Psychological issues in pediatric obesity.

Pediatric obesity is a major health problem and has reached epidemiological proportions today. The present paper reviews major psychological issues in pediatric obesity from a developmental perspective. Research and literature has shown that a number of developmental, family, maternal and child factors are responsible in the genesis of pediatric obesity. Family food habits, early developmental lifestyle of the child, parenting, early family relationships and harmony all contribute towards the growth and development of a child. The present review focuses on the role of developmental psychological factors in the pathogenesis of pediatric obesity and highlights the developmental factors that must be kept in mind when evaluating a case of pediatric obesity.

Obesity, an important health problem, has definitely increased in prevalence in the past few decades throughout the world, more so in the developed countries. And as the developing countries increasingly adapt to the Western lifestyle and food habits, the problem of obesity seems to be turning into epidemic proportions in these nations too, involving the extremes of ages as much as the middle age populace. More and more children and adolescents with obesity are being detected today worldwide.[1] Obese persons accumulate so much body fat that it might have a negative effect on their health, not only physical like cardiovascular disease and Type 2 diabetes, but also mental health.[2]

It has been noted across various reviews that measurement of adult obesity is easier than measurement of pediatric obesity.[3] As per the World Health Organization (WHO), measuring overweight and obesity in children aged 5 to 14 is difficult since there is no standard definition of childhood obesity applied worldwide. The use of the same body-mass index (BMI) cutoff centiles passing through the adult BMI cutoff of 30, has been suggested as reasonable,[45] although there is still a debate regarding the cutoff limits of BMI to define overweight and obesity in children.[6] Studies on pediatric obesity vary as per the definition of the condition and BMI cutoffs.[5]

CHILDHOOD OBESITY: SCOPE OF THE PROBLEM

Prevalence of childhood obesity is rising around the world.[78] Once considered a problem of affluent countries, it is now becoming a common problem even in the developing countries.[9-11] More than 1.1 billion adults and 10% children are classified as overweight or obese.[12] WHO figures are somewhat similar and estimate at least 20 million children under the age of five years as overweight.[3] Childhood obesity is now being rightly referred to as a global epidemic[10] and WHO estimates that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million children and adolescents will be obese. The global prevalence of childhood obesity varies from 30% in the US to less than 2% in sub-Saharan Africa. The prevalence of overweight and/or obesity in school children is 20% in the UK and Australia, 16.2% in Brazil, 15.8% in Saudi Arabia, 15.6% in Thailand, 10% in Japan and 7.8-10.9% in Iran.[13-15] The prevalence of childhood obesity was found to be much less in the two Indian cities of Delhi and Chennai (6.2% and 7.4% respectively).[1617] With rising prevalence, we need to focus on the holistic management of pediatric obesity without neglecting developmental factors and psychological issues that may play a crucial role in its pathogenesis. Children in developing nations presently suffer from a double jeopardy of malnutrition; urban children are afflicted with over-nutrition while the rural and slum children suffer from effects of under-nutrition.[18] Childhood obesity is associated with a higher chance of premature death and disability in adulthood[1920] with 50–80% of these obese children growing up to become obese adults.[21-24] The vicious cycle of obesity thus starts in childhood, when the child starts gaining weight due to less physical activity and intake of more junk food.[25]

METHOD OF CONDUCTING THE CURRENT REVIEW

For identifying articles that focused on pediatric obesity and its developmental factors, the terms ‘pediatric obesity’, ‘developmental factors’, ‘childhood factors in pediatric obesity’, ‘family factors in pediatric obesity’, and ‘psychological issues in pediatric obesity’ were used. For identifying articles that focused on specific terms, ‘diet’, ‘family functioning’, ‘depression’, ‘eating habits’, ‘parental factors’, ‘junk food’, ‘genetic factors’, and other terms were used. These two search strategy results were combined with an “and” statement in the following databases with the timeframe being specified from 1995 through 2011. The databases used were Medline, Pubmed and the Cochrane Database on Systematic Reviews. In total, 229 articles were identified which included reviews, mini reviews and randomized controlled trials in populations with pediatric obesity.

