Understanding Weight Dysregulation © 2018 SPOON 1

UNDERSTANDING WEIGHT 19 DYSREGULATION Module Overview

Total Time: 35 minutes

Learning Objectives • Explain what weight dysregulation is. • Understand the causes of weight dysregulation in foster children. • Demonstrate understanding that healthy children come in many sizes. • Discuss guidelines for caregivers to promote health at every size. • Demonstrate understanding of how to interpret growth charts of children.

Topics 19.1 About Weight Dysregulation 19.2 Health at Every Size 19.3 Understanding Growth Charts

Materials SUPPLIES ACTIVITY SHEETS HANDOUTS o PowerPoint slides o Flip chart o Markers o 25 Sticky notes o Speakers o Growth Charts (5 o Questions to Ask a o “Health at Every Size: copies) Professional Poodle Science” video (2:49 min) embedded into PowerPoint or link: https://bit.ly/2ET6X2Y

Prerequisite • Module 1 (Nourished and Thriving Children Overview), Topic 1.2 • Module 3 (Overview of Nutrition for Children in Foster Care), Topics 3.1 and 3.3

ABOUT WEIGHT DYSREGULATION 19.1

Supplies: • PowerPoint slides • Flip chart • Markers • 25 Sticky notes 10 Activity Sheets: • None minutes

Handouts None •

Learning • Explain what weight dysregulation is. Objectives • Understand the causes of weight dysregulation in foster children. Introduction • Introduce the topic by explaining the Definition of Weight Dysregulation from the Trainer's Notes. • Tell participants that children have a natural way of growing that is right for them. They are born with the ability to regulate the amount they need to eat to support this growth. Children often do not start gaining weight, losing weight, eating too much, or eating too little, for no reason. Something is causing it and we must identify what it is in order to address it. It is crucial to understand that often the core reason for weight dysregulation is not eating fast food and too many sweets. There is more to it than just the foods that children eat.

Causes of Weight Dysregulation Group Activity • On a flip chart, draw a 4x5 table (4 columns and 5 rows). Above the table write Learning ‘Causes of Weight Dysregulation'. Label the columns with the following Activities categories: ‘Psychosocial’, ‘Environmental’, ‘Medical’, and ‘Dietary’. • Divide participants into four groups and assign a category to each group. • Distribute markers and five sticky notes to each group. • Ask participants to think of five factors within their assigned category that can lead to weight dysregulation in children (i.e., factors that could result in children gaining or losing weight at a rapid pace). • Ask participants to write one factors per sticky note and to come up to the flip chart and place their sticky notes in the squares under their assigned category. • Once all of the squares have been filled, or after 5 minutes, review the responses with participants.

Summary • Provide additional information on Factors that Could Lead to Weight Dysregulation using the Trainer’s Notes.

Definition of Weight Dysregulation • Weight dysregulation is a term used to refer to when a child's weight is moving at a pace that is slower or more rapid than what is typical. • The more commonly used terms are ‘overweight’, ‘obese’, and ‘underweight’. However, these terms can be confusing and stigmatizing for parents and children. Many children labeled as ‘underweight’, ‘overweight’, and ‘obese’, on growth charts are in fact healthy. • We use the term ’dysregulation’ because weight gain in foster children (also in children outside the system), whether slow or fast, is a complex issue that can be influenced by a range of dietary, environmental, genetic, medical, and psychosocial factors and their interactions. This makes it hard for some children to ‘regulate’ their weight.

Factors that Could Lead to Weight Dysregulation Weight is not as simple as calories in, calories out. Two children eating the exact amount of foods may gain weight very differently. Genetics largely determine the shape and size children grow into. And while dietary factors are important to keep in mind, it is often the psychosocial, environmental, and medical factors that play the biggest role in weight dysregulation.

