COMMENTARY

Weigh But Don't Tell

William G. Wilkoff, MD

Disclosures

April 18, 2022

Reports of long waiting times at mental health clinics and anecdotal observations by healthcare providers suggest the pandemic has generated a dramatic increase in the incidence of eating disorders among the pediatric population. Of course this should come as no surprise to pediatricians.

Eating disorders come in many different forms and a triggering event is sometimes difficult to define. Often the adolescent or preadolescent is searching for some sense of stability in a life tossed on a stormy sea roiled by hormonal and physical change. Wresting control of their bodies during a period of uncertainty may result in a downward spiral into dangerously unhealthy weight loss. If nothing else, the pandemic has been a period of dramatic uncertainty unlike what most children and few adults in this country have ever experienced.

Dr William G. Wilkoff

With the unprecedented increase in eating disorder cases, providers in several disciplines are searching for novel strategies to ease the burden on their patients and their practices. I recently learned of a pediatric practice in California that is considering blinding all patients aged 12 and older to the body mass measurements obtained at their health maintenance visits.

Blind weight checks for children with eating disorders, particularly those who seem to be nearing recovery, has been a common and often helpful practice. However, I am unaware of any practice that has made it a universal office policy. I'm unsure of the rationale behind this practice's policy, but on several fronts, suppressing body mass measurements in the age group most vulnerable to eating disorders makes some sense.

Universal blind weight checks could minimize the risk of in-office shaming. However, careful training of support staff and thoughtful placement of the scales could serve the same purpose. This new policy acknowledges not only the ubiquity of the problem but also that many, maybe even most, children with eating disorders appear normal. And of course, there is the unfortunate fact that body mass is a poor screening test for eating disorders.

As I thought more about this novel approach I came to see its educational value for patients, parents, and even physicians. I can envision how a 13-year-old's first health maintenance visit would go after the roll-out of the new policy. "Dr Smith, aren't you going to tell us how much I (or my daughter Jenny) weigh(s)?" This could, or more likely, should launch a discussion about weight and body image. It might continue with questions like, "How much do you think you weigh?" Or, "Do you think you are too heavy or too thin?"

Or, the conversation could include the provider's observations that weight is just one measure of health and in fact not a very good one. Other ingredients in a healthy life style, such as sleep and physical activity, are not as easy to measure as weight but in many cases are more important.

As my mind struggled to restructure a health maintenance schedule that included blind weight checks, I wondered why we should wait until age 12. Of course, it is unreasonable to expect parents to stick with a pediatric practice that seems to ignore their infant's weight. I'm sure that, like me, you have always discouraged new parents from having a baby scale at home because in the first few months too-frequent weighings can usually cause more angst than good.

It might make sense to remove a within-earshot discussion of a child's weight from the health maintenance visit as soon as the child can absorb and digest the discussion; say, around age 3 years. In a perfect world, the provider should have already elicited a history that suggested a young child's vulnerability to obesity before the scale and the growth chart told the unfortunate story. But, neither you nor I are perfect providers and so we will always need the scale to document our concerns. However, when and how we report that one vital sign to the patient and his or her parents is a topic ripe for discussion and improvement.

Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including "How to Say No to Your Toddler." Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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