Presented at Conference on
Optimal Management of Type 1 and Type 2 Diabetes in Pediatrics
Thurs. June 16, 2005 – Park Nicollet Institute, St. Louis Park, MN
At an alarming rate, obese children are increasing dramatically in our society. Obesity rates in children have at least doubled in the past 20 years and approximately 15% (1 in 7) of children between the ages of 6–19 are considered obese. Disadvantaged children show even higher rates of obesity, diabetes, depression, and heart disease than children in general. Mexican American and African American children are twice as likely to be overweight compared to Caucasian peers (Blom-Hoffman, 2004). Thus, it behooves pediatricians, educators, counselors, nurses, dieticians, other professionals, and parents to combat childhood obesity.
Obesity is a serious health condition that can be both physically and emotionally destructive. There is much documented research that obesity is strongly linked with heart disease, diabetes, cancer, high blood pressure, osteoarthritis, premature death, sleep apnea, asthma (Blom-Hoffman, 2004) and a number of other physical health concerns. Recent research is accumulating that childhood obesity also is associated with a number of serious emotional factors.
Recently, a study by Williams, et. al. (2005) found that overweight and obese children had a lower quality of life. Obese children showed decreases in physical and social functioning compared with children not overweight. Health-related quality of life begins to decline as soon as a child is above average in weight. The Institute of Medicine of the National Academics (2004) have listed the primary emotional health consequences of obesity in children and youth as low self-esteem, negative body image, and depression. The social health consequences are stigma and social marginalization. The Institute also stated that “obese children and adolescents are at high risk for becoming obese adults with many costs to society”.
Body size stigmatization has many negative consequences for social interaction of overweight children. Research by Musher-Eizenman (2004) and her colleagues at Bowling Green State University have shown that negative attitudes about child obesity are present in children as young as 3 years of age. The negative perceptions are even more strongly felt if the child believes that an obese child can control their weight. Children believe that obese children possess more negative personality and behavioral characteristics than do other children and even obese children hold negative attitudes toward obesity. These characteristics include being mean rather than nice, stupid rather than smart, not friendly rather than friendly, sloppy rather than neat, ugly rather than attractive, and loud rather than quiet. As a child becomes older their attitudes toward obesity become more extreme and if an individual blames the obese child’s condition as the fault of that child, then those negative attitudes are felt even more strongly. Musher-Eizenman (2004) implies that obese children are judged responsible for their plight and are viewed as “sinners or sick”. Furthermore, children’s attitudes toward obesity are more negative than individuals with other stigmas.
Locally, research by Marla Eisenberg (2003) and her colleagues at the School of Public Health at the University of Minnesota found that teasing and chiding lowers self-esteem in overweight and thin Twin City teenagers. Over 4700 Twin City middle and high school students were surveyed about teasing in a research project on adolescent nutrition called Project EAT. About 1/3 of girls and 1/4 of boys were teased by peers and close to 1/3 of girls and 1/6 of boys were teased by family members. Those who were teased by both peers and family had more severe emotional problems. Half of the girls in that group thought about suicide and 1/4 had attempted it. About 1/3 of the boys thought of suicide and about 1/8 of boys attempted it. The rates for suicide thoughts and attempts were much higher for this group as compared to all Minnesota teenagers, according to data from the Minnesota Health Department. The study also found that about half the girls had symptoms of depression and poor body image. For boys in the group about 1/6 had low self-esteem. Those teenagers teased by family members had somewhat higher rates of depression, suicide thoughts, and suicide attempts than those only teased by peers. Regardless of body types or size, teenagers who were teased about it were two to three times more likely to think about or attempt suicide than those who were not teased.
Studies of bullying (Espelage and Swearer, 2003) indicate bullying occurs often starting as early as kindergarten and peaks in Jr. high school. Seventy-seven percent of adolescents admit they have been victimized by bullies. Victimization can be done physically or verbally and these negative actions are difficult to defend. Examples of verbal bullying include withdrawal of friendship, rumor spreading with intent to damage a relationship, gossip, social rejection and alienation, power to manipulate and control, group harassing and teasing, and name calling. The result of victimization includes depression, low self esteem, somatic complaints, bed wetting, and a number of other stress reactions. The most visible and vulnerable target of a bully is an obese child.
Thus, obese children are at high risk for peer or family teasing, victimization, and rejection and these consequences should also motivate an obese child and his or her parents to seek treatment.
Obese children and their parents need to seek professional help and, fortunately, treatment is available and recovery is possible. Treatment and care can be provided by licensed health professionals such as primary care physicians, psychologists, psychiatrists, social workers, nutritionists, and nurses. The care should be coordinated among the health professionals and most clients respond to outpatient psychotherapy including individual, family, or group along with medical management by the primary care provider. When the situation is life threatening or when there are severe behavioral or emotional problems, inpatient care may be needed.
