C H A P T E R

24
The Emotional Impact of Obesity on Children
Robert E. Cornette
Department of Nursing, Berea College, Berea, Kentucky

INTRODUCTION questions: Do all obese children suffer some emotional

consequence merely from being overweight? What are
“Fatty, Fatty, two by four, can’t fit through the kitchen the immediate and long-term emotional tolls of being
door.” Most of us have heard either this taunt or similar an obese child? Are current treatment modalities effica-
ridicule directed toward a peer in school. Whether you cious in addressing these emotional symptoms? Finally,
were the perpetrator, the victim, or a bystander, you whereas other chapters of this book will investigate
were acutely aware of the profound influence of these possible solutions to prevent childhood obesity, this
attacks. We really never knew why overweight children chapter examines some possible interventions to
were the targets of such harassment. Possibly because prevent or treat the emotional consequences of obesity
they looked different (that may explain why children during childhood.
that were taller, shorter, thinner, etc. were also the targets
of verbal derision), or was it because of the stereotypes
associated with obese people? Stereotypical beliefs that OBESITY AND PSYCHOLOGICAL
obese people are: lazy, weak, dumb, helpless, spoiled, DISORDERS
or just different. After all, when members of the baby-
boomer generation were children during the 1950s and Obesity itself is not a psychological disorder accord-
1960s, overweight children accounted for only about ing to the Diagnostic and Statistical Manual IV (DSM).
4% of the population as compared to about 35% today Some researchers are investigating the possibility of
(12- to 19-year-olds) [1]. moving obesity out of the realm of the medical arena
Certainly, as children we did not consider the conse- and into the science of the psychological. The possibility
quences of the name calling or teasing these young chil- of considering obesity as a mental or behavioral problem
dren suffered beyond the immediate crying or fleeing by has been explored. The moralistic view of obesity (i.e.,
the victim. But what is the emotional toll suffered by people are obese because they choose to eat too much)
these victims, and are the effects only short-lived or does not take into account that appetite is influenced
more enduring? Are the emotional consequences of by genetic and environmental factors that may super-
being an obese child solely the result of taunting by sede conscious control [2]. One researcher concluded
others, or are there other, more intrinsic sequelae that that if eating was controlled solely by homeostatic
manifest during adolescence or as an adult? With the mechanisms we would be at our ideal body weight
declaration that obesity has become an epidemic in the and eating would be a mundane and unexciting activity
United States as well as numerous other countries, like breathing [3]. An association between nonhomeo-
much attention has been given to the physical conse- static eating (i.e., energy consumption in excess of
quences of obesity on children and even the fiscal cost energy expenditure) and factors that contribute to
for taxpayers. But little attention has been focused on compulsive drug use explains research findings that
the emotional, psychological, social, and spiritual effects an addiction to food is similar to an addiction to drugs
of living as an obese child. This chapter focuses on the and alcohol and shares the characteristics of tolerance,
metaphysical consequences of obesity on children and withdrawal, and substance-seeking behavior [4, 5].
adolescents. In addition, we will attempt to answer these Lastly, the behavior of nonhomeostatic eating as a coping

Global Perspectives on Childhood Obesity 257 Copyright Ó 2011 Elsevier Inc. All rights reserved.
258 24. THE EMOTIONAL IMPACT OF OBESITY ON CHILDREN

