’ roles and which are the kids’ roles. We also reassure families, because sometimes what we say just goes right over younger kids’ heads. We tell these parents that weight should be important, but that the child’s reaction is an appropriate one developmentally. What is important to the child are things like playing outside, making friends, and remembering to hand in their homework so that they don’t get into trouble. What should be important to parents is not necessarily important to their kids. We highlight those things, because if we define this issue clearly, then frustrations are less likely to happen. Jennifer Rein, MSW
The other thing that I point out clearly is that there is stigma associated with food and weight. So if families have one shelf of food that is just for the overweight child, that’s not going to work. The child would be all by himself and would feel singled out and targeted, and that’s not the goal. And most parents will say, “No, no— I don’t want him to feel different.” The challenge comes when one kid needs to gain weight and one kid needs to lose weight— how do you balance that? I also really focus on asking people, “If you’re cooking a meal, isn’t it a whole lot easier to cook the same thing for everybody? Work on making enough food to feed everyone there, but don’t worry about having seconds or thirds or leftovers.” In fact, we don’t need leftovers. Jennifer Rein, MSW
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Hospital Boston Department of Psychiatry. All Rights Reserved. The information on this website should not be taken as medical advice, which can only be given to you by your personal health care professional. July 10, 2005 |
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