Psychological Strategies for Pediatric Weight Management

Almost everyone has tried to stop a bad habit or change a negative behavior – it’s hard! Think about all the New Year’s resolutions you’ve made, and how successful you have been at keeping or reaching these goals. The biggest challenge typically isn’t identifying what one needs to change, but actually making that change.

This is the often the biggest barrier encountered when working with children who are overweight or obese and their caregivers. We know that children with a BMI at or above the 85^th percentile are more likely to be overweight or obese adolescents and adults. Therefore, early intervention is necessary in order to reverse the obesity epidemic. Motivational interviewing and behavioral strategies have been shown to be effective treatments in pediatric weight management along with appropriate activity and nutrition education.

Motivational Interviewing

Motivational interviewing is a patient-centered, collaborative counseling approach. It emphasizes a patient’s values and motivators for changing in a non-judgmental, non-confrontation climate. The aim is to enhance intrinsic motivation by highlighting discrepancy in behavior and goals. It recognizes that ambivalence and resistance towards change is normal.

As a provider, one of the biggest challenges is to let go of the “righting reflex” of identifying a problem and giving the patient advice and instead, helping patients think about the pros and cons of changing and how and what to change. Recommended methods include use of open-ended questions, affirmations and reflective listening.

Behavioral Strategies

Along with the use of motivational interviewing, there are four specific behavioral strategies recommended for with a pediatric weight management population: goal-setting, self-monitoring/tracking, positive reinforcement and modeling.

Goal-setting: Setting goals may sound easy, but there is more to it. In the spirit of motivational interviewing, goals should be patient/family-driven and involve shared decision making between the patient and the provider. For example, the recommended guideline is 60 minutes of moderate to vigorous physical activity every day, but the patient may only be ready to go on a 5-minute walk three days per week – and that’s okay.

Goals should be SMART.

Specific: “I want to lose weight” versus “I’m going to exercise three days a week for 15 minutes with my mom.” It is helpful to answer the 5 W’s (who, what, where, when, and why).

Measurable: Putting numbers on goals helps to track and monitor progress. Ask questions such as “How much or how many?” and “How will you know when this goal is accomplished.” There are lots of apps to help with goal monitoring and tracking.

Attainable: You want the patient/caregiver to achieve this goal. This provides them with a feeling of success and accomplishment, which can provide intrinsic motivation to achieve the next goal.

Realistic: The goal should be something the patient is willing and able to do. If the patient hates running, completing a 5K isn’t a realistic goal. It can be helpful to think about what the patient has been successful at accomplishing in the past.

Time bound: Create a realistic time frame. Decide when you will start and finish the goal. Giving a time frame allows for greater ease of monitoring of behavioral progress and re-assessment of the attainability of the goal.

Monitoring and tracking of behavioral progress: Monitoring can be done by the caregiver in the form of food logs, activity tracking (pedometer, Fitbits), or daily charting on a specific behavior (i.e., ate breakfast, ate a fruit and vegetable today). The use of technology with apps or Fitbits can help make monitoring easier, more objective, and more fun or exciting. Monitoring can allow providers and families to recognize the effort without the goal of perfect adherence.

Positive reinforcement: There is some controversy about the use of positive reinforcement or tangible rewards as the focus is on extrinsic rather than intrinsic motivation, but I think patient and family efforts and progress should be recognized. In fact, I compare it to working: I love my job, but if I were not getting a paycheck, I wouldn’t come to work as much. Positive reinforcement may be verbal praise, attention or a sticker on a chart when the desired behavior is being completed. Or it could be monetary or earning access to a preferred activity such earning video game or screen time once physical activity for the day is completed. Food should not be used as a reward. It is also important that rewards are given immediately and consistently.

Modeling: Everyone in the house should be making healthy behavior changes and expectations should be consistent across children and caregivers. Having adults in the house as healthy role models is even more crucial when working with toddlers and school-aged children, as caregivers are often the agents of change. Kids can help make behavior change, but they cannot do it by themselves. It is imperative that both caregivers and providers have developmentally appropriate expectations.

Realistic expectations for children include

• Helping to keep track of goals
• Learning and identifying different food groups
• Learning and identifying various forms of physical activity
• Understanding the difference between every day (green or go) foods, sometimes (yellow or slow) foods, and rarely (red or no) foods.

Unrealistic expectations for children include

• Tracking goals on their own
• Remember or taking vitamins or other medicines independently
• Making healthy choices on their own
  • For example, deciding to engage in physical activity instead of engaging in a more sedentary, preferred activity
• Recognizing that diet and activity choices now will impact their future health

Increasing Long-Term Success

Implementing and sharing these strategies with your patients and their caregivers can improve their chances of achieving healthy behavior change and a healthy weight. Children and caregivers are likely to struggle with making these life-altering changes on their own, even when they are aware the patient’s health depends on it. Psychological support, including motivational interviewing and behavioral strategies are essential for long-term success.