Fed up and friendless?

Obesity is now firmly on the UK's health agenda, and children are increasingly the number one priority. Those already overweight or obese need immediate and expert help. Those who are not are potential targets of initiatives to prevent obesity. This spotlight on children is not just powered by health concerns, it reflects political concerns. Vulnerability and protection issues mean that the government can afford to take on the 'nanny state' role when it comes to society's youth. And given the monumental cost of the problem, they can barely afford not to: targeting children is therefore politically expedient, especially if prevention or early intervention is successful. Yet among all that has been written, psychological issues play a very minor part. The irony is that societal rejection of obesity and stigmatisation of those with excess weight has been acknowledged and researched for nearly 40 years (Puhl & Brownell, 2001). Does being overweight and growing up in a society riddled with anti-fat attitudes have a psychological impact? If so, how is it expressed?

Depression

Studies of people's stereotyping of fat body shapes reveal contradictory attributions of affect. On the one hand, obesity is associated with more prevalent emotional problems. On the other, obese people are more commonly seen as humorous and warm (DeJong & Kleck, 1986). This 'jolly fat' association has virtually no support in the modern literature. Neither has the association between obesity and depression been compelling. Dogged by past methodological problems, evidence for a relationship is now starting to emerge.

Cross-sectional research in children and adolescents mirrors some of the recent findings in adults. Depression is most apparent in clinical samples of obese adolescents (e.g. Britz et al., 2000), but may be entirely unassociated with obesity in community samples (Lamertz et al., 2002). Obese girls show the clearest vulnerability to depression (Stunkard et al., 2003). However, in pre-adolescent girls at least, the association, rather than being a direct correlation, may be explained by the girls' concerns about weight and dieting: the relationship between obesity and depression becomes non-significant when controlling for such concerns (Erickson et al., 2000).

Research with participants from birth cohorts and national surveys of adolescent health reveals a methodologically more robust and intriguing picture. Several studies now show that depression in adolescence is associated with later weight gain and a two-fold increase in risk of subsequent obesity, even when controlling for a range of potential confounds (e.g. Goodman & Whitaker, 2002; Richardson et al., 2003). Most, but not all, show this is specific to girls. At this age obesity poses very little risk for the development of depression. Indeed, this direction of influence has only been shown in older adults, aged 55 and over.

Quality of life

Surprisingly, there is very little research into the quality of life of obese children. One study of hospital referrals found significantly lower health-related quality of life on all measures than in healthy controls (Schwimmer et al., 2003). In all, 49 per cent had impaired health-related quality of life, and as a group they were indistinguishable from children receiving chemotherapy for cancer. In a second study, parentally completed assessments showed that a community sample of obese 8- to 11-year-olds had twice the risk of low psychosocial health compared with normal-weight peers (Friedlander et al., 2003).

Some caution is necessary, since the child's and parent's views do not always match. In the clinical study, parent proxy report scores were significantly lower than their children's in most areas. Parents especially overjudged the impairment to their child's psychosocial health (although clearly it could be that the children are attempting to make light of or cover their problems).

Self-esteem

The relationship between obesity and global self-esteem strengthens with age from pre-adolescence into young adulthood, is more apparent in females than males, and overall shows a small to moderate-sized association between the two (Miller & Downey, 1999). The modesty of relationship surprises many but is due in part to past limitations in scope and assessment of self-esteem.

The multidomain approach of Susan Harter has been especially informative (e.g. Harter, 1993). Using this we have found that a community sample of obese nine-year-old girls scored significantly lower on physical appearance and athletic competence than their normal-weight peers (Phillips & Hill, 1998). Their mean scores fell just below the mid-point of these scales, indicating that on average these obese girls identified with the depictions of an unattractive and unathletic child. While global self-worth was lower than that of normal-weight girls, the difference just failed to reach significance.

In further studies we have shown that obese 12-year-olds also differed from their lean peers in athletic competence and physical appearance. Likewise, older and fatter children attending the children's weight loss camp in Leeds differed from normal-weight comparisons on every measure other than peer acceptance (Walker et al., 2003). However, weight loss resulted in improvements to those features most affected, namely athletic competence, physical appearance and global self-worth.

