Diet Interventions – Overweight

 Decrease Calories

Strategies to decrease calories (or increase activity level) are used to stabilize a child’s nutritional status (e.g., improved weight to height ratio) and promote improved health status. Calories are avoided by removing calorie rich foods/beverages when menu planning. Another strategy is to decrease the typical volume of intake by the child at meal and snack times.

Background Education for Providers

Children need calories for both metabolic energy expenditure but also for growth and weight gain. When children eat in excess of their needs, they store the extra energy as adipose tissue. Children can also gain excess weight by eating high-calorie, minimal nutritional quality foods. By decreasing the caloric intake, a child presumably will decrease their weight velocity to a point which energy expenditure and growth needs are more closely matched by the dietary intake. One consideration for treatment is the physical activity of the child. Children should have no more than two hours of sedentary activity each day. Common problems include: television viewing; computer use; video games; and time spent using telephone, cell phones, and/or texting. Children should also include one hour of moderate to vigorous activity each day. This exercise period does not need to be continuous but can be distributed across the day. This can be measured by an accelerated heart rate, breathing faster, and sweating. Before beginning any planned increase in exercise frequency or intensity, consultation with a physician is advised.

Treatment Issues

Lower calorie foods – Avoiding foods that are higher in fat and sugar content will decrease calorie intake by the child. Examples: fried foods, commercially prepared food items, sweetened beverages, junk food, etc.

Reduced calories-Selecting items with reduced fat content and/or low-sugar or sugar free items that the child already accepts will decrease calorie intake. Examples: low-fat or fat free milk, sugar free beverages, lean meats/protein, etc.

Decreased intake-Decreased volume of intake also decreases the total number of calories consumed by the child. Strategies to decrease the volume typically stem from behavioral interventions including goal setting with differential reinforcement applied for reaching volume goals.

What may work best for one child/family combination may not work best for another. The value gained by changing a nutrition behavior is also going to be guided by how much the child was engaging in that behavior prior to treatment. Example: a child who drinks 20 ounces of fruit juice daily is going to see a greater benefit by removing the fruit juice vs. a child who only drinks 8 ounces of fruit juice two times per week. Much of the determination of what nutrition behaviors should be altered will depend on where the family is starting from, and which ones they are willing to change.

There are common areas that you can investigate with the family when working toward better nutritional habits for weight management. Consider the following: meal in-consistency (skipping meals), over consumption of sweetened beverages, high frequency of snacks and/or poor quality snack choices, high frequency of eating meals from restaurants (high calorie, high fat), unbalanced intake of food from each of the food groups.

It is important to remember that the nutritional quality of the foods remains important. The general goal is to maintain a healthy diet while decreasing the calorie intake. Families may inquire about restrictive diet plans, weight-loss meal replacements, or supplements which claim of great weight loss. These products/plans should be avoided as there can be health risks associated with these products and only provide a short-term result (if any) while using the product instead of establishing lifelong healthy behaviors. Instead families should be encouraged to use one of the strategies described above to decrease the intake of calorie-rich foods and replace them with lower calorie nutritious foods.

From the “areas of concern” identified on the Secondary Screener, share results with the family. Briefly explain how each of these behaviors will contribute to potential health complications if not changed. Ask which one(s) they feel would be easiest to address. After the family has identified 1-2 areas to work on, share the corresponding educational handouts and guide the family as to how they can make better “food and beverage choices” to improve their health.

If the family completes the nutritional changes suggested, you can discuss additional changes with the family. Some families will be eager and willing to address changes to improve health. Others may be overly challenged by the changes and need more time before proposing additional changes. If you have been working with a family for some time and you are not seeing a decrease in the rate of weight gain in relationship to height velocity, then you should consider a consultation with the Nutrition Network staff.

Supplemental Materials

 Correct Nutrient Imbalances and/or Deficiencies

Even though a child may carry excess weight, medical providers should consider the risk of micro and macro nutrition imbalances and/or deficiencies. Many children are consuming diets of poor nutritional quality and limited variety. Our goal is to provide strategies which will correct and/or prevent imbalances through food selection changes or supplements.

Background Education for Providers

Deficiencies or imbalances are going to vary widely from one child to another. Therefore, clinicians must assess the full range of nutrition for each child. Macro nutrient assessment includes estimating proportionality of carbohydrate, fat, and protein or distribution of food choice across the food groups. Micro nutrient assessment includes estimating intake of vitamins and minerals.

First, we encourage families to follow the recommendations of the USDA to meet their nutrition needs through their diet. Please refer to for age appropriate recommendations. This may require support by the clinician to help the family find and understand basic nutrition for a healthy diet. The second, and perhaps the easier strategy, is to supplement nutrition by adding a daily multi-vitamin/mineral.

Clinicians are advised that a child with a well balanced diet does not need nutrition supplementation (e.g., vitamin). Also, for families that require or desire a vitamin, NOT all vitamins are equal. Recently, gummy vitamins have increased in popularity but be advised that this product is nutritionally incomplete (does not contain a broad coverage of vitamins and minerals). Furthermore, clinicians should be aware of any herbal, holistic or weight loss supplements/products and any use of these products should be made known to the providers. These products may or may not have an affect on the nutritional or medical disposition of the child. Other products may pose a severe risk and need to be avoided.

