At the Nemours Eating Disorders Evaluation and Management Program, we see teenagers who pinpoint the onset of their eating disorder to comments made by well-intentioned doctors, coaches, or health teachers.

It may happen when the primary-care provider diagnoses an adolescent with obesity at a yearly checkup, or when the track coach comments “Your time might improve if you lose a little weight,” or when the health teacher has students measure their abdominal circumference in front of their classmates. While the goal is to promote health, the opposite often occurs.

We are not asking anyone to ignore national statistics: Among youth ages 2 to 19, 1 in 6 are obese and 1 in 17 are extremely obese. And guidelines recommend that overweight teenagers lose weight through diet and exercise. But what we’re seeing is that many teens are trying to lose weight in unsafe ways.

Half of all teenage girls and 1 in 4 teenage boys have tried dieting. Teens who diet have lower self-esteem, feel less connected to their families and schools, and feel less in control of their lives.

When teens lose weight, it is often done by starvation, purging, or over-exercising. They receive praise for losing weight, which further reinforces these behaviors and can further contribute to the development of an eating disorder. Is it any wonder that almost 3% of adolescents ages 13-18 are diagnosed with an eating disorder?

Focusing on weight and BMI is not only ineffective at producing thinner and healthier bodies, but it may also have the unintended consequences of food and body preoccupation, yo-yo dieting, poor self-esteem, and eating disorders. Perhaps we need to rethink how we talk to our teenagers who have a weight issue.

Consider Health at Every Size, or HAES, a growing multidisciplinary movement that shifts the focus from weight loss to health promotion. HAES promotes healthy behaviors for people of all sizes without focusing on weight. The Association for Size Diversity and Health (ASDAH) includes international members who are committed to HAES principles. “ASDAH envisions a world that celebrates bodies of all shapes and sizes, in which body weight is no longer a source of discrimination and where oppressed communities have equal access to the resources and practices that support health and well-being.” HAES is endorsed by many eating disorder professional organizations, including the Academy for Eating Disorders, the Binge Eating Disorder Association, the Eating Disorder Coalition, the International Association for Eating Disorder Professionals, and the National Eating Disorder Association, as well as the civil rights groups National Association to Advance Fat Acceptance and the Council on Size and Weight Discrimination.

What is the evidence that HAES works? Randomized controlled clinical trials in adults have shown that a HAES approach improves blood pressure, cholesterol, self-esteem, body image, and health behaviors around eating and activity. HAES achieved these health outcomes more successfully than treatments that focused on weight.

We suggest that health-care practitioners, coaches, health teachers, and anyone else who interacts with our youth begin to discuss size and weight more effectively. ASDAH and the Academy for Eating Disorders have suggested interventions that:

  • Emphasize health, not weight, and are referred to as “health promotion” rather than “obesity prevention.”
  • Avoid such stigmatizing language as “overweight” and “obesity.”
  • Focus on behaviors that can be modified only when such changes will improve health; weight is not a behavior and therefore not an appropriate target for behavior modification.
  • Discuss physical activity and eating in a compassionate way that encourages self-care.
  • Promote self-esteem, body satisfaction, and respect for body size diversity.
  • Address physical, emotional, social, occupational, intellectual, spiritual, and ecological aspects of health.

Although some teens do need to lose weight due to problems such as diabetes, heart disease, sleep apnea, liver disease, and joint problems, and some teens may even need bariatric surgery, it is our hope that we can all begin to approach weight and health with more sensitivity:

  • Encourage body acceptance.
  • Encourage intuitive eating, that is, trusting our bodies to eat when hungry and stopping when full.
  • Encourage meaningful movement, that is, physical activity for movement and health rather than for weight loss.
  • Be careful about making comments concerning weight as they may cause significant harm.

Rima Himelstein is a pediatrician and adolescent-medicine specialist at Nemours/Alfred I. duPont Hospital for Children; Kidian Martinez, is a licensed clinical social worker and clinical coordinator for Nemours Eating Disorders Evaluation and Management Program.