Telling pediatric patients when they are obese

Experts: MDs should be direct

Tip-toeing around the issue of childhood obesity does more harm than good, an expert panel of pediatric health professionals has decided, so doctors should stop using terms like "at risk of overweight" and instead tell parents clearly when their children are overweight or obese.

The Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity — convened by the American Medical Association (AMA), Department of Health and Human Services, and Centers for Disease Control and Prevention (CDC) — spent nearly two years debating and drafting a list of recommendations aimed at helping pediatricians and other health providers address the growing problem of childhood obesity.

The recommendations (see box) cover the management of overweight and obese children, and include a directive that physicians should stop calling obese children "overweight" and overweight children "at risk of overweight."

Benjamin H. Levi, MD, PhD, FAAP, a practicing pediatrician and associate professor of humanities and pediatrics at Penn State College of Medicine, says he hasn't seen any data on how prevalent the practice of "sugarcoating" obesity language might be, but says it's not difficult to see why doctors might choose euphemisms rather than direct — perhaps harsher — language.

"My guess is that there's a big difference between talking to the parent alone, and talking while the child is in the room," says Levi. "What this is is risk communication."

'Softening the blow' to keep conversation going

While some physicians might skirt the issue of obesity by using euphemisms because they want to avoid having an uncomfortable conversation, Levi suggests that the more likely reason is that they don't want to lose the opportunity for real progress in working with obese and overweight patients.

"Do I close down my opportunity if I tell mom that her kid is obese?" Levi asks.

Kelly Meade, MD, co-director of the Healthy Eating, Active Living (HEAL) program at Children's Hospital and Research Center in Oakland, CA, says physicians are also sensitive to the fact that there is a social stigma attached to being overweight.

"And having an overweight child can have an effect on the parents' self-esteem, as well," says Meade. "If you tell a parent that their child is obese and could suffer chronic health problems as a result, the parents can perceive that they are being told they are not good parents."

Meade says a statewide survey conducted in California of 240 health care providers revealed that almost all — more than 90% — said they need training in strategies and skills for communicating with parents about children's weight problems.

Doctors did not come up with the descriptions of overweight and "at risk of overweight" on their own — the terms come from CDC guidelines that may be outdated. The CDC is considering the expert panel's recommendations and will decide whether to adopt them.

Levi says honesty is the best approach, but most physicians want to have the discussion in confidence with the parents, and that's not always possible with a child in the examining room with the parent.

"However, many schools are doing these BMI [body mass index] report cards, and they don't mess around," Levi adds. "They send home a number and a score, and the parent comes in [to the pediatrician's office], and says, 'This says my child is obese,' and then what the pediatrician has to do is figure out whether that's true or not."

Health risks demand direct approach

The expert panel's recommendations come as the United States is experiencing dramatic rates of child obesity. According to a study by the National Survey of Children's Health (www.cdc.gov/nchs/about/major/slaits/nsch.htm), the rate of childhood obesity more than tripled from 1980 to 2004.

About 17% of American children are obese, and one-third are overweight, using the committee's recommended definitions. Health risks related to overweight and obesity include diabetes, high blood pressure, cholesterol problems, musculoskeletal injury, and other ailments more commonly found in adults.

Besides recommending changes in terminology, the expert panel urges assessing weight and body mass index at least yearly, and evaluating eating habits and activity levels at all well-child visits.

The recommendations are posted on the AMA's web site, and have been endorsed by the American Academy of Pediatrics, the American Dietetic Association, the American Academy of Child and Adolescent Psychiatry, and the American College of Preventive Medicine.