Instructions for Provider

A primary practice is to recommend vitamins that are “COMPLETE” and should be designated as such on the label. Dosing of the vitamin should also be checked on the label. Generally, a toddler between 1-2 years of age is given ½ of a tablet, and children older than 2 years receive 1 full tablet. Above 12 years, children are recommended 2 tablets. Individualized micronutrient supplementation should only be provided in consultation with your medical treatment team.

In the overweight population it can be common to find a disproportionate intake of foods. Generally, this consists of high concentrations of carbohydrates and fats along with a poor intake of fruits and vegetables. To evaluate the risk of macronutrient problems, you can most easily compare the child’s current intake to the recommended intake from You may also want to look in the appendix for additional resources of recommended intake of each food group. After the macro nutrition habits of the child/family are well understood, you can work with the family to substitute healthy food choices to promote greater balance across the food groups.

Supplemental Materials

 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):

  1. Encouraging the child to smell, touch, and taste a variety of different foods and tracking their experiences on the Taste Challenge handout.
  2. Beginning to place one new food on a child’s plate with each meal.
  3. 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.
  4. The caregiver should also praise the child for taking the bites and ignore any arguing, tantrums, or gagging responses.
  5. 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:

  1. 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.

Supplemental Materials

 Provide Nutrition Education on Typical Feeding Patterns

To advise family’s on appropriate dietary intake one must first consider the developmental age of a child and understand the “normal” fluctuations in dietary habits. Typically, children who are overweight have achieved the developmental milestones for eating the full range of foods (beyond a developmental age of two or older). However, some children have developmental conditions that might affect their accepted foods (e.g., mental retardation, pervasive developmental disorders & autism, genetic conditions including Prader Willi Syndrome). Children with these delays may be unable or unwilling to advance to a chronologically age appropriate diet (e.g., delayed dependence on formula, soft or pureed foods).

Background Education for Providers

In the first two years of life, children are learning to eat. Families need to know how to identify their child’s developmental stage, what the child’s physical skills are, what the child’s eating skills are, how to accurately identify a child’s hunger and fullness cues, and what the range of appropriate foods and textures are. Most children who are overweight have the skills to eat a full range of menu choices. Specifically, children beyond the age of two should be able to drink all consistencies of fluids, and eat all textures of foods including: smooth/puree/mashed foods, soft cooked foods, dissolvable solids, chewable solids, and mixed textured foods.

For children with developmental disabilities, food offerings should be consistent with their child’s developmental age. Families may also benefit from additional assessment of their child’s developmental level. Therefore, consideration of a referral for a developmental evaluation should be discussed with the family.

To encourage a child to consume a balanced diet, it often is recommended that caregivers offer small portions of various nutritious foods and permit the child to determine what and how much of these items he or she chooses to eat. It is important to work closely with families to assess their knowledge of appropriate portion size as parents may deliberately overfeed or underfeed children secondary to incorrect beliefs about children’s nutritional needs. Other parents may offer an overly narrow range of foods to support a balanced diet.

Instructions for Provider

Children beyond two years of age should be able to drink all consistencies of fluids and eat all textures of foods. Fluids range in consistency from thin liquids (e.g., water) to thick liquids (e.g., milkshake consistency). Smooth/puree/mashed foods consist of gelatin, pudding, yogurt, and meat spreads. Soft cooked foods include cooked vegetables, and canned fruits. Dissolvable solids include breads, crackers, dry cereal, chips, and popcorn. Chewable solids (foods that do not dissolve in saliva) include raw vegetables and meats. Mixed textured foods are foods which consist of more than one texture. Examples include casseroles and soups. To evaluate completeness of accepted textures, families should complete a verbal recall of foods commonly consumed by the child. Alternatively, a formal food record may be completed and reviewed at a later session.

Providers are advised that exclusion of any one or more of the above categories in a typically developing child above the age of two warrants further evaluation with a developmental specialist and/or a speech and language pathologist.

Supplemental Materials

 Elimination of Juice/Empty Calories

Eliminate the dietary practice of excess consumption of sweetened beverages (including fruit juice).

Background Education for Providers

Overconsumption of sweetened beverages can be a common practice among children who are overweight. For the purpose of weight management, sweetened beverages will be defined as any beverage having no more than 3 grams of sugar per 8-ounce serving (other than low-fat or non-fat white milk). Common sweetened beverage choices of pediatric patients include: 100 percent fruit juice, regular Kool-Aid®, regular soda, sports drinks, juice drinks, flavored milks, lemonade, coffee drinks, and some flavored “waters”. Guidelines for healthy, normal-weight children include up to 8-ounces of 100% fruit juice per day. For the child who can benefit from weight management, sweetened beverages should be avoided as much as possible as they can provide a significant number of excess calories with little to no nutritional benefit.

