Extended Interview with
Thomas Robinson, MD, MPH

How big a problem is childhood obesity?

Childhood obesity is probably the biggest public health problem we face as a country and as a world over the next century, and I think that’s because what we’re seeing in children today is going to manifest in adults in the future. What we’re seeing now is just the tip on the iceberg. [We see] adults who are overweight as adults - who are having the manifestations of their obesity, their heart disease, their strokes, their cancer - and those are adults who, many of them, became overweight as adults. Now we’re seeing a whole new generation of children who are starting to be overweight early in childhood. That means the risk factors that they’re being exposed to are occurring over their entire lifespan. We have no idea how much more serious that will be or how they’re going to suffer from the effects of their obesity compared to the adults that we’re seeing now. We expect to see heart attacks and strokes and diabetes occurring at a much earlier age and in much greater numbers as the current generation of children turns into overweight adults.

What is the distinction between obese and overweight, and how big is the difference in risk?

Right now our definitions of obesity and overweight are somewhat arbitrary in that they are based upon population distribution, so based upon the percentage of children above a certain level. And the Center for Disease Control and Prevention has decided that the best place to draw those cutoffs are at what is referred to as the eighty-fifth percentile and the ninety-fifth percentile of the distribution of body mass index that we had from the 1960’s through about 1980. So taking all the studies that were done in the United States of children between the 1960’s and 1980, combining them and looking at what the eighty-fifth percentile for boys are girls, and the ninety-fifth percentile of boys and girls were at each age. That was sort of designated as overweight, over the eighty-fifth percentile, and obesity over the ninety-fifth percentile. Those are then used to look at how the prevalence changes over time, or how the percentage of children above those percentiles changes over time. So in some ways, they give us a good gauge of the number of children who are above - who would have been considered really substantially overweight in the 1960’s through 1980, but we don’t know how those directly relate to all the problems we have in adulthood. We know that children over the eighty-fifth percentile who are defined as overweight have many more problems than children who are below, and suffer a lot more problems as they become overweight as adults, and children above the ninety-fifth percentile even more so. Also, children over the ninety-fifth percentile, obese children, are much more likely to become overweight or obese adults, and are also more likely to have a higher BMI in adulthood. And the higher BMI as an adult, the more problems you have.

I’m a parent listening to this… How do I know when my child has a problem?

Well one thing we know is that parents as well as pediatricians aren’t very good at just looking at a child and saying, “You’re overweight or you’re obese or you’re normal weight.” And some of that is with the way children dress now with lots of baggy clothes, and it’s hidden. Another part of that is that the whole society has become heavier, and our norms or what we see as normal has changed. And so you may look as a kid and say, “They look like everybody else in their class,” but they may be substantially overweight.

So the first thing is to actually measure the BMI, and that is defined as the weight divided by the height squared, measured in kilograms in meters, and there’s also a way of doing it in pounds and inches. Once you’ve measured a body mass index, then you can plot it on the growth charts that we have that are just like how we plot height and weight in the pediatrician’s office or the family physician’s office. Based on that, we can tell you whether your child is overweight, higher than we would like them to be, or obese. The best way to know whether your child is overweight is to measure their Body Mass Index and plot it against the national standard. However, in some cases, whether your child is functionally overweight is also important. And so, if your child is being teased at school, or worried about their weight, or if your child’s pediatrician or family physician or nurse practitioner identifies problems such as high cholesterol, or high blood pressure, or a low HDL cholesterol, which is the good cholesterol, or a high insulin level or pre-diabetes, those are things that also suggest that your child’s weight is a problem and that losing weight should be important to them. Other things might be if your child is not fit and out of shape such that they are out of breath when they are trying to be physically active; when they are playing in physical education or when they are playing games or in little league or in other types of activities, even just with the family. Those are other indications that your child would benefit from doing something about at least their fitness, if not their weight as well.

There are a number of causes for this. Can you rattle off the biggest culprits?

If I had to pick one major cause, it would be capitalism. And it doesn’t mean that we have a way of changing that, but we live in a society that’s all based on consumption and acquiring more and more, and also in which we reward people for their success and getting people to consume more. We live in a world in which we have encouraged the food industry to create cheaper and cheaper food that has more and more calories, is more satisfying, that tastes better, and so we’re surrounded by a toxic environment in which we have a very cheap, very tasty food all around us, available all the time, and marketed to us heavily so that we’ll consume it. On the other side, we live in a world in which we have engineered physical activity out of our lives. We have purposely come up with lots of ways to become less and less active. Everything from the automobile, which, of course, was a major invention, to the remote control, which might seem small, but has made it a lot easier to just sit on your tail and stare at the TV, to video games, which allow you to play sports without leaving your living room. So you’re not getting much physical activity -- too many things that distract you from other activities that might be more active, such as just going out and playing. In addition, we have a world in which parents are told, mainly from the media and other sources, that we have a very unsafe world. The data suggests that the world is safer for children now that it has ever been, and continues to get safer. But parents don’t want to leave their children unoccupied outside, so you don’t see children walking to school, you see children being driven to school. You don’t see children playing outside after school, or on their own, because parents are concerned. I’m not suggesting that parents shouldn’t be concerned, but the reality is that we have a very safe world compared to the world even that we grew up in several decades ago.

