Childhood obesity has become a health crisis in the U.S. across all socioeconomic levels. CDC statistics from 2017 through 2020 indicate the following for children and adolescents ages two through 19:

• Obesity prevalence was 19.7 percent and affected about 14.7 million children and adolescents.
• Obesity prevalence was 12.7 percent among 2- to 5-year-olds, 20.7 percent among 6- to 11-year-olds, and 22.2 percent among 12- to 19-year-olds.
• Among Hispanic children, obesity prevalence was 26.2 percent; non-Hispanic Black children, 24.8 percent; non-Hispanic White children, 16.6 percent; and non-Hispanic Asian children, 9.0 percent.
• Obesity-related conditions include high blood pressure, high cholesterol, type 2 diabetes, breathing problems (such as asthma and sleep apnea), and joint problems.

Pediatric health care practitioners are on the frontlines communicating with patients and families to combat this unhealthy trend.

What you say and how you say it matters

Weight stigma or weight bias refers to a person’s negative thoughts or perceptions toward individuals because of their weight and size. Weight bias can come from many sources, including peers, family, educators, media—and health care professionals. Bias by health care practitioners toward patients with obesity is well documented.

Conversations about weight between health care professionals, pediatric patients, and their parents can have profound, long-term effects on a child or adolescent. Communications that lack compassion, empathy, and sensitivity can exacerbate or even result in an eating disorder, lead to a breakdown in the practitioner-patient relationship, or prompt patient complaints.

Unintentional comments, blame, or judgment by health care practitioners while attempting to increase patient motivation can contribute to patient depression, social rejection, isolation, low self-esteem, poor body image, feelings of discrimination, substance abuse, and self-harm (including suicidality). Insensitive communication can also increase the chances that the patient won’t return for future visits. Weight bias may cause the practitioner to spend less time in the appointment, limit discussion with the patient and family during office visits, and offer fewer screenings or preventive care. Patient reactions to insensitive communications and practitioner bias result in the patient’s health care needs not being met.

Weight bias creates liability risk due to the potential for misdiagnosis. The practitioner may assume that obesity is the cause of a patient’s health care problem without pursuing other diagnostic and treatment options. Weight bias assumptions may also inhibit appropriate care for primary and secondary conditions, such as diabetes mellitus, and result in adverse patient outcomes. (See the American Academy of Pediatrics clinical practice guideline for more information on evaluating and treating obesity-related comorbidities.) It is, therefore, important for health care practitioners and their staff to understand and remain aware of their personal biases when communicating with children, adolescents, and their families about obesity.

Case example

The following case example illustrates how bias and miscommunication among the patient, family, and health care practitioners can lead to diagnostic error and adverse patient outcomes.

An 11-year-old female and her mother presented to a pediatrician for a well-child visit. The child was overweight and had been experiencing behavioral problems. At this visit, her urinalysis was normal.

Several days later, she began treatment with a psychologist. During a follow-up visit with the psychologist, the mother reported increased aggressive behavior and bedwetting. This information was never shared with the pediatrician. No recommendation was made for a physical workup for the bedwetting.

During a subsequent visit with the pediatrician, a history of anxiety disorder was noted. The child’s weight had dropped 9 pounds from her previous visit three months earlier. When asked about the weight loss, the mother reported that the child was anxious about starting school. The pediatrician did not document the conversation. The mother made no mention of bedwetting or other physical concerns. A referral was given for psychiatry.

That evening, the patient became lethargic with slurred speech. The family called 911. Emergency services noted a glucose of 300 mg/dL (high) and mottled skin. The mother reported recent urinary frequency. The emergency room physician noted a two-week history of polyuria. Urinalysis was 4+ for glucose and ketones. The child was admitted to the pediatric intensive care unit (PICU), where the PICU physician obtained a history from the mother of recent polydipsia and emesis. The mother later reported to the endocrinologist that the patient had a cousin with type 1 diabetes (not previously reported). The patient was subsequently discharged home with a diagnosis of insulin-dependent type 1 diabetes.

The family filed a suit against the pediatrician, alleging a delay in diagnosis that resulted in diabetic ketoacidosis, hospitalization, and possible brain damage.

Contributing factors in this case include:

• Inadequate patient history and physical assessment.
• Narrow diagnostic focus with the assumption of a chronic/previous diagnosis. Diabetes was not considered, and no workup was done. The pediatrician assumed that the patient’s weight loss was due to anxiety based on what the mother told him. Also, the pediatrician expected some weight loss from previously recommended diet modifications.
• Lack of communication among practitioners regarding the patient’s condition.
• Communication gaps between patient/family/practitioners. The mother failed to tell the pediatrician about recent bedwetting, polydipsia, polyuria, or that the patient had a young relative with type 1 diabetes.
• Insufficient/lack of documentation about the mother’s comment that the patient was not eating due to anxiety about school starting soon.

Practice improvement strategies

Implementing best practices can help practitioners discuss weight with children or adolescents and their parents. (See the American Academy of Pediatrics policy statement for strategies to improve clinical practices and mitigate weight stigmatization.) Additional strategies include:

• Recognize personal biases and focus on evidence-based clinical judgment when assessing patients.
• Use open-ended questions when interviewing patients and families in order to obtain a complete medical history.
• Use neutral and nonjudgmental word choices when communicating with patients, families, and health care team members. For example, use “body mass index” or “unhealthy weight” instead of “obese.”
• Document the patient record in a nonbiased and neutral manner.
• Use compassion and empathy when communicating with patients and families about weight management. Give encouragement and recognition for positive outcomes.
• Provide patients and families with behavioral health support services and resources to support lifestyle changes and weight loss.
• Educate health care professionals in the pediatric setting about complex causes of obesity and weight bias to promote successful patient interactions and positive patient outcomes. Communication skills training, role-playing, training videos, and traditional lecture-style learning are effective methodologies.
• Adopt a zero-tolerance policy for all staff to eliminate weight bias.

Resources are available to pediatric health care practitioners through The Obesity Action Coalition, The Obesity Society, and the University of Connecticut’s Rudd Center for Food Policy and Health for help with addressing issues such as respecting diversity and avoiding stereotypes, using appropriate language and terminology, displaying appropriate images that represent individuals affected by obesity, and finding resources to address bullying.

For further information, see our articles, “Implicit Bias Against Obesity: An Opportunity to Improve Patient Safety” and “Overview of Obesity-Related Malpractice Claims.”

Patti L. Ellis is a nurse and patient safety risk manager, The Doctors Company.