When Stephanie’s daughter, who was adopted, was about 6, a nurse practitioner said something odd about the girl’s weight during a visit to the pediatrician’s office.
“She looked at my daughter’s BMI (body mass index) — and both my daughters were in the room with me — and she said, ‘So do you know any history about her origin story?’ and I said, ‘You mean the adoption? Sure, we met her birth mother,’” Stephanie, who requested her last name not be used to protect her now-teen daughter, told TODAY Parents. “(She said), ‘Do you know how her birth mother got pregnant with her? I mean, was it rape or incest?’”
Dumbfounded, Stephanie couldn’t believe anyone would say that. The nurse practitioner pressed on, saying such a back story could help explain why her daughter’s BMI was “too high.” Then the nurse practitioner gave Stephanie unsolicited dietary advice.
“She was like, ‘We have a lot of families like yours where one kid really needs to gain weight so the parents add olive oil to their dinner and the other child needs to lose weight so they don’t get to have olive oil,’” Stephanie said. “My daughter was like, ‘Wait, olive oil? I like olive oil.’”
Stephanie thought the suggestion seemed ridiculous and realized she needed to protect her daughter.
“I looked right at her and I said, ‘I’m sorry I don’t feel comfortable about the way you’re talking about this,’” she said.
Stephanie then requested that the nurse practitioner never treat her children again. While the details of her story are unique, her family isn’t alone. Many parents grapple with some form of weight bias in pediatricians’ offices and children’s hospitals, and the encounters can be detrimental.
“We have quite a bit of research that shows that children and adolescents who experience weight bias and stigma internalize these negative attitudes,” said Ximena Ramos Salas, director of research and policy for Obesity Canada and co-author of a paper on weight bias in children. “Kids can have reduced quality of life if they have self-stigma or internalized stigma. They have more signs and symptoms for depression and anxiety. They have lower self-esteem … many of them develop disordered eating.”
Weight bias in pediatrics
Weight bias or stigma occurs when people assume certain harmful things about people who have larger bodies. Often people incorrectly believe someone has obesity because they are lazy, eat too much junk food or aren’t smart. But researchers know that obesity is a chronic condition that often has multiple causes.
“There’s so many factors contributing to pediatric obesity — not only genetics but other biological disorders, economic or psychological aspects,” Dr. Andrea Haqq, professor of pediatrics at the University of Alberta and co-author of the paper with Ramos Salas, told TODAY Parents. “There’s probably a huge gap in education even within the health care profession.”
She works at a clinic that examines and treats genetic causes of obesity and sees how families react when they hear they are not to blame for their child’s weight.
“I’ve had quite a few families break down in tears when I tell them their child has a particular mutation that’s causing the obesity,” she said. “They have a huge sense of relief that ‘Oh my gosh, someone believes me that this is not my fault.’”
Despite increasing evidence about obesity, weight bias remains common in all aspects of society, including media, schools and health care. In a small study, Dr. Elizabeth Halvorson examined weight bias in pediatric hospitals and found that health care providers know it exists — and it can impact a child’s hospital stay.
“Providers talked about different ways that weight could actually influence the care we provide in the hospital,” Halvorson, an associate professor of pediatrics at Wake Forest School of Medicine, told TODAY. “There’s some data that children with overweight or obesity may have worse outcomes when they’re in the hospital. There are some studies suggesting that they are more likely to have to stay in the hospital longer, that more money has to be spent during their hospital stay.”
She says more research is needed to understand why this happens: Does weight change disease processes, do these children have more co-morbidities, or does the medical team treat them differently?
“Nobody wants to think about that,” she said.
When children and parents encounter weight stigma in outpatient care, they tend to skip much-needed treatment and screenings.
“(Weight bias) has been shown to decrease the willingness of people to seek care when they need it,” Dr. Sarah Armstrong, chair of the executive committee for the American Academy of Pediatrics' section on obesity, told TODAY Parents. “Missing those visits because of a stigma is an important consequence that we need to think about.”
Armstrong said that parents who have experienced weight bias themselves or have children that experience it are more likely to miss well visits, meaning children don’t receive vaccines, vision and hearing tests, and regular screenings for conditions. More importantly, shaming people about their weight does not encourage them to engage in health-promoting activities, such as moving their bodies or eating nutritious foods.
“A lot of health care professionals believe that if I shame the parent or shame the child or adolescent, that they might change their behaviors and … lose weight,” Ramos Salas said. “The science shows that the opposite is actually true. People who feel self-stigma, who feel self-shame, who feel bad about their own bodies, will avoid ... health-promoting behaviors like healthy eating or exercise in social settings because they don’t want to be blamed for their weight.”
What’s more, children with larger body sizes are at risk of developing disordered eating thanks, in part, to the stigma they experience.
“We have a society that so values fitness and kids are living in that society and they’re paying attention,” Armstrong said. “They are on their own trying to cope with a bigger body in a culture that shames them for having a bigger body and they’re likely to adopt some pretty unhealthy strategies.”
How to talk about weight with the pediatrician
Living in a larger body can be associated with health conditions, such as high blood pressure or Type 2 diabetes, for example, and conversations about such conditions might include talking about weight, exercise or eating. But parents can make discussions better by thinking about “the terminology and words that the child and the family want to use.”
“A parent would be well within their grounds to have a conversation with their child up front about what words they want to use to discuss weight … and let the doctor know,” Halvorson said. “That would ease that conversation because the literature shows so many of us do worry about how to bring it up without causing harm.”
After deciding how the family wants to address weight, parents can have a private conversation with the pediatrician about their preferences.
“(Parents can say), ‘I want you to have a weight-related conversation with my child but I want you to focus on health and well-being, not on looks or aesthetics,’” Ramos Salas said.
Armstrong says the American Academy of Pediatrics has been training pediatricians on weight bias and how to have better conversations about health and weight. She urges parents to share their preferences on weight discussions with their children's pediatricians.
“I think asking to talk about growth neutrally but not to show numbers or discuss numbers in front of the child is 100% acceptable,” she said.