Psychosocial factors • Stress and trauma caused by Childhood Adverse Experiences (ACEs), which children in foster care will unavoidably experience, often result in an unhealthy relationship with food, a disrupted sense of hunger and feeling full, an challenging behaviors around mealtimes that could lead to overeating or undereating. Some Trainer’s factors that cause trauma and stress in foster children include the following: Notes o Food insecurity (being stressed about not getting enough to eat may lead to food hoarding and overeating) o Low household income o Abuse o Neglect o Parental drug use o Family dysfunction

Environmental factors • Lack of mealtime structure. • Food restrictions, regardless of the reason, can cause fear of going hungry and result in overeating when food is available. Any food restriction, even when mild and well-intentioned, can have the opposite effect. When we say to a child, "eat your vegetables before dessert," "how about carrots instead of cookies," "you only get two bites of this cake," "eat this because it's good for you..." we mean well and it may seem positive, but we are putting pressure on a child. And any time we put pressure on a child, it usually backfires. • Being rewarded, soothed, or reprimanded with food may cause emotional eating or overeating. • Unresponsive feeding (feeding that is not based on children’s hunger and fullness cues) disrupts the child's ability to internally regulate food intake and grow appropriately. • Misinterpreting a child’s growth when looking at growth charts may lead to under- estimating or overestimating how much a child needs to eat to support their growth.

• Lack of physical activity.

Medical factors • Medications like steroids, seizure medications, antidepressants, psychiatric drugs, and birth control for teenage girls may cause increased or decreased appetite or have weight gain or weight loss as a side effect. • Feeding difficulties due to developmental delays or disabilities (e.g., cerebral palsy, Down syndrome) may lead to limited food intake. • Heightened oral sensitivities can lead to limited food intake. • Dysregulated eating and eating disorders. • Problems with digestion or absorption of food. • Celiac disease and Crohn’s disease affect the gut and can cause children to have poor weight gain. • Severe acid reflux especially in children with neurological issues and low muscle tone. • Hypothyroidism (under-active thyroid gland) or hyperthyroidism (over-active thyroid gland) are endocrine conditions that affect the body’s metabolism, causing rapid or slow weight gain. • Genetic or metabolic disorders may affect weight gain (e.g., Prader-Willi Syndrome).

Dietary factors • A diet that is not adequate and well-balanced with essential nutrients including vitamins, minerals, carbohydrates, fats, and proteins may lead to delayed growth or rapid weight gain. o High intake of sugary and fatty foods may lead to rapid weight gain. This can be a result of food hoarding, emotional eating, and lack of access to other types of foods, among other reasons. o Low intake of protein and calories may lead to slow weight gain. This can be a result of dysregulated eating, picky eating, and poor appetite, among other reasons. • Portion sizes that are too large or too small for what children need. • Participants will be able to define weight dysregulation. Evidence of • Participants will be able to list three factors that may lead to weight dysregulation Learning in foster children.

HEALTH AT EVERY SIZE 19.2

Supplies: • PowerPoint slides • Speakers • “Health at Every Size: Poodle Science” video (2:49 minutes) embedded into PowerPoint or video link: 10 https://bit.ly/2ET6X2Y minutes

Activity Sheets: • None

Handouts • None

Learning • Demonstrate understanding that healthy children come in many sizes. Objectives • Discuss guidelines for caregivers to promote health at every size. Introduction • Tell participants that in order to address weight dysregulation, it is important to understand what is typical when it comes to children’s weight and size. Tell participants that people often think they can tell who is healthy or not by looking at the child’s weight. The video gives another perspective on the link between weight, health, and wellbeing.

Health at Every Size Video Learning • Show the video Health at Every Size: Poodle Science. Activities • Facilitate a group discussion by asking the following questions: o How does this video apply to children? o What key messages did you take away from the video? o What can caregivers do to promote wellness and health at every size among their young children and teens?

Summary • Summarize the activity by referring to Healthy Children Come in Many Sizes and How to Promote Health at Every Size in the Trainer’s Notes.

Healthy Children Come in Many Sizes • It is important to remember that healthy children come in many sizes. Children who are fed regularly with a balanced diet, who sleep well, who are active, and who are attached to loving adults are likely to grow in a healthy way, whether big or small, tall or short. Children will eat, move, and grow in the way that is right for them, if we trust them and let them. • Foster children come with varying experiences around food and feeding, which may have influenced their current weight. Their environment can override their internal regulators for hunger and satiety. It may take them a while to trust that an adult will let them eat as much or as little as they want and to discover their own feelings of hunger and satiety. With time and appropriate support from their caregiver, these children will start showing signs that they are able to regulate their food intake, which in turn may or may not affect their weight and size but will enhance their wellbeing. In the meantime, caregivers should not worry about their weight and should accept them for whatever size they are.

