PsychEd4Peds: child mental health podcast for pediatric clinicians

25. Weighty Conversations with teens: How to emphasize health instead of weight with Dr. Peggy Greco

• Elise Fallucco, Peggy Greco • Season 1 • Episode 25

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Dr. Peggy Greco shares practical tips for navigating challenging conversation with teens who have eating disorders and/or obesity including:

*  How to shift the conversation from WEIGHT to focus instead on HEALTH 
* How to focus on non-weight metrics of health such as:
·       mood

·       energy levels

·       activity levels

·       healthy eating habits

·       clarity of thinking
* How to understand why teens with eating disorders may be resistant to treatment

Dr. Peggy Greco, PhD is a pediatric psychologist with over 30 years of clinical experience. She serves as the Assistant Vice President, and Chief Patient Experience Officer for a large children’s healthcare system. One of her clinical areas of interest is in working with kids and families with eating disorders.

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Dr. Elise Fallucco:

Welcome back to psyched for Peds, the child mental health podcast for pediatric clinicians. I'm your host, Dr. Elise Fallucco- child psychiatrist and mom. So whenever I need help or advice to have a challenging conversation, I reach out to my friend and colleague, Dr. Peggy Greco. You may remember her from our previous episodes on anxiety, but Dr. Greco is a talented and highly respected pediatric psychologist with over 30 years of clinical experience. One of her many areas of clinical expertise is in caring for children and families with eating disorders. So to continue our series on eating disorders today, we're going to be talking with Dr. Greco about how to have challenging conversations with teens who are resistant to treatment for their eating disorder. And how to have conversations with children and teens who are struggling with obesity. And to discuss health in a way that limits their risk of developing an eating disorder or worsening underlying disordered eating. So without further ado, let's begin our conversation with Dr. Peggy Greco. Dr. Peggy Greco. To help anchor our discussion. I want to start with a little case presentation. We have a teenage girl with a restrictive eating disorder. She's very underweight. She's fallen off of her growth curve and medically, we know it looks like she has an eating disorder. But of course on her part, she's denying things or minimizing and saying, she's just fine. She doesn't need help. It's not a problem. How do you address this treatment resistance? And what is the most important thing that a pediatric clinician can do in working with kids and teens with eating disorders?

Dr. Peggy Greco:

Well, thank you, Dr. Fallucco for, I think what is probably the most typical case presentation. I don't think I've met yet a teen who admitted to having an eating issue and wanting help with it. So you asked a really important question because there are so many aspects of treatment involved in working with a teen or a child with an eating disorder. And I think for pediatricians, the most important aspect is monitoring and maintaining health. So it, you really don't have to convince the patient that they have an eating issue or accept that they have an eating disorder. You only have to focus on health and have them understand that you have to take certain actions because of their health.

Dr. Elise Fallucco:

I just want to highlight what you said, because I think it's so important. The pediatric clinician does not have to convince the team that they have an eating issue or eating disorder. The goal is just to shift the conversation from weight and eating to one about health. And at the same time, recognizing that teens are not going to acknowledge that there's a problem.

Dr. Peggy Greco:

As you had pointed out, They're not going to be happy. And they're going to be resistant and they're going to be defensive, but they're resistant for a couple of different reasons. One is that for most teens who have started to restrict and lose weight, you get sort of a high from that. They feel good. They feel accomplished. They feel in control. They're losing weight.

Dr. Elise Fallucco:

And people compliment them. All of a sudden you're getting noticed and people will say, oh, you look so good or, oh, did you lose a weight? As in, this is a positive thing. And so it's reinforcing this idea that you're on the right

Dr. Peggy Greco:

track. Exactly. Yes. And the reinforcement comes from their own friends from relatives from initially even their, probably their own family. So you have this really reinforcing cycle of restricting and having positive impacts from it. So that's one reason for resistance. The other to think about is that. It is more important. For most teams to fit in, to feel good about their body, to feel like they're accepted. And sometimes in the moment that's more important than their health. Because they don't have developed capability to value health in the future. Teens are not able to care about long-term health, which seems so far in the future.

Dr. Elise Fallucco:

They're very much in the moment. I'm doing what feels like the best thing for me right now.

Dr. Peggy Greco:

Exactly. And another reason, and probably the most significant reason why they're resistant is because their brain is starved. And there's a lot of different terms for that. So some people might call it brain. Fog or not being able to think clearly. But you get an increase in obsessions. You get an increase in irrational thoughts. You are not always conversing with a logical person when you have a teen who is starved. So to keep in mind that again, they're going to be resistant and defensive for a number of those reasons. So you really don't have to convince them that they have an eating issue. Only that there's a health issue that needs to be addressed.

