Weighty Issues for Parents

By Lori Oliwenstein

It's not easy watching your own history repeat itself. At first, Jo--a 49-year-old mother of two from Georgia--thought she would be spared having to witness her children relive her long struggle with obesity. Indeed, when Jo's second child Renee was born 12 weeks early, weighing just 2 lb. 11 oz. (1.2 kg), obesity was the last thing on Jo's mind.

Today, things are different. Now 11 years old, Renee (a pseudonym, as is Jo) weighs 126 lb. (57 kg) and stands 4 ft. 5 in. (135 cm) tall--and Jo worries about obesity all the time. She worries about the health consequences of Renee's weighing too much, the ones she has experienced throughout her own life. She worries about her daughter's being teased or ostracized on account of her weight, just as Jo was teased and ostracized as a child. And she worries that she's not doing enough--or that she's doing too much--to change things, as she tries to avoid the mistakes she feels her parents made during her childhood. Most of all, Jo worries about losing sight of Renee amid all her own concerns surrounding her daughter's weight. "I feel like she's experiencing my weight issues all over again, living my obsession with food," Jo says. "I feel like I'm watching a train wreck, and I can't do anything about it."

She's not alone. As more and more kids pack on more and more pounds--climbing inexorably from a healthy weight to excess weight to full-blown obesity--parents find themselves grappling with questions they never had to deal with when the only weight problems they had to think about were their own. How do you effectively control another person's eating behavior? How do you motivate someone--especially a young, impulsive, pleasure-driven someone--to make smart food choices, to get up off the couch, to turn off the television? And how do you accomplish that without making that young person feel deprived, coerced or--worse yet--judged and found wanting? Perhaps most vexing for parents who are themselves veterans of weight-loss wars, how do you credibly persuade a child to take hold of an issue that you may never have been able to control yourself?

The stickiness of the childhood-obesity problem begins with a simple truth: most of us just don't think our kids are fat. It's right there in the stats; one study found that only 36% of parents of overweight or obese children ages 2 to 17 identified them as such. An Australian group found that only 11% of parents of overweight 5- and 6-year-olds and 37% of parents of overweight 10-to-12-year-olds were aware that their children had a weight problem. And a 2005 British study found that fewer than 2% of parents of overweight kids from ages 3 to 5--and just over 17% of parents of obese kids of the same age range--saw things for what they were.

Part of this blindness may come from parents' not really believing that kids--especially very young kids, swaddled in no-longer-quite-so-delicious layers of baby fat--can actually be obese. Part of it may have to do with our fears about using such pejorative terms about our children, especially if they were once hurled at us by playground bullies. And part of it may be that, in a society in which obesity is omnipresent, a slightly hefty child looks pretty normal, relatively speaking, says psychologist Susan Carnell, the lead researcher for the British study on parental perceptions, who is now at the New York Obesity Research Center at St. Luke's--Roosevelt Hospital. "The parents are likely to be overweight. The clinician who sees the child could well be overweight. It's a sensitive issue from all sides."

All of which might begin to explain why so many physicians report finding it difficult to talk to parents about their child's weight. According to a 2005 study, only 12% of pediatricians admit to feeling effective about a child's weight problem during office visits, even if that problem is an obvious one. For many practitioners, there's a fear that not only are the parents unaware of the situation but also they will be angered or upset by the information. More worrisome is how the news will make the child feel, particularly during the emotional storms and ego swings of adolescence.

The problem is, with such a huge and growing population of overweight kids, sparing a family's feelings may be a luxury we can no longer afford. That's why obesity experts believe that not only does the message have to be delivered but it also has to be delivered in a way that is sure to get through. In 2007 a group of pediatric-obesity experts convened by the American Medical Association (AMA) and co-funded by the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention issued a report on childhood obesity, which included a strong argument that the language of weight gain had to change. A decade ago, kids whose body mass index (BMI) tracked at or above the 85th percentile for their age were dubbed "at risk of overweight." The new recommendations urge doctors to cut to the chase and simply call such children overweight. Similarly, a child with a BMI above the 95th percentile--who would previously have been labeled overweight--would now officially be called obese.

The idea behind the language discussion in the recommendations, says Dr. Samantha Rosman, a fellow in pediatric emergency medicine at Boston Medical Center and a trustee of the AMA, was to make sure parents hear what their kids' doctors are telling them. "The stronger wording was a call to action," Rosman says. "This is a really important health problem that has the potential to be devastating to our society if we don't do something about it."

Doing something about it, of course, is going to take more than a vocabulary lesson. But the time is now. According to the HHS, 7 out of 10 overweight adolescents will become overweight adults. If the adolescent has an overweight parent, that figure rises to 8 out of 10. Parents have heard the recommendations a million times: Children should be eating five or more servings of fruits and veggies daily. They should be eating breakfast. They should be getting at least one hour of moderate physical activity each day. They should be spending fewer than two hours in front of a TV, video or computer screen each day.

Or, rather, the entire family should be doing these things. In fact, if you were to boil down the myriad recommendations for preventing and dealing with childhood obesity to a single word, you would come up with this: modeling. We need to think about the messages our behaviors send to our kids, the experts insist. If your daily diet revolves around bologna, potato chips and Ben & Jerry's Chunky Monkey ice cream eaten straight out of the carton, guess what Junior's going to start craving? And if you can name every celebrity from the past five seasons of Dancing with the Stars, chances are your kid can too.

