(Photo: Thomas Anderson/Flickr)

The French-born American author Anais Nin wrote that “we don’t see things as they are, we see them as we are.” Nin wasn’t a doctor, but doctors—particularly practitioners who are treating overweight and obese patients—would do well to heed her words.

There’s a growing health care problem in the United States: unrecognized abnormal weight status among families. For these families, the image in the mirror is not necessarily what is reflected. But the concern is not only for personal but also for public health because rising rates of youthful obesity theoretically account for life-shortening of two to five years, and are expected to reduce life expectancy in the U.S. for the first time in more than a century.

Over the past three decades, obesity in the United States has escalated such that nearly 70 percent of American adults are either overweight or obese and, notably, over 30 percent of children are now classified as overweight or obese. These findings are striking, particularly since childhood obesity predicts adult obesity; 50 percent of obese children are likely to become obese adults. Such children and young adults are also more likely to be carrying risk factors like elevated cholesterol, diabetes, and high blood pressure that predict heart disease. Excess weight puts them at risk for other life-altering chronic ailments including orthopedic issues and early arthritis, gall bladder problems and sleep disturbances. Many of obese adolescents already meet criteria for the so-called “metabolic syndrome”—a constellation of metabolic risks that predicts an increased incidence of heart disease and stroke.

Children with overweight or obese parents and schoolmates are more likely to underestimate their own size, possibly because they have been desensitized about normal weight or due to the stigma of being "fat."

We need to learn more about intergenerational attitudes in families, but here’s what we do know now: Obesity in one or both parents influences the risk of obesity in a child as a consequence of both shared genetics and environmental factors. And children of overweight parents are likely to be reared in environments promoting accelerated weight gain, the so-called “obesogenic household,” and such children are likely to become overweight or obese adults, with the prospect of heart disease, which is the leading cause of death among American men and women.

While the overall weight problem is only getting worse, it seems that pre-adolescents of low-income racial and ethnic minorities are 10 percent more likely to be obese compared to their white peers. Cultural standards may be to blame. Some have observed that minority parents are more likely to desire larger sizes for their children, for example; among minority mothers, two-thirds with overweight pre-school children are either satisfied with the child’s current size or wish them to be heavier. Among Hispanic families who recently immigrated to the U.S., mothers frequently underestimate overweight children as normal weight, which is often attributed to socioeconomic status and standards in the community.

The younger generation is affected as well. Children with overweight or obese parents and schoolmates are more likely to underestimate their own size, possibly because they have been desensitized about normal weight or due to the stigma of being “fat.” Moreover, children of obese mothers often underestimate their mother’s size. If excess weight is not perceived as an issue, or if families do not appreciate the link between current and future health, they may not initiate actions to prevent obesity.

There is a void in the medical community’s understanding of how families see themselves and understand their weight. We can start correcting that by including patients in the conversation in the practitioner’s office. Currently, less than 15 percent of pediatricians and other health care providers follow recommended evaluations for co-existing conditions associated with abnormal weight status, and fewer than 50 percent of primary care providers communicate with the parents of patients regarding obesity prevention.

At the doctor’s office, patients are rarely asked about perceptions of their own weight. But it’s important, because it involves patients in their health; opens a discussion about prevention that can include counting calories and carbs, limiting portion size, encouraging shared family meals, reducing television time, and exercising; begins an exchange about recommended weight; and can lead to setting goals for a healthier life. The interrelated failures of a practitioner to appreciate how a patient visualizes herself and a patient to properly assess weight constrains good behaviors. TV shows, the Internet, popular magazines, and advertisements—regular sources for those seeking guidance about weight—can be misleading and filled with misinformation. As far as this goes, even the TV host and cardiovascular surgeon Mehmet Oz was recently chided by a U.S. Senate consumer protection panel because of unfounded claims he made about weight loss aids.

If we want to understand the rise of obesity in this country, first we need to ask families what they think they look like and guide them to what is within normal limits. The consequences of flawed weight classification, beginning in childhood, can set in motion life-long distorted perceptions of what is recommended and contribute to adult obesity. We will be closer to meeting the challenge of escalating familial obesity in the U.S. when providers partner with patients to recognize that the mirror reflects images, not as we perceive them to be, but rather, as they are.