#59: Weight Weight…Don’t Tell Me! Countering Weight-Stigma While Providing Evidence-Based Nutrition and Preventative Health Counseling

August 10, 2022 | By Sam Masur

Summary

Weight weight…don’t tell me!! Dr. Channing Brown joins us for this data-filled, practice-changing episode on countering weight-stigma while providing evidence-based nutrition and preventive health counseling for our pediatric population. Using frameworks drawn from a Health At Every Size model, Dr. Brown teaches us to focus on nutrition and activity, not number on a scale; how to use weight-neutral language in counseling patients and families; and most importantly evidence-based ways to support overall pediatric health.

Credits

• Producer, Writer, Infographic: Becca Raymond-Kolker MD
• Executive Producer: Nick Lee  MD
• Showrunner: Sam Masur MD
• Cover Art: Chris Chiu MD
• Hosts: Chris Chiu MD, Justin Berk MD, Becca Raymond-Kolker MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Channing Brown MD

Weight-Neutral Health Pearls

1. Health does not equal thinness nor does obesity equal comorbidities: Patients of all body sizes should be given guidance on health-promoting behaviors at well child visits..
2. Be inquisitive and consider the background factors contributing to weight gain: trauma, ACES, stigma, family environment, access to food, education status. 
3. When counseling patients with obesity, address underlying risky behaviors rather than focusing on weight: Use BMI as a tool, rather than a diagnosis.
4. Dieting for intentional weight loss is a risk factor for both obesity and eating disorders.

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What is Health at Every Size? 

The HAES framework is a way of approaching nutrition counseling with the assumption that individuals can pursue health regardless of their weight or body size. This paradigm focuses on health-promoting behaviors when counseling patients rather than encouraging lifestyle changes with the goal of weight loss. This means that a patient of “normal BMI” should get the same advice as a patient with a BMI classified as overweight or obese. This model essentially challenges the mindset that thinness is healthy and fat is unhealthy and instead embraces that everyone regardless of body size or weight can be healthy.

How do we talk to patients about this approach?

Patients in larger bodies tend to experience a lot of weight stigma, both from medicine and society in general. When patients implement health promoting behaviors, their risk of disease is changing even without any weight change. It’s important for us to acknowledge that weight and  nutrition are very emotionally charged topics for us as well as our patients. This approach challenges a lot of what we are taught in traditional medical education which is the weight loss paradigm. 

The science of obesity and disease

Correlation between obesity does not mean causation of those health comorbidities or chronic diseases. It’s not easy to study whether obesity is correlated or causative of health conditions. While it is true that many studies show short term (1-5 year) health parameter improvements associated with weight loss, at long term follow-up around 90-95% of individuals who lose weight through dieting will regain that weight and more. The other 5-10% frequently demonstrate eating disorder behaviors like restriction and binging/purging. 

What is weight cycling?

Weight cycling is a term used to describe the pattern of weight loss followed by weight gain frequently seen in patients who are chronically dieting. The basis of the HAES movement is providing another framework in which the goal is to avoid “weight cycling” and instead pursue sustainable health-promoting behaviors without the goal of intentional weight loss. Patients may note changes in their weight as they make these lifestyle changes but our focus is on encouraging behavior change, rather than encouraging weight loss.

Clinically, how do we think about weight changes?

When we are looking at growth parameters in our pediatric patients we know to start thinking a little more when we see a change in growth percentiles. Many of us already have a clear framework for looking into the underlying cause of a decline in growth percentiles (i.e. weight loss). It’s important for us to be just as inquisitive when we have a patient with an increase in their growth percentiles rather than automatically characterizing an increase in body size or weight as a diagnosis in and of itself (i.e. obesity).

• Vitals: Is height velocity normal? Consider screening for hypothyroidism symptoms +/-  other endocrinopathies. Look at blood pressure: consider an underlying cause for hypercortisolism or a need to screen for OSA. 
• History: Expert opinion Increases in weight are often a sign/symptom of something else going on. Think about times when we as adults have fluctuations in weight: this may be related to stressors at work, major life events, a crazy personal schedule, difficulty getting to the grocery store to buy fresh ingredients. The same thing goes for children with weight changes. Any recent changes in the patient or family’s life? I.e. stressors, ACES, change in school, family member sick. If any of these things are true–table lifestyle counseling and focus on supporting the patient through these changes rather than adding an additional stressor to the family at this visit by prescribing exercise/nutrition changes.
• Screen for dieting/restrictive eating behaviors: Dieting with the goal of intentional weight loss is a risk factor in and of itself of pediatric obesity and often leads to weight gain or binge eating behaviors. Ask: “Have you been skipping meals? Have you been avoiding certain foods/food groups?”Screen for food insecurity: it is debated whether this has a direct correlation with weight but certainly has psychosocial implications.

