Psychological complications

Five comprehensive reviews of the literature on the psychological complications of pediatric obesity have been written, including those by Friedman and Brownell, Hebebrand and Herpertz-Dahlmann, Puder and Munsch, Puhl and Latner, and Wardle and Cooke. Precise rates of psychological complications are uncertain owing to differences in methodology, use of community versus treatment-seeking samples, failure to control for relevant demographic characteristics, and failure to take into consideration additional variables, such as parent psychopathology. Psychological complications with small to moderate associations with child and adolescent obesity include body dissatisfaction, symptoms of depression, loss-of-control eating, unhealthy and extreme weight control behaviors, impaired social relationships, obesity stigma, and decreased health-related quality of life, whereas complications with negligible to small associations include low self-esteem, clinically significant depression (of diagnostic severity, associated with significant distress and/or impairment, or inclusive of serious symptomatology), suicide, and full-syndrome eating disorders. Additional complications manifested in later life include decreased educational and financial attainment.

Associations between pediatric obesity and anxiety disorders are less well documented, although a recent study found modest associations after controlling for age, race, and Tanner Stage, and a Swedish study found that psychosocial stress in the family was associated with increased odds of obesity at age 5. Similarly, the association between child obesity and externalizing disorders, such as attention deficit hyperactivity disorder or oppositional defiant disorder, is less well documented, although recent literature suggests that aggressive and destructive behaviors at 24 months of age were predictive of disproportionate gains in BMI by age 12 among a nationally representative sample, and a Finnish study suggested that conduct problems among boys at age 8 were predictive of disproportionate weight gain by young adulthood, after controlling for hyperactivity and sociodemographic factors.

Overall, the association between child obesity and psychological complications is not as strong as one might suspect; rather, the strength of this association depends on important mediating characteristics, as depicted in Fig. 1 . Potential demographic mediators include age, gender, race, and ethnicity. For instance, the self-esteem of obese children tends to decrease as they grow older. Obese girls tend to have a greater prevalence of body dissatisfaction and low self-esteem than obese boys. Self-esteem issues tend to be more prevalent among white than African American or Hispanic girls. Further, some evidence suggests that childhood depression predicts the development of obesity, but that childhood obesity seldom predicts the development of depression. This evidence suggests that, for some children, the treatment of childhood depression may help prevent the development of obesity. Unfortunately, the risks associated with pediatric obesity tend to increase over time. Additional characteristics worthy of consideration include maternal mental health and socioeconomic status.

The associations among pediatric obesity, psychological complications, and mediating characteristics. SES, socioeconomic status.

In addition to demographic characteristics, the strength of the association between pediatric obesity and psychological complications may depend on teasing, obesity stigma, and treatment-seeking status. Obese children face greater levels of obesity stigma than nonobese children. Obesity stigma may be evidenced in the form of negative stereotypes (eg, less attractive, less intelligent, less physically capable), victimization (ie, physical, verbal, or relational), and social marginalization. Obesity stigma may come from peers, educators, or parents. Overweight parents, as well as overweight youth, are just as likely to endorse negative stereotypes as are thin parents and youth, suggesting that with time, obesity stigma may be internalized.

Obesity stigma is associated with adverse effects on self-esteem, depression, and body image; social marginalization; disproportionate weight gain; decreased physical activity; and lower academic achievement, and tends to be more prevalent among girls. Unfortunately, the negative effects of obesity stigma may be self-perpetuating. That is, the negative impact of obesity on academic performance, emotional disturbance, or social difficulties may reinforce stereotypes and negative expectations. Despite increases in the prevalence of youth overweight, obesity stigma appears to be increasing.

An important manifestation of obesity stigma is weight-related teasing and peer victimization. Weight-related teasing is associated with degree of overweight, follows the development of obesity, and tends to increase with age before leveling off during adulthood. Weight-related teasing is associated with depression and body dissatisfaction above and beyond gender, ethnicity, or weight status, and is associated with additional psychological complications, including lower self-esteem, suicidality, anxiety, loneliness, binge-eating tendencies, reduced liking of physical activity, and a preference for isolative activities. The prevalence of psychological complications according to teasing status in a sample of 4746 adolescents reported by Eisenberg and colleagues is provided in Table 1 . As can be seen, weight-related teasing nearly doubled the rates of psychological complications endorsed.

Obese youth presenting for weight loss treatment have a greater number of psychological complications than population-based samples of obese youth, particularly if they endorse body dissatisfaction. Obese youth presenting for weight loss treatment have higher BMIs, as well as higher family conflict, ineffective parental styles, and maternal distress, than population-based samples of obese youth, which may be driving the greater prevalence of psychiatric problems. Among severely obese children with BMIs greater than or equal to 40 kg/m ² presenting for bariatric surgery, 38.7% reported depressive symptomatology in the clinical range and marked impairments in both generic and health-related quality of life.

