In Practice

How Pediatricians Think About Kids & Weight Now

“People need to feel empowered. They need to feel understood. They need to feel not judged.”

Originally Published: 
Kids & Weight

When a kid sees a doctor like Susan Sugerman, a pediatrician and adolescent medicine specialist, their parents are sent ahead to the exam room while a medical assistant takes their vitals. Blood pressure, heart rate, and temperature are recorded for the doctor while Mom waits in Room 4. The assistant then asks them to step on the scale backward for what’s called a blind weight. The child will never face the scale numbers. In fact, at Girls to Women Health and Wellness in Dallas, Texas, disordered eating and body issues are so prevalent that by default, no one is told their weight.

When a patient asks their weight, Sugerman tells me, her first response is to ask them why they want to know. “What does it mean to you? Are you going to feel good or bad about yourself if I tell you it goes one way or the other way? What are you going to do with the information after I give it to you?” The discussion that follows is seldom about numbers; it’s a long conversation, and one that Sugerman thinks should be standard practice.

But most doctors aren’t Susan Sugerman. At the average pediatrician’s office, a patient’s weight is announced to parent and child alike, whether with a practiced neutrality if you’re lucky or a cluck of disapproval if you’re not. Typically at some point in the checkup, after asking a kid their favorite foods, three vegetables they like, and how often they drink juice (“Only as a special treat!” the parent might chime in, unprompted), the doctor will turn their computer screen to the adult in the room and show that parent or guardian where their child is on the growth chart. Attention is drawn to whether the variables of her height and weight hug a swooping, gentle curve — one that, if you stay on track, heads upward at just the right velocity. The message, sometimes implicit and sometimes explicit, is that the child’s weight can either be “good” or it can be a “problem” that needs solving.

More and more, kids aren’t hugging that gentle curve. In 2013, in an ostensible effort to increase access to care and decrease shame and stigma, the American Medical Association defined obesity as a chronic disease requiring medical attention. In the decade since, being classified as obese has only become more prevalent for adults and children. Over the past 30 years, rates of childhood obesity, defined by the Centers for Disease Control and Prevention as having a BMI at or above the 95th percentile, have tripled in the U.S. In February of this year, the American Academy of Pediatrics (AAP) published its long-awaited clinical practice guideline “for the Evaluation and Treatment of Children and Adolescents With Obesity.” The first guideline of its kind, it pronounced obesity one of the most common pediatric chronic diseases, affecting “the current and long-term health of 14.4 million children and adolescents.”

How and whether these recommendations change the day-to-day practice of pediatricians in America will depend on what kind of practices they had to begin with. The doctors I spoke to for this story already view their relationships with patients and their families as highly collaborative and invest considerable time and energy figuring out family dynamics, home environments, and motivations for change. For pediatricians who don’t, their 20-minute appointment windows will be even more crunched for time as they attempt to tailor recommendations to the individual child and counsel them about making small changes in their daily lives, sometimes referring families to behavior-modification programs (think group exercise classes and cooking lessons), if they’re accessible nearby (although the guidelines explicitly acknowledge that the availability of said programs is “generally poor”). The new guidelines also lent unprecedented endorsement to the safety and efficacy of weight-loss medication for children from age 12 and even bariatric surgery referral for kids as young as 13.

In Sugerman’s clinic, not much will change. If blood pressure is problematic or lab values are abnormal, she says, “then, yes, we have a medical and moral obligation to figure out how to talk about that and how to address it in the most effective way possible.” But if the only number causing alarm is the one on the scale? “Then the question is: Can someone really be healthy at any size?” asks Sugerman. “There’s some debate even about that. I personally believe that, absolutely, people can be.”

Sugerman is referring to Health at Every Size, a clinical approach and theoretical framework gaining traction in adult medicine that encourages the acceptance of bodies of all sizes and rejects the equation of health status with weight (among other principles). Given that 19% of children are clinically obese, it will be increasingly relevant for pediatrics, too. Part of the initial outcry from parents and the media after the publication of the new AAP guidelines could be attributed to the growing awareness and embrace of ideas like this. It was jarring and upsetting to many who approach parenting from this mindset to read a document that frames a child’s body size as a long-lasting problem with significant health risks.

