Exam Room Nutrition: Where Busy Clinicians Learn About Nutrition

13 | Do's and Don'ts of Weight Conversations with Kids

September 26, 2023 Colleen Sloan, PA-C, RDN Episode 13
Exam Room Nutrition: Where Busy Clinicians Learn About Nutrition
13 | Do's and Don'ts of Weight Conversations with Kids
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Show Notes Transcript

Has the parent of your patient ever said, "What can I do to get him (patient) to lose weight?" Finding the right words to address weight concerns can be extremely challenging, but it's essential for you, as the clinician, to foster a healthy relationship with food and body image. Join Colleen and pediatric Registered Dietitian, Leah Hackney, in this thought-provoking episode as we unpack the sensitive topic of weight and nutrition concerns with children.

You'll learn how we can address parents' weight concerns about their child without causing any harm or damaging the child's self-esteem. You'll be armed with numerous questions you can ask that will shift the focus off the child's weight and onto the behavior and family eating environment. 

Learn how to create an environment of acceptance, hope and support for your patients!

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Disclaimer: This podcast is a collection of ideas, strategies, and opinions of the author(s). Its goal is to provide useful information on each of the topics shared within. It is not intended to provide medical, health, or professional consultation or to diagnosis-specific weight or feeding challenges. The author(s) advises the reader to always consult with appropriate health, medical, and professional consultants for support for individual children and family situations. The author(s) do not take responsibility for the personal or other risks, loss, or liability incurred as a direct or indirect consequence of the application or use of information provided. All opinions stated in this podcast are my own and do not reflect the opinions of my employer.


Exam Room Nutrition is the podcast where nutrition, medicine and communication collide

Speaker A: I find that the more we really just listen and try to gather information is how we can navigate some of the next steps and really actually focus on the behavior changes that are more impactful. We can't fix everything all at once and or we also shouldn't assume that a certain way of eating is the way that everybody should be eating.

Speaker B: Are you ready to transform the way you communicate about nutrition with your patients? Welcome to Exam Room Nutrition, the podcast where the worlds of nutrition, medicine and communication collide. Whether you're a seasoned physician or a healthcare student, this podcast is for you. So stick around and let's make our patients healthier one exam room at a time.

This week's podcast focuses on discussing weight with children

Speaker C: Hello, and welcome back to the exam room. Nutrition. Podcast. I'm your host, Colleen Sloan. I'm a registered dietitian and pediatrics PA. Our topic this week is going to resonate with a lot of listeners because we're going to learn how we can address parents'weight concern about their child without causing any harm or damaging the child's self esteem. We're gonna uncover the do's and don'ts of discussing weight with children. We're going to explore the impact of our words and our actions on their self perception and their overall well being. Finding the right words to address weight concerns can be extremely challenging. That's why I'm so thrilled to introduce my guest today, Leah Hackney. Leah, is a pediatric registered dietitian in both the US. And Canada, and she is also a specialist in pediatric nutrition. She works virtually with families all over the world to help them with infant feeding, picky eating, and raising kids to have a healthy relationship with food. I highly recommend you go over to her Instagram page. I follow her and learn so much from her at Kids Nutritionist. So, Leah, welcome to the show.

Speaker A: Thank you so much for having me.

The topic of childhood nutrition and weight can feel overwhelming for pediatricians

Speaker C: Well, as a pediatric PA, I am very excited for our conversation today because this is a topic that I deal with on the Daily. Even just yesterday, I was doing a well check for two brothers, I think they were ages eight and ten. And the very first thing the mom had said is, what can I do about his weight? How do I help him lose weight? So the topic of childhood nutrition and weight is very difficult and it can feel very overwhelming because it's a really broad topic and we can go down so many different avenues with that. So today I really want to focus on how do we navigate the child's size and weight with the family? So we're going to take that situation that I was in as our scenario for today and learn from Leah about how we can use our words appropriately. So let's imagine we've got a child who's in the 95th percentile, and the parent asks us, what do I do to help him lose weight? So, Leah, where do we start? Because this can feel extremely overwhelming, and there are so many different things we can say. But where do we start when the.

