Definition and epidemiology
Childhood overweight and obesity constitute a major public epidemic
affecting up to 32% of youth 6-17 years old in the United States, with even
higher incidence in certain ethnic minorities and families with lower
socioeconomic resources.[1] In children and adolescents, obesity is frequently
diagnosed by calculating body mass index (BMI = weight in kg/height in m2) and
plotting the score on a gender and age specific growth chart. Youth with BMI
scores between the 85th and 95th percentiles for gender and age are considered
overweight, whereas youth with BMI scores at or above the 95th percentile are
considered obese.[2]
Overweight or
obese youth are at increased risk for a multitude of medical comorbidities
affecting almost every major body system. Certain psychiatric and psychological disorders
are also more common in overweight or obese youth (see Table
1).[3]
Recent expert committee guidelines for the prevention, evaluation, and
treatment of child and adolescent overweight and obesity recommend screening for
specific psychiatric concerns and intervening at the family level with a focus
on behavioral changes.[2] Thus, familiarity with common emotional and behavioral
risk factors and presentations in overweight and obese youth is essential to
provide a comprehensive evaluation and treatment plan.
Depression and anxiety
Children and adolescents who are overweight or obese have increased rates
of depression and depressive symptoms. Research suggests that the association
between excess weight and depressive symptoms may be bi-directional, where the
presence of one condition may increase the risk for the other condition.
Furthermore, the presence of depression will likely impede clinical efforts to
promote healthier eating and physical activity in patients.
Symptoms of depression in overweight youth may include negative affect or
irritability. Other symptoms include anhedonia, or decreased interest in
previously enjoyable activities, significant increases or decreases in sleep, a
decline in school performance, psychomotor retardation, less engagement with
peers, or rapid weight gain in the absence of other medical causes. These
symptoms can leave youth trapped in a cycle that only perpetuates increased
weight gain and negative affect. Symptoms of depression can be assessed through
clinical interview or the use of brief self-report screening instruments such as
the Children's Depression Inventory (CDI).[4]
Overweight or obese youth may also experience anxiety. Symptoms of
anxiety may present around eating, physical activity, or in social settings.
Anxiety around food consumption should serve as a red flag to assess eating
behaviors in more depth.
Concerns about body size or past experiences of teasing may lead to
avoidance of social activities. Avoidance may be overt and clear (eg, "I don't
want to go!") or more subtle. Somatic complaints such as headache and
stomachache at the time of the anxiety-inducing activities can be common in
anxious youth. Symptoms of panic or anxiety may include racing heart rate,
sweaty palms, and concerns for health. Organic causes for physical symptoms
should always be assessed in conjunction with evaluation of triggering events,
common settings or timing of symptoms, and consequences of the complaints.
Symptoms of anxiety can be assessed through clinical interview or the use of
brief self-report screening instruments such as the Screen for Child Anxiety
Related Emotional Disorders (SCARED).[5]
Eating-disordered behaviors
Eating-disordered behaviors are also more common in overweight youth.
Binge eating has been reported at increased rates and adolescents appear to be
particularly vulnerable. Binge eating is characterized by eating more food in a
distinct period of time than most people would eat in the same time frame and
environment and a feeling of lack of control over eating during the
experience.[6] Binge eating may or may not be accompanied with inappropriate
compensatory activities such as purging. The use of laxatives, diuretics, "crash
dieting," or excessive exercise should also be assessed.
Other common eating-disordered behaviors may include eating in secret,
feeling that it is difficult to stop eating certain foods, or skipping meals.
Use of over-the-counter diet supplements should be carefully monitored to
prevent inappropriate use or abuse. Binge eating and other disordered eating
patterns are important to assess because they may directly contribute to
overweight and addressing these behaviors will directly affect weight management
goals. Any of these behaviors could serve as red flags to clinicians to assess
further or refer the patient to a nutritionist and mental health specialist for
evaluation and treatment. The Children's Eating Attitudes Test (ChEAT) is a
brief patient-report questionnaire that could assist in screening.[7]
Poor self-esteem and body dissatisfaction
Self-esteem and body dissatisfaction (or poor body image) may be lower in
overweight or obese youth. Self-esteem refers to an overall perception of
self-worth, whereas body dissatisfaction refers to negative perceptions about
physical appearance. Self-esteem is an important construct to consider in
children because low self-esteem has been linked with behavioral disorders and
emotional concerns, whereas improvements in self-esteem have been linked with
improvements in other behavioral problems. Furthermore, self-esteem rates in
adolescence may persist throughout adulthood.
The data on rates of self-esteem for overweight or obese youth is mixed,
but certain factors appear to increase the risk for lower rates. Body
dissatisfaction appears to be a major component of self-esteem, particularly for
adolescents, females, and youth who place a higher value on identification with
cultural standards for beauty and slimness. Individuals who are teased about
their weight are also more likely to have lower rates of self-esteem. Signs of
poor self-esteem or body dissatisfaction may include lack of confidence, shame
about body shape or size, or desire to keep the body hidden or covered at all
times (eg, difficulty with changing clothes in gym class). Self-esteem and body
dissatisfaction can be assessed by asking open-ended nonjudgmental questions
about a child's or adolescent's perceptions of self (eg, "How do you feel about
yourself?" or "Do you wish that you or your body were different?").
