Sunday, April 4, 2010

don't let your child's doctor label your child "obese"

Recently I talked to a pediatrician who shared that any child with a BMI over 85% ("overweight cut-off") whether there is a health concern or not will get an official "diagnosis"code of overweight or obese. This means it will become part of the child's medical record list of diagnoses.

Once this BMI > 85% is recorded, that family gets a handout on how to do things better (that handout means the doctor can then bill for services on obesity counseling.) It has advice like: no more than 2 hours of TV a day, no more than 4 ounces of juice, and my favorite- one hour minimum of uninterrupted aerobic activity outside of school (how likely is that for most kids every day.) Strap a pedometer on your kid for 10,000 steps a day! That's like, 4 miles plus. Or, don't let your child be sedentary for more than 30 minutes at a time. So do you have a stopwatch while Timmy is doing homework and have him run laps in the basement?

I digress...

Why does it matter if your doctor "diagnoses" and codes/labels your child as "overweight" or "obese?"

1) your child is open to possible discrimination in terms of future employment, health insurance etc (not sure I believe totally that the health insurance reform will deal with the "pre-existing conditions.") There have been cases where children have been denied insurance because they were "overweight," and also "underweight."
2) labels and shame are not good motivation for positive change. (Are you listening Jamie Oliver?) In fact a child labeled as overweight or obese, regardless of BMI is more likely to feel flawed in every way, more likely to diet, practice disordered eating and gain weight. They are also less likely to participate in physical activity. Words matter.
3) once something is in the chart, it is hard to get out. Think about this. Before any physician, lab tech or nurse meets your child she will see that label on the list of diagnoses. It is well known that medical providers have a bias against "overweight and obese" patients.
  • CDC: "BMI is used as a screening tool to identify possible weight problems for children." and "BMI is not a diagnostic tool. For example, a child may have a high BMI for age and sex, but to determine if excess fat is a problem, a health care provider would need to perform further assessments. These assessments might include skinfold thickness measurements, evaluations of diet, physical activity, family history, and other appropriate health screenings." I doubt that the diagnosis of obesity put into the chart is based on anything other than BMI which often mislabels the individual...
  • "BMI is not a reliable predictor of health": American Heart Association
  • Child BMI not reliably predictive of adult BMI: United States Preventive Services Task Force: "a substantial proportion of children under 12 or 13 even with BMIs > 95% will not develop adult obesity." (note, there is increasing predictability as BMI increases and the older the child is)
  • a child growing consistently, even at a high percentile is (by definition of the bell curve) larger than the majority of her peers, but to label her as "over" weight when it is likely a perfectly healthy weight for that child is wrong and implies a health risk that is likely unfounded.

At your next pediatric visit, if your child's doctor discusses your child's weight consider this:

1) ask that she do so without your child present
2) ask that the physician not code for or put the diagnosis of obesity in the chart unless there are further diagnostic tests (take in the above quotes.) Point out that BMI is a screen, not a diagnostic test.
3) ask to see the growth chart. If your child is large, but the growth is stable, there is likely not a problem. Ask your doctor to look at the rate of growth. They may not understand or accept this.
4) it is reasonable to look further if there is acceleration of weight gain, or your child is increasing in percentiles. There could be a medical problem, or getting help with feeding might help. (Read Your Child's Weight: Helping Without Harming, Ellyn Satter.) It could also be a pre-pubertal weight gain or otherwise normal pattern, but acceleration or deceleration on the growth chart warrants further eval.

if you get handed one of those handouts consider this

1) ask the physician if their children do one hour of uninterrupted daily exercise outside of school or wear a pedometer.
2) mention that if it's such useful advice, every child should benefit from it
3) point out that there is at best conflicting evidence about the efficacy of any of the interventions mentioned. Don't get me wrong, watching 8 hours of TV a day is not ideal for any child, but no studies have shown that recommending limiting screen time in the primary care clinic setting lowers BMI
4) if you are already doing the behaviors on the list, let them know

Just a couple of thoughts. What do you think? What have your experiences been with your children and getting labeled by the doctor?


  1. Excellent post. I don't have kids and have no real experience except being told I was a fat kid, not by a doctor, but by my parents. If they had attached a pedometer to me, I think I'd have just shaken it all day long to get some outrageous number just to mess with my parents.

  2. I love it! Thanks. It goes back to intrinsic motivation, respect, loving yourself, separating from your parents and so much more. I remember my mom saying things like, "you don't need another pork chop." while I'm thinking, "oh yeah? Watch me eat two more!"
    ugh. This is what all the money and effort is going to with our "war on obesity." think it will help or harm?

