Dr. Joseph Skelton: Thank you, everyone, for joining. The topic for today's roundtable discussion is a recent article in the New York Times called “Leave Fat Kids Alone.”
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I thought this would be a great topic given all of our different experiences to discuss this idea of stopping this language about ending the war on obesity. However, due to some of the talk and some of the controversy that the article generated, I want us to talk today a lot about how we can end the war on obesity. Can we still provide weight management without causing harm? I want to kick off the conversation with asking your opinions about the article. Are we better to do nothing? Let us start with the question of what you thought about the article.
Dr. Susan Wolford: My first strongest impression in reading this article was the pain that the author experienced. That pain just came through the entire article and although it is important for us to help where we can, it highlighted the importance of improving health without inflicting harm. Reading this article made me feel that we all or, at least, I felt personally the need to redouble my efforts in that regard.
Dr. Asheley Skinner: My first perception was very similar to Dr. Wolford's in that it was just really obvious that the author experienced a lot of really difficult things as a result of this, but it really highlights for me is the sense that it is very hard to try to treat something you do not have treatments for. When everything ends up focusing on the changes or behaviors of the specific individual, it becomes very easy to internalize those.
Dr. Sarah Barlow: I agree with Dr. Skinner that our interventions are focused on behavior, and that it becomes so hard to propose a behavior change without simultaneously suggesting that there is a responsibility or a blame to be placed. Practitioners may want to say, “it's not your fault,” but that carries the risk of implying that “there's nothing you can do.” And conversely if you say you would like for a patient to adopt a better behavior because that would be healthier, it is difficult to not at the same time imply that the patient is not doing what they should be doing, that their obesity is their own fault. This problem is so complicated and it presents such a dilemma that we face about how to address it in a way that shows support for what the patient is experiencing while still encouraging change.
Dr. Sarah Hampl: I echo what has been said by Drs. Woolford, Skinner, and Barlow. The author of this piece in The New York Times was very honest and articulate in expressing her feelings. As I read the article, knowing there are many other individuals who have felt these same things, I wondered how many other people have not been able to have this forum to be able to vocalize or share their opinions. It made me think about the relatively little attention that I pay as a provider to how patients are feeling about their weight or how their weight could be making them feel and really exploring that. That is a painful area for us to go into as providers because we do not always have the cure or the treatment for obesity. These feelings can also be painful for the patients to voice, but yet I think there is a need for us to understand better the impact that the child's weight has on the child individually.
So this was like a light shining in a corner that we do not always have the bravery to explore, or the resources to explore. To a degree, this article may have made us as practitioners feel like we failed in a way as a medical system for this patient, and I wonder about how many other patients we may have failed over the years. In thinking about where we can go from here, like Dr. Skelton said in his editorial from the first issue of this year of Childhood Obesity,
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quoting from Dr. Bill Dietz, “complex problems require complex solutions,” and it is going to be very necessary to reach out to help not just the patients and families, but also our colleagues, the providers.
Dr. Sarah Armstrong: I agree with Dr. Hampl. I read the opinion piece with respect because the author really spoke her truth, which was a fairly raw truth, with remarkable bravery. It was a really hard story to tell. But I also read it with the same dismay that I think Dr. Hampl has expressed because, she is right in many ways, I think we now know from the literature that physicians, not all physicians, but a large fraction of physicians are the leading source of stigma and shame for people with obesity. I mean, it is true. And I think we have to own that at times we have wielded our knowledge of obesity and its health risks as an excuse to pass judgment on people. I think at times as medical professionals there may be a tendency to confuse our patient's body mass index (BMI) with their willpower or confuse their weight with their character; these things are not the same. I think we have to be really careful and proactive about approaching this problem differently from the health care perspective.
Dr. Suzanne Lazorick: I also echo what everyone else has said. I had some of the same initial reactions on both fronts from the pain of the patient, as well as the ways we need to respond as providers. The only thing I want to add to what has already been said is that this opinion piece brought up the complexity of dealing with a child patient. We also often have an adult parent who has their own pain tied to this issue. And thus we need to address not only the child as the patient, but also the family and the individuals within the family. It is like a landmine of potential triggers you are trying to respond to in a certain way. It is really hard to get that right. The art of finding the one thing that works for one family might not work for another family. The second part of that is just the complexity based on different ages of the patient, even just thinking about how to respond to Dr. Hampl's point about the person's feelings, it is different for a 5-year old, than an 8-year old, than a 12-year old.
