The girls of the Bold and Beautiful Club are on the move. In sneakers, sweatpants, and T-shirts or tank tops, they burst out the doors of Walker Upper Elementary School into the warm spring afternoon. There’s Marcie, a broad-shouldered, wisecracking girl in a bright yellow top. There’s Brianna, quiet and bespectacled with pigtails. There’s JaNia, a cheery, talkative girl with straightened black hair, and her giggly walking partner Noelle, whose precise braids frame her head. Eight girls—tall ones and short ones, African Americans and whites—set off up briskly up a hill with two female guidance counselors on an after-school walk in suburban Charlottesville, Virginia. What these girls have in common is the reason they were invited to join this club: they are all what they prefer to call “big.”

Their bodies fill—and in many cases strain—the fabric of their pants and tops. They are fifth- and sixth-graders, aged 10 to 13, but some are already physically developed and could be mistaken for high school students. Walking uphill in the sunshine is difficult for most of

them. They puff and sweat as they march along, some girls swaying with every step as they throw one ample leg slightly out to the side to ease it past the other. Each set of partners has been given the same list of things to look for—a red bird, a flower, a female jogger, a parked blue car, a small child playing, evidence of roadkill—and they eagerly scan the streets and lawns, shouting as they spot an item on the list to check off.

For its members, the Bold and Beautiful Club meetings on Monday afternoons are a high point of the week. Each session starts with some exercise—walking, dancing, aerobics—and then moves on to a lesson on nutrition or personal health and hygiene. There’s usually a healthy snack that the girls eat and learn how to make at home. And there are special attractions: guest speakers, field trips, swimming parties, sessions on skin care or makeup. “It’s a lot of fun,” confides JaNia. “There’s a lot of activities, and I like it.”

Halfway through the walk, nobody has spotted a red bird, roadkill, or a runner. “If you want to check off a female jogger, you have to do a little jogging yourself,” says Minda Barnett, a counselor who is the club’s coleader. Nobody takes her up on that suggestion, but the girls do pick up their pace as they start down a steep slope. Marcie throws herself to the ground and lies supine on the pavement. “Here’s your roadkill,” she says. Everyone laughs. By the time they reach the bottom they’re getting hot and tired. The pair in the lead spots a child playing in a park at the end of a lane; the panting stragglers try to get away with checking off that item without going to look. “Oh, no,” chides Barnett. “You have to go up there and see the kid.”

Back in their classroom, club members drink lots of water and eat “ants on a log” (celery spread with low-fat cream cheese and sprinkled with raisins or sunflower seeds). Miss Lamb, a science teacher, arrives with creams, lotions, washcloths, and makeup mirrors to teach them how to give themselves a facial. She passes out the supplies and talks about skin care. The girls set up the magnifying mirrors and peer at their faces intently.

“What do you see?” asks Miss Lamb.

“I see bumps,” says Ashley, a girl with braids and big dark eyes.

“I got dry skin,” says someone else.

Miss Lamb shows them how to apply a cleanser and moisturizing cream. For the next few minutes the room is all but silent as the girls concentrate on making small circles with their fingers, rubbing in cream until their cheeks and foreheads are shiny. Suddenly they’re children again, giggling and playing peekaboo with the mirrors.

“Raise your hand so I know you’re listening,” says Miss Lamb. “What have you learned from this today?”

“Not to use bar soap,” says JaNia.

“What if you did this every day?” asks Miss Lamb.

“Oh, you’d be beautiful,” sighs Ashley.

Like many communities in the United States, Charlottesville has a burgeoning epidemic of childhood obesity: a 2001 survey of third-grade students in the town’s public schools found that almost 42 percent had BMIs above the 85th percentile for their age, meaning that they were already either overweight or at risk of becoming so. The Bold and Beautiful Club is so named for good reason. Barnett founded it about seven years ago for fifth- and sixth-grade girls who were overweight and, in the opinion of their teachers or counselors, had low self-esteem. With help from local nutritionists, Barnett and fellow guidance counselor Atalaya Sergi developed an after-school program aimed at making club members feel better about themselves, fostering friendships with other girls, and encouraging them to adopt healthier eating habits and increase their physical activity. A comparable program for overweight boys has also been offered at the school, but this year Barnett could not find any male teachers or counselors to lead it. Similar school-based programs for overweight children have been implemented around the country. Such programs provide vulnerable children with needed social support and may increase the likelihood that they will adopt healthier habits, although so far there has been little formal evidence that they prevent or reduce obesity. In the Charlottesville program, the goal is improving girls’ self-esteem and promoting healthy behavior, not producing weight loss; girls are not weighed at the sessions, and dieting is not encouraged. Since no study has been conducted to compare BMI changes among Bold and Beautiful members with those in a similar group of nonparticipating girls, it’s impossible to determine whether the program reduces girls’ obesity risk.