Three more observations are of note. First, the impact of overweight on girls' self-competence may start young, and has been detected in five-year-olds in the US (Davison & Birch, 2001). Second, boys appear resistant to these effects, at least while they are young. We have found no relationship between obesity and low self-esteem on any aspect of perceived self-competence in 9- and 12-year-old boys. Other research notes that it was only in 13- to 14-year-old boys that a small but significant decrease in global self-worth became apparent (Strauss, 2000). Third, surprisingly few of the obese children in our studies actually have low global self-worth: only a third of the obese girls had low scores, and for the boys being underweight was as risky to self-worth as was obesity.

Social self-perception

An alternative perspective on self-esteem derives from Charles Cooley's notion of the looking-glass self. Here self-esteem is regarded as primarily social in nature and based on judgements that we imagine others to make of us. Those with low self-esteem perceive others to have little regard for them and feel demeaned, neglected or socially isolated. Especially influential are significant others (such as parents for children) and successful people who we imagine judge us more harshly than those less successful or virtuous.

So what does this perspective hold for obesity? None of our studies described above using Harter's measure showed any weight-related differences in perceived social competence. Indeed, this positive social view has some external credibility. We have used a peer-nomination procedure to investigate children's popularity with their same-sex peers (e.g. Phillips & Hill, 1998). This required children to identify up to three others in their school class group that they would choose to sit next to in class, play with at breaktime, or invite home to tea. Neither 9- nor 12-year-old obese girls or boys were disadvantaged in terms of peer choices. They were as likely to be chosen as their lean peers as people to socialise with inside and outside of school.

Age may again be a key factor. US researchers Strauss and Pollack (2003) analysed data on social network mapping from the 90,000 school students aged 13–18 included in the National Longitudinal Survey of Adolescent Health (Add Health). Overall, overweight and obese adolescents were significantly more likely than normal-weight peers to have three or fewer nominations from other adolescents. Conversely, those of normal weight were significantly more likely to have six or more friendship nominations compared with overweight or obese children. Although most of those overweight had at least one friendship nomination, they received fewer reciprocal nominations (i.e. from peers they had picked). The relative failure to be named as a friend by people you nominate suggests that friendship ties involving obese adolescents are weaker as well as less plentiful.

Victimisation

Mark Leary has extended the social view of self-esteem to question its basic function (Leary, 1999). Sociometer theory proposes that the self-esteem system evolved primarily as a monitor of social acceptance, the motivation being not to maintain self-esteem per se, but to avoid social devaluation and rejection. Accordingly, self-esteem is lowered by failure, criticism or rejection and raised by success, praise and events associated with relational appreciation.

Taking Leary's perspective on self-esteem, it is pertinent to note that between a quarter and a third of teenagers report being teased by peers for reasons of weight (Eisenberg et al., 2003). Interestingly, there was a gender-by-weight interaction in that obese girls and thin boys reported the highest levels of teasing. Regardless, victimisation was associated with psychological distress. Those teased about their weight had low body satisfaction, low self-esteem, and higher levels of depressive symptoms and suicidal ideation, even after controlling for differences in body weight.

Like most others, that study didn't distinguish victimisation for fatness from that for thinness. Our own research has looked specifically at being teased, bullied, or called horrible names for being fat, using questionnaire items inserted into Harter's self-esteem assessment. In one study of 12-year-olds, 12 per cent of girls and 16 per cent of boys identified themselves with the description of a fat-teased child (Hill & Murphy, 2000). Although these children were heavier than their non-victimised peers, fewer than half were either overweight or obese. Again, being fat-teased was associated with low body-shape satisfaction and low self-esteem in all domains except behavioural conduct. Fat-teased girls in particular saw themselves as unattractive, unathletic and with low global self-worth.