It takes a relationship being built over time to figure that out and we may never figure it out for every patient. To me, this article underscored the complexity and the challenge of trying to get it right for both the patient and the family group.
Dr. Joseph Skelton: This next question is tough. We as health care professionals have a directive, which is, “First do no harm.” We have to sometimes ask ourselves—whether you are a researcher or a primary care physician or an obesity subspecialist—have we done harm in the past? Is there a time that you think that you may have done harm? I will just briefly share a story of a when a child was not told that they were coming in to see an obesity medicine specialist; they were just told they were going to see a doctor. I began asking questions about weight, and saw a horrified look on the child's face; I realized they did not know this was a weight management clinic.
Seeing the patient realize that their weight was why they were there, and how upset they seemed, was something I will not forget. I do not fault the parent for any of that, but it made me wonder how much harm I may have done in the past without even knowing it. I would like to welcome the panelists in this roundtable discussion to please share if there is a time that comes to mind for you when you think either you individually, or others who you know about in attempting to help, may have inadvertently done harm when interacting with pediatric patients with obesity.
Dr. Asheley Skinner: Because I am not a clinician, I can say that yes, some providers have certainly done harm when treating or interacting with pediatric patients with obesity. I think it is very important that we keep the necessary context that the harm is certainly not intentional. I think it is reflective of how a lot of times in medicine new discoveries are made. We can all look back into the history of medicine and see times where, for almost every disease we can think of, doctors have done harm either through treatments that were harmful or through blaming individuals or families for illnesses that they may have. Families of children with epilepsy used to be told it was because of evil spirits in their loved ones. I do not think in that way that these consequences are unique to patients with obesity. So, I think it is very important that we not say providers are just unwilling to find ways to help people without hurting them. I do not think that is true. I think that when you do not have a lot of great information, and you are using the best of what you have, then harm can happen.
Sarah Barlow: There are certainly times when a discussion starts with the child and parent and the child immediately withdraws or even becomes tearful, which is just the worst feeling for all parties involved. Because of the sensitivity around obesity, it is really important for the parent to feel supported and not blamed for the child's high weight. Sometimes there is a challenge because the parent seems to be blaming the child, and it is tricky to support the child but redirect the parent without undermining them. You get an example of what is happening at home in terms of how the parent and child are interacting about weight and it is obviously a major problem that is very damaging to the child. I often feel inadequately equipped to help, in a way, because I need to be in alliance with the parent at least, in part, because the parent is responsible for making changes in the child's lifestyle.
Sarah Hampl: I am really glad you shared that, Dr. Barlow, because I also see that happening in front of my eyes sometimes in clinic where the parent will start talking and we immediately pick it up, so there are a lot of negative emotions happening here. Oftentimes, I think parents come from a position of true concern about the child and their health and the parent may have their own health problems related to weight, or they may have a loved one who has had health problems related to their weight and they want to avoid that for their child. Sometimes there is this disconnect between what parents understand is the child's ability to really understand the implications of their obesity, so I think also the list of responsibilities we as primary care providers have to cover has grown and grown.
Sometimes obesity has not been discussed fully because there have not been adequate treatment resources, but also I think there is frustration among primary care providers, because we do not have enough time to really discuss a child's weight in the depth that it needs to be discussed during the well-child visit and to ask the family to come back, which may involve another copay or additional time off school and work. It is a very difficult situation overall, such that sometimes avoidance is what happens and the child's weight is overlooked for years and years. As a tertiary care specialist, I hear families say, “Well, my primary care provider never said anything about it until now, and I don't understand why because I was worried years ago.” Or that they felt that the child would outgrow their weight. I think some of it is that providers need to learn the skills, to be able to sensitively discuss weight in a quick timeframe and set up follow-ups such that a more in-depth discussion can occur.