We included trials and quantitative studies with sample sizes of more than 40 participants and that reported either mean scores or percentages with appropriate statistical analysis. All authors reviewed all the review articles and trials and the most relevant ones were chosen for this review. The papers reviewed in this article include those on pediatric obesity interspersed with knowledge based on clinical practice by all the authors in this field. All the authors are psychiatrists working in a tertiary hospital and medical college where there is a consultation liaison between the pediatrics and psychiatry departments on a regular basis.

DEVELOPMENTAL PSYCHOLOGICAL FACTORS RELATED TO EATING HABITS AND FOOD ENVIRONMENT

A large number of studies have shown that the early food environment of obese children differs markedly from that of other children.[26] Children who are obese often consume a greater quantity of food and the quality of food is often high in caloric content. They often have elevated food portion sizes, increased fat intake and eat fewer fruits and vegetables from an early age compared to normal weight children of the same age.[27] Obese children also have less hours of physical activity and spend a greater amount of time watching television or playing video games. In the modern era, easy availability of private cars and elevators has contributed equally. This sedentary lifestyle in tune with high caloric intake often contributes to obesity.[28] It is well known that a large number of children with pediatric obesity have parents who are obese too. Obese parents contribute to specific food environments being created from an early age. There is an exposure to high-fat foods from an early age with an orienting towards fatty food from the toddler years. Shopping patterns with high caloric food that is often stocked up at home serves as easy access to these food stuffs and weight gain ensues.[2930] Certain studies have also mentioned the continuous use of air conditioning from birth and eating habits as determinants of pediatric obesity.[31]

Food orientation is determined in some ways when food serves a reward for desired behavior. This is often done by parents in their behavioral training of the child from his toddler years who seems to derive pleasure from food. There is thus a greater desire for food and eating is looked forward to.[32] There is a marked discrepancy between energy expenditure and energy intake in children with pediatric obesity. Obese children engage in repeated high caloric snacking and bingeing throughout the day with little or no physical activity.[33] Obese children have a preference for high-fat sweet foods like cakes, ice cream, soft drinks and biscuits. Food is often a source of comfort rather than a mere source of nutrition. Many of them lie or cheat regarding food and may hoard food in their rooms which they snack upon from time to time.[34] Obese children are known to eat more in the evening (after 6 pm) and eat less in the morning. This also depends on the social dietary habits of the family. Obese children also eat more at night, have heavier dinners than breakfasts and eat out more often than their non-obese peers.[35] Such children are known to eat more in groups than alone and they gulp down their food taking fewer bites per morsel than their non-obese peers.[36] It is well known that eating in groups leads to eating more than what one normally would. Families who eat out more often are known to have more children who are obese. Excess soda and soft drink consumption from an early age has also been linked to pediatric obesity. Increased number of family members has been identified as a risk factor for pediatric obesity though no direct theory has been proposed.[37] There has been an association between night eating syndrome and adult obesity. Night eating is a common phenomenon in pediatric obese children but there is a dearth of studies supporting an association.[38]

DEVELOPMENTAL FACTORS AFFECTING BODY IMAGE DISCONTENT AND SELF-ESTEEM IN PEDIATRIC OBESITY

Body shape discontent has been noted in the pediatric obese population. Many children with pediatric obesity are unhappy with their body shape and feel they are not good-looking. This often starts early in their life when they often face ridicule from parents and family members for their body size and shape.[39] There is marked low self-esteem and self-worth noted in children with pediatric obesity. Overweight parents have a preference for thinner babies and often ridicule their own children if obese, causing greater damage to their child's self-esteem.[40] An obese child is often victimized at school and subjected to bullying and calling of nicknames by his peers. The child is often made fun of with respect to his body size and fatness. In some instances, even teachers may call these children certain names in the classroom. This is a phenomenon noted across both young children and adolescents.[41] Apart from being the victim, the obese child may be the bully too. He may at times bully others due to his size and very often the bullying is a result of wanting to feel superior and powerful over others while trying to overcome feelings of inferiority that lie within owing to his own obesity and body image discontent. Bullying in this manner often starts at kindergarten and continues thereafter.[42]