How to Promote Health at Every Size Children learn through observations. If caregivers place too much value on appearance and weight, it is likely that the child (especially teens) will too. That is why it is important for caregivers themselves to evaluate their relationship with food and their shape and size and the importance they place on weight in their homes. Trainer’s The American Academy of Pediatrics recommends that caregivers follow these Notes guidelines and, as important, model these recommendations themselves: • Avoid encouraging dieting behaviors. These may include o counting calories, o skipping meals, o celebrating restraints in eating, o labeling foods as “good” or “bad”, and/or o using exercise as a way to compensate for eating too much. • Avoid “weight talk”. This includes commenting on the child’s weight and your own weight. Whether they are direct or subtle, well-intended comments can be hurtful and harmful for children. • Avoid teasing children about their weight. Teasing and weight-shaming happens at home more than at school. An attempt at humor by caregivers and family members may lead to unhealthy weight-control behaviors and emotional eating among children. • Increase the frequency of family meals. Research has shown that eating meals as a family plays an important role in promoting wellbeing. Caregivers can take this opportunity to interact with children and model healthy eating behaviors. • Provide opportunities for eating a balanced diet and for exercise. Caregivers can make sure children have access to a diverse selection of nutritious foods to choose from and many chances to be active. These should be implemented to promote wellness and not weight loss or weight gain. • Participants will be able to demonstrate an understanding that healthy children Evidence of come in many sizes. Learning • Participants will be able to describe three guidelines for promoting health at every size.

UNDERSTANDING GROWTH CHARTS 19.3

Supplies: • PowerPoint slides

Activity Sheets: • Growth Charts 15 minutes Handouts • Questions to Ask a Professional

Learning Demonstrate understanding of how to interpret growth charts of children. Objectives Introduction • Tell participants that children generally gain weight in proportion to their height and age. So, during a doctor’s visit, a nurse usually measures the child's weight and height and uses a growth chart to see if the child's growth is within the expected range. It is important for caregivers to know how to read growth charts and feel empowered to ask healthcare providers questions. • Explain the various components of a growth charts by referring to About Growth Charts in the Trainer’s Notes.

Growth Chart Activity • Divide participants into five groups. Learning • Distribute the Growth Charts, one per group. Activities • Give participants 3 minutes to discuss these questions: o Are you concerned about the child's growth? Why or why not? o What are two questions you would ask the healthcare provider about the child’s growth? • Offer each group the opportunity to share their answers. • Offer additional information from the Growth Charts Answer Key in the Trainer’s Notes.

Summary • Share information on When to Get Professional Help in the Trainer’s Notes. • Distribute the Questions to Ask a Professional handout to participants as a reference.

About Growth Charts • Growth charts were created by the World Health Organization (WHO) and the Center for Disease Control and Prevention (CDC) to evaluate a child’s growth. They are based on measurements from thousands of children who grew up in healthy environments. • In the U.S., it is recommended to use WHO growth charts for children below the age of 24 months and CDC growth charts for children 24 months and older. • Boys and girls have different growth charts, which include measurements like weight and height, age, and lines that tell us how well the child is growing. o The vertical line usually indicates measurements like length/height, weight, body mass index (BMI), and head circumference. o The horizontal line usually indicates age and sometimes length/height. o The middle line (or 50th percentile) is the average of how children should grow if they are well-nourished and cared for. So, if we were to average all the children’s weight and draw a line over time, it would look like the middle line. o Above the middle line means the child is taller or heavier than average. o Below the middle line means the child is shorter or thinner than average. o Most children will not grow at the 50th percentiles for weight and height; only 1 out of every 100 children will be at the 50th percentile. Most children will fall above or below the 50th percentile. • Every time a child is weighed and measured, a point is plotted on the growth chart. A series of measurements gives a series of growth points demonstrating the child’s pattern of growth. Multiple measurements over time provide more valuable information than a single measurement. Trainer’s • The WHO and CDC found that it is most concerning when children are below the Notes 2nd percentile or above the 98th percentile. However, this does not always mean these children are not growing well. What is more important than a child’s position on a growth chart (e.g., 25th percentile, 90th percentile) is their pattern of growth. Remember, health can exist at various shapes and sizes! • When children do not grow at the expected rate (e.g., slow or rapid weight gain), there is cause for concern. In this case, it is important to identify if there are any worrisome factors contributing to the weight dysregulation and discuss them with the healthcare provider.