For children of both sexes, but especially for girls, being overweight can be a daunting social and emotional burden. In the idiom of mainstream American culture, fat is considered unattractive. In films, television, advertising, and other media, the dominant images of physical beauty are inextricably linked with slenderness: thin thighs, wasp waists, muscular arms and buttocks. This societal obsession with thinness is pervasive and infectious: studies reveal that even in the early elementary grades, many girls begin to fret about their body shape and say they want to lose weight. In a survey by Stanford University researchers of more than 900 California third-grade students, 35 percent of white girls, 44 percent of Latinas, 28 percent of Asian American and 50 percent of African American girls said they wanted to lose weight. Among Latina and Asian American girls, studies suggest that the desire to be thin is every bit as strong as among white girls. In African American culture, large women have traditionally been considered attractive and sexually desirable, a shared value that has helped protect overweight African American girls from some of the distress suffered by heavy girls of other racial or ethnic groups. Among white girls, higher socioeconomic status and higher levels of education are associated with lower levels of obesity; those patterns have not consistently been found among African American girls. But there is some research evidence, such as the Stanford study mentioned above, that the media-driven taste for thinness also influences the self-image and eating habits of African American girls.

The girls of Bold and Beautiful are clearly vulnerable to such influences. Outside Barnett and Sergi’s office hangs a poster made by club members, a collage showing glamorous African American and white models. Almost all are willowy, long-legged women wearing sexy, revealing fashions. Other photos depict short skirts, elaborate hairstyles, and handsome, well-muscled men. Only one image shows a voluptuous large woman, her legs hidden beneath a long full skirt. Barnett said club members made the poster after being instructed to look through women’s magazines and find images of women they thought were beautiful. After they had assembled the collage, the counselors told them about the techniques used by photographers to touch up and modify images, and they discussed the high incidence of eating

disorders among young female models. Then they asked the girls to peruse the magazines again, this time searching for a picture of someone who looked like a real person. “Many of the girls said they couldn’t find anyone who looked real to them,” Barnett recalled.

On the day I visited, I received an impromptu lesson about how easily a discussion of children’s body size can slip into the territory of value judgments and self-esteem. The girls asked me what my book was about. I explained that more and more children in our country are becoming “big” and that bigness is a problem because carrying extra weight is not healthy for kids. When I told them I didn’t yet have a title, they piped up with suggestions.

“The Bad Behavior Story,” offered Ashley.

I said I didn’t think being overweight meant that a person was “bad.”

Casey, another student, came up with an alternative. “How about Big People, Small World?”

Helping overweight children without adding to the shame and stigma many of them already feel is a challenge that confronts parents, doctors, and anyone else who works with kids. In the past, fear of causing children psychological distress, fear of making them weight obsessed, and even fear of triggering an eating disorder have sometimes prevented doctors from trying to treat children’s obesity. “It’s like the emperor with no clothes,” says Nazrat Mirza, a pediatrician at Children’s National Medical Center, in Washington, D.C. “Obesity has been gradually increasing. Somehow we’ve really turned a blind eye to it…. The epidemic is here and we haven’t done anything.”

A vibrant and idealistic doctor who earlier in her career treated malnutrition among the Masai in her native Kenya, Mirza was stunned, on moving to the United States, at how many of her young American patients were overweight. She says that often, when she begins to counsel parents about an overweight youngster, they tell her she is the first doctor who has ever mentioned that their child has a weight problem. “Nobody addresses it,” she says. “They are afraid to tip the scale into eating disorders. I’m not saying that’s not something we should be sen-

sitive to, but I don’t see why we shouldn’t address the obesity. Obesity kills.”

Conversely, Nancy McLaren, a clinical associate professor of pediatrics and medical director of the Teen Health Center at the University of Virginia, in Charlottesville, says she believes that most pediatricians today are fully aware of the obesity epidemic and are attempting to grapple with the problem. “There’s so much more in the medical literature and so much more at conferences—and there’s much more on the news,” she says. “They are trying to take a more proactive role with it.”

Mirza says that, in the past, she has heard pediatricians worry that raising concerns about overweight could cause a vulnerable child to develop an eating disorder. The most dreaded one is anorexia nervosa, a rare but life-threatening condition that most often affects white teenage girls. Anorexia nervosa, estimated to affect between 0.5 percent and 3.7 percent of women during their lifetime, is commonest during adolescence, and appears to be especially rare in African American girls. Its relative frequency in other racial or ethnic groups is uncertain. A girl with anorexia nervosa obsessively reduces her food intake to lose weight, and may remain convinced that she is fat even when she has become dangerously emaciated and ill. A somewhat commoner eating disorder, bulimia nervosa (estimated to affect between 1.1 percent and 4.2 percent of females sometime in their lives), is characterized by deliberate, repeated, and often secret vomiting or laxative use to prevent weight gain, often after episodes of binge eating. Both of these conditions can cause serious, even fatal, medical complications—but so can obesity, which is far more widespread among children in the United States, where almost one-third of our nation’s children are obese or are considered medically at risk of becoming so.

Binge eating disorder is a third, more frequent condition that can coexist with and contribute to obesity, although most overweight children and adults are not binge eaters. During any given six-month period, between 2 percent and 5 percent of Americans are thought to experience binge eating disorder. Symptoms include frequent, recurrent episodes of overeating associated with feelings of guilt and loss of control—but not accompanied by unhealthy compensatory measures like self-induced vomiting or laxative use.

“The relationship between eating disorders and obesity is a complex one,” notes Susan Yanovski, an obesity expert at the NIH’s National Institute of Diabetes and Digestive and Kidney Diseases. “For example, obesity is a risk factor for the development of eating disorders, but there are also data suggesting that disordered eating may play a role in the development of obesity in susceptible individuals.”