DEVELOPMENTAL FAMILY ISSUES IN PEDIATRIC OBESITY

A large number of developmental family factors have been studied as mediators of pediatric obesity. From an early age, parents of children with pediatric obesity may fail to understand their baby's cues and every signal from the baby is treated as a want of food. Thus the baby gets tuned to the fact that food is a source of comfort and this serves as the only source of satiation for him or her.[43] Obese parents are more rigid about food habits and may often criticize their own child if he puts on weight. They are also more rigid about discipline and stringent about food allocation to the child. The child may in turn get defiant right in early childhood and eat when the parents are away or eat from places outside the home contributing further to their own weight gain.[44] It is well known that parents of obese children directly criticize the child with respect to his weight and there is a differential handling of children in the family.[45] Studies have demonstrated that obese children belong to families that are less cohesive. There is a weak marital alliance in such families with existing interpersonal parental stressors. Overprotective mothers and weak, timid fathers is a pattern that has been noted in families of children with pediatric obesity.[46] In some cases, absence of one parent (due to being away on work or due to death) may lead to overprotection and pampering by the other parent which in turn along with food leniency may be causative for pediatric obesity.[47]

DEVELOPMENTAL PSYCHOLOGICAL PROBLEMS IN PEDIATRIC OBESITY

It is well known that children with obesity face an enormous amount of psychological stress. Anxiety as a symptom as well as disorder has been reported in this population.[48] Many of these children are over-protected and pampered leading to a separation anxiety from their parents whenever a stressful situation may arise. They also harbor an anxiety related to their weight and food habits. They may be fussy over food while checking their weight many times a day once anxiety regarding further weight gain creeps in. They are anxious even when they think of overeating or under-eating. Many of them resort to crash dieting only to end up eating more.[49]

Children with obesity suffer from depression too. They often may not present with a depressed mood or frank depressive symptoms but with somatic and bodily symptoms which often confounds the diagnosis. Depression may also manifest in the form of aggressive behavior, anger, conduct problems, bullying (where the obese child is a bully rather than a victim) and oppositional defiant symptoms.[5051]

Many of them have sub-threshold depression where they may not match the clinical criteria for depression but may still have isolated or few symptoms of depression.[52] Depression in these children is associated with guilt regarding weight gain and food consumption. Low self-esteem and poor self-worth may be another factor. Often being bullied and being ridiculed by parents and family members, serves both as a causative and aggravating factor for depression in this population. This may be coupled with loneliness and body image discontent.[53] Fatigue may often be a presenting symptom of depression in many children coupled with poor academic performance. In fact it may be the masquerading symptom of the vegetative signs of major depression in these children.[54] Suicidal ideations and suicidal attempts have been noted in this population in a frequency slightly greater than the general population, but it is still an area that needs intervention.[55] To conclude, one must note that depression and anxiety serve as both a cause and a consequence of pediatric obesity.

It is worthwhile to mention that subtle cognitive impairments have been noted in pediatric obesity. These children score lower than normal controls on various performance tests and also generate IQ scores 3-10 points lower than the normal population for their age.[56] Certain neuroimaging studies in pediatric obesity have demonstrated white matter lesions in these children at an early age mimicking certain findings seen in Alzheimer's and vascular dementia. This is an area that needs to be further researched and the findings need validation.[57]

