Is it okay for doctors and parents to tell children and teens they're fat?
That seems to be at the heart of a debate over whether to replace the fuzzy language favoured by the U.S. government with the painful truth telling kids if they're obese or overweight.
Labelling a child obese might "run the risk of making them angry, making the family angry," but it addresses a serious issue head-on, said Dr. Reginald Washington, a Denver pediatrician and co-chair of an American Academy of Pediatrics obesity task force. "If that same person came into your office and had cancer, or was anaemic, or had an ear infection, would we be having the same conversation? There are a thousand reasons why this obesity epidemic is so out of control and one of them is no one wants to talk about it."
The diplomatic approach adopted by the federal Centers for Disease Control and Prevention and used by many doctors avoids the word "obese" because of the stigma. The CDC also calls overweight kids "at risk of overweight."
Those favouring a change say the current terms encourage denial of a problem affecting increasing numbers of U.S. youngsters. Under a proposal studied by a committee of the American Medical Association, the CDC and others, fat children would get the same labels as adults overweight or obese.
The change "would certainly make sense. It would bring the U.S. in line with the rest of the world," said Tim Cole, a professor of medical statistics at the University College London's Institute of Child Health.
The existing categories are convoluted and "rather ironic, since the U.S. leads the world in terms of obesity," Cole said. "There must be an element of political correctness."
The debate illustrates just how touchy the nation is about its weight problem. Obese "sounds mean. It doesn't sound good," said Trisha Leu, 17, who think the proposed change is a bad idea. The Wheeling, Illinois, teen has lost 60 pounds (27 kilograms) since March as part of an adolescent obesity surgery study at the University of Illinois at Chicago.
"When you're young, you don't understand what obese means," Leu said. "I still don't understand it."
The CDC adopted the current terms in 1998, using weight-to-height ratios and growth charts from a generation of children much slimmer than today's.
Children are said to be "at risk for overweight" if their body-mass index is between the 85th and 94th percentiles. They're "overweight" if their body-mass index is in the 95th percentile or higher - or greater than at least 95 percent of youngsters the same age and gender.
Many paediatricians understand the first category to mean "overweight" and the second one to mean "obese," said the CDC's Dr. William Dietz. He said the word "obese" was purposely avoided because of negative connotations but conceded that many paediatricians find the current language confusing. Adding to the confusion is the fact that about 17 percent of U.S. children are in the highest category, and that almost 34 percent are in the second-highest category. That sounds like a mathematical impossibility, but it's because the percentiles are based on growth charts from the 1960s and 1970s, when far fewer kids were too fat. In children, determining excess weight is tricky, partly because of rapid growth especially in adolescence that can sometimes temporarily result in a high body-mass index.
For children in at least the 95th percentile, high BMI "is almost invariably excess fat," Dietz said. But there's less certainty about those in the second-highest category. So to avoid mislabelling and "traumatising" kids, the CDC chose to be diplomatic, Dietz said.
The committee, set up by the American Medical Association, involves obesity experts from 14 professional organizations including the American Academy of Pediatrics. Their mission is to update recommendations for prevention, diagnosis and management of obesity in children.
Final recommendations are expected in September, and the participating groups will decide individually whether to adopt them. Dr. Ronald Davis, the AMA's president-elect, said it's unclear whether the expert committee can develop a consensus on the obesity terms.
"There are seemingly legitimate arguments on both sides," said Davis, a preventive medicine specialist with Henry Ford Health System in Detroit.
Maria Bailey of Pompano Beach, Florida, whose 12-year-old daughter, Madison, is self-consciously overweight, opposes the proposed change. She said their paediatrician has told her daughter to exercise more and see a nutritionist, but "hasn't told her that she's in a (weight) category."
"We're already raising a generation of teenagers who have eating disorders," Bailey said. "I think it would just perpetuate that." Paola Fernandez Rana of Fort Lauderdale, Florida, has a 9-year old daughter who at 40 pounds (18 kilograms) overweight is considered obese. Rana said doctors "refer to it as the 'o-word' " in front of her daughter "in an effort not to upset her." "They very clearly told me she was obese," Rana said. But she said she agreed with the term and thinks that at some point it should be used with her daughter, too.
"Obviously I don't want my daughter to be overweight, but ... in order to change the situation, she is ultimately going to need to hear it," Rana said.
Dr. Michael Wasserman, a paediatrician with the Ochsner Clinic in Metairie, Louisiana, agreed. Using the term "at risk for overweight" is misleading, creating the perception "that I'm only at risk for it now, so I don't have to deal with it now," said Wasserman, who is not on the committee.
"There's a tremendous amount of denial by parents and children," he said.
Chicago paediatrician Rebecca Unger, also not a committee member, said she likes using the term "at risk for overweight" because it gives patients hope that "we can do something about it."