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"I'm, Like, SO Fat!"
Helping Your Teen Make Healthy Choices about Eating and Exercise in a Weight-Obsessed World
By Dianne Neumark-Sztainer
The Guilford Press Copyright © 2005 Dianne Neumark-Sztainer
All rights reserved.
If It's Not One Thing, It's Another
Dealing with a Spectrum of Weight-Related Problems
Sarah is 12 and going through puberty. Like many girls her age, she's spending more and more time in front of the mirror. While she's there, she talks to herself—"I look SO fat"—and makes faces, pinching the flesh on her newly rounded hips.
David just got his driver's license, and now a few times a week dinner is a burger with fries or a Super Grande "Works" Burrito instead of a home-cooked meal with his family.
Home for a visit after her first semester at college, Amanda has lost 15 pounds. The food at school is "horrendously disgusting," she protests while pushing her dad's specialty pasta primavera around on her plate. The next morning her parents awake with a start when they hear the front door slam at five o'clock and look out the window to see their customarily late-rising daughter jogging down the street.
When Joe comes home from middle school, the first thing he does is tell his mother how much he hates his school because the kids are so mean about his weight. The second thing he does is grab some chips and soda pop and sit down in front of the TV.
Maybe you know some of these kids. Possibly you've got one like them living in your house. If you do, you probably have the same worries their parents have. Is Sarah just going through a phase of negativity about her body? Will David's health start to suffer if he keeps substituting burgers and fries for balanced dinners? Why is Amanda behaving so differently—is something wrong? And can Joe's mom help him accept himself and reject the cruelty of teasing while also encouraging him to change habits that contribute to overweight? Can she do so without sounding like she's taking sides with the kids who demean her son?
Joe's mother is facing the dilemma we're all up against today: It's hard enough to find answers to the questions that come up about weight, food, exercise, body shape, and all the physical, mental, and emotional health factors connected to these topics. But even when we do have some of the answers, how do we talk to our kids in a positive, productive way? My goal in this book is to help you with both.
Most teenagers experience some type of eating-, activity-, or weight-related problem as they transition from childhood to adulthood. For some teens these problems are mild; for others they can be quite extreme. Often the progression of a problem and its final outcome depend on its early identification and appropriate intervention. That's why it's so important to seek answers to your questions and then act on them.
The trouble is, it's all so complicated. Joe's mother knows it's right to make her son feel good about himself and to instill in him zero tolerance for taunting people about their appearance. What mother wouldn't? She also knows her son would probably lose some weight if he did something active after school rather than watching TV and ate snacks composed of something other than junk food. But if she tries to deliver these messages simultaneously, she's afraid that one message might cancel out the other. So how does she handle it?
The parents of the other kids face similar challenges. Sarah's parents want to assure her that her body is normal and that she can take pride and enjoyment in maturing. But they also want her to know that she's made up of a lot more than flesh and bones and that she has many other strengths. How can they make her feel good about her body without making it seem disproportionately important in a world that tells her it is? And how do they know whether she's just going through a phase that will pass as it should if they don't say anything?
Amanda's parents have more pressing concerns: Their daughter has lost a lot of weight and seems determined to lose more. Is she developing an eating disorder? What will happen to her once she goes back to school and is away from their watchful eyes? What can they do right now to protect Amanda from unhealthy weight loss? What shouldn't they do—to ensure that the lines of communication stay open?
David's parents want to allow him the freedom he's earned, but they don't want it to undo all the good work they've done to instill healthy eating habits over the previous 16 years. And they miss having him at the dinner table, where they can find out about what he's been up to all day. They're now realizing what they've always taken for granted—that family meals are not just about food.
If issues like these aren't complicated enough, there are the mixed messages that we're barraged with: Pick up a super-duper-sized, fat-laden quick-fix lunch at the drive-through every day, but make sure you can fit into that size-2 swimsuit. Play a sport, get buff, join a health club, no excuses—unless, of course, you're too busy trying to beat the newest videogame or you just have to catch the latest reality show episode. Go ahead and treat yourself to dinner at the new gourmet Italian place, but when they plunk a plate mounded with pasta in front of you, try not to eat more than a third of it. As adults we all fall prey to such pressures, and it's easy to pass on our confusion and ambivalence to our kids. Imagine how hard it is for teenagers to sort out everything they see and hear about food, exercise, and body image. Many of them can't, with the result that the prevalence of weight-related problems among our sons and daughters has never been higher, and their consequences have never been as serious:
The prevalence of obesity in teenagers has tripled over the past 20 years. Currently 15% of teenage girls and boys are overweight.
