How doctors can stop stigmatizing -- and start helping -- kids with obesity

Kids with obesity face a host of health problems related to their weight, like high blood pressure, diabetes and joint problems.

Research points to another way heavier children and teens are at risk: their own doctors' bias. This prejudice has real health consequences for kids, making families less likely to show up for appointments or get recommended vaccines.

I am a family physician at a community health center in Washington, D.C., and many of my young patients have obesity. It's no surprise. Obesity is the most common chronic disease that affects children and teens in the U.S. One-third of American kids are overweight or obese.

But I often feel totally unprepared to talk about it in a way that puts kids at ease. We have to cram in a physical exam, shots and parent questions into a 15-minute appointment, and a discussion about a healthy lifestyle sometimes feels like an afterthought.

I remember one recent visit with a teenage girl and her mom, tripping over the words I chose. "Let's talk about your weight," I said, offering a reassuring smile.

It didn't seem to work. I still think about the look of shame on my patient's mom's face, as if her daughter's obesity were a personal failing.

I spent the next few minutes offering canned advice like joining a sports team or cutting back on soda. My patient, meanwhile, sat silent and uncomfortable.

I certainly didn't intend to make her feel bad. But the constraints of working in a community health center with tight resources — the short appointment, not knowing each other well — made me fumble awkwardly for the best way to talk about it.

There's also not a lot of evidence that my attempt to counsel her would even help. Multiple studies have demonstrated that most primary care interventions don't work particularly well to help patients get to a healthy weight.

It left me wondering whether part of the reason so many patients feel ashamed when their physician brings up their weight is because it feels like a throwaway comment. If, as a physician, I'm not going to offer you effective tools to help you with a health problem, does it even help to bring it up?

Most other doctors aren't doing much better choosing language that helps their patients feel comfortable.

In a major 2012 study of over 2,200 physicians, for example, researchers found that most doctors harbor significant prejudice against patients with obesity. When researchers surveyed almost 2,500 people about weight discrimination, women reported that doctors were the most common source of stigma about their weight.

We physicians are supposed to help our patients stay healthy, but instead we're making them feel judged.

And when patients feel judged, they may not trust their doctors — and get the health care they need. Not only are we doctors doing a lousy job helping our patients lose weight, but also our stigmatizing behavior may stop patients with obesity from getting other preventative care. Teen girls with obesity, for example, are less likely to get the HPV vaccine than normal-weight teens, according to a study published in January 2019. This puts them at an increased risk for cervical cancer. When asked what they would do if a doctor described their child's weight in a stigmatizing way, nearly a quarter of parents in a 2011 study said they would simply avoid future medical appointments.

So I set out to learn how doctors can be more thoughtful when we care for kids with obesity. If we can help our patients feel comfortable when they come to see us, maybe we can chip away at some of the health disparities they face — and help them fight obesity-related diseases like high blood pressure and diabetes.

A group of pediatric obesity specialists is working to change the conversation. At centers across the country, they offer intensive support for kids with obesity with teams of doctors, psychologists, nutritionists and health coaches. And they take a radical approach: Don't make kids feel bad about their weight, they say, and it just might be easier for them to lose it.

One example of this type of center is close to where I practice in Washington, D.C. It's the IDEAL Clinic at Children's National Hospital (IDEAL stands for Improving Diet, Energy and Activity for Life), and I often refer my patients there. I met with medical director Dr. Nazrat Mirza, who says the key to helping kids lose weight is treating families with dignity.

"Everybody recognizes the respect that they're getting here," Mirza says.

The clinic I visited is a colorful, upbeat space with murals of athletes on the exam room walls. IDEAL opened their first site in 2006 and, according to Mirza, had a 500-person waiting list within three months. Now the IDEAL team cares for about 5,000 patients at several locations in the Washington area.

When patients and their families first enroll, they come to see Mirza and her colleagues every few weeks. Everything about the intake process is designed to help families talk about obesity in a neutral, factual way, avoiding words that compound the discrimination kids feel in their daily lives.

