It’s well known that you never ask a woman her weight, but I am here to tell you that If you think adults are sensitive about their own weight they are REALLY sensitive about their children’s weight. Whether the weight is on the high side, the low side or even normal, the parental stress is palpable.
All over the internet and instagram, I see people saying “don’t allow the pediatrician to discuss your child’s weight in front of your child”. I think they are wrong. I am here to say that we can use the scale as a data point. Not the ONLY data point, but one very useful data point. Having a weight in the overweight or obese range carries short and long term health risks which I think are well known.
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Why should you allow your pediatrician to discuss weight in front of your child?
- Growth is one of the most important reasons children go to the pediatrician for well child checks. We spend 3 years of our life learning about the many varieties of normal and abnormal growth trajectories and essentially growth charts are our tea leaves. You must trust your doctor (or find a new one) and have an open mind and listen to what they have to say.
- Parents don’t know without us. There have been several studies showing that parents aren’t good at identifying whether a child’s weight is in the healthy range. Of parents of children with a weight in the overweight range, 88-95% will identify their weight as healthy. Parents of children whose weight falls in the obese range miss it around 80% of the time. There are a lot of factors at work here, obesity is so common it seems normal. We are primed to see bigger kids as healthy because they aren’t starving. But knowing the facts is important. You may say, well my child is in the obese range but is very active and has a very healthy diet so I think it’s ok. Fine! Thoughtfully doing nothing is a valid path. But you should spend 5 minutes a year thinking about whether those statements are really true or if any habits could be improved.
- Kids know when they are overweight. Anti-fat bias is a real part of our culture and has been shown in children from age 3. Certainly doctors can be insensitive at times, but we are not only or primary driving factor here. The child likely knows their weight. When we allow space to discuss their feelings about it, children often reveal making sometimes very misguided efforts to change their body (skipping meals or purging behaviors I have seen as young as 5). Allowing a health professional to reinforce the importance of healthy and body-positive behaviors can help. “I can never get my son to eat vegetables but after you told him how important they are he has started.” It’s not always that the doctor says it differently, but we say it from a place of authority which sometimes can sway children.
- Lastly, we are on your side. Whether we work in private practice, at a hospital, in a subspecialty, we have no reason to insult you or your child’s self-esteem. On the contrary we only want to help you and inform you of what’s best for your child’s long-term health. Leave your people pleasing at the door and be real with your doctor. We have heard worse. For me the case that comes to mind was a single mother who had every stressor you can imagine on her plate, who told me she added table sugar to her baby’s bottle. My first thought was “why didn’t I counsel her better to prevent this”. My second thought was “wow she must be desperate and need more help”, and my third thought was “of course that is going to be a tough habit to break”. Note none of my thoughts – honestly – were she is “stupid”. It’s ok to say to your doctor that advice makes sense, but it won’t work for our family. It just wastes everyone’s time to fib about your habits.
Now, let’s talk about how I discuss weight with families. I have had at least 1,000 conversations with families about their children’s weight and I have had ample opportunity to refine my practice. Perhaps some doctors will see this and learn.
The most important thing I do to come from a place of respect. This means asking a lot of open-ended questions and listening. This means using motivational interviewing techniques. This means including empathetic and true statements such as “healthy food can seem more expensive” or “it can be hard to find a way to exercise regularly when the weather is bad”. For me, I can also admit that I have had times in my life when I was heavy or when my habits weren’t as healthy, and this is what I have personally found to be effective.
Example 1:
An elementary school age child comes in for well child care. Mom’s main concern is picky eating and she is getting him to eat by preparing a narrow list of foods which are acceptable to him. She feels like she can’t take him out to dinner without risking a meltdown. When you look at him without his shirt on you see his ribs. After looking at his growth you notice he is growing at the right rate for his trajectory as you inform the mom his height and weight are normal. The mom looks surprised, “his weight is normal?” she says. “We all think he is so skinny and dad gives him protein shakes. That’s why at meals I make him whatever he wants to make sure he eats something”.
- It’s normal to see kids ribs.
- It’s normal for kids to skip meals and not something to stress over.
- Hunger is the best spice in enticing a child to eat more.
I have to add this because even my very smartest Ivy League friends don’t always seem to get this. When we discuss the percentiles, we don’t aim for 100%, we don’t aim for 50%, we aim for a child to be more or less consistent in THEIR percentile. If your doctor says your child is not too skinny and doesn’t recommend changing anything please listen to them. Do not buy pediasure and continue to harass your child to eat more to get them from their steady 10th percentile to the 20th. It’s not going to help.
