BOOT Camp (Beating Obesity With Occupational Therapy): A Holistic Pediatric Program

Editor's note: This text-based course is a transcript of the webinar, BOOT Camp (Beating Obesity With Occupational Therapy): A Holistic Pediatric Program, presented by Ashley Love, MOT, OTR/L.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to evaluate age-appropriate, play-based exercise strategies to improve strength, endurance, and motor coordination in children with obesity.
• After this course, participants will be able to evaluate nutrition education techniques and routine-building strategies to support healthy eating habits and sustainable lifestyle changes.
• After this course, participants will be able to design caregiver coaching plans that reinforce positive health behaviors and promote long-term progress in home and community settings.

Introduction

I am excited to be here with you today. Whenever I speak to professional groups, I find it helpful to provide background on my experience so you can feel confident in the insights I share. As was mentioned in my introduction, I am Ashley Love, and while I am speaking to you today as a doctoral professional, my clinical roots are in occupational therapy. The target audience for this presentation includes occupational therapy practitioners, physical therapists, ABA therapists, and the assistants joining us. I have included several reflection questions throughout the session. I also created a workbook to accompany this course that will be very useful as I explain how to implement and market this program. I want to be clear that I have no financial interest in this product and I am not selling it elsewhere; it is provided solely for educational purposes, as are any other products mentioned during this session.

Our learning outcomes for today focus on three main areas. We will evaluate age-appropriate, play-based exercise strategies designed to improve strength, endurance, and motor coordination in children. We will also examine nutrition education and routine-building techniques for both the child and the family. Finally, we will learn how to design a coaching plan that reinforces positive health behaviors for long-term success.

I have been an occupational therapist since my graduation in 2013. During my career, I started, operated, and eventually sold my private practice, Love Occupational Therapy Services, in Texas. I am quite proud of that venture. We provided both occupational and speech therapy, serving 200 to 250 clients per week. It was a thriving practice, but during those seven years, I also had three children. After my last child was born, balancing the demands of the practice became increasingly challenging. When my husband was offered an incredible professional opportunity, we decided to transition. I brokered the sale of the practice, which continues to flourish today, and they still reach out to me for occasional consultation.

Since then, I have applied my clinical skills to homeschooling my children. Two of my daughters are left-handed, which allows me to practice modulating various handwriting activities. It is a true joy to be the one who teaches my children how to read and write. As their teacher, I am responsible for their entire development, including social and physical skills. I noticed a significant gap in physical education options, so I began teaching a PE course. My students do not realize they are receiving therapy, but I cannot help but implement those clinical strategies. If I want my children to be successful in sports, I must provide a solid foundation in how their bodies move, how their muscles grow, and how their systems work. I am also proud to support my husband in his ongoing research. We will now begin module one, which addresses the challenges of childhood obesity.

Module 1: The Problem

What is Childhood Obesity?

When we look at childhood obesity, the CDC defines it as a Body Mass Index at or above the 95th percentile. Much of the research I have gathered for this presentation comes directly from the CDC to ensure we are utilizing the most accurate and up-to-date data. It appears that many of you are witnessing a high prevalence of obesity in your clinics and share my professional commitment to helping parents raise healthy families. This mirrors exactly what I was observing in my own clinical practice. I have included a chart that outlines these percentiles for your reference. In our typical therapy practice, we are often accustomed to treating underweight children, perhaps those who are selective eaters or struggling with sensory processing issues. However, we are now seeing a significant increase in children who fall into the overweight and obese categories as well.

BMI Calculator

I have provided a link to the CDC BMI calculator in our resources. Because children are constantly growing, their BMI calculations and interpretations differ slightly from those for adults. It is important to use a specific pediatric tool to gather this information when working with a client, as age- and sex-specific percentiles are necessary for an accurate assessment. Having this assistance ensures you interpret the data correctly for the child's developmental stage.

BMI Defined By CDC

Children and adolescents are constantly growing. If you have children of your own, you know that one of the first things a pediatrician does during a visit is measure height and weight to plot them on a growth scale. Generally, if a child is tracking consistently with their own history, a physician might not be overly concerned. For instance, if a child has always been in the 95th percentile and remains there, it may simply be their established growth pattern. However, a sharp upward trend or a sudden uptick in those percentiles serves as a significant red flag. Because these values are specifically scaled for a child's age and sex, it is vital to use the proper calculator to obtain an accurate clinical value. We will be practicing with this tool a bit later in the session to ensure everyone feels comfortable navigating those nuances.