mechanism in response to internal or external stressors prized as a symbol of status and prosperity. But as early
should be recognized. Although not the result of phys- as 400 BC, Hippocrates, the father of medicine, wrote of
ical influences, overeating as a coping mechanism to the association between obesity, disease, and early death
stressors could be considered as a manifestation of [9]. Early Egyptians were concerned with diet as a means
a psychological dysfunction and, in fact, treatment of maintaining health [8] but utilized extreme measures
approaches that have focused on dialectical behavioral to limit the quantity of food they digested such as
therapy rather than nutritional management have been purging, vomiting, and fasting [10].
promising [6]. Early writings regarding the stigmatization associ-
Clearly, there are some psychological disorders that ated with being obese occurred in medieval Japan.
manifest with compulsive eating (e.g., pica, anorexia Scrolls from the 12th century depict a wealthy woman
nervosa, and bulimia), but one study found that whereas who became obese. It explains that the woman could
binge-eating disorders only affect 2% to 3% of the no longer walk easily, needed assistance with her activ-
general population, they are reported in 25% or more ities of daily living, perspired profusely, and gasped for
of obese people [7]. Nevertheless, obesity remains breath [11]. The culture in Japan at the time saw this
a physical or medical condition that results from nonho- woman’s obesity as a result of her greed and selfishness
meostatic eating. Although the excessive caloric intake [12]. In Europe, even during the culture of voluptuous
may result from metabolic conditions such as Prader- women depicted in the paintings of Rubens and Renoir
Willi syndrome, a genetic disorder characterized by [13], society was being influenced by the Christian ideol-
uncontrolled, compulsive eating, more often it is the ogy that obesity was a characteristic of gluttony, which
result of the individual eating more calories than he or would eventually be categorized in the 5th century as
she expends. Possibly because obesity has been consid- one of the Seven Deadly Sins [14]. Obesity was not
ered a medical rather than a psychological condition, only seen as a moral failure but now it was a transgres-
little attention has been focused on the psychological sion against God [13].
ramifications of living as an obese individual. Often,
healthcare professionals counsel obese patients on
methods to lose weight and educate on the physical THE METAPHYSICAL CONSEQUENCES
consequences of failing to do so. Rarely, this counseling FOR OBESE CHILDREN
includes surveillance of the patient’s emotional state or
assumes that any emotional trauma from being obese For the first time in recent history, children today may
will be alleviated with weight loss. be facing a shorter life span than their parents due, in
large part, to the alarming rise in obesity [15]. Thirty
states have rates of childhood overweight (body mass
THE PSYCHOLOGICAL HISTORY index [BMI] of or greater than 85th percentile for age
OF OBESITY and gender) and obesity (BMI of or greater than 95th
percentile for age and gender) for children age 10 to 17
For most people, the issue of the rapidly rising above 30%, with one state, Mississippi, obtaining
number of overweight and obese children, adolescents, a rate of 44% [16]. Overall, one in three children (10 to
and adults is one that has just recently come into the 17 years old) is overweight or obese [17]. A national
public’s consciousness. Although the current number survey found that obese adolescents had the following
of overweight and obese people is the highest our planet risks:
has seen, it is fair to say that overweight people have
• A 60% higher risk of being diagnosed with anxiety or
existed throughout history. And though the perception
depression
of these overweight individuals may have varied
• A 40% greater risk of having feelings of worthlessness
according to the predominate culture, these views may
• A 40% greater risk of parental concerns about their
shed some insight into the origins of the development
child’s self-esteem
of current labels, stereotypes, or biases regarding the
• A 70% greater risk of being told by a healthcare
overweight and obese.
provider that they have behavioral problems
It may be impossible to determine when the first
• A 30% greater risk of being withdrawn
obese person existed in history, if he or she were a child,
• A 40% greater risk of bullying others [18]
or what emotional consequences that individual experi-
enced as a result. We do know that figurines, called the Given the increase in the rate of obesity in children, it
Venus of Willendorf, date back 30,000 years and depict could be assumed that there would be a reduction in the
an obese woman. It is uncertain if the figurines were stigmatization of obese children; yet negative views of
fertility symbols or erotic tokens [8]. Obesity in early obese children are higher now than that of four decades
history most likely rarely occurred and may have been ago [19]. Nonobese children have stated that they would