Dr. Elise Fallucco:

That's got to take a whole lot of relief off of the shoulders of pediatric clinicians, especially thinking about people in primary care. It's very easy to get in a power struggle with a teen about what is this and what's causing this. I love your simple practical advice to really just focus on this as a health issue and let the psychologist, psychiatrist, the rest of the members of the eating disorder team and the eating disorder specialists really focus on the label of eating disorder and what does that mean? And your job is focusing on we want to get you to optimal health, and right now we're not there and here's what we need to do. Practically speaking, if you're focusing on improving their health and let's say they've restricted, they're the ninth grade student who is significantly underweight and fell off the growth curve and you need to support them in their goal to get back on the growth curve and to increase calories. any practical tips for how to do that or what. What is the pediatrician's role there?

Dr. Peggy Greco:

Another great question. It's Understandable knee-jerk reaction of we've got to get them to eat. And if you are underweight, we have to increase their calories. Again, we can relieve that burden. You do not have to get them to eat. You do not have to monitor calories. You don't have to take over any aspect of their eating, as long as they are in treatment with a psychologist, psychiatrist, and or nutritionist. And so that gives you the luxury of not focusing on eating, but what you can focus on, that's going to have the impact on health is exercise activity level. So when you think about the simple formula of what impacts weight, you have another professional working on intake eating aspect, and there are so many emotional aspects of that. That's a really appropriate therapeutic setting for that. But you, as a pediatrician can set guidelines in terms of what are safe limitations on activity and or exercise.

Dr. Elise Fallucco:

So that you're not taxing your body, which is under nourished and putting too much a strain on your heart.

Dr. Peggy Greco:

Exactly. I mentioned value system before and how peer input, for example is important. Another thing that's really important for many teens who restrict is having control over activity. Many of them overexercise. So when you think about this is something they want to do, then we're getting to motivation. They really want to exercise. They want to be active. And so if you are putting clear guidelines in place, as far as. I want you to exercise too. Let's talk about what needs to happen for you to have the ability to exercise.

Dr. Elise Fallucco:

They're highly motivated to exercise, so they're going to work towards that goal. They may not be highly motivated to eat more. And in fact, exactly. Opposite. Often. Yes. Yes. So then you use that as a token or sort of leverage to say, all right, let's work together towards our common goal of exercising and activity by doing the following things. Exactly.

Dr. Peggy Greco:

You joined with a teen in terms of, exercising is healthy. It's good for you. I want this for you too. I know how much you enjoy it as great for your mood. Let's talk about what you need to do to make that happen. So it may be weight limits you set or it may be frequency. It may be comprehensive such as the extreme being a teen who's on bed rest. Or it may be simple in terms of a certain number of minutes per day. But it's really essential to exercise that power and to model for the parents too. That's their role at home that you'll set those guidelines. They're going to be the ones implementing it. And that's the side of the equation where you're going to have much more chance of being

Dr. Elise Fallucco:

effective. And just to reiterate the point. Let's shift the focus and emphasis away from the eating and the calories and have the pediatric clinician focus more on limiting activity. Why do you think it's harder to focus on the eating itself? And why is it great when you do have access to a team of professionals to help with the eating part?

Dr. Peggy Greco:

In your question, you made a really important point and that is that eating is different than many other behaviors. Eating's a very intimate action typically done in conjunction with those we love or those we enjoy spending time with.

Dr. Elise Fallucco:

Or your family members.

Dr. Peggy Greco:

All sorts of variations. When you think about the dynamics. So you not only have the most typical eating situations that kids and teens are in there's power dynamics going on at the table. There's. Verbal interactions. There's. Monitoring there's emotional types of influences. It's a very intense situation that isn't just about the act of putting a fork or spoon up to your mouth and swallowing.

Dr. Elise Fallucco:

I've talked with a lot of Parents and they're like, I don't understand why can't they just eat? Eating is so complicated and it's occurring in the context of family relationships and power struggles with parents, with other family members. There are so many dynamics that make it so much more than just like you said, taking your fork and putting a piece of food in your mouth.

Dr. Peggy Greco:

Exactly. For anyone who isn't engaged in restricted eating. Eating is about fulfilling your caloric needs, but it also, there's some emotional aspects in there as well, in terms of a lot of us eat when we're stressed. A lot of us eat when we're unhappy. But for the teen who is engaged in restricted eating. There are so many other layers of meaning on that bite of food and so many obsessions and fears about what that could do to them and what might happen if they were to eat that bite of food.

Dr. Elise Fallucco:

Which explains why it's so hard to restore weight and to do nutritional restoration for anybody who's struggling with an eating disorder. Excellent point. So we've talked a little bit about the pediatrician's role in working with kids who are restricting, who are underweight and how we should not focus so much on the actual eating and total calories per day especially if we have a nutritionist on board and other specialists, but shift the emphasis towards almost like a behavioral plan, motivating them to be able to earn back or healthily, be able to return to exercise and activity. So what about the other end of the spectrum? One of my colleagues said, that they have a lot of kids in their practice with obesity who are really working hard to do what they need to do to make their bodies healthier and some of that may involve losing weight. Knowing that there are a lot of kids struggling with obesity and that we're trying to encourage to become healthier, how do we approach this in a positive way so that we don't tip the scales. Not to use a bad pun over in the opposite direction. How do we talk about being healthy and making healthy choices to manage obesity in a way that doesn't inadvertently set them up for disordered eating?

