Lesson 9: Childhood and Adolescent – Psychological Aspects of Obesity and Its Treatment

Table of Contents


Introduction

In the last lesson I discussed some of the various physiologic consequences of childhood obesity, as well as the impact on adult health when this is maintained in adulthood. When obesity is treated prior to adulthood many of the health effects are very significantly mitigated. I also presented literature regarding obesity’s association with appetite dysregulation, and I provided practical tips to address this concern. Of interest for this lesson, the aberrant appetite regulation is one reason why individuals with obesity should not necessarily feel guilt or shame about their obesity; it is not their fault that their appetite is working against them.

I will continue discussing consequences of obesity and its treatment in this lesson, where I will focus more specifically on the various psychological considerations.


Psychological impact of stigma, shame, and stress associated with obesity

There has been a substantial amount of published literature regarding the psychological effects of obesity, as well as the impact of weight stigma and associated stress in general. I will discuss some of that literature here; similar to above you can click on the expandable box if you want to read summaries of several publications, and I will highlight the main points below.

Individual studies:

  • In a 2015 study where focus groups were conducted for children aged 10-12 years who were positive obesity outliers (children who actually decreased their BMI relative to most people in the area who did not), a few topics emerged from the general discussions.(Sharifi, 2015) The children were more comfortable discussing illustrations of fictional characters than talking about their own experiences. They viewed obesity in negative moralistic terms and thought that children with obesity had inferior abilities to participate in athletic & social contexts. All of the children expressed bullying as a major issue and some found this to be a motivating factor to work on treating their obesity. They identified authority figures such as doctors & parents as providing motivation to change behaviors. Relationships with peers & families were the main influences on initiation & maintenance of healthy behavioral change. Several noted that behavior change was hard at first but became easier over time. The children measured their success by tracking progress socially & physically. Resolution of bullying, social stigma, and exercise intolerance were some of the most meaningful outcomes from having an improved BMI.
    • One caveat to this study is that there is likely selection bias when only choosing children who were successful with weight management; thus these findings likely do not apply to all children, but they do indicate what may be some of the most motivational components to spur success.
  • A 2018 study found that adolescents in a weight loss camp who took a survey about different terminology generally preferred the terms “weight problem” and “unhealthy weight” as opposed to terms such as “overweight”, “big”, “heavy”, “large”, “curvy”, “obese”, and “extremely obese”.(Puhl, 2018) For the adolescents with obesity the term “chubby” was generally viewed favorably, possibly as this may downplay the overall severity of obesity. However, none of the terms that were on the survey were universally well-received, and thus there is likely a large degree of individual preference when it comes to terminology associated with one’s weight.
  • A 2019 longitudinal study with 1-15 years follow-up for participants who were an average age of 12 years at baseline and all with overweight or obesity found that those who experienced more weight-based teasing at baseline gained ~91% more fat mass per year; it’s not clear if this finding was correlational or causal.(Schvey, 2019)
  • A 2021 study of 141 youth, mostly adolescents, found that those with elevated body weight and chronic stress (potentially due from stigma associated with obesity) were more prone to emotional eating; the authors suggested that obesity interventions may want to include a stress-reduction component.(Wijnant, 2021)

A policy statement:

  • A 2017 policy statement on weight stigma in childhood obesity summarized several lines of research, stating(Pont, 2017):
    • Children & adolescents with severe obesity have quality of life scores worse than those the same age who have cancer.
    • Negative weight-based stereotypes start as young as age 3 years.
    • Students are less likely to offer help to peers with overweight & obesity.
    • Overweight and obesity increases the likelihood of being bullied.
    • Teachers have lower expectations of students with obesity and rate their performance as worse.
    • Physicians associate obesity with noncompliance, hostility, dishonesty, poor hygiene, laziness, lack of self-control, and decreased intelligence.
    • Two-thirds of children aged 9-11 years who perceive themselves as having excess weight think they would have more friends if they could lose weight.

