Teaching tots — what our youngest children are internalizing from the war on obesity

This is one of the most heartbreaking studies you may read about this year. Within its findings is the hurt felt by every child who is born with a body that doesn’t fit the norm. This small study of disadvantaged, minority preschoolers in a Southwest community won’t likely make major news. There is nothing to interest commercial or political stakeholders, and nothing to sell … but the need for compassion and understanding. It calls upon us to stop, look and listen what our culture and well-intentioned health interventions are teaching children.

By the age of four they have learned prejudice. Not only towards others, but are also internalizing it against themselves.

The intensity of the stigma the young children in this study exhibited against fat was staggering. The full significance of this study may be missed among many, if not most, who read it. Yet, it highlights that today’s focus on childhood obesity and healthy lifestyles is not benign and is having unintended consequences that can jeopardize children’s health and futures.

The messages about fat are inescapable — in media, schools and healthcare settings — and are predominately negative and reinforce popular prejudices. Even toys, books and video games for preschoolers and health lessons piped into elementary school classrooms across the country encourage prejudicial beliefs. For decades, psychologists have been reporting widespread harassment of fat children and body size stigmatization beginning as early as nursery school, said the authors of this new study just published in the journal Obesity.

Researchers in 1995 at the Health Behavior Unit in London, for example, found that 4-11 year old children attributed nearly all negative traits to pictures of overweight children and were less likely to view fat kids as having friends, being clever, kind or pretty, or to want to play with them, compared to thinner ones. Professors Phebe Cramer and Tiffany Steinwert at Williams College in Williamstown, MA, reported in a 1998 issue of the Journal of Applied Developmental Psychology, that 3-5 year olds assigned terms like “mean” to pictures of a fat child and “nice” to a thin child. This is the same study that found that by the time girls enter elementary school, they fear looking fat more than getting cancer, a nuclear war or losing their parents.

For this new study, Shannon S. Rich, Ph.D., and colleagues at Texas Woman’s University in Denton, Texas, set out to repeat those two earlier studies, which had been done on mostly middle-class Caucasian children, to see if disadvantaged Hispanic children were internalizing the same anti-fat social messages. They said that they’d found that Hispanic parents were more likely to see heavier toddlers as healthy and wanted to see if this was having a moderating effect on the social stigma exhibited by these children. They also set out to see how parents’ dissatisfaction with their own weights might be affecting children’s weight prejudices.

They examined 70 Hispanic four-year olds and their caregivers (parents, grandparents or guardians who primarily provided the children’s daily care, 97% were female) in a pre-Kindergarten program in Denton, Texas. This preschool program enrolled primarily Hispanic children who were economically disadvantaged, didn’t speak English, or were homeless. The preschoolers were asked to assign 18 positive and negative adjectives to pictures of fat, average and thin children. The children were also shown drawings of figures of various sizes, skin and hair tones to select the picture they thought they looked like. The caregivers’ perceptions of their own body sizes and their child’s were similarly assessed; and to assess the caregivers’ degree of body dissatisfaction, they were asked which figure they would like to look like and would like their child to look like.

The findings were stunning. These four-year olds were already attributing dramatically more negative traits to the fat pictures than to the thin ones. More than half of the children saw the fat figure as ugly — twice the percentage of thin figures. Similar percentages of children considered the fat figure stupid, lazy, lies, selfish and likely to be teased.

Strikingly fewer preschoolers also attributed positive traits to the fat figures, and were two and three times as likely to attribute them to the thin figures. The fat figures were less likely to be described as having the most friends or someone they would like to play with, as pretty or handsome, happy, clever or kind. The only positive attribute that these 4-year olds attributed to the fat figure was strong.

The researchers found no difference yet between the boys or girls in their perceptions of the fat figures. The young fat children in this study were also not yet more likely than their thinner peers to ascribe negative adjectives to fat figures, which has been well documented among slightly older children and, to date, to most affect Caucasian females.

