I direct a nutrition clinic in a large center for children with special needs. My kids can have everything from mild learning disabilities to genetic disorders that affect growth and development to profound intellectual and physical impairments that cause them to be unable to walk, speak or even scratch their heads. My most seriously involved kids are completely dependent for all their care.

Children who are somewhere in between — for example, children who are unable able to walk but who can feed themselves and communicate with others — pose challenges if they become overweight or obese. That’s because some of the usual advice we’ve all heard, “Eat less and exercise more,” is less applicable to a child (or an adult, for that matter) who is not ambulatory and can’t be physically active. Even if such children can walk with crutches or other assistance, their ability to move is impaired, so such advice remains less applicable. They cannot and should not take the stairs, for safety reasons. No going for a hike or a bike ride. Even parking too far from their destinations can be hazardous. There’s a reason they need crutches, and having central nervous systems that don’t properly send messages to their leg muscles can mean harder work for them even to go one block. Cardio machines at the gym, and even treadmills, are out of the question. Too risky.

Activity is low but appetite is high

This doesn’t mean that these children don’t have appetites; they do. They also get bored, and if you’ve ever eaten out of boredom (and who hasn’t at some point?) then you know that it’s a great way to overconsume calories. What complicates obesity in these children is that they don’t have the option to spend an extra hour playing to burn off the cookies or the slice of pizza they ate. Indeed, they may never have that option, and that places them at increased risk for obesity.

While their calorie needs may be diminished, their desire for food is just as strong as in any other children — sometimes even stronger. They have fewer options for keeping themselves occupied and stimulated, and this can lead to frustration, boredom and a desire for food that is often mistaken for hunger.

Sure, you could say that their parents have to take charge and simply limit what they allow their kids, but that’s not so easy as you’d think. It’s difficult enough to manage kids’ diets when their physical development is normal. When children have physical challenges and can’t walk or ambulate without assistance, or at all, their need for calories is diminished, sometimes by 30 percent or more.

When the children have deficits that are both physical and intellectual, or when their speech or language skills are impaired, they may express their frustration, irritability, boredom or other emotions through behavioral outbursts such as pounding on a table, screaming or throwing objects within their reach. Worn-down parents learn quickly that giving the child a snack will often stop this negative behavior, usually just temporarily, but to the parent, a few minutes or an hour of peace and quiet can sound like heaven on a plate. The calories add up, however, and before you know it the child is ten, twenty, or seventy pounds heavier and has learned that food is a great “quick fix” for whatever ails him or her. Not really the lesson we want kids to learn, so where do we go from here?

I start by telling parents and caregivers that this method of rewarding children or controlling their behavior is not sustainable — and, indeed, for health reasons shouldn’t be sustained. Then we work to leverage the children’s positive food preferences. Maybe a child happens to have a thing for broccoli (don’t laugh; it’s actually the favorite vegetable of more kids than you think) or strawberries, so we bring these foods into that child’s regular snack repertoire and serve them a lot and often, but in place of higher-calorie treats.

Enjoying food, but not only food

Then it’s time to help the children learn to develop pleasures that don’t involve food, and whenever possible, activities that involve using their hands. Sometimes that means toys that require their participation to work or to move (think toy cars with movable parts, appropriate puzzles, small instruments, etc.) or even some “screen-oriented” games suitable for the children’s abilities. Anything that interests them and provides stimulation and isn’t food-oriented.

Children with normal intellectual abilities need to develop nonfood pleasures as well, and I explain that this isn’t just to help them lose excess weight but to help them develop a different way of thinking about having fun and making food a lesser part of their fun, because it needs to be if they’re going to be healthier. Just as important, however, is to let them know that fun and enjoyment will certainly be a part of their lives daily; they’ll just have a different slant. They’ll be about the children having their favorite fruit more than their favorite cookie or chip.

Of course, given that two out of three adults are overweight or obese, you could say that this is a concept that lots of us need to learn. Oftentimes, it’s a lesson that many of my families do learn, because by changing the diet of their physically challenged children, they gradually begin to make dietary improvements as families. In my world, that’s a two-fer.

Keith-Thomas Ayoob is director, nutrition clinic, Children’s Evaluation and Rehabilitation Center, Albert Einstein College of Medicine, Bronx, NY. He blogs at The Doctor’s Tablet.