Pediatric obesity experts emphasize that there is no evidence that a sensitive effort by a doctor to treat an overweight child increases the risk of triggering an eating disorder. On the contrary, some studies suggest that teaching healthier eating habits to obese children and their families may actually reduce the incidence of eating disorders.

There are other reasons why many doctors may be reluctant to confront the problem of overweight kids. Getting into the issue with families is delicate and time-consuming; it’s a sensitive subject requiring tact, a detailed discussion about the child’s and family’s eating habits and activity levels, and plenty of parent education. The doctor needs to teach parents strategies to address the child’s weight problem other than “putting the child on a diet,” a frequent parental response that, as I will explain, can be counterproductive and even harmful. It is virtually impossible to pack all of the necessary questions and information into a “well-child” visit, which typically is a 15- or 20-minute annual checkup that includes a physical examination, immunizations, and brief counseling about a variety of other topics. And obesity in children or adults currently is not a “reimbursable diagnosis,” as Mirza points out: insurance typically does not cover the cost of separate visits to a doctor or dietitian for treatment—until obesity has become severe enough to cause a medical illness. That may change in the future, because government officials recently asked federal Medicare administrators to gather evidence on whether particular treatments for obesity are effective and should be covered by the plan. If Medicare begins to cover obesity treatment, other insurers are likely to follow.

In addition, physicians have traditionally received little nutrition education or training in how to assess a growing child’s caloric needs and how to counsel the mother or father of an obese patient. “They don’t know what to do,” Mirza says. “We say, ‘Refer the patient to the nutritionist.’” But because of the demands on nutritionists’ time at her

hospital, she notes, “If I refer to the nutritionist today, they might be seen in two months or three months.”

Considering these disincentives, it is little wonder that doctors and other health care providers often do not address excess weight adequately in children and may not even record it as a problem in the medical record. A 2002 study found that the medical evaluation of overweight children and adolescents fell far short of nationally recommended practice guidelines. Fewer than 10 percent of practitioners answering a national survey followed all the guidelines when taking a medical history and examining overweight children. A majority did not routinely perform recommended checks for bone and joint abnormalities, sleep disorders, or impaired glucose metabolism that could signal impending diabetes, all serious problems that can develop in obese kids. “Oftentimes a pediatrician sees a child who is overweight and then you wonder, OK, do I really want to go into the spiel of the disease complications?” Mirza says. “Obesity is a chronic problem and there’s a lot of work involved. Most providers would say they’re unsuccessful [in treating it]. There’s this feeling of futility.”

Defining “overweight” in children is more difficult than in adults, because a child’s body mass index, or BMI—the ratio of weight to the square of height—changes as the child grows. BMI normally goes down during early childhood (until around the age of 5 or 6), because during this period boys’ and girls’ height is increasing faster than their weight. Through the rest of childhood and early adolescence, BMI rises steadily as children grow taller and put on weight. In both sexes, BMI continues to increase throughout the teenage years, though somewhat more gradually for girls than for boys.

BMI does not correlate perfectly with fatness, because changes in body mass reflect changes in both fat and muscle. Thus, for example, an athlete with a large muscle mass could have a relatively high BMI but very low body fat. Accurately measuring body fat stores is too complicated and expensive to use as a screening method for identifying those who are overweight, so BMI has been adopted as a surrogate measure that correlates reasonably well with fatness for most people. If a child has a high BMI and there is uncertainty about whether the measurement reflects excess body fat or muscle mass, a doctor or other

health care professional can easily check by using calipers to measure skin-fold thicknesses at various points on the body, which is another way to assess fat stores.

Parents are not necessarily good judges of whether or not their children are carrying too much body fat. In a study of more than 600 mothers of preschoolers (aged 2 to 5), Amy E. Baughcum and colleagues found that 79 percent of the mothers with overweight children failed to perceive their kids as overweight. (They were somewhat more realistic about their own body size: 95 percent of obese mothers accurately believed that they were overweight, but one-third of normal-weight women also thought of themselves as too heavy!)

A larger national study that included a wider age range—5,500 children between the ages of 2 and 11—found that nearly one-third of mothers whose children were overweight failed to correctly classify their children as overweight. A mother’s race or ethnicity had no impact on how likely she was to misjudge her child’s weight status. The study also exposed an interesting difference when it came to gender. Girls whose BMI placed them in the “at risk of overweight” category were almost three times more likely than boys in that same group to be judged “overweight” by their mothers. That finding suggests that mothers may hold daughters to a stricter body size standard than sons, perhaps because of the cultural emphasis on female slenderness. “Mothers’ negative perceptions of their daughter’s weight status may contribute to young girls being extraordinarily pressured to engage in weight control practices,” the authors commented.

Making parents aware of the health risks for children of being overweight—and getting them to act when a child is gaining too much weight—is the focus of a policy issued in 2003 by the American Academy of Pediatrics (AAP). It recommends that doctors should measure and chart BMI at least once a year in all children and adolescents. It also urges doctors to identify and track young patients at special risk of becoming overweight because of a family history of obesity, an unusually high birth weight, or various socioeconomic, ethnic, cultural, or environmental factors. And it recommends that doctors watch for too-rapid changes in BMI (signaling that a child’s weight is climbing faster than expected) to identify those children at risk of becoming overweight and take early preventive action.

