STANFORD, CALIF. – Setting goals with families to reduce childhood obesity must be specific, explicit, and unambiguous to be effective.
Instead of encouraging them to walk or bike to school more often, try a goal of walking or biking to school 2 or more days per week. Don’t just say, "Watch less TV," but recommend that the child watch no television on school days, Dr. Thomas N. Robinson said at a pediatric update sponsored by Stanford University.
Courtesy CDC/Amanda Mills
A goal of walking to school twice a week is better than a goal of walking to school "more."
"Keep it simple," and only set one or two short-term goals at a time, said Dr. Robinson, the Irving Schulman M.D. Endowed Professor in Child Health at the university, and director of the Center for Healthy Weight at Lucile Packard Children’s Hospital at Stanford.
Talk with the child and parents to identify specific behaviors and routines that could be targets for change. "If you can’t count it, you can’t change it," he stressed.
If your aim is to modify eating behaviors, don’t focus on consumption of calories, fat, carbohydrates, fiber, or the energy density of foods, which are hard to track. It’s easier to focus on more specific categories like specific high-calorie foods, sweetened drinks, high-calorie food preparation methods (such as frying), eating out or eating fast food, or a specific eating pattern such as having multiple "dinners." A rule of thumb for a child’s "portion" is the size of a parent’s palm. Suggest that they use smaller plates or bowls for children, or never let the child eat something right out of the box.
To promote activity instead of inactivity, it’s relatively easy to count transportation to school, organized sports or classes, time spent playing outdoors, chores, physical education, and sedentary behaviors such as time with TV, video games, phones, or computers.
A more specific goal than exercising as a family might be to take a family hike every Sunday afternoon. Rather than, "Eat less junk food," perhaps aim to limit trips to McDonald’s to once a week, he said. "Drink less soda and juice" is not nearly as helpful and specific as "No soda or juice, only milk and water."
Parents can set goals for their own behaviors to help their children, such as not keeping sugar-sweetened beverages in the home, or keeping a bowl of fresh fruit in the kitchen and a bowl of cut vegetables in the refrigerator. Approximately 85% of school-aged children have televisions in their bedrooms (a practice that’s most likely in lower socioeconomic groups), so moving the TV out could be a parental goal, he said.
Parents may aim to offer no rides to school. "They can have a walking school bus where a parent walks home to home, picking up kids along the way to school. They can even have a wagon for backpacks," Dr. Robinson said. Or, starting new family routines or traditions could help, such as the Sunday afternoon hike.
Commonly, the parents of an obese child don’t perceive obesity to be a problem because everyone in the family is obese. Instead of focusing on weight loss, work with them to set short-term goals around nutrition and physical activity because those are about making their child healthy, he suggested. "Over time, you can talk about metabolic risk, etc., but start with short-term goals."
Think less of what motivates you, and more about what will motivate your patients. External rewards for a behavior – especially food or money – may work in the short term, but will backfire over time. Build intrinsic motivation by helping patients and families pick goals that are challenging but achievable, not too easy or too hard.
It’s extremely important that the child and parents know that they have choices and control. It’s the same concept employed in the strategy of getting a child to go to bed not by saying, "Time for bed," but by asking which they want to do first before going to bed: brushing teeth or putting on pajamas. Help children and parents identify the target behaviors that are motivating for them and individualized to them.
Contextualized fantasy (also called gamification) may build intrinsic motivation in children. For example, the parent might propose that they build a house out of vegetables and then eat it. Cooperation, competition, and social interaction – doing things in groups – also build intrinsic motivation.
"If you can’t count it, you can’t change it."
A behavior intervention doesn’t need to feel and smell like health education. Look for "stealth interventions" that are motivating in themselves and have the side effects of reducing inactivity or changing diets, Dr. Robinson suggested. Ethnic dance classes appeal to girls in his area, for example. Dr. Robinson and his associates created sports leagues specifically for overweight children, and the youngsters love it, he said.