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Children are often cruel to one another, and onecan often see evidence of this when it comes tosports and the infamous “choosing of sides.” The

slow, the unskilled, the unpopular and, finally, the over-weight child, are nearly always chosen last. This actionmay have devastating and long-lasting effects on a child’sself-esteem and spirit. While physical problems such ashypertension, orthopedic problems, diabetes, metabolicsyndrome, hyperandrogenism, heart disease, respiratory

disorders, and sleep disorders are well-documented com-plications associated with obesity, the psychologicaleffects associated with obesity can be just as devastatingto a child and his or her family.1 Often, this aspect ofcare is neglected by the health care provider, whobecomes more focused on the plan to decrease the child’sweight or body mass index (BMI).

Being obese today, while increasingly common, hasan impact on both how children view themselves and

ABSTRACTObesity is on the rise in this country, and obesity among children has become amajor issue for health care providers. While we are well aware of the many healthrisks associated with obesity, we may not be as aware of the psychological implica-tions of obesity in children. This article discusses the psychological implications ofobesity in children and suggests ways in which the health care provider can improveoutcomes among children and their families.

Keywords: childhood obesity, psychological implications of obesity

© 2010 American College of Nurse Practitioners

The Last One Picked: Psychological Implications of ChildhoodObesity

Linda Sullivan

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how others see them. Many children with weightproblems develop low self-esteem, which may in turngive way to emotional and behavioral problems such asdepression, oppositional defiance, bullying, and poorschool performance.2 For a child with weight prob-lems, being unable to be as mobile as his or her coun-terparts can become a gigantic hurdle to overcome, andmany cannot.

The Centers for Disease Control and Prevention(CDC)3 has defined specific criteria for both overweightand obesity. Overweight is defined as having an age-appropriate BMI between the 85th and 94th percentile,while obesity is defined as having a BMI in excess of the95th percentile. BMI, althoughan imperfect measurement, canbe useful in estimating whethera child is overweight. It is calcu-lated by dividing a child’sweight in kilograms by his orher height as meters squared.4

Other long-term sequelae ofobesity reported in the literaturefeature that overweight femalesare less likely to be married,often fall into a higher poverty classification, and have lessformal schooling. Research conducted by the Universityof Texas has shown that obese girls are 50% less likely toattend college than their slimmer counterparts.5 The onlyadverse effect reported for males in this study was thatthey were less likely to be married.6 However, playingsports, success in the job market, and other aspects of lifeare likely to be negatively affected by obesity in males.

When working with the obese child, the health careprovider should be looking not only at physical problemsrelated to and often caused by obesity, but behavioral andemotional problems as well. It is important, when utiliz-ing a holistic approach, to focus not only on the obviousproblems, but also those that may be the result of orcaused by the primary diagnosis. The psychologicalimpact of obesity has far-reaching implications for a childas they mature into young adults.7 The advanced practicenurse (APN) must become more proactive in dealingwith obesity, so as to prepare an anticipatory plan of carethat addresses the entire problem and minimizes theimpact of this very complicated problem. While simplylosing weight would eliminate the problem completely,this is easier said than done for many children.

BACKGROUND Obesity can impact the child on many different levels.Current estimates are that about 65% of all Americans arenow classified as overweight and 40% of all children areeither overweight or obese.8 The incidence of obesity hasdoubled among the 6- to 11-year-old age group andtripled in the 12- to 17-year-old age group since 1980.Obesity is currently deemed the single most stigmatizingand least socially accepted condition of childhoodbecause in many ways it is perceived as something thateither the child or his or her primary care givers shouldhave prevented.9 Poor school performance has also beenlinked to weight issues, and studies have indicated that

obese children miss 4 timesmore school days thannonobese children.10

Obesity, while for some acultural norm, is increasingand can now be seen through-out the world, even in coun-tries where prior to 1990there were significantly lowernumbers of obese children(eg, Mediterranean region,

Ireland, Greece, Portugal).11 Monitoring trends in obe-sity is essential to thwart the inevitable serious medicalproblems caused by its complications. Evidence sup-ports the likelihood that obese children and adoles-cents will then become obese adults and suffer theconsequences of obesity in their adult years. Increasedreliance on fast foods by working parents andincreased availability and use of technology such astelevision, computer, and the phone also play a part inthe increase of obesity.12 Because of the rampantincrease in weight-associated problems, it is imperativethat health care providers evaluate not only the physi-cal risks for obese children, but in addition, the psy-chological complications that are often evidenced asemotional and behavioral problems, to treat the childin a thorough and holistic manner.

EMOTIONAL COMPLICATIONSGenerally speaking, the quality of life is worse amongobese children. This is due in part to the child’s own self-image, which invariably is poor. While self-esteem isaffected in both overweight boys and girls, girls who areseverely obese often exhibit moderate to severe depres-

The incidence of obesityhas doubled among 6- to 11-year-olds and tripled in 12-to 17-year-olds since 1980.

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sive symptoms and 35% of these girls self report highlevels of anxiety.13 Research has demonstrated that obesegirls are more likely to have attempted suicide thannonobese girls.14 In general, adolescents who are obeseare often more isolated and peripheral to social networksboth in school and the community.

