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Childhood obesity
EDITOR'S COLUMN
Childhood obesity Obesity in childhood is one of the most complex and least understood clinical syndromes in pediatric medicine. This can be related partly to the multiple causes and manifestations of the condition, which defy the simple causeand-effect principle that we like in traditional biologic medical practice. In addition, there is no single treatment approach to satisfy our cherished "diagnosis and cure" model for medical practice. There is a strong genetic predisposition, imp.ortant cultural features, dramatic correlations with socioeconomic background, or evident emotional factors in certain cases. Overeating and reduced physical activity are among the known causes of obesity. Subtle metabolic and endocrine events, and processes during embryology and in the first few months of life that may be critical have yet to be clarified. The role of neurotransmitters as a contributing factor undoubtedly will also emerge more clearly. With a condition that is this overdetermined and includes so many qualitative, quantitatively, and diverse processes in its etiology, the therapeutic approach cannot be simple. There are programs for treatment based on each of the possible causes or on varying combination thereof-each touted to be more effective than the others. Some of the mechanical approaches to treating obesity, such as surgery (intestinal by-pass procedure, stapling of the stomach, insertion of balloons into the stomach, wiring jaws closed to prohibit ingress of food), fortunately have not been found justified for general application in growing children and adolescents. Most programs have looked toward reduction in weight gain rather than actual weight loss for growing children, and in recent decades have been based primarily on nutritional changes with emphasis on physical activity and psychosocial intervention. Individual and group approaches have been tried. Short-term results have sometimes been gratifying, long-term ones almost universally disappointing. In adults, especially in groups, long-term improvement has been noted in some cases when behavior modification resulted in improved self-esteem and psychosocial equilibrium) I am unaware of any similar findings relating to the childhood population. What is known about children who are obese is that there are long-term public health implications, because many of them continue to be obese into their adult lives.
There are also significant psychosocial effects. Obese children are stigmatized, starting at an early age, not only by adults who have more established prejudices, but even by their peers. There are depressing observations that even very young children demonstrate negative attitudes toward their obese peers as early as kindergarten, 2 and tend to avoid them. The classic work of Richardson et al. 3 showed that a child who chooses a partner in play will prefer a child with a major physical handicap or in a wheelchair to an obese child. Other studies indicate that school-aged children, when asked to characterize obese children from stylized drawings, tend to attribute to them undesirable social characteristics. 4 In the adult population it is not difficult to find examples of extremely pejorative attitudes toward obese individuals of all ages. In the last few decades some groups in the community have developed more nonjudgmental attitudes toward various addictions, including alcoholism; however, there is a regrettable tendency to consider obesity simply a matter of"character," with the unrealistic attitude that a little bit of self-control and will power is all See related article, p. 367
it takes to lose weight. In many social occasions, lean members of our society take advantage of the opportunity to castigate their fatter friends and acquaintances. There is no hesitation in telling even casual acquaintances what they should or should not do when it comes to eating a meal, whereas in many other walks of life there is a certain amount of appropriate diffidence to offering gratuitous advice. Thus obese individuals, in addition to their other problems, lead a life in which a great deal of social stigma surrounds their appearance and in which they are subject to both overt and covert criticism and disapproval, unfortunately also from professionals, who should be nonjudgmental and compassionate. The extent to which all of these troublesome features of the life of the obese individual are culturally determined is hard to assess. The assumption that certain cultural groups, for example, Latin Americans, have nonjudgmental attitudes toward the obese individual has not been well
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Editor's column