Modeling weight-neutral language

Using weight language is using any language around weight. Kids are concrete thinkers (especially children under age 12) so it is helpful to take care with the language we use when discussing their weight. Focusing on weight gain or using terms such as “overweight” “obese” or “fat” can lead to internalized weight stigma which we know can cause physical and psychological harm to children. Long term implications of children exposed to weight-centered language include increased dieting, unhealthy weight loss techniques (i.e. purging via vomiting, diet pills, laxatives), binge eating and eating disorders. Kids exposed to weight stigma are also less likely to participate in exercise.  Dr. Brown keeps this in mind when going into a visit to discuss the growth chart. 

Nutrition counseling

• Gather information about what family and patient do already eat
• Ask about patients’ understanding of nutrition using the MyPlate Model. 
  • Teaching that growing bodies need all kinds of macronutrients ie “building blocks.”
•  Counseling about physical activity: how do you like to move your body? 
  • Dr. Brown uses language such as “helping them grow healthy and strong, and building their strong muscles and bones”

Food insecurity and structural inequity

Access to fresh foods, distance to parks, places to safely move and exercise, parent availability to facilitate outdoor activities in one study were all associated with an increased risk of pediatric obesity. There is a dose dependent increased risk of adult obesity with Adverse Childhood Events (ACEs). The most feasible thing we can do in the clinic with patients (outside the sphere of advocacy) is identifying and preventing ACEs and meeting families where they are at to make positive changes for their children.

Where does Pediatric BMI come from?

The CDC website states that the data used to create the BMI scales were derived from information collected on national surveys of growth measurements of children in the US from 1963-65 and 1988-1993. The percentiles by age were created based on expert consensus (lowest level of evidence when it comes to population health screening). It may be a useful tool in some situations but we need to be looking at the patient as a whole when helping assess their health rather than relying on the BMI scale. Several studies (1, 2) have pointed out flaws in the application of the pediatric BMI scale (both in research and clinical practice) as  there is significant variability between children of different racial/ethnic backgrounds and a lack of reliability in predicting risk of metabolic syndrome. 

Evidence based recommendations:

• 5-2-1-0 Model. Because it focuses on actionable health-promoting behaviors rather than putting the focus on weight loss or food restriction. 
  • 5 fruits or vegetables per day 
  • 2 hours or less of screen time
  • 1 hour of movement daily
  • 0 sugary sweetened beverages daily
• Eating at least one meal with family 7 days a week was predictive of increased vegetable/fruit intake, long term healthy eating patterns, and protective against EDs, binge eating, and dieting. 
• Encouraging parents to avoid weight talk when encouraging healthy behaviors: which has been associated w/ dieting, purging, binge eating, and eating disorders. 
• Parents should strive to foster a healthy body image: Patients that had healthy body image (regardless of BMI) were also more likely to pursue healthy activities like exercise and eat healthfully without the desire to change their body size
• Parents should be encouraged to offer healthy options at structured meal times without pressure to their children to eat specific foods preferentially. Allow the child to decide how much of each food to eat. 

Links

• Intuitive Eating: A Revolutionary Anti-Diet Approach by Evelyn Tribole and Elyse Resch

• Christy Harrison, author of Anti-Diet and podcast producer of Food Psych Feeding Littles

• How to Raise an Intuitive Eater:  Raising the Next Generation with Food and Body Confidence 

• “Lose Hate Not Weight” Ted Talk and You Have the Right to Remain Fat by Virgie Tovar

• Pediatrics: “The utility of body mass index as a measure of body fatness in children and adolescents: differences by race and gender”

• Pediatrics: “Do changes in body mass index percentile reflect changes in body composition in children? Data from the Fels Longitudinal Study”

Goal

Listeners will be able to describe the principles behind a health at every size approach, gain evidenced based nutrition and activity recommendations for all children, and develop skills to utilize and model weight-neutral language in counseling. 

Learning objectives

After listening to this episode listeners will…  

1. Be familiar with the Health At Every Size model and its shift from a weight-loss paradigm
2. Recognize the importance of weight-neutral language in clinical practice
3. Develop a framework for investigating weight changes in pediatric patients
4. Utilize the 5-2-0-1 Model in counseling
5. Describe several evidence-based interventions to reduce pediatric eating disorders and promote healthy nutrition and activity behaviors

Disclosures

Dr. Brown reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Raymond-Kolker R, Brown C, Lee N, Masur S, Chiu C, Berk J. “#59: Weight, Weight…Don’t Tell Me! Countering Weight-Stigma While Providing Evidence-Based Nutrition and Preventative Health Counseling” The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ August 10, 2022.