- Stimulus Control Strategies
Stimulus control strategies are a type of behavioral interventions for weight management that are supported by research as being efficacious. Stimulus control strategies involve identification and modification of environmental factors that influence eating patterns. The goal of stimulus control strategies is to reduce environmental characteristics or situations that serve to trigger maladaptive eating behaviors, such as excessive oral caloric intake.
Background Education for Providers
Excessive oral caloric intake in children who are overweight and obese may result, in part, from lack of attention to satiety cues (i.e., feelings of fullness), eating portion sizes that are too large, or failing to eat meals and snacks at appropriate intervals (i.e., every 4-5 hours).
Each of the above issues can be addressed through techniques to modify the environment to create more structure around eating and to reduce cues that may be associated with overeating.
Children may lack attention to satiety cues (i.e., feelings of fullness) because they are paying more attention to other things in the environment (e.g., television, computer, etc.) than they are paying to the food that they are eating. By removing such distractions, it helps the child to attend more to their internal feelings of hunger and fullness.
Children may consume portion sizes that are too large because of availability of more food than is necessary during the meal time. By limiting the food present to the appropriate amount that the child should eat, this can help to reduce excessive caloric intake.
Finally, children may consume too many calories because of a lack of structure in their eating schedule. Children should eat a meal or snack every 4-5 hours.
Instructions for Provider
For children who fail to pay attention to satiety cues, it is recommended that the primary care provider talk with the family about implementing the following things at home:
- Eating all meals at a table or counter.
- Eating all meals in the same place.
- Treating all eating like a meal (including snacks like meals) and thereby eating these in the same place meals are eaten.
- All eating is treated like a meal by using plate/bowl and utensils (avoid eating out of packages or bags)
- Implementing a family rule so that all “screens” (i.e., TVs, computers, videogame systems, etc.) are turned off during meal times.
For children who consume portion sizes that are too large, it is recommended that the primary care provider encourage the family to implement the following strategies. If primary interventions are not sufficient to lead to a reduction in portion sizes, then secondary interventions can be implemented.
- Caregiver plates all of the child’s food in the kitchen
- Caregiver puts extra food away immediately after meal time
- Second helpings are limited to only fruits and vegetables
- The plate method is used as a strategy for guiding the family in balancing the food groups at each meal.
- Use smaller plates and bowls to give the perception that the child has a larger portion size
- Use the 20 minute rule (described below)
For children who have a lack of structure in their eating schedule, the following is recommended as interventions to discuss with the family:
- Eat 3 meals per day
- Meals and snacks should be scheduled every 4-5 hours
- Constipation Alleviation through Fluids/Fiber/Meds
Constipation is a common problem in childhood and is estimated to account for 3% of all general pediatric visits and 25% of all pediatric gastroenterology visits (Sonnenberg & Koch, 1989). Unfortunately, many children who experience constipation will have decreased interest in eating or may develop eating habits which result in a worsening of symptoms. Often, with medical management alone symptoms of constipation improve. However, some children will require a combination of behavioral and medical treatment.
Instructions for Provider
- Children generally have between 2 stools daily and 1 stool every other day. Stools should be soft and easily passed.
- Foods which are high in fat may slow the motility of the gut and cause or worsen symptoms of constipation (e.g., concentrated dairy foods)
- A higher fiber diet with adequate nutrition may help alleviate constipation. A good general rule to follow is to add five to a child’s age to estimate their daily grams of fiber and multiply that sum by 3 to estimate their hydration need. For example a 5 year old child would need about 10 grams of fiber each day and 30 or more oz of fluids.
- If you suspect that a child has a constipation problem a medical evaluation should be recommended.
- Behavioral Methods for Increasing Food Variety
Behavioral methods are useful in increasing food variety in youth who are overweight or obese. Behavioral methods include the use of repeated exposure to new foods and varied textures, positive reinforcement for trying new foods or textures, and use of ignoring (extinction procedures) or punishment for reducing unwanted behaviors related to trying new foods and textures. The goal of these methods is to increase the child’s acceptance of a variety of foods, thereby improving the quality of their oral intake.
Background Education for Providers
Suboptimal nutritional intake in children who are overweight or obese may result, in part, from consuming a restricted range of foods and refusal to eat a variety of foods or textures. It is common for children to exhibit neophobia, a preference of familiar foods over novel foods. Temporary neophobia is considered an adaptive response, in that unfamiliar foods may be dangerous and should be approached with caution. Parents often respond by removing the item from the child’s diet, thereby failing to broaden the variety of foods that the child will accept. Unfortunately, this may cause parents to stop offering previously rejected foods, and many parents will often fail to experiment with new foods, assuming that new foods would only result in food battles.
A number of strategies can be helpful in increasing the diversity of foods that a child will eat including repeated exposure to the new food, positive reinforcement for trying the food, and use of ignoring or punishment for reducing unwanted behaviors related to trying new foods.
One simple but fundamental technique for countering a child’s resistance to new or unfamiliar foods is to repeatedly offer the foods by placing them on the child’s plate, even though the child may not be required to eat them. Previous research has shown that preferences for novel foods increase markedly after approximately 10 exposures, regardless of the taste of the food, but that children must actually taste the new foods to change preference judgments, rather than simply seeing or smelling the foods.
Positive reinforcement involves the delivery of a desired stimulus (e.g., praise, stickers, points toward a reward), contingent on performance of a target behavior (e.g., taking 3 bites of a new vegetable). This reinforcement strengthens the probability that the desired behavior (trying the vegetable) will occur in the future. Typically, affectionate or approving forms of attention are used as positive reinforcement for young children. For school age children, the use of a sticker chart or point system in which points can be accumulated to earn prizes or privileges may be of value. For positive reinforcement to be effective, the child must have a strong desire for the reinforcement and must only get the reinforcement if he/she satisfies the goal.