“Trust me, we pediatricians never run to medications and surgeries first. Our job is to prevent things from happening. Our job is to create good habits from the beginning — that’s why most of us went into pediatrics.”

The pediatricians I spoke to were taken aback that parents were even reading the AAP guidelines, much less taking them to heart. They were adamant this wasn’t a document for parents, more an obsessively researched and painstakingly detailed document found at pediatric conferences and academic journals — summarizing the latest evidence-based research that features in review articles and other forms of specialty education.

“I don’t blame parents for having that response like, ‘Oh, no, now my child is going to have to have surgery and be put on meds,’” says Dr. Ana, who is one half of the popular TikTok and Instagram account PediPals, which she and a colleague started as a passion project to combat online misinformation and educate parents about, for example, not making your own formula at home. (Ana did not want to be identified by her last name because she says Internet trolls have issued death threats.) “I understand those fears, but trust me, we pediatricians never run to medications and surgeries first. Our job is to prevent things from happening. Our job is to create good habits from the beginning — that’s why most of us went into pediatrics.”

How did pediatricians familiarize themselves with the new guidelines, I asked Sugerman. Is there a big meeting, a nationwide email thread? She laughs and tells me basically everyone is aware of new AAP guidelines and they read them, or skim them, when they have the time. “We’re all just pedaling as fast as we can,” she says. Usually new publications from their professional association serve as “reassuring support to keep doing what we’re doing.” They help with decision-making; they identify treatment options that might otherwise have been on the edge of their awareness. And from a malpractice perspective, they give you lanes to practice within: As long as what you’re doing is supported by the guidelines, you’re acting reasonably.

When I ask her if pediatricians “have” to follow them, it’s clear she is affectionately exasperated with me. The AAP guidelines aren’t about what doctors should do or what they must do, she explains, but what they can do. You’re not required to offer something; bariatric surgery, for example, is now included in the range of things that can be done. “The idea is you do the other things first.”

In fact, many of the doctors I spoke to stressed that they were less concerned about what percentile your child was on the growth chart than whether there were any sudden changes in weight — if your kid was in the 25th percentile at their last well visit, say, and then 80th percentile this year. “Every growth chart tells a story,” says Dr. Rebekah Fenton, M.D., a primary care provider at a community health center in Chicago, where she specializes in adolescent medicine. She told me that when she sees a sudden change in weight, there is “an opportunity to open up a conversation in a very open-ended, nonjudgmental way” to figure out what if anything has changed in the lives of her patients. She wants to dig into these structural issues before emphasizing numbers on a scale.

Sometimes, it’s that a kid used to be part of a sports team but this year the family’s too busy. Maybe there is more stress or the family went through some type of traumatic experience and they’re focusing on getting by, for now. Fenton has had kids whose parents work at a restaurant or in fast food, and they rely on that food for sustenance.

In the AAP guidelines, life circumstances like the ones Fenton describes are called “social determinants of health,” and doctors are advised to take them into account (along with underlying genetic, biological, and environmental factors) when developing a treatment plan for each specific child. The inclusion of these factors was a far cry from the individual blame-and-shame approach to weight of the past few decades — and many doctors greeted them with enthusiasm. “I understand that some people were shocked [by the AAP guidelines], but when my partner and I read the guidelines, our reaction was, ‘Finally, someone’s talking about it,’” says Dr. Ana. “This is way overdue.”

“No matter how you’re labeling obesity, the concept still inherently has a stigma because you’re essentially saying a kid in a bigger body is a problem. As if that’s an issue that needs to be addressed in itself.”

The issues raised in the AAP guidelines — income disparity, racism, food access — are things Dr. Ana and her partners deal with every day in their real-life practice, and she appreciated that the AAP finally decided to have a full discussion about it. “When I read them, I was even more relieved that it was a very nuanced discussion. It wasn’t just plain and simple.”