Speaker A: Patients ask us this great question, my response will be similar for parents who are navigating this in the toddler years and or kind of the preteen, elementary school years and or the teen years. But there are going to be some nuances between how you would handle that, depending on the child's age and development. But, for example, for a ten year old at ten, we have a lot more data that we've collected on their growth trends. So the first thing as a practitioner that I really encourage everyone to look at is the overall growth trends. And if you can get a gross history on what their growth charts have been like, that can be incredibly impactful on what decisions, need to be made moving forward. So, for example, if this child is above the 95th percentile for weight, the one thing I like to look at is where is their height? So if they're at the 95th percentile also for their height, this may be kind of where their body and their weight is naturally trending. They may be a larger stature. So instead of just immediately looking at the weight, we also need to kind of, adjust. I also like to look at where the parents and maybe grandparents fall genetically. If you can get this history at all and just see what kind of growth patterns did maybe they experience when they were children. In the pediatric population, it's really common to see what I call like a peak and a plateau in growth, where you have some rapid times of growth and you might have some plateaus. We especially know this in the infant period, like that first year, we know and we see it drastically, and then we see a slower growth into toddlerhood, and then we also see some peaks kind of entering around that ten year mark, ten to 13. We see some peaks, and then we see some peaks again, later, especially for boys. So taking a look at where they're at developmentally as a clinician, really taking into consideration age, any peaks and plateaus in where their growth may be falling, and also anticipating in the future, he also as a boy, we know they grow even past 18 years. So he may have ten plus more years of growth. So in this way, it's really helpful to also kind of look at that bigger picture first. So after you've gathered that bigger picture, whether that's asking a few more questions just about some growth patterns and trends, I really like to just ask very open ended questions. Now, I know this is difficult when you have 15 minutes with the patient and you have 30 people in the waiting room and you have a lot going on, but I like to just see if you can get a little bit more of a history, because I find, as clinicians, it's really easy to want to just jump in and fix the problem and say, well, you need to actually cut out this, cut out this, and then just eat more fruits and vegetables. But that doesn't address the child's preferences for food, especially at ten. They have some stronger preferences. That doesn't address the family's eating environment, cooking methods. That doesn't address food accessibility. So just because they're at your office, they paid the copay, maybe that was a lot of money for them. Maybe this is something that is really expensive and food accessibility is really challenging. We know we have crazy inflation with food right now all across North America. So then also think about education. Some people may be able to afford certain foods or have access to certain foods, but in terms of cooking competency and education, maybe they're just not as confident as a family. Maybe there are five children and this is the middle child, or maybe this is the oldest. What if this child is the one who is doing the cooking? I've see this a lot with families where maybe the older child is actually the one who is cooking because parents are working multiple jobs. So the more you can know about the history of the family and the eating environment, the better. And that's where I really just like to ask the question, can you tell me more about, your family's eating environment? And the first thing I would ask is to get a little bit more specificity. I would ask, can you tell me about what kind of fluids, he, she, they are drinking throughout the day? And can you tell me about how many meals and or snacks they, are getting? Once you've received that information, you can kind of then divert where you would like to focus. If you're finding that a child is consuming maybe something like a large amount of juice and or sodas or anything like that, then that's where maybe you can see if the family is also willing to make these changes. So if they're asking about weight, if they're asking about what can I do to navigate this weight situation, I would then also see where they're willing to focus their changes. There are some changes some people are not willing to make regarding food and their eating environment and their nutrition.