Review articles:

  • A 2018 systematic review and meta-analysis (“SR/MA”) evaluating maintenance interventions after weight loss in children with overweight and obesity found that the greatest predictor of success was continued motivation.(van der Heijden, 2018) Other helpful aspects were high self-efficacy, self-management skills regarding food intake, and support from peers and parents.
  • A 2020 review of weight stigma in youth found that children are more likely to be bullied for their weight and physical appearance than other factors, children as young as age 4 can possess negative biases & judgements of peers with high weight, 1st graders with obesity can be rated as less popular and less preferred as playmates, youth who are teased or bullied about their weight have elevated depression, anxiety, body dissatisfaction, and lower self-esteem, and it seems the stigma of weight rather than the weight itself is the origin of the psychological distress.(Puhl, 2020) Weight-related teasing in families was found to be a consistent correlate of binge eating in children. Additionally, the stigma can lead to unhealthy weight control behaviors for many years after the stigmatizing episode(s) occurred.
  • Two 2020 SR/MAs from the same group of authors evaluated the impact of a variety of obesity treatment interventions on various aspects of mental health, finding benefits for depression, self-esteem, body image, and weight-related outcomes.(Gow, 2020; King, 2020) The amount of weight loss did not influence the psychological outcomes indicating there may be benefit even if weight is not lost. Of note, it was not clear how much of the benefit was from the actual impact of the interventions versus regular contact with the study teams.
  • A 2021 SR of facilitators and barriers to child participation in nutrition, physical activity, and obesity interventions found that from the child’s perspective they wanted to change their own behaviors, build confidence & self-esteem, and aid their own health.(Clayton, 2021) Additionally, if parents showed interest & willingness to participate than it was more likely that the child would too. Children were also more likely to stay involved if it allowed them time to spend with their peers.
  • A 2021 SR including 24 studies found that adverse childhood experiences (“ACEs”) were associated with childhood obesity in 21 of the 24 studies.(Schroeder, 2021) Females may have a greater risk than males and sexual abuse may lead to worse outcomes than the other ACEs. Additionally, experiencing multiple ACEs appeared to associate with greater risk.
  • A 2021 SR evaluated 16 studies assessing the impact of parent-adolescent weight-talk on adolescent health outcomes, finding that in general conversations focused on health were associated with healthy weight control behaviors, while discussions regarding weight were associated with unhealthy weight control behaviors.(Yourell, 2021)
  • A 2021 SR/MA evaluated 25 articles regarding weight stigma in childhood obesity and found not only that this was highly prevalent but it also led to greater increases in weight gain regardless of initial BMI.(Ma, 2021)
  • A 2021 review discussing stigma related to childhood obesity noted that shaming can promote unhealthy coping strategies while weight-based teasing in youth is associated with weight gain and impairs long-term weight loss maintenance.(Haqq, 2021)

Summarizing the main points of the above literature:

  • Many youth with obesity experience stigma and a significantly decreased quality of life.
  • Stigma and shame contribute to unhealthy behaviors and increased weight gain long-term.
  • Motivation and success with making healthy changes is aided by parental and peer support.
  • Neutral terminology (ie, “unhealthy weight” instead of “obese”) is generally preferred though individual preferences vary.
  • In general, focusing on healthy behaviors rather than weight when discussing these topics with adolescents leads to healthier behavioral outcomes.

It is clear that many youth with obesity experience shame and stigma; many of the implications highlighted above are included in the following table.

Reproduced from: Haqq AM, Kebbe M, Tan Q, Manco M, Salas XR. Complexity and Stigma of Pediatric Obesity. Child Obes. 2021 Jun;17(4):229-240. doi: 10.1089/chi.2021.0003. Epub 2021 Mar 29. PMID: 33780639; PMCID: PMC8147499.

When this topic comes up it can be helpful to take a step back and realize that there are several factors that contribute to obesity, and only some of these are in any one person’s control. This is highlighted in the following figure.

Reproduced from: Haqq AM, Kebbe M, Tan Q, Manco M, Salas XR. Complexity and Stigma of Pediatric Obesity. Child Obes. 2021 Jun;17(4):229-240. doi: 10.1089/chi.2021.0003. Epub 2021 Mar 29. PMID: 33780639; PMCID: PMC8147499.

Emphasizing that there are several contributing factors can help remove some of the stigma, shame, and guilt that is experienced. As these emotions all contribute to stress, which itself leads to hormonal dysregulation favoring unhealthy lifestyle choices and coping behaviors, anything that helps decrease these negative feelings may prove beneficial to a degree. At the same time, you can place greater emphasis on health-promoting behaviors that empower children and adolescents to improve their own health. This is shown in the following table that highlights some of the components for cognitive behavioral therapy for pediatric obesity management.

