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    Treating obesity at ground zero


    First steps

    Dr. Riba's Health Club (DrRHC) began as a half-day-a-week program with a multidisciplinary team that included a psychologist, social worker, medical assistant, registered dietitian (RD), case manager, and pediatrician, me. We started seeing 1 child at a time in a very comprehensive manner. Each of us met with the families, then we sat as a team and discussed each case. The RD would complain, “I can’t get this mom to serve vegetables.” The social worker would chime in, “Well, that’s because they are living in a garage and they don’t have a refrigerator.” Given barriers like that, the concept of developing healthy habits is a luxury. These families are on survival mode just trying to get through their day. 

    These were tough cases. Every one required my team to piece together what was going on at the home and how best to support the family. My social worker taught me to stop trying to solve each family’s immediate needs all on my own and instead link them to appropriate resources so they could learn to solve their own problems. We connected family members to dental access and medical homes. We referred for counseling, shelters, and even food banks. For the family living in the garage, we helped them find more suitable housing and even found a way to get a refrigerator donated to them. 

    The psychology of feeding children

    Stress is an important component. It is never about just the food. It is never about just the eating. You really do have to treat the whole family and their whole life.

    Having said that, of course, when it comes to obesity, food is something you can’t ignore. My RD, in a very unassuming way, found a way to teach the whole team about nutrition while innocently explaining for each case what foods were in the house, who was feeding the child, and how she educated that family and overcame barriers. She also dragged me to an Ellyn Satter Institute conference and indoctrinated me into what I call the proper psychology of feeding children, which is grounded in Ellyn Satter’s Division of Responsibility in Feeding: Parents are responsible for what is being served and when, and children are responsible for if they are going to eat and how much.

    As I applied these principles in my patient care, I found that the psychology with which we approach food could make all the difference in the world. One major revelation is that portion control creates more psychological harm than it does physical good. Maybe a few children will have short-term success with portion control, but the majority will convert to a lifetime of dysfunctional relationships with food, just as intimidation tactics and shaming are detrimental to children.

    One patient, an 80-lb, 3-year-old boy (whose weight should have been around 33 lb at that age) came to see me, and he was carrying a measuring cup. I thought it was so cute, that maybe he wanted to be a chef when he grew up. I discovered that he had previously seen an RD, who told him that he could only eat carbs in a quantity that would fit into the cup. So, he was carrying the measuring cup with him everywhere he went in anticipation of his next portion of food. Not only did this restrictive  portion control make him completely insecure about food, but he also proceeded to escalate from overweight to obese. This is the sort of psychologically damaging effects I have seen because of portion control, which makes a strong case for when it just doesn't work. 

    Adding more models

    In 2008, I obtained additional funding that enabled my team to begin treating childhood obesity throughout the county. I started to evaluate our program because I wanted to know if we were helping only an anecdotal few or making a statistically significant impact. I wanted to know what was working or not working and make adjustments to improve success.

    We also began to create other models to treat and prevent obesity, and our current programs include:

    • Health Club: Individualized patient care plans are delivered by a multidisciplinary team. Our latest evaluation found that 84.5% of patients improved their BMI percentiles.
    • Fit Club: The program targets children aged 4 to 18 years who are at risk for childhood obesity and type 2 diabetes, and offers year-round after-school and summer sessions. This year, our after-school session found that 93.3% of overweight or obese children improved their BMI percentiles and 100% improved their fitness levels.
    • PC-Fit (Parent-Child Feeding Interaction Therapy) Program: A collaboration between DrRHC and the Child Guidance Center, and recently funded by the Harvard Institute of Coaching, PC-Fit aims to prevent and treat eating disorders.
    • ·Fit Scouts: This troop of children is dedicated to having a healthy heart through nutrition, exercise, and helping others.
    • Medical provider education and training: DrRHC offers provider education and training programs conducted by a pediatrician or RD on the appropriate psychology of feeding children.

    • Community education classes: DrRHC encourages teaching obesity prevention and health concepts at an early age through specially designed classes on health and nutrition for parents and young children.

    Today, we continue this multidisciplinary approach and look at everything—obstructive sleep apnea (OSA), exercise, and psychology, to name just a few. The team now consists of 2 dietitians, 3 fitness instructors, 3 medical assistants, a case manager, and me. We see patients at 4 different clinics and refer to social workers, psychologists, and other specialists. We treat everyone the same way—obesity, underweight, failure to thrive, and picky eaters. In fact, we also treat all family members of all sizes the same way.



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