Susan Woolford: I agree with the previous comments about the sensitivity associated with this topic and the ways in which we discuss it with patients and families. One of the points that stood out to me from this article was that maybe the manner in which we frame the conversation has not been the best. I really liked the author's perspective about this war against childhood obesity, as opposed to a war against poor nutrition. Maybe there is a way that we can, for example, promote a push to protect pediatric patients. Maybe that is the framing that would allow us to address the health concerns without causing harm. It is so important for us to wrestle with this dilemma because we do not want to do harm by not addressing childhood obesity when we can help because that would be unethical. We do not want to avoid treatment when we should treat, but on the other hand when we treat, we want to frame it in a way that can be heard and does not cause some of the negative feelings that were being expressed.
Dr. Sarah Armstrong: I will just add one more point. I think we also have some structural issues working against our ability to be effective communicators, particularly in primary care settings. The evidence is clear that blame and shame lead to a dysfunctional relationship with food and eating. Blame and shame do not motivate behavior change, so we should not be blaming and shaming. On the contrary, having open-ended conversations meeting patients where they are and trying to help develop the rapport around behavior change in a positive way takes time but is more effective. In our current structured system in primary care, we simply do not have the time to be able to do this work in a way that is not harmful. It gets reduced to measuring a patient's BMI and telling them what their BMI was, and diagnosing obesity if that BMI is too high. If we do want to do better, we are also going to have to think about the system elements around us.
Dr. Joseph Skelton: Actually, that is a very interesting question. As an obesity medicine specialist, families are often very open in discussing their past experiences in pediatric weight management. Plus, it has been thoroughly shown in research, especially in the qualitative literature, what children and parents and families go through when they are struggling with weight. What would you suggest or what can we do when you hear about bad experiences that families have had?
I am hearing some stories about coaches making comments on children's weight and offering advice on weight loss. Similarly, well-meaning health care providers might make a comment such as, “You need to lose five pounds if you're going to get off this medication.” Is there something that we can do in these situations? It is a very tough situation to reach out to other health care providers or coaches to alert them to the potential harm these comments can cause. How can we best handle that, and help prevent others from doing harm?
Sarah Barlow: First of all, I try to be very proactive when I am with colleagues, whether it is other faculty members or students, or whoever, to really emphasize the people-first language and just remind people about the stigma. And if it is a peer, I will call them out quickly if they use insensitive language, like saying “fat” or saying something that implies that children with obesity are annoying or to blame. I do not know that I have ever actively contacted a provider or a coach of a child after the family has described stigmatizing comments from these people, to explain the pain they have caused. I would be interested in other people's experiences doing that.
Susan Woolford: On the occasions where patients have shared with me about a negative encounter they have had with providers who have addressed obesity in a stigmatizing way, I spent a lot of time apologizing because I feel that if someone in our profession does something that causes such pain and hurt, then even if I do not know the provider, I will apologize profusely for what the patient and their family members have experienced. I have actually written a letter to a coach to try to encourage them to think about weight differently and the impact it might have on a growing young woman to have certain stereotypes perpetuated. I do not know whether it had any impact, but we wrote the letter and sent it. As far as helping providers avoid doing harm, I think my main approach is to provide training through a number of educational conferences and training events.
Sarah Hampl: I agree with that, and I think there are so many great resources that are pretty quick to go through that you can share with colleagues. I think about the AAP Change Talk app, which is a really nice tool to provide an introduction to motivational interviewing. I think about the Next Steps tool that they have. All of us want to help kids reach a healthier weight, and I think there is a lot of frustration out there among primary and tertiary care providers how best to do it. When I see parents in my practice who are critical of their kids, I have tried to use that as an opportunity to role model in the room, praising the child and really pointing out their positive attributes, while also praising the parent and coaching them in trying to take a strengths-based approach to the situation.
What has the parent or child done well before? Where are the successes that they have had in changing behaviors in the past and really helping them build on their strengths as a family and even the grandparent who is critical, you want to validate their legitimate concern about their child's health, but gently help them realize that the way that they are talking about it may be really harmful.
It may be helpful to simply acknowledge the complexity of the illness of obesity and how it is not easy to be a healthy weight these days. Many of the parents are also carrying extra weight themselves, and providers can discuss that these changes are healthy for everybody in the family regardless of their weight status. Other benefits are that they can grow closer as a family and grow healthier as a family, by engaging in some of these changes.
