Q&A: Dr. Madeline Joseph

Assessing readiness: “Entry to the program is with a psychologist who screens for depression, bullying and eating disorders. She also evaluates the child’s level of readiness for change. Sometimes, the parents are excited and eager, but the child is not. In that situation, we say we’d rather you come back when you’re ready. We don’t force them to do anything. Most of the time we win them over.”

Goal setting:“We do something called motivational interviewing. The idea is to find out what is important to them. Some don’t want to be bullied anymore or called names. Some want to be faster in sports and don’t want to get short of breath. Some don’t want to wear adult-type clothes — they want to be more fashionable. We use whatever their motivation is instead of taking the approach of, ‘I’m the doctor. You’re the patient. And you have to do X, Y and Z so that you don’t get high blood pressure.’ That might not mean anything to them.”

Starting point:“I ask them, ‘What is the one habit you think is making you gain weight?’ It’s amazing. Even a 7-year-old can answer that question. They usually say, ‘I eat too much at night’ or ‘I eat too many snacks’ or ‘I eat too fast and then go for second servings.’ The answer is actually within the child.”

Regimen:“It depends on how complicated the case is. If they have hypertension, pre-diabetes or fatty liver, I see them every month. But if they’re really just overweight and healthy otherwise, I probably see them every six weeks. We try to schedule the dietitian in between, so that we’re seeing them every two to three weeks. We do this until we see that they’re losing weight and they feel a sense of mastery. We don’t want them to feel like they have to depend on us forever. At the same time, we have patients who have reached their goals but still request to see us every three months or so.”

Insurance coverage:“Some insurance plans will cover psychology to a certain degree, but the dietitian is not really covered. That makes it very difficult for sustaining programs like ours. If you look at a 4-year-old girl who’s prediabetic, she’ll probably be diabetic by age 10 if we don’t do anything. Imagine the costs, not to mention her quality of life.”

Measuring success: “We’re part of a national registry for multi-disciplinary pediatric obesity centers. We track over time the number of patients we’re seeing, their decrease in BMI, blood pressure, cholesterol, insulin, etc., and get quarterly reports. Our program is among the top three programs in the registry as far as outcomes are concerned.”