III. PSYCHOLOGICAL AND BEHAVIORAL FACTORS

 EMOTIONAL CONSEQUENCES 259
prefer to befriend a child with a physical disability, [30, 31]. Physically aggressive behavior is more common
such as a missing limb or blindness, than an obese child in boys, with girls engaging in more relational aggres-
[20e23]. The consequences for obese children are varied sive behavior such as threatening to withdraw friend-
and can be categorized as teasing and bullying, ship or rumor spreading [32]. Often the verbal teasing/
emotional problems, and school and daily functioning bullying by obese children is in the form of attacks on
problems [24]. These categories will serve as an outline a peer’s ethnic, religious, or sexual characteristics in
to examine the emotional consequences of obesity on order to divert attention from themselves and the focus
children and adolescents. on weight [33].
Evidence indicates that the negative stereotypes asso-
ciated with obesity in childhood appear to decline with
TEASING AND BULLYING age, especially for boys [34]. However, the incidence of
perpetrating bullying behavior by obese children
At the beginning of this chapter, you read a poem appears to increase as these youth move into adoles-
used to taunt overweight and obese children. Although cence [35, 36], possibly as a means of initiating domina-
it may appear silly and inconsequential on initial inspec- tion of their peer group during the time when peer
tion, these words, as well as those similar in nature, are group recognition is most important [33]. The following
capable of inflicting profound and enduring wounds on sections further examine the impacts of weight-based
their victims. Obese children are the victims of teasing victimization (e.g., greater levels of loneliness, sadness,
three times more often than their average weight peers and nervousness [35]; poorer academic performance in
[25]. Evidence is revealing that the consequences of high school and decreased college acceptance [36, 37];
such teasing may impact all areas of the child’s develop- and decreased likelihood of marrying as an adult and
ment, including the child’s psychological, social, lower household incomes than their nonobese counter-
emotional, academic, professional, and spiritual devel- parts [38]).
opment, not only during growth into adulthood but
possibly well into middle age and beyond. One study
found that 98% of obese adults reported being the victim EMOTIONAL CONSEQUENCES
of harassment, criticism, or teasing from family
members and friends. Seventy-five percent reported With the growing public awareness regarding the
that they were criticized or teased at work, whereas epidemic of obesity plaguing our youth, we have been
50% indicated that the criticism or teasing came from exposed to a plethora of information pertaining to the
their supervisor, and 33% reported being called negative physical toll excess weight takes on our health. In
names by a heathcare professional [26]. Children are contrast, far less attention has been focused on the
most frequently teased by unfamiliar children and class- psychological, social, emotional, and spiritual conse-
mates, then familiar classmates and siblings, and even quences of being an obese child or adolescent. As
parents, adults in their lives, and adult strangers [24, a result, little evidence is available regarding the
25]. In a study examining the attitudes of high school nonphysical ramifications of obesity experienced by
teachers on obesity, the teachers indicated their belief children during their childhood and adult lives. It is
that obese teens were unkempt, emotional, less likely fair to argue that the nonphysical consequences of child-
to succeed, and had more family problems. Forty-three hood obesity are as devastating as the physical conse-
percent of the teachers believed that people felt uncom- quences, if not more so, because of their ability to
fortable around obese people, 55% believed that obesity affect numerous aspects of a person’s life.
stemmed from a lack of love or attention, and 28% Although there are a multitude of conditions that can
believed that becoming obese was the worst thing that affect the human psyche, this discussion focuses on the
could happen to a person [27]. consequences of obesity pertaining to self-esteem/
Although the frequency of teasing varies between image, mood (e.g., depression), and anxiety disorders.
boys and girls, girls indicate that the teasing is more Obese children are more likely to suffer from negative
stressful and results in greater incidents of emotional or decreased self-esteem or self-image, increased
problems, such as anxiety and sadness, than that anxiety, sad affect, and symptoms of depression [24].
reported by boys, who exhibit greater behavioral prob- One study found that 42% of obese children met the
lems and fighting [28, 29]. Although many obese chil- DSM-IV criteria for a mood disorder and 40% for an
dren are the victims of teasing and bullying, it should anxiety disorder [39]. There is a direct correlation
be noted that obese children are also the perpetrators between the baseline body mass index (BMI) and lower
of bullying. Bullying behavior can manifest in various self-esteem [40] in adolescents, but the inverse (i.e.,
forms including name calling/teasing, threats, physical lower self-esteem correlated with increased body
harm, social rejection, rumors, or sexual harassment weight) was not noted. Interestingly, whereas girls

