Body Shaming In The Pediatrician’s Office Causes Real Harm

It started when my daughter was 5 years old. At a routine well visit, the pediatrician looked at her growth chart, looked at me, and said, “I’m worried about her weight.”

I wasn’t prepared for the conversation. Not only was my daughter an energetic, happy, and active little kid about whose health or body size I had zero concerns, but as a parent, I make it a point not to discuss weight with my children. Unfortunately, before I had time to react, the doctor invited my daughter into the conversation. She started asking rapid fire questions: Do you drink a lot of soda? Do you like sweets? We need to be careful not to eat too much candy and fruit snacks. How much television do you watch?

After the interrogation, she turned back to me. “She’s in the 90th percentile for BMI. I’d like it if she didn’t gain any more weight by her next appointment,” she said. “Limit snacks. Small meals. Ideally, she’ll add height without adding any weight and everything will even out.”

I was flabbergasted. Not only had the doctor just made the assumption that I fed my 5-year-old a steady diet of soda and candy, but was she actually suggesting I withhold food from a kindergartener? Worst of all, she said all of this in front of an impressionable 5-year-old girl whom I had worked overtime to protect from the damage of diet culture and negative body image.

Needless to say, we never went back to that pediatrician. That night, I left an angry voicemail so long the recorder cut me off, and I went in search of a new provider. I’m not new to body shaming — at the doctor’s office or elsewhere. As a plus-size woman who is the daughter of a former model, my first experiences with diet culture and body shaming happened in my own home, where my mom tried to force salads on me in elementary school and warned me not to wear horizontal stripes because they make me look “wide.” I spent the first three decades of my life hating my body, eventually landing in therapy to recover from binge eating and body dysmorphia. I’ll be damned if I’m going to let the same thing happen to my kids.

In almost every instance, these conversations take place with the child present, the doctors dissecting their body size with the same casual ease they might use to talk about the weather.

Unfortunately, in the years since that first pediatrician experience, it’s become clear that body shaming is happening to far too many kids, and a lot of it is coming directly from the health professionals their parents trust to keep them healthy. Like a lot of moms, I’m involved in several parenting groups on social media. Every week, it seems, there is a new post from a panicked parent whose pediatrician just told them their child is “too big.” In almost every instance, these conversations take place with the child present, the doctors dissecting their body size with the same casual ease they might use to talk about the weather. But these conversations are not innocent, and the shame and fear they create is putting kids at risk.

Over the past several years, weight and body mass index (BMI) have taken center stage as main metrics doctors use to determine if a child is healthy. The BMI percentile assesses children’s body size relative to other kids of the same sex and age using CDC growth chart data collected from 1963-1965 and 1988-1994. According to these charts, kids whose BMI falls in the 85th to 94th percentile are labeled “overweight,” while those whose BMI is in the 95th percentile or above are classified as “obese.”

Unfortunately, the numbers on these charts have become license to make wild assumptions about parents’ choices and to tell young children their bodies are somehow wrong. Sarah Beth Gorden, a parent from Dayton, Ohio, says she was accused of feeding her daughter too much junk food after the toddler landed in a higher percentile at her 18-month checkup. “I was told to watch her snacking because ‘toddlers tend to eat chips and crackers all day,’” she says. “The doctor never even asked what she normally eats. For the record, she hadn’t tried chips yet.”

Billie K., a parent of two from Des Moines, Iowa, says her 3- and 7-year-old’s pediatrician made weight-shaming comments during a well visit last spring. After going over growth charts, the doctor said the kids were in a higher BMI percentile and cracked a joke about pandemic weight gain. “Both of my kids were low-weight at birth, and there was concern about them not gaining enough,” Billie says. “Now, at the 86th percentile, the doctor is adding this other unnecessary concern. I was most upset that she made this comment in front of my 7-year-old, who is already starting to notice appearances. It added nothing to the evaluation.”

Importantly, the systemic focus on weight distracts from crises like food insecurity, poverty, and early life adversity.

While growth charts and BMI percentiles help pediatricians keep an eye on the big picture of a child’s development, these numbers alone are not reliable indicators of a child’s health. Research shows that in kids younger than 9 years old, BMI is a poor predictor of both body fat percentage and total fat mass. Even in adults, BMI measurements have been found to incorrectly label more than 54 million Americans as “unhealthy,” even though they are not. Additionally, BMI ranges often misclassify Black, Hispanic, and Asian people because the measurement does not account for body diversity across races and ethnicities.

“Not only is BMI useless for individuals, it’s harmful,” says Katja Rowell, M.D., a family doctor and child feeding specialist in Washington state who’s written several books on healing children’s relationships with food and eating. “It implies that kids in the so-called overweight and obese categories are at risk when many are not, and then for kids in the so-called normal range, it’s like, ‘Their weight is fine, so they’re healthy.’ Doctors miss opportunities to explore health-promoting behaviors for those kids. Importantly, the systemic focus on weight distracts from crises like food insecurity, poverty, and early life adversity.”

Not only do BMI and weight percentiles fail to tell the whole story, but negatively discussing children’s body size can cause real damage. Eating disorders are most common in adolescents, but they are increasingly being recognized in children ages 5 to 12, according to a 2016 report by the American Academy of Pediatrics. The report also states that diet talk, such as encouraging kids and teens to eat fewer calories or try to lose weight, is associated with greater weight gain and increased rates of binge eating in both boys and girls ages 9 to 14.