  3. My doctor told me that my child was in the 95th percentile for her height and 90th percentile for her weight. She then said...and I quote..."That means she's actually skinny". She went on to say that what they look for is the numbers to match in both height and weight...and since my 9 year old daughter's numbers did not, she made a point of telling me not to worry about her weight.

    That word "skinny" struck me right between the eyes. I wasn't expecting it, though I suppose she used that word because many parents have the obesity panic running rampant in their minds. I am a fatty fat Mom who found a great pediatrician who understood the focus of my concern was for my child's HEALTH...not weight. It doesn't hurt that this dr. was once as big as me. She lost her weight cutting out sugar and walking (I only know this because I asked her). But..she refuses to preach to anyone else about weight loss and doesn't focus on the child's weight...just their health. For this, I respect the hell out of her and will be sad when the day comes when my daughter will be too old to see her anymore.

    If I had to contend with doctor's bashing me over the head about the pre-pubescent pudginess of my daughter...then I would find another doctor.

  4. Thanks for all the great info on your website! My daughter is still young (13 months) so I'm not quite yet to the stage of worrying about all this, but I'm trying to soak in all the information so that I'll be better prepared when that time comes... I feel like my husband and I are going to have differing opinions on how to handle things, and I want to be well-informed! :)

  5. Cindy, I hope you'll consider getting Child of Mine, also by Satter, especially if you think you and your husband may start to see things differently. You are heading for the toddler/preschool years where feeding can become more challenging because if the child's developmental task of individuation. You can become informed, and share that info with your partner. (Let's be honest, I, and most of the other mom clients I have are the ones reading the books...)

  6. Regina,
    You're lucky that you have a doc who gets HAES. I wonder why she used the word, "skinny?" Is that another label? What if the ratio changes and your daughter is no longer "skinny?" I would love to hear more about why it "hit you between the eyes?" What would you have thought if she had just said, "Your child is growing in a way that is healthy for her?" I'm really asking because I do lecture to pediatricians and primary care docs and would love to know how to help them say things in a way that is helpful! I hope you've added her name to a HAES registry. I agree with you about finding a new doctor. FInd a partner in health.

  7. Great post! I like the specific recommendations.

    My children are both relatively slender. Actually my daughter is downright small, and I worry about labels for her as well. My pediatrician is pretty sanguine about weight issues, which is good.

    I love the image of shaking the pedometer. Short of welding the thing to my children I can't really see them tolerating that for very long... Lol, I doubt they would sit still long enough for me to put it on:)

  8. ...continuation of last post.

    I consider a child anyone under 18. Are you considering it as under 18 or under 12, because pre-post pubescent groups can have very different evaluations. The fact is that we have a lot of overweight and obese teenagers,and even some pre-pubescent children (I was one) in this country, and unfortunately childhood obesity is a big problem in our country. So many parents just feed their kids crap all the time, and it becomes much more real after puberty when everyone's metabolism slows a bit. I was probably an obese teenager, and now I'm a morbidly obese adult. I blame a lot of my weight as a child, and the habits it set up on my parent's lack of guidance, excessive processed food, and little encouraged exercise, with unlimited TV and video games. There are still a ton of parents out there who feed their kids mac and cheese and pizza ALL the time. The fact is that they need some education. It could definitely be handled with more tact if doctors are telling 12 and under kids that they are obese, as that medical word has a negative connotations, but it's not like they don't know. I knew. I wish someone would have told my mom "hey, get the processed food out, feed your kid whole foods, and don't let her watch all the tv and play all the video games she wants." But I don't think anyone ever told her until it was too late and my habits were concret And unfortunately as this country stands right now, my situation is the norm, not the exception.

    I think the correct form of action would be to put the diagnosis in the medical record if necessary, because it is what it is. Also to make sure they are evaluating BMI based on HEIGHT not age. However the counciling shouldn't stop at obese children, because clearly they are not the only ones with bad nutrition and not all of them grow up to be obese adults. The counciling on tv restrictions, no juice, etc needs to go to ALL parents, and as far as I'm concerned it does. Healthy People 2010 did make that one of their big objectives, and it has been implemented in most states. Just because a kid isn't obese/overweight, doesn't mean they are getting the right nutrition. It's on our generic sheet from the pedi every time we are there, and he goes over the general rules with us. I know it's not just me that he's talking to because it's on the sheet, but even if it was - I'm glad he would council a parent who might not have the best idea on nutrition to what her child should be eating.

