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Med J Aust 2000; 173 Suppl 7 August: S10-S11

Psychosocial problems are the most prevalent form of morbidity associated with childhood obesity. While these problems are most evident during adolescence, they are appearing at primary school age and in girls more than boys.⁶²

Perception of obesity
Children in First World countries are rapidly socialised into a rejection of obesity. They perceive fatness as less acceptable than a variety of obvious and limiting physical disabilities. Fat body shapes are most likely to be branded as lazy, less intelligent, socially isolated, and unhealthy.⁶³ This "fat is bad" stereotype is voiced by lean and overweight children alike. However, holding these negative attitudes does not necessarily generalise to children's self-perception in that overweight children rarely describe themselves in such a derogatory way.

Self-worth in obese children
Body shape discontent is evident by the age of nine years. While among children generally, girls have a tendency to prefer slimmer figures, this preference is particularly marked among overweight children. In one study, nearly 80% of overweight and obese children desired a thinner body shape.⁶⁴ Commensurate with this is lower body-esteem in overweight youngsters. However, unlike adolescents, their overall self-esteem shows little difference from that of lean peers.⁶⁵ Looking in detail at perceived self-competence, there is little impact of preadolescent overweight on social, home or school abilities, but there are impairments in athletic competence and physical appearance self-esteem.⁶⁶

The importance of physical appearance increases during early adolescence. From then onwards, evaluation of appearance takes precedence over every feature of self-perception as the primary predictor of self-esteem. This explains the reduction in self-worth evident in many obese adolescents.

Social functioning
Obese preadolescent girls are assessed as being less attractive, but not as being unpopular, by their classmates.⁶⁶ The consequences for obese boys are unclear. Anecdotal reports of peer teasing about overweight are beginning to stimulate research. About one in seven 11-12-year-olds report being victimised for being overweight, although only half of these children would be classified as overweight.

Dieting and weight control
Preadolescent weight concern and desire for thinness are associated with motivation for weight control. Over a third of 7-12-year-old girls have already tried to lose weight, most often by dieting.⁶⁷ Boys more frequently endorse exercise for losing weight. Although dieting is reported by a minority of underweight girls as early as the age of seven or eight, generally the extent of dieting increases with increasing body weight. The particular relevance of overweight for girls by the age of eight years is evident, as girls most aware of dieting are generally heavier and have lower self-esteem.⁶⁸ This association has not been shown in boys.

Evidence is also accumulating that children's reports of dieting are linked to the weight concerns and dieting of their mothers.^69,70 However, although girls appear to model their own concerns on those of their mothers, both parents may be actively involved in controlling their child's eating or encouraging dieting. Further, recent research suggests this behaviour starts in the preschool years, highlighting the importance of examining parental attitudes to their own shape and eating when dealing with children who are overweight.

Disordered eating
The degree to which dieting reports are translated into changes in eating behaviour is uncertain. Some studies fail to reveal any undereating, others find a degree of energy restriction, but with most indicators of nutritional quality still within acceptable levels. The most likely behavioural changes are a tendency to miss meals (especially breakfast) and to choose diet foods (such as diet soft drinks).⁷⁰ By the age of 12, past and current dieting is associated with attempts at fasting. However, the use of other extreme weight control methods, such as laxatives or vomiting, is extremely rare before this age.⁷¹ Full syndrome eating disorders are also rare, as most cases occur after the age of 14. Accordingly, it is difficult to say if there has been an increase in very early onset eating disorders. Weight consciousness, dieting awareness and dieting attempts by girls have increased and are seen at younger ages. Most frequent in heavier girls, these factors can make children vulnerable to disordered eating in adolescence and beyond.

Andrew J Hill

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