documented. On the other hand, cultural patterns of eating and images of the desirable body habitus vary greatly in different cultures. The paper by Kaplan and Wadden in this tissue of The Journal demonstrates that one group of obese school-aged children, belonging to a black inner-city population, did not show significant impairment in self-esteem as measured by the Piers-Harris Self-Esteem Scale, one of the most widely used and accepted measures of this aspect of psychologic and personality function. Findings of other studies are consistent with this. An as yet unpublished study by our group, utilizing a number of personality assessments including the Child Behavior Checklist, Perceived Self-Competence Scale, and the Family Environment Scale, showed that a group of obese children fell in the borderline range between children thought to have normal personality profiles and those requiring clinical referral for attention to behavioral or psychosocial problems (Banis HT, unpublished thesis, 1985). I believe these findings are not inconsistent with most other studies showing that there is a measurable personality disturbance in these children but that they are not clinically, psychosocially ill. Thus, in childhood obesity we are faced with an overdetermined problem involving numerous types of causes, manifested in various ways, being responded to differentially by different cultural groups, and requiring complex intervention incorporating many aspects of children's and families' daily life that are notoriously hard to change. The multifaceted nature of the problem makes it difficult to understand, unsatisfactory to treat, and difficult and
The Journal of Pediatrics August 1986
expensive to study. There is a regrettable lack of support for treatment of obesity from third-party payors, and lack of support for research efforts on this problem by many funding resources, yet it represents a serious hazard to personality and to longevity and to the level of functioning for individuals and whole groups of individuals. I welcome the effort of Kaplan and Wadden to cast some light on even one aspect of functioning in this group of children. More research is needed, and more compassionate attention to obese individuals needs to be developed. Fortunately, as the knowledge base increases, judgmental emotional reactions and prejudices toward a phenomenon usually diminish. It is hoped that we can look forward to a period of better understanding of obesity in children and adults, leading to reduced social stigma and to the development of more effective approaches to therapy. Barbara Korsch, M.D. Children's Hospital 4650 Sunset Blvd. Los Angeles, CA 90027 REFERENCES
1. Stunkard AM, Pennick SB. Behavior modification in the treatment of obesity. Arch Gen Psychiatry 1979;36:801806. 2. Lerner RM, Gellert E. Body build identification, preference, and aversion in children. Dev Psychol 1969;5:456-462. 3. Richardson SA, Boodman N, Hastorf AH, Dornbush SM. Cultural uniformity in reaction to physical disabilities. Sociol Rev 1961;26:241-247. 4. Staffieri JR. A study of social stereotype of body image in children. J Pers Soc Psychol 1969;10:337-343.
Childhood obesity Obesity in childhood is one of the most complex and least understood clinical syndromes in pediatric medicine. This can be related partly to the multiple causes and manifestations of the condition, which defy the simple causeand-effect principle that we like in traditional biologic medical practice. In addition, there is no single treatment approach to satisfy our cherished "diagnosis and cure" model for medical practice. There is a strong genetic predisposition, imp.ortant cultural features, dramatic correlations with socioeconomic background, or evident emotional factors in certain cases. Overeating and reduced physical activity are among the known causes of obesity. Subtle metabolic and endocrine events, and processes during embryology and in the first few months of life that may be critical have yet to be clarified. The role of neurotransmitters as a contributing factor undoubtedly will also emerge more clearly. With a condition that is this overdetermined and includes so many qualitative, quantitatively, and diverse processes in its etiology, the therapeutic approach cannot be simple. There are programs for treatment based on each of the possible causes or on varying combination thereof-each touted to be more effective than the others. Some of the mechanical approaches to treating obesity, such as surgery (intestinal by-pass procedure, stapling of the stomach, insertion of balloons into the stomach, wiring jaws closed to prohibit ingress of food), fortunately have not been found justified for general application in growing children and adolescents. Most programs have looked toward reduction in weight gain rather than actual weight loss for growing children, and in recent decades have been based primarily on nutritional changes with emphasis on physical activity and psychosocial intervention. Individual and group approaches have been tried. Short-term results have sometimes been gratifying, long-term ones almost universally disappointing. In adults, especially in groups, long-term improvement has been noted in some cases when behavior modification resulted in improved self-esteem and psychosocial equilibrium) I am unaware of any similar findings relating to the childhood population. What is known about children who are obese is that there are long-term public health implications, because many of them continue to be obese into their adult lives.