    Now I'm going to go make my son's nutritious breakfast. I'm thinking a box of juice, some teddy grams and some leftover Easter Candy. ;)

  9. Someone linked me to this article on facebook and I had to respond. This is pretty long, but keep in mind I'm in nursing school and I just read the obesity chapter in my text last night, and this issue does hit very close to home for me too as I was an obese child starting around age 9, obese teenager, and now am a morbidly obese adult.

    These are the stats from Lewis' Med Surg nursing text 2009 that we are given:
    Children and teens 6-19 - 16% are overweight or obese.
    65% of Americans over 20 are either overweight or obese.
    But the part that is concerning for doctors and the reason they do need to council parents is that since 1980, the number of young people who are obese has tripled. That means we are doing something wrong as a society at whole, and they do need to have some counciling overall unfortunately.

    I don't consider most pediatricians are out there to "get you" and council you for the sake of billing you. The fact is that obesity is a medical description, and yes that description will go in your chart if you are in fact obese. Charts are to document history for medial purposes, and they are necessary, and to not document is to assume you didn't do it/see it, which unfortunately leaves doctors open to litigation in many instances. Doctors do not however review your childhood chart as an adult to see if it says you are overweight or obese. If you state in a physical that "you were overweight as a child" they might have that, but that chart wont predisposition all future appointments. Usually they are just looking at the most recent information the nurse has collected. I haven't seen my chart any time lately, but I'm very sure that it has my adult BMI and obesity level recorded, but nothing about my childhood weight and that just is what it is. Even if they don't record it, it's a pretty easy height/weight calculation which is always recorded. Do I think children under a certain age should be labled so harshy as a "fatty fat," no. But Obese isn't saying "fatty fat," it's a medical, descriptive term that unfortunately can draw the same conclusion. It's hard to say, but it's a harsh reality, and just like any diagnosis, a parent has the right to hear the diagnosis and make an educated decision without their children in the room, and that is what is most often done. I'm not sure if you had an experience where a doctor told you this in front of your child, but if you did - you should call that doctor on his ethics and bedside manner. be continued (got cut off by blog limits)

  10. Ok a couple more comments, I know I seem obsessed but:

    Regarding your recommendation to look into it being something else, there are two types of obesity, primary and secondary. Primary is usually obesity due to imbalanced nutrition/exercise. Secondary is obesity R/T another etiology like hypothyroidism, cushing's syndrome, etc.

    According to my text, the first thing you do after the obesity dx, is to determine primary or secondary as your course of action is different for each. However you won't determine it until you first note the obesity. So I understand your fustration with the label, but it's a necessary medical label.

    The other thing - I do agree that our BMI scale needs an update. For instance, different races REALLY need a different BMI scale. IE. Native Americans and African Americans have a higher "obesity and overweight" epidemic, but their bodies are actually built different with a different makeup over time/evolution/etc, so really there should be some race leeway in the BMI scale. Michelle Obama putting her kids on a "diet" - umm no. Encouraging whole foods and exercise is great, but making your children poster children when they don't really need to be is just not right.

  11. Erica,
    Thanks for your great comments. You remind me of me early in my practice. There are so many points to cover. First, I wonder if you have been exposed to any other evidence or discussion on this issue. Have there been any Health at Every Size lectures? Any discussion about the controversy of BMI? How it is to be used properly? You obviously care about children being healthy and happy. I highly recommend reading 2 things. 1) online, CHIld of Mine, Chapter 2 (look under resources section)
    Second, a journal article with a great review of the evidence, "Health at Every Size : A Compassionate, Effective Approach for Helping Individuals with Weight related concerns (PArt 1 and 2) Jon Robison et al AAOHN Journal April 2007 Vol 55.
    I'd LOVE to hear back from you after you read those.
    I'm sorry you were not given the best start health wise. Did you also diet somewhere in there out of curiosity? Does knowing that you are "morbidly obese" motivate you to more healthy behaviors?
    My biggest problem with your premise that "obesity" is a medical diagnosis, is that that is an issue that is very hotly debated. There are folks with BMIs of 30 who run triathalons, with perfect blood work. Is there a health problem? BMI itself is not DIAGNOSTIC. It has high rates of false diagnoses. (20% in a study from last year at least.) BMI is based on the bell curve, that is the natural biodiversity of the human population. That means, 15% of the population will be above 85% and that is normal and healthy fora population. We are misdiagnosing healthy people as having a health problem, and missing normal weight people who are not healthy. Now, there are people who are in tthe "obese" percentiles who are clearly not healthy, and as you point out, there are "normal" weight folks who also ate processed food all day long and played video games as kids. What we need to look at is the PATTERN of growth with children. The boy pictured in my post is "obese." We don't know if he is healthy or not, but the mere label of "obese" is meaningless in this case. What do you think is the benefit or harm of labeling that child? What if it was a girl? If there is growth acceleration, by all means, document it, work it up, help the child. I KNOW there are major problems, we have more kids who are seeing weight acceleration, we also have 2/3 teens dieting, half of whom use extreme measures, more diagnoses of eating disorders and 10% iron deficiency anemia in teen girls. We have a major problem, but the standard way of addressing it (your text books, my old text books, journal articles and "evidence based" guidelines on the treatment of childhood obesity) doesn't work. I've been there and done that, and it doesn't work. I know peds are not out there to get patients. I wasn't either, but I just didn't know what I didn't know. There is a sense of urgency, and out of that comes the "we have to do something!" and that something often doesn't help, and may make matters worse. (I have clients who have been on diets since age 2 because of misdiagnosis of growth charts. The intervention has caused major problems.)
    I just want medical professionals to be exposed to more than one side of the story, to get the full understanding of how to use BMI. I hope you will keep in touch. Feel free to read my other blog posts on the topic. My frustration with the standard approach led me to my current career. I get to focus on health behaviors, on the feeding relationship- on helping kids grow up with a healthy relationship to food and their bodies. Gotta run, but could also write a longer response. Hope that explains it a little better.

