Abstract

Treating obesity in children and adolescents is not a cakewalk. Asking them directly to get up and run, or just serving them a four-quadrant plate won’t serve the purpose at all. An obese child is already under the repercussions of oppressive remarks by the society. If at home as well, their mental milieu is not taken care of, there are chances of them being trapped in the shackles of depression. To avoid such drastic consequences, one must be prudent enough, while conversing with their children/patients regarding their weight. Motivation enhancement is very crucial in childhood obesity management, as the required changes in diet, behavior and physical activity are difficult to carry out with an insufficient level of motivation.¹ The motivational hacks presented here might be helpful for parents and health care professionals in convincing their children/patients to stride through the road to health.

Keywords: Childhood obesity, obesity motivation, child health, child motivation, weight control, diet, behavioral modification

Obesity in children is defined as body mass index (BMI) above certain level as per age and gender of the child. It is the result of an interplay of genetic, environmental and behavioral factors. The changing lifestyle and unhealthy dietary patterns make genetically predisposed children more vulnerable to gain weight at abnormally higher pace. The unprecedented situation during COVID lockdown has paved the way for emergence of another pandemic, especially in children, the pandemic of obesity. Childhood obesity is now a growing public health concern in India as well as other parts of the world. According to UNICEF’s World Obesity Atlas for 2022, India is predicted to have more than 27 million obese children, representing 1 in 10 children globally, by 2030.² The social stigma of obesity puts the children at risk for discrimination, teasing, bullying and isolation along with physical afflictions like hypertension, type 2 diabetes, coronary heart disease and psychological problems including low self-esteem, poor body image and depression. Considering its adverse effects on the child’s physical, psychological and social functioning, controlling this pandemic is of utmost importance.

The four pillars of obesity management are nutrition, exercise, behavioral modification and medications. However, just being well versed with the solution does not rectify the problem automatically. The real challenge is to convince the children to execute these pillars. Though medications are not recommended in children, the foundation for other three pillars is effective motivation.

APPROACH FOR MOTIVATING AN OBESE CHILD

Before discussing the hacks of motivating a child, it is extremely important to identify the correct approach for the same. Persuading a child individually to perform the actions differently while all the other family members are following their favorite routine, is never acceptable and hence the efforts go redundant.³ A 1998 study by Golan and colleagues found that treatments that involve the parents are associated with better childhood weight control than those treatments that involve only the child.⁴ Rather than isolating the child for special diets and special exercise regimens, all family members are encouraged to follow healthy lifestyle together.

LEVELS OF MOTIVATION

The grounds on which obese children must be motivated depend a lot on their level of insight into the problem. Trying to set motivational goals without knowing the mental status of the child may lead to early termination or inadequate treatment outcomes.⁵ So, it’s a prerequisite to depict the level of motivation needed by a particular child and to trigger the spark within the child’s mind, as summarized in Table 1.

Level 1: Motivational Interviewing

At this level, the child has no insight about his/her problem as well as associated repercussions. The major purpose of a health care professional at this level is to educate the children about their current level of health and to counsel them regarding the need to bring a change. It is efficiently done by applying the tool of Motivational Interviewing, an empathic person-centered counseling approach that prepares people for change by helping them resolve ambivalence, enhance intrinsic motivation and build confidence to change.⁶

• Being compassionate and maintaining a level of under­standing is the key. “How you discuss a child’s weight problem can make a huge difference in helping her deal with it,” says Jamie Calabrese, MD, Medical Director of the Children’s Institute in Pittsburgh and a member of the American Academy of Pediatrics (AAP) Task Force on Obesity.⁷
• The first encounter of a primary care physician with such a child should just be an attempt to engage him/her in the conversation, with empathy. “Can we take a few minutes to discuss your growth in terms of weight and height?” “Well, you are doing good. I want to know your opinion about your own weight and height.”
• While questioning, following terms should be avoided and replaced with less hurting words:
• Overweight/obese/heavy/fat: use ‘unhealthy weight’ instead.
• Focus on your ‘weight’: use focus on your ‘lifestyle’ instead.
• Junk food/bad food: use ‘unhealthy food’
• Physical exercise: use ‘activity/play’ instead.
• Parents should be counseled to avoid using dis­couraging words to the child at home to prevent the onset of doubts on his/herself-image.
• Once an insight about the condition has been inculcated into the child’s mental milieu, he/she can then be given an appointment for instilling the seed of motivation.

Level 2: Motivational Induction

At this level, the children probably have appropriate insight and know all the answers to the question ‘what all is to be done to lose weight and stay fit?’ But they are not convinced enough to apply those techniques in daily life. The following tips, to be executed by the parents, are effective in motivating their children towards a healthy lifestyle.

