Pediatric nutrition notes: How to talk about weight with kids

Colleen Sloan, PA-C, RDN | Image credit: Provided by author

“Look at that chubby belly! You've gained 30 pounds this year. You need to start watching what you eat and exercising more.” Reading this might make you cringe a little, but it's unfortunately language that many pediatricians use. But does such a statement truly motivate positive change or simply inflict emotional harm on our most vulnerable patients? Evaluating a child's growth should be a routine part of every annual well check. However, the question arises: Should the child's weight be discussed in front of them? Does this knowledge benefit them?

Discussing a child’s weight is often an uncomfortable situation for everyone in the room, and most importantly, for the patient. Navigating discussions about a child's weight presents a unique challenge for healthcare providers, despite our confidence in discussing other sensitive topics. On one hand, we aim to avoid stigmatization or fat-shaming, while on the other, we recognize the importance of addressing obesity risk through risk assessment, anticipatory guidance, and education.

According to a 2023 JAMA Pediatrics systematic review and meta-analysis, more than 1 in 5 children and adolescents exhibit disordered eating behaviors, which may include skipping meals to generate a caloric deficit, feeling guilt and shame around food, preoccupation with food, weight or body image and feeling the need to “make up for bad foods” consumed.1 Although its impact on health is minimized and often celebrated, disordered eating should be closely evaluated because it can evolve into eating disorders. Notably, in 2019, nearly 14 million people, including almost 3 million children and adolescents, experienced eating disorders.2 While disordered eating patterns and diagnosed eating disorders differ, it's concerning that disordered eating can potentially evolve into more severe conditions. It's noteworthy that disordered eating is more prevalent among young people with excess weight than in their counterparts with normal weight, underscoring the need for sensitivity and careful evaluation in this population.

The focus of education during an annual physical should be on helping the child make behavioral changes to support long-term health and wellness, rather than fixating on numerical changes on a chart. Emphasizing improvements in behavior, physical activity, and dietary variety over mere food restriction is crucial. Overly restrictive behaviors often backfire and lead to fixation on weight and disordered eating patterns.

When evaluating a child's growth, it can be used as a clue for you to consider what a significant increase or decrease might represent. It’s also essential for you to determine whether this weight gain is normal, developmentally appropriate changes you’d expect to see in prepuberty and puberty. Additionally, ensure you are looking at their overall growth trends, as opposed to 1 measurement alone. Rather than telling the patient how much they currently weigh or how much they’ve gained since the last visit, ask about what they typically eat in a day, how they move their body and how they feel about their body.

Here are 5 questions you should consider when evaluating a patient that could have a significant impact on their food choices and weight.

1. Have there been any changes to the family dynamic like a death, move, divorce or new baby?

2. Is the family having trouble accessing or affording food?

3. Is the child struggling emotionally in some new way?

4. Does the child have any feeding difficulties or physical abnormalities that impact her appetite?

5. Are there any concerns about eating behaviors, such as excessive snacking, skipping meals or secretive eating?

Simply telling a patient to eat more fruits and vegetables does no good if the family is struggling to buy groceries or is currently homeless. Addressing underlying issues rather than simply prescribing dietary changes is essential for effective intervention.

As pediatricians, the language we use and the way we discuss weight can influence a child's perception of themselves and their relationship with food well into their adult lives. If you must discuss the child’s weight and they are younger than 18, it is highly recommended to do so privately with the parent. In cases where you feel it is appropriate to discuss weight directly with the child, it is essential to prioritize their comfort. Prior to initiating the conversation, it is recommended to ask for the child's permission. For instance, a simple statement such as, “Are you comfortable with discussing your growth and weight today?” not only demonstrates a commitment to patient-centered care but also affords the child a sense of autonomy regarding discussions pertaining to their body.

While time constraints may limit comprehensive discussions, advocating for patients in a supportive and empowering manner can foster positive changes for their well-being. For an even deeper discussion about weight conversations with kids, check out The Exam Room Nutrition Podcast Episode 13 called the Do’s and Don’ts of Weight Conversations with Kids.

You'll learn how we can address parents' weight concerns about their child without causing any harm or damaging the child's self-esteem. You will be armed with numerous questions you can ask that will shift the focus off the child's weight and onto the behavior and family eating environment.

References:

1. López-Gil JF, García-Hermoso A, Smith L, et al. Global Proportion of Disordered Eating in Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Pediatr. 2023;177(4):363–372. doi:10.1001/jamapediatrics.2022.5848

2. Kurdak H, Tiyekli E, Özcan S, Özer ZY, Nur Topuz A. Eating disorders, primary care, and stigma: an analysis of research trends and patterns. Front Psychiatry. 2023;14:1243922. Published 2023 Sep 29. doi:10.3389/fpsyt.2023.1243922