Ask your pediatric dietitian what you can do to help kids lose weight

Speaker A: So just asking that open ended question of like, where do you feel you can also focus on any changes and or what do you feel is a reasonable change for your family? Some of those questions seem very broad, but you might be able to get that one quick tip, that one change, that one lifestyle change that will be more impactful for them for the long run. I also like to again, think about the long run with their nutrition. The changes will not be immediate. It is challenging. It is a behavior change as well as food accessibility, as well as the whole family kind of getting on board with this being something that they want to navigate. I also want to emphasize this too, with parents, because the child is growing. I don't actually, at this age of ten, and even kind of under these 18 years, I actually rarely recommend anything that is indicating we want weight loss. We want to actually see them eating a variety in their diet, drinking water as one of their main fluids, and we want to see where their growth is going to go. So if we have some foundation for a wide variety of diet that includes fiber, fats, proteins, carbohydrates that also has water as a main fluid, then we also want to see them where their body is going to naturally fall. So in terms of necessarily a parent ask, what can I do to get them to lose weight? I actually would kind of backtrack with them to see if we can change their mindset, because weight loss a lot in the pediatric population is not always necessarily a good thing, and it's not necessarily something that we are really looking to have as a final outcome because their bodies are growing. And the reason why I say this is, a lot of clinicians may not agree with me, but what I actually call it is you are wanting to see their weight stabilize. We're not wanting to see it increase. We're not wanting to see a, huge peak. We're wanting it to stabilize. And we're wanting to see where their body grows to catch up. We know with a lot of kids, especially before some growth spurts, they may grow out before they grow up. So in that sense, I would rather, as a pediatric dietitian, see their weight stabilize. And I would rather see the behavior changes to support longer term health and wellness versus a number falling up and or down on a chart. So it is a little bit of a mindset shift, because sometimes when someone comes in and they ask us, what do I do to lose weight, we just want to say, hey, here's the answer. Here's the fix. Drink water, eat vegetables. How that's where parents are probably thinking, how so? Depending on what their response is, where they're navigating fluids. So I'll give fluid as one example. Let's say you find out at ten they are drinking four glass that are eight to ten plus ounces of milk a day, or they are drinking four cans of soda a day. That would be something where you would ask, is this something that your family is willing to work on to make water a little bit more of a priority? And you can talk about the American Academy of Pediatric guidelines. You can know the American Academy of Pediatrics really does recommend, water as one of the main sources of fluid for kids. How do you feel about making some of the changes? What would be a reasonable change to maybe see if we can get to that goal where water is the primary source of fluid and kind of see if they can even come up with some examples themselves. Because if we're tossing examples to them and they're very unrelatable or inaccessible to them, it kind of already automatically closes off that trust and that relationship with the provider. If you're really running out of time, that's where maybe you can refer to them for some of the American Pediatric websites and guidelines. So that's what's great about having a lot of those guidelines is you can say, hey, you know what, I know we're running a little bit on time. These are some of the guidelines and I'd love to send you some more information or the receptionist or someone can help give you some more information on this. one thing we can also educate on too, is if they are maybe filling up on milk and or soda or juice, then you might find that educating them on the fact that if they are also struggling with something like picky eating or not eating as much, that can actually improve other areas of their nutrition or of their eating habits. So you can kind of mention they might come to meals a little bit more hungry if they're not drinking milk or juice or whatever between some of these meals. Because I have an all foods fit approach, I would say that we do not necessarily need to have no soda, no juice, no milk as the goal. We want to try to improve behavior, change and improve wellness, and add some more variety in their diet. Not necessarily just restrict, restrict, restrict. And the reason why I do say that is because we do have some evidence that some of these overly restrictive behaviors can actually backfire for some kids in the long run and lead to fixation on those foods and or overconsumption when they do have access to foods like that