What is the best way to discuss pediatric obesity?

Many of the pediatric nurse practitioner students I train are confused about how to share findings that a child is obese with parents or caregivers. And for good reason – the topic is often difficult to discuss.

Although I have a lot of experience treating patients, asking and answering questions about overweight and obesity is never easy, especially not when a patient is only 2 years old, and one or both of the parents are also overweight or obese.

I’m going to walk you through a recent clinical scenario, and then discuss whether or not my approach was the best way to motivate behavioral changes.

The other day, I saw a new 32-month-old patient. After introducing and determining the reason for the visit, one of the first things I do during each patient encounter is review the patient’s growth charts and explain to parents what the figures mean.

Height for age comes up first and is expressed as a percentile. I explain to parents that the dot on the graph represents their child in relation to100 kids of the same age. If the child is in the 95^th percentile, as was the case with this child, then the information on the graph means that the patient is taller than 95 out of 100 children the same age group.  

Next up is weight for age. In the case of this patient, there was no visible dot on the chart to represent this child’s weight in relation to peers. It took me a second to realize that the child’s weight must have been so high that there was no place on the chart to plot it.

I explained this to the child’s parents, and suggested that we move on to the next chart – BMI. Luckily,  the dot representing the child’s weight was visible on this chart, although it was way above the 99^th percentile. 

This is when many of my students in similar situations ask me, “What should I do now?” 

Data on how best to discuss obesity with patients is scarce. In fact, much of the available literature shows that many health-care providers are really good at avoiding discussing the topic of weight all together.

A 2002 study by Barlow et al showed that among 940 pediatricians, NPs and registered dietitians who responded to a survey, the majority used clinical impressions and height-weight charts, but not BMI, to evaluate weight status in children.

In a separate 2008 study, Huang et al found that fewer than 50% of a nationally representative sample of family physicians and pediatricians surveyed assessed BMI in children; and 58% reported they never, rarely or only sometimes traced patient’s weight or weight-related behaviors over time.

Similarly, in 2010 Kihne et all surveyed practicing NPs, and found that only 67% were comfortable addressing obesity with parents.

Given the continual  rise in childhood overweight and obesity in the United States, it seems like nothing (including health-care providers) is able to effectively get through to the public about the seriousness of this problem. 

Lately, I have taken to using the words “obese” and “overweight” when the terms apply. If a child is obese, I tell parents that the medical community defines his or her weight as such. Then I ask them if they are interested in doing anything to decrease the health risks associated with their child’s obesity.

Although I am well meaning and this clearly communicates the situation to parents, it may not be inspiring the changes I hope for. Health-care providers recently gained a little more guidance as to which weight terminology parents of overweight and obese children find most acceptable. Results of a 2011 survey involving 445 parents indicate that the terms “unhealthy weight” and “weight problem,” were the most desirable in terms for promoting favorable behavior changes.

Furthermore, if stigmatizing terms, such as “fat” or “obese” were used, 59% of participants stated that they would find a new health-care provider or avoid future medical appointments. Although I may have not had the best approach from the start, at least now I know which terms I’ll be using to discuss pediatric overweight and obesity in the future. 

Julee B. Waldrop, DNP, FNP, PNP, is the Director of the MSN-DNP Program and an associate professor at the University of Central Florida. She provides health care to children at a local community health center.

References

1. Huang TTK et al. “Pediatricians’ and Family Physicians’ weight related care of children in the U.S.”  Am J Prev Med. 2011;41(1):24-32.

2. Kihne B. Willingness of nurse practitioners to address parental perception of childhood weight. 2010. ProQuest, UMI Dissertation Publishing: Ann Arbor, Mich.

3. Barlow S. et al.  “Medical evaluation of overweight children and adolescents: Reports from Pediatricians, Pediatric Nurse Practitioners and Registered Dietitians.” Pediatrics. 2002;110(1):222.

4. Puhl RM et al. “Parental perceptions of weight terminology that providers use with youth.” Pediatrics. 2011;128(4):e-786-e794.