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summary of cutoffs labeling “overweight” and “obese” for kids

Posted by on May 18, 2011 in Blog Posts | 4 comments

I enjoyed the adoption and feeding webinar yesterday. Great questions from the attendees. I found myself often recommending “Your Child’s Weight: Helping Without Harming” by Ellyn Satter. One area where I find medical professionals do a lot of harm is in labeling children as “obese” or “overweight” (also note my recent post about the harm of labeling a child as “failure to thrive.” Are you getting the idea that arbitrary cutoffs and labels generally do harm?) Check by to my post, “Don’t let your doctor label your child as obese,” and read Ellyn Satter’s latest Family Meals Focus newsletter on the topic, printed below with permission.
May 2011 • Family Meals Focus #57 • Labeling Overweight Children as Obese

In reading the research, you may have noticed that childhood overweight/obese designations have changed. Now, children whose BMI exceeds the 95th percentile are labeled obese rather than overweight, and those whose BMI exceeds the 85th percentile labeled overweight rather than at risk of overweight. This slippage grew out of a January, 2007 Committee Statement and recommendation1 and was made official by a recent National Health Statistics report.2 To its credit, NHS authors temporize about the legitimacy of such designations. Less than half of ”overweight” children (those with BMI ≥ 95) have a high percentage of body fat. Moreover, the consensus in the literature is that it is difficult to come up with any definition of child overweight or obesity.2

The problem arises from the manner in which those terms – and definitions – are used. How ever the BMI levels are labeled, they are statistical cutoff points established for the purpose of population-wide evaluation. As such, they are not appropriate for diagnosis of individual children. Despite the shortcomings of the definition, that is exactly the way they are used. Little wonder that parents are unwilling to accept and act on a weight-related diagnosis for their child.3

To remind you, the Satter Feeding Dynamics Model (fdSatter) says that the issue with weight not high weight per se, but weight acceleration: Abnormal upward weight divergence for the individual child. Such divergence gives a clue to distortions in feeding. Those distortions can be corrected by instituting a division of responsibility and feeding optimally throughout the child’s growing-up years.4 The whole issue of whether or not the child is overweight can responsibly be side-stepped – it really isn’t important. What is important is helping parents do a good job with feeding and letting the child grow up to be the weight that is right for him or her.

The bottom line is do no harm. Do words cause harm? Let us count the ways:

  • Children who are labeled overweight feel flawed in every way: not smart, not physically capable and not good about themselves.5 How much worse is it for children labeled obese?
  • Parents who are concerned about child overweight or have anti-fat attitudes are likely to restrict children’s food intake.6 Parental feeding restriction is associated with increased child food intake and higher child body weight.7 How much greater will parental tendencies and child weight gain be if children are labeled obese?
  • Controlling for child weight, increased child BMI z scores over several years correlate strongly with parents’ concern about child weight and perceived child overweight.8 How much more will BMIs accelerate if children are labeled obese?
  • Children whose food has been restricted have an increased likelihood of restricting themselves as they get older. Currently, at least two-thirds of adolescent boys and girls restrict their food intake to lose weight.9 How many more adolescents will diet if they are labeled obese in earlier life?
  • Such dieting is as counterproductive for adolescents as for younger children. Controlling for beginning weight, adolescents who diet by either healthful or unhealthful means are heavier five years later than adolescents who do not diet.10 What would those adolescents have weighed if they had been fed well, given opportunities to be active, and allowed to develop—and value—the bodies that nature intended for them?

References

  1. Barlow SE, and the Expert C. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120(Supplement_4):S164-192.
  2. Ogden CL, Flegal KM. Changes in terminology for childhood overweight and obesity. Hyattsville, MD: National Center for Health Statistics;2010.
  3. Rhee KE, De Lago CW, Arscott-Mills T, Mehta SD, Davis RK. Factors Associated With Parental Readiness to Make Changes for Overweight Children. Pediatrics. 2005;116(1):e94-101.
  4. Satter EM. Your Child’s Weight: Helping Without Harming. Madison, WI: Kelcy Press; 2005.
  5. Davison KK, Birch LL. Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics. 2001;107:46-53.
  6. Musher-Eizenman DR, Holub SC, Hauser JC, Young KM. The relationship between parents’ anti-fat attitudes and restrictive feeding. Obesity (Silver Spring). 2007;15:2095-2102.
  7. Birch LL, Davison KK. Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatr Clin North Am. 2001;48(4):893-907.
  8. Faith MS, Berkowitz RI, Stallings VA, Kerns J, Storey M, Stunkard AJ. Parental feeding attitudes and styles and child body mass index: Prospective analysis of a gene-environment interaction. Pediatrics. 2004;114(4):e429-436.
  9. Neumark-Sztainer D, Hannan P, Story M, Perry C. Weight-control behaviors among adolescent girls and boys: implications for dietary intake. Journal of the American Dietetic Association. 2004;104:913-920.
  10. Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later?Journal of the American Dietetic Association. 2006;106:559-568.