Reproduced from: Kang NR, Kwack YS. An Update on Mental Health Problems and Cognitive Behavioral Therapy in Pediatric Obesity. Pediatr Gastroenterol Hepatol Nutr. 2020 Jan;23(1):15-25. doi: 10.5223/pghn.2020.23.1.15. Epub 2020 Jan 8. PMID: 31988872; PMCID: PMC6966224.

In this way important information for healthy weight management can be taught while also providing the skill set needed to address the negative psychological effects of obesity, which at least in theory should lead to better health outcomes overall.


Does working on weight management trigger eating disorders?

A big concern and question in general is if any effort to guide children and adolescents to healthier eating/exercise/lifestyle habits may inadvertently lead to a harmful outcome, such as developing an eating disorder. Several analyses have been published that address this concern. For those curious, I am including brief summaries of some of the recent published literature in the expandable box below, and for those who do not wish to read through all of this information I am including the key points and general takeaways underneath the expandable box.

  • A 2019 SR evaluating 9 studies examining the association between childhood obesity treatment and eating disorder symptoms found that multidisciplinary treatment had positive influences on eating behavior and in teaching how to react to emotional stress and external stimuli.(De Giuseppe, 2019)
  • A 2019 SR/MA included 36 articles of 29 studies and found that obesity treatment did not increase the risk of eating disorder development or symptoms.(Jebeile, 2019) The authors did note that high-risk adolescents were probably not included in the interventions and that the studies may have included protective factors such as increasing nutrition knowledge or psychosocial components that may have negated potential risks. Additionally, the studies generally reported averages of data, and if only a small number of individuals developed eating disorders this may have been overlooked.
    • A letter in response to this publication noted that one study found it took 27 months for eating disorder symptoms to develop in adolescents after dieting, but only 3 studies in this analysis included follow-up beyond 27 months.(Adams, 2020) These 3 studies had a total sample size of n=195 and 5-9% of these adolescents had an increase of at least 1 type of eating disorder symptom.
    • The authors of the initial analysis responded by noting that the study that found it takes 27 months for eating disorder symptoms to develop in adolescents after dieting was not performed in a treatment-seeking population.(Jebeile, 2020) Additionally, the development of symptoms of an eating disorder does not necessarily lead to the development of an eating disorder itself. Nonetheless, the authors acknowledge more long-term research is needed, though they do subsequently address the concern of increasing the eating disorder symptom of “dietary restraint” (see below).
  • A 2020 SR evaluating the impact of obesity prevention programs aimed at individuals aged 10-19 years evaluated 35 studies and compared 20 that were energy-balance interventions with 15 that worked on shared risk factors of obesity and eating disorders (ie, improving body image and maladaptive responses to weight-based teasing).(Leme, 2020) Overall, neither set of interventions were very effective but a subset of the latter studies did improve several risk factors for eating disorders that were sustained at follow-up despite not aiding weight loss.
  • A 2021 SR examining the association of weight management (with dietary components) and dietary restraint or dietary behaviors in treatment-seeking youth populations with overweight or obesity evaluated 23 studies including mean ages of 4.7-15.3 years.(House, 2021) Dietary restraint was reported in 20 studies with an increase found in 10 studies. Disordered eating behaviors and cognitions were evaluated in 17 studies and all found that these were decreased or unchanged. Regarding body image, all 8 studies evaluating this had improvements or no change. Regarding self-esteem, 8 of 9 studies had improvements or no change. Overall, all evaluated metrics of eating disorder symptomology either improved or did not change except for dietary restraint; thus, dietary restraint is likely not harmful in the context of weight management interventions. This seems to be particularly true when focusing on positive self-regulation strategies.
  • A 2021 review of eating disorder concerns within pediatric obesity treatment found the overall risk of inducing an eating disorder is likely low but more empirical evidence is needed.(Lister, 2021)
  • A 2021 review of obesity and eating disorders in children noted that in general the most common eating disorders associated with obesity are binge eating disorder followed by bulimia nervosa. There are several risk factors including teasing, bullying, societal pressure to be thin, high parental demands, adverse childhood experiences, and more that can collectively contribute to low self-esteem, negative self-evaluation, and high body dissatisfaction. This may lead to dieting which can then contribute to subsequent overeating and binging, which leads to a vicious cycle. In contrast, most children in supervised obesity treatment interventions have either no change or improvements in eating disorder risk profiles, even when weight is not lost, indicating that structured interventions sensitive to these issues are generally safe.(Stabouli, 2021)
  • A 2021 secondary analysis of the TEENS+ intervention in adolescents that utilized caloric monitoring with predefined weight loss goals and made weekly adjustments based on progress (determined by self-weighing), in conjunction with behavioral therapy and dietary teaching, found that this improved all measures of eating disorder assessment with the exception of dietary restraint (this increased but as mentioned above this is likely a positive change when done for the purpose of eating healthier as part of a dietary strategy).(Raynor, 2021)
  • A 2022 review of the relationship between dieting, dietary restraint, caloric restriction, and eating disorders found that in youth studies weight gain prevention interventions either do not impact or actually decrease eating disorder symptoms. These interventions do not strictly focus on calorie reduction and rather focus on topics such as food being fuel for the body and how to make healthier food swaps from less-to-more nutritious options. Additionally, structured obesity treatment programs decrease eating disorder symptoms and shape & weight concerns. Structured interventions seem safe as long as they utilize proper screening and perform ongoing monitoring for eating disorders.(Stewart, 2022)