How do you feel about David Kessler’s idea? He doesn’t use the word “addiction”, but he talks a lot about engineering food rather than cooking or preparing foods to appeal to the palate, almost becoming irresistible by changing the structure of the brain. Can you talk about that?

I think that the food industry in particular is doing exactly what you would expect it to do. And that is to try to find the products that will sell the best that people will like the best. So they have used science to formulate their food in a way [that is] highly appealing. And I don’t know if they are doing anything special that anybody else isn’t doing, we try to do the same things in promoting healthful eating, we try and find ways and we use science - in particular, psychology and what is now being termed as behavioral economics - to identify the ways in which we can make food more fun, more tasty and more desirable in kids and adults too. The food industry has a lot more resources than we do, and they have put a lot more effort into it, and they have a single-minded goal, which is to sell their product, but we would like to be just as effective as they are at creating healthful foods that families can enjoy.

Does the mind re-engineer itself or respond to foods in an addictive way that actually changes the structure of the brain? Does an addiction set in?

In terms of addiction, there is a lot of controversy over how to really define addictions when it comes to food. And the idea of being addicted to food in particular has been something that has been argued for several decades. Depending on whom you talk to, you are probably going to get totally different answers. We know that the brain changes over time. Every time you create a new memory, the brain is changing. We know our taste preferences are very malleable, that they change very easily. And so, the more you’re exposed to a certain food, the more you’re going to like it. The context in which you eat it changes the way you like it.

We did a study with three- to five-year old Head Start children, low-income students from Head Start centers around this area, and we gave them two samples of food, identical foods. One was either in or on top of a McDonald’s wrapper, and one was in or on top of a plain wrapper that was the same color, same material, same shape, it just didn’t have the McDonald’s golden arches on it, and children were asked to taste one food, and then the other, and we were behind a screen so they couldn’t see our faces or anything else, and they were told to taste one, taste the other, and tell us, do they taste the same (Which was the correct answer because they were the same foods)? And even at three to five years of age, children overwhelmingly said that they thought the one that they thought was from McDonalds tasted better. So it had changed their appreciation for taste, not just what they wanted; it wasn’t “which food do you want more?” Based on advertising of familiarity, they actually thought it tasted different, tasting these identical foods side by side. This was true for hamburgers, French fries, chicken nuggets, milk in a cup, and even baby carrots, which McDonald’s doesn’t sell. And so we saw that just that exposure to a familiar brand and that branding had already had an impact on what kids’ perceptions of taste were. So that’s an example of how the environment that we’re in, or the things we’re exposed to, or in what kind of context, whether you’re having a fun meal with your family, whether it’s marketed and advertised a lot, whether it’s in a place that you really like - those things can impact how much you like food, and those stick with you in terms of your preferences for taste, and they will alter your perception of how that food tastes.

What are the biggest risk factors and what can be done about them?

The major risk factors for developing overweight and obesity are really simple; lack of activity and eating too much. Within that context, there are a lot more ways that that occurs, the behaviors that occur. So if we think about it from the eating-too-much side, it might be eating too many calories, but those might come from eating too much food, too many prepared foods, eating on plates that are too large so that you consume more, and that influences how much you eat, eating too many sweets, rewarding kids with sweets such that they like them more, all of those types of behaviors lead to eating too much or taking in too many calories. On the physical activity side, the displacement of physical activity through too many sedentary activities such as television and video games, movies, and all the entertainment options that we have provided for our children that substitute for activity. In addition, just the lack of opportunities for activity, whether you live in a neighborhood in which there aren’t a lot of activities, on whether they’re unaffordable because now instead of playing sports at school you have to pay to participate in sports, and to be on the team. It may be that your parents aren’t able to put you into little league or supervise because they’re working, that we’re not providing activity at school through physical education, or even recess, because that has been taken away in some schools. One big one that we’ve studied quite a bit is media use: television, videotapes and video games, which act both through decreasing activity and increasing your intake. In fact, sort of unexpectedly, I think, more and more of the data is suggesting that the role of television in particular is probably through increasing how much you eat more than through reducing how active you are.

Lets just talk about television and media.

Television leads to obesity through three main avenues, the first being decreasing or displacing physical activity, which seems pretty obvious. If you’re watching TV, then you’re not doing something more active.

The second is through increasing how much you eat while watching TV, and that is probably through a distraction mechanism. And we know that if you’re distracted while you’re eating, whether it’s through TV, or through conversation, or through reading a book for that matter, that you will consume more during a sitting. And part of that is that while you’re watching TV, your body doesn’t pay as much attention to when it’s getting full, or the taste that you’re experiencing. So you don’t get tired of those tastes as quickly, or you don’t get full as quickly, and you probably eat until the show is over or until the plate’s empty or until the bag of chips in empty as opposed to stopping when you’re full.

The third way that Television affects weight in eating is through the effects of advertising and we now have a tremendous amount of data that suggests that advertising really does influence what children eat, and parents will not argue about the fact that their children are nagging them. Many parents experience nagging from their children for foods that the kids have seen on TV and want purely because they’ve been advertised to, not because the kids know that they like them.

Talk to me about satiety, those internal cues, and mindless eating, especially with an eye on prescription for parents… to help them out.

One of the big problems is that different cues in our environment affect how much and what we eat. And some of the important ones are things like the size of the plate you eat on. The larger the plate you use, the more food you’ll consume, and, in fact, the longer it will take for you to get full, because people tend to eat based on these visual cues as opposed to how full they are. Similarly, the larger the serving size, which goes along with the larger plate as well, the more you’re going to be consuming.

