CHARLESTON, S.C. — Primary care physicians should provide brief, focused advice to parents whose school-aged children are on the brink of overweight and by doing so, they can make a real difference, Dr. Stephen Cook said at a pediatric meeting sponsored by the Medical University of South Carolina.
“Only 20% of overweight kids aged 5–11 years are identified in the primary care office,” said Dr. Cook, a pediatrician at the University of Rochester (N.Y.).
One should start with a body mass index (BMI) measurement. “The BMI is a great first trigger point at a well-child visit,” Dr. Cook said.
“The BMI is going to open your eyes to kids in the problem range.” But be sure to review correct BMI measurement with your staff, he added. The children can be clothed, but ask them to remove shoes, jackets, and hats.
Although the BMI is not perfect, it is a simple tool that fairly accurately assesses weight status in prepubertal children, Dr. Cook said. If the child's BMI is on the cusp or indicates just slight overweight, use a motivational interviewing tactic and ask the parent and child whether they think weight is a problem.
“I ask, 'On a scale of 1 to 10, how important is it to you right now that the child's weight status might be unhealthy?'” he said.
“There is enough to do in a well-child visit that extensive counseling for obesity” may not be possible during that time, Dr. Cook said. But you can identify that weight is a potential problem, make the family aware of it, and document it in the record.
In some families, the child's weight simply is not a priority. If the family is not interested in talking about weight, then offer a nonjudgmental response, suggest a reasonable time for a follow-up visit, and move on, Dr. Cook advised. But if families do express some concern about weight, listen to their responses to the following question: “The BMI shows that your child is overweight; what do you think about that?” After you have listened, briefly share some tips about how simple changes—such as cutting down on juice and moving the TV out of the bedroom—can make the difference in keeping children within a healthy weight range. Invite the family for a follow-up visit as soon as possible for positive reinforcement and more tips on keeping the child's weight in the healthy range.
The calorie shift in prepubertal children is very small, only about 150 calories a day, Dr. Cook noted. That's equivalent to one juice box or one can of regular (nondiet) soda.
Behavior changes for a prepubertal child with a motivated family can be explained in depth by a nurse or other nonphysician provider in a follow-up visit. In some cases, a second visit is the time to identify barriers to behavior change and how to address them.
Identify problems related to diet and exercise habits, such as caretakers who give children high-calorie or junk foods and excessive snacks. Ask about opportunities for exercise and play, such as school recess and gym class; options for walking or biking to school; and ways to replace some “screen time” with physical activity, either indoors or outdoors.
One should also remember that medical statistics do not motivate children. Children are motivated by peer approval, a sense of accomplishment, and a desire to please a parent or other adult, Dr. Cook pointed out.
“The small steps we can make in these younger age groups can really effect some change, and the parents feel enabled,” he noted.
A primary care physician may not be able to do much for the morbidly obese 5-year-old who needs a referral, but doctors who stay alert to changes in BMI and listen to patients and families can make a difference for a 5-year-old who was normal weight last year but slightly overweight this year, Dr. Cook said.
A brief office visit is not the best time for the doctor to overwhelm a family with information about rising childhood obesity rates and the increased risk of health problems that could arise later in life.
Instead, one should try creating a single-page handout that focuses on a few practical points, such as “Children who watch more than 2 hours of TV daily or have more than two sweetened drinks a day are more likely to become overweight or obese.”
The handout should be given to the family, and that may be as far as you are able to go that day in discussing weight. The handout may go directly into the trash, or it may give children and families food for thought.