Guiding young patients toward health

For children living with overweight or obesity whose medical providers have recommended weight loss for health reasons, navigating health-related behavior change can be complex. Multidisciplinary care that includes psychologists is the gold standard in pediatric obesity medicine. APA’s own clinical practice guideline on childhood obesity and overweight recommends intense family-based, multicomponent behavioral interventions that include behavior change, physical activity, and diet.

A psychologist specializing in pediatric obesity care, Eileen Chavesopens in new window, PhD, MSc, works on such a multidisciplinary team at the Center for Healthy Weight and Nutrition at Nationwide Children’s Hospital in Columbus, Ohio.

Hers is a relatively uncommon subspecialty—most children’s hospitals have only one such provider. Her main focus is supporting children and adolescents in their journey to improved health through eating behavior and physical activity changes, integrating principles of health psychology and pediatric psychology. She and other members of the team work with children to make lasting changes to their health and behaviors while also addressing any underlying issues such as weight-related bullying or teasing and socioeconomic barriers to health.

APA asked Chaves to talk about how she works with children and youth to meet their health goals and why weight loss is “a lot more complex than society tells us.”

I did a fellowship at a federally qualified primary care clinic in Denver, frequently working with patients who had uncontrolled Type 2 diabetes. Many of them couldn’t access or afford fresh foods recommended by their medical providers and didn’t have access to safe spaces to be physically active. During my second fellowship in pediatric psychology, I did a rotation in a weight management clinic. I really enjoyed being able to get to know kids and their families and help them overcome challenges related to physical activity and nutrition changes.

In these environments, I realized weight loss is a lot more complex than society tells us and that simplistic messages like “eat less and move more” often overlook systemic barriers to change. But making changes can be very challenging, especially for kids who don’t have access to safe places to move and play or can’t afford after-school sports or fresh food. As a psychologist specializing in pediatric obesity care, I want to help children and their families address some of these challenges and find ways to make sustainable changes in their lives.

We talk about weight in terms of health. We don’t use calorie counts and very rarely talk about the weight number. If I do show youth or families their growth curve, I always ask permission to talk about this first. Many patients have experienced weight bias and stigma in other medical settings, where a medical provider pulls up their weight or growth curve and starts talking about their concerns in front of [the patient’s] parents without asking permission to do so. We want our patients to feel comfortable letting us know what’s best for them.

To encourage behavior changes, I integrate principles of health psychology to encourage small behavioral changes recommended by the medical provider. A youth’s medical provider, for example, might recommend eating 50 grams of protein and exercising 30 minutes a day. These changes can feel big and overwhelming for many children and teens. I help break down the medical provider’s recommendations into smaller goals kids feel like they can meet. I try to help families make realistic, doable goals they feel like they want to do and can include daily or weekly into their schedules. Many of the kids I work with are very picky eaters, so I might start by helping kids make a swap from regular French fries to sweet potato fries or simply touching or smelling a vegetable at mealtime before making the leap to putting it in their mouths.

Rather than talking directly about exercise, I encourage joyful movement. Many kids in larger bodies have experienced weight stigma in gym class or at recess, so they may associate physical activity with teasing or bullying. I want to help kids find ways to be active that they actually enjoy, because then it’s more sustainable long-term.

In the process of making health changes, we try to focus on celebrating wins that have nothing to do with the number on the scale. At times, our goal might also be weight maintenance, knowing that kids are going to get taller as they grow. Helping families recognize that the daily changes they are making has helped their child maintain their weight while they are also growing taller is a big win.

Maybe a kid feels more energized [or] confident or is eating more fruits and vegetables on a regular basis. Those things can be indicators that a child is heading in the right direction for their health, and recognizing these milestones can help encourage self-efficacy and fuel their momentum to continue to make changes.

Patients are referred to our clinic from primary care providers [or] can be self-referred by caregivers or other medical subspecialists. Each child has a care team with a medical provider, a psychologist, a physical therapist (PT), a dietitian, and a medical social worker. We all work together to help kids meet their health goals in different ways. We work in a shared space, so we talk all the time about how we can best support patients and families. Providers often refer patients to me for appointments, and we also collaborate as a team during medical appointments.

For example, maybe during a medical visit, the PT realizes a patient was very uncomfortable in the gym. The PT and I may talk to the patient together about negative experiences they’ve had with exercise. Sometimes for kids in larger bodies, being out of breath feels like anxiety. If they have a history of panic attacks, they might feel uncomfortable getting winded on a treadmill. In that case, I’d work alongside the PT and help provide interventions to self-soothe, such as visualization and diaphragmatic breathing.

I also collaborate with social workers to help families access resources to support their children’s health, such as food pantries or SNAP (Supplemental Nutrition Assistance Program) benefits to use at the farmers market. For families in difficult legal situations—such as parents with kids who miss school due to bullying or anxiety—we can connect them with lawyers to help them work through this.

Obesity is very complex. There are many social and genetic factors that play into weight and body size that people cannot control. Still, society has given us messages about how our bodies should look. As psychologists, it’s important we’re aware of and work to overcome our implicit biases related to weight and body size.

Psychologists play an integral role in supporting children’s physical and mental health. If you work with someone in a larger body, know it may be helpful to talk about how they feel about their body, even if that’s not their presenting concern. Many times, the kids I see are in psychotherapy for other mental health conditions. But when I ask, they say they haven’t talked about their body, eating, or related teasing or bullying with their therapist. They say it never comes up or they don’t feel comfortable talking about it with their therapist. If they say they don’t want to talk about it, that’s OK. But it’s our job to provide a safe space for people to talk about this part of their life if they would like.