Of course, whether a child can--or, rather, should--diet is a more complex question. Most clinicians don't even like to use the word; instead, they talk about "lifestyle changes" and "weight-management protocols." Says nutritionist and family therapist Ellyn Satter of Madison, Wis., considered by many a pioneer in the field of child feeding: "Even the most conventional people will say, 'Don't put kids on diets,' but then they'll go on to talk about how you should reduce their sugar or fat intake. There's an awful lot of dieting in disguise."

Does dieting even work for kids? Many clinicians say no. "We actually find that children who diet gain more weight than their peers," says pediatrician Dr. Alison Field from Children's Hospital Boston, who has been following the weight-control behaviors of almost 17,000 kids. It's not just that kids who diet tend to gain back the weight later; it's that dieting brings up all sorts of unbidden psychological responses that sabotage the process. After all, self-deprivation is one thing; being told by someone else that you can't eat--even when you feel hungry--is another.

"Renee whines to me about being hungry all the time," says Jo. "She knows I'm a softie and might just let her have another snack. I've done nothing but diet all my life, and I know how it feels." That feeling of deprivation, according to Satter, is a recipe for disaster. "You end up putting a lot of pressure on food," she says, "and the kids end up losing track of how hungry or full they are. They get into a habit of eating while the eating is good, instead of simply eating until they are full."

There's evidence to suggest that she's right. One study of preschoolers, for instance, found a link between overeating and overweight children--and an even stronger link between overeating and kids whose parents regularly control their portions. And so, Satter says, we need to start making the process of eating less fraught by letting kids decide whether they are hungry and how much to eat of the foods we provide at the times and in the places we provide it.

Carnell, who has also looked at the eating behaviors of children whose food choices are restricted, says the key is the way in which you seek to limit a child's food intake. "If you have a house full of goodies and say, 'Johnny, you can't have this,' then that could be damaging," she says. "But if the way you restrict your child is just to provide a healthy home environment where you allow them a little bit of choice--apples or grapes for dessert, for instance--then you're giving children a chance to decide for themselves while also helping them develop healthy habits."

For experts focusing on the best ways to control weight or increase activity, the job pretty much ends here. Parents, however, have it harder; they have to think about the whole child. "If dealing with my daughter's weight issues was as simple as following a few nutritional and exercise guidelines, she wouldn't be overweight," says a Southern California mom. "But the whole thing is so much bigger and messier than that. I don't just care about what she weighs; I care about her growing up healthy and happy and feeling good about herself. And that is where it gets difficult."

Dr. Beth Marcus, a family physician at Verdugo Hills Hospital in Glendale, Calif., knows all about these difficulties. "I don't think there's any way in our culture to have kids feeling 100% good about themselves when you're telling them they need to lose weight," she admits.

If that has always been the case, it's getting to be more so all the time. When billboards, magazines and TV shows are filled with Photoshopped, Pilates-toned, silicone-enhanced models, it's hard to maintain any kind of perspective on what a real person is supposed to look like. And while that's long been true for girls, it's increasingly true for boys, who now must measure themselves against waxed and buff athletes and models who are steadily raising the male-attractiveness bar higher and higher.

Then too there are the messages kids are bombarded with from well-meaning strangers ("Oh, he's a chunky one, isn't he?") and critical relatives ("Ah, she's going to grow up to be just like fat Aunt Sue!"). Schoolmates--at least those not yet claimed by the obesity epidemic themselves--may soon join in the chorus. All of this can hit a child's still developing ego hard. On the whole, overweight children are more likely than healthy-weight kids to be anxious, unhappy and depressed. The science is mixed on which kids suffer the most. One study finds that self-esteem takes a bigger hit in black kids than in white kids; another sees the problem as being worse for Hispanic children. One study finds significantly higher rates of depression in overweight girls; another finds overweight boys taking a huge self-esteem hit when teased by their peers. No matter who feels the most pain, however, they're all getting hurt.

What parents, who suffer all this pain by proxy, must realize is that they are never going to change the hard realities of schoolyard taunts and a thin-obsessed culture. What they must do instead is teach their kids to value those things less--and value other things more. Kelly Lowry, a postdoctoral fellow in the department of child and adolescent psychiatry at Children's Memorial Hospital in Chicago, says the key lies in accentuating the positive. "Parents need to emphasize health behaviors, not the numbers on a scale," she says.

Those behaviors should be positive. Maybe your son tends to scarf his food; rather than criticize him, get him to scarf fruits and vegetables instead. Maybe your daughter spends too much time on the couch; rather than scold her for it, applaud when she gets some physical activity. The reward of your approval may be enough to encourage her to seek more.

In addition, any changes made in terms of the kinds of foods served or the time allotted for TV viewing should be made "at the family-wide level," Lowry says. "This will prevent the overweight child from feeling targeted." And new self-esteem standards should be applied to the whole household too. If you're walking around commenting on how fat your butt looks in your new jeans, not only is your daughter going to hear you, but she may also begin making generalizations about how she looks.

Finally, you can try to lighten the guilt load a bit. "There's a lot of parent-blaming that goes on," says the New York Obesity Research Center's Carnell, part of a British team trying to tease out just how genetics affect appetite, "and I think that's probably unfair. Parents are a powerful influence, but there are other influences as well--like genes." Recognizing that at least some cards in the obesity hand are dealt even before a child is born can be an important first step for parents and kids accustomed to thinking their weight woes are all their own fault. Recognizing that there are a lot of cards they can still play is the next--even more important--one.