Review
Psychosocial characteristics of obese children/youngsters and their families: implications for preventive and curative interventions

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Abstract

A profile will be given of the psychosocial characteristics of obese children and youngsters, as well as those of their families. Then several attempts of (particularly) preventive interventions will be sketched. Differences found between clinical and non-clinical groups of obese children and youngsters do not permit generalized statements regarding specific psychosocial characteristics. Just as little as there exist a simple and unequivocal image of family functioning with these children. There are great differences between the psychological assumptions and the biological concepts about obesity. Whereas, biological concepts are relevant for the whole obese population, psychosocial characteristics seems to hold mainly for the clinical group of obese persons. The gap between clinical versus non-clinical as well as curative versus preventive approaches will be explained. There are remarkable differences between curative versus preventive intervention goals in terms of the extent to which they focus on life style habits or psychosocial (dys)functioning. Where prevention strategies focus more on enhancing physical activities, curative interventions focus more on changing eating behavior patterns and (depending on chronicity and seriousness of obesity) modifying psychosocial dysfunctioning.

Introduction

Obesity is a physical phenomenon, characterized by an excess of stored body fat. It is therefore, customary to adhere to physical criteria. Obesity is defined as a chronic physical illness by the World Health Organization (WHO). However, most obese adult patients often find it difficult to accept their overweight as an illness. Nevertheless, many obese persons suffer from psychosocial problems, including self-depreciation, low self-esteem, and loneliness. In fact, just their social stigmatization as ‘voracious persons’ leads easily to isolation and loneliness. As such many chronic obese patients appear to seek paradoxically comfort in excessive eating, which may lead to a permanently unhealthy lifestyle (eating too much and exercising to little). So, the circle has been closed: concern, shame and guilt related to low self-esteem in many obese persons is finally related to excessive overeating.

Recently, Seidell [1] has sounded the alarm concerning the worldwide epidemic growth in obesity. The prevalence of obesity body mass index (BMI > 30) amounts to 5–10% among adults. In most countries the prevalence of overweight (BMI > 25) is about two or three times as large. Even though comparison of prevalence data in children and adolescents around the world is difficult (lack of standardization), prevalence of childhood obesity has been steadily increasing too over the past several decades. Using a conservative estimate of overweight (>95th percentile), data from the 1976–1980 National Health and Nutrition Examination still showed prevalences, of around 7.6% in children (aged 6–11 years) and 5.7% in adolescents (aged 12–17 years); a decade later these percentages have increased to14% in children and 12% in adolescents, respectively [2]. In The Netherlands, a similar growth in prevalence has been observed: in children between 5 and 16 years of age, the estimated prevalence of overweight (BMI > 97th percentile) was 14 % (in 1994/1995), whereas, 8% was found 4 years earlier [3]. These increases in the prevalence of obesity among children and adolescents demonstrate the need of universal as well as selective preventive interventions (Section 4). Childhood obesity is a strong predictor for adulthood obesity. Targeting high-risk individuals and high-risk periods of life should be encouraged [4]. Because, obesity is not readily amenable to treatment, especially with adults, prevention should be give high priority in public health [1], [5].

Psychological–theoretical approaches have primarily been tested in clinical/empirical research with obese adults [3]. Since, overweight and excess of body fat can be detected from a very early age, professional attention should be more directed to children. Various psychological theories, such as ‘emotional eating’, ‘externally-oriented eating’, and ‘restrained eating’ offer some explanation for the resistance to change of unhealthy eating habits and lifestyle [3], [6]. However, these theories fall short of a satisfactory explanation of the causality of these phenomena. Unhealthy eating habits, insufficient exercise, and a generally unhealthy lifestyle, mostly present already at an early age, are particularly fatal for individuals with a (physical) predisposition for obesity. An extremely economical ‘engine’ (their remarkably low energy expenditure) physically handicaps them, and this is doubly complicated by extremely excessive energy consumption. In short: a combination of nature and nurture is at work.

Against this background, we will first sketch a profile of the psychosocial characteristics of obese children and youngsters, as well as those of their families, based on empirical studies. Secondly, we will sketch several attempts of particularly the preventive intervention programs. Finally, we will discuss the implications that (possible) psychosocial maladjustment or family dysfunctioning may have for curative and preventive interventions that focus on lifestyle habits and/or psychosocial functioning.

Section snippets

Psychosocial characteristics of obese children and youngsters

First of all, research into personal characteristics of obese children has been focused on their self-concept, in particular their body- and self-esteem. Various studies found lower self-esteem among 6–18-year-old obese children, compared with their non-obese counterparts [7], [8], [9], [10], [11]. Other (more dated) studies, however, did not find convincing differences [12], [13], [14]. French et al. [15] reported in their review that only 13 of the 25 cross-sectional studies analyzed showed

Family characteristics in relation to obese children and youngsters

Bruch's theoretical assumptions [35] have played a central role in research into family characteristics of obese youngsters. Her conceptualization of developmental obesity is distinct from other (psychosomatic) approaches in that a determining role is assigned to the mother. In her view, the predominant and exclusive gesture of comfort and protection of these mothers, in response to the child's signals of discomfort, should be provision of food. For that reason, obese children do not have

Preventive intervention programs

Once established, obesity is difficult to treat, especially when the obese state has become chronic. As a consequence, prevention is not only appealing, but also necessary. However, remarkably little work has been done on obesity prevention in general, and on prevention of childhood obesity in particular. Preventive interventions have traditionally been classified as primary, secondary, or tertiary. When applied to obesity, this typology implies distinctions between attempts to reduce [1] the

Discussion and conclusion

Up to now, research into psychosocial aspects of childhood obesity has provided few unequivocal results. Serious methodological shortcomings might be the cause of the inconsistencies in the available research data. Besides these disappointing empirical findings, individual psychosocial and family characteristics with regard to obesity, chiefly have been described by clinical workers or therapists. Therefore, one easily makes the ‘classical’ mistake of assuming that those who register as a

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