Listen to your doctor, not your friends, about overweight 5-year-old

Posted by Barbara F. Meltz  April 25, 2012 06:00 AM

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At my beautiful five year old daughter's check-up, I was informed that her BMI was in the 95th percentile, and that we should see a nutritionist (together). I asked if I go go alone, and they told me that she needs to be there. I'm not sure what to do.

I know a good deal about nutrition. We eat a healthy diet. My daughter doesn't drink juice, doesn't eat processed food beyond the occasional oreo cookie in her lunchbox, and eats a well-balanced diet -- fruits and vegetables, whole grains, poultry and fish. She is definitely active, running around like crazy at the playground and doing organized activities (gymnastics, soccer, and swimming) on the weekends. She has a pot belly and isn't a skinny kid, but does not appear fat -- she's just heavier than she is tall. Her older sister is on the opposite end of the weight charts, and I can't help feeling that the baby just got the wrong end of the genetic stick. My husband was a skinny kid, I was not, and while we are both at a healthy weight as adults, one child takes after each of us.

I thought I would go to the nutritionist just to have a check-in, but friends have counseled me that having a little girl see a nutritionist -- a little girl who is not super skinny -- is just a straight ticket for an eating disorder.

What do you suggest? I feel like we are caught up in the childhood obesity epidemic, and I want to do what is right for my family -- now and in the long term.

Many thanks.

From: Alice, Cambridge, MA


Dear Alice,

Point #1: Let's be clear what we're talking about here. If an overweight child is in the 95 percentile it means she weighs more than 95 percent of children her age. That's a big deal. It's also the cutoff for health practitioners in identifying someone whose trajectory puts them at risk. In other words, she's not at risk now, but, put bluntly, this child could face dramatic medical problems, from heart disease to a shortened life span, not to mention dealing with the social stigma our culture attaches to over-weight children.

Which brings me to Point #2. Knowing about point #1, how could any friend urge you away from any potential help? What kind of friends do you have, anyway? (And why do they have such a negative opinion of nutritionists?)

I asked Michael Leidig, Clinical Director of the Center for Youth Wellness at Floating Hospital For Children at Tufts Medical Center, for his take on your email. He said it's not as if a nutritionist is going to put a 5-year-old on a restrictive diet or make her feel as if she has a problem. "That is," he added, "not if you go to a pediatric nutritionist," a point he stressed in our conversation.

He agreed with your practitioner that you have lots to gain by meeting with a pediatric nutritionist. "Even though it seems like this mom is recounting a relatively healthy diet and that this child is active, maybe there are some things the mom thinks are healthy that aren't. Or maybe the mom needs help with portion size," he said. "This is also not just about one child's eating habits, it's about the family's habits," he said. Especially with young children, the solution is not a regimen that gets foisted on any one individual. It needs to be embraced by everyone in the family.

Leidig is not sure why your practitioner is so adamant that your daughter go with you to the nutritionist. At his Center, a parent often comes alone initially.

"If the child does go," he said, "you want to know beforehand that the focus will be not on the child's weight but on how the family can learn to eat more healthy. And that's exactly how I would bill this to the child before the appointment: 'I want to learn how we can eat the healthiest food possible as a family. You can help me.'"

Since you are questioning your doctor's insistence that your daughter accompany you to the appointment, the best thing to do is pick up the phone and ask him, "Why is this so important?"


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10 comments so far...
  1. The letter writer says the BMI is in the 95th percentile, not her weight--not sure if this is just a typo. These are not the same measures.

    While I'm not sure why the pediatrician is insisting that you go with your daughter to see the nutritionist the first time (although I would imagine they want to confirm the height/weight/BMI and get a look at the child, but I really think why he/she wants it is unimportant and I wouldn't bother asking. When you call the schedule an appointment, you can ask how the nutritionist does things and follow their lead. It sounds like if you go see the doctor quoted here, you won't bring her the first time.

    And your friends are wrong about this leading to an eating disorder.


    Posted by ash April 25, 12 10:56 AM
  1. I'm a healthy adult who eats whatever I feel like.

    My BMI is so low, it doesn't exist on the charts.

    BMIs are nothing but quackery. Find another pediatrician.

    Posted by AP April 25, 12 12:25 PM
  1. I think it is time to find a good pediatric nutritionist and talk to that person. She or he is a professional who sees kids all the time, and whose reputation would be dirt fast if she had a habit of berating children.

