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The Problem with Fat-Talk at the Pediatrician’s Office

“His BMI is on the high side of normal. See?” The pediatrician showed me a chart. “This is something we need to keep an eye on.” I had brought my younger child for his seven-year-old checkup, a pro forma ritual as far as I was concerned. Our pediatrics practice always asks my kids if they eat vegetables and run around every day, but this was new. I felt suddenly worried and defensive. It seemed like we should talk about it, but I was reluctant to do it in front my son.

“He looks healthy to me,” I said to the doctor. “Are you concerned?”

“Well, it’s high side of normal. You need to be aware. We should monitor this.”

I listened as he probed my son’s answers to questions about vegetables, athletics, and screen time. I could tell that in our soccer-and-lacrosse-obsessed suburb, my child’s lack of interest in organized sports was raising red flags. “Look,” I said, “my kids walk to and from school every day. Our dinners usually include brown rice and kale. I don’t regularly serve snacks or dessert. We have good habits.” The doctor let it drop, after one more warning glance at me.

When I look at my kids, I see generations going back: me and my husband, our parents, our grandparents. It’s amazing and beautiful to me to see how my kids are very much their own selves, and yet so many family traits are readily apparent. My older son looks just like my husband, and my husband’s mother and grandfather. He is slight and earnest, with a sudden, winsome smile and plentiful dimples. Buying him jeans is a chore, because even the “slim” sizes often look baggy. I think of my husband, and how skinny he was when we met in college. It was in the early 1990s, when Body Mass Index (BMI) first became a “thing.” The first time we saw a BMI chart, we laughed that my husband’s existence was apparently physically impossible, since he fell beneath the bottom of the “underweight” section of the chart. My elder son is not quite that skinny, but it is clear which side of the family he resembles.

My younger son looks like me, and my side of our family. He is robust, solid, a bold mover with a big grin. He has flesh on him, as he has since birth. I suspect that like me, if he picks up a sport, he’ll easily put on muscle. My sturdiness feels great to me, and it makes me happy to see him share it with me.

It was jarring and painful, then, to hear the doctor suggest that he might have a problem.

I was pretty sure the doctor was wrong. My husband and my parents were confident that my son was fine. The doctor’s comments, though, threw me for a loop. I felt strongly that I did not want my son to worry about his eating or his health, but I started watching in a different way. I offered healthy dinners, but he ate the chicken and not the vegetables. Was that a problem? I started trying to nudge him toward the broccoli, and requiring him to try the spinach. He had no interest in being told what to do. I could taste the frustration and impotence of this awful kind of parenting assignment, where you are supposed to change something about your kid, but you can tell you will just aggravate the very thing you are trying to fix.

Thankfully, I had the social support and the confidence to ultimately trust my own parenting skills and nourish my children in the way that I know is best for my family. The pressure to worry lifted, too, since my son’s BMI came down a bit by the following check-up. Still, I now send my husband to pediatric check-ups in my stead so he can be my filter for the “fat talk” that threatens to become a wedge between me and the pediatrician.

Public health campaigns have long assumed that health and nutrition goes hand-in-hand with weight loss. (US National Institutes of Health/US National Library of Medicine)
Public health campaigns have long assumed that health and nutrition goes hand-in-hand with weight loss. (US National Institutes of Health/US National Library of Medicine)

Reading anthropologist Susan Greenhalgh’s recent book, Fat-Talk Nation, I felt a jolt of recognition. Using autobiographical essays from her Southern Californian undergraduate students, Greenhalgh demonstrates how damaging the “war on obesity” has been, robbing children of their self-confidence, alienating kids from their parents, and turning food and bodies from sources of pleasure to sources of dread and shame. Not only did this “war” come with incredible collateral damage, it has not remotely been won. In 2014, approximately a third of adults and 17% of children were classified as obese, continuing a long term upward trend. We know how to make overweight people miserable, but we have no idea how to make them thin. Chances are, if I had taken my pediatrician’s warning to mean that I needed to control my child’s weight, I would have added another unfortunate statistic to this “war.” I felt like I had dodged a bullet.