What can parents do to help kids listen to themselves?

Another environmental cue that affects how much you eat is whether you’re eating in front of a television. And eating in front of a television distracts you, and you’ll consume more, and probably consume higher calories eating in front of a television that not. In fact, some of our studies consistently suggest across different samples that the average child consumes between a quarter and a third of their daily calories in front of a television screen. We know that kids are consuming quite a bit.

So, the types of things parents can do to counter these environmental cues are, first of all, be aware of them. The first thing I would tell a parent to do is to stop eating in front of the TV. The TV shouldn’t be on during meals and, if possible, not during snacks or other eating too. It’s possible for parents to make rules that forbid eating in front of the television screen, and that would be an easy way of addressing that cue to eat more.

Another thing that families can do is start using smaller plates, smaller dishes, narrow and taller glasses, as opposed to short fat glasses. Those are the types of things that we’re actually going to be testing in a trial that will be starting soon. Our pilot data suggests that’s one way in which you can reduce intake and the amount that kids eat at a single time. And there’s laboratory research that suggests that just changing that plate size or changing the serving size that you serve to children will reduce their overall intake and that they won’t make up for it at other meals or other times of the day.

Can you talk about enjoyment of food and how that fits into this?

I think we definitely encourage families to continue to enjoy food. Food and meals should not be a negative thing; they should be a positive thing. But the focus doesn’t have to be on the types of foods that have been heavily marketed or that we sometimes associate with fun, such as sweets and desserts. If the focus and enjoyment of the meal is on the family being together and on the interacting with the family and having a good time as a family as opposed to on the specific foods, I think that’s a much healthier way of enjoying meals than just to focus on whether you have dessert or not.

Assuming we are all born with satiety, do kids lose their ability to say, “I’m full”?

Research in child development suggests that young children are better at controlling what they eat and keeping that constant than older children and adults. So before school, in the preschool years, where a lot of these studies have been done, children do a pretty good job at maintaining the same calorie intake or the same energy intake from day to day. If they eat more at one meal, they eat less at the next. They sort of monitor that, and their body is pretty good at controlling the natural intake of calories. We’ve been able to overcome that now in this very toxic environment in which food is everywhere and we are seeing a lot more overweight young children. But for the most part, children are better at that before school age than after.

As they start to socialize and spend more time in school and are exposed to more environmental cues, those tend to overcome the natural ability of people to control their intake and monitor their fullness or their satiety. And so children, as they go into the school years, aren’t very good, and adults are even worse, at sort of paying attention to those satiety signals and instead are eating in response to environmental cues such as the way the food is served, what food is being served, what the social context is, whether they are in front of a television set and the show’s not over so they continue eating, or the show is over and they stopped eating, whether they’re out to dinner with friends, etc. And so those are the types of things that tend to overcome our natural internal cues for satiety; they tend to be overwhelmed by all the external cues we have.

What about the idea that it’s okay to be fat if you’re fit?

There are some data from adults, mostly observational data (meaning data in which you don’t do experiments, you just look at what happens, measured by what happens over time), that suggests that there is a group of adults who are overweight but who are physically fit. They have not lost weight, so they continue to be overweight, and they have lower risk than people that are thin but unfit. So there are a number of people who have been arguing that it’s really fitness more than fatness that is important in this obesity epidemic and that we are concentrating on the wrong thing. I think that there is some truth to that, but it’s a little of both.

In general, you are going to find a really small number of people who are overweight and fit. That really doesn’t apply to most people. Most people who are overweight are not going to be fit. We would encourage them to become as fit as possible, so I wouldn’t discourage anyone who is overweight to become as fit as possible even if they’re not seeing lots of weight loss associated with it. Most children who become physically active will, in fact, lose weight, so they tend to go together. I don’t think it’s one or the other. I hate the idea that people within our world who are all advocating for our health say one thing is much more important that the other, or one thing is no longer important, and we’re really focusing on the other - because really it’s a mixture of all of these things. And I think we need to promote fitness, I think we need to promote both, because they’re both important for health.

How much do most parents know and how much do they not know and what would you most like them to know?

I think most parents are very familiar that if you eat too much and you don’t exercise enough that they are going to gain weight, and that their children are going to gain weight. I don’t think that’s rocket science; I don’t think it’s a secret. What is difficult for most parents is knowing how to balance that intake and that expenditure. I think the easiest way, the best way, to explain it to parents, especially if they have an overweight child, is that it’s really difficult to measure these things, but the easiest thing to measure is their weight. And that’s something that they can measure at home, that we know is much easier to measure than how much activity they’re doing and how much they’re eating, how much they’re taking in. And so I encourage them to think about how if their child is continuing to gain weight or is overweight, then that balance is clearly out of whack, for whatever reason. It may be that their child is just genetically and biologically more efficient that other children, and so they don’t need to eat as much, and they still continue to grow. It may be that they’re just consuming much more. But it doesn’t really matter, because we know that there is an imbalance there and the calories in are more than the calories out. And so what I encourage them to do is really to focus on this: if your child is gaining weight, then you either have to reduce the intake, or increase the physical activity, or both, because what’s happening now isn’t enough.

Do you find in your programs that parents or kids come to you afterwards and say, “I had no idea that…it was a big surprise that…” and then (fill in the blank)? Do they say, “I thought I knew, and I had no idea”? What are the surprises?