Why This Matters

Why does this matter so much? This is the first time in documented human history that this issue has been classified as an epidemic. It is found worldwide, with over 100 million children currently struggling with this concern. As I investigated the research, I learned that this condition affects almost all organs of a developing child's body. A paper by Simons and Llewellyn points to increased rates of premature death by age 30. There are also significant issues with inflammation, which naturally degrades the immune system. It is a critical issue for overall health, and I believe it is very pertinent to the clinical situations we are currently facing.

Epidemiology

In terms of epidemiology, current research from the CDC indicates that 18% of children are classified as obese. When we look closer at the demographics, it is interestingly noted that the data shows Hispanic children have an even higher rate of obesity compared to the general population. Understanding these specific trends allows us to better tailor our interventions and consider the cultural or environmental factors that may be contributing to these statistics in the communities we serve.

Obesity Trends By States

I am highlighting a graph in your handout that illustrates which states are currently facing the greatest challenges with childhood obesity. Having practiced in Texas and being currently based in New Mexico, I find it striking that both states fall within the fifteen to nineteen percent range on this scale. If you would, please indicate in the chat now if you are seeing increased rates of obesity in your clinic that correlate with what this chart shows for your specific state. I see a comment here noting that teachers often ask about this issue during consultations. I have also had many physicians express a strong interest in this topic, and they frequently ask for my clinical input on management strategies. It seems we agree that we are seeing this trend across the board. I see responses for Michigan and North Carolina confirming these patterns as well. This feedback is very helpful as it underscores the widespread nature of the concern.

Case Study 1: Brianna

I have our first case study to discuss. I am not sure if you remember the reporter Lisa Ling, but she was quite popular in the early 2000s and produced a series of documentaries for the Oprah Winfrey Network. In 2013, she released a series focusing on various aspects of life in America. As background, I have a degree in anthropology, so I have a deep appreciation for culture and ethnology. I love learning about how people live. In anthropology, we learn that there are only a few universal things all human beings do, and eating and cooking are among them. Looking at food is a great way to observe how a culture functions, which is what first drew my attention to this documentary. As we go through this, you will see other elements that caught my eye, specifically as a therapist.

Our first case study comes from this documentary. The subject is a twelve-year-old girl named Brianna. She is a sweet girl from the South who, at the time of filming, weighed over 325 pounds. This placed her BMI well over the 50 mark. The video begins with her in serious emotional distress as she relays what life is like for a girl of her size. She comes from a two-parent home that seems stable and loving. She is supported, yet when she goes to the doctor, they provide dire information about her future if changes are not made. She speaks about being bullied, the mean things children say to her, and how she is excluded. Her father is also incredibly frustrated and angry about the situation. What stuck out to me in this dialogue was the total lack of a solution. Both parents feel helpless and unsure of how to help her.

The documentary follows the family to the grocery store, where the mother reports that she does almost all of her shopping from the center aisles. As we know, the layout of a grocery store typically places fresh items like produce, meat, and dairy around the perimeter, while processed foods are in the interior. The mother mentions that she rarely shops the outskirts except for milk or perhaps some cabbage and onions. She is an attentive and loving mother who cooks for her family, yet she does not seem to correlate their eating habits with the impact on her child’s health. Eventually, Brianna herself reaches a breaking point and tells her parents she needs to lose weight. She has the impetus to change, but the family has no clear goal or path to follow. She is a precious girl with so much potential that is simply not being tapped into. This case really caught my eye years ago while I was researching this topic. Moving forward, a paper by Hampel and colleagues provides an excellent breakdown of the consequences of childhood obesity.

Consequences

We all recognize that there will be consequences for these health trends, but the scope is far greater than I initially realized. Of course, we see significant issues with metabolic disorders, such as type 2 diabetes and insulin resistance, which are to be expected. There are also cardiovascular concerns like high blood pressure, high cholesterol, and even early hardening of the arteries. Furthermore, a tremendous physical load is placed on the musculoskeletal system. Consider a child like Brianna, who is twelve years old. Her skeleton is not yet prepared to carry such a large load, and her growth plates may not even be fully set. This can lead to early onset osteoarthritis from excessive weight, an altered gait that increases the risk of falls, and significantly reduced endurance. We also see a higher prevalence of respiratory problems, including asthma and sleep apnea, which can reduce lung capacity. Finally, there are real issues with hormonal disruption that can eventually lead to fertility challenges in both males and females as they reach adulthood.

Mechanisms of Pediatric Obesity

This paper included an excellent chart outlining the specific mechanisms underlying pediatric obesity. One of the primary points it makes is that, for the first time in human history, our struggle is not about obtaining enough calories. For the vast majority of human existence, the question was how to find enough energy to survive. People ate grains and vegetables, which were lower in calories and required significant effort to produce. A hundred years ago, if you wanted bread, you had to make it yourself. Meat might have been available for purchase, but it was often an expensive treat. Today, we have constant access to high-energy dense foods that are very easy to obtain.

