I wrote the bulk of this a few years ago. It wasn’t a “letter” then and I only shared a printed version with local docs. But recently I’ve learned of a new atrocity in the “fight against childhood obesity” thanks to Weight Watchers’ greed. Weight Watchers is opening its doors to teenagers this summer. And it’s a freebie. Which means they will be sucking young girls in to the cycle of yo-yo dieting when they are most impressionable. To quote the fabulous eating disorder dietitian, MarciRD:
“Weight Watchers is fully aware that its financial success is founded upon the fact that dieting (yes, WW is a diet) doesn’t work for the majority of people. Dieting is a primary risk factor for future weight gain, poor mental health, reduced self-esteem, negative body image, and eating disorders. Weight Watchers is the literal antithesis of what is best for teens during a critical time of identity formation and development. Just no.”
The whole idea flies in the face of the AAP’s own recent statement about Preventing Obesity and Eating Disorders in Adolescents. So…
I know you care deeply about helping kids grow up to be healthy, and supporting parents in the process. So I know you do your best to speak compassionately when it comes to sensitive issues. I know you choose your words carefully. Because of this I want to give you some things to consider before you broach the topic of “obesity” with the parents of a child who happens to have a large body.
Being called “too fat” makes girls fatter.
A study at UCLA found that girls who were called “too fat” by someone before age 10, were more likely to be obese at age 19. This is inline with other literature which suggests that weight stigma and dieting make kids gain more weight than they would have otherwise. I’m not saying that YOU ever would dare to say to a child “you’re too fat.” But I wonder if you have explored the culture of the family and how often the child receives either overt or subtle messages that say the same thing. If not, it’s worth looking into. When parents leave your office, their fear of making their child feel not-good-enough should far exceed any fear of fatness. Because the worst consequence of weight stigma is not weight gain, but feeling unworthy of love and belonging.
It’s not only what we say, but how kids and parents interpret it.
While I consider the term “fat” a neutral descriptor, our society has made it into a very loaded, very negative term. Even though health care providers don’t use this word when talking to patients, kids are very perceptive to subtle messages that their bodies, appetites, and food preferences are either “wrong” or “a problem.” Kids quickly figure out that certain body types are unacceptable and food is either fattening/bad or slimming/good. Parents often feel pressure to respond to weight concerns with food restriction and dieting. The way health care providers address the issue, can influence how parents respond and how children feel about themselves.
Typical Advice Common Misinterpretation by Parents Common Consequences
|Increase fruits/veg||– Push and coerce fruits/veg. Make dessert dependent on fruit/veg consumption.
– Scold and nag about fatness if kids don’t eat fruits/veg.
|– Turning kids off to fruits/veg because they are “work” to be done as penance for fat body.
– Power struggle at the table.
|Keep “junk” food out of the house||– Parents are at fault for what they are buying.
– Parents must immediately switch to foods that are unpalatable, expensive and unappealing.
|– Feelings of deprivation.
– Feelings of blame.
– Feelings of guilt for liking the “bad” food.
– Enhanced preoccupation with forbidden food items & disinhibited eating of forbidden foods when opportunity presents.
|Control portions||– Parents should only allow kids to eat a set amount regardless of feelings of hunger.
– Parents should limit certain foods every time.
– Kids’ hunger is not to be trusted if they are large.
– Kids’ don’t know when to stop eating if they are large. If parents don’t control portions, kids will always overeat.
|– Kids believe they are untrustworthy around food and it becomes a self-fulfilling prophecy.
– Food sneaking.
– Food preoccupation.
– Disinhibited eating when opportunity presents.
Often missed causes of accelerated growth.
As the above chart suggests, the same kinds of food restriction measures employed to help a heavier child can actually exacerbate the issue. This is because food restriction creates food insecurity, making the child fear going hungry. Interestingly, unreliable and inconsistent meals and snacks often result in the same consequences because, to the child, it feels like food insecurity. In the same vein, lack of structure with feeding and interference with the child’s job of eating, can, over time, undermine that child’s ability to internally regulate food intake and grow appropriately. None of these causes have anything to do with food choices, yet it is at food choices that most advice is directed.
Telling parents to change food can do more harm than good.
The common belief is that parents can magically produce a thin kid with no negative consequences merely by changing food choices. But, in the absence of a full nutrition and feeding assessment, even seemingly innocent advice to increase fruits and vegetables tends to lead parents into controlling feeding practices. Controlling feeding practices (such as restricting portion size and offering only “healthy” low-calorie foods) undermine a child’s self-regulation and generally backfire by making those kids fatter and more troubled about food. For these reasons, a foundation of healthy feeding practices (not food selection) must be established before any advice on “what to eat” is given. So what is a conscientious health care provider to do? We certainly can’t ignore a growth or health concern and say nothing. Yet we also don’t want to offend the child and parents or scare them into making the problem worse.
Focus on growth changes, not static points and help parents respond appropriately.
Discuss the growth chart with parents long before there are concerns. Explain that typical growth means growing consistently at approximately the same percentile over time. A single data point is not indicative of a problem because healthy children come in all sizes. While their use can’t always be avoided, keep in mind that the terms “obese” and “overweight” are focused on a single data point and tend to be alarming. In the case of weight acceleration, growth velocity is the issue to emphasize, not the child’s present weight. Do mention that their child’s weight is increasing at a faster than typical pace and it would be wise to get a feeding assessment (in addition to your medical assessment) from a dietitian. It is critical that parents don’t panic and put their child on a diet, or single-out their child and feed him/her differently than other family members are fed. Emphasize to parents that good feeding practices are a long term investment and will support healthy growth over time, rather than changing weight now.
Refer out for added support.
I know you don’t have time for an hour feeding assessment where you get into the nitty gritty of what’s going on at home, the pressure parents feel, the pressure the child feels, nutrition understanding, body image concerns and all the food battles that may or may not be happening.
Enter the dietitian and therapist. That’s what we’re here for. We’ve got the time and expertise to work with families until they feel confident about feeding and kids are well supported to eat and grow as their bodies are designed. Sometimes this is going to involve living in a larger body. But good feeding practices and parenting will help that child live with confidence, provide some inoculation against future yo-yo dieting, and create a healthy relationship with food. And that is setting up kids for success regardless of their size.
So dear caring pediatrician, please let your compassion and wisdom win over your fear of fatness. Give kids and parents a fighting chance at not getting sucked into diet obsession. You will set the stage for true health and happiness.
Adina the Dietitian
P.S. Extra reading for parents and docs:
Patterns and Prevalence of Disordered Eating and Weight Control Behaviors in Women Ages 25–45 (relevant because this is what early dieting frequently leads to)