There are also significant psychosocial effects. Obese children are stigmatized, starting at an early age, not only by adults who have more established prejudices, but even by their peers. There are depressing observations that even very young children demonstrate negative attitudes toward their obese peers as early as kindergarten, 2 and tend to avoid them. The classic work of Richardson et al. 3 showed that a child who chooses a partner in play will prefer a child with a major physical handicap or in a wheelchair to an obese child. Other studies indicate that school-aged children, when asked to characterize obese children from stylized drawings, tend to attribute to them undesirable social characteristics. 4 In the adult population it is not difficult to find examples of extremely pejorative attitudes toward obese individuals of all ages. In the last few decades some groups in the community have developed more nonjudgmental attitudes toward various addictions, including alcoholism; however, there is a regrettable tendency to consider obesity simply a matter of"character," with the unrealistic attitude that a little bit of self-control and will power is all See related article, p. 367
it takes to lose weight. In many social occasions, lean members of our society take advantage of the opportunity to castigate their fatter friends and acquaintances. There is no hesitation in telling even casual acquaintances what they should or should not do when it comes to eating a meal, whereas in many other walks of life there is a certain amount of appropriate diffidence to offering gratuitous advice. Thus obese individuals, in addition to their other problems, lead a life in which a great deal of social stigma surrounds their appearance and in which they are subject to both overt and covert criticism and disapproval, unfortunately also from professionals, who should be nonjudgmental and compassionate. The extent to which all of these troublesome features of the life of the obese individual are culturally determined is hard to assess. The assumption that certain cultural groups, for example, Latin Americans, have nonjudgmental attitudes toward the obese individual has not been well
299
300
Editor's column
documented. On the other hand, cultural patterns of eating and images of the desirable body habitus vary greatly in different cultures. The paper by Kaplan and Wadden in this tissue of The Journal demonstrates that one group of obese school-aged children, belonging to a black inner-city population, did not show significant impairment in self-esteem as measured by the Piers-Harris Self-Esteem Scale, one of the most widely used and accepted measures of this aspect of psychologic and personality function. Findings of other studies are consistent with this. An as yet unpublished study by our group, utilizing a number of personality assessments including the Child Behavior Checklist, Perceived Self-Competence Scale, and the Family Environment Scale, showed that a group of obese children fell in the borderline range between children thought to have normal personality profiles and those requiring clinical referral for attention to behavioral or psychosocial problems (Banis HT, unpublished thesis, 1985). I believe these findings are not inconsistent with most other studies showing that there is a measurable personality disturbance in these children but that they are not clinically, psychosocially ill. Thus, in childhood obesity we are faced with an overdetermined problem involving numerous types of causes, manifested in various ways, being responded to differentially by different cultural groups, and requiring complex intervention incorporating many aspects of children's and families' daily life that are notoriously hard to change. The multifaceted nature of the problem makes it difficult to understand, unsatisfactory to treat, and difficult and
The Journal of Pediatrics August 1986
expensive to study. There is a regrettable lack of support for treatment of obesity from third-party payors, and lack of support for research efforts on this problem by many funding resources, yet it represents a serious hazard to personality and to longevity and to the level of functioning for individuals and whole groups of individuals. I welcome the effort of Kaplan and Wadden to cast some light on even one aspect of functioning in this group of children. More research is needed, and more compassionate attention to obese individuals needs to be developed. Fortunately, as the knowledge base increases, judgmental emotional reactions and prejudices toward a phenomenon usually diminish. It is hoped that we can look forward to a period of better understanding of obesity in children and adults, leading to reduced social stigma and to the development of more effective approaches to therapy. Barbara Korsch, M.D. Children's Hospital 4650 Sunset Blvd. Los Angeles, CA 90027 REFERENCES
1. Stunkard AM, Pennick SB. Behavior modification in the treatment of obesity. Arch Gen Psychiatry 1979;36:801806. 2. Lerner RM, Gellert E. Body build identification, preference, and aversion in children. Dev Psychol 1969;5:456-462. 3. Richardson SA, Boodman N, Hastorf AH, Dornbush SM. Cultural uniformity in reaction to physical disabilities. Sociol Rev 1961;26:241-247. 4. Staffieri JR. A study of social stereotype of body image in children. J Pers Soc Psychol 1969;10:337-343.