The guidelines struck many doctors as genuinely progressive. Dr. Sapna Parker, M.D., a board-certified pediatrician in Pittsburgh, Pennsylvania, says the AAP report actually made her hopeful. “I do think finally there’s a lot of stuff being brought up that hasn’t been before, like systemic racism and readiness for change, and just this more holistic way of looking at things.”

Part of that holistic approach, also a principle of Health at Every Size, is acknowledging the ways that weight bias and stigma often make health outcomes worse, independent of a patient’s “excess adiposity.” The emotional fallout of internal as well as external weight stigma (often from primary health care providers themselves, as the guidelines acknowledge) often leads to poorer mental health, increased social isolation, binge eating, decreased physical activity, and avoidance of health care services — and the cycle continues. It’s something that all the pediatricians I spoke with have seen play out firsthand in the lives of their patients.

“I know from all of the patients I see that body dysmorphia, body shame, and poor self-esteem related to associating one’s value with shape or size has devastating psychological consequences on somebody’s long-term emotional, psychosocial development,” says Sugerman. “And the risks to that development far exceed the benefits, in my opinion, of lowering someone’s cholesterol 10 points. I don’t have evidence-based data to support that, but I know it to be true.”

Fenton for her part says she appreciates that there has been more acknowledgment, from the AAP and elsewhere, of the role of weight stigma and racism in health outcomes, but sees the guidelines themselves as implicitly contributing to said stigma. The language establishing obesity as a disease or a problem that needs to be fixed is stronger than she’s seen it before. “No matter how you’re labeling obesity, the concept still inherently has a stigma because you’re essentially saying a kid in a bigger body is a problem. As if that’s an issue that needs to be addressed in itself.”

That weight bias and stigma is enacted in the field of medicine at an alarming rate is well-established and notably, getting worse. Dr. Ana says she has seen lots of doctors unknowingly perpetuate that stigma, whether it’s how they present or display growth charts in a way that leads to obsession or an offhand comment made by a provider that stuck with a patient for years. “My biggest goal as a pediatrician when I am talking about weight,” she tells me, “is to never word things in a way that could make a child push them over the edge to an eating disorder.”

“We’re not here to make people skinny. We’re here to keep people healthy enough.”

It’s clear that helping kids find one or two healthy changes that work for them is slow work that depends on strong relationships. It also doesn’t yield results that are easy to document or even quantify. “You have to set realistic expectations that we’re not here to make people skinny,” says Sugerman. “We’re here to keep people healthy enough. Especially with something as chronic, and both biologically and behavior-based as weight, there’s no single 10-minute conversation that’s going to change somebody’s life and fix everything. It doesn’t work that way.”

This essential truth is part of why the new AAP clinical practice guideline struck so many as cognitively dissonant: The document opened with a nuanced, even radical, discussion of the many complex, confounding factors that might lead to childhood obesity— like race, poverty, genetics, to name a few that cannot be medicated or changed by behavior modification — and then went on to recommend medical interventions like pharmacology and surgery referral that collapse all of the complexity.

“A lot of things in medicine I think are influenced by how much time we have,” says Sugerman. “And we often don’t have enough time to really have considerate conversations. And weight and nutrition, those are conversations that are never quick or easy. People need to feel empowered. They need to feel understood. They need to feel not judged. And they need advice they can use that makes them feel like they’re part of the solution, not shamed because they are a problem. So, can you do that in a 15-minute appointment? OK, good luck.”

Parker agrees. “There’s no way,” she says. “We’re squeezed in every direction. There’s a million questions; there’s a million things to address.” Parker notes that because of the pediatric mental health crisis, the No. 1 priority for many providers right now is simply keeping kids alive. “I’ve realized I can’t do everything in one visit.” A thoughtful doctor will schedule follow-up appointments to give the subject of weight and health their proper due, but that often means long wait times and more of a logistical burden on parents, not to mention additional co-pays.

Physicians may have been able to stretch those 20-minute appointment windows pre-pandemic, before burnout and increasingly grim insurance payout rates brought on a health care labor shortage. In 2022, the average wait time for a new-patient doctor’s appointment was 26 days.