III. PSYCHOLOGICAL AND BEHAVIORAL FACTORS

260 24. THE EMOTIONAL IMPACT OF OBESITY ON CHILDREN

who are greatly overweight reported lower self-esteem Body Dissatisfaction

than girls who were not as overweight, the same was
not true with boys [41]. In fact, the overweight boys Body dissatisfaction is higher in overweight and
reported higher self-esteem, possibly because of the obese children and adolescents, especially in obese girls
value placed on weight and strength in sports such as [52]. Similar to depressive symptoms, research has found
American football. The greater dissatisfaction with that weight-related teasing has a negative relationship to
body image and self-esteem in girls may explain why body image in both male and female youths and the
girls are more likely to participate in dieting as a means development of eating disorders in females [53]. The
to improve their self-worth [42]. greater the teasing as a child, the more likely the child
will suffer body dissatisfaction as an adult and, subse-
quently, lower self-esteem [54]. Additional research has
Self-Esteem determined that the weight-related teasing rather than
Even though early studies indicated that there was no the child’s weight was the stronger predictor of body
significant relationship between being obese and low dissatisfaction [53], and when body image was modified
self-esteem in children [43], subsequent studies revealed without weight change, self-esteem improved [55].
interesting correlations between self-esteem and obesity
in children. Obesity has been found to be a determinate
of future low self-esteem in children [35, 40, 44e46] and PROBLEMS WITH SCHOOL AND SOCIAL
obese children whose self-esteem decreased over FUNCTIONING
a period of a few years were at greater risk of engaging
in unhealthy lifestyle behaviors, such as smoking In 1967, researchers first recognized that peers treated
tobacco and alcohol use [35]. It is speculated that the overweight and obese children differently [56]. They
lower self-esteem observed in these children may result found that overweight boys were least likely to be nomi-
from lower self-perceptions of physical appearance and nated as a close friend by their peers. Other studies have
athletic competence [47], poorer body esteem, and found that normal-weight children characterize obese
perceived cognitive capacities [45]. Other contributing peers as mean and they are among the least liked and
factors to lower self-esteem in obese children may least desirable playmates [57]. Since that time, research
come from the child’s internalization of the responsi- has unveiled that overweight and obese youths are
bility for the additional weight. Children, especially more likely to be isolated and spend less time with their
girls, who experienced the perception that they were friends, more likely to report that they felt their friends
being blamed by their parents for their obesity reported did not care about them, less likely to have ever dated,
negative self-perceptions [45], as did children who more dissatisfied with their dating status, and less likely
believed that they were responsible for their condition, to marry as an adult [38, 58e60]. Of normal-weight chil-
rather than external causes beyond their control [48]. dren, only 12% indicated that they ever dated an over-
weight peer (with girls more likely to date an
overweight peer) and they were uncomfortable dating
Depression obese peers [61]. Not only do obese adolescents report
Like self-esteem, the relationship between depression experiencing more social rejection and isolation, but
and obesity in children is tenuous. Whereas some their normal-weight friends may also experience stig-
studies indicate that obese children are more inclined matization as a result of socializing with the obese teens
to suffer depressive symptoms, other studies fail to [62]. As much as 50% of obese boys and 58% of obese
find these results. When weight-related teasing was girls report experiencing significant problems with
examined regarding its influence on depression, a posi- peer relationships [24].
tive relationship was found but raised the question of Obese girls experience more social marginalization in
whether the weight or the teasing contributed to the the form of ostracizing, having rumors or lies spread
depressive condition [49]. Interestingly, research has regarding them, or being given the silent treatment
focused on the inverse relationship by investigating [60, 63]. In all age ranges, girls experience more social
whether children who suffer depressive symptoms are victimization than boys and, interestingly, experience
more likely to become obese in adolescence or adult- more stigmatization by their parents than boys [25, 61,
hood. Although the research in this area is not conclu- 64]. Girls may also experience more social victimization
sive, evidence indicates that children who experience as their social economic status rises [65]. The increased
depressive symptoms are more likely to experience vulnerability obese girls experience to psychosocial
higher weights in their youth or adulthood [50], and victimization may contribute to their decreased
the findings are more characteristic of female rather academic and social competencies [66]. One study found
than male youths [51]. that obese girls in the 7th, 9th, and 11th grades were