An additional 15–20% of teenage girls and boys are at risk of becoming overweight.
Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.
Dieting has been found to lead to weight gain, and not to weight loss, in teenagers.
Girls who diet frequently are 12 times as likely to binge eat as girls who don't diet, and boys who diet frequently are at a 7 times greater risk for binge eating.
One-half of teenage girls and one-fourth of teenage boys are dissatisfied with their bodies.
Approximately 1 out of 200 adolescent girls and young women develop anorexia nervosa.
The prevalence of bulimia nervosa is 1–3% among adolescent girls and young women. Thus, out of 100 females, 1–3 will develop bulimia nervosa.
Although eating disorders are more common among girls than boys, a significant number of teenage boys develop serious eating disorders, and many more engage in harmful weight-loss or muscle-gain behaviors.
Undoubtedly, you've already heard some of these statistics. You can hardly help it when it seems impossible to open a magazine or newspaper or watch television without reading or hearing about weight-related problems: "The new obesity epidemic!" "Lose five pounds in one week without breaking a sweat!" "Award-winning pop artist admits she has an eating disorder!" When I see the cover of a major magazine such as Newsweek or Time focusing on the "obesity epidemic," I have mixed feelings. As someone who works in the field, I'm pleased that weight-related problems are getting the attention they deserve. Unless we take problems such as the increasing prevalence of obesity among children seriously, they will continue. But I also get concerned about how vulnerable individuals may react when the alarm is sounded. I get particularly worried about teenagers, who may already have excessive concerns about their weight and appearance. On one side of the tightrope that we're forced to walk today is the risk of obesity; on the other, the risk of eating disorders. How do we keep our balance?
I believe the only answer is to consider all the weight-related issues together.
Why We Need to View Weight-Related Problems as a Spectrum
Too often when we address eating-, activity-, and weight-related problems, we focus on only one issue. When I say "we," by the way, I mean my colleagues and I in scientific research, doctors treating patients, journalists, and parents—all of us. We may worry about preventing obesity without paying enough attention to promoting a positive body image or preventing eating disorders. Sometimes we dismiss mild problems, such as skipping meals, body dissatisfaction, or unhealthy dieting, as normal for teens and wait until such problems become more severe to intervene. As the kids introduced at the beginning of this chapter illustrate, however, we aren't one-dimensional, and neither are our weight-related problems. Therefore, over the years I've become more and more convinced that we need to:
1. Pay attention to the different types of weight-related problems. In trying to get our kids to make healthier food choices, we don't want our efforts to lead to an obsession with counting fat grams or calories. In trying to prevent eating disorders in our teens, we cannot ignore the dangers associated with being overweight.
2. Be alert to mild shades of weight-related problems. We can't afford to wait until our teens develop eating disorders to intervene; we need to step in much earlier. When they say things like "I feel so fat" or "I'm starting a diet tomorrow," we need to have a constructive response. We need to pay attention to the number of family meals they have missed recently or the disappearance of food from the kitchen.
The spectrum of weight-related problems includes five dimensions, ranging from healthy to problematic (as illustrated from left to right):
1. Weight control practices, from healthy eating to clinical eating disorders.
2. Physical activity, from moderate to either excessive or absent.
3. Body image, from satisfied to very dissatisfied.
4. Eating behaviors, from regular eating practices to binge eating.
5. Weight status, from healthy to severely underweight or overweight.
These five dimensions are interrelated and, in fact, can be tightly intertwined in any one person. This means that when you see one problem in your child, other problems may lie below the surface or may appear in the future. Sixteen-year-old Karen is overweight, so she begins to experiment with fad diets. She says she hates what she sees in the mirror and absolutely has to lose weight before the prom. Seeing how unhappy she is, and knowing the health risks that come with obesity, Karen's mother naturally wants to help her move toward a healthier weight. But that will involve more than putting balanced meals and reasonable portions on the table to steer her daughter away from a crash diet. She'll also need to help Karen develop a positive body image, override the influence of peers and advertisers who tell her that she can lose 30 pounds in 30 days, help her find physical activities that appeal to her, and help her avoid binge eating. Unless Karen and her parents look at all the dimensions on the spectrum, they won't have much success in solving the surface problem and may inadvertently trigger additional problems.
