Even when we’re not in the middle of a terrible pandemic, there are a great many tensions around what to say and do at pediatric visits when a child’s weight is increasing too quickly.
There’s the issue of self-image and fat stigma; some people remember forever the moment when a doctor first called their weight a problem, ripping the child out of the happy innocence of feeling comfortable in his or her body.
The pandemic has raised worries about children’s weight gain, perhaps exacerbated by the absence of school, not to mention sports and other activities that used to give structure to the day and mark off some no-eating zones. Economic hardships and curtailed grocery shopping may be limiting some families’ ability to make healthy food choices.
“Parents should allow themselves some grace,” said Dr. Eliana Perrin, professor of pediatrics and director of the Duke Center for Childhood Obesity Research. “Families are having a tough time, kids are having a tough time, there’s increased food insecurity, people have lost their jobs, kids may have lost school meals.”
Dr. Sandy Hassink, a pediatrician who devoted her career to taking care of children with obesity and now works with the American Academy of Pediatrics at the Institute for Healthy Childhood Weight, and who worked on the academy’s interim guidance on obesity, said, “Even in pre-Covid times, I noticed as a clinician that nutrition and activity tend to go out the window in a time of stress.”
[Click here for the recent A.A.P. statement on healthy nutrition and physical activity during the pandemic, and here for its statement on obesity management during the pandemic.]
There are so many factors that have made it more difficult for families to maintain a healthy lifestyle during the pandemic, Dr. Hassink said, from increased sedentary time and screen time to the increased snacking and dysregulated sleep which sometimes come with being at home. Families may have less access to fresh food, she said, and then, of course, there’s stress eating.
Pediatricians often find themselves struggling to find the right balance in what to say to a family in these situations. Somehow, in those fraught moments in the exam room, real or virtual, you have to find words to acknowledge the complexity of the problem but also, most pediatricians feel, to recognize that parents do have some power and some agency, and to offer them hope and encouragement for making at least small adjustments to help the family establish healthier patterns.
Dr. Perrin and her colleagues at Duke pediatrics collected a set of suggestions for families, but before they got to the specifics of dietary change, increased activity, screen time and sleep, they started with a category they called “Survival,” advising families to pay attention to “mind, heart, body, spirit,” to avoid blaming themselves, to look for opportunities to congratulate their children for healthy behaviors and good decisions.
“Forget what ‘needs’ to get done for physical activity goals and ‘perfect’ meal goals,” Dr. Perrin wrote. “Do their best to eat at home and just ‘show up’ every day in terms of physical activity.” Specific suggestions around food include involving children in the cooking, and using the government MyPlate site to plan healthy meals on a budget. For physical activity, find some way to get moving, even a little, every day.
“As always, try to focus on behaviors, not weight,” Dr. Perrin wrote. “What’s important is making sure families are eating as well as they can — whole grains, proteins, fruits and vegetables, drinking water — rather than a ton of fast foods or sugar-sweetened beverages, and making sure they are staying active.”
Among the harshest lessons of this terrible pandemic year has been how health disparities play out across the life course, as we’ve watched higher death and disease rates in Black and brown communities. There are many issues to tackle here in terms of health equity, but for children growing up in at-risk populations, childhood obesity is yet another serious health disparity, linked to some of the underlying conditions that put people at higher risk for severe Covid-19 disease.
These disparities require complex systemic fixes — from access to healthy food, to safe places for outdoor activity, to improved mental health services, to other supports that can reduce stress on families. Instead, parents and children often encounter blame and stigma.
“Obesity itself as a disease presents a risk for more severe Covid infection,” Dr. Hassink said. “If I substituted the word asthma for obesity, people would not be blaming people for having asthma, they would be saying, let’s make sure your environment doesn’t have allergens, let’s make sure you get the right meds, the right medical care, but not blaming the child.”
Dr. Michelle White, an assistant professor of pediatrics at Duke, is a health services researcher who studies what might be protective for families at high risk of obesity, looking at environmental and family factors, including the ways that neighborhoods can contribute to obesity risks — or solutions. “Some families reporting significant impact by Covid-19 are still able to demonstrate resilience to stress and behaviors such as physical activity and healthy diet,” she said. “I think we have a lot to learn from these families.”
Dr. White said it was important not to view pandemic weight gain as a product only of diet and exercise behaviors. “The social context and the physical context of our families is so incredibly important in terms of their risk of weight gain,” she said.
My colleague Dr. Mary Jo Messito, who directs the pediatric weight management program at N.Y.U. School of Medicine and Bellevue Hospital, said, “My patients are suffering terribly.” They face many barriers to exercise because of fears of being exposed to Covid, she said, and also food insecurity and a very high level of stress. “So many people don’t meet their goals because they have unaddressed mental health needs,” Dr. Messito said, pointing to the need for more mental health resources for low-income communities.
“I work to try to give people resources where they are,” she said, offering handouts and information about healthy food for people on limited budgets, but acknowledging, “it’s not going to compete with fast food for calories for dollar.” She recommends in-home exercise programs or talks about how to mask up and go outside safely, and she talks about avoiding sugary drinks.
Dr. Elsie Taveras, a professor of nutrition in the department of pediatrics at Harvard Medical School and the chief of general pediatrics at Massachusetts General Hospital, said that the challenge ahead will be to find ways to “go beyond surface counseling,” to help families find ways to turn this around, perhaps looking for help from experts in mental and behavioral health. Doctors will need to think about the dual burden of weight gain combined with the social risks brought on by the pandemic.
“If a patient with obesity comes in for a visit and I also know the family is living in a motel or they’re food insecure,” she said, “I need to adapt my plan to circumstances rather than say, ‘increase fruits and vegetables.’”
Pandemic weight gain is a problem for adults as well as children, Dr. Taveras said. “We’re home more, have more access to our beds, our refrigerators, our screens, we are experiencing extreme stress and uncertainty, and food and rest are things people turn to for comfort.”
“It’s important for people to have self-compassion here,” Dr. Hassink said. And it’s overwhelming to tackle all of this at once. “Maybe we should be helping people pick one thing they think they could change to make it healthier, strategize about how they might make progress on one thing.”
A parent might try to keep healthier food in the house, thereby eliminating all the individual decisions that have to be made “when your child starts to grab for that unhealthy snack.”
Maybe start by setting a time for a particular meal, she said. Maybe make a deal with a child to stand up and walk around the house for five minutes for every so much screen time.
“Take it one thing at a time that you might want to change, get help from your pediatrician about what resources might be available in your community for food and physical activity, and don’t beat yourself up,” Dr. Hassink said. “Take one small step and then be encouraged to take the next step.”