Dr. Sarah Armstrong: I agree with everything that has been said here, and in particular I support our efforts to use person-first language, which can make the conversations we have more comfortable. The first time people use “children with obesity” instead of “obese child,” or describing a child as “having obesity” and not that the child “is obese,” it can be a little tricky. People's tongues can trip over the language a little bit and that is okay. We have to be able to gently correct people so that they really understand that children with obesity are children first, and they have many other things about them that has nothing to do with their obesity. They could be great at a musical instrument or a sport, or be really good at school or any of the very number or things that children define themselves that do not have anything to do with their weight.
The other thing that I think we can do is when we write for journals or we get interviewed for articles or we put together PowerPoint presentations or talks that we make sure that the images that we use really support person-first approaches in an authentic way. We should be choosing images that show children of all different weights and shapes and sizes doing their thing as kids, not highlighting the obesity in the context of a child carrying a McDonald's bag or sitting in front of a TV or doing something else that makes them seem unhappy, sad, or lazy. There are obviously many more dimensions to a child than just their weight. I do not think I have ever talked to a coach, but I called many and many teachers over the years.
I think the public school teachers in Durham, North Carolina, are quite tired of me at this point because of our advocacy for children with obesity. I think they need to understand how they handle teasing and bullying in their school settings is very important. I think the attitudes is still very much that kids are kids, and you have to toughen them up, and weight still seems to be commonly accepted as something that is okay to laugh about. We see it in the media and cartoons all the time. It is a funny jolly stereotype, and it seems to be so socially acceptable, but I think teachers need to understand the impact this type of teasing and bullying is having on kids and how it affects their opinions of themselves. If we can just help by educating and informing teachers about that, we can help to influence that whole environment for many people.
Dr. Sarah Barlow: Dr. Armstrong, it would be interesting to hear what you say to the teachers and what response you get.
Dr. Sarah Armstrong: The short answer is that it does not always go over well. But, most important, I always start off with describing how much influence they have in the child's life and how wonderful it is that they are supporting the child. I present myself as an ally and as someone who is on the same team. I treat it sort of the same as motivational interviewing by really trying to find that shared mission and goal and ask whether there is anything I can do to help support them in making sure their classrooms are a safe and welcoming place for everybody.
Dr. Joseph Skelton: There is an approach that I have developed that I would love to share that I am sure all of you have seen before. If I am in clinic and a family member, usually a parent, is making comments that I know the child is perceiving very negatively, which includes less-sensitive language (terms such as “they're just lazy,” “they're not motivated,” “they're so picky”), I will ask the child to give me a little bit of time to talk alone with their family member (typically their parent). I do this regardless of the child's age, but typically it is going to be the younger preadolescent child. I have asked kids to leave when siblings are making negative comments. I ask the patient to actually leave and that gives me the opportunity for a dialogue with the parent, sibling, or family member, and I will share with them why I did that.
I say to the parents “I know you were just trying to explain so I can understand, but I asked your child to leave for a reason. When you say things like that, your child is hearing “You're ugly, you're lazy, you're not smart, you're not good enough,” and all of these things translate to the child as, “You're not loved.” I know you didn't mean that, but that is what your child may hear and feel when you say that. Because again, that's what the research tells us children are often feeling. I share all of this with the parents very openly. I assure them, “I'm not criticizing you, because I know you love your child. That's why you're here, that's why you brought them here, but I can tell you those negative things are what your child was hearing right now. I want to have open conversations, but I don't want your child to feel bad.”
I have only had that not go well once when I had a parent get very angry with me about this. Usually they understand and are very apologetic. This can be tough to do, and sometimes it has a moment of discomfort, but usually this helps the family member understand how their language is harmful. You can observe this anywhere—from public health campaigns, to clinical settings, to the research that we do. Thinking about this and learning about the experience that this author talked about in the article, what do we and others need to keep in mind and trying to help children with obesity without causing any undue harm? How do we help families who want to change behaviors? How do we help without causing harm?
Dr. Suzanne Lazorick: I do think we can help and not harm. I think keeping the message about health is important. It is almost like we need a public health campaign about obesity being a disease, and not a character trait. We need to promote that this is not about willpower or choice. It would be good to have a forum or messaging campaign for this underlying theme as a prominent message because it really has not been part of the public health messaging in widespread media. Focusing on health, positivity, and strengths-based ideas and also being willing to accept small changes toward a positive behavior, or a desired behavior, are the things I think that would be more effective.