We also live much more sedentary lives. I want you to hear this not as a criticism, but as a simple reality of modern life. I recently listened to a speaker who had defected from North Korea, and she was stunned to learn that in America, we actively try to burn or limit calories. In her experience, the daily goal was simply to consume enough to stay alive. We are in a vastly different situation now, where much of our work is done at a computer. We have to artificially schedule physical activity because our environment does not always require it. Depending on where you live or the weather, access to outdoor recreation can be quite limited.

Our portion sizes have also grown significantly. This reminds me of the early days of parenthood, when you are constantly worried that your tiny baby is not getting enough to eat. Since they cannot tell you with words, you monitor their intake closely. I think sometimes we fail to adjust that mindset as children grow and become more capable of self-regulation; we fall into the trap of thinking more is always better. The types of food readily available are often high in sugar and have a high glycemic index, which triggers various health issues. Some of the long-term consequences I was surprised to learn about included increased risks for multiple sclerosis, various cancers, and polycystic ovarian syndrome, which ties back into those significant fertility concerns. This chart serves as a powerful reminder of why our intervention is so necessary.

Case Study 2: Ethan Benard

This brings us to our next case study, and I have to admit that this individual is a personal favorite of mine; I have been closely following his weight loss journey. He is currently twenty-five years old, but he discloses that he has been obese since childhood. He also comes from a stable, two-parent home. At his heaviest, he weighed 660 pounds, and though his weight is now around 450 pounds or perhaps even lower, the impact on his health has been profound. Because of the strain of carrying that weight, his immune system was severely compromised. He contracted pneumonia and ended up in the intensive care unit for several weeks because his body simply could not fight the infection as effectively as a typical person his age.

This situation resulted in significant occupational impairment, which is what first caught my professional eye. In the first video I saw of him, he reported a major non-scale victory: he was finally becoming completely independent. While he still lives with his parents at twenty-five, he is now able to manage his own complete care. Prior to this, he was unable to put on or take off his own socks and shoes. He required assistance with tasks like fastening a belt or buttoning a shirt, and he had to use a seatbelt extender to travel safely in a vehicle. He also reported incredibly low testosterone. One thing I had not fully realized before researching this is that adipose tissue is estrogenic; large amounts of fat tissue act as a major hormone disruptor, particularly for males. This creates a difficult cycle, as they need testosterone to build the very muscle required for metabolic health.

Beyond the physical, he has experienced profound social isolation and a general decrease in immune function. One of his primary goals is to grow up and function as a full adult. He wants to be in a relationship, but he has been so isolated over the years that he has not had the opportunity to develop those social connections. Now, he is working incredibly hard not only to repair his immune system and normalize his hormone levels but also to learn how to navigate the social world as a young man.

In our field, we often say that early intervention is the best intervention, and that certainly applies here. He mentions that his parents did attempt to manage his weight when he was younger, but their strategy was to eat only organic food and dispose of the microwave. Looking back, he feels the core issue was actually portion control rather than the specific food source. He has learned a great deal and is gaining vital skills as he continues his successful journey.

Impact on Occupations

The impact of obesity on occupations is significant, as it negatively affects nearly all the domains within occupational therapy. This is precisely why this topic caught my eye; it convinced me that occupational therapists are uniquely well-suited to tackle this issue. We see challenges in basic activities of daily living, such as being able to wash one's body completely in the shower or managing personal health with total independence. There are also numerous performance skills, particularly motor skills, that are affected, which I will discuss in more detail as we progress. This leads me to our next reflection question: Can you think of an area of occupation where obesity would not have an impact? If you have an idea, please indicate that in the chat.

I value occupational therapy for its holistic approach, which is the core focus of this course. We are looking at the whole person, who is always situated within a family system. This program is designed to address that entire context. We must ask if a child is able to sleep well, socialize with friends and family, and learn how to care for their body. This care involves immediate tasks like dressing and fastening buttons, but it also involves a future perspective where caring for oneself now provides a positive benefit for the person they will become. One of you mentioned a person's entire sense of well-being, and I agree that it is vital.

Consider the role of sleep. If a child is suffering from increased sleep apnea, they are not resting well enough for the nervous system to repair itself or for the neural connections necessary for learning to solidify. As a result, they fall into an even greater developmental deficit. Another participant mentioned skin integrity, which is an excellent point. There is also the matter of dignity. Having the dignity to participate without constant worry is essential. If we think back to Brianna, being twelve years old is difficult under any circumstances. It is an awkward age where the body is already changing. To make it more complex, she is in middle school and is essentially stuck with a cohort of students. As adults, we have the agency to change jobs or finish a difficult class and move on, but children do not. She felt truly trapped in her situation, and I believe an occupational therapist could have significantly benefited her academic and social experience.

