Interaction/Management Interventions – Overweight

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  Positive Reinforcement

Reinforcement is one of the most powerful strategies to teach a child what to do. A reinforcer is anything that increases or strengthens a behavior.

Background Education for Providers

Positive reinforcement is defined as the delivery of a desired stimulus (e.g., praise, stickers, points toward a reward), contingent on performance of a target behavior (e.g., eating fresh fruits and vegetables), that strengthens the probability that the target behavior will occur in the future. Typically, affectionate or approving forms of attention are used as positive reinforcement for younger children. For older 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. Thus, an integral component of most behavioral intervention programs is social approval contingent on desired eating habits.

Another common technique to reinforce desirable behavior is based on the Premack Principle, using a high-probability behavior (ability to earn screen time) to reinforce a low-probability behavior (engaging in aerobic exercise). Often children will benefit from a clearly described plan with incentives to increase the amount of physically active periods they engage in. For example, a child may earn 30 min of screen time for each 30 min of physically active time they spend each day. Rewarding exercise with another desirable behavior should increase the frequency and intensity of exercise periods each week. Be sure to check with a child’s pediatrician before deciding on the correct amount of time each child should be active, and to discuss which types of exercise the child might most benefit from.

Instructions for Provider

Healthcare providers should discuss with parents their normal mealtime patterns, and the positive and negative behaviors that occur during mealtimes. Healthcare providers should provide information for parents on appropriate mealtime behaviors that should be reinforced, and the appropriate ways to provide positive reinforcement. Remind parents that attention is one of the most powerful reinforcers that they can use with their children. Handouts on positive reinforcement strategies and sticker charts (if age appropriate) should be given to parents to help them apply positive reinforcement strategies at home.

Supplemental Materials


Elimination of rewards paired with a behavior which decreases the likelihood of the behavior occurring in the future.

Background Education for Providers

The overall goal of extinction is to reduce or eliminate a behavioral response (e.g., a tantrum when a child is asked to eat a non preferred food). The most common example of extinction in feeding therapy is to ignore problem behaviors such as refusals or tantrums. Typically, differential social attention (paying attention to desirable behaviors while ignoring problem behaviors) maximizes the child’s opportunity to learn the behaviors that are desired by the feeder. Parent training in differential attention procedures often needs to include modeling and practice to refine caregivers’ skills and to provide emotional support during intervention.

Instructions for Provider

Healthcare providers should discuss with parents their normal mealtime patterns, and the positive and negative behaviors that occur during mealtimes. They should identify the inappropriate mealtime behaviors that should be extinguished and provide handouts on decreasing negative behaviors using differential reinforcement. Providers should be sure to discuss with parents the possibility for an extinction burst where the child’s inappropriate behavior may increase before it decreases (this is a normal phenomenon).

Supplemental Materials

  Mealtime Structure/Schedule

Providing a consistent environment and a fixed daily schedule of meals and snacks.

Background Education for Providers

Children, similar to adults, often benefit from a fixed schedule of activities across the day. When meals are set at fixed times each day, children become accustom to the routine and are comforted by the predictability of the similar characteristics of each meal. Further, children will develop a predictable pattern of hunger that coincides with the schedule of meals and snacks, which in turn motivates the child to feed.

Families should also have a feeding environment which is free from distractions, which has appropriate seating for the child, and allows the adult caregiver the ability to monitor feeding for the duration of the meal. Children typically feed best when eating at a table with food placed in front of them for the duration of the meal. At minimum, the child should be supervised one–to-one throughout the meal by a responsible adult. Ideally, the adult supervising the feeding is also eating so that they are able to model appropriate feeding and nutrition behaviors for the child. The feeding environment should be free of distractions (e.g., no toys or TV at the table) as this will help the child to focus on the task of eating as well as focus their attention on the adult supervising the meal. The child should be seated so that they are comfortable and secure (with safety strap as appropriate).