Dr. Susan Woolford: From a public health viewpoint, I also think that we often consider obesity and excess weight as an individual problem. It is so clearly not an individual problem. In the same way that there is a greater realization of the importance of embracing antiracism at the moment, we also need an antistigma movement, and we should be actively against obesogenic environments as well. There needs to be advocacy for changes within our society that will make it easier for children and adults to have a healthy weight. It will help so many of us. We need more action at the community and societal levels to help support families who are dealing with these issues.
Dr. Sarah Hampl: I agree with that approach. I am going to bring it down a little bit more to the individual provider approach and share a quote from one of Dr. Woolford's colleagues, Dr. Ken Resnicow, who did motivational interviewing training with us many years ago. He encouraged us and our colleagues as primary care providers, and said you just have to get the bat on the ball; you do not have to do it perfectly, but your care and compassion for the family will come through. You should equip yourself with the education you can through Change Talk, for instance, take advantage of other CME opportunities to learn about how to talk with families, but listen more than talk, try to convey some of those basic tenets of motivational interviewing, and help them realize they do not have to get it perfect the first time or all the time, but just get the bat on the ball.
That was something that stuck with me to help me realize that even if I did not have the wording exactly right, the family would still see and learn from my approach. I have learned that listening more than talking, really seeking to understand their barriers to change, what they want to work on, and what they feel could work are really important.
Dr. Joseph Skelton: A favorite commentary that I quote all the time is one written by our own Drs. Skinner and Armstrong. To paraphrase the commentary, a family made a great change. They quit drinking sugar-sweetened beverages, they started taking walks together, but the child's weight status did not change a bit. Are they failures? When it comes to the research that we do and how we measure success, we need to think about that. I know a lot of us talk about wanting to mainly focus on health, but I think there is a little bit of needing to “walk the talk” to really live up to that, which goes to the author's statement of “leaving them alone.”
I am here to help patients change behaviors, to improve their health in many different ways, and if you make these changes, even if you do not change your weight, I can promise you have improved your health in some way. We need to believe in that. That is something we need to spread a little bit more. I am not sure whether that is what Drs. Skinner and Armstrong intended with the commentary, but that is how I interpreted it.
Dr. Sarah Armstrong: I agree with that, Dr. Skelton. As Dr. Hampl said, we should listen more than we talk. I think that is really important. To help reduce the potential that I might bring my own biases and judgments into the patient examination room with me, I have learned to put my hand on the door handle and pause before I go in. I use this pause to remind myself to not make assumptions. If I am in a rush, I tend to focus on what is going wrong, trying to “fix” that for my patients, and to tell them how to improve, rather than asking what might have worked for them already or checking in about what we can start with today to start making things better. That reminder has been helpful for me; as I go into the room, I literally check judgment at the door so that I can meet people where they are.
Dr. Sarah Barlow: I will often start the conversation by simply asking permission to move on to a topic. So again, it could be a lot more complex but that is the basic approach that helps me make families feel like I am being supportive and not confrontational.
Dr. Joseph Skelton: Let us circle back to the author's title: “Leave Fat Kids Alone.” Is it okay to not address weight, especially if there is concern about harm or there is a lot of resistance? I always tell my adult weight management colleagues, you are often seeing people who are coming to you to help with their weight. With children with obesity, the patients are being referred to us either because their primary care doctor is concerned with their weight, there is a health complication, or there is a comorbidity that is involved in and the patient is being sent to us to help with that.
As a result, I feel like I am seeing children and families that are not pursuing weight loss, they are being referred to me. They are being told they need to address the child's weight. So, is doing nothing even an option? Is that even an appropriate model, where referral is pushing patients to us instead of the patients or their families actually seeking our help out? That is a big question, but it might be something worth wrestling with.
Susan Woolford: When patients are referred to us, they are usually open to getting some level of help if they make it into our offices. Referencing back to Dr. Barlow's motivational interviewing training video, the patient's parents or caregivers may not be interested specifically in weight loss, but they may be interested in decreasing the child's screen time, or they may be interested in seeing the child become more active. In partnership with parents and patients, it is often possible to identify other aspects of health, which are related to weight, that families would like to address as the initial treatment focus. I would like to emphasize that it is important to avoid assumptions and instead see what the family wants and needs. Partnering with families and showing an interest in what they are interested in mean there will be fewer times when we just have to say, “Oh, there's nothing we can do.”