Psychosocial Impact

There is undoubtedly a significant increase in low self-esteem and depression, along with social isolation and academic challenges. Pervasive fatigue and sleep deprivation can severely impact a student's grades. It is not simply a matter of missing class; these children often struggle with poor concentration. When a child experiences blood sugar spikes and subsequent crashes, it directly hinders their cognitive ability to focus and learn. This creates a substantial psychosocial impact that ripples through every area of their development.

As we examine these cognitive and emotional hurdles, we must consider how they intersect with the physical limitations we see in the clinic. These children often carry a heavy internal burden that mirrors the physical load they bear, making it even more vital that we provide a supportive, nonjudgmental environment for growth.

Impact on ADLs

There is also a profound impact on activities of daily living, play, and leisure. The primary occupation of childhood is play, and we must ask ourselves if these children are truly able to fully engage in play as they should. I would argue that they are not. They often suffer from reduced endurance and are physically unable to run and play for extended periods. Building friendships often requires time and sustained engagement in shared activities, and if a child is forced to sit out or stop early due to physical exhaustion, they miss those critical social windows.

This lack of participation further isolates them from their peers and limits their opportunities to develop both motor skills and social bonds through natural play.

Impact on Play & Learn

To gain that sense of belonging, these children may choose more isolated or solitary play to avoid the physical strain or the social risk of falling behind. I also find that they are often not selected as leaders in games, which means they are being excluded from developing those critical leadership and organizational skills during their formative years. When you are consistently left out of the fast-paced roles in group play, you miss out on the chance to navigate social hierarchies and build confidence in your ability to guide others.

This exclusion creates a cycle where the child retreats further into sedentary or solitary activities, which only exacerbates the physical and social challenges they are already facing. It is our job to find ways to break this cycle and provide them with the tools to re-engage with their peers effectively.

Impact on Education

There is real evidence that supports lower academic outcomes for children struggling with obesity. Beyond the social and physical barriers, a physiological component also plays a role in brain health. Specifically, growth hormone production can be negatively impacted. This is significant because growth hormone plays a vital role in memory and cognition.

When these hormonal levels are disrupted, the biological foundation for academic success is weakened. The child is not just fighting against fatigue or social stigma; they are also dealing with a compromised internal system for processing and retaining information. This further highlights why our role in managing health routines is so critical for their overall development.

Impact on Social Participation

The profound reality of social isolation is evident in the lives of both children we discussed. Brianna shared the painful experience of being bullied and the mean things other children say to her, which naturally leads to a sense of being excluded. Ethan reflected on how his life involved significant withdrawal from the world around him. This social isolation is not just about being alone; it is a lack of opportunity to participate in the shared experiences of childhood and young adulthood. When a person is withdrawn like Ethan was, they miss the formative moments that teach us how to navigate relationships and community.

This isolation often stems from a combination of the physical inability to keep up with peers and the emotional toll of weight-related stigma. As therapists, we have to recognize that when a child or young adult withdraws, they are losing more than just physical activity; they are losing the social practice necessary for long-term emotional health. This is why our intervention must go beyond just physical metrics and address the person's ability to re-enter their social environment with confidence.

Interoception & Self-Regulation

The next topic I want to bring forward is one I think will be especially interesting to occupational therapists: interoception and self-regulation. Being able to accurately identify hunger and fullness cues can be a significant challenge, and for many children, these internal signals must be explicitly taught. Often, there is a pervasive disconnection from the body. I feel that when we are zoned out and simply consuming calories without presence, we miss out on the pleasure of eating and the vital social components that come with a meal.

In the clinic, I frequently heard complaints when asking children to engage in physically challenging tasks. This is often because they are unable to distinguish between normal muscle fatigue—the buildup of lactic acid—and true pain. While this can be difficult for any child or even some adults, frequent exercise provides a unique remedy. Through movement, you begin to trust your body. You learn to recognize that specific burning sensation not as something harmful, but as a sign that your muscles are becoming stronger.

Living in our bodies requires us to understand them. We must bridge this disconnection and teach children how to listen to and care for their physical selves so they can navigate their environment with confidence.

First Law of Thermodynamics

I have another reflection question for you. The first law of thermodynamics states that energy is neither created nor destroyed; it is only transformed. My question to you is, how do you think this applies to human bodies? If you consume calories, what happens to them? To look at this logically, imagine you were stranded on a desert island. Regardless of whether you had a metabolic issue, a thyroid condition, or if you started out obese or very thin, what would you look like when you were finally rescued? Logically, we know you would be smaller because your energy intake was reduced.

