When Beth Nathan was 10 years old, her pediatrician grabbed her belly and said, “OK! Time to switch to skim milk!”
Nathan estimates that she weighed “maybe four pounds more” than her friends at school at that point. Until then, she had never thought much about her body. But the doctor’s comment hit its mark. Nathan began thinking about her weight more and went on her first diet in high school. Though she never met the criteria for an eating disorder, she also never shook the expectation that she should be thinner. She continued dieting off and on through college and medical school. And then, Nathan (not her real name; she asked to use a pseudonym to protect her employment status) became a pediatrician herself.
As Dr. Nathan, she now works in a busy private practice in New Rochelle, N.Y., which means she looks at growth charts and thinks about weight and body mass index (BMI) every day. She’s never grabbed a kid’s belly, of course. “I think having some sensitivity to being gentle and nice is how most pediatricians roll,” she says. But for many years, she advised parents to cut down on snacks between meals. “My general line was, ‘This has nothing to do with how you look, you are beautiful, you are wonderful, I just want to make sure blah blah blah,’” she says. “But I knew it landed flat. Kids are clever.” They knew she was prescribing weight loss because she was.
Nathan was also still pursuing weight loss herself. A little over 20% of doctors in larger bodies said they were actively restricting calories, doing Paleo, or following another weight-loss plan, according to a 2014 survey of more than 31,000 American physicians representing 25 medical specialties. But a nearly equal percentage of doctors in thinner bodies said they were following the same kinds of eating plans, which suggests that dieting is common across the medical profession, regardless of weight status. In a survey of 873 women physicians conducted by Michigan University researchers, 72% said they did intermittent fasting, 46% were on a keto diet, and 26% were trying to eat low calorie and low carb. And they all said they were likely to recommend the diets they were using to their patients.
None of this is obvious to parents when we show up for the annual well visit and a nurse pops our child on a scale. But we do notice when a pediatrician judges our child’s body size, BMI, and growth trajectory. We may watch our child absorb a stray comment like “maybe less juice, Mom,” and wonder how deeply it will embed in their sense of themselves.
Many parents are even more anxious about how weight will be addressed at their children’s check-ups since the American Academy of Pediatrics (AAP) released guidelines for the treatment of childhood obesity that instruct doctors to refer children as young as 2 for “intensive behavior and lifestyle treatment” programs, and to consider weight-loss drugs for kids with high BMIs starting at age 12 and evaluations for bariatric surgery starting at age 13. We may feel like we have to follow such advice because it’s coming from a doctor we’ve otherwise learned to trust and respect. But before we do, it’s worth understanding the broader context doctors are operating in, and the way that anti-fat bias informs their thinking and medical practice. Because doctors exist in the same diet culture we do—and are perhaps even more vulnerable to its messaging.
Deconstructing Provider Bias
Dr. Andrea Westby practices full-spectrum family medicine at a University of Minnesota clinic in Minneapolis. Around three years ago, she stopped routinely weighing her adult patients. “It is pretty radical and I’m a little surprised, since I do work in a larger health system, how easy it was for me to ask my medical assistant not to weigh my patients, and she just doesn’t,” Westby says. She does check weight in a few specific circumstances, such as patients with heart failure, where fluid levels need to be monitored, or who are in eating-disorder treatment. But for the most part, not weighing patients frees Westby up to have very different conversations with them. “It creates a more collaborative relationship with families,” she says, “and we can talk about what’s going well, or what might help them.”
Westby is aware that her approach might make colleagues uncomfortable. Doctors are steeped in diet culture, she says, and that impacts how they look at data, and the conclusions they draw. Indeed, every M.D. is taught in the same, weight-centric medical model. Research shows that future doctors come into medical school with plenty of built-in fatphobia. One 2019 survey of 4,000 medical students found that nearly 75% displayed implicit bias. Thinner medical students and male medical students, as well as those working in specialties versus primary care, were more likely to show this bias. “From the very beginning of medical school, when we talk about risk factors [like obesity], we talk about them as if they are inherent and causative,” says Westby.
Dr. Rebekah Fenton, an adolescent-medicine fellow and pediatrician in Chicago, agrees. “You hear all the time that correlation does not equal causation, except when you’re learning about obesity research,” she says. Then, the idea that high weight causes poor health is never questioned. For Fenton, a Black doctor in a larger body, that experience was particularly disorienting. “The assumption in every lecture on obesity seemed to be that they were talking to an audience who wasn’t personally affected by this,” she says, recalling presentations that featured photos of people in larger bodies eating fast food. “I’ve heard professors and colleagues make stigmatizing comments about large bodies, maybe thinking it doesn’t apply to me. But it does, or it applies to someone in my family. I would leave those lectures and feel like, ‘I have to go straight to the gym.’”
When Fenton began her pediatrics residency, she says that once again, weight bias was front and center in her training: “It was growth chart, growth chart, growth chart,” she recalls. Then one day, she brought up the growth chart to an 11-year-old patient who was starting puberty and had gained a significant amount of weight since her last visit. “She started crying,” Fenton says. “And it took me right back to crying myself when I saw my own doctor in college, after gaining some weight.” Fenton’s doctor was unnerved by her reaction. “She just sat there awkwardly while I cried,” Fenton recalls. “So then, fast-forward to this patient crying, and here I am, the perpetuator of that.”