When girls hit puberty, they become especially vulnerable to weight concerns from misguided parents, school personnel and even medical professionals. Girls are most likely to fear they’re fat and to be thought to be getting fat, or misdiagnosed as overweight, when they enter puberty because it’s a time when it’s normal and healthy for them to gain 20 or more pounds, even in a single year, as their bodies prepare for childbearing, and for them to add up to 20 percent of their body weight in fat that is needed to begin normal menstrual cycles.

The factor most predictive of the four-year olds in this study who saw fat figures negatively was those whose adult caregivers were heavier or dissatisfied with their own bodies. In other words, the authors noted, the role of these women caregiver most determined the children’s learned weight stigma. “Body dissatisfaction has previously been found to be associated with increased verbal criticism of one’s body shape and size, which is internalized and modeled by the child,” they explained. This internalization leads fatter children to associate larger weights with negative emotions, they said, adding:

In caregivers who experience body dissatisfaction, the guilt and shame of perceiving that one has not met cultural ideals may be transmitted to the child. As Fontaine states, “Mothers who are obsessed with their weight and hate their bodies teach their daughters to do and feel the same.”

Even a young woman writing for her Georgia university newspaper last year was shocked to hear four-year olds girls worrying about their weight and about being fat. She lamented that kids their age should be allowed to just be kids and not be worrying about such things. She wrote reflectively about the effects women’s own body issues were having on young girls.

The heavier youngsters in this study were already being taught to not see fat in a positive light, which has a direct bearing on how naturally-fat young people will feel about themselves. The heavier the four-year old children were, the less likely they were to see the fat pictures positively. “This corresponds to previous findings that overweight children do not report anything positive or good about being overweight,” said the authors, and their findings demonstrate that by the age of four, even lower socioeconomic, Hispanic children already show self-stigmatization related to weight.

Internalized stigma is not healthful, and has been shown related to more health problems and risk behaviors, such as higher rates of smoking and drinking, and poorer grades among children. Amidst the popular concerns over media and social messages, the downsides of seemingly helpful health and weight messages receives little attention. Yet, as they noted:

Increasing weight loss messages in the media, schools, and health-care systems emphasize the individual responsibility of controlling weight related health. These messages may have the unintentional effects of increasing body size stigmatization, decreasing self-esteem, and increased dieting behavior not only in adults who view the messages but also in the children of those adults.

Stigma of fat means fat children are especially targeted for teasing, harassment and bullying, which has been shown in the medical literature to have significant adverse physical, academic and emotional health consequences. Bullying is exceedingly stressful for children, and parents and pediatricians see it exhibited in more headaches, getting sick, nightmares, tummy aches, failed grades and school absenteeism, body aches, nail biting, fear of going to school, sleep problems and vomiting. Weight-based teasing is especially concerning as it’s been associated with disordered eating behaviors such as fasting, taking diet pills, self-inducing vomiting, and using laxatives or diuretics; depression, suicidal ideation, and suicide attempts.

Last year, a special issue on bullying looked at research on the stigma of fat children by their peers. Since the classic studies in the 1960s, weight prejudices have been recognized as a learned behavior that can be seen in kids as young as three years old. Those early studies had asked children to rank six pictures of children with different physical characteristics and disabilities, in order of who they would most like for a friend. Most of the children ranked the picture of the fat child last — after pictures of children with crutches, in a wheelchair, with an amputated hand and even with a facial deformity.

When those studies were replicated forty years later, prejudice against fat children had worsened, increasing 40%. The researchers observed that today’s cultural efforts to increase acceptance of diversity have lessened stigmatization against those with some physical differences, but have not extended to weight. Fat children, especially girls, are more likely to be bullied, teased and harassed about their bodies.

Failing to address weight stigma early makes it more difficult to address. As Dr. Rich and colleagues said:

With young children, punishment for teasing may actually lead to increased body size stigmatization as the punishment may cause the child to harbor ill feelings toward the obese child. Therefore, alternative techniques should be explored.

