treating overweight in children current views. two models for treatment behavioral management...
TRANSCRIPT
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Treating overweight in children
Current views
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Two models for treatment
Behavioral Management Outpatient Nutrition Clinic
Summarized from: Building Block for Life; vol. 25(3):2002
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Behavioral Management
Three person team: MD, RD & Psychologist First step: assess readiness to change
– Family has to be the unit of change not just the child.
– Defer treatment if not ready to change because of possible impact of failure on child’s self esteem and negative effects on future treatment.
– Note from Dr. K, think about stage of change theory & family centered care. You want to be perceived as a helper.
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Goals of therapy
If deferring treatment : RD provides information on health consequences and offers to help in the future.
Goal in uncomplicated obesity– Change eating and physical activity behaviors;
Not a change in weight
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Skills to teach families
How to assess current eating and physical activity behavior to determine where changes need to be made.
Identify problem behaviors ;– eating high calorie/high fat foods– barriers to physical activity
Focus on a few small permanent changes at a time Monitor the behavior and learn how to problem solve
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Dietary Intervention
Assess eating behavior to identify BOTH foods and patterns of eating that lead to excessive intake– # occasions of eating– preferred or disliked foods, dietary restrictions,
allergies– frequency of eating outside of home– 24 hr recall and 3 day record
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Dietary intervention
Reduce and stabilize caloric intake Reduce fat Follow dietary guidelines If necessary, add restrictions for complicating
conditions Refer to pediatric obesity center for intensive
treatment– Weight control information network– Http://www.niddk.nih.gov/NutritionDocs.html
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Dietary interventions
Don’t count calories, but teach to rely on internal cues of hunger and satiety.
Teach low calorie, low fat choices Traffic light diet: all foods can fit!
– green: nutrient dense and unlimited – yellow: average value– red: low nutrient density and high calorie
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Dietary interventions
Teach how to make food choices away from home:– school, stores and vending machines– restaurants: teach to be assertive and ask for
modifications.– portion sizes:
what is a healthy portion? discuss how to modify
– small hamburger or cheese burger not a Big Mac
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Physical activity
Kids find periods of set physical activities boring. Individualize recommendations to activities child can
accomplish and enjoy. Suggestions:
– limit amount to TV or video games– Play outside every day– Walk after dinner– Bright Futures in Practice: Physical Education
www.bright futures.org also nutrition info
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Parenting skills
Psychologist, with your assistance– Find reasons to praise child related to behavior not
appearance– Never use food as a reward!– Establish daily times for meals and snacks– Choose the type of food and the time, let the child decide
how much– Be observant so you can praise appropriate behavior– Model appropriate behavior, even how to deal with set
backs!
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Goal setting
Focus on behavior change NOT weight! Specific, achievable and measurable
– switch from whole to 1% milk– drink only 2, 12 oz pops a week
ONLY ONE OR TWO PHYSICAL OR EATING BEHAVIOR GOALS IN TOTAL AT ONE TIME!
Add additional goals when first set is achieved
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Self monitoring
Key component Record daily eating and physical activity in
notebook. Habit books reviewed by parents daily and at
treatment team visits REINFORCEMENT
– praise and point system– don’t use food, money , or expensive items
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Self monitoring
STIMULUS CONTROL– change the environment to reduce cues and
opportunities associated with eating– Alter access: remove food from house, meal
times– Establish new routines: family walks, housework,
after school activities
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Duration of treatment
Weekly or bi-weekly until eating an appropriate diet
3-6 month follow up Long term commitment by health care team
and family!
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Part 2 :Hints from a Nutrition Clinic
Medical history– collect as much as possible ahead of time
Have the family state the problem in their own words– Ask: Why are you here? What do you think we
are going to do today?– You will get lots of emotion: seize the moment to
redefine the problem and offer hope
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Redefine the problem
Define the problem as one of balance
1. Children need energy to grow in height and weight.
2. More energy has been coming in than is needed.
3. Today, we will look for ways to increase energy going out and decrease some of the energy coming in.
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Assess food and activity
Bring 3 day record Ask child to go through a typical day ‘s food,
schedule and activities. 24 hr recall Be sure to ask about spending money, as
this is usually spent on food!
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Keep it simple!
Focus on 1 or 2 changes that will make the most difference!
Beverages are easiest first change to make– Have list with caloric value of juice, soda and milk
Snacks: not just “junk”– list of good snacks– plan timing – are part of healthy eating
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Keep it simple!
Bring lunch from home?– Make night before– Not just sandwiches– Don’t skip meals, as that encourages overeating
later
Less fast food– better choices
Increase fruit and vegetables
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What about calories?
Not the focus of the intervention Some basic information is OK
– 3500 kcal = 1 lb
Often weight gain can be explained by 80-150 kcal/day, or an extra soda, or more TV time.
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Decrease sitting around time
Limit TV, computer and video came time– >4 hours/day associated with obesity
Have some real suggestions for other activities in your community– not just organized sports
Don’t’ “exercise”, dance or do an exercise tape with a parent or friend
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Plan for difficulties
Hunger – limit choice of foods– encourage activity
Food as distraction– have a basket of games and crafts to bring out
when “bored” and want to eat.– Keep away from temptation. Alter routines
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Kids spend all day trying to get attentions and maintain their territory.
Could it be that “hunger” is really a need to slow down and be filled up with some special attention?
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End of the visit
Family has committed to two or three changes
Agrees to keep a behavioral monitoring notebook
Don’t talk about it!– Focus should be praising activity and working on
the changes, not weight.
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Long term goals
For young child: maintain weight For older child: 1 lb per month
No fast fixes! Follow up as possible. If not identify
community resources for families to use. Think about a group class using a purchased
program