One of the things that kids find surprising is when they write down what they eat, how much they’re eating. If you actually keep track of what you eat, you realize there are all kinds of food that you totally forgot about or that you’re maybe having a snack at a certain point, or every afternoon you’re having a candy bar, or an energy bar or an energy drink that you forgot about because it’s just part of your routine, or you don’t think of as extra calories, but once you see it on paper and once you acknowledge it, you realize, wow. That’s something that I could cut out. Every extra soft drink a day – you may think that a soft drink isn’t a big deal because it’s just part of your routine, but then when you realize that every soft drink a day is another 140 - 150 calories, or every glass or juice, that adds up over time. You know that’s the same energy equivalent of about 14 or 15 pounds over a year if you do that every day. Kids, when they start to monitor and look at what they’re doing, start to see things that they didn’t recognize before.

It seems to me there are two parts. One is the awareness and the knowledge of the problem and yourself; the other is the implementation, making those changes. Which is harder?

Most kids that come to us, especially by the time they come to our clinic in which we treat overweight kids, or one of our programs in which we help them try and lose weight, they’ve already realized that they’re doing something that isn’t working. And they’ve already decided that they don’t like being overweight, that they don’t like being too heavy, either because they’re being teased, or they just don’t like the way they look in the mirror, or they know it’s unhealthy… maybe their doctor has told them they have high cholesterol or they have evidence of pre-diabetes. So the awareness of having a problem is pretty evident to most children and a lot of their parents, although we do get some who come to us not knowing why they were referred to us. But in general, most families recognize that they have a problem.

Doing something about it is much more difficult. And it requires, first of all, prioritizing it as a problem because parents have so many things that they are worrying about now. And it’s not an immediate problem for a lot of them, in that if their child is going to have diabetes in the next ten, twenty years, yeah, that’s an important problem, but it’s not immediate like the problems that they are facing, like getting their kids to go to bed that night and not stay up all night watching TV. And so it tends to be something that isn’t always the top priority.

It also requires a lot of work and a lot of commitment. Changing the habits we’ve ingrained in our families is really difficult. So you may be eating a certain way, cooking a certain way, you may have a certain routine, how you spend your time after school. Those are very difficult to change, especially if you’ve been doing them for a long time. What we find is that if we can find ways to make those first steps, making those initial changes, and families making those initial changes, we find that they can create new habits. And we can do it relatively quickly. So some of these things that seem to be very ingrained, if you can make it over that first difficult challenge of changing them in the first place, you can start new routines and new habits pretty quickly, especially if you do those in a way in which they are rewarding to do in the first place. We focus a lot on the process of behavior change as opposed to the outcomes.

A lot of people come to us saying, “I want to lose weight because…” or “I want to exercise more and eat better because I want to lose weight.” Or they come and say, “I want to lose weight because I’m really worried about getting diabetes or heart disease in the future.” Or their grandparents and their aunts and uncles all had early heart disease. Those are the outcomes. Our approach is to say, “well, those outcomes are what motivate us as health professionals and those are the things you hear about in the press and in the media about being problems with obesity and problems with our poor eating and physical activity, but to make changes in behaviors we need to make those rewarding in themselves”.

So we focus more on that process or behavior change. If you can make physical activity fun, if you can make eating healthily more rewarding, tastier, more fun, in a better context, then those things are going to be easy to change and you’re going to continue doing them. Not because of the end goal; that is tough to keep in mind when you are faced with that chocolate bar or you are faced with that dessert, but because you know at the time that it’s a positive thing. So a lot of our research right now has been focusing on how we make physical activity and eating fun. And the way we do that is by thinking about ways in which these things already are fun.

For example, we’re doing a study now, we’ve done several studies actually, in which we do after-school ethnic dance classes for girls. The idea here is we found a physical activity which is really fun and that people do, not because it’s physical activity. They may initially join it because they think that this is going to be a good activity as well as fun, but they’re also going to learn something about ethnic dance. It’s fun to be in a group, so we’ve formed this so they are part of a dance group. It’s fun to create costumes, it’s fun to perform in front of your family and friends, and we find that it becomes highly rewarding to become involved in these dance classes. The idea of dance as being physical activity is lost very quickly, but kids persist at it because it is really fun and they love doing it, and all of these other factors. So when I’m working with a family and trying to get them to incorporate physical activity into their child’s life, I tell them, “What are the things that the child likes to do? Do they like to play basketball? Do they like to dance? Do they like to walk the dog? Do they like to do other things? Can you identify some things that are physically active, but are also really fun to do, so that they would do anyway, even if they weren’t physically active?” I tend to call these stealth interventions, and that’s what we call them when we write them up, because from the point of view of the child, they’re doing it for a different reason. You may have designed it so that they will get more physical activity, but they’re doing it because it’s so much fun. And so those are the types of things we try and do.

I can extrapolate from this, but I’d like you to spell it out very briefly – the equivalent on the eating side, the stealth interventions with food.

