"We frequently see parents who fail to recognize the role of the family in establishing and maintaining obesity in children," pediatrician Katherine Kaufer Christoffel, M.D., founder and medical director of the clinic, told Psychiatric News. "They bring the kids in and push them toward the doctor and say ‘fix ’em,’ or ‘tell him what to do—he doesn’t listen to me.’ "
In fact, she said, the adverse eating habits and genetic background that predispose to obesity reside in families. "Typically, heavy kids come in heavy families," she said. "If the kids are couch potatoes and eating at McDonald’s every night, they aren’t liable to be doing it on their own dime. The kids didn’t buy the TV."
Moreover, Christoffel said that she prefers to work with children who are very young—before the age of 7. That’s because she and colleagues have learned to appreciate the extraordinary difficulty of changing ingrained dietary and sedentary habits, and the profound psychosocial factors that influence those habits, as children grow older.
"I am increasingly disinclined to undertake treatment in a medical setting of overweight children after the early years," Christoffel said. "There are a number of reasons for this, and one of them is that we have come to see how difficult it is to treat obesity after that age. When we try to do so, giving kids and their families weight-reduction tasks to accomplish, we set them up for failure.
"The family comes to focus unduly on the child’s weight, and the kids see their visits to the doctor as a time to be scolded," she said. "This compounds the psychosocial stressors that come their way anyway related to their overweight."
The approach taken by Christoffel and colleagues at Children’s Memorial highlights a gathering consensus among pediatricians and nutritionists that childhood obesity is more than a medical condition affecting one child, but a public health problem with critical psychosocial dimensions, involving the family, the community, and the society at large.
The web of psychosocial factors that may predispose a child to obesity, or complicate it in later years, is complex, but researchers and clinicians say that teasing by peers and even by family members is a prominent and serious issue for some overweight children as they grow into their teen years.
Christoffel said such teasing by family members, including parents, is surprisingly common, with parents labeling their overweight children with such epithets as "greedy," "lazy," or "little piggies."
"Parents can be an integral part of the problem, adding to the mental health morbidity by the way they treat their kids," she said.
That view—and the frequency of weight-based teasing at the hands of family members—appears to be confirmed by a report in the August Archives of Pediatrics & Adolescent Medicine titled "Associations of Weight-Based Teasing and Emotional Well-Being Among Adolescents."
In a school-based sample of 4,746 teenagers in grades 7 to 12 at 31 public middle and high schools, 30 percent of teenage girls and 24.7 percent of teenage boys reported being teased by their peers. But 28.7 percent of girls and 16.1 percent of boys reported being teased by family members. (Approximately 14.6 percent of adolescent girls and 9.6 percent of adolescent boys reported teasing from both of these sources.)
Teasing about body weight was consistently associated with low body satisfaction, low self-esteem, high depressive symptoms, and suicidal ideation and attempts, even after controlling for body weight. These associations held true for both boys and girls, and across racial and ethnic groups.
The study was supported by grants from the federal Maternal and Child Health Bureau and the Centers for Disease Control and Prevention.
Importantly, the associations also held true across weight groups, suggesting that it was the teasing itself—whether it was about obesity, excessive thinness, or any other aspect of body shape and size—that was crucial.
"Weight-based teasing is not as harmless as people may think," study author Marla Eisenberg, Ph.D., told Psychiatric News. "The common thinking is that everyone has to get used to it, but it does appear to be a major problem for kids. And a key finding is that it is the teasing—not body size or body shape—that is crucial. The association was the same for kids who were teased, whether they were normal weight or overweight." She is a research associate at the University of Minnesota.
Child psychiatrist David Fassler, M.D., who reviewed the study for Psychiatric News, underscored the importance of the finding of family teasing.
"I was not at all surprised by the reported incidence of teasing by peers," he said. "But the finding regarding family members was interesting and quite concerning. We know that difficulties with weight tend to run in families, and we have good research showing that teasing can have a very detrimental effect on emotional growth and well-being."
Fassler said the finding points to the value of public health interventions. "Sometimes kids and adults really don’t understand the impact of this kind of teasing on a child," he said. "I could imagine education videos and public-service announcements that could really increase awareness and sensitivity and make people think twice about teasing."
The research on weight-based teasing appeared in the same issue with other studies related to mental health implications of obesity in children and teens. These included studies on social marginalization of overweight children, body satisfaction in children after dietary counseling for atherosclerosis prevention, and a longitudinal evaluation of adolescent depression and adult obesity (see box).
Fassler told Psychiatric News, "It is helpful the articles were published in a pediatrics journal, because so many of these kids are seen by pediatricians and primary care physicians. They may receive little if any mental health treatment. Part of the challenge is to work with colleagues in primary care to enhance the awareness of the association between childhood and adolescent obesity and mental health problems."
Experts agree that whether obesity precedes behavioral problems in children or vice-versa—or whether the two work to compound each other—is a question research has barely begun to answer.
At Under the Rainbow/Child and Adolescent Behavioral Health, an outpatient clinic of Mt. Sinai Hospital in Chicago, the number of overweight children and teens with behavioral problems has prompted clinicians there to seek funding for the expansion of programs to address the problem specifically and to study the most effective interventions.
"Our interest in this work has stemmed from the high number of overweight kids we treat for low self-esteem, depression and other mood disorders, abuse or neglect, social anxieties, and posttraumatic stress disorder," said Richard Macur Brousil, Ph.D., in an interview. "It is usually difficult to ascertain whether there is a causal effect between the obesity and the behavioral symptoms, but since the behavioral issues are the reason for the referral, that is usually our treatment focus. But since there appears to be a link between the two, it makes sense that we address both in treatment. As of now, that happens in a hit-or-miss manner."
Brousil and colleagues hope to expand programs at the clinic to include therapy groups for children who are aged 6 to 18 and have been identified as overweight. Children would receive one of two interventions—either an educationally based intervention providing nutritional and dietary information or a more traditional group-therapy intervention in which children would explore shared issues related to their weight.
Nearly all of the children served by Under the Rainbow are on public aid, and the social and psychological pathologies encountered by clinicians are many. Regardless of whether obesity is a consequence or a cause of behavioral problems, Brousil believes the problem calls for a multidisciplinary approach involving psychiatry, social work, pediatrics, nutrition, and, in cases of children with diabetes, endocrinology.
"In so many hospitals the professionals refer patients to each other but never talk to each other," Brousil said. "We say, ‘This kid’s fat; send him to nutrition.’ I would like to see more professional networking."
Such an approach would appear to be necessary given the confluence of factors that affect, and are affected by, obesity. Peers, siblings, and parents—all these contribute to the complex psychosocial web; ultimately, experts say, responsibility for the national epidemic of overweight children widens to include the entire society and culture.
"Predominantly, kids become overweight because our society is structured to create overweight," Christoffel, of Children’s Memorial, said. "Recreation is sedentary, transportation is sedentary. We don’t cook at home, but eat fast foods full of fat in large portions. If you were to design a society to foster obesity, ours is the society you would come up with."
The articles on obesity in the August Archives of Pediatrics & Adolescent Medicine are posted on the Web at http://archpedi.ama-assn.org/content/vol157/issue8/index.dtl. ▪