‘There is something wrong with my body’

I vividly remember realizing I had to change the way I talk to patients about weight. I was a second year resident, rotating through a rural practice. As I worked through my routine of preventive visits, the mantra “growth chart, growth chart, growth chart” was always ringing in my head. Before starting a conversation about growth and nutrition, I looked at the growth chart and then turned the computer to my patient and her caregiver. I explained percentiles, where her son was on the curve, and what they meant. I described my concerns if they were at the extremes, the labs they needed if they were at the high end, and continued with the children in the middle, under the pressure of limited time. One day, when I gave this explanation to a girl and her mother, thinking that she was doing the right thing, she cried herself. She hadn’t said anything rude or demeaning, but the message was received: “There’s something wrong with my body; my body isn’t good enough.”

I saw myself in the tears of that patient. I gained weight during my high school years and tried to lose some weight in college. I went in for a physical and my internist praised my efforts, but when I returned the following year after recovering everything, an EPIC alert popped up warning her of my significant weight gain. Seeing my “failure” highlighted made me cry. My doctor saw my tears. However, instead of offering words of comfort or reassurance, she said nothing and proceeded with the date. The realization that he had been trained to cause the same damage I had experienced hurt me deeply. I needed to change my focus for that young lady and my future patients.

I recognized my patient’s tears. I told him there’s nothing wrong with his body and celebrated the things it allows him to do, like learn, grow and play. He told me that he played sports regularly with friends and we reviewed his typical nutrition. In the end, I had no advice: she was doing all the right things and it turned out that she gained weight in early puberty. I can only hope that she doesn’t remember that day.

This experience sparked a search for me to learn a better way. In my work with eating disorders, I have heard several patient stories begin with a clinician’s comments that triggered disordered behaviors, such as restricting or bingeing/purging. In our intent to care for the health of our patients, we may cause significant emotional and physical harm. I didn’t want to go down this road.

Of The body is not an excuseI learned how society and its oppressive structures tell people, even the heaviest, that our bodies are bad and ask us to find radical self-love despite these forces. I learned about the Health at Every Size movement, which doesn’t see weight as an indicator of health. In respect for the body I reviewed studies showing that 90% of diets fail and that yo-yo dieting leads to even higher weights than baseline. fearing the black body it helped me understand that fatphobia has racist origins; thinness became the standard for white women in the 18the century to represent their restraint compared to enslaved blacks in larger bodies who were considered out of control. He also described the origins of BMI tables, which were created by a mathematician for insurance policies and later co-opted for health care. belly of the beast brought this all together by demonstrating how fatphobia, anti-blackness, and transphobia are perpetuated by systemic oppression and put the onus on institutions to bring it all down. These works have inspired me in my development of a weight-neutral, affirmative approach to health.

There is a discussion in adult medicine about not weighing patients unless it is relevant, or at least allowing them to opt out. For pediatric and adolescent medicine, patients continue to grow, so weight is a critical vital sign as a trend, not as an isolated point. One of my assistants told me, “every change tells a story.” We don’t need to look beyond the COVID-19 pandemic to see how circumstances affect weight. When I see weight go up or down significantly, I approach it with curiosity and nonjudgment to understand what may be going on in that young person’s life. I ask about recent food intake and physical activity, as well as new or worsening symptoms to assess for medical causes, such as thyroid disease or chronic pain. I also consider psychological factors, such as mental health issues, trauma and stress, etc. If they don’t report changes, I create them and investigate further to rule out or identify medical issues. Detection enables core problems to be identified and addressed.

In a routine appointment, I ask all teenagers if they want to know their weight. I explain that it’s just a number on a graph that in itself has little meaning to me. If they refuse, I won’t mention it. Regardless of where they fall on the growth chart, we’re talking about behaviors that contribute to health. I use “physical activity” and “nutrition” instead of “diet” and “exercise” to reduce stigma. We talked about how they feel about their bodies and if they’ve ever tried to change their weight through eating disorders because eating disorders can affect anyone of any size, gender, race/ethnicity, or socioeconomic level. Through motivational interviewing, I help anyone create goals for improvement, like eating breakfast before school or getting 8 hours of sleep.

In my counseling, I use “nutrition sensitive,” not “obesity-related,” to describe conditions like diabetes, high blood pressure, or high cholesterol. I also recognize the role that genetics, racism, and health oppression play in countering the assumption that patients are solely responsible for their health outcomes. Even when a patient has abnormal labs indicating a nutrition sensitive condition, I never recommend weight loss. After instituting lifestyle changes, labs typically change before weight. Weight loss is not necessary for control. If a patient still wants to lose weight, I explore the reasons behind her goals. I offer referrals who will provide support without emphasizing weight, such as therapists for those struggling with body image or wanting to process traumatic experiences, and dieticians for those wanting nutritional guidance. I refer to an obesity specialist if you express interest in learning about medical management.

I’m always learning new languages ​​and approaches, but the gratitude I’ve seen from patients and families for feeling celebrated and not embarrassed during these conversations is the confirmation I need that I’m on the right track.

Dr. Rebekah Fenton, is a Chicago-based Adolescent Medicine Graduate Fellow and adolescent health advocate with a health equity perspective.

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