Seek First to Understand

For some children and adolescents with obesity, discussions about weight can be difficult and emotionally upsetting.^1,2  Stigmatizing words and behaviors can negatively affect mood, weight control behaviors, self-esteem, and social engagement.³  In this issue of Pediatrics, Puhl et al⁴  provide insight into youth perceptions and preferences when talking about weight with parents.

In addition to deepening our knowledge of how youth perceive weight-related conversations, this research provides much-needed information on preferences and emotional reactions of youth and parents from a racially and ethnically diverse cohort. For example, Hispanic and Black youth prefer parents to use terms like “curvy” or “thick” — language that is often dismissed by medical providers as not being serious enough to convey weight-related health concerns. The authors also evaluated differences in youth perceptions according to sex, sexual orientation, and weight status, drawing attention to the intersectionality of weight with other important aspects of identity, culture, development, and socialization. To use terms like “overweight,” “fat,” and “extremely obese,” provoke feelings of embarrassment, shame, and sadness. At home or in the clinic environment, feelings of shame or embarrassment can manifest as ambivalence or lack of motivation that can further perpetuate a cycle of frustration between parent and child.

Although sexual minority youth often react more negatively to weight-related talk compared with heterosexual youth, Puhl et al⁴  did not look at perceptions and emotions of transgender and gender diverse youth (TGD). This is an important omission given that TGD youth, especially those with obesity, experience more violence, weight-based victimization, depressed mood, and suicide attempts compared with cisgender youth with obesity.⁵  Furthermore, the relationships between body habitus, gender identity, and gender expression are complex. Many TGD youth feel unwelcome and misunderstood by their parents.⁶  Any discussions about weight could intensify negative emotions and internalization.

The research of Puhl et al⁴  reiterates the importance of being intentional about making sure that every child feels seen and heard. Otherwise, at the intersection of race and ethnicity, sex, sexual orientation, and weight status lies a misunderstanding with potentially painful emotional consequences. There is still much work to be done to better recognize these intersections. More research is needed to describe parental experiences with weight terminology, weight-based victimization and marginalization, and the generational impact on their children and how they talk to their children. For those youth affected by minority stress⁵  — social and psychological stress experienced by stigmatized and minoritized groups because of their observed place in society — recruiting and studying more diverse cohorts will also provide additional insight into how these additive or related experiences affect perceptions and emotions.

Medicalized terms, like obesity, can trigger feelings of judgment and perpetuate weight bias and stigma. When children and families feel judged in a medical space, they are less likely to return or seek treatment of all medical conditions, including conditions related to weight.⁷  When medical providers try to understand how children and adolescents want to talk about their bodies and their health conditions, it helps to build a more trusting relationship, decrease weight bias and stigma during medical appointments, and support the anticipatory guidance given to parents.

Consider the following, when discussing weight in the clinic or hospital setting:

• Ask permission to approach the topic, ie, “Is it okay if we talk about your weight?”

• If the answer is “no,” move on, eg, “Ok. I understand you don’t want to talk about it now. What would you like to discuss today?” Encourage parents to do the same.

• Recognize that the disease of obesity and the use of the terms “obese” or “obesity” can induce shame and often carry negative social connotations.

• Seek input from the child or adolescent, ie, “When we talk about weight, what terms would you like me to avoid using? When at home, what terms would you prefer your parents use?”

To use such methods is not ignoring the health-related risks associated with obesity. Neither is it preventing discussions about ways to make changes to nutrition or physical activity. Instead, taking a patient-centered approach to communication is an opportunity to first understand the patient before “getting them to understand” you. It is also a reminder that in the care of children and adolescents, our messages need to be delivered in a way that is appropriate for their age and stage of development.

We can change the way children, adolescents, and their families feel about accessing their medical home when weight is discussed. We can help parents and caregivers find words to talk about weight. We have the potential to create spaces where children and adolescents feel respected, encouraged, and included when we seek first to understand their perceptions and preferences.

TGD

transgender or gender diverse