How to talk to your patients about weight issues

How to talk to your patients about weight issues © fizkes - stock.adobe.com

Our pediatric patients, particularly post pandemic, are facing an epidemic of chronic physical and mental diseases, and the management of conditions such as being overweight,¹ being underweight, and disordered eating² may involve a clinician, family member, or child bringing up the topic of weight. Our practices commonly see children who are overweight or obese, have type 2 diabetes, and/or have nonalcoholic fatty liver disease; however, we also see patients who are underweight, have a poor appetite, are picky eaters, or have avoidant/restrictive food intake disorder (ARFID), rumination syndrome, relative energy deficiency in sport, or eating disorders (EDs). What is the optimal way to determine when to discuss this topic? What is the role of various indicators in this discussion, ie, scale, body mass index (BMI), and blood tests? How can we effectively address nutrition and exercise in our discussions?

The basic tenet of medicine encapsulated by the Hippocratic Oath is “First, do no harm.” Yet, well-meaning clinicians and family caregivers who are concerned about the weight status of their patients/loved ones (whether overweight or underweight) can sometimes adversely affect the treatment trajectory by the inadvertent use of harmful words and actions.

In my clinical practice, families will sometimes present with concerns about undereating in one child and overeating in another. Often these families do not realize that their well-intentioned approaches of forcing or restricting food is counterproductive. Although certain diagnoses, depending on severity, may require more acute levels of care (hospitalization, intensive outpatient programs, medication, or surgery), behavioral lifestyle intervention (whether primary or adjunct) is always first-line treatment. Surprisingly, the same principles can benefit children regardless of the type of concern. A sensitive,³ family-centered, multidimensional, behavioral approach builds collaboration and motivation. Indeed, helping patients learn optimal weight management strategies while avoiding dieting or disordered eating demonstrates the art of medicine. Keep the following principles in mind:

1. First, do no harm. Physical conditions and mental conditions associated with being overweight¹ or underweight, or having disordered eating⁴ share many similarities including a complexity that requires multidisciplinary approaches: lack of diagnosis, effects of social determinants of health (not moral failing), and high stigma.⁵ Overweight and underweight patients and patients with EDs at normal weight are often associated with the same pain points—patient distress and caregiver stress. EDs are the second leading cause of mental illness–related death,^6,7 only second to opioid–related deaths, and they are associated with many comorbidities. Inadvertently contributing to disordered eating is something clinicians want to avoid at all costs.
2. Be sensitive to weight stigma and the harm of weight bias. Weight stigma refers to the labeling, stereotyping, and discrimination of people based on body size or weight.^8,9 Children with larger or smaller bodies may experience stigma from multiple sources: parents, family, teachers, and health care providers with ensuing counterproductive physical and mental health repercussions.^10,11 For example, children experiencing weight stigma are more likely to binge eat as a coping mechanism and use unhealthy weight control practices. They are more likely to avoid exercise, delay or avoid seeking health care, and even engage in substance abuse. If weight stigma becomes a chronic stressful experience, it can lead to the activation of inflammatory pathways that increase the risk of disease. Children who are underweight are also subject to stress. A child is more at risk for failure to thrive if they are in a family facing poverty, high stress, or poor parental coping skills. Research on ARFID shows that creating a positive emotional context surrounding food and eating with others may reduce psychosocial impairment and increase food variety in people with severe food avoidance.^12,13
3. Be aware of our own biases. Acknowledge one’s own weight-related experience, history, trauma, or even the avoidance of the topic due to the difficult nature of its discussion. Because weight bias is so prevalent,¹⁴ most health care professionals will have weight bias whether they realize it or not.
4. Realize that words matter. The 2017 American Academy of Pediatrics policy statement on weight stigma⁹ provides 6 clinical practice and 4 advocacy recommendations regarding the role of pediatricians. Recent evidence shows that neutral words like “weight” and “BMI” are preferred by adolescents with overweight or obesity, whereas terms like obese, extremely obese, fat, or weight problem induce feelings of sadness, embarrassment, and shame if parents use these words to describe their children’s body weight. Youth are acutely aware of and have strong opinions on language about body weight.¹⁵ Furthermore, using people-first language is one step to help reduce the use of potentially stigmatizing language (eg, a child with an elevated BMI rather than an obese child).
5. Start the conversation. Ask caregivers and patients permission to discuss the issue of weight, and choose terminology that is respectful.¹⁶ Use language that is centered on acceleration or increases across percentiles over a period of time. Invite curiosity about whether these changes are indicators of health issues, changes in the patient’s life, or family habits/patterns. Nonjudgmental, open-ended questions are more likely to get to the root cause.
6. Seek first to understand. Listen to the patients and families. Be curious. Often stressors or changes in life circumstances can cause a history of disordered eating in the patient or caregiver to surface.
   1. Listen to the caregiver¹⁷: What do you hear?
      1. I struggled with bulimia at this age, and I don’t want this to happen to her.
      2. Eating healthily is too expensive for us, and I don’t have time to cook, especially something different for him.
      3. We show love by feeding our family. I love when they eat a big meal.
      4. Three months ago, she was told to go on an elimination diet. Now she has cut out food groups, only eats 3 foods, and avoids social events to avoid stomachaches. I don’t know what to buy for her, and I am worried about her.
      5. We are a busy family, so fast food is the easiest to pick up. It’s the only meal she will touch.
   2. Listen to the teenager: What do you hear?
      1. I was bullied¹⁸ in school today because of my weight.
      2. I am not going to give up [name of an ultraprocessed food].
      3. I hate being weighed; it’s embarrassing.
      4. I feel awkward doing sports and don’t enjoy gym. Plus, I hate changing in the locker room.
      5. My last pediatrician made me
         feel terrible.
      6. I want to make the varsity team (or be prom king) so I have to lose weight.
      7. I’ve tried [names of fad diets]. None of them work. I am tired of feeling hungry and irritable all the time.
      8. I’m don’t have time for breakfast, and school lunches are nasty.

