When Weight Is the Issue, Doctors Struggle Too

July 21, 2009
18 and Under
When Weight Is the Issue, Doctors Struggle Too

By PERRI KLASS, M.D.

The mother came out of the exam room to intercept me: she knew I would probably have to talk to her daughter about how she was gaining weight, she said, but please don’t use the word “fat,” or even “overweight.” Don’t make her feel bad about herself.

The girl was about 8, and when I plotted her growth chart, it was clear some balance had shifted over the past year, and her weight was increasing much too fast relative to her height. It was worth talking about.

But I was as conscious of my own body as I was of hers. How on earth, I was thinking, am I supposed to give sound nutritional advice when all they have to do is look at me to see that I don’t follow it very well myself? How to reconcile that with her mother’s reasonable request: Don’t make her feel bad about herself? And taking it all together, how am I supposed to help stem the so-called epidemic of childhood obesity when not a week goes by that I don’t break my own resolutions? What price the not-skinny doctor?

“The advice we’re supposed to give in pediatric clinic, it boils down to ‘Eat less, exercise more,’ ” said Dr. Julie C. Lumeng, an assistant professor of pediatrics at the University of Michigan Medical School and an expert in childhood obesity. “This is such blasphemy, but when I deliver this advice to families, my heart’s not in it, because I just feel like so often the families are just glazing over, and when that advice is delivered to me, I glaze over, too.”

What does it mean when the doctor clearly cannot follow the doctor’s own advice? I asked that question of Dr. David Ludwig, director of the Optimal Weight for Life Program at Children’s Hospital Boston, a multispecialty program for the care of overweight children.

“This is an issue that can cut in every possible direction,” he replied. “The doctor who is herself struggling with her weight will have the advantage of personal experience from the patient’s perspective — which may increase compassion and provide other insights that a primary-care practitioner without the problem may not have.

“On the other hand,” he continued, “the patient may view a doctor who is substantially overweight or unfit as lacking the basic understanding of the problem to put those principles into effect in his own life.”

The drumbeat of concern about childhood obesity has grown louder in recent years, with much new research and more and more clinical trials and interventions. But in the meantime, the children of America have gotten heavier, I have diagnosed Type 2 diabetes in too many of my patients, and I haven’t done any major shrinking myself.

We’ve learned more about risk factors. For example, a 2007 study by Dr. Lumeng found that the fewer hours of sleep children got in the third grade, the more likely they were to be obese in the sixth grade, regardless of other family factors. Her current research centers on how mothers’ beliefs about obesity and diet affect their children’s risk of obesity.

But Dr. Lumeng has struggled with her own weight — she says she lost 50 pounds in the past year after a gestational diabetes scare — and she understands how hard it is to translate her own beliefs into daily practice. When she gets home from a long day at work, she told me, she knows she really ought to tell her three children to turn off the television and ride their bikes, while she is cooking broccoli and salmon for dinner.

“I know it all, I do research in this,” she went on. “But in the moment I’m exhausted, it’s been a long day at work, everyone’s sort of irritable. You can know what you need to do, but when the moment comes ... .”

I could make the admittedly self-serving argument that it’s easier to find common cause with your patients when you understand their frailties. Talking to an adolescent who is experimenting with drugs, or a parent who is smoking around a young child, I can easily take on the paternalistic resonance of moral rectitude: How can you possibly persist in this destructive, dangerous behavior, now that I have told you how destructive and dangerous it is?

On the other hand, you could argue that when the doctor gives advice she obviously finds difficult to follow, there’s an underlying — and undermining — complicit wink: Now that I’ve told you about healthy eating, let’s have a cookie together — we’ll change our habits tomorrow!

In the end, Dr. Lumeng is left with the same advice that made her glaze over: “I’ve had patients who say to me, ‘Wow, doctor, you’ve really lost weight — how did you do it?’ And I have to say, ‘Well, I exercise more and I eat less!’ ”

Back in the exam room, with that 8-year-old, I took some early and unsure steps toward discussing the topic. I showed her her growth chart, on the pink (for girls) graph paper. See, I said, you’re growing — you’re getting taller, and you’re adding muscle to your body as you grow. But we need to give you time to get taller before you add more weight.

And we talked nutrition (cut back on sweet drinks, fast food, eating in front of the TV), and we talked exercise (how about tap dancing, soccer, swimming lessons?).

And finally I looked the mother in the eye and said, without planning to say it, “If this were easy, I would be thin and fit.”

http://www.nytimes.com/2009/07/21/health/21klas.html?_r=1&ref=health