Doctors and Weight: Help Without Harming

by Ellyn Satter, MS, MSSW, Dietitian and Family Therapist

For a PDF of this Family Meals Focus, click here.

Before we get started, know this: I have put the medical terms “obesity” and “overweight” in quotes to make clear that these are terms used by some others but not by me. Now to the issue at hand.

You can address children’s weight without having to persuade parents of a child’s “obesity” or “overweight” diagnosis. Instead of trying to get parents to do something about their child’s weight, do prevention by encouraging them to follow the Satter Division of Responsibility in Feeding (sDOR): Parents do the what, when, and where of feeding; the child does the how much and whether of eating. Use abrupt or considerable weight acceleration from the child’s usual trajectory as an indication for trouble-shooting with sDOR.

• To prevent child weight accelerations, establish a developmentally appropriate sDOR from birth and trust the child to grow in a way that is genetically right for them.
• To address child weight acceleration at any age, correct distortions in sDOR and trust the child’s own homeostasis to restore appropriate growth.

Weight-loss interventions don’t work

Why diagnose when you have no effective treatment? According to the 2016 US Preventive Services Task Force review,¹ behavioral interventions of 52 to 114 contact hours show reductions in BMI z-scores of only 0.2: about 3 or 4 lb. Office-based interventions show a fraction of that. Standard weight-management guidelines from policy makers and those who sit on consensus committees^2-4 are hypothetical and have no data to support them. These standard guidelines include limiting sugar-sweetened beverages, encouraging fruits and vegetables, encouraging low-fat dairy foods and whole grains, and limiting portion sizes.

Parents don’t want to be food cops

Parents want to nurture; Following even general weight-management encouragement turns them into food cops. Parents know that accepting the “overweight” or “obesity” diagnosis means no more relaxed and enjoyable family meals, holidays, and birthday parties; lots of struggles to get their child to eat vegetables, to eat less, to stay away from high-fat, high-sugar food. Some parents say: Just-don’t-mention-weight! Their instinctive unwillingness to become controlling with feeding is backed by evidence: Children who are labeled overweight get fatter, not thinner.^5,6,7 Children who get the idea they are “overweight” feel flawed in every way—not smart, not physically capable, and not worthy.⁸ Nine- year-old girls classified as overweight at age five years showed increased restraint, disinhibition, weight concern, increases in weight status, and body dissatisfaction.⁹ They eat only a little bit on purpose so they don’t get fat.⁹ That’s pretty sad, isn’t it? Children are entitled to be free from worry about eating, moving, and weight.

Don’t do nothing at all

 The American Academy of Pediatrics (AAP) essentially recommends sDOR: “Empower parents to promote children’s ability to self-regulate energy intake while providing appropriate structure and boundaries around eating.”

You can do what the policy-makers say, just do it so it helps. In the midst of its own right-and- wrong-food advice, the American Academy of Pediatrics (AAP) puts forth sDOR, although not by that name: “Empower parents to promote children’s ability to self-regulate energy intake while providing appropriate structure and boundaries around eating.”⁴ To properly apply sDOR, unhampered by right-and-wrong-food advice, see the handout, Your Child’s Weight: Helping without Harming. It is also available in Spanish.

• Have regular, reliable, and rewarding sit-down family meals and sit-down snacks. This would be AAP’s “appropriate structure and boundaries around eating.” The rewarding part is important. Consistently providing family meals is a lot of work. Parents who provide food they and the family enjoy get intrinsic reinforcement for making meals a priority.
• Include a variety of good-tasting foods. Families who eat regular meals get around to including fruits, vegetables, whole grains, and other wholesome foods. And they eat them because they enjoy them, not because they have to.
• Include “forbidden foods” in meals and snacks.  It limits consumption to give children a  time and place to enjoy high-sugar, high-fat snack foods rather than allowing PRN access or forcing children to sneak to get them. More importantly, children come to regard high-calorie, low nutrient foods and beverages as everyday food that they consume the same as other food: sometimes a little, sometimes a lot.
• Trust the child to decide what and how much to eat from the food parents provide.  Children whose parents follow sDOR do well with managing their own portion sizes: They eat as much as they want, then stop, even in the middle of a bowl of ice cream.
• Don’t encourage “slimming” foods.¹⁰ The evidence doesn’t support recommending low-fat dairy foods.10 Whole grains and fruits and vegetables are nutritious, but they aren’t slimming. Moreover, making eating them an obligation takes away enjoyment.

Keep your nerve   

It takes more nerve to get sDOR in place and let nature take its course than it does to follow a weight management path, however ineffective. Discourage limiting what and/or how much children eat, by parents or by children themselves. Encourage parents to follow sDOR and be persistent in your encouragement. It takes parents time to establish family meals and more time after that for them to stop interfering with what and how much their child eats. After parents get feeding in place, children’s eating becomes more extreme while they test whether parents really mean it and they discover their own stopping places. In the short run, know that sDOR is working when family meals are pleasant and the child is relaxed and positive about eating. In the long run, continue to encourage parents to follow sDOR, keep your nerve about the child’s weight, and think years. Until the end of the middle grades, children have a greater than even chance of slimming down.^11-14

 Consider the 7-minute intervention

• Teach sDOR and assess weight in an sDOR-consistent fashion. Support consistent growth, even if weight or BMI is high or low enough to be “diagnosable.”
• Avoid diagnosing. Instead, identify weight acceleration or faltering early.
• Head off obesogenic parenting by giving Your Child’s Weight handouts.
• If sDOR appears not to be working, do trouble-shooting.¹⁵
• Encourage parents to follow a division of responsibility in activity.
• Be prepared for the long haul.

Set up sDOR-friendly office routines

• Incorporate feeding dynamics education into your anticipatory guidance handout routine. Accessing ESI How to Feed articles is free.
• Show the Feeding with Love and Good Sense Waiting Room DVD (also in English/Spanish) in your waiting room.
• Give the Feeding with Love and Good Sense booklets to all parents (6^th grade reading level) and staff.
• Encourage parents who read books to read Your Child’s Weight: Helping without Harming.