“By age 5, if your child is significantly overweight, you’re already on the path to disease outcomes,” says Deborah Young-Hyman, a clinical psychologist and obesity researcher at the NIH’s National Institute of Child Health and Human Development. “There seems to be a disconnect, currently, between parental understanding of overweight and its health risks that potentially is a new hook for pediatricians to start engaging parents in intervention.”

Following the policy will require pediatricians to change their behavior. Pediatrician Nazrat Mirza notes that doctors have traditionally been trained to react quickly when a growth chart shows that a child is failing to gain weight as expected, a condition medically known as failure to thrive. “All the alarm bells begin to sound,” she says. “We start getting really aggressive.” In contrast, when a growth chart shows that a child’s BMI is climbing upward, crossing percentile lines (a much commoner situation among kids in the United States today), “no alarm bells sound,” Mirza points out.

It’s a good idea for parents to ask their pediatrician to provide them with a copy of the standard growth chart used in children’s medical records so they too can keep track of their child’s height and weight at the time of each annual physical (and at other medical visits, if they are measured then). Current growth charts also show the range of normal BMIs for age and sex, so parents can take the chart along to appointments and ask the pediatrician to mark the child’s BMI on the graph.

Some school districts, concerned about the pediatric obesity epidemic, have decided not to rely on doctors to alert parents whose children are overweight. Instead, they’re sending home health and fitness report cards—nicknamed “fat letters” by some critics—to encourage families to instill healthier habits. At least one state—Arkansas—is in the process of adopting such a program statewide. A study of one such effort in Cambridge, Massachusetts, found that among parents who received such letters, 42 percent of those with overweight kids reported efforts to boost their children’s physical activity, 25 percent said they would consult the child’s doctor, and 19 percent said they planned to put the child on a diet. Among parents of overweight kids who did not receive such reports, only 13 percent reported plans to take any of those measures.

The Cambridge study also suggests one of the pitfalls of informing parents that they have an overweight child without giving them much guidance about what to do next. The study’s authors were pleased about parents planning to encourage physical activity or consulting their child’s pediatrician but were upset that almost one-fifth said they intended to try to control their child’s weight through dieting. Educational materials sent home with the reports had urged families to limit children’s TV time to no more than two hours per day, to encourage an hour a day of physical activity, and to try to make sure that children got at least 5 daily servings of fruits and vegetables. These materials also specifically discouraged parents from trying to place their overweight child on a restrictive diet, an approach that various studies have shown can actually be counterproductive. Medically unsupervised, do-it-yourself weight-loss diets are not a safe or healthy option for children and adolescents, and efforts by a parent to tightly control a child’s food intake are likely to backfire. A recent three-year study by researchers at Harvard Medical School found that girls and boys who were frequent dieters gained more weight annually than those who never dieted and were also more likely to become binge eaters. Dieting has become such a common behavior pattern in our society that many parents apparently assumed it was the right approach.

Sherry Arria, mother of an overweight 10-year-old, described to a New York Times reporter the mixed emotions she felt on receiving one of those “fat letters” from the Cambridge Health Department. Diabetic since childhood, Arria had grown up craving all the foods she wasn’t allowed. Now she found herself locked in a food struggle with her daughter. “If I walk out of the kitchen, she’ll jump up and eat food real quick,” Arria said. “I hate that. I don’t want to run back to catch her, because I don’t want her to feel bad about it…. I don’t want my daughter to be obsessed with her weight. Briana’s weight has even been an issue with my family. They hate the fact that Briana is heavy and try to pin it on me…. Meanwhile, I’m struggling to figure it out myself.”

Parents do need to monitor their children’s eating patterns, but those who focus obsessively and critically on a child’s weight or eating may do considerable harm. Some research suggests that too-tight parental

control over a child’s food choices and intake may be counterproductive, working against children’s innate ability to monitor their own hunger or satiety. Such findings are an important reason why experts advise parents not to respond to a child who seems to be gaining too much weight by “putting the child on a diet.”

Nutrition researchers Leann L. Birch, Susan L. Johnson, and Jennifer O. Fisher have done extensive studies on how parenting affects young children’s ability to adjust how much they eat in response to their hunger level and to the calorie density of food. In a 1994 laboratory study of 77 boys and girls between the ages of 3 and 5, Johnson and Birch found that the very children whose mothers tried hardest to control how much they ate were the ones least able to regulate their own intake.

Birch and Fisher have also periodically studied a group of 140 Pennsylvania girls and their parents, recording the children’s weight and height, and gathering information and experimental data when the girls were 5, 7, and 9 years old. They classified the girls according to whether they were overweight or lean and also according to the level of restriction (high or low) mothers exerted over their food choices and intake. At each of the three ages they also performed a laboratory experiment in which the girls were fed an ample lunch and were then given access to a variety of tasty snacks during a brief play session. The researchers measured how much of the available snacks the children (who all reported after lunch that they were not hungry) ate. They found that “eating in the absence of hunger,” as measured by the after-lunch snacking, increased for the entire group between the ages of 5 and 9, suggesting that children’s eating becomes more influenced by cues from the environment as they get older. However, eating in the absence of hunger increased more among those girls whose mothers had used higher levels of food restriction when they were 5 years old. Girls who had been overweight at 5 and whose mothers had also highly restricted their food intake showed the greatest degree of overeating at the age of 9.