I bring this up because there is an overwhelming amount of information online. You can find every imaginable diet and exercise plan, and even as a therapist, I found the conflicting information very confusing. However, if we start with this basic premise, we find a firm foothold. I understand that humans are complex biological systems and not truly closed systems in a physics sense, but this remains a universal principle. By starting here, we can understand the fundamental process of gaining and losing weight. We will certainly add layers of complexity as we go, but I want to keep our starting point simple to avoid getting lost in the weeds too early.

Module 1 Summary

In summary for module one, we must recognize that obesity has become a worldwide epidemic. It negatively impacts both current and future health, creating long-term risks that persist into adulthood. As we have discussed, it impairs all domains of occupational function, from basic self-care to complex social participation and play. This leads to a decrease in overall quality of life and, perhaps most importantly, reduces childhood joy during a time that should be fundamentally happy and lighthearted.

Module 2: The Solution

What is the solution to this growing challenge? While working with my clients at the clinic, I realized this issue was surfacing so frequently that it required a formal response. I began to notice a significant uptick in these specific behaviors, particularly as we transitioned out of the pandemic. After a long period of staying at home, children were finally returning to the clinic, and the shift in their environment brought these patterns to the forefront of my practice. Witnessing this trend firsthand made it clear to me that we needed to develop a proactive strategy to support them.

Why Are Therapists Ideal?

I believe that therapists are uniquely suited to address this issue. We already possess the prerequisite skills necessary to tackle these challenges effectively, and throughout this discussion, we will explore how to implement the solution within a clinical framework. Each discipline brings distinct and valuable expertise to the table, a significant asset to our collective approach.

Research on behavior modification, particularly in the context of weight management, consistently shows that clients who work with a dedicated professional achieve superior outcomes. Occupational therapists naturally focus on functional occupations and exercise, while physical therapists ensure mobility and exercise safety. Furthermore, practitioners focused on behavioral health contribute essential strategies for sustainable change. Each of us offers a specialized perspective that enhances the program's overall effectiveness.

OTPF Alignment

The American Occupational Therapy Association provides resources that clearly support our role in addressing this challenge. They offer a professional handout that can be printed and shared with physicians or other healthcare providers to advocate for our involvement in this area. This document serves as an excellent tool to demonstrate how our unique scope of practice allows us to effectively manage these health issues within a multidisciplinary team. You can easily locate this resource on their official website to help establish our place as professionals equipped to tackle pediatric weight management.

Frameworks That Apply

This brings us to our practice frameworks. For occupational therapy practitioners, I believe the frameworks that apply most directly to this issue are the Model of Human Occupation, the Canadian Model of Occupational Performance and Engagement, and the Person-Environment-Occupation model. Additionally, the biomechanical frame of reference is essential for addressing the physical components of this challenge.

Model of Human Occupation (MOHO).

This model was developed by Dr. Gary Kielhofner. While the version I studied was from 2003, the core principles remain consistent and highly relevant to our current discussion. He proposed three primary components that drive human occupation.

First, we have volition, which is the internal drive or motivation to engage in an activity. Second is habituation, which involves integrating that activity into a consistent habit or routine. Finally, there is performance capacity, which refers to the physical and mental ability to perform the task, as well as the individual's belief in their own capability, known as personal agency or personal value. I believe that addressing childhood obesity within this framework is an excellent fit for our practice.

Physical Therapy Biomechanical Framework.

Physical therapists and occupational therapy practitioners are exceptionally well-suited to use the biomechanical framework, as we constantly evaluate movement to ensure safety and identify areas for improvement. This framework is particularly relevant here because obesity causes significant alterations to gait and reduced movement, leading directly to a deficiency in strength. One of my primary concerns regarding this issue is that these children are in a critical stage of growth and development.

Since the brain is not yet fully developed, we must consider whether vital motor pathways are being established when children do not participate in play activities as they should. When working with an adult client who has experienced a stroke, we are dealing with a brain that has already established those motor pathways, allowing us to potentially find an alternate route to the desired motor action. However, if a child never develops the motor pathway in the first place, we face a much more difficult challenge. Children must practice moving their bodies to develop the foundational ability to move effectively throughout their lives.

Key Biomechanical Areas PTs Evaluate in Children With Obesity

In physical therapy, there are several key biomechanical areas we must address. We have to consider joint loading, as excessive weight puts significant stress on the hips, knees, and ankles. This often goes hand in hand with poor postural alignment; you might even see issues with basic sitting balance. Core weakness is a prevalent challenge among many pediatric patients, but it is especially pronounced in heavier children, as the core must work much harder to stabilize a larger frame.