Summarizing the main points of the above literature:

  • In structured weight gain prevention and weight management interventions in youth there does not seem to be a significant risk of developing eating disorders.
    • The only symptom that seems to increase with these interventions is “dietary restraint”, but as indicated in several of the publications this is likely a good thing in the context of trying to follow a healthier dietary strategy that leads to less food intake and weight loss.
    • Many symptoms of eating disorder pathology and overall mental health improve as a result of the interventions.
  • Caveats include the facts that higher risk individuals are likely excluded from interventions, interventions may not be of long enough duration to determine long-term negative consequences, and these interventions will frequently include experts who can monitor participants for eating disorder pathology and intervene if indicated.

Note: The question then becomes if the findings in structured interventions can be applied to non-structured environments that most children experience on a daily basis. I have not come across great research evaluating this question. I believe they can in the context of the healthcare system where children participate in weight management with their healthcare provider. In the home setting without medical supervision, attempting to emulate the interventions in teaching about nutrition in a healthy and positive way will likely be beneficial; caregivers should focus on discussing and practicing healthy lifestyles and habits and avoid focusing directly on weight loss.(Athanasian, 2021)

If at any point in time any concerns for disordered eating, eating disorders, worsening mental health, or other unhealthy behaviors emerge, then I do believe it would be a good idea to discuss this with the child’s healthcare provider so appropriate treatment can be initiated, if indicated.


Conclusion

In this lesson I presented literature describing the psychological health consequences of obesity and considerations for how to approach healthier lifestyles and weight management in a way that will yield positive psychological outcomes. This largely entails using neutral language, attempting to remove stigma and shame, and focusing on healthy behaviors rather than focusing solely on weight. Collectively this will help the child be in a better position to make positive changes and will likely decrease the chance of them developing an eating disorder.

Now that I have discussed various health considerations of childhood obesity, in the next lesson I will discuss the actual definition of childhood obesity and various considerations when applying this definition.