One of the first things that parents can do is to get a child “health report card” of height, weight, and fitness level. Parents can address any weight problems in their child and most parents are happy to receive this information. Parents who were given the “health report card” were more likely to start a plan to help their child lose weight in elementary school children. The appropriate plan is to have overweight children increase physical activity and change nutritional habits, not to go on a diet. There are many diet plans that are popular in the United States, particularly for adults. However, a recent medical study by Dansinger, et. al. (2005) at Tuffs University in Boston, found that obese adults with a cardiac risk factor could only lose about 5 lbs. on average after one year. The biggest problem was the lack of adherence to the diet for these adults and this would probably be the same issue for obese children. The strongest predictor of obesity in adulthood is obesity in adolescence. Various studies on obese children, particularly girls, indicate that those who diet to lose weight are more likely to gain weight and become a greater risk for obesity by more than 3 times greater than normal children. Those children who diet strenuously and use radical weight loss efforts such as laxatives, diet pills, vomiting, etc. gain more weight through binge eating. Diet and exercise habits are learned at an early age and are usually maintained into adulthood. Thus, proper habits need to be learned early in childhood. (Keenan 2004).
Instead of dieting, healthy eating should be promoted. Certain diet alternatives can be substituted for high fat snacks and sugared soft drinks at home and school. Exercise is encouraged while sitting in front of the TV or monitor should be limited. Psychological counseling of obesity must address the symptoms and the underlying interpersonal and cultural forces that contribute to or maintain obesity. The primary therapeutic technique is cognitive behavior therapy (CBT). CBT helps obese children normalize their eating by identifying and restructuring any maladaptive thoughts and beliefs toward eating, body shape and weight. CBT should include body size acceptance and a realistic weight loss goal. Standard behavioral weight control can be effective with standard calorie restrictions. CBT also will assess readiness and motivation for change. Obese children may be more likely to reduce binge eating but less likely to restrict their eating. The therapist and parents will insure that no negative consequences will occur if the child is open about their resistance to change.
The first step in starting treatment is to establish an effective working relationship and to orient the child to the treatment. The weight problem will already be assessed regarding the history of the weight problem and any prior attempts to lose weight and their outcome. The assessment also includes typical eating habits, physical activity, reasons to lose weight, attitude toward appearance, weight goals and physical health. The continuing assessment will also address the child and parent motivation and premature discontinuation of treatment. The child and parent will then monitor food and drink intake and count calories The child will start a weight graph and will be weighed weekly. Thoughts or feelings, the circumstances, or the context in which eating occurred should also be noted by child or parent.
A second step is to design homework assignments with the child and parents. The homework should be specific, achievable, and understood. The homework should be written down so that it is not forgotten and any difficulty completing the homework should be addressed. Praise completion of homework and problem solve any part not completed. Review progress and set one or two goals for the forthcoming week. Special situations and circumstances such as restaurants, eating at a friend’s house, pressures to eat, vacations, snacks, and special occasions will also require planning and problem solving. If child or parents do not comply well with homework assignments or set up barriers to weight loss these problems will be assessed and addressed.
Next, activity level should be increased. The benefits of increasing overall activity will be explained and any misconceptions about exercise will be corrected. Three types of activity should be recorded which includes inactivity (sitting or lying down), life style activity (incidental activity that is part of everyday life), and formal exercise exertion. Sedentariness should be decreased while lifestyle activity and exercise should be increased. Learning appropriate nutrition and exercise habits are important components of the treatment program.
When the child or parents have concerns about body image these concerns should be evaluated an addressed and a positive body image should be developed. Body image concerns are particularly important if unhappiness with their body shape leads to overeating. Negative thoughts and beliefs about the body including recurrent critical thoughts and dysfunctional beliefs need to be corrected and alternative, positive thoughts should be inserted. Having made important changes, the child and his or her parents needs to learn to accept their body and weight and even though they may desire further change, this may not be possible.
The next step is to identify weight goals. The ideal weight is what the obese child would like to weigh but it is probably unrealistic. The desired weight is what the child should be able to achieve during treatment but it will require effort. The tolerable weight would be the highest goal weight the child and parents could accept. During treatment the child and parents should understand that some aspects of being overweight can be changed while others cannot. The treatment plan should help the child change what can be changed and accept what cannot, particularly what is genetically determined. Realistically, a 10-15% weight loss range should be the expected goal and this range should be discussed with the child and parents. If the expectation is to lose more than this range it will probably not happen but the client should not view the treatment or themselves as a failure since it is quite an achievement first to lose the weight and keep it off. A 10-15% weight loss is very beneficial for the obese child and family. The child’s appearance will be improved and the waist line reduced giving the child a general sense of well being and self esteem. There should be a reduction in any negative eff3ects on health and an increase in quality of life. Common primary goals will be met with a 10-15% weight loss. These goals include improving physical appearance, feeling healthier and fit, having more self-respect and self confidence, increasing a choice of clothing, having better relationships, and taking part in activities previously avoided.
During treatment there will be an emphasis on healthy eating. To reduce fat consumption, a low-fat diet will help long-term weight maintenance and reduce any risk of health problems. By eating bread, cereal, rice, and pasta these foods provide energy and fiber and reduce the likelihood of eating fatty foods. Fruits and vegetables should be increased to also lower risk of health problems and increase fiber. The key is to establish a long-term adherence to healthy eating. The successful treatment plan would take 25-30 sessions over a 50-65 week period.
