I vividly remember when I realized I had to change how I talk to patients about weight. I was a second-year resident, rotating in a rural practice. As I worked through my well visit routine, the mantra “growth chart, growth chart, growth chart” always rang in my head. Before starting a conversation about growth and nutrition, I examined the growth chart, then turned the computer towards my patient and their caretaker. I explained percentiles, where their child fell on the curve, and its meaning. I described my concerns if they were at the extremes, the labs they needed if they were at the higher end, and moved on for the kids in the middle, under the pressure of limited time. One day, when I gave this explanation to a young girl and her mother, thinking I was doing the right thing, she cried. I had not said anything rude or demeaning, but the message was received: “There is something wrong with my body; my body is not good enough.”
I saw myself in that patient’s tears. I gained weight during my high school years and tried to lose some of it in college. I went in for a physical and my internist praised my efforts, but when I returned the following year after regaining it all, an EPIC alert popped up, warning her of my significant weight increase. Seeing my “failure” highlighted made me cry. My doctor saw my tears. Yet, instead of offering words of comfort or reassurance, she said nothing and proceeded with the appointment. Realizing I had been trained to cause the same harm I had experienced hurt me deeply. I needed to change my approach for that young girl and my future patients.
I acknowledged my patient’s tears. I told her there is nothing wrong with her body and celebrated the things it allows her to do, like learn, grow, and play. She told me she played sports regularly with friends and we reviewed her typical nutrition. In the end, I didn’t have any advice — she was doing all the right things and happened to gain weight in early puberty. I can only hope she does not remember that day.
This experience sparked a quest for me to learn a better way. In my work with eating disorders, I have heard several patient histories start with a doctor’s comments that triggered disordered behaviors, such as restricting or binging/purging. In our intent to look after our patients’ health, we can cause significant emotional and physical harm. I didn’t want to go down this path.
From The Body Is Not an Apology, I learned about how society and its oppressive structures tell people, including those at higher weights, that our bodies are bad and calls on us to find radical self-love in spite of these forces. I learned about the Health at Every Size movement, which does not see weight as an indicator of health. In Body Respect I reviewed studies showing 90% of diets fail and yo-yo dieting leads to even higher weights than baseline. Fearing the Black Body helped me understand that fatphobia has racist origins; thinness became the standard for white women in the 18th century to represent their restraint compared to enslaved Black people in larger bodies who were seen as out of control. It also described the origins of BMI charts, which were created by a mathematician for insurance policies, then later co-opted for healthcare. Belly of the Beast tied this all together by demonstrating how fatphobia, anti-Blackness, and transphobia are all perpetuated by systemic oppression and places the responsibility on institutions to tear it all down. These works have inspired me in my development of an affirming, weight-neutral approach to health.
There is discussion in adult medicine about not weighing patients unless relevant, or at least letting them opt-out. For pediatric and adolescent medicine, patients are still growing, so weight is a pivotal vital sign as a trend, not an isolated point. One of my attendings told me, “every change tells a story.” We do not need to look further than the COVID-19 pandemic to see how circumstances impact weight. When I see weight significantly increase or decrease, I approach it with non-judgmental curiosity 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 evaluate for medical causes, like thyroid disease or chronic pain. I also consider psychological factors, like mental health concerns, trauma, and stress, etc. If they report no changes, I believe them and investigate further to rule out or identify medical issues. Screening allows for identifying and addressing core issues.
In a routine appointment, I ask all adolescents if they want to know their weight. I explain it is just a number on a chart that in itself has little meaning to me. If they decline, I will not mention it. Regardless of where they fall on the growth chart, we talk about the behaviors that contribute to health. I use “physical activity” and “nutrition,” instead of “diet” and “exercise” to reduce stigma. We talk about how they feel about their bodies and if they have ever tried to change their weight through disordered eating because eating disorders can impact anyone of any size, gender, race/ethnicity, or socioeconomic background. Through motivational interviewing, I help anyone create goals for improvement, such as 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 acknowledge the role that genetics, racism, and oppression play in health to counter 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, the labs often change before weight. Weight loss is not necessary for management. If a patient still desires to lose weight, I explore the reasons behind their goals. I offer referrals that will provide support without emphasizing weight, such as therapists for those who struggle with body image or want to process traumatic experiences, and dietitians for those desiring nutrition guidance. I refer to an obesity specialist if they express interest in learning about medical management.
I am always learning new languages and approaches, but the gratitude I have seen from patients and families at feeling celebrated and not shamed during these conversations is the confirmation I need to know that I am on the right track.
Rebekah Fenton, MD, is a graduating adolescent medicine fellow based in Chicago, and an adolescent health advocate with a health equity lens.