The spectrum of eating-, activity-, and weight-related concerns.
The use of the spectrum also makes it easy to address budding problems early, when they are easier to solve. Too often parents and doctors get stuck in the dichotomy of "normal" versus "abnormal." When we can say, "No, this teenager doesn't have a serious problem," we absolve ourselves of the need to do anything about that gut feeling that something is not quite right—until we are forced to say, "Yes, now there is a serious problem." Then we intervene. Sarah, described in the first scenario at the beginning of this chapter, has normal developmental concerns about the changes going on in her body. Her parents can help prevent these concerns from blossoming into more serious problems in a slew of different ways. They can talk to Sarah about the normal changes that occur during adolescence. They can make an active effort to be positive role models. They can stay aware of the messages their daughter is getting from the media and advocate for positive, healthy advertising and marketing. And they can explore what Sarah really means when she says she feels fat. If they think about weight-related problems as falling along a continuum, from mild to severe, Sarah's parents won't wait until their daughter is in real trouble to take these and other kinds of actions.
Maybe the figures in the table come as a surprise to you. Maybe they just confirm what you've suspected all along about the magnitude of weight-related problems among our teens. To protect our sons and daughters, however, we have to know where the dangers lie. Let's take a closer look at each dimension and the hazards lurking at the extreme ends of each.
1. Weight Control Practices: Reasonable or Irrational?
How many people do you know who have never dieted? In our society, dieting is so common as to seem normal. But that doesn't mean it's harmless, particularly in children and teens. For some teens, the feelings of hunger and deprivation that often accompany dieting lead to binge eating and, somewhat ironically, to weight gain. Research has also shown that all too often simple dieting can turn into unhealthy dieting, and in some teens can be the first step toward a more problematic eating disorder. How to prevent dieting from causing problems for your teen is discussed throughout this book, particularly in Chapter 6. The key features of some of the more severe eating disorders are described here.
ANOREXIA NERVOSA: NOT JUST TOO MUCH DIETING, BUT THAT CAN BE WHERE IT BEGINS
Anorexia nervosa is perhaps the most severe condition included on the spectrum of weight-related disorders. It's a very serious illness, requiring long-term treatment with a health care team that specializes in eating disorders. If you suspect your child may be developing this problem, it's essential that you contact a professional immediately. Also read Chapter 15.
Characteristics of anorexia nervosa include self-starvation and a strong fear of being fat. Some of the symptoms include weight loss, severe body image disturbances, dry skin, intolerance to cold, fatigue, constipation, and irregular menstrual cycles, although not all of these may appear. Teens may develop unusual eating habits, such as limiting the types of foods they are willing to eat, avoiding family meals, pushing food around on the plate, cutting food into small pieces, and weighing or portioning food. They may engage in intense and compulsive physical activity as another weight control strategy.
Teens often begin the process by dieting for weight control purposes, but as dieting behaviors lead to weight loss, feelings of control, and compliments from others about weight loss, anorexia nervosa can develop in vulnerable individuals. Once it does develop, anorexia nervosa seems to take on a life of its own as the need for control over eating, activity, and other behaviors becomes extreme and somewhat obsessive. Consider the scenario, at the beginning of this chapter, about Amanda, who has just returned from college and appears to be displaying anorexic behaviors. Although her parents are concerned, Amanda may be getting compliments from others about her weight loss. These compliments can reinforce her unhealthy behaviors. I have seen this happen many times, and it is very disturbing to concerned family members who are aware of the underlying problems that others may not be seeing and are inadvertently reinforcing. Imagine how 13-year-old Linda's parents felt when she returned from long-term inpatient hospital treatment for anorexia nervosa and her neighbors, remembering how overweight Linda had been when younger, complimented her on how good she looked at her lower weight! About nine out of ten individuals with anorexia nervosa are female. This doesn't mean you should ignore the signs of anorexia nervosa in your son, however. Because of its relative rarity in males, it is possible for health care providers, educators, and parents to overlook those signs in boys, which means the condition may be recognized only in its later stages, when treatment may be more challenging.
Excerpted from "I'm, Like, SO Fat!" by Dianne Neumark-Sztainer. Copyright © 2005 Dianne Neumark-Sztainer. Excerpted by permission of The Guilford Press.
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