I promise if anything your thorough doctor will identify, problem solve and refer any child who is struggling to gain weight. If anything we show concern for too many cases. In most cases, if a child is at an appropriate baseline manipulating their diet will NOT change their body. It WILL make the child and the parent more anxious about food and eating, it WILL worsen the power dynamic about food and fussy eating and it MAY teach them bad habits about food. It will not make them taller. High doses of protein can be harmful for young children’s kidneys and the American diet is already quite heavy in protein so in most cases you don’t need a protein shake. It is a good idea for everyone to focus on healthy eating habits1.
So in this setting, a child with normal weight, a parent should feel reassured. The family should feel motivated and reminded about what healthy habits are. I cover standard advice.
Example 2:
The child is heavy. I am calling the parent from the school to discuss the child’s asthma. I know that carrying more weight causes more asthma and is a risk factor for more poorly controlled asthma. I bring up the child’s weight by saying something very cautious like “how do you think his weight is affecting him?” In the more vulnerable neighborhoods where I work with kids living in shelters and have every stressor you can imagine, the parent speaking with me has approximately a 25% chance of breaking into tears because they are so anxious about the child’s weight. The parent has diabetes, the parent was also overweight and bullied, or the parent hates his or her own body. The parent KNOWS that it is a problem. What makes these parents so upset is not the weight or the consequences of the weight, but they feel overwhelmed, guilty and powerless.
- The first thing that I do is empower them. If it’s true I note that they are a loving, caring parent, and they want what’s best for them child. I talk about how they have just admitted there is a problem. I inform them that the child’s weight problem is not their fault. We know culture, grocery stores, microbiotic flora, genetics, and the very structure of our society lead people to be obese. The role of the parent is to identify and admit a problem, and it is the doctor’s job to help solve it.
- Step 2 is to find out if other people agree. We all know it takes a village and a nanny, father, grandparent may not agree with the assessment. Until everyone is on the same page, meaningful change cannot happen. Spending time getting on the same page is very important.
- Step 3 is taking a thorough history and identifying where the highest yield problem is. In most cases it’s one of these: Diet – too much food, wrong type of food, food at wrong times. Activity – not active enough or too much screen time.
- Step 4 is deciding what is the best thing to change. Changes absolutely involve everyone in the house. Based on what I have identified in my discussion with the family I identify 2-3 options that I think will have an impact and be feasible. Stop buying juice or start walking 15 blocks to the park every Saturday as a family etc. We choose one small and specific change and one change only for at least a week, more likely a month. Changing more things at once or making more changes too quickly makes it less likely to be sustainable. These changes should be introduced and sold as “our family needs to take care of our bodies and be healthy together” and negative thoughts need to be avoided. This is not a punishment or something anyone did wrong. This is a great chance for authoritative parenting. Make a new rule confidently and stick to it and don’t give in.
In closing, I hope you can tell that some pediatricians have put a lot of thought into providing assessment and education about a child’s weight with sensitivity. Doctors are people too, and as I think back on the 1000 discussions I have had about children’s weight, of course I have a few comments I would love to edit or take back. I am a human not a robot. But for the most part I know that the conversations I have had are helping more than they are hurting.
After challenging myself to be familiar with different view points, such as the Health at Every Size coalition and the Full bloom podcast, I also suspect that part of the reason I feel my approach is OK is that I actually don’t talk about the number very much. I never comment on someone’s appearance as I have mentioned before I strive to treat all children the way I would want my own child treated. I have only brought up a number a few times when I was REALLY worried for example, “I see that you have fatty liver disease, type two diabetes, high blood pressure and knee pain. You are 14. Your weight is over 100 pounds over the 99th percentile.” Even in these cases I go on not to recommend a “diet” or a goal weight, but to recommend lifestyle changes to help with the underlying medical issues.
Another reason I can be so confident about this is because I’ve only practiced in specialized areas where I had more time with families. To do this well takes time. So if your doctor hasn’t been able to go through all this or if your doctor asks you to come for a weight check visit to discuss the issue, please understand that they may be dealing with a different system than I have been faced with.
1) I consider healthy eating habits to include family meals, vegetables and fruits, less processed foods more whole foods, a variety of healthy fats (olive oil, avocado, salmon, dairy) and proteins (chickpea, edamame, nut, animal based, dairy), generally not eating too often, and not drinking your calories on a regular basis (ie. juice or large quantities of milk).