We also need to evaluate gait mechanics and general movement efficiency. Tasks that should be fluid for a child—like standing up from the floor or sitting back down—become exhausting. If you watch a typical group of children play, they are like a little anthill: constantly up and down, moving incessantly. That is their natural state.

There is often a misconception regarding metabolism in this population. While people assume a larger body size indicates a "slow" metabolism, these children actually have a high basal metabolic rate because it takes more energy to move and maintain a larger mass. This is why they fatigue so much faster than their peers; they are burning through their energy reserves just to perform the basic mechanics of movement.

Case Study 3: Taylor Reed-PT and Mobility

Our third case study features Taylor Reed, a young man in his 20s who has struggled with obesity since childhood. At approximately 470 pounds, his journey—documented on social media—illustrates the critical need for professional clinical reasoning. Watching his gym footage can be anxiety-inducing for a therapist. We aren't judging; we are clinically assessing the environment, wondering whether he can safely negotiate a curb or a step without falling.

In one specific video, Taylor is working with a personal trainer and is tasked with using a treadmill. What should be a simple task becomes a significant barrier. It takes him several minutes just to step up. From a biomechanical perspective, he struggled to offset his body weight, maintain single-limb balance, and generate enough hip flexion to clear the treadmill deck. The trainer was positioned at the opposite end, completely unable to provide a steadying assist if Taylor had stumbled.

This led to frequent, persistent leg pain. When he sought help at urgent care, the radiologist's report was inconclusive because the soft-tissue density obscured the bone on the X-ray. This lack of clarity is a major barrier to medical management.

From the Model of Human Occupation (MOHO) perspective, this experience is devastating. If a client lacks the initial volition (motivation) and has not yet established the habituation (habit) of exercise, an injury right at the start can be a total derailment. He may not have the problem-solving skills to think, "My leg hurts, so how else can I reach my goal?"

A physical therapist would have recognized that a treadmill—especially for someone who uses a front-wheeled walker—was likely inappropriate. Instead of a high-entry treadmill, we could have implemented:

• Sit-to-stands to increase heart rate while maintaining a safe center of gravity.

• Walking on a flat track to eliminate the trip hazard of the treadmill belt.

• Water-based exercises to reduce joint loading while building strength.

By intervening with the correct skill level, we could have extended his window of activity rather than seeing him injured and discouraged immediately.

ABA and Obesity

Next, let's discuss Applied Behavior Analysis (ABA). I truly enjoy collaborating with ABA practitioners because of their exceptional observation skills. They are trained to look closely at a situation to identify the antecedent—exactly what happens before a specific behavior occurs. In the context of weight management, understanding those triggers is incredibly valuable.

A 2009 paper by Donaldson explored the use of goal setting, self-monitoring, and feedback to increase caloric expenditure, and the results were quite impressive. I believe the ABA framework is highly appropriate for addressing this issue because it provides the structure needed to change long-standing habits.

By identifying the cues that lead to sedentary behavior or poor nutritional choices, an ABA professional can help the family restructure the environment to promote healthier outcomes. This systematic approach to behavior modification complements our focus on functional movement and daily routines perfectly.

Scope of Practice

Naturally, we must operate strictly within our scope of practice. It is our professional responsibility to ensure we are not overstepping our bounds. As occupational therapists, we do not diagnose; rather, we rely on referrals. While we can evaluate a patient to identify functional barriers, we cannot initiate therapy until we have received a formal referral from a medical doctor.

I have found that working hand in hand with MDs is incredibly effective. In my experience, physicians are very receptive to this program and the concept of therapeutic intervention for weight management because it addresses the functional "how" that they often don't have time to cover in a brief office visit. By adhering to our professional licensure and maintaining clear communication with the primary care team, we ensure the highest standard of care for the child.

Case Study 4: Jaylen and Mother

Our fourth case study focuses on Jalen, a six-year-old boy weighing 101 pounds, who is classified as morbidly obese. During a clinical visit with his mother, he is seen by a multidisciplinary team including a physician, a nutritionist, and a physical therapist.

The interaction in that office is a stark example of where the traditional medical model often fails families. Jalen’s mother is clearly attentive and has sought help because she recognizes the problem, yet she is met with harsh criticism. The physician provides a bleak outlook for Jalen's future but offers no practical bridge to reach a healthier one. The "advice" given—to simply refuse food to her child—is not only reductive but fundamentally ignores the complex behavioral and emotional dynamics of a household. For any parent, simply withholding food from a hungry child without a structured plan is neither sustainable nor compassionate.

This mother doesn't need a lecture on the risks; she needs a solution-oriented framework. This is exactly where a "boot camp" or intensive therapeutic program becomes invaluable. Unlike a brief office visit that focuses on "what" is wrong, our approach focuses on the "how"—the practical, daily routines and environmental modifications that a family can actually implement. We bridge the gap between medical warnings and real-world success.

