Carmen was a 6-year-old Latina girl who lived with her parents and grandmother. She was referred to a multidisciplinary weight management program due to concerns about her body mass index (BMI), which was at the 99th percentile for her age and gender. Her pediatrician made the referral after talking with the parents about possible health risks Carmen faced due to her high BMI. Carmen’s family spoke Spanish at home, although she was also fluent in English, and all sessions were conducted using an in-person interpreter. The family had limited financial means and reported significant stress due to uncertain immigration status.
At the beginning of treatment, Carmen’s psychologist used motivational interviewing with Carmen and her parents to establish rapport and mutually agreed-upon treatment goals. During these early interviews, Carmen’s mother reported that she was very concerned about her health, but struggled for several reasons to help her make healthy changes. She said that Carmen became distressed when she was hungry or when she could not have the foods she preferred. She also noted that she resisted participating in physical activity. Finally, she told the psychologist that Carmen’s grandmother took care of her after school, and they disagreed on food selection and physical activity—Carmen’s grandmother felt that she was healthy, and that allowing her to eat whatever she wanted was appropriate. Her grandmother also prepared foods from their country of origin, which tended to be higher in fat and carbohydrates.
The family also had ongoing appointments with other providers of the weight management program. For example, the mother met with the program dietician to talk about typical eating patterns at home. The dietician provided basic nutritional information appropriate for a 6-year-old’s developmental needs and gave the mother age-appropriate handouts focused on consumption of fresh fruits and vegetables. In addition, a physician monitored Carmen’s overall health and provided additional recommendations.
The psychologist focused on two areas for brief treatment. The first was to improve Carmen’s eating behaviors by ameliorating her distress around changes to her food routine, as well as by addressing family dynamics regarding food selection and decision-making. The second area of focus was on improving Carmen’s physical activity by finding ways she could enjoy being active. The family arrangement and expectations of the culture of origin were considered in formulating each of these treatment goals. The psychologist worked primarily with Carmen’s mother, given Carmen’s developmental stage and reliance on her parents for nutrition and decision-making around physical activity.
The psychologist used a collaborative, solution-focused approach to goal-setting with Carmen and her family. The psychologist helped Carmen’s mother identify ways she could address her concerns about after-school food and physical activity with Carmen’s grandmother (her mother). Carmen’s mother said that she might be more successful with her mother by emphasizing Carmen’s health and suggesting ways to make their preferred foods healthier. The focus was kept on Carmen’s health rather than on her weight or size. This was for her benefit, as well as to avoid conflict with her grandmother about whether she was an appropriate weight. Carmen’s mother came up with some ideas about how to approach these topics with Carmen’s grandmother in a respectful and collaborative way, and was successful in gaining her grandmother’s cooperation.
Next, the psychologist and Carmen’s mother discussed stimulus control as a method of reducing Carmen’s consumption of unhealthful foods. These conversations included the importance of presenting healthful food in a fun and appealing way, the utility of substituting healthier options in preferred dishes (e.g., using sandwich thins instead of bread, and using nuts or fruit instead of chips as a snack), and behavioral methods for reducing picky eating. Between sessions, Carmen’s mother tried a number of strategies and was able to identify many that were successful. Additionally, the psychologist and Carmen’s mother discussed the importance of self-monitoring. The psychologist asked Carmen’s mother to take pictures of Carmen’s food and bring them into subsequent sessions so together they could identify areas for improvement. The psychologist also provided education on portion sizes.
In their sessions together, the psychologist presented Carmen with a visual analogue hunger scale at an appropriate developmental level. Carmen also learned to recognize sensations of hunger and fullness more effectively by drinking more water to feel full, and by asking her mother to practice with her before and after meals. The combination of these efforts significantly reduced her distress around desire for particular foods and her resistance to trying new foods.
For physical activity goals, the focus was on finding enjoyable activities that Carmen and her mother could do together. Ideas included neighborhood scavenger hunts, child-oriented exercise videos on YouTube, and creating obstacle courses in their living room. Between sessions, Carmen and her mother tried these ideas and found a number of activities they enjoyed.
In order to promote these changes, a colorful chart was created and Carmen could earn a sticker when she tried new foods, or engaged in sustained physical activity or exhibited other, new healthy behaviors. After earning a specified number of stickers, Carmen could get a non-food reward such as a trip to her favorite park or special time with her parents. Carmen was very excited about this idea, and it proved to be very motivating to her.
Working with the psychologist at the beginning stages of the multidisciplinary weight management program, Carmen and her parents were able to make important changes related to food consumption and physical activity. Carmen’s BMI began to decline, and the family’s self-efficacy about making healthy changes increased.
The multi-generational nature of the household was an important consideration in Carmen’s successful treatment. Additionally, the psychologist recognized and respected the meaning and value of food traditions from the family’s country of origin, while also helping adapt them to include more healthful choices. As a result of motivational interviewing and solution-focused approaches, Carmen’s mother was able to produce solutions that were culturally appropriate and attainable. From her use of behavioral tools and environmental controls, Carmen was able to accept the changes that her family made. A focus on parent behaviors was important, given her developmental stage. Additionally, given the family’s limited finances, it was important to find physical activities with no cost and healthy food items at prices similar to those the family purchased previously.