Recent data also show that parents and adolescents have different motivations for engaging in or avoiding weight communication.19 In some situations, parents were motivated for engaging or avoiding weight communication by protecting adolescent body esteem, but adolescent motivations for weight communication with parents stemmed from health concerns and worry about their weight. It is important to listen carefully to all parties, and remember that every family situation is different.

7. Let the patients/families drive the conversation. Patient-centered motivational interviewing aims to solve issues important to the patient/family in the order they desire. When we give advice for which they are not yet ready, we risk driving them away. While someone in the precontemplative stage of the transtheoretical model of change²⁰ may be viewed as not being interested in change, be curious to discover what other stressors are more pressing to them at the current time. Focus on their priorities, help them find a healthy habit touchpoint that resonates with their concern, and let the synergy of lifestyle habits²¹ operate until they are ready to work on weight. This is ultimately more effective with patients/families feeling empowered as the drivers, and clinicians feeling freed from being powerless coaches.

If patients/families want to discuss weight, how do we approach this?

Focus on health habits rather than weight or body size.

Take the focus off body size, and instead support the development of healthy lifestyle habits^.22 Focus discussion on health, longevity, and developing sustainable healthy habits. Start early with the same healthy messaging in all visits, regardless of body size, not just when there is a weight problem. Let kids know that dieting and especially unhealthy weight control behaviors may be counterproductive. Do not recommend any specific diet or weight loss program without the appropriate support (eg, multidisciplinary pediatric clinic).

Think beyond the numbers.

If a parent or child asks, “How do I lose weight?” or “How much should Johnny weigh?” emphasize that the number on the scale is much less important than day-to-day habits regarding eating, joyful movement, sleep, etc. Explain that body weight is impacted by both habits and genetics, so it is important to focus on adopting healthy habits. Body weight will adjust based on genetic potential. The goal is to create sustainable healthy habits. Avoid overly simplistic messaging such as “eat less, move more.”

There are many times when it may be necessary to measure weight in the office, such as during well checks and for calculating medication doses. Be thoughtful about methods used and how often to obtain weight for children presenting for frequent follow-ups. If a patient has a sensitive history regarding weight (eg, an eating disorder), consider having them weigh standing backward, weigh in a private area, and remove data from printed patient materials. Sometimes proactive parents will send a note discreetly to the medical assistant requesting that their child not be weighed in the office. But sadly, that often comes from wisdom learned from previous negative experiences at a medical practice. If you find a method that works well for a patient, note this in their chart for future visits.

Promote positive relationships with food and weight.