While many psychological problems besiege pediatric obesity, it may also be an accompaniment to many psychosomatic illnesses. Pediatric obesity is known to be found in a greater proportion in children with bronchial asthma where steroid inhaler use may be a contributing factor. Pediatric obesity is not a risk factor for childhood-onset asthma but many children who suffer from asthma have pediatric obesity.[58] Sleep problems are well known in pediatric obesity. Such children have shorter sleep duration than normal peers and also suffer in greater frequency from obstructive sleep apnea. This may be a contributory factor to the cognitive impairment noted in this group. Reduced sleep may alter hormones ghrelin and leptin that may in turn increase the risk of weight gain.[5960] Lack of breast feeding by the mother, irrespective of causes, has been demonstrated to be another risk factor for pediatric obesity. The associations between the two as well as the cause and effect relationship are not yet clear.[61] Infections in early life, with consequent steroid use in infancy and toddlerhood are known to trigger endocrine or metabolic pathways that may lead to pediatric obesity at a later stage.[62] Pediatric obesity may be seen in a number of endocrine conditions and mental retardation, discussion of which are beyond the scope of this review.[63] Thus psychological factors that affect the obese child early may lead to various long-term sequelae.

LONG-TERM DEVELOPMENTAL PSYCHOLOGICAL CONSEQUENCES OF PEDIATRIC OBESITY

Overweight and obesity go hand in hand with an increased health risk, both physical and mental. As early as 1940, authors began to show interest and discuss the psychological functioning of obese children and adolescents and their long-term effects.[64] Obesity in children in particular may have negative social and economic consequences[65] owing to the young age and particular sensitivity of the child, since identity formation, body image and self-esteem are major issues in this age group. There are more chances of overweight individuals being often negatively stereotyped.[6667]

Overweight children and adolescents are at a greater risk of being bullied and teased about their weight by school friends and even family members than average weight adolescents. This is a process that may start in early childhood and continue through school years into the late teenage years.[68] Weight-related teasing may lead to various deleterious consequences in the long run[69] and psychological comorbidity like depressive symptoms and suicidal ideation. In some cases depression may have multiple relapses and remissions and run a prolonged longitudinal course with suicidal attempts interspersed between episodes.[70]

Overweight children are at a higher risk of low self-esteem and poor emotional wellbeing,[7172] poorer social skills and social difficulties[7374] depression,[5051] anxiety[74] and disordered eating behaviors.[75] These psychological comorbidities coupled with unhealthy weight control and disordered eating behaviors may be early warning signs of more severe eating disturbances later on in life. There is also a possibility that morbidly obese children may be less anxious and depressed, for the simple reason that they have been obese for a long time or because they have become fatalistic regarding the large amount of weight that they have to lose.[73]

These overweight children and adolescents with comorbid psychiatric problems and issues with socialization and self-esteem form a special at-risk sub-group within the obese adolescent population and thus need special interventions.

THE IMPACT OF URBANIZATION AND INDUSTRIALIZATION ON CHILDHOOD OBESITY

With changing times, there have been changes in patterns of food consumption, dietary practices and eating. It is well known that obesity in adults has been linked to urbanization and the sedentary lifestyle that comes with it.[76] There are pathways wherein industrialization has contributed to childhood obesity in its own way. This could in a way be attributed to the increasing industrialization and economic changes that are taking place, somehow leading to a more sedentary working lifestyle and massive changes in our food systems, a macro process often called the nutrition transition. Nutrition transition also refers to the substantive shifts that have been seen in recent times in diets of people across different countries and has been hypothesized to accompany the closely linked processes of urbanization, modernization, industrialization and globalization. This transition encompasses a gradual shift of foods to more processed ones that are laden with sugars and saturated fats and is accompanied by simultaneous transitions in lifestyles that promote sedentism.[77] This calls for an in-depth exploration of factors in such obesogenic environments that may contribute to these variations in nutritional parameters. This term ‘obesogenic environment’ was coined to argue that the physical, economic, social and cultural environments of the industrialized nations encouraged positive energy balance in their populations.[78]

MANAGEMENT OF DEVELOPMENTAL PSYCHOLOGICAL ISSUES IN PEDIATRIC OBESITY

While it cannot be underestimated that one should strive to decrease the prevalence of obesity, it is equally necessary to promote the psychosocial and physical wellbeing of overweight individuals and ensure that they are not being ill-treated for being overweight. It is harder to treat obesity in adults than in children.[79] Effective prevention and management of childhood obesity is easier and may result in effective prevention of adult obesity.