in the future. It really is a little bit of a moderation approach and really seeing where you can make small changes for the long run. Now, if you are finding that you have someone they're drinking water or that's their main source of hydration is something like water, then I would actually see, okay, where are some changes that we can make in the diet. I again have more of an approach where it's an add in approach. So adding in those fruits and vegetables for fiber, for fullness and satiation, and also for helping with things like constipation, bowel movements, et cetera. So in terms of what we can add, I think that's also helpful to see where the family is at nutritionally and what their eating environment is like. If you're finding that food insecurity is really a problem, then that's where you can actually refer to services that help with that. If you're finding that it's competency or cooking or time which is very, very common with a lot of families. That's where maybe you can say, hey, you know what, maybe a pediatric dietitian would be a great reference to help give you some options to help you save time or some recipes or something that will actually fit with your lifestyle. Because I find practitioners, as practitioners, we don't have to be cooks and chefs. That's my job, right? We don't have to be cooks, chefs. We don't have to be thinking about that all the time. We really need to know where our expertise is. And so if you're finding that time and recipes and competency around food is something that they're having a barrier on, then that's a great reference for pediatric dietitian. If you're also finding that they are maybe skipping certain meals, this can be a great way to kind of acknowledge that sometimes skipping meals may actually be leading more towards a binge and restrict cycle where they maybe are overcompensating with certain meals and or snacks later in the afternoon or wherever at a different time of day. And that's where you can emphasize routine. And I like to call them eating windows or eating opportunities. You don't necessarily have to have a rigid at, ah, 1130 or twelve. We always eat until 1215 or 1230. It can be something that is fluid and flexible with your lifestyle. Windows of opportunity for the child to eat. When that window is closed, it's okay to be done eating. And as a practitioner, I also encourage you, once you get a little bit of that eating history, ask a few deeper questions of do you feel like this is a season in your life? Or do you feel like, how long has this been going on? That's always a question that you can't really go wrong with, because most people can kind of acknowledge, hey, I just had my first or my second or third or whatever baby. I now have a puppy. my child, my preschooler is going into preschool. All these other things going on, and all of that extra life stuff comes up, and that's okay to acknowledge. Hey, nutrition right now may not be the biggest priority in this season. And right now, feeding your child and making sure you are, getting three meals a day and trying to drink water is going to be something that is the priority. And then we can work on behavior change for adding foods to their diet six months a year down the road. So I think sometimes it's really easy to jump to that conclusion of, like, they asked to lose weight. Here are the step by step, here's what the Academy of Pediatrics says to lose weight. But if we are not acknowledging the humanness and people's living experiences behind what is going on with their eating, then we're really missing the you know, for example, if you're asking that know, do you feel like this is a season with their nutrition and or how long has this been going on? If they mention something like, you know what? They have always really with dinner. They've just been eating, eating, eating, or with this food or I find that there's something else going on and they're just really emphasizing something that's very concerning for them. I think it's always important to trust that parent gut. They know their child well and that's a red flag for them. And that's a great time to say, you know what, let's check into that with a pediatric dietitian. Let's check into that with another specialist so that we can figure out what's going on. I find that the more we really just listen and try to gather information is how we can navigate some of the next steps and really actually focus on the behavior changes that are more impactful. We can't fix everything all at once and or we also shouldn't assume that a certain way of eating is the way that everybody should be eating. So just because something that has worked for our family or for us doesn't necessarily work for other people. And it's really important to recognize that just the statement of eat your vegetables and drink water and have proteins and have some healthy fats, that that statement, the variety of which that looks like with people's cultural cuisine, with their traditions, with everything going on in their life is a huge variety. So that would be one thing that I would really recommend, is asking those questions.

