Question:

A 13-year-old girl is brought to the office by her mother for a well-child visit. The patient's mother states that her daughter does well at school and spends most of her free time doing homework or reading books. She has been reluctant to enter any extracurricular activities but recently expressed interest in trying an after-school soccer program; she is apprehensive because she has never played a competitive sport. The patient eats her meals at home and frequently consumes carbonated sweetened beverages. She has no chronic medical conditions and takes no medications. Family history includes obesity in multiple members of the family, and diabetes and coronary artery disease in her mother and father. The patient's weight is at the 99th percentile for her height; a year ago it was at the 93rd percentile. Blood pressure is 117/68 mm Hg and pulse is 82/min. The patient is alert and engaged during the physical examination. Encouragement is provided regarding the patient's interest in physical activity, and a discussion about healthy habits is initiated. Which of the following is the most appropriate approach to open a discussion with the patient regarding her weight?

"Many people in your family have conditions such as diabetes, which are affected by weight. Let's talk about how you can lower your risk with small lifestyle changes."

"Obesity is a serious health condition, but it can be treated with simple steps that we can work on together."

"Obesity is strongly influenced by diet and exercise. Let's talk about how you can improve these habits to lose weight."

"Some people gain weight more easily than others. I'd like to help you grow into a healthy weight that helps you feel stronger and faster."

"Your current weight is above recommended levels. Let's talk about what an ideal weight looks like for you and how to achieve that."

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Explanation:

Motivational interviewing: components
Engaging	Start a nonjudgmental, open-ended conversation Collaborate to set the agenda Elicit patient strengths
Focusing	Ask the patient to identify 1 or 2 behavior targets
Evoking	Elicit change talk to get the patient's: Commitment Reasons to change
Planning	Guide the patient toward: Identifying specific next steps Anticipating obstacles Deciding how to measure success

This patient's weight for her height (ie, body mass index [BMI]) has increased and is now ≥95th percentile, which is consistent with pediatric obesity. This increasingly common condition is associated with serious, long-term comorbidities (eg, diabetes, cardiovascular disease) but must be approached with sensitivity and support, particularly in children.

Rather than focusing on an "ideal weight"—which may be unrealistic and, in children, often changing due to continued growth—counseling should focus on sustainable behavioral modifications with an approach that is nonjudgmental and collaborative (Choice E).

Nonjudgmental: Because patients (particularly adolescents) may be self-conscious of their weight, it is best to avoid potentially offensive terms such as "obesity" and instead focus on achieving a healthy weight through a well-balanced lifestyle (Choices B and C). In addition, it is important to avoid placing blame on the child or family and to instead acknowledge that some people gain weight more easily than others.
Collaborative: Open-ended language should be used to understand the areas that are challenging and unique to the patient, such as consumption of sugary beverages in this case. Efforts should be made to set specific and realistic goals to improve health (eg, limiting sweetened beverages). In addition, the child should be involved in decision-making when possible; in this case, the patient's apprehension about competitive sports can be a motivating factor to make effective change and improve her functional abilities (ie, strength, speed).

This approach allows for discussion about long-term healthy habits instead of short-term weight loss. Regular follow-up is necessary to ensure accountability and reevaluate the patient's goals, achievements, and weight.

(Choice A) Discussion of potential long-term comorbidities associated with obesity is reasonable, but emphasizing diabetes prevention as a primary goal in children is often perceived as a scare tactic and is unlikely to generate sustainable behavioral change.

Educational objective:
Counseling on pediatric obesity (body mass index ≥95th percentile) should focus on achieving a healthy weight and improving functional status (eg, stronger, faster) without placing blame or using offensive terms (eg, obesity). In addition, making specific and realistic goals is more likely to result in behavior change than trying to attain an "ideal weight."