When primary goals are met or when the “costs” of attempting to lose more weight seem to outweigh the possible benefits a weight maintenance plan should be developed. The emphasis is to minimize the risk of regaining the weight they have lost that is beyond the normal expectation of the growing child. The maintenance plan should not attempt to lose any more weight but to learn to maintain a new stable weight for at least a 6 month period. Weight maintenance will be less reinforcing because there is no weight loss goal. Acceptance of weight and shape may have previously been undesirable, the time period will be indefinite and the child may receive little encouragement from others. The child and family will have to balance energy intake with energy expenditure and this should be regularly monitored. Special situations or circumstances and set backs also must be addressed. The child and parents should write up a maintenance plan that include reasons not to regain weight, good eating habits to keep up, good activity habits to keep up, and danger areas to consider. The plan should also include weekly weight monitoring and when and how to take action when a setback occurs.
As early as 1980, Epstein and colleagues demonstrated the effectiveness of behavior therapy in treating childhood obesity. They found that the addition of nutrition education to the behavioral techniques of contingency contracting, self-monitoring of caloric intake and weight, praise, and stimulus control significantly improved weight loss in obese children. Epstein also found parent-child treatment had significantly better changes than any other control group.
It is also possible for the obese child to be effectively treated even if they do no actively participate in treatment as long as the parents are actively involved. Both child and parent together or child and parent treated separately lead to weight reduction. The gradual number of sessions (8 sessions over 15 weeks) had more significant weight change than the rapid (8 sessions in 4 weeks). The child and parents need to process and master sequential components of behavior change. Frequent reinforcement for weight change is also important for obese children.
Both parents and child say they will engage in behavior to eat healthy and exercise but to ensure decisions will be acted on these intentions should be specified in terms of where and when. For example, “I intend to eat low-fat food for supper and exercise ½ hour at 4 PM each day starting Wednesday” will be more likely to be performed than if the intention is unspecified. Parents and child can set a schedule and the child can be reinforced for implementation. This form of self-monitoring and follow through will be strengthened without the need for additional information and the presence of a therapist. Thus, motivation alone is not sufficient to lose weight but when accompanied by voluntary action strategies they become self-directed and more effective.
In summary, obesity in children is a serious problem and it is increasing dramatically. There are many emotional factors which include lower quality of life, depression and anxiety, low self confidence, negative body image, teasing and other forms of bullying, and social alienation. However, obesity can be treated and the child can recover with proper care by licensed health professionals. Counseling, using primarily a cognitive behavior therapy format, can be effective in working with the child and his or her family. After a thorough assessment, a comprehensive psychotherapy plan can be implemented that will require about 25 sessions over 12-15 months. Accounting for normal childhood growth and maturation, a weight loss of 10-15% would be realistic. Parents, educators, and mental health professionals should be alert to the social, cultural, and external influences that promote obesity and be ready to take action and make referrals for treatment.
Blom-Hoffman, J., “Obesity Prevention in Children: Strategies for Parents and School Personnel”, (2004), National Association of School Psychologists Communiqué, Vol. 33 (3).
Dansinger, M. L., Gleason, J. A., Griffith, J. L., Selker, H. P., and Schaefer, E. J. (2005), “Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for Weight Loss and Heart Disease Risk Reduction.”, Journal of the American Medical Association, Jan. 5, 2005; Vol. 293 (1) pp. 43-53.
Eisenberg, Marla (et. al.) (2003), Archives of Pediatrics and Adolescent Medicine, 2003 August.
Also reported as “Teasing About Weight Takes Its Toll On Kids, U Study finds” by Josephine Marcotty, Minneapolis Star Tribune, Aug. 12, 2003, B1, B4.
Epstein, L. H., Wing, R. R., Steranchak, L., Dickson, B. and Michelson, J., (1980), “Comparison of family based behavior modification and nutrition education for childhood obesity”, Journal of Pediatric Psychology, Vol. 5, pp. 25-36.
Espelage, Dorothy L. and Swearer, Susan M., (2003), ”Research on School Bullying and Victimization”, School Psychology Review, (2003), pp. 365-383.
Institute of Medicine of the National Academies (2004), “Childhood Obesity in the United States: Facts and Figures-Fact Sheet”, (Sept. 2004).
Keenan, J. C., “Guidelines and Outcome Evaluation for Prevention and Treatment of Obesity in Children”, National Association of School Psychologists communiqué, Vol. 33 (3) 11-12.
Musher-Eizenman, D.R., Holub, S.C., Miller, A.B., Goldstein, S.E., and Edwards-Leeper, L. (2004). “Body Size Stigmatization in Preschool Children: The Role of Control Attributions”, Journal of Pediatric Psychology, 2004, 29(8) 613-620.
Williams, J., Wake, M., Hesketh, K., Maher, E., and Wates, E., (2005), “Health-Related Quality of Life of Overweight and Obese Children”, Journal of American Medical Association, (2005), pp. 70-76.
CDC Growth Charts – Educational Materials section