Children should only be offered foods and beverages at specified meal or snack times. However, water should be offered and encouraged throughout the day. Children should learn that meal times are finite and that opportunities to feed in a given day are limited to the fixed schedule. Studies have shown that children who adopt a grazing meal pattern (e.g. frequent intake of small portions of food and caloric beverages through the day) take in fewer nutrients in a 24 hour period when compared to children that eat on a fixed schedule. Specifically, grazing reduces appetite and intake secondary to disruption of the hunger and satiation cycle.

Finally, unstructured feeding patterns can result in ambiguity as to who controls the food selections. If a child is granted even occasional control of menu selections, the child may erroneously conclude that they are in control of food choices and that they are entitled to select whatever foods they wish. Ultimately, the parent may lose all ability to control the mealtime environment (food selections, meal schedule, meal duration).

Potential negatives: Tantrums, begging, sneaking snacks.

Not every family is able to follow the same feeding schedule due to logistics, culture, or regular family practices.

Instructions for Providers

The use of schedule and environmental factors to increase the positive effects of mealtime include: promoting appetite improving intake, providing a mealtime environment that minimizes distractions, promoting parental control, and improving overall nutrient intake.

Before Meals

  • Avoid eating between scheduled meals and snacks. Do not allow children to graze on snacks or juice throughout the day. This way your child can come to the table hungry.
  • Try to have meals and snacks around the same time every day. Keeping to a routine every day can be hard, but try to keep to routine on most days.
  • Make one meal for the family (with at least one item that your child enjoys) and expect that everyone eat what has been made (or they don’t eat at that meal). Do NOT act as a “short order cook!”

During Meals

  • Turn off the TV and put all toys and other distractions in a different area.
  • Eat all meals and snacks at a table with your child seated in a chair that fits him/her. Do not allow children to wander around the house with food/drink
  • Meals should last a maximum of 20 to 30 minutes. Younger children (under 5) may have 15 to 20 minute meals.
  • As often as possible, try to have family meals.

Ending Meals

  • Release your child from the table after the time is up (remember 20 to 30 minutes for kids over 5 and 15 to 20 minutes for kids under 5). Do not try to make a child sit at the table “until their plate is clean.”

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

  Behavioral Contracting

A behavioral contract is a written agreement between a caregiver and a child to help them to achieve a specified goal. In a medical context this tool is generally used to help with adherence to a medical plan. Typically, the goal is stated in clear terms that the caregiver and the child understand, the behavior is defined, and a reward is agreed upon which is available upon completing the conditions of the contract.

Background Education for Providers

Using behavioral contracts to treat nutrition problems is a common practice. Previous studies support the use of this technique, especially when a clearly defined behavior is identified which can be easily modified and monitored.

Typically a behavioral contract includes (1) who the caregivers and child are, (2) the targeted problem to change, (3) the goal or objective, (4) method of monitoring, and (5) consequences, which may include both positive and negative consequences dependent upon the child’s progress.

When developing a contract make sure that each participant is aware of their role. Typically, the caregiver is responsible for monitoring progress and giving rewards/consequences as appropriate. The child must follow the behavioral objective guidelines (engaging in a specified behavior or refraining from a specified behavior) to earn the reward. The most effective contracts have only 1 or 2 target behaviors which are clearly defined and which are easily monitored. Monitoring should be done daily and rewards and/or consequences should be given at the appropriate interval. Rewards and/or consequences should match the difficulty of the task. In other words, do not over reward believing this will improve the likelihood a child will comply. Past studies show that children who are over compensated actually decrease the frequency of the target behavior! Likewise, rewards and consequences should be in close proximity to the behavior otherwise the reward/consequence loses its effectiveness to change behavior.

Instructions for Provider

A behavioral contract is a written agreement that allows a child to earn a small reward or privilege by demonstrating a desirable behavior. Effective contracts are negotiated between adult caregivers and a child. In negotiation, the caregivers and child decide on a clearly defined target or goal, choose measureable short term objectives, establish methods for tracking progress, arrange for frequent positive consequences for meeting the terms of the contract, and specify dates and times for evaluation and renegotiation of the contract.

