Preventing, not perpetuating, eating disorders in the doctor’s office

Content warning: Eating disorders, disordered eating.

Imagine yourself as a 12-year-old girl – Your reflection is changing; you look different than just months ago. Your body is preparing you for puberty, but all you see is a new number on the scale. Messages from all around threaten how you perceive these changes. What makes you you, others are saying, needs to be changed. No one asked what size and shape you wanted your body to be when you hit pre-puberty. You were born with this body and know you will have it for life. It always has felt a bit larger than others, but now it feels like that with an exclamation point. If you’re being honest, it is starting to make you feel angry at your own body. On top of that, adults you look up to, inescapable media, and friends you adore seem to be saying that this body you walk around in, run in, sleep in is too much. You begin to do the best you can to ignore this body that feels like it’s betraying you.

Then you have a wellness visit with your doctor that includes the standards – height, weight, vision, hearing, and maybe a vaccination. Your doctor tells you that you’ve grown (as if you didn’t know that) and shows you a graph with a line for height and weight with percentiles, and where the “average” (you read “acceptable”) weight and body mass index (BMI) is for other young people your age. Your numbers are higher than the average. You are, it feels, getting this failing test result from this medical professional: an F. You want an A. You deserve an A. If you work hard enough, you will get an A.

This was my experience and the experience of many others that I connect with in my role as executive director of WithAll, a nonprofit helping children and young people foster a positive body image and relationship with food. Young people with higher than “average” BMIs or weight often feel that their growing bodies are failing, aren’t what they “should be,” and are disappointing. Without realizing it, adults, both in and out of health care, endorse this message. What I and those I work with now heard following doctor’s visits was whatever we were doing was not going to cut it, and we had to work much harder if we wanted an A for weight and BMI. So we did, you better believe we did, and we worked our way straight into an eating disorder. That’s what happens when a kid wants to succeed and is inadvertently and indirectly, but repeatedly, told that their body is failing and is outside of our culture’s “thin ideal.”

As I get to meet and talk with many others who have lived with disordered eating and/or eating disorders, I now know my experience as a young person was very common. I wish someone had told me when I was 12 that I wasn’t the only one who felt like this. Better yet, I wish even more that adults around me ensured that I understood my body was exactly where it was supposed to be – that I was healthy and thriving. I wish they would have told me that nothing about my body size or shape needed changing. Because, as I know now, that was the truth.

Over the course of the last several years, I’ve also learned that many pediatric primary care practitioners feel that growth conversations centered on height, weight, and BMI aren’t serving young people. One pediatrician I encountered said clearly, “We know talking about weight and BMI is not helping kids, but we don’t know what to say instead.”

Here’s the good news for young people, parents, and pediatric health care practitioners: Research confirms that we should shift the focus away from BMI, weight, and percentiles and instead focus on health behaviors that we know matter to health. For example, here is how a health provider could lead that conversation:

How is school? Do you feel like you have tools or things to do to manage times of stress? What do you like to do for stress?
How are friendships? Do you feel like you are connecting well with friends? Tell me more about things you and your friends do to enjoy time together.
How are you managing your screen time? How much time per day do you spend on your phone or iPad or laptop?
What physical movement do you do most often? What is your favorite? Are you finding time each day to move? Do you have movement activities that you can do outside and inside that make you feel good during and after the activity?
Do you enjoy art, music, or creative projects that help you stay in touch with those parts of yourself?
How are your meals and snacks? Are you eating a good mix of fruits and vegetables? Are you able to eat cooked foods and not just easy snacks in bags and boxes? Are you making time to fuel up with nourishing snacks and meals during the day? Are you drinking water?
How do you feel about your body? A lot is changing at this growth stage and it can feel different. Do you have questions?

Checking in with young people on these factors, and encouraging them to focus on these behaviors, teaches them about health and living a healthy lifestyle. Not one question deals with weight or percentiles, because we know if a child is managing the daily health behaviors choices well, the weight/BMI questions are almost certainly no longer relevant (except in rare instances where a deeper look is required to rule out serious health concerns).

Here’s even better news: WithAll has built training for pediatric health care providers to equip them with this approach to growth conversations. If you do not work in health care, but are a parent or guardian, you may wonder what this all has to do with you. You are a key part of this effort, because we know providers are likely to take in information or participate in training if a parent or guardian requests it. Ask your child’s doctor to consider reviewing What to Say Healthcare to avoid unintended harm to your child’s body image or food relationship.

Eating disorders don’t just begin out of the blue. They develop over time, quietly. Once we see an eating disorder, the harmful thoughts and behaviors have been around for a period of time. And while full recovery is always possible, the longer we wait to address these harmful patterns, the more difficult the path back to health can be. As adults – parents, doctors, teachers, and coaches – taking steps to be aware, change the environments, and alter what we communicate to young people is life-saving work that can have a lasting positive impact.

Lisa Radzak is the executive director of WithAll, a nonprofit organization committed to ending eating disorders by raising awareness and equipping adults to support kids’ healthy body image and positive relationship with food.

The views and opinions expressed in this blog solely belong to the author, and external content does not necessarily reflect the views of Mental Health America.