Eating Disorders

A variety of factors have contributed to the country’s ballooning weight — poverty, inactivity, poor nutritional education, lard-rich fast food. A disproportionate number of overweight children continue to come from lower-income families. But as issues of obesity invade middle-class homes, parents who are versed in the four basic food groups and have the money to provide healthy meals are tongue-tied by a new conundrum: Having done their perfect-parent best to protect their children, in particular their daughters, from the dangers of eating disorders and self-loathing, they have ended up with a generation of fat children (not to mention adults) who now need to lose weight. But as they prepare themselves to finally confront their children about their weight, they find themselves bound and gagged — deprived by the experts of appropriate language for the task.

As any parent who has even dipped into parenting manuals knows, it is absolutely against the rules to call extra attention to a child’s eating habits, even when they are toddlers, for fear of creating “lifelong issues” with food and irreparable harm to self-esteem. So how exactly do we coerce a dangerously overweight child to slim down, without mentioning the cause of obesity, or even the subject of weight?

Many pediatricians and so-called “feeding experts” cling to the notion that it is worse for a child to be shamed by the mention of weight than to be burdened with excessive fat. Faced with alarming statistics about childhood obesity, these advisors bob and weave, suggesting that the topic be broached in surreptitious ways, insisting that parents must still avoid making direct comments about weight or appearance. But an increasing number of parents, and a handful of experts, have begun to reorder their priorities, sacrificing the focus on self-esteem to make blunt comments about their child’s weight — to their children. Some have even decided that diets, long forbidden in the realm of pediatric advice, may be appropriate.

In the past, experts placed few constraints on parents dealing with an overweight child. In “The Kid-Slimming Book,” a 1976 weight-loss guide for parents of overweight children, author Audrey Ellis writes: “Fat is not fit. Fat is not beautiful either. An overweight child may be teased, rejected as a playmate, and the object of hostility at school, however much he is cherished at home.” Another book, from 1985, “Beyond Baby Fat” by Frances Sheritan Goulert, warns parents that fat children have more accidents in P.E., are involved in more pedestrian-automobile accidents and are more likely to burn themselves, because they move more “slowly” and are less “dextrous” than children of normal weight. Goulert also reports that a fat child has a 50 percent less chance of getting into college. And she is merciless in her definition of overweight: “If your offspring has rolls around her middle, an extra chin, or lumpy legs, she is fat — period,” she writes.

This brand of unapologetic parent-baiting is now politically incorrect and considered psychologically harmful. But is it medically called-for? The Centers for Disease Control and Prevention reported in March that the percentage of overweight children ages 6 to 11 increased from 11 percent to 13 percent between 1994 and 1999. For ages 12 to 19, the percentage jumped from 11 to 14 percent. And parents are hardly working out as role models: As many as 50 percent of American adults are overweight.

Worse news, perhaps, is the potential impact of the numbers. When it comes to body type, childhood provides a blueprint for the adult. In 1997, the New England Journal of Medicine reported that more than 50 percent of obese children over the age of 6 will continue to be obese into adulthood, and 70 to 80 percent of obese teenagers will remain obese as adults.

In other words, without early intervention by parents, fat children are very likely to grow into fat adults. And there is even more pressure when it comes to girls: Substantial weight gain in very young girls frequently triggers premature puberty — as early 8 or 9 in some girls — and puberty triggers additional weight gain. Once a girl begins to menstruate — typically two years after the onset of puberty — she soon reaches her full height, meaning that she can’t “grow into” the weight she has already put on. (Testosterone may cause some fat to be exchanged for muscle in overweight boys, but it can’t be counted upon.) In fact, children whose extra weight gain in childhood triggers premature puberty will often lose inches in height that they would otherwise have achieved.

Even as they face these facts, today’s enlightened parents (supported by their physicians) have attempted to follow advice like that given in the 1995 book “Let Them Eat Cake: The Case Against Overcontrolling What Children Eat.” In it, pediatric nutritionist Ronald Kleinman and his co-writers Julie Houston and Michael Jellinek argue that parents have been overly concerned about children’s eating habits. “The extreme standard of thinness that prevails today has no known health or medical benefits, but still it casts the idea of being moderately overweight, or even normal weight as a problem,” write the authors. “Thin, heavy or average in stature, if a child is healthy, then the notion of acceptance by parents can not be overemphasized or overencouraged.”