Dr. Peggy Greco:

On the face of it. Obesity wouldn't seem to have a lot in common with restrictive eating. But there actually are a lot of similar principles in mind. And I think the. The single most important that I'd love to stress is that a focusing on health. So the same principle applies when you have a patient with restrictive eating as someone who is overweight or heading towards obesity. Again, the focus is on health. Health does not equal weight. It is a common misconception that weight is the most important thing to focus on. It's usually the easiest thing to focus on. We all have scales in our offices. It's objective. You can track change. But to really be productive in helping these kids in doing so in a way that doesn't leave them vulnerable to developing eating disorder means being creative about developing other objective metrics of health. Not weight. And I can give you a few examples. One might be tracking steps. So how many steps a week is the child taking? It might be how many activities they engage in per week

Dr. Elise Fallucco:

or how many times they go and do a certain yoga class or walk around the block or something like that. Exactly.

Dr. Peggy Greco:

It might be eating more salads, fruits and vegetables. I try to steer clear of specific recommendations around food, but instead just increased awareness of food habits that are healthy. So it might be, for example, eating out less often per week, healthy eating habits sitting down when you eat. Being with others, eating more slowly. These are all goals that work to benefit health.

Dr. Elise Fallucco:

To recap, weight is an objective number, but it's only one of the measurements that we put into the equation to determine how healthy somebody is. And so when we're talking with the kid, who's obese, obviously we're checking weights and we're monitoring that as one of many other things. And so shifting the conversation with the teen and with the parent, To their activity levels. Thinking about how many steps they're taking in a day, how many activities they've done per week. Shifting to talk about healthy eating habits. Like you said, sitting down when you're eating, eating slowly.

Dr. Peggy Greco:

I would say though, to de emphasize weight. And I know you pointed out in terms of, it can be one of the metrics in conjunction with some of the others that I'm suggesting. But it's worth even considering for particular child, would it be better for them not to know what their weight is? Not have that be the center of conversation. You will know you'll be tracking it, but in that way, it makes it easier for the interaction to be more health focused, rather than weight focused.

Dr. Elise Fallucco:

I know we do blinded weights often for kids who are restricting so that when you put them up on the scale, they can't see what the numbers say, would you recommend that for kids with obesity?

Dr. Peggy Greco:

Absolutely. And for a couple of reasons, why one is, it helps to deemphasize that over-focus on weight. The second is one of the common things with all eating issues is that lack of connection between your body's needs and your behaviors. So you're trying to reconnect someone with how their body feels, what their body needs. And in the case of kids who are overweight you really want them to be focused on things such as their energy level. Are they feeling that they have more energy they're sleeping better? Their mood is better. They're thinking more clearly. And if they're blinded to the weight, it's much easier to focus the conversation on those aspects of the effects of the behaviors that they're changing.

Dr. Elise Fallucco:

I love that. And practically that, that has so much more meaning than a number on a scale. If We thought about our review of systems For eating disorders, checking the four things, sleep, mood, energy and the clarity of your thoughts? They reflect more about the quality of our life and the quality of our health.

Dr. Peggy Greco:

Exactly. And you may have to shift the conversation because it's human nature. That if let's say there is an awareness of wait. And the child's excited. I lost four pounds. Since I last saw you. To say that's great. But what I'm really excited about is the energy you have, how much you're exercising, that you really continue to model for the child and the parent. That shifted focus to health. And I know we're talking about overweight, but just a quick point in terms of that shift away from weight is at parallel with those that are restricting. I know we talked about someone who's overweight might be happy they've lost weight. Someone who's underweight is going to be not so happy that they've gained weight. But that's where you shift the conversation to more thinking. Clearly they may be getting better grades. They may be feeling better. Their skin may look clear. They may be sleeping better. And again, shift back to some of the things that are meaningful for them that are happening in the direction. They'd like.

Dr. Elise Fallucco:

So before we close, I just want to recap some of the key points that we covered. When we're working with kids with restricted eating disorders. Remember that you don't have to convince them that they have eating issues. Instead focus on health and monitoring activity levels in terms of exercise. When working with children with obesity who may or may not have disordered eating habits. Shift the conversation from weight to one of health. So instead of talking about weight, talk about how they're doing in terms of sleep, energy mood, and the clarity of their thoughts. These really important, meaningful aspects of their life. Well, thank you again for helping us with these really difficult conversations. And for our friends and colleagues who are listening, we hope you'll join us next week. As we continue this conversation with Dr. Peggy Greco and address. The challenges of talking to parents and supporting parents of children with eating disorders. For those of you who are listening, we continue to appreciate your comments and questions. Thanks for reaching out on Instagram. Or through our website, psyched the number four paeds.com. If you have any other ideas for potential topics or questions for future episodes, please give us a buzz. Thanks again for joining us. See you next time