    A phone conversation will either allay a lot of your fears, or confirm them, in which case find a different pediatric nutritionist! The nutritionist will be able to help you make decisions about how this is presented to your daughter.

    One possibility is that your whole family could get involved. Not to "fix" your daughter, mind you, but I think everyone, even health conscious adults can use a tune-up now and then. Maybe it could be your family project to eat healthier, to choose foods and cook together and discuss healthy eating together. Just because your older daughter is naturally very slender doesn't mean she is getting all the fruits and veggies she needs, or essential nutrients, or exercise, for that matter!

    Here is the thing: She is coming into an age where kids start to notice and comment, and not in a nice way. She is also coming into an age where habits tend to be set. If there is a way of getting her on a healthier track, there is no time like the present. A nutritionist can help set the stage for a lifetime of healthy eating.

    Let's face it, there is so much bad "healthy eating" advice out there and it is easier to get bad advice than good. It is best if her Mom and a nutritionist gives her good information rather than she gather it from her peers. Speaking from personal experience, the zeal for fad diets and impossible body image comes from peer pressure and random advice, and that, paired with insecurity and a sense of being larger than peers is what leads to an eating disorder. Not gentle, sensible child friendly advice from experts and loving Mom.

    Posted by Meri April 25, 12 12:58 PM
  1. My sister always seemed overweight as a child, despite the healthy diet and activity level in our household. After years of scolding from the pediatrician, my mother pressed further testing, and we finally learned that she suffered a hormone imbalance (early onset of her adrenal gland, I think). As a mom, knowing how hard it is to hear that one's child is anything less than perfect, I wholeheartedly support the idea of visiting a pediatric nutritionist to get a family check-in on your diet and portion sizes. Just in case. But if changes in diet and activity level don't help her BMI to moderate, consider looking at other causes. And consider having both parents attend the visit with the nutritionist, so that one of you can distract your daughter or take her to the waiting room if you'd like to ask any questions that you'd rather your daughter not hear.

    Posted by momoftwo April 25, 12 01:25 PM
  1. Typically a visit to a pedi nutritionist involves keeping a food diary for 3-7 days prior to the visit. Often 1-2 visits is all that's needed (unless your child has a chronic medical issue). Pedi nutritionists are some of the best medical professionals I've ever worked with-- extremely practical, focused taste and lifestyle as well as health, and very sensitive to the needs and moods of children.

    Your concerns are well worth discussing prior to the first appointment. I'm sure the nutritionist (or her assistant) can describe what to expect at the appointment and put your mind at ease.

    Posted by bos_mom April 25, 12 02:05 PM
  1. You may know "a good deal about nutrition", but an RD has studied it rigorously for years with a year of full-time clinical experience to boot. Might the RD know a little more than you and your neighbors?

    An RD may talk to you about lifestyle changes (if needed), but the focus almost certainly won't be on "dieting". The people who develop eating disorders are those who obsess about their weight WITHOUT seeking professional guidance.

    Look at it as a positive. If you are doing everything right, then the RD will pat you on the back and assure you that you are on the right path. If there is something you haven't thought of, then shouldn't you welcome the input?

    Posted by TF April 25, 12 03:59 PM
  1. Before you schedule any appointments at all, ask the doctor to print out a copy of the table together with the weight and height being used to calculate the BMI that forms her assessment of your daughter for counselling/treatment. It is certainly possible to make a numerical error such as using an adult BMI range for a child, as well as doing the calculation wrong.

    If your child does not appear obese and this would be judged by looking at the girth of upper arms, child's ability to fit into normal clothing sizes, and
    general ability to burn all calories taken in, then there is a reason to question the doctor's assessment. Many MD programs spend less than one month out of that 4 years training in a clinical nutrition rotation and classes are equally sparse in medical school.

    Second, you the parent have every reason to meet with the pediatric nutritionist before you expose your child to a form of treatment that will not respect your family values or well established healthy habits. The nutritionist will need to ask YOU how much the child eats, how the meals are prepared, how many physical activities are regular, and the family history of any obesity or heaviness (and your husbands's family has to be included). The nutritionist will then see the child and make measurements to see if the initial assessment was in fact correct.

    After that, you rely on the professional judgment of the nutritionist who has had 5+ years of graduate training in nutrition studies plus clinical rotations. Most likely, if your child is as physically active as you say, the nutritionist will give you a formal assessment of "no problem". You then make very sure that a copy of this report makes it back into your child's original medical records.