Click here to proceed to Lesson 10


References

  1. Adams L. Letter to the editor: Concerns regarding “Meta-analysis on pediatric obesity treatments and eating disorder risk” of Jebeile et al. Obes Rev. 2020 Mar;21(3):e12968. doi: 10.1111/obr.12968. Epub 2019 Nov 10. PMID: 31709725.
  2. Athanasian CE, Lazarevic B, Kriegel ER, Milanaik RL. Alternative diets among adolescents: facts or fads? Curr Opin Pediatr. 2021 Apr 1;33(2):252-259. doi: 10.1097/MOP.0000000000001005. PMID: 33605628.
  3. Clayton P, Connelly J, Ellington M, Rojas V, Lorenzo Y, Trak-Fellermeier MA, Palacios C. Facilitators and barriers of children’s participation in nutrition, physical activity, and obesity interventions: A systematic review. Obes Rev. 2021 Dec;22(12):e13335. doi: 10.1111/obr.13335. Epub 2021 Sep 1. PMID: 34472191.
  4. de Giuseppe R, Di Napoli I, Porri D, Cena H. Pediatric Obesity and Eating Disorders Symptoms: The Role of the Multidisciplinary Treatment. A Systematic Review. Front Pediatr. 2019 Apr 3;7:123. doi: 10.3389/fped.2019.00123. PMID: 31024868; PMCID: PMC6463004.
  5. Gow ML, Tee MSY, Garnett SP, Baur LA, Aldwell K, Thomas S, Lister NB, Paxton SJ, Jebeile H. Pediatric obesity treatment, self-esteem, and body image: A systematic review with meta-analysis. Pediatr Obes. 2020 Mar;15(3):e12600. doi: 10.1111/ijpo.12600. Epub 2020 Feb 4. PMID: 32020780.
  6. Haqq AM, Kebbe M, Tan Q, Manco M, Salas XR. Complexity and Stigma of Pediatric Obesity. Child Obes. 2021 Jun;17(4):229-240. doi: 10.1089/chi.2021.0003. Epub 2021 Mar 29. PMID: 33780639; PMCID: PMC8147499.
  7. House ET, Gow ML, Lister NB, Baur LA, Garnett SP, Paxton SJ, Jebeile H. Pediatric weight management, dietary restraint, dieting, and eating disorder risk: a systematic review. Nutr Rev. 2021 Sep 7;79(10):1114-1133. doi: 10.1093/nutrit/nuaa127. PMID: 33608718.
  8. Jebeile H, Gow ML, Baur LA, Garnett SP, Paxton SJ, Lister NB. Treatment of obesity, with a dietary component, and eating disorder risk in children and adolescents: A systematic review with meta-analysis. Obes Rev. 2019 Sep;20(9):1287-1298. doi: 10.1111/obr.12866. Epub 2019 May 26. PMID: 31131531; PMCID: PMC6851692.
  9. Jebeile H, Gow ML, Baur LA, Garnett SP, Paxton SJ, Lister NB. A response to the comments by Ms Adams on our paper “Treatment of obesity, with a dietary component, and eating disorder risk in children and adolescents: A systematic review with meta-analysis”. Obes Rev. 2020 Mar;21(3):e12971. doi: 10.1111/obr.12971. Epub 2019 Nov 8. PMID: 31702109.
  10. Kang NR, Kwack YS. An Update on Mental Health Problems and Cognitive Behavioral Therapy in Pediatric Obesity. Pediatr Gastroenterol Hepatol Nutr. 2020 Jan;23(1):15-25. doi: 10.5223/pghn.2020.23.1.15. Epub 2020 Jan 8. PMID: 31988872; PMCID: PMC6966224.
  11. King JE, Jebeile H, Garnett SP, Baur LA, Paxton SJ, Gow ML. Physical activity based pediatric obesity treatment, depression, self-esteem and body image: A systematic review with meta-analysis. Mental Health and Physical Activity. 2020 Oct;19. doi: 10.1016/j.mhpa.2020.100342.
  12. Leme ACB, Haines J, Tang L, Dunker KLL, Philippi ST, Fisberg M, Ferrari GL, Fisberg RM. Impact of Strategies for Preventing Obesity and Risk Factors for Eating Disorders among Adolescents: A Systematic Review. Nutrients. 2020 Oct 14;12(10):3134. doi: 10.3390/nu12103134. PMID: 33066501; PMCID: PMC7602154.
  13. Lister NB, Baur LA, Paxton SJ, Jebeile H. Contextualising Eating Disorder Concerns for Paediatric Obesity Treatment. Curr Obes Rep. 2021 Sep;10(3):322-331. doi: 10.1007/s13679-021-00440-2. Epub 2021 May 10. PMID: 33970441.