Non-flavored (aka white milk) naturally has 12 grams of sugar per 8-ounce serving. Due to the numerous other health benefits of low-fat or non-fat white milk, white milk can remain as a consistent beverage choice as long as the child does not consume excessive amounts. Please refer to the USDA Dietary Guidelines for the age-appropriate amounts of milk.

Outside of meal and/or snack times, the preferred beverage choice for children is water. If the child was previously drinking sweetened beverages, the transition to water may be more challenging and flavored “sugar free” can be used as a substitute for the sweetened beverages. Suitable beverage choices would include those with no more than 3 grams of sugar per 8-ounce serving. Examples include: sugar free Kool-Aid®, diet soda, low calorie flavored “waters”, reduced calorie sports drinks, sugar free lemonade. Due to the popularity of these products, you can also encourage families to look for store-brand varieties of these products.

If the child does not routinely drink water, misunderstood cues for thirst are often interpreted as “hunger” by a child. In the context of structured meals and snacks, do not allow the child to graze only offer water between meal and snack times. If the child frequently asks for food and/or snacks, first offer water.

Instructions for Provider

Steps to achieve a reduced consumption of sweetened beverages can happen through a variety of ways. Talking with the family about the different ways and what they feel will work best will likely lead to the best results. You can use any of the below techniques, or a combination of the below techniques. Keep in mind that the steps to work toward better beverage choices may need to be done without children observing the changed beverage items.

  • Dilute 100% fruit juice with extra water. Initially have a 50/50 ratio of juice to water. Progress to 25% juice and 75% water. Then advance to mostly water and a “splash” of juice.
  • If purchasing flavored milks, start making your own with low-fat or non-fat white milk and limited amounts of flavoring or using sugar free varieties of flavored syrups/powders (examples: HERSHEY®’S syrup, Nesquik® powder).
  • If a family has never tasted sugar free varieties of beverages before, have them conduct “taste tests” to find the ones they like.
  • If sweetened beverages are routinely purchased by the family, establish agreements to reduce the amount purchased. Can be replaced with sugar free varieties or water.
  • Purchase water bottles for family members that can be re-used.

Supplemental Materials

 Nutrition Tracking/Diet Record

Tracking of dietary intake can offer additional nutrition details to the providers in their treatment of nutrition disorders.

Background Education for Providers

Typically, families that are asked to complete food records are asked for three to seven days of data. Generally, families are provided with tracking forms which they are asked to complete after each meal or snack their child eats. Studies have demonstrated that verbal recall of range of foods and volumes consumed beyond 24 hours is unreliable. Families of children who are overweight tend to underreport intake, and families are more likely to report intake that is consistent with the overall dietary recommendations for good health. Diet journals (daily written food records) have been shown to be more reliable but unfortunately are also subject to the halo effect (families biasing their report in a direction they believe the provider wants). Therefore, providers are advised to interpret all such materials cautiously. Families that complete tracking each day are the most likely to provide accurate data. Other research has shown that daily tracking has beneficial effects and may also be considered an intervention in and of itself.

Instructions for Provider

Food records can be used for the purpose of obtaining additional detail of typical intake or assist the patient and family in making nutritional modifications to current intake. Families should be given a copy of the food record and provided with an example of how the form should be completed. It is advisable to read the instructions aloud as this will likely cue the family to ask any questions that they might have and to overcome any confusion that the family may have related to the tracking task. Families are strongly encouraged to complete the form immediately after each meal and with as much detail as possible to enhance the reliability of the report. After a family has been asked to complete diet records, they should return shortly after completing the prescribed duration of tracking. This will help to reduce any errors due to poor documentations and enhance the provider’s ability to extract accurate information from the family by way of oral interview.<

In overweight children, clinicians completing an analysis of food records commonly find: excess of sweetened beverages, lack of meal schedule consistency, excess restaurant/convenience store foods, excess of calorie dense and/or fried foods, lack of fruits and vegetables, or disproportionate balance across the food groups.

Supplemental Materials

 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). Another possible trigger for overeating is patterns of interaction between the child and caregiver.

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 in 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:

  1. Eating all meals at a table or counter.
  2. Eating all meals in the same place.
  3. Treating all eating like a meal (including snacks like meals) and thereby eating these in the same place meals are eaten.
  4. All eating is treated like a meal by using plate/bowl and utensils (avoid eating out of packages or bags)
  5. 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.

Primary Interventions:

  1. Caregiver plates all of the child’s food in the kitchen
  2. Caregiver puts extra food away immediately after meal time
  3. Second helpings are limited to only fruits and vegetables

Secondary Interventions:

  1. The plate method is used as a strategy for guiding the family in balancing the food groups at each meal.
  2. Use smaller plates and bowls to give the perception that the child has a larger portion size
  3. 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:

  1. Eat 3 meals per day
  2. Meals and snacks should be scheduled every 4-5 hours

Supplemental Materials

Contact Us

E-mail the Nutritional Disorders Telehealth Network Project Team

Please contact us if you are interested in using any of the project materials or if you would like more information regarding the project.

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Page Updated 03/31/2015