Growth Chart Activity: Answer Key Note: The activity mostly focuses on weight-for-age or weight-for-length growth charts for children 0-2 years of age. BMI-for-age growth charts for young children and teens should be similarly interpreted. This means focusing on the growth pattern and not the position of the children on the growth chart.

• Manuel: Manuel’s growth followed one pattern for the first four months of life (between 10th and 25th percentile) and then shifted to a new pattern (between 5th and 10th percentile). The shift in pattern can be completely normal, especially that Manuel’s rate of weight gain over time has been typical for his age. But caregivers should discuss any changes in their child's rate of growth with their healthcare provider. Questions that the caregiver can ask the healthcare provider: o What is causing the shift in Manuel’s growth pattern? o Are there any conditions that Manuel might have? o Does Manuel need further testing and evaluation? o What is the outlook for Manuel’s growth?

o Do I need to make any changes to Manuel’s diet, feeding, or mealtime routine? o When should I be back for a follow-up? • Tom: Tom’s growth indicates that he is undernourished and is falling off the growth curve (other terms that can be used include "falling behind in growth" and "falling behind in weight gain"). He is below the 2nd percentile in weight and, more importantly, the rate of his weight gain (and gain in length) is much slower than what is expected for his age (weight dysregulation). His weight growth curve looks almost flat. Questions that the caregiver can ask the healthcare provider: o What is causing Tom’s slow growth? o Are there any conditions that Tom might have? o What further testing and evaluation does Tom need? o What is the outlook for Tom’s growth? o What is the potential impact of Tom’s slow growth on his long-term health? o How should I talk to family members about Tom’s growth? o What changes do I need to make to Tom’s diet, feeding, or mealtime routine? o Are there any supplements that can help Tom grow better? o When should I be back for a follow-up? o Can you point me to resources in my area for more information and support? • Lucy: Lucy is consistently plotting above average for her age in both weight and height. Lucy is following a consistent pattern and is growing at a healthy rate. Questions that the caregiver can ask the healthcare provider: o Should I be concerned that Lucy is getting close to the 90th percentile? o Are there things I need to look out for to make sure Lucy continues to grow at a healthy rate? o When should I be back for a follow-up? • Maya: Maya's growth measurements fall between the 2nd and the 98th percentiles on the weight-for-length growth chart which is within the healthy range. Her growth is catching up; she started around the 2nd percentile but by 9 months of age she was between the 5th and 10th percentile. Although she places lower on the growth chart, she is gaining weight at a healthy rate for her age. Questions that the caregiver can ask the healthcare provider: o Why is Maya on the lower side of the growth chart? o Are there any conditions that Maya might have? o Does Maya need further testing and evaluation? o Will Maya catch-up closer to the 50th percentile? o What changes do I need to make to Maya’s diet, feeding, or mealtime routine? o When should I be back for a follow-up? • Brady: Brady's weight is below the 50th percentile for the first 3 months. At age 6 months, his weight begins moving upward across lines. At 12 months, his growth crosses to above the 98th percentile, indicating that his weight is high for his age. Brady is gaining weight at a rapid rate. Questions that the caregiver can ask the healthcare provider: o What is causing Brady’s fast weight gain? o Are there any conditions that Brady might have? o What further testing and evaluation does Brady need? o What is the outlook for Brady’s growth?

o What is the potential impact of Brady’s fast growth on his long-term health? o How should I talk to family members about Brady’s growth? o What changes do I need to make to Brady’s diet, feeding, or mealtime routine? o Are there any supplements that can help Brady grow better? o When should I be back for a follow-up? o Can you point me to resources in my area for more information and support?

When to Get Professional Help • Change in the child’s pattern of weight gain should be discussed with the healthcare provider so that they can rule out health and feeding problems. It is important to cultivate a relationship with a doctor who understands feeding and trauma and does not rush to use conventional methods that may or may not work for children in foster care. Professional help should be sought if o the child's growth veers upward or downward abruptly, o the caregiver worries a lot about the child's eating or growth, o the caregiver suspects nutrient deficiencies, or o the caregiver and the child have continuous struggles about eating.

Evidence of Participants will demonstrate understanding of how to interpret growth charts of Learning children.