By Dr Annelise Wan
MBBS BAppSc MPHTM FRACP

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In paediatrics we often see families with multigenerational obesity and unhealthy attitudes towards eating. The conventional approach of dietary and exercise plans often yield no long-term rewards, which is disappointing and frustrating for the families involved.

In my practice I tend to come at things from a different angle and work less on food groups and calories and far more on the social behaviors that drive children to eat.

First the family has to recognise that there is a problem and decide to do something about it

It's very common to hear parents use language such as- well built, big boned, chunky, just like me, puppy fat, built for comfort not for speed. These terms can down play the problem and the impact on the child’s health now and in the future.

Once a child’s BMI gets to the 85th percentile or higher, we consider the child to be overweight.

While factors such as portion sizes, more exercise and veggies, less unhealthy fat, sugar and salt are important, my focus is to begin with lifestyle modifications that are much easier for parents to undertake, rather than instructions on healthy foods and exercise that they’ve probably heard many times before.

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Instead of language describing a child “going on a diet” or “losing weight” its best to talk about being “too heavy for their current height”.

Below are some helpful lifestyle modifications that can be the first step to a healthier family.

Stage one:

1. Eat only at meal times and define what is a “meal time”. 
Many families have lost the concept of mealtimes. It’s not uncommon to see families eating meals in food courts at 3 pm or 10 am.  It can be challenging for some families who are busy or under pressure to stick to a good household routine with clear mealtimes, but this is necessary to prevent constant grazing throughout the day.

The concept of control and a period of fasting is often new in these days of instant gratification, and food is no different. Families may need reassurance that some feeling of hunger between meals is normal.

The first step is for the family to declare three proper meals a day, with nothing in between until the next declared meal. The only foods recommended between meals if ‘starving’ are carrots and celery.

When the family has established a routine and restricted eating to meals times topics like portion control and healthy food choices can then be broached.

2. All eating should be done while still.
Eating should take place at a table rather than walking or moving around. Screens should not be in view (including ipod, iPad, TV, games etc). Meals should be social, enjoyed with other people and conversation.

3. Only water to drink
Juice, sweetened milk, sports drinks and soft drinks are not a necessary part of a child’s life.

Stage two:

1. Once the family has made these simple lifestyle changes we can spend time exploring What, Why, When, How and Who of eating.

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Why do you eat? Parents often begin to see reasons for eating (or allowing children to eat) other than hunger, such as loneliness, habit, or to pacify or please children. 
When do you eat? Is the family still eating late at night? Or at times other than meal times?
How do you eat? Is eating rushed, consuming calories with little enjoyment or even awareness?•  Who do you eat with? Avoid children eating alone and try to have someone there to chat while eating. This topic brings up many interesting discussions.

2. Kitchen Control

  • Parents need to take control of their cupboards as well as meals.
  • Little children should not have free access to kitchen contents.
  • Parents need to be empowered to say ‘no’ to their children when they complain, especially straight after they have just eaten.
  • The kitchen should be a “rubbish free zone” and parents need to be motivated to only bring healthy food into the house.

3. Organized sport and disorganized play

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  • As well as the food/meals/behaviour it’s important to recognise the need for organized sport and/or disorganized play
  • Not all children can or want to participate in organized sport, but given the opportunity for active (disorganized) play, especially in an environment with potential, most children will naturally enjoy the sort of activity they need to be fit.  On the Gold Coast there are many parks and beached to explore for active play opportunities.
  •  Active play is essential for all children, regardless of their weight. Swapping one hour of screen time for one hour of active play or sport can be enormously beneficial. 

4. Sleep and screens
Sleep and screen usage are huge areas for discussion. Healthy routines around quality and quantity of sleep and screen use are important for healthy weight and mental well-being.

Clearly weight prevention is much better than the cure. There is no one proven management strategy that will work once the child has become obese and often the only way to effect long lasting change is bariatric surgery.

A recent study in JAMA Pediatrics offered some evidenced based food for thought. The study compared conventional medical exercise and dietary treatment with bariatric surgery for adolescents who were severely obese with type 2 diabetes. The findings showed 70% of those who underwent surgery achieved a normal A1c at two years and had lost 30% of their initial weight, compared with only 3% body weight decrease in the medical treatment group. 

Lifestyle and behavioural modifications are important to prevent a child becoming severely obese and it’s crucial for the whole family to be involved to ensure the most successful and happy passage through childhood into healthy adult life. 

The take home message is that doctors and families should focus on identifying and acting early to avoid unhealthy weight gain and obesity in the first place, because conventional lifestyle and medical solutions, once the young person is obese, are very difficult with often disappointing results.

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