Recently I talked to a pediatrician who shared that any child with a BMI over 85% (current “overweight” cut-off on growth charts) whether there is a health concern or not will get an official “diagnosis” code of overweight or obese. This means it will become part of the child’s medical record list of diagnoses.
Once this BMI > 85% is recorded, that family gets a handout (the doctor can bill for services on obesity counseling). It has a mix of good and some dubious advice: no more than 2 hours of TV a day, no more than 4 ounces of juice, and my favorite—one hour minimum of uninterrupted aerobic activity outside of school. (How likely is that for most kids every day?) “Strap a pedometer on your kid for 10,000 steps a day!” That’s what, 4 miles plus? Or, “Don’t let your child be sedentary for more than 30 minutes at a time.” So do you have a stopwatch while Timmy is doing homework and have him run laps in the basement?
Why does it matter if your doctor “diagnoses” and codes/labels your child as “overweight” or “obese?”
1) Your child is open to possible discrimination in terms of future employment, health insurance etc. (Not sure I believe totally that the health insurance reform will deal with the “pre-existing conditions.”) There have been cases where children have been denied insurance because they were “overweight” and also “underweight.”
2) Labels and shame are not good motivation for positive change. In fact a child labeled as overweight or obese, regardless of BMI is more likely to feel flawed in every way, more likely to diet, practice disordered eating and gain weight. They are also less likely to participate in physical activity. Words matter.
3) Once something is in the chart, it is hard to get out. Think about this. Before any physician, lab tech or nurse meets your child she will see that label on the list of diagnoses. It is well known that medical providers have a bias against “overweight and obese” patients.
- CDC: “BMI is used as a screening tool to identify possible weight problems for children.” and “BMI is not a diagnostic tool. For example, a child may have a high BMI for age and sex, but to determine if excess fat is a problem, a health care provider would need to perform further assessments. These assessments might include skinfold thickness measurements, evaluations of diet, physical activity, family history, and other appropriate health screenings.” I doubt that the diagnosis of obesity put into the chart is based on anything other than BMI which often mislabels the individual…
- “BMI is not a reliable predictor of health”: American Heart Association article
- Child BMI not reliably predictive of adult BMI: United States Preventive Services Task Force: “a substantial proportion of children under 12 or 13 even with BMIs > 95% will not develop adult obesity.” (Note, there is increasing predictability as BMI increases and the older the child is.)
- A child growing consistently, even at a high percentile is (by definition of the bell curve) larger than the majority of her peers, but to label her as “over” weight when it is likely a perfectly healthy weight for that child is wrong and implies a health risk that is likely unfounded. FYI, the boy in this picture is “obese” at 90th%.
At your next pediatric visit, if your child’s doctor discusses your child’s weight consider:
1) Ask that she do so without your child present.
2) Ask that the physician not code for or put the diagnosis of obesity in the chart unless there are further diagnostic tests (take in the above quotes). Point out that BMI is a screen, not a diagnostic test.
3) Ask to review the growth chart. If your child is large, but the growth is stable, there is likely not a problem. Ask your doctor to look at the rate of growth. This may be a new concept for your child’s doctor.
4) It is reasonable to look further if there is acceleration of weight gain, or your child is increasing in percentiles. There could be a medical problem, or getting help with feeding might help. (Read Your Child’s Weight: Helping Without Harming, Ellyn Satter.) It could also be a pre-pubertal weight gain or otherwise normal pattern, but acceleration or deceleration on the growth chart warrants further evaluation.
If you get handed one of those handouts consider this:
1) Ask the physician if her/his children do one hour of uninterrupted daily exercise outside of school or wears a pedometer.
2) Mention that if it’s useful advice, every child should benefit from it.
3) Point out that there is conflicting evidence about the efficacy of any of the interventions mentioned. Don’t get me wrong, watching 8 hours of TV a day is not ideal for any child, but no studies have shown that recommending limiting screen time in the primary care clinic setting lowers BMI.
4) If you are already doing the behaviors on the list, let them know.
Just a couple of thoughts. What do you think? What have your experiences been with your children and getting labeled by the doctor?