Suggestions for parents, which may not be met with enthusiasm, include cutting down on sweetened drinks and making an effort to create a safe space in the home for toddlers to move freely, or to visit places, such as zoos, parks, or indoor play areas.
However, many physicians feel uncomfortable raising the issue of weight. No one wants to hear that their child is overweight, and especially not obese, said Dr. Johnson, who works with extremely obese pediatric patients and families in a tertiary care center. Also, in some cultures, plump babies are considered healthy, and parents don't recognize that they might be laying a foundation for childhood obesity by overfeeding their infants and toddlers.
It's also important to phrase questions about a young child's weight in a nonaccusatory way, Dr. Johnson said. Instead of saying “Your child needs to lose weight,” try asking, “Do you have any concerns about your child's weight?” Depending on the parent's response, offer some tips for reducing energy intake and increasing activity, or you may have to drop the subject for that particular visit if the family is not receptive or willing to make any changes.
A child who has exceeded the 95th percentile on growth charts can be a conversation starter. Dr. Johnson said that when she uses phrases such as “your child is growing faster than 95 of 100 children,” she can make an impact on parents. Use of sensitive language is important, however, because parents don't want to hear their children labeled as overweight or obese. Dr. Johnson uses phrases such as “Your child seems to be getting ahead of himself,” which sounds less accusatory than “your child is overweight.”
Ask parents, “What do you think is going to happen if this growth rate keeps up?” If the parent comes up with an answer, the doctor is taken out of the role of accuser, she noted. If parents get the idea at that point that their child needs to stop gaining weight so rapidly, the doctor can introduce some ways to “slow things down a bit.” If the parents don't recognize the problem, offer some information about potential health risks: “If your child continues to go on this way, here's what can happen.”
“I often start with 'is your child being teased?'” Dr. Johnson said. That gets people's attention because it's not a number or a percent; it is a painful situation for the child. Ask the parents what they want to do to mitigate the weight problem and thus cut down on the teasing. Listen to what the parents think is important, and have concrete strategies on hand to offer them.
Parents can't see how much food goes into the baby when they are breast-feeding, and some parents find security in “just topping it off” with some formula, because they can see an empty bottle. “It is important to stress that breast-feeding is enough, because the infant's growth is proceeding fine,” Dr. Johnson said.
Tips for Controlling Calories, Increasing Activity Levels
Dr. Johnson shared her tips for families about how to control calorie intake and keep toddlers from “getting ahead of themselves” in terms of weight:
▸ Cut down on sugar by avoiding sweetened beverages, except on special days.
▸ Limit juice to one-half cup per day of 100% fruit juice.
▸ Don't put juice in bottles. Promote children to a cup (not a sippy cup) by age 18 months.
▸ Find other ways to console a child besides candy. (Note to parents: granola bars are more like candy bars than “health food.”)
▸ Keep offering vegetables. Young children reject most foods on the first few tries; this behavior is not a poor reflection on parents.
▸ Choose foods in which whole grain is the first ingredient.
▸ Encourage breakfast. Breakfast provides children with cognitive benefits and prevents overweight. The number of toddlers reportedly consuming breakfast has dropped during the past two decades.
▸ Limit eating in the car. “I don't consider the car to be an eating environment,” Dr. Johnson said. It promotes overconsumption because parents can't keep track of what the child is eating, and it is unsafe, since parents behind the wheel can't help a child who starts to choke.
▸ Ask parents how many fruits and vegetables their child eats in a day, and which ones he or she likes. Help parents to focus on the ones that the child likes, and make sure these fruits and vegetables are available.
▸ Ask about both over- and underconsumption of milk. Current guidelines call for toddlers to consume 15–24 oz/day of milk; some children drink as much as 60 oz/day. You can have too much of a good thing.