  14. Ma L, Chu M, Li Y, Wu Y, Yan AF, Johnson B, Wang Y. Bidirectional relationships between weight stigma and pediatric obesity: A systematic review and meta-analysis. Obes Rev. 2021 Jun;22(6):e13178. doi: 10.1111/obr.13178. Epub 2021 Feb 2. PMID: 33533189.
  15. Pont SJ, Puhl R, Cook SR, Slusser W; SECTION ON OBESITY; OBESITY SOCIETY. Stigma Experienced by Children and Adolescents With Obesity. Pediatrics. 2017 Dec;140(6):e20173034. doi: 10.1542/peds.2017-3034. Epub 2017 Nov 20. PMID: 29158228.
  16. Puhl RM, Himmelstein MS. Adolescent preferences for weight terminology used by health care providers. Pediatr Obes. 2018 Sep;13(9):533-540. doi: 10.1111/ijpo.12275. Epub 2018 Mar 24. PMID: 29573233.
  17. Puhl RM, Lessard LM. Weight Stigma in Youth: Prevalence, Consequences, and Considerations for Clinical Practice. Curr Obes Rep. 2020 Dec;9(4):402-411. doi: 10.1007/s13679-020-00408-8. Epub 2020 Oct 20. PMID: 33079337.
  18. Raynor HA, Mazzeo SE, LaRose JG, Adams EL, Thornton LM, Caccavale LJ, Bean MK. Effect of a High-Intensity Dietary Intervention on Changes in Dietary Intake and Eating Pathology during a Multicomponent Adolescent Obesity Intervention. Nutrients. 2021 May 28;13(6):1850. doi: 10.3390/nu13061850. PMID: 34071560; PMCID: PMC8228549.
  19. Schroeder K, Schuler BR, Kobulsky JM, Sarwer DB. The association between adverse childhood experiences and childhood obesity: A systematic review. Obes Rev. 2021 Jul;22(7):e13204. doi: 10.1111/obr.13204. Epub 2021 Jan 27. PMID: 33506595; PMCID: PMC8192341.
  20. Schvey NA, Marwitz SE, Mi SJ, Galescu OA, Broadney MM, Young-Hyman D, Brady SM, Reynolds JC, Tanofsky-Kraff M, Yanovski SZ, Yanovski JA. Weight-based teasing is associated with gain in BMI and fat mass among children and adolescents at-risk for obesity: A longitudinal study. Pediatr Obes. 2019 Oct;14(10):e12538. doi: 10.1111/ijpo.12538. Epub 2019 May 29. PMID: 31144471; PMCID: PMC6728169.
  21. Sharifi M, Marshall G, Goldman RE, Cunningham C, Marshall R, Taveras EM. Engaging children in the development of obesity interventions: Exploring outcomes that matter most among obesity positive outliers. Patient Educ Couns. 2015 Nov;98(11):1393-401. doi: 10.1016/j.pec.2015.06.007. Epub 2015 Jun 22. PMID: 26166630; PMCID: PMC4609258.
  22. Stabouli S, Erdine S, Suurorg L, Jankauskienė A, Lurbe E. Obesity and Eating Disorders in Children and Adolescents: The Bidirectional Link. Nutrients. 2021 Nov 29;13(12):4321. doi: 10.3390/nu13124321. PMID: 34959873; PMCID: PMC8705700.
  23. Stewart TM, Martin CK, Williamson DA. The Complicated Relationship between Dieting, Dietary Restraint, Caloric Restriction, and Eating Disorders: Is a Shift in Public Health Messaging Warranted? Int J Environ Res Public Health. 2022 Jan 3;19(1):491. doi: 10.3390/ijerph19010491. PMID: 35010751; PMCID: PMC8745028.
  24. van der Heijden LB, Feskens EJM, Janse AJ. Maintenance interventions for overweight or obesity in children: a systematic review and meta-analysis. Obes Rev. 2018 Jun;19(6):798-809. doi: 10.1111/obr.12664. Epub 2018 Jan 23. PMID: 29363283.
  25. Wijnant K, Klosowska J, Braet C, Verbeken S, De Henauw S, Vanhaecke L, Michels N. Stress Responsiveness and Emotional Eating Depend on Youngsters’ Chronic Stress Level and Overweight. Nutrients. 2021 Oct 19;13(10):3654. doi: 10.3390/nu13103654. PMID: 34684656; PMCID: PMC8540677
  26. Yourell JL, Doty JL, Beauplan Y, Cardel M. Weight-Talk Between Parents and Adolescents: A Systematic Review of Relationships with Health-Related and Psychosocial Outcomes. Adolescent Res Rev. 2021;6. 409-424. doi: 10.1007/s40894-021-00149-2
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