    Posted by Irene April 25, 12 05:31 PM
  1. I took my 5 year old picky eater to a nutritionist and it was a waste of time, probably bc she is not a parent and her suggestions were ridiculous! However, in your situation, I doubt one visit will lead to ED, that is far more complicated.

    Posted by Marie April 26, 12 05:44 AM
  1. Marie, I was not aware that only parents can be knowledgeable about children and their health. If parents know everything just by giving birth, then I suppose when can just tell everyone who works in pediatrics to find a new profession. You're certainly entitled to your opinion but that generalization is insulting.

    Posted by Linney April 26, 12 01:53 PM
  1. My DD and I were at her annual (4 year) check up, and the pediatrician scolded me about her juice intake(1 glass a day, split up with water) and told me that she was borderline obese(small pot belly, pure muscle arms and legs...) One week later I sent her to school in a shirt that fit; when she came home(7 hours later) nearly 1 inch of her wrist was showing. Oh, and her "pot belly was gone. I kid you not. No wonder she was crying at night that her "bones hurt"! (Tylenol helped a lot) We had noticed that right before a growth spurt, she's constantly hungry and she gets a belly. Most doctors try hard at what they do, but 1) they are not god, and 2) they often see their patients once a year(if that in a multi-doctor practice.) I would see the pedi-nutritionist alone first, to gauge their style and have a quiet talk without your child worrying that they have done/there is something wrong. Just my opinion.

    Posted by Mummy KitM July 29, 12 11:05 PM
 
10 comments so far...
  1. The letter writer says the BMI is in the 95th percentile, not her weight--not sure if this is just a typo. These are not the same measures.

    While I'm not sure why the pediatrician is insisting that you go with your daughter to see the nutritionist the first time (although I would imagine they want to confirm the height/weight/BMI and get a look at the child, but I really think why he/she wants it is unimportant and I wouldn't bother asking. When you call the schedule an appointment, you can ask how the nutritionist does things and follow their lead. It sounds like if you go see the doctor quoted here, you won't bring her the first time.

    And your friends are wrong about this leading to an eating disorder.


    Posted by ash April 25, 12 10:56 AM
  1. I'm a healthy adult who eats whatever I feel like.

    My BMI is so low, it doesn't exist on the charts.

    BMIs are nothing but quackery. Find another pediatrician.

    Posted by AP April 25, 12 12:25 PM
  1. I think it is time to find a good pediatric nutritionist and talk to that person. She or he is a professional who sees kids all the time, and whose reputation would be dirt fast if she had a habit of berating children.

    A phone conversation will either allay a lot of your fears, or confirm them, in which case find a different pediatric nutritionist! The nutritionist will be able to help you make decisions about how this is presented to your daughter.

    One possibility is that your whole family could get involved. Not to "fix" your daughter, mind you, but I think everyone, even health conscious adults can use a tune-up now and then. Maybe it could be your family project to eat healthier, to choose foods and cook together and discuss healthy eating together. Just because your older daughter is naturally very slender doesn't mean she is getting all the fruits and veggies she needs, or essential nutrients, or exercise, for that matter!

    Here is the thing: She is coming into an age where kids start to notice and comment, and not in a nice way. She is also coming into an age where habits tend to be set. If there is a way of getting her on a healthier track, there is no time like the present. A nutritionist can help set the stage for a lifetime of healthy eating.

    Let's face it, there is so much bad "healthy eating" advice out there and it is easier to get bad advice than good. It is best if her Mom and a nutritionist gives her good information rather than she gather it from her peers. Speaking from personal experience, the zeal for fad diets and impossible body image comes from peer pressure and random advice, and that, paired with insecurity and a sense of being larger than peers is what leads to an eating disorder. Not gentle, sensible child friendly advice from experts and loving Mom.

    Posted by Meri April 25, 12 12:58 PM
  1. My sister always seemed overweight as a child, despite the healthy diet and activity level in our household. After years of scolding from the pediatrician, my mother pressed further testing, and we finally learned that she suffered a hormone imbalance (early onset of her adrenal gland, I think). As a mom, knowing how hard it is to hear that one's child is anything less than perfect, I wholeheartedly support the idea of visiting a pediatric nutritionist to get a family check-in on your diet and portion sizes. Just in case. But if changes in diet and activity level don't help her BMI to moderate, consider looking at other causes. And consider having both parents attend the visit with the nutritionist, so that one of you can distract your daughter or take her to the waiting room if you'd like to ask any questions that you'd rather your daughter not hear.