The stealth interventions for food are a little more challenging because a lot of recommendations that people hear are about cutting back. We tend to focus on the positives of eating more fresh fruits and vegetables. We want them to eat fewer foods, and, in particular, we want them to keep tracking, and when they’re in the treatment program, they’re keeping track of the foods they are eating. We want to highlight all the positive things about healthy foods. One of the things I like to do with families now, these days, is to focus on the other benefits of eating a healthy diet. So right now, kids have a lot of interest in the environment, and some of them in global warming, and they’re hearing about it in school, and they’re hearing about it in the news, and hopefully they might be doing things like that. And so global warming and environmental sustainability overlap with our goals for obesity very well in that we want kids to eat more fresh fruits and vegetables, and for saving the planet they will be wanting to eat more locally grown fruits and vegetables, things that have less of a carbon footprint and require less transportation to get to them, and then avoid the types of foods that are high risk for both obesity and the environment, such as meat, and, in particular, beef. And so you’re getting them to move their diet in a positive way, as opposed to just saying that you have to cut back on something that you really like. So if you change your diet to really save the planet, you feel good about not eating meat. You don’t feel bad about neglecting a part of the diet or about trying to cut back on something and denying yourself a pleasure. Instead, you feel that it’s more pleasurable because you’re doing something that’s helping the planet, and doing something positive.

But when push comes to shove, there’s deprivation; you have to take in fewer calories and burn off more calories than you have done in the past. How do you counsel parents and kids to deal with that deprivation?

Well, we know that if you’re overweight, you’re taking in more calories than you’re burning. To address that, you’ve got to switch that balance. You’ve got to reverse it so that you’re taking in fewer calories than you’re burning. There’s two ways, one is through increasing activity levels; the other is through reducing intake. A combination of both is probably the best. There is sometimes the feeling, particularly in parents, they they’re depriving their children of certain foods and they don’t want to deprive them of anything. In fact, it is logical to think that if you’re gaining weight, you’re taking in more than you need. So you’re not really depriving them of anything, you’re altering, and you’re giving them what they need.

Sometimes, we get parents who really resist cutting back on certain foods for their kids because they feel that they are depriving them. And because they feel guilty in some way, that their kids aren’t getting what other kids are getting, or maybe they feel bad about not spending enough time with their kids, or whatever the reason, they don’t want to deprive their kids of anything. We try and work with them to reframe that as the importance of being a parent, and doing what they know they need to do to help their children learn the skills to control their own behavior. And so instead of trying to frame it as, “I’m taking stuff away from my child,” it needs to be reframed as “I’m doing something to help my children develop, and build skills to control their own behavior.”

In doing so, I think we can work with parents in helping them recognize that actually setting limits and providing guidance to their children is a very positive thing. And, in fact, we know from a lot of research of children in other ways that children really do need limits, and a part of their development is to see what those limits are. They don’t learn how to take care of themselves, they don’t learn how to make decisions for themselves, unless the parents set those examples for them, and really help them learn that. We try and reframe it as a very positive parenting approach as opposed to, “Your children aren’t going to like you as much if you take away their sugary cereal.”

I know there’s a fine line between too much control and not enough, but I also know that Ellen Satter, with her model, really worries about deprivation and control, specifically in light of a backlash. If you control the kids and the environment at home, they’ll binge elsewhere; if you try to control them too much now, ten years down the line the pendulum will swing the other way. How do you deal with the backlash of control or deprivation or intervention?

There are some people who fear that if parents exert too much control, children will not learn the ability to control themselves, or may respond contrary to that and spend a lot more time trying to overcome those controls, and it actually could backfire in a way in which the children consume more when they’re not being observed by the parents. In fact, we do see that when the parents are trying to police the children. It’s more motivating and more fun for the children to try and overcome the policing and get around the rules than it actually is to follow them even though it would be easier just to follow them. That’s sort of a normal part of development as well: trying to figure out what you can get away with. So we do a lot of work with parents and, while we tell them it’s very important to set limits and have rules and they’re in charge - I mean, families are not a democracy, the parents are still in charge - is that instead of being the police all the time, to really be there to help the children.

We know it’s difficult to change your eating and activity behaviors, especially when kids are in an environment in which they’re getting so many messages to the contrary. We work with parents to address their kids, not as being the police, so not as going around trying to find out when the kids have broken the rules, but instead to say, “Hey we know this is difficult, we know you’re going to have trouble with this, how can we make it easier for you? What can we do as your partners, as opposed to being your police?”

One of the ways we do that is through the way we set goals with parents and kids in that we have the parents and kids negotiate a goal that they think works for both of them, and part of that goal is a reward from the parent to the child. Part of the contract that the children sign is a reward. So if the children achieve their goal, the parents give them a reward, and the child and the parent negotiate that in a way that is beneficial to both of them. We teach the parents a lot about what appropriate rewards are, and we teach the kids about how to negotiate for those rewards. So when kids are able to acknowledge and parents and kids together say, “Here’s a certain type of food that you have a lot of trouble with,” the goal for the child may be to eat less of that food, whether it’s dessert, or candy bars around the house.

Then the parents also have a goal, and we try and make the parent’s goal something that’s focused on helping the child achieve their goal. So the parents goal may be that they’re going to try not to buy these any more, and not bring them into the home. And if the parents achieve their goal, then the child does something nice for them. If the children achieve their goal, then the parents do something nice for them. And the types of rewards we try and encourage parents to do are not material rewards like money (because those tend to backfire as well, because then you’re doing it for the money, not for the joy of doing it) but something related to the goal in the first place. So, for example, if they’re in a program like ours in which they’re trying to lose weight, the reward may be some way they are spending time together that is also healthful. So it may be, “I’m going to go ice skating with you or, if we both achieve this award, then we are going to go out and go boating in the park, or we’re going to go and walk around Golden Gate Park, or go out to Angel Island, or do something like that.”