The way the system currently works, going over the time limit with one patient can mean either missing your last patient of the day, missing dinner at home, or staying up late to do paperwork. As one might imagine, this does not do wonders for morale. “We’re all human, too,” Parker reminds me. “We have kids. We’re going through our own stuff. I do think sometimes people forget that.”

While doctors are undeniably as human as the rest of us, Fenton surmises that another factor shaping how doctors speak to patients about weight is a “fixer” personality. Prescribing a medication or an exercise regimen can feel like they’ve checked an item off of their list of problems. “That’s how our training is,” she tells me. “See problem; fix problem.”

“It kind of is the easy way out — even if it’s not effective — to be able to say, ‘Oh, I see this problem. You’ve gained weight. My solution, change this,’” says Fenton. “Even though 90% of diets fail and the idea of calories in and out is not real, and how our bodies metabolize things is much more complicated than that.” Pediatricians cannot eliminate food deserts, for instance, or unwalkable cities. They can, far more easily, dispense Wegovy.

This does not mean you have to fill the prescription — or even stay with the doctor who suggests a treatment plan that is not right for your family. If you find yourself uncomfortable with how your kid’s doctor handles weight, you are not alone, and if you can, you should try to find a pediatrician who better meets your kid’s needs. (They’re out there, they’re just tired, and they have long waitlists.) Parker emphasizes that parents should think of their relationship with the pediatrician as a collaborative one. It should feel like a partnership. “Honestly in the room, you know whether it’s a partnership or not. You can tell,” says Parker.

It’s certainly not a pediatrician’s job to pressure patients into anything they’re not comfortable with. “We’re trying to be supportive,” stresses Parker. “We don’t have any other job.” Dr. Ana told me that to help patients and their families see her as a partner, she gives them the mechanic analogy: “When you go to a mechanic, you’re like, ‘OK, what do I do? Are my brakes OK, you know?’ ‘Can I drive my car?’ They give you your assessment, right? And then it’s your decision: Can you get a new car, you get new brakes? Can you afford new brakes?”

“My message to parents would be to just keep standing up for your kid and protecting their feelings.”

Of course, not all families have the kind of health insurance that lets you choose providers, and nearly 20% of children in the United States live in a rural area, where health care options are often scant and providers are less racially diverse and, one imagines, less likely to practice weight-inclusive care. Fenton, for example, did a fellowship in the rural mountain west when she realized she might be “the only Black pediatrician that these children get a chance to see.” It was a positive experience for her, but made her think a lot about how racism and weight stigma overlap in medicine. In an ideal world, patients would have doctors who are sensitive to genetic predisposition, as well as structural issues that contribute to weight differences. But Fenton’s impression is that many in the field are still learning about this. Any time she tries to talk about weight on Twitter, say, “there’s somebody who comes in and vehemently disagrees with me and talks about obesity as a problem.”

If you aren’t lucky enough to find a provider like Fenton, then what? “My message to parents,” she says, “would be to just keep standing up for your kid and protecting their feelings.” Every doctor I spoke to encourages parents to advocate for their children actively; never hesitate, for example, to send a message on the patient portal ahead of time that provides more context. They’re not only used to it; it’s helpful to them. It’s OK to ask if you can step on the scale backward. It’s OK to tell your provider in advance that you don’t want to know your weight. It’s OK to ask to have conversations privately with your child’s doctor, or for your child to ask to talk to their doctor without you in the room.

Fenton reiterates that she believes doctors genuinely want to do what’s best for their patients. But new guidelines notwithstanding, most pediatricians don’t have a framework for how to help their patients manage their weight and health, in all its complexity, with real sensitivity. “I think we just honestly haven’t seen what the impact of doing this right looks like,” she says. Doctors stick to the status quo out of fear — and that perpetuates the kind of weight stigma we know to be harmful. What’s needed are recommendations that help doctors to guide their patients toward being as healthy as possible — without putting their mental health at risk. Because, says Fenton, “the world is hard enough.”

If you or someone you know has an eating disorder and needs help, call the National Eating Disorders Association helpline at 1-800-931-2237, text 741741, or chat online with a helpline volunteer here.

Header Image credit: Getty Images, CDC Growth Chart

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