The Journal for Nurse Practitioners
Volume 6, Issue 4 , Pages 296-299, April 2010

The Last One Picked: Psychological Implications of Childhood Obesity

  • Linda Sullivan

      Affiliations

    • Linda Sullivan, RN, DSN, PNP-BC, FNP-BC, is the director of advanced practice for the Mississippi Board of Nursing in Jackson.

Article Outline

Abstract 

Obesity is on the rise in this country, and obesity among children has become a major issue for health care providers. While we are well aware of the many health risks associated with obesity, we may not be as aware of the psychological implications of obesity in children. This article discusses the psychological implications of obesity in children and suggests ways in which the health care provider can improve outcomes among children and their families.

Keywords:  childhood obesity , psychological implications of obesity

 

Children are often cruel to one another, and one can often see evidence of this when it comes to sports and the infamous “choosing of sides.” The slow, the unskilled, the unpopular and, finally, the overweight child, are nearly always chosen last. This action may have devastating and long-lasting effects on a child's self-esteem and spirit. While physical problems such as hypertension, orthopedic problems, diabetes, metabolic syndrome, hyperandrogenism, heart disease, respiratory disorders, and sleep disorders are well-documented complications associated with obesity, the psychological effects associated with obesity can be just as devastating to a child and his or her family.1 Often, this aspect of care is neglected by the health care provider, who becomes more focused on the plan to decrease the child's weight or body mass index (BMI).

Being obese today, while increasingly common, has an impact on both how children view themselves and how others see them. Many children with weight problems develop low self-esteem, which may in turn give way to emotional and behavioral problems such as depression, oppositional defiance, bullying, and poor school performance.2 For a child with weight problems, being unable to be as mobile as his or her counterparts can become a gigantic hurdle to overcome, and many cannot.

The Centers for Disease Control and Prevention (CDC)3 has defined specific criteria for both overweight and obesity. Overweight is defined as having an age-appropriate BMI between the 85th and 94th percentile, while obesity is defined as having a BMI in excess of the 95th percentile. BMI, although an imperfect measurement, can be useful in estimating whether a child is overweight. It is calculated by dividing a child's weight in kilograms by his or her height as meters squared.4

Other long-term sequelae of obesity reported in the literature feature that overweight females are less likely to be married, often fall into a higher poverty classification, and have less formal schooling. Research conducted by the University of Texas has shown that obese girls are 50% less likely to attend college than their slimmer counterparts.5 The only adverse effect reported for males in this study was that they were less likely to be married.6 However, playing sports, success in the job market, and other aspects of life are likely to be negatively affected by obesity in males.

When working with the obese child, the health care provider should be looking not only at physical problems related to and often caused by obesity, but behavioral and emotional problems as well. It is important, when utilizing a holistic approach, to focus not only on the obvious problems, but also those that may be the result of or caused by the primary diagnosis. The psychological impact of obesity has far-reaching implications for a child as they mature into young adults.7 The advanced practice nurse (APN) must become more proactive in dealing with obesity, so as to prepare an anticipatory plan of care that addresses the entire problem and minimizes the impact of this very complicated problem. While simply losing weight would eliminate the problem completely, this is easier said than done for many children.

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Background 

Obesity can impact the child on many different levels. Current estimates are that about 65% of all Americans are now classified as overweight and 40% of all children are either overweight or obese.8 The incidence of obesity has doubled among the 6- to 11-year-old age group and tripled in the 12- to 17-year-old age group since 1980. Obesity is currently deemed the single most stigmatizing and least socially accepted condition of childhood because in many ways it is perceived as something that either the child or his or her primary care givers should have prevented.9 Poor school performance has also been linked to weight issues, and studies have indicated that obese children miss 4 times more school days than nonobese children.10

Obesity, while for some a cultural norm, is increasing and can now be seen throughout the world, even in countries where prior to 1990 there were significantly lower numbers of obese children (eg, Mediterranean region, Ireland, Greece, Portugal).11 Monitoring trends in obesity is essential to thwart the inevitable serious medical problems caused by its complications. Evidence supports the likelihood that obese children and adolescents will then become obese adults and suffer the consequences of obesity in their adult years. Increased reliance on fast foods by working parents and increased availability and use of technology such as television, computer, and the phone also play a part in the increase of obesity.12 Because of the rampant increase in weight-associated problems, it is imperative that health care providers evaluate not only the physical risks for obese children, but in addition, the psychological complications that are often evidenced as emotional and behavioral problems, to treat the child in a thorough and holistic manner.

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Emotional Complications 

Generally speaking, the quality of life is worse among obese children. This is due in part to the child's own self-image, which invariably is poor. While self-esteem is affected in both overweight boys and girls, girls who are severely obese often exhibit moderate to severe depressive symptoms and 35% of these girls self report high levels of anxiety.13 Research has demonstrated that obese girls are more likely to have attempted suicide than nonobese girls.14 In general, adolescents who are obese are often more isolated and peripheral to social networks both in school and the community.