Is there a problem with introducing external rewards; does it take you away from leading you back to your intrinsic rewards?

There is quite a bit of research on extrinsic or intrinsic motivators or rewards. In general, external rewards, particularly money, big things like, “We’ll give you a bicycle if you eat your peas,” tend to backfire quite a bit because kids are doing it for the reward, and it makes the reward more appealing, and makes the behavior that they had to do to get the reward less appealing. So if you tell your child, “If you eat your vegetables, you’ll get dessert”, that makes them like dessert more and vegetables less. We try and turn that around so that the rewards are in some way related to the goal in the first place, or something that’s not monetary or material so it can’t be quantified and take the attention away. For example, if the child is in our weight loss program and trying to change something and increase their physical activity or eat less, the reward may be a new basketball, or a new pair of rollerblades, or something like that which will help them achieve their ultimate goal as well. And that way, the reward is something that they value as well for their ultimate goal and is fitting with their goal in the first place.

What does this program do for kids like Dominic and Kelly that other programs don’t do?

Our program is really based on a lot of research that was done back east by Leonard Epstein and his colleges that documented the effectiveness of the behavior approach to weight loss in children. And they have data that shows that now, ten years later, about a quarter of the children are no longer overweight. Epstein’s program is the one that has been most heavily documented with long-term follow-up data, showing that it has effectiveness even ten years later. And the changes that they’ve seen are better than - in fact, greater than - all the programs that have been done with adults. So that’s why we based our program upon that framework. In addition, we tried to adapt it so it would be more easily implemented outside of our research setting in a regular clinical setting because our goal was really to provide a program that would be open to lots of families who maybe couldn’t meet the criteria or couldn’t fully follow the program in a research setting.

In doing so, we expanded the program, and learned through our work with families that they really wanted it to be longer and longer. We started out with three months, and they said, “We need much more time than that.” We ended up with six months for our program, and I think that even at the end of six moths families would say, “We wish it went further,” but I think our experience is that it would be much tougher to get families to sign up for the program if it were longer than six months in the first place. So we made it much longer, and we also made the visits more frequent, and, for practical purposes, we had to reduce the amount or individual counseling and individual contact.

At its core, what are the one, two, maybe three tenets that make it different from other programs?

I think what makes our program different from other programs, is: one, it’s really based on research that’s out there on behavioral approaches to weight loss. The second thing is that it tends to be more frequent, more intense, and longer than most programs that are available. A lot of programs are pretty short, have intermittent meetings; our program is six months of weekly visits for both the parent and the child. And there’s a third aspect too. Some programs focus just of parents alone, some focus on children alone. This program focuses on bringing the children and the parents together which, again, is based upon the best research that’s out there.

On that first one, behavior change, I thought all weight loss programs were behavior change. What is it that you guys do that’s different?

By saying that our program is very behavioral, it means we use approaches that focus mostly on changing behavior, as opposed to the way people feel about their behavior, or even what the sort of ultimate psychological root causes are to their eating. The behavior approaches tend to focus on changing the behaviors specifically and not spending as much effort on the thinking that’s going beneath that or what led to it.

When I refer to behavior programs, what I really mean is focusing on skills to change. Our program is very behaviorally focused, and that means we focus on teaching specific skills to change behavior. So it’s not as much about feelings as it is about skills. In our program, we focus quite a bit on the classic behavioral skills, which are: monitoring your behavior, in this case monitoring what you eat - so keeping track of how much you eat and how much exercise you do and how much TV you’re watching, setting goals to change that - so based upon how much you’re doing, setting a goal to change how much you’re doing the behavior, identifying rewards to give yourself, or, in our case, for the parents to give to the kids or for the kids to give to the parents for achieving those goals, coming back and revising those goals based upon how well you succeeded or didn’t succeed, and then continuing that process over time. And problem-solving for what the barriers there are to achieving those goals - sort of classic behavior strategies which sound not very glamorous, but tend to have been shown over years and years to work very well at changing behaviors – are the types of things you should use to change any behavior.

One of the things that we find that kids find extremely helpful is the monitoring, the self monitoring, or keeping track, what we call our food diaries or our physical activity diaries. Kids and adults dislike filling them out. When you ask them later, “What was your least favorite part of changing your behavior or of doing this?” they say, “Filling out the diaries. Filling out what we ate and how much exercise we did.” But they you say, “What do you think was most effective, or what helped you the most?” It was “Filling out the diaries or keeping track of what we ate, how much exercise we did”. And, “What would you tell other kids to do if they wanted to change their behavior?” – “Keep track of what they ate and what they did”.

These behavioral tools, and these skills, are key to changing behavior and there’s nothing fancy about them, it’s just implementing them in a very pure way so that they’re not influenced as much by making excuses.

One thing we see a lot in families and in kids is that human beings are wonderful at rationalizing their behavior. We can come up with a reason for doing just about anything, or for why we did just about everything, even if it’s not in our best interests. Even if we know we didn’t want to do it, we come up with a reason to do it, which some people might call excuses, but it’s just normal behavior and normal rationalization. We try and take that out of it. We try and take all the ambiguity out of things. Our program focuses on being as explicit as possible, so that all the behaviors are things you can measure specifically and explicitly without ambiguity, because if you can’t measure it that way, there is all kinds of wiggle room for how you interpret your behavior.