Module 3: Implementation of BOOT

In Module Three, we shift our focus from the "why" to the "how." Transitioning from theory to clinical application requires a structured approach to ensure our interventions are measurable, reproducible, and, most importantly, effective for the families we serve.

Introducing BOOT

The "Boot Camp" model is built on a three-pronged approach, derived directly from clinical evidence regarding what effectively drives sustainable weight management in the pediatric population. To be successful, we cannot address one area in a vacuum; we must integrate all three simultaneously to create a holistic shift in the child's environment and habits.

Session Components

These are the three pillars of this program: Exercise, Food Education, and Parent Education.

I want to emphasize that there are typically no major safety concerns for this program. Most children can participate fully because, at its core, this is a form of behavior modification, which is a fundamental part of what we already do every day in therapy. We are simply applying those familiar skills to a different set of habits.

The other essential component to keep in mind is that this must be longitudinal. As we know from our clinical experience, meaningful change in therapy takes time. We aren't looking for a "quick fix" that fades after a few weeks; we are looking to rewire a child's routines and a family's lifestyle over the long term.

One-on-One Intervention

This highlights another reason therapists are well-suited for this program: it is most effective when delivered in one-on-one sessions. While group dynamics can be helpful for social support, the individualized nature of therapy allows us to tailor the physical demands and the educational content to the specific needs of the child and their family.

As I’ve emphasized, parent participation is not just an added benefit; it is an absolute requirement for success. Because children do not control the grocery shopping, the meal preparation, or the family schedule, the parent serves as the primary "environmental architect." By working one-on-one with the parent-child dyad, we can address the unique barriers in their home life and ensure that the strategies we develop in the clinic actually translate to the living room and kitchen table.

Structure of Sessions

Each session in our clinic was structured to be 60 minutes long (or 53 minutes to align with unit-based billing). Ideally, participants should attend two to three sessions per week.

Each session is comprehensive, including food education, exercise implementation with a workout, and the parent portion. Before starting the program, it is necessary to conduct a thorough intake to establish a baseline for the participant.

What to Measure

When you are working with your client, you must remember that children are growing, so you will need to utilize the BMI-for-age growth charts to get an accurate intake of their biometrics.

It is essential to communicate your goals clearly. You must define what you are measuring, why you are measuring it, and how you will judge success. Sharing this information with your clients is critical, as is gathering baseline information to understand their current level of knowledge.

Assessments Used

What would be most motivating for you to measure if you were a client? As health professionals, we know the first order of business is to get through the intake packet and take the metrics, because we have to measure something to track progress.

You can use the assessments you already have in your clinic. If you are working in a pediatric setting, you could use the BOT-2 (Bruininks-Oseretsky Test of Motor Proficiency) to gather motor information. You could also use the REAL (Roll Evaluation of Activities of Life), which is an assessment of activities of daily living.

Even a standardized Manual Muscle Test (MMT) can work. I have used the Miller Function & Participation Scales (M-FUN); though it is a lengthy test designed for preschool-aged children, it is an option.

The next step is to take biometrics, including height, weight, and BMI. You can also measure resting heart rate and heart rate recovery. Waist circumference provides really good information, as do $O_{2}$ saturation levels. Additionally, you can use non-standardized assessments or tools, such as a daily mood scale or the Beck Depression Inventory, which is available for free online, to gather supplemental information.

Intake Forms

I also spoke with Dr. Michael Pizzi, who developed the Pizzi Healthy Weight Management Assessment (PHWMA). As an OT himself, he created this assessment specifically for this area of practice. If you contact him, he provides the parent/guardian version of the assessment for free.

Additionally, I completed some training courses with SickKids Hospital in Toronto. They offer an online, hospital-style intake packet that they provide for free to use as well. These are excellent resources to incorporate into your evaluation process.

BOOT Workbook (See handout)

To make this program truly functional, I developed a workbook born out of necessity. In my clinic, therapists were enthusiastic but often hit a wall, asking, "What exactly do I teach today?" I realized that for this to work, it needed to be a "plug and play" system. I created 10 food lessons and 10 exercise lessons that you could print out tomorrow and use immediately. Each lesson includes a specific Home Exercise Program (HEP), parent reflections, and assignments to ensure the caregiver is an active participant.

The beauty of this framework is its flexibility. While it provides a structured path, you can easily grade the challenges up or down based on the child's abilities. When it comes to movement, I follow the World Health Organization’s perspective: the best exercise is simply the one that actually gets done. In our sessions, we let kids try different activities to discover what they enjoy, guiding them through the process rather than forcing a rigid routine.

