In my years of practicing pediatrics, I constantly advocated for healthy behaviors for my overweight and obese patients and their parents. I taught them about healthy eating, exercise, and portion control. Like most pediatricians, my successes were limited. My patients hated being fat, yet they struggled to lose weight or maintain it. If they lost weight, they soon gained it back.

I proposed the simple notion of cutting in half whatever they typically ate and saving half for later, so they really wouldn’t lose any of the food they loved. Nevertheless, most kids weren’t able to resist eating the whole thing at once. My patients were frustrated, and so was I. Something else was going on and defeating their efforts.

In my determination to find some answers, I set up an interactive, open-access Web site, where I invited overweight and obese kids to share their stories and struggles. Kids welcomed it as a safe haven to help each other.

After receiving several million visitors – mostly kids – and 134,000 anonymous messages over 10 years, I’ve learned a lot about kids’ views on obesity and its challenges, including their thoughts about the roles of their physicians and parents.

These kids proclaim that information about healthy eating and exercise hasn’t done much to help them. Further, 37% of those sharing their struggles explicitly describe turning to food when depressed, stressed, angry, anxious, lonely, fatigued, or bored. In the words of one 17-year-old girl (5’4”, 184 lbs.): “I want/need to lose weight ... yet I’ll just keep eating those choc bars to numb whatever feelings I have at that moment.”

For many, or perhaps most, this “comfort eating” appears to be unconscious or mindless, as a 17-year-old girl (5’7”, 181 lbs.) related: “I’ve been stopping myself from emotional and comfort eating and I’m only realising how big of a problem it was for me that I was in total denial of.”

The disaster is, even when they realize that they comfort eat, the kids may be unable to stop, as a 13-year-old girl (5’6”, 177 lbs.) agonized: “I hate when I comfort eat. ... I DONT KNOW HOW TO STOP. ITS KILLING ME.”

Many get trapped in vicious cycles, where they eat to comfort the anguish of being obese itself, as one 14-year-old (5’6”, 171 lbs.) lamented: “Every time I’m stressed I eat and my weight is making me stressed.”

It’s my observation that kids initially overeat because “the food is there” – it simply tastes good. But once their brains realize that pain, stress, and boredom are eased by the pleasure of food, the kids may become dependent on this comfort eating and unable to stop, even when distressingly obese. Actual tolerance may develop. One 14-year-old girl (5’2”, 201 lbs.) remarked that food is “like a drug. What used to satisfy you before now has no effect. I feel like I’ve become immune to the foods that used to comfort me.”

This compelling evidence points to a serious dependence on the pleasure of eating, quite similar to dependences on tobacco, alcohol, and even drugs. The way these youth describe their relationship with food comes close to satisfying all of the DSM-IV substance dependence criteria. Many kids – when bored, stressed, or depressed – use food as a “drug of comfort” that is more acceptable than alcohol and drugs of abuse. Dependence on highly pleasurable foods appears to be on a “continuum.” Overweight kids would seem to be partially dependent (partially addicted?); obese kids fully dependent (fully addicted?); and morbidly obese kids are likely in addictive tolerance mode and eat more or worse foods to obtain the same coping effect.

Comfort eating may induce brain changes. Neuroimaging studies reveal that low dopamine D2 receptor levels in the striatum are strikingly similar in obese and drug-addicted individuals (J. Addict. Dis. 2004;23:39-53).

A 16-year-old girl summed it up this way: “A teen who does drugs or smokes would get in trouble if their parents found out. But no one’s going to ground you for eating, which can be equally as damaging, and is equally as difficult to stop.”

We should be asking obese kids about their lives and how they feel when they seek food. And we should be advising their parents to listen to their kids’ answers, which may alert them to a comfort eating dependence, and let the kids know that they care. A 12-year-old girl (5’3”, 186 lbs.) remarked: “If parents took the time to actually listen to their kids ... less kids would go to the fridge when they were depressed.” Too often, parents assign blame to their overweight children, which may induce further comfort eating. Pediatricians also need to be aware of this and that scaring their obese patients with health risks may be counterproductive, as this 13-year-old girl (5’6”, 254 lb.) expressed: “I am really scared about one thing my doctor told me ... if i gain anymore weight I might have to have surgery ... thats been giving me nightmares and stress ... and as I said before stress makes me eat more ... agggh!!!”

Obese kids need major support to break their dependence on the pleasure of eating, including ways to cope with life other than food, such as hobbies, pets, meditation, and counseling. Kids may not be in touch with their emotions and may be unaware that they use food to cope; they may say simply, “I just love to eat.”

I encourage you to take the following two steps to help your patients to stop the pattern of “comfort eating” that can result in a lifetime of obesity and its associated comorbidities: 1) Make the time to ask every fat kid you see in your office about his/her life and relationship with food. 2) Advocate for legislation to put a tax on junk food to protect our kids.

Here are five questions to ask when evaluating your overweight patients:

–Do you ever feel stressed, sad, or bored?

–Do you find yourself eating to make yourself feel better? (A positive answer may indicate mindless eating.)

–Do you struggle to resist cravings for rich food, like junk food or fast food, knowing full well that you don’t want to gain any more weight?

–Do you feel that your eating is “out of control”?

–Do you find yourself eating to comfort the distress you feel about being so heavy?

As I manage my overweight patients with “comfort eating” patterns, I have shifted my focus from portion control to stress control. Here is my written prescription for my patients. I hope it works for your patients as well.

Rx to Overcome Comfort Eating

–Write down your reasons to not overeat, such as: a) so I won’t be so out of breath, b) so I won’t be teased, c) so I can fit in cool clothes, d) so I can get dates, e) so I can play sports, and f) for my health.

–Do three things to reduce your stress each day. These might include relaxation, deep breathing, meditation, taking a walk, doing a hobby, shooting hoops, and playing a musical instrument.

–Write down a list, with a description, of each of your problems, such as “I just can’t understand algebra,” or “My mom bugs me about my weight.” Under each problem write a plan, such as, “Ask the school for a math tutor,” or “Write a letter to my mom saying that her nagging makes me eat more.”

–Talk about your problems with your parents, friends, doctor, minister, or a counselor.

–Avoid junk food and fast food, including sugar-sweetened drinks. Ask your parents to not have them in the house.

–To get unhooked from problem foods, try to stay completely away from the one food you have the biggest problem with. Your cravings for that food should lessen within 1-2 weeks. Don’t abuse a new food once you get off the one with which you have the biggest problem. Do this withdrawal process with as many problem foods as you can, one at a time.

–Find sources of comfort other than food, such as pets, volunteer work, books, hobbies, and clubs.

I hope my suggestions will help you treat your overweight patients.

Dr. Pretlow, who is board certified in pediatrics, lectures frequently on overweight in children and teens and use of the Internet in medicine. He is founder and director of www.weigh2rock.com, an online weight loss system for teens and preteens. Dr. Pretlow may be contacted at: director@weigh2rock.com or 206-448-4414. He also has started a blog called Childhood Obesity News for pediatricians, parents, teachers, counselors, and kids. The Web site www.weigh2rock.com is owned by eHealth International Inc., Dr. Pretlow’s company, as is his book, “Overweight: What Kids Say” (Seattle: CreateSpace, 2010).