I think there’s a fine line in the eyes of some between “pure” and “rigid”; if you have compliant kids who love structure, I can imagine it works. What about if you have kids who are rebellious, who aren’t compliant? How much does it backfire? Or how much does it simply fail? Because it’s a pretty detailed program; every food has a color label; every food has to be written down. It seems to be that unless you have the right personality that can handle that, it wouldn’t work.

Our program requires quite a bit of compliance to be successful, and if you follow it, you will succeed. We tell families that if they just follow it, they will succeed. That doesn’t make it easy. There are some kids who have much more trouble with following specific strategies or following the skills that we try and teach them. We do some screening up front. Some people may think this is a weakness, but we don’t want families in our program who aren’t ready to make changes. We don’t suggest that our program is the solution for everybody; it’s the solution for families ready to make a commitment to make a change. And then we give them the skills and we give them a very specific way of implementing those skills that they can follow.

This isn’t the only way that we address obesity in our work. We’re doing primary prevention programs in the schools and in communities. We do programs where we work with individual families around prevention. We think that we need to work on public policy and on changing tax systems like taxing soda and other things, and advocating for changes in the environment that will make it much easier for people to maintain their weight as opposed to the current environment, which makes it very difficult.

We see this as filling a niche for families who have overweight children and who are committed and ready to make changes. I don’t believe it does any family any good to put them through a program where they’re destined to fail. If you have a child who is not going to keep track of what they eat and is unwilling and is going to resist every step along the way, then I think you are doing them a disservice to put them into a program in which you’re just going to create more conflict in the family and the kids are going to rebel even more, and they’re going to have another failure experience. The last things overweight kids and overweight families need is more evidence that they can’t achieve changes.

So if you are dealing with those who are more than halfway there because they have already bought into it, what advice, if any, do you have for the parents of kids who say, “I don’t want to do anything about this. I’m fine, go leave me alone.”

We do get some families who come to us where the parents might be motivated and the children aren’t. We also get the other way around too. If you have a family where the child really doesn’t want to participate, we say, “You know this isn’t the right time, let’s wait until they’re ready, until they see this as an important change for them to make.” They may be rebelling or they may not be interested because they perceive it as something that the parents want them to do, as opposed to themselves. We know that something is much more highly motivating to you if you came up with the idea than if someone else, including your parents, came up with the idea. So we encourage them to back off a little bit, we encourage parents to make the household a healthy place, to make it easier.

There’re lots of things parents can do without their kid’s buy-in. You can stop bringing soda into the home, you can stop bringing junk food into the home. You can start serving fruits or other more healthful desserts as opposed to sweets. In fact, you don’t have to have dessert at all. You can have rules about not eating in front of the TV, or you can turn off the TV during dinner, if that’s the way you do things in your family. There are lots of things parents can do that they don’t need permission from their kids to do. If the child has to change their behavior, then you need that child to have buy-in, and you need them to want to change.

It may be that the child is being teased at school. It may be that they can’t find the clothes that they want. There are a lot of kids who come to us, and if you talk to them about finding clothes, I’ve had girls who have really broken into tears because they can’t find clothes that they like. It’s very difficult if you have a school uniform and the only options are things that don’t fit, and you have to come up and wear something different than every other kid because the vendor doesn’t have a size big enough for you. Those are the types of things that are triggers that we often see. Kids say, “This is really important to me.” Or it may just be that they’re ready and they want to feel better about themselves.

Can you paint a picture of the heartbreak that a family might be going through when they arrive on your doorstep?

Children and families come to us for a lot of different reasons. Sometimes, it may be for a health reason; someone in the family just had a heart attack or has diabetes and it’s scaring them. Sometimes, it might be that they were screened by their doctor and found they have high cholesterol or high insulin levels and it puts them at risk for diabetes and that’s scary to them. However, that tends to be more in a medical setting.

I think much it’s more common that when you start talking to families, those things may have triggered their visit, and convinced them that it was important to seek medical care and an intensive treatment program, but when you talk to kids about what it’s like to live their life overweight, many of these kids show up feeling socially isolated. Whether they really are or not, they have the perception that they are. Feeling like they can’t find clothes that fit them and feeling isolated or alienated because of that, feeling unhappy about themselves because they’ve tried to make changes, or they’ve tried to lose weight and it hasn’t been effective so they don’t have much confidence in themselves. So you can get kids who have all other kinds of issues that they’re dealing with, really brought about by their weight.

One of the things I really try to impress upon families at the beginning is that this isn’t a problem with self-control or your own personality. This isn’t an issue because you are no good or you’re ineffective. It’s that we live in an environment that is extremely difficult to behave healthily in. We’ve created this environment where tasty, high calorie, cheap food is everywhere, and where there’s no opportunity for physical activities and, as a result, we really need to learn skills for how to deal with this environment. Other kids may be lucky that they have those skills, or are lucky in that they are more resistant in whatever ways than you are. It’s not your fault, but there are ways that you can fight back against this. And that can be motivating for kids as well; really it’s other people, or this environment, doing it to you; it’s not you doing it to yourself.

What can you do for the parents with respect to the sort of baggage they bring in?