A non-negotiable part of this process is the final 15 minutes of every session, which is reserved strictly for parent education. We discuss the wins and hurdles of the previous week and set the goal for the next. This accountability is vital because children don't control the environment; they don't buy the groceries or drive to the fast-food window. We need parents to model these behaviors and build a rapport that validates their experience. By keeping the parent involvement positive and avoiding criticism of the child, we help the child build self-esteem alongside physical health.

Of course, we have to be selective about who enters the program. Beyond requiring an MD referral, we exclude children under age two, those with unstable medical conditions, or families facing food instability. We also screen for eating disorders, addictions, or suicidality to ensure we are providing the right level of care.

To track our success, the workbook includes trackers for food, exercise, and biometrics. Each lesson is structured with a clear topic, reflection questions, and resources. I always make sure the parent leaves with a physical handout so there’s no room for "I forgot."

Case Study

So let's walk through a potential case study. So we have a six-year-old male. He's just been diagnosed with being overweight. He's healthy, has no comorbidities, has strong family support, is homeschooled, and is highly intelligent and articulate, but he lacks exposure to gross motor play, likely because of homeschooling. He weighs 70 pounds, is 4ft tall, and has a 28-inch waist.

He had a normal BOT, heart rate, and all of his bios are normal, and his manual motor is not normal. So what areas should we focus on?

Tailoring for Diagnoses

We can also adapt this for children with special needs, who statistically face higher risks of obesity. Using the PEO model, we can modify the environment and occupation to fit the child’s unique needs.

GLP-1

On a final note, I often get questions about GLP-1 medications; while they are used in pediatrics for Type 2 Diabetes, they aren't currently indicated for weight loss in children, and we simply don't have the long-term safety data yet.

Marketing BOOT

When I marketed this to MDs, I found them incredibly receptive. They are often relieved to have a place to send families that offers more than just a lecture. If you choose to reach out to local physicians, you'll likely find a very enthusiastic audience—you just have to remind them that you are the solution they’ve been looking for.

Summary

You're very welcome to the workbook. I hope it's helpful and makes your job as a therapist easier, because I know creating lessons and things like that can be challenging during your work Week.

Thank you for attending.

Questions and Answers

If a parent or child doesn't come to you directly, how do you address weight concerns without being offensive?

Selecting the right client is key; if someone isn't ready to participate, you won't have much success and may face pushback. If I have an existing client who is struggling with obesity but the family hasn't raised it, I find it best to go through their Medical Doctor (MD). I might reach out to the MD to share my observations and ask if they recommend the child participate in the program. Letting the MD address it and "shunt" the referral to you is often more successful. Ultimately, you’ll see the best results when you promote the program and let the families who are ready for change come to you.

How is this program covered by insurance?

This is highly specific to your state and the individual insurance provider. For example, in Texas, obesity is not typically a primary diagnosis, which can lead to pushback. However, if the child has a primary diagnosis like ADHD or Autism, your functional goals (like improving muscle weakness or coordination) may be approved. You should defer to your clinic’s specific billing procedures. This also makes for an excellent private-pay supplemental program, such as a summer intensive.

Has there been research on this specific "boot camp," or is it based on case studies?

While this specific curriculum is a clinical application, it is built on high-level evidence. The Hampel et al. meta-analysis of weight management programs identified three essential pillars—nutrition education, exercise, and parent participation—as the keys to the best results.

What diagnoses are typically referred to this program, and what billing codes are used?

We saw a high volume of children with Autism, ADHD, Intellectual Disabilities, or Down Syndrome. Many were also referred for general motor coordination issues where the MD wasn't yet sure of a specific diagnosis. For billing, we often focus on codes related to muscular incoordination or muscle weakness, provided there is a primary diagnosis to support the claim.

Would you suggest using a calorie-counting app?

Research shows that if we can simply get children to eat the recommended daily caloric value and stop the weight gain, that is a success. I personally recommend using AI-powered apps where you take a photo of the food to calculate calories. They are increasingly accurate and, more importantly, they are easy. If it's easy, families are more likely to stay consistent.

Do you ever incorporate group sessions for socialization?

We considered it, and I think it would be a fantastic activity. It could be especially beneficial to mix children in this program with those receiving food therapy for "picky eating." The social engagement could offer unique benefits to both groups.

How would a private practitioner start this program if they notice a need in their community?

Start with the MDs you already have a strong relationship with. Pitch the idea to them and see if they will support a pilot cohort. This allows you to work out the bugs and identify pitfalls on a small scale before expanding the program.

Are there other similar resources available?

The Hospital for Sick Children (SickKids) in Toronto has a robust obesity program. While it follows a medical model (with nurses and doctors), it offers excellent behavioral resources and free weekly webinars that are well worth exploring.

References

See additional handout.