Early Life Nutrition: Treating Children With Obesity
By Joanna Foley, RD
Today’s Dietitian
Vol. 26 No. 3 P. 12
Why Weight Loss Diets Aren’t the Answer, and What Can Be Done Instead
Obesity in childhood has been a major topic and health concern in this country for decades. So much so that it’s been deemed an “epidemic,” which began gaining traction
in the 1980s and 1990s when the prevalence of obesity in children and teens tripled.1
While managing obesity in children is important, not all measures to achieve this are safe or efficacious for this age group—specifically in infancy through elementary school. Strict measures like putting children on weight loss diets aren’t appropriate solutions to weight control. Taking this route makes prioritizing optimal nutrition and physical activity of greater importance.
This article discusses the prevalence of obesity in children, its causes, alternatives to weight loss dietary patterns, and counseling strategies for RDs.
Definition and Prevalence of Obesity in Children
For children aged 2 and older, obesity is defined as having a BMI of greater than or equal to the 95th percentile for age and gender. If the BMI percentile is at or above the 120th percentile, it’s considered severe obesity.
In 2017 to 2020, 14.7 million children had obesity, or nearly 20% of American children.2 According to the American Academy of Child and Adolescent Psychiatry, obesity in children usually begins between the ages of 5 and 6, yet it also can begin at any age during adolescence.3 Studies have shown that children who develop obesity between the ages of 10 and 13 have an 80% chance of becoming an adult with obesity. This is unfortunate since it’s well known that obesity is linked to numerous physical and psychosocial problems, including chronic diseases like diabetes, CVD, and asthma, as well as mental health conditions such as anxiety and depression. To avoid such health problems, prioritizing good nutrition in early life is essential.
In infancy, good nutrition starts with consumption of breastmilk or a nutritionally robust formula that provides a variety of essential vitamins and minerals, including vitamin D, iron, zinc, choline, and more. Infants who are solely breast-fed or who receive a combination of breastmilk and formula should receive vitamin D supplementation at a recommended 400 IU per day, according to the CDC.4 Once children start solid foods around 6 months of age, good nutrition continues to be imperative. Their diet should include a variety of food sources from all major food groups, as tolerated.
What’s Causing Obesity in Childhood?
Obesity can develop from complex interactions between genetic, biological, environmental, socioeconomic, and cultural factors. While genetics and biology are unmodifiable, the remaining factors are modifiable. The modifiable factors that may be the biggest contributors to the obesity epidemic in childhood are the overconsumption of energy-dense foods and the lack of adequate physical activity. These factors cause excess energy reserves, contributing to fat accumulation and weight gain.
A variety of foods and beverages are likely to increase the risk of overweight and obesity in young children. “The Dietary Guidelines for Americans 2020–2025 report that the majority of children and adolescents exceed the recommended limits for added sugars, saturated fats, and sodium. The most common sources of these are sugar-sweetened beverages, sandwiches, and packaged foods,” says Colleen Tewksbury, PhD, RD, an assistant professor at Penn Nursing, University of Pennsylvania, and a spokesperson for the Academy of Nutrition and Dietetics (the Academy). Fast foods and desserts are other big contributors.
In addition, other factors like excessive snacking habits and unstructured or irregular meal times also can present a problem.5,6
Why Weight Loss Diets Aren’t the Solution
It’s well known that following strict weight loss diets is a popular means of shedding pounds and preventing obesity. Yet, while preventing and treating obesity in children is important as a means of protecting their current and future health, putting them on a weight loss regimen isn’t an appropriate intervention. The following four reasons explain why.
1. Diets don’t work long term. Much research shows that diets aren’t an effective means to promote long-term weight loss.7 Any weight that’s lost in the short term is likely to be regained. And the process of weight cycling can harm an individual’s health and increase the risk of CVD.8,9
2. Restrictive eating patterns reinforce weight stigma, which involves negative stereotyping of people with larger bodies leading to discrimination. “Weight stigma is seen in children as young as 3 years old and is closely tied to parental bias. Weight stigma and the internalization of that stigma (believing it about yourself) is associated with delaying preventive care and worse health outcomes.10 Further stigmatizing childhood obesity rather than viewing it as the chronic disease it is only further perpetuates harm,” Tewksbury says.