Participation in activities of interest to the child that allows him or her to
feel a sense of confidence or success may help improve self-esteem. Clinical
intervention efforts should focus on healthier eating and physical activity
behaviors, not weight, to promote a sense of body health, not body
size.
Peer victimization
Despite the increasing prevalence of obesity, negative stigma towards
obesity has not normalized, but intensified. Although a mild degree of teasing
may be normative for all children, overweight or obese youth are more likely to
be teased by their peers, experience more severe forms of teasing, and may be
vulnerable to the negative experiences. Experiences of peer victimization may
also increase the likelihood of a child becoming socially isolative or anxious
in social settings. Signs that a child is being victimized by peers may include
a sudden lack of interest in school, a preference for isolative activities, or
attempts to avoid peer activities. At-risk children and adolescents may have
difficulty making or sustaining friendships or have unrealistic beliefs that
weight loss alone will improve peer relationships.
One way to assess the rate and intensity of teasing of patients is to
query children and/or parents whether they think the child is teased more often
than other same aged children. Parents can discuss any concerns with a teacher
or other school personnel who are familiar with their child and the school
social environment. Although individual interventions on behalf of a specific
student can be beneficial, parents should be encouraged to speak with school
personnel about classroom or school-wide policies to decrease bullying. This
will prevent the child from feeling targeted or singled out, which may lead him
or her to be less likely to report future negative experiences.
Family functioning
Less than 10% of all current cases of youth obesity are thought to be
caused by medical or genetic conditions alone. The combination of
genetic-environmental or environmental influences on child weight and health are
significant and many parents of overweight or obese children may also be
overweight. Youth and young children in particular may have little control over
food purchasing decisions or physical activity opportunities. Therefore,
successful interventions to promote healthier lifestyles will require a
family-based approach. Family members may be successful at choosing small
meaningful goals for behavior (eg, have 1 additional fruit or vegetable each
day, be active for 30 minutes for 2 days next week). However, not all family
members may be at the same level for desire to change current behaviors and
habits.
The concept of motivation to change, or readiness to change, is a popular
term to describe the assessment and attempts to tailor interventions based on an
individual's willingness to make changes in a specific behavior. The concept is
straightforward, but putting it into clinical practice with children and parents
can be challenging, particularly if family members differ in their desire to
make changes. Often a parent is ready to make changes, but a child may be less
motivated. This may be reflective of an overall pattern of parent difficulty
with child behavior management or an isolated problem. General suggestions on
behavior management or referral to a mental health specialist may be helpful if
parents report difficulty implementing changes in child behavior.
If both the parent and child are not yet ready to make changes, health
education and motivational interviewing approaches may be more beneficial until
the family is ready to commit to a more intensive treatment plan. Numerous
studies have shown that many parents of overweight children do not recognize
that their child is overweight. At this stage, sensitive and nonjudgmental
education about the child's weight risk may be sufficient until the family
recognizes the risk. In general, clinical discussions of weight and behavior
change should be patient-centered and participatory (vs. prescriptive).
Nondirective questions (eg, "What concerns, if any, do you have about your
child's weight?") may be less threatening to parents. Reflective listening and a
respect for the family's values and current health practices are imperative.
Both the parent and child should be engaged in the discussion of selecting
target behaviors, and a specific plan with confidence ratings should be
established (eg, "On a scale of 0-10, with 10 being the highest, how confident
are you that you can eat 2 vegetables every day?"). For a sample 15-minute
obesity prevention protocol based on these approaches, please refer to the
recent American Academy of Pediatrics (AAP)
recommendations for treatment.[2]
Mental health referral
Careful screening and assessment of comorbidities at the primary care
level will be essential to provide comprehensive treatment to obese youth and
their families. As with the need for specialist referrals for medical
comorbidities, a referral to a mental health specialist may be necessary. The
purpose of the referral is to provide the primary care practitioner with
important information on diagnosis, risk, and treatment recommendations. A
referral should be made anytime psychiatric or psychological concerns are
impeding overall functioning (familial, academic, peer). Furthermore, an
untreated psychiatric disorder or poor psychological functioning is likely to
impede success in weight management.
References
[1.] Ogden CL, Carroll MD, Flegal KM. High body mass index for age among
US children and adolescents, 2003-2006. JAMA 2008;299:2401-2405.
[2.] Barlow SE, et al. Expert committee recommendations regarding the
prevention, assessment, and treatment of child and adolescent overweight and
obesity: Summary report. Pediatrics 2007;120:S164-S192.
[3.] Lowry KW. Obesity. In: Dulcan M, ed. Textbook of Child and
Adolescent Psychiatry. In press.
[4.] Kovacs M. The Children's Depression Inventory (CDI). Psychopharmacol
Bull 1985;21:995-998.
[5.] Birmaher B, et al. The Screen for Child Anxiety Related Emotional
Disorders (SCARED): Scale construction and psychometric characteristics. Journal
of Amer
Academy of Child &
Adolescent Psychiatry 1997;36:545-553.
[6.] American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association;
2000.
[7.] Smolak L, Levine MP. Psychometric properties of the children's
eating attitudes test. Int J Eat Disord 1994;16:275-282. | 