In related studies, Birch and Fisher reported that young children whose mothers restricted their eating were more likely than other children to be overweight. They also found that mothers who had a per-

sonal history of dieting and unhealthy weight gain tended to try to exert more control over their daughters’ intake. The researchers suggest that such early dietary restriction may predispose girls, at least, to develop a variety of unhealthy eating patterns. Such findings are controversial. Birch and Fisher have mainly studied middle-class white girls, and they emphasize that their provocative conclusion—that parental dietary restriction may impair girls’ ability to regulate their own food intake—might not apply to boys or to other races and ethnic groups. Indeed, some other scientists have failed to replicate their findings. Stanford researchers studied almost 800 third-graders from diverse ethnic and socioeconomic backgrounds and concluded that girls whose parents controlled their food intake tended to be less overweight, not more so.

Birch and Fisher’s findings do not answer the question of whether too much parental control over a child’s food intake can actually cause the child to overeat, or whether it is the child’s innate or genetic propensity to overeat that has triggered the parents’ control efforts, notes William H. Dietz, an expert on pediatric obesity at the federal Centers for Disease Control and Prevention. “Are these parents who are controlling children’s intake because they already know [the children] can’t control themselves, or is lack of control on the part of the child a consequence [of the parents’ approach]?” he asks. To answer that question, he added, researchers would need longitudinal studies that would follow children over a longer period of time. “I think she [Birch] has shown, at least to my satisfaction, that parents who control their children’s intake have children who are less capable of doing so themselves,” Dietz says. “I think that this kind of parenting affects food choices. But it may not affect weight long term.”

Attempts by researchers to investigate whether parental feeding styles can contribute to childhood obesity “generally show very inconsistent results,” notes Jane Wardle, a professor of clinical psychology at London’s University College. Some studies suggest that the strongest parental efforts to control children’s eating occur not when a child is overweight but when a parent perceives a child as underweight and “neophobic”—unwilling to try new or unfamiliar foods. Wardle notes that at a well-regarded pediatric obesity treatment program at Great

Ormond Street Hospital, in London, a study found that parents of overweight children entering the program were relatively unlikely to have tried to control their children’s diets prior to the start of treatment. During treatment, however, they became more likely to monitor intake and to prompt their children to eat healthy foods. At the same time, the parents of children being treated also became less likely to use food as a reward or as an all-purpose remedy for emotional distress.

Those findings underscore a point made consistently by experts in childhood obesity: effective strategies for changing eating behavior should involve teaching the entire family, not just the overweight child, new habits.

How bad does a child feel about being fat? Does being overweight cause depression in children? Conversely, can being depressed cause obesity? Although hundreds of studies have been done to explore such topics, there are no simple answers. The short answer to all three of those questions appears to be: it depends.

Children and adults become overweight because some combination of environmental influences interacts with their body’s genetic propensity to store fat. But once a child is overweight, the way those excess pounds affect how that child feels about himself or herself depends on many factors, including the child’s age, sex, and personality; the child’s relationships with family members; the response of friends and peers; the child’s racial or ethnic group; and the social and cultural environment. “One assumes that obesity is detrimental to children’s psychological adaptation, and it just isn’t necessarily so,” says psychologist Deborah Young-Hyman. “It depends on a whole constellation of things.”

Children’s self-esteem depends on how they assess their abilities in a variety of areas—whether they feel smart, strong, and capable, whether they can make and keep friends, whether they feel loved and valued, as well as how they feel about their bodies. For toddlers and young children, much of that self-assessment reflects the feedback they get from parents, siblings, and others in their immediate family. Once children enter school, the responses of others their age begin to influ-

ence the picture—and become increasingly important as they get older, especially in adolescence. School-age kids and adolescents are also highly influenced by positive and negative feedback from other powerful adults in their lives, such as teachers, coaches, doctors, and members of their extended families.

Modern American culture teaches children to stigmatize those who are fat. In a study conducted in 2001 of several hundred fifth- and sixth-grade students, Rutgers researchers asked participants to rank six drawings of children—including one showing an obese child, several showing children with disabilities, and one of a child who was thin and not disabled—according to how well they “liked” each child. The students ranked the drawing of the slender child without disability highest and the drawing of the obese child lowest. Compared with results of a similar study performed in 1961, the difference in “liking” between the top-ranked nondisabled child and the obese child was about 40 percent greater in 2001, suggesting that stigmatization of overweight children has worsened in recent decades, despite the fact that such children have become far more numerous.

Because overweight children tend to be taller than their peers, adults often assume they are older than they are and may subject them to unrealistic expectations. It’s not entirely clear why most overweight children are also taller than average, but their rapid growth in height may be due to the effects of elevated levels of insulin and related circulating “growth factors,” combined with an abundance of building material in the form of nutrients. In girls, high levels of body fat are also associated with hormonal alterations that often lead to an earlier-than-average onset of puberty, with accompanying body changes that can provoke or intensify teasing by other kids.

Discrimination may continue into young adulthood, especially for women. One study found that overweight girls, even though equally academically qualified, were less likely to gain acceptance to elite colleges than their slender peers. A large government-funded study, the National Longitudinal Survey of Youth, found that women who were obese in late adolescence and young adulthood achieved lower levels of education, had lower incomes, had higher rates of poverty, and were less likely to marry than peers who were not overweight.