There may be some children for whom it is just not the right time and it might be best to delay treatment until some point in the future. In some cases, it may not be the right time for the child, but maybe the parents are very willing to make changes and the child just gets to exist in that healthier environment, and that can be helpful. So I think there are a number of approaches that one can take, even if a child is not ready at that moment to address concerns around weight.
Dr. Sarah Barlow: I agree. There are many different approaches to being healthier that do not necessarily involve talking about weight loss. And there are times when allowing them to not come back again is appropriate. I have had teen patients who have been dragged in by their parents and I have found that it is appropriate to invite the teen to make a decision about coming back. I tell them, “I'm happy to see you any time, but you don't need to come back and you can make that decision.” A good chunk of the time they do come back. If too much emphasis on weight loss is causing harm, then there is no point in them coming back, but they know you will always leave the door open, and sometimes they come back a year or two later.
Dr. Suzanne Lazorick: I agree and have also done similar things with teenagers in particular, or whenever a patient is really adamant. But, I think, in terms of just the general statement, to quote, “leave fat kids alone,” we cannot just make that generalized statement. I want to make sure that the family or the child is making that decision from an educated standpoint with a focus on health. It remains important to make sure that the family knows what the concerns are; but certainly as a field, as general pediatricians, we can make sure weight is addressed the first time in a sensitive, appropriate, and health-focused way.
Dr. Sarah Armstrong: I think sometimes the “leave fat kids alone” approach has to be moderated when you have discordant beliefs between the parent and child. Sometimes they have really different objectives. I had a young teenage patient brought in by his parents recently. He clearly did not want to be there. He had a slight degree of obesity and he had no medical problems, so we did a little bit of discussion around his goals and hopes for his own physical health and emotional health, and set a prolonged follow-up because it was not one of those situations where you need to be monitoring very closely. Well, the parents called me that night on a Friday night and said that they really needed me to be more upfront with him and tell him that he was going to be really sick if he did not change his ways because he was doing X, Y, and Z at home, and they brought him to me to scare him. I am sure all of you have experienced a similar situation.
But scaring children is not our role as providers, and we have to be careful not to be put into that role by parents. So in that case, it really was about parental education. They had heard a lot of TV news reports about the severity of obesity and what a big problem this was, so they were just trying to address what they saw as a major health problem, but they did not have the nuanced understanding of how to approach it when it is mild versus moderate, versus severe. I think thatis where we can do some protecting of kids by helping their parents understand that, too.
Dr. Asheley Skinner: As the public health person in this discussion, I think the question of “leaving fat kids alone” raises an important point that often providers are working within a system that public health messaging and clinical messaging are not matching. If you think about the Strong4Life campaign (in Georgia), how did having to see posters depicting that people are obese because of the buffet line change how providers then needed to talk to their patients and families? What are they coming in with? Are they already scared? Is that what they need—to be made to be more scared? Or do they actually need the opposite of scare tactics? I think being aware and cognizant of what is it, the families are already believing and feeling as they decide whether or not this is a change that they want to make is important. Of course, everybody has that right to change or not change.
Dr. Joseph Skelton: This New York Times article highlights a lot of the research in weight stigma. We have to remember there is a huge body of literature on weight stigma, and particularly stigma within families.
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I think everyone participating in this discussion has shared some stories pertinent to that stigma. In addition to us not trying to do harm, we actively need to encourage our colleagues, and there is an opportunity to encourage family members to reduce stigma around weight as well. Dr. Skinner, I have always said, when people asked me, “What public health campaign would you support?” I would say, “Family meals!” Not that it is a panacea, but the beneficial side effects that we get from family meals go far beyond just health care and go way into other aspects.
Not that family meals together from an early age would answer everything, but I think there is definitely an alignment there that needs to happen. I would love to hear any last thoughts, not necessarily based on the article, but based on our conversation here that you would want to leave any potential reader with.
Dr. Asheley Skinner: My bottom line point here is that children with obesity are children. This has already been stated, but when we are trying to support families everyone needs to remember and to understand that kids are just kids, and the job of adults is to give them what they need to be healthy.
Dr. Joseph Skelton: That is a heavy one to follow. Maybe we should end on Dr. Skinner's message of love. I like that to end on that note. Thank you to everyone for participating.
