Verbatim: “You Mean Because I'm Fat?”

Recently, one of my teenage patients was in to see me. I’ve seen him a lot this year. I think about him nearly every day because I’m desperately trying to help him. I’m just so stinking worried about the choices he’s making. At the end of the visit, I said, “We’ve got a lot of work to do so I’ll see you in 2 weeks.”  He responded, “You mean, because I’m fat?”
No, I didn’t. We hadn’t even talked about his obesity at the visit. We’d talked about all the other stuff clogging up his path to happiness, long life, good health, generous love and earnest support. He’s had a heap of trouble this past year. He’s run away from home about 4 times (once for over 40 days–his poor mom), he’s currently living in a shelter, he was using drugs, he was self-tattooing with an ink pen under her skin (eeeeep!), he stopped taking his daily medicines, he’s obese and gaining weight, he got an STD….it goes on and on. My worry is real and rationale, you see.
But his comment at the end of our visit reminded me about how hard I work to talk to children and their families about overweight in ways that don’t alienate them. And how I obviously need to work harder. A new study points out the importance of letting kids know they are overweight.
I’m a straight shooter, but think about how to use language around “fat” and “obese” and “overweight” that doesn’t insult parents. I remember one mom this past fall saying, “Just don’t say that word, obese!”  But I did. I had to, it was her daughter’s true diagnosis. Being honest about what I know and what I don’t know remains a priority for me in my clinical work. Yet, of course, I never want the diagnosis of overweight to stifle, embarrass, stigmatize or stun a child into bad behaviors. Or make parents feel terrible. I think about it terms of trying to help families know where they really are. I want to arm them with information to make change.
For adolescents, knowing they are overweight is a big part of the battle.
The worry about how to talk with overweight teens intrigued a friend of mine enough to conduct a study. My friend Nick (his other name is Dr Nicholas Edwards) told me Wednesday that although we used to worry a lot about discussing weight concerns for children with anorexia and bulimia, the focus of how we counsel children about weight is changing in pediatrics. “Overweight kids now far outnumber children who suffer from anorexia and bulimia. How we counsel and inform children about their abnormal weight may be essential in motivating them to make healthy choices,” says Dr Edwards. Most pediatricians worry at one point or another that their diagnosis of overweight may stigmatize, insult or embarrass a child. We worry this emotional response could motivate them to lose weight in unhealthy ways (skipping meals, purging, beating themselves up about being “fat”). It turns out, how we frame the problem may be as important as addressing the problem.
“Dr Nick” set out to understand more about who these overweight teens are as a way to start to understand how to improve discussing overweight with them.
His study was published Tuesday this week in Pediatrics. He and his colleagues found:

• Nearly 3 in every 10 overweight teens were “misperceivers” about their weight. That is, they didn’t believe they were overweight yet their self-reported weight and height proved they were.
• Boys were twice as likely to misperceive than girls. Maybe because teen boys often want to be “bigger” and our cultural context allows or encourages that.
• Black children (both girls and boys) were even more likely to misperceive (4 in every 10 teens). Clearly there are many cultural differences in what is expected for our weight that we need to investigate.
• “Accurate perceivers” (teens who were overweight and knew it) were more likely to work to lose weight than those who didn’t think they were overweight.

The big deal is this: if teens know they are overweight, they are more motivated to make changes to decrease their weight and improve their health.
Dr Edwards found that overweight teens who were accurate perceivers (they knew they were overweight) were significantly more likely than misperceivers to report trying to maintain or lose weight, exercise for weight control, and actively eat less for weight control. Therefore, helping teens know they are overweight is a great start!
The study can encourage all of us to find out where we fall on the weight/height curves. Dr Edwards reminds me and all other providers that while we worry about over-doing and insulting teens with a diagnosis of overweight, we need to inform teens. Helping teens know an accurate weight status is essential to battling the epidemic of obesity in children. Understanding who these teens are and how they understand their weight problem is essential while we determine better ways to message the news of being overweight.
Clearly I have work to do in understanding how to help at least one of my patients re-frame his understanding of overweight.  Thanks Dr Edwards for the nice reminder of why…

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