BMI-based Evaluation and Management in Children — Tips for Discussing Weight — Clinical Pathway: Outpatient Specialty Care and Primary Care

BMI-based Evaluation and Management in Children Clinical Pathway — Outpatient Specialty Care and Primary Care

Tips for Discussing Weight with Families

What is weight stigma? The rejection and devaluation of one or a group of people because they do not fit society’s norms for body weight, shape, or size (Tomiyama, et al., 2018).

Weight bias is pervasive. 33-59% of children and 18-72% of adolescents report experiencing weight stigma from family, peers, or medical professionals (Goldfield et al, 2010; Eisenberg et al., 2012; Madowitz et al., 2012; Olvera et al., 2013; Puhl et al., 2017).

Beliefs that contribute to weight bias: People with larger bodies are lazy, have limited self-control, and are less smart; weight is analogous with degree of health; weight is controllable by the individual (Puhl & Heuer, 2010) (Nutter et al., 2016) (Tomiyama et al., 2018).

Weight stigma is related to: (Pont et al., 2017).

  • Higher levels depression and anxiety, lower self esteem
  • Higher rates of suicidal tendencies and substance abuse
  • Increased social isolation
  • Decreased engagement in physical activity
  • Increased insulin levels
  • Disordered eating behaviors (e.g. restriction, purging, binge eating)

How to make sure you are not perpetuating weight stigma: (Golden, Schneider, & Wood, 2016)(Pont et al., 2017) (Tomiyama et al., 2018) (Hunger, Smith, & Tomiyama, 2020)

  • Understand your own bias – take an Implicit Association Test  .
  • Monitor how biases may be impacting your interactions with patients/families
  • Distinguish between the person and the problem
  • Treat people with respect and empathy
  • Use sensitive language
  • Focus on strengths, not problems
  • Acknowledge that making health behavior change is HARD
  • Acknowledge the challenges of societal, media, and cultural pressures on body image/weight
  • Recognize that weight is NOT a behavior, rather the result of a complex interaction of genetics, environment, and structural factors in society

How to talk about weight/nutrition (Puhl & Heuer, 2010)(Golden, Schneider, & Wood, 2016)(Pont et al., 2017) (Hunger, Smith, & Tomiyama, 2020)

  • Ask permission before talking about weight
  • Discussion should focus on neutral outcomes NOT weight. Neutral outcomes include health behaviors, lab values, self-esteem, body image, and general wellbeing
  • Do NOT use “fat,” “obese,” “extreme obesity”
  • Preferred terms when you need to discuss weight– “extra weight,” “BMI,” “weight gain”
  • Avoid labeling foods as “good” or “bad.” All foods are okay sometimes.
  • Do not praise weight loss! Praise health behavior change.
  • Shaming patients into weight loss or healthy habits does not work and can have the opposite effect
  • Notice and discourage negative or stigmatizing comments from parents/family about child weight status.

How to encourage healthy habit change without perpetuating stigma or causing harm

  • Identify areas the family is motivated to work on.
  • Introduce a long term goal then scale it WAY back to feel manageable.
  • Choosing an attainable goal, especially at the beginning of intervention, is critical to instilling family feelings of self-efficacy.
  • Goals should be SMART (Specific, Measurable, Attainable, Relevant, and Timely)
  • Use your motivational interviewing skills
    • Open ended questions
    • Reflections
    • Active listening
    • Empathy
    • Notice and encourage change talk
    • Resist jumping right into education
  • Encourage low risk, evidence-based behaviors and habits (Golden, Schneider, & Wood, 2016).
    • Family meals
    • Positive role modeling by parents and caregivers
    • Setting a limit on screen time
    • Daily physical activity for pleasure and its benefits on mental and physical wellbeing
    • Avoiding diet or weight talk at home

Example scripts:

  • “There are so many things that make it hard to eat healthy and exercise. What do you think makes it hard for you?”
  • “If you could change anything about your eating or exercise habits what would it be?”
  • “Is there any information about nutrition I could get for you that would help you support your child?”
  • “Eating healthy and exercising is important to make sure your body works the best way it can and so that you have energy to do all the things you want to do.”

References

  1. Eisenberg, M. E., Berge, J. M., Fulkerson, J. A., & Neumark-Sztainer, D. (2012). Associations between hurtful weight-related comments by family and significant other and the development of disordered eating behaviors in young adults. Journal of behavioral medicine, 35(5), 500-508.
  2. Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing obesity and eating disorders in adolescents. Pediatrics, 138(3), e20161649.
  3. Goldfield, G., Moore, C., Henderson, K., Buchholz, A., Obeid, N., & Flament, M. (2010). The relation between weight-based teasing and psychological adjustment in adolescents. Paediatrics & child health, 15(5), 283-288.
  4. Hunger, J. M., Smith, J. P., & Tomiyama, A. J. (2020). An Evidence‐Based Rationale for Adopting Weight‐Inclusive Health Policy. Social Issues and Policy Review, 14(1), 73-107.
  5. Madowitz, J., Knatz, S., Maginot, T., Crow, S. J., & Boutelle, K. N. (2012). Teasing, depression and unhealthy weight control behaviour in obese children. Pediatric obesity, 7(6), 446-452.
  6. Nutter, S., Russell-Mayhew, S., Alberga, A. S., Arthur, N., Kassan, A., Lund, D. E., ... & Williams, E. (2016). Positioning of weight bias: Moving towards social justice. Journal of Obesity.
  7. Olvera, N., Dempsey, A., Gonzalez, E., & Abrahamson, C. (2013). Weight-related teasing, emotional eating, and weight control behaviors in Hispanic and African American girls. Eating Behaviors, 14(4), 513-517.
  8. Pont, S. J., Puhl, R., Cook, S. R., & Slusser, W. (2017). Stigma experienced by children and adolescents with obesity. Pediatrics, 140(6).
  9. Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: important considerations for public health. American journal of public health, 100(6), 1019-1028.
  10. Puhl, R. M., Wall, M. M., Chen, C., Austin, S. B., Eisenberg, M. E., & Neumark-Sztainer, D. (2017). Experiences of weight teasing in adolescence and weight-related outcomes in adulthood: a 15-year longitudinal study. Preventive medicine, 100, 173-179.
  11. Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC medicine, 16(1), 123.