Naturally fat young people have few role models teaching them acceptance or appreciation of natural diversities among body sizes and shapes, and they never hear positive qualities associated with bodies that look like them. Even young people trying to be fat accepting hold and promote the same weight prejudices about their health, diets and lifestyles. Dr. Rich and colleagues urged:

As with cultural diversity programs, an emphasis on acceptance of all individuals regardless of size should be incorporated into the school curriculum as early as possible. In preschool, this can be done through reading size diversity books or completing art projects that emphasize the beauty in individuals of all sizes and shapes. In addition, self-evaluation by educators needs to occur as many teachers and school administrators may also show body size stigmatization.

What has not been proven to help, like any prejudice, is trying to address weight stigma and bullying by trying to change the victim to make them look more socially acceptable and reinforce beliefs that they are diseased and have bad diets or lifestyle. As Canadian research of school health curriculums published in the journal Body Image a few years ago reported, ‘healthy eating and healthy weight’ educational approaches send mixed messages and actually increase anxieties about body weight and foods.

Even when the evidence is available suggesting striking and disturbing adverse consequences for children and teens of anti-childhood obesity programs promoting healthy eating and exercise, there’s a disconnect in recognizing the negative messages they reinforce.

The largest, most expensive and comprehensive state healthy eating and activity child obesity program in the country, the Arkansas Act 1220, recently found that after four years, the program had had no effect on children and adolescent weight classifications or in making healthful behavioral changes, but had significantly increased weight concerns. The youngest pupils had been the most adversely affected by weight concerns. For example, 31% of children under age ten had been reported as being concerned about their weights before the program began, compared to 69% four years into the program. Weight-based teasing had also increased among young people, with those larger than their peers most affected. Fat teens were nearly nine times as likely as nonfat peers to experience weight-based harassment.

Especially worrisome, the most recent 2007 Youth Risk Behavior Survey (YRBS) data, released in the CDC Morbidity and Mortality Weekly Report on June 6, provided the most troubling indications of adverse consequences. Arkansas teen girls, for example, were about 20% more likely to engage in unhealthful and risky behaviors trying to lose weight as compared to their peers nationwide — even though they were not fatter. For example:

● 16.9% of Arkansas teen girls admitted to going without eating for 24 or more hours to control their weight (compared to 15.8% national average).

● 9.2% of Arkansas teen girls admitted to taking diet pills and liquids (compared to 7.5% national average)

● 8.1% of Arkansas teen girls admitted to vomiting or taking laxatives to manage their weight (compared to 6.9% nationwide)

The results of the Arkansas experiment supports concerns raised for years by childhood development and eating disorder experts that young people are not ready to grasp or appropriately act on even positive nutritional messages. It also sadly bears out the concerns of the Childhood Obesity Working Group of the U.S. Preventive Services Task Force about professionals and government health officials forging ahead with BMI screening and childhood obesity interventions before they have evidence of being beneficial, and that they may put young people at risk of harm.

To date, not a single childhood obesity program is evidence-based. The U.S. Preventive Services Task Force, after reviewing 40 years of evidence and about 6,900 studies and abstracts, found no quality evidence that any program to reduce or prevent childhood obesity — no matter how well-intentioned, comprehensive, restrictive, intensive, long in duration, and tackling diet and activity in every possible way — had been effective, especially in any beneficial, sustained way; nor demonstrated improved health outcomes or physiological measures, such as blood lipids, glucose tolerance, blood pressure or physical fitness. Nor has any diet or exercise interventions in children been shown to lead to better health outcomes in adulthood.

Since the USPSTF report, the long-awaited results of the intensive two-year study of the model for school-based nutrition policies to address child obesity, in accordance with the U.S. Centers for Disease Control and Prevention’s “Guidelines to Promote Lifelong Healthy Eating and Physical Activity,” were published in the journal Pediatrics. It found no effect on childhood obesity. The results were in effect buried.

So, too, will the results of this study of four-year olds be unlikely to make headline news. Yet, it shows more powerfully than any government report what we are teaching our youngest children and, more importantly, what they are learning.

© 2008 Sandy Szwarc