The Hidden Suffering

A clinical psychologist reports how children who are overweight often experience emotional difficulties

Childhood obesity is a major public health issue, not least because of the associated health risks that increase as these children enter adolescence and adulthood. These risks include the development of diabetes, heart disease and certain cancers, amongst others. Even if weight loss is achieved by the time children reach adulthood, it has been suggested that mortality rates are higher amongst adults who have been overweight or obese as children. Whilst these physical health risks are of great concern, what can be more pervasive – yet often overlooked – are the profound psychological issues that can affect the child who is overweight.

More research is needed in the area that explores the psychological impact of obesity in childhood, but from the studies that have been conducted, it is evident that overweight and obese children suffer from stigma and discrimination related to their size. They are often bullied and teased and consequently can become socially isolated and depressed. This isolation increases the likelihood of weight gain and so perpetuates the cycle of eating, weight gain, social stigmatisation and feelings of low self-worth. Such patterns of complex behaviour become easily entrenched and for this reason, achieving sustainable weight loss should involve more than merely reducing calorific intake and increasing physical activity. The psychological components of this cycle need to be addressed too.

One reason why the psychological elements related to obesity are often overlooked stems from the long held stereotypes that we as adults, and children, have of overweight or obese people. ‘Fat’ kids are often perceived as jolly and happy, despite the fact that they are ‘teased.’ British expatriates of a certain age may be able to recall the tales of Billy Bunter, the cartoon character, who was obese, greedy, lazy and had a constant preoccupation with food. Nevertheless, he was perceived by others as being cheerful and happy within himself. A more recent media representation would be Po, the main character from Kung Fu Panda, who we could characterise in the same terms. There are many others that can be brought to mind, but the crucial element here is that these stereotypical, yet inaccurate views have now moved firmly out of the realms of literature and the movies and now exist as a form of ‘fattist’ prejudice. This psychological bullying from peers or siblings impacts on how a person measures their own intrinsic value self-esteem and feelings of self-worth and throws up yet another challenge for the young person to overcome.

There are many reasons cited as to how and why young children and adolescents become overweight or obese, but there is no clear consensus as to the cause. Much of the medical and professional literature report inconsistent findings, or there is insufficient evidence from research studies from which to draw conclusions. There is general agreement, however, that the development of these conditions is multi-factorial. The solutions to weight loss must reflect these different dimensions.

From a psychological standpoint, we can consider how our relationship with food, the activity of eating and the development of our body-image are closely associated and how these may play a part in the development of disordered eating practices. As soon as we enter the world and are weaned as babies, food begins to play an important part in our lives. As a small child, feeding is predominantly a one-way event, with our parents or caregivers selecting, preparing, and presenting our meals for us. However, at the same time, the provision of food is accompanied with messages that tell us to ‘eat everything up to become big and strong’ or ‘if you eat all of your food then you can have dessert’. Likewise, the persuasion used by adults to attempt to get children to eat certain foodstuffs (usually vegetables) by suggesting that they are tasty introduces to the child the notion that their caregivers are not always honest. Similarly, food is often used to reward good behaviour, be this in the form of candies or a visit to a fast-food restaurant. Conversely, food can be withheld as a way to punish unwanted behaviour; e.g. ‘if you don’t eat all of your vegetables then you won’t get any dessert.’ And so we learn from an early age how food can induce certain behaviour and the power that the providers have over other parts of our lives. These formative years can shape how food is subsequently viewed by the young person and the role that it plays in family life.

Young children are not only at the behest of their parents for the provision of food, but also at the hands of advertisers. As adults, a day doesn’t go by without obesity or overweight issues being highlighted in the popular media. Pick up any glossy magazine and there are bound to be several articles relating to the health and beauty implications of not losing weight. These take the form of nutritional advice and diets, suggestions for increasing our physical activity levels to halt burgeoning waistbands and recommendations for products that will tackle cellulite-riddled thighs. In the same lifestyle publication we are bombarded with images of sylph-like, youthful, flawless people, whose very bodies and faces have often been digitally enhanced into manifestations that the average person can never realistically hope to achieve. This paradox is pervasive and equally so in advertisements targeted at young children and adolescents.

Young children and teenagers represent a fast-growing market for manufacturers and the effort and expenditure dedicated to targeting them continues to expand. Food products have consistently constituted a large portion of television advertising per se, but account for as much as half of all child-targeted advertising, with fast-food restaurants, sweetened cereals and soft drinks being the most frequently promoted. Advertising of ‘healthy’ food products (e.g. milk) often account for fewer than 5% of advertised food products. What young children and adolescents are more likely to see when viewing food advertisements are happy, slim, attractive families eating fat-inducing chocolate cake, pizza, burgers and sugar-filled soft drinks.

The promotion of such high calorific food aired throughout children’s television channels and in-between programmes or movies aimed at young people, has been a longstanding public health concern. However, the relationship between food advertising and obesity is not so straightforward. Just as the manufacturers have become more knowledgeable at advertising their products, young people are now more technically literate, multi-media sophisticated and product savvy than any previous generation and the notion that children and adolescents are passively persuaded is not the full picture. It has been suggested, for example, that weight gain in childhood may in fact be down to the number of hours spent watching the television rather than what is watched. Whether this is due to the sedentary behaviour that accompanies the activity, the consumption of snack foods whilst watching television, or the effects on dietary behaviour as a consequence of the advertising, remains unknown.

As childhood obesity continues to take up media space, it also needs to be remembered that there is a parallel growth in other eating disordered behaviours, many of which are at the other end of the body weight scale. The age of onset for 85% of all eating disorders has been placed at between 11 and 20 years and whilst being overweight accounts for a large proportion of this statistic, there remains a significant number of young people who have conditions related to being underweight. Anorexia nervosa, characterised by an abnormal fear of becoming obese and a distorted self-image, a persistent unwillingness to eat and severe weight loss is one such disorder, as is bulimia nervosa, which manifests itself through binge eating followed by feelings of guilt or depression and sometimes self-induced vomiting, laxative use or fasting. The pressure to be thin portrayed through glossy magazines, television advertising, movies or from peers, can see young women consuming less than 200 calories a day. As with all of these disorders, there appears to be negative body image that is accompanied with anxiety and/or depression, regardless of whether the young person is underweight, overweight or obese. It is clear, therefore, that weight loss or weight maintenance in young children and adolescents needs to be undertaken with professional guidance, as too much emphasis given towards achieving a ‘perfect’ weight or ‘perfect’ body shape could lead to a fixation resulting in the development of another eating disorder.

Whether underweight, overweight or obese, the incidence of any of these disorders is multi-factorial and no one cause can be pinpointed to account for their development. Furthermore, the psychological risks that accompany these disorders are complex and will differ from one young person to another. The consistent message from health professionals should be for families and caregivers to maintain a healthy view toward food and physical activity with their children and to ensure that fresh fruit and vegetables comprise a major part of their children’s diets, with a restriction placed on processed and high-sugar foods. Such a balanced diet, combined with daily exercise can go a long way to combat the incidence of obesity across all sections of society, not only in children and adolescents.

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