In that pediatrics office, several historical threads came together to weave the web in which I felt trapped. The first: the doctor automatically weighed my son, measured his height, and charted it. As historian Laura Dawes describes in Childhood Obesity in America: Biography of an Epidemic, by the 1920s, pediatric assessments typically included measures of height and weight because they were objective, easy to measure, could be tracked over time, and seemed like an intuitive indicator of whether a child was thriving (p. 23). It may or may not be the best measure, but it’s easy to do, so it has become routine. When the concept of BMI came along, pediatricians could adopt it without much effort or reflection, because they were taking the relevant measurements already.

The second: the doctor assumed that parents, especially mothers, have the ability to mold their children, and delegated me primary responsibility for monitoring and presumably controlling my son’s weight. Mothers have been given cultural authority to shape their children since the time of the American Revolution, but the expectations placed on mothers have ramped up in recent decades. It’s not at all clear how much control mothers actually have over long-term, global outcomes like obesity. But facts don’t matter when it comes to mother-blaming.

The third: in our zeal to monitor our health and prevent future problems, we have expanded the criteria for defining who is “at risk” for future illness. For example, historian Jeremy Greene has described how, during the last several decades, millions of healthy Americans have begun routinely taking drugs to reduce the future risk of heart disease, stroke, and diabetes-related disability. Doctors measure an array of risk factors, tally a composite score, and prescribe according to the number. In deciding that my child might be at risk for obesity, the pediatrician did not eyeball my kid and render a judgment; he reached his conclusion after charting my son’s height and weight. When I said, “he looks normal,” I directed my physician’s attention to my son. The pediatrician pointed me instead to the chart. Perhaps looking for subtle signs of risk and addressing it is the right thing to do. But any treatment comes with side effects, so over-treating is not benign. In the case of childhood obesity, the situation is particularly problematic: as Greenhalgh showed, haphazard parental attempts to control kids’ weight can, in fact, be highly damaging and counterproductive.

As a society, we certainly do need to figure out how to build a healthy food environment, and give our kids the structures and tools they need to have healthy bodies. Obesity is hard on kids, and even harder on the adults they will become. But I am skeptical that the mechanism for societal change will be pediatricians closely monitoring BMI scores and scolding parents about their children’s weight. Let’s figure out a better way, and put parents and their children on the same side in that effort.

Further Reading

Laura Dawes, Childhood Obesity in America: Biography of an Epidemic (Harvard University Press, 2014).

Susan Greenhalgh, Fat Talk Nation: the Human Costs of America’s War on Fat (Cornell University Press, 2015).

Jeremy Greene, Prescribing by Numbers: Drugs and the Definition of Disease (Johns Hopkins University Press, 2008).

Sharon Hays, The Cultural Contradictions of Motherhood (Yale University Press, 1998).

About the Author

12 Comments

swithycombe

Excellent points Lara! I was torn between shock and giggling at the ridiculous notion when my son’s pediatrician talked about his BMI starting at his 6-month appointment. Do we really want/need to be talking about infant and toddler BMIs?? And now I’m worrying about what do about those clinical encounters when he’s old enough to understand the doctor discussing his height and weight charts. It may not be enough to outlaw the word “fat” and try to focus instead on the functionality of our bodies at home if the “experts” are so caught up on the numbers. Lots to think about.

larafreidenfelds

It’s astounding to me that pediatricians are now talking about BMI in infants. If a kid isn’t eating solids yet, he can’t “overeat,” at last if we believe in feeding babies on demand. I think the pediatricians would do much better to hand out healthy recipes, and a list of prepared foods that are the healthy choices. It could also be good to reassure parents that it’s ok when babies and toddlers don’t want to eat much — they go through phases, growth spurts, etc., and we want to teach them to listen to their bodies. And, most importantly, this ought to be education and support for everyone, whatever their BMI!