3. Weight loss diets may increase the risk of disordered eating. Children are especially susceptible to cultural messages about body image. When kids feel shamed or judged for their weight, it may harm their relationship with food and cause them to engage in disordered eating behaviors, such as following rigid food rules and having an extreme preoccupation with food. According to Amy E. Reed, MS, RD, CSP, LD, a pediatric dietitian at Cincinnati Children’s Hospital Medical Center and spokesperson for the Academy in Cincinnati, “Placing a child on a diet could lead to an unhealthy relationship with food and disordered eating. Diets can also be restrictive of certain nutrients that children need for proper growth.”
4. Eating disorders may develop. Adolescence represents a time of highest risk “for developing an eating disorder over the lifespan, and restrictive eating behaviors are a strong risk factor,” Tewksbury says. “Self-directed dieting or even going on a weight loss plan intended for adults is associated with increased risk of disordered eating. Adult-based interventions are not meant for children,” she continues, “so we are always concerned when children and adolescents are instructed to make nutrition changes intended for adults.”
What Can Parents Do?
While putting a child on a weight loss diet isn’t the answer, parents and caregivers can take the following six steps to ensure good health for their children.
1. Focus on health, not weight. Even if the desire is to reduce their child’s weight, it’s important for parents to emphasize other aspects of health. Research has shown that practicing a weight-inclusive approach to health can improve blood pressure and increase physical activity.11 So, instead of focusing on the number on the scale, parents and caregivers can discuss why it’s important to take good care of their bodies, no matter their body size.
2. Encourage healthful eating habits. Healthful eating benefits everyone, regardless of their weight. According to the American Heart Association, examples of healthful, nutrient-dense foods for children include fruits, vegetables, whole grains, beans, nuts and seeds, and lean proteins. Minimizing added sugars, sodium, and saturated fat also is an important part of healthful.12 For children who are resistant to eating nutrient-dense foods, there’s help. “Some of my favorite strategies include helping to develop a love of healthful foods through gardening, farm visits, getting kids involved in cooking, and food games such as blindfolded taste testing; teaching parents and caregivers how to model healthful eating, and removing discretionary foods from the home, turning them into ‘sometimes’ foods for the whole family,” says Melanie McGrice, an Australian Advanced Accredited Practicing Dietitian and founder of Early Life Nutrition Alliance, based in Melbourne, Australia.
3. Promote adequate physical activity. Being physically active benefits overall health for children and adults of all body sizes. While exercise can lead to weight loss, weight shouldn’t be the primary focus for children. According to the CDC, the following are the physical activity guidelines for children13:
• Ages 3 to 5. Children should be physically active throughout the day for normal growth and development.
• Ages 6 to 17. Children should get at least 60 minutes or more of moderate- to vigorous-intensity physical activity each day, such as:
- Aerobic exercise: Walking, running, or anything that increases their heart rate. At least three days per week should involve vigorous aerobic activity.
- Muscle-strengthening exercises: Climbing, pushups, games such as tug of war, and other related activities at least three days per week.
- Bone-strengthening exercises: Hopping, skipping, jumping, running, gymnastics, and other activities are recommended at least three days per week.
It’s best for parents to help children find activities they enjoy so they’ll want to be physically active. Putting a limit on screen time is also a way to encourage more physical activity.
4. Evaluate habits and behaviors. Parents and caregivers should identify habits that may be interfering with their children’s health. When they identify habits, they can discuss with their children positive ways to change them without criticizing them. “When working with parents and caregivers, we emphasize focusing on behaviors, not outcomes. So, instead of the number on the scale (the outcomes), focus on the items the child has determined to try to modify, such as sleep, fruit and vegetable intake, portion size, monitoring hunger and satiety,” Tewksbury says. Celebrating positive health behaviors can further help reinforce and encourage children to continue practicing them.
5. Become a positive role model. Children model their parents and family members from a young age. “Kids often watch, not listen, so it’s important to be cognizant of what you do, and not just what you say when supporting a child in weight management treatment,” Tewksbury says. Factors such as family meals, exposing children to a variety of nutritious foods, and avoiding watching television during meals can help create a positive food environment that decreases the chance of developing obesity.
In addition, “It’s also important for parents to model body positivity by not speaking negatively about their own bodies in front of their children,” Reed says.