In a study entitled “Are Overweight Children Unhappy?” a team of

researchers measured weights and heights of more than 800 third-grade students in northern California public schools and asked the children to complete questionnaires about body weight concerns and symptoms of depression. They found evidence that high BMIs correlated with depression in the girls but not in the boys. Those girls who expressed concern about their weight were also most likely to report symptoms of depression.

In other studies of northern California students, Stanford University researcher Tom Robinson and colleagues found that by the age of 8, worries about weight and body dissatisfaction are common among both girls and boys, regardless of ethnic group or socioeconomic status. Among white, Hispanic, and Asian girls in the sixth and seventh grades, Robinson found, body size (as measured by BMI) was the strongest predictor of body dissatisfaction. But in a group of more than 100 overweight African American children living in Baltimore, Deborah Young-Hyman could find no significant impact of weight on the children’s overall self-esteem, even though many of the children in the study (who ranged in age from 5 to 10) were very obese. Among children 8 or older, those who were very overweight did have more negative feelings about their appearance, as did those children whose parents considered them overweight. These findings may reflect the fact that in African American communities large body size is more culturally acceptable than among other racial and ethnic groups in the United States.

A key point identified in Young-Hyman’s study and in several others is the importance of weight-related teasing as a cause of psychological damage in overweight children. In her study, the fattest children reported more frequent peer teasing and less social acceptance. Those children were also most likely to have fought with others because of their weight, using aggression to defend themselves from teasing but, as a result, often getting into trouble with their parents and teachers. Young-Hyman notes that aggressive behavior may have helped these children preserve their self-esteem.

Among adolescents, teasing and social stigmatization of fat kids seem to be more severe than among younger children, and the consequences are especially troubling. For both boys and girls in middle

school and high school, regardless of race or ethnic group, being teased about weight is linked with low self-esteem, symptoms of depression, thoughts of suicide, and even suicide attempts. In a study of more than 4,700 students in grades 7 through 12, Marla E. Eisenberg of the University of Minnesota found that it was the teasing, rather than the children’s actual weight, that predicted depression and suicide risk. Teasing was particularly hurtful when it came not just from peers but also from a child’s family. For example, Eisenberg found that almost one-quarter of adolescent girls teased about their weight by both peers and family members reported that they had attempted suicide, compared with about 8 percent of adolescent girls who had not been teased. Among both boys and girls, those who had suffered weight-related teasing (whether for being overweight or underweight) were two to three times more likely to consider or attempt suicide than those who had not.

Overweight adolescents tend to have fewer friends than lean children do, according to a national study that surveyed more than 90,000 middle and high school students about how many people they considered to be their friends. Overweight children were almost twice as likely as lean children not to be named as a friend by any other child. Tracey Saxon, a teacher in Charlottesville, says she sees the damaging effects of teasing and social isolation on some of the overweight sixth-graders she teaches. “I think that their body images right now vary,” she says. “If they have friends and are accepted, they’re kind of indifferent. If they have been picked on, then they’re very upset. They have very low self-esteem. And that carries over, obviously, to the classroom.”

At the urging of researcher Michael Rich, a few overweight Boston-area teenagers have captured on video some of the personal pain hidden behind the scientific findings. Rich, an adolescent medicine specialist at Boston’s Children’s Hospital, gave some of his young obese patients a camcorder and asked them to record their lives or their thoughts, creating what he calls a visual illness narrative. He asked his subjects’ permission to study the videotapes and to use them as a tool for teaching doctors, health care workers, and others who work with children about the psychological impact of obesity. Some kids talked directly to the camera; some set it up as a silent spectator as they went

through their days. “The camcorder sort of functions as a confessional,” Rich says. “They show things to the camcorder that they are not able to share with the physician.”

In one clip, a heavyset girl wearing a red kerchief tells the camera, “I think sometimes the reason why I eat the way I eat is because I’m either mad or I’m sad or people look at me strange…. It’s like I’ll eat even if I’m not hungry. If I’m hurting, sometimes that’s when I eat the most.” In another, a dark-haired, overweight boy stares impassively into space while his father, sitting nearby, criticizes him: “Lazy—lack of direction—lack of ambition….”

In another sequence, a fat boy rants about Leonardo DiCaprio. “He sucks! He just has to shake his hair back [to get a girl], and we have to work so hard to get a date.” A curly-haired, obese girl tells the camera defiantly, “I like myself the way I am! On the other hand, if you want to lose the weight, do it for yourself and do it because you want to and not because other people are forcing you, not because of the pressures of society…. I could have lost the weight five years ago, but I never did because it was like me saying, ‘F—you’ to the whole world. I don’t have to conform to your images.”

Despite the social isolation and criticism many overweight kids endure, studies suggest that the majority of overweight children and adolescents are not clinically depressed. Depression in children, however, is a serious and underrecognized problem that should be identified and treated whenever present. An illness in its own right, it carries a risk of suicide. Some research suggests that it also increases the likelihood that a normal-weight child will become overweight and that an already overweight one will continue to gain.