There is a possibility that overweight children and youth are somewhat less likely to engage in health-promoting behaviors.[80] Evidence also shows that treatment compliance is poor in obese children and adolescents with comorbid psychiatric disorders. Interventions with healthcare providers, parents, school personnel, and policy can contribute to the prevention of teasing and its associated weight-related attitudes and behaviors.[8182] Promotion of efforts to reduce excess caloric intake with efforts to increase energy expenditure should receive paramount attention in the design of health programs. It is important to promote the development of culturally appropriate intervention strategies that are shown to be effective among youth of diverse backgrounds.[83]

There are many parallels between obesity and addictive behavior. Because of common neurobiological pathways in the brain, addiction and obesity have shared certain methods of research and treatment. Motivational enhancement and cognitive-behavior therapeutic strategies used in addiction treatments are equally useful in the treatment of pediatric obesity.[84] Cognitive-behavioral therapy combined with family-based intervention proves most effective, especially for children who are morbidly obese and have life-threatening medical conditions. The program involves a series of treatment modules: (1) starting treatment: preadmission phase; (2) establishing and maintaining weight loss; (3) encouraging acceptance, addressing realistic expectations to body weight, and addressing body image concerns; and (4) long-term weight maintenance. The program must include family intervention and physical activity intervention. The treatment team must be multidisciplinary and must involve a pediatrician, psychiatrist, counseling psychologist, family therapist and physiotherapist. Some programs involve use of a pediatric social worker who visits the home of the concerned child and monitors the interventions and family environment during the treatment program.[85]

There have been significant increases in the use of second-generation antipsychotics (SGAs) for adolescents from 1996 to 2010.[86] Newer antipsychotics are associated with rapid weight gain and with other adverse effects, such as dyslipidemia. Clozapine and olanzapine produce the greatest weight gain, ziprasidone and aripiprazole produce less weight gain, and quetiapine and risperidone cause intermediate effects. Appetite stimulation is probably a key cause of weight gain, but genetic polymorphisms can modify the weight response during treatment with SGAs. Nizatidine, amantadine, reboxetine, topiramate, sibutramine, and metformin have been used in preventing or reversing SGA weight gain with some success, but side-effects exist for these agents as well. Metformin has been the most studied.[87] Few agents are approved for obesity, and there have been many safety concerns. Rimonabant (Acomplia), which blocks the endocannabinoid system, showed promise, but it was not approved by the US Food and Drug Administration (FDA) because suicidal ideation was identified during clinical trials.[88] The combination of fenfluramine and phentermine produced primary pulmonary hypertension and harmed many patients, and it serves as a warning to put safety first in the treatment of obesity.[89] Sibutramine acts on the brain to inhibit deactivation of norepinephrine, serotonin, and dopamine, and it decreases appetite. Orlistat blocks fat absorption by reversibly inhibiting pancreatic lipase.[88]

Although there are risks associated with obesity surgery, there is some evidence to show that laparoscopic gastric banding and other bariatric surgical approaches may be useful in the management of pediatric obesity in older children. Studies have shown long-lasting efficacy of 5-8 years’ weight maintenance with such procedures though further studies in the adolescent population are still warranted.[90] It is prudent that psychological support and counseling plays a huge role in the long-term management of weight gain after such surgeries.[91]

Interventions at the school and community level that promote awareness and education about healthy eating habits, lifestyle patterns and regular exercise are essential to prevent obesity in children.[9293] Stringent advertisement guidelines and media intervention that prevent false propaganda of unhealthy foods by celebrities that children adore is another step in this regard.[94] Thus interventions at a biopsychosocial level using a multidisciplinary team approach forms the cornerstone in the effective management of pediatric obesity.