When parents bring their kids to our program, there is often some feeling of guilt or ineffectiveness in that they have been unable to raise a child who could maintain their weight, or that they’re doing something wrong for their children. Other parents feel that it’s totally on the child, and the child won’t listen to anything and the parents do everything they can, and it’s all the child’s fault. A lot of the parents are there because they care a lot about their kid and they don’t want their kids to suffer. They come to us feeling like they have failed in being able to do their job and they need skills as well, or they need help in doing so as well. Whether they feel like it’s mostly their children’s fault or like they’ve failed, they need answers so that they can feel better as parents.

Is there a sense of failure among your patients?

By the time families get to us, they’ve already probably failed several times at trying to control their weight. And I don’t think that’s unusual, I don’t think that’s because we are a referral program, I think that’s because the basic truth is that it’s really difficult to make these changes. Almost everybody out there has experienced failure in trying to change their ways. One of the difficult things is, most of the families that come to us have overweight parents and overweight kids. Not all of them, but most of them. I think parents may have memories of their own childhood and of being overweight children themselves and not wanting their kids to go through what they went through. They may be unsatisfied with themselves now as adults and not wanting their child to feel the same way. Our society puts so much emphasis on weight, and weight is so visual. It’s so obvious to everyone what your weight is that I think parents and children put a lot of emphasis on it. As a result, parents who all really care about their children don’t want their children to grow up where their life is going to be harder because they don’t fit in.

I know you’ve said diets don’t work. To what extent is your “red light,” “green light,” “yellow light” approach not a diet?

You often hear, “Diets don’t work.” That’s because when people go on a diet, they cut back. They may have short-term benefits but they don’t help them over time. I’m not sure I literally believe that diets don’t work, because we know that if you just reduce your calorie intake, they will work. The tough part is not what you’re doing; it’s how you do it. One thing we focus on is skills to maintain healthier eating as opposed to something you’re doing just to lose weight. We focus on those skills, like the self-monitoring, like the rewards and revision of goals, and making contracts as well, that are tools that help people maintain their eating habits over time and get used to and establish new habits. It’s really not that diets don’t work, it’s the way we implement diets that don’t work, in which you do deprive yourself and it’s all about cutting back as opposed to taking measures to really control your eating in a much more positive way.

How often do they get it right, the seventy percent?

One of the things we found when looking at a national sample of parents with children who were under the age of seven is that only about thirty percent of parents with overweight kids designated their kids as being overweight. We looked at national data in which children were measured for their height and weight so we knew what their actual height, weight, and BMI were, and then the parents were asked, “Do you think your child is underweight, normal weight, or overweight?” We found that out of those parents whose children really were overweight, only thirty percent of them said their child was overweight, and seventy percent thought their child was normal weight, and some of them even thought their child was underweight.

It’s really tough to tell, and most people’s perceptions of whether their child is overweight or normal weight are really inaccurate. You really do need to have a measurement done and be plotted to know whether the child really is overweight.

Is your program just a diet in disguise?

“Diet” really means just what you’re eating. Our program is more than just a diet because we really focus on skill-building and how to maintain healthier eating and physical activity. It’s not about just telling people what to eat and what not to eat, it’s about giving them the skills they need to maneuver a healthy lifestyle within an environment that really makes it difficult to eat good foods, healthful foods and be physically active.

I really do want to get that message across that it’s not about personal responsibility. Even though all our programs focus on taking personal responsibility, it’s important that that’s done in the context of trying to change the environment we live in.

Another thing we would like to incorporate in a lot of the programs we do is turning our families into advocates, in which they are trying to change the environment as well. It’s one thing to change your home environment and not bring home soft drinks and not bring home sweets, not bring home candy bars, and things like that so it makes things easier in your home to eat a healthful diet. It’s another thing to go beyond that and say, “How can we make it easier when we leave the home, how can we make it easier for our children when they’re in school, how can we make it easier for them when they’re out in public?”

One thing that I think is very motivating for families and potentially empowering is to get them involved in advocating for changes in the school lunch. Work with your PTA and your school counsel and your principal in trying to change what the content of your school lunch is. Pull together a group of parents to make it a more healthful school lunch than it is now. Write to your elected representatives and tell them you don’t think food companies should be advertising to children, or that you think maybe they should tax soft drinks or junk foods, or that you want your children to grow up in a healthful environment that makes it easier for them to grow up and be healthy adults.

I love chocolate. There are certain things that I really love and I have on a daily basis in moderation. And I’ve often though, “Maybe I really shouldn’t have my See’s Chocolate in the house.” What about junk food in moderation?

A lot of people talk about, “Everything in moderation is okay,” and it really depends on the context. If you’re trying to lose weight, if you have a child who’s trying to lose weight, then you want to make it as easy for them as possible. It may be that if you can keep junk food out of the house totally, it’s going to be easier for them. If you have a child who’s normal weight and doesn’t have a weight problem and you don’t have a weight problem and you’re doing just fine now, then it’s probably okay to occasionally have junk food in the house. It really depends on the context and your goals.

We know that it’s very difficult to accurately monitor what you’re eating, and what you’re taking in, how much physical activity you’re doing. As a result, the best way to monitor that is through weight gain. If you are gaining weight, it means you are taking in too much or not exercising enough. If you’re maintaining your weight, then you know you’re in balance. A lot of it depends on where you are, whether you’re moving up, whether you’re moving down, or staying the same. That gives you hints on whether what you’re doing now is working or not. The idea is that if it’s not working now, then something has to change, and you might as well target the things that are the easiest to change.