So I would really look at overall history, growth history, see if there's genetic component

Speaker A: So I kind of want to circle back to some of the questions that I think I asked previously that I would potentially ask is I would really look at the overall history, growth history, see if there's a genetic component of what's going on, see where their weight falls, see where their family history regarding weight and or growth has trended. And really just asking, can you tell me more about the eating environment? You can even just be broad. Tell me more about what they're drinking throughout the day and tell me more about their meals and snacks, how many they're having, what that looks like for your family. And then once you're kind of going from there, I like to really address either fluids and our food and then after that, really stay in your lane of what you feel comfortable with. And I mean, stay in your lane as nicely as possible of just that we cannot fix everything. And that just the blanket statements of eat your vegetables, eat this, eat X, Y and Z are going to look really different for every family.

Speaker C: This is why you are the expert. And I am so grateful that you are here because what an excellent answer to what can sound like an easy question, right? Like I want my child to lose weight, give me a meal plan, is essentially kind of what they're asking for. And it was so important that you broke that down for us so we can really get down to the bottom of it.

Not focusing on weight, the number that's on the scale, and focusing on healthy lifestyle

Speaker C: Now, I wanted to focus in on something that you mentioned specifically, not focusing on the weight, the number that's on the scale, and focusing more on the healthy lifestyle. Because what I see that happens. I watch the patient when the mom says, he's too fat, he needs to lose weight. He drinks soda, he this, that patient or that child's. Body language completely just shatters. And it's heartbreaking because they feel so embarrassed and they feel so bad about themselves because maybe they don't eat very healthy. Maybe the things mom's saying is true, but it's very hurtful. So how can we, as the clinician who's supposed to be that beacon of trust and hope and help for them, reframe the conversation as mom is sort of attacking their weight, how do we reframe that? And is it okay to maybe ask the patient, what do you think about that? Or do you want to work on eating a little bit healthier? Especially for the older kids, where it is their life, it is their body. How much autonomy can we give to that patient instead of directly asking the.

Speaker A: Parent, okay, I love this question. I'm so glad you brought this up. I'm going to break it up, my answer, and I'm going to address a few other age groups because I know you'll come across this even with younger kids. So when we have kids who are maybe in the elementary school age, for sure, and I would even say the toddler years going into kind of the elementary school age, it's important to recognize that parents are the ones bringing the food into the house. And that's something we can have loving boundaries around food as parents, but that's something to really educate the parents on. And I would actually work on educating the parents on something called the Division of Responsibility, where it's really up to, the parent to provide a variety of foods when meals are occurring. and then it's actually up to the child to decide if they eat the foods that are offered and how much they eat of the foods offered before. We're talking about weight, especially around a child who's older and maybe a little bit more aware of the conversation. I would really, actually take that moment to pause. And it's okay to actually see if there is a time where there needs to be a separation of the child and the parent in that setting of like, hey, is it okay if I actually talk about this with your parents really fast? Or I'd like to just discuss something x, Y and Z with your parents really fast and actually see if it's even possible to have the child, I don't know, sit outside the door or something where it's just a little bit less, of this kind of we're talking about you situation. But also use your discretion on is that going to feel isolating for the family? Like, really just use your discretion. If you're finding that's not possible to talk about this without the child, then I would actually use fairly neutral language as much as possible and I would actually see if it's possible to pull up the chart. I know a lot of people use EMR now, so if you're on the chart, I think it's possible to pull up the chart and just really kind of identify, you know, what, this is where they're at for their growth. This is where they're, looking at for their trends and really talk about it slightly neutrally to the parents. And then kind of mention this is where we're looking for what their body is going to do with their growth and just explain that to parents. We're really trying to figure out where their body is going to fall with growth in a way that supports their wellness and health. I would kind of say something like that and then move towards if the parent is kind of shaming. Again, that's also a moment to kind of look at. Tell me about where they're getting the foods from. And it's a little bit, of a hard question to ask, but tell me more about who's buying the groceries. Tell me more about things like that, where it's a little bit of this moment of, okay, well, I am okay, so then how do you feel about some of the food choices that are going on and how do you feel about the options that are available in the house? And where do you find there might be some adjustments we can make or you would like to make? Some of those questions can be a little bit more neutral, a little bit more of kind of bringing people back to reality. And I also, as a clinician and as a practitioner, I would really advocate a little bit for your patient on if the verbiage gets a little bit aggressive and or borderline really making you uncomfortable and or them uncomfortable. That's where it is okay to say, you know what, actually, how about I'd love to talk with X, Y, and Z just a little bit more about and, you can even say something unrelated to nutrition and wellness. You can even just get an excuse to get them alone and then see if you can kind of really adjust the dynamic of where the conversation is flowing. I have found, especially when I've worked in the eating disorder population, it's so easy for parents to we want to feed the kids, it's our job. But also we can't micromanage that because we know that does really backfire for us. So I find, especially with parents, it's helpful to kind of say, even though this might seem counterintuitive, let's see if we can navigate some of this situation without talking about the food or the meals or whatever. Exactly. Let's talk about the feeding environment and a place of connection what's going on there. Because if, for example, the child is consuming a certain number of snacks or foods or sodas or whatever it is. What parents and some people don't always realize is sometimes those are emotional eating responses to their environment. Sometimes we have some negativity. People are really maybe it's anxiety, maybe there are other things going on where the child is feeling like, well, I know I can control what goes in my body, so this is something that I am using as a way to compensate for certain emotions. Or if we have a parent who is kind of nagging like that already in front of the office, that's where I think we really need to look at that feeding environment and then see if we can make some decisions, on you can't fix everything in that moment. So that might be something where a pediatric dietitian that you trust can really help navigate and change that dynamic. And when I see parents or situations like this, I do always like to advocate for the patient. And when they say, well, my child, they eat X, Y and Z. I like to say, you know what, I can tell that this eating environment is just feeling really stressful for everyone. And in order to support so and so's relationship with food as well as their body and wellness for the long run, I would recommend, that you might be able to navigate easy ways to support everyone's wellness and health by seeing a pediatric dietitian. I really find that if we can just lead with kindness and really lead with understanding and kindness and relatability that we're not aiming for any kind of perfection. And that also explaining to parents that all foods can fit in a diet and there can be wellness supported as well for kids can definitely be something that is challenging for parents, some parents to hear, but also something that maybe a message they do need to hear. And I know that especially for those situations, if it's possible really also knowing the red flags on if there is other eating environment issues, other pediatric feeding disorder issues. Binge eating if you're seeing kind of a binge and restrict cycle, if you're seeing some tendencies on those, that could be a whole other episode. But if you are really seeing some of these red flags and there's something in your gut, refer out because in those 15 minutes you won't be able to tackle it all. But you can advocate for your patient in a way that makes them feel more psychologically safe and physically safe to make some of these changes for their wellness.