6. Treat the whole person. “Engaging in a comprehensive program specifically intended for children and adolescents—with support of a trained physician, psychologist, registered dietitian, exercise specialist, etc—has been shown to reduce the risk of disordered eating and negative psychological health outcomes,” Tewksbury says. In addition, it’s vital to help children know their worth aside from their weight since a confident child will be one who’s more receptive to health messages. Parents and caregivers can get in the habit of talking about what they like about their child that doesn’t involve their appearance, such as how they act towards others, or how responsible or helpful they are in their daily lives.
Counseling Strategies for RDs
Since these recommendations focus less on weight and more on various health behaviors, “The efforts to address childhood obesity are starting to become more holistic,” Reed says. “In the last 10 years, we have moved from equating health with a smaller size and promoting the ‘eat less, move more’ message to address all factors that may contribute to childhood obesity, like sleep patterns, screen time, and genetics. As RDs, we need to continue to be involved in the conversations to make sure children with obesity are getting compassionate and comprehensive care,” she says.
RDs can follow these three guidelines when supporting children who have or are at risk of obesity.
1. Be sensitive. Use person-first language and minimize the risk of creating a stigmatizing experience, Tewksbury says. “For example, RDs working in oncology wouldn’t refer to a child as a cancerous child; they are a child with cancer. Obesity is no different,” Tewksbury says.
2. Focus on the parents or caregivers. “When it comes to children who are already struggling with excess weight, it’s important to work with the parents and caregivers, not the child, to avoid weight stigma,” McGrice says. RDs should remember that parents and caregivers often have a greater influence on a child’s decisions and habits than the child does, so making them the focus is more appropriate.
3. Provide consistent, unbiased recommendations. Reed says the recommendations she makes to families to promote health are the same no matter the size of their children. “All families are encouraged to model healthful behaviors like regular physical activity, drinking water, practicing good mental health, and encouraging bedtime routines,” Reed says.
“Ultimately,” Tewksbury adds, “the best advice we can give to families looking for help is don’t do this alone.”
— Joanna Foley, RD, is a freelance health writer based in San Diego and author of two cookbooks. Learn more about her writing services at joannafoleynutrition.com/press.
References
1. Tiwari A, Daley SF. Balasundaram P. Obesity in pediatric patients. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK570626/. Updated March 8, 2023.
2. Childhood obesity facts. Centers for Disease Control and Prevention website. https://www.cdc.gov/obesity/data/childhood.html. Updated May 17, 2022.
3. Obesity in children and teens. American Academy of Child & Adolescent Psychiatry website. https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Obesity-In-Children-And-Teens-079.aspx. Published October 2023.
4. Vitamin D. Centers for Disease Control and Prevention website. https://www.cdc.gov/nutrition/infantandtoddlernutrition/vitamins-minerals/vitamin-d.html. Updated July 22, 2021.
5. Gobbling up snacks: cause or potential cure for childhood obesity? USDA Economic Research Service website. https://www.ers.usda.gov/amber-waves/2012/december/gobbling-up-snacks-cause-or-potential-cure-for-childhood-obesity/. Published December 3, 2012.
6. Adnan D, Trinh J, Bishehsari F. Inconsistent eating time is associated with obesity: a prospective study. EXCLI J. 2022;21:300-306.
7. Jabbour J, Rihawi Y, Khamis AM, et al. Long term weight loss diets and obesity indices: results of a network meta-analysis. Front Nutr. 2022;9:821096.
8. Blomain ES, Dirhan DA, Valentino MA, Kim GW, Waldman SA. Mechanisms of weight regain following weight loss. ISRN Obes. 2013;2013:210524.
9. Rhee EJ. Weight cycling and its cardiometabolic impact. J Obes Metab Syndr. 2017;26(4):237-242.
10. Abrams Z. The burden of weight stigma. American Psychological Association website. https://www.apa.org/monitor/2022/03/news-weight-stigma. Published March 1, 2022. Accessed December 13, 2023.
11. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014:983495.
12. How can I eat more nutrient-dense foods? American Heart Association website. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/how-can-i-eat-more-nutrient-dense-foods. Updated December 18, 2023. Accessed January 12, 2024.
13. How much physical activity do children need? Centers for Disease Control and Prevention website. https://www.cdc.gov/physicalactivity/basics/children/index.htm. Updated June 30, 2023. Accessed December 13, 2023.