The result of this chastising, which has been reinforced by leading child-development experts, is that we find ourselves in a conspiracy of silence about children and weight: A word like “fat” must never be mentioned — and not only because it is considered psychologically incendiary. Another reason is that “fat” has become a completely meaningless phrase: We know that 80 percent of girls think they are overweight — even when they are not. So “fat” is now a word used to describe someone whose thighs (or tummy or butt or hips) are a few inches larger than is appropriate to fit into a Marc Jacobs minidress and look “hot.” And the perversion of the word’s meaning has made it almost impossible to distinguish, in discussions about weight, between being less than thin (i.e., normal weight) and being overweight, or even obese.

As the f-word has lost its currency in the parental vocabulary, well-intentioned media campaigns have attempted to make kids feel better about themselves, whatever their size may be, a strategy that conveys, sometimes unintentionally, the message that being fat is fit, that being fat is beautiful. (For example, the “Love Your Body” campaign launched by Anita Ruddick of the Body Shop during the mid-1990s, featured the famous “fat Barbie,” reclining in an odalisque position, with the caption: “There are 3 billion women who don’t look like supermodels and only eight who do.”)

The most recent attempt to confront, and perhaps obliterate, the “skinny is beautiful” conundrum on the teen level was launched by Christina Kelly, editor in chief of ym magazine, one of the largest-circulation magazines for teen girls in the country. Kelly publicly resolved to ban diet articles and begin using plus-sized models in fashion spreads. “It was really important to me to take a stand,” she says.

In fact, teen girls already are fluent in the body-positive, beauty-comes-in-all-sizes rhetoric of the last few decades, whether or not they read ym. A popular teen e-mail circulating the Internet, with the subject line “It’s Beautiful Woman month,” basically recapitulates the figures that a decade ago wouldn’t have been seen outside of women’s studies courses — “Marilyn Monroe was a size 14! The average woman is 144 pounds and a size 10! Models in magazines are airbrushed — not perfect!”

But even as they pay lip service to the feminist notion that beauty comes in different sizes in the abstract, many girls frequently enforce the retro skinny standard on themselves and their peers. On the ym message boards, for example, many girls were screaming for their diet and exercise articles and baiting girls for being fat. A typical example is the girl who wrote: No one gives a crap except for other fat people. So go form a support group and stop bothering everyone else. No one wants to look at a size 13 grl in a bikini.”

And the irony is that, even as the perfect size 2 ideal is maintained by the daughters of feminist mothers, many of these same girls are fat. And they are protected in this interesting disconnect of intellect and obesity by parents who have no idea how to promote exercise and good eating as a health issue, without seeming to reinforce the notion that weight loss is necessary as an aesthetic issue.

Says Kelly, “I’m not opposed to exercise per se. But I want to keep the focus on the joy of doing the sport. I don’t want to tell girls: Do this exercise and you will have a flat stomach, even if the byproduct of doing an exercise you enjoy may be a flat stomach.”

Therein lies the conflict that intimidates so many parents who must reconcile the issue of self-esteem with the fact of fat. Many pediatricians and childhood dieting experts deal with the conundrum by encouraging parents to focus on the “fun” of exercise and good eating, and to always invoke the word “health,” rather than focus explicitly on the goal of weight loss. Some, like Laura Walther Nathanson, the author of “Kidshapes,” even go so far as to offer parents weird subterfuges to get out of directly addressing the issue of calories: She suggests, among other things, that parents confronted by children who want a Ding Dong should invoke the laxity of FDA regulations with regard to junk food, and maybe even gross them out by commenting on the potential conditions of the factories in which they are made.

Above all, the word “diet” is suggested by many of these experts to be as deadly as the word “fat.” We know, of course, that quick-fix diets found in just about every women’s magazine — “Lose 10 pounds in two weeks!” “Trim your thighs before bikini season!” — have done little to help girls and women maintain a lifelong, healthy body size. And “yo-yo dieting” is demonstrably responsible for long-term excessive weight gain. Children are even more susceptible to the damage of dieting. In fact, most pediatricians concur that while a child is growing, it is actually dangerous for that child to lose weight.