For more information, read Your Child’s Weight: Helping without Harming. To help parents do a good job with feeding, consider Ellyn Satter’s Feeding with Love and Good Sense II DVD and affiliated products.

To comment on this issue, please join on us FaceBook. NEW! ELLYN SATTER IS ON FACEBOOK!

Copyright © 2011 by Ellyn Satter. Published at www.EllynSatter.com.

Rights to reproduce: As long as you leave it unchanged, you don’t charge for it, and you include the entire copyright statement, you may reproduce this article. Please let us know you have used it by sending a website link or an electronic copy to info@ellynsatter.com.

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4 Comments

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  1. Christine

    Unfortunately, the form was faxed to camp the same day. This was just the hard copy for my records. I know that nobody at camp is really looking at these forms – they’re just filed away. But the pointlessness of it all is extremely frustrating. You’re obese, don’t forget that for one second. Back pain? I don’t need to weigh your backpack because I already have your BMI. That tells me all I need to know – you’re obese. Going to camp? Good for you. Exercise and have fun. But remember, you’re obese. We need to make sure the camp counselors know that, too, so let’s make sure that’s on your form. Twice.

  2. Christine

    Just a little background: several months ago, my 14 year old daughter was seen at our family practice for back pain. The treating doctor and I both agreed it was probably due to the very heavy backpack she carries and all his recommendations were aimed at easing the load on her back. She was prescribed an NSAID to use as needed. Last week she had a pre-camp physical. Our regular family practitioner was unavailable, so we saw a different doctor. I just received my copy of the physical form today and I’m so angry I could spit nails. Appearance/nutrition: Obese. I hadn’t listed the pain meds under medications because I didn’t intend to send them to camp. But the doctor had listed them with the following: “mild back pain secondary to strain +/- central obesity.” Katja, as an MD, could you please explain what labeling my kid as “obese” twice on a camp physical form could possibly accomplish? Are they really and truly blind to the stigma this causes?

    • katja

      Oh, Christine, I am so sorry. What happened is good olf-fashioned weight bias. He didn’t see her for her back strain, which is caused by the 40 pound back pack. You are darn right not to send that form on, and I would go further and ask that until a diagnostic test is done, that if it is based solely on a screening test, which the BMI is, that I would ask to have that label removed from the record. (If you followed the link to my post, you will see why…) Does he know anything about her behaviors? If she eats a balanced intake, enjoys physical activity? In one sense, if he didn’t say it to her face, you are lucky. It’s part of this movement, not to “sugar-coat” things. Many docs and RDs are being taught to be really aggressive about the label, with the misguided hope that it will make someone make healthier choices, which in fact, it does the opposite. Glad you are an advocate for your girl, sorry that we parents have to be in this day and age… Yes, they are really and truly blind to the stigma. they just don’t know. i spend a lot of time when I talk to docs (most of whom REALLY do want to help) reviewing the evidence that labels harm, and don’t help…

    • jaed

      Are they really and truly blind to the stigma this causes?

      The terrible thing is that I don’t think they’re blind to it at all. They rely on it. They feel that weight gain is usually due to insufficient verbal abuse (I paraphrase somewhat, but that is scarily close to things I’ve heard medical professionals say), and that stigma from doctors and abusive comments from parents, teachers, and strangers on the street will “encourage” the target to “lose weight and get healthy!” It is all too perverse for words.

      (Christine, you might want to check in with your daughter about what he might have said to her during the exam. He may not have said anything unpleasant or untrue about her appearance, but it’s possible you might want to do a little counteracting if need be.)