As recently as 2016, the AAP published a clinical report advising doctors to avoid discussing weight and weight loss with their adolescent patients because they might “misinterpret obesity prevention messages” and start dieting. But their recent pivot to encourage weight loss discussions suggests that maybe kids and parents haven’t been misinterpreting what their doctors say, so much as directly absorbing their anti-fat bias. After analyzing audio recordings of 208 patient encounters by 39 primary-care physicians, researchers found that doctors established less emotional rapport with their higher-weight patients, according to a study published in a 2013 issue of the journal Obesity. A 2016 survey of 308 nurses and support staff at an urban pediatric hospital found that those providers were more likely to believe that body weight is entirely controllable, a common misconception that then leads providers to blame patients who “fail” to control their weight.
Patients pick up on this bias. One 2014 study found that 21% of patients with overweight and obese BMIs felt that their doctor “judged them about their weight”—and as a result, they were significantly less likely to trust their doctor, which caused a breakdown in communication and reduced the quality of their care. This can lead to skipping routine checkups and other preventive care, which means that when patients in larger bodies finally do seek treatment, they are sicker than they might otherwise have been. This could be another explanation for the often-cited correlation between higher weights and worse health outcomes.
As a family-medicine provider, Westby treats children as well as adults. And while she feels good about her decision to stop weighing adults, figuring out a weight-inclusive approach to pediatric care has been a little more complicated. A dramatic weight loss can be a common early symptom of an eating disorder or juvenile diabetes. And on a more mundane level, most children’s medications—even the over-the-counter Tylenol we give for fevers—are dosed by weight. So, pediatricians need to know how much kids weigh, at least periodically. But that doesn’t mean they need to talk about it in ways that cause harm.
Westby says she’s stopped reviewing growth charts with parents at every visit, unless a parent asks what percentile their child is in. “I don’t think it’s helpful in having the conversations I want to have with my families,” she says. She now looks at weight as a clue and gets curious about what a significant increase or decrease might represent. And in addition to physical health issues like diabetes or a heart condition, Westby thinks holistically: Has the family experienced some sort of big disruption, like a death or a move, since the last visit? Are they having trouble accessing food? Is the child struggling emotionally in some new way? If the answer to any of these questions is yes, then that’s the problem she works with the family to solve.
This approach makes intuitive sense, but we don’t yet have much hard data to back it up. “Right now, there is so much focus [in the research] on trying to prevent children from being large rather than accepting that some of them will be,” says Dr. Lesley Williams, a family-medicine doctor who specializes in eating-disorder treatment in Scottsdale, Ariz. She coauthored a review paper for the journal Current Opinion in Pediatrics in 2021, which drew on the small body of evidence that does exist to outline how to adapt the weight-inclusive health care model known as Health at Every Size (HAES) to adolescent medicine.
Williams argues that weighing kids less often, or not discussing numbers when you do weigh kids, is just one part of shifting how we think about weight in health care settings. The bigger challenge is getting providers to identify and work on their own biases around weight, as well as gender, sexual orientation, race, socioeconomic status, and ability—since all these intersecting identities are more likely to face inequity in the health care system. “And one hurdle to that happening is the fact that there is no potential financial gain in body-size acceptance,” she says. Pharmaceutical companies can’t sell drugs for it—and the frenzy around Ozempic, a type 2 diabetes drug increasingly prescribed off label for weight loss, has shown that there is lots of money to be made that way—and diet companies can’t sign us up for body-size acceptance plans. “But convincing a parent you can prevent their child from becoming fat has financial promise.”
What both parents and providers eager for less weight talk have in our corner is the substantial pile of evidence that prescribing weight loss is bad for kids’ health, along with a more slowly accumulating body of research demonstrating that a weight-inclusive model of health care can be good for it. A 2020 analysis that assessed evidence from 10 randomized control studies found that weight-neutral, HAES–informed protocols led to small improvements in adult patients’ blood pressure, cholesterol, blood glucose, and hemoglobin A1c levels that mirrored what patients following a weight loss-protocol experienced, though presumably without the potential for dieting’s negative side effects. Other research suggests that patients treated according to HAES principles tend to exercise more consistently and eat more fruits and vegetables than patients assigned to control groups. But the measure of success where the weight-inclusive model shines is in how it improves patients’ relationship with food and reduces disordered eating behaviors. “The benefits of HAES interventions on eating behavior and psychological well-being more broadly outweigh the potential risks of weight-focused care,” Williams wrote in the paper she coauthored in 2021.
The power of weight-inclusive health care to reduce disordered eating is what should make it so appealing to so many doctors still caught in the weight-centric medical model, as well as their own personal body struggles. Nathan, the doctor in New Rochelle, still takes weights, but her nurse faces every patient away from the scale. For a while, she asked for permission to discuss weight with patients, and always respected it when they said no. But when we speak again a year after our initial interview, she reports that she’s stopped bringing it up at all because she’s so convinced it has the potential to do harm. “In the past two years, have I seen any kids develop type 2 diabetes or hypertension? No,” she says. “But I have seen a lot of kids hospitalized for eating disorders and they often tell me a conversation with a pediatrician planted seeds.”
Nathan does talk with every kid about finding ways to move their body for pleasure, but she emphasizes that weight loss is not the goal. For parents who have spent years on the defensive about their child’s body size, finding a doctor who doesn’t automatically jump in with judgment and prescription is reassuring. “I’m still deconditioning myself to think, Yes, I still did a good physical even if we didn’t talk about their weight,” says Nathan. “It still feels slightly illicit. Am I allowed to just totally flip this paradigm, after 30 years of life and 10 years of medical training? Can I do that and still be a good doctor?”
She won’t be the same doctor. But she might be a much better one.
(c) 2023 by Virginia Sole-Smith. From Fat Talk: Parenting in the Age of Diet Culture (Henry Holt & Co., April 25, 2023)
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