Instead, the preferred method for dealing with excessive weight — favored by Nathanson and others — is to allow children to “grow into” their weight. In this approach, a parent’s goal is to help his or her child maintain their current weight, until they catch up in height. But it isn’t nearly as easy as it sounds. Nathanson herself points out that it can take, on average, more than a year and a half to work, which doesn’t help the young obese girl who is in danger of early puberty and its attendant risks of excessive weight gain in childhood. And once that girl hits puberty, it’s pretty much over as far as “growing into” her weight is concerned. “The most important thing for parents of chubby girls entering puberty to remember,” writes Nathanson, “is that it is futile, fruitless, and cruel to expect their daughters to slim down at this point. Restricting food, ‘having a chat’ about diet and exercise, imploring the pediatrician for prescriptions for appetite suppressants — these cries of anxiety from parents produce only guilt and anger, self-consciousness, and a feeling of helplessness in a young girl.”

“The obvious thing that everyone understands now is that you can’t put a child on a diet,” says Laura Fraser, author of “Losing It: America’s Obsession With Weight and the Industry That Feeds on It.” Fraser defines a “diet” as any external means of control about food, including such things as restricting calories and keeping food diaries. “They will rebel, both psychologically and physiologically, by overeating and sneaking food. It’s a recipe for obesity.” Indeed, parents typically are told that they should never divide food into “good” and “bad” categories, for fear that banning a food will only fetishize it; nor should they use food as a reward or bargaining tool — i.e. eat your broccoli and you can have a piece of cake — because it sends the message that broccoli is less desirable than cake.

The authors of “Let Them Eat Cake” argue that the most dangerous aspect of denying food to a child is the consequences to that child’s self-esteem. “Outlawing certain foods and snacks and criticizing food choices can lead to a no-win power struggle that sends a clear, negative message to the child that he or she has a ‘weight problem.’ As this in itself is more damaging than the presence of excess pounds (low self-esteem lingers on long after weight disappears), food and weight should never be made a big issue for children, regardless of what the charts show.”

This sort of heart-rending assertion has held sway for years, especially among parents who have soaked up guilt like sponges. The threat of serious health risks has derailed this philosophy for some parents and a few “feeding experts,” but the voices in the wilderness calling for food control and even diets remain weak.

Parents are more likely to turn to experts like Ellyn Satter, the author of three books on feeding children including “How to Get Your Kid to Eat — But Not Too Much.” Satter, a nutrition guru, is primarily concerned with developing “eating competency” in children, which involves teaching a child to love food, and respecting a child’s autonomy — though in practice, it suggests a sort of denial in disguise. She operates a clinic in Madison, Wis., where “the division of responsibility” between parents and their children is the core principle. Satter says it is up to parents to decide “what, when and where” a child eats. The child decides “how much and whether” to eat. In other words, “junk” food and between-meal snacks aren’t taken away — they simply are not made available in the first place.

The idea is that the child will learn gradually to regulate his or her own food intake and thus develop eating competency. It is a sensible approach meant to tread lightly on self-esteem, but like much of the parental advice already available, it works best, as Satter admits, if you follow the guidelines “from birth on up.”

And what advice does she give the parent who missed Satter at birth and now has an overweight 8-year-old approaching puberty? Won’t the child notice if her parents suddenly stop buying potato chips and start structuring meal and snack times?

“Well, in that case,” says Satter, “you would have to do a secondary intervention. You need to have someone who understands feeding do a complete evaluation. Is the child really gaining weight, or are they just plumping up pre-puberty? If they are gaining weight, how much? Is the family following the division of responsibility with regard to food? Are they restricting the child’s food intake, causing the child to rebel? Is there stress in the family which is causing the child to use food for comfort?”

Satter’s secondary intervention includes a review of medical records from birth, nutritional analysis of seven days’ food intake, office interviews and a videotaped observation of several family meals. It is a process, she admits, that is certain to alert a child to her parents’ concern about weight, but, says Satter, sometimes a child is ready to be open about the problem.

“If a parent is concerned about a child’s weight, that child already knows,” says Satter. “Most of the time, a child is relieved to hear it stated out loud; it makes them hopeful that something will be done about it.” She says she supports an “open dialogue” about weight, if that dialogue takes place between “knowledgeable professionals” who know what they are doing. But without professional guidance, she says, “Too often it takes the form of a parent who tells their child, ‘You have to cut back what you are eating. You are getting too fat.’ That is a horrendous oversimplification of the problem and doesn’t help anyone.”

