November 20, 2017
I weigh my words (pun intended) every time I address the topic of a child’s obesity in the exam room. Yes, I know, you probably want to tell me that I shouldn’t use that word — “obese” — and I promise that I don’t. But in the child’s electronic medical record, that’s the official coding if the child’s body mass index is at or above the 95th percentile for age and gender. And medical providers, just like parents, may find themselves walking a difficult line as they try to discuss this fraught subject without increasing the distress that many children are already feeling.
“Guilt and blame don’t motivate change, they just make people feel bad, and when people feel bad, they don’t tend to be motivated toward healthy behavior,” said Dr. Stephen J. Pont, an assistant professor at the University of Texas Dell Medical School.
Dr. Pont is one of the lead authors of a new policy statement from the American Academy of Pediatrics on “Stigma Experienced by Children and Adolescents With Obesity.” The statement, published online Monday in the journal Pediatrics, advises pediatricians to use neutral words like “weight” and “body mass index” rather than terms like “obese” and “fat.” The authors also suggest we use language that puts the person before the condition, as in, “a child with excess weight” rather than an overweight or obese child.
More broadly, the authors advise that medical practices need to look carefully at their procedures and their attitudes to make sure they aren’t building in biases against overweight children, and beyond that, they want us out there advocating against this kind of stigma in society. And they put this advice in the context of an extensive research literature on how very common it is for children to be teased and bullied because of their weight, and how very counterproductive that is.
For all the attention paid to weight and its health effects in medical settings, the social and emotional side is often neglected, said Rebecca Puhl, a clinical psychologist who is a professor in the department of human development and family studies at the University of Connecticut, and the other lead author on the policy statement. “Weight is now one of the most frequent reasons kids are teased or bullied,” she said. In addition to the well-documented effects on children’s mental health and self esteem, she said, research has shown very harmful effects on children’s eating behavior, and increased risk that they will stay sedentary and gain weight.
In a study published earlier this year in the journal Preventive Medicine, Dr. Puhl and her colleagues looked at the longitudinal effects of teenagers being teased about their weight. The study involved over 1,800 people who had been followed for 15 years and are now in their mid 30s.
“Weight-based teasing in adolescence predicted obesity, and also eating food to cope with emotions,” Dr. Puhl said. “These teasing experiences have long-lasting implications for health and for health behavior.” For women especially, these adolescent experiences of teasing by peers or family members were associated with binge eating, poor body image, obesity, and a higher B.M.I. 15 years later, she said; for men there were some of the same associations, including obesity as adults, if they had been teased by their peers as adolescents.
Research shows that two-thirds of adolescents in weight-loss camps report being bullied or teased about their weight, over 90 percent of the time by their peers, Dr. Puhl said. A third report that they are also teased by family members. “Pediatric health professionals may be one of the few allies to offer support and try to prevent harm.”
My colleague Dr. Mary Jo Messito, the director of the pediatric obesity program at Bellevue Hospital, said, “the worst thing to do is go into the room with an 11-year-old girl and say, your child is obese, the child will start to cry.” She recently saw a boy whose mother kept bringing up, “‘You don’t want to be like uncle so and so, he had to have this operation, he almost died’ — the kid is now terrified.”
Katherine Bauer, an epidemiologist who is an assistant professor in the department of nutritional sciences at the University of Michigan School of Public Health in Ann Arbor, cited what she called “the prevalent belief that people don’t know they’re heavy, and if we just inform them they will magically be motivated for behavior change.” In fact, she said, weight stigma does exactly the opposite; criticizing and inducing shame only make people feel terrible about themselves, not motivated or capable of making changes.
We are all, including our children, living in a culture that is profoundly critical of excess weight and at the same time constantly offering opportunities and advertisements for overindulgence. “It’s important to focus on positive reinforcement and not jump to negative,” Dr. Pont said. What this means, for parents and for health providers, is to make sure we see the child, not just the number on the scale. “Recognize that a child is far more than what their weight is, praise them for all the positives, so when we get to some of the more challenging topics, they can still maintain their self-esteem,” Dr. Pont said.
And that time in the exam room has to include talking about nutrition and exercise, but “the focus should be on health or health behavior rather than looking thin, fitting into certain pants,” Dr. Puhl said. So it’s absolutely reasonable to talk about eating patterns, about family meal times, about what foods kids choose at home and at school, about screen time and exercise. Of course, excess screen time or too much junk food are problems even if you’re thin.
The most effective way for parents to help a child is to make healthy changes for the whole family, regardless of shape or size, Dr. Pont said. Try making small changes slowly, like adding one new green vegetable into the family diet, not keeping sugary drinks in the home or walking to school instead of driving.
And yes, to bring up the big turkey in the room, Thanksgiving is upon us; here come the relatives. If you have a child for whom this is a sensitive subject, try to make sure that no one spoils that child’s day. When it comes to a child’s weight or eating habits, “the Thanksgiving table is not an appropriate place to be commenting,” Dr. Puhl said.
“Public discussions at the table that are teasing or negative are not helpful,” Dr. Messito said, and some people will overeat in response to feeling stressed.
And all the experts recognize that one essential message to children is that however important healthy changes in their diet may be, they can still enjoy special days and special treats and special meals. “Enjoy the holiday; make the changes not on a holiday,” Dr. Pont said.
“Food is our way of connecting with people, especially around Thanksgiving, our way of bringing people together and showing thankfulness,” said Dr. Bauer. “Let’s have a shaming-free Thanksgiving where we just enjoy ourselves.”