Goals should be likened to specific behavioral changes as opposed to clinical outcomes. For example, eating 3 servings of vegetables a day is a better goal than reaching a weight goal. Once the desired behavior has changed for a sustained period the contract should be renegotiated to promote continued progress on nutrition goals.

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

  Education on Physical Activity

Overweight or obese youth who have been cleared for physical activity (i.e., those with no medical or developmental factors that restrict their activity) are recommended to obtain 60 minutes per day of moderate to vigorous activity and to limit their screen time (TV, computer, videogame, etc. time) to 2 hours or less per day. The goal of increasing physical activity and reducing sedentary activity is to maximize caloric expenditure and promote healthy physical development.

Background Education for Providers

The American Academy of Pediatrics Recommends that school age children and adolescents engage in 60 minutes of moderate or vigorous activity on a daily basis. For children and adolescents, this activity may take the form of developmentally appropriate games, or certain every day activities (e.g., yard work) and does not necessarily require involvement in traditional exercise activities that adults engage in (e.g., running on a treadmill). This 60 minutes is suggested to occur outside of school.

Moderate activity refers to the level of effort which a person should experience while engaging in an activity. By definition, moderate activity is any activity that burns 3.5-6 calories per minute. Practically speaking, moderate activity leads to an increase in heart rate, feeling slightly out of breath or having difficulty holding a conversation, and results in sweating. Examples of developmentally appropriate moderate activity include playing:

  • hopscotch
  • dancing
  • jump rope
  • climb stairs
  • walking longer distances (20-30 minutes)
  • playing in water (Marco Polo)
  • vacuuming
  • washing windows
  • scrubbing floors
  • mowing the lawn
  • baseball
  • basketball

Vigorous activity is activity that raises heart rate, breathing rate, and gets you very sweaty. It is more intense than mild or moderate activity. By definition, vigorous activity burns 7 calories or greater per minute. Practically speaking, vigorous physical activity makes it nearly impossible to engage in a conversation. This is what people commonly think of when the word exercise is used. Examples of vigorous activity include:

  • Team sports like basketball, baseball, volleyball, soccer
  • Swimming to the other side of the pool and repeating several times
  • Long bike rides (20-30 minutes)
  • Jogging, running, playing tag
  • Running up and down stairs at home

Youth should not be expected to engage in physical activity alone. To the extent possible physical activity should incorporate family or peers. Most youth are not intrinsically motivated to engage in physical activity, so offering rewards for engaging in activity would be appropriate in these cases.

Physical activity could be broken up into 15-20 minute increments, with several opportunities for activity throughout the day. The 60 minutes of activity does not need to occur all at once.

Screen time refers to time spent in sedentary activities such as watching TV, playing video games, using a computer, etc. The American Academy of Pediatrics recommends that overweight or obese youth limit screen time to less than 2 hours per day.

Instructions for Providers

For children presenting with low levels of physical activity, it is recommended that the primary care provider talk with the family about implementing the following plan at home:

  1. Identifying a list of physical activity options that the child enjoys.
  2. Identifying the people who can engage in that activity with the child.
  3. Using the Physical Activity Goal Worksheet to develop a specific plan for activity.
    1. Activity should be implemented gradually (e.g., in 15-20 minute increments) and increases in physical activity should occur only once the smaller activity goal has been met. Activity can be increased either in terms of duration on a given day or by the frequency of occurrence. For example, if an initial goal of physical activity is being active for 20 minutes three times a week, once that is mastered, appropriate next goals could include increasing activity to 40 minutes 3 times per week, or increasing activity frequency to 20 minutes 5 times per week.
    2. Activity can be broken up into 15-20 minute increments.

If Steps 1-3 are not effective in increasing physical activity, the family can consider implementation of a token economy system to encourage physical activity. Refer to the setting goals and using rewards handouts.

Supplemental Materials

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Email 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.