A similar study of nine-year-olds showed that 21 per cent of girls and 16 per cent of boys were fat-teased (Hill & Waterston, 2002). Like the older group, fat-teased children scored significantly lower on global self-worth and on all measures of self-competence. Overweight and obese children were four times more likely to be fat-teased than their normal-weight peers, who were not themselves immune, with 14 per cent reporting being fat-teased.

Two further points on this research are necessary. First, while being fat-teased was much more common in overweight and obese children, at least half did not report these experiences. We know very little about what protects these children or what makes the other half vulnerable. Second, in neither study did victimisation have an effect on the perceived importance of any of the domains of perceived self-competence. It would appear that these children did not manage their low self-esteem by modifying the importance of domains in which they judged themselves less competent.

Conclusions

The evidence presented above suggests that obese children are not predestined for depression and do not view themselves as being without merit. While global self-worth may be reduced, many see themselves as well-behaved, good at school work, and as having friends. Perhaps not surprisingly, it is their physical appearance and athletic competence that are most greatly affected. Age, gender and degree of obesity strongly determine this self-perception. On average for girls, these effects are detectable before puberty. For boys, it is only during early teenage years that self-competence is impaired. As teenage years advance, an increasing number of competencies become influenced by their obesity and the extent of damage increases with greater obesity.Social interaction is key to self-perception. For younger children, their weight has little implication for their perceived or actual friendship status. By teenage years, peer relationships become problematic, obese adolescents being more at risk of marginalisation and outright victimisation. Presumably this reflects the different basis on which friendship networks are organised as children mature, and as dating and sexual relationships commence. Those obese children victimised for their obesity have low self-esteem, which in some areas is crushingly low.

Causal or linking evidence on psychological distress is extremely rare. In an application of covariance structure modelling to a longitudinal study of adolescent girls, Thompson et al. (1995) found that level of obesity had a directional influence on appearance dissatisfaction and depression measured three years later. Teasing history at Time 1 was also predictive of weight and appearance dissatisfaction. But as the earlier evidence on obesity and depression shows, these causal relationships are not unidirectional. For example, while victimisation may lower self-esteem, low self-esteem invites victimisation. There is both need and opportunity for more integrative conceptualisations of these issues in obese children and adolescents.

It is important to recognise that this analysis derives mainly from community samples and that a significant proportion of obese children appear protected from, or resistant to, the psychological consequences of their obesity. It is unclear whether they will remain so as adults. However, this group could provide direction about how we assist in the rehabilitation of those deeply affected.

It also means that professionals should not go looking for psychological distress in every obese child. And even if it is found, we should question whether its cause lies in their obesity or is determined by something else.

The psychosocial issues outlined above are critical to the way child obesity is managed. Depression, low self-esteem and impaired social functioning are legitimate, even necessary, targets for child obesity treatment. Change in psychosocial state is a very desirable treatment outcome. Interventions, even if they involve only changes to physical activity or eating behaviour, should therefore include a psychological assessment. This is especially important when the goal of child obesity treatment is weight stability rather than substantial weight loss. Finally, depression and low self-esteem are predictors of drop-out from paediatric weight-management services (Zeller et al., 2004). Not only is their assessment necessary but their monitoring and, in some cases, active management may also underpin successful treatment.

- Dr Andrew J. Hill is in the Academic Unit of Psychiatry and Behavioural Sciences, School of Medicine, University of Leeds. E-mail: [email protected].

Weblinks

Association for the Study of Obesity: www.aso.org.uk
International Obesity Task Force: www.iotf.org/
Sustain's campaign for the Children's Food Bill: www.sustainweb.org/child_index.asp

Discuss and debate

What are the vulnerability and protective factors for psychological distress in obese children?
Is children's psychological distress a barrier or motivator to engagement in weight management?
What is needed to support those with psychological distress within and outside a weight-management setting?
Do parents fail to seek help in addressing their child's overweight because they fear distressing them more?
What is the relationship between an obese child's psychological distress and that of their parents?
Have anti-bullying campaigns made any difference to fat-teasing experienced by overweight and obese children?
Have your say on these or other issues this article raises. Write to our Letters page, on [email protected] or at the Leicester address – 500 words or less, please.

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