At pediatric checkups, my kids always enjoyed learning how much they’d grown. It’s an opportunity to say, “wow, you’re really growing up!” It’s a metaphor for other kinds of development. It’s so sad to create anxiety around that measurement. If the BMI thing had come up again, I think I would have called the office ahead of time to ask them to discuss it with me privately if they had any questions or concerns.

Rhonwyyn

The article was good until the last paragraph. “Obesity” is hard on children and adults because of the bias against fat bodies. Fat bodies are not inherently wrong; they are not problems to solve.

Lara Freidenfelds

I appreciate your perspective, and your correction. I agree that fat bodies are not inherently wrong. I do worry, though, about the health issues that frequently stem from fat carried on the body over time. Having watched people I love struggle with type 2 diabetes related to obesity, for example, I would like to help my children and others not have to face that problem.

Deb Lemire

We have to be careful to not mix causation with correlation. Weight does not cause diabetes. There are thin people with type 2 diabetes and there are fat people who will never develop it. The BMI measurement was never meant to be used on individuals and is not a reliable measure of health. People can maintain or work toward healthy behaviors at any size. Only when we get to the statistical extremes on either end of the weight spectrum does it have a detrimental impact. There are some really great people working in the field addressing this bias. Some research and contacts can be found at http://www.sizediversityandhealth.org if anyone is interested.

Yvonne Brown

Well I don’t want to be perceived as being totally cynical but I have thought for a long time that the “well-baby checkup,” the regular doctor visit for healthy children, and even the yearly check-up for healthy adults probably causes more problems than it solves. As you said, it raises anxiety and the context seems conducive to finding something that has to be watched or worried over, and in the case of many adults, medicated. I don’t think most general doctors know very much about all the causes of obesity or can even predict future obesity in a 6 or 7 year old. I don’t place all the blame on doctors, but the relationships are still unequal, particularly in the deep South where I live. Perhaps some physicians still think they have to be experts on everything. As you demonstrated, you know more about your own family history and child than he/she does. But that is just my two cents worth of opinion:)

larafreidenfelds

I agree. Perhaps we need to re-think the purpose of a well-check. What if we thought of it as an opportunity for a parent (or an adult) to ask all those little, nagging semi-medical questions that have piled up but haven’t driven us to an actual doctor appointment? We’d mostly be getting reassurance, and the doctor’s role would be to answer questions, and only sound the alarm if something appears way out of whack. That approach might serve everybody better. Perhaps it would be best as a “wellness visit” with a nurse, with enough time to really talk.

Sarah T

This article is frustrating. As a parent, I would want to know my child’s status on different measurements. BMI is only one glimpse at their weight status, but it is correlated pretty strongly with future health risks. As a nutritionist, I have had to tell parents that their child’s BMI was in an undesirable range. It’s tough! Pediatricians are not trained in counseling or motivational interviewing. They tell you the facts in the little time they have and hope you can figure out the rest. A different approach is to ask you if are concerned about your child’s weight and actively assess what efforts you are making to help your child be healthy. Like the doctor in the story, other risk factors for obesity and chronic disease include physical activity, screen time, use of sugar sweetened beverages, fast food consumption, ect. If a child is active and eating healthy, but gaining weight rapidly, other medical concerns should be assessed.
If a parent is not concerned (like the author of this article), then offering to monitor the child’s weigh periodically at least gives a better picture of your child’s growth. Most kids do not grow in a linear fashion. It’s more like a staircase, they gain weight and then nothing for a while, then more, then none. They will also stop growing periodically if they have been very sick. Children are a critical period of their lives to set up the trajectory of their future, healthy selves. Having a doctor who would like to monitor your child’s weight and is honest with you about their concerns is a good thing. Most pediatricians I have worked with won’t say anything for fear the parents will be mad. This is ridiculous. Actually, my biggest problem is when people talk about a child’s weight with the kid present. Whenever possible, children should not be apart of conversations about their weight and encouraged to eat healthy because it will make them feel good and strong.