• Mindful conversation:⁸ Girls may be more interested in hearing how lifestyle changes will improve their appearance. Tell your daughter how shiny her hair will look if she eats more fruits and vegetables. Or say, “If you keep playing outdoor games, you’ll get into better shape, and we’ll probably need to go shopping for some new clothes.” Instead of saying, “You are obese and need to lose weight,” say “I know you don’t like being heavier than your friends. But you can change that by spending less time sitting around and more time moving your body.”
• Being good role models: Physical activity can be inculcated by parents in their children’s daily routine by becoming good role models themselves. Scheduling outdoor times with the child like park outings, family walks as well as being active indoors like by asking for help in household chores as per feasibility, dancing sessions, playing ball game, joining swimming classes, etc., are some of the ways parents can accompany the child.
• Assign a time slot as ‘activity hour’ in an ‘activity area’ of the house like a backyard or a balcony or an outside park in the society and ensure that everyone must do some activity or the other during that 1 hour. Playing a family game together can also be another way to spend the ‘activity hour’. This would provide an extra edge to parents to interact with their children. They must take advantage of this time to explain the importance of physical activity to the child. However, they should avoid talking about losing weight. Just helping them understand that moving their body would help them feel better in other aspects of life, is enough.
• Being sneaky: Parents are the mastermind of their children’s health as they can adopt sneaky ways to get them active without them realizing that they have been doing it. For e.g., parking the car far away from the exact destination, allotting them the task of taking the dog out for a walk, encouraging them to ditch the elevators by challenging them with stair climbing race, taking a walk to the nearby market instead of reaching there in the comfort of a vehicle, spending the weekend at a trampoline park or kids-friendly trek expedition rather than at a movie or a brunch, encouraging indoor movements by involving them in household chores of their interest, etc. For younger children, they can buy toys that promote physical activity. The key is to stick to the plan and to keep executing such movement-focused ideas. Gradually, the child will develop a habit to stay active without even realising it.
• Screen time reduction hacks: Tricky ways to reduce screen time in children are removing televisions and computers from their bedrooms, assigning screen-free zones at certain areas of the house like dining area, bedroom, balconies and lawns, and by replacing pre-sleep gadget time with a pre-sleep family fun time as a daily ritual.
• Healthy food hacks: Taking advantage of the essence of patriotism, the concept of tricolor in Indian flag can be used in meals as well. They can offer a plate containing Indian flag colors. The child might consume it with full interest. At least one meal a day should be planned as a family mealtime as controlling the potion size becomes easier. The rule of ‘self-service’ should be followed by everyone during the mealtime rather than serving the meals on the table. It’s a good idea as well to reserve smaller colorful plates for the child. One should never forget to unstock sweetened beverages and processed foods from the house. Children should accompany the parents to the grocery shopping at least once in a fortnight where they can explore various healthy options available. Involving the children in cooking process as well, inculcates a sense of respect for the food.

Once the goal of induction of motivation has been achieved, move on to the next level.

Level 3: Motivational Intensification

Performing well at this level is the hardest part of the mission for health care professionals as well as parents. The child was motivated enough initially, but the spark usually declines after a week or two. Keeping in mind, the recommendations for an effective activity period of at least 60 minutes a day in order to lose weight significantly, it is imperative to keep that spark alive for a longer period.

• Constant appreciation for as little endeavors as a 5-minute activity, is a strong driving force for them. A word or two of appreciation from the relatives as well, is enough for them to get going.
• Little changes and big rewards strengthen their tendency to persevere. Well, it’s important to remember not to give junk foods like candies, chocolates, ketchups, fries, pizza or carbonated beverages as rewards. Additionally, reward must not include extra TV time or video game bonanza or a movie date. The best of rewards would be going for a joyful picnic, taking them to an adventure park, buying them a pair of roller skates or a cricket set or a tennis racket, gifting them a Fitbit smart watch that can track their daily steps. Girls have a special predilection for their favorite dress, beautiful hair accessories, a nice pair of shoes, etc.
• Joining a regular sports activity: Once the child develops a habit of being active throughout the day, which usually happens in a month or so, he would like to join a regular physical activity such as any sports of interest, daily swimming classes, aerobics, etc. One should keep the goals modest at first, so he/she does not think of exercise as a chore or punishment. Looking at the numbers on the weighing machine as a criterion for achieving the goals can give rise to demotivation as the process is very gradual.
• Set qualitative goals like fitting into their favorite dress, completing one round of park without getting tired, climbing the stairs in one go, rope skipping for 5 to 10 continuous minutes.
• Break down the goals further into smaller and more achievable sub-goals. Even a slight progress should be taken as an achievement and celebrated. Seeing progress is a great motivator in itself, and improves self-esteem of the child. Parents should continue to set new goals every month and let the child tackle one goal at a time so that he/she doesn’t feel overburdened. Keeping the momentum, helps it feel more automatic over time.
• Keep a positive environment in the family and encourage the child to have positive self-talks like ‘I am the best’ or ‘I am doing great’.
• Activity-tracking apps can be installed in parent’s mobile phone to keep a record of their children’s activity. The improvement in their fitness scores cal­cu­lated by such apps is an excellent motivator.

Rightly said by Karen Salmansohn – “Don’t wait until you reach your goal to be proud of yourself. Be proud of every step you take.” So, parents must make their child feel proud of every small step they take every day.

SUMMARY

A motivational and autonomy-enhancing approach to behavioral family-based pediatric obesity treatment is a viable alternative to the standard intervention approach.⁹ For motivation to be effective, one must proceed at a slow and steady pace taking the child’s frame of mind into consideration. Applying the various motivational approaches in a phased manner as depicted above, an obese unmotivated child can evolve into a motivated, activity-conscious, goal-oriented child.

REFERENCES

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