Systematically discontinuing a reward following a response decreases the future probability of the response occurring. The most common example of extinction in behavioral feeding programs is to ignore undesired child behaviors such as refusals or tantrums related to trying new foods. Differential social attention involves combining the techniques of providing positive social attention contingent on cooperative behavior and ignoring the child briefly contingent on misbehavior, which presumably maximizes the child’s opportunity to learn the behaviors that are desired by the feeder.
Punishment involves delivering an unwanted stimulus (e.g., giving a time out) or removing a rewarding stimulus (e.g., losing a point, loss of parent attention) contingent on undesired behavior (spitting out food, tantruming about trying new food). Punishment weakens the probability that the undesirable response will occur. Punishment procedures involving highly aversive stimuli are recommended only when less intrusive procedures are not successful, the target behavior is damaging to the child or others, and when carefully monitored by trained personnel.
Instructions for Provider
For children who present with eating a limited variety of foods, it is recommended that the primary care provider talk with the family about implementing the following things at home (in the following order):
- Encouraging the child to smell, touch, and taste a variety of different foods and tracking their experiences on the Taste Challenge handout.
- Beginning to place one new food on a child’s plate with each meal.
- Encouraging the child to try 5 bites of a new food on their plate. A caregiver may offer a developmentally appropriate reward (stickers, points, etc) for each time the child takes 5 bites.
- The caregiver should also praise the child for taking the bites and ignore any arguing, tantrums, or gagging responses.
- The above steps should be repeated up to 10 times (on consecutive days) until the child accepts the new food.
If after 10 trials, the child still refuses the food, the following steps could be implemented:
- The child could be informed in advance that a failure to take 5 bites will result in a developmentally appropriate consequence such as a time out (for preschool children) or loss of a point/token/sticker/privilege for older children.
Parents should be instructed that the reward for trying a new food should be paired with significant verbal praise.
Parents should be instructed that the reward should be given immediately after the goal is met (i.e., the child has taken 5 bites).
Parents should be instructed that only one new food should be tried at a time.
- Medical Evaluation
Background Education for Providers
Children who present with a BMI in the 85th percentile or greater are considered overweight or obese. Their elevated weight puts them at an increased risk for a variety of weight-related medical conditions. Certain medical conditions may also contribute to the child’s increased weight. Therefore, it is important that providers be aware of the possible disorders that contribute to obesity, and the weight-related medical conditions that can be a consequence of obesity. In addition, it important to understand that there is a strong genetic contribution to the development of obesity and weight-related conditions. Weight-related conditions such as high BMI, cardiovascular disease, and insulin resistance are particularly heritable and are especially prevalent in families of non-European ancestry. It is strongly recommended that clinicians obtain a family history to determine the child’s susceptibility to obesity and obesity-related conditions.
Contributing Factors to Obesity:
There are single-gene disorders that may result in extreme obesity; however, these are very rare. The most well-known disorders that may cause obesity include: Prader-Willi Syndrome, Bardet-Biedl Syndrome, Alstrom Syndrome, and Cohen’s Disease. If a genetic disorder is suspected, the child should be referred for genetic testing. Listed below are the characteristic signs of these disorders.
Prader-Willi Syndrome: Short stature, acromicria, characteristic facies, hypotonia, developmental delay
Bardet-Biedl Syndrome: Short stature, developmental delay, retinitis pigmentosum, polydactyl
Alstrom Syndrome: Photophobia, sensor neural, insulin resistance
Cohen’s Disease: Developmental delay, microcephaly, hypotonia, myopia, retinal dystrophy, hyper mobility, characteristic facial features.
Hypothyroidism is a condition that is often a concern of parents who have overweight children. However, this condition is relatively uncommon (effects 1 in 1000 children) and does not usually cause severe obesity. Hypothyroidism can be suspected if the child presents with the following symptoms: fatigue, diminished school performance, cessation of linear growth, and goiter.
Obesity can exacerbate many medical conditions and can also cause new weight-related conditions. Below are listed some of the more common weight-related issues that are seen in obese children:
Sleep Problems: Obstructive Sleep Apnea, Obesity Hyperventilation Syndrome
Note: Asthma often results in shortness of breath and exercise intolerance, and it should be managed in order for the child to not be limited in their physical activity.
Gastroenterology: Nonalcoholic Fatty Liver (NAFL), Gallstones, GERD, Constipation.
Endocrinology: Type II Diabetes, Hypothyroidism, Primary Cushing Syndrome, Extreme early onset of Puberty
Nervous System Disorders: Pseudotumor Cerebri
Cardiovascular: High blood pressure, Lipid level abnormalities
Orthopedics: Blount’s Disease (Bow-Legged), Slipped Capital Femoral Epiphysis
Screening for these conditions has not been shown to cause any harm to the child. In fact, it has been shown that obesity screening may actually increase healthy eating behaviors.
Instructions for Provider
Complete a full family history that includes the medical history of both the parents and grandparents. Most importantly, it should focus on the presence of high BMI, Cardiovascular disease, and insulin resistance to assess for the future risks for these conditions and future comorbidities. It may be helpful to develop a checklist of symptoms and family history forms for parents to complete at the appointment.
If a genetic disorder is suspected, providers should refer child for genetic testing.
Complete a standard physical evaluation that covers all of the systems to assess for all weight-related conditions.
If a specific weight-related condition is suspected and treatment is needed, the patient should be referred to a specialist in the field.
If the child has a BMI in the 85th percentile or above, the child should be referred for a fasting lipid profile, fasting glucose test, AST, and ALT, in order to test for Type II Diabetes.