Mirza points to a pair of studies which looked at which terminology adolescents and their families prefer that health care providers use when talking about excess weight. Most participants didn't want their doctors to use words like "obese," "fat" or "extremely obese." Terms like "unhealthy weight" or "high body mass index," however, were more acceptable to families. Advocacy groups are working to make this kind of language the norm in all doctors' offices, not just specialty clinics like IDEAL. The American Medical Association passed a resolution in 2017 designed to teach health care providers to use "people-first language" that "places the person before the disability or disease." This means, for example, describing a "patient with obesity" rather than an "obese patient."

This kind of culture change in the doctor's office could help kids start to understand the multiple factors that influence body weight and that it's not their fault that they have a disease.

According to Dr. Susma Vaidya, another pediatrician in the clinic, as kids start to work with the IDEAL team, they realize their weight is rooted in biology and the environment they live in, not willpower.

"An adult is more able to understand," Vaidya says. "With kids, there's just so much stigma."

Part of the IDEAL team's strategy to destigmatize talking about pediatric obesity is a holistic approach to care. The clinic has more specialized staff than my primary care office, for example, and longer visits. Kids meet regularly with a nutritionist, a psychologist and a health educator.

"Your food habits are impacted by so much more than hunger," says Julia Jankowski, a registered dietitian who works at the IDEAL clinic. "A dietitian is kind of like a therapist."

Caring for children who are at an unhealthy weight is different from treating adults. Kids, of course, can't go grocery shopping or get a gym membership on their own. So the approach needs to take the whole family's health into account.

Matilde Palmer, the clinic's health educator, puts a particular emphasis on parenting skills, helping caregivers learn to show their love and reinforce positive behaviors with tools other than food.

Even if a preschooler demands juice every day, she says, a parent can find positive ways to rewire the habit and avoid tantrums. "You have more control than you think," she adds.

Compared with the occasional primary care visits that many families are used to, the IDEAL clinic's interdisciplinary model can feel intense. Some families aren't ready for biweekly visits to the clinic or an overhaul of an entire household's eating habits.

"We do live in a culture where we're snacking all the time," Vaidya says. "By the time they're 3, they're eating french fries."

Some of the changes that the IDEAL clinic recommends can be tough for poor families. So this approach might be hard to bring to some of the kids who need it most. We know that low-income children are more likely to have obesity than their wealthier counterparts, a disparity that Vaidya says is likely caused by many factors: the difficulty of finding fresh fruits and vegetables in poor neighborhoods; parents unwilling to let their kids play outside if they think the neighborhood is dangerous; the challenge of making home-cooked, sit-down meals when parents are working multiple jobs.

Still, some pediatric obesity researchers say that even though this all-in, family-focused approach is difficult, it's the best model we have to help kids who are at an unhealthy weight.

"What the evidence shows is that you need frequent, intensive contact with multidisciplinary teams," says Brooke Sweeney, a pediatrician and the medical director of Weight Management Services at Children's Mercy in Kansas City, Mo., a program that takes a similar approach to IDEAL. "Making ... changes is extremely difficult. You need lots of support to actually do this," she says.

Sweeney points to a 2010 review article looking at kids' weight management programs. The more frequently families met with clinicians and the more comprehensive the approach — that is, interventions that targeted diet, exercise, behavior and family dynamics all at once — the more helpful the programs seemed to be.

The challenge for many of these centers, Sweeney says, is keeping up with the demand. When she talks with colleagues doing similar work across the country, they say many of their programs have long waiting lists. Insurance sometimes doesn't pay for the nonmedical parts of these programs, she adds, and they often rely heavily on grant funding.

Still, Sweeney is heartened by the success stories. And success, she adds, isn't always defined as significant weight loss. It's more important that kids learn to move their bodies and enjoy healthy foods.

"If you intervene pretty early, we have a really good chance of being successful," Sweeney says.

Mara Gordon is a family physician in Washington, D.C., and a health and media fellow at NPR and Georgetown University School of Medicine. Copyright 2019 NPR. To see more, visit https://www.npr.org.

(2019-06-05 04:00:00 UTC):

An earlier version of this story misspelled Matilde Palmer's first name as Mathilde Palmer.