The obese child can become the victim of bullying andthis can then lead to an increased loss of self-esteem andeven overwhelming feelings of hopelessness, which in turngive way to depression. It is no secret that the obese indi-vidual is often the butt of many jokes and the object ofscorn from many others who are not obese. Just as the cul-turally inappropriate joke or the misspoken word causespain, this type of treatment can have far-reaching psycho-logical effects on the individual. Many times, when actingin self defense, the overweight or obese child resorts to bul-lying, usually with poor outcomes, and this then sets uphim or her for further ridicule.

Other behavioral issues can emerge for the over-weight or obese child. These can be the result ofincreased anxiety and poor social skills. The child is oftenseen as disruptive or acting out in class. The child mayget suspended, or simply not goto school, more often than theirslimmer counterparts. This isturn leads to poor school per-formance, which is directlycorrelated to a higher numberof missed school days for theoverweight and obese child.15

Sleep problems associatedwith obesity, particularly sleepapnea, can also affect mood andthe ability to concentrate.Depression, which so often issecondary to poor self esteemand poor body image, is common among obese chil-dren.16 The resulting higher degree of social isolation,leading to feelings of hopelessness, increases the incidenceof depression in this group. When depressed, the child willlose interest in everyday activities and become morewithdrawn, exhibit increased somnolence and crying, orbecome emotionally flat, not reacting to everyday con-cerns or stimuli. In the most extreme case, suicidalideation can be the direct result of obesity and feelings ofhelplessness within the child.17 These signs and symptomsshould not be ignored by either teachers or the child’s

primary caregiver, and should be shared with the child’shealth care provider so that some immediate form ofintervention may be initiated.

INTERVENTION STRATEGIESThe health care provider must be cognizant not only ofthe physical health risks associated with weight issues butthe psychological risks as well. If a patient is noted to beoverweight or obese it is essential that the health careprovider explores both the physical and emotional impli-cations associated with this condition with the child andhis or her parent. Interviewing the child in a nonthreat-ening environment and utilizing a nonjudgmentalapproach is critical to success in treatment. The purposeof establishing rapport with both the parent and child isto increase the likelihood of compliance with treatmentregimes suggested by the health care provider. In manycases, the health care provider will see the parent withsimilar weight issues and therefore it is critical to neitherplace blame nor be overly critical of the situation.Rather, it is important to establish a safe environment forboth the child and caregiver so that they can become

involved in seeking solutionsand expressing their feelingsopenly and honestly.18

It is essential that thehealth care provider delve intothe psychological well-beingof the obese child by assessingbehavioral issues, school per-formance, and social well-being. This involves askingquestions of both the childand primary caregiver. Onceproblems are divulged relatedin the physical or emotional

realm, the health care provider, child, and primarycaregiver(s), working as a team, should seek to developsolutions to the problems that have been identified.

Treatment of childhood obesity should take intoaccount the child’s age and any underlying medical con-ditions, along with any emotional issues that are disclosedduring the exam and interview. Changes in diet and levelof activity can be part of the treatment regime; however,for children with behavioral or emotional problems, consultation with and referring to a psychologist, psychi-atrist, or behavioral counselor is imperative.

It is important to establisha safe environment for bothchild and caregiver so they

can become involved insolutions and express their

feelings openly.

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For actual weight loss treatments, the health careprovider should be cognizant of the child’s age, as it isrecommended that children under the age of 7 beencouraged to maintain their weight rather than to diet,as this allows for height to increase but not weight. Forchildren over the age of 7, slow, steady weight loss strate-gies should be introduced, with a goal of a weight loss of1 pound per month or, in more aggressive approaches, 1pound per week.19

Often, discovering new activities that the childenjoys and increasing the level of his or her physicalactivities can have a 2-pronged effect for the over-weight or obese child. It can improve the emotionalwell-being of the child in concert with weight loss.Primary caregivers need to be encouraged to join inthe activities and make exercise a fun part of the dayrather than a chore to be accomplished or a punish-ment for the child’s weight. This joint approach, wherethe child and the caregiver are equally involved,increases the child’s self-esteem and sense of controlover his or her own weight issues. The end result is toincrease the probability of success.

Decreasing television, telephone, and computer timecan help decrease the isolation that children who areobese feel, and may in turn decrease the likelihood ofdepression. The health care provider, along with the care-giver, need to find ways to praise all of the child’s effortstoward losing weight.

When more complicated psychopathology is evident,long-term medication and, in some cases, even hospital-ization, may be necessary. Family psychotherapy may beanother avenue to explore with families, as often it is notjust the obesity but a myriad of other problems that con-tribute to the child’s problems.

SUMMARYConcerns related to being overweight or obese can bechallenging and complex problems both for the patient andthe health care provider. The complications of these prob-lems include a myriad of physical problems and psycholog-ical issues that can have long-term and devastating effectson the child and his or her family. It is important for healthcare providers to address all aspects of the problem whentreating the child so as to maximize the potential for ahealthy outcome. It is imperative that health care providersfully understand the detrimental impact of obesity on thepsychological well-being of the child.

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Linda Sullivan, RN, DSN, PNP-BC, FNP-BC, is the direc-tor of advanced practice for the Mississippi Board of Nursing inJackson. She can be reached at lmsullivan60@yahoo.com. Incompliance with national ethical guidelines, the author reports norelationships with business or industry that would pose a conflictof interest.

1555-4155/10/$ see front matter© 2010 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2010.01.024