“A comment that the pediatrician thinks is harmless and helpful, like ‘just cut out dessert or a couple hundred calories a day’ can absolutely trigger some very serious and negative ways of relating to food,” Rowell says.

Oona Hanson, a parenting coach who has a degree in educational psychology, knows this firsthand. Hanson, who lives in Los Angeles, says a pediatrician’s comment about her 14-year-old’s weight “kicked off the perfect storm” that ultimately led to her teen developing anorexia. “The doctor remarked that weight gain had led to going above the growth curve,” Hanson explains. “The advice was to eat fruits and vegetables and get plenty of physical activity. The pediatrician certainly felt this was helpful and reasonable guidance, but the unspoken message was clear to my teenager: change your food and exercise in order to lose weight.”

‘I hate to admit that it took having my own child in that position to question my training. I cared tremendously for my patients and thought I was doing the right thing.’

Hanson’s teen was later treated for their eating disorder and needed to restore weight in order to recover. Even then, she says, the pediatrician was concerned about the number on the scale going “too high.”

“To protect my child’s recovery, I had to remind the pediatrician not to discuss weight, food, or exercise, and to leave those topics to the eating disorder professionals,” she says.

Most pediatricians don’t intend to cause harm when discussing children’s weight. As a physician, Rowell says she was trained to look at weight as a proxy for health. She only began to question that training when her young daughter was considered too big according to growth charts. “I worried,” she says. “I was trying to feed my daughter so she wouldn’t grow up to be considered ‘obese,’ and I worried about anorexia because I had worked with eating disorders in a college health setting. It was spectacularly horrible.”

Rowell implemented the standard health and diet advice she shared with her patients, but trying to control her daughter’s size backfired. Rowell says her daughter became preoccupied with food, and it wasn’t until Rowell found Ellyn Satter’s Division of Responsibility, an evidence-based approach to feeding that encourages intuitive eating and trusting your child’s body, that she realized she needed to challenge her own biases about weight.

“I hate to admit that it took having my own child in that position to question my training,” Rowell says. “I cared tremendously for my patients and thought I was doing the right thing. The medical field is incredibly weight biased. Providers are fed constant panic about ‘obesity’ and early intervention ‘solutions’ that don’t help. They mean well, but by focusing on weight, they’re doing harm, not just to children in larger bodies, but to all children.”

Nicole Cruz, a registered dietitian from California and the creator of the popular family-focused intuitive eating Facebook group Joyful Eating for Your Family, says if doctors and parents want kids to be truly healthy, we must move away from the idea that health is inherently linked to body size. “Children grow at different rates and into all different body sizes,” Cruz says. “What’s best and healthiest for your child is actually the body that they naturally grow into.”

Of course, sometimes parents and doctors might genuinely have concerns about a child’s eating habits or sudden, drastic changes in their growth. Those are important to explore with the right experts, Cruz says, but focusing on weight alone does kids a disservice. “There are so many things to consider,” Cruz adds. “Are there thyroid issues? Is there something emotional going on? How are families feeding at home? Are kids being bullied at school? We might be missing underlying concerns.”

When assessing a child’s health, Cruz tells parents to focus on behaviors, not weight. “I encourage parents to take a step back and ask themselves: ‘If my child was in a smaller body, would I be worried? Are there concerning health behaviors going on or is it only body size?’ That's a really important distinction because if there aren’t concerns, then that likely is the body that’s right for your child to grow into,” she says.

As for those weight conversations in the doctor’s office? Both Cruz and Rowell say the topic should be off limits when kids are in the room. Rowell co-authored a letter parents can download and file with the pediatrician’s office requesting that growth chart discussions happen sans kids. Cruz also suggests calling or emailing providers before appointments if you’d like to head off weight conversations before they happen. If the topic comes up unexpectedly, parents should feel empowered to step in. “You can say, ‘You are welcome to have this conversation with me, but please do not do it in front of my child,’” Cruz says.

Ultimately, parents and doctors have the same goal: healthy kids. But creating shame around weight and food isn’t the best way to get there. “You can always look and see if there are areas like sleep or activity or eating more produce where you can make adjustments, but that is separate from body size,” Cruz adds. “We really need to accept that there's more body diversity than just what shows on a growth chart.”

Studies referenced:

Cassandra Vanderwall, R. Randall Clark, Jens Eickhoff, Aaron L. Carrel (2017) BMI is a poor predictor of adiposity in young overweight and obese children. BMC Pediatrics, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5457636/

A J Tomiyama, J M Hunger, J Nguyen-Cuu & C Wells (2016) Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005–2012. International Journal of Obesity, https://www.nature.com/articles/ijo201617

Neville H. Golden, MD et al. (2016) Preventing Obesity and Eating Disorders in Adolescents. American Academy of Pediatrics, https://publications.aap.org/pediatrics/article/138/3/e20161649/52684/Preventing-Obesity-and-Eating-Disorders-in

Experts:

Katja Rowell, M.D., family doctor and child feeding specialist

Nicole Cruz, registered dietitian