A key study sheds helpful light on the chicken-and-egg question about whether being fat is a risk factor for becoming depressed or vice versa. Researchers Elizabeth Goodman and Robert C. Whitaker performed a prospective study of more than 9,000 children in grades 7 through 12 who were interviewed at home on two different occasions, one year apart, for a large government-funded survey of adolescent health. Overweight adolescents were no more likely to be depressed than lean ones, according to the results of the baseline interview. (Of the total sample, 8.8 percent were depressed, as measured by a ques-

tionnaire that assesses depressive symptoms. Among the obese children, 8.2 percent were depressed, compared with 8.9 percent of the non-obese ones.) Surprisingly, the results indicated that being fat did not increase a child’s risk of developing depression over time either. At the follow-up interview a year later, children who had been obese at baseline had the same frequency of depression as children who had been lean.

But a depressed child or teenager, whether fat or lean, is at risk of gaining unhealthy amounts of weight, the study showed. Children who had been depressed at the baseline interview were significantly more likely to be obese a year later, compared with those who had not been depressed. Among kids who were already obese at the baseline interview, those who were also depressed gained more weight during the follow-up year than those who were not. Goodman and Whitaker suggest that there may be a subgroup of children or adolescents who respond to depression by developing an increased appetite or binge eating episodes; treating the depression effectively might prevent such individuals from developing obesity. There is also evidence from other research that depression or chronic stress can lead to persistently high levels of cortisol, a hormone that promotes weight gain as well as abdominal fat deposition and some of the other features of the metabolic syndrome. Such findings are a powerful argument for paying attention to children’s emotional well-being as an important influence on their physical health.

Some children also gain unhealthy amounts of weight as a response to physical or sexual abuse or emotional neglect. Doctors should ask questions that can help identify such factors when evaluating a child who is gaining too much weight.

Leonard H. Epstein, director of a nationally known treatment program for overweight children in Buffalo, New York, says he often sees cases in which depression or other psychological problems, such as binge eating disorder, developed before a child became heavy but were ignored or left untreated. “Parents, a lot of times, think, ‘If my child was just thin, the depression would go away,’” Epstein says.

When it comes to a child’s body size and self-esteem, there are many factors that parents simply can’t control. They can’t do anything about their genetic inheritance, which may include a propensity to gain weight that they have passed along to their offspring. They can’t completely shield their children, whether fat or lean, from exposure to the unhealthy aspects of modern society, from being influenced by the opinions or behavior of their peers, or even from hurtful teasing. They may not be able to prevent their child from becoming overweight or from suffering some of the physical and psychological consequences of carrying excess body fat.

But there is much that parents and other caring adults can do to raise children who are self-confident and resilient, who value themselves and other people for who they are on the inside and not just for what they look like on the outside. Adults impart such qualities and values as much by their own, often unconscious, behavior and attitudes as by what they say. Talking with a child who may be developing a weight problem, teaching a child about why healthy eating and exercise habits are important, will be far easier if that child feels loved and valued by the person who is doing the talking. And listening—paying attention to children’s feelings and opinions, finding out about their friendships and interactions with others—is just as important as talking, perhaps more so.

Parenting is a complicated job, one that human beings do not instinctively know how to do. It takes years—and plenty of help and guidance from others—to become an expert. Nevertheless, a number of valuable lessons and strategies have been developed by people who have worked with families in research and treatment settings. They have found that parents can learn to use language, styles of interacting, and positive reinforcement to maximize the likelihood that their kids will adopt healthier habits—by choice, not under duress.

Learning to accentuate the positive is vital, states Epstein. He believes that his treatment program for overweight kids owes its high long-term success rates to its focus on teaching highly effective parenting techniques and using behavior therapy to change the habits of the entire family. He urges parents to use praise, not blame or criticism, to influence their kids. “One of the things I’ve been most sur-

prised about is how hard it is for parents to generalize” this principle, he says. “When we teach them to praise kids for eating healthier, you would think they would start thinking, ‘I can use praise, then, for other behaviors.’ They don’t. They don’t generalize.”

Children are acutely sensitive to criticism by parents and other family members, even though they may not show it and may even seem to shrug it off. Marla Eisenberg’s study dramatically showed how overweight adolescents suffer when teased about their weight by others in their families. Charlottesville teacher Tracey Saxon says her former sixth-graders would sometimes tell her that their normal-weight parents were “disgusted” with them for being fat—and she has seen how badly children are hurt by such attitudes. NIH researcher Sue Yanovski says she tells parents of overweight children, “Your kids know that they’re fat. You don’t have to constantly remind them of it. You need to let them know you love them regardless of size.”

Whether trying to prevent children from becoming overweight or helping those who are already too heavy, adults must teach kids the benefits of choosing healthy foods, watching their portion sizes, and staying active, and they should model those habits. They should emphasize that the most important reason for adults and children to try to avoid becoming too heavy is that it is bad for their bodies. If an overweight child needs treatment, parents should address this with the child as a medical problem, not as a matter of physical appearance or as a focus for blame.

Leonard Epstein and his staff teach parents how to positively reinforce the behaviors and habits they want to encourage in their children, rather than constantly criticizing kids for things they do wrong. He said such a shift makes children feel as if they are the ones in control. “It makes a tremendous difference in the way kids approach things,” he says. “Say a parent wants to get the child to do their homework. The parent recognizes that one of the things that competes with doing homework is TV. Most parents would say, ‘You can’t watch TV until you finish your homework.’” But a parent using positive reinforcement would say, “After you finish your homework, then you can watch TV,” Epstein adds. “It’s a huge difference in the [child’s] perception of what the parent is trying to do.”