Some experts on childhood obesity have begun to advocate an even more aggressive intervention with overweight children. Mary Savoye is the director of the Bright Bodies program, a diet and exercise program for children at Yale University. She also is a certified diabetes educator, fluent in all of the health dangers that can accompany obesity, especially those that accompany Type 2 diabetes, which is often induced by excessive weight. “Let’s see,” she says. “You have heart disease, nerve damage, eye disease, kidney disease …”

What frightens Savoye is that she is seeing younger and younger patients. “Most of these complications we don’t see in patients until adulthood — 35, 40, 50. But if you have a child who is morbidly obese at 10, we are going to start seeing 18- and 19-year-olds who have obesity-related health problems. Our children are the heaviest they have ever been. No one knows what will happen. It’s a real problem.”

The Bright Bodies program, which serves children from 9 to 16 years old, does not hesitate to confront participants about their eating and exercise habits. In the first of two sessions, kids attend a nutrition class with their parents. Next, participants (without their parents) attend a behavior modification class where they discuss how they feel about their bodies, how to be more aware of what they are eating (including keeping food journals), and how to pay more attention to environmental triggers, such as eating out of boredom, or eating while watching TV.

For those who believe that the stigma of having a “weight problem” is more damaging to a child than excessive pounds, this program might even be considered dangerous. But Savoye says she has discovered in working with overweight children that it may be possible to help a child to actually lose — rather than simply maintain — weight.

Savoye says that she still believes it isn’t healthy to push the issue of weight with a child who is no more than 20 pounds overweight, unless the child brings up the subject. “But if a kid is 50 to 60 pounds overweight, you have to intervene. It then becomes a health issue.” And she has begun to believe, after conducting some informal research, that in some cases it may be appropriate to put a child on a diet.

Last year, in response to pressure from desperate parents who had tried everything to help their children to lose weight, Savoye finally agreed to put some children on a diet. She was concerned, however, about doing harm, so she set up a pilot study: She divided 62 children into two groups, matched for age, gender, approximate weight and motivational level. One group was taught to lose weight according to conventional wisdom about children and weight — they learned about nutrition and how to make good food choices. The other group was put on a traditional diet with a structured meal plan and restricted calories. Along the way, Savoye measured both groups for weight loss and self-esteem.

The program lasted one year. At the end, Savoye was shocked by the results: The group on the traditional diet had been more successful at losing weight and scored higher than the other group in self-esteem.

Savoye is careful to point out that her study was tiny, and that she would have to undertake a larger study over a longer period of time to come up with conclusive results. It also is too early to tell if the original group will maintain their new weight over the long term. “Of course, my hypothesis is that they will not,” says Savoye. “But my hypothesis the first time was that the kids on a diet would not do as well as the other group and when we gave them the diet, against all the literature, we were surprised by the results.”

Savoye is aware that even the suggestion that a diet may work for some children is likely to inflame her fellow childhood-obesity researchers. “My advisor keeps trying to get me to publish this study, but I’m a little afraid of all the angry phone calls I will get.” She emphasizes that even in the case of a child who has to lose weight, a diet would be the absolute last resort. “There are so many other things that can be done first,” she says. “You can eliminate the cookie jar, substitute popcorn and pretzels for chips, bottled water instead of soda or juice, cut Nintendo and TV time, get the child outside.” Only after a family has done all of these things, and the child is still overweight, would Savoye consider offering a diet.

Whatever the method of weight loss, the Bright Bodies program is a remarkable development in that it favors an honest, unblinking response to childhood obesity — which conscientious and tongue-tied parents of overweight children may find liberating. And their children may be equally grateful. “I was overweight at 17 and I didn’t lose it until I was 25,” adds Savoye. “Of course I felt bad when someone called attention to my weight. But is being overweight good for you? No. And in my experience, being overweight wasn’t good for self-esteem either.”

No one wants children to grow up feeling bad about themselves. But silence about weight isn’t helping children or parents. The actual formula for anyone who is trying to maintain a healthy weight is ridiculously low-tech: Eat less, exercise more. But in order to be in a position to offer this simple solution, we need to stop encouraging girls to pursue an unrealistic body weight in the name of beauty, so that we can encourage them to maintain a realistic weight in the name of health.