    Posted by momoftwo April 25, 12 01:25 PM
  1. Typically a visit to a pedi nutritionist involves keeping a food diary for 3-7 days prior to the visit. Often 1-2 visits is all that's needed (unless your child has a chronic medical issue). Pedi nutritionists are some of the best medical professionals I've ever worked with-- extremely practical, focused taste and lifestyle as well as health, and very sensitive to the needs and moods of children.

    Your concerns are well worth discussing prior to the first appointment. I'm sure the nutritionist (or her assistant) can describe what to expect at the appointment and put your mind at ease.

    Posted by bos_mom April 25, 12 02:05 PM
  1. You may know "a good deal about nutrition", but an RD has studied it rigorously for years with a year of full-time clinical experience to boot. Might the RD know a little more than you and your neighbors?

    An RD may talk to you about lifestyle changes (if needed), but the focus almost certainly won't be on "dieting". The people who develop eating disorders are those who obsess about their weight WITHOUT seeking professional guidance.

    Look at it as a positive. If you are doing everything right, then the RD will pat you on the back and assure you that you are on the right path. If there is something you haven't thought of, then shouldn't you welcome the input?

    Posted by TF April 25, 12 03:59 PM
  1. Before you schedule any appointments at all, ask the doctor to print out a copy of the table together with the weight and height being used to calculate the BMI that forms her assessment of your daughter for counselling/treatment. It is certainly possible to make a numerical error such as using an adult BMI range for a child, as well as doing the calculation wrong.

    If your child does not appear obese and this would be judged by looking at the girth of upper arms, child's ability to fit into normal clothing sizes, and
    general ability to burn all calories taken in, then there is a reason to question the doctor's assessment. Many MD programs spend less than one month out of that 4 years training in a clinical nutrition rotation and classes are equally sparse in medical school.

    Second, you the parent have every reason to meet with the pediatric nutritionist before you expose your child to a form of treatment that will not respect your family values or well established healthy habits. The nutritionist will need to ask YOU how much the child eats, how the meals are prepared, how many physical activities are regular, and the family history of any obesity or heaviness (and your husbands's family has to be included). The nutritionist will then see the child and make measurements to see if the initial assessment was in fact correct.

    After that, you rely on the professional judgment of the nutritionist who has had 5+ years of graduate training in nutrition studies plus clinical rotations. Most likely, if your child is as physically active as you say, the nutritionist will give you a formal assessment of "no problem". You then make very sure that a copy of this report makes it back into your child's original medical records.

    Posted by Irene April 25, 12 05:31 PM
  1. I took my 5 year old picky eater to a nutritionist and it was a waste of time, probably bc she is not a parent and her suggestions were ridiculous! However, in your situation, I doubt one visit will lead to ED, that is far more complicated.

    Posted by Marie April 26, 12 05:44 AM
  1. Marie, I was not aware that only parents can be knowledgeable about children and their health. If parents know everything just by giving birth, then I suppose when can just tell everyone who works in pediatrics to find a new profession. You're certainly entitled to your opinion but that generalization is insulting.

    Posted by Linney April 26, 12 01:53 PM
  1. My DD and I were at her annual (4 year) check up, and the pediatrician scolded me about her juice intake(1 glass a day, split up with water) and told me that she was borderline obese(small pot belly, pure muscle arms and legs...) One week later I sent her to school in a shirt that fit; when she came home(7 hours later) nearly 1 inch of her wrist was showing. Oh, and her "pot belly was gone. I kid you not. No wonder she was crying at night that her "bones hurt"! (Tylenol helped a lot) We had noticed that right before a growth spurt, she's constantly hungry and she gets a belly. Most doctors try hard at what they do, but 1) they are not god, and 2) they often see their patients once a year(if that in a multi-doctor practice.) I would see the pedi-nutritionist alone first, to gauge their style and have a quiet talk without your child worrying that they have done/there is something wrong. Just my opinion.

    Posted by Mummy KitM July 29, 12 11:05 PM
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Barbara F. Meltz is a freelance writer, parenting consultant, and author of "Put Yourself in Their Shoes: Understanding How Your Children See the World." She won several awards for her weekly "Child Caring" column in the Globe, including the 2008 American Psychological Association Print Excellence award. Barbara is available as a speaker for parent groups.

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