Weight bias may affect eating behavior by increasing stress, in response to which unhealthy eating may be a common although misguided coping strategy. Further, greater social isolation may result in reduced opportunities for physical activity, greater inactivity, and greater overconsumption of food. Unhealthy weight control behaviors may be driven by obesity stigma, lower perceived acceptance, and relational victimization as a way of fitting in, and may reflect a lack of knowledge of healthy weight control behaviors.

Unfortunately, psychosocial difficulties are associated with decreased weight loss success. Baseline depression, loss-of-control eating, greater parental distress, and parent BMI are associated with higher rates of weight loss treatment dropout. Improvements in weight status are associated with improvements in social problems, adjustment, and reductions in maternal distress. Conversely, the presence of fewer psychological complications predicts better long-term weight loss maintenance. Greater social marginalization is associated with increased television viewing, decreased sports participation, and decreased school club participation, which may adversely affect weight status.

Models of pediatric obesity and psychological complications

The association between pediatric obesity and psychological complications is clearly multidirectional. As evidenced in the preceding presentation, ecological models that take into consideration individual, psychosocial, physical, and macrolevel environments are best suited for understanding the associations between child obesity and psychosocial difficulties. Wilfley and colleagues applied Bronfenbrenner’s model of child development to the treatment and maintenance of pediatric weight loss and regain. The resulting socioecological model addresses the relationships between the child and the child’s family, peers, and community, including the child’s school and neighborhood.

Consistent with the bioecological paradigm, interventions aimed at the child’s family, lifestyle, and broader environment appear to hold the most promise with regard to treating pediatric obesity ; however, no single factor has been identified as having a significant impact on the pediatric obesity problem. Lifestyle interventions, defined as any combination of diet, physical activity, and/or behavioral treatments, have produced significant treatment effects compared with no-treatment wait-list control groups, as well as information/education-only control groups.

In an excellent application of this model, Wilfley and colleagues tested two family-based maintenance approaches to childhood weight loss in children ages 7 to 12 with at least one overweight parent: (1) behavioral skills maintenance (BSM), and (2) social facilitation maintenance (SFM). Children in both maintenance groups with fewer initial social problems demonstrated better long-term maintenance compared with controls, with slightly larger effects observed in the SFM group. Consistent with the bioecological theory, these interventions addressed the more immediate family social context, but also the broader peer environment. These findings highlight the importance of addressing these issues before the initiation of weight loss treatment or, at the very least, concurrently. The addition of social facilitation and skills building may prove to be a core improvement to lifestyle intervention programs.

Interpersonal therapy (IPT) has recently been identified as a targeted intervention strategy for the appetitive traits and social environmental factors associated with pediatric obesity. This treatment aids in drawing connections between interpersonal triggers and behavior; eating outcomes are modified through social skills training and role negotiation. IPT was piloted as a randomized treatment to adolescent girls at risk for weight gain with standard health education implemented as a control. IPT resulted in fewer instances of loss-of-control eating episodes, and girls in the IPT group were less likely to increase BMI and BMI percentile over 1 year.

Another promising approach involves the application of multisystemic therapy (MST), a home-based treatment originally designed for the treatment of antisocial behavior, to the treatment of pediatric obesity. Similar to IPT, MST is based in social-ecological theory and works by addressing the multiple systems in which the child is raised, including the family, peers, school, and community. MST was recently piloted as an intervention for obesity among African American adolescents. Results showed significant reductions in percent overweight in the treatment as compared with a control group.

On a broader scale, social policies that encourage after-school programs offering an environment conducive to physical activity and social interaction may counteract both behavioral and social-environmental aspects of childhood obesity. Thus, in addition to social aspects of treatment, an expansion of preventive interventions to include earlier age of intervention and the larger system of family, peers, and community of the child may increase effectiveness of treatment. The social facilitation component of these interventions addresses the crucial mediating factors of weight-related teasing and obesity stigma.

The serious psychological complications of pediatric obesity are an important focus of treatment. Treatments, such as IPT, may prove to be more effective at preventing or treating pediatric obesity than more simple behavioral change strategies focused on either side of the energy balance equation. Consistent with a bioecological model, successful interventions for psychological complications and healthful weight in children must be achieved by engaging in activity that promotes these outcomes on a regular basis over an extended period of time, slowly becoming increasingly complex, with initiation and response in both directions within the environment. Early intervention in the feeding environment, treatments that target the psychological correlates of pediatric obesity, including depression, self-efficacy, appetitive habits (eating in response to stress), and social skills training related to increasing interpersonal effectiveness, are likely to hold promise.