Nutrition counseling strategies and resources for overweight and obese 2- to 5-year-olds

The Canadian Pediatric Society, the College of Family Physicians of Canada, Dietitians of Canada, and Community Health Nurses Canada recommend the adoption of the World Health Organization growth charts in Canada to replace the CDC growth charts. Growth charts can be found at www.dietitians.ca/growthcharts. With use of the new WHO charts BMI is calculated. This should alert physicians to early trends in overweight/obesity. 

Provincial training materials have been developed for public health staff and primary care physicians to support the implementation of these new WHO growth standards. 

The materials include guidelines on how to use, plot, and interpret results on the new growth charts; how to provide appropriate guidance to parents; and when to refer children with growth concerns for further follow-up. They can be found at www.health.gov.bc.ca/women-and-children/children-and-youth.

Obesity and overweight affects over 20% of preschoolers. Obese pre­schoolers are more likely to become obese adolescents. Physicians have a critical role as children’s primary health care providers to assess growth patterns and reinforce healthy life­styles. New research supports approaches that focus on healthy eating and active living rather than prescriptive eating and exercise strategies for intervention.

BMI-for-age is an effective screening tool for obese/overweight children over 2 years of age.

• Normal BMI for 2- to 5-year-olds is 13 to 18 (compared with 18.5 to 25 for an adult).
• The definition of overweight/obesity is different in children under 5 years of age because caution is needed to avoid categorizing young children too early (see Table 1).
• Serial measurements are recommend­ed.
• Healthy children come in all shapes and sizes.
• A consistent high (or low) plot along a particular percentile may be normal. 
• An abrupt shift in BMI-for-age percentile warrants more frequent monitoring, even if it remains within the healthy range. 
• BMI must be used in conjunction with a thorough medical and biopsychosocial assessment.
• Consider secondary causes of overweight/obesity (CMAJ 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children—Chapter 8).

Using a motivational interviewing approach
Research supports motivational interviewing as best practice to effect change. Motivational interviewing strategies resist the urge to tell the parent how to “fix” the problem and focus on trying to understand the parents’ concerns and motivations. Attempt to listen for the ideas and answers to come from the parents and empower them to use these for change. 

For example: “Sam” is a preschool­er who presents in your office with his parents (see Table 2).
Educating parents/caregivers about their roles and responsibilities and their children’s roles in feeding can be empowering and goes a long way to preventing eating issues:

Parents’/caregivers’ roles
• Offer three meals and two to three snacks each day, at regular times.
• Offer healthy foods most of the time; limit less healthy foods.
• Sit down and eat healthy foods with children.
• Decide what foods are offered to children in the home or away from home.
• Do not praise or punish children bas­ed on the amount of food they eat. 
• Do not use food as a reward.
• Do not withhold food as punishment.
Children’s roles
• Decide whether to eat. 
• Decide how much to eat from the foods offered at each meal or snack.

Shapedown program at Children’s Hospital
This program services children be­tween 6 and 16 years of age with a BMI greater than 95% or with a BMI between 85% and 95% if certain medical conditions are present. Go to www.bcchildrens.ca/healthyweights for information to deal with obesity and to find valuable tip sheets. 

—Kathleen Cadenhead, MD
Chair, Nutrition Committee
—Barbara Leslie, RD
—Baljit Pawa, MD
—Shefali Raja, BSc, RD
—Margaret Yandel, BHE
—Helen Yeung, MHSc, RD