• Take the pressure off. When counseling families, discuss Ellyn Satter’s Division of Responsibility in Feeding: The parent is responsible for when, where, and what food is available. The child is responsible for how, how much, and whether to eat the food.²³ Encourage exploration of food in friendly, nonjudgmental environments. For example, “positive peer pressure” provided a way for pediatric oncology patients with oral aversions to build strength and meet nutritional needs through a peer-supportive cooking class.²⁴ Similarly, the Nibble With Willow program²⁵ demonstrated that children given the opportunity to explore, touch, smell, and taste produce using all their senses were much more amenable to eating fruits and vegetables.
• Focus on what food can do for the body. Avoid binary language (good/bad, healthy/unhealthy, clean/junk food). Encourage parents to avoid reacting negatively to a child’s distaste. When counseling families, model with neutral language and age-appropriate facts. Some examples are: Orange food helps you see in the dark. Purple foods give you a strong brain. Candy can give fast energy but that ends quickly. Protein gives you energy and is good for your muscles.
• Promote family-powered habit change rather than focusing on one child. For example, the whole family eats at the table device-free, walks together for 10 minutes after dinner, or gives compliments to each other.
• Encourage mindful eating and nonjudgmental curiosity. Teach kids to be curious and to listen to their own bodies.
• Focus energy on active, enjoyable family activities. Avoid focusing on physical appearance, and model appreciation for the body’s capacity to become more energetic and stronger.
• Help patients find their “jam” or superpower. Personalize the conversation by connecting with the patient and learning what most engages them.

For patients who like to cook, consider asking them about their favorite spices as an entry point to discuss the health benefits (eg, of ginger, garlic, turmeric, and cinnamon) or share cooking and food preparation techniques that improve nutrition. For example, chopping garlic increases allicin; add mustard, which contains antioxidants, to cruciferous vegetables.²⁶ Some of my adolescent patients with chronic conditions have become creative recipe curators following their personal health crisis.

For environmentally conscious patients, consider exploring together how food choices can help with climate and environmental health (eg, eating more nutritious, low-cost, soil-benefiting beans/pulses, which are the edible seeds from legume plants; reducing red meat consumption²⁷; sprouting/fermenting during offseasons; eating locally produced foods; and creatively using all parts of produce²⁸ in healthful low-
carbon recipes.

For adolescent athletes interested in maximizing performance, this may be a golden opportunity to discuss balanced and healthy habits, bringing in “stealth” nutrition.^29-31

To engage patients who enjoy self-care,³² refill the office lollipop jar with herbal tea bags or trail mix; suggest a ritual of sitting with a warm or cool beverage mindfully, possibly accompanied by journaling; or suggest colorful and fun hydration (water with fruits, herbs, or phytochemical
rich flowers).

To engage patients who enjoy the outdoors, consider decorating your office with small herbal plants (rosemary, oregano, basil), invite them to smell the herbs and add them to food, experiment with gardening/ sprouting, interact with indoor plants, and spend time outside.^32,33

Common Challenges and Strategies for Harm Reduction

1. Recognize the challenges of expanding taste preferences in food-insecure households. When addressing nutritional change, it is important to consider social determinants of health. Be mindful that caregivers in low-resource settings face tremendous stress, often working multiple jobs, seeking to avoid wasting food, and wanting to avoid conflict with their children whilemaking them happy. They may even seek to maximize calories by choosing fast food items with the highest number of calories for the price. The physiological stress to the caregiver (and trauma to the child) of running out of food can lead to hoarding, other socially unacceptable behaviors, and more pressured feeding behavior to young children.³⁴ Taking into account Satter’s Hierarchy of Food Needs35 (from the bottom, enough food, acceptable food, reliable ongoing access to food, good tasting food, novel food, and instrumental food), first connect families with resources to address their immediate need,³⁶ then connect caregivers to resources^37-41 that give an opportunity to explore a variety of novel food without fear of cost burden or waste.⁴²

2. Explaining the role of medical tests, measurements, and bloodwork. Having a BMI that is 95% or higher can increase the risk for a variety of chronic and serious health problems, including type 2 diabetes, high blood pressure, heart disease, high cholesterol, nonalcoholic fatty liver disease, arthritis, and even some types of cancer. The physician may recommend 1 or more tests (bloodwork, urine, ultrasound, sleep study) depending on the specific concerns they have for the patient. Rather than using body dissatisfaction as a motivator for change, model appreciation for “what our body does for us” and recognize that we can consider change without being judgmental about ourselves.

Conclusion

A mindful, compassionate, sensitive approach predicated on generous listening and collaboration can serve as a gentle entrance to a patient/family-guided conversation without the discomfort or fear that often surrounds conversations about weight. This ultimately serves to support patients/families in the most effective and
lasting way.

References:

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