A CDC study found that only 23 percent of overweight kids know they're at an unhealthy weight. Pediatricians need to step it up.

There are plenty of touchy subjects I am happy to discuss with my patients and their families. When a child is brought to see me, especially for an annual check-up, I ask about all aspects of his or her life.

I ask about school performance and behavioral concerns, which can sometimes be dicey. I routinely ask my teenage patients about substance abuse and sexual activity. Working in a clinic during my training to specialize in adolescent medicine, I got used to discussing all manner of extremely sensitive topics frankly and without embarrassment.

But I absolutely hate talking to patients about being overweight.

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Given that more than a third of American children and adolescents are now overweight or obese, with obesity rates for children doubling and for adolescents quadrupling over the past 30 years, it's a subject I know I have to tackle. However, I am all too aware of how very important it is to do so in a respectful and nonjudgmental way, and to make it clear that the focus is on health rather than appearance.

When even a professional athlete can't escape being fat shamed during a sports awards show, and when it is considered a subject of open debate whether or not a potential candidate is too fat to run for president, it is imperative that I consider the impact my words can have on a child's self-esteem and psychological wellbeing. I've taken care of enough patients with eating disorders to see the potentially catastrophic outcomes of communicating a weight-loss message in an insensitive or pejorative manner.

As a big fan of Emily Yoffe's, I was dismayed last year when she advised a writer to "Dear Prudence" to send an anonymous letter to the pediatrician of her daughter's friend, expressing concern about the child's weight and diet. That advice is terrible. Not only am I well aware that my overweight patients are overweight without receiving anonymous letters alerting me to that fact, but I can think of no worse way of broaching such a fraught topic than mentioning the opinions of unnamed busybodies. Now the child can potentially feel upset not only about what I have to say, but also about the judgment of some unspecified other adult in her life! Nobody should waste their time penning letters that any pediatrician with a whiff of insight will ignore.

The most straightforward explanation for the disconnect between children's understanding of their weight and the reality of how healthy it is the prevalence of childhood obesity in this country.

Reading the results of a new study from the Centers for Disease Control (PDF), I couldn't help but wonder if other medical providers are even more reluctant to talk about weight with their patients than I am. Using survey data collected from children ages 8-15 from 2005 to 2012, the study finds that roughly a third of children and adolescents misperceive their body status. Only 23 percent of overweight children knew they were heavier than was healthy, and 41 percent of obese respondents thought their weight was about right. Younger children were more likely to misperceive their weight than adolescents, and white youth had lower rates of misperception (27.7 percent) than black (34.4 percent) and Hispanic (34.0 percent) youth.

The most straightforward explanation for the disconnect between children's understanding of their weight and the reality of how healthy it is the prevalence of childhood obesity in this country. When many of your peers look roughly the same way you do, it's reasonable to conclude that you're all healthy. Given the higher prevalence of obesity in non-white children, it follows that the rates of body status misperception would be higher in those kids. The only gauge of normality that young people have is their observation of each other.

When overweight children are roughly similar in appearance to many of their peers, it takes someone telling them their weight is unhealthy for them to realize it. Though the study does not report on the reasons for the rate of body status misperception among overweight children, I strongly suspect it's that those conversations simply aren't happening. Further, I suspect they're not happening because they are so challenging.

Trying to tell little girls and boys that their weight is too high without making them feel bad about themselves or their appearance is a daunting task. It's relatively easy to give across-the-board recommendations about what comprises a healthy diet and getting enough physical activity. Discussing what changes a specific child might need to make to get back into a healthy weight range is trickier, and clearly isn't happening nearly as often as it needs to be.

As important as fostering self-esteem in children is, medical providers cannot be so afraid of damaging it that they sidestep sensitive but clear conversations with patients and their parents when the child's weight is unhealthily high. There can be serious long-term consequences of untreated childhood obesity, and failing to address it directly can contribute to a host of preventable diseases and even early mortality. As difficult as these discussions may be, they are necessary, and this new study should serve as a wake-up call to pediatricians and other caregivers that they are doing their patients no favors by avoiding them.