The obese child can become the victim of bullying and this can then lead to an increased loss of self-esteem and even overwhelming feelings of hopelessness, which in turn give way to depression. It is no secret that the obese individual is often the butt of many jokes and the object of scorn from many others who are not obese. Just as the culturally inappropriate joke or the misspoken word causes pain, this type of treatment can have far-reaching psychological effects on the individual. Many times, when acting in self defense, the overweight or obese child resorts to bullying, usually with poor outcomes, and this then sets up him or her for further ridicule.

Other behavioral issues can emerge for the overweight or obese child. These can be the result of increased anxiety and poor social skills. The child is often seen as disruptive or acting out in class. The child may get suspended, or simply not go to school, more often than their slimmer counterparts. This is turn leads to poor school performance, which is directly correlated to a higher number of missed school days for the overweight and obese child.15

Sleep problems associated with obesity, particularly sleep apnea, can also affect mood and the ability to concentrate. Depression, which so often is secondary to poor self esteem and poor body image, is common among obese children.16 The resulting higher degree of social isolation, leading to feelings of hopelessness, increases the incidence of depression in this group. When depressed, the child will lose interest in everyday activities and become more withdrawn, exhibit increased somnolence and crying, or become emotionally flat, not reacting to everyday concerns or stimuli. In the most extreme case, suicidal ideation can be the direct result of obesity and feelings of helplessness within the child.17 These signs and symptoms should not be ignored by either teachers or the child's primary caregiver, and should be shared with the child's health care provider so that some immediate form of intervention may be initiated.

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Intervention Strategies 

The health care provider must be cognizant not only of the physical health risks associated with weight issues but the psychological risks as well. If a patient is noted to be overweight or obese it is essential that the health care provider explores both the physical and emotional implications associated with this condition with the child and his or her parent. Interviewing the child in a nonthreatening environment and utilizing a nonjudgmental approach is critical to success in treatment. The purpose of establishing rapport with both the parent and child is to increase the likelihood of compliance with treatment regimes suggested by the health care provider. In many cases, the health care provider will see the parent with similar weight issues and therefore it is critical to neither place blame nor be overly critical of the situation. Rather, it is important to establish a safe environment for both the child and caregiver so that they can become involved in seeking solutions and expressing their feelings openly and honestly.18

It is essential that the health care provider delve into the psychological well-being of the obese child by assessing behavioral issues, school performance, and social well-being. This involves asking questions of both the child and primary caregiver. Once problems are divulged related in the physical or emotional realm, the health care provider, child, and primary caregiver(s), working as a team, should seek to develop solutions to the problems that have been identified.

Treatment of childhood obesity should take into account the child's age and any underlying medical conditions, along with any emotional issues that are disclosed during the exam and interview. Changes in diet and level of activity can be part of the treatment regime; however, for children with behavioral or emotional problems, consultation with and referring to a psychologist, psychiatrist, or behavioral counselor is imperative.

For actual weight loss treatments, the health care provider should be cognizant of the child's age, as it is recommended that children under the age of 7 be encouraged to maintain their weight rather than to diet, as this allows for height to increase but not weight. For children over the age of 7, slow, steady weight loss strategies should be introduced, with a goal of a weight loss of 1 pound per month or, in more aggressive approaches, 1 pound per week.19

Often, discovering new activities that the child enjoys and increasing the level of his or her physical activities can have a 2-pronged effect for the overweight or obese child. It can improve the emotional well-being of the child in concert with weight loss. Primary caregivers need to be encouraged to join in the activities and make exercise a fun part of the day rather than a chore to be accomplished or a punishment for the child's weight. This joint approach, where the child and the caregiver are equally involved, increases the child's self-esteem and sense of control over his or her own weight issues. The end result is to increase the probability of success.

Decreasing television, telephone, and computer time can help decrease the isolation that children who are obese feel, and may in turn decrease the likelihood of depression. The health care provider, along with the caregiver, need to find ways to praise all of the child's efforts toward losing weight.

When more complicated psychopathology is evident, long-term medication and, in some cases, even hospitalization, may be necessary. Family psychotherapy may be another avenue to explore with families, as often it is not just the obesity but a myriad of other problems that contribute to the child's problems.

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Summary 

Concerns related to being overweight or obese can be challenging and complex problems both for the patient and the health care provider. The complications of these problems include a myriad of physical problems and psychological issues that can have long-term and devastating effects on the child and his or her family. It is important for health care providers to address all aspects of the problem when treating the child so as to maximize the potential for a healthy outcome. It is imperative that health care providers fully understand the detrimental impact of obesity on the psychological well-being of the child.

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References 

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 In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.

PII: S1555-4155(10)00065-6

doi:10.1016/j.nurpra.2010.01.024

The Journal for Nurse Practitioners
Volume 6, Issue 4 , Pages 296-299, April 2010

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