Speaker C: I absolutely love your approach that as clinicians, we are to be their advocate. We aren't there to team up with mom and poke fun and maybe just make the situation worse because we are not there in their home every hour of the. Day, watching what's brought in, watching where they're going to eat, so we don't know the nuances of, their feeding environment. So just having that compassionate approach to ensuring that their psychological well being is first and foremost healthy and appropriate before we even address the weight or the number on the scale, I think that's a really helpful approach in helping clinicians navigate this very difficult topic of weight in childhood. So, Leah, I would love to have you back again, and we can probably dig into this a little bit deeper, maybe about some specifics on really some practical tips that maybe in that well check visit the clinician can provide to the parents to help the patient get to more healthful eating and healthy behaviors with food. So thank you so much for your time. I can't give you this time back, and I am so grateful for your experience and your expertise. And I know my listeners have gleaned significant information from you. So we look forward to the next time you can come on with us. 

Speaker A: Thank you so much for having me.

When discussing weight, it is important to not stigmatize or fat shame

Speaker C: All right, guys, now it's time for my nutrition notes. In this section, you know, I share my favorite top tips, an interesting quote or a fascinating case that I've come across. So today I'm going to share with you a nutrition tip. So when discussing weight, as we've discussed during this episode, it is so important to not stigmatize or fat shame. And the worst thing that you can do as a clinician when you're discussing weight with whether it be a child or adult, is using the language and calling them fat. That is extremely shaming, it's extremely demeaning, and it can cause significant negative impact later on in life and all throughout an individual's life. It actually oversimplifies health, because really, we know that their weight isn't always the problem. The problem is their poor food choices and lack of exercise. This also demeans and devalues that individual, and it can foster some negative attitudes about themselves and likely about you as being a judgmental, harsh, or hurtful clinician. So, at all costs, avoid calling any patient fat. And instead, why don't you compliment them on their hair or on their shoes, or admire some other characteristic or quality about them? All right, guys, that's it for today. If you found value to this, please like and subscribe to my channel. You can also follow me on Instagram at exam room. Nutrition. If you would like to have any specific content, or have any questions, go ahead and send me a message on Instagram. Well, let's continue to make our patients healthier one exam room at a time.