Lara Freidenfelds

I appreciate your desire to help families be healthy. I absolutely share that with you. I’m just very skeptical that this approach helps more than it hurts. Perhaps at the point that you, a nutritionist, talks with a family, you are able to offer guidance that has good results. Do you know? Do you have evidence of outcomes? I would love to see pediatricians give out concrete nutritional guidance to every family (since thin people also eat a lot of junk, and may be even less likely to realize it’s a problem, since everyone praises them for their low BMI). I know it took me a lot of time and thought to figure out how to send my kids to school with fresh fruit snacks, for example (you need the right containers, and only some kinds of fruit work well). I read every darn label at the grocery store, and figured out which two kinds of crackers are whole grain and have no added sugar. What if my pediatrician made a list of healthy snacks that are available at our local grocery store, and included a link to containers that work well for packing fruit? What if he offered moral support for being a “countercultural” foodie? I often explain to my kids that some of our family practices are countercultural, and I acknowledge that yes, it can be hard to be the only kid who doesn’t have chips and dessert in his lunch, but we feel strongly about our family’s values. I think these approaches to talking about food and health at the pediatrician’s office are much more likely to produce good outcomes for more people. They are positive, they acknowledge the problematic food culture we and our kids have to navigate every day, and they are appropriate for people of every size.

Sarah T

Unfortunately, pediatricians have little training in nutrition. They have training in growth and understanding measurements and statistics. They are very knowledgeable about disease and medicine. But there is much to be desired when it comes to disease prevention or nutrition counseling. If there are parents who would like guidance on feeding their children, there are nutritionists (specifically Registered Dietitians) who can help you with individualized and respectful help. We don’t go to the doctor for help with a tooth ache, we go to a dentist. When you are worried about your child’s weight or diet, find a nutritionist. If it was up to me, a check up with a nutritionist would be included every year and insurance would cover it like they do other preventative care. And yes I do have evidence of positive outcomes with this approach, both anecdotally with my own clients and also statistically.

http://www.eatright.org/resource/food/resources/learn-more-about-rdns/what-an-rdn-can-do-for-you

Weight is one measurement that we focus way to much on, but it is still useful information. For example, I had a client who’s child was gaining weight normally and then suddenly started gaining rapidly. After talking with mom over two sessions, we figured out what had changed. Mom was sending her child to school with healthy snacks, but the girl was trading them on the bus for junk food. While we can’t control every place or item your child eats, mom was able to talk with her about junk food and was able to connect it with why she was always tired after school. Mom also enrolled her in a swim class to increase her physical activity. The child did not lose weight (we never want children to lose weight, we just like them to gain weight normally in a way that is healthy for their bodies), but she got back on track and was gaining normally. If a child is not gaining weight or gaining weight to rapidly, it gives us a clue (only 1 clue in a sea of clues) about what is going on.

Lara Freidenfelds

It sounds like pediatricians need to learn how to respectfully refer patients to qualified nutritionists (and perhaps on the basis of what they say about their diet and eating practices, not just BMI).

Tcln

Unfortunately, doctors know very little about nutrition, and the food industries market all kinds of processed junk as healthy. All long-lived, healthy populations, throughout the world, have been primarily plant-based. Yet, our culture views that type of diet as extreme. Meat consumption has more than doubled since 1900, and you can look at crowd photos from 50-100 years ago, and you’ll rarely see an overweight person much less an obese one. The answer is right there in front of us. It’s not about feeding your child chicken and broccoli. Take the chicken off the plate, at least most of the week, and replace it with more whole plant foods and fruit. No dairy or oil. There won’t be a weight issue. Only 3 species on the planet have weight problems – humans, cats, and dogs – because we’re not eating our natural diet. For more info, watch the movie Forks Over Knives.

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