  12. Erica,
    please check out my interview on
    it explains so much more than i did in that response. Write back your thoughts!

  13. I agree with you on some points, it could probably be damaging to a kid to be called obese and mocked... but do pediatricians really do that ? I doubt it. And exercizing, playing outside, running, riding your bike, skiing... what is wrong with that ? Isn't it a better way to spend your day as a child (obese or not) than staying hours in front of a TV ?

  14. Cecile,
    I'm not sure what you are asking what pediatricians do. Can you clarify?
    I agree! Kids should play and exercise and ride bikes and not watch TV! My concern is that only kids who's BMI is >85% get this counseling in some clinics. ALL kids should be active and have fun! Also, do you think putting a pedometer or a stopwatch on a kid will get them more active? I think we need to stress that being active is fun, healthy and everyone should do it, not that you should exercise only to lose weight (one kid said to a colleague who did research: "I exercised every day for 2 weeks and ate really good and didn't lose weight. What's the point?") Kids need to exercise because it's fun, not a chore or need to get on a treadmill.)

  15. Hi Katja. I was asking if you heard of pediatricians talking about obesity in a way that can make the child feel bad. I agree with you that all kids should get exercise and good nutrition... and I thought you were joking about the pedometer ! Did a doctor really suggest that ? I cannot imagine putting one on my kids...

  16. I know! That handout I scanned is too small, but actually recommends putting a pedometer on your kids for 10,000 steps, and the other stuff. I think there are pediatricians out there who do use the word "obese" and use very scary language, one ped at a talk said, "If I know a family isn't serious about change, then I really bring down the hammer." I guess I don't know what that means for the patient but I imagine it's not very pleasant . Docs need to talk more about behaviors, fun, sustainable, intrinsically rewarding changes that feel good and are more likely to be maintained.

  17. Excellent suggestions on how to empower parents to talk with our Pediatricians. My son is only 4, however I dealt with pre-pubescent weight problems myself and the comments by my family members hurt me to this day. I applaud your suggestion of Ellyn Satter, she has great advice on dealing with obese children.

  18. I wholeheartedly agree that BMI should not stand alone. My husband is 7 ft tall. He is literally "off the charts". Guess what? Our two sons are too! Neither was enormous at birth, but both started growing immediately. They also have spent most of their lives as a tiny handwritten dot above curve on the growth rate charts. It's just who they are. So, when I found out this year that PE teachers were being required to measure BMI (not the school nurse, mind you) and adjust their curriculum to help kids with high BMIs, I was very frustrated. My son is 9 yrs old, over 5 ft tall and weighs about 100 lbs. He wears a men size 7 shoe. He runs, plays soccer, bikes, etc...He's just always going to be the biggest kid in his class. Same with my younger son. He's leaner than his older brother right now, but I expect he'll bulk up a bit as he gets closer to puberty. Standard charts are never going to be accurate for my kids. I can only imagine how it will be when they have kids!

  19. Thanks for your story April. I hear so many stories like this at the park! (OK, maybe not with 7 foot fathers, but some variation on the theme!) I encourage you to ask your school to stop measuring BMI. The notion of tailoring curriculum based on BMI makes alarm bells go off big time! I'd love to hear how this all works out for you! Remember the United States Preventive Services Task Force explicitly recommends AGAINST measuring BMI in the schools....