III. PSYCHOLOGICAL AND BEHAVIORAL FACTORS

 INTERVENTIONS 261
more likely to have been held back a year in school [69]. but rather interventions should be developed that
One study found that 16-year-old girls in the top 10% of reduce or eliminate the bias against obese individuals
the BMI range earned 7.4% less income when they were that is the source of the marginalizing of these youth.
23 years of age [67]. Overweight girls tend to receive less Research has demonstrated that bias against obesity
financial support for education from their parents, are can develop in children as young as 3 years of age
not as represented at prominent universities as obese [74], suggesting that the foundation of this bias may
men, and are less likely to finish college [68, 69]. come from parents as well as from social and media
For both sexes, researchers have found that obese sources. Research has determined that parents can
children need twice as many learning aids as normal- convey weight bias in subtle forms such as portraying
weight children [70] and consider themselves below- overweight characters in stories in negative manners
average students, with obese boys being more likely to or through their efforts to control their child’s weight
expect themselves to quit school [69]. In addition, they [75]. To the child, these messages communicate that fat
report that they often enjoy fewer sports and athletic is synonymous with undesirable characteristics.
activities, such as running or walking, and activities of Teachers and school officials who perpetrate the stereo-
daily living, such as buying clothes, dancing, or eating types discussed previously, only serve to reinforce these
out with friends [71]. messages. Even healthcare professionals may, in their
zeal to improve children’s health, convey a message
that fat is bad and children should achieve and maintain
SUICIDAL BEHAVIOR a healthy weight. This illustrates that bias and victimiza-
tion of obese youth is a socially sanctioned behavior
Without a doubt, the most disturbing consequence of among children and adults [76]. As a result, interven-
obesity victimization is the development of suicidal tions to address the stigmatization of obese youth will
ideation or behavior. After consideration of the need to challenge the sanctioning of these behaviors.
numerous psychosocial consequences of being an obese One theory states that negative stereotyping behavior
child or adolescent, it is not difficult to conceive that will decrease if the perpetrator of the behavior believes
obese adolescents are more likely to consider suicide as that the obesity is not within the victim’s control [77].
an escape from the torment they experience [59, 71]. Studies conducted to examine this theory found that
Obese girls are 1.7 times more likely to attempt suicide when obese children were identified as being over-
than their normal-weight peers and research has demon- weight because of a medical condition, perpetrators of
strated that BMI and self-perceptions of being over- negative stereotypes were less likely to victimize them
weight, even slightly, were positively associated with but they tended to avoid interacting with the obese child
suicidal ideation in Caucasian, Hispanic, and African [78]. This suggested that the medical explanation may
American girls [72]. Research into the effects of teasing have also served to illustrate the differences between
on obese youths has revealed that obese teens who the two children. Clearly, interventions intending to
were teased about their weight were two to three times explain the cause of obesity are not as effective as inter-
more likely to develop suicidal ideation than obese teens ventions designed to abate the social sanctioning of
who were not teased [49]. More specifically, 51% of girls behavior intended to marginalize an obese person. Inter-
and 13% of boys who were teased about their weight ventions to decrease the social sanctioning of negative
reported suicidal ideation compared to 25% and 4%, stereotyping should include the following:
respectively, of those who were not teased [25]. These
numbers speak to the need to focus on the quality of • Targeting parents by increasing their awareness of the
life experienced by obese children. Although it may intentional and unintentional messages they may
not be surprising than obese children report a lower convey to their children
quality of life than their normal-weight peers, it may • Challenging the negative beliefs teachers may have
be alarming that obese children report a quality of life toward obese children while increasing their
similar to children suffering from cancer [73]. awareness of the impact negative biases have on
children
• Instituting antiweight teasing rules in school to
prevent portraying obese people in a negative manner
INTERVENTIONS
in students’ lessons and to begin portraying them in
a more positive manner
After considering the significant psychosocial and
• Targeting societal beliefs that fat is bad and changing
emotional impact associated with the stigmatization of
media messages that promote weight bias [79]
obese children and adolescents, we can appreciate the
need for interventions to address this issue. Interven- In addition, interventions should be developed to
tions should not just focus on the reduction of weight, help obese youth develop effective coping mechanisms

III. PSYCHOLOGICAL AND BEHAVIORAL FACTORS

262 24. THE EMOTIONAL IMPACT OF OBESITY ON CHILDREN

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