As part of Epstein’s program, parents and children agree on goals—such as reducing the number of hours a child watches TV and substituting some form of physical activity. They also agree on rewards the child can earn by achieving the goals. The rewards must not be food or things that cost money, such as toys. Instead, they are usually privileges or activities the child and parent agree to do together. Epstein’s research suggests that a vital ingredient in the success of his program is that the child is given choices. For instance, children can choose the kind of activity they want to do, and when they are hungry, they can choose a snack from a variety of healthy foods. Allowing some choice “is just critical,” Epstein says. “I think that’s what good therapists do: they get people to do what they want them to do, but make it appear as if it’s their choice. If it’s your choice, you buy into it. If you are doing it just because somebody told you to do it, it doesn’t necessarily make you buy into it.”

This doesn’t mean that a child’s choices should be limitless. William Dietz of the CDC emphasizes the importance of teaching children that the evening’s dinner menu is whatever a parent has prepared. Parents shouldn’t get into protracted negotiations with children who refuse what is served, Dietz believes. “Parents need to set limits on that. It’s OK for a parent to say, ‘If you ask me one more time, you’re going to have to take a time-out.’ They need to be able to buffer themselves from these kinds of incessant requests or complaints.”

Consistency is key, which means double standards within families don’t work either. Children will see them as unfair and will quickly rebel. For example, parents cannot expect to drink soda or eat doughnuts at home but forbid a child to have those items. In addition, they should not forbid an overweight child to have candy or potato chips while allowing the child’s normal-weight siblings to eat them. “It creates second-class citizenship for the child in the home,” says psychologist Young-Hyman. Rather than being food policemen, Epstein suggests, “Rearrange the environment. Give the child the choice of 2, 5, 10, or 15 healthy things” as snacks, and make the same choices available to everyone in the household.

Children can and should be included in family discussions about why parents choose to offer certain foods at home and not others.

“Have candid discussions with kids,” says David L. Katz of the Yale University School of Medicine’s Prevention Research Center. “Say, ‘Look, in our family we are going to balance eating the things that taste really good with the importance of eating things for our health. We’ll make compromises, but we’re going to pay attention to the way we eat to make sure we protect ourselves.’ That way, nobody is being disciplined, nobody is being punished or made to feel bad.”

Food should never be used as a bribe or as a reward, nor should restricting or forbidding food ever be used to punish a child. One aspect of teaching children how to recognize and respond to their own internal signals of hunger and satiety is to try to separate food, as much as possible, from some of the other ways in which it has come to be used in our society. We all grow up in cultures where food has traditional roles and meanings. Our lives would be impoverished if all of those meanings were removed. Yet to fight the obesity epidemic that threatens our children’s health, we must identify some of the societal and cultural reasons why adults and children eat more than they need, and we must be willing to change those patterns. We may have to abandon habits learned in childhood or revise our beloved but unhealthy family recipes.

“Eating is how most of our cultures evolved,” notes pediatrician Nazrat Mirza. “We celebrate birth with eating. We celebrate death with eating. You tell your kids, ‘OK, you’ve been so good, let’s go to McDonald’s.’ It’s kind of all wrong. We really have to change our way of thinking about how we’re going to reward children. We have to show them that, yes, we can celebrate without food.”

Just as we, as a society, must change some of the ways we use food, so we must also work to shift cultural perceptions so that obesity is recognized as a threat to health, not a cosmetic problem. Tracey Saxon embodies that distinction for the girls of the Bold and Beautiful Club. She is 36 years old, overweight, and diabetic. Not long ago she weighed 350 pounds. “You are the person you are because of a lot of things,” Saxon says she tells the club members. “Weight is one of them. It’s nothing to be ashamed of.”

The daughter of a high school football coach, Saxon was a gifted athlete who played Division I field hockey and lacrosse in college. She was always overweight—but she was physically active, outgoing, and had plenty of friends. “I was proud to be big and strong,” she recalls. She grew up feeling great about her body. “My mom is close to 6 feet tall and overweight,” she confides. “My dad says every day that she’s the most beautiful woman in the world.” She says she promised herself, however, that if her size ever caused health problems or prevented her from doing something she wanted to do, she would try to lose some of the excess pounds. That day arrived a couple of years ago when her doctor discovered that she had diabetes. He warned her that she could lose her feet or her eyesight if she did not lose weight. She cut back on potatoes, bread, and other carbohydrates. She joined a gym and began working out daily. Over a period of months she lost 70 pounds and brought her diabetes under control. “My goal out of this is not weight loss,” she says. “I want to be healthy. My doctors say they think that healthy for me is going to be around 200 pounds. With my body type and the way I’m built, that may be perfect for me…. Healthy comes in different numbers.”

Although Saxon says she feels well, having diabetes has changed her life. She wishes she had learned earlier that the disease runs in her family. “One of the things I tell the girls is, talk to your parents,” she says. “Ask them questions. Heredity plays a major role, especially if your family has a history of obesity.”

“I’ve had to learn a lot about food and how to do these crazy [calorie] counts,” she adds. “It’s a pain for me. I tell the girls, if you can learn to make just a couple of better choices a day, you’ll never get to this point…. My big